The problem of mental disorder a study

Table of contents :
PREFACE......Page 5
CONTENTS......Page 9
SECTION I THE CHARACTER OF THE PROBLEM......Page 11
SECTION II CURRENT POINTS OF VIEW: A REVIEW AND A COMPARISON......Page 17
I. CLINICAL PSYCHIATRY......Page 24
II . MEDICAL PSYCHIATRY......Page 38
III . THE NEUROLOGIST'S POINT OF VIEW......Page 49
IV. THE PSYCHOBIOLOGICAL POINT OF VIEW......Page 61
V. THE PSYCHOANALYST'S POINT OF VIEW......Page 81
I. PROBLEMS IN CEREBRAL ANATOMY AND PHYSIOLOGY......Page 101
II . ELECTROPHYSIOLOGY OF THE BRAIN......Page 110
III . ELECTRICAL MEASUREMENT OF ACTIVITIES INNERVE AND MUSCLE......Page 123
IV. NEUROCYTOLOGY......Page 136
V. CERTAIN ASPECTS OP THE CHEMISTRY AND METABOLISM OF THE BRAIN......Page 152
VI. NEUROPATHOLOGY OF THE BRAIN......Page 168
VII . THE ORIGIN, PLAN, AND OPERATIONAL MODES OF THE NERVOUS SYSTEM......Page 174
VIII . FACTORS OF NEURAL INTEGRATION AND NEURAL DISORDER......Page 187
IX. GENERAL BIOLOGY AND GENETICS......Page 206
X. HUMAN CONSTITUTION......Page 217
X I . ENDOCRINOLOGY......Page 224
XII . THE PATHOGENESIS OF NEUROCYTOTROPIC VIRUS DISEASES......Page 231
XIII . NUTRITION......Page 245
XIV. PHARMACOLOGY......Page 256
XV. GENERAL AND EXPERIMENTAL PSYCHOLOGY......Page 265
XVI. CLINICAL PSYCHOLOGY AND THE PSYCHONEUROSES......Page 304
XVII. THE COMPARATIVE PSYCHOPATHOLOGY OF INFRAHUMAN PRIMATES......Page 317
XVIII . PSYCHOTIC SYMPTOMS AND SOCIAL BACKGROUNDS......Page 329
XIX. CULTURAL ANTHROPOLOGY......Page 336
XX. EDUCATION......Page 344
SUMMARY......Page 362
SECTION IV COMMENTS AND REFLECTIONS......Page 367
INDEX......Page 373

Citation preview

THE PROBLEM OF MENTAL DISORDER

T

H

E

P

E

O

B

L

E

M

I

S

O

E

D

OF M

E

N

T

A

L

D

A Study Undertaken by The Committee on Psychiatric Investigations N a t i o n a l Research Council

MEMBERS OF THE COMMITTEE MADISON BENTLEY, Chairman Sage Professor of Psychology, Cornell University

E. V. COWDRY Professor of Cytology, Washington University

First Edition

This Study was Supported by a Grant from The Carnegie Corporation

McGRAW-HELL BOOK COMPANY, Inc. NEW YORK AND LONDON 1934

E

E

Copyright, 1934, by t h e M c G r a w - H i l l Book Company, Inc. PRINTED IN THE UNITED STATES OF AMERICA A l l rights reserved. This book, or parts thereof, may not be reproduced in any form without permission of the publishers.

THE MAPLE PRESS COMPANY, YORK, PA.

PREFACE While serving the National Research Council as divisional chairmen, E. V. Cowdry and Madison Bentley frequently discussed the present state of psychiatry. Both inclined toward the opinion that our knowledge of mental disorders is extremely imperfect and that the treatment of the disordered is correspondingly unsatisfactory. There is, of course, nothing novel in this opinion. I t is shared by many psychiatrists, who are impressed by their heavy responsibilities to society and who are turning to the basal sciences of life for new knowledge, sounder principles, and more effiacious methods. Out of these discussions in the Council grew a tentative plan for determining more exactly what the actual state of psychiatrical knowledge is and for suggesting certain possible means of advancing our understanding and control of the mental disorders. A considered inquiry of this character would seem to be useful at the moment, for disturbances of human behavior now present to civilized states and peoples one of the gravest, most persistent, and most baffling of all the urgent problems involved in self-government and self-direction. The immediate result of the informal discussions was the appointment of a Committee on Psychiatric Investigations. The two divisional chairmen named above and Robert H. Lowie, incoming chairman for the Division of Anthropology and Psychology, were appointed to the committee, Dr. Lowie resigning after the close of his official term. Upon the authorization of the National Research Council, the committee sought funds for the prosecution of its work. These were generously provided by the Carnegie Corporation. The plan pursued by the committee began with a large number of conversations between members of the committee and various individuals actively and professionally engaged in studying and treating the disorders; that is to say, in the psychiatrical arts of cure, in problems of commitment and classification, in the general problems of incidence, in the tasks of hospitalization, [v]

PREFACE in the Investigation of origin, cause, and nature of the disorders, in control and prevention, in teaching, and in the executive control of psychiatric instruction. A considerable part of the time of the chairman of the committee has been devoted for the last two years to this kind of survey of existing theories and methods. The examination of general treatises, of important researches in progress, of current texts and articles, and of associational reports and discussions has been a necessary accompaniment to this work. Out of the primary reconnaissance has come the preparation of the five Current Points of View in psychiatry which make up the second section of this report. Here representative investigators have written in a like tenor and to a common end, each author acquainting himself with the writings of his fellows. The second step was the placing of these authoritative writings, proceeding from leaders in psychiatry, in the hands of persons chosen from the field of the natural sciences both for their abilities in productive investigation there and for their capacity to suggest methods and issues of research in the sciences which give promise of improving our understanding of mental disorder and its origin and control. At this point lay the central interest of the committee; namely, to discover how well the natural sciences are prepared to form a basis of support, in the way of fact, method, and principle, for the psychiatrical arts and for a sound doctrine of the relation of the abnormal to the normal in human activity and behavior. I t has seemed to the two men primarily responsible for the study that a choice will have presently to be made in civilized countries between those proposals and methods which primarily rest upon speculation, creed, cult, and organized professionalism, and those proposals and methods which primarily rest upon the methodology and productive issue of the natural sciences. The sciences have not until now really been put to the test in a general and fundamental way. While descriptions, schemes of classification, doctrines of origin, and curative measures in this 'mental' field have, to be sure, referred to, and to some extent been documented by, the sciences, their spirit and method have, on the whole, been chiefly determined by professional and philosophical tradition. All too frequently, when the sciences have been appealed to, the appeal has been to such abstract and speculative theories as those touching 'the nature of disease,' 'hereditary causes,' or 'the powers of the mind' and not to sober fact and attested principle. [vi]

PREFACE When we consider, on the one hand, the present limitations in psychiatrical knowledge found in most persons devoted to research in the physical, biological, and psychological fields, and, on the other hand, the limitations in scientific training commonly found among professional psychiatrists, we shall not expect too much of a hurried and crude attempt to bring together the field of fundamental knowledge and the field of curative art. But we may reasonably hope to see what scientific support can be brought to light by a first methodical survey and to derive some definite intimation of promise from this quarter. In crises and in the most stubborn problems of living, men still turn naturally to divination, to simple rules and formulas, to superstitions hardened by centuries of tradition, and to creeds and doctrines. In very few of the great human emergencies— possibly only in the issues of death—has the temptation to resort to primitive logic, to magic, and to cultish beliefs been so great as it has been in those dreadful afflictions which alienate and incapacitate the individual. Here the temptation is undoubtedly increased by the stupendous problem of caring for hundreds of thousands of hospitalized patients and for more hundreds of thousands of unhospitalized persons unfit for making their way and their living in the community. The family, the neighborhood, and the state are all desperate. The temptation is still further increased by the failure to educate, train, and professionally equip the army of men and women required to diagnose, classify, segregate, and suitably care for and treat the vast number of disordered in our midst. Now in desperate circumstances and under emergency it is necessary to face the problem in hand, to invent solutions, and to provide adequate knowledge and means of relief. In our present situation, therefore, this may be a suitable occasion to ask—after a full century of the medical conception of 'mental disease'—whether our fundamental knowledge of nature and of man cannot be used in a broader and more effective way to improve our understanding of the disorders and presently to lead to a more effective control. Cornell Univebsitt,

' "

September, 1934. The authors alone are responsible for the facts and views presented in this volume. Under its general policy with respect to publications proceeding from the activities of its divisional committees, The National Research Council holds itself free from any such responsibility. [vii]

CONTENTS Page v

Preface Section I. The Character op the Problem .

...

. 1

Section I I . Current Points op View: A Review and a Comparison Introduction . I. Clinical Psychiatry Dr. C. Macfie Campbell Boston Psychopathic Hospital I I . Medical Psychiatry Dr. A. Myerson Medical School, Tufts College III. The Neurologist's Point of View Dr. I. S. Wechsler Columbia University IV. The Psychobiological Point of View Dr. Adolf Meyer Johns Hopkins Hospital V. The Psychoanalyst's Point of View Dr. Lawrence S. Kubie New York City Summary . .

. . . . .

.

7 14 28 39 51 71

.

91

Section III. The Supporting Sciences: Present Contributions and Future Research Introduction. . . . . 96 I. Problems in Cerebral Anatomy and Physiology 111 Dr. Stanley Cobb Harvard Medical School II. Electrophysiology of the Brain . . 120 Dr. George H. Bishop Washington University Medical School III. Electrical Measurement of Activities in Nerve and Muscle 133 Dr. Edmund Jacobson University of Chicago IV. Neurocytology . 146 Dr. E. V. Cowdry Washington University Medical School V. Certain Aspects of the Chemistry and Metabolism of the Brain 162 Dr. Irvine H. Page Rockefeller Institute for Medical Research [ix]

CONTENTS Page VI. Neuropathology of the Brain . 178 Dr. Wilder Penfield McGill University V I I . The Origin, Plan, and Operational Modes of the Nervous System 184 Professor G. H. Parker Harvard University V I I I . Factors of Neural Integration and Neural Disorder 197 Professor C. Judson Herrick University of Chicago IX. General Biology and Genetics . . 216 Professor H. S. Jennings Johns Hopkins University X. Human Constitution. ... 227 Dr. Walter Freeman George Washington University X I . Endocrinology . . 234 Dr. R. G. Hoskins Harvard Medical School X I I . The Pathogenesis of Neurocytotropic Virus Diseases. . . 241 Dr. Ernest W. Goodpasture Vanderbilt University Medical School XIII. Nutrition. . 255 Dr. George R. Minot Boston City Hospital XIV. Pharmacology. . 266 Dr. K. K. Chen Lilly Research Laboratories, Indianapolis XV. General and Experimental Psychology. 275 Professor Madison Bentley Cornell University XVI. Clinical Psychology and the Psychoneuroses 314 Dr. Joseph Jastrow New School for Social Research, New York City X V I I . The Comparative Psychopathology of Infrahuman Primates 327 Dr. Robert M. Yerkes and Dr. Ada W. Yerkes Yale University X V I I I . Psychotic Symptoms and Social Backgrounds. . 339 Dr. Mandel Sherman and Dr. Irene C. Sherman University of Chicago X I X . Cultural Anthropology. . . 346 Professor A. L. Kroeber University of California XX. Education ... 354 Dr. Leta S. Hollingworth Teachers College, Columbia University Summary 372 Section IV. Comments and Reflections . Index. .

.

. [x]

.

377 383

SECTION I THE CHARACTER OF THE PROBLEM In distinction from all those human diseases and disabilities which primarily afflict the bodily members and the bodily functions, it has for a long time been common to speak of a class of 'mental' diseases. This distinction rests partly upon the fixed tradition in Western knowledge that everything in the universe which cannot be conveniently brought under the category of body and matter must be treated under the complementary category of spirit and mind. But the distinction between physical and mental disease rests also in part upon the fact that when medicine discovered the 'mental' class it also discovered that it had to deal with a new kind of symptom and with new methods of diagnosis, and had to prescribe novel modes of treatment. In spite of these differences in 'physical' and 'mental' disease, medicine has persistently tried ever since to deal with the mental sort as if it were a mere lateral extension of the older conception of physical disease and bodily pathology. That has obviously been the most effective way of maintaining a complete and undivided authority in the entire field of psychological, as well as bodily and physiological, derangement. Within the realm of disease and of morbid anatomy, medicine has had no rival. We shall understand, therefore, its reluctance to admit a class of ' functional' disorders revealing no pathological agent or lesion. The more clinically inclined tend to accept this class, while the strict pathologist maintains with a stout heart that the qualification 'functional' is only a concession to our present ignorance, to be removed of course so soon as we penetrate further the anatomical and organic mysteries of disease. The actual history of mental or psychological medicine has been one of uncertainty and vacillation. The nature of mental disorder has clearly called for special concepts, distinctive methods, and a unique training; but the contention that all disease must rest upon pathological lesion within, or pathological damage to, the body has made all mental, private, and social [1]

THE PROBLEM OF MENTAL DISORDER factors merely incidental. The result has been to produce every shade of compromise from two extreme positions. The one extreme declares the disorder to be not merely mental symptoms and indicators, but a disease of mind; the other extreme maintains that disease must imply pathology and that pathology always appears in bodily tissue. The logic of the case has not been clarified by a tenacious tradition of two distinct but related series of events, bodily and mental, which run a parallel course with or without causal interference. The practical outcome of this confused state has been to produce two branches of psychiatry, the one calling itself 'psychological' and the other 'neurological'; the one tending to modify disease by standing for a real mental variety of it, the other maintaining a more traditional and restricted view (often called by its adherents the 'scientific' view) which looks always and hopefully for neural lesions. The eclectics usually occupy middle ground. The more extreme parties fashion unlike names, the mentalist seeking to retain only for himself the term 'psychiatrist,' his opponent preferring to be called 'somatist,' 'organicist,' or 'neurologist.' Here, as elsewhere, confused concepts and issues engender partisan emotions. Both extremes are confident and condescending, while the intermediates place their allegiance where they can, or become adherent to some related science, e.g., to biology, psychology, or endocrinology, i The partisan attitude also determines the method; the psychiatrist (in the narrower sense) prefers the clinic and the examination of many cases, while the neurologist is apt to be a laboratory man making detailed studies of the individual case and consorting with the anatomist and the histologist. Associational meetings and publications show the same cleavage and represent the biases of the respective parties. Of late these fundamental distinctions among the doctors of mental medicine have been cut across by outside influences; by the increasing prestige of biochemistry, endocrinology, genetics, and the like, and more fundamentally by inroads from sociology, anthropology, psychology, a popular hygiene, and psychoanalytical theory and practice. These latter influences have been most disturbing, first because they have threatened to alienate a certain part of the regular medical practice and secondly because they have challenged the term 'disease' as the [2]

THE PROBLEM final and fundamental concept underlying the disorders. To be socially maladjusted or out of touch with one's particular culture, or inadequate in psychological functioning, or unhygienic, or suffering from a mother-fixation, may not at all signify disease but something to be better understood and treated in quite another context. Thus the disorders stand at the present time in a confused— many would say in a disordered—state. Beside the fundamental difficulty of adapting to their description and treatment a concept of disease and pathology which had been designed and elaborated primarily for plain physical ailments, we now see introduced into the field of mental medicine many other concepts, many new interests, and not a few nonmedical methods. These internal differences and these disturbing inroads on the field of mental medicine might have only professional or theoretical interest if practice were competent, understanding sufficient, and control efficacious. I t is, however, widely agreed and commonly admitted that present knowledge and existing agencies are quite inadequate to the problem in hand. We may reasonably assume, therefore, that most persons who are actively and responsibly concerned with the disorders and the disordered would agree that new knowledge and new instruments of research brought together from the wide field of the sciences are just now urgently needed to supply new facts, to correct orientation, and to free the subject from the domination of speculative creeds. Possibly we should exempt from such a reasonable assumption the position of those who are chiefly concerned with the routine of classification and of care, or with the responsibilities of hospital operation and management. These matters of great importance in the psychiatrical arts are not specially designed to divert men engaged in them toward present deficiencies in fundamental grasp and in the comprehension of the nature and the cause of disorder. We may also doubt whether those men who derive their points of view and their modes of treatment less naturally from a descriptive account of the abnormal organism than from a philosophy of medicine, of mind, or of primal forces in man, seeking first to envisage disorders in the framework of doctrine or theory, would regard an extension of knowledge on the side of the natural sciences as of primary importance to their beliefs and their profession. Where men are convinced [3]

THE PROBLEM OF MENTAL DISORDER that they have already discovered the springs of mental derangement, whether through the principles of organic pathology or by a descent into the hidden depths of human nature, the sciences of life are not likely to be their first concern, nor research, as it is commonly pursued there, their favorite means of advancement. When we turn from professional considerations to the disorders themselves, we find a problem of very great difficulty. While the curative arts are constantly discovering new measures and medicaments for preventing and relieving many of the graver ills of the body, no like agency is successfully coping with the mentally disordered in public and private institutions for the insane and in the open life of the community. A vast host of the restrained psychotic and of the unrestrained neurotic afflict themselves, distress their families, trouble the logal community, disturb business and profession, and create an enormous economic loss—one single type of disorder alone costing the United States something like a million dollars a day. But it is not primarily the financial cost of maintaining and operating institutions for the insane that makes the high incidence of these disorders one of the gravest and most alarming of human problems. I n the first place, nearly every hospitalized patient means a disturbed and disorganized family. I t is obvious to everyone that the committing of a member to the hospital for the insane much more deeply and seriously disturbs the family and the community than does a temporary absence for bodily ills. I n the second place, the mentally disturbed and ungoverned outside the hospitals probably exceed the hospitalized cases. No one knows the numerical relations between the hospitalized and the ambulatory, because no reliable means of enumeration has yet been discovered. Among the afflicted who are abroad in society and who are almost invariably working mischief in the family and in the neighborhood, we must include not only the neurotic and the psychoneurotic who are under the care or the advice of physicians, psychoanalysts, healers, magicians, cult leaders, quacks, astrologers, radio advisers, and the like. We must include also a great number of the queer, the vagrant, the flighty, the incorrigible, the suspicious, the irascible, the unstable, and the reclusive. All these are social hazards. All are individuals who, because of defective self-direction and of unbalanced performance, are more or less incapacitated for effective living and for that measure of contribution to society which its members [4]

THE PROBLEM are called upon to make in the well-ordered state or community. From this intermediate zone, moreover, come many of the more serious and permanent derelicts who make up the distinctly dangerous classes of society. We must further observe that the gravity of the problem of human disorder and maladjustment inheres as truly in the complexity of the problem itself as in its personal, social, and economic issues. The problem resolves into a whole series of part-problems, and these part-problems must be set in array before a deliberate and reasonable attack can anywhere be made. First appears the part-problem of incidence and extent. An adequate survey would touch upon the number and the variety of the major and the minor disorders, of hospitalized and unhospitalized patients, of the neurotic and the psychotic. This task should be undertaken not only to improve our exceedingly imperfect knowledge, but also as a preliminary means to prophylaxis, catching incipient defects and restoring many aberrant individuals to a fuller measure of social competency instead of permitting a further increase in disability. Beyond these introductory studies of incidence lie inquiries into the difficulties and the failures of diagnosis, into meager knowledge of cause, predisposing conditions, course, stages, and outcome, and into the present defective classification of kinds. The candid consideration of the present unsatisfactory state of all these special phases of the general problem would lead of necessity toward a review of all those human instrumentalities involved in description, advice, and relief; means which include the diagnostician, the researcher for fundamental knowledge, the practical disposition of the patient, and the prescription of medicaments and dietaries. After more adequate knowledge concerning ailments, causes, and relief has been found, there must be faced the proper and sufficient selection and education of men and women who are to deal humanly and professionally with the disordered.1 This special and very important undertaking demands in turn a frank and thorough inquiry into the success or failure of systems and agencies which have been in use a sufficient length of time for an adequate trial. I t seems feasible 1 So far as this problem pertains to the medical schools, it has received a timely discussion in R. A. Noble, Psychiatry in Medical Education, National Committee for Mental Hygiene, New York, 1933. This author believes that "The whole question of education in psychiatry must be approached through the medical curriculum" (p. 49); but he finds that "constructive thought is being given" to this subject " i n relatively few schools" (p. 15). [5]

THE PROBLEM OF MENTAL DISORDER to investigate in this direction the effects upon the disorders of large and small hospitals, of cottages and home-care, of the training of the young psychiatrist in the medical schools, the psychoanalytical institutes, and elsewhere; to discover the fate of patients released as cured; and to make a wide comparative study of the results of private practice, of rest-cures, hospital-care, psychoanalytical methods, and the like, upon cure, relief, abatement, failure, exacerbation, and death. To be effective, such an examination would take into account the biological and biographical histories of the patient and distinguish the main types of disorder. Only in this way are the current claims of doctors, schools, cults, and theories likely to be objectively weighed and adjudged. With all of these primary aspects of the problem of the disordered intelligently surveyed, there would still remain the pressing necessities of public and private financing, building, housing, maintenance, and administration of all the institutions and agencies set up to care for and to minister to the disturbed and the deranged. I t is obvious that a comprehensive survey would involve many means and instrumentalities, consume time, and require large resources. While it is true that certain of these part-problems (e.g., incidence and psychiatrical education) have recently been brought into serious discussion, it has seemed possible that a more general and fundamental approach might be made by undertaking an inventory of the scientific support which may now profitably be used to extend knowledge of the disorders and of the best ways and means to direct the arts of diagnosis and therapy. I t may reasonably be held that any thoroughgoing attempt to improve the present state of confusion, contention, and ineffectiveness must take stock in a direct and business-like way of the relevant and usable knowledge actually at hand and of the agencies and instrumentalities at command for increasing and solidifying that knowledge and of applying it, without doctrinal or professional bias, to the concrete problems of description, etiology, prevention, and relief. There follow in Section I I five psychiatrical points of view, set forth in parallel, and in Section I I I various proposals from those sciences which touch descriptively the life of man and which bear, by way of fact and method, upon his maladjustive disorders. [6]

SECTION I I CURRENT POINTS OF VIEW: A REVIEW AND A COMPARISON INTRODUCTION I n the preceding section an intimation has been given of the character, extent, and social import of the human derangements and incapacities commonly called 'mental disorders.' If these disorders are to be ultimately checked or prevented, it is obvious that men must comprehend them and divine their origins. The task of understanding is therefore primary. That task is exceedingly difficult. Until now no science, no art, no combination of the sciences of knowledge and the arts of practice, no considered mode of healthful and successful living, has proved equal to the task. Defective understanding and control are shown today by the high incidence both of the graver and of the lesser forms of derangement, in spite of a century of medical experience, the expenditure of millions, and the rapid advancement of the sciences of nature and of man. A first approach to the mental disorders may well make use of the views of representative men in the various schools and branches of psychiatry. Nothing would seem so clearly to define, or at least to suggest, the present state of our problem as plain statements made by those whose professional lives are spent among the disordered and whose efforts are directed toward understanding and relief. I n this section we bring together parallel writings of this sort which set forth the points of view in this large and complex subject. The varieties of psychiatry described are clinical (Campbell), medical (Myerson), neurological (Wechsler), psychobiological (Meyer), and psychoanalytical (Kubie). These varietal names—clinical, medical, neurological, and the rest—which have gradually crept into the language of psychiatry should not obscure the fact that the various kinds and schools mainly treat of one and the same group of disorders, observe the same traits and symptoms, and agree in large part [7]

THE PROBLEM OF MENTAL DISORDER upon the same rough modes of classification. They also have much in common with respect to history, etiology, and therapy. With one exception, the large class of derangements which they hold chiefly in common is the class of the hospitalized insane; though the discussions frequently extend over a far wider range to include many persons whose disorders are not included in the insanities. The term 'insanity' is primarily legal, denoting a mental disorder so serious in its expression and its consequences as to incapacitate the individual for a free life among his fellows. I t also suggests the wisdom of segregating and treating 'insane' persons. The medical word 'psychosis' has a similar designation, although it refers rather to behavior and mental condition than to legal and social status. The word 'psychoneurosis' is frequently used in medicine to indicate disorders which fall short of complete disorientation and incapacity but still imply a maladjustive condition. Common forms of psychoneurosis (or simply neurosis) are hysteria and states of morbid fear and anxiety. Still milder disorders without number are to be found in the unstable, the incorrigible, the lawless, the queer, the irascible, the anxious, the suspicious, the cruel, the naughty, the moody, the erratic, the reclusive, and the ungoverned. So many and so various are the forms and the issues of mental disorder and disability that the problems of recognition, description, and care touch upon many subjects, notably upon law, education, psychology, penal practice, and the biological and social disciplines, as well as upon the various medical arts. These wide implications of our problem suggest richness of resource, but they also hint at obscurity, confusion, and misunderstanding. Furthermore, we may well observe here that, wherever factual knowledge and practical control of a difficult matter are deficient and inadequate, men are tempted to resort to speculation, to magic, and to doctrinal conceits. That temptation is notably strong in attempts to understand the physical universe and the meaning of life. I t likewise appears in the present context, where the necessity for care and cure of the mental disorders has until now gone well beyond the knowledge and the skill of man. Here schools of doctrine, bold theories of origin, and extravagant proposals of relief have done their part to cloud the primary issues and to retard fundamental research. [8]

CURRENT POINTS OF VIEW When we consider the tremendous inherent difficulties of coping with the disorders, then add the wide involvement of institutions and interests, and, finally, take into account the deep temptation in human affairs to speculate, to invoke magical agents, and to form sects, schools, and parties, we shall not wonder either at the complexities of the entire situation or at the contentions and contradictions still to be found among schools and practitioners. Nevertheless, we may contend that never since medicine began to substitute 'disease' and 'human affliction' for 'madness,' 'fury,' and 'demoniac possession' has the opportunity been so great as now for sound and catholic understanding and for sane and reasonable methods of care and treatment. With respect to the writings which immediately follow, we shall find our representative authors approaching the same body of facts from their several points of view and expounding each in his own perspective. Dr. Campbell distinguishes six great orders of defect which supply the actual material presented to the clinical psychiatrist for diagnosis and treatment. I n all this material, it is the understanding and the relief of deranged and defective functions of the personality which fall—as he affirms—to the psychiatrist. The personality means the individual in action, with his behaviour and his beliefs. It includes all the partial functions which may be studied in other disciplines; it includes all the chemical changes; it includes all the physiological activities as well as all the overt reactions, all the thoughts and emotions and strivings of the individual. . . . The statement in psychological terms, however, includes implicitly all that is included in the physiological statement and in the chemical statement. The psychological idiom is different and does more complete justice to the total situation than the idiom of physiology and of chemistry. Dr. Campbell also suggests a half-dozen avenues of research leading toward an extension of psychiatrical knowledge. Dr. Myerson explains that the point of view of the medical psychiatrist is "fundamentally that of the physician." His approach is "permeated by the knowledge of disease in general." His primary search is therefore for the pathological condition underlying the symptoms presented. This search has been well rewarded in general paresis and it has been encouraged in a few other disorders, e.g., pellagra, senile dementia, and toxic psychoses. Myerson counsels against the term 'functional [9]

THE PROBLEM OF MENTAL DISORDER disorder' and in favor of a more thorough search for bodily disturbances. Where no "well-established pathology" has been discovered, as in various forms of dementia praecox, there is still "no ground for the assertion that there is no organic alteration." Again, manic-depressive disorders may well be regarded as diseases because of the regular alternation of phases and the obvious reference to hereditary antecedents. As a physician searching for bodily derangement, Myerson naturally prefers the physiological to the psychological approach, though he would not separate mind and body and he "is prepared to believe . . . that chronic emotional states may produce pathological alteration." Dr. Wechsler makes it clear that the view of the neurologist coincides, in many places, with the view of the medical psychiatrist. The neurologist is a somatist or structuralist, his interest centering in neural or nervous aspects of the disorders, which he regards as "diseases of the nervous system." But Wechsler also adds other factors to the neural. He recognizes psychological factors, hereditary patterns, education and tradition, direct social influences, and the unconscious. His approach is dual; neurological and psychopathological. He nevertheless distinguishes his field from that of the clinical psychiatrist, "who is departing more and more from neurology and general medicine into ever wider social and philosophical fields." The non-neurological factors (to be derived from psychology, psychoanalysis, genetics, anthropology, the clinic, and other sources) cannot, to be sure, be overlooked. However fond the hope or firm the conviction that the soma, particularly the nervous system, holds the key to the ultimate solution of the riddle of the mind, the neurologist cannot fail to take an interest in the study of the vast number of psychological and sociological factors which enter into the problem. He must not shut his eyes, however much he may insist on the rigorous application of scientific method, to the fact that, in the study of human behavior, scientific rigidity is no less inimical to progress than congealed dogma, and that there are a great many avenues of approach to the solution of any given problem. He must also recognize that the complex totality of numerous behavior reactions may represent a product which differs enormously from its more simple component parts and that one cannot in the present state of knowledge speak of normal and abnormal behavior or even of simple mental processes in terms of anatomy and physiology alone [10]

CURRENT POINTS OF VIEW While recognizing the plain dilemma in the outlook of the openminded neurologist, Wechsler concludes: " I should be false to the neurological point of view if I did not re-emphasize the neurologist's insistence that complete understanding of mental disease can only come from an understanding of the workings of the nervous system in its reciprocal relations with bodily organs, that is, from a full understanding of structure and function." Many others, both within and without psychiatry, have felt both the urgent need and the sheer impossibility of giving a transcript of human behavior and accomplishment in terms of known neural functions. Dr. Meyer bases his understanding of the disordered individual upon a conception which has been called psychobiological. This conception is related to a kind of psychology once recognized as American functionalism, a movement of protest. I n its psychobiological and some other current forms, this mode of envisagement emphasizes the active unity of the living organism and also the dependence of organic activities (called responses or reactions) upon environmental agencies (called stimuli). Meyer regards the unitarily active organism as the person, which he describes as "the consciously or mentally or psychobiologically integrated organism." Our chief aim in the study of man is the determination of the r6Ie and range of operation of man, affecting his own course of life and that of others and of our common background, and the determination and control of the special factors making for success and failure, for health, happiness, efficiency and creativeness. . . . It occupies itself with those entities and relations that form, or pertain to, the 'he's' or 'she's' of our experiences—the bodies we find in action, as far as we have to note them in the behavior and functioning of the 'he' or 'she.' We are aware of a contrast between the activity of detached or detachable organs such as the heart or the stomach or the brain, and the activity of these same parts assigned to the 'he' or 'she* or "you' or ' I . ' When in adjustment the organism may be regarded as normal; when out of adjustment it is disordered. A normal activity Meyer calls an ergasia. Ergasias are "actions and reactions and attitudes of the 'he' or 'she' or ' y ° u ' or '!»' *-e-> mentally or more or less consciously integrated behavior." The disorders Meyer looks upon as deranged ergasias (jpathergasias) of various forms corresponding to the specific nature of the maladjustment [pligergasia, kakergasia, holergasia, purergasia, etc.). Starting [11]

THE PROBLEM OF MENTAL DISORDER with this "organismal" conception of the deranged organism, Meyer proceeds to collect biographical and social data upon the disordered person in order to determine the type and quality of the maladjustment or pathergasia. Meyer shows how his conception is made the basis also for the training of the professional psychiatrist, an operation which is essentially biological (not physiological or psychological) but which involves " a l l the sciences entering into the understanding of the human lifeprocesses and life-problems." I n explaining the psychoanalytical point of view in psychiatry, Dr. Kubie draws a useful and timely distinction between (1) actual practice in diagnosis and relief and (2) the theories and hypotheses used by the psychoanalyst in description, etiology, and treatment. The general point of view, preliminary to both, is that human behavior and social living—whether adequate or deranged—depend directly upon the organism's history; and that this history contains both a biological life-course as common among men at large and a biographical sequence of events which is specific and differential for the individual under examination or treatment. The biological life-course suggests physiological methods; the biographical history suggests a method directed primarily to mental, personal, family, and social occurrences. Kubie proposes psychoanalysis as an instance of this second sort of method. As for the procedure of psychoanalysis, the exposition presents free association, which demands a patient and an analyst. The procedure assumes that the patient can learn, under the tuition of the analyst, to indicate in detached words and phrases, not directed by coherent and topical thinking, fragments of biographical material. I t further assumes that the mere temporal conjunction of these verbal fragments often points to a significant connection of them at some earlier time. The significance is especially implied by the occurrence of emotion, which often involves (through 'transference') the psychoanalyst present. Since the character of the disorder is not to be immediately read off from the verbal fragments uttered and from the sheer display of emotion, it is obvious that the divinatory inference of the psychoanalyst must rest (at least so the exposition assumes) upon a theory of interpretation. The basal point in this theory, as Kubie explains it, is that the significant connections hidden [12]

CURRENT POINTS OF VIEW in the verbiage exist in the unconscious, not in the "consciously critical personality." The unconscious is therefore invoked to explain the assumed hidden connections discovered by the psychoanalyst and judiciously revealed to the patient for therapeutic reasons. As an agent of disorder, the unconscious is assumed to be dynamic in the sense of "energy-charges." The psyche is said to be tripartite (id, ego, and superego) and to imply various "psychic mechanisms." As the psychoanalytic doctrine is in active flux, Kubie is reserved and temperate in his espousal of these mechanisms. As for research, he emphasizes the importance of discovering the neurotic origins and tendencies of childhood, and, as for improving the procedures of practice, he counsels rigid, methodical, and liberal training of the practitioner.

[13]

I. CLINICAL PSYCHIATRY By C. Macfie Campbell, M.D., Boston At the present time the actual material with which the clinical psychiatrist deals may be in general grouped under the following headings: 1. The overt mental disorders, recognized as such, where the advice of the physician may if necessary be supplemented by the authority of the court (legal commitment). This group includes those patients commonly referred to as insane; their disorders are referred to as psychoses of various denominations. Mild degrees and early stages of psychosis may be camouflaged under such general terms as nervousness, a run-down condition, overwork, and neurasthenia, and under various special terms. 2. Certain mental disorders, due to a disturbance of the internal personal equilibrium, where the grasp of social relations and of the external world is not disturbed, and where the patient recognizes that he has symptoms and is in need of help. The most familiar types are the morbid fears, scruples, compulsions, hysterical episodes, and hysterical physical symptoms. The term psychoneuroses is commonly used for this group. 3. Cases of physical invalidism where a thorough review by the impersonal methods of internal medicine and its specialties has revealed no adequate basis for the total incapacity of the patient. Estimates by judicious observers suggest that between 30 and 40 per cent of those who go to general out-patient departments with somatic complaints are really handicapped by difficulties in their instinctive, emotional, and social life. 4. Individuals who, as a rule, are not considered either mentally or physically sick but whose behavior is socially disturbing or socially inadequate. The individual himself may realize the unsatisfactory nature of his behavior and may spontaneously appeal for technical help. This group includes patients referred by the authorities, by the courts, and by the police, on account of behavior which is in conflict with the statutes; the delinquent and the criminal. I t includes also the alcoholic, many cases with perplexing sexual behavior, and examples of economic inefficiency and maladaptation. [14]

CLINICAL PSYCHIATRY

5. A number of individuals who, without having shown or being conscious of any definite symptoms of recognized medical type, feel that their general response to the demands of life is unsatisfactory and who wish to have a systematic stock-taking in order to attain a better equilibrium; in some cases friends see that some review of the situation is required and persuade the individual to have this study made. I n this group are included individuals with feelings of inferiority, feelings of discrimination, feelings of jealousy, suspicious trends, ill-balanced enthusiasms for individuals, causes, and hobbies, with emotional waves of one nature or another, aggressive individuals in the service of some special cause, retiring, asocial individuals, embittered individuals, individuals who may have much to do with labor unrest or social and political fermentation. 6. Children who are brought for a great variety of reasons, including even overt mental and nervous disorders, but also difficulties of training, formation of poor habits, disturbing conduct of one type or another, sometimes complicated with the problem of mental defect. I n some cases it is the lack of school progress which is the basis of the consultation. These children may be brought for such divergent problems as bed-wetting, thumb-sucking, capriciousness with regard to food, tantrums, wetting and soiling, masturbation, lying and pilfering, precocious sex curiosity or activity, unusual cruelty or aggressiveness, wandering episodes, night terrors, special attitudes to parents, attitudes either of antagonism or of overdependence. The above clinical material represents the actual problems which are likely to be brought to the psychiatrist for study and treatment; i t represents the material which is seen in the wards of hospitals, in out-patient departments, in private consultation. With some psychiatrists the material may be almost altogether limited to one of the special groups referred to above. Thus the psychiatrist may confine his work to the study and treatment of the psychoneuroses, or may specialize in the psychopathology of childhood, or may limit his work to the problems of the court. Many individuals who fall within the above groups are never referred to the psychiatrist at all. The delinquent may be dealt with purely by the court, the wayward pupil may be dealt with purely by the school system. Where the individual is brought for consultation it may be not to the psychiatrist but to some other specialized worker. The child with nervous or mental [15]

THE PROBLEM OF MENTAL DISORDER symptoms may be taken to the pediatrist; the psychoneurotic patient may be treated by the organic neurologist, the clinical psychologist or the lay analyst. While recognizing that much is tentative and fluid in the organization of the medical profession and of its ancillary workers to meet the needs of the community, it seems reasonable to look upon the field of psychiatry as those disorders in which one is forced to go beyond the impersonal categories of internal medicine and to take account of the more complex functions which make up the personality. Where the problem can be thoroughly dealt with at the level of the categories of internal medicine, where one is dealing with simple environmental noxae and the reaction of the tissues to these noxae and with the ensuing clinical pictures with their physical signs and symptoms, one is in the field of internal medicine. Where one is forced to take into account the reaction of the individual to a social environment, where one has to reintroduce factors which internal medicine has provisionally discarded and to consider such factors as emotions, instincts, and personality, on the one hand, and the complicated values of the social environment, on the other hand, one has passed into the field of psychiatry. A human individual has been studied psychiatrically in so far as one studies the detailed symptoms of disorder on the broad background of the reaction of the personality to the specific environmental situation. Such a study involves a systematic and detailed review of the dynamic factors which go to make up the personality and of the complicated environmental forces which impinge upon the personality. I n the center of clinical psychiatry is the concept of personality, the individual, the concrete patient as we know him not only from the objective study of behavior and its component mechanisms but also from our own experience of what life is, from our own experience of our feelings, our thoughts, our fantasies, our conflicts, our strivings. The concrete problem which clinical psychiatry always has before i t is the reaction of the individual in face of the total situation with which he has to deal. Internal medicine discards the complex integrations as far as possible and takes cognizance of them only when the simpler categories prove obviously insufficient. The internist who has found that the purely internist study of the cardiovascular system has not thrown light on the symptoms of his patient [16]

CLINICAL PSYCHIATRY may feel himself forced to consider the sexual life of the patient, the emotional life of the patient, the past experiences, the present situation. He has to go beyond the merely physiological analysis of the condition presented to him and to take into account the psychological aspect of the situation. He has to pass beyond an impersonal pathology to psychopathology. He has to consider the patient from the psychiatric standpoint. The fundamental problem of the psychiatrist is the disturbance of the adaptation of the personality to the total situation; the functions by means of which man adapts himself to his environment, the special derangements of these functions, and the special stresses and strains which the environment lays upon the person are the material with which the psychiatrist works. The personality means the individual in action, with his behavior and his beliefs. I t includes all the partial functions which may be studied in other disciplines; it includes all the chemical changes; it includes all the physiological activities as well as all the overt reactions, all the thoughts and emotions and strivings of the individual. I t is only for purposes of investigation that one separates in human biology the simpler from the more complex functions, the chemical from the physiological, the physiological from the psychological. The chemical changes take place in the setting of a physiological reaction, which again is merely one aspect of the behavior of an individual in the setting of a complex cultural code. There is no conflict between the chemical and the physiological, between the physiological and the psychological; nor is it a question of coordination between chemical and physiological, between physiological and psychological. The statement of the special situation in purely chemical terms does less justice to the total situation than the statement of it in purely physiological terms, and again the statement in physiological terms does less justice to the total situation than the statement in psychological terms. The statement in psychological terms, however, includes implicitly all that is included in the physiological statement and in the chemical statement. The psychological idiom is different and does more complete justice to the total situation than the idiom of physiology and of chemistry. While interested in the psychological integrations and the interplay between them and the social environment, and talking in a psychological idiom, the psychiatrist must always be conscious [17]

THE PROBLEM OF MENTAL DISORDER that the latter includes a reference to component functions which can only be studied accurately and experimentally when one provisionally discards the fullness of the situation—the psychological setting in which the simpler functions are found—and takes up in the physiological or chemical laboratory a detailed investigation of these special functions in a more simple setting and perhaps experimentally isolated from the rest of the working of the organism. I t is on this basis of accurate physiology that impersonal medicine has been built up. Physiology comprises the institutes of medicine, but upon a physiology that remains a pure physiology, detached from the concrete totality of the organism, only an impersonal or "guinea-pig" medicine can be built up, one which is not adequate even for the needs of internal medicine, still less for the needs of the patients of the psychiatrist, who are not suffering merely from impersonal disturbances of the tissues, from faulty metabolism, from the invasion of pathogenic organisms. I t may well be emphasized that while the idiom of the psychiatrist may be psychological, the psychological terms which he uses have not become scholastic abstractions to him but are to him the symbols of processes which can also be studied at the physiological and at the chemical level. To the psychiatrist the idea of a burglar is not a psychological entity which may somehow or other become associated with other psychological entities; it is a term used as a symbol for an experience which involves strained attention, modified respiration, rapid heart action, complicated visceral changes, mobilization of chemical and physiological resources. The psychiatrist may have to lead a somewhat amphibian life or at least to be bilingual. He has at one time to use the psychological idiom, at another time the idiom of internal medicine. He realizes that complex functions may be disturbed by interference at the impersonal level, at the chemical level, the physiological level. Thus he knows that thought and emotion and effort may be disturbed by vitamine deficiency, by adrenal insufficiency, by brain tumor. He has to admit also that the more simple physiological changes which go on in the system may be thrown out of gear by a complex social situation, that vague reverberations of internal conflicts may disturb the ordinary nutritive processes. The psychiatrist, therefore, whose primary problem is the study of the disorders of the personality, has always to be alert [18]

CLINICAL PSYCHIATRY to the fact that the personality can be disturbed from two sides. I t may be disturbed in a secondary way by a disturbance of the simpler impersonal chemical or physiological processes, which are essential elements in the total dynamic system called the personality. Thus mental disorders, morbid fears, delinquent behavior may be the result of some inadequacy of diet, some disturbance of the endocrine balance, some other physiological inadequacy, the presence of some pathogenic organism or parasite. I t is obvious, therefore, that the psychiatrist will need to be familiar in a general way with the various factors which may upset the chemical, physiological, or immunological equilibrium of the system, will be interested in the researches carried on in regard to these special topics, and will be willing to utilize the results which are attained by those who are working at these special topics with methods which are appropriate to these topics. He will be glad to indicate to such workers how far in the psychiatric field there are indications for research along their special lines. As, on the one hand, the psychiatrist will be interested in investigating those disturbances at the simpler levels which may enter into and disturb the more complex functions of behavior and belief, so will he be sensitive to those factors in the environment which are of importance for the organism, which either by excessive demand or by deficiency may lead to a disturbance of the equilibrium of the individual. I n a review of the total situation the psychiatrist does not limit himself to the obvious, to striking emergencies and crises, to overwork or depressing occupational and domestic situations; he tries to appreciate the complexity of the forces in the cultural environment, to realize the effect on the personality of the early conditioning experiences of that cultural environment; he studies in detail the way in which the personality with its complex needs adapts itself to the specific situation of the individual life. He realizes that in the adaptation the organism mobilizes not only its biochemical and physiological equipment, but also its rational and its imaginative endowment, and the individual organism may even take the attitude that it has a creative part to play in the universe, that it is itself a living force, that it is not purely a reactive mechanism. The various ways in which the individual with his own special endowment, his own inner difficulties of equilibrium, his own past experiences, his present situation, adapts himself [19]

THE PROBLEM OF MENTAL DISORDER to the conditions of his life by word and thought and action form the object or study of the psychiatrist. Research in Psychiatry. Psychiatry has for its field the disturbances of the adaptation of the individual to the environment. I t is, therefore, interested in the mechanisms of adaptation of the individual to the environment, in the internal and external factors which modify these mechanisms, in the various environmental stresses which may lead to the breakdown of these mechanisms, in the various therapeutic procedures. Our knowledge of the adaptive mechanisms is inadequate; in many directions psychiatry wishes to supplement its inadequate data and to investigate further the mechanisms involved in human adaptation. Research of a chemical nature and of a physiological nature may throw much light upon the chemical or physiological components of the psychological phenomena which are the immediate data of the psychiatrist. Through contributions dealing with chemical or physiological categories not only theoretical advance but practical results of the first importance have been obtained in the field of metabolism and of the infective disorders. The chemist, purely interested in his special problems, in his investigations, may come across important facts which are of immediate value to psychiatry. His goal may not have been a psychiatric goal; his starting point may not have been a psychiatric question; the valuable result may have been only a by-product of the chemical work. If his interest had been limited to those problems and methods which seem to be in immediate connection with the problems of psychiatry he might not have come upon the results which proved to be so useful to psychiatry. Psychiatry may, therefore, derive great benefit from the work of those engaged in the fundamental medical sciences. On the other hand, while psychiatry gains from the work of those in the fundamental medical sciences who are working at problems quite apart from a special psychiatric setting, psychiatry has its own immediate problems, problems in which the methods and data of the fundamental medical sciences are of importance and which seem to require for their solution further research at a physiological or a chemical level. I n this case the problem may be referred to as coming within the specific sphere of research in psychiatry, because the problem presented is a psychiatric [20]

CLINICAL PSYCHIATRY problem, and although the methods invoked may be the methods of chemistry, physiology, or immunology, the relationship of the results to the original psychiatric problem is not lost sight of and the investigation is not pursued into remote channels, perhaps of great chemical or physiological or immunological interest but involving considerations purely of an abstract chemical or physiological nature with no special relationship to any psychological phenomena. The behavior and the emotional life of patients may bring up the question of the role of the thyroid gland. The physiology of the thyroid gland is a topic of some complexity. The internal secretion of the thyroid gland, its chemical composition, and the formula for thyroxin are problems of physiological and chemical interest. The psychiatrist faced with his complicated clinical material, analyzing the complex behavior into the simpler components, curious about the special r61e played by disordered thyroid activity in the problem before him, may take up as a topic for research the activity of the thyroid gland and its relation to the dynamics of the individual, his output of energy, his emotional life, his thought processes. Research into the chemical constitution of a hormone may start from research into the role played by a certain gland in the stability and efficiency of the personality, and may have as its goal a fuller knowledge of variations in personality; but the fact that certain researches on a hormone may have started from a psychiatric problem does not mean that all the research on this hormone is to be looked upon as research in psychiatry. Much of the work may be research of a purely chemical nature in which the guiding principles and interests and methods are chemical and which may be carried on quite irrespective of any bearing of the facts on the special problems of psychiatry. I t is true that as a result of these technical chemical researches results may be achieved which may be incidentally of great value to psychiatry and which may throw further light on its problems, but an incidental or secondary gain from the chemical research does not entitle it to be considered as research in psychiatry. Similarly research in physics has developed methods which have been of the greatest value to physiology, to internal medicine, to psychiatry, e.g., the x-ray tube, the string galvanometer, the technique of radio amplification. In so far as any of these improvements in method have been attained owing to the special [21]

THE PROBLEM OF MENTAL DISORDER interests of physiology and internal medicine and psychiatry their elaboration would come under the heading of physiological or medical or psychiatric research, but otherwise they remain as part of the activities of research in physics. Research in psychiatry is research which starts from the problems of psychiatry but which is free to use the technical methods of sociology, of psychology, of internal medicine, of physiology, of chemistry, of physics. So long as there is maintained an obvious organic bond between the investigation and the psychiatric problem which acted as its inspiration and as the directing force, the investigation can be looked upon as research in psychiatry. I t may be carried on by a psychiatrist who has special interests or special training, or it may be carried on by a nonpsychiatric colleague trained in a special field. Where the investigation loses contact with the original problem, where its interest is no longer in relation to the field of human behavior but is derived from its special relation to other problems in the chemical or physiological field, then the research can no longer be looked upon as research in psychiatry and can no longer claim support on this ground, but must be supported on the ground of the special value of that research for the general promotion of chemical or physiological or immunological knowledge. I t is well to realize that in the individual case i t is often difficult to draw sharp distinctions. Investigators have complex interests which vary from period to period. Investigations open up new leads, and the important thing is to continue the search for truth no matter though one may be passing from one territory into another; all formalities of passports and visas should be dispensed with. On the other hand, the investigator who has traveled a long distance from his original territory and whose work is now in a different territory should realize that he now must derive support from the special territory where he is working and that his work in the latter field cannot be looked upon as research in psychiatry even although as a by-product of that work results may be achieved which incidentally are of great value to psychiatry. Beginning with the psychiatric problem of hallucinations the worker may do some research in radio-amplifying technique, not on account of his interest in physics but in order that he may perfect a more finished tool of investigation for his psychiatric [22]

CLINICAL PSYCHIATRY research. Beginning with problems of the cerebrospinal fluid the worker may take up questions of the chemistry of the proteins, which are also being dealt with by the biochemist; the latter, however, comes to his problems with no special interest qua biochemist in the relationship of his chemical work and results to the field of human behavior and its disorders, but with interest in the promotion of chemical knowledge and in the solution of technical chemical problems. The reaction of stuporous patients to the administration of carbon dioxide and of various drugs suggests research into various problems which touch the physiologist and the pharmacologist; the interest of these latter, however, is determined by the background of their special field and by lines of investigation quite apart from psychiatric problems. A chemist, even though working in a psychiatric institute, is no longer engaged in research in psychiatry if his investigations have lost all contact with the special problems of psychiatry and derive their interest purely from the interest of the general chemical field and of its problems. So the physiologist, working in a psychiatric institute, may not be engaged in research in psychiatry even though he is investigating the physiology of the brain, if his investigations have lost contact with the special problems of the psychiatric field and have their own justification in the promotion of detailed physiological knowledge. How difficult it is to define the situation may be illustrated by the type of work which has been done by Cannon and his workers, work which has produced results of the very greatest value to psychiatry: When Cannon began to study the swallowing mechanism in the goose by means of the newly discovered x-rays he was not guided by special psychiatric interest, and many of the steps in his investigation of the functions of the vegetative nervous system were inspired by an interest in the detailed impersonal physiological mechanisms quite apart from their role in psychological integrations. His persistent attack on the problems which arose in his own chosen field of physiology were finally to furnish data which threw a flood of light upon the emotional reactions and upon the resources at the disposal of the personality for dealing with the emergencies of life. If a discussion of research in psychiatry is to be more than an academic exercise with verbal symbols, it is well to have in mind the concrete activities represented by these words and the actual [23]

THE PROBLEM OF MENTAL DISORDER setting in which they occur. I t may, therefore, be opportune to refer to some of the investigations actually being carried on or projected, which start work not from academic considerations but from the challenge of disordered human lives and their need for intelligent help. I n regard to general nosology, much work has to be done to separate cases into natural groups as a preliminary to studying the detailed mechanism of the disorder in each group; in each group are problems of constitutional make-up, of clinical evolution, of outcome, of the importance of endogenous and of exogenous factors, of environmental influences and of environmental strains, of detailed symptomatology, of methods of study, and of treatment. In some personality disorders the primary disturbance may lie at the level of structural alterations (e.g., tumor), of infective processes (e.g., encephalitis; focal infections), of metabolic or nutritive anomalies (e.g., pellagra; endocrinopathies; pernicious anemia; cardiovascular-renal and other disorders; alcoholism); in other disorders the main trouble seems to lie in the nature of the constitutional endowment, the molding influences of milieu and experiences, the evolution of the personality, the actual life situation with its specific values for the individual patient. In all cases both aspects of the situation have to be duly considered. In regard to constitution one requires further insight into individual variations in constitutional endowment, laws of heredity, psychological types, correlation of physical structure with mental traits, relation of endocrine glands to personality. The genetic study of the personality requires experimental work on conditioning factors (Pavlov and his school); research into the development of the infant in the nursery, and of the child in the conditioning atmosphere of the home, the nursery school, the kindergarten and school (Lewin, Piaget, Gesell) will supplement and control the results derived from the psychological analysis of the adult. The analysis of the nervous disorders of childhood is not only of therapeutic value, but is an important part of scientific investigation in this field of personality. These various investigations will throw light on the variety and nature of constitutional defects or liabilities, on the results of methods of training in nursery and school, on the role of the father, mother, and siblings in the development of the per[24]

CLINICAL PSYCHIATRY sonality, on the evolution of the sex-life, on the development of likes and dislikes, repressions, compensations, and of the individual's code of values and outlook on life. I n addition to such investigations into the factors which determine the structure and degree of vulnerability of the adult personality, there are many detailed problems for research in the symptomatology of mental disorders at the psychological level— the nature and genesis of schizophrenic symptoms, the mechanism of elation and depression, the various types of thought disorder, the nature and origin of hallucinations and of delusions, symbolism, archaic and primitive modes of thought, emotional expression and visceral reactions, disturbances of the sensorium, amnesia, the significance of dreams, etc. There is an important field for research in the relation of psychiatric conditions to superstitions and creeds, to the social code of school, college, and caste, to the general sexual code of the community, to the conditions of school life, of industrial life, and of the wider social life, to the conflict between cultures in the home of the immigrant, to the disintegration of culture in certain urban districts. Moreover, the attitude of the individual to the authority of home, college, state, and church, to authority in peace and war, as well as the role of nonrational factors in the social and civic action of the individual are psychiatric topics of research of obvious sociological importance. I n the complex symptomatology of psychiatric disorders the role of the simpler somatic functions has to be scrutinized and many problems await elucidation. I n hysteria one may emphasize the emotional factors, the sex conflict, the repression, but there still remains the problem of the choice of the specific symptom—cardiovascular, gastrointestinal, neurological, etc. The nature of the special sensitivity of the different systems in the hysterical and the neurasthenic requires investigation with the aid of all the technique of modern medicine. While the general symptomatology of the so-called functional psychoses is well known, the fundamental nature of the disorders is extremely obscure; it is the province of research to translate the descriptive 'affective instability' of the manic-depressive into a much more precise formula, and to reduce the serious involvement of the schizophrenic to a simpler expression. I n the study of these conditions, while alert to the psychological and social factors involved, it is also necessary to consider the [25]

THE PROBLEM OF MENTAL DISORDER possibility of the disordered psychological functions being the expression of an endocrinopathy, focal infection, or obscure metabolic disorder, and to make the necessary investigation. I n the study of schizophrenic conditions, with their kinship to certain organic and toxic conditions, pharmacological, biochemical, and neuropathological methods are required; the experimental catatonia of the bulbocapnized animal, the relaxation of some catatonic stupors under certain drugs, the similarity of some catatonic symptoms to postencephalitic symptoms, the reported neuropathological changes in the brains of schizophrenics offer a program of research in this field. From another direction serious beginnings of research have been made to determine the role played in these disorders by the endocrine glands. On the other hand, much of the behavior of the schizophrenic may have to be interpreted in the light of the psychology of religion, of the evolution of human culture, and of what is known of suggestion and hypnosis. The topic of suggestion offers a wide field for research. I t is not necessary to outline in detail the problems for research in regard to the socially important topic of alcoholism and the alcoholic psychoses; even the nature of the underlying mechanism of delirium tremens is practically unknown. Epilepsy is another topic which has important contact with the psychiatric field, and offers serious problems for research along psychological as well as neurophysiological and chemical lines. The problems awaiting solution in regard to the symptomatic psychoses (including the organic and toxic psychoses) are of great variety. This group embraces the organic psychoses {e.g., brain syphilis, cerebral arteriosclerosis, senile conditions, encephalitis, brain tumor), the toxic and infectious psychoses {e.g., drug psychoses, fever delirium, mental confusion and other mental conditions associated with infection), and mental and nervous conditions found with the greatest variety of physical disorders {e.g., gastrointestinal disorders, endocrine disorders, anemia, injuries and operations, genito-urinary conditions, respiratory disorders, cardiorenal disease, and metabolic disorders). In all these conditions there is much research to be done from the point of view of psychiatry, for the problem in each case is not that of an isolated somatic disorder but of a disorder of the personality in which the respective r61es of the simpler and of [26]

CLINICAL PSYCHIATRY the more complex factors have to be evaluated. While all the technique of internal medicine may have to be requisitioned, the results of the investigation at this level have to be integrated into the more complex functions of the personality. I n conclusion I would again emphasize two principles. 1. Research in psychiatry, beginning in problems of individual human behavior and attitude, seeks to determine the various component factors which are integrated into the complex result a,nd thus is led into the fields of anthropology and sociology, of psychology, physiology, and biochemistry, and undertakes investigations which require to be carried out with the special methods, facilities, and standards appropriate to these special disciplines. In any research which can appropriately be called research in psychiatry, even though for the time being the worker has provisionally discarded many of the complex factors in the situation and is following a special physiological or chemical clue, it is always possible to place the problem on the broad background of psychiatric investigation and to show its specific place in the general perspective. I n each such research there is an organic bond connecting the investigation with the original field of interest, and no matter how exclusive the interest of the investigator may be in the isolated problem which for the time being occupies him, the psychiatric background has a directing influence on the course of the investigations. 2. Wherever in the course of investigations, either anthropological, sociological, psychological, physiological, or biochemical, the directing influence of the psychiatric standpoint is lost and the investigation proceeds quite irrespective of what bearing it may or may not have upon the field of psychiatry, and where the direction of the investigation becomes absolutely determined by the special interests and perspective of the special discipline, the research cannot be classified under research in psychiatry even though it should be carried out in a psychiatric unit and even though later it should furnish conclusions of great value to psychiatry.

[27]

I I . M E D I C A L PSYCHIATRY By A. Myekson, M.D., Boston I take it that the medical psychiatrist is one whose point of view is fundamentally that of the physician, who enters psychiatry with a background of knowledge of internal medicine and surgery, with that organized approach which is permeated by the knowledge of disease in general, and who is actuated by the belief that the organism can only artificially be separated into a mind and body. Whether a disease is or is not an entity, in fact, whether or not there are entities in a universe which is in constant flux, with no especial fixed points, is not a question for discussion here, belonging, as it does, to metaphysics and logic. The point of view of the medical psychiatrist is that, whether or not our present understanding of the major mental diseases qualifies us to speak of them as pathological units, our working hypothesis will be more fruitful if we postulate that they are such units, provided that we realize that our classification is a mere scaffolding, to be discarded without emotion or egoism when a more solid structure appears. Certain of the mental diseases have reached the point of development and understanding where there are etiology, recognizable clinical syndrome, diagnostic criteria, pathology, and therapeutics. Paradigm of General Paresis. The great example of this progress is the case of general paresis or dementia paralytica. By a long and distinguished series of researches, there has been an evolution of scientific understanding from that time, a century ago, when certain of the patients in insane hospitals were noted to have ideas of grandeur together with dementia, and were isolated, so to speak, out of the conglomerate mass of the insane. There came in sequence the discovery by Argyll-Robertson that some of these individuals had pupils which did not react to light but did react to accommodation; the introduction of the reflex examination which showed that the tendon reflexes tended to be exaggerated, or, in instances when the disease was combined with cord changes, to be diminished. Later, there came the [28]

MEDICAL PSYCHIATRY epoch-making formulation of Fournier and Erb that syphilis was the cause of this group of conditions, though as yet there was no proof of this almost intuitive conclusion of these distinguished clinicians. Then followed a stage of intensive pathological study, with Nissl and Alzheimer and a host of others contributing, until the cerebral pathological picture was quite definitely established. The introduction of the lumbar puncture into clinical practice and the discovery of the Wassermann reaction gave a definite biochemical and biophysical approach which has become so exact that at the present time the diagnosis of general paresis can be established, practically speaking, without seeing the patient at all, on the presentation of the spinal fluid and blood-changes. The discovery by Noguchi and his co-worker Moore that spirocheta pallida are present in the brain of paretics completed the pathological and etiological picture. Then came the introduction of arsphenamine in one form or another by Ehrlich and those who followed him; later the introduction of malarial therapy by Wagner-Jauregg, and finally the creation of artificial fever by the use of the electric current. Thus a vague and empirical stage evolves into one of sharp and scientific definition; a disease, untreatable and hopeless only so short a time ago as twenty-five years, becomes treatable, even if not curable, so that many cases are arrested, others are even relieved of all symptoms, with the definite prospect that with advance in fever treatment, we shall reach the climax in medical progress, the cure. This is an example of progress. I cite also the disease pellagra, which usually has mental symptoms and in which our efforts have been crowned with true, scientific knowledge. I n some measure, that knowledge has reached the ideal of medicine, the stage of prevention and cure, by purely physiological and dietary means. The pathology of senile dementia has become definite through the study of the plaques which appear in this disease; and we know that some diseases occurring earlier in life are merely plaque diseases of presenile type, such as Alzheimer's disease. I n other words, to cite no other examples, easily available, the so-called "organic diseases" are much better understood and some of them much better treated than they were a quarter of a century ago. Others still wait for pathology and therapeutics and for the advance and refinement of chemistry and physics. [29]

THE PROBLEM OF MENTAL DISORDER Difficulty of Dealing with Psychological Criteria of Diagnosis. The diagnosis of the other mental diseases presents the inevitable difficulties of imperfect knowledge when there are no pathological criteria and when one must depend upon such subjective conclusions as to whether or not an individual is hallucinated or whether he has delusions, whether he is blocked by splitting or retarded by emotion, etc. The use of such diagnostic criteria as negativism, resistiveness, and apathy—in other words, clinical-psychological symptoms, the recognition of which is difficult, upon which agreement is often almost impossible— results in frequent mistakes even though there is agreement as to what constitutes a specific mental disorder. Thus the studies which have been made through the Harvard School of Public Health and the Massachusetts Mental Hygiene Society show that what one community hospital calls dementia praecox or schizophrenia another hospital in the immediate neighborhood may finally label manic-depressive psychosis; so that the disagreement between the two hospitals is so great as to render a statistical approach to the problem of these diseases impossible. Years ago I pointed out the same disagreement as obtaining among other Massachusetts hospitals and indicated the impossibility of making true statistical analyses of the incidence of certain psychoses because clinicians radically differed, not in diagnostic criteria but in the actual recognition of the symptoms. Some of the Great Disease Groups. There has been a great deal of recent revolt against the classifying of the diseases dementia praecox and manic-depressive psychosis, the pathology of which we do not know. The work of Kraepelin, the great systematist, has been bitterly assailed, and there is a strong trend away from classification and a movement toward the establishment of a psychiatry of the individual as part of the same general tendency which, for example, disregards the criminal type and makes the basis of criminology the study of the individual delinquent. Nevertheless, i t is part of science to classify, to disregard minor individual differences, to see broad points of resemblances, and to make those generalizations in which progress is finally recorded. Thus there are groups of cases in which the individuals gradually become more and more shut in or retreat from the activities of the world around them. They tend to become fixed in their reactions. Ordinarily they deteriorate in personality and also in [30]

MEDICAL PSYCHIATRY those more specific qualities which we call memory, interest, alertness, and sociality. They frequently have hallucinations and delusions which are markedly stereotyped. Their conduct, also, becomes more and more limited in pattern. These groups are classified as belonging to dementia praecox or schizophrenia, the latter term indicating a splitting in personality which undoubtedly takes place but which I believe represents too general a process to be labeled a disease. I see no advantage in the substitution of the term schizophrenia for that of dementia praecox, when, as a matter of fact, most clinicians use the two terms as more or less synonymous whatever their theory of differentiation may be. The term schizophrenic as an adjective has value in indicating a split-up, whether of processes or of personality. The difficulties in diagnosis which this group presents do not take away the fact that there is such a group or groups; the fact that we have no criteria of absolute merit does not detract from the statement that over a long period of time dependable criteria of diagnosis for this group appear. One fallacy, so i t seems to me, appears in the general clinical approach of the psychiatrist to this and other psychoses, for which Kraepelin is in large measure responsible; namely, the idea of the course as determining the diagnosis. Thus, if a man presenting dementia-praecox symptoms gets well or nearly so, the question always arises whether he really had dementia praecox. This seems to me to disregard the essential observations throughout the whole of medicine, namely, that other diseases run remarkably variable courses according to the nature of the reaction between the individual and the etiological agent. One man with tuberculosis will be riddled with tubercles in a week from the onset of the symptoms and die as if bacteriological lightning had struck him; while another, infected with the same disease, lives long, maintains his essential organic integrity, and carries on almost as if perfectly well. We do not say that the man who recovers from tuberculosis did not have the disease because of the mere fact of recovery. And the same is true of syphilis, cancer, and a host of bodily conditions. Some psychiatrists limit the appearance of this group to the ages under forty-five; others, like myself, feel that the disease may come at any period of time and that we need not hesitate to diagnose a case as schizophrenia or dementia praecox, even though the age of onset appears to be sixty. I t seems to me, [31]

THE PROBLEM OF MENTAL DISORDER judging by the rest of medicine, that the age of onset does not determine the disease type, for, while it is rare for an individual to have diphtheria at fifty, we do not hesitate to make this diagnosis if the criteria of diagnosis are present. Some men take a pessimistic view of the future possibilities of neuropathology in this and other so-called 'functional' mental diseases. M y answer to this is that year by year neurophysiology and anatomy make progress, that this progress has not been utilized by neuropathology, and that even with our present technique, few brains of the thousands studied has ever had more than a shockingly superficial examination. We might defer our pessimism in this regard until thoroughness has been substituted for the inadequate work done in our psychiatric laboratories. Meanwhile, though there is no well-established pathology, there is, as Spielmeyer pointed out, no ground for the assertion that there is no organic alteration in dementia praecox, and there is some evidence that the third layer of the cortex is involved, that there is a deficiency of catalytic iron in the brain, that bromides do not diffuse as they should. Even though there are no biochemical changes to which we can turn with assurance and comfort, there is an attack all along the line of this group or groups, which, in the case of the catatonic form, has been startling even though the results are evanescent. This group, as most studies show, has some linking up with the germ plasm. I n other words, it occurs in family groups far too frequently for this to be accounted for by mere chance. Moreover, the work on constitutional types, of which the great exponent is Kretschmer, is based upon a hypothesis which needs to be followed and to be developed with greater refinement and precision. I t is, I think, perfectly proper to call the second of the great disease-types, manic-depressive psychosis, a disease. I n the first place, its symptoms, which switch from depression to exaltation, in whatever order this occurs, are a sequence as regular as that observed in the somatic diseases. Moreover, it is in this condition that heredity can be invoked as accounting for its incidence far more certainly than in any other psychiatric condition. Whatever may be the difference of opinion as to the r61e heredity plays in mental diseases, no one who has seriously studied manic-depressive psychosis from a statistical angle doubts its occurrence in family groups. Even though we have [32]

MEDICAL PSYCHIATRY no pathology or biochemistry, the similarity of the repeated attacks and the linking up with the constitution and heredity tend to give us a biological basis, which in its turn must rest upon some structural anomaly. These two diseases or conditions, which have been split up into subvarieties and forms, constitute—if we except the organic diseases—the bulk of the cases which reach the asylums. Other less common diseases may be briefly discussed. The paranoid psychoses have no stamp of unity in that they occur in the course of infectious diseases, as a result of alcoholic poisoning, as part of the picture in the toxic diseases, and often as part of the syndrome of the organic diseases. There is a relatively small group of cases which have nosological unity, namely, a group which appears in middle life with a tendency to a stereotyped anxiety and stereotyped motor agitation, with delusions which have a similar general pattern, the so-called 'involutional melancholia.' Of great theoretical importance for those who look for an organic background for mental disease are the toxic psychoses, those which occur as a result of alcohol, of infection, from a large variety of exogenous influences, and which may be found in the wards of the general hospitals though rather infrequently represented in the hospitals for mental diseases. I believe that our classification is in many instances too refined for our present knowledge. Splitting up dementia praecox or schizophrenia into many types is of no avail so long as we know little or nothing of the pathology, or when such disagreement as I have indicated above exists as to the diagnosis of the individual cases. I t may be that dementia praecox will itself be divided into many diseases, but at the present time it is wiser to avoid finicky diagnosis and to make the classification along broader lines. A Dichotomy in Psychiatry and Medicine: 'Organic' and 'Functional.' This brings me to a concept which, perhaps, should have been discussed at the beginning of this article since i t is used in all psychiatry as the broad basis of classification, namely, the differentiation between organic and functional. If the term 'organic' is used to mean that there is a structural alteration which can be recognized post-mortem or which during life appears as a change represented by biochemical alteration, I see no objection at all to the term. But frankly I do not understand the logic of the term 'functional' except as a matter [33]

THE PROBLEM OF MENTAL DISORDER of convenience in the subject matter of psychiatry or medicine. I do not know of any function without a structure. From a metaphysical standpoint, structure and function are incomprehensible without each other. I n fact, they do not exist alone and may be merely two aspects of the Great Unknown. From a more limited but more practical point of view, no function exists without structure or organic background of some type, even though we may not know the intricacies of the chemicophysical, structural relationship. If we mean by the term 'functional disease' that etiology and pathology are unknown, it would be better to say so. I t would seem to me better to avoid the term altogether and parallel the indefiniteness of our knowledge with the indefiniteness of our classification. I n the psychoneuroses, for example, it would profit us to make the basis of classification the main presenting symptom and thus to speak of the fatigue states, the anxiety states, the obsessional states, etc. These cases could then be studied individually as to the source of the fatigue, the anxiety, the obsessiveness. There is every reason to suppose that a fatigue state, for example, might definitely and readily have its genesis either in a physiological alteration or in some matter of psychology, such as a conflict, complex, social maladjustment, or what you will. I believe that the physiological approach to these conditions would be very profitable, that in the long run it would tend to be more precise than the psychological approach, but there is certainly no a priori reason for limiting oneself to either one or the other of these approaches. There is no reason to posit anxiety states as all alike in their genesis. I t might well be that a shift of the libido, if there is such a thing, might have as its background some deficiency in water metabolism. I see no reason to split up the universe of psychiatric study into physiological and psychological. For myself, I see man as an organic fragment of an organic universe. Whatever form it takes, physiological or psychological, the environment flows in and out of him in so intimate a way that he almost seems to be a mere reaction-node in the great web of life. And every psychological event is as organic as every physiological event, for whatever we see or hear is an organic current to which we reverberate by a huge medley of organic responses. The medical psychiatrist sees many neurasthenic states occurring in the course of other diseases, and multiple sclerosis [34]

MEDICAL PSYCHIATRY often declared to be hysteria; notes that fear and anxiety are often the early symptoms of general paresis; and observes the common occurrence of fatigue, sleeplessness, lowered appetite and endurance, depression, and personality-alterations, in the course of every great bodily disorder. Therefore he cannot afford to be cocksure of the functional character of the neurosis he meets and for which he can find no adequate organic basis. He remembers that paralysis agitans was declared to be of functional origin until its definite relationship to brain structure appeared as the result of brilliant research. He knows the work of Minot and others who have shown that typical neurasthenic syndromes occur in the more occult anemias, which disappear on adequate diet and the use of iron. Yet he recognizes that fear may destroy appetite and sleep and produce fatigue, that the emotions are great organic events, whatever their source; and he is prepared to believe, though it has not yet been shown, that chronic emotional states may produce pathological alteration. I n brief, he has no use for the metaphysics which separates mind and body. I n the case of the neuroses, I do not deny the validity of the psychological approach of whatever school, provided it does not become the all-in-all and establish itself on the high throne of certainty. We must go on making studies of the functions of the gastrointestinal tract in the neuroses where gastrointestinal symptoms are so common. We must study sleep in conditions where disturbed sleep is universal, and we cannot neglect the physical basis of energy in conditions where fatigue is almost an inevitable complaint. Some psychiatrists, at least, will stick to the traditional r6le of the doctor, studying the total setting of the individual, sociologically, psychologically, and physiologically; using drugs, physical therapeutics, advice, and psychological and sociological analyses as these seem indicated by the exigencies of the individual case. Another Dichotomy: 'Heredity' and 'Environment.' All dichotomies are to be avoided; just as the separation of the mind and body has no meaning in medicine, so the separation of heredity and environment inevitably leads to false emphasis. The publications of Jennings and much scientific work which I have elsewhere cited indicate that every bit of protoplasm, whether it is that of the sperm, of the ovum, or of any other cell in the body, is constantly permeated by environmental forces, on the constancy of which depends its qualities. The union of [35]

THE PROBLEM OF MENTAL DISORDER sperm and egg produces results broadly typical for the species. The environment, however, by its penetration, may even increase the mutation rate or injure the genotype for several generations, as has been shown by a host of experiments. The term ' blastophthoria' was introduced by Forel to indicate the injury to germ plasm by environmental agents. I believe it would be better for psychiatry to adopt, as a working hypothesis, the view that many of its problems which seem to rest upon the constitution of the individual, rather than upon his experience in life, are due to blastophthoric influences and that even if a condition of disease runs in families, environmental agents may have injured the family stock, and therefore environmental agents may be found to counteract the blastophthoric agent. The discovery of the tubercle bacillus dethroned heredity as the cause of consumption. Yet the belief in tuberculosis as hereditary was once as firmly based as the belief that manicdepressive psychosis is hereditary. At present the interest in family studies has waned. I t needs to be revived but placed on a sounder and more critical basis. A Few Words about Epilepsy. Our knowledge of a disease apparently runs in reverse ratio to the importance we lay on heredity. Where little is known, much is declared to be due to congenital or germ plasmatic factors. Perhaps this is the scientist's manifestation of his inferiority complex. If one reads the earlier writings on epilepsy, the term ' heredity' occurs as the basic etiology in almost every book or special article. Today the journals are full of studies of epilepsy and, except for the psychoanalytical writings, one reads of brain-injury, of encephalograms, of the dependence on acid-base metabolism, of water intake and output, of spinal-fluid pressure, etc. Even though we have reached no definite conclusion as to the mechanism of epilepsy, it is definitely realized that brain-injury plays a larger role than we thought. I t is quite certain that agents which produce alkalosis increase the number of attacks and the agents which produce acidosis decrease the number of attacks. Here and there, someone says something about constitution and heredity; but the real importance has disappeared in the use of these terms for the study of the condition known as epilepsy. Feeble-mindedness. The study of feeble-mindedness has suffered from the overemphasis laid upon certain exceptional sociological situations, namely, the occurrence of so-called [36]

MEDICAL PSYCHIATRY families who really represented ecological groups and who have come down in history as the great paradigms of the sociological and biological threat and danger to the race by the feebleminded. The Nams, the Kallikaks, the Tribes of Ishmael, the Virginians, and others of the royal families of the feeble-minded became the basis of generalizations which were, as a matter of fact, based on flimsy evidence, on what may really be called statisticalized gossip. Papers appeared in great profusion showing the enormous percentage of feeble-minded in the criminal population, a statement based fundamentally on the fact that we did not know how low the general community level of intelligence really is and overestimated Mr. Average Man. All this is of the past. I t is now recognized that the real criminals of the world are not feeble-minded. The fecundity of the feeble-minded has been grossly exaggerated and, as a matter of fact, there is no such unity as is implied in the term feeble-mindedness. There are, as a matter of fact, groups of individuals who present as part of the syndrome by which they are differentiated from the normal the symptom of lowered intelligence. Thus the cretin, the Mongolian imbecile, the feeble-minded with organic brain-disease, brain-injury, past encephalitis, etc., represent groups not at all biologically related to one another, except in the appearance of mental defect. Elsewhere I have made a tentative classification of the hypophrenias, to which article I refer the reader for a more comprehensive study of the situation in feeble-mindedness; and especially do I call attention to the statistical studies of Dayton, which, in my opinion, represent very sound and scientific views on the subject. I t may be stated that in those groups of the feeble-minded concerning which we have some definite knowledge, heredity does not appear to be a factor of any real importance; that in those groups where we have little real understanding, and where the appearance of the individual corresponds more to that of the so-called normal, heredity appears to be of great importance. I t , may safely be stated that there is some correspondence, on the whole, between diffuse bodily defect and inferiority, on the one hand, and mental inferiority, on the other. I t also appears quite certain that we are not yet at the point in understanding where we can speak of feeble-mindedness as anything like a biological unit for which we may expect Mendelian ratios. [37]

THE PROBLEM OF MENTAL DISORDER Very important studies by a group of Chicago sociologists show the importance of the early environment in the development of the intelligence of the human being. Intelligence, of course, is no unit. There are degree and direction of attention, the nature of the purposes, the organizing capacity. There is memory in all its intricacies. Intelligence represents the learning process and the plastic functions of the higher centers of the brain. I t is therefore no surprise to learn that intelligence grows by early use and social cultivation. The quality of the research done in feeble-mindedness is on the whole inferior because it has been dominated by the misleading concept that feeble-mindedness is some kind of biological unit. Here and there work has been done on the anatomy of the brain of the feeble-minded. Very creditable studies have been done on the cretins because this subject linked itself up with the definite subject matter of endocrinology. A few radiographic studies have appeared. Sporadic biochemical papers appear in the literature. Most of the work on feeble-mindedness appears in psychological studies, which really only measure the quantitative effect but give us no hint as to causation. Surveys galore have been made at great expense largely to bolster up preconceived ideas. I t is a striking commentary on the schools for the feeble-minded that very few of them have clinical directors, and one can count on the fingers of one hand the places where pathology, biochemistry, and physiology are used in the studies of the hypophrenias. This great problem needs clinical investigation in all its forms. The psychological and sociological studies should go on; but the basic investigations into the nature of the individual who is feeble-minded can hardly be said to have started.

[38]

I I I . T H E NEUROLOGIST'S POINT OF VIEW By I. S. Wechsler, M.D., New Y o r k City Paradoxical as it may seem, I think the statement is true that with increasing experience and the accumulation of knowledge it is becoming more and more difficult to deal adequately and scientifically with the subject of mental disease. While the difficulty derives essentially from the obscurity and complexity of the subject, it is tremendously increased by differences in points of view and the conflict between theory and fact. The difficulty becomes almost insuperable when the neurologist, trained to rely solely upon scientific experimental evidence, tries to solve the problem in organic or somatic terms, that is, in terms of anatomical structure and physiological function. So long as purely psychological or rather pseudopsychological concepts prevailed, the question was fairly simple; but when anatomy and physiology began to dominate medicine, yet were unable to vouchsafe adequate explanations, the problem became not only complex but confusing as well. From the early Hippocratic days down to about the seventeenth century, notions about mental disease were built essentially about the psyche or soul, with magic, religion, and metaphysics as the errant handmaidens of medicine. Despite the fact that Greek medicine caught a true glimpse, the trail was lost even before the era of Galen, and throughout the succeeding centuries the most weird and fantastic notions prevailed. With the advent of more positive knowledge, the conviction slowly grew that impairment of the nervous system, more particularly the brain, was the underlying cause of mental disease. This view so dominated nineteenth century medicine that not even Charcot's great adventure in psychological medicine, namely, his researches into hysteria and hypnosis, could shake the conviction of medical organicists. None the less that master laid the fairly solid foundations of psychopathology, upon which numerous investigators have subsequently built extensively though not very firmly. Up to this point, however, psychological medicine was still mirrored against an organic background; while physiological psychology, initiated by Wundt [39]

THE PROBLEM OF MENTAL DISORDER and reaching its greatest fruition in Pavlov, sought in reactions of the nervous system an interpretation of mental processes and of intelligent behavior. Sigmund Freud alone evolved a purely psychological conception of the neuroses, on which are based etiology, views as to mental mechanisms, and a system of therapy. For the moment one may leave out of consideration the offshoots of the psychoanalytical school as well as the hybrid theories which try to combine the organic with the psychological to the confusion of both.1 The fact worthy of emphasis at this point is that at the present time two schools of thought dominate the psychiatrical field: one, the psychological or psychopathological; the other, the organic or pathophysiological. In approaching the problems of mental disorders, in which are included the psychoneuroses as well as the psychoses, the neurologist is therefore faced with a serious dilemma. Because of his constant need of thinking in terms of the anatomy, physiology, and pathology of the nervous system and his preoccupation with clinical manifestations as they present themselves in practice, he must look upon mental disorders as diseases of the nervous system. By 'disease' he means a temporary or permanent derangement of physiological function, a departure from what is known to be, or is commonly regarded as, normal. He finds it difficult to divide diseases into organic and functional or to make sharp distinctions between brain and mind. Not that it is not possible to advance philosophical, psychological, or even • clinical arguments for such distinctions, but the only scientific language he can acknowledge is that which speaks in terms of structure and function. When the last two work harmoniously he regards the result as normal; when there is impairment of structure and (or) derangement of function he looks upon the resultant behavior of the human organism as abnormal. He would therefore discard the term functional in an etiological or psychogenic sense as both useless and meaningless. If mental behavior is a function of the nervous system, then any disturbance in that system, whether obviously anatomicopathological, physiological, or psychological, is functional, just as pathological disturbance in the working of the liver, kidney, or heart is a disturbance of a normal function. To use the word 1 Obviously the scientifically trained physician can only dismiss with contempt the numerous religio-magic and other cults which emanate from the self-deluded and the charlatan and appeal to the credulous and gullible. [40]

THE NEUROLOGIST'S POINT OF VIEW functional when one means psychogenic is to do violence to logic and to confuse issues. The neurologist recognizes, of course, that, though the central nervous system is the highest correlating mechanism of the human organism, it is not an independently functioning structure. He knows that it is intimately bound up with the vegetative nervous system, of whose function he knows but little; and that it has reciprocal relationship with the glands of internal secretion, whose specific activities he is just beginning to understand. He realizes, therefore, that there can be disturbance of the function of the central nervous system as the result of abnormal working of either the endocrine or the autonomic and sympathetic system; just as there might be impaired activity of the glands of internal secretion or of the vegetative nerves secondary to deranged function of the central nervous system. He also knows that mental disease may be the result of abnormal function of other bodily organs and of general toxic or infectious processes which indirectly affect the nervous system. That he frequently cannot demonstrate the pathological process in mental disease does not disturb his logical premises, which are rooted in experience and based upon scientific method. He simply confesses ignorance and waits for more accurate knowledge of anatomy, physiology, and pathology, and especially of physics and biochemistry, to fill in the gaps in knowledge. But though the neurologist, or, for that matter, the general physician, is of necessity an organicist or somatist, as a student of human behavior he must reckon with a great many other factors. And while he observes mental disorders of all kinds as the result of organic brain disease, he sees exactly similar disorders in the absence of demonstrable pathological lesions. With increasing knowledge and mellowing of bias he is also becoming more and more aware that psychological factors, which he cannot precisely evaluate and which he cannot at all define in terms of anatomy and pathology, are capable of producing behavior disorders or mental diseases, and that he can employ those factors in the readjustment, if not the cure, of those disorders. He recognizes that 'affect' or emotion, which eludes definition and sometimes understanding, is capable under appropriate circumstances of being so intensified as to work havoc with mental and physical behavior, or so congealed or attenuated as to make normal function altogether impossible. [41]

THE PROBLEM OF MENTAL DISORDER He realizes that, whatever views one may hold and however one may seek to define them, there are powerful instincts or innate behavior patterns, of which those pertaining to sex have come to be regarded as extremely important, which, if interfered with or allowed to run rampant, may become the source of abnormal behavior or mental disease. From his knowledge of comparative anatomy he has the deep conviction that structural patterns within the nervous system are fixed; that it has taken eons and eons to lay down these patterns; that no reckonable number of generations can alter anatomical pathways for the conduction of function; and that patterns of behavior which depend upon those anatomicophysiological structures are not easily influenced by outside factors operating after birth and during early development. He suspects, therefore, that heredity, which at present lies beyond his control, plays a tremendous r6le, even though he does not quite know how, and feels that the pendulum of emphasis has swung much too far in the direction of environment; though he concedes the justification for that emphasis in the face of the fact that at the present time only the environment is directly subject to influence. Parenthetically, and without entering into a detailed discussion of the subject, it may be pointed out that education also is a vital part of environment, that it has a definite continuity, and that it may, in one sense, be regarded as a form of inheritance. I t has often been called an 'external' or social inheritance. With the invention of writing and the accumulation of records, the facts of experience which serve to mold behavior have been handed down in a continuous stream. Experience is no longer lost and the individual does not need to reinvent guides to social and individual behavior. The continuity of knowledge becomes an inheritance of the race or culture, therefore, which supplements structural endowment. Obviously the neurologist knows that the human being is not an isolated individual throughout life. Man reacts to, and is acted upon by, the family, the larger social groups of which he is a part, and the general environment to which he is exposed. Mental disorders frequently result from the inharmonious interaction between the individual and the group and between the individual and his general environment. Finally, in the treatment or management of patients, the neurologist is keenly [42]

THE NEUROLOGIST'S POINT OF VIEW conscious that scientific method alone frequently fails him; that the organic or somatic approach often is unavailing; that there are mental processes outside of conscious intelligence; and that personality as at present understood is something more than an aggregate of smoothly functioning tissues and organs which go to make up the individual. The neurologist, then, in contradistinction to the psychiatrist, who is departing more and more from neurology and general medicine into ever wider social and philosophical fields, is faced with this dilemma. He views mental disorders as disease entities exactly as he views other diseases and yet he cannot define or deal with the former in the same terms as the latter. He may express the opinion, rightly, I believe, that ultimately he will be able to use precise scientific language for the one as he does for the other; for the present he must be content with a dual approach. His dilemma is further increased by his frequent inability to deal therapeutically with mental problems in the same way as he treats organic diseases and by the need of resorting to psychological methods if he would have any success at all. He is compelled in the present state of knowledge to adopt a psychopathological point of view, for both the understanding and the treatment of various mental disorders, even though he clings to the mental reservation that there must be a pathophysiological background to abnormal mental processes. But just because of his adherence to strict scientific method the neurologist cannot concede its inapplicability to the study of mental problems. Without making a fetish of science or denying the possibility of its erroneous approach and the need for the evolution of new ways of study of normal and abnormal psychology, the neurologist can only feel secure in methods whose validity and fruitfulness are beyond question. He must, if he is to remain true to his own discipline, refuse the substitution of old soul-psyche concepts, however modernized they may appear, or other metaphysical speculations for what he is trained to regard as facts of experience. Finally, he does not feel it incumbent upon him to solve or to advance explanations for universal problems all at once and, unlike his more metaphysically-minded fellow psychiatrist, is content with arithmetical progression. For he knows that the advancement of knowledge is a slow process and that only when man gave up his claim to omniscience and became satisfied with the solution of small problems in an orderly manner did progress begin at all. [43]

THE PROBLEM OF MENTAL DISORDER The neurologist, then, puts emphasis first and foremost on the study of structure and function for the understanding of normal and abnormal mental behavior and insists upon the utilization of scientific experimental methods. His main concern is with the study of the nervous system, both cerebrospinal and vegetative, which is to include comparative anatomy and embryology and take full cognizance of anthropological research. He is equally concerned with the physiology of the nervous system, especially experimental physiology, is intensely interested in experimental researches into the structure and functions of the glands of internal secretion, and puts great faith in general biochemical research of the nervous system. As a practicing physician he must, obviously, at all times think in terms of pathology and pathophysiology and correlate both with anatomy on the one hand and clinical symptomatology on the other. As a trained clinician he must put faithful reliance on clinical observation, on the accurate utilization of his senses and on bedside experience; and he feels that clinical methods accurately employed are not only highly valuable but absolutely essential, and that clinical facts are just as valid as facts obtained in any other way. Finally, the neurologist is firmly convinced that the study of mental disorders and the practice of neurology and psychiatry are intimately bound up with general medicine. But however fond the hope or firm the conviction that the soma, particularly the nervous system, holds the key to the ultimate solution of the riddle of the mind, the neurologist cannot fail to take an interest in the study of the vast number of psychological and sociological factors which enter into the problem. He must not shut his eyes, however much he may insist on the rigorous application of scientific method, to the fact that, in the study of human behavior, scientific rigidity is no less inimical to progress than congealed dogma, and that there are a great many avenues of approach to the solution of any given problem. He must also recognize that the complex totality of numerous behavior reactions may represent a product which differs enormously from its more simple component parts and that one cannot in the present state of knowledge speak of normal and abnormal behavior or even of simple mental processes in terms of anatomy and physiology alone. I t is imperative, therefore, at any rate for the time being, to resort to the language of psychology and psychopathology, which differs so much from that of [44]

THE NEUROLOGIST'S POINT OF VIEW neurology and pathophysiology. Assuming the correctness of the preceding observations, the study of mental disorders requires a great deal more than the neurologist alone can contribute. Therefore, without in the least receding from the neurological point of view, which adheres to the paramount importance of structure and function—particularly of the nervous system—for the understanding of mental disease, it may be well to indicate some of the other lines of research in which he is interested and the methods which he would pursue. First, as to the psychological approach. At the present time, this consists of academic and physiological psychology, including reflexology and behavioristic psychology, and psychoanalysis. With regard to psychology it may be conceded that its various forms utilize laboratory methods and adhere more or less strictly to accepted scientific standards. Thus far psychology has contributed modestly to the advancement of the understanding of the working of the mind and promises considerably more. Pavlovian psychology and reflexology, of which behaviorism is a lusty offspring, supply answers to a number of simple questions and will no doubt furnish many others, but do not by any means answer all. They certainly cannot, if based on the facts gathered so far, be set up as wholly satisfying explanations of extremely complex behavior or of the higher thought processes, much less of instinctual urges and motivated conduct. With psychoanalysis the problem is quite different. This is not the place for an extended scientific critique, nor is it necessary for our immediate purposes. No unbiased observer can doubt that psychoanalysis has thrown great light on normal and abnormal behavior and that it has been the most important contribution to psychiatry for the past two or three decades; but its metaphysical or metapsychological postulates stand in urgent need of scientific testing. The anthropomorphization of such concepts as the id, the ego, and the superego, for example, however necessary these terms may be to hypothetical structures, allows an enormous violence to logic and leads to a vast amount of loose and unscientific thinking. All stereotyped phraseology is beset with the danger that it furnishes glib explanations and ready answers to complex questions. Furthermore, uncontrolled interpretations have the defect of interposing variables between stimulus and response and thus of vitiating scientific procedure. I t is imperative, therefore, in view of the fact that [45]

THE PROBLEM OF MENTAL DISORDER psychoanalysis is so preeminently an individual psychology, that statistical methods be applied in a large series of cases, lest conclusions from insufficient data be accepted as valid and universally applicable. But, whatever its inherent methodological defects, psychoanalysis has been tremendously fruitful. I t constitutes the most elaborate psychology of motivation, and no neurologist can study psychopathology or practice psychotherapy —much less criticize the discipline—without a full acquaintance with it. However, it must be clearly recognized that psychoanalysis is but one of a number of methods and that i t cannot be reared into either a philosophy of medicine or a philosophy of life. For unless this is borne in mind there is the danger, long ago pointed out by Huxley, that new truths which begin as heresies often end as superstitions. The criticism just made on the use of metaphysical and metapsychological concepts in neurology must not be misinterpreted to mean that ideas, particularly those tinged with emotion, are incapable of influencing behavior or bringing about physiological and pathological results. I t is only necessary to recall the physiological changes ranging from pallor to nausea, palpitation, tremor, sweating, diarrhea, and fainting, which may follow a sudden threat to life, or point to profound depressions and hyperthyroidism which may be precipitated by unrelieved fear, anger, and sorrow, to convince even the most hardened organicist that intangible ideas can bring about very definite physical effects. The question, therefore, is not whether ideas can initiate physiological processes, but whether metaphysical postulates built around theoretical concepts are capable of doing anything at all. I n so far as metaphysics partakes of schizophrenic thinking it may, of course, paralyze action and inhibit the very thoughts which it tries to set in motion; but this is not our problem. The quarrel at this moment is not with metaphysics but with its application to neurology and psychiatry and with the naive view, which does so much violence to logical thinking, that because a concept is anthropomorphized therefore i t becomes concrete and physiologically operative. The neurologist regards the study of heredity or genetics as extremely important for the understanding of mental disorders, but, so far as the physician or neurologist and psychiatrist are concerned, it must undergo (as a matter of fact it is slowly undergoing) an almost complete revolution. With few honorable [46]

THE NEUROLOGIST'S POINT OF VIEW exceptions, practically all the statistical data hitherto gathered by physicians are not only worthless but actually misleading. Ignorance of biometrics, lack of application of Mendelian laws, insufficiency of facts, comparative paucity of cases or figures on which studies have been made, the irrelevancy of fleeting concepts of morality which have no place in science, personal bias of investigators, and the utter unreliability of most conclusions are the obvious reasons for an urgent need of a newer and more truly scientific estimation of the whole subject. The understanding of normal behavior which has in many instances resulted from the study of the abnormal has led to an absorption in the problems of mental disorders to the considerable exclusion of the normal. The neurologist, therefore, feels that more emphasis is necessary on the study of the normal, and also that more accurate, though less rigid, definitions are needed. To a large extent, the talented, the genius, the 'sport,' and even the much maligned 'neurotic' belong with the normal. A more elastic conception of what is normal and a less militant urge to create a scientific standard of mediocrity may not only help in the understanding of minor mental disorders, but may be of great social significance. I t is becoming increasingly evident that regimentation and standardization only lead to the idealization of a low common denominator. I t is hardly necessary to point out how vitally important i t is to understand the role which the instincts and emotions play in the genesis of the neuroses, but one must insist on their investigation not merely from the point of view of psychology but from that of neurology, physiology, and comparative biology. Hitherto all the emphasis has been put by psychologists and others on intelligence or on what the neurologist would call "intelligent cortical behavior"; instinctive or emotional behavior of the more fixed subcortical patterns, to use once more neuroanatomical and physiological concepts, is at least as important. Such studies have great educational possibilities. So far all efforts at education have been directed to conscious intelligence; they have been extensive rather than intensive. Because of its accessibility and pliability, intelligence has been able to utilize the educational tools put at its disposal. I t remains to be seen what educational methods can be evolved to effect changes in more primitive, instinctual modes of thinking and acting. But the great need is for facts and not theories, laboratory[47]

THE PROBLEM OF MENTAL DISORDER controlled scientific investigation and not armchair philosophical speculations. I t is becoming evident that the complexity of the social order and the varieties of social organizations have direct bearing on the genesis and the incidence of neuroses and psychoses. But here, again, one must insist on accurate biometric and comparative statistical studies of very large numbers and not be satisfied with haphazard statistics of a few cases. The neurologist, therefore, looks forth to field investigations which shall help to determine the types, character, and incidence of neuroses and psychoses among various peoples and races (including the primitive) in many countries, under many social and economic structures, and at various religious, social, and cultural levels. The student of human behavior cannot fail to be interested in the influence of industrial and economic systems on the development of the individual, on the relation of the social structure to human welfare, or on the role these systems play both in the genesis of neuroses and psychoses and in the production of social and antisocial traits. Sound economic and industrial investigations by unbiased observers can throw considerable light on this phase of the subject. The influence of religion and ritual, both past and present, of varieties of religious dogma, of various types of religion and cult, on the production of neuroses and psychoses, in individuals as well as in groups, requires unprejudiced scientific investigation by trained sociologists versed in psychiatry and anthropology. The neurologist cannot be impressed with the views of religious, impotent, and reformed moralists, with the antics of the modern descendants of magicians, or with the promises of peddlers of panaceas. There are, possibly, other fields of investigation relating to the study of mental disorders which are the legitimate concern of scientific investigation; but I have tried to sketch briefly those which are of immediate interest to the neurologist. Unfortunately the subject of human behavior lends itself to uncritical study, to armchair speculation, to fluctuating emotional coloration, to facile generalization from particulars to universals, and to general unbridled thinking. The tendency of the human mind is to run to extremes, to seek short cuts to truth, and to build philosophical systems to take the place of knowledge. Wherefore the insistence on patient investigation, on scientific method, on [48]

THE NEUROLOGIST'S POINT OF VIEW the study of the nervous system, and on accurate biometric investigation. Finally, there is the factor already alluded to which is in danger of being overlooked; namely, the need for reliable clinical observation. Amidst the numerous efforts to establish psychological theories and to interpret mental behavior in grandiose ways, the clinical manifestations of the psychoneuroses and psychoses are sometimes ignored and the medical aspects frequently regarded as irrelevant. The multitude of clinical signs and symptoms which the experienced physician observes and can well explain in terms of physiology and pathology, of disturbance of function of various bodily organs, and as the expression of fairly common medical disorders, are brushed aside as too simple or too commonplace and as inconvenient nuisances. Sometimes their reliability is impugned on the generally fallacious assumption that clinical methods lack accuracy; but it is to be feared that the cavalier fashion in which these facts of experience are sometimes treated is rooted in a desire to exclude reality when it interferes uncomfortably with fantasy. However, it may be stated with complete assurance that to deal with mental diseases the neurologist must have wide medical knowledge and experience and, if he be a man of intellectual integrity with sound judgment and understanding, his clinical observations are not only very important but do have the objective scientific validity which the laboratory-controlled experiment possesses. In conclusion I should like to state that I have attempted to give as objectively as possible the neurological point of view. Perhaps in trying to be fair I have weakened the argument for organic neurology and given the false impression of being apologetic. I have also touched rather lightly on subjects which require lengthy discussion and thus I may have given the impression of superficiality or naivete. Unfortunately the limitations of time and space and, paradoxically, the large number of ancillary fields in which neurologists are interested, impose brevity. Nor do I wish it to be understood that I have tried to minimize or slur over the difficulties and limitations of the neurological approach. Many of them are admittedly insuperable in the present state of knowledge. But I should be false to the neurological point of view if I did not reemphasize the neurologist's insistence that complete understanding of mental disease can only come from an understanding of the workings [49]

THE PROBLEM OF MENTAL DISORDER of the nervous system in its reciprocal relations with bodily organs, that is, from a full understanding of structure and function. The neurologist is further of the opinion that much which passes for current 'psychology' will, with the accumulation of facts and the advancement of knowledge, turn out to be plain gibberish. Not that the neurologist disdains theories, but history has taught him—as it has every other scientist—that he must eschew metaphysical speculation in medicine and must strengthen his conviction that objective experience alone should forever remain the touchstone by which any theory can be tested. For, unless all the facts gathered since Copernicus and Galileo gave the great impulse to scientific method and Vesalius laid the solid foundations of anatomy and physiology are worthless and the method of research itself is wrong, the neurologist cannot relinquish his point of view.

[50]

IV. T H E PSYCHOBIOLOGICAL POINT OF VIEW By A d o l f Meyer, M.D., Baltimore In behalf of an effort to bring together current points of view and doctrines and methods of dealing with the abnormal conditions constituting the field of psychiatry, I am requested to give an account of how objective psychobiology as a mode of approach to the study of the organism differs from several other modes in the field, all of them having in common the direct and factual approach to a more or less unified and unitary organism, perhaps clarified most usefully and concretely by considering the instruction and training of men in our field. So many empirical and working monisms in the biological sciences are perhaps merely verbal and formal. To what extent does this reduction of man to singularity and unity prove itself to be both factual and effectual in the envisagement and treatment of the disorders? This is the question put to me. The formulation of an objective psychobiology is the upshot of a number of concurrent needs and urges. I n the first place, there is back of it the natural desire of any worker to organize his human interest in the material with which he deals, with the smallest number of assumptions or gaps or contradictions. The domain is one in which a number of fairly well organized sciences take a share. Moreover, it is the field in which man has probably the most elaborate amount of personal experience, although, as it happens, also an undue share of tradition and the actual experience strongly colored by these traditions. I n a kind of birthday letter1 to one of my teachers, August Forel, I have outlined the factors that contributed to the shaping of my theoretical conceptions. Although I was happily spared the fate of having to undo any great amount of traditional training, still, on the other hand, I found myself confronted with a great many disturbing tendencies in the presentation and management of the facts necessary for effective work, and felt the need of making an effort to do justice to our best critical and scientific common sense with a general formula of stating or singling out the topic, the conditions of occurrence, the factors, their 1 J . f. Psychol, u. Neur., 38, 1929, 71-81.

[51]

THE PROBLEM OF MENTAL DISORDER working, the results and the modifiability, i.e., a method of approach to the consideration of nature's experiment, formulated in harmony with the best knowledge and experience of the day. Is there a way of dealing in the same terms with the 'he' or 'she' we recognize in the other, and with what that 'he' or 'she' speaks of in terms of ' I ' ? What is implied by the use of these pronouns for which apparently we have but the proper name of the specific individual? Is it what the average unbiased person with present-day experience would be inclined to find and say and do, or what the one or the other recipe called 'organized science' would urge? Are reality and actuality made up of irreducible facts demanding radical divisions and contrasts? Are the methods of approach radically different? Should we speak of different aspects of the same thing or of special sets of facts or combinations of things and relations, when we speak of special sciences ? These and similar questions are involved in the formulation of the upshot of my first-hand familiarity with the facts and problems of a number of competing sciences and their representative claims and hypotheses (particularly—in my case—comparative and human neurology, and neuropathology), and the urge and duty to give to beginners opportunities of experience and guidance in the study and understanding of facts and literature and the possibility of effective work, and training also to those who are becoming specialists and to our lay helpers, and to the public, the patients, and their friends. What are our problems, what have we before us, our habits and special resources of procedures, and helps? What are our usual goals? Shall we begin with the rehearsal of standpoints, as was and is done in the philosophy courses? Or shall we begin with the array of sciences constituting the division of labor in science and practical life? Or begin the best we can with the facts met? I am inclined to do the latter. By the time a man can be expected to apply himself in a systematic and effective way to critical and systematic work and thought concerning man and all that is involved, he has acquired individual experiences and formed for himself ways of sensing and feeling and doing that cannot be pushed aside as unimportant, as in the sciences of physics and chemistry and anatomy and physiology, or replaced by an organized body of laboratory theory and practice of a prescribed and proved type. In the struggle for a place in the [52]

THE PSYCHOBIOLOGICAL POINT OF VIEW attention (and also the tolerance) of man for the various sciences, various compromises and conventions were made in the way of delimiting the domains, and in our fields, especially those of physics and chemistry, biology (botany and zoology), anatomy, and physiology, with biology as the comprehensive concern with all living things and functions. On the other side, there were the practical domains of training in religion, morality, and education, in law, in sociology and medicine, with tendencies to divide man into mind and body, or body and soul, as different sets of facts, entities, and functions, or as different aspects or mixtures of these divergencies. In medicine we find those who wish to reduce everything to physics and chemistry, or to anatomy, or to physiology, and within that to neurology or to endocrinology; but there is also an increasingly aggressive group that wants to emphasize the mind, either on the ground of common experience or on more or less highly specialized and systematized conceptions. Our general formula for all the sciences urges a common point of view. Man meets a world of fact, to be studied for what it is and does, whether the inquirer is there or not; to be studied by observation of the material accessible to common experience, with a genetic-dynamic background and a willingness to accept and use all the facts according to their r61e and importance in working and thinking in terms of experiment upon man or nature. Our chief aim in the study of man is the determination of the role and range of operation of man, affecting his own course of life and that of others and of our common background, and the determination and control of the special factors making for success and failure, for health, happiness, efficiency, and creativeness. Psychobiology starts not from a mind and a body or from elements, but from the fact that we deal with biologically organized units and groups and their functioning. I t occupies itself with those entities and relations that form, or pertain to, the 'he's' or 'she's' of our experiences—the bodies we find in action, as far as we have to note them in the behavior and functioning of the 'he' or 'she.' We are aware of a contrast between the activity of detached, or at least detachable, organs, such as the heart, stomach, or brain, and the activity of these same parts assigned to the 'he' or 'she' or 'you' or ' I . ' We see the legs active in walking and dancing, but we also see the knee-jerk when, in proper position, we strike the slightly [53]

THE PROBLEM OF MENTAL DISORDER stretched tendon. We know that this can be produced on the detached reflex-preparation. Something similar can be shown in a psychoneurotic woman whose foot kicks out as soon as one comes near the knee with the hammer—evidently an anticipative response of the person, not a mere reflex, the operation resembling a delayed reflex, a reaction presupposing that she anticipated. What then is she? The person, the consciously or mentally or psychobiologically integrated woman or organism, functioning in a specific manner of subject-organization with the help of symbolizations, through pictures of past or of possible patterns of attitude, reaction and action and the so-called "content of consciousness," a special form of waking state, a state of function —orientative, perceptual, and discriminative-associative-affective-reactive-active, characteristic and essential for certain types of behavior adjustments. This behavior is what we have an understanding for, summary or detailed, correctly grasped readily or only with difficulty, i.e., with chances of error and requiring effort and a personality-state favorable to the correct association and mustering of resources. I t is specific situations and their mastery, tasks and solutions, that interest us in what we call objective psychobiology. I t is behavior, overt and internal or implicit, that concerns us, so far as it works as the 'he' or 'she,' that entity which is more than the body as found in a corpse, viz., function including rises in status nascendi, in the now and here, as the reaction in and to the situation, including in the presentation also re-presentations of experience, past, remote, and anticipating, and general or abstract, through its organization as a subject or agent-andreagent and its participating live resources. I n order not to involve ourselves in unproved and possibly misleading hypotheses, we speak of functions of the organism as a unit, as the 'he' or 'she' (in contrast to what detachable parts can do) operating in a specific 'state of function' or hanging together, in more or less consciousness and subject-organization. Those who speak of mind seem to us to limit themselves unduly to the introspective data of consciousness (including an 'unconscious' in the form of the less readily aroused assets) with implications apt to disregard the objective reality with which and by which we work, owing to their assuming too exclusively an egocentric view which science is trying to get away from, without, however, having to ignore it and the advan[54]

THE PSYCHOBIOLOGICAL POINT OF VIEW tages of a personal study and amplification where it can be made accessible to common knowledge and work. We rather speak of ergasias—actions and reactions and attitudes of the 'he' or 'she' or 'you' or 'I'—i-e-> mentally or more or less consciously integrated behavior, to be studied for the role they play in definable situations, from mere sensory and perceptual or affective to intentional-volitional performances, as opposed to the nonmentally integrated functioning. In the matter of food and nutrition we distinguish the personally integrated appetite and the finding and using of food and its incorporation. Digestion is attended to automatically, in nonmentally organized function, while the evacuation of the residue again becomes a 'personality' function, personally and socially regulated. As further instances I might point out the distinction between ordinary breathing and the psychobiologically integrated singing or speaking; or the acceleration of the heart in exertion or in emotion. Other functions of obligatory consciousness are the dreams and the waking life. The processes holding them together are the subject-organization with representative movements, perceptions, and trends of what we may summarily call imagination or mentation. These processes are studied not merely as functions of the brain, but, in view of the many interdependencies, as functions of the individual. The total-activity is indeed organized in a way that differs from the function of detached parts in that total-activity hangs together in terms of functions not only of direct effect but involving a flow of meanings which go much further than the mere physicochemical and physiological state and processes of detached structures. The integrated total-function represents an ever new condition of status nascendi operating with meanings, with a system of symbolization making it possible to utilize the immediate orientation, together with re-presentation of experience of the past, and anticipations in the form of more or less consciousness and subject-organization. We speak of psychobiology in contrast to psychology because we wish the conception to refer to the total-reaction, to an ergasia (the same root as 'working'). This term is used because the English term 'behavior' has neither a plural nor a usable adjective. This function constitutes the material for a science of psychobiology, a specific domain of study of specific persons (others or [55]

THE PROBLEM OF MENTAL DISORDER self) with specific facts and specific methods of study and control, open to observation as the function of the organism as a unit or individual, in the literal sense of this word, the 'he' or 'she,' responding to varying situations, external and internal, and described in terms of function in a life-record and biographical frame. There is a definite preference for the common-sense view that takes the individual organism as the entity, the total-function of which is mentally integrated life. Neither life, nor mind as a special part of life, or as it is sometimes represented, a special aspect, would receive special recognition as an independent detachable entity or fact (although naturally and unquestionably usable again in the human and spiritual relations of those who do carry on and can include the experience of the person, but definitely not in a magic sense). We deal with specific states of function of specific organizations; these states of function do not exist without specific 'content.' They are characterized by a specific mode of hanging together and functioning inherent in the nature of the specific organisms and the nature of their functions. I t is the picture of the organism or body in action that comes to mind when we speak of a person, very much as in the most authentic record we can make today, in a moving picture, with or without the additional sound record. The organism is a time-limited entity, starting as a bud from a kindred unit, a product of conception, reproduction, growth, and development characteristic of the species, with characteristic life and characteristic subject-formation or 'mind,' which is not a new material substratum of the economizing symbolization, but is inherent in the structure, in structure-formation and interfunctional activity. That this is not the only view occurring to modern man is shown by the discussion of another view in The Biological Basis of Human Nature, by H. S. Jennings, who speaks of "persons that have from studies in philosophy or other fields reached the conviction that the self is the only certain reality, that relation to it is the touchstone of knowledge, and who from that conviction have drawn further conclusions. To such persons it may well seem that some other alternative must be found."2 Jennings finds in the occurrence of the same genes forming an T' (and another T in the case of twins) "questions to which biology has no answer," and he cites the supposition that "There is a limited store of selves ready to play their part, that the mere 2 Jennings, p. 296. [56]

THE PSYCHOBIOLOGICAL POINT OF VIEW occurrence of two particular cells which may or may not unite has no determining value for the existence of these selves, but merely furnishes a substratum to which for reasons unknown they may become temporarily attached."3 To this common sense has no answer either, nor reasons, nor foundation, because common sense would probably doubt that something so variable as the self should be "the only certain reality." Twenty centuries after Aristotle had written his De Anima, with its psychological studies merged in what would now be regarded as purely biological questions, the mathematician Descartes claimed an absolute separation of two sciences, that of the body as a pure machine and that of the soul or unit "generally accepted by the scientists." Owing to this "acceptance" and the deductions drawn from Descartes's argument, "Psychology has tended to play the part of the poor relation to the natural sciences."4 Psychobiology is a frank and noncompromising formulation of "behavior with mentation" or ergasia, behavior integrated in a flow of economizing and yet amplifying system of signs or symbolization, constituting a specific set of facts and not only a special aspect, the mentally integrated functioning of the live human organism. We recognize in the study of man certain discontinuities by no means limited to the step from matter to mind, or from the inorganic to the organic ("the emergence of life"), or from vegetative life to the appearance of consciousness, but best met with the general concept of integration. We find as the decisive principle of the specifically psychobiological fact of personalityfunction the emergence of a system of symbolization and interrelations as meanings. All that which we know as thus integrated is to be studied for what it does and is. Taking this view, we are prepared to study the facts found in actual operation, the conditions under which they do or do not occur, the factors entering into the patterns, their working and the results and their modifiability, their formulation and their reconstitution as 'experiment of nature.' What I am disposed to call the paleontology of man's most distinctive addition to the biological equipment, i.e., etymology, 3 Idem., pp. 296-298. 4 G. F. Stout and C. A. Mace, Ency. Brit. (14th ed.), 18, 675. [57]

THE PROBLEM OF MENTAL DISORDER gives manifold corroborating evidence that this organismal conception of the nature and function of mind was consciously or unconsciously the common-sense basis of the gradual development of the terminology of man's experience with man-function. Although other factors tended to create concepts making a kind of substance out of mind and many of its features, and although, with some, deduction and inference gravitated in the direction of the view mentioned by Jennings (in harmony with Plato's and the Hindus' conception of migration of souls), it is the basic organismal conception that is the frame of the psychobiological view here taken: the total functions integrated with the help of symbolization and constituting the behavior and mentation, overt and implicit, with varying consciousness. How can psychobiology be presented and how does it make itself active ? In its strictest genetic procedure, psychobiology would start from the first evidences of reaction as a unit, in a stimulusresponse pattern and in patterns of spontaneous total-function. I t describes and analyzes the common traits of reactive and spontaneous functioning of the pertinent biological type, in terms of reflexes and delayed reflexes, the delays of which prove to be the inherent differentiation of total-function as primary pictorial and secondary verbal and conceptual symbolizations, implicit (economizing) or overt. Symbolization is made up of overt or economizing (pictorial) attitudes, reactions, and actions, implying or standing for what is intended or belonging together. I t is this system of symbolization that constitutes the specific differentiation of the primitive biological response, the 'content' of the delayed reflexes. I start the description in terms of what is most likely to give me the distinctive and comprehensive account. I start with enough of a biography to put mistakes of identity out of question; and I begin to study samples of function likely to bring me closest to the nature of what I aim to formulate in a way that might serve for reconstitution of the set of facts or events to be discussed, for reobservation and control of the formulations or hypotheses. The question arises as to what type of science shapes itself in dealing with this type of occurrence and material. This is probably easiest to present with reference to such formulations as are contained in the Psychologies of 1925 and [58]

THE PSYCHOBIOLOGICAL POINT OF VIEW Psychologies of 1930, and, particularly, the comprehensive statements of Madison Bentley. The specific urge that makes me speak of psychobiology in contrast to the traditional psychology lies in the obligatory organismal time-bound nature of the material. The facts present themselves as the total-function of individuals and groups. Speaking with Bentley of a separate "psychological organism" and a "biological organism" is definitely replaced by focusing on the total-function with but the one organism, and with function viewed in the light of the objective and subjective evidence of more or less consciousness, i.e., a specific mode of integration or hanging together, constituting a solvent as it were, a flow of contacting in the form of sign-function or of symbolization holding together or integrating the attitudes, reactions, and actions making up our behavior. I use the picture of subjectorganization as government-formation, allowing concrete activities or mere representative functionings or organized signs to have the lead as the very self, or a subordinate position in the temporary state or process. The question is one of formulation and delimitation. I n my own mind I can operate with the experience of a tremendous relativity of overtness of the material, or mere referential or mere suggestive tendencies, in a gesture or word, without any obsessive need of overspecification. We can single out and describe or imply broad patterns or special components of emphases, operating with remarkable plasticity, and a principle perhaps best described as absence of fixed and binding rule such as mere structure would entail, a 'rise,' with varying order and temporary dominance of leading interests or drives or emotions or volitions, or purposes or reasons or whatever we may find as motivations or leading factors, in the main as a natural culmination of personality, character, temperament, as specific performance or agent in situations characteristic for the person. I speak of a natural system, as that which naturally shapes itself in a person or entity without necessarily a dominant and persisting boss. I t would be the ideal democracy with the maximal individual freedom compatible with effective unity, but without God-ordained or fixed proprietary governmental representation, rather with a kind of natural self-regulating merit system within a reasonable regularity of happenings and outlooks. In such a setting we are forced to work with samples. I n order to be on the safe side, we choose our samples primarily [59]

THE PROBLEM OF MENTAL DISORDER from among the types of functions which express to the fullest extent what we consider specific for the field in which we work. We should prefer to choose complex examples which actually represent psychobiological function and on which we can bring to a test all the essentials of our conception, rather than give preference to what might appear simpler and at least logically detached and more definable as datum of introspection. I t may be a great concession to necessity, but to my mind no great sacrifice and departure from the facts as they are, to deal with functions that cannot be detached from a good many implications and contingencies, but that after all constitute topics of concern and importance sufficient to deserve all the trouble we may have in working with them. One of the great difficulties in psychology has been the relative futility of the matters chosen and often the merely logical detachment of the specific samples. Psychology has got away from the specific by putting more emphasis on the whole range of particular functions of special sense organs than on the total-function, that is to say, by discussing sensations, perception, image-formation, but also on memory, ideation, association, affect, emotion, and activity-tendencies. And to get rid of meanings and implicating inferences, it has taken up the ingenious device of working, for instance, with nonsense syllables but really thereby creating only particular new situations recalling the predicament of a man with an artificial nose: "Before I had it the kids shouted, 'There is the man without a nose,' and now, 'Look at the man with that nose.'" Without any disregard for all these particular interests, an orientation in psychobiology would much rather start with the whole liferecord and then single out performances in particular situations, making sure that they are adequately specified and studied for the conditions that make them possible or impossible, the factors entering, their working, their effects and results and modifiability—realizing that we always deal with a fraction the denominator of which is made up of the total personalityrecord or potentiality of the person and the numerator of which is the particular sample of performance. This may be tantalizing because the denominator evidently has what I would call an open definition, something unfinished (unless we deal with a dead object that can no longer change and must be tested in mere retrospect). And even with the numerator, the sample of perfomance, we have to recognize the relativity of the sample and [60]

THE PSYCHOBIOLOGICAL POINT OF VIEW the natural variability from day to day. If this is the nature of the material with which we have to work, it is best to adapt our methods rather than insist on methods devised for other material. If generalizations finally get more the character of a pattern than of a law, this also may be one of the characteristics of the science with which we deal. The question arises, How can such work be systematized and taught? Being more or less in the beginnings of such work, it may be well to proceed with samples rather than with dogmatic categories, but also to use to best advantage what categories have proved dependable and suggestive so far. If we prepare a student to make examinations of sensibility, the experimental equation of the examination is relatively simple. We determine the range of responsiveness to the qualities and quantities of the special sensory field or perhaps merely the capacity to rise to the average standard. The same broad principle has been used for the wide range of sampling of such methods as were initiated by Binet and Simon, where we are satisfied with the question of success or failure. The utilization of these methods has made it clear that the issue finally is one of the extent to which the individual actually uses his or her capacities. This calls for a new type of inquiry, into the past record, and the trial under varying conditions. Here again we may be satisfied with the success or failure in relation to a conventional or special standard; but again we may be prompted to go further. We may turn the equation around and try to determine the conditions of existence and particular working of various factors and components such as attention, memory, endurance, foresight, intellectual and emotional 'conscience,' and whatever we may single out as a topic of concern. I n order to familiarize a group of students with the type of facts, topics, methods, presentation, and controls of the rank and file of facts in the psychobiological field, an equivalent of laboratory work has been worked out in the formulation of the personality study, starting with a biographic sketch sufficient for a beginning and to be amplified where need occurs; next a brief survey of the judgments and prejudices more or less systematized in the evolution, from childhood up, of the student's spontaneous or taught formulations concerning mind, body, and the sciences that might come into question, and the dynamics and logic of the operation of the material. This is done partly to arouse [61]

THE PROBLEM OF MENTAL DISORDER attention to one's habits of thought and to what they may be measured by or brought to an issue on, and it takes the place of, or enlivens, the impersonal review of the history of philosophicepistemological concepts. We next take up a survey of functions of the person beginning with the full-fledged performances and achievements and attempts that give an idea of the individual, the personal care, the jobs and hobbies, and the activations in various directions, such as family, sociability, public life, education, religious activity, etc. I t is obvious that our common sense leads us to specify also interests and ambitions, the ratio of one's perceptive life (sensual and aesthetic gratifications), dreaming, thinking, acting, and what we speak of as the temperament. From the very start we make the student conscious of the fact that there are no absolute measures but that we recognize certain rhythms and orders in the functioning, activity, and rest phases, conditions of having enough and being in a state of composure or of unrest and nonsatisfaction. With such a preliminary occupation with concrete facts and their relations, the student can get his ideas straight with regard to the facts, formulations, concepts, and relationships one has to be prepared to work with. There may be some difficulty when we approach the next topic and have to meet the question whether, in the division of the field, we shall use the old concepts of cognitive, conative, and affective data. Inasmuch as we do not accept 'elements in pure culture,' we realize that a division is essentially a matter of emphasis and that it should be made along lines of what the functions serve and how they are logically grouped. I therefore make a division between topical (cognitive and conative) and essentially diffusely regulative (affective) functions, a division which falls into line with the emphasis on content and mood so important and helpful in the examination of pathological conditions. I t is doubtful whether speaking of sensing, acting, and feeling in the abstract, without a statement of specific quality and content, leads us very far either theoretically or practically. I t would seem to me that in the field of psychobiology the 'science' part in its strict sense should also concern itself with the specific content and meanings and not wash its hands of them. Those who want to see science only where there is generalization or formulation of laws can nevertheless get their satisfaction, [62]

THE PSYCHOBIOLOGICAL POINT OF VIEW although in many respects that ambition is more in the nature of proving the obvious than along the lines of any creative addition. I have in mind particularly Weber's and Fechner's laws and other proofs and evidences that we really are dealing with biological and actual material. Or, in order to do justice to tradition, let us speak of psychobiological material but under no circumstances with any intimation that thereby we are condoning a contrast of natural and nonnatural sciences. Or, if we wish to distinguish natural or factual as opposed to formal sciences, we certainly would include psychobiology with the natural sciences without thereby denying that it furnishes the material for the most important formal sciences. There is no belittling involved when we group together mathematics and logic and the other divisions of metaphysics (like aesthetics and ethics) as necessarily based upon particular issues of data dependent on the nature of biological functioning and actually part thereof. On the other hand, there is no call for fanaticism and finding fault with those who, in concession to other issues, maintain a special province for these fields of preoccupation and study. I should only emphasize that when philosophy, religion, and the occupation with the formal sciences learn to recognize biology and its fullest scope and implications, they will have taken a very important, vital, and valuable step and they can do so in a system of relativities in which there is no particular emphasis on high or low, letting these valuations depend on wherever the valuator happens to stand. The outline of the personality study directs the questions so that there is every opportunity for the student to think and discuss special topics and problems connected with them, such as the range of simultaneous functioning, interaction and association, analysis and synthesis, etc. This leads us to the consideration of variations of the range of fitness, attention, fatigue, and the like, and it brings out quite emphatically the need of the recognition of the sets or levels of integration, physicochemical, structural-functional, and function-functional (i.e., interfunctional), and the general rule that no single set of integrations can be self-sufficient. Each of them studies specific data and sets of relations and not merely different aspects of the same thing, and certainly not the whole. After the discussion of what can as well be studied in the relatively detached individual, the student is led to consider the [63]

THE PROBLEM OF MENTAL DISORDER social relationships, the actual status and position in the family, and the dependencies and degrees of emancipation, the relations within friendships and broader social connections and all the modalities and concepts pertaining to these relations; and within this setting a study is made of the psychobiology of sex, again strictly based on concrete data, the study of concrete data being the main justification of psychobiology in contrast to discussion and debates about generalities. Throughout the study we aim at an understanding of patterns, which ultimately are studied for their synthesis into a personality, with particular attention to the formation of types and the factors essential in determining them. After the collection and consideration of concrete samples pertaining to one individual as compared to dissimilar individuals within reach, the student is in a position to make a survey of the grouping of the sciences and fields of work as he sees them. With a study of some outstanding differences and normal difficulties and reactions to disappointments, and the like, the capacity of students for the selection of facts, their specification, formulation, and control, is brought to a test; and the attention is led over to the methodology of general and special topics in the study of personalities and their functioning, such as may be used with the normal or with the sick. The question naturally arises as to what theoretical and practical questions and inquiry we may wish to raise. Emphasis is put on the fact that we deal with objective data which are or are not present and functioning with or without integration with symbolizations, rather than on the question of whether they belong to what has so long been emphasized as the 'physical' or the 'mental' field. They inevitably belong to both when mentally integrated functions; they are then overt or implicit, largely objective or largely subjective. I do not erect any theoretical barrier to the inclusion of anything that pertains to the perhaps sometimes rather widely stretched range of the neighbor of the self-tormenter of Terence, Homo sum; humani nihil a me alienum puto. This does not interfere with my using some judgment as to what relations enter into the discussion of one or another problem or line of inquiry; but I should positively decline to close my eyes to any problems of tact, aesthetics, ethics, religion, or other issues if they figure as such, for instance, in the form of conscience, preferences, aversions, etc., in the [64]

THE PSYCHOBIOLOGICAL POINT OF VIEW problems of the person. On the other hand, the general outline and the sense and demands of the purposes have to weigh the sufficiency or insufficiency of our data. The basic point in this attitude is the recognition of the number of discontinuities which justify the demarcations of the sciences. While I recognize the fact that in the study of any problem we have to face the interpenetration of various sciences, I most emphatically stand for as much differentiation of categories as practical sense concerning the nature of the material and the methods requires and as actual work may force us to recognize; but I repeat that, while we still might speak of a hierarchy of sciences, there is no distinction between high and low but only a logical grouping and grading according to the temporary and other importance for the specific questions under consideration. This has many implications of considerable significance. In the first place we do not assume or admit that any one science can exhaust the whole field and swallow up all the rest. A study of man, of any serious and responsible character, should presuppose reasonable dependability on general biology, psychobiology, and physiology, knowledge of the structures and, equally, knowledge of what is usually included under sociology. In order to deserve any degree or certificate of competency there should be evidence of an adequate training in these fields, and also in the formal sciences necessary for the correct formulation and interpretation of the data. When we come to the domains in the medical sciences, I should require a basic training in these fields as obligatory for all those who assume the responsibilities of the physician. No specialist should make himself exclusively responsible for merely one field. This means that the attitude of nonmedical workers does not measure up to what is required and considered desirable. The attitude of certain neurologists which makes of psychobiology a mere subordinated appendix, useful for diplomatic reasons, is not considered a wise and correct attitude to keep before the public. As a rule, one should recognize that whoever assumes responsibility for the patient must in the main be able to handle all the emergencies, at any rate with enough knowledge to serve until more competent help can be made available if necessary. I t is obvious that with the concept of psychobiology we imply essentially the fundamental perspectives which I trust give ample space and recognition to any [65]

THE PROBLEM OF MENTAL DISORDER specialized pursuits and methods even if they choose to develop any otherwise oriented foundations or principles. The chances are that the structuralist or physiologizing investigator or the Freudian analyst or the representative of individual psychology or the general biologist or anthropologist will in the main operate with methods that can be readily brought into psychobiological perspective. I t may make a difference in the ultimate clearness whether there is any recognition of involvement of sign functions and symbolizations and subject-organization, which are particularly emphasized by this particular type of psychobiology. A great deal of the work that is carried on under this system of concepts would not in its statements and reports voice specifically the tenets of the theory. As a matter of fact, the general conception and its use aims to be in line with the best critical common sense so that in the actual rendering of the data there is nothing that would specifically bring out any exclusive characteristics. I t is sensed as a desideratum that intrinsic allegiance should express itself by fact and act rather than by a conspicuous badge. After all, the virtue of a good deed does not depend on its being called "good" in the description. Probably the most concise and most adequate summary of the background and general organization of the psychobiological point of view is offered in a brief outline given the students as a 'summary of subject-organization.' The point of view is essentially that of making sure that psychobiology is given a place among the natural sciences or, we might perhaps better say, the sciences directly related to substances and substantial organisms and their functioning, and the study of interrelated forces. I want to draw attention especially to one of the last paragraphs so emphasizing the correlation between a very broad conception of objective fact and the conception of symbolization for the system of formulation that I come to speak of a factual logical 'parallelism' or, what would undoubtedly be much better, a factual logical correlation. The logical aspect can undoubtedly be treated as a particular topic, but I feel that a great deal of the difficulty of philosophy comes from the fact that its biological foundation is not adequately realized or given consideration to. The relativity of symbolization may appear too relative to those who are accustomed to ' the absolute,' and yet it is difficult to see what better formulation one could give to what, after all, is as human as even the formulation of man-made 'eternal' principles. [66]

THE PSYCHOBIOLOGICAL POINT OF VIEW The most fundamental and characteristic feature of the genetic-dynamic psychobiological viewpoint lies in the fact that there is perhaps too little conspicuousness on the part of the principles in the presentations of obligatorily concrete material. The principles have to show in what one does; and one has to bear with the appearance of the ordinariness of a large amount of the material. This appearance is inevitable and has to be met by order and perspective in the handling of the data and the capacity for obtaining brevity by a summary rather than by an arbitrary singling out of essentially nondetachable items. M y attention is drawn to the fact that there is not enough mention of analysis of the material and systematization of deductions. This is purely a question of what the human being is able to stand and to make useful. I t does not, on the other hand, exclude a concentration on topics of particular temporary interest, although in the main one would feel happier if more generally digestible standpoints could be so favored rather than the psychoanalytic overemphasis which tries to make a transference situation the center of attention and of work in spite of the fact that we know that it is probably one of the most problematic and difficult foundations on which to bring the range of human capacities to a unitary measure and evaluation. M y earlier standby was that of habit-formation and habit deteriorations. I n a period when our human institutions are conspicuously unstable, it also becomes difficult to specify groupings of habits which deserve categorical attention. Today growing attention is being paid to personality-types and characterology, but it would seem that from the psychobiological point of view a collaboration with sociology would be particularly profitable in the direction of singling out critical relationships and patterns of the problems most frequently forming the determiners of matters requiring our attention. The difficulty there is also in the fact that social relations are considerably disorganized and in flux. In the application in the field of pathology and therapy, the reduction to terms of an experiment of nature and a study of the conditions and factors and their working and the modifiability of the experiment is the basic formula. Emphasis is put on the survey of the assets including the liabilities and a formulation of the process at work, nonmental structural or structuralfunctional, or functional among other functional processes. [67]

THE PROBLEM OF MENTAL DISORDER Among the interfunctional developments, I recognize reactionsets forming relatively frequent and intelligible patterns. In the statement of the physician I want these expressed in concrete terms so that one can work with them in cooperation with patient, family, and home-physician. The reaction-set is not a diagnosis. I t has to include a full statement of the causal and motivating components and the evidences of any possible lesions, somatic or situational disorders, and the factors inherent in the make-up of the patient on grounds of heredity and life-record. I do not refer much to the standard 'mechanisms' or 'dynamisms' since they can be much more usefully expressed in the terms of the concrete case. I urge the student to accumulate a set of patterns, the systematized upshot of which shows in his procedure of examination and his sense for adequacy or insufficiency of the material and its formulation. The systematic organizations of the pathology and therapy consist of the teachable principles and generalizations by which the specific case can be checked up and allocated for statistical work. The plan here outlined offers a satisfactory place for the upshot of practically every other scheme of pathology and therapy. I t is nondogmatic, but critically discriminating; although it frankly places itself on the ground of the best common experience and the best trained common sense rather than authority derived from scientific system on ground of limiting theory. Psychobiology explicitly is but one of the domains to be experienced and worked with in the study of man. For principles of collaboration it requires attention in all cases; for specific and essential attention it may be the strategic or only a subordinated domain. The common ground is the total experience with the case, the formulation of the complaint with utilization of all the corrections and directions offered by the work with the patient and his situation. If I had to make a comparison between this approach and various forms of psychology, I should emphasize the definitely biological rather than physiological character of the problem and methods here described. What interests us is the functioning in a situation with content of varying bearing upon the life-curve. This does not exclude the other problems, such as the definitely physiological ones, or the localization issues. The recognition of integration-sets allows us to study human nature as it is actually organized, and we are guarded against the old mistake of hasty [68]

THE PSYCHOBIOLOGICAL POINT OF VIEW and unjustified identification of parts of the mentation pattern with parts of the neurophysiological or the architectonic brain patterns. I t becomes quite questionable whether aphasia studies will lead to more functional patterns in the psychobiological or the psychophysiological sense. For pharmacological and endocrinological studies the task is but slightly different, and we are likely to look for standardized behavior-functions by which to measure the effect of the drugs. We may be more interested in quantitative work with relatively easily comparable samples of psychobiological functioning. I t is deplorable that centers of brain-surgery have so little collaboration with services which are prepared to study the psychophysiological and psychobiological relations. Interesting problems arise in connection with the foundations of mental hygiene which should follow a course quite different from that of pathology, as a study of variants not primarily medical and their conditions and management. Concerning the correlation of psychobiology and psychopathology and the other sciences we have to admit that collaboration is difficult to establish unless the workers are all well trained in psychiatry. Specialists not so trained are usually expensive guests and their work should be specially supported so as not to become a tax on the anyhow costly burden of the patients, their families, and the hospital. One usually seeks the solution of difficulty in the pushing of detail in the existing preoccupations, where in reality there should be a simultaneous pulling together on common ground. There is no doubt that discoveries are apt to be made in specific fields and specific interests. But if they are not brought together from a multiverse into something of a universe, from overspecialization to common ground, there is bound to be difficulty in balancing. To find common ground under changing conditions is the big problem of life, and also of that part of life we call science. There has to be a cultivation of common ground and common sense. If I had to summarize the answer to the questions raised on our first page, the following statement might be of help. M y work, and indeed also my whole philosophy, makes for as much unification and condensation as possible, but with a very clear right to define the units and to choose them so as to satisfy my need of consistency and comprehensiveness. The person [69]

THE PROBLEM OF MENTAL DISORDER and the group being my problem, I have to take the person as one of the units and I do so without dividing it into a biological and a psychological body. I do, however, recognize a personalityfunction of a type that stands over against the part functions, because of the special categories of data and the methods required to manage and control the data. The psychobiological domain demands the control of facts forming part of a life-record, the present and past situation, and the outlook. Since we deal with biological entities we demand an adequate orientation and practical training in all the sciences entering into the understanding of the human life-processes and life-problems. Moreover, since we deal with a science that has an essential historical component and with entire life-records, training in the organization of the material is of the utmost importance. Hence the rule that apprenticeship has to be the setting of the theoretical training. Hence our emphasis on actual occupation in the field and room for the training in all the sciences dealing with the component sets of facts and relations entering into the human life-experiment. The actual program of training for our staff consists of ward and dispensary work alternating with periods of digesting the pertinent material and basic work in neurology (the reconstruction of a brain and seminar and practical work in nervous diseases), in the internal-medicine problems; and in the psychological laboratory in connection with various techniques (Rorschach, skin reactions to emotional stimuli, concentration and attention and judgment tests). A survey of the facts and problems of the successive phases of life is another topic. I t is the work in the practical course that allows personal questions, a study of methods, and a review of current investigations to come to the front.

[70]

V. T H E PSYCHOANALYST'S POINT OF VIEW By Lawrence S. Kubie, M.D., New Y o r k City Psychic Determination of the Disorders. I t is the point of view of psychoanalysis that every psychological production in an individual's life, whether it be normal or pathological, is a composite outcome of earlier physiological events and biographical occurrences. No one has stressed this fact more emphatically or more explicitly than Freud; and he has warned his followers repeatedly that there are limits to the realm in which psychogenetic forces play the dominant role. I t is exceedingly difficult, however, to define clearly the boundaries of that realm; and we tend therefore to shrink or to expand it, not on the basis of scientific observations but rather in accordance with individual and emotional bias. For this reason, it would seem that in the present state of our knowledge, the only sound approach is the empirical approach. Let the physiologist make his investigations, and let the worker whose training and aptitude are in a more psychological sphere take every individual case, or even each individual symptom, and see how completely the conscious and the unconscious history of that case or symptom suffices as an explanation. I n both cases the aim is identical, i.e., to find a variable factor with which to account for the deviation from an accepted norm. The organicist seeks the variable in some aspect of physical structure; the analyst seeks it in some aspect of human experience. I t is only an unresolved emotional bias which makes either party belittle the efforts of the other or contend that all variables will be found by his own particular approach. This amounts to a policy of taking 'psychic determination' simply as a working hypothesis. With it one attempts to explain everything that one can, but one must be ready to abandon it when the facts force one back to biological factors which are drawn from a simpler level of integration. There are certain obvious dangers in this pragmatic approach, chief among them the danger of over-enthusiasm about the validity of one's psychological data and the tendency to blind one's self to the necessity of seeking additional dynamic forces from other levels. The care with which this pitfall is avoided depends upon the [71]

THE PROBLEM OF MENTAL DISORDER integrity of the individual and his capacity for self-criticism. To safeguard this, our best means lies at present in the increasingly rigid standards which the psychoanalytic institutes throughout the world sustain in the training of psychoanalysts. I t must be emphasized again that, for the present, each individual case and individual type of symptom must be approached as a problem in itself. I t is not possible to generalize about the applicability of psychic determination to the disorders taken as a group, nor even to say of any one form of psychoneurosis that in all such cases the main sources are, or are not, psychogenetic. Within each type of psychoneurosis it is possible to find cases in which the psychological material seems to offer an adequate explanation of most, if not all, of the symptoms; whereas another case within the same group may impress one with the apparent importance of organic, constitutional, or hereditary factors. Undoubtedly, we can look forward to a time when such generalizations may be made with validity, but this must wait upon the development of an etiological classification of the disorders, in place of the present phenomenological or symptomatic groupings. Furthermore, our present methods of investigating constitution in a physiological sense are not sufficiently developed to afford substantial help. Nor have the available methods yet been applied to individuals who have been studied analytically. Therefore it is not possible to correlate physiological studies with analytical categories. This is obviously one of the most pressing needs in current psychoanalytical psychiatry. I t brings up, however, two grave and important technical difficulties. On the one hand, there are certain methodological problems in the constitutional and the physiological investigations; and, on the other hand, there is the problem of the proper means of introducing physiological methods into the analytical situation without disturbing the process of analysis. This is not the point at which this question can be discussed at length; but it is obviously one which demands serious thought. One may say, in general, that the analyst believes that the psychic determination of specific symptoms has in many cases been adequately and abundantly proved by analytical methods; though he does not make this claim for all symptoms. Furthermore, he recognizes the fact that there may well be some obscure quantitative and variable factor which determines the intensity of the [72]

THE PSYCHOANALYST'S POINT OF VIEW symptomatic explosion, and which may, in many cases, swing the balance between health and disease. Here again, however, the analyst is not ready to accept any sweeping generalization, either on the one side or on the other. Fundamentally, moreover, he finds that most arguments and discussions of this issue are in no sense empirical but rather express clinical intuitions and impressions and, above all, the emotional bias of the observer. We have spoken of an obscure quantitative factor. This implies that the issue will remain in doubt until it is clear what this variable factor is and how it may be measured. Until he gets this datum (from, say, the physiologist) the analyst is forced to explore his field with psychic determination used as a working hypothesis to be applied to the very limit of its usefulness. He will grant that at times he will inevitably push it too far. But it will be only by learning from these mistakes that the boundary of the realm of its usefulness can be established. This problem of the variable quantitative factor may perhaps be clarified by a further comment. I t is possible to make a rough working division of the mental apparatus into two spheres: (1) the machinery of thought and conduct and (2) the energy which charges that machinery, either consciously in the form of emotion or unconsciously in the form of instinctual forces. The analyst, of course, concentrates his attention very largely upon the variations in the latter sphere. This attitude on his part involves a tacit assumption that the undoubted variations in this domain of human experience are more significant and also more remediable than are the variations in the machinery itself. The validity of certain aspects of this tacit assumption is tested day by day in the course of careful analytic work; but a comparably minute and exact scrutiny of the variations in the machine has hardly been undertaken at all. Such work as that of Dr. S. T. Orton on the problem of cerebral dominance may be an important opening in this direction. Again it must be emphasized, however, that with increasing precision in our observation of physiological and constitutional variations it becomes ever more necessary to be correspondingly precise and detailed in our psychoanalytic methods. An effort will presently be made to show that at present psychoanalysis is a very important instrument of precision in psychological observation, and an instrument revealing certain aspects of human experience which, wanting that instrument, would remain quite [73]

THE PROBLEM OF MENTAL DISORDER hidden. If the methodological significance of psychoanalysis is accepted as valid, then the conclusion follows that analysis is essential in order to make possible a study of the organic components of these subtle and otherwise hidden aspects of human activity. The Relevance of Biographical History in the Disorders. Now it is obvious that, if one takes psychic determination as a working hypothesis, one must gather every bit of biographical material that is available. In this matter orthodox psychiatry and psychoanalytic psychiatry are in accord. Nevertheless, there are certain differences in the approach of these two branches of psychiatry to the material of an individual's biography. Orthodox psychiatry uses what is in essence the method of the questionary, the questions being directed to the patient himself and to various friends and relatives. That such a method as this yields abundant and valuable material cannot be disputed. Furthermore, in dealing with psychotics and with children, the analyst must often gather his data in similar ways; and with psychoneurotics it is sometimes valuable to use such material as a check on, or in corroboration of, the data obtained by the analytical method itself. On the other hand, the analyst feels that this method of fact gathering, by prepared questions, is not only inadequate, but also entails the following dangers. 1. There are obvious limitations to what a patient knows and remembers about himself. 2. This method is unable to penetrate through the patient's store of readily available memories to his store of less accessible memories. 3. Too often the most intimate facts of a patient's instinctual life are unknown to anyone except the patient, and cannot therefore be learned from anyone but the patient himself. 4. I t is an obvious and banal criticism of the method of questioning to point out that by its impersonal atmosphere it may chill the patient's confidence and his sense of the warm, direct interest of the physician in his welfare, thus tending to stifle all real confidences. I t must be admitted, however, that a tactful and genuinely sympathetic inquirer can infuse his questions with the quality of his own feeling towards the patient and thus overcome this difficulty. I t is a far more significant criticism, however, to affirm that to any question which touches the roots of the [74]

THE PSYCHOANALYSTS POINT OF VIEW patient's neurosis it will be literally impossible for the patient to give an accurate answer. All such questions can be answered only by slow and patient digging into the patient's past emotions and fantasies. Out of this, in time, the investigator can find the answer to these questions and tell them, to the patient, who in turn can recognize the validity of such reconstructions and make the necessary corrections. All of this assumes that the work has been properly conducted between patient and analyst. This is obviously a condensed and dogmatic presentation of the whole analytic point of view. To prove its truth would involve proving the entire concept of repression and the neuroses, a task which cannot be undertaken here. I t would, however, be possible and interesting to compare histories which have been gathered from exceedingly intelligent and cooperative patients by the usual questioning method with those which in the same cases were secured by the analytical approach to the same material by the use of free association. 5. A further serious objection may be advanced against this method of history gathering because of certain abuses to which it is peculiarly liable. As used in hospital practice it involves a subtle distortion of emphasis by placing a higher value on the quality of the hospital-record than on the welfare of the patient. Indeed it is not going too far to say that it often results in a higher valuation being placed on an appearance of completeness in the hospital-record than on the actual accuracy of the data contained in that record. I t assumes, for instance, that an agile and incisive worker, with a capacity to organize quickly the anamnestic data into logical and chronological categories, can put together a full and accurate history of a patient in one or two sittings. I t is not at all unusual for a large and busy hospital to expect an interne to compile every day a complete life-history of a new patient, including a complete mental and physical examination, with a history of all mental and physical ailments and an analysis of his personality. In smaller, private institutions a man may have two or three days to perform this task, and, in addition, he may have an opportunity to review the material and to revise it from time to time. In the larger institutions such a record often stands throughout most of the patient's hospital life as the chief source of information and of diagnostic fact. The folly in this is evident. I t is surprising only that such records can approximate truth as far as they sometimes do. [75]

THE PROBLEM OF MENTAL DISORDER 6. Finally, one is forced by experience to an even more fundamental criticism of the questioning method; namely, that even when the data so gathered are accurate, they are often unusable with the patient. I t is not at all infrequent to find that one can work effectively with a patient only on the material which he is able and willing to give one himself. From the point of view of therapeutic utility the rest of the record is very often deadwood in the lumber yard of the hospital's record room. The Analytical Approach to Biographical Material. A. The Method. I t is less important, however, merely to criticize the methods of orthodox psychiatry than to establish the validity and the special advantages of the method of so-called "free association," which forms the cornerstone of the psychoanalytical structure. For it is the approach to biographical fact through the method of free association which gives to psychoanalysis its distinctive place in the psychological field. That the analytical method has been constructed upon this particular cornerstone is no accident. The consciously organized part of our biographical and psychological material can all be fitted together and understood on the basis of the logical relations of ideas and the chronological sequences of memory. This means that all such facts are accessible to introspection. That other part of our mental processes, however, which is unconscious is not—as psychoanalysts believe—organized according to any such simple and accessible pattern. Neither logical nor chronological sequences seem to govern its associative connections. Its structural outlines, therefore, can be traced only by some method which follows, records, and analyzes the random movements of undirected thought. Any such method must, by definition, be one of free association. I n essence, therefore, the psychoanalytical method tries to enable a patient to relax sufficiently to let his thoughts drift idly, from one image to the next, without noting or caring where these thoughts are leading him. This might seem at first to be simple and easy; actually it is the most difficult task (and the most essential) in the entire technique of analysis. Nor is it possible to keep any patient in that compliant attitude all the time. Indeed there are many patients with whom it is possible to achieve it only at rare moments; and it is not an uncommon experience to have to work months with some patients before attaining any truly free production of material. Glover, in his [76]

THE PSYCHOANALYST'S POINT OF VIEW book on technique, said that it can almost be laid down as a law that the analyst's chief purpose is to keep free associations flowing; and that when he achieves this the analysis is going satisfactorily, but that when he fails to achieve it there is no analysis. From this emphasis upon free association, certain theoretical and practical consequences inevitably result. The patient who is allowing his thoughts to flow in this completely undirected fashion soon becomes lost in the labyrinths of his own associative pathways. I t is as impossible for him to recall such scattered, interrupted, and fragmentary thoughts as it is to recall a long chain of nonsense syllables. Whenever a patient has a clear recollection of the sequences of his own ideas, it is easy to prove that the ideas have not been freely produced at all, but under the influence of some guiding preconception. Even the trained introspectionist must observe and report his data systematically and thus he restricts the freedom of his material. I t is clear, therefore, that in order to study the uncharted paths of 'unconscious' association, either one must have an observer present, to watch closely and attentively the patterns traced by the patient's productions, or else one must resort to some method of mechanical recording. I t is possible to conceive that, for research purposes, a method of mechanical recording would be a valuable adjunct to use in addition to the human observer; but for reasons which introduce us to an entirely new aspect of our problem, it is inconceivable that the human observer should be dispensed with. I t must be remembered that analysis has two aims; one of these is to survey the unconscious material of the patient's mind through the application of the method of free association, and the other is to show the influence which that unconscious material has upon the patient's relationship to other human beings. Correspondingly, the analyst finds himself playing a dual role. In the first, he maps out the unconscious territory and describes to the patient in a quiet, friendly, but impersonal, manner the significant connections which he sees between the various components of the patient's associations. This, strictly speaking, is the analytical approach to the patient's biographical material. Unfortunately, however, one rapidly learns that this work does not proceed in an emotional vacuum; and no matter how quietly encouraging and impersonal the analyst remains, no matter how little the patient knows about him in reality, he soon becomes the storm center for highly significant emotions which [77]

THE PROBLEM OF MENTAL DISORDER have to be continuously described, explained, and resolved, in order to make it possible for the work on the biographical material to proceed successfully. This is what is known technically as 'the analysis of the transference-situation'; and it can readily be seen that it is a constant and necessary companion piece to the biographical analysis. If it is neglected, the biographical work and the production of material soon cease. We have just said that it is unfortunate that the analysis cannot proceed in an emotional vacuum; but this misfortune is purely from the point of view of the labors which the analyst himself must perform. From the point of view of the patient, the analysis of the transference is one of the most valuable of the experiences through which he goes. The reason for this is simple. The analyst himself is, or should be, a man who is little known to the patient. He keeps himself as much in the background as possible, out of clear focus and definition, quietly friendly, but always impersonal and reserved. He becomes, as far as it is humanly possible, a mere peg on which the patient can hang his fantasies. Therefore, when the patient's emotional relationship to the analyst is being analyzed, it is, in reality, not a relationship to a real individual which is studied but rather the unconscious fantasies and feelings which that patient might generate about almost any human being. I n the presence of the analyst the patient may experience moods of anxiety, anger, hate, affection, jealousy, and the like. By thus working out with the patient the unreasonable storms of feeling which play into the analytic relationship, it becomes possible, therefore, to show him how his unconscious fantasies warp his relationships to other human beings. I t is this that makes the analysis of the transference-situation so highly significant and therapeutic. And it is this which has to be worked upon continually in order to make it possible for a patient to produce his own free associative material. I t is, after all, just because it is done in the presence of another human being that it is so difficult for many patients to relax their guard and to abandon themselves freely to their own spontaneous fantasies. In summary, then, one finds that two great obstacles to the processes of free association are (1) the anxieties which patients feel at giving themselves up to the processes of free association in the presence of the analyst; and (2) the emotional storms which sweep over the patient in his relationship to the analyst. I t is [78]

THE PSYCHOANALYST'S POINT OF MEW noteworthy that these same two processes form the greatest obstacles to free activity of any kind in the lives of human beings: to wit, anxiety in the presence of others and blind emotional storms directed against others. This, then, is the most fundamental reason why there must be not only a patient but also a human analyst in whose presence and on whom the patient works out his problems. And this is necessary, and will continue to be necessary, whether or not one finds it possible to make use of any accessory methods of mechanical recording. We are forced, therefore, to the conclusion that there can be no such thing as a purely objective and unemotional pursuit of biographical facts through the process of free association. We find instead that this most natural of all forms of thought is also the most sensitive to emotional influences, and that it is constantly being played upon by stormy winds of feeling which have as their focus this impersonal object of conscious and unconscious fantasy, the analyst. To pursue accurate objective data, therefore, we are constantly forced to clear the air of these obscure clouds, whether they be clouds of fear and hate or clouds of love. The analysis of the transference is therefore the continual and necessary companion of the analysis of free associations. B. The Theoretical Basis of the Method. Throughout this discussion it has been implicitly assumed that there is an underlying sense and meaning to the free associations of a patient, and that the pattern which the patient's wandering thoughts make is traceable by the analyst who watches him as he goes. I t is legitimate, however, to ask on what basis this tacit assumption is made and what principle guides the analyst in his interpretation of the patient's material. This question can be briefly answered. Although it was not realized at first, there is sound physiological support for the premise on which the analyst operates. The tacit assumption behind the analyst's interpretation is this. Whenever two ideas appear in a patient's mind in a definite sequence or relationship in time, even if there is no discernible logical relationship between these two ideas, and even if there is at first blush no possibility of understanding why these two ideas have occurred together, nevertheless the mere fact that they have appeared with a definite time-sequence is evidence that there is some functional relationship between the two ideas in this particular patient's mind. When put in this way, it must be evident that this has a very close dependence upon the work of [79]

THE PROBLEM OF MENTAL DISORDER Pavlov. The nucleus of Pavlov's work is the observation that when two influences impinge upon the central nervous system, with no other relationship except that of time, by reason of this time-relationship alone they establish a functional interconnection in the central nervous system. The analytical premise, upon which rests the entire technique of free association, is the logical extension of this principle: to wit, that any mental acts which concur in time must be related, whether they are the responses to immediate incoming influences or whether they are expressed as delayed efferent productions of the nervous system. Free associations may therefore be most accurately defined as thoughts or feelings which arise in the nervous system with no superficial logical relationship but connected in some recognizable time-sequence. At this point will arise the question, "How does the analyst make use of this fundamental principle in his interpretation of the patterns of free association?" The answer is clear. The analyst observes and mentally records the free sequences of ideas until certain recurring sequences appear with sufficient frequency gradually to impress him with their importance. This makes him ask, "What is the latent thought which would express a relationship, however fantastic, between these two apparently disconnected ideas that are so often reappearing together?" By pointing out the sequence to the patient and by other technical devices, such as using various elements in the sequence as a starting point for new paths of free association, the material fills in and the latent thought takes shape. In time it becomes possible to suggest to the patient that the reason for this sequential pattern is a certain attitude, frame of mind, or feeling of which he has not been previously aware. This suggestion, which we call an interpretation, becomes in turn a fresh point of departure for the patient's free associations, which in the end will either confirm or correct the interpretation. Advantages and Difficulties of the Method. From the foregoing exposition the special advantages and difficulties in this approach to biographical data may now be made evident. The analytical method has been aptly compared to a microscope. I t reveals countless interconnections of ideas and feelings which never are glimpsed by any method which confines itself to the exploration of the well-worn paths of logical and chronological thinking. By the insistent reappearance of certain of these [80]

THE PSYCHOANALYST'S POINT OF VIEW connections, in conjunction with observable emotional states, it gradually focuses upon those unconscious connections which are highly charged with 'affects,' and from the less significant of the unconscious patterns selects for special emphasis and study those which recur with high emotional charges. Furthermore, the method of free association proves to be a subtle diagnostic instrument of great significance. The opportunity which arises to watch the play of undirected associations and their interplay with emotional states gives to analysis a diagnostic and prognostic value of growing importance. I t is possible to observe in normal people and in those who have minor characterological disturbances thin rivulets of fantasy and feeling whose relationship can be traced step by step to the headlong torrents of the frankly psychotic or psychoneurotic patients. In the course of time, this may fundamentally affect our systems of classification. I t is the writer's persuasion, however, that it is not as yet desirable to discuss in detail the tentative classifications which are being built up within the field of analytical theory as well as their relationship to orthodox nosology. This aspect of analytical theory is in a state of constant flux and tentative formulation; and it is only the more blindly partisan of analytical theorists who look upon these formulations as more than tentative at present. Current Classificatory Systems; Their Differences, Their Validity, Their Uses, and Their Limitations. As already indicated, the classification of the disorders seems to the present writer to be a matter which is still so tentative, and so much a question of theoretical detail, that it cannot yet be profitably discussed. I t is much better to look upon such details as necessarily in a state of constant change and evolution. Essentially all psychoanalytic classifications of mental disorder have grown out of orthodox psychiatry. Therefore they rest fundamentally upon the superficial psychiatric description of gross symptomatology. Progress here must parallel the general phases of medical evolution. I n every field of medicine it is true that the first approach to a classification of diseases must be by description of the superficially observable phenomena. Then certain groupings of phenomena are seen to occur repeatedly together. These come to be recognized as syndromes of symptoms. A tentative hypothesis is then built up that each syndrome must proceed [81]

THE PROBLEM OF MENTAL DISORDER from a single origin. If this hypothesis is substantiated, a permanent grouping is created on an etiological basis. A disease is finally recognized as being a condition due to a unit-cause or group of causes. This is the aim both of psychiatry in the orthodox sense and of psychoanalytic psychiatry. But psychoanalytic psychiatry had necessarily to begin with the descriptive entities which had been isolated by orthodox psychiatry. To what extent a psychoanalytic classification can be built upon the basis of unconscious phenomena alone is a question which cannot as yet be answered, although it is of the greatest importance. The problem then becomes one of working out a system of classification on the basis of unconscious content, and of seeing to what extent such a classification supports and amplifies that of the conscious and overt symptoms, or how far the two systems of classifications diverge the one from the other. I n the latter event, one would face a problem which has not as yet even been approached, i.e., that classification which would best give an understanding of the etiological bases of the various types of illness. Factual Evidence of the Validity of the Analytical Account of the Disorders. I t is impossible at present to give this question an adequate answer. Certainly no one who reasons clearly would dare to use either the success or the nonsuccess of a therapeutical method as evidence for the truth or untruth of the theory behind the method. This is always a fallacious process. The history of medicine is full of instances of therapeutical maneuvers which have been successful even when their accepted theoretical explanations have been completely unsound; and, on the contrary, there are many instances of theories which are sound as far as they go, but which, for various reasons, remain for years therapeutically sterile. The apparent success of psychoanalytic treatment cannot, therefore, be used as evidence for the truth of the theory; but it is equally necessary to stress the fact that failure cannot be used as conclusive evidence of the untruth of that theory. One may say only either that, if therapy fails, the theory must be incomplete or that the technique of its application was inadequate in the face of special difficulties. The Concept of Mechanisms. The concept of a 'psychic mechanism' is not in any sense mystical or divorced from the realities of neurology or neuropsychiatry. In simplest terms of common sense it is merely the recognition of a fact which every [82]

THE PSYCHOANALYST'S POINT OF VIKW human being recognizes, namely, the fact that one mental state has an influence upon another. That such a relationship must be mediated by a nervous system and a body goes without saying. The term ' psychic mechanism' stresses the fact that the significant variations are in the psychological reverberations of the phenomena rather than in the structural basis of the machinery. Furthermore, it is implicit in this concept of mental mechanism, as used in psychoanalysis, that the mechanism is not necessarily one of which the individual is conscious. Fortunately, however, it is possible to establish the experimental proof of this implication outside the field of psychoanalytical observation itself. One need go no further than the realm of hypnosis to find in the phenomena of posthypnotic suggestion the experimental proof of the fact that an unconscious mental mechanism can have sufficient dynamic force to influence profoundly the behavior of a human being even against his own best judgment. Therefore one speaks in psychiatry of 'unconscious mechanisms,' 'unconscious fantasies,' 'unconscious feelings,' and the like. The words seem to imply an intrinsic contradiction. The phenomena, however, are directly observable, and with a minor correction of the phrases the apparent paradox drops away. For instance, one may say that a patient acts as though he had such and such a theory, although he would never consciously voice such an idea. In other words, his consciously critical personality would correct and reject an erroneous idea, although his total behavior will obey the erroneous theory. A banal and frequently recurring example is that of the patient with a pronounced sexual neurasthenia who may discuss intelligently the whole problem of sexual physiology and yet behave on the basis of an unconscious belief that every time he loses semen he is depriving himself of large quantities of blood and of a vital spirit which emanates from his brain. Such a latent and unconscious thought we call an unconscious fantasy, and it may operate as a mechanism to disturb the patient's entire psychosexual adjustment. This is only one of many comparable illustrations of what is meant by a mental mechanism. I t is perfectly true that such ideas lurk in the background of the minds of many people, and that they are not equally potent in disturbing the equanimity of all. Here again is a point at which constitutional and organic factors may play a significant r61e. I t is not possible to say why in one individual a certain unconscious fantasy apparently is so [83]

THE PROBLEM OP MENTAL DISORDER highly charged that it can upset all of the patient's adjustment, whereas in another individual the same unconscious fantasy is demonstrably present but devoid of sufficient energy to disturb the patient's life. To what extent this difference in the energycharge of the concept is explicable on a constitutional and physiological basis, or to what extent it depends upon biographical data in the patient's life-story, is not a question upon which generalizations are at present possible. Similarly it is not wise to enter today into a detailed theoretical discussion of what mechanisms are essential to psychoanalytic theory. Analytic theory is in a state of flux, as it has been ever since its birth forty years ago. With increasing depth of insight, and with the necessary correction from increasing experience in the analysis both of normals and of sick patients, the concept of the essential mechanisms has constantly shifted and will continue to shift. The history of psychoanalysis freely acknowledges this fact. I t is possible to say only that some of the fundamental problems which analysis faces today are these: (1) the origin of anxiety in childhood, and the factors which determine the variations in infantile anxiety; (2) the transformations of anxiety, both in early childhood and in later life; (3) the origins of aggressive and sadistic energy, both in infancy and in later years; (4) the origin of deep-seated tendencies towards passivity and submissiveness; (5) the varying forms and intensities of the transient neuroses of childhood and their adult correlates. Each one of these fundamental adult orientations towards life is accompanied by an elaborate and fantastic superstructure of ideas, unconscious theories about bodily functions, and the like. I t is of fundamental importance to know to what extent these tendencies are dependent upon early psychological events in the lives of the human being. These psychological events may be of extraordinary subtlety and may demand the most minute and microscopic observation of the lives of infants and of young children. I t is to this end that the application of psychoanalytic theories, and especially the method of free association, to the study of the development of ideas and of their expression in language in infancy and childhood is of such pressing significance in current research. In summary, then, one may say that one finds varying temperamental qualities expressing themselves in relation to certain [84]

THE PSYCHOANALYST'S POINT OF VIEW universal human problems. These temperamental qualities have to do with anxiety and its various transformations, and with aggressive impulses or tendencies towards passivity. The play of all these, reactions must be observed in relation to the universal human dramas: to wit, the relation of the individual to the various members of his earliest family group, the various components of the individual's attitudes and impulses towards the parts of his own body and to the various parts of the bodies of others. Subsidiary to these, one has to work out the individual's fundamental unconscious conceptions of dirt, disease, mutilation and injury, gain and loss, growth and shrinkage, and birth and death. Finally, one endeavors to get a picture of the quality of the individual's object-relationships as contrasted with his narcissistic or self-directed values. Out of all these varied dramas certain outstanding problems have been specially emphasized by the use of rather striking names, such as the Oedipus drama, the castration problem, and the like. When used with proper understanding, these scientific short-cuts, or condensations of complex phenomena, are useful. That they can readily be misused is obvious; but here again the greatest safeguard is not the abandoning of a useful system of shorthand in terminology but the adequate training of those who are to use this terminology. There is one fallacy which frequently creeps into analytic writing on the subject of psychic mechanisms which it is well to acknowledge, because the most thoughtful analysts are constantly warning others against it. This fallacy grows from a legitimate effort to see how far temperamental variations can be explained solely upon an experiential basis. I t has given rise to a fallacious doctrine, however, the doctrine of the 'psychic trauma.' In its earliest and most naive form it was thought that psychosexual trauma in early adolescence, or in the preceding latency-period, could explain all later neurotic sensitivity. This was soon proved to be untrue, because not all traumata were followed by neuroses, and not all neuroses were preceded by traumata. Presently, however, the same type of reasoning reappeared, but concerned itself with an earlier period, and scenes witnessed in infancy became the ' d i m ' trauma. I t is clear that here one always begs the essential question, i.e., "What determines the intensity of the initial reaction ? Why is the same type of scene so much more disturbing to one infant than to another?" I t is [85]

THE PROBLEM OF MENTAL DISORDER not possible to say as yet how far the difference is due to differences in the type of experience, nor how far it is due to the inherent constitutional tendencies of the infant to anger, fear, or passivity, or to oral, genital, anal, or other special fields of vegetative discharge. I t is important, however, to reemphasize the point that it is just here that Freud warns against overlooking the constitutional component in the response. Subdivisions of the Psyche. Again we deal with a current detail of analytic theory which could be discarded without altering the more fundamental methodological contributions of psychoanalysis. Nevertheless, it is worth while to consider for a moment the significance of this present element in psychoanalytic theory. Analysis makes a fundamental division of psychological forces into three departments. The first is the id. The id is a name for a reservoir of fundamental instinctual drives.1 I t is implied that in some way all of the instinctual components of the id have a tendency to operate in close alliance with one another. The various drives seem to have some capacity to supplant each other. Their energies are a reservoir of psychic force. The second component of the psyche, according to current psychoanalytic formulation, is the ego. This is a psychological name for a psychophysiological entity: to wit, that portion of our apparatus which brings us into relation with the environment through our senses and through our effective motor apparatus. I t is the personal mechanism of sensation, action, and self-awareness. The final element of this psychic apparatus is the superego. Again this implies the existence of a department of human thinking and feeling which is self-critical in its function, in part consciously and in part unconsciously. I t is that part of our mental apparatus which operates as a check, as a control, as an idealization, and as a struggle to achieve an ideal, in our human existence. The only principle involved in the descriptive recognition of these three aspects of human mental life is that each department seems 1 Psychoanalysis uses the word instinctual not as synonymous with the biological word instinct but rather as synonymous with the German word Trieb. This German word means deep emotional drives, whether on a hereditary basis or acquired in the life of the individual. There is no definite English equivalent for it; and in psychoanalytic terminology the word instinctual has been used as the equivalent of this German word in contrast to the word instinctive with its biological-hereditary connotation. [86]

THE PSYCHOANALYST'S POINT OF VIEW to a certain extent to have a tendency to operate as a unit in mental affairs. I t is possible to overestimate the importance of this segregation of functions. Nevertheless, popular usage recognizes the validity of some such subdivision. Thus it is customary to talk, not merely of this or that carnal appetite or lust, but to group all lusts together and speak of the animal aspect of a man as contrasted with his religious or spiritual aspect. This implies a realization of the fact that instinctual drives, and the conscious and unconscious critical attitude which the individual himself takes up towards his instinctual drives, are not merely separate and unrelated aspects of the individual's nature. On the contrary, the individual tends to manage all of his instinctual drives in more or less similar ways, and his conscience is most likely to be either vigorous or flabby in all directions. The analytical conceptions of an id and a superego are closely analogous to these popular truths. Just as the popular expressions have proved useful helps to understanding superficial aspects of human nature, so, too, in analysis, the recognition of a reservoir of instinctual energy, of an aspect of a psychic mechanism which is concerned largely with perception, response, and self-awareness, and of a third element which is concerned primarily with self-criticism has proved useful, not only in understanding certain clinical phenomena, but in the formulation of concrete research problems in regard to the development of these aspects of human nature in infancy and early childhood. That there are certain dangers in them is also true, but these dangers again lie largely in the anthropomorphic misuse of the concepts rather than in the concepts themselves. A Comment upon the Training of Psychoanalysts. I t is an accepted commonplace to say that in every science progress depends upon the development of a method which enables one to observe new facts, first qualitatively and then quantitatively. I t is equally true, however, that a method cannot be said to have been adequately tried or exploited until a sufficiently large group of workers, with unlike antecedents, with different points of view and diverse training, have all had the opportunity thoroughly to master the method and to apply it. There can be no doubt that the most serious handicap to the progress of knowledge of the contributions which psychoanalysis has to make to psychiatry has been the totally inadequate training—not [87]

THE PROBLEM OF MENTAL DISORDER only in the associated fields of neurology and psychiatry, but even more particularly in psychoanalysis itself—of the larger part of those who have professed to be analytical practitioners. This fact is well known and deplored in analytical circles; and it is to the credit of analysts that, at the cost of a great deal of effort and money, and with internal dissension and strife, they have finally been able to undertake a kind of internal house-cleaning and reorganization. In every country the history has been comparable. A t first, an interest in analysis drew people together. A t that time anyone who professed such an interest could join a psychoanalytical society, whose sole function was to meet occasionally to hear a lecture or to discuss a paper. Members of the society, whether they had any special training or not, could then set themselves up as analysts and practice what they pleased. I t gradually became apparent that this condition was open to very grave abuse. Sometimes perfectly honest and well-meaning men, who were themselves seriously neurotic and who were drawn into the field because of their own inner difficulties, made serious blunders in practice because of their neurotic inclinations and their inadequate training. In other cases, actual dishonesty, with exploitation of the name of psychoanalysis, was possible. As is usual in medical things, the public had no way of discriminating between the honest, well-balanced, and well-trained analyst, on the one hand, and the neurotic, dishonest, or inadequately trained man, on the other. In order to combat these evils, the international society finally took upon itself the task of laying down certain minimal requirements before it would accept an individual as an adequately trained analyst. The carrying out of these regulations was put in the hands of the various member societies all over the world, who in turn delegated this function to their several training committees. This very necessary change has been growing in Europe within the last ten years. Within the United States the growth of training institutions has begun in recent years. The hope and expectation is that gradually the general public and the profession will come to recognize the relative security which this training of the Psychoanalytic Society provides; and that it will turn to its accredited members for instruction and advice on analytical matters, instead of to any 'wild analyst' who advertises himself in subtle ways and so captures the public ear. [88]

THE PSYCHOANALYST'S POINT OF VIEW That such a close organization with its guild-like character entails certain dangers, notably that of overstandardization, is undeniable. For the present, however, this is the lesser of the two evils, and ultimately the pressure of younger well-trained men will diminish this danger. There is included in the training regulations a provision for the training of laymen in theoretical aspects of psychoanalysis and for work with children. This has been a thorny problem; and up to the last few years the American analysts stood very firmly against this practice. Even despite the provisions in the training regulations, the local spirit is against a free exploitation of this privilege. The institute is unwilling, however, completely to shut its doors to laymen. There are certain great contributions which the layman can make to psychoanalysis. I t is literally impossible for a man who has been through the many years demanded by the medical discipline to equip himself also in the fields of sociology, philology, ethnology, psychology, anthropology, and education. Nevertheless, all these fields are of vital importance to psychoanalysis. I t is obvious, then, that someone must be thus equipped. This would seem to make it necessary to train a certain number of carefully selected laymen for this work. If one accepts this conclusion, it follows inevitably that such laymen must be allowed to do a certain amount of analytical work. Fortunately, moreover, there is an extremely wide field of work for the lay analyst in such activities as the investigation of children and the analysis of normal persons for research purposes and for training. These activities provide an opportunity to achieve a mastery of the technique.2 The following note on the training of psychoanalysts has been prepared by Dr. Franz Alexander, Chicago. In the medical curriculum psychoanalysis should have two places. In the preclinical semesters its basic principles should be taught parallel with physiology and anatomy, completing the somatic with the psychic knowledge of man. Its second place should be during the clinical years in psychiatry and should constitute the basic part of it. Until the situation is ripe for the incorporation of psychoanalysis in the present academic system, the existing institutes for psychoanalysis must develop 2 See the pamphlet, Training Regulations of the New York Psychoanalytic Society.

[89]

THE PROBLEM OF MENTAL DISORDER the standards of this new discipline and be the places for training and research in it. At present, the bulk of the students in these institutes are students of psychiatry and these include a great number of practicing psychiatrists who have become dissatisfied with their previous training and now feel the necessity for a farreaching re-orientation by undergoing a postgraduate training in one of the psychoanalytic institutes. But the institutes for psychoanalysis must also be open for students of the theoretical and practical social sciences (anthropology, history, sociology, criminology, pedagogy, etc.) who require knowledge of psychoanalytic psychology in their own fields. For lack of other places these institutes must unify the medico-therapeutic and the sociological aspects of psychoanalysis and satisfy the increasing need for the study of psychoanalysis in both of these fields.

[90]

I. PROBLEMS I N CEREBRAL ANATOMY A N D PHYSIOLOGY By Stanley Cobb, M.D., Boston Psychology is the study of the mind; psychiatry is the study of the abnormal mind; neurology is the study of the organ of the mind (the brain and its nerves). Obviously, in order to understand any one of these, the student must have a knowledge of all three. Forel1 says "Als wir friiher Hirnanatomie trieben und ihren Zusammenhang mit der Psychologie und der Psychopathologie suchten, lachte man uns als Utopisten aus; wir haben doch nicht verzagt." Such a courageous statement from the Nestor of psychiatry should confound those psychiatrists who say that nothing can be learned from the study of the brain, and those neurologists who look on psychological problems as too complex to be worth studying. The great stumbling block to effective cooperation is the widely and complacently accepted idea that all diseases can be divided into two categories, and classified as either 'functional' or 'organic' Most physicians and many psychiatrists still cling to these outworn categories. I t is extraordinarily difficult to explain to a man trained in the school of pathological anatomy that his criterion for calling one disease organic and another functional is entirely artificial, that the deciding factor is the instrument he happens to use to record the abnormality of the organ under observation. Just at present the instrument most relied upon is a microscope with a limit of magnification of about twelve hundred diameters. Suppose that some physicist tomorrow invents a microscope with a much greater useful magnification. At once abnormality may be seen where none was previously visible. And in all probability diseases formerly said to 'have no pathology' (and hence called 'functional') will be found to have microscopic variations from the normal and will be accepted as 'organic' An example of just this is paralysis agitans, which twenty-five years ago was classified as a functional neurosis and is now known to have a localized cellular pathology in the diencephalon and mesencephalon.2 1 Quoted by Vogt, / . / . Psychol, u. Neur., 40, 1929, 108. 2 Jelliffe expresses this well where he says, " I talk of 'reversible and irreversi[111]

THE PROBLEM OF MENTAL DISORDER But why confine ourselves to the microscope ? Certainly there are other ways of recording abnormality of the human organism besides visual observation of fixed and sectioned tissue. For example, the spectroscope may show that a certain type of sugar is found in the urine of an athlete before a contest. This is an observation which may be recorded photographically; it is a phenomenon which can be shown to occur regularly; by chemical methods the sugar may be estimated quantitatively. The average histopathologist, nevertheless, will strenuously maintain that there is no organic pathology in this anxious athlete, and that the disease is 'merely functional.' What the histopathologist really means is that after an autopsy on this athlete no lesion would be visible in stained sections of tissues, with a microscope of the type used in the year 1934. To attack the subject from another angle one has only to consider the numerous diseases where chronic functional disturbance leads to organic lesion. For example, the evidence is impressive that in certain individuals prolonged worry leads to gastric hyperacidity and eventually to gastric ulcer. I t is known that sudden fright may precipitate Grave's disease, with exophthalmia, enlarged thyroid gland, and increased basal metabolic rate. A somewhat more complicated situation was presented to me by a patient who came to the clinic with the mental, neurological, and dermatological symptoms of pellagra. At autopsy, the nerves, cord, and brain showed typical neuronal lesions. Yet primarily, as the history showed, the patient's trouble was fear. This had early made him a recluse, later led to restriction of diet and eventually to pellagra. In this case there was certainly gross and microscopic organic pathology. But who can draw a line showing where ' mental' cause ceased and ' physical' cause began ? I t may seem pedantic to expatiate upon the impossibility of drawing a line between organic and functional, but experience shows that it is necessary to emphasize that no such line can logically be drawn. If it is drawn arbitrarily, its position is ordained by the point to which technology has advanced in that year. I t depends on what kind of a ' scope,' ' graph,' or ' meter' is used by the observer. I n other words, the line between organic and functional (and between physical and mental) is an artefact. ble' organic changes, never of 'organic' changes. Organic changes are always taking place in all functioning organs. Any one should know that; whether within the physiological range and whether reversible or not is the important consideration." Arch. Neur. and Psychiat., 30, 1933, 239. [112]

CEREBRAL ANATOMY AND PHYSIOLOGY The body acting as a whole is an organism; anything that happens in that organism is organic. Although we may yet have no methods for recording and observing them, I believe that glycosuria, tachycardia, and even dreams have an organic basis. Structure and function are inseparable. Having once discarded the stultifying distinction between 'functional' and 'organic,' between 'mental' and 'physical,' one is able to approach psychiatry in an unbiased way; one can accept facts at face value from any source, so long as the facts have been carefully gathered. In the field of cerebral anatomy much has been learned by comparing the brains of various animals and correlating the differences with differences in behavior. Thus it has become apparent that the development of the frontal lobes of the brain is related to an increase in intellect (i.e. an ability to delay reflexes and to act in the light of past experiences). Another important problem concerns the phylogenetically old rhinencephalon which takes up a large part of the human brain. Although the human sense of smell is rudimentary it has an inordinately great emotional effect. Careful comparative studies might give one more knowledge as to why "smells are surer than sounds or sights to make your heartstrings crack."3 In cerebral histology there is evidence that certain characteristics in the cortical cellular arrangements4 are correlated with certain mental abilities, a fact which suggests a comparative investigation of the cerebral architectonics of races, criminals, and mental defectives. Since the time of Rolando (1809), Gall (1809), and Flourens (1824) there has been great interest in the localization of brain function. In 1870 the electrically excitable area of the cortex was discovered, and from then until 1900 the concept of localization grew and became more specific and complex, until absurdly minute chartings of the cerebral areas were produced to indicate the seats of alleged memories and faculties. Recently there has been a reaction against this specific localization. Franz and later Lashley denied the existence of cortical localization; they did not believe in the specialization of function in a specific part of the cerebrum; they considered that the 'equipotential' brain acts as a whole. A t first Lashley held that loss of an area of the brain does not mean loss of a 3 R. Kipling, Lichtenburg, The Five Nations, 1903. 4 Cf. O. and C. Vogt, J.f. Psychol, u. Neur., 25, 1919, 279; 40, 1929, 108. [113]

THE PROBLEM OF MENTAL DISORDER special function, but more recently6 he has modified his views to approach those of the Gestalt school. This is an important point of view, worth keeping in mind in discussing cerebral function. Doubtless activity of any part of the brain affects many, if not all, other parts of the brain. I n that sense the organ acts as a whole, and the functions are so interdependent that no area can act alone. But to say that there is no localization is to disregard a great deal of important evidence. Anatomical evidence of local functioning is convincing and physiological experiment corroborates it. For example, the electrically excitable cortex, where electrical stimulation causes movement of local muscle-groups, corresponds well with the area of cortex which has a special histological structure; moreover, removal of this area causes paralysis. Electrical stimulation of the first temporal convolution causes the patient to hear noises, and bilateral removal of this area causes deafness. Operative ablation of the visual cortex is found to cause blindness. Painting the postcentral cortex with strychnine solution brings out hyperaesthesia in certain definite skin areas. These main cortical localizations of function are easily observed throughout the mammalian series up to man. They keep their same general positions and relations to one another, but become separated by the development of new cortical areas. These phylogenetically newer cortical elements are developed largely in two main locations: in front of the motor area (frontal lobe) and behind the somatic sensory area (i.e., the middle part of the parietal lobe and the posterolateral part of the temporal lobe). Histologically these new areas are not so distinct as the main receiving stations, nor do they have such definite tract connections. Their characteristic seems to be rather a richness of connections with other areas. I t is the great development of these 'associative' mechanisms that gives to man his intellectual superiority. Whereas in the rat only about ten different types of cortex are histologically recognizable, Vogt has mapped out and described over one hundred in the cortex of man. Not only do these special studies show that there is much localization of function in the cerebral cortex, but a mass of clinicopathological data indicates how focal lesions in the human brain cause specific neurological and psychological abnormalities. In reviewing the available evidence it seems to be proved that, in K K. S. Lashley, Science, 73, 1931, 245. [114]

CEREBRAL ANATOMY AND PHYSIOLOGY lower mammals, lesions of the motor area cause only temporary paralysis, and lesions of the visual area cause only temporary loss of visual functions. But for man this does not hold. Functional loss from cortical injury returns little; in other words, localization in man is more fixed, and one general function is specifically associated with one type of cortex. I t is difficult to explain in words just what the function of the cortex cerebri really is. Perhaps Fulton's term long-circuiting best explains it.6 Short reflex-arcs across the cord, medulla, or other lower centers give rapid, automatic reflexes which can be looked on as short circuits. When a nerve impulse is shunted up the cord to higher levels—as most impulses normally are—then long-circuiting begins. This shunting allows for an enormous increase in the possibility of neural association. Long-circuiting in itself thus gives higher integration and may lead to delayed action. This process of spread is essential for coordination. Its acme is found in the cerebral cortex where stimuli arriving at one receiving station (e.g., the visual) spread in innumerable directions to many other cortical areas, stimulating habitual responses, memories, etc. This leads to a delay in response, clearly a most useful process, for spread and consequent delay may allow the past experience of the individual to affect his behavior; this activity of the 'associational' paths is the very essence of mind. Pavlov7 has devoted his later years to the study of conditioned reflexes, and his results have not only made him a leader among physiologists, but also have oriented in a new way certain points of view in psychology and psychiatry. His methods have been repeated and extended by a few physiologists and psychologists in this country, but better reports of his work must be published before one can accept his theory of cerebral physiology. The most difficult thing to understand in Pavlov's work is his theory of 'inhibition,' a much-abused word. Just what he means by the term is obscure. His idea that the cerebral cortex is a kind of mosaic of excitatory and inhibitory spots is too naive. Repetition of his experiments and new experiments are greatly needed to discover just what cortical inhibition is. One knows that, at lower levels, stimulation of the vagus nerve inhibits the heart, probably by simple chemical means. Inhibition in the spinal 6 J. Fulton, Muscular Contraction and the Reflex Control of Movement, Williams and Wilkins, Baltimore, 1926. 7 I. P. Pavlov, Lectures on Conditioned Reflexes, Internat. Publ., New York. 1928. [115]

THE PROBLEM OF MENTAL DISORDER cord is not yet understood; although Forbes, Sherrington, and others have described mechanisms that help to elucidate this complex process. Cerebral inhibition is the most important problem—one of the key-problems of psychiatry. At present it is entirely unsolved. I still feel, as I felt six years ago,8 that what most psychologists and psychiatrists call inhibition in man is best described as long-circuiting. I t has nothing to do with the type of inhibition found in the autonomic system and in the spinal cord. I t is a matter of widespread association. The human cerebrum gives such enormous possibilities of spread and interconnection to any impulses reaching one of its main receiving stations, that the afferent impulses reach many parts of the brain; immediate reaction is thus delayed by long-circuiting, allowing the 'associative' mechanism a chance to alter the reaction so that it results in a considered and 'thoughtful' response. The organism responds " i n the light of past experience." This allows us to act intellectually instead of instinctively and reflexly. But this is only a theory and urgently needs investigation. Cannon9 has made a great contribution to psychiatry by his work on the sympathetic nervous system and the endocrine glands. He has given us an understanding of the mechanism by which certain emotions affect the central nervous system, and he has given a lead as to the localization within the brain of the ganglionic masses which subserve the function of emotional expression. Moreover, he has presented evidence for a mechanism to keep the body in equilibrium (homeostasis) even in emergencies. All this has a direct application to psychiatry, and many workers in mental hospitals are applying Cannon's animal experiments and theories to human medical problems. The recent investigations of Adrian,10 Wever,11 Forbes,12 Davis,13 and others seem to prove that the older conceptions of the nerveimpulse are inadequate. Apparently the nerve tracts within the central nervous system act as peripheral nerves do and carry impulses of various frequencies and rhythms. These may be 8 S. Cobb, Arch. Neur. and Psychiat., 19, 1928, 981. 9 W. B. Cannon, Bodily Changes in Pain, Hunger, Fear and Rage, Appleton, New York, 1922. 10 E. G. Adrian, The Mechanism of Nervous Action, Univ. of Penn. Press, Philadelphia, 1932. 11 E. G. Wever and C. W. Bray, Paper read before A.N.A. meetings, Atlantic City, June, 1932. 12 A. Forbes, Science, 64, 1926, 163. 13 L. Saul and H. Davis, Arch. Neur. and Psychiat., 29, 1933, 255. [H6]

CEREBRAL ANATOMY AND PHYSIOLOGY recorded by electrical devices which pick up, amplify, and record action-currents. For example, Davis' neurophone is a portable amplifier equipped with a loud speaker and with a mirror oscillograph for photographic recording. I t can be used for detecting by ear or eye localized electrical activity in the central nervous system. The neurography is an amplifier which records relatively slow potential changes in the central nervous system; with this apparatus action-currents from the brain have been detected even through the intact cranium. With these techniques, studies of auditory and optic reflexes have been made; the hypothalamus is being investigated. I t is obviously important to go on to more complex relationships; to inhibition, facilitation, conditioned reflexes, and emotional outbursts. A whole new field is thus opened up that should lead to remarkable advances in cerebral physiology. The cerebral circulation has long been studied, but new facts have recently come to light. I t has been shown that the cerebral blood-supply is controlled in a number of different ways: (1) by a passive reaction to distant systematic changes in circulation, e.g., splanchnic constriction with a great rise of pressure forcing more blood into the cranium, or the opposite effect with splanchnic dilation; (2) by a vasomotor mechanism causing contraction and dilation of the pial and, perhaps, of the deep vessels of the brain; and (3) by physicochemical changes in composition of the blood exerting an immediate effect upon the cerebral vessels either with or without changes in systematic vascular pressure. The importance of this chemical factor seems to be greater than the others. For example, an excess of carbon dioxide causes marked dilation of the pial vessels and a small dose of adrenalin in the blood-stream causes them to contract. Lack of oxygen is another important factor. I t occurs not only in conditions of true anemia, but whenever the cerebral blood-stream is slowed; in fact, congestion is a common cause of anoxemia, as when compression of the jugulars results in unconsciousness. Such changes in cerebral blood-supply have marked psychological concomitants. Animal experimentation is one approach to the problem but the clinical phenomena are poorly understood, in spite of their frequency and importance.115 14 S. H. Bartley and G. H. Bishop, Amer. J. Physiol., 103, 1933, 159; A. E. Kornmiiller, J. f. Psychol, u. Neur., 45, 1933, 172. 16 S. Cobb, Annals of Inter. Med., 7, 1933, 292. [117]

THE PROBLEM OP MENTAL DISORDER The cerebrospinal fluid is another important part of the ' internal environment' of the brain. I t acts as a water jacket, protecting the brain, and as a bath to wash away katabolic products. Arising largely from the choroid plexuses, it flows from the ventricles, to the subarachnoid space, where it probably receives small amounts of additional fluid from the perivascular spaces. The fluid flows about the base and fills the pockets known as cisternae, finally spreading to the convexity of the cerebral hemispheres to be filtered into the great venous sinuses via the arachnoid villi. The fluid also flows down around the cord, where it is in a blind pocket and can circulate little; but because of diffusion and bodily movement enough exchange takes place to make the fluid in the lumbar sac a fair sample of the cerebrospinal fluid. From the chemical standpoint, the cerebrospinal fluid is almost identical with Locke's solution. Its chief differences from plasma are the almost complete absence of protein, lipoids, pigments, and ferments, and the much higher chloride content. The unequal distribution of chloride ion between plasma and spinal fluid varies with the protein differences between these fluids, and appears to depend upon the Donnanmembrane equilibrium. Cerebrospinal fluid may be reproduced artificially by filtering plasma through a membrane impermeable to protein. Consequently the cerebrospinal fluid may be considered a protein-free filtrate in equilibrium with the plasma.16 Little is known about the way in which these fluid media—the blood and the cerebrospinal fluid—affect cerebral activity. They obviously control the metabolism of the brain and keep it in homeostasis, to use Cannon's term. Recent work is solving some of these problems, and the physicochemical study of the fluid media in which the brain works is a most fruitful field for research. There is urgent need to gather more information about the oxidation processes in the brain, the reaction of nerve-cells to oxygen and lack of oxygen, the factors that control the bloodsupply to the brain, and the question of cerebrospinal-fluid circulation and lymph circulation in the brain. I t seems probable that by cooperative studies of (1) the blood-flow in the brain, (2) the composition of the blood, and (3) the chemistry and dynamics of the fluid which filters from the blood to bathe the nerve-cells, we have the background for a study of the internal environment of the brain and the local control thereof. Such an 10 P. Fremont-Smith, Arch. Neur. and Psychiat., 17, 1927, 317. [118]

CEREBRAL ANATOMY AND PHYSIOLOGY understanding will give a clue as to how the brain works as a total system. The extension of such studies to the kidneys and lungs makes it possible to understand changes in cerebral function in the light of changes in the functions of the organism as a whole. These are some of the investigations that are at present bringing psychiatry closer to the fundamental sciences.17 Many more problems will appear. Let us realize that there is room for all good workers, and there is work aplenty. The charlatan and the fanatic must be ruthlessly eradicated; but there is no place for skepticism towards any intellectually honest work. There should be no respect for the pusillanimous attitude that nothing can be done in the scientific study of mental phenomena. Let us keep the goal in sight—though we know that we ourselves shall never reach it—so that in the end we can say with Forel, " W i r haben doch nicht verzagt." 17 It is important to remember that, of the six major contributors to psychiatry in the last twenty-five years (Kraepelin, Freud, Sherrington, Pavlov, Wagner von Jauregg, and Cannon), three are physiologists.

[119]

n . ELECTROPHYSIOLOGY OF T H E B R A I N By George H. Bishop, Ph.D., St. Louis I n view of the unlikeness of the categories in which psychological and neural phenomena are conveniently and convenionally placed, it is difficult to discuss the psychiatrical application of neurophysiology without coming to some conclusion as to the immediate relationship between these two groups of events. The ultimate relationship can be taken for granted. Mental phenomena and neurophysiological phenomena I shall regard as two aspects of the same brain function, whatever else they may be. Were it possible to go beyond this general statement and to discover a direct and detailed correlation between mental and physiological functioning, the result would unquestionably be profitable to both sides. I n a few cases (e.g., paresis, where a definite anatomical pathology can be recognized) correlation of a sort can be made. But even here such knowledge as is available upon brain-lesions gives only general information as to the derangement of physiological function that might be correlated with mental derangement. The occasion for this state of affairs might serve to illustrate the general case; perhaps the difficulty lies in our ignorance of what such a lesion as that of brain syphilis does to the physiological functioning of neuronal groups. Before any extensive destruction of tissue can be anatomically detected, there must have been a considerable derangement of normal function in these same tissues, and even if an earlier recognition of the pathological condition is possible, no adequate methods have been developed to study directly and in detail the functioning of the cells involved. Thus anatomical and neurophysiological studies are at least two removes from mental phenomena; first is the necessary step to a demonstrable presence or absence of cellular function, and beyond that to the manner of functional impairment. Even such functional tests as abnormal reflex action furnish no exception; for, while the abnormal function of cells may be thus detected, these functions are not observed at their origin but only through secondary effects on peripheral endings. Discovery that a pathological condition increases or decreases the activity of a specific mechanism does not [120]

ELECTROPHYSIOLOGY OF THE BRAIN explain the effect, however valuable it may be as a diagnostic sign, until the impaired activity can be stated in detail. I t has not been demonstrated, however, that all types of abnormal mental function are referable to pathological lesions. Indeed, a good case can be made for an opposite conclusion. Aside from the fact that such lesions cannot always be found, it is a fact that human behavior changes for nonpathological reasons. At what point such behavior might be called abnormal is a matter of opinion. Kroeber points out in this series of studies that a psychotic derangement in a higher culture may resemble closely normal activity in a lower, and that, as in lower cultures magic is commonly appealed to under conditions of stress, so in higher cultures derangements similar to belief in magic are apt to occur in mental crises. What we regard as peculiar and perverse notions in savages are not due to bodily disease, but are functions of a physiologically normal brain. I t is certainly possible that deranged mental activity may likewise be activated by nerve-cells that would be regarded as physiologically sound and healthy under any functional test. Two types of mental derangement may then be recognized, or rather two causes of abnormal function: one due to specific anatomical or physiological defect, as from accident, intoxication, drugs, or disease, and the other due to 'purely mental' causes, such as suggestion, anxiety, or repression. We realize that all complications of the two may exist, to be sure, and that neither can always be distinguished from the other by the mental manifestations. I t might be conceded that the first type should be amenable to physiological investigation. Does the second type lie outside the proper realm of neurology? I t appears to the writer that the first type lies peculiarly within the special provinces of the psychiatrist and the pathologist, because here the immediate problem is to find what is wrong with the patient, and the problem is solved in a sense when a correlation can be established between physiological cause and mental effect. The removal of the cause, when possible, is a matter for medical or surgical technology, and of no further scientific interest. Furthermore, if the cause is known it is immaterial whether the effect is or is not thoroughly understood. If malaria will cure syphilis, psychiatrists are then relieved from the necessity of studying the mental sequellae of spirochete infection. I n the second type of case, a solution of the problem [121]

THE PROBLEM OF MENTAL DISORDER involves knowing what is right with the patient; i.e., it involves a differentiation between two manners of functioning both physiologically normal, but one of them socially or personally undesirable. Without an understanding of what normal mental function is based on, treatment of such mental abnormality may indeed be possible, by the cut-and-try methods of the practitioner, and a set of rules and relationships may even be elaborated entirely in terms of mental phenomena. (The question may be raised whether even this is required; whether psychoanalysis, for instance—apparently effective at times in treatment—cannot be formulated in terms of a factual psychology; and concerning Christian Science the question need not even be raised.) But the effectiveness in treatment of mental cases under such a conception of normal and of abnormal behavior is no fundamental solution of the question. I t is here that the physiologist might contribute by attempting to find the relationship between two sets of experimental observations, one of the mental behavior of individuals and the other on the physiological activity of groups of nervecells. If, as seems possible, mental derangement can result from an alteration of the functional relationships of normally active and healthy neurones, the fundamental approach to a study of this derangement must involve a study of these functional relationships, and this study lies very properly within the province of neurophysiology. The more complicated functions of the nervous system, including mental activity, differ from the simpler in the degree of specificity of action. Mental activity differs from reflex activity —that is to say—in the ease with which it can be altered and in the variety of actions (not to say choice) of which it is capable. I n physiological terms, this implies that the pathways through networks of neurones which a nervous impulse may take are more complicated in the higher centers, and the conditions that determine which of possible pathways shall be traversed are still more complex. I t may mean further that the forces required to direct such impulses are actually less in the higher centers, and that slighter disturbances will send such impulses astray, with a consequent derangement of mental activity. What it more probably means is that the higher centers are peculiarly liable to be affected by certain influences, e.g., by certain nervous impulses themselves, such, for instance, as are received by the special sense-organs of eye and ear and elaborated in the cortical projec[122]

ELECTROPHYSIOLOGY OF THE BRAIN tion-areas of the brain. The complexity of mental activity appears to be correlated with the importance acquired by certain processes, e.g., those by which we command spoken or written speech. I n acquiring the ability to respond to these sensory impressions as elaborately as we do, the nervous system has obviously succeeded at the expense of specificity of action; in physiological terms, this means that neurones have become less particular about their associates. In a complex society of neurones the results of such individual departures from the paths of conventionality might be disastrous. What is more to the point here is that they might also be capable of physiological investigation. But, at present, the question as to what extent a knowledge of neurophysiology would advance psychiatry cannot be answered because there is not sufficient information about the detailed functioning of brain-cells and cell-groups to afford an opportunity for a fair attempt. I n this situation a scientific approach to the question must be experimental, and any a priori assumptions as to the distinctness of mental and physiological categories may be ruled out of consideration. The question is practical, What is the immediate prospect of being able to investigate brainfunction in physiological terms and in such detail that a precise correlation can be made between mental and physiological activity ? If this prospect is hopeful, it is next in order to inquire under the auspices of which branch of science—psychiatry, physiology, or neurology—progress can best be made. The aloof attitude of some psychiatrists toward neurophysiology is not without a reasonable basis. I n view of the rapid and successful advances that have been made in simple nervephysiology and in the physiology of reflex activity, there has seemed to exist a strange indifference among neurophysiologists to the functioning of the higher centers of the nervous system. Even where attempts have been made to study cerebral functions, they have often taken the form of investigating within the higher structures such mechanisms as have previously been investigated in lower levels, i.e. pathways, reflex or autonomic centers, anatomical localities, and special sense-mechanisms. Even the work of Pavlov seems to envisage the brain as a magnified reflex apparatus. The idea that, because the brain consists of nervecells similar to those of the spinal cord and of outlying ganglia, its functions should therefore be interpreted in terms of the func[123]

THE PROBLEM OF MENTAL DISORDER tioning of those groups of neurones more available to an experimental approach, has prevailed in physiological laboratories almost as persistently and as universally as the idea of an immortal soul, separable from these brain-cells, has prevailed in the realm of orthodox theology. Perhaps no concrete evidence has yet been brought against either of these dogmas. I n physiology, at least, the truth of this proposition has not been adequately established. There is therefore a good reason for examining the brain physiologically for evidence of more than the reflex type of activity, or for whatever elaboration of that activity the brain may show; and more especially for investigating the functioning of nerve-cells as such in the brain, even though it is evident that there do also exist there, as a development of a simpler nervous structure, many mechanisms for the reflex type of function. This view becomes more cogent when we consider that there has never been a demonstrable correlation of this reflex type of function with consciousness or with mental function in its more subtle manifestations. I t need not be emphasized that the seat of mental activity itself has never been ascribed to the spinal cord or brain-stem. I t might be further argued that there is at present no evidence that such activity can be ascribed to those mechanisms existing in the brain itself which obviously function after the pattern of reflexes, however much reflex activity may be employed in the expression of mental activity. I t is reasonable to suppose that something functional has been added to the higher order neurones as a physiological counterpart of mental activity, and it would surprise the present writer if this addition, however physiological, were merely numerical. Neural function has been studied at various levels; there is a physiology of nerve-fibers, of nerve-cells, of the synapse, of the sense-organ, of the reflex-arc, of the higher centers, in increasing order of physical or functional complexity. Naturally the simpler structures have been studied more, and more successfully. What further we may learn about conduction in nerve-fibers will presumably not avail much in the study of brain-function. I t is apparent that wherever fibers exist their function is to conduct impulses when stimulated, but not to originate impulses. The functioning of sense-organs as such is mainly a problem of the periphery, not of the central system. The neurophysiological study of cells and synapses has largely been incidental to, or [124]

ELECTROPHYSIOLOGY OF THE BRAIN involved in, the study of reflex action, where inhibition and facilitation have been assigned to the synapse without any very definite differentiation between synapse and nerve-cell-body. Whether the functions of the synapse as we know it in the periphery (i.e., facilitation, inhibition, and one-way conduction) are involved in the functioning of the higher centers can at present only be inferred. The main facts we know about the activity of nerve-cells in the periphery are that they may respond repetitively to a single or multiple stimulus and that they may alter in potential when stimulated. Whether they respond automatically without specific stimulation is perhaps in doubt; and, if they do, whether the actual origin of such activation is to be assigned to the cell-body or to the synapse is not established. In view of the present state of ignorance as to the physiology of the brain, it is not to be wondered at that psychiatry has been unable to derive much benefit from neurophysiology. The prospect for the future is, in a sense, to be predicated upon the prospect for further development of neurophysiological research in general. Prospects for Research in Neurophysiology. Insufficient emphasis has been given to the fact that, while nerve-fibers, however different in type, all function similarly, nerve-cell-bodies (synapses?) show wide diversity of activity. Sensory neurones and certain neurones in the autonomic pathway (cervical sympathetic ganglia) respond only when stimulated, and apparently respond only once; i.e., they do not essentially modify the impulse that they conduct, their presumable function being entirely trophic. Neurones at the apices of reflex-arcs respond singly or repetitively in their own rhythm, more or less independently of the rhythm of incoming stimuli. Automatic-center neurones probably have essentially spontaneous activity, however much their rhythms may be affected by impulses afferent to them. One would expect to find other phases of their activity than mere proficiency in responsiveness to correspond to this variation in complexity of response. Such properties have been little investigated. The point here is that the next step—to the brainneurone—has not been investigated even to the extent of knowing whether, as an individual element, it has a greater proficiency in responsiveness than that of the automatic center or reflexneurone, and one can only speculate as to what the next higher degree of functioning might involve. With this problem in [125]

THE PROBLEM OF MENTAL DISORDER view, the whole range of complexity of function of neurones at various levels needs investigation, as an ascending series of elements, the significance of whose differences of functioning is certainly more important than the mere fact of those differences themselves has so far given evidence of. Furthermore, taking as the special province of neurophysiology the study of the physiological responses of nervous tissues, little has been done in directly recording the responses of brain-tissue. Since most of our knowledge of the neurophysiology of the brain has resulted from examining complicated systems of which the brain forms only one link, the functioning of the brain thus manifesting itself in terms of the functions of other parts {e.g., reflexes), a situation has arisen somewhat analogous to studying an infection without being directly acquainted with the pathogenic organism. The typical procedure in attacking the neurophysiology of the brain is to alter, by ablation or otherwise, the brain or parts of it and to watch for changes in the functioning of the periphery. But there is no a priori reason why this procedure should not be diametrically reversed; the periphery having been altered, to look directly for changes in the functioning of the brain itself. The difficulties here are of two kinds. The first is technical; recording apparatus has not been adequate to detect brainresponses with precision and in detail. The second is physiological; the brain itself is so complex that any responses obtained might also be too complex for significant analysis. There is justification for stating that the first difficulty is rapidly being overcome by recent technological progress, and that the second difficulty may not be so serious as anticipated, and, at any rate, it can only be estimated after the more recent and refined methods have been applied to brain-physiology. The recent technical advances referred to are those in the field of electrical recording. The known physiological responses of nerve-cells might be classed as thermal, chemical, and electrical. The heat produced by nervous tissue is so slight as to be unsuitable as a measure of the response, and, furthermore, the means so far developed or in prospect for recording it fail to give accurate time-measurements of the response. Again, there are serious difficulties in recording physiological heat-output with the tissue normally placed in the body. Chemical responses offer, in general, similar difficulties in recording, because the [126]

ELECTROPHYSIOLOGY OF THE BRAIN result cannot usually be obtained without destruction of the tissue; it is quantitatively estimated only some time after the experiment is performed; and it does not give accurate timerelations of the cellular processes. Electrical activitities, on the other hand, appear to accompany cell-activity so immediately and to follow the course of the principal cell-activity so closely as to justify the presumption that the propagated response of the nerve-cell—the means by which it affects other cells and is affected by them—is the electrical response itself. At any rate, the identification of the electrical response of nervous tissue with the characteristic physiological activity of that tissue is so close that neurophysiology and the electrophysiology of nervous tissue have come to be practically synonymous. The technique of neurophysiology therefore becomes more and more that of recording electrical impulses of very low intensity and of very brief duration. Instruments of great sensitivity are usually slow in action while instruments that will precisely follow or record impulses of brief duration require considerable power to operate. Two recent developments, in these two respects, have been employed in nerve-physiology. First, the radio amplifier is capable of multiplying the power of weak impulses without significantly altering them either in form or in time-relationships. Secondly, several oscillographs have been devised that are sufficiently prompt in action to record neural impulses, operating on the power that is available from suitably designed amplifiers. Thus, by a combination of these two devices, a fundamental dilemma in electrical recording has been obviated, and it is now possible to record impulses of the order of a thousandth of a millivolt in intensity and a ten-thousandth of a second in duration without alteration of the time-relationships or of the form of such impulses. Furthermore, by a suitable choice of registering devices (a revolving mirror, for instance, or a fluorescent screen in the cathode-ray oscillograph), such impulses not only can be recorded photographically, but can be visually observed while they are actually occurring, as if by a physiological television apparatus one could watch the cells concerned in one of their essential activities. These technical appliances have been employed most extensively in the study of excised nerve-trunks or of reflex or sensory mechanisms in the body where a length of peripheral nerve may be exposed by surgical means for recording, the electrical impulses [127]

THE PROBLEM OF MENTAL DISORDER so recorded serving as indices of activity in the centers to which these nerves are connected. An estimate of the results to be anticipated from the direct application of similar recording methods to the brain may be drawn from a brief consideration of what has been accomplished elsewhere. The impulses in peripheral nerve-fibers have been analyzed as to duration of activity, intensity of electrical potential, refractoriness after a first impulse, etc., to a precision well within the limits of normal variation in the tissues. The electrical process has been shown to consist of two parts, a response proper and an after-potential that appears to bear some relation (so far ill-defined) to the process of recovery from activity. Fibers can be separated into groups which differ in essential respects, i.e., in refractoriness, duration of potential, conduction-speed, etc., and these groups are being correlated with the histological properties of the fibers on the one hand (size, myelination, rate of degeneration and regeneration), and on the other hand with the functional centers or peripheral organs with which these fibers are connected. The potential sign of activity is being related to the chemistry of nerve, and it is being employed as an index to the degree of injury of nervous tissue by such a disease as poliomyelitis. Action-potentials serve as the most precise measure of the reflex activity of the central neurones in arcs of which they form a part. Impulses from sense-organs can be picked up from exposed nerves without severing their central connections; in suitably small nerves single impulses in a single fiber have been so recorded. Potentials from the retinal sense-organs and ganglion-cells themselves have been reported, from ganglion-cells of the ventral nerve-cord of insects, and from the medullary centers of fishes. Besides the actual progress in neurophysiological research, greater precision in recording has stimulated and made possible a corresponding improvement in other phases of experimentation, e.g., in accessory apparatus and in the maintenance of experimental conditions not too far removed from the normal to nullify the advantages of greater precision in the record. Finally, a record visible to the experimenter while the experiment is proceeding is of inestimable advantage in adjusting or modifying the conditions as the occasion demands—instead of carrying out a procedure more or less in the dark—in order to arrive at a suitable arrangement of the experiment by successive repetitions. The whole technique of neurophysiological experimentation has indeed developed to a stage where it can profitably be applied [128]

ELECTROPHYSIOLOGY OF THE BRAIN to more complicated problems, such as those of brain-physiology will obviously be. Some small beginning has already been made. From the surface of the cortex have been recorded continuously changing potentials, of an order of duration quite different from that of nerve-fiber activity and presumably assignable to cellbodies. These irregularly oscillatory potentials can be shown to be made up of simpler or more regular rhythms superposed; as if in several groups of neurones each group with a simple rhythm but each out of phase with the others were contributing its own potential to a common activity. These groups of cells can sometimes be isolated by simple surgical procedure without disturbing their fundamental rhythm. The activity appears to be greater in the so-called association-areas than in the projection-areas, at least until adequate stimulation of afferent nerves alters the ' spontaneous' picture. Then specific responses of the cortex are called forth, in those regions where our knowledge of anatomical localization in the cortex would lead one to expect them. Such specific responses of the cortex can be experimentally modified, e.g., by drugs, anaesthetics, cortical surgery, etc. I n the optic cortex what are at least the most prominent features of a complicated response to optic nerve-stimulation can be outlined. This response, after a single stimulus applied directly to the optic nerve, persists (in the rabbit) for about a second and consists of at least two types of events, one of which is a series of five separate potential complexes. Responses to light stimuli applied to the retina have also been recorded. They show similar features, complicated, as might well be expected, by the fact that the retina delivers a succession of impulses to the optic nerve-fibers for each stimulation. There is some reason to believe that the activities of several groups of cells are being recorded successively from the optic cortex after each nerve-stimulus. This work has not progressed far enough to do more than suggest further possibilities; but it is obvious that even the present technique can be employed to push the investigation much further. I t has also been possible to detect certain phenomena which may have a more fundamental bearing on general cortical activity, as indicating in what manner impulses passing over the cortex are directed and modified by the cells over which they pass. For instance, slight amounts of strychnine applied to the surface of the cortex can be shown profoundly to modify the periodicity of the normal or 'spontaneous' response of the cortical cells and to disorganize the pathways over which such impulses normally [129]

THE PROBLEM OF MENTAL DISORDER travel, and, finally, to modify the cortical response to specific stimulation of the optic nerve. Again, in the normal cortex, the ability to respond to nerve-stimulation can be shown to depend in a complicated way on the number of fibers stimulated in the nerve. I n fact, the cortex varies rhythmically in its ability to respond at all to nerve-stimuli. The further analysis of this inherent rhythmic excitability of the cortical structures gives evidence of complicated relationships between groups of neurones, and between cortex and thalamus, which are certainly capable of more detailed analysis. At present the limitation to this type of work is probably the complexity of the brain itself; if too many things are happening at once and at the same place, i t will be impossible to sort them out. There is the further probability that only the most prominent responses can be recorded. Even if the apparatus is made sufficiently sensitive to record the weaker responses (i.e., the responses of smaller cell-groups) these may be overshadowed to the point of indistinguishability by more prominent responses. Yet it is not to be expected that the importance of the activity of a group of cells is always proportional to the number of them active in unison. There is thus a good prospect that at least the main features of central function can eventually be described in terms of electrical responses of the cells concerned, and that, by suitable experimental procedures, the activity of larger cell-groups than would normally be in evidence in any casual situation can be made to stand out for purposes of analysis. I t is also obvious that simplification of structure by surgical procedure may result in cortical remnants still functional, but more capable of analysis than is the whole brain, and the correlation of the behavior of such operated animals with their cerebral physiology seems promising. We have discussed two general fields in which the writer believes research in neurophysiology to have a direct interest for psychiatry: (1) a comparative study of the neurone as such, at various levels of function, corresponding to the current study of the various types of nerve-fiber, and (2) a study of the electrical responses of neuronal groups or patterns as normally functioning in the various structures of the intact brain. Assuming that those studies can be successfully carried on—an assumption which appears justifiable in view of the present status of [130]

ELECTROPHYSIOLOGY OF THE BRAIN neurophysiology—what, it may properly be asked, will be the significance, for an understanding of mental function, of a knowledge of brain-activity expressible in terms of electrical action-currents? To what extent will such a correlation as might be drawn between two such seemingly distinct categories as those of mental and physiological phenomena be of any value? This can only be answered after the attempt has been made; but it is no more than fair to consider the reverse relationship. Certainly a knowledge of mental function has been of primary importance in interpreting the physiology of the brain. The correlation of mental defects following brain-injury with the location of the anatomical or physiological defect has been one of the chief aids in the study of brain topography; and the current uncertainty as to the degree of physiological localization of mental functioning arose only when psychologists had reexamined the work of anatomists in terms of behavior rather than of structure. The resolution of this uncertainty as to localization will constitute a real step in progress. Similarly, when functional patterns in terms of action-currents are observed, their relationship to mental function will be no less important for their interpretation than their relationship to neurological structure. I n somewhat the same sense that information as to mental processes aids in analyzing physiological patterns, the reverse will certainly prove true when adequate information has been made available as to the functional pattern of brainneurones. Due to the fact that man can express himself in terms of language, a vast fund of information upon mental processes has made the balance sheet between mental and physiological science rather one-sided. With the promise offered by current methods in physiology, the study of brain-function will in the future be more widely carried on from this point of view than in the past. Work will surely be done; what work, and to what purpose, will be largely determined by the conditions of its guidance. Given sufficient time, even if left to blind chance, the physicists tell us that everything possible will eventually occur. Blind chance is not the only factor, however, in determining the direction of research. What has already been done successfully in neurophysiology has been largely concerned with the functioning of nerve-fibers as such, with reflexes as such, with the action of peripheral senseorgans, etc. The natural next step will be to study the brain as [131]

THE PROBLEM OF MENTAL DISORDER a complex of the same sort of nervous structures as we already know most about, without any evidence that these nervous mechanisms are the mechanisms which correspond to mental activity. I n the study of brain-function as a whole, which is the counterpart in physiology to the study of mental function, the forest is still in danger of being obscured by the trees. For the expression of certain kinds of sentiments, the French language has been said to be better adapted than the English; for other literary endeavors, English might be more suitable than the German. Neurophysiology offers another medium, in addition to psychology and anatomy, in whose terms certain phases of brain-function may be best expressed. The promise of accomplishment in an investigation is, in a sense, in pretty direct proportion to our ignorance of the question to be investigated. I n the present case, our ignorance is the more profound the nearer we view the 'seat of consciousness.' This thought has been an unfailing source of encouragement to one who frequently has occasion to inquire "What resolution may be gained from hope, if not what consolation from despair?" I t is offered in the present instance as the most practical estimate available of prospects for research in neurophysiology.

[132]

I I I . ELECTRICAL MEASUREMENT OF ACTIVITIES I N NERVE AND MUSCLE By Edmund Jacobson, M.D., Chicago Many nervous and mental disorders are similar in three significant respects. The first is an activity in muscle and nerve peculiar to a given symptom; the second is the common presentation of certain states of excitement and irritability, either temporary or lasting, and either generalized or localized; and the third is the appearance of fatigue following the states of excitement and irritability. In the second and third respects, the characteristics first seem to be, to a marked extent, nonspecific. But the more these disorders are studied the more i t appears that the precise neuromuscular patterns and their concatenations are really specific, while highly variable from occasion to occasion, for each disorder and to a certain extent for each individual. While careful laboratory procedures seem essential to test for patterns and their variability, evidences of excitement, irritability, and fatigue can be grossly discerned in the clinic.1 Let us consider examples. The features mentioned are obvious in what Beard called 'neurasthenia.' They appear also in various forms of 'nervousness,' whether acute or chronic, and again in the more or less serious 'emotional disturbances.' These three fairly vague terms cover a large number of the neurotic conditions presented in the daily practice of the general physician, particularly if states of anxiety are included. Anxiety detrimental to health and efficiency is frequently concerned with financial losses, sorrow, social grievances, love, personal inabilities, and matters of health. A common manifestation is hypochondria. Whatever the source of concern, the evidences of nervous irritability and excitement can readily be noted by the clinician trained in adequate methods of observation. Another common neurotic disorder is insomnia. Pieron concluded in 1915 that the onset of sleep is marked by general relaxation. Observations to this effect had already been 1 Cf. E. Jacobson, Progressive Relaxation; A physiological and clinical investigation of muscular states and their significance in psychology and medical practice, University of Chicago Press, Chicago, 1929. [133]

THE PROBLEM OF MENTAL DISORDER described by the present writer. I n a series of studies with normal sleepers, as well as with insomniacs, it had appeared that, with the elimination of proprioceptive sensations in advancing relaxation, the onset of sleep was effected. Further evidence has been gathered by various investigators, including particularly Eleitman and Johnson, favoring the view that wakefulness is a function of proprioceptive sensations. And it more and more appears that excitement and irritability are something more than mere concomitants of insomnia. Frequently the subject reports that his mind 'keeps on working' when he should sleep. I n many instances fear of sleeplessness and of resultant fatigue apparently acts further to ward off sleep, the diurnal habit being disturbed by persistent excitement and irritation. At moments when phobias are active, agitation is clearly marked. As can readily be observed, the fear is temporarily in abeyance when the individual is relatively free from irritability and excitement. I n the 'compulsive act,' clinical observation suggests that at least that part of the organism which engages in the act is in a state of excitement not present in normal subjects. Furthermore, there is evidence that the compulsive neurosis, like the phobia, occurs only in individuals who are in a state of general irritability and excitement or the resulting fatigue. In tics or habit-spasms evidence of the localized neuromuscular excitation is clear. For example, a facial grimace or a shrugging of the shoulders appears recurrently; but, in addition, the subject usually manifests general nervous excitement. To students familiar with symptoms of stammering and stuttering, no explanation need be adduced that these are manifestations of irritability. The facial muscles during stuttering clearly reveal excessive contraction. Physiological studies, by various investigators, directed to the diaphragm and abdominal muscles plainly indicate that spasms occur in these regions, often with temporarily increased heart-beat and blood-pressure. Many patients complain of depression which they cannot throw off. This state may occur at any age after adolescence. The patient may report that he is depressed over such concerns as those enumerated above in connection with anxious states. Frequently his troubles seem even to the objectively-minded physician great enough to warrant depression for a brief time; but the depressed state continues for an unduly long period. Again, the depression may be marked by tears and wailing, [134]

ACTION POTENTIAL IN NERVE AND MUSCLE although the source of concern would not seem to others to merit such marked signs. I n severe cases the irrational element becomes more obvious. According to Kraepelin, such depressed states—however mild and relatively rational—are forms of manicdepressive insanity. This view has been widely accepted; but since the etiology of this form of disease still remains unknown, it seems well, while respecting Kraepelin's opinion, to defer judgment. I n the severe grief and depression of what is commonly called manic-depressive insanity (the cyclothymic state), what is most readily noted by the casual observer is often limpness or lassitude. But it is observable that patients in this condition manifest at times evidence of concern and anxiety over specific matters, which they entertain either rationally or irrationally. They show signs of undue excitement, the only outward evidences of which may be seen in the apparatus of speech and vision, although overt acts commonly occur. That depression does not occur without antecedent agitation over some concern was noted by a German psychiatrist more than a half-century ago. In dementia praecox or schizophrenia, finally, excitement is manifested at times in all forms of the disease, except in the stuporous state. Even in catatonic stupor neuromuscular tension frequently is persistent. That increased tension in psychosis is not limited to the external musculature but often involves the viscera as well is clearly suggested by the findings of several investigators. I n the author's series of x-ray studies, the spastic esophagus and colon are generally characteristic of the neurotic state. Frequently symptoms due to marked spasticity are part of the general picture presented by the neurotic. The x-ray and other objective indicators of spasticity are suited to research purposes, supplementing the patient's statements which often underrate as well as often exaggerate the severity of the condition present. Another characteristic of the neurotic state is a somewhat shifting blood-pressure. Limits of space prevent more than a passing reference to the spastic viscera; we face here the problems of general medicine in relation to neurosis. The above review of the various conditions of nervousness, neurosis, psychoneurosis, and psychosis, while not complete, indicates the prevalence of these common physiological states, increased nervous excitement and irritability, at one time or another, in the course of the disorder. When the disorder [135]

THE PROBLEM OF MENTAL DISORDER subsides, the nervous excitement or irritability usually subsides at the same time and vice versa. As in the case of insomnia, evidence has been growing that in certain of the disorders at least the nervous excitement and irritability in part condition the presence of the disorder. Accordingly, we are led to consider the place of relaxation in methods of research on the nature and treatment of nervous and mental disorders. I t is obviously important to be able, for control-tests, to diminish states of nervous excitement and irritability, particularly if the method of relaxation can subsequently be permitted, in desired instances, to lapse or otherwise to be nullified in effect. We then can observe whether, with the coming and going of the relaxed state, there occurs concomitant variation of the essential symptoms of the disorder under study. In such studies treatment is limited strictly to methods of relaxation alone. Were we here considering therapeutic relief, we should also call attention to the control offered both to the bodily processes and to the associated mental activities by the method of inducing relaxation. I n any event, the method of relaxation would seem to have a place in research which is directed toward treatment. Training under strict and methodical control is either for general or for local relaxation. After general relaxation, carried on while the subject is lying down, the person is trained to relax sitting up and during such activities as writing, reading, and conversing (differential relaxation). Certain muscular contractions evidently are essential to the task in hand. These are called 'primary tensions.' Certain other tensions are unnecessary to the performance of that task; e.g., those which arise when the individual is distracted or when he reflects about irrelevant matters. Such tensions are termed 'secondary.' The method of progressive relaxation seeks to abolish secondary tensions, and to reduce primary tensions wherever these are excessive. A feature of the method of training to relax, in subjects whose mental states permit them to observe, is the cultivation of habits of recognizing sensations which arise from muscular contractions.2 2 Descriptive reports by the subject or even by the patient should not be neglected. If untrained in report according to the strict methods of the psychological laboratory, the patient's comments and descriptions are characteristically interpretative, and not set in terms of what he observes at the moment of experience. He engages in what psychologists used to call 'morbid introspection' rather than in reports showing careful and trained observation. Traditional neurology and psychiatry do not train patients to observe and [136]

ACTION POTENTIAL IN NERVE AND MUSCLE The relevance of the trained patient's report to hypertension and also to actual relief is illustrated by a case of phobia wherein the patient feared that he would jump from a high place. He was trained to relax and also to report with care sensations from the muscles, as well as memorial and other forms of imagery. During active fear he had visual images of himself jumping from a window, along with sensations from the eyes, as if looking toward the window, and strains ('tensions') from the legs, first of moving toward, and later from, the fearful place. When trained differentially to relax the ocular and leg muscles on such occasions of fear, while continuing at his work, the strains and other sensations disappeared and the symptoms of fear as well. Studies on hysterical anesthesia or hysterical paralysis are lacking. We do not know whether the inculcation of habitual relaxation in itself is sufficient to abolish such hysterical stigmata. This remains a matter for investigation. I n any event, it is reasonable to believe that the method of relaxation will prove useful toward eliminating various nervous tendencies in hysterical patients. That relaxation also is useful in reducing the spells of exaltation or depression in manic-depressive insanity is indicated in studies already made. I n these conditions spontaneous recovery is, of course, the rule. But not alone does a particular spell appear to be influenced in its course under methodical relaxation; the spells occur, in a significant number of studies, less periodically and less frequently after treatment. Clinical results do not in themselves make science. What is needed is extensive investigation of conditions of abnormal mental activities, employing as suggestive leads the method of auto-sensory examination, but basing conclusions also on the changes shown by laboratory records. report. But since this training is included in the present approach, a few words may be said regarding its origin. This is traced chiefly to the well-known methods of report introduced by Binet and various members of the Wiirzburg school and applied to the so-called "higher intellectual activities." With modifications, these methods were employed in 1911 by the writer in a study on meaning and understanding. Letters, words, and printed sentences were briefly exposed to permit the observers to note what took place. It was found that they could report on the character of their visual and other sensations and separately state what meanings were present from instant to instant. Such an examination of sensory experience was termed "auto-sensory examination." For convenience, statements of meaning were separated by parentheses. Training in the observation of his own states enables the patient clearly to describe certain experiences of the first importance. His reports then prove to be informative for clinical purposes and for laboratory research. [137]

THE PROBLEM OF MENTAL DISORDER Few students of the various neuroses have been inclined to assume that nervous irritability and excitement are merely symptomatic of an underlying disorder, although this view has been widely held concerning the insanities. I n the present limited state of our knowledge, it would seem less important to have views as to underlying causes than to have scientific methods to investigate the facts. I t seems safe to say that, whatever those causes may ultimately be shown to be in the various disorders, there is evident promise that the study of nervous and mental disorders can be scientifically furthered when accurate measurements of nervous states are made?

Measurement of Certain Activities in Nerve and Muscle. I t has long been known that during states of nervous excitement reflex activity in man is increased. I n 1886 Mitchell and Lewis concluded that "The responsive jerk brought about by striking a stretched tendon is the most refined measure we possess of deciding as to the tone of the muscle." Since that time it has been generally accepted that any reflex that can be studied with quantitative accuracy may be used as an index of functional conditions in the central nervous system. The influence of complete muscular relaxation on reflex activity was investigated in 1908 during a study of the 'nervous start. '4 This quick start may occur upon a sudden noise while the individual is otherwise engaged. The movement, when extensive, generally includes a straightening of the trunk; but jerks of the limbs or head are also common and any external muscle-group may be involved. In order to excite the reflex repeatedly, a sudden loud sound of fairly constant character is employed under conditions where the subject does not see or otherwise attend to the source of the sound. Extent of movement was very crudely recorded in these early tests by means of a kymograph. When subjects are requested to keep the muscles of their limbs and trunk in moderate but fairly steady contraction, a marked start generally follows upon the sudden noise. If the contraction has been slight, the start very often appears visibly less. If the subjects relax completely, the rule is for little or no start to follow. An extensive literature has appeared 3 We are reminded of the progress that has been made in the scientific study of hyperthyroid conditions since measurements of basal metabolic rates have been applied. 4 Progressive Relaxation; University of Chicago Press, Chicago, 1929, 101-126. [138]

ACTION POTENTIAL IN NERVE AND MUSCLE concerning measurements of bodily states following various sudden and strong stimuli. Better adapted to quantitative measurements is the flexion reflex. In our procedure, the subject lies comfortably with two right finger tips in two cups of 1 per cent salt-solution through which a painful stimulating current is passed. For each subject a suitable voltage, amperage, frequency, and duration of induced current are selected and kept constant. The shock occurs unexpectedly to the subject and is followed by a quick withdrawal of the hand. Extent and speed of this reaction are graphically recorded. I n trained subjects, during approximately complete relaxation, the reflex is slow, as a rule, to appear and slight in extent or altogether absent. With tension the reflex appears promptly and markedly. The knee-jerk has been widely used as a test of functional as well as of organic condition of the nervous system. Forward kick of the foot can be recorded in degrees of arc—the only accurate means of measurement. The patient is requested to relax or to give attention to some nearby object, else he is likely to hold the leg stiff, preventing the kick. Under these conditions, if he is excited or if his muscles are generally in a state of moderate contraction, the kick is marked. During extreme relaxation, in subjects previously trained to relax or in subjects who relax without training, the kick is diminished or absent (Jacobson and Carlson). Investigation of the reflexes cited above affords evidence that the extent of muscular contraction following a sudden stimulus depends upon the general state of neuromuscular tonus. The results indicate that greatly diminished general tonus tends to bring diminution or absence of response and that heightened general tonus tends to bring increased response. When the general tonus is low, little affect is reported; but when high, the sudden stimulus is said to be shocking and disagreeable. Results confirming this view have been reported by Freeman. The involuntary start is particularly marked in persons commonly called 'irritable,' 'excitable,' or 'nervous.' I t tends to be marked in most of the neuroses and psychoses. Events of slight importance and pains with slight objective pathology are particularly likely to arouse distress and complaints from such individuals to the point of interrupting their useful pursuits. In fact, the symptoms of distress appear to mount according as the [139]

THE PKOBLEM OF MENTAL DISORDER patient becomes increasingly irritated and excited. I t seems probable that the underlying physiology is a generally heightened neuromuscular tension (increased tonus and contraction of striated and smooth muscles, with correspondingly increased impulses in the afferent and efferent nervous supply), which would readily account for many characteristics of individuals in a neurotic state.6 Direct Measurement of Neuromuscular Potential during Specific Mental Activities. Systematic investigation of matters fundamental to psychiatry evidently must include a rigorous examination of the question, "What occurs in the organism simultaneous with, and indispensable to, mental activities?" Although it is well known that the cerebrum is functional then, the possibility remains that specific change in neuromuscular tissues, varying in locality, also occurs.6 I n 1907 Piper applied the string galvanometer to the study of muscular contraction in man. During the next twenty years other investigators used the same instrument, chiefly in order to estimate frequencies of action-potentials. I n 1921 Forbes and Thatcher employed thermionic amplification with the string galvanometer, leading the way for others to secure increased sensitivity for physiological purposes. Since that time, others had made use of similar or modified devices, but usually—as I believe—with inadequate sensitivity. For the methodical investigation of muscular contractions or tonicities and complete relaxation, I found it necessary to increase the sensitivity and the constancy of this type of galvanometer. The apparatus finally developed made it possible for the first time to secure measurements of extremely brief potential differences as small as one-millionth of a volt. During a study of relaxation extending through twenty-five years, individuals (including the writer) who were trained to observe and to report have agreed in detecting characteristic sensations as from slight or pronounced muscular contraction marking the occurrence of some mental act. I t would, of course, be unwarranted to conclude from their reports that such con6 Differential relaxation occurs as a rule in healthy exercise, thus distinguishing the latter from the neurotic state. 6 No answer to this question is secured by measurements of resistancechanges in the skin—the 'galvanic skin reflex.' The results of all investigators here agree that the skin-response, as detected by the galvanometer, follows the stimulus after a distinct interval of one or more seconds and is only indirectly related to neural change. [140]

ACTION POTENTIAL IN NERVE AND MUSCLE tractions actually occur; but the possibility is thus opened that these reports, if carefully and critically secured, may put us on the track of observations to be objectively verified for the whole range of our mental experience. Most of our subjects have been trained to relax. This is generally necessary because restless movements occurring in untrained subjects occasion action-potentials which obscure the readings significant for mental activities. I n our present-day studies the subject lies relaxed in a darkened, quiet, and partially sound-proof room. His eyes are closed. He is instructed to engage in a particular mental activity at the first click of a telegraph key and to relax any muscular tensions present at a second like signal. A special electrode connected with the recording apparatus is inserted in a muscle, e.g., a flexing muscle of the right forearm. Thus is secured a permanent photographic record of electrical changes from instant to instant in a single muscle-group. When a trained subject is instructed to remain relaxed, an approximately straight line appears on the photograph. But when, for instance, the instruction is to imagine the lifting of a weight with the right forearm, the record commonly shows a series of long up-and-down lines which cease after the signal to relax. If the instruction runs, "Imagine bending the left foot," no action-potentials are recorded from the right arm. Various other control-tests prove negative. Devices for mechanical registration, applied simultaneously with the electrical, clearly show that action-potentials from muscles signify the presence of contraction.7 I n order to test whether action-potentials detected in specific muscles during particular mental activities are artefacts introduced during the course of training to relax, subjects have been used who relax naturally—that is to say, with no antecedent training. The results secured with these subjects have been in harmony with those secured with the trained subjects. These methods, with suitable controls, have been applied in the present investigations to imagination and recollection of various muscular acts involving the limbs; to visual imagination and recollection (during which the records generally show that the eyes turn in the direction in which the object is depicted); and 7 As previously said, action-potentials from muscle under contraction have also been recorded by other observers. Allers and Shiminsky reported that muscle contraction while 'thinking about' bending an arm could be detected by means of a suitably arranged amplifying system. [141]

THE PROBLEM OF MENTAL DISORDER to verbal imagination and recollection of abstract as well as of concrete matters (where the contractions have been identified and measured chiefly in the tongue and lips). Studies made on a patient who had suffered the amputation of an arm gave concordant results; for example, when he imagines bending the lost forearm, contractions occur in the corresponding muscles of the intact limb, in the remnant muscles of the amputated limb, or in both limbs.8 The methods described, then, register in quantitative and significant form certain neuromuscular processes which are shown to be characteristically related to specific mental activities. This quantitative registration would seem to be useful to the understanding of the many disorders which involve these processes and the associated mental activities. Potential as an Index of Excited or Relaxed States. That states of nervous irritation and excitement in man are marked by increased contraction in specific muscles can—as we have shown —be investigated with precision. With this investigation in view, the subject reclines with the electrodes connected with (say) the flexor muscles of one arm, being requested to relax as fully as he can, while a graphic record is taken over a long interval. The photographic record indicates tonus or contraction in a muscle or muscle-group, including the variations from moment to moment during periods up to a half-hour. Action-potentials are indicated with sufficient accuracy by the length of vertical deflections on the record. A graph plotting voltage against time, for the whole period, indicates both magnitudes and variations of tension. Peak-voltages per unit-length or unit-time are averaged for the entire period. The mean peak-microvoltage has significance for the individual or for a group. The electromyograms have been obtained from fifty nervous and mental patients and from twenty-one university students apparently 'normal.' 8 A product of this series of investigations which cannot here be described is a method for certain objective measurements of our reporting procedure by the subject. Besides his Progressive Relaxation, the following recent publications by the author may be consulted; Electrophysiology of mental activities, Amer. J . Psychol., 44, 1932, 677-694; Measurement of the action-potentials in the peripheral nerves of man without anesthetic, Proc. Soc. Exper. Biol, and Med., 30, 1933, 713-715; Electrical measurements of neuromuscular states during mental activities, Amer. J . Physiol., 91, 1930, 567-608; 94, 1930, 22-34; 95, 1930, 694-702, 703-712; 96, 1931, 115-121, 122-125; 97, 1931, 200-209, and Electrical measurements concerning muscular contraction (tonus) and the cultivation of relaxation in man, ibid, (in press). [142]

ACTION POTENTIAL IN NERVE AND MUSCLE I n a group of six normal subjects complete relaxation (as attested by the records) was maintained for six to twenty-four minutes, in a thirty-minute period; in a like neurotic group of six (including psychoneuroses and mild manic-depression) the range was zero to four minutes, with high microvoltages. I t was observed, however, that certain disordered patients attained the 'normal' amount of relaxation in 'calm' intervals, and that some approached complete arm relaxation when lying down. To simplify the interpretation of our results, treatment (in the case of the abnormals) was strictly limited to the method of relaxation. After from six to twelve months of this method the action-potentials were greatly reduced. They then fell below those of the untrained normal students. This reduction was clearly shown in the average peak-micro voltages. Direct measurement of electrical impulses in nerve-tissue can be made by methods similar to those above described. Here the electrodes are inserted directly into well-localized peripheral nerves. No anesthetic is required, since the pain is insignificant and momentary. When afferent impulses are to be studied, stimuli are applied to the skin or other superficial regions and potential changes in the nerve recorded. Relaxation-time. This term, when applied to individuals, means the interval elapsing between the occurrence of a signal and the moment when approximately complete relaxation is attained and maintained for a full minute. After bending the arm, thirteen out of fourteen students failed to relax completely at the end of one second. Contraction may be marked even several minutes after the signal. Following a period of training, which varies for each subject, the results are striking. I n a group tested, relaxation generally appears promptly, being complete often in less than one to two-fifths of a second and is well maintained during succeeding minutes. Not alone are these results greatly improved, as compared with the records before training, but they also show more speedy and complete relaxation than in normal but untrained students. The findings concerning relaxation-time, then, harmonize with those concerning electromyograms and neurograms as above described. Relaxation-time also has been measured where, upon signal, the subject engages in some specific mental act during which potentials are recorded from muscle or from nerve. I n trained subjects the intervals required for specific relaxation under [143]

THE PROBLEM OF MENTAL DISORDER these conditions have generally been very brief, frequently as brief as one-fifth of a second, although somewhat longer intervals are common. Occasionally when no verbal instruction at all has been given, but action-potentials are being recorded, potentials suggest the presence of mental activity, but the instruction to relax is promptly followed by subsidence of the electrical activities in trained subjects and not, as a rule, in the untrained. Methods derived from these observations have been clinically applied in the treatment of nervous disorders. These first records of tenseness and of nervous excitement, made directly upon the human subject, represent only a beginning in this type of research. I t would seem that further development of the method would lead toward a better understanding of certain aspects of nervous and mental disorders. Suggestions Looking toward Future Researches. We have considered three research methods: (1) relaxation, (2) potentials as indicators of specific types of mental activity, and (3) potentials as indicators of nervous excitement and irritability. 1. The combined method of training and subject's report may well be extended to psychoses not yet adequately studied, as well as applied to larger groups of patients during various disorders. This will be necessary, in order to show not only what the method can accomplish, but also what its limitations are. A vast variety of studies also is suggested concerning the role of neural and muscular activities in specific symptoms. The influence of training to relax upon the mental symptoms characteristic in each disorder should be investigated not alone as to the lasting effects, but particularly also as to whether the symptom studied disappears if certain specified muscles are completely relaxed or if relaxation is general, but reappears later when contraction returns. On the side of treatment, the results already secured in various disorders by progressive relaxation seem to warrant an extension of the method and of the underlying research. Excepting in acute cases of nervousness, the results are slowly obtained and therefore not spectacular. But since they depend upon habits gradually and firmly acquired by the patient, it is not surprising that the improvement attained should have notably endured over a term of years. Available methods will supply objective indications of the patient's progress, and objective registration is better than mere opinion of patient or physician. [144]

ACTION POTENTIAL IN NERVE AND MUSCLE St. The method of electrical registration may well be extended to various types of mental activity not yet studied, such as perceptive and emotional states in normal individuals as well as in the disordered. The important investigations now being conducted in many laboratories on electrical currents in the brains of experimental animals unfortunately cannot be duplicated in man. But electrical measurements from muscle and peripheral nerve are harmless, and when we are able to use the potential changes as definite indicators of mental and cerebral functions they are significant. Here a new field of study is opened. 3. Electromyograms and electroneurograms indicating the generalized or local excitement should be obtained simultaneously from various bodily regions, from many patients, and at various stages in the course of a given disorder. The results should be brought into relation with psychological studies and with chemical studies, e.g., of blood, urine, and expired air. These methods of electrical recording are equally applicable to testing the results of other methods, including psychoanalysis. Such investigations would require apparatus, materials, and technical assistance if they were to be carried out on an adequate scale.

[145]

IV. NEUROCYTOLOGY By E. V. Cowdky, Ph.D., St. Louis I t is doubtful how far present-day cytology can afford new leads for research in contemporary psychiatry. But the cytologist is undergoing a metamorphosis. His ability to project his work into the field of psychiatry is conditioned by this change and by special limitations which attend the cytological study of the nervous system. No longer is he a strict morphologist, capable of using only the microtome and the microscope. His vision has been broadened from an inspection of tissues soaked in alcohol, cut in slices, and stained all the colors of the rainbow, to a realization of the value of the experimental method. He has found that the experiments may be of two kinds, both equally informative: those which he makes himself when he purposefully alters some vital activity, and those made by nature; for if he restricts his study to the physiological, neglecting the so-called pathological, his horizon will be narrow indeed. Though his training in physics and chemistry is poor as compared with that of the physiologist, he admits his failing and tries to make good. The modern cytologist likes to be called a physiologist and his point of view is really not very different. His ambition is to deal directly with the cells as ultimate living units, whereas the physiologist usually contents himself with the investigation of organs and tissues made up of many cells. For this reason the cytologist must employ somewhat different methods, but both are equally alive to the importance of physical and chemical changes in the body fluids and both realize that the entire organism is the actual unit. The success of the cytologist will depend more and more upon his ability to adapt the technique of the physiologist, the physicist, and the chemist to his needs. But he is not altogether a parasite thriving on the achievements of others, for he gives something in return. Sherrington, Erlanger, and Adrian could have made little progress had it not been for the earlier cytological studies of Golgi, Cajal, and Van Gehuchten. Even now methods of physiological analysis become more fruitful when the base of operations nears the cytological level; witness the correlation [146]

NEUROCYTOLOGY between the electrical studies on nerve-fibers and the cytological investigation of their structural attributes, as in Bishop's presentation in this series of the principles and the methods of the neurophysiologist. In the study of nerve-cells the cytologist is handicapped at the start. These cells are not relatively simple globular elements which can easily be investigated in the living state as the cells of the blood can. Instead, they are thread-like structures whose length is often measured in feet and whose width is only a few thousandths of an inch. They are, moreover, so tightly bound together that the eye of man has probably never seen a single living adult nerve-cell with all its processes. The cytologist must therefore be satisfied with the examination of parts of cells. And there is the further complication that the parts are not at all alike either structurally or functionally. Methods of tissueculture are useless. Consequently and much against his will, he must, in the investigation of the nervous system, rely chiefly upon the study of sections supplemented by this very difficult examination of fragments of dying nerve-cells. But it is possible that he can still be of some use in bridging the gap existing between the fundamental sciences and psychiatry. I t should not be a question of simply building upward blindly. The cytologist should rather take thought as to the problems which must be ultimately faced in psychiatry—and in clinical neurology, which is not so far afield—and try to shoulder his responsibility. I t seems to the writer that the part that he can play best is to attempt to bring physical and chemical methods to bear directly upon the cells which make up the nervous system; that is to say, to supplement the examination of cells en masse by the accurate study of individual cells, for we know that nervecells are of many varieties which differ in their structure, in their function, and in their response to injuries of various kinds. We may take as our point of departure the following statement by Walter Freeman:1 Most clearly indicated is the r6Ie of water balance in epilepsy, although this also involves such mechanisms as hydrion concentration, oxidation-reduction and salt equilibrium. Moreover, the r61e of defective oxidation in the nervous system in schizophrenia also rests on considerable evidence, and the striking parallels, from the chemical 1 W. Freeman, J . Amer. Med. Assn., 97, 1931, 293-296. [147]

THE PROBLEM OF MENTAL DISORDER standpoint, between the phases of manic-depressive psychosis and the hibernation cycle of certain mammals, point to some phasic alteration in colloidal dispersion and electric potential. Among the reaction systems that fluctuate normally between narrow limits may be mentioned electric potential, oxidation-reduction, aggregation and dispersion, hydration and dehydration, sodium-potassium and calcium-magnesium ratios, and hydrogen ion concentration. Too great a shift from equilibrium in any one of these systems is certain to be attended by manifestations of disordered functions of the brain. Conditions are made more complex, moreover, by the fact that no single system can be thrown out of equilibrium without exerting an effect on one or more different systems, the repercussions of which may lead to generalized disturbances of phasic recurrence and dramatic manifestations. To consider the more important reaction-systems one by one is obviously an unwarranted philosophical abstraction; but we must do so in our program of passing from changes in bulk to those in the individual cells. A beginning has been made, which it is desirable to extend.2 1. Colloidal Dispersion. This can, within limits, be determined directly by the examination of still living nerve-cells. Light reflected by very small, electrically charged particles can be observed with the help of the ordinary dark-field equipment; a Zeiss binocular microscope, with cardioid condenser, special 3 mm. iris objective, and paired compensating oculars of various strengths is recommended. I t is important to have a strong and constant source of illumination. The chief difficulty is in the isolation of single cells without too much injury. This can best be done by making, with the aid of a razor blade, fairly thick sections of the tissue to be studied. The sections are then placed in a fluid as nearly isotonic as possible and dissected under low magnification with glass needles. A few nerve-cells can be detached by the cutting of their processes, but without other visible damage to their cytoplasm. When this is done quickly, study in the dark-field reveals particles which are stationary except for slight mass-movements in the cytoplasm, conditioned perhaps by unequal mechanical pressure on the surface of the cell membrane; in other words, Brownian movement is absent. The new Spierer lens, manufactured by Zeiss, is a valuable adjunct to the standard dark-field equipment. I t may eventu2E. V. Cowdry, Textbook of Histology, Lea and Pebiger, Philadelphia, 1934. [148]

NEUROCYTOLOGY ally be feasible to make moving pictures of the behavior of the charged particles under various experimental conditions. The point is that, until these particles have been directly studied with all possible controls in nerve-cells, an element of uncertainty will remain in theories of etiology of insanity3 based on supposed alterations in colloidal aggregation and dispersion. We are told that there is an aggregation in activity-states and a dispersion in stuporous states, which is the reverse of what one would expect on general principles. Bromides are believed to cause dispersion and morphine aggregation. The chances of discovering a deviation from the normal will clearly be greater in chronic cases of some standing than in acute cases. The change may be strictly limited in a regional sense, for the reactivity of different categories of nerve-cells is not at all the same. Hence, in this case and in the study of the other properties to be mentioned, a survey would have to be made of the principal types, special attention being paid to those which the psychiatrist informs us are most likely to be altered. Mott and Marinesco alone have made beginnings which have never been followed up. This is an angle of the problem that cytologists are equipped to tackle. 2. Nature of the Proteins. The colloids are largely proteins and the recognition and distribution of proteins in the nerve-cell is a chapter in cytology which remains to be written. Many of the tests for proteins are color-reactions which cannot be applied to sections of fixed tissues owing partly to loss of the proteins and partly to the mordanting action of fixatives. There is another difficulty, namely, that color changes which are pronounced in a test tube are so reduced in intensity in a section about 5/* thick as to be practically invisible. During the past year a technique has been published by Gersh which may prove revolutionary. I t is a modification of a method used by Altmann over forty years ago. The essential steps consist of suddenly freezing the tissues in liquid air, dehydration in vacuo while still frozen, direct infiltration with paraffin in vacuo, the cutting of sections and mounting on slides without the use of water. Shrinkage is thereby avoided and fixation and dehydration with alcohol entirely dispensed with. As Gersh remarks (and as we have found) the procedure is not devoid of danger to the experimenter, who should wear goggles for the s W. D. Bancroft and G. H. Richter, J. Phys. Chem., 35, 1931, 1606-1623. [149]

THE PROBLEM OF MENTAL DISORDER protection of his eyes in case of explosion. Bensley states in a personal communication that this technique . . . affords an opportunity for study of the cell that has never before been equaled. The protein substances in the cell remain almost unchanged chemically and are capable of differential extraction for each of the special organoids of the cell. We even hope to be able to determine the specific isoelectric point of each constituent protein. What can be done with the nervous system remains to be seen, but the outlook is distinctly promising. 3. Water Balance. Neither the physical state nor the chemical nature of the cellular colloids could be maintained without a balance in water content. Freeman says with truth that this in turn " . . . is intimately bound up with the acid-base equilibrium, carbohydrate utilization and ionic equilibrium." The cytologist is not in a position to investigate directly the water balance of individual cells, but he can supplement the studies of chemists, employing some improvement of the Rubner method as modified by Robinson (which is at present open to criticism) on the water-binding capacity of the brain-colloids through direct parallel studies on colloidal dispersion. I n epilepsy there is a retention of water before and diuresis after the fits. The braincolloids may be relatively unstable. The alteration to be anticipated with retention of water, if the water actually enters the nerve-cell in larger amounts than usual, is increase in tendency toward Brownian movement. I t is conceivable, though unlikely, that progress could be made by ultramicroscopic examination of nerve-cells removed immediately after death; at any rate it would be interesting to ascertain whether they respond in any unusual ways to hypotonic, isotonic, and hypertonic saltsolutions. Here again the best chance would be to investigate the nerve-cells of animals in experimental tetanic seizures, highly significant observations concerning which have been made recently. 4. Acid-base Equilibrium. I n respect to acid-base equilibrium the cytologist may be able to make a small contribution—everything he does is on a small scale. He has at least three possible methods of procedure. The first is to attempt to refine the methods of Rous,4 by which indicators were injected into living animals. The coloration of the tissues obtained thereby gave 4 P. J. Rous, Exper. Med., 41, 1925, 739-759. [150]

NEUROCYTOLOGY valuable information, but the tints were so faint that they were only perceptible when a considerable number of cells were observed at one time, giving a summation. A study of available, relatively nontoxic, dyes of high diffusibility might reveal some which would yield brighter colors. The second is to perfuse anesthetized or recently killed animals with indicators of the kind which Harvey and Bensley used in their investigation of hydrochloric-acid formation in the stomach. The third and most direct way would be carefully to isolate the cells and inject the indicators in stronger solutions directly into them by means of the micropipettes devised by Kite and Chambers. This has been accomplished with other cells and there is no obvious reason why it cannot be done with nerve-cells. But, like all studies on still living cells, time would be a factor because with injury there is a swing of the reaction toward the acid side. Carbohydrate utilization and ionic equilibrium are perhaps better left to the chemist. Microchemical tests for sugar in cells are conspicuous by their absence. Folin, Trimble, and Newman6 have afforded convincing evidence that the skin acts as a reservoir for sugar, taking it up from the blood when it occurs there in excess and releasing it again when required. The brain, being also ectodermal, may behave in the same way. Ionic equilibrium depends essentially upon the distribution of electrolytes which are for the most part simple inorganic substances. The topographic arrangement of some of them in the tissues and even in single cells can in some measure be determined by the new technique of microincineration, which will be considered later under the heading of mineral constituents. 5. Oxidative Processes. Various factors in cellular respiration are enumerated by Keilin as follows: The activity of this system depends . . . on a certain tension of oxygen, on the activity of oxidase, on the presence and distribution of suitable carriers (cytochrome and possibly other, as yet unknown, substances), on the activity of dehydrases, and on the presence of suitable molecules (metabolites) for activation.6 The simple-minded cytologist is rather bewildered by the number of factors involved and by the thought that many others may lurk in the background. Yet it is his privilege to single out 6 O. Folin, H. C. Trimble, andL. H. Newman, J. Biol. Chem., 75,1927, 263-281. 6D. Keilin, Proc. Roy. Soc, Ser. B., 104, 1929, 206-251. [151]

THE PROBLEM OF MENTAL DISORDER those which he can study directly by methods which he is capable of using. The indophenol reaction for oxidases has been employed for years in the investigation of blood-cells. That it can be used in the direct study of nerve-cells has been shown by Marinesco, and we may look for considerable developments along this line since i t is applicable to frozen sections so that topographical details are retained. One has to be cautious, however, in the interpretation of these findings. A negative reaction may mean only absence of detectable amounts of oxidase available for the oxidation of paraphenylenediamine owing to saturation of the oxidases with other molecules. Keilin also warns that "the full activity of the indophenol oxidase towards paraphenylenediamine and other reagents can be observed only when the dehydrogenases are destroyed, inhibited, or desaturated, by starvation or washing the cells." Cytochrome is not a single chemical substance, but a mixture of at least three materials. I t has the distinction of being an almost universal constituent of aerobic living protoplasm. Only when present in high concentration can it be seen directly. Spectroscopic examination is necessary for routine identifications. The absorption bands of cytochrome in the reduced state are very definite. There is, moreover, a distinct advantage in the fact that by contrast hemoglobin-absorption bands are only exhibited in the oxidized condition. Keilin's quantitative studies of cytochrome were based upon "the relative depth of tissue necessary to reveal a clear absorption with four characteristic bands. A more precise indication is obtained by the thickness of the compressed tissue at which band C is extinguished." Tissues which possess much cytochrome also give strong peroxidase reactions with benzidine and hydrogen peroxide. This respiratory catalyst is oxidized by the air and reduced by the tissue itself during examination, which means that the tissues had best be mounted in glycerine as Keilin suggests. Cytochrome is known to occur in abundance in the brain. I t should not be a difficult matter so to adjust the technique that its distribution can be mapped out in various categories of cells and changes in amount determined in various physiological and pathological conditions. Such a study is long overdue in view of the apparent discovery by Walter Freeman7 that there is a deficiency in 7 W. Freeman, Arch. Neur. and Psychiat., 24, 1930, 300-310. [152]

NEUROCYTOLOGY catalytic iron in the schizophrenic as compared with the paranoid states. I t is to be hoped that the control-investigation of iron in normal brains which Freeman was unable to make on account of lack of material will soon be completed. His work was based on the hematoxylin test, devised by Macallum, which, though very delicate and somewhat difficult to standardize, has been of the greatest service to cytologists, supported by the much less reliable Prussian-blue reaction. The Feulgen reaction for thymonucleic acid, which has the merit of being almost foolproof, should likewise be applied to the same material. All the indications point to the likelihood that this would also reveal a fundamental chemical difference in the nerve-cells of schizophrenics and paranoids. I t is more discriminating than the Macallum test for masked iron. Obviously other elements besides iron may act as catalysts even though they may occur in almost infinitesimal amounts. Of these, copper may be of importance and it is in conformity with the policy of cytologists in "leaving undone those things that they ought to have done" that the emission spectra of small fragments of different parts of the brain have not been examined by the method of Fox and Ramage.8 An entirely new field of investigation might thereby be developed. I t would, however, be limited on the quantitative side and by difficulty in localizing the tissue with sufficient precision to yield information of topographical value. Following the work of Hopkins, much has been written about the role of glutathione and other substances containing the sulphydryl group in oxidative processes. The time is ripe for the direct extension of this study into the nervous system, for there is reason to believe that by various tinctorial reactions the exact localization of these substances can be determined even in respect to parts of cells. Reference should be made to the investigations of Giroud9 and to the evidence which he supplies that we have to do with two kinds of compounds, one relatively diffusible and one rather firmly fixed to the cytoplasmic proteins. 6. Mineral Constituents. Under this heading may be given the principal recommendation as to how the fundamental science of cytology can come to the support of psychiatry. Inadequate 8 H. M. Fox and H. Ramage, Proc. Roy. Soc, Ser. B, 108, 1931, 157-173. 9 A. Giroud, Protoplasma, 12, 1931, 23-41. [153]

THE PROBLEM OF MENTAL DISORDER reference has already been made to various minerals and their participation in the interlocking and dependent systems outlined by Freeman. Except for the Macallum reaction for iron, we have had to rely in the past upon very gross analyses of mineral components of the nervous system based upon the chemical determination of elements in comparatively large amounts of ash, attention being paid only to those which predominate, the rare ones being neglected. Data gained in this way are of course useful but not in the topographic cytologic sense because they cannot be referred to individual cells or even to groups of nervecells of the same sort. To Policard we owe the demonstration that under certain conditions thin sections can be incinerated in such a way that the mineral residue occupies almost exactly the same position in which the inorganic components occurred in the living state. This is not the place to describe in full the technique of microincineration, interesting though it is, for it can be found in recent publications by Scott.10 But it is necessary briefly to outline the method in order to make intelligible a discussion of the kind of information which it can give relative to alterations in cellular activity in mental disorders. The tissues are fixed in an energetic coagulant (absolute alcohol plus 10 per cent of formalin) which does not introduce any inorganic substances. The formalin supplied by the Will Corporation is satisfactory. Evidently no salts can be used in neutralizing it. Experiments completed by Scott but unpublished show that the device of freezing in liquid air and dehydration while frozen is more effective as a preliminary to incineration. This is, however, time-consuming and expensive. The blocks of tissue are embedded and sectioned at 4/j in the usual way. They must be mounted on slides by the dry-method without the use of water. Each slide is then placed on a support in an electric oven and the temperature is raised at a definite rate to 600°C, which results in the burning away of all organic material. Immediately after it has cooled a cover glass is placed over the ash and sealed about the edges with paraffin. The residue is examined in the dark-field supplied by a cardioid condenser with a special 3 mm. oil immersion lens and paired compensating oculars. I t then appears in the form of brightly shining particles on a black background. The routine is to make serial sections and incinerate those on alternate sides, staining the others by various 10 G. H. Scott, Protoplasma, 20, 1933, 133-151. [154]

NEUROCYTOLOGY methods for control. The value of the technique will depend upon the fulfillment of three conditions: (1) exact topographic correspondence between the ash and the original material yielding it, (2) ability to analyze the ash qualitatively, and (3) ability to estimate it quantitatively. On examining preparations of this kind one is impressed by the fact that many structural details observed in the control stained sections are revealed in the ashed specimens. There is little or no shrinkage or distortion of the cells after the fixation mentioned and none after freezing. The cellular and nuclear membranes are always clearly outlined by a fine ash. The chromatin (in the fixed coagulated state) leaves a heavy ash, while the mineral residue of the nucleolus is invariably a very conspicuous feature. Some ash is left by the cytoplasm. So accurate is the method that Scott has been able to investigate for the first time the behavior of mineral constituents within, and attached to, the chromosomes during the process of cell-division. But in a departure so new as this, it is well to make haste slowly, for the possibility remains that some of the minerals may have altered their position at some step in the technique. For this reason the fixation, the changes in temperature, the source of illumination, and other factors must be noted in each case to facilitate the repetition of every experiment. Qualitative analyses of the ash are difficult, but there is no doubt that iron can be identified by the red color of its oxide and silica by its birefringence in polarized light. Most of the flat white-looking ash is certainly calcium, though some of it may be magnesium. When a thin film of a known calcium salt is incinerated, a similar ash remains. The ash gives a positive Kossa reaction and gypsum test. Moreover, it is abundant in foci of experimental medial sclerosis in monkeys, in which calcium is known to occur. Some salts of potassium are probably volatile at the temperature used. Policard has suggested that the blue ash sometimes seen is sodium, but the color may be merely conditioned by the dispersion. Scott and Kooyman are extracting sections of tissue frozen and dehydrated by the Altmann-Gersh method with various solvents, testing the resulting fluid, and incinerating the sections with a view to determining the substances lost. This will be supplemented by examination of the original and the remaining ash by the spark spectrograph. [155]

THE PEOBLEM OF MENTAL DISORDER Measurement of the amount of the ash is difficult, but where calcium is known to be abundant, as in lactating mammary glands and in sclerotic vessels, the white ash is seen in unusual amounts after incineration. That there may be a loss in mineral constituents at some stage in the process cannot be denied. Estimations by members of the Lyons school show, however, that it cannot be great. I t has not been possible thus far to express the ash as seen in the dark-field in grams per cubic centimeter of tissue. Though absolute measurement eludes us, Scott has made relative determinations with a high degree of accuracy. The ash of sections cut 1 /j, thick is assumed to be located in a single plane, so that with constant illumination the light reflected will be conditioned by its amount. All light except that emerging from the small area (say, 400 sq. /x) under examination is blocked out. The remainder is measured by a photoelectric cell with suitable amplifying apparatus. If the ash of a part of one cell is taken as standard, all the others in the same specimen can be measured and expressed in percentages of it. At this early date any discussion of the usefulness of the method of microincineration as an approach to psychiatric problems must be largely speculative. Schied11 has made a study of senile dementia and some other states, but he apparently employed sections 10 to 20 n in thickness and low powers of the microscope, so that he was not able to get down to a truly cellular basis. The technique with all its recent improvements has only been consistently applied to the nervous system in experimental rabies,12 herpetic encephalitis13 and poliomyelitis.14 I n the first, the mineral constituents become condensed in the Negri bodies; in the second, they leave the developing herpetic intranuclear inclusions; and in the third, they first increase and later decrease in the lesions. By its very nature the technique is different from any other that has hitherto been used. We may expect it to bring to light changes of a kind which altogether escaped the older methods of examination of the nervous system based on fixation and staining or impregnations with various metals. The latter give no information about the occurrence of mineral salts which (in the 11 K. F. Schied, Virchows Arch., 277, 1930, 673-693. 12 W. P. Covell and W. B. C. Danks, Amer. J. Path., 8, 1932, 557-571. 13 L. E. Rector and E. J. Rector, ibid., 9, 1933, 587-591. 14 W. E. Patton, ibid, (in press). [156]

NEUROCYTOLOGY ionized state) are the carriers of electricity. I t is the distribution of electrolytes which is primarily concerned in all the reactionsystems which we have so briefly considered; but whether alterations in any of them leave an imprint in the nerve-cells which would be brought to light by microincineration is an open question. Perhaps evidence of a disturbance in the calcium metabolism of individual cells or of cell-types might be found in manic-depressive psychosis. Other possibilities may occur to the psychiatrist or to the chemist, for the cytologist does not pretend to have the broad outlook or personal experience of either. 7. Summary. This survey is obviously of limited scope. Many important lines of investigation are not mentioned. I t is restricted not only to nerve-cells but to the parts of them which contain nuclei and much cytoplasm—that is to say, to the cellbodies. Some justification is found in the fact that the cellbodies are trophic centers. They are also the largest parts of the neurones and most favorable for the investigation of the reaction-systems. The nerve-fibers are discussed by Bishop. No mention is here made of the Nissl substance, mitochondria, Golgi bodies, and so on, not because they are of little importance but only for the reason already given, that the writer believes that cytology can be of the greatest service to psychiatry by focusing chemical investigations upon nerve-cells. Unquestionably cytology itself will be enriched by the molding of new tools to its use. But these new methods must be employed hand in hand with the older and more familiar techniques, and the cytologist is likely to come to grief unless he seeks the advice of chemists and physicists and even mathematicians at almost every turn. The best of these advisers have less training in biology than he has in their subjects, so that he must go to them, for they will not of their own initiative attempt to develop the science which lies between. He can cooperate to advantage with the psychiatrist, though he will never fully understand the psychiatrist's problems. I t will be necessary for the cytologist to study human brains in special cases and to some extent routinely as a check on the applicability to man of experimental observations on animals. There can be little room for doubt that the advance will be in this fashion. In mental disease the patient seldom dies at the moment that is most auspicious for the collection of material. Instead he [157]

THE PROBLEM OF MENTAL DISORDER often goes on living for years and is carried off by pneumonia or some other complication. Early and therefore significant lesions are extraordinarily difficult to secure. Orton remarked not long ago that in fifteen years of autopsies he found only one case of dementia praecox which met his requirements for a thorough study. A still more serious drawback is the almost complete lack of data concerning the cytology of the normal brain of both sexes at different ages to serve as a basis of comparison. Nissl is said to have searched all his life for a normal brain and to have died without finding one which satisfied him. I t is the duty of the cytologist working with the neurologist by patient labor over many years to establish this essential norm. Such a prospect, however, is not very alluring. Experiments are more attractive because they are a gamble and the results are sometimes surprising. Opinions will differ, but the writer thinks that success will depend upon making the questions asked of nature as simple as possible and by using every conceivable means properly to read the answers. The brain is an organ shielded from mechanical injury by a bony case and linked with the rest of the body by sensory and motor fibers and by the blood-stream. Some will elect to ask the questions by stimulation or injury of nerve-fibers and others by changes in the blood-stream. An excellent case can be presented for either means of approach. But let us consider here only the latter. The first and most natural question to be asked is, How do the cells of the nervous system react to a decreased blood-supply? An attempt would be made to produce the maximal reduction compatible with life by temporarily ligating one or both internal carotid arteries. The vertebral arteries would not be interfered with. Recovery from complete temporary shutoff of blood-supply would be best studied in the lower spinal tracts and ganglia following ligation of the thoracic aorta and operating under mechanical respiration at increased atmospheric pressure, as Tureen is now doing in this laboratory. After many preliminary experiments with various animals, Rhesus monkeys would be chosen as material because they approximate more closely to man, especially in cortical structure, which is important for the problem in hand, than any other animals that can conveniently be kept in the laboratory. They are, moreover, of sufficient size for the collection of blood and tissue for gross methods of chemical and physiological study. [158]

NEUROCYTOLOGY In the observation of the resulting changes it would be essential to displace the time-honored individualistic research by the organized cooperative inquiry of several specialists. The best that one man could do would be to investigate the changes, if any, in the oxidase reaction, the amount of masked iron and of glutathione and in the Feulgen reaction; because, as has been indicated, all of these are feasible and are definitely linked together; but this would be very time consuming, for the alterations should be observed not only in a single area of the brain, as, for example, the motor cortex, but in various carefully selected parts at different functional levels. Moreover, the results could not be properly interpreted without parallel observations with the ultramicroscope on the dispersion of the cytoplasmic colloids and on the mineral constituents after microincineration. These in turn should be supplemented by chemical studies on water content, hydrogen ion concentration, and oxidation-reduction potential, which are likewise mutually supportive, and so on. Such observations may seem unnecessarily complicated. The underlying idea is that, in our attempt to learn how the nerve-cell works—for the proper approach to psychiatry is more and better physiology—we should begin by correlating changes in the cells conditioned by a simple functional alteration and, further, that it is advantageous to study not one but many of these changes. All activities of living cells are regulated and dependent in some way upon one another. I t can be argued that if we fully understood oxidation-reduction in all its aspects and consequences our conception of life would be complete. Knowledge of this integration will help to explain the nature of the various factors. Even as a basis was laid for investigations in the physiology of the nervous system by Sherrington's study of the integration of simple reflexes, so an appreciation of the nerve-cell will be gained by a determination of the relation of such variables. The chances of securing worth-while results will depend upon the number of variables which we can study, in situations of gradually increasing complexity, with sufficient accuracy to lend value to the data. But the cell-body is not a unit comparable to a simple reflexarc.15 I t is merely the most readily observed part of the entire 16 The author's description of the nerve-cell follows in part his Textbook of Histology (Lea and Febiger, 1934). [159]

THE PROBLEM OF MENTAL DISORDER nerve-cell. Consideration of the relation of the part to the whole is essential. The cell-body serves as the nutritional or trophic center for the processes which carry impulses to it and away from it. Obviously, also, the cell-body gathers together the impulses received from the afferent processes and transmits them to efferent processes. The two activities may be contrasted, though they are in the last analysis interdependent. The first is fundamental, basic, and deeply seated, involving the cellmembrane, the cytoplasm, and even the nucleus—in other words, a sufficient, microscopically visible structure for the approach mentioned to be effective. The second is tied up with the surface-properties of the entire cell and of the synapse also. That the trophic and special activities can in some measure be dissociated is evident, because people can die from starvation without becoming irrational and patients suffering from mental disease are often well nourished. I t is in the investigation of the surface-phenomena probably involved in conduction, threshold, correlation, and inhibition that methods of cytological analysis are of but little value, and these are, after all, of the utmost importance. But they are in turn conditioned by changes in the fluid about the cell-membranes and in the cytoplasm within, both of which can be investigated. Only one possibility may be mentioned. When correlation is altered and new associations and inhibitions are established, one would look for alterations in the effectiveness of the afferent processes which gather impulses into the cell-body. They are more numerous than the efferent processes and less protected by myelin investments. I t is an old story that efferent processes may be occasioned by changes in old contacts, by their actual loss, and by the establishment of new ones. Such alterations are, however, in the vast majority of cases, entirely hypothetical and incapable of verification by present methods of direct study. The writer has the feeling that this problem should be further explored. At present the only evidence is from analogy and therefore precarious. Some moving pictures, made at high magnification by Carrel and Ebeling, reveal for the first time agonal changes in blood and connective tissue-cells. Unfortunately, these have attracted only passing attention and have not been investigated as carefully as they deserve. The dying cells quiver and shake, swell and contract, throw out processes and retract them in a most distressing way. I t is to be remem[160]

NEUROCYTOLOGY bered that the contortions are actually much slower than they appear on the screen. I t is not to be expected that nerve-cells should behave in exactly the same way. Since the trophic cell-body is often far removed from the ends of the afferent processes, agonal changes may occur in the latter (while the cell still lives) as a result either of their local injury or of their death through failure of the cell-body to sustain them on account of its own depleted vitality. I t is conceivable that the cell, as a whole, may survive for relatively long periods of time and, further, that the involvement of cells may be successive, so that the functional manifestations might persist even for years and explain some types of insanity. If this theory has any justification, the correlated physicochemical approach outlined might well be supplemented by purposeful efforts to improve the technique already in vogue for the investigation of cell-contacts.

[161]

V. C E R T A I N ASPECTS OP T H E CHEMISTRY METABOLISM OF T H E B R A I N

AND

By I r v i n e H. Page, M.D., New Y o r k City Today the application of chemistry to the study of the brain is considered new, yet in 1884 important steps had already been taken in this direction by one of the chemical geniuses of his century. I n the intervening period of forty years interest has lapsed, not because Thudichum's work was not important but probably because it was too technical and too truly the fundamental chemistry of the brain to find immediate application in the clinic. Thudichum made the results of his extensive investigations available in a book, Chemical Constitution of the Brain, one edition of which was published in English in 1884 and a second in German in 1901. At the outset it is extremely important to understand clearly what the chemist means by the "chemistry of the brain." This is all-important, because so much misunderstanding arises from an inadequate definition of the aims involved. The chemist is principally concerned with the qualitative and quantitative determination of the substances present in the brain and with their interaction. I t must not be forgotten that what we in recent years have chosen to call the biochemistry of certain organs is only the fruit of long and patient 'pure' chemistry applied to the living organism. I t was necessary for the von Baeyers, the Perkins, the Grignards, the Fischers, the Willstatters, and unnumbered others to separate and determine the structure of a multitude of substances before we could even begin to have any understanding of the reactions involved in living processes. I t has been a long and expensive apprenticeship, but now we are seeing the results of this great effort—the application, if you will. Just why the central nervous system has been studiously neglected is somewhat puzzling, but nevertheless this is true. Thudichum started the work of isolating the substances making up cerebral tissue, but until recent years few have carried the task further. This wide hiatus of inactivity has been overlooked, giving us false hopes as to what may be expected from brain chemistry at the present day. This phase [162]

CHEMISTRY AND METABOLISM OF THE BRAIN of investigation of the work has not kept pace with other chemical developments, consequently we have still not advanced much further than the 'analytical' stage of Thudichum. In order that our understanding of the chemical reactions of the brain may develop logically, the field must be brought, by some group of investigators, to the contemporary level of chemical comprehension. This task lies simply in painstaking isolation, characterization, and synthesis of those substances which are found in the central nervous system. Such work is definitely the province of the chemist. I t is work which to the clinician must seem dull and fruitless. The clinician does not understand that the often necessarily inexact methods and results of the clinic seem chaos indeed to the chemist. If it is asked what relation or application this structural organic chemistry has to the problems of behavior or to neuropathology, the answer is no more and no less than that it will furnish us with the building stones with which all understanding of chemical processes must begin. With this approach immediate application seems somewhat remote, but on it future development will ultimately rest. Whose responsibility is it to see that this foundation is laid? Apparently, no one has accepted it, nor is it likely to be undertaken by anyone competent to carry on the problem successfully unless by chance another Thudichum is found. What it amounts to is that there are too many other problems that offer more immediate and tangible returns to the chemist. This important phase of brain chemistry will probably rest undisturbed until, urged by the necessity for certain special knowledge, an investigator will delve into the grab-bag and pull out the substance in which he is interested. Is it too much to hope that sufficiently clear vision will be shown by the establishment of laboratories in which the study of the substances in the brain will be carried out by competent chemists for the sake of the study of the substances themselves, and not for what the study will yield of value to the clinic? This is the long, hard way, but it has always been the way of chemistry. There are other approaches, countless other approaches, but this approach is the logical, infallible basis on which other methods may secure a footing. We must not confuse our wishes and immediate necessities with what may be ultimately the sure road to the solution of our [163]

THE PROBLEM OP MENTAL DISORDER problem. No one knows how building blocks may be put together once they are available. There should be no misunderstanding. A problem of the first magnitude on which the ultimate development of brain chemistry rests lies in the characterization of the chemical substances in that organ. This is a chemist's work. I t has its own rewards. If not supported and financed by psychiatrists and neurologists, it will have to wait until more chemists are interested in the brain, and that may be a long time. 1. The Chemical Composition of Brain. Brain-tissue is peculiar in its make-up. Lipid substances are present which are either not present at all or are present in minimal amounts in other tissues. An arbitrary division of the substances of the brain is somewhat as follows: a. Inorganic Salts and Water. The brain is surprisingly stocked with almost all inorganic elements found in nature. Elements such as calcium are present in large amounts and are very mobile. Thus in rickets the calcium falls to some 30 per cent of its normal value. Extremely little is known of the normal amount of any electrolyte in brain; therefore we are at a loss to recognize pathological values when they are found. The calcium content of brain is believed to rise in narcosis and fall during stages of excitement. Various anatomical regions of the brain contain widely different amounts of electrolytes. Thus the cerebellum is rich, while the hemispheres are poor, in calcium. From time to time claims have been made that the irritability of the nervous system is controlled by the antagonistic tetrad Ca—Na | | • The evidence is as yet so incomplete that not even a Mg—K tentative judgment is justified as to the correctness of this hypothesis. Catatonic rigidity is believed to be associated with low brain-calcium, although catatonia is not a symptom of rickets, in which there is little doubt that the calcium content is reduced. Copper and zinc are stored in the brain during intrauterine life and increase very slowly after birth. Magnesium is present in the fetal brain in larger amounts than in any other fetal organ. In patients suffering from Wilson's disease, the copper content of the basal ganglia, as well as of the liver, is much increased. [164]

CHEMISTRY AND METABOLISM OF THE BRAIN Bismuth and arsenic seem to have little avidity for brain tissue but selenium and tellurium are deposited in the gray tissue from selenious acid with great specificity. After treatment of an animal with intramuscular colloidal selenium large amounts are found in the gray matter but none in the white. These facts appear of importance as regards the treatment of cerebral disease by heavy metals. Inorganic lead tends to be deposited in bone but organic combinations, such as tetraethyl lead, attack nervous tissue with great power. Lead is not rendered harmless in the brain-tissue as in bone. Mercury accumulates in the liver and kidneys but the brain stores extremely little of this metal. I t is not known whether heavy metals do not reach the nervous system or whether cerebral tissue does not combine with them; presumably the latter is true. The iodine content of brain seems to bear a close relationship to its thyroxin content. The iodine content of the tuber cinereum and the hypothalmic region rises markedly when thyroxin is given by mouth or intravenously. Bromine is thought to parallel very closely the mental state of the patient, being reduced in the blood during stages of excitement. The anterior hypophysis contains fifteen to thirty times as much bromine per unit of weight as most organs. The iron of the brain shows so many variations that it is impossible to discuss its significance here. Enough examples, it is hoped, have been cited to illustrate the rich field of research that is open to investigators interested in inorganic salts. The water content of whole brain and its various anatomical subdivisions may vary independently. This has not been studied in relation to function. Much of the water of the brain must be 'bound' water, i.e., unable to exert dissolving power. No study has been made of this fundamental distinction between 'bound' and 'free' water. Brain may absorb water and store it either intra- or extracellularly. Presumably the former produces the so-called 'dry, swollen brain,' and the latter the 'wet brain.' The brain of the child may swell much more acutely than that of the adult. Certain variations in chemical composition suggest a reason for this difference in behavior. [165]

THE PROBLEM OF MENTAL DISORDER b. Lipids (Lipoid and Fat). Under the heading of lipid are included substances of fatty nature regardless of their chemical structure. No other organ in the body is so richly endowed with lipid as brain. No other class of substances in biochemistry has been so poorly delineated. The following are sufficiently well characterized to justify their inclusion in a classification. Neutral fats: Glycerides of fatty acids Phosphatides: Cephalin (glycerol, fatty acid, phosphoric acid, and aminoethanol) Lecithin (glycerol, fatty acid, phosphoric acid, and choline) Sphingomyelin (fatty acid, phosphoric acid, sphingosin, and choline) Cerebrosides: Phrenosin (sphingosin, fatty acid, and galactose) Kerasin (sphingosin, fatty acid, and galactose) Nervon (sphingosin, fatty acid, and galactose) Cholesterol: (A terpene-like, secondary alcohol) Cholesterol esters (probably principally fatty acid esters) Carotene and vitamin A Ergosterol and vitamin D This outline presents, of course, only the roughest subdivisions, for there can now be no doubt that such names as ' cephalin' and 'lecithin' connote groups of substances and not unitary bodies. There is good evidence to believe that in the mixture we call lipoid many substances are present which have never been isolated. The fat metabolism of the brain will probably not be greatly clarified merely by use of lipophilic stains such as Sudan I I I . Most of the 'fats' of the brain do not stain differentially to any appreciable extent. Neutral fats (glycerides of fatty acids) are notable for their scantiness in brain-tissue. These substances in general serve as depot material and there is reason to believe that when they appear in brain-tissue, in any quantity, the metabolism has taken a pathological trend. Much of the lipid in brain is phosphatide (principally cephalin with smaller amounts of lecithin). Phosphatides are substances which occupy a unique position among the lipids. They are at once water-soluble and organo-soluble; they are very readily oxidized; they are usually highly unsaturated; and, finally, they are composed of peculiarly interesting building stones, i.e., fatty acid, glycerol, phosphoric acid, and two bases, choline and amino-ethanol. What function they subserve in the body is unknown. Apparently they are involved in the transport of [166]

CHEMISTRY AND METABOLISM OF THE BRAIN fatty acids and thus presumably in the nutrition of the brainPhosphatides are, for example, the only lipids that may be injected parenterally without causing either local or general foreignbody reactions. Increase in the phosphatide content of the blood has been reported in certain mental diseases. General paralysis is associated with loss of large quantities of phosphatide from the brain-tissue. Trauma and hemorrhage into the brain-substance cause very rapid mobilization and loss of this group of substances. Phosphatides are selectively deposited in Niemann-Picks and Tay-Sachs diseases. The excessive deposition of so labile a substance as phosphatide is, indeed, a most extraordinary phenomenon. Many more interesting but isolated facts are known about the phosphatides, but this is no place for a detailed list. Sphingomyelin, while present almost exclusively in the brain, remains true to its name, given by Thudichum in commemoration of the many enigmas presented to the enquirer. We know nothing of its function, nothing of its quantitative distribution, and not a great deal of its chemical structure. Cerebrosides, of which three (phrenosin, kerasin, and nervon) have been sufficiently studied to deserve recognition as definite compounds, usually do not make their appearance in brain before medullation begins. I t has therefore been assumed that they either act as insulating substances or are in some way involved in the nutrition of the axis cylinder. They are almost limited to cerebral tissue and only in the disease known as Gaucher's splenohepatomegaly are they to be found in quantity in other parts of the body. The only known lipids which contain sugar (galactose) are the cerebrosides. Ordinarily galactose is not readily metabolized by the body, but brain-tissue seems to be able to utilize it more readily than other tissues. Of the base sphingosin nothing is known regarding its function. How little these compounds have been investigated is well illustrated by the fact that the cells filled with 'lipoid,' which are so characteristic of Gaucher's disease and which have been observed by two generations of pathologists, have never been subjected to the simplest chemical analysis. We are altogether too often lulled into inaction by such catch words as 'lipoid' and by flamboyant scarlet-stained slides. [167]

THE PROBLEM OF MENTAL DISORDER Cholesterol. To indulge oneself in a brief consideration of this important substance is to do an injustice to the knowledge already gathered. I t is no longer possible to dismiss cholesterol from the metabolic landscapes because data are insufficient. Adequate methods are now available for its quantitative determination, therefore leniency should assume no place in the critique of future investigations. The literature has been choked by a mass of material—some of it even concerning nervous and mental disease—which is utterly confusing. Karl Ludwig said, "Die Methodik ist alles." We need another Karl Ludwig today. Why is cholesterol so important ? The answer to this question lies in a discourse on sterols. Suffice it to say here that chemically it is related to vitamin D, a female sex hormone (folliculin), the bile acids, vitamin A, toad-skin poison, carcinogenic substances, and strophanthidin. Cholesterol is present in larger amounts in brain-tissue than in any other tissue in the body with the exception of the adrenal cortex. Fatty acid esters of cholesterol are not found in brain except in traces. This is a most unusual state of affairs as all other organs contain much esterified cholesterol. The body can synthesize cholesterol, and recently it has been shown that it can also break down cholesterol. Does the vital store of sterol in the brain come from local synthesis or is the brain dependent on the blood-stream for its supply? This is no academic question, because it will be recalled that the carbohydrate requirements of the brain must be met by the blood and not, as so often erroneously supposed, from local tissue-glycogenolysis. Cholesterol exhibits certain more or less characteristic alterations during the course of various psychoses. Little study has been given to the sterol metabolism of neurological diseases, except in epilepsy. The results of this study, if true, are most interesting. Some believe that the most characteristic change occurs in the cholesterol-phosphatide ratio, which in turn is believed to be related to the water metabolism of the body. There is much evidence that indicates that cholesterol is intimately involved in the water metabolism of cells. No one questions any more that the central nervous system is susceptible to changes in its hydration. In order to relate these changes [168]

CHEMISTRY AND METABOLISM OF THE BRAIN to pathological states we must know a great deal more of their normal relationships. Ergosterol is the precursor of vitamin D, and vitamin D is a regulator of calcium-phosphorus balance. The ergosterol content reaches its highest level in the fetal brain and is rapidly depleted directly after birth, when ossification is at its highest level. Skin exhibits the reverse relationship; that is, during intrauterine life practically none is present, but shortly after birth the percentage rises sharply. Is it possible that brain acts as a source of supply for ergosterol and that, as the demand arises, the sterol is sent to the skin for irradiation ? Incidentally, it may be mentioned that the sterol content of skin has some, as yet ill defined, relationship to the formation of dermal neoplasms. Overdosage of vitamin D causes arterionecrosis and metastatic calcification. I t is not known whether the body can synthesize ergosterol. Vitamin D is easily absorbed by the gastrointestinal tract and, contrary to certain statements in the literature, small amounts of ergosterol may also be absorbed. These substances are of the highest importance to the proper development of the central nervous system as well as to its maintenance. Fat appears to be able to pass the placental barrier but whether sterols have this power remains uninvestigated. Is the fetus dependent on its mother for these essential constituents? We do not know, yet methods are available. Carotene and Vitamins A, B, and C. Carotene is the precursor of vitamin A. Both are to be found in brain. Vitamin A and B deficiency causes serious injury to the nervous system. We know too little of the mechanism of its action to attempt an explanation of its manifold activity in animal economy. The same must unfortunately be said for the vitamin B complex. This complex is found in brain-substance. Present evidence indicates that vitamin C is identical with ascorbic acid—an acid isolated from adrenal glands and cabbage leaves. I t is intimately concerned in certain oxidation-reactions occurring in the body. Undoubtedly the brain shares in the activity of these substances, but how? c. Carbohydrates. The reserve store of carbohydrate in the central nervous system is very small, and that which is present seems curiously stable. An animal may die during insulin convulsions with quite sufficient glycogen in its brain were it [169]

THE PROBLEM OF MENTAL DISORDER only utilized. Brain cannot utilize glucose directly. I t must first be converted to lactic acid. The brain appears to possess large stores of lipid and protein which it parts with grudgingly, but, strangely, it is dependent for its sugar on the blood-stream. I t has thrown itself open to the mercies of the pancreas, the liver, and a whimsical appetite. Paradoxically, the brain of a diabetic animal normally metabolizes carbohydrate, otherwise the neurologist or psychiatrist might have welcomed the diabetic to the fold. Little has been said regarding what carbohydrates are present in brain. Seemingly, not a great variety. Glycogen is sparingly found; glucose in proportion to the amount in the blood; pentose combined as nucleotide; and galactose held in the cerebroside molecule. That curious poly-alcohol, inosite, is also present; indeed, equally curiously classified as a carbohydrate. The respiratory quotient of brain is usually about 1.0 and this has often been taken to indicate that brain is burning largely sugar. This does not follow. Much evidence suggests that sugar may not be the principal source of nervous energy. The brain is a more powerful lactic acid producer than most other organs, presumably because this substance is so vital to its carbohydrate metabolism; yet no complete Meyerhof cycle is found. This clearly indicates that it is unsafe to apply the criteria for carbohydrate metabolism derived from studies on other organs. In this connection it is also interesting to recall that brain-tissue forms one of two notable exceptions to the rule of 'normal adult tissue' as regards glycolysis. Both brain and retina resemble malignant neoplasm in respect to their glycolytic quotients. Creatine-phosphoric acid, the so-called " phosphagen," which has recently attracted so much attention in muscle-biochemistry, has also been found in brain. Except for the demonstration of its presence, no further studies have been made of this important substance. In peripheral nerve it undoubtedly acts as one source of energy for the impulse. d. Nitrogen Compounds. The chemistry of the nitrogen compounds in the brain reaches probably the lowest level in our categories of information concerning brain-tissue. Creatine and creatinine are present, but nothing is known of their physiological or pathological significance, except the very recent announcement that the amino acid glycocoll may be their [170]

CHEMISTRY AND METABOLISM OF THE BRAIN precursor. This has proved to be of the greatest importance because it could be shown that patients suffering from muscular dystrophy are markedly benefited by feeding them this substance. A number of investigators have measured the nonprotein nitrogen of the brain under various experimental conditions. The changes seem to be very great, but other factors have not been sufficiently well controlled to allow the results to be satisfactorily interpreted. Ammonia has recently been recognized as a truly interesting substance; probably largely because its source in brain was found to be adenylic acid. I t belongs to that class of excessively labile substances which must be determined within seconds after the removal of the sample. This is accomplished by dipping the specimen in liquid air directly after its removal, thus bringing all chemical reactions to a stop. The ammonia may then be determined at leisure. I t seems not unlikely that such substances eventually may prove to be the most illuminating for the delicate reactions which must be going on in the brain. We know so little of the kind of proteins present in brain that there is little to say other than that most of the amino acids present in the proteins of other tissues are also to be found in the brain. Cerebral proteins can presumably be reversibly denatured, as most other proteins are. The most accurate method that we know (and it seems very accurate) for the measurement of this reversibility is the determination of the sulfhydrite group. Particular caution must be exercised about assertions as to the colloids of the brain. There seems little reason to believe that they are composed of protein alone. Glutathione is present in reasonably large quantities in normal brain. Pathological variations have not been investigated. e. Enzymes. Twenty-one different enzymes have been identified in brain-tissue. Few quantitative measurements have been made and there is little reliable work on the variations of enzyme-activity during alterations in the state of the tissue. Within such a short space it is futile to attempt any discussion of this phase of brain chemistry. The chemistry of the action of enzymes is very involved, and experience is required in the interpretation of results. Not many years ago riotous speculation held development in this field close to a standstill. Today, [171]

THE PROBLEM OF MENTAL DISORDER with reasonably accurate methods and more critical understanding, we may hope for better things. 2. The Physiological-Chemical Approach. Just as soon as really adequate methods are made available, physiological-chemical investigations are in a position to make rapid progress. One cannot inveigh too strongly against the adoption of uncritical methods for animal or clinical experimentation. Why many of the already standard methods in biochemistry have not been adopted by those interested in the chemistry of nervous and mental disease is hard to understand. Application of worthless methods can only bring the whole subject into chaos and disrepute. The problems which must be faced are exceedingly complicated, so that one feels that a few experiments carefully done or a few patients carefully studied will give data of far greater importance than routine study which lends itself to glib statistical analysis. I t seems somewhat of a prostitution of the freedom of the research spirit to present a list of problems and the method which the writer may deem a desirable approach. Facts or seeming facts challenge the intellect and stimulate the imagination. Therefore, in the next section as in the one preceding, certain observations are set down with no effort to relate them or to fit them into any theory. The writer knows of no set of observations which have been carried sufficiently far to justify the formulation of a theory relating chemical metabolism to any single function of the brain. These are strong words, but they seem just. A number of approaches are open to the study of the chemistry of the brain. (1) Brain-tissue may be removed at operation and analyzed. (2) Blood may be drawn from the internal jugular vein and carotid artery for analysis. (3) Cerebrospinal fluid may be analyzed. Hardly another organ is so readily approached and is so free from the contaminating influences of closely associated organs. No other organ offers a second bathing medium to the investigator with such easy access and with such generosity. Nature has, indeed, made it too easy for us. Emphasis has been placed on the effort to understand what the fundamental chemical reactions which take place in the brainsubstance are, not because they are the most practically studied but because it is felt that thereby a deeper understanding can be gained of the reaction-products found in the more easily accessible blood and spinal fluid. The alternative is that we are [172]

CHEMISTRY AND METABOLISM OF THE BEAIN ever in the position of the observer who sees his chemicals enter the mill but at the outlet knows their facets no longer, and they pass under his eye unheeded. While at the present time we may plead for a 'chemistry of the brain' because of the need to center attention on this neglected organ, there can be no possible excuse for ignoring its relation and reciprocal dependence on all other organs of the body. Surely, however, no serious investigator need be further annoyed by being reminded that the body must be considered 'as a whole.' Investigation of the order of appearance and the quantitative development of the various substances in the brain; and comparison of the substances, both as to quality and quantity, in the brain-tissue of various animals seems likely to yield results of real import. Comparative and developmental biochemical investigations of brain-tissue seem to have attracted little attention. The analysis of brain of lower animals has never been attempted. I t might be possible to shed much light on the biological significance of the brain-components, were such work carried out in conjunction with careful psychological and neurological studies. I t has been possible from the analysis of brain to determine the equivalent chemical ages of the albino rat and the fetal pig. Ages so determined correlate to a surprisingly close degree with the psychic activity of the animal. Chemical investigation has shown that differentiation of the brain during growth may be separated into four distinct periods definitely characterized by either the appearance of certain substances or their rate of accretion, which delimits the stages. The method offers distinct possibilities in the study of the concept of abiotrophy. Problems concerning the physical chemistry of the brain confront us at every turn. Probably the one pressing for most immediate solution is that concerning water-metabolism. Any number of reliable methods are available for such a study. I t is indeed encouraging to see that in various laboratories important progress has already been made. Interesting results have been obtained by study of the effect of narcotics on brain-tissue. I t could be demonstrated that all narcotics have one property in common: that of inhibiting at low concentrations the oxidation of substances essential in the metabolism of carbohydrate, such as glucose, lactic acid, and [173]

THE PROBLEM OF MENTAL DISORDER pyruvic acid. The results suggest that narcotics do not interfere with the access of oxygen to the brain-cell or with the activation of lactic or pyruvic acid. There is some reason to believe that hypnotics are adsorbed to varying extents in different parts of the brain according to the chemical nature of the hypnotic and the constitution of the particular part of the brain, and that their specificity of behavior depends ultimately upon specific adsorption. The mechanism of the processes of oxidation in brain is a problem which requires early solution. There seems to be some evidence that in certain psychoses oxidation is seriously reduced. If we could obtain some conception of the manner in which the brain carries out its oxidative conversion of foodstuff we might have a rational basis on which to proceed to an understanding of disease-processes. Here we arrive at the same impasse which usually confronts us, namely, that, until the substances which are being oxidized and the enzymes which bring about these oxidations are at least separated, we must flounder in speculation and content ourselves with recognizing that something is wrong with the utilization of oxygen. I t is of course known that cytochrome and various dehydrogenases are present in brain and that these enzymes are very much more active in gray than in white substance. The reactions of brain-tissue have been studied with the simple method of p-phenylenediamine treatment, but it seems probable that we must now attack this problem more seriously and intensively. This, indeed, would require an individual thoroughly grounded in the fundamentals of the chemistry of enzymes, particularly as related to the problem of oxidation. Such investigators exist! Hand in hand with the investigation of the problem of oxidation must be reckoned that of the study of the reactions involved when gas mixtures containing about 25 per cent of carbon dioxide are inhaled—the well-known Loewenhart phenomenon exhibited by catatonic patients. Certain groups of workers are beginning to take an interest, but it is slow in coming. The phenomenon was described in detail in 1929. There is a distinct need for a thorough study applying the methods so admirably described in Peters and Van Slyke's book. I dare say that little change would be necessary in simply and directly duplicating the type of experiment which has, for example, been carried [174]

CHEMISTRY AND METABOLISM OF THE BRAIN out on the metabolism of the kidney. I t can be recorded with pleasure that a serious start has been made by the Boston group of investigators. Measurements of the gaseous metabolism by employment of the methods of calorimetry have been of importance in demonstrating a reduced metabolism in schizophrenia, but on the whole they have been disappointing if one had expected too much from the method. While the determination of the basal metabolism of the whole body is now a standard part of our armamentarium, other lines of approach to the problems of the metabolism of the brain easily suggest themselves which hold out the promise of more fundamentally important results. The determination of the respiratory quotient is suggestive of the burning of this or that substance, but since it is now possible to determine the quotient of each organ separately, more questions have arisen than seem likely to be answered by the method because we will now have to be really sure that a quotient of 1.0 means that carbohydrate is being burned. Enough work has now been done to establish that some relationship exists between the respiration, the respiratory center, and the metabolism of the brain. Certain evidence points to a disability in the respiratory center in certain psychotic individuals. This is a problem requiring the utmost cooperation of clinician, physiologist, biochemist, and chemist. Such an attack has been started at the Maudsley Hospital in London. From the truly vast literature concerning disturbances in carbohydrate metabolism in psychotic patients, one might draw the conclusion that the carbohydrate metabolism is continually in a state of chaos. I suspect, however, that the chaos is to be found in other directions. As this phase of brain chemistry furnishes such an excellent example it might be well to make a suggestion which seems to the writer important. Would it not be more profitable to publish articles dealing with brain chemistry in chemical journals ? This would appear to be a most gratuitous statement but one cannot avoid the feeling that in most cases a chemist is the most competent judge of things chemical. Recent work has shown that glucose-tolerance curves and blood-sugar determinations may be clinically of real diagnostic and prognostic value. Any serious understanding of what these abnormal curves mean in psychotic patients must await further extension of routine clinical study, clinical investigation, and [175]

THE PROBLEM OF MENTAL DISORDER fundamental researches into the carbohydrate metabolism of the brain. A large gap in our knowledge caused by inadequate headway which has been made in the investigation of lipids is now becoming increasingly felt. I should hesitate to suggest to anyone to attack the problems of nervous and mental disease at the "lipoid front" until he had become thoroughly familiar with the chemistry and methods employed in pure chemical investigation of the lipids. No one could doubt, I venture to say, that the overwhelming proportion of lipid in the brain might play at least a subordinate role. Unfortunately the methods of fat metabolism are exceedingly difficult—truly more difficult than those for many substances—therefore a note of warning must continually be sounded against using the difficulties as license for presenting uncritical work. I do not propose to suggest even examples of the problems which seem immediate in this vast field of lipid metabolism. Such suggestions could only be misleading without a thorough discussion of the conditions required by the investigations and that, obviously, cannot be presented here. There is just one other phase of brain chemistry that should be mentioned before concluding this brief and sketchy review and that is the relationship of diet, vitamins, and the development and maintenance of the nervous system. Much factual material collected in recent years demonstrates beyond doubt that both the diet and vitamins play a part more subtle than we had heretofore accepted. Not many months ago the suggestion that vitamin B or an associated substance was intimately involved in the anemia problem sounded preposterous; and the anemia problem is associated with combined posterolateral sclerosis. Lack of vitamin produces nervous and mental changes which may be important both theoretically and practically. Unsaturated fatty acids are essential in the diet and a certain proportion of lecithin in the food is necessary to prevent fatty degeneration and death in depancreatized diabetic dogs. These are isolated but, I suspect, exceedingly important and suggestive facts considered in connection with the nutrition of the brain. I could go on building up a patchwork quilt of examples, but I believe that sufficient have been presented to point out the vastness and importance of the chemical method of approach. I have tried to show that at least two broad methods of approach [176]

CHEMISTRY AND METABOLISM OF THE BRAIN are feasible and must go hand in hand. Few subjects offer such a multitude of complex situations; therefore, the best that chemists can give is none too good, which signifies that they must be competent chemists. I t seems not improbable that the days of the routine collection of inadequate data tabulated under the heading 'research' are numbered. A trained and imaginative chemist, with proper assistance, equipment, and cooperation from the clinician, will doubtless go far toward the solution of problems in the domain of the neurologist and the psychiatrist, but he must be given a long period of untrammeled investigation in the pure science of brain chemistry.

[177]

V I . NEUROPATHOLOGY OF T H E B R A I N By W i l d e r P e n f i e l d , M.D., M o n t r e a l Psychiatry has always been farther removed from neuropathology than is the sister specialty of neurology. Yet it will always be necessary for psychiatry to attempt to cast her anchor in the depths of pathology however seductive may be the sea of pure psychology. For most disorders of the mental state no adequate cerebral pathology has yet been demonstrated; but the discovery of the spirochaete of syphilis in the brain of the sufferer from dementia paralytica is too recent an event to permit the final conclusion that these other disturbances have no pathological counterpart. Further advance in neuropathology may have to wait upon fundamental discoveries of another nature. Extended recapitulation of the advances and failures of the past would be tiresome and unnecessary. If a paper of this sort is to serve a useful purpose, it should indicate those lines of pathological investigation which seem most likely to be of help in the field of psychiatry today however limited the writer's knowledge of that field may be. To the neurosurgeon come special opportunities for the observation of neuropathological processes. He sees cerebral disease in vivo, is able to stimulate the cortex of conscious patients, and finds it necessary on occasion to remove selected areas of the brain. This opens a new horizon to pathological study as well as to physiological and psychological observation. The contribution which neurosurgery, as distinct from neurology, may make to psychiatry lies chiefly in the field of neuropathology. The increased insight that comes to the neuropathologist with each new technical advance in his science causes him to turn and scan anew unsolved problems in the field of psychiatry. And yet for the most part neuropathologists are too prone to depend upon a certain few routine stains with which they are most familiar. One man may conclude that a brain is normal after examination directed chiefly to nerve-cells, ignoring neuroglia. Many others draw their conclusions almost entirely from the blood-vessels, perivascular spaces, and leptomeninges, as demonstrated by [178]

NEUROPATHOLOGY OF THE BRAIN common hematoxylin stains. Still others rely largely upon the interstitial cells (neuroglia and microglia) to tell the story of the brain's condition. But the failure of neuropathology to keep pace with the classifications and descriptions of psychiatry is not due alone to the inadequacy of histological technique. Still more important in this failure are the unsolved complexities of the anatomy and physiology of the brain. In the study of the neurone changes in Nissl substance and neurofibrils are most easily observed and may be taken as the measure of the effect of some diffuse inflammatory or toxic process. But the other cytoplasmic constituents should not be ignored. The Golgi apparatus, although it occupies a space in the cytoplasm almost equal to that of the Nissl substance, is largely overlooked because of the difficulty of demonstrating this network. Mitochondria and pigment granules as well as other granules should also be taken into consideration before passing judgment on the functional state of the nerve-cell. But something more than technical excellence is prerequisite to success in the study of neurones. The demonstration of cellular components may be as complete as possible, but before such study can have a truly effective application to psychiatry one must discover the r61e played in mental processes by nervecells of different areas and of different layers in these areas. I t is important, no doubt, to know the condition of the nerve-cells in general, but it would be much more important if we knew the function of the particular nerve-cell which we were studying. The work of charting out geographically the neurones in all the cortical areas has been begun by Otto Vogt in Berlin and by the late von Economo in Vienna. The task of making this map is very great and it is a field of work which may well challenge psychiatrists and psychiatric institutions, for mental capacity and mental defect will no doubt one day be charted in terms of neuronal arrangement. There should be other institutes devoted to the study of cellular patterns and their relationship to psychological processes. And this is a field of endeavor which is properly psychiatrical even more than neurological; but a field in which one day neurology and psychiatry may mingle and again become one. Generations of cytologists and psychiatrists will labor on this problem before a pathology of cell-layers in relation to mental states can come into existence. But come it will. [179]

THE PROBLEM OF MENTAL DISORDER The blood-vessels and leptomeninges are of importance in any study, particularly where an inflammatory process is to be considered. They can be well studied by ordinary nonspecific stains. But to have studied a brain by means of the hematoxylin and eosin method only is not to have studied the brain at all. The interstitial cells (neuroglia and microglia), when properly understood, are in some respects the most sensitive indicators of the functional state of the brain. These cells play a role that is no doubt secondary to that of nerve-cells. They have to do with the nourishment of the axone and dendrite and probably also of the nerve-cell. They play the most important r61e during destructive processes; phagocytosis is carried out by microglia while astrocytes replace the deficit which occurs after the destructive process is over. Any influence which may destroy a nervecell and cause it to disappear completely leaves a legible record of the event in the surrounding neuroglia. Increase in the number of oligodendrocytes takes place as the result of influences which are as yet little understood. Satellitosis about nerve-cells is usually due to an increase of oligodendrocytes. Such increase is a response to some change within the nervecell; but the principles underlying these changes call for an elucidation not yet forthcoming. Nearly all destructive processes in the brain leave behind them a gliosis characterized by an increase in the number of astrocytes and an increase in the number and size of the astrocyte fibers. This is, of course, common knowledge. Study of the nerve-cell may indicate that it is being destroyed, and at a later time study of the neuroglia will indicate that nerve-cells, formerly present, have disappeared. But psychiatrists are interested less in frankly destructive processes and more in disorders of the continuing elements of the brain. Their interest is in malfunction rather than in disintegration. I n as much as many psychiatrical disturbances are cyclic and almost all are variable, it is to be expected that any directly associated cytological alteration will be reversible. A priori, the psychiatrist might demand that if cells within the brain show associated abnormality they should at a later time return to something like normal. As a matter of fact, there are changes, already described, in neuroglia which would answer these requirements. These are the so-called degenerative alterations known as acute swelling [180]

NEUROPATHOLOGY OF THE BRAIN of oligodendroglia and to a lesser extent the ameboid alteration of astrocytes. In oligodendrocytes the early stages of this change come on very quickly, are reversible, and are associated with alterations in the mental state as will be pointed out below. This is a field which has not been investigated as far as psychiatrical problems are concerned for the following reasons. Adequate stains have only been available a short time and the mechanism of change in these cells was not understood until still more recently. Furthermore, changes of a similar nature take place in these cells during agonal coma and in the first few hours after death, changes which completely mask the condition of the cell as it must have been before the terminal illness. Consequently ordinary autopsy material is of little use for such study. The degenerative alterations just mentioned apply to neuroglia, not to microglia, and of the neuroglia the oligodendrocytes are the more susceptible, astrocytes being considerably less so. Acute swelling of oligodendroglia is characterized by progressive distention of the cytoplasm of the cell-body and expansions. If this process continues, the expansions break up and the cell-body eventually extrudes the nucleus, resulting in obvious cell-death. But there are earlier stages through which the oligodendrocyte passes and during which the process is reversible, as has been demonstrated both experimentally and clinically. For example, a chronic epileptic (reported more fully elsewhere) had been in status epilepticus for several days and was in a condition of stupor between attacks. Cylinders of brain were removed in a hollow needle under local anesthesia. Everywhere throughout the removed cerebral tissue the oligodendroglia was in a condition which resembled the first stages of acute swelling. Several years later the same patient was again operated upon when her condition was quite normal except for occasional seizures. Cerebral tissue was again removed and the oligodendroglia were found to be normal in amount and in appearance. The process in these cells had reversed itself and the cells had returned to normal as the patient had herself recovered from her stupor. Astrocytes, too, show an ameboid change which has its early and probably reversible stages, and here again autopsy material is unsatisfactory. These cells are, however, less sensitive indicators than oligodendrocytes. [181]

THE PROBLEM OP MENTAL DISORDER What influences produce this alteration? To answer this question completely much more work must be carried out. But acute swelling of oligodendroglia seems to be the invariable accompaniment of coma, which may arise in response to many different pathological agents. I t does not appear as the result of simple surgical anesthesia. Acute swelling also accompanies febrile delirium, which likewise may occur in the course of many different illnesses. I n these varying conditions a common or comparable agent may be in circulation which produces by its effect upon the brain both the mental change and the associated alteration of oligodendroglia (and, if severe enough, of astrocytes as well). Here, then, is a cytological alteration which is associated with disturbance of mental function or with abolition of mental activity when it is produced by a so-called " intoxication." What would these cells show in the acute phases of the various psychoses? No material may be used for such a study unless it is removed immediately (within an hour) after accidental death or is removed surgically. Herein lies a fertile field for a combined study by psychiatrists and neurosurgeons. Epilepsy, which lies for the most part in the province of neurology, also offers a great opportunity to the psychiatrist. Clinical studies of this condition gave to Hughlings Jackson the insight necessary to solve many neurological problems and to foreshadow the solution of others. The sudden losses and alterations of consciousness and the changes in mental state which occur in this condition are of the greatest variety. Nothing argues more clearly for a regional localization of the "substratum of consciousness." The march of a local or Jacksonian seizure reveals the fact that hemispheral representation of hand movement is adjacent to that of arm movement which is in turn adjacent to the representation of face movement on the opposite side of the body. A localized attack which begins with a buzzing sound in the patient's ear may be characterized next by movements of mastication. The conclusion follows that a masticatory center lies near the temporal lobe, where the representation of hearing is found. If one examines in the same way simple primary loss of consciousness in an epileptic, it is evident that the loss may occur with no outward manifestation other than a blank expression and the arrest of speech. But in a more severe petit mal seizure there [182]

NEUROPATHOLOGY OF THE BRAIN are other phenomena habitually associated with the loss of consciousness, namely, "deep pallor," alteration in pulse, a "slight wave of universal movement," and sudden failure of the mechanism for maintaining erect posture.1 If there is an aura preceding simple loss of consciousness, it is most often an epigastric or visceral sensation. If now one considers for a moment that consciousness has a localizable representation in the brain, just as movement, vision, hearing, and speech have, one might argue from the above observations that it finds its topographical location near to the localization of the associated phenomena, i.e., near to the representation of autonomic function to be found in the hypothalamus and close to the third ventricle. From this area facial blanching might be produced and here visceral sense may be represented. In this position it would be adjacent to the mid-brain, where lies the upper end of the neuronal circuit which maintains the erect posture. Following this line of reasoning, the substratum of consciousness might be localized by means of what is known of those phenomena which are commonly associated with disturbance of consciousness in a local seizure. This is not the place to pursue such a theme too far. But the elaboration of an anatomy and a physiology of conscious processes is a prerequisite to the creation of a true psychopathology. In a psychiatric clinic today, the pathological study of a patient's brain may often seem to bear no relationship to the study of the mental state from which that patient had suffered. This discrepancy may be due in part to the fact that what we consider misuse of the brain is, nevertheless, use, and as such produces no pathological alteration. The discrepancy is also due to the shortcomings of histological technique, but most of all it is due to the gaps in our knowledge of the fundamental processes underlying conscious activity. This gap cannot be bridged by an experimentalist in his laboratory nor by minute inspection of dead tissue. The physician must now make common cause with the anatomist and the physiologist, for pathology and clinical science must ever wait upon the halting advance of anatomy and physiology. 1 The quoted phrases are from Hughlings Jackson. [183]

V I I . T H E ORIGIN, PLAN, A N D OPERATIONAL MODES OF T H E NERVOUS SYSTEM By G. H. Parker, S.D., Cambridge From the standpoint of the comparative neurologist, as well as from that of the zoologist, man is only one of the million or more described species of animals that now inhabit the surface of the globe. Scholars have long since abandoned the idea that he is a being unique in character and essentially independent of the rest of creation. To understand him aright we must know not only his near relatives but his more remote connections in whose day steps were taken essential to his evolution. These steps, a part of man's organic history, are in a measure preserved to us in many of the simpler animals whose present states thus dimly shadow phases in man's racial development. Hence the importance in a summary like this of a consideration of the simpler forms of animate life. Effectors. All animals, including man, respond to environmental changes through special organs, the effectors. Of these muscle is the chief but not the only effector, for a survey of the animal kingdom brings to view half a dozen or more such sets of organs. Man and the earthworm agree in possessing three and by a strange coincidence the same three, namely, cilia, glands, and muscles. In us muscles have far outrun our other two effectors. By muscles we produce all the varied movements of our bodies, locomotion and what man can do with his hands from digging a ditch to playing a violin or modeling a statue. Muscles, too, give us facial expression and all those thousands of slight and almost imperceptible motions that express inward character. Most of all, muscles give us speech from the inarticulate cry to the mostfinishedform of language. Muscle is the artist's tool and serves not only as his means of portraying to us his ideal worlds, but enables him on the stage to arouse in us a wealth of self-imposed emotions, none the less telling in consequence of their artificiality. These and a host of other actions we owe to our muscles. They are our supreme effectors. How great the contrast between what muscle means in us and in an earthworm. Origin of the Nervous System. I n a certain measure some effectors may be said to have emerged from the protozoans and to have been passed on to the multicellular animals; among these [184]

ORIGIN AND OPERATIONS OF THE NERVOUS SYSTEM may be counted muscle. A number of the simplest multicellular forms, such as the sponges, possess muscle but no nerve. Nerve appears to have arisen in types above the sponges such as the coelenterates, for in a number of these animals, as for example the sea anemones, single receptor cells reach from the surface of the outer skin to the subjacent muscle and serve as simple triggers by which the muscles are excited to activity. Such receptor neurones are apparently the most primitive type of nervous tissue. They are, however, reproduced in the sensory equipment of a wide range of higher animals including even man himself, whose olfactory epithelium contains such cells which differ from those in coelenterates chiefly in that they terminate in a nerve-center instead of in muscle. Thus nervous tissue arose in what may be called its receptor phase as a means of exciting muscles to action. Nerve-nets. I n the more complex parts of coelenterates the receptor neurones connect with numerous deep-seated nerve-cells whose branches coalesce and thus constitute a nerve-net that spreads over a large part of the animal's body. These nerve-nets are primarily conducting systems by which nerve impulses excited in the receptor neurones of one part may be transmitted to muscles in other very distant portions and thus call forth appropriate responses. As a rule, such nerve-nets are not polarized and the impulses spread in any direction, a condition which is dependent among other things upon the absence of synaptic connections between the several nerve-cells. Such cells have been called, therefore, protoneurones to distinguish them from the synaptic neurones of the nervous systems in higher animals. Nerve-nets of the type just described show no special concentrations in the animals in which they occur. They spread diffusely throughout the animal's body without forming nervecenters. Such a nervous system may be termed a diffuse nervous system as contrasted with a centralized one and may be recognized not only by its structural peculiarities but also by the reaction-patterns that it imposes upon its possessor. If a tentacle from a large sea anemone is cut off and appropriately held in sea water, it can be stimulated by placing food upon it and in response it will turn, twist, and deliver the food to that side where the mouths would have been, had the tentacle remained normally in place. This is due to the fact that that part of the diffuse [185]

THE PROBLEM OF MENTAL DISORDER nervous system and the musculature needed for these responses are contained in the tentacle itself and that reference to a single nerve-center somewhere else in the body is unnecessary for these reflexes. How different in this respect is the tentacle of a sea anemone from the leg of a dog which, if once cut from the dog and thus separated from the controlling nerve-center, can no longer respond in a serviceable way. These examples illustrate the profound difference between the reactions associated with a diffuse type of nervous system and those carried out through a centralized one. Nerve-nets of the kind just described have been transmitted in part to more complex animals, even to man himself. They occur, for instance, in the walls of our blood-vessels, of our digestive tube, and in other like places. I n consequence the functional independence of these parts is remarkable. As is well known, a piece of vertebrate intestine after removal from the animal will transmit a bolus much as it might under normal circumstances. Central Nervous Organs. The nerve-nets of the coelenterates, however, have not only yielded a type of nervous organization that characterizes certain parts of the more complex animals, they have served as the soil out of which the central nervous or adjustor systems of these complex types have grown. Placed as the nerve-net of the coelenterates is between receptors on one hand and muscles on the other, it occupies the exact location of the future central nervous organs. I n fact when a wide range of appropriate animals is studied it is impossible to draw a hard and fast line between the nerve-net on one hand and the true central nervous organ on the other. The transition is a gradual one and consists chiefly in steps of local polarization whereby diffuse conduction of nerve impulses in the net is replaced by conduction limited to particular tracts and to given directions. Such a differentiation begins to appear in some of the coelenterates, but it first assumes significant proportions in the simpler worms and is strikingly characteristic of such animals as the arthropods, the molluscs, and the vertebrates. I n the deepseated nervous organs of these forms the nerve-cells which collectively make up these organs are no longer united as in the nerve-nets but show synaptic relations in that their terminals are so adjusted as to transmit impulses in only one direction. Thus nerve-conduction is limited in direction by something [186]

ORIGIN AND OPERATIONS OF THE NERVOUS SYSTEM between nerve-cells that is valve-like in action. Moreover these nerve-cells, probably as a requirement of this type of conduction, do not appear to be in direct connection one with the other. They are merely in contact, for, notwithstanding the opposition to this idea raised by Apathy, Bethe, and their followers, the original contact-relation, as first clearly stated by Waldeyer in his enunciation of the Neurone Hypothesis, has slowly but steadily gained support as shown by the work especially of Harrison on the growth of nerve-fibers and the still more recent and remarkable studies of Speidel on living, growing nerves. Nerve-cells thus related one to another through points of contact or synapses may be called neurones proper as contrasted with the more primitive protoneurones of the undifferentiated nerve-nets. These synaptic neurones are the elements which make up the nervous organs of the more complex animals and which in endless variety and in incredible numbers underlie all higher nervous organization. Types of Neurones. Although the differentiated neurones in the complex types of nervous systems are immensely diverse in form and arrangement they can be conveniently classified under three heads: receptor neurones, effector neurones, and internuncial neurones. The receptor neurones are those which connect a receptor region, often an external surface, with the central organ. They are cells which, so far as their nuclei and consequently their cell-bodies are concerned, belong to one of two types, the invertebrate and the vertebrate. In the invertebrate type, these neurones have their cell-bodies commonly located at the level of the integumentary epithelium, which is ordinarily one cell thick. Here these cell-bodies, usually called "sense-cells," give rise each to a single nerve-fiber, which extends inward through the subjacent tissue and terminates in the central organ. In the vertebrates the cell-body of the receptor neurone has migrated centrally and, as a ganglion cell sometimes on the line of the fiber and sometimes attached to this by a long single process, lies close to the central organ and constitutes there, with others of a like kind, the ganglion of the nerve. Centrally the vertebrate receptor neurones end in fine branches in the central organ and peripherally in ramifications either in the manylayered epidermis of the skin or in other receptor positions, tendons, muscles, and the like. The type of receptor ending, especially in the epidermis, is the so-called "free nerve[187]

THE PROBLEM OF MENTAL DISORDER ending." In other instances the nerve-terminals may have investments, as in the Pacinian and other corpuscles, or the endings may be associated with secondary sense-cells, as in the gustatory buds and in the auditory organs. The effector neurones are those which extend from the central apparatus out to some effector. In general they must be at least as numerous in kinds as the types of effectors that they control. They may be divided into six classes: secretory neurones supplied to glands; luminous, ciliary, and chromatophoral neurones to their respective end-organs; and motor and electric neurones. Motor neurones fall into two subdivisions, those for smooth-muscle fibers and those for cross-striped elements, divisions clearly marked in the vertebrates. Their organization has been worked out in most detail in the motor neurones supplied to the cross-striped muscle fibers of vertebrates. Here, as Sir Charles Sherrington has clearly pointed out, each neurone as it extends peripherally divides into from twenty to a hundred branches on the end of each of which is a cross-striped muscle fiber. This neurone with its numerous attached effector muscle fibers is known as a 'motor unit,' for it acts as a single unit in contraction. Gradation in muscle action cannot be reduced below these units. Thus, as Eccles and Sherrington have recently shown, the gastrocnemius muscle of the cat is composed of about 430 such units. Hence this muscle in going into action may pass through as many as 430 steps between quiescence and full activity. Thus the gradation of muscular contraction is truthfully a step by step process. The internuncial neurones are those nerve-cells whose bodies and processes lie entirely within the limits of the central nervous organs. They are the means of communication between the receptor neurones on the one hand and the effector neurones on the other. Although in many instances they must be exclusively concerned with the relatively simple process of transmitting impulses, they must also represent that body of nervous material in which the higher functions take place. Notwithstanding the fact that in some worms and other invertebrates the simplest reflex-arc may consist of a receptor neurone discharging into an effector neurone, in most instances of this kind and probably always in the vertebrates, receptor neurones connect with effector neurones only through internuncial elements. Thus the more complex types of reflex-arcs probably always involve [188]

ORIGIN AND OPERATIONS OF THE NERVOUS SYSTEM the three classes of neurones already described and of these the internuncials may often predominate. In the ventral nervechain of an earthworm all three classes of neurones are present and are perhaps numerically not far from equal. In the vertebrate spinal cord on the other hand the internuncial neurones have unquestionably gained in number over the other two classes. In the vertebrate brain this increase of internuncials has far outrun the receptor and effector elements. Moreover, the nature of this overgrowth points very clearly to the great functional importance of the internuncials. Among the fishes the brain weighs less, often very much less, than the spinal cord. I n some of these animals it is in fact a relatively diminutive structure at the anterior end of the cord. In frogs the cord and brain are approximately equal in weight. In the higher vertebrates the brain steadily gains over the cord till the extreme is reached in man where the weight of the brain is roughly fifty times that of the cord. This excessive growth of the brain in the higher vertebrates when studied in detail is seen to depend upon a disproportionate increase in two of its parts, the cerebellum and, particularly, the cerebrum. Of these two parts the cerebellum has to do with muscular tone, adjustment, and coordination and the cerebrum with the psychic functions. Both these features play most important parts in the evolutionary history of the higher vertebrates, and of these two the growth of the psychic functions is especially characteristic of man. In human beings the conservative stem of the brain, which in many respects resembles the spinal cord, is only a little over 2 per cent of the total brain-weight, whereas the cerebellum, about 10.5 per cent by weight, and the cerebrum, about 87.5 per cent, together account for almost 98 per cent of the total weight of the brain. Since these two parts are composed almost exclusively of internuncial neurones and since this type of neurone makes up more than half the weight of the stem, i t follows that internuncial neurones are of first significance in the brain of man. Vertebrate Central Nervous Organs. The growth of the vertebrate central nervous organs, as it can be seen in the series of animals from the fishes to the mammals, shows regions of great uniformity and neural conservatism as contrasted with regions of striking and progressive change. The autonomic nervous system with its double set of fibers, sympathetic and parasympathetic, controlling glands, smooth muscles, and chromatophores, presents [189]

THE PROBLEM OF MENTAL DISORDER much uniformity throughout the vertebrates. In a similar way the spinal cord shows few important changes from fishes to mammals. But the brain, asalready pointed out, has undergone profound transformations in this evolutionary series. Its most anterior and probably the most primitive portion, the olfactory brain, was followed in the course of phylogeny by the optic or mid-brain which in turn had added to it the otic brain, with its equilibrational and auditory functions. From the connection between the otic and the optic brain arose the cerebellum. This organ, a simple dorsal lobe in the lower vertebrates, took on in the mammals important lateral lobes with their ventral connections, the pons. From the space between the olfactory and optic brains arose the cerebral hemispheres first represented by the archipallium or primitive olfactory cortex of the lower vertebrates, which became overshadowed by the efflorescence of the mammalian neopallium with its universal sensory and motor fields. All these striking external changes were associated with equally profound internal readjustments. The so-called "nuclei" of the cranial nerves, masses of neuronic endings of relatively homogeneous character, shifted in the course of phylogeny from position to position for improved functional relations. The principles upon which these shifts occurred have been enunciated by Arien Kappers in his theory of neurobiotaxis. In all such readjustments the undifferentiated neuroblast is what shifts and, after its final position is taken, its axon and other processes grow out, its distant connections become established, and it assumes the condition of a differentiated neurone. I n these final steps polarization appears in that the nucleated body of the neurone assumes a definite position in relation to the direction of nerve-conduction. I n practically all internuncial and effector neurones in both invertebrates and vertebrates, the nucleus (and in consequence the cell-body) is located close to the receptive end of the element and opposite to the discharging end. Nerve impulses from an adjacent neurone are delivered into any given internuncial or effector neurone at its cell-end, pass through the length of this neurone, and are discharged at its far end. Thus the neurone shows both morphological and physiological polarization. The occasion of this polarization is not easy to discover. The nucleus of the neurone, like that of any other cell, is unquestion[190]

ORIGIN AND OPERATIONS OF THE NERVOUS SYSTEM ably its metabolic center. Perhaps, as Golgi long ago maintained, this is the real function of the cell-body, for there has never been any conclusive evidence advanced for the current idea that the cell-body with its contained nucleus is the seat of central functions. Since this metabolic interpretation rests on sound cytological considerations, it may be safe to conclude that the position of the nucleus in the neurone is determined by the demands of metabolism and that the receptive ends of all internuncial, effector, and invertebrate receptor neurones are regions of extra metabolic requirements. From this standpoint the reception of an impulse may be considered to be a more expensive process, so to speak, than its discharge. To this general conclusion the vertebrate receptor neurone is the one significant exception. Here, as already noted, the cell-body has taken a position near the central organ, that is, near the discharging end. Why this migration, for such it seems to be, should have taken place is difficult to surmise. Possibly it is connected with the unusual environment of the peripheral terminals of most vertebrate receptor neurones, namely, in a densely multi-layered epidermis or special cellular corpuscle which may in some way substitute for the cell-body. But however this may be, most receptor neurones differ from those in the other two classes in one important particular. These neurones originate as well as transmit impulses, the other types merely transmit them. The kind of polarization concerned with pure transmission seems to call for the location of the cell-body at the receptive end; that for origin and transmission, at least in the vertebrates, apparently requires no such location. Synaptic Relations. The functional interrelation of neurones, whatever may be their type of polarization, is through the synapse. Each synapse, as already stated, is a minute area of contact between the processes from adjacent neurones like the points of contact between the finger tips when the fingers of the two hands are opposed. I n the contact areas of neurones one side is a discharging side and the other a receiving one. What travels from one to the other can only be surmised. The nervous impulse that passes over the length of a neurone appears to be a wave of ionic disturbance which shows itself on a polarizable membrane, a disturbance which is quickly succeeded by the normal condition through a restorative wave of chemical change. What the impulse does when it reaches the synapse is difficult to [191]

THE PROBLEM OF MENTAL DISORDER say. Gerard has stated the alternatives with much clearness in the sentence "Either the same kind of ion migration and chemical response which represents successive activation of one region of the nerve-fiber by another must also take place at the synapse, or . . . the end of the axon acts as a minute gland and, when stimulated, produces some chemical which is able to excite an adjacent or neighboring dendrite." I n speculating on synaptic transfer two facts must be kept in mind; first, this transfer occurs in only one of the two possible directions and, secondly, it involves a considerable retardation in time as compared with impulse-transmission, a retardation which in the higher animals may amount to from six to eight thousandths of a second. Something of the nature of the synaptic transfer may be inferred from what occurs between effector neurones and their end-organs. Twenty years ago it was shown by Demoor that if the spittle from a dog whose chorda tympani had been electrically stimulated is injected into a second dog, the salivary glands of the second dog will begin to secrete and discharge saliva. This response is easily understood if it be assumed that the excited nerve-endings in the salivary glands of the first dog deliver a substance into the glandular tissue which not only excites that tissue to action but, in part at least, escapes with the secreted saliva and may thus be used to excite the salivary gland in the second dog. In a similar way, following the experimental procedure of Loewi, the fluid from a frog's heart, rendered inactive by the stimulation of its vagus nerve, will call forth appropriate responses from the stomach musculature of a second frog when this fluid is transferred to the circulation of the second animal. Thus it appears that secretory and other nerves act on their effectors by producing substances which may be drawn off and used to activate the effectors of other individuals. These substances approximate very closely the nerve-secretions suggested by Gerard and their presence affords good ground for that conception of synaptic transfers, involving secretions rather than direct ionic wave transmission. The excitation of one neurone by secretions from another would make clear the valve-like action of the synapse, for the nonsecretory side would be unable to excite its opposing side. Transfer could therefore go on in one direction only, that is, from the secretory to the nonsecretory side. The secretory inter[192]

ORIGIN AND OPERATIONS OF THE NERVOUS SYSTEM pretation of synaptic transfer, moreover, offers an explanation for the delay involved in the process; secretion and excitation are collectively not such rapid processes as the passage of an ionic wave. Neurohumoralism. I t is probable that the substances that have been shown to be concerned with the nervous control of the salivary glands and the heart are produced by the nerves themselves rather than by their effectors, for it would be strange for effector cells to produce substances to excite themselves when the excitation is known to come from the nerve. Such substances have been designated neurohumoral substances or simply neurohumors and they have been found abundantly in connection with the color-cells or chromatophores of the lower animals. By the expansion and contraction of these cells the bodies of many of the lower forms may be rendered dark, light, or variously colored, often fitting in a truly remarkable way the shades and tints of their surroundings. As might be expected, such responses depend upon the animal's powers of vision, for, if from a given form the eyes are removed, all such color reactions cease. A common American shrimp shows these changes in a most striking way. When it is placed in an illuminated darkwalled aquarium it becomes dark; when on a light background it becomes light. These reactions depend upon the integrity of the eyes, for when these organs are removed the reactions cease. If now the eyestalks of a light shrimp are cut off, crushed and extracted with water, and the extract thus obtained is injected into a dark shrimp even when it is on a dark background, the animal will soon become pale in color. The action of light on the retina of the shrimp in some way causes the formation in the tissues of the eyestalk of a neurohumor that induces the contraction of the chromatophores with consequent light coloration in the animal. I n the absence of this substance the chromatophores expand and the animal darkens. Many fishes show similar reactions, but with much more complicated nervous relations. Thus common flatfishes reproduce in a most remarkable way not only the tint but the pattern of the background on which they rest. If the blood from a flatfish, dark in consequence of a long sojourn on a dark background, is drawn and injected into a light fish, a dark spot due to the expansion of dark chromatophores will appear in the region of injection and remain there some time. The converse of this experiment is also [193]

THE PROBLEM OF MENTAL DISORDER true and a light spot may be produced by injecting the blood of a light fish into a dark one. Plainly here both expanding and contracting neurohumors must be involved, for the injection of pure physiological salt-solution has no effect on the color of the flatfish. I n certain other fish two classes of nerve-fibers, expanding and contracting, have been identified and there is thus good reason to believe that these animals are provided with one set of nerve-terminals that secrete a contracting neurohumor and another set producing an expanding one. Thus the responses of chromatophores afford even better evidence in favor of a neurohumoral interpretation of nervous activity than the reactions of other effectors do. The application of neurohumoralism to an understanding of the synaptic nervous system as a whole may be perhaps premature, but it must be clear from what has been said that such an application has much in it that is inviting. Neurohumoralism finds its most ready exemplifications among the effector neurones. I t has never been demonstrated positively for central neurones though such profound students of this field of neurology as Sir Charles Sherrington have intimated that such a principle, or something very like it, is necessary as a basis of understanding the interrelation of central elements. From a histogenetic standpoint it is well known that secondary sense-cells such as are represented in the vertebrate taste buds and in the lateral-line organs of these animals disappear when their nerves degenerate and reappear only after these nerves have regenerated. Here again it is easy to interpret the phenomena involved from the standpoint of neurohumors, but the final proof of such an interpretation is still to come. However, the neurohumoral concept appears to be well founded as a principle of interrelation among certain effector neurones and their end-organs and is a promising avenue of approach for other parts of the nervous system. In the foregoing outline nothing has been said of mental disorder in animals. This is due to the fact that, as Dexler has observed, such disturbances are really quite rare. The inner life of a lower animal is in one respect necessarily inaccessible to man, but it is not this aspect of the subject that renders the lower animal so barren a field for the study of nervous disturbances. These organisms appear to be to a very large extent exempt from such troubles. Were they as generally subject to [194]

ORIGIN AND OPERATIONS OF THE NERVOUS SYSTEM nervous disaster as man is, naturalists would long ago have recognized this condition in their changed responses. But states of this kind are not common occurrences, as the history of the subject shows. Less than a decade ago Brun noticed an ant whose movements were so unusual that he was led to make an examination of its central nervous system and he found that the animal was suffering from a brain tumor. Herter at about the same time came into the possession of a frog that at each jump tended to roll to the right. A post-mortem examination showed that the animal's right internal ear and the associated parts of the brain were deficient. Examples of this kind show that, when lower animals are nervously defective, these defects appear in their reactions. Since instances like these are relatively rare we are forced to conclude that the lower animals suffer relatively little from such abnormal states. Even in the higher warm-blooded forms, the birds and the mammals, instances of mental disorder are not common. The bodily diseases of these animals are not infrequently accompanied by reaction-patterns that often run a very characteristic course and that indicate disturbances of a distinctly mental nature. Thus a spirochaetosis of the fowl is associated with somnolence, and even paralysis. Hydrophobia in dogs involves a profound and characteristic disorganization of the mental make-up of the animal. The blind staggering gait of sheep results from the invasion of the brain of these animals by an early stage of a tapeworm. Hydrocephalus is known to occur among the higher animals and with characteristic mental symptoms. The low grade of response found in human cretinism is repeated in other mammals and from the same cause. These and other instances show that the nervous organization of the warm-blooded animals can respond by exhibiting signs of mental disturbance much as man does, but the brute does so only on unusual provocation whereas the human species teems relatively with mental defects. This contrast is apparently entirely well founded and its explanation probably lies in the excessive and sudden brain development which man shows as contrasted with other animals. When it is recalled that the maximal weight of the brain of the orang and of the chimpanzee is about four hundred grams and that that of the much larger gorilla is five hundred grams, the weight of man's brain, from thirteen hundred to fourteen hundred grams, is obviously very exceptional. Such a sudden phylogenetic increase [195]

THE PROBLEM OF MENTAL DISORDER in brain substance, an increase that must have called for over thrice the number of cells for the human brain as compared with that for the chimpanzee, would be very likely to be associated with much variability in the organ concerned. As evidence of this, functional human brains are known to range from the microcephalic type with as low a weight as three hundred grams to maerocephalic with over nineteen hundred grams, a range reproduced in the brains of no other mammal. Such a condition has not only made it possible for man to be the preeminent mammal that he is, but it has also carried with it at times that degree of mental instability which separates him from his nearest relatives. Comparative neurology may seem to touch only in a remote way the really pressing problems of man's mental disorders, but no portion of the general science of neurology can flourish vigorously without its related parts. In fact the interlocking of all science is a condition necessary for successful progress. If, then, the sketch of comparative nerve-study that has been attempted in this brief survey seems to show a remoteness from that which may apply to human abnormal nervous states, it must be kept in mind that only by seizing upon the whole range of normal activity can an effective position be gained for a real attack upon the abnormal. Such a position has justified itself again and again in the past and there is every reason to believe that it will continue to do so in the future.

[196]

V I I I . FACTORS OF NEURAL INTEGRATION A N D NEURAL DISORDER By C. Judson H e r r i c k , Ph.D., Chicago Comparative neurology is tangential to psychiatry at several points, notably on the genetic side in connection with problems of the embryological and phylogenetic origin of behavior-patterns and the organic apparatus involved. With respect to nosogenical problems in this field, it is to be borne in mind that the advancement of our structural and functional knowledge of the human nervous system rests on a comparative basis, for most of the significant discoveries have been made on nonhuman material and then applied, with the necessary corrections, to man. In neuroanatomy this is obvious without argument, and on the functional side the same is true of nearly all experimental physiology. I n psychology the resources of the comparative field are being diligently explored. The applications of this knowledge in psychiatry have been retarded, partly by difficulties intrinsic to the subject matter and partly by preconceptions, traditional taboos, and mythologies which rest on a metaphysical rather than on a scientific basis. Mythologies and traditional dogmas bulk large throughout the history of all of the natural sciences, and in those disciplines which deal with the nervous system and its functions they have been and still are especially tenacious and obstructive. The wide gaps in our knowledge are bridged by hypothesis and the tendency seems to be irresistible to reify if not to deify these abstractions and to endow the artifacts which we have thus constructed by the exercise of scientific imagination with some occult individuality and creative power. The fabulousmonsters of ancient mythology have been replaced by modern idols or icons to which we are inclined to make a slavish obeisance, in shaping the course of our thinking and experimentation. I t is easy to be seduced by the fallacy that having found a name for a problem we have its solution. The temptation to personify our patients' symptoms and our symbolisms derived from them is very strong. Gene, neurone, synapse, reflex, chronaxy, resonance, Gestalt, complex, id, libido—these are verbal symbols which express, in each case, the abstraction, from a wide experience, of certain [197]

THE PROBLEM OF MENTAL DISORDER common features. Such symbols and the concepts for which they stand are useful and necessary tools of research, to be employed as long as found helpful but revamped or discarded promptly if wider experience so requires. To permit any one of these symbols of fluid and growing experience to crystallize into a dogma as immutable as an Olympian god or a Kantian category is to destroy its usefulness and transform it into a bar to further progress. This is graphically illustrated by the history of the concept of "reflex" as recently written by Fearing. During the eighteenth century the mystic haze which enveloped all human and animal behavior was penetrated and the reflex emerged as a scientifically validated concept embracing a wide range of our activities and exhibiting an intelligible mechanism. The nineteenth century saw this field intensively cultivated. Numberless specific reflexes were critically defined and the mechanism localized. The laws of these reflexes were sufficiently well formulated to permit wide use of them in clinical neurology. Physiologists and psychologists eagerly seized this new and efficient tool of research. I n Europe there arose a school of objective psychology which culminated in the monumental work of Pavlov, and in America this was paralleled by feverish activity in the field of animal behavior. These movements led in some quarters to an apotheosis of the reflex and an attempt to construct a working model of the nervous system and all that it does in terms of hierarchies of reflex-arcs conceived as rigidly insulated systems of conduction built after specifications resembling those of an automatic telephone exchange. The twentieth century has seen the collapse of this imposing structure. The reality of reflexes cannot be challenged and their usefulness in physiology and clinical diagnosis has not been impaired; but it is clear that simple reflexes are not the elementary units of behavior, and the actual conduct of animal and human bodies is not fabricated by monumentally piling up simple reflexes. Such a structure is not stable and would fall apart. The traditional stimulus-response physiology which goes no farther than this is an inadequate basis for either animal or human psychology, and in psychiatry its limitations are still more obvious. The problem has now changed front and the attack has shifted to a different sector. The analysis of behavior into reflex units [198]

NEURAL INTEGRATION AND NEURAL DISORDER can take us no further toward the goal than can the technique of the dissecting room. What are we going to do with these fragments of conduct and of corpses that we have spread out before us? These analytic procedures must be followed by a synthesis or our labors are wasted. Attention, accordingly, has now turned to the integrative functions. The technique of investigation of these integrative functions also involves, as Lashley says, "analysis and ever more analysis," yet the goal is synthesis and ever more inclusive synthesis. Most of this research has been done with nonhuman forms. Sherrington, working on dogs, has probably contributed more than any other individual to our precise analysis of reflex. And it is significant that, when at the turn of the century he published the well-known summary of his program, he entitled it The Integrative Action of the Nervous System. The history of the anatomy of the nervous system, both human and comparative, is similar. The bulk of the literature (and it is of enormous volume) has hitherto been devoted to descriptions of the larger and more conspicuous nervous pathways and centers, those displayed in Weigert and Nissl preparations. The value of this knowledge to clinical neurology is very great; its significance to psychiatry is less obvious. Having now blocked out the chief pathways of reflex conduction in man and other vertebrate types—what may be regarded as the lines of preferential discharge—the detailed structure of the apparatus of coordination, association, and integration is receiving more attention. And here again comparative material is proving most instructive. The complexities of the human brain baffle us, especially in the cerebrum, where the interest of psychology and psychiatry is chiefly centered. Intensive study of the apparatus of adjustment in the brains of lower vertebrates, where both behaviorpatterns and nervous organization are very primitive, yields unexpected results which are far more significant to psychiatry than the most detailed analysis of reflex-arcs. For many reasons the generalized Amphibia (salamanders) are especially instructive in this connection. Methodology. The advancement of our knowledge of the structure and functions of the nervous system has been dependent at every step on the invention of improved methods of examination. The possibilities of direct examination of living nervous [199]

THE PROBLEM OF MENTAL DISORDER tissue of vertebrates are very limited; and the value of these observations is greatly impaired by the laceration and shock involved in the preparation. For these tissues are extremely labile and unstable, and normal relations cannot be expected in any vertebrate nerve-cell or fiber which has been subjected to the insults commonly employed to make it visible under the microscope. The spectacular results recently achieved by Speidel with the simplest possible procedures have opened a promising field for the study of living nervous tissues in undisturbed normal relations. The ordinary processes of fixation, embedding, sectioning, and staining of brain-tissue produce distortions and artifacts of most serious moment. From that time in the 1840's when Stilling first hardened brain-tissue in potassium bichromate to the most recent refinement of plunging the living tissue into liquid air and dehydrating the frozen block at low temperatures in vacuo, histologists have sought to perfect their methods of coagulating the protoplasm in as nearly normal relations as possible and then by further treatment to stain or otherwise to render visible its component parts. At every step in these complicated procedures a fresh artifact is introduced, and the histologists' problem is to play off one against the other the 'equivalent pictures' thus produced in the hope of finally justifying some inferences regarding the original organization of the living stuff. The physiologists' difficulties are similar. Even the simple phenomena of nervous transmission revealed by a nerve-muscle preparation or an oscillographic record from a dissected nerve cannot safely be transferred to the normal intact living body without critical controls. Despite these difficulties progress has been registered, and with the shift of interest from the analytic procedures of reflexology to problems of synthesis and integration, to which reference has already been made, new methods of attack have been devised. The advances in knowledge which have followed the introduction of the new procedures associated with the names of Golgi, Weigert, Nissl, Marchi, Pavlov, and countless others have not come by accident. A new technical method is the fruit of a germinative idea. New experimental problems are conceived with each shift of interest, and this usually follows the lead of some enthusiastic propagandist with insight and courage. Comparative Physiology. Comparative physiology and comparative psychology have developed hand in hand, for the [200]

NEURAL INTEGRATION AND NEURAL DISORDER methods of both are necessarily objective and whether the results are used physiologically or psychologically depends entirely upon the interest and attitude of the experimenter himself. From this field we shall select only a single illustration. Problems of the type suggested by the Gestalt psychology have been investigated by the methods of animal behavior, and it is found that animals as low in the scale as rats and birds can make certain generalizations from experience. For instance, the maze-running habits of a rat can be conditioned—i.e., the rat can learn—in terms of general relations, such as larger-smaller, lighter-darker, square-and-triangle, regardless of the actual dimensions of the objects used as cues. Here we have an objective demonstration of a capacity for generalization, for the abstraction from diverse experiences of a feature common to all of them, and for building up a new, or learned, behavior-pattern in terms of the abstracted factor. Still other experiments show that these rats have a clear, though limited, capacity for such 'insight' as Kohler found in apes; that is, they can, in learning to adjust to a new situation, combine the essentials of two or more previously isolated experiences immediately without trial-and-error or random fumbling. This type of integration "requires the ability to bring together spontaneously two elements of past experience without having them previously associated by contiguity."1 I t is radically different from the ordinary conditioning of reflexes and, as Maier points out, cannot be distinguished objectively from the simpler forms of reasoning exhibited by humans. I t is apparently in rats a cortical function, whereas some forms of conditioning may be performed perfectly by animals which lack the cerebral cortex. These and all other kinds of individual learning are rather sharply set off against the stable and innate patterns of behavior typified by reflex, common to all members of the race or species. They involve the selective abstraction of certain components of mixed experience, the recombination of these in new patterns, the retention of these patterns, and their recall upon presentation of the appropriate cues. This is a synthetic and integrative process. I t is, as Coghill would say, a total pattern, not a partial pattern. I t is organismic, for it is the whole organism that learns, not the LN. R. F. Maier, Comp. Psychol. Monog., 6, 1929 (no. 29), 1-93; J. Comp. Neur., 54, 1932, 45. [201]

THE PROBLEM OF MENTAL DISORDER reflex-arcs or any other local or partial apparatus. Yet these are not disembodied functions, and it is the neurologists' problem to discover what is the apparatus of learning, retentiveness, and recall, where it is, and how it works. To this problem Lashley and his school in particular have devoted themselves with great industry and consummate skill. This program has now reached the point where the active cooperation of expert neurohistologists will yield immediate returns of great significance. These neurological questions can be answered by intensive histological study of experimentally trained and operated animals and normal controls. Now these and many similar questions must be answered before psychiatry can hope for complete mastery of her own problems. For the symbolisms with which psychiatry of today must too often remain content no doubt have some sort of organic correlate, some physical or chemical deviation of a local apparatus, some constitutional peculiarity, or perhaps a fluctuating instability of functional pattern resulting from an atypical or unbalanced interaction between wide fields of synaptic neuropil. If and when the organic correlates of the so-called "functional diseases" are discovered, there is reasonable hope that some, at least, of the psychoses which now are refractory to mental therapy alone will yield to treatment or prophylaxis in which mental therapy is united with rationally directed organic therapy. The history of dementia paralytica and some of the toxic psychoses justifies this hope. But this progress is dependent upon that of the supporting sciences. The mental symptoms of pernicious anemia could not be relieved in advance of knowledge of the organic deficiencies with which they are related. So the way will doubtless be opened for more successful treatment of other mental disorders when we know more about the normal structure and operation of the apparatus involved and the nature of the disturbing agents. The experimental studies which have just been mentioned are selected merely as samples of a large number of researches in comparative physiology and comparative psychology which have yielded substantial knowledge about the actual mechanisms of conscious experience and promise far more in the immediate future. Comparative Embryology. The embryological approach to the study of mechanisms of behavior has been opened up most [202]

NEURAL INTEGRATION AND NEURAL DISORDER fruitfully by Coghill and his followers. In view of the wellknown advantages of the Amphibia for research in experimental embryology at large, Coghill selected the salamander Amblystoma for intensive study. During more than twenty-five years of very laborious research he first established by experimentation on statistically adequate numbers the normal sequence of maturation of behavior-patterns from the first response to stimulation onward to swimming, feeding, and other more complex reactions. This was followed by careful histological analysis of the neuromuscular apparatus operative in physiologically tested specimens at the successive stages. The results of this study have been illuminating, indeed revolutionary. The most significant features from the present standpoint are that the behavior is fully integrated from the start, that the early reactions are mass-actions of the total available musculature, that local reflexes come in relatively late by progressive emancipation from the total patterns, and that even in adult animals the local reflexes are still evidently under more or less control by the total patterns of behavior. The parallel anatomical studies reveal the neuromuscular apparatus for successive stages of complication of the total reactions and the structural changes accompanying the emergence of the local reflexes. The phase last mentioned is now under active investigation. The integrative mechanisms of preneural states are still imperfectly understood. They certainly include the physiological gradients of Child, various hormones, differential electrical potentials generated by growth and specialization of tissue, and doubtless many others. I n the early neuromotor stages the nervous apparatus has been quite completely charted and its progressive complication at successive stages recorded. The nervous elements are so connected that integrated behavior— some sort of mass-action—is the only possible response. There are no local reflexes or reflex-arcs. The more complex behavior of the adult is not built up by compounding and conditioning of simple reflexes: the reflexes appear rather late and they are never simple elements of behavior. Nor are the reflex-arcs the structural elements out of which the complicated anatomical patterns of the brain are fabricated. The nervous mechanisms that integrate the simpler total responses are well understood. The details of the nervous apparatus which maintains the unity [203]

THE PROBLEM OF MENTAL DISORDER of the behavior pattern in later stages and provides for conditioning of reflexes and other more labile functions remain to be discovered, though progress in this direction has been made. Parallel with Coghill's program and in large measure inspired by it, various similar studies have been inaugurated on fishes, rats, and cats. The study of human prenatal and early postnatal behavior has received a new impetus, and this too is accompanied by renewed attack upon the morphogenesis of the human brain in correlation with the maturation of behavior-patterns. These correlated physiological and anatomical studies of the development of behavior-patterns lay a broad foundation which is as important for psychiatry as for normal psychology. They reveal the early patterns as intrinsically determined by hereditary and intraorganic agencies, and when environmental influences impinge upon these early patterns they modify them in ways that come under the general category of learning. During the whole course of development of neuromuscular mechanisms the intrinsic and extrinsic agencies are operative and they are more or less antagonistic. One is conservative, tending to reproduce stable ancestral patterns of integrated mass-action and coordinated local reflexes; the other is more plastic, tending toward modification of the innate stable patterns in terms of adjustment to local and transient external events. Normally a workable balance is struck between the conservative and the progressive agencies and development proceeds in an orderly way, exhibiting the standardized patterns characteristic of the species and various personally learned modifications dependent upon the specific experiences had by the individual in question. If this normal balance is disturbed, either by atypical internal organization or by untoward external conditions, either developmental defects or developmental asymmetries are likely to appear. The earliest behavior, as already pointed out, is firmly integrated from the start; it is mass-movement, a 'total pattern,' and the neurological apparatus employed has been clearly analyzed. With the emergence and complication of local reflexes, or 'partial patterns,' special apparatus of integration is differentiated in the higher centers of the brain, and in mammals the cerebral cortex is the dominant member of this system. These higher adjustors mature relatively late in development; their tissue is undifferentiated and plastic, readily modified by [204]

NEURAL INTEGRATION AND NEURAL DISORDER personal experience; accordingly, here is the chief apparatus of conditioning, learning, and (in man) intelligent types of adjustment. Throughout the entire period of development the local reflexes emerge overtly as components of the total pattern and they are under its dominance. Instinct is conceived by Coghill as "the total pattern overtly in action." The mechanism of the total pattern is, accordingly, a growing organ; and from the first it grows in an expanding embryonic neural matrix from which new elements grow progressively into it. This, according to my conception, is the organ of the so-called instinctive behavior. But in the nervous matrix, particularly in the cerebral cortex, the most embryonic part of the brain, in which this organ of the total pattern grows, there is a constant tendency toward individuation, which tendency is the organic basis of partial patterns of all ranks, from local reflexes to multiple personalities. . . . Normal behavior requires that the total pattern maintain sovereignty over all partial patterns; but through decadence of the organ of the total pattern, or hypertrophy of mechanisms of partial patterns, that sovereignty may give way to the dominance of parts that are normally its subjects, and, as a result of this, behavior may cease to serve the individual as a whole appropriately; that is to say, it may cease to be normal.2 This internal rivalry or conflict of dynamic patterns is inherent in the vital process everywhere, but it comes to especially acute expression in the higher adjustors and integrators of the brain, and especially in the human cortex. This adjustor consists in part of projection-neurones in direct connection with subcortical mechanisms and in larger part of intrinsic or internuncial neurones lying wholly within the cortex itself. These associational neurones are the integrators par excellence, and the amplification of this apparatus gives to the human brain its greater plasticity, its "central freedom and sufficiency,"3 and at the same time it tremendously complicates the problem of maintaining the whole in proper balance or a workable equilibrium. As somewhere pointed out by G. H. Parker, this internuncial or associational cortical apparatus more than doubles in mass and intricacy of interconnection as we pass from ape to man. Since this is preeminently the plastic or learning tissue, it is largely responsible for the individual differences between people. I t is also especially liable to give way under stress, 2 G. E. Coghill, Psychoanal. Rev., 20, 1933, 1. 3 M. Bentley, personal correspondence (cf. his The New Field of Psychology, Appleton-Century, New York, 1934, chap. iv). [205]

THE PROBLEM OF MENTAL DISORDER with resulting temporary or permanent disturbance of mental balance. Here also we find the explanation of the unique prolongation of human infancy which has been remarked since the time of Aristotle. The rigid innate patterns of behavior are modified with difficulty. Conditioning of reflexes is at best a slow process. If complex reflex and instinctive patterns are to be adjusted to the specific situation of the individual growing child by an educational procedure, the speed and precision of this personal adjustment are more readily attained where these patterns develop from their inception under the control of the apparatus of individual learning rather than by the process of conditioning the reflexes after they have fully matured and their reflex-arcs are structurally stabilized. Accordingly, in the human infant, whose cerebral cortex is still embryonic at birth, the maturation of reflexes and instincts is retarded and during this period of helplessness the cortical adjustors are rapidly growing. By the time the child begins to coordinate his locomotor reflexes and to have good muscular control of his hands the cortical apparatus of learning is functioning efficiently. Intentionally directed learning, accordingly, assumes more or less control over the formation of the more complicated reflex and instinctive adjustments from their first appearance. The stable patterns of behavior mature under cortical control and to this extent blind instinctive impulse is replaced by habits acquired with more or less conscious participation. This transfer of the dominant integrator from the brainstem to the cortex cannot be effected until the cortex has matured far beyond its new-born stage, and the organization of the more complicated reflexes and instincts is delayed until this has been accomplished. This makes for more labile, free, and selfsufficient conduct than would be attainable if the action-system were fully stabilized in more rigid patterns in advance of cortical maturity, as happens in other mammals, especially the lower members. From these illustrations it is clear that one of the basic biological functions of the animal body is the maintenance of the integrity of the individual during the flux of local and competing activities excited by external events and internal changes. This is the task of the central adjustors, and especially of the cortex, a task whose difficulty increases in more than geometric ratio [206]

NEURAL INTEGRATION AND NEURAL DISORDER with the complication of sensory experience and motor capacity and the partial or local patterns associated therewith. In mankind, with the development of language and other symbolisms permitting abstractions of high order, the integrating mechanism becomes much more labile, for these symbolisms are far removed from the stabilizing control exercised by direct connection with immediate sensori-motor experience. Yet even in the lower mammals we find illustrations of conflict and disorganization of normal patterns of behavior which seem comparable with human psychoneuroses. These will repay much more careful study than they have so far received, for they can be experimentally produced and controlled. The mental defects characterized by Henry Head as semantic involve symbolisms of a higher order of abstraction than any employed by brutes, and yet it is not improbable that they arise from disturbances of internal equilibrium which rest on a biological basis fundamentally similar to that which gives rise to the disordered behavior of rats and monkeys. Comparative Anatomy. The technicalities of neuroanatomy, especially as exemplified in the lower vertebrates, seem far more remote from the interests of psychiatry than are the fields just surveyed. The amount of descriptive detail recorded is very extensive, far greater than is appreciated even by most neurologists. And this mass of detail has stubbornly resisted correlation and interpretation. But here again times have changed and these problems may be envisaged from new angles. A survey of the vertebrate series reveals some features of the brain-stem that are surprisingly constant, and other features— notably the cortical adjusters—that exhibit the most spectacular transformations known. The constancy of pattern of the primary sensori-motor connections of the brain-stem is correlated with the essential similarity of peripheral connections. The sense organs of all vertebrates are much alike except for a revolutionary change in the receptors for vibrations at the transition from water to land habitat: lateral-line organs are replaced by the cochlea. On the motor side this revolutionary change is even more significant. Locomotion of fishes is chiefly a mass-movement of the total bodily musculature; local reflexes play a relatively small part. No matter how extensive their sensory experience, there are very few things that they can do about it. The terrestrial quadrupeds, on the other hand, live [207]

THE PROBLEM OF MENTAL DISORDER in a much more diversified environment and they have a far wider range of possible reactions to it. In fishes both the lower and the higher centers of adjustment discharge into a few final common paths which regulate the massmovements. The more diversified responses of quadrupeds with a larger repertoire of reflex-arcs demand much more elaborate apparatus of correlation and integration; there are more dilemmas of conduct to be solved because a wider range of response-patterns is possible. The part played by the differentiation of effectors in the elaboration of animal behavior has been graphically portrayed by Parker. This is reflected in the organization of the brain, especially among vertebrates in the transition from primitive mass-movements to intricate complexes of reflexes in the higher types. The central adjusters undergo radical transformation during this process; and this phylogenetic history is in modified form repeated in ontogeny. In all vertebrates the midbrain is the dominant center of adjustment of the elementary mass-movements and the striothalamic complex of local reflexes. With the complication of stable reflex and instinctive patterns seen in reptiles and birds, the strio-thalamic complex is enlarged in corresponding measure. These are stereotyped and largely innate behavior-patterns. Learning power is small. A simple and scanty cerebral cortex appears in reptiles, though obscure cortical primordia can be recognized in amphibians and some fishes. The physiological role of the reptilian cortex is as yet entirely unknown. Between reptiles and the lowest extant mammals the cortex undergoes a tremendous enlargement and complication and this process of differentiation continues throughout the mammalian series, with another abrupt expansion between the higher apes and man. Throughout this evolutionary series we can recognize the same conservative and progressive factors that appear in the embryological sequence. The conservative and rigid behavior-patterns predominate in the lower forms; while in mammals the progressive, plastic, or modifiable patterns predominate, and progressively more so until they culminate in man. The most primitive vertebrates, like the youngest mammalian embryos, chiefly exhibit simple, but well integrated, mass-action. In the land animals, with the elaboration of successive hierarchies of local [208]

NEURAL INTEGRATION AND NEURAL DISORDER reflexes and the corresponding complication of the adjustors of the brain-stem, the integration of the partial or local reflexes with the total patterns is maintained without undue rivalry or friction, because the patterns of the integrating apparatus are mainly innate and stereotyped, yielding very complex behavior of the sort characterized by Coghill as instinctive. I t is only in man that the more labile patterns of learned behavior assume the dominant role in the process of integration, and here, accordingly, the rivalries previously mentioned between the various sorts of motivation of conduct may assume the character of psychological conflicts upon a background of unrecognized physiological impulses or suppressed desires. In view of the obvious dominance of the cerebral cortex in the adjustment of human behavior and of the mystery which still obscures the details of its operations, it is of interest to inquire into the early evolutionary stages of its emergence from the noncorticated brains of fishes and to learn if possible the nature of the morphogenic agencies responsible for its differentiation. The Amphibia are the critical transitional types, and during the past twenty-five years these brains have been subjected to intensive histological study with results of considerable general interest. Without attempting to summarize these laborious studies here, it may be pointed out that the hope of finding in these generalized brains a simple schematic pattern of reflex-arcs at all conformable with the simple behavior of these animals was not realized. On the contrary, it is hard to find in the brain of a salamander any well-defined reflex-arcs at all. The nervous elements have widely ramified fibrous processes which interweave to form a nervous feltwork or neuropil of baffling intricacy, and the main lines of transmission which serve the standardized behaviorpatterns are threaded through this tangle of cells and fibers in so disperse formation as to be recognized with great difficulty. In the higher centers these interwoven fibers are mostly unmyelinated, and since every contact is a synaptic junction the entire feltwork may be activated diffusely by every nervous impulse that enters it from any source. This neuropil is spread throughout the brain and as a whole it is a diffuse synaptic field within which every neurone is embedded and no sharply localized functional activity can be performed by it. I t is not, however, physiologically equipotential, for [£09]

THE PROBLEM OF MENTAL DISORDER the fibers of which it is composed are in various parts of the brain derived from different sources with different peripheral connections (optic, olfactory, tactile, etc.). This relatively homogeneous matrix formed by the neuropil is evidently an efficient integrator. Within it local groups of neurones show various grades of differentiation and some of these form well-defined 'nuclei' and 'tracts' and evidently serve as apparatus of preferential discharge activating the standardized patterns of behavior. Local fields of neuropil also may be highly specialized and some of these can be recognized as precursors of specific 'nuclei' of mammals, even though here they contain no cell-bodies at all. These local fields have no neurones of their own and they can be activated only by collateral discharge of neurones whose chief connections are made elsewhere. They seem well adapted to serve as apparatus of conditioning reflexes. The cerebral hemispheres contain no cortex, no superficial, lamellated gray matter; yet the pallial fields, within which a welldefined cortex does appear in reptiles, can be recognized. Within these fields there are instructive early stages of differentiation of neurones, tracts, and neuropil in directions which point toward the cortical type of organization. These are cortical primordia, the raw materials out of which the definitive cortex of higher animals was fabricated. Further histological analysis of these primordia yields evidence of some of the physiological morphogenic agencies which are operative in early stages of cortical differentiation, and on the basis of this anatomical knowledge a further experimental attack upon these problems can be more fruitfully directed than has been possible hitherto.4 These studies reveal an unexpected complexity of organization in the generalized brains and a different pattern of organization from that postulated by traditional doctrines of reflexology. The adjustors of the brain-stem show no well-insulated reflexarcs and no sharply localized gray centers organized after the model of an automatic telephone exchange. Large masses of tissue are activated diffusely by any incoming excitation whatever, and the direction taken by the final efferent discharge is determined by factors of central excitatory state, differential internal resistance, or other variable dynamic agencies as yet undiscovered. 4 C. J. Herrick, J . Com-p. Neur., 59, 1934, 239. [210]

NEURAL INTEGRATION AND NEURAL DISORDER Whatever the details of the mechanism employed here may prove to be, it is obvious that the apparatus of the brain-stem as a whole is an efficient integrator. In the course of further phylogenetic differentiation more sharply denned reflex-arcs are elaborated within this matrix and the successive steps of this process are readily seen as we pass from generalized amphibians to higher mammals. The differentiation of these localized centers and tracts is effected under the influence of their specific peripheral connections, and the localization becomes less precise the further we pass inward from the peripheral end-organs. These localized mechanisms in their entirety constitute the "analyzers" of experience in Pavlov's sense. There are some parts of the brain which are largely exempted from this type of localized specialization. The thalamus region in particular is a sort of no-man's land interpolated between the ascending sensory (lemniscus) systems and the descending olfactory system of conductors. I t is not under the physiological dominance of any of these systems, but is the common meeting place of collateral discharge from all of them. In lower vertebrates this is the narrowest and least specialized part of the brain. In tetrapods, with complication of the local reflexes, it undergoes rapid evolution as the chief adjustor and integrator of these partial patterns. Certain organismic functions expressed as constitutional peculiarities are probably also regulated by the periventricular thalamic gray matter. Even in man these latter functions, as well as those generalized types of sensorimotor control called protopathic by Henry Head, appear to be mainly thalamic. The epicritic functions, on the other hand, involve a more refined analysis of experience than can be mediated by the thalamic type of adjustor. With the emergence of this more refined type of analysis, we find a corresponding enlargement and diversification of the sensory radiations which pass forward from the thalamus into the cerebral hemisphere. These systems of sensory projection-fibers and the separate cortical projectioncenters with which they are connected (somesthetic, optic, auditory, etc.) are extensions of the corresponding analyzers of the brain-stem, and for their efficient operation must be segregated and localized. This, in fact, is the arrangement found, and the cortical localization of projection-systems becomes more precise as we pass from lower to higher mammals. [211]

THE PROBLEM OF MENTAL DISORDER Parallel with this elaboration of the localized cortical analyzers there is still greater enlargement of the nonspecific and diffuse apparatus of integration, conditioning, abstraction, and synthetic functions in general. The tissue involved here is directly derived from the diffuse neuropil and reticular formation of the brain-stem, and the stages of its differentiation can be followed in the phylogenetic series. This is the internuncial tissue of Parker, the cortical associational tissue of human neurology. I t is this tissue which is so enormously increased when we pass from higher apes to man as to double the weight of the brain. The functions performed by it are various, including general and differential inhibition and facilitation of subcortical reactions, abstraction from complex experiences of common factors, synthesis of the abstracted features in new patterns, and the maintenance of the integrity of the personality during the flux of adjustment to countless external and internal events. In man, as in other animals, many of these functions are performed nonconsciously; but the distinctively human organization permits the fabrication of high-order symbolisms in mentalistic terms. These symbols are constructed from components of mixed experience which have been abstracted perhaps quite unconsciously; but when the symbol is consciously formulated it becomes available as a tool of types of semantic thinking (language, mathematics, and the like) which are forever impossible to animals like apes, which lack this kind of bodily organization. And evidently serious semantic types of mental disorder occur more frequently in those animals which have developed these semantic types of thinking at high levels of abstraction.6 The preceding paragraph, of course, includes an excursion into the realm of theory, but it has sufficient factual basis to justify further consideration, observation, and experimentation. Enough has already been accomplished to justify faith in the comparative method as a profitable approach to problems of human adjustment. With the help of guiding principles derived from study of more generalized brains and of direct experimental attack upon them by recently devised methods (including oscillographic records of action currents drawn off with microelectrodes) the fundamental features of cortical physiology can be discovered. I n the long view, and perhaps in the near future, continued research in these fields may be expected to yield results that will 6 A. Korzybski, Science and Sanity, Intern. Non-Arist. Libr., New York, 1933. [212]

NEURAL INTEGRATION AND NEURAL DISORDER clarify the obscure problems of both psychology and psychiatry. More precise knowledge of the organic mechanisms of cortical activity will surely hasten the day when our control of these processes, both normal and pathological, will be improved. Conclusion. A neurological survey of the vertebrates reveals two patterns of behavior and of adjusting mechanism which may be characterized as (relatively) rigid and labile, innate and acquired, conservative and progressive. Between these tendencies there is, by the nature of things, more or less rivalry, competition, or conflict. I n the lower vertebrates and in early embryonic stages of all vertebrates the stable patterns predominate; in the higher types, and especially in adult man, the labile, acquired or learned patterns predominate. This evolutionary sequence can be read in terms of both behavior and the structural organization of the brain. In the course of this evolution we can follow the transition from the simplest sort of mass-action to very complex reflex and instinctive patterns and from the latter to control of behavior by individually learned and cortically directed analysis of experience which culminates in the fabrication of conscious symbols and rational control. On the structural side we see a gradual transfer of the center of physiological dominance and integration from the midbrain to the strio-thalamic complex and, in the third stage, to the cerebral cortex parallel with the shift from physiological conditioning to intelligently directed motivation. The physiological conflicts to which reference has been made are resolved automatically in the lower ranks either by a biological readjustment of disturbed equilibrium or by elimination of maladapted individuals. I n mankind, where there is vivid awareness of some at least of the competing motivations, these internal conflicts assume the forms seen in the major psychoses. Yet the roots of these rivalries and antagonisms strike down very deeply into fundamental biological processes. The study of animal drives, especially under laboratory conditions where conflicts of motivation are experimentally set up and controlled, brings out in sharp relief some of the dynamic factors and the parts which they play in resolving problems of behavior. This always involves some disturbance of vital equilibrium or balance of adjustment among many bodily processes of the most diverse sorts. A lowered general vital tone from any cause may so depress the more sensitive higher adjustors [213]

THE PROBLEM OF MENTAL DISORDER as to release the primitive drives that ordinarily are kept under curb. Disturbance of the endocrine balance may result in differential effects on the various cerebral integrators with resulting disorganization of conduct. And within the brain itself, where integration is normally maintained by the interplay of numberless diverse neural mechanisms bound together in a fabric of inconceivable complexity, any enduring depression or abnormal excitation of any one of these component parts may disrupt the dynamic equilibrium of the whole so that well-controlled function is impossible. The higher centers of the brain, and the cortex of the cerebellum and the cerebrum in particular, contain tremendous reserves of potential energy of nonspecific sorts which may be and are drawn upon as needed to maintain the balance of ordinary adjustment. In functional disorders of the types just mentioned these reserves may be released with explosive violence and maniacal outbursts, or they may be cut off with resulting general depression. These fluctuations in energy-levels in functional disorders have their parallel in various organic disorders, though, of course, with different clinical pictures in accordance with the differences in the apparatus involved. Many cases of disorderly behavior of experimental animals show strikingly similar symptoms, and these can be systematically analyzed under laboratory control. Some disturbances of mental balance are readily corrected by removal of a single exciting cause, as by operation on a toxic goiter or relief from a financial or other worry. But most mental disorders are more complicated than this. Our conduct is motivated by a flowing network of events of extraordinary complexity. Of some of these we are conscious; others lie below the threshold of awareness. The strongest strands of this fabric are those biological impulsions of self-preservation and gratification of sense which are common to all animals—the elementary survival values. The most potent of these are normally for the most part nonconscious or dimly recognized. So far as they are nervous, these functions are controlled from the brain-stem. The conduct of the successful civilized man is not dominated by the primitive impulsions; these are kept under curb by intelligent analysis or intelligently acquired habits, a cortical function; motivation is rationally controlled. This control of subcortical by cortical functions always and inevitably involves rivalry and [214]

NEURAL INTEGRATION AND NEURAL DISORDER competition of motivations; this is the normal course of events, and in normal individuals the more acute conflicts are resolved after intelligent analysis and the integrity of the personality is preserved. If, as Coghill points out, the integrating apparatus is enfeebled or any one of the motivating factors is abnormally strengthened, there is temporary or permanent disturbance of mental balance. If the exaggerated motivating factor is below the level of awareness, the patient cannot by conscious effort restore the balance because he is ignorant of its cause. Here appropriately directed mental therapy may come to his rescue by bringing the concealed factor out into the open and so enabling him to evaluate it and to apply a rational control. Dr. Myerson's introductory paper in Section I I lays the foundation upon which this discussion has been elaborated. Dr. Wechsler says truly that comparative neurologists generally stress the fixity of structural patterns, and the same may be said of the human neurologists. But in both cases attention is now shifting to the variable factors in the situation, and as the bodily apparatus of these more labile functions is clarified psychiatry can receive more help from its basic sciences than has hitherto been available. Dr. Meyer's psychobiological analysis is directed toward the "reduction of man to singularity and unity." I t requires no elaborate argumentation to establish the fact that this unity, this integration of all vital processes at both nonconscious and conscious levels, is the primary and most fundamental of all biological phenomena. This unity is normally maintained by an equilibration of motivating factors among which there is more or less rivalry or antagonism, and if a practicable working balance cannot be maintained the psychobiological fabric will be torn apart with various pathological manifestations.

[215]

I X . GENERAL BIOLOGY A N D GENETICS By H. S. Jennings, Ph.D., Baltimore What lines of investigation in biology have proved useful for the theory and practice of psychiatry ? The progress of investigation in genetics has shown that all characteristics and properties of organisms, including those with which psychiatry deals, are products of the interaction of the materials with which the individual begins life, the genes that it receives from the parents, with the conditions under which the individual develops. Thus all characteristics are influenced both by the nature of the genes that the individual bears and by the environmental conditions, no characteristic being due to one of these classes of factors alone. By appropriately altering the genes, any and all characteristics of the organism can be altered. By appropriately altering the conditions of development, many of the characteristics of organisms can be altered. Different types of characteristics differ greatly in their susceptibility to change through alteration of genes or environment. The differences between individuals in respect to color of eyes, form of features, and the like, are almost entirely due to diversities in the genes borne by the different individuals. Diversities in mentality and behavior, on the other hand, may be due either to differences in the genes borne by the individuals or to differences in the conditions under which the individuals develop and live, i.e., differences in the experiences they undergo. The student of mental phenomena and the student of psychiatry are therefore bound to pay attention to both these classes of factors, if they are to make their analyses adequate. The Role of Genes. Individuals begin life with different sets of genes, derived from the two parents; they have correspondingly different characteristics, physical, physiological, and mental. (Some or all of these characteristics may be changed by altering the environment or conditions, as set forth later; here we deal only with diversities resulting from differences of genes under a uniform environment.) If the r61e of genes is to be clearly distinguished from the r61e of environmental conditions, it must be understood that it is only specified differences between particular individuals that can be attributed exclusively [216]

GENETICS AND DISORDER to genes or exclusively to environment. An example may make this clear. Is a dark complexion to be attributed to the effect of genes or to the effect of environment? (1) If we compare two individuals, one of whom is light, the other dark, while both have lived under similar conditions of exposure to sunlight, the difference between them is due to a difference in their genes. (2) But if the same dark individual, who has been much exposed to sunlight, is compared with another light individual that has not been exposed to sunlight, the difference between them is (or may be) due to the different conditions under which they have lived. Such a comparison of the characteristics of different individuals is essential for clear thinking on these matters. (To avoid multiplication of words, such comparisons will not in all cases be explicitly made, but they should be supplied mentally by the reader.) I t has been shown that there exist many defective genes, and that to the presence of these are due many weaknesses and defects in developed individuals, including mental weaknesses and defects. (That is, the difference between such defective and normal individuals is due to the difference between defective and normal genes present in the two classes.) The incidence and behavior in inheritance of such weaknesses and defects are determined in large measure by the method of action of the genes, their reactions to environmental conditions, and thenmethod of distribution from parents to offspring. The relations just set forth have been discovered and demonstrated in two main ways. On the one hand, the genes are distributed from parents to offspring in peculiar and extremely characteristic ways. Characteristics that depend on differences between the genes of the different individuals follow in inheritance these unmistakable methods of distribution; the rules of Mendelian and sex-linked inheritance. Any characteristics that are inherited in these ways are thereby shown to depend on differences in the nature of the genes of the different individuals. The second and still more exact method of determining what characteristics are affected by the nature of the genes is through the study of identical twins, in comparison with other individuals, and particularly in comparison with twins that are not of the identical or one-egg type. Identical or one-egg twins have the same genes throughout; the two are derived from one single egg which has developed two centers of growth, and each of the twins [217]

THE PROBLEM OF MENTAL DISORDER has the set of genes that was present in the single egg. All other individuals are diverse in their gene-combinations; this is true also of the fraternal or two-egg twins, derived from separate eggs with unlike sets of genes. I t thus becomes possible to determine what characteristics are alike when the gene-combinations are alike, and what are diverse when the gene-combinations are diverse. In this way, by the studies of Muller, Newman, Hirsch, Lange, and many others, it is demonstrated that all classes of mental characteristics, all temperamental and intellectual peculiarities, are deeply affected by the nature of the genes. I n general, the progress of genetics has made it clear that (as might be expected) there are no characteristics of organisms whatever that are not affected by the nature of the materials of which the organism is made, that is to say, by the genes. For understanding the relation of mental disorders to genes, certain facts, often misunderstood, must be held in view; facts regarding the nature of the genes, their method of action, the relation of their action to that of other agencies, and the way in which the genes are distributed to the offspring at reproduction. The main points may be summarized as follows. The genes are the preparatory stages or 'germs* of all the chemical materials which later play a role in development and functioning; the enzymes, hormones, secretions, tissue-differentiations, and the like. They are a set of diverse reagents, present in great number (five hundred to one thousand or more) in the nucleus of the fertilized egg, and passing thence into all the cells of the body. The operation of the genes is by interaction; with the cytoplasm of the cells, with the products of other genes, and with agents from outside the organism. Through these means the mature individual is produced, its characteristics depending largely on the nature of the genes with which it began life. Any part or characteristic of the individual requires for its development the cooperation of many genes. There is indeed reason to believe that all of the many genes affect all parts of the body. But in addition to their general effects, some of the genes affect more strongly certain particular parts or functions, others other parts; and these specific effects of particular genes are very marked. By modification or imperfection of any one or more of the many genes that cooperate to produce a part or function, that part or [218]

GENETICS AND DISORDER function may be greatly modified or rendered defective. Imperfection of even a single gene of the great number that are at work, may very greatly change the part; may have a very great effect, as the effect of a physician's prescription is greatly changed by alteration of a single ingredient. Imperfection of a particular single gene in Drosophila results in an individual that completely lacks eyes. Imperfection of a single gene in man may possibly result in feeble-mindedness or in other serious defects. (These relations are discovered through the fact that such defects show the characteristic 'single-gene inheritance.') In such cases it must be conceived that the single gene in question plays an important r61e in laying the very foundation of the organ or part, so that when that gene is defective, the part is either not produced at all or is produced very imperfectly. In all such cases it can be clearly demonstrated that many other genes play a role in producing this part, but that their product is imperfect when an important single gene fails. By imperfection of any of the other cooperating genes, some other change or defect in the product is brought about. Thus defectiveness or weakness of any part or function, as in the brain or other part of the nervous system, may result from imperfection of any one or more of many different genes carried by the individual. The Role of Environmental Conditions. What a given set of genes shall produce is greatly influenced by the conditions to which the developing individual is subjected. This is shown strikingly in the development of the various cells of which a single individual is composed. I t can be shown that all (or most) of the cells of the young embryo contain all the genes, and that each cell can produce any part of the body. Transplantationexperiments show that this is due to diversities in the cellular environment. What the genes of a given cell shall produce depends on the surrounding conditions. Under one set of conditions they produce a part of the eye; under another set of conditions a part of the ear, or of the spinal cord, or of the skin. The nature of the individual produced by a given set of genes also depends in large measure on the conditions to which the genes are subjected. A set of genes that under usual conditions produces an individual with the female secondary sex characters, will, when subjected to the male hormone, produce the male secondary sex characters, and vice versa. A set of genes that produces under usual conditions an axolotl, brings forth, when [219]

THE PROBLEM OF MENTAL DISORDER subjected to an active thyroid secretion, a very different creature, an amblystoma. Modified or defective genes that under certain conditions produce an individual that is defective, may under other conditions produce an individual that is normal. I n the fruit fly, a certain defective gene produces 'abnormal abdomen' when the individuals are developed under moist conditions; not when they develop under dry conditions. But without the defective gene, 'abnormal abdomen' is not produced under either set of conditions. Another defective gene produces at low temperatures supernumerary legs, but not at higher temperatures. A third produces gigantism, provided the young are well-fed at a certain period in their lives; otherwise it does not yield gigantism. In all these cases, diversity of environment may make all the difference between a normal and an abnormal individual. To understand the results, then, both the nature of the individual's genes and the nature of the environment under which he develops must be considered. Altering either one may alter the type of individual produced. There is reason to believe that such relations are extremely common, particularly in connection with physiological and mental disorders. There can be no doubt, in view of the observed facts, that individuals having certain combinations of genes are more liable to tuberculosis or to diabetes than those bearing other combinations. But the conditions under which the individual lives are the finally decisive factor in determining whether he shall fall a victim to tuberculosis (or to diabetes); it is these conditions that must be made the point of attack in warding off the disease. Even with relation to acute environmental difficulties, the genes play a r6le. There can be little doubt that, other things being equal, some genetic constitutions are more readily attacked by plague, by smallpox, by typhoid, than are others; just as some combinations of genes yield more readily to extremes of temperature than others; just as some combinations are more likely than others to come off victorious in a struggle with a wild cat, or to survive a bite from a rattlesnake. I n all these things the nature of the genes has a r61e; the nature of the environment a still more important r61e. There is reason to anticipate similar situations in the relations of genes and environment to mental defect. At one extreme may be found cases in which mental defectiveness has resulted from injuries at birth, from accidents, or from contagious diseases. [220]

GENETICS AND DISORDER In such cases the nature of the genes carried by the individual plays little or no part. At the other extreme may be found cases in which there exist defective genes having consequences so serious that the best environment can do little or nothing to remedy the injury so produced. Such defects should show typical inheritance, by the Mendelian or sex-linked methods. Between these extremes should be found an entire series of gradations from cases in which weak or defective genes are the main cause of the defect, with a possible ameliorating effect from favorable environmental conditions, to cases in which the derangement is due, in the main, to difficulties and troubles that the individuals meet in the course of life, the genetic basis merely yielding to the trouble more readily in some combinations than in others. Only in the cases in which the mental defect is clearly due to defectiveness of a single gene, and hence shows Mendelian or sex-linked inheritance, is the relation between the genes and the defect to be considered of a specific character. I t is to be anticipated that there will be many grades of susceptibility to mental disorder, depending upon many diversities in gene-combinations. I t is to be remembered that no two individuals (except in identical twins) are alike in their gene-combinations; there may be expected, therefore, a great range of diversity in susceptibility. Whether these expected conditions are realized can of course be determined only by those expert in these fields, by the psychiatrists themselves. As is well known, there are indications that some cases of feeble-mindedness fall at one end of the scale, being due to birth injury or to acute disease or the like; while other cases fall at the other extreme, being inherited in Mendelian fashion, and hence the direct result of single defective genes. Some types of mental disorder have a higher incidence in certain families, and this indicates that defectiveness of genes plays a r6le in their production, although environmental difficulties may be required to bring them out. In many cases environmental factors may be the main occasion for the onset of a mental disorder, although the genes play a r61e in that certain gene-combinations succumb more readily than others. There is, from the standpoint of the geneticist, no reason for assuming, for any type of mental disorder, that the cause must be sought exclusively in gene-defects. I t would be disastrous if recognition that [221]

THE PROBLEM OF MENTAL DISORDER genetic factors play a r61e in mental disorders should lead to neglect of environmental factors. For the study of those types of mental disorder which result mainly from gene-defects, or in which gene-defects play a conspicuous role, it is necessary to have in mind the peculiarities of inheritance of such characteristics. Characteristics resulting from peculiarities of particular genes show a puzzling hide-andseek behavior, in their descent from parents to offspring, that for centuries baffled investigators, and still presents difficulties, although the key-relations have been found. The essential points for understanding how such inheritance occurs are perhaps the following: (1) The many genes are arranged in the cells in linear series, like strings of beads. Each gene, having a specific effect, has its invariable place in the series, so that by proper means it can be located and named or numbered. (2) There are two such series of genes in the fertilized egg, one series coming from the father, one from the mother. (3) Thus the genes are in pairs, one of each pair derived from each parent. Each parent thus contributes one gene of each of his pairs to each of the offspring. (4) The two members of any pair of genes have in general the same function, but one may perform this function in a somewhat different way from the other. One gene of the pair from father or mother may be defective, inferior, or modified in various ways. In some cases both genes of a pair may be defective; or both may be without defect. When one gene of a pair is defective, the other not, there are two possible results, observed in different cases. a. Usually the gene that is not defective performs the required developmental function perfectly or nearly so, so that the individual manifests no defect; the defective gene produces no consequences. I n such a case the defect is said to be recessive. Only if both the genes of the pair are defective, is the defect manifested and the individual is feeble-minded or the like. Such defective recessive genes are carried singly by many normal persons. When such normal individuals mate, some of their offspring will receive a defective gene of the pair concerned, from each parent, so that such a child will manifest the defect. Other children of the same parents will receive no defective gene or only one; these will be normal. These will in such cases be on the average about three normals to one defective child. b. But there are defective genes whose effect prevails over that of an accompanying normal gene; such prevailing genes are said [222]

GENETICS AND DISORDER to be dominant. In such cases the individual having but one gene of the pair defective will manifest the defect. And half of his children will receive the dominant gene, and will likewise manifest the defect (unless the surrounding conditions are such as to counteract the effect of the defective gene). The defective individual bearing two recessive defective genes gives, when mated with a normal individual, offspring that do not manifest the defect, since they receive one dominant normal gene from the normal parent. I n later generations the defect is manifested again when two of the defective genes get together in the same pair. The defective single individual that bears in one of his pairs two dominant defective genes, when mated with a normal individual, yields offspring that are all defective, since each receives a dominant defective gene from the defective parent. Two defective individuals, each carrying in the same pair one dominant defective gene, will yield offspring most of which are defective, since they receive one or two dominant defective genes. But about one-fourth of the offspring will receive a normal gene for this pair from each parent, and these individuals will not be defective. A further complication in the rules of inheritance results from the fact that two parents may manifest similar recessive defects, and these may be due either to defects of the same pair of genes in the two, or they may be due to Jefects of different pairs of genes in the two. The results in inheritance are very different in the two cases. If the two defective parents have their recessive genes in the same pair, the offspring are all defective, like the two parents. For each of the offspring receives a defective gene for that pair from each parent, hence each must manifest the defect. But if the two defective parents have their two recessive defective genes in different pairs, the offspring do not manifest the defect; they are all normal. For suppose that one parent has both genes defective in pair 2, but both genes normal in pair 4, while the other has both genes normal in pair 2, both defective in pair 4. Then each of the offspring will get a normal gene in pair 2 from one parent, a defective one from the other; a normal one in pair 4 from one parent, a defective one from the other. A normal gene will then be present in both pairs, and as the defect is recessive, none of the offspring will be defective. Defective parents may thus produce normal offspring. [223]

THE PROBLEM OF MENTAL DISORDER Still further complexities in the rules of inheritance result from the way the genes are grouped in the cells. As before set forth, the genes are arranged in serial order, like a string of beads. But not all are in a single series; rather is the string of genes divided into a number of sections, which are known as chromosomes. In man the string of genes from each parent is divided into twenty-four independent sections, so that when the two are brought together in the fertilized egg there are forty-eight sections or chromosomes. As a rule (but with exception due to 'crossing over'), all the genes that are together in one section go together into the offspring. But genes of maternal origin, for example, that are in one chromosome, may go to one of the offspring, while the maternal genes of another section go to a different one of the offspring. To this is to be added the fact that one of the twenty-four pairs has in the male no functional mate, so that in the male the genes of this chromosome are not in pairs, while the corresponding ones of the female are in pairs. Characteristics depending on the genes in this chromosome are therefore inherited in a different manner from the others; they show 'sex-linked' inheritance, while the rest show typical Mendelian inheritance. Thus the precise method of inheritance of any defect depends upon just where in the sectioned string of genes is located the defective gene to which it is due; as well as upon whether that defective gene is dominant or recessive. All this makes the determination and prediction of the method of inheritance of any defective condition a matter of much complexity, dependent on precise knowledge of the structure and physiology of the system of genes in that particular organism. Such knowledge and predictability have reached a high degree of adequacy for certain organisms. But unfortunately this cannot be said for man; many years must elapse before detailed knowledge of his genetic system will be available. When to these difficulties inherent in the complexities of the genetic system are added the difficulties due to the fact that environmental conditions may make a great difference in the results produced by a given set of genes, it becomes clear that the adequate investigation of the relation of the genetic system to mental defects and disorders meets with great difficulty. I t can be carried out only by the aid of persons expert in the study of the mental delinquencies. [224]

GENETICS AND DISORDER For cases resulting from a seriously defective genetic constitution, where there is little or no chance for aid through the environment, the cutting off of the propagation of the individuals bearing the defective genes is the only effective measure of control. This measure is not of simple application, since, if the defective genes are recessive, as is very often the case, many normal individuals carry them and may transmit them to descendants, where they may manifest themselves in mental disturbance. These normal carriers of defective genes are much more numerous than the actually defective individuals, so that the difficulty they present is serious. Defective genes of a given type are rare as compared with the normal genes of the same type. (If the number of individuals bearing normal genes of the given pair is originally n times as great as the number of individuals having the genes of that pair defective, then, in later generations, provided there is random mating with respect to these genes, the number of normal carriers of the defective genes is %n times as great as the number of actually defective individuals.) In such cases of serious mental disturbance resulting from an irremediably defective gene, the cutting off of the propagation of the actually defective individuals is of course indicated, if control of the disorder is to be undertaken. But, in addition, investigation is required to determine, so far as is possible, which normal individuals carry the defective genes, in order that they too may be prevented from propagating. Thus the lines of further investigation likely to be helpful in these relations are somewhat as follows: 1. Family histories need to be obtained, so far as possible, showing the incidence of mental disorder in successive generations. For determining the type of inheritance involved, as many individuals as possible should be included, those free from mental disorder as well as those affected. The history of at least three generations is requisite for determining certain types of inheritance. A general recording of family histories in the population, such as is attempted on the Eugenics Record Office at Cold Spring Harbor, N. Y., will, if it is ever realized on a large scale, be of very great value in this and similar studies. Examples of the required types of pedigrees will be found in the works of Baur, Fischer and Lenz, and of Gates.1 1 E. Baur, E. Fischer and F. Lenz, Human Heredity, New York, 1931; R. R. Gates, Heredity in Man, London, 1929. [225]

THE PROBLEM OF MENTAL DISORDER

2. From these family histories or pedigrees the type of inheritance needs to be determined. For this purpose one should make oneself acquainted with the course of two main types of inheritance, the typical Mendelian or autosomal, and the sexlinked, as manifested both when the defect in question is dominant and when it is recessive; also with the rare possibilities of inheritance through the Y-chromosome (in the male line only). Such a textbook as that of Sinnott and Dunn's Principles of Genetics2 will be useful for this purpose. I t is unfortunately a fact that when the type of inheritance for a given type of disorder is determined for a certain family history or pedigree, one cannot certainly know that in other families the same type of inheritance will be found. This is because disorders of similar character may result from defects of different genes, and the type of inheritance depends on where the particular defective gene is located, in the case of the particular family dealt with. Also, it is known that similar defective conditions are inherited in some pedigrees as dominants, in others as recessives. Thus for each affected family the method of inheritance needs to be worked out separately by an examination of its history. 3. One must discover whether the incidence of the disorder is determined entirely by the possession of the defective gene or genes; or whether it is dependent also on environmental conditions. I n the latter case, the family pedigree will show some individuals normal that on exclusively genetic grounds would be expected to be abnormal. Such situations are very common. Only by thus determining the method of inheritance of the particular disorder in the given family history does it become possible to discover how the disorder can be controlled in future generations, by preventing the propagation of individuals bearing the defective genes resulting in the disorder. I t appears probable that for some kinds of mental disorder this method of control may become of great importance. I n other types of mental disorder, on the other hand, peculiarities of the genes presumably play but a subordinate r6le. In such types, environmental control offers the only hope of amelioration. I t is for psychiatrists to determine to which types actually occurring cases belong. 2 E. Sinnott and L. C. Dunn, Principles of Genetics, McGraw-Hill Book Company, Inc., New York, 1932. [226]

X . H U M A N CONSTITUTION By W a l t e r Freeman, M.D., Ph.D., Washington From early times it has been recognized that constitution has much to do with bodily disease, but constitutional factors in mental disease have been much less studied. Scientific investigation in this field, as in so many other branches of human knowledge, has followed the penetrating observations of poets and playwrights. There is little in the medical classics showing even an appreciation of the concurrence of certain types of body-form and peculiarities of behavior, and as late as the time of Spurzheim it was stated that melancholia could occur equally in the sanguine and the bilious temperaments. The first serious search for physical correlates of behavior was by Lombroso among criminals, and the doctrine of physical stigmata grew to overwhelming proportions until control investigations revealed similar defects in bodily make-up in individuals whose social behavior was entirely exemplary. The good in Lombroso's work was largely lost in ridicule. With the growth of physical anthropology, investigations extended from the delineation of racial peculiarities to similar studies upon the more homogeneous material of single population groups. The age-old tendency to classify and codify was responsible for the division of all individuals into two or more types, the number of classifications now rapidly approaching legion: the herbivorous and the carnivorous; the mesontomorph and the hyperontomorph; the linear and the lateral; the cerebral, respiratory, digestive, and muscular; the asthenic, athletic, and pyknic—to mention but a few. I t seems to be the general rule that anyone who starts out to classify human beings begins by condemning other forms of classification, showing the errors and fallacies of trying to classify, and then proceeds to erect a personal system which has all the advantages and none of the disadvantages of previous systems. Sic semper! The stage of direct measurement was followed, or better accompanied, by the calculation of indices comprising two or more measurements. This reached its high point in the study of Wertheimer and Hesketh,1 who calculated thirty-seven various 1 F. I. Wertheimer and F. E. Hesketh, The Significance of the Physical Constitution in Mental Disease, Baltimore, 1926. [227]

THE PROBLEM OF MENTAL DISORDER indices from fifty-three measurements upon a material scarcely larger than the same number of patients. These authors finally chose one of their own devising, expressed as follows: leg length X 1000 transverse chest diameter X sagittal chest diameter X trunk height As an index it is good though slightly cumbersome. I t does what all others do, divides the group into several classes with a unimodal frequency distribution. No single index or even index of indices has satisfactorily shown anything but a unimodal frequency curve with typical contrasting examples at either end and less characteristic intermediary types in between. Selected groups unquestionably show preponderance of this or that type of make-up, depending upon the criterion of selection. Thus the Pignet index will average much higher in the schizophrenic than in the manic-depressive, but it will not separate the two groups from one another. While it is true that any group of individuals can be arranged in a homogeneous series from one end to the other by using a single criterion, such as body-length or costal angle; and by using any single index it is also true that average measurements of an unselected group may be misleading. The 'average soldier' that was depicted as the result of averaging the measurements obtained on the first million draftees in 1917 was probably not exactly duplicated by any one of the subjects, and if he had been, his normality might have been called into question, at least from the artistic standpoint. I t still remains to be shown whether an unselected group of individuals can be divided into classes on the basis of physical measurements without considerable overlapping in the indeterminate middle zone. The study of correlations between somatic factors and visceral, behavioral, and sociological factors may be approached from at least two directions. Graves, for instance, has studied intensively a single structural feature, the inner border of the scapula, in relation to age, sex, race, visceral disease, social position, mental capacity, mental reaction, and so on. Pende,2 on the other hand, picks out characteristic examples of endocrine 2 N. Pende, Constitutional Inadequacies (trans, by Naccarati), Philadelphia, 1928. [228]

HUMAN CONSTITUTION disorder, and then separates his material into various groups tending to resemble now one, now another, of these types. The correlation of physical types with visceral disease has been carried to its acme by Draper,3 who recognizes a peptic-ulcer race, a gallstone race, a pernicious-anemia race, and more recently a poliomyelitis race, based particularly on the characteristics of the face, the measurement of the gonial angle, the interpupillary distance, the length of the middle face, etc. The most important phase of the study of physical types in relation to mental disorders was begun by Kretschmer in his justly celebrated Physique and Character.4' He showed statistically what had long been recognized by clinical students, that there was a very definite relationship between the asthenic habitus and the schizophrenic syndrome, and between the pyknic habitus and the manic-depressive syndrome. His work went farther than previous classifications, mostly through the separation of intermediate bodily types upon which he conferred the designation athletic. Moreover, Kretschmer was largely responsible for a valuable and apparently valid psychiatric classification, splitting off the paranoid types from the other two forms of mental reaction. Lewis ably followed this lead, showing that the overcompensating forms of schizophrenia, characterized by systematized delusions, should be classified apart from the ordinary dementia precoxes. Lewis was inclined to lay the blame for such differences upon the endocrine and circulatory systems, but his data have not been sufficiently elaborated to find justification. No matter what the angle from which one approaches the problem of human constitution in relation to mental disease, one is met with the possibility of alteration of the individual from one type to another during development. This was well expressed by Jelliffe, who cited himself as a characteristic example of adolescent introverted asthenic, collegiate athlete, and mature pyknic extrovert. Most individuals can find in their past some change, both in physical type and in mental outlook.5 3 G. Draper, Disease and the Man, New York, 1930. 4 E. Kretschmer, Physique and Character, New York, 1925. 6 Perhaps this is the criterion of normality. After listening to a contribution by me, describing ways of distinguishing the schizoid from the paranoid and from the cycloid, a physician laughingly said: "Doc! Them's my symptoms exactly. I've got 'em all." The retort courteous was, "That proves you're normal." [229]

THE PROBLEM OF MENTAL DISORDER I t seems reasonable that outstanding types of behavior should develop early and remain relatively pure throughout life, just as some people are asthenic and some pyknic throughout life, but the great majority of individuals would seem to be pluripotential, at least in some degree, both in regard to behavior and to bodytype. Otherwise there would be a much greater divergence of both physical and mental types than is shown by the general population. A further complication is the imposition upon the bodily structure of the mental reaction of some disease that brings about significant alterations in soma and psyche. I need not for the present remark upon such entities as hypothyroidism or dyspituitarism, but rather consider the development of an asthenic state in the emaciation dependent upon tuberculous or cancerous disease, and the psychoses conditioned by syphilis or arteriosclerosis of the brain. That there are symptomatic psychoses is quite obvious, just as there are symptomatic epilepsies. The important feature lies in the fact that persons react differently to their organic braindisease. One individual will develop the systematized delusions of a paranoiac, while another will show the silly behavior and hallucinations of a schizophrenic in response to cerebral arteriosclerosis or syphilis. The point at issue is: Does the behavior of the individual, when his brain has sustained damage, reveal the fundamental nature of his personality, and is such an individual to be classed respectively as a paranoid or a schizoid, comparable to the individuals who have developed similar behavioristic patterns without any visible structural alteration in the brain? The answer will probably depend upon the findings in the constitutional sphere, since our means of anatomical investigation of the brain are so pitifully inadequate in contrast to our psychological methods. If it can be shown that the paranoid individual is much the same in physical type and chemical type whether his brain does or does not show the lesions of syphilis, a considerable step in advance will have been taken. The problem is made more difficult by the fact that individuals showing symptomatic psychoses may present the characteristic symptoms in diluted form, and also that the organic features of the psychosis, directly conditioned by the disease of the brain, may overlie and more or less conceal the underlying deviation in personality. This latter factor would seem to be operative [230]

HUMAN CONSTITUTION particularly in dementia paralytica, the excitement and elation during the early period tending to place the individual in the cyclothymic group, while in the later course of the disease, or after the paretic process has been arrested by the exhibition of malaria, the individual may deteriorate into a typical schizophrenic. This same problem, of course, is met with in other psychoses whose genesis is obscure, so that it is only by continued observation of the patient, by longitudinal section, so to speak, that the correct diagnosis is made. Many patients with organic disease of the brain do not live long enough to allow this period of prolonged observation, however, and errors in diagnosis are certain to be made. Nevertheless, if one is to classify, the data available are those upon which the classification must be made. Human constitution has been likened by Pende to a pyramid, the base of which is formed by heredity, and the three faces respectively, the structural, chemical, and psychological facets of the whole personality. No study is complete, therefore, which leaves out of consideration the chemical aspects. The immensity of this side is indicated not only by the organic and inorganic constitutions of the body, but also by the endocrine secretions, the serology, and the whole field of immunities and susceptibilities to disease. Studies of the chemical constituents of the blood have yielded relatively little useful information in the differentiation of the various types of the psychoses. I t is true that the blood-sugar tends to be low in dementia praecox and high in manicdepressive psychosis, and that the water balance is quite labile in the latter. However, one is always faced with the presence of wide variations of blood-sugar, as well as of other constituents, in individuals whose mental processes are entirely normal. Moreover, the symptoms brought out by severe departures from the normal in the chemical constitution of the blood bear little resemblance to the manifestations of the psychoses of which we are speaking. The symptoms produced by drugs are to be subjected to critical evaluation in the same way before arriving at conclusions. Manic-depressives are more sensitive than are schizophrenics to the action of ephedrine and to various biologicals such as thyroxin and epinephrine. Drugs that produce significant mental symptoms do not bring out a single typical reaction in every individual, even of the same mental reaction-type, and they do not duplicate and seldom even imitate any of the major deviations. Some of them, however, [231]

THE PROBLEM OF MENTAL DISORDER such as alcohol, will apparently suppress controlling factors in the individual's personality, permitting the appearance of underlying mechanisms of one type or another. Here again, however, the characteristic symptoms of alcoholism may overlie and obscure the basic trends of the individual's personality, so that no drug method has been found of great service in distinguishing the underlying trends of normal persons. The pharmacodynamic tests as ordinarily used to distinguish the vagotonic from the sympathicotonic, while valuable in outstanding cases, yield conflicting results when applied to unselected cases. The field of endocrinology has been a fertile one for those who would thus explain mental abnormalities. Certainly there are examples of psychoses associated with abnormality of one or another of the endocrine glands. The only one worthy of consideration, however, is the common concurrence of schizophrenic symptoms with underactivity of the thyroid, and their clearing when the deficiency is rectified. Nevertheless, schizophrenia occurs without thyroid deficiency in six times as many cases, and many examples of known thyroid deficiency show none of the schizophrenic mental aberrations. I t remains to be shown whether any other glandular disturbances are similarly connected with mental deviations. This division of constitutional investigation depends upon the isolation, biological assay, quantitative determination in the circulation, and effects of substitutiontherapy, of the various endocrine products. This problem is well under way at the present time, and the results may prove extremely gratifying. Another method of investigation of the endocrines in their relation to the mental reactions is the study of the glands themselves as obtained at necropsy from psychotic patients. There are many complications to this problem. The involution, senescence, and pathologic changes may prevent any estimate of the functional capacity of the gland under investigation. The gross measurements can hardly take into consideration the component parts existing in most of the endocrines, and the histological details are so variable that false deductions may be drawn. This particular problem, however, is under investigation at the present time at St. Elizabeth's Hospital, where some twelve hundred cases have been submitted to comprehensive biometrical study. I t seems not improbable that certain gross differences will be found in the endocrines among the schizo[232]

HUMAN CONSTITUTION phrenics, the paranoids, the cycloids, and the epileptoids, but the component parts and the functional capacities of the glands can hardly be surmised even roughly from average figures for weight. The causes for the psychotic reaction-types will not be found in the endocrines. Studies in metabolism are yielding some interesting data, showing that people differ in the activity of their chemical processes just as much as in their physical habitus. This is not remarkable, but some insight into the nature of the psychoses is to be expected from further investigations in this field. I have dealt with a few of them in a paper entitled Psychochemistry. I mention these considerations here merely to emphasize the importance of the chemical aspects of the personality. Finally, peculiarities in susceptibility and resistance to disease in relation to personality-reaction furnish some of the most interesting and suggestive leads to further research. Lewis has dwelt upon the susceptibility of the schizophrenic to tuberculosis and of the paranoid to malignant disease, and I have elaborated somewhat upon this feature.6 Moreover, the incidence of tuberculosis has been found to be greater in the families of schizophrenics than in the families of manic-depressives or in the general population, while the incidence of diabetes has been found greater in the families of cycloids than in those of others. Diabetes and epilepsy would seem to be as much polar opposites as Graves' disease and myxedema. Conclusions. The study of the constitution will reveal welldefined constellations such as the asthenic-tuberculous-schizophrenic, and the athletic-cancerous-paranoid, the pyknic-angiopathic-cycloid, the dysplastic-exudative-epileptoid. The study of the constitution will reveal the slight part played by the endocrine glands as such (with the exception of the thyroid) in the development and direction of the psychoses, and the dominant position of these glands in the ordering of bodily growth and form. The study of the constitution will thus clear the field for more penetrating researches on the chemical aspects of the problem of mental disease, and dissolve the mists that surround the one irresistible conclusion that faulty cortical function is synonymous with psychosis. 6W. Freeman, Psychochemistry, J. Amer. Med. Assn., 97, 1931, 293; The psychological panel in diagnosis and prognosis, Ann. Int. Med., i, 1930, 29. [233]

X I . ENDOCRINOLOGY By R. G. Hoskins, Ph.D., M.D., Boston With the exception of a few 'organic' psychoses, such as general paresis and psychoses dependent upon the degenerative conditions of old age, surprisingly little is known of the etiology of the mental disorders. Several lines of evidence suggest that the 'functional psychoses,' schizophrenia, involutional melancholia, cyclothymia, and others, are in general dependent upon two sorts of causes. As in many other disorders, we have to distinguish the 'predisposing cause' and the 'precipitating cause.' That the functional psychoses are immediately brought about by emotional stresses seems, in many cases at least, to be sufficiently evident. That they arise only in soil previously prepared for them seems, on the whole, equally evident. I t would appear that many individuals go through the most acute mental torment to emerge but the stronger for the experience, while others become psychotic with only trifling antecedent emotional stress. To the extent that the psychoses are conditioned by 'hereditary tainting' the conception of a causal liability-factor is inescapable. The fact that double incidence of psychoses in monozygotic twins as compared with ordinary siblings is of notably high occurrence points of course in the same direction.1 The problem of participation of the endocrines in the psychoses demands consideration as regards the r6les of these glands both as precipitating and as predisposing factors. In those cases in which an endocrinopathy leads to personal disfigurement, as in acromegaly or thyroid obesity, the subjects may suffer from long-continued chagrin of an intensity that well might precipitate mental derangement. The "inferiority complex" of Adler would thus be set up with diagrammatic clarity. Likewise, a deficiency in strength and vigor that is characteristic of many endocrine disorders leads often to chronic failure or mediocrity in accomplishment with consequent worry and discouragement from which the subject may take flight into a dreamworld (schizophrenia) or into activity (hypomania), or he may waste 1 D. G. Humm, Mental disorders in siblings, Amer. J. Psychiat., 12, 1932, 239. [234]

ENDOCRINOLOGY his life in futile psychic conflicts (psyche-neurosis). The hormones may also play a part as predisposing causes in establishing a defective milieu in which the psychoses arise. The hormones have a primary influence upon brain and body development. They seemingly exert throughout life a crucial regulatory influence upon both brain and body, and they may even play a part as a direct factor in affectivity. On a priori grounds, then, we might anticipate that the endocrine glands would play an important r6le in the etiology of the psychoses. That they actually do, the evidence is by no means conclusive. The problem presents three outstanding aspects: first, Is there a significantly high incidence among psychotics of the morphological stigmata of endocrine abnormalities? Secondly, Are the physiological and the metabolic functions distorted in the psychoses as they are in endocrine disorders? And, thirdly, Do the endocrine glands of the psychotic subjects show characteristic pathological changes ? As to morphological stigmata, the evidence is suggestive but not compelling. Kretschmer's studies on the constitutional concomitants of the psychoses are well known and in general support the thesis that mental disorders are especially likely to arise in a dysplastic body. More recently Wertham has reported a study of bodily abnormalities in 923 unselected psychotic patients.2 He considered skeletal abnormalities, lack of symmetry, bodily disproportions and malformations, anomalies of primary and secondary sex characteristics, of fat distribution, of hair distribution, and of complexion. More than a third of his schizophrenic group showed such disorders. The 'thymolymphatic constitution' seems to predispose to psychosis. This is a condition marked by scanty beard, axillary and sternal hair, slender thorax, rounded contour of the upper arms and thighs, and genital hypoplasia. Such constitutional deviations are interpreted by most students as commonly due to endocrine abnormalities. Altogether the gross morphological evidence lends some plausibility to the theory that endocrine abnormalities are important in the genesis of the psychoses. Rather more weight can be laid on the evidences of deviations from metabolic normality in the psychoses. I t is a truism of modern physiology that metabolism is intimately under the 2 F. I. Wertham, The incidence of growth disorders in 923 cases of mental disease, Arch. Neur. and Psychiat., 21, 1929, 1128. [235]

THE PROBLEM OF MENTAL DISORDER control of the hormones. I t is likewise sufficiently evident that metabolic deviations are characteristic of the major psychoses. Schizophrenia is marked by a generalized hypometabolism, manifested particularly in a reduction of the basal metabolic rate, the basal blood pressure, and the basal circulation rate. This basal hypometabolism, however, is so frequently submerged by the ability of the individual temporarily to rise to normality under stimulation as to have escaped detection at the hands of more than a few investigators. The characteristic is to be brought out convincingly only in subjects so habituated to testing as to be capable of being studied in a basal as contrasted merely with a quiescent state. Our own studies point toward the conception that the most fundamental metabolic characteristic of this psychosis is defective oxygen-assimilation. The fact recently emphasized by McFarland that numerous schizophrenic traits can be induced in the normal subject by exposure to atmosphere of low oxygen-tension supports this conception.3 The other psychoses have been less intensively studied in their metabolic aspects, but these too, as pointed out by Wexberg, show characteristic deviations from normality.4 I t would seem probable that, given the necessary technical competence, the metabolic pictures of all the psychoses could be reproduced by suitable combinations of endocrine deficiency and hyperactivity. I t is correspondingly probable, then, that the metabolic disturbances of the psychoses could be produced by the operation of endocrine factors, whether as a matter of fact they are so produced or not. The involutional psychosis arising at a period that is characterized by disturbances of endocrine balance is particularly suggestive in this connection. The cumulative weight of these considerations, however, as evidence of endocrine etiology of the psychoses is by no means conclusive. The possibility remains open that the metabolic disorders may result from, rather than cause, the psychoses. I t is likewise not improbable that a completely parallel series of abnormalities could be set up by disordered functions of the hypothalamus, as indeed the classic endocrinopathies themselves might be. We come then to the question, Do the endocrine glands of psychotics commonly show structural abnormality? Here 3 R. A. McFarland, The psychological effects of oxygen deprivation (anoxemia) on human behavior, Arch, of Psychol., 1932 (no. 146). 4 E. Wexberg, Die objektiven kbrperlichen Symptome bei funktionellen Psychosen, Zentbl. f. d. ges. Neur. u. Psychiat., 35, 1924, 1. [236]

ENDOCRINOLOGY again we are confronted with a fundamental ambiguity. A high incidence of pathological changes in the glands has been reported by numerous investigators. But unfortunately the material for study has been collected almost exclusively from subjects dying of intercurrent organic diseases, and the question remains whether the pathological changes are due to these alone. Thus the conclusion from the convergence of the three lines of evidence just discussed is that the psychoses may be importantly determined by antecedent or concurrent endocrine abnormalities, but that none of the evidence compels that conclusion. Corresponding interest attaches to the relationship between deviations in personality—which are the essence of the psychoses, superficially considered—and the hormones. I t is probable that, had the psychology of the hormones been investigated as searchingly as have the physiology and the functional pathology, we should now recognize that the endocrinopathies are characterized by quite as marked repercussions in the personality as in the organic functions. I t is unfortunate that competent psychologists have been little attracted to endocrinology and that endocrinologists have shunned the intangibilities of psychology. Thyroid deficiency, when present to a degree to cause myxedema or cretinism, commonly results in a marked slowing of the mental processes and in a 'washing out' of the personality. Less widely recognized but equally characteristic, however, are irritability and anxiety. I n extreme cases genuine psychoses result. Hyperactivity of the thyroid gives rise to restlessness and irritability that likewise may go to psychotic extremes. Parathyroid deficiency results in enhanced neuromuscular irritability and has occasionally been reported likewise to give rise to such marked defects as temper-tantrums or extreme irascibility. The terminal stage of adrenal deficiency is marked by insomnia, petulance, incooperativeness, then delirium and final coma. Contrariwise, recent observers have remarked upon the property of potent adrenal cortical extracts to induce even in normal subjects a state of well-marked euphoria. The relation of the gonads to personality is proverbial even among the laity to whom 'red-blooded virility' or 'engaging femininity' are the hallmarks of romantic adequacy, whereas the eunuch is an object of universal contempt. Probably more subtly important than any of the other glands in determining personality is the pituitary. [237]

THE PROBLEM OF MENTAL DISORDER This structure dominates the production of gonad-hormones, hence it is a major factor in determining masculinity or femininity. Such direct evidence as we have indicates a high incidence of pituitary abnormality among problem children. Despite many a notable gap in our knowledge, it is safe, then, to say that the hormones contribute importantly to the determination of personality. Hence, the conclusion can scarcely be escaped that they significantly influence those aberrations of personality that make up the psychoses. To what extent the influence is crucial remains, generally speaking, an open problem. Were there a direct step-by-step correlation of endocrine-disorders and personality-disorders we should expect both a high incidence of psychoses in the frank endocrinopathies and conversely a high incidence of unmistakable endocrine-disorders among psychotics. But Notkin has recently emphasized the fact that neither contingency is realized.6 If we postulate endocrine-abnormality as an important factor in the psychoses, we have to account for the fact that it is limited, by and large, to relatively minor objective manifestations. This consideration leads to the probable conclusion that more fundamental than the endocrine abnormalities is a disturbance in the hypothalamus of the regulatory centers of 'vegetative * functions. Even so, however, the endocrine aspects of psychiatry demand exhaustive research. A knowledge of the hormonal factors might go far to elucidate the mechanisms of genesis of the psychoses. If not the first link in proximate causation, they may, none the less, be important intermediate links. If, to change the figure, they constitute an essential segment of a vicious circle, that segment may, with increasing knowledge, prove to be the one most amenable to therapeutic attack.6

The same general view of the relation of the disorders to the disturbances of endocrinal function is expressed as follows by Professor A. J. Carlson of the University of Chicago. 6 J. Notkin, A clinical study of psychoses associated with various types of endocrinopathy, Amer. J . Psychiat., 12, 1932, 331. 6 The evidence upon which the foregoing discussion is based is treated at greater length by the author elsewhere. Cf. his Endocrine factors in dementia praecox, New England J. Med., 200,1929, 361; Endocrine therapy in the psychoses, Amer. J . Med. Sci., 184, 1932, 158; The tides of life; the endocrine glands in bodily adjustment, W. W. Norton & Company, Inc., New York, 1933; Psychoses and the internal secretions, in Cyclopedia of Medicine, Philadelphia, Davis (in press). [238]

ENDOCRINOLOGY 1. There exists at present practically no reliable information either in the clinical or in the experimental field on the question of the endocrines as causative or as contributory factors in mental disorders. To be sure, histopathological studies are available, showing the incidence of atrophies or hypertrophies of some of the endocrine glands in patients with mental disorders. On these data I wish to make the following comments. a. I t is precarious to draw physiological conclusions from histological evidence alone unless the latter is extreme atrophy. b. We do not know whether these histopathological endocrine changes found in persons with mental disorders are causative factors in the disorders, contributory factors, sequellae, or merely parallel phenomena. 2. I t seems significant that nothing that could with certainty be interpreted as behavior disturbance bordering on serious upset in the nervous mechanism has as yet been established in the experimental field on the lower animals or that might be interpreted in the way of mental disorders, either by excessive administration of hormones or by ablation of the glands so as to produce varying degrees of gland or hormone deficiencies. To be sure, marked hypothyroidism produces sluggishness; absence of the parathyroids produces hyperexcitability and convulsions; marked deficiency of the adrenal cortex produces ultimate debility and depression. Excessive administration of the thyroid hormone produces restlessness and 'nervousness' in dogs. The depression in animals in the case of hypothyroidism and hypoadrenalism (cortical hormone) could be interpreted as simulating depressed mental conditions in man, but, in my judgment, such extrapolations are not warranted at present. I am well aware of the difficulty of studying mental or behavior problems in animals below man as witnessed by the difficulties that researches in behavior-psychology in the lower animals have unearthed. Nevertheless, the data that we have at present from definite known or produced hyper- and hypo-activity of the endocrine glands in the lower animals yield only negative results as to these glands being primary causative factors in nervous disorders in man. 3. If the conditions of nervous instability or latent nervous disorders are present in man, it seems highly probable that marked disturbances, particularly of the thyroid gland, of the anterior hypophysis, of the parathyroids, and of the gonads may [239]

THE PROBLEM OF MENTAL DISORDER be contributory factors in intensifying or actually releasing the phenomena. I believe this statement will be concurred in by most thoughtful workers in the clinical, the psychological, and the more specific physiological fields. Unfortunately, there has been a tendency unduly to emphasize the endocrines or hormones as causative agents in human behavior, in both health and disease, and to put them in the place of the spirits or demons of several centuries ago. The hormones or endocrines are undoubtedly more significant in human behavior than are those demons, at least as now understood; but the actual significance of hormones in mental disorders is still a research problem and a problem that may yield data of extreme importance both in diagnosis and in therapeutics.

[240]

X I I . THE

PATHOGENESIS OF NEUROCYTOTROPIC VIRUS DISEASES

By Ernest W. Goodpasture, M.D., Nashville I t has been considered appropriate to include in a broad survey of the nervous system, in relation to problems of psychiatry, a report upon such neuropathic infectious diseases as poliomyelitis, whose devastating epidemics are well known, rabies, constantly menacing in epidemic form, lethargic encephalitis, and like diseases in which there is reason to believe that similar etiological agents are concerned. Poliomyelitis, rabies, and certain other neuropathic infections are known to be caused by viruses. Although the etiological agent of lethargic encephalitis is not yet known there are grounds for suspecting that it also is a virus. The term virus, originally meaning a poison, is becoming more and more restricted to connote a characteristic type of infectious agent whose peculiar activity may be recognized in certain ways. Just what these viruses are is not definitely known, but what they do and, to some extent, how they do it are becoming more and more apparent as investigations in this field increase. I t is not certain that any virus has yet been seen even with the most powerful microscope, consequently there are no known morphological attributes to distinguish them. Most viruses are certainly extremely small, for they will pass through filters which hold back even minute bacteria; but some of them may not be ultramicroscopic. No virus has yet been cultivated with certainty in the absence of living cells, hence there are no cultural characteristics, such as contribute largely to our knowledge of bacteria, to identify them. I t has been discovered, however, that some viruses increase in quantity in the presence of the living cells of susceptible hosts growing in tissue cultures. This fact and many others favor the view that most viruses, and probably all of them, require under natural conditions the internal medium of living susceptible cells for their multiplication. This hypothesis would probably be retained even though some viruses prove to be living things and others inanimate substances. [241]

THE PROBLEM OF MENTAL DISORDER The effects of most viruses upon the cells which they alter as a result of their local activity are quite characteristic, and the relationship between the cellular changes and the multiplication of virus seems so intimate that viruses of this kind have been appropriately called 'cytotropic viruses.'1 All of the known virus diseases of the nervous system are probably caused by cytotropic or more specifically 'neurocytotropic' viruses. Some of these diseases are observed only under experimental conditions, others occur as natural infections. Studies of the experimental infections are helpful in understanding the natural diseases. The outstanding experimental cytotropic viral diseases of the nervous system are those induced by the viruses of herpes simplex and of yellow fever. The more important of those found under natural conditions are poliomyelitis, rabies, and enzootic encephalomyelitis or Borna disease of the horse. No attempt will be made here to classify the various neuropathological processes, possibly of an infectious nature, with reference to viral diseases. This undertaking would not be cognate to the general purpose of this article, and it has recently received attention in a review by Rivers.2 Therefore only those infections of the nervous system will be here considered whose etiological agents have been proved properly to belong in the cytotropic virus group. Much important knowledge, which sheds some light upon the pathogenesis of other cytotropic virus diseases of the nervous system, has been derived from experimental studies of herpetic infections in lower animals, especially the unusually susceptible rabbit, consequently this experimental disease will receive first and most detailed consideration. Herpes Simplex. The herpetic virus, in my judgment, is properly classified as cytotropic. To justify such a classification a virus should not only be filterable, but, as I have pointed out elsewhere, it should manifest in relation to its essential lesions certain characteristics which are indicative of a specific reproductive relationship to the cells primarily and peculiarly affected. In order that this evidence may be elicited it is necessary that the essential lesion be reproducible in series in a susceptible host. 1 E. W. Goodpasture, Etiological problems in the study of filterable virus diseases, The Harvey Lectures, 25,1929-30, 77; T. M. Rivers, The nature of viruses, Physiol Rev., 12, 1932, 423 (full bibliography); C. P. Li and T. M. Rivers, Cultivation of vaccine virus, J. Ex-per. Med., 52, 1930, 465. 2 T. M. Rivers, Relation of filterable viruses to diseases of the nervous system, Arch. Neur. and Psychiat., 28, 1932, 757. [242]

THE PATHOGENESIS OF NEUROCYTOTROPIC VIRUS DISEASES Under these circumstances the virus should be capable of inducing its specific cellular changes when the tissue in which its essential lesions are observed in the natural disease is inoculated; it should reproduce itself at the site of the specific lesion; and it should present a definite relationship to the changes in form or function of the cells which it primarily affects. The primary cellular effect may manifest itself by hyperplasia, necrosis, and lysis, or by the presence of characteristic cellular inclusions. The virus should be reproduced before the death of the affected cells occurs, and the specific cellular changes should antecede an inflammatory response. All of these conditions seem to be fulfilled by the viruses of herpes, yellow fever (in the mouse), poliomyelitis, rabies, and Borna disease.3 The herpetic virus infecting rabbits is of especial importance in the study of pathogenesis because it induces local lesions in the central nervous system at its site of entrance from a peripheral focus and thus affords a visible means of demonstrating the pathways which it follows. The specific cytopathological change which it induces is recognizable by the presence of acidophilic intranuclear inclusions and subsequent necrosis. Distinct peripheral lesions result from inoculations into the cornea, skin, mucosae, and in several parenchymatous organs. Consequently one may readily follow the course of infection from a peripheral focal infection to the terminal extensions in the brain or spinal cord. As a result of experimental studies of herpes it has been conclusively demonstrated that the blood-stream may be eliminated as an effective means of transport of virus from the periphery to the central nervous system. On the other hand, it has been revealed beyond question that the virus may proceed from a focal peripheral lesion along the course of nerves, whether sensory, motor, or sympathetic, which supply the area of primary infection. In contact-infections the virus gains admission to the susceptible host (rabbit) through the mucous membrane of the mouth and throat, where it may, and probably always does, induce a local infection from which it proceeds to the central 3 E. W. Goodpasture, Cellular inclusions and the etiology of virus diseases, Arch. Path., 7, 1929, 114; W. A. DeMonbreun and E. W. Goodpasture, Infectious oral papillomatosis of dogs, Amer. J. Path., 8, 1932, 43; C. E. Woodruff and E. W. Goodpasture, The relation of the virus of fowl-pox to the specific cellular inclusions of the disease, Amer. J . Path., 6,1930, 713; E. W. Goodpasture, Borreliotoses: Fowl-pox, Molluscum Contagiosum, Variola-Vaccinia, Science, 77, 1933 (no. 1987), 119. [243]

THE PROBLEM OF MENTAL DISORDER nervous system by way of the sensory fibers of the fifth and ninth cranial nerves. That it may progress with equal facility along the same group of nerve-fibers centripetally and centrifugally with respect to the central nervous system has been demonstrated by the development of a zosteriform eruption in the skin of guinea pigs and rabbits following a local inoculation in the skin.4 The intimate relation with the entering nerve and the unilateral location of the initial lesion in the nervous system following a focal, peripheral infection on one side preclude the possibility of transport of the infecting virus either through the blood-stream or through the cerebrospinal fluid. Since trauma and attendant bacterial infections, which might break down the normal protective barriers which encase the central nervous system, are eliminated by the nature of the experiment, there remain to explain the neural transport of the virus only the possibilities which may be inherent in the nerve itself. From a mechanical standpoint one must consider a passive and active transport of virus within the perineural fluids of the nerve. If there should exist—which seems improbable—a centripetal flow of fluid along the peripheral nerve into the central nervous system, i t might be possible for virus to be borne inactively by this current from the periphery inwardly. Should such a circulation be demonstrable, the facts of herpetic infections are contradictory to the assumption of a passive transport, because the virus progresses with equal readiness centrifugally as well as centripetally. Furthermore, there is no early dissemination of virus within the cerebrospinal fluid with subsequent indiscriminate infection of central nervous tissue, but the central lesions are directed in their course and distribution by the bundles of nerve-fibers. One might imagine an active growth of virus in the perineural lymph, which would progress in either direction. Against this assumption is the absence of all evidence that virus can reproduce itself in tissue-fluid, including that which bathes the central nervous system. Thus it seems that all the mechanical routes which bacteriological concepts have invoked to explain invasion of the central nervous system by infectious agents must be eliminated on 4 E. W. Goodpasture, Cytotropismus und das Vordringen der Virusarten im Nervensystem, Zsch. f. d. ges. Ncur. u. Psychiat., 129, 1930, 599; E. W. Goodpasture, Herpetic infection, with especial reference to involvement of the nervous system, Medicine, 8, 1929, 223; E. W. Goodpasture, The pathways of infection of the central nervous system in herpetic encephalitis of rabbits contracted by contact, etc., Amer. J . Path., 1, 1925, 47. [244]

THE PATHOGENESIS OP NEUROCYTOTROPIC VIRUS DISEASES rational grounds, and one is left only with the possibilities which the neurocellular substance itself may have to offer in explanation of the phenomenon of neural transmission of virus. I n the absence of knowledge of other possible extracellular channels in continuity from the periphery to the central nervous system, one is forced in this eventuality to question the possibility of a viral transport through the living substance of the constituent nerve-cells themselves. Not only is there no positive evidence that the myelin of medullated sheaths plays a part, but experimentally it has been demonstrated that virus will progress with precision and rapidity along nonmedullated nervefibers, without leaving a morphological or an inflammatory trace of its progress. By the process of elimination one is forced to accept the only remaining channel of communication, namely, the axiscylinder, as a means of transport of the virus, or otherwise, eliminating this on the basis of contrary facts, to admit an inability to understand the phenomenon in the present limitation of knowledge. Fortunately, positive knowledge does not necessitate such an intellectual impasse, for there is much acceptable evidence that virus may progress along the axis-cylinder. As a possible analogy for this concept we recall the phenomena attendant upon the neural transport of the neurotoxin of C. tetani, which one has reason to believe is an inanimate biological poison. I t is possible to demonstrate a progress of tetanus toxin along nerve-trunks, and in the opinion of Meyer, Ransom, and others this progress is achieved by means of the axis-cylinders.6 But since tetanus toxin is an inanimate material its transport must be considered a passive one in so far as the toxin itself is concerned. There is evidence that an affinity between certain nervous substances and the toxin exists which permits it to become affixed to this medium, and that the poison may spread passively from a locus of highest concentration along this favorable medium. But such a passive transport is insufficient to explain the phenomenon of the neural progress of virus, for the simple reason that virus demonstrably reproduces itself in the favorable environment of nervous tissue and leaves in its wake evidences of its destructive effect upon the neurone. 5 H. Meyer and F. Ransom, Untersuchungen tiber den Tetanus, Arch. f. exper. Path., 49, 1903, 369. [245]

THE PROBLEM OF MENTAL DISORDER Under these circumstances one is justified in hypothecating an active progress in contradistinction to a passive physical transport of virus. This concept of the pathogenesis of herpetic infection of the central nervous system from a peripheral focus lends its support to the view, expressed by several investigators, that certain viruses have the capacity of multiplication within the environment of living protoplasm; and, so far as we now know, they require this environment, under natural conditions, for their regeneration. The axonal processes of the neurones offer this favorable medium as a continuous channel of communication between the remotest peripheral areas to the depths of the brain and spinal cord, and positive experimental evidence definitely indicates that this is the determining condition for the pathogenesis of all cytotropic viral infections of the central nervous system. A convincing experiment to test this hypothesis has been performed by inoculating herpetic virus into a masseter muscle of a rabbit and following the evidences of progress of the infection from that peripheral locus into the pons. I n these experiments virus was found to induce its earliest secondary changes in the motor ganglion cells of the corresponding fifth motor nucleus. I t seemed under these circumstances that the virus progressed along the axis-cylinders of the motor neurones and was insulated from surrounding susceptible tissue by the well-developed myelin sheaths until the motor nucleus was reached. Thus evidence gained from experimental studies of herpetic infection of the nervous system not only supports the cytotropic hypothesis, but the facts seem to demand such a concept to explain the pathogenesis of this disease. Yellow Fever. The virus of yellow fever is of especial interest in connection with a study of viral diseases of the nervous system, because of the recent demonstration of the possibility of varying the tissue predilections of a virus under experimental conditions. In the laboratory of Professor A. W. Sellards, Dr. Max Theiler discovered that yellow-fever virus can be made neurotropic by passage through the brains of mice. The mouse strain introduced into the brain of monkeys (M. rhesus) induces no longer yellow fever but a specific viral encephalitis.6 6 M. Theiler, Studies on the action of yellow fever in mice, Ann. Trop. Med., 24, 1930, 249; A. W. Sellards, The behavior of the virus of yellow fever in monkeys and mice, Proc. Nat. Acad. Sci., 17, 1931, 339. [246]

THE PATHOGENESIS OF NEUROCYTOTROPIC VIRUS DISEASES The distribution of encephalitic yellow-fever virus in susceptible experimental animals indicates that it is disseminated by way of neural channels, and its cytopathological effect is such as to leave little doubt that it is, at least in its neuropathic modification, a neurocytotropic virus. The practical possibilities which this discovery offers for prophylactic immunity will be discussed at the proper place. Poliomyelitis. Not only does the virus of poliomyelitis fulfill the general conditions requisite to a classification among the cytotropic viruses but the recent work of Fairbrother and Hurst, demonstrating a selective localization of virus in the central nervous system, finds a reasonable explanation only on the assumption of an axis-cylinder transmission. This work is a refreshing contribution to the pathogenesis of a disease which has defied the older bacteriological concepts for the past thirty years. Acceptable experimental evidence that poliomyelitis virus reproduces itself within the neurones and spreads from one focus to another along the cytoplasmic processes of the nervecells has an important practical bearing upon current serological methods of treatment.7 Rabies. The natural history of rabies is such as to have attracted attention for many years to the possibility of a neural transmission of the virus; and experiment has confirmed this view. The alternate hypothesis that the cerebral infection represents a secondary localization of virus from the blood-stream is not supported by experimental fact. The more recent work of Goodpasture and of Gantt indicates that the axis-cylinders, as with herpes and poliomyelitis, are the media through which the virus is transported from the periphery by an active reproduction.8 Borna Disease. The experiments of Nicolau and Galloway have shown that the virus of Borna disease is spread in the infected host by way of the nerves. Its transport is either centrifugal or centripetal with respect to the central nervous system, depending upon the original site of inoculation. When virus is injected into a nerve it soon reaches the central nervous system; if the initial injection is intracerebral, virus is demon7 R. W. Fairbrother and E. W. Hurst, The pathogenesis of, and propagation of, the virus in experimental poliomyelitis, / . Path, and Bad., 32, 1930, 17. 8 E. W. Goodpasture, A study of rabies, with reference to a neural transmission of the virus, etc., Amer. J. Path., 1, 1925, 547; W. H. Gantt and A. W. Ponomarew, Ueber den Mechanismus der Verbreitung des Tollwutvirus (Virusfixe)im Organismus, Zsch. f. d. ges. exper. Med., 66, 1929, 582. [247]

THE PROBLEM OF MENTAL DISORDER strable in the peripheral nerves with the onset of symptoms of cerebral infection. I n the infected host virus was not demonstrated in the blood, and Nicolau and Galloway express the judgment that natural infection of the central nervous system results from a neural transport of virus from a peripheral focus; and they conclude also that the virus regenerates within the nerve-cells.9 Encephalitis Lethargica. Although lethargic encephalitis has not been proved to be caused by a filterable virus, there has been so much discussion and experimentation directed toward this contingency that a presentation of this sort would seem incomplete without at least a brief etiological consideration of the status of the disease. Progress toward solution of the problem of etiology depends in large measure upon the discovery of a susceptible experimental host in which the lesions may be studied. I n view of its importance, adequate attempts should be made to transmit the disease to apes and to any other living medium or host which offers promise of success. The recent studies of Dawson have demonstrated hitherto unrecorded cytological evidence of a viral infection in a group of cases diagnosed clinically as lethargic encephalitis, and these observations indicate that the clinical disease may not be an etiological entity. Further morphological studies are therefore indicated in an effort to establish more specifically the cytopathology of this, at present, variable clinical group. Recent reports also indicate that the St. Louis epidemic of encephalitis (1933) was caused by a filtrable virus transmissable to monkeys and mice.10 To summarize this brief consideration of the cytotropic virus diseases of the nervous system, it may be said that there is experimental demonstration in each instance of a neural transport of virus; there is no acceptable evidence that the blood-stream is concerned in the transfer of virus from the periphery; and finally the pathogenesis of these diseases has its best and perhaps only explanation in the hypothesis that there is a spread of the virus 9 S. Nicolau and I. A. Galloway, L'encephalo-myelite enzootique experimentale (maladie de Borna), Ann. Inst. Pasteur, 45, 1930, 457. 10 J. R. Dawson, Cellular inclusions in cerebral lesions of lethargic encephalitis, Amer. J . Path., 9, 1933 (no. 1), 7; R. S. Muckenfuss, C. Armstrong, and H. A. McCordock, Public Health Reports, 57, 1933, 793; L. T. Webster and G. L. Fite, Science, 78, 1933, 463. [248]

THE PATHOGENESIS OF NEUROCYTOTROPIC VIRUS DISEASES from one focus to another by an active regeneration within the medium of the cytoplasm of nerve-cells and their processes. From the point of view of cytotropism there is, in addition to the mode of transport of virus by means of axis-cylinders, the important problem of the natural portal of entry through which the infectious agent may gain access to the central nervous system. This problem requires an investigation of the susceptibility of various types of cells to the particular virus concerned; and as yet there is insufficient knowledge at hand to explain completely the pathogenesis of all of the diseases under consideration.11 I n the case of experimental herpetic infections knowledge upon this point is most complete. I t has been demonstrated that notwithstanding the great susceptibility of nervous tissue to a potent strain of this virus, there is a wide variety of susceptible tissues in the rabbit host, including cells derived from all three germinal layers. Demonstrable local infections have been induced in the rabbit cornea, conjunctiva, oral and tracheal mucosae, skin, retina, liver, adrenal, ovary, and testis. Inoculation of virus into any of these tissues results in a local infection followed by an encephalitis or myelitis at the site of the entrance of the virus into the central nervous system along the nerve supplying the peripherally infected focus. An initial nervous lesion is always induced at the site of ingress, and this is followed by a dispersion of the virus along neural pathways. All of these tissues therefore are potential portals of entry. In addition to those mentioned, an experimental herpetic myelitis has followed inoculation of the virus into the mucosa of the small intestine, consequently this tissue also may be included among those susceptible. I t has further been shown experimentally that the extent of a peripheral corneal infection determines in some measure the severity of the ensuing encephalitis. An interpretation of these experimental facts has led to the conclusion that, in the case of the tissues mentioned, an initial infection of the respective tissue-cells is necessary to a subsequent extension of the infection to the central nervous system along the axis-cylinders of corresponding nerves. This interpretation does not apply, however, to the experimental results of inoculation into voluntary muscular tissue. I t has been repeatedly demon11 E. W. Goodpasture, A. M. Woodruff, and G. J.JBuddingh, The cultivation of vaccine and other viruses in the chorio-allantoic membrane of chick embryos, Science, 74, 1931 (no. 1919), 371. [249]

THE PROBLEM OF MENTAL DISORDER strated that an injection of virus into the muscle will lead to an extension of the virus along local nerves to the central nervous system; but thus far evidence of a local infection by herpetic virus in voluntary muscle cells is lacking, despite extensive study directed upon this point. Consequently one must assume that in so far as voluntary muscle is concerned, the initial infection with this virus occurs within the nervous tissue, probably in the end-plates which offer a considerable mass of medium for its reception. The natural portal of entry for herpetic virus in infections of the nervous system brought about by contact between a normal rabbit and one bearing an herpetic keratitis is by way of the oral and pharyngeal mucosa; and while an immediate infection of nervous tissue through an intact mucous membrane has not been excluded, local herpetic lesions in the mouth have been demonstrated which presumably occur in all instances and offer injured and exposed nerves for the reception of virus. One may infer from this that under natural conditions the herpetic virus gains entrance to the mouth and results in local infections of the epithelium of the mucosa from which nerveendings and fibers become involved, followed by an extension along infected axis-cylinders to the brain by way of the sensory fibers of the fifth and the ninth cranial nerves. I n no instance of infection by contact has evidence appeared that virus entered by way of the olfactory cells and fibers. The natural portal of entry of the virus of rabies in most cases seems obvious. The bite of a rabid animal so tears the tissues that the possibility of introducing virus directly into or upon injured axis-cylinders or muscular end-plates is apparent. No one has brought forward acceptable evidence that cells other than those of the nervous system are susceptible to infection by the agent of rabies, and in the present state of knowledge one is justified in considering i t to be an obligatory neurocytotropic virus. I t is well known, however, that the virus of rabies may enter the nervous system through apparently intact skin, although one is not able to exclude minor injuries which might expose susceptible nerves under these circumstances. The elimination of virus in natural rabic infection is through the saliva, and theoretically at least the virus reaches the salivary glands by a centrifugal extension along axonal channels from the infected central nervous tissue. [250]

THE PATHOGENESIS OF NEUROCYTOTROPIC VIRUS DISEASES Much attention has been directed to the problem of the portals of entry for the virus of poliomyelitis, with the result that the view which attributes nervous infection to an invasion through the nasal mucosa is generally accepted. I t is possible experimentally to infect monkeys by applying virus to the nasal mucosa, but other pathways from the oral, pharyngeal, and intestinal mucous membranes have not been excluded. Experimental evidence for an initial infection through the olfactory cells is at present conflicting, and final judgment must await further investigations. There is no evidence at hand indicating that any tissue-cells other than those of nervous origin are susceptible to the virus of poliomyelitis, and further study of this problem is needed. At present, however, one must assume that the poliomyelitic agent, like that of rabies, is an obligate neurocytotropic virus. The fact that adults quite generally have recently been proved to possess serological evidences of immunity to poliomyelitic virus leads one to suspect that local infections, perhaps of nonnervous epithelial cells of the nasal or oral mucosae sufficient to confer immunity, may occur without extension to the central nervous system. I t is possible, however, judging from experiments with herpes, for immunizing infections of very restricted extent, even in nervous tissue, to result in a few or no symptoms. The more limited experiments with the agent of Borna disease have not added materially to knowledge of the mechanism of infection by neurocytotropic viruses. THE TEEND OF EXPERIMENTAL RESEARCH Etiology. The present trend of research with respect to the etiology of the cytotropic virus diseases of the nervous system is directly away from the older concepts of bacteriology and protozoology and toward the more promising concept of a necessary reproductive relationship between these viruses and the living susceptible cell. The time-worn and unproductive notion that these diseases are due to visible bacteria or protozoa is doomed, in my judgment, to eventual abandonment. The more recent excursions of certain bacteriologists into this field in uncritical attempts to identify so-called filterable forms of known bacteria with cytotropic viruses are without justification in fact.12 12 E. W. Goodpasture, Cytotropic viruses, with reference to filterable forms of bacteria and cancer, Amer. J . Hyg., 27, 1933, 154. [251]

THE PROBLEM OF MENTAL DISORDER Attempts to cultivate viruses in association with living cells in tissue-cultures will no doubt lead to valuable knowledge, but such experiments should take into account the fact that living cells from the same and different hosts vary in their susceptibility to infection by a given virus. From this point of view the experimenter with tissue-cultures should endeavor to cultivate cells which are presumably susceptible to the particular virus under consideration, other cells having failed to induce growth. For example, cultures of nerve-cells from susceptible hosts should be employed if possible in the case of the apparently obligate neurocytotropic viruses. The very difficult problem of the essential nature of viruses apparently will await solution for some time. Should they be animate, as some facts indicate them to be, the discovery of a suitable lifeless medium in which they may be cultivated would apparently be necessary to the demonstration. A t the present state of knowledge regarding these agents there are many more immediately profitable and inviting lines of investigation, both from a theoretical and a practical standpoint. Pathogenesis. One of these lines of investigation is in the field of pathogenesis. Experimental progress at present is definitely in the direction of attempts to discover the facts concerning the nature and locus of the original infection, the manner of transport of virus from the portal of entry to the central nervous system, and the channels of dissemination within this susceptible tissue. The point of view of cytotropism is directing these studies by affording an experimental hypothesis which the older concepts do not offer. The solution of pathogenesis with reference to any of the neurocytotropic virus diseases will involve a knowledge of the susceptibility of various cells to infection by the virus and of the natural mode of contact between the receptive cells and the virus concerned. This implies a knowledge of the manner of elimination of the virus from the infected host. I n the case of poliomyelitis, cell-susceptibility and the natural portal of entry offer immediate problems which seem soluble by experimental methods. Likewise the problem of neuronal transmission of virus needs much more extensive investigation, not only in experimental poliomyelitis, but also in experimental rabies, Borna disease, herpes, and the encephalitis of yellow fever. The methods which promise productive results have already been successfully employed and recorded. [252]

THE PATHOGENESIS OF NEUROCYTOTROPIC VIRUS DISEASES Immunity. The concept of cytotropism of viruses casts an invigorating light upon the experimental approach to problems of immunity in relation to virus diseases of the nervous system. I t offers an experimental hypothesis which will inevitably lead to important knowledge of these diseases. Since this hypothesis presupposes, on good evidence, that virus must reach the interior of living cells in order to find requisite conditions for its reproduction, it lends theoretical support to a prophylactic use of sera which possess demonstrable antiviral effects, because viruses possibly may thus be prevented from entering their essential medium; or if admission has been gained, other cells may be protected from infection provided virus must become extracellular before reentry into other cells. On the other hand, the hypothesis of cytotropism casts a grave doubt upon the efficacy of antiviral sera in the treatment of homologous infections of the nervous system in case the active agent has already reached the central nervous tissue. The experiments of Rivers and of Andrewes demonstrate that, once virus has entered susceptible cells, antiviral serum cannot restrain its activity.13 Inasmuch as the cells of nervous tissue are so intimately connected by cytoplasmic processes, which are susceptible to invasion by virus and through which the active agent spreads from one place to another presumably without becoming exposed to immune substances or adverse conditions existing in the circulating media, the treatment of well-established infections with antiviral serum does not appear to offer much hope of success. Efforts in the direction of prophylactic vaccination against cytotropic viruses are rational and hopeful under the hypothesis of cytotropism. Active virus introduced into an insusceptible tissue in the absence of injury to nerves might afford an opportunity for an immunizing response by the organism without danger of inducing the infection. Likewise a vaccine consisting of active virus admixed with antiviral serum might be effective without danger, because an entrance of virus into susceptible cells might be prevented by the presence in sufficient concentration of the opposing effect of the serum. This combined vaccine is now being used with success in prophylaxis against yellow fever. Chemotherapy. A practically unexplored field for the experimental investigation of prophylaxis and therapy of cytotropic virus diseases in general, including those of the nervous system, seems to me to be thrown open to exploitation by the hypothesis 13 C. H. Andrewes, Immunity in virus diseases, Lancet, 1, 1931, 989, 1046. [253]

THE PROBLEM OF MENTAL DISORDER of cytotropism. The directions for the attack are as yet only vaguely outlined, but the theoretical possibilities seem urgent and attractive. I t is well known that many of the cytotropic viruses, including several of those which invade nervous tissue, are quite selective in their effect upon cells. I n some instances only one type of squamous epithelium, for example, will respond to inoculation. This fact indicates that cytotropic viruses are very exacting in their requirements of an intracellular medium, and that a delicate intracellular balance must obtain between the active agent and its host in order that infection and reproduction of virus may occur. We have frequently had occasion to observe the inhibiting effect of intercurrent disease or malnutrition upon viral infections, for example in oral papillomatosis of dogs, where apparently only the intermediate squamous epithelium of the mouth offers an acceptable medium to the virus for its reproduction. If, according to the experimental hypothesis of cytotropism, viruses require an intracellular medium for their reproduction (and this medium may be varied in the direction of greater or less favorableness), the possibility of altering the cellular medium by chemical means offers immediately an attractive field for experimental attack. I t is particularly with reference to the cells of the nervous system that recent experimental inquiry has proved the possibility of a selective chemical action by certain organic compounds. I refer to the experiments of Dr. M. I. Smith of the National Institute of Health, which have opened a tentative line of approach to this problem in the discovery of the selective neurocytotoxic effects of certain cresol and phenol compounds with phosphoric acid.14 These and similar compounds should be investigated with reference to a possible inhibiting effect upon viral infections by altering unfavorably the required reproductive medium. Similar studies are indicated with the purpose of rendering naturally susceptible cells impervious to virus. I n the search for the desired chemical effects empirical methods must at first be employed, but the directing influence of the hypothesis of cytotropism would in time, as I believe, lead to a successful outcome of such an urgent and worthy quest. 14 M. I. Smith, E. W. Engel, and E. P. Stahlman, Further studies on the pharmacology of certain phenol esters with special reference to the relation of chemical constitution and physiologic action, Nat'l Inst. Health, 1932, Bull. no. 160. [254]

X I I I . NUTRITION By George R. M i n o t , M.D., Boston For centuries it has been recognized that alertness, initiative, and the sense of well-being were to be associated with suitable food for man. Both Aristotle and Cicero recognized and described the influence of a proper diet upon temperament and genius. Tiedemann noted in 1836 that diet "preserves intellectual activity, reflective power and imagery, free will and self control."1 Cornaro, in the seventeenth century, and George Cheyne, in the eighteenth, are among other observers who noted the mentally depressive effects of excessive eating,. Today a chronic excess of food is recognized as leading to lethargy and inertia. The harmful effects of excess, rather than deficiency, have received much consideration in the past, but modern studies indicate that disorders from improper diets are due much more often to deficiency than to excess. Pronounced undernutrition and diseases from a distinctive dietary deficiency are relatively rare, but a departure from an optimal diet leading to ill health is common. I n spite of many nutritional studies in the past twenty years and the rapid advance of knowledge in this field, the literature contains little information concerning nutrition in relation to mental disorders. This can be accounted for in part by the circumstance that the modern conception of dietary deficiency has been derived largely from animal experimentation. The earlier evidences of disease in man from unsatisfactory diets have been studied but little. They demand the careful attention of physicians. Among the problems worthy of careful study is the influence on mental functions of various diets and dietary factors over prolonged periods of time, particularly from the point of view of deficiency. Since this seems the important aspect, no further mention of excess will be made, although a modern survey of this state of affairs could be undertaken with profit. All studies require, of course, various suitable controls. A distinction must be made between the direct effect of dietary factors on the nervous system and the effect on the body as a 1 Quoted by G. Lusk in Nutrition, Paul B. Hoeber, New York, 1933. [255]

THE PROBLEM OF MENTAL DISORDER whole leading to ill health with mental symptoms arising from a reaction caused by a nonneural condition. Undernutrition. There is no question as to the coexistence of disorders of the nervous system and undernutrition. The development of instability of personality has been repeatedly described in starvation. Lusk and Benedict have noted in carefully controlled observations that this occurs in lesser degrees of undernutrition.2 Most of the neuroses of childhood entirely depend, as Holt has observed, upon disorders of nutrition. The headaches, insomnia, habit spasms, hysterical manifestations, and a multitude of others are relieved only by correcting the faulty diet and habits which are the basis of disturbed nutrition. It is, indeed, quite astounding to one who witnesses it for the first time to observe the rapid improvement in such cases with no other treatment than rest and a normal adequate diet.3 I n adults undernutrition leads to irritability, nervous tension, inability to relax, insomnia, weakness of ambition, and even lethargy, together with various vasomotor symptoms such as attacks of acute transient anxiety and dizziness, especially with changes of position or upon exertion. An unstable personality is a feature of adults with undernutrition and, to be sure, this state of affairs may originally have contributed to the unsatisfactory diet taken by the person, but the condition increases with chronic departure from an optimal diet and it improves with proper food. As noted by Strang and Evans, in the extreme state of anorexia nervosa there is a close relationship between undernutrition and central neural function.4 When this advanced state is reached, it is difficult to determine what is cause and what is effect. With proper feeding, the disappearance or marked decrease of the original symptoms noted with mild or severe undernutrition is pleasing. I t is the rule to see great improvement in the degree of irritability and nervous tension. Levine has reviewed the effects of undernutrition on the sympathetic nervous system.5 He especially notes its undesirable action on the vagus nerve. Abnormalities of the nervous system 2 G. Lusk, The physiological effect of undernutrition, Physiol. Rev., 2, 1921, 523; F. G. Benedict, Human Vitality and Efficiency under Prolonged Restricted Diet, Carnegie Inst, of Washington, Publ. no. 280, 1919. 3 L. E. Holt, Food, Health, Growth, The Macmillan Company, New York, 1923, 41. 4 J. M. Strang and F. A. Evans, Undernutrition and its treatment by adequate diet, Ann. Int. Med., 7, 1933, 45. 6 V. E. Levine, Modern aspects of nutrition; pathology of malnutrition, Nebr. State Med. J., 12, 1927, 134. [256]

NUTRITION certainly are frequently secondary to insufficient food, but a disturbance of this system has been postulated as an etiological factor in some cases of undernutrition. Centers in the midbrain8 may play some r61e in the regulation of metabolism, and there may be intervention of the sympathetic nervous system in the metabolism of food.7 Nutritional studies on organisms during growth are apt to be particularly profitable, for during this period of life the requirements of the body are relatively great and disorders arising at this time can be more readily appreciated than in adult life. I t is indeed during youth that steps should be taken to correct nutritional deficiencies and to prevent ill health in later life arising from disordered nutrition during the growth period. The effects of malnutrition in children have been reviewed by Roberts and information given below is freely drawn from her book.8 When the mass of conflicting material is carefully studied a few certain things become apparent. The bulk of evidence first of all goes to show that physical and mental growth go hand in hand. . . . Good nutrition favors good mental development and poor nutrition tends to retard it (p. 168). Physical growth is, of course, directly dependent upon diet. When large numbers of children are considered in proper fashion, as by Baldwin and other investigators, the physically welldeveloped children are also mentally superior. If too small groups are studied the results may be conflicting. Underweight children are frequently high in intelligence and excel in their school work. The widely different hereditary mental endowment of . . . children . . . , the varying degrees of undernutrition, and the lack of exact standards for selecting cases of undernutrition or 'normal' children for controls, will all in a measure explain why no easily demonstrable mental effects of undernutrition are forthcoming when small groups of individuals are concerned (Roberts, p. 168). Blanton's studies9 of rather severe malnutrition in children in the war zone have helped materially to explain some of the 6H. Zondek and G. Koehler, tjber cerebral-hypophysare Magersucht,

Devtsch. Med. Wochnschr., 54, 1928, 1955. 7 S. Ederer and J. Wallerstein, Die specifisch-dynamische Wirkung und daa vegetative Nervensystem, Biochem. Zschr., 206, 1929, 334. 8 L. J. Roberts, Nutrition Work with Children, University of Chicago Press, Chicago, 1933. 9 S. Blanton, Mental and nervous changes in the children of the Volkschulen of Trier, Germany, caused by undernutrition, Mental Hygiene, 3, 1919, 346. [257]

THE PROBLEM OF MENTAL DISORDER findings. These children showed decrease of energy for mental tasks, inability to concentrate, slowness of comprehension, poor memory, and inattention. Some were dull, listless, phlegmatic; others were hyperirritable, excitable, and overenergetic. The difference appeared to depend not only upon the degree of malnutrition, but also upon the nervous stock of the individual. Children of good mental inheritance showed pronounced resistance to the effects of malnutrition. Though in poor physical condition, their essential mental functions were unimpaired. When the hereditary mental equipment, on the contrary, was of lower grade, it appeared to require but a slight decrease of the mental processes by malnutrition to create an apparent or real subnormality. The undernourished child may be up to grade and his mental ability good. His margin of intelligence, however, may be so great that even with only a slight drop it is sufficient to enable him to perform superior work. His powers of concentration and attention may be less than normal for him, but adequate to all that is required of them. A similar decrease by malnutrition in the intellectual powers of a child who has but a narrow margin will place him in a backward group, depending on the hereditary endowment and the degree of chronic disorders of the nutritional state. "Malnutrition may then be the determining factor in defective mentality where the potentiality already exists."10 Of course, not all forms of nervousness in children and backwardness in mentality can be cured by remedying malnutrition. I t is true, however, that a child may be mentally inferior to what he should be because of improper diet. Nervousness in school children may be definitely related to hunger in spite of an apparently adequate diet, but here again the problem is to supply food in an appropriate way, which often means additional meals. The prevention of nutritional disorders is vastly more simple than the cure, and prevention can accomplish more than cure. Many further studies concerning nutrition in relation to mentality and nervousness should lead to valuable information for all classes of persons. The studies must concern problems in fields as divergent as sociology and chemistry. Partial Dietary Deficiency, Especially Calcium. We know something about the effects on the mind of general undernutrition from insufficient caloric intake, but we know very little about the 10 Blanton, op. cit., p. 170. [258]

NUTRITION importance of a partial deficiency of one or another factor contained in an optimal diet. This is of distinct importance, for an individual may be essentially normal in weight and appearance and yet suffer from a chronic dietary deficiency which is not suspected until proper studies are made, including a careful and detailed dietary history, and until the effects of additional selected food are observed. McCollum has noted11 that rats on low calcium diets become "nervous and apprehensive" yet have a normal appearance. Corlette has postulated12 that many disturbances of nerve function may be due to a lack of calcium, and that vitamin D may be as truly antineuritic as vitamin B, with a particular action on the autonomic nervous system, a point also made by F. Brunetti.13 The calcium deficit in tetany leads to nerve irritability and the lack of calcium utilization in rickets causes insufficient and depressed mental function. Laird and associates have suggested14 that deficiency of calcium plays a r6le in at least certain cases of nervousness in children who are free from obvious general undernutrition and organic disease. They find that special feedings of food-concentrate, to build up calcium metabolism, bring improvement in nervousness. In England studies of large groups of children, apparently healthy, show that those given extra feedings of milk and fruit, in addition to a basic diet and cod-liver oil, developed physically and mentally better than those given the same basic diet and cod-liver oil, but with extra feedings of cereal and bread, so that the caloric intake in each group was essentially the same. Calcium again was thought to play a r6le and it should be recalled that calcium occurs in large amount in the brain and is very mobile (see article of this series by Dr. Irvine H. Page). The importance of studying the effects of partial dietary deficiency in man will be mentioned again further on. First, however, statements concerning the effects of certain outspoken dietary deficiency diseases on the central nervous system will be referred to. Appreciation of what can happen to this system in specific deficient states suggests what lesser 11 E. V. McCollum and N. Simmonds, The Newer Knowledge of Nutrition (4th ed.), The Macmillan Company, New York, 1929. 12 C. E. Corlette, Calcium deficiency in relation to nerve distrophy, especially of the autonomic system, Med. J. Australia, 1, 1929, 614. 13 Quoted by E. Browning, The Vitamins, Williams & Wilkins Co., Baltimore, 1931, 192. 14 D. A. Laird, M. Levitan, and V. A. Wilson, Nervousness in school children as related to hunger and diet, Med. J. and Rec, 134, 1931, 494. [259]

THE PROBLEM OF MENTAL DISORDER disorders might be expected when life is maintained on diets suboptimal in one or more factors. Specific Dietary Deficiency. Lethargy, irritability, apathy, and allied symptoms are features of all dietary deficiency diseases and may appear independent of weight-loss and undernutrition from insufficient caloric intake. The severe forms of nervous disorders due to lack of dietary factors are to be identified with the specific deficiency conditions. The mechanism of action and relative importance of factors involved are among problems to be solved. Distinction should be made between an upward or downward turn of a normal neural mechanism such as may occur in simple undernutrition and the development of an abnormal neural mechanism such as may arise in pellagra. Studies to indicate in what ways the mental-symptom complex varies with lack of specific factors are desirable. In iron deficiency, as occurs in long-standing idiopathic hypochromic anemia, it is the rule to find the patient nervous, with a quick temperament, unreasonable, and difficult to handle. These individuals are prone to be undernourished, but it is striking to see their personalities change for the better as they recover under large doses of iron. Indeed this improvement may be observed when the diet remains inadequate and the mental condition does not seem to be entirely attributable to anemia per se. The effects of iron deficiency on the nervous system and the mental aspects of patients with hypochromic anemia associated with defective nutrition are worthy of study. I t has been suggested by Sargant,16but not yet confirmed by other physicians, that iron may have a favorable effect on certain organic lesions of the central nervous system, and it has also been recorded, but not proved, that lack of iron may in some way play a r61e in pellagra. The diseases associated with a lack of the vitamin-B complex, pellagra, beri-beri, and certain other cases with multiple neuritis, characteristically show lesions of the central nervous system. Likewise, in macrocytic anemias, due to a lack of a factor occurring often in material rich in vitamin B and usually conditioned by a defect of gastric secretion, the classic example of which is Addisonian pernicious anemia, lesions of the central nervous system occur with very great frequency. Patchy atrophy of the 16 W. Sargant, A case of combined sclerosis without anaemia treated by intensive iron therapy, Brit. Med. J., 1, 1933, 306. [260]

NUTRITION spinal cord leading to a multiplicity of symptoms of combined system-disease, and also degeneration of the peripheral nerves, are features of pellagra and pernicious anemia. I n pellagra, degeneration of the nerve-cells throughout the brain occurs, leading to serious forms of dementia and other psychotic states.16 Less often there is a similar state of affairs in pernicious anemia. The onset of pellagra is often associated with change in personality and character, the patient becoming fractious and suspicious. In pernicious anemia the mental symptoms occasionally precede the anemia, just as combined system-disease may do, and they may remain mild for a long time or may rapidly become severe. An underlying hereditary predisposition to mental disease will be found in many instances, and some of the well-marked psychoses of patients with pernicious anemia are probably not wholly dependent upon lesions caused by dietary deficiency, but are brought forth by this state of affairs. I t is striking, however, to observe that liver and allied therapies often totally alleviate the mental symptoms, except when the psychosis is severe. Cases with mental symptoms for some months, or even years, and with little anemia, are rare and but seldom diagnosed correctly until outstanding anemia appears. Yet in such cases with little anemia adequate amounts of potent material may dramatically change the patients mentally in a few weeks. Dietary procedures can also beneficially affect many cases of pellagra with mental symptoms. One cannot expect regeneration of nerve-cells. When the disease process is far advanced, important changes do not follow dietotherapy. There is evidence, however, in pernicious anemia and pellagra that if adequate amounts of potent material for the given case are administered, lesions of the nervous system do not develop, or they remain arrested, and frequently symptomatic improvement is obvious. Adequate amounts for this purpose are apparently greater than for regeneration of blood or alleviation of certain other symptoms, such as skin symptoms in pellagra or regeneration of the papillae of the tongue in pernicious anemia. Disappearance of neuritis due to lack of vitamin Bx occurs with regularity when this substance is supplied in proper amounts. There remains a great deal to be learned about the relation of the vitamin-B complex to lesions of the nervous system, and deter16 G. R. Minot, M. B. Strauss, and S. Cobb, 'Alcoholic' polyneuritis; dietary deficiency as a factor in its production, New England J. Med., 208, 1933, 1244. [261]

THE PROBLEM OF MENTAL DISORDER minations should be made to decide whether the factors alleviating the anemia of pernicious anemia and the skin lesions of pellagra are the same as, or different from, those that play a role in the production of lesions of the central nervous system. Studies of mental disorders from the lack of factors associated with the etiology of beri-beri, pellagra, and pernicious anemia may reveal that there is a much wider group of such cases than is appreciated, because they may occur without the more usual evidence of these diseases. Partial deficiency of the vitamin-B complex has been considered a factor in the development of fretfulness and nervousness in infants. Hoobler has shown17 that such symptoms may be alleviated by the ingestion of vitamin-B concentrates. Animal experimentation has indicated18 that psychological changes occur in rats deprived of vitamin B2. They become irritable and suspicious and bite on the least provocation. The learning ability of rats to thread their way through a maze also has been shown to be impaired by the lack of vitamin-B complex. There is thus evidence that lack of this material or material associated with it causes serious injury to the nervous system, but in what chemical and physiological way it operates is unknown. I t is probable that deficiency of other vitamins may lead to central nervous injury, for deficiency of vitamin A has been considered responsible for lesions of this system while deficiency of calcium and vitamin D, or both, may have such an effect as indicated above. Vitamin-C deficiency may cause hemorrhages into the central, peripheral, and sympathetic nervous systems and thus lead to mental disorders. Disorders of carbohydrate and fat metabolism have also been blamed for mental disturbances. The beneficial effects of a ketogenic diet in epilepsy have a bearing on the problem; but the acidosis sometimes precipitates psychotic symptoms. Loew has suggested19 that increases of fat in the diet may be favorable for mental activity. Almost nothing is known, however, about the effect of such substances per se upon the mental functions. There are, then, numerous facts concerning the r6le that vitamins, minerals, and other 17 B. R. Hoobler, Symptomatology of vitamin B deficiency in infants, / . Amer. Med. Assn. 91, 1928, 307. 18 G. M. Pindlay, Pellagra-like lesions associated with deficiency of vitamin B2 in the rat, J. Path, and Bad., 31, 1928, 353. 19 O. Loew, Uber den Einfluss der Diat auf Laune und Befinden (Synopsis), Nutrition Absts. and Rev., 2, 1933, 825. [262]

NUTRITION dietary factors may play in mental disorders, but there are obviously many sorts of observations needed to understand clearly the action and importance of the elements in an optimal diet and to determine the frequency and sociological effects of such mental disturbances arising from dietary deficiency. Certain Aspects of Partial Dietary Deficiency. In conducting dietary studies on man, it is particularly important to attempt to observe the effects of partial deficiency created by long-continued suboptimal diets. The cumulative effects of single or multiple deficiencies in suboptimal quantities are most important to learn about, for one will seldom see outstanding deficiency diseases where the diagnosis is obvious. Certain further aspects of partial deficiency are as follows. Border-line states of nutritional instability due to deficiency or maladjustment of quality or quantity of one or more factors obtained from food are much more common than is usually appreciated. There is a wide zone between optimal nutrition and the level at which classic symptoms of recognized deficient states develop, e.g., from a lack of a vitamin or a mineral. Man seldom so selects his food that he has only a deficiency of a single food factor. One must expect to observe multiple effects. The undesirable influence of a faulty diet in the zone of partial deficiency may become detectable only after years or generations. Temporary gross dietary deficiencies do not produce symptoms, but departure from an optimal diet, even if slight, may produce ill health when operative over a long period of time, especially if combined with digestive disorders. Such adverse factors as infections, arteriosclerosis, chronic fatigue, and excesses of various kinds can also aid to precipitate deficiency disorders when a state of nutritional instability exists. This state of affairs is of great importance to recognize because no symptoms may be present until mild or severe infection arises. Often the infection is then blamed for symptoms developing in convalescence from the infection. One may go further and show that the unstable nutritional state was the chief factor that permitted the infection to produce symptoms. Latent scurvy often becomes the typical disease in this fashion. Undernourished typhoid-fever patients probably develop psychoses more often than those who have been well fed during life and who are given during their illness an optimal diet. This is a problem worthy of study. How often the minor depressed and irritable mental states seen in conva[263]

THE PROBLEM OF MENTAL DISORDER lescence from mild and severe infections can be credited to suboptimal nutrition is unknown. Adequate knowledge of this sort might lead to a decrease of considerable social and economic waste. Although rapid improvement occurs in patients with dietary deficiency when properly treated, quick results, as Sherman has noted, are not to be expected in health and longevity of a people through better dietary. He says: One of the most impressive features in recent discoveries regarding the relation of food to health and vitality is that the benefit of better feeding usually becomes fully apparent only when it is continued throughout a large part of the life cycle and often benefit is greater to the second generation than to the first.20 I t is quite possible that a given race could be made to have an average better mentality through better diet—a problem of interest for study on a large scale. The diet adjusted ideally, with respect to all its essential constituents, at an optimal level for each given person, permits development to proceed smoothly and the health of the individual to be maintained at as high a level as possible. I t seems probable that, if all individuals in the future took with regularity throughout their life an optimal diet, there would be a distinct decrease in neuroses and the less severe mental disorders and that there would be progressively fewer cases of this sort as generations passed. Concluding Remarks. Although information exists concerning the direct and indirect effects of diet upon the mind, much of the total desired knowledge is yet to be obtained. I t will probably necessitate the cooperative observations of men trained in various ways. Creative work should determine the exact qualitative and quantitative influence of dietary factors alone and in combination with each other and with various other factors on the production of neural lesions and mental symptoms. I t is most important to know for the welfare of nations and individuals the influence upon thought and social life of optimal diets. Carefully collected data of many sorts concerning the effects of optimal diets and all sorts of suboptimal diets on mentality, if 20 H. C. Sherman, Some recent advances in the chemistry of nutrition, J . Amer. Med. Assn. 97, 1931, 1425. [264]

NUTRITION continued over a long enough time (perhaps for several generations), would probably yield important information. The history of the people of this world could be written perhaps in terms of diet; initiative, progress, success, and the happiness of a people tend to go hand in hand with an abundance of food and a good diet.21 21 No attempt has been made to give a complete bibliography. References are given only to communications made by individuals whose names are mentioned.

[265]

X I V . PHARMACOLOGY By K. K. Chen, Ph.D., M.D., Indianapolis Superficially regarded there appears to be but a slight relationship between pharmacology and psychiatry. One is concerned with the action of drugs while the other deals with mental disorders. In the treatment of psychogenic ailments, as in somatic diseases, the ideal method is to remove the cause, which is the mental conflict. I t will certainly be expecting too much of a drug that it should replace psychoanalysis in suitable cases, suggestion and persuasion in hysteria, or occupation in some forms of psychosis. The limitations of drug-therapy often are very great. On the other hand, the patient's confidence is not always won, the rapport between the physician and the patient cannot always be established, and careful studies of various types of psychosis have not always been crowned with success in the sense of cure. As a result, psychiatry still looks to itself and to the supporting sciences for more extensive investigations and future progress. Remote as the two fields may seem to be from each other, pharmacology has helped in developing the subject of psychiatry, particularly in the line of treatment. The writer will give in the following account a few representative examples of contribution from pharmacology, and along these lines discuss what further pharmacological studies may be undertaken in the interest of psychiatry, that there may be a better understanding as well as more efficient treatment of mental disorders. Since pharmacology and therapeutics are so intimately associated with each other that it is almost impossible to separate the two, no attempt has been made to distinguish between them. I t may be pointed out, too, that psychiatrists have already carried out researches of a pharmacological nature. 1. Mental Disorders Which Involve Structural Changes. Paresis. The introduction of tertain malaria inoculation in paretic cases marks a distinct advance in the treatment of neurosyphilis. The beneficial effect is apparently due to hyperthermia, and one of the observed facts is the stimulation of the reticulo-endothelial apparatus, leading to a new formation of [266]

PHARMACOLOGY macrophagic tissue in various organs. The plasmodium infection can be terminated at will by the administration of quinine. Relapsing fever, the organisms of which can subsequently be eliminated by the injection of arsphenamine, has also been advocated for the treatment of paresis. Almost as efficacious as malaria therapy is the employment of tryparsamide, a product of systematic research. This compound has a high arsenic content, and yet it possesses relatively low toxicity. Its introduction into medicine represents one of the most careful procedures ever recorded. Nevertheless, additional information is still desirable regarding the control of paresis. I t remains a puzzling question as to why tryparsamide, feeble in spirillicidal action and practically inert in the primary and secondary stages of syphilis, should be particularly useful in paresis. What mechanism is involved in the improvement of the clinical picture? Does it differ from the malarial inoculation? Is there any stimulation of the reticulo-endothelial system? The fact that a clinical cure of early syphilitic cases does not always forestall the development of neurosyphilis in later years indicates that arsphenamine and its allies are not fully adequate to eradicate the disease. There is needed a new drug having a more penetrative power which can be used as a substitute for arsphenamine or to supplement it for the protection of the central nervous system. For this reason, the work in the laboratories of experimental syphilis should be continued in spite of its costliness. Arteriosclerotic Psychoses. Little progress has been made concerning the etiology and treatment of arteriosclerosis. Various depressor substances have been proposed for the temporary lowering of the high blood-pressure; they include nitrites, choline derivatives, and extracts of either animal or plant origin. The question still remains whether hypertension is initiated by a pressor substance circulating in the blood-stream, and whether a transient fall of the pressure is of any real value to the patient. A significant contribution to the solution of this problem will equally profit psychiatry in those cases where arterial disease is manifested by abnormal behavior. Epilepsy. I t has been generally stated that phenobarbital (luminal) is a drug of choice in treating epileptic seizures. This seems to be a justifiable teaching, because phenobarbital, the first drug introduced for such a purpose, has the longest effect. [267]

THE PROBLEM OF MENTAL DISORDER Other barbituric acid derivatives have a relatively briefer action and require more frequent doses to produce equivalent results. Paralysis Agitans. Sufferers from Parkinson's disease and postencephalitic parkinsonism react more favorably, both neurologically and mentally, to Datura stramonium than to hyoscine, the chief active principle of the drug. Apparently other constituents of the plant have a beneficial effect on the patient's condition. The nature of these substances may be revealed by further investigation. 2. Drug or Chemical Psychoses. Addiction. Morphine and cocaine habituation will remain as a psychiatrical problem as long as these two alkaloids are available for use. The National Research Council has already supported an important piece of research to find substitutes for morphine. While no prediction can be made concerning the outcome of this investigation, the method of procedure is undoubtedly the most logical one. I t may be pointed out that dilaudid does not appear to be free from the induction of habit-formation, and, in this respect, cannot be considered a satisfactory substitute for morphine. Cocaine is probably easier to replace. There are several synthetic local anesthetics which are effective by both infiltration and surface application. Some of them have a lower toxicity than cocaine. According to recent reports, a few of them show a pressor action. The ultimate method of handling morphine and cocaine, after substitutes for them have been decided upon, should correspond to that followed for heroin by the League of Nations. Carbon Monoxide Poisoning. The extensive use of carbon dioxide-oxygen inhalation has probably revived a large number of individuals poisoned by carbon monoxide. I t would be interesting to ascertain whether or not there is any decrease in the incidence of psychoses following the physical recovery. The efficacy of methylene blue by intravenous injection in carbon monoxide poisoning requires confirmation. Experiments on animals do not seem to substantiate the claims made for this dye. 3. The Minor Psychoses. For the alleviation of somatic complaints before the specific mental conflict is discovered the psychiatrist has at his disposal a large number of drugs. Most of them are the results of systematic researches. Thus there is a long list of hypnotics variously prompt in action and with a variable duration of hypnotic effect. Insulin has been recently [268]

PHARMACOLOGY shown to stimulate the appetite. For vagotonia, atropine has been administered with benefit, and for sympatheticotonia, choline preparations have been found to be effective remedies. By further investigations, other products may be added from time to time to this list. 4. The Major Psychoses. Although pharmacology has not contributed much to the management of major psychoses, yet a good beginning has been made. An intravenous injection of a dilute solution of sodium cyanide in schizophrenics has given rise to brief lucid moments, and inhalation of a carbon dioxide-oxygen mixture has yielded even better results. With the latter procedure, relaxation has temporarily replaced catatonia. Intelligent conversations can be carried on with mentally inaccessible patients, and sometimes the painful experience is voluntarily told. Unfortunately, these lucid moments do not last longer than two to twenty-five minutes, and the real value of the carbon dioxideoxygen therapy has therefore strict limitations. With sodium amytal, a hypnotic drug of the barbituric series, remarkable results have been obtained. Daily intravenous injections of this preparation have precipitated the manic phase of manic-depressive psychosis into profound and prolonged sleep, and have shortened the course of the illness. The catatonia of schizophrenic cases has been made to disappear; mental insight is restored and food is taken by the patient without persuasion. Convulsions from status epilepticus can be effectively relieved by the same procedure. The writer knows of a case in which a large amount of sodium amytal was taken with suicidal intent. The attempt was unsuccessful, but after awakening from a long sleep, the patient thought life more attractive than ever, and met her difficulty with a most logical solution. Results similar to those obtained with sodium amytal have been reported with alcohol, ether, and ethyl chloride. I t appears that psychotherapy can be advantageously employed in conjunction with these medicaments. The whole class of hypnotics may deserve further study. I t consists of a large number of compounds, several of which have not been thoroughly tried in psychiatry; ether, ethyl chloride, hyoscine, chloral, bromide, paraldehyde, barbital, luminal, amytal, ipral, neonal, nostal, pentobarbital, sandoptal, dial, and phanodorn. The last ten are derivatives of barbituric acid. Although they are similar in action, yet they have significant [269]

THE PROBLEM OF MENTAL DISORDER differences, such as speed and duration of action, effect on the vagi, method of elimination, and individual variation of responses. I t is only by a comparative study that a better understanding of mental disorders and improved methods of treatment can finally be obtained. The exact manner in which the hypnotics act on the psychotic cases is not known. I t is conceivable that sleep or narcosis induced by a hypnotic or anesthetic prevents the fatigue and exhaustion of those mentally unbalanced, but a question at once arises as to how a reaction between a chemical substance and the central nervous system can change abnormal to normal behavior. A speculative answer might be formulated, but important facts can be gathered only by continued investigation. The lipoids of the brain, obscure as they seem, in all probability play an important part in the functioning of the nervous system, especially in the physicochemical property of the cell membrane. If a mental process is the result of an impulse or impulses, it may be expected to manifest itself as a change or difference of electrical potential between the two sides of the cell-membrane. I n mental disorders of psychogenic origin it is not impossible that a normal impulse has been exaggerated, or an abnormal one has arisen. I n course of time, such an impulse may become dominant and establish a vicious cycle. The condition is then said to be a well-developed case of psychosis. According to one of the theories which have been advanced, the action of a drug depends upon the potential gradient between the concentrations of the drug outside and inside the cells. Indeed, in some instances, the responses of organs to drugs are almost indistinguishable from those to nerve impulses. For example, epinephrine reproduces the effects of splanchnic stimulation, and pilocarpine those of vagal stimulation. I t would not be surprising, therefore, if hypnotics or anesthetics should be able to alter an abnormal impulse or actually break the vicious cycle of the mental disorders and to restore the normal impulse. The mere fact that individuals take to alcohol or morphine in order to escape from their unpleasant thoughts seems to indicate that hypnotic effects shield and relax mental conflicts; otherwise, these patients would possibly develop a more serious and outspoken psychosis. Experimental Possibilities in Animals. I t must be admitted that owing to the lower intelligence of animals and the absence [270]

PHARMACOLOGY of a language for free communication, the limitations of animal experimentation along psychiatrical lines are really very great. There are a few drugs, however, that are known to cause psychic effects in men and most likely produce similar responses in animals, as exhibited in their motor activity. The following examples may be of interest and deserve further investigation. Manic-depressive State (?). I t is well known that morphine depresses dogs but stimulates cats. The exact reason why such a difference occurs has not been satisfactorily explained, but the results in cats are of an unusual nature. Following a suitable dose of morphine, the cat's pupils become dilated and the eyes widely open. The animal scratches purposelessly, claws, runs about, charges, and sometimes howls. I t does not respond to ordinary calls, and is not interested in its usual prey, the rat. The stream of activity, which lasts for hours, is often followed by a period of depression, during which the respiration is slow, analgesia is often present, and the animal appears apathetic with gradual recovery. Catalepsy. Bulbocapnine, an alkaloid of Corydalis cava, appears to cause catalepsy in cats, dogs, and monkeys. The grasp reflex is best elicited in infant monkeys. Recently Corydalis B and K, two alkaloids of Corydalis ambigua, have been reported to produce similar effects in mice, cats, and dogs. Hallucinations. The intoxicating action of Cannabis sativa is well known and the use of this drug in the Orient antedates written history. In men hallucinations and other psychic alterations are of common experience. In dogs the drug when given by mouth produces ataxia and excitement, followed by narcosis. Mescaline, an alkaloid of Anhalonium Lewinii, which has been used for centuries by the American Indians in religious ceremonials, is also able to induce hallucinations, with auditory and visual aura. Preliminary studies on animals have been made, but they can be advantageously extended. Harmine is another substance that causes psychic changes. This alkaloid can be isolated from two distinct plants, one being Pegnum harmala, which has been employed as an anthelmintic in Asia Minor, and the other being Banisteria caapi, which has been used as a drink by the Indians of the Amazon and Andes in their ordeals. The Indian is said to turn deadly pale, to tremble in every limb, and to appear horrified. He then bursts [271]

THE PROBLEM OF MENTAL DISORDER into a perspiration, seems possessed with reckless fury, seizes any weapon at hand, and inflicts violent blows on the ground or the door-posts, calling out all the while, 'Thus would I do to mine enemy (naming him by name) were this he.' In about ten minutes the excitement has passed off, and the Indian grows calm, but appears exhausted. White men who have partaken of caapi feel alternations of cold and heat, fear and boldness. The sight is disturbed, and visions pass rapidly before the eyes. Harmine, the active principle of the plant, produces signs of an unusual nature in animals. Dogs, for example, receiving this substance assume an unsteady gait as if walking in clouds. These three drugs, cannabis, mescaline, and harmine, deserve a more thorough study in higher mammals, particularly in monkeys and chimpanzees which Yerkes recommends as the best possible substitutes for men as experimental subjects. Elation. There are two well-known alkaloids which have a cerebral stimulating action both in men and in lower animals. The effects of atropine have been described as exaltation, restlessness, excitement, and delirium, and those of caffeine as a quicker and clearer flow of thought, more sustained intellectual effort, and more prompt association of ideas. I t is not impossible that elation can be demonstrated by laboratory experimentation. Depression. In contrast to stimulants, hypnotics in suitable doses can elicit various degrees of depression. They are able to change the mood, impede memory, and inhibit or diminish activity. In the preceding paragraphs it has been shown that certain drugs can at least produce in animals signs that simulate those of psychoses in men. Probably more interesting results will be obtained in monkeys and chimpanzees. I t must be emphasized that the question of dosage of each drug is a factor of prime importance in eliciting the effects that are looked for by the investigator. When studies of behavior under the influence of these medicaments have been completed, attention should be at once directed to controlling these conditions by antagonistic drugs so that recovery to the normal state is actually hastened by counteracting substances. For example, the depressive action of barbituric-acid derivatives can be quickly removed by picrotoxin, ephedrine, or caffeine. I n case of catalepsy induced by bulbocapnine, sodium amytal may be first tried. Finally, [272]

PHARMACOLOGY similar investigations, directed especially to the improvement of therapy, should be made on men. The criticism may be made that 'psychoses' or 'signs of psychosis' in animals caused by drugs cannot be compared with human disorders. The former may be said to be artificial and transient, and to depend upon the physicochemical reaction between the drug and the cell, while the latter may arise from a mental conflict, sexual trauma, or unadjustable constitution, continuous in its course, and apparently not accompanied by anatomical changes. The final answer can be given only after more information is available. The fact that delirium, hallucinations, depressions, or paranoid states can be due to infectious diseases, brain tumors, toxins, drugs, or a protest of the subconscious against the current life, and that diagnosis is frequently made by exclusion, offers hope for animal experimentation since the same or similar patterns of mental disorder may be possibly produced by available means, such as chemical substances. The relatively short course of the drug action is not particularly a disadvantage, for the investigator can easily repeat the procedure, either on the same or another animal, and by so doing he may make closer observations than in a single experiment. With the improved methods of neurophysiology and neurochemistry, more knowledge may be gained concerning the physicochemical conditions of the cortical cells and their changes under various influences. One may ultimately be able to distinguish a normal from an abnormal phase, and attempt to convert the abnormal to normal by suitable therapeutic measures. Conclusions. I t is clear that there is a close relationship between pharmacology and psychiatry. Advances in the former may be beneficial to the latter. I t has been pointed out that search should be continued for a new antisyphilitic drug having a more penetrative power into the nervous system, so that the incidence of neurosyphilis may be eventually reduced. Regarding drug-addiction, one may say that cocaine can be well replaced by synthetic compounds, but morphine substitutes have not yet been found. The results with sodium amytal and other hypnotics in several types of psychosis are striking and promising, and a critical examination of the whole series may give rise to additional useful information. There is a group of drugs which cause psychic effects in men and peculiar activities in animals simulating the signs of human [273]

THE PROBLEM OF MENTAL DISORDER psychoses. I t is suggested that they should be carefully investigated in animals, including monkeys and chimpanzees. If it becomes possible to produce synthetic cases of psychosis in animals, the question of therapy may more easily be solved. A word of warning may be given in closing. In undertaking these researches, the investigator must take a modest and conservative attitude. He should bear in mind that his results, however interesting they may be, will require thorough confirmation, and their practical applications will depend upon a large number of cases. He should be especially reserved in making statements to newspaper reporters. Time and again a premature and sensational story has been detrimental to the investigator, hindering the establishment of a good reputation by a young student or ruining the prestige of a mature teacher.

[274]

XV. GENERAL A N D EXPERIMENTAL

PSYCHOLOGY

By Madison Bentley, Ph.D., Ithaca general orientation The relation of psychology to the study of the mental disorders is both intimate and unique. When medicine speaks of 'mental diseases' there is an implication either that the diseases themselves are of a mental sort or that they are typically expressed in mental terms or 'symptoms.' Sometimes the one view is sustained, sometimes the other. On either view psychological facts have to be taken into account in a primary way.1 One natural result of these close relations between psychology and the psychiatrical branch of medicine has been decidedly unfortunate. Medicine has sometimes found the experimental psychologist's studies of the abnormal badly adapted to its purposes and the activities of the clinical psychologist aggressively competitive in manner or uncongenial in professional pretension. And, on the other side, psychologists have now and again found the medical theorist uninformed, speculative, and irresponsible when he entered the mental domain and the medical observer at times untrained, naive, or old-fashioned in his psychological descriptions. Neither attitude encourages the entente cordiale that is necessary if the two parties are to aid and to supplement each other. I n the past, this problem of sharing a common field has worked itself out in various ways. When psychology was chiefly based on philosophical reflection and gross observation a 'medical psychology' was easy. Examples are the psychologies of the nineteenth century French physicians, which exploited the subconscious and the automatized in action and behavior, and the late psychological medicine of British flavor which was built upon the persistent doctrine of associationism. The later impress of biological theory and point of view upon psychology has also been adopted here and there in medicine, generally in some form of behaviorism or psychobiology. The prevalence of instinct, 1 Dependence upon psychological facts and principles is clearly implied by the main rubrics of systematic medical works upon the mental diseases. See, e.g., Handbuch der Oeisteskrankheiten (O. Bumke, ed.), J. Springer, Berlin, 1928, vol. i, 318-711, vol. ii, 1-91. [275]

THE PROBLEM OF MENTAL DISORDER habit, heredity, and the total or unpartitioned organism in current psychiatrical writings is an indication of this influence. Still another working alliance has been suggested in the revival of the age-old doctrine of unconscious powers, a speculative doctrine recast to explain the disorders. F. W. H. Myers and S. Freud were active in turning to medical account this doctrine, which appears prominently in the great historical systems of Leibnitz, Herbart, von Hartmann, and many other philosophers and theologians. Because this hypothetical principle is spiritual rather than material, the adherents have often spoken of their doctrine and their procedure as psychological. Since, however, the doctrine and the methods are quite unlike—both in derivation and in spirit—the current empirical or observational psychologies, it is important that psychology be sharply distinguished in all contexts from psychoanalysis, an apt term chosen and adopted by Freudians and related schools. The only persons who overlook this distinction are those who, wanting historical perspective, believe that psychoanalysis is 'the new psychology,' destined to displace all others. Some of these persons are propounders and theorists; but most are converts and disciples. For the distinctive features of psychoanalysis we may refer again to the authoritative exposition in Section I I . Again, as careful writers commonly distinguish psychology and psychoanalysis, so do they distinguish the abbreviation 'analyst' (now incorporated in the technical phraseology of the Freudians) from analytical procedures and methods in the field of general psychology. The want of this distinction has made the phrase 'analytical psychologist' wholly ambiguous and misleading. Our reference to the various historical attempts to establish a working relation between medicine and psychology clears the way for a consideration of the opportunities now presented to the psychologist who desires to make a contribution in the field of the abnormal. First we limit and simplify our present problem by setting aside for a different context most matters pertaining to psychoanalysis. We then further limit our inquiry by omitting in this section— which is directed toward scientific support brought by way of experimental investigation—all reference to practical aids in the clinic, the ward, or the statistical office, in the form of diagnostic test, classification, or therapeutic means. This would defer for another sort of treatment the branches and activities of clinical [276]

GENERAL AND EXPERIMENTAL PSYCHOLOGY psychology not directly concerned with controlled investigation. Those who regard this branch of the subject as primarily an experimental branch may well object, however, if due regard is not paid to their methods and results. We do include, for reasons which will presently be obvious, an article which sets forth a clinical psychologist's understanding of the psychoneuroses. Since the books and articles on psychotherapy are chiefly concerned either with doctrine and theory or with practice and cure, we may also omit them. Upon social and genetic psychology we must pause for a comment. Those who are not satisfied with the psychoanalyst's means of recovering the relevant past of the sick or disturbed individual will eagerly seek substitutive facts derived from other sources. Here the biologist's accounts of development are in order. They are scanty, however, even as a record of the typical human organism. Comparative morphology and physiology are of some help, and the facts and principles of racial and family determination must not be overlooked, though they should never be resorted to merely to save the face of the physician whose etiological notes are scanty. Behavioristic studies of the child and other animals are decidedly in place. Careful observations in the home, the school, and the public institution sometimes throw light upon emerging derangement. The fact that all these sources taken together are, however, insufficient and inadequate to the reconstitution of individual history is doubtless one reason why many men have lent an ear to speculations upon infantile sexuality, the inferiority complex, the early lust for power, and, in practice, to the psychoanalyst's "free association." A good genetic psychology, one that should trace the development of the psychological functions and the means of their government, from infancy to adult life, would be a very great help. This account should also include a history of the individual's relations to other human beings, to human institutions, to groups, to traditions, and to taboo, rules, moral threats, and laws. Recent researches on fetal, infantile, childish, and adolescent periods have already supplied rich materials for this developmental history. When carried further, when integrated, and when sound principles of sequence and succession have been drawn out, the basis for a real psychology of individual development will have been laid. We shall then have not only the generic history, we shall also see where individuals diverge, [277]

THE PROBLEM OF MENTAL DISORDER proceeding toward various aptitudes and proceeding also toward diverse defects and disorders. Until now adult interest in advancing the sprouting and imperfect infant—by means of school-grades, maxims, punishments, and gifts—toward the perfected stage of adulthood, where parental and educational responsibility may be relaxed, has not been conducive to an objective and scientific appraisal of the growing child. Current insistence upon the social origins and influences in the disorders now prompts us to revise our social psychologies, basing them upon psychological facts and principles instead of— as heretofore—upon sociological and biological doctrines. Research here lies largely in the future, though serious beginnings have already been made.2 The psychoanalyst may sensibly contend that however complete our knowledge of the general laws of deviation toward defect in childhood and youth, the diagnosis and treatment of the individual case will demand the private and biographical probe which he is prepared to administer. The contention is obviously forceful. We may remark, however, that it cannot be sanctioned by the alleged therapeutic value of the probe until competent men are more fully agreed upon the psychoanalytic therapy.3 And we may remark again that methods of recovering the individual's past are by no means restricted to the analytic procedure. In psychiatric practice itself other methods are becoming common. Whatever the method, the results of the historical inquiry are never connected by any logic but the psychoanalyst's with the Freudian interpretations. An interpretation which the experimental psychologist would greatly prefer would be based upon empirical investigations of the nature of childhood and of its normal and disturbed development, without an overlay of doctrine. A natural place to look for psychological implications in the disorders is in the recent treatises called 'psychologies of the 2 These beginnings are well exhibited in the volume Experimental Social Psychology, by G. and L. B. Murphy, Harper and Brothers, New York, 1931. The main psychological approach to 'personality' and 'character' should be through social psychology. Most individual 'trait' studies are scientifically worthless. Recent experimental articles on personality and the disorders are reviewed in Psychol. Bull., 30, 1933, 209-236, 467-487. 3 The claim that only the 'analyzed' are competent is plainly a subterfuge. As well might we limit the competent in the chemistry of food-cooking to those who have suffered flesh-burns in the kitchen or the informed in respiratory difficulties to those who have been gagged and choked. At the very least we should wait for an assurance that these intimate confessions were free from the effects of a violent and upsetting experience. [278]

GENERAL AND EXPERIMENTAL PSYCHOLOGY abnormal.' Such a survey, however, would not be without disappointment. These works may be roughly divided into those written by medical men and those written by psychologists. Instances of the authors from the first group are Myerson, Burr, Coriot, and MacCurdy. The psychologists include Conklin, Morgan, McDougall, Fisher, and Moss and Hunt.4 Among the medical writers, Burr describes the insanities with a trite preliminary essay on the faculties of the mind and the anatomy of the brain. Myerson's little book is a psychiatrical treatment of "the mentally sick," describing diseases and symptoms in conventional terms and laying emphasis on bodily lesion and heredity; in these diseases he asserts that the psychiatrist is "the only authority mankind has." Coriot shows the spirit of the French physicians, enlarging upon the subconscious and the picturesque hypothesis of dissociation. MacCurdy combines in his form of 'dynamic psychology' the Freudian doctrine of psychoanalysis with the theory and art of suggestion. If we can safely infer from their titles to their intent, these books may be taken to illustrate what the 'medical' psychiatrists commonly regard as psychology. To them might well be added the entire lot of books expounding Freudian doctrines which are written by psychiatrists who confuse psychoanalysis with psychology. The range of treatment by the psychologists cited is just as wide and more chaotic. Moss and Hunt have virtually written a medical psychiatry, closely following Myerson and devoting their attention chiefly to the "true mental disorders" (i.e. those with " a definite underlying physical cause and tissue pathology"), leaving the "pseudo-mental disorders" or "bad habits" to the behaviorists. Moss and Hunt are obviously not at home among mental categories. There is a resulting defect in the description of diseases without a known bodily basis. Not many psychologists, e.g., would regard hysteria as "pseudo-mental," however vigorously a Myersonian psychiatrist, discouraged in his search for a specific "pathology," might desire to regard it as pseudo-medical. Morgan takes up 4 A. Myerson, The Psychology of Mental Disorders, 1927; C. B. Burr, A Handbook of Psychology and Mental Disease, 4th ed., 1914; I. H. Coriot, Abnormal Psychology, 1910; J. T. MacCurdy, Problems i n Dynamic Psychology, 1922; E. S. Conklin, Principles of Abnormal Psychology, 1927; J. J. B. Morgan, The Psychology of Abnormal People, 1928; W. McDougall, Outline of Abnormal Psychology, 1926; V. E. Fisher, An Introduction to Abnormal Psychology, 1929; and F. A. Moss and T. Hunt, Foundations of Abnormal Psychology, 1932.

[279]

THE PROBLEM OF MENTAL DISORDER the disorders under the older psychological headings of perception, association, memory, and the like, and adds essays on sleep, dreams, hypnosis, etc. The primary aim is a pedagogical presentation of mental hygiene or "successful adaptation to the varying phases of life." Conklin regards his psychology of the abnormal as a "basic science" to medicine. Leaving aside treatment and cure, he gives a descriptive account of all forms of abnormality with a catholic view of theories and schools but without a consistently integrated psychology. The Pillsbury is little more than an encyclopedia of terms under the conventional headings. McDougall's purposive psychology is favorable both to the Austrian psychoanalysts and to the dynamical views of the French physicians. He writes, however, not as psychiatrist or medical specialist but as " a student of human nature." The treatment has the rare advantage of incorporating the facts into a coherent presentation. Fisher derives from McDougall, building upon the personality, which he represents as suffering from derangement of the Freudian mechanisms. If it is permissible to comment at large upon current and diverse treatments of the abnormal labeled 'psychological,' we may note that the medical men usually place their emphasis either upon pathology or upon psychoanalytic theory; while the psychologists produce a medley of biological, medical, therapeutic, and psychological facts and doctrines with a varying emphasis, but (barring a few exceptions) with no basal psychology which serves to order and to interpret the facts of abnormality. The limited success of psychology in this direction will be better understood if we observe what the main varieties of this subject have been and note the aptitude or inaptitude of these varieties in dealing with the mental disorders. When we follow the main and persistent trends in psychology, we discover that three general conceptions of the human organism have there competed with each other; namely, the triple man, the double man, and the single man; in other words, the organism regarded as body-mind-soul, as body-mind, and as body. The triple man derives from philosophy and theology. Its current representative is psychoanalysis, which adds an underlying 'dynamic' element (unconscious, instinct, libido, id, etc.) to the bodily framework and the conscious processes. The bodymind comes from a dualistic philosophy, which represents the [280]

GENERAL AND EXPERIMENTAL PSYCHOLOGY two fundamental existences, physical and mental, as somehow meeting in the living organism. The single man appears both in the more pronounced forms of behaviorism, which discard the mental or conscious and describe bodily performance alone, and that form of functional psychology which discovers a living body active in two ways, a physiological way and a psychological way. Under this second view, man is structurally and morphologically single (i.e., a body) and functionally plural. Mind is not an existent part of the organism to be deranged or damaged, and neither is it an explanatory agent. Wishing, perceiving, understanding, and emoving are basal functional performances, just as breathing, secreting, and digesting are; but they are not lodged in, or supported by, a conscious or an unconscious mind. They are kept going, whether adequately or inadequately, by the body. A derangement of these functions may imply 'disease' but very often it no more implies disease than clumsy movements, deficient gastric juices, or rapid breathing implies disease. On this view of the single man or working-body, functional variation or aberration (of either kind) may or may not be symptomatic, i.e., an indicator of lesion, trauma, or bacterial agent. To be disordered is therefore not the same as to be diseased.5

Now the triple man is invoked wherever a hypothetical force, in the nature of the soul or hidden spirit, is assumed in order to explain the disorders. This is the basal contention of psychoanalysis. I t has also been invoked to satisfy the craving of man for a permanent existence and a compensating paradise or 'after life.' In psychiatry it suggests a theory of the mechanisms and forces of the unconscious. This triple man appears in medicine (often under the biological guise of 'instinct') just at the time when hidden causes and agents tend to be discarded both in physics and in psychology. The appeal to the double (or body-mind) man seems to rest upon the currency of a tenacious dualism. This dualistic belief provides that anything not physical (in the physicist's sense of atomic and molecular structure) shall be thrown into the class of things called mental. One vicious outcome of this view is the 6 This functional conception of the single man, which holds that physiology and behaviorism are wholly inadequate to a complete factual description of the performances of man, has been more fully treated than the others because it is not so well known in the present context. Cf. M. Bentley, Mind, body, and soul in medical psychology, Amer. J. Psychol., 45, 1933, 577-591; and The New Field of Psychology, D. Appleton-Century Company, New York, 1934. [281]

THE PROBLEM OF MENTAL DISORDER mind-body problem, which is as much of a bugbear to medicine as it is to all of the other sciences and arts which treat of the human organism. A formal escape popular at the present time is a verbal declaration that the organism is unitary, organismal, or psychobiological. Since this declaration is invariably followed, however, by citing now mental and now physical factors in the organism, the problem would seem to be but thinly veiled by a covering term of ligation and not really and lastingly disposed of. Both the tripartite man of psychoanalysis and the dual man of mind-body psychologies have vexed medical and neurological psychiatrists because they have suggested psychogenic causes and purely mental or functional disturbances, two proposals which orthodox medicine is unable to cope with or to assimilate to its fixed notion of the pathological. A more fundamental rapprochement would seem to call for concessions on all sides. One concession will be effective if and when the hidden part of the triple man is translated into bodily and social residues of function, with a reduction in claims for fantastic mechanisms involving the unconscious. Another concession would be the psychologist's surrender of mental entities and agents. This concession might well be made without the least neglect of the actual facts of daily living, which as clearly display the functions of perceiving, believing, remembering, and desiring as they display the operations of digesting and secreting. The third concession would come from the psychiatrist, who might be persuaded to take less seriously and apply more critically his cherished category of disease and observe more factually the forms of disordered function. His demand for a bodily support for function is basically sound; though he overlooks the fact that disorders frequently inhere in a relation between the organism and something else, i.e., the physical order, social organization, or the products of psychological functioning. His demand for a pathological seat for all disturbances has broken down as a universal guiding principle for deflections and variations, whether of a physiological or a psychological kind. I t now seems obvious that if medical psychiatry is to insist on pathology, whether pathology is demonstrable or not, various other guiding principles and various other methods of description are bound to share prominently in the domain which medicine has until now exclusively claimed in the name of pathology and disease. [282]

GENERAL AND EXPERIMENTAL PSYCHOLOGY If we were to ask for the guiding principles of a psychology which might be useful here, at the point of a proposed rapprochement, we should suggest that the logical tangles of the double (or mind-body) be avoided if possible and that the bold speculations of a hypothetical trinitarian man be left to the theologian and to the cultist in therapy. We should then start with the bodily organism which is capable, as we all observe, of physiological and of psychological modes of operation. The psychological modes have been observed to fall into primary classes; first, a primitive search; then the apprehending (perceiving, remembering, and imagining) and the executive (acting and emoving) functions. Thereafter appear other classes, just as important but derived from these in a developmental sequence; i.e., inspecting, comprehending, and elaborative thinking. We may take any given psychological performance of the day and find that it is factorable into one, two, or more of these nine modes of function. So soon as we advance beyond functional description toward causes and explanations, we shall discover—just as we discover with the physiological operations of breathing, digesting, and the distribution of oxygen or of nutrient materials—that the agencies responsible for performance are all bodily. We shall find it unnecessary to assume either mental or unconscious agents, forces, and substances. The addition of magical forces and powers is always an illicit short-cut which does not satisfy the demands of a scientific account. I t appears that the strong desire for psychological or psychogenic causes will have to be satisfied with two observations: the first that the world of things, activities, men, customs, and institutions in which we move is largely the product and issue of psychological functions (both ours and all others who have bequeathed us their functional residues), and the second that this factual world is the codeterminer, with the individual living body, of all our activity. Upon any theory of causation with which we elect to annoy ourselves, nothing therefore is more really the spring of all our activities, normal and morbid, than the products of the psychological functions, albeit these functions are wholly sustained by bodily mechanisms. So keen has man been to return half these functional products to the receptacle of a 'mind'—calling the products 'mental' processes, activities, causes and the like— that he has overlooked the imaginary and fantastic nature of the assumed receptacle. [283]

THE PROBLEM OF MENTAL DISORDER The bodily system alone does; but it physiologically does only by an active interaction with other physical systems and it psychologically does only by making use of its own products and issues. Now the dialectic of living body and functional product, which produces what men like to regard as the powers of the soul and the operations of the mind, demands government and control. Upon the view here proposed, this active interplay does not sustain itself and its requirements by directive powers of such mental agents as purpose, libido, instinct, unconsciousness, or will. Then whence government and control? and, incidentally, whence the loss of control which is the central fact in the disorders called 'mental'? Every coherent psychology has assumed a governor; behaviorism runs its organism by stimulus; assumed inherent and unconscious forces run the psychoanalyst's triune man; purpose governs the hormic psychologies; the parallelist runs on his nervous system, which throws off parallel mental processes; the biological psychologist controls his organism by genes; the actpsychologist by such initiating and guiding agents as attention and thought; the associationist by alleged bonding powers; the psychobiologist by personality or by biological energies; one popular form of dynamic psychology has recourse to drives; the social psychologist assumes innate dispositions and instincts, and so on with all the rest. Each psychology has its preferred theory of government, while psychiatry accounts for the misgovernment of its patient by appeal to any one or all of the doctrines enumerated, according as interest, influence, information, or training directs. Not all these theories of governing mechanisms and principles to direct the organism can be wholly true. As a matter of fact, each has some element of reasonableness, but all are one-sided, and many propose mythical or magical powers which cannot be scientifically sanctioned. If we turn our back on theories and speculations and actually observe the organism functionally operative in planning, doubting, believing, perceiving, emoving, or thinking, we shall see that government, control, and effective operation are provided from three cooperating sources, i.e., government is the resultant of many factors which may be conveniently brought under three [284]

GENERAL AND EXPERIMENTAL PSYCHOLOGY headings: (1) extraorganic factors, (2) the state of the organism, and (3) historical residues. 1. Government from beyond the organism is multifarious. I t contains many moments. Although the living body is a relatively independent physical system, maintaining through the life-span its integrity of being and of activity in the face of many attacking systems and agencies, its course is variously shaped and governed from the outside. We may write the main factors in this imposed form of government as follows. Extraorganic Factors in Government: a. Physicochemical interchange. b. Energies delivered at receptors. v. Molar objects and their activities. d. Living individuals and groups (chiefly human). e. Immanent human modes and traditions. u. The first includes the taking of food, the inward and outward flow of heat, moisture, and gases, and the processes of elimination. Psychological modification by them is easily demonstrated by defective diet, impure air, hot moist climate, and so on. b. The localized energies become stimuli when they excite receptors. Most psychologies take into account these governing powers, which the behaviorist exaggerates and the purposivist undervalues. c. The 'environmental panorama' is very effective in its direction of the organism. Some regard it as holding the fate of helpless man. We should note, however, that its effects are exerted less through the mere sense-organ than through the psychological functions operative in the individual organism. This environment (the effective environment) is itself largely determined (especially in man) by the selective operations which are psychological. We have only to lose memorial recall (as in amnesias) or adequate comprehension (as in schizophrenic defects) to realize how completely the panorama of living may change under psychological loss. d. Dependence upon human individuals and human groups is too impressive and too multiform to call for comment. Not even the isolation of the recluse or the shipwrecked survivor removes this source of government, for there always remains the socialized self-object from which there is no escape. e. Not only is the organism guided and misguided by socialized objects; it is profoundly impressed by the products of these which play upon it in the form of modes of behavior, rules, canons and laws of conduct; in short by the unspoken direction exerted by its race, clan, people, or kind. At almost every moment in its waking hours, therefore, is the organism directed, instructed, set tasks, hinted at, warned, encouraged, or inhibited by objects, activities, and accustomed ways which lie essentially beyond itself, albeit interpreted and tempered by its own psychological operations. On the social side of this control the most important single factor is undoubtedly approval or disapproval. 2. Government is always an interactive affair. Objects and energies do not simply invade the organism to work their effects [285]

THE PROBLEM OF MENTAL DISORDER there. The powerful and independent environment of the formal biologist has no place in psychology, where outcome and output depend quite as much upon the state and status of the living organism as upon the extraorganic component in operation and government. We discover here the following chief determining moments. The State of the Organism as a Source of Government: a. Structural provisions. b. Physiological resources. c. Functional trends. a. A general condition of government is the character and degree of bodily integration. Given the same outside conditions, the results (e.g. with and without a cortical brain system) are quite unlike. With the development of the mammalian cortex many new factors of control replaced, or at least modified, the outside influences. One of the most striking evidences of this shift of control to the central nervous system is shown in the memorial and imaginational substitutes for the perceptual panorama. Here the psychological functions are, for the time, relatively independent of surface receptors, taking their essential way and controlling also deliberative action and elaborative thinking from within the organism. Another striking evidence of the substitution of organic for extraorganic moments of control appears in the foreshortening and short-cutting of function in the symbolic forms, notably by the use of verbal counters. This is a provision made possible by cerebral development, and it incredibly extends the range of organic control. 6. Among the primary physiological resources of government stand preeminent the neuromuscular integrations which involve the skeletal muscles. A striking demonstration is Dr. Jacobson's discovery (see his article above) that general atonicity here, under relaxation, brings marked changes—even elimination—of the psychological functions. In man especially (where the training of childhood has been judicious) have the muscular tensions and contractions been made instruments of government and control of these operations. c. Neural and neuromuscular patterns are seldom momentary. They take a course and the course has direction; i.e., it has progressive phases leading toward an outcome. The incipient and early stages of these functions are therefore anticipative in the sense that they naturally lead on to a defined end. It then becomes possible, by controlling trends of function, to govern issues. Organic priming, is, as we see, important. One common, if rough, means is by encouraging good habits, the point being that on an occasion which offers rival trends, the right trend will be effective. Individuals who apply themselves to a task in hand have a means of control wanting to the scatterbrained and the flighty. The experimental psychologist, who is alive to the importance of understanding and of directing the immanent functional trends, makes free use of the various forms of instruction: (1) the formal or verbal instruction, (2) the occasional instruction which directs the organism from the presented occasion in which both organism and the outside setting of the stage are involved, and (3) the selfinstruction through which the individual authoritatively appeals to its selfobject with such comments as ' I can if I try,' ' I should be ashamed to fail,' 'It is [286]

GENERAL AND EXPERIMENTAL PSYCHOLOGY beyond my abilities' 'I am afraid,' and thousands of others which serve as so many bits of control and direction (or their lack), quite without implying any mysterious mental agents of 'will' or 'conscious effort.' 3. The third great group of governing factors is the most difficult to know and the most difficult to manage. This is especially important because it is the origin of very common mismanagements in the psychotic and the psychoneurotic disorders. I t represents the factors and occasions from the organism's past which are nevertheless effective in the present. The past must therefore be taken into account as a part of government, although it may not at all be present as the past. Believing in mental agents which rule the organism, the psychoanalyst picturesquely represents the past as persisting in the form of unconscious forces. A clear acknowledgment of the efficiency of the organism's history in governing and misgoverning need not, of course, imply any such doctrine. I t does, however— and here psychology makes its acknowledgments to the doctrine —usefully distinguish the biological and the biographical pasts of the organism, finding them both effective (in ways to be determined) in the present and future control of the organism, a control which usually affects both the physiological and the psychological functions. Government by Historical Residues: a. Biological history. Stock. Growth and exercise of physiological functions. 6. Biographical history. Developmental course of psychological functions. Use by the organism of its psychological products. Biographical effects of the self-object. a. The first heading distinguishes the bodily factor of parental and racial stock without which no organism lives and by which every organism is permanently attuned to its functions. On a given occasion the functions may be relatively modified from this source to a great, small, or negligible degree. So many other moments in government, however, temper the psychological functions— which appear and develop well after birth—that an explanatory reference to stock as heredity should be made with great conservatism and never for doctrinal reasons. Always the fashioning of the organism during growth and under the exercise of the great physiological functions must be taken into account among the biological factors. The biological history is therefore an unanalyzed resultant of the active growing and maturing organism of a certain stock and undergoing a certain biological development. 6. Coeval and coincident with this history is the growing biography of the individual. To this biography the course of psychological functioning is of [287]

THE PROBLEM OF MENTAL DISORDER primary importance. The individual becomes by perceiving, remembering, comprehending, acting, and so forth. Thus does the functional history in developing individualize and biographize the organism. But besides this genetical history the individual constantly sweeps up the issues of its own performances, making use of its memorial, imagined, and perceived objects, its executive resolutions and emotional situations, its values and significances inspected and comprehended, its discoveries under search, and its thoughtmaterials wrought out by elaboration. These it fits to the common world of its family, its neighborhood, its church, and its nation. This stock-in-trade world, partly worked out and partly adopted from others, is woven into biography. The process of its gradual acquisition from infancy on through life is biographical history, and its impact at any moment is a governing residue. Finally, functional growth and functional product taken together make the self-object, a concrete socialized being which the organism apprehends and appraises as himself. Living intimately with, and being solicitous and responsible for, the self-object, that object acquires approvals and disapprovals, reproaches and encomiums, which enormously enrich and individualize the biographical history. Furthermore, in every cross-section of the history there appears a residue of the unceasing commerce with the self-object which supplies one of the most powerful means of government or misgovernment, widely affecting the fortunes of the individual. Thus the timid infant, the parading child, the tortured adolescent, and the 'self-made' man are all tuned by a satisfactory or an unsatisfactory, a. reassuring or a, disheartening, self-object. Good government here requires certain satisfactions. So important is the self-object to health and sanity that an intolerable phase of it—e.g., an absence of peace, respect, comfort, faith, or dependence—may lead to serious disorder. In crises with an intolerable selfobject, men will contribute every available means or device to relieve themselves. Common devices are the flights and fugues through alcohol and drugs, travel, vagabondage, sleep, writing of poetry, prose, and autobiography, murder, and suicide. While a flat, quiescent, and undisturbing self-object may make a dull companion, it obviously tends to minimize the hazards of government which frequently threaten more turbulent and more complicated lives. The only excuse which psychology can advance for thrusting its problems of control and government into the study of the abnormal is its belief t h a t the wide range of human disorders exemplifies in a significant way the mismanagement and the uncontrol of life by reason of failure or defect in every one of the factors which have been hinted at in describing the three main directions (extraorganic, organic, and historical) from which the safe passage of life, throughout its long course, is secured or is imperiled. The necessities imposed by living are many. They include getting about, avoiding physical dangers, maintaining the integrity of the body and its fundamental processes, readjustment to the turns and stages of life, the acquisition of cultural modes, and the establishment of livable and working relations w i t h one's self and one's fellows. Each culture weights in its [288]

GENERAL AND EXPERIMENTAL PSYCHOLOGY own way each of these necessities. Where the culture is highly demanding or where individual fortune lays a heavy hand, crises arise, government breaks down, and the organism suffers defeat and disorder. A competent understanding of these exceedingly complex and difficult matters would seem to call for at least a generation of united and intelligent work. This would not be too great an expenditure of time and effort, however, if i t pointed practically to saner modes of living and to more effective means of prevention and relief. PSYCHOLOGICAL RESEARCH AND THE DISORDERS Research in the natural sciences usually implies experimentation. This implication is as significant in psychology as i t is in physics, chemistry, and physiology. Critical and historical studies are, i t is true, to be found among the sciences of nature, and whenever these follow the methods and the rigors of experimentation i t is common to include them under the heading of research. This historical kind of investigation does not often appear, however, in the present context; although a psychologist might, e.g., profitably research upon the relations, past and present, of psychology to psychiatry. A more difficult disposition appears w i t h the methods of the tests, the scales, the questionary, and the more informal examination of the clinic; methods which have lately competed, in some quarters, w i t h experimentation and which are commonly met in the application of psychology to business, to education, and to the medical arts of practice.6 I n these applied fields, tests and the like are often 6 The clinician in this field is frequently included among 'Consulting Pychologists,' a group whose members are widely employed in school, community, and psychiatrical clinics, as well as in institutions for the delinquent, the feebleminded, and the criminal. An Association of Consulting Psychologists is incorporated in New York State "for the purpose of establishing and maintaining professional standards of work in the various fields of applied psychology." This association includes a branch of clinical psychology which recognizes three ranks of clinician, student, junior, and senior. The duty of the first two ranks is to administer tests and examinations; the duties of senior clinical psychologist include the direction of the lower ranks and the control of "psychological research." Preparatory training prescribed for clinical psychologists emphasizes experience with tests, examinations, and scales, and with the means of practical guidance and relief. While this whole class of consultants obviously stands on the side of practice and application, any original studies done there, of a primary and investigative sort, may be readily recognized and rewarded, as they are in the clinical fields of medicine. In some educational institutions, researches are labeled 'clinical' where they might just as appropriately be set under experimental psychology, physiology, or neurology. This overlapping is well illustrated by a volume of Studies in Clinical Psychology under the direction of Dr. L. E. Travis (in Stud, in Psychol., Univ. of Iowa, 16, 1933). Dr. Travis [289]

THE PROBLEM OF MENTAL DISORDER called "researches": but when we apply here the same scrutiny and caution that the physicist or the physiologist would use where his fundamental methods are borrowed, simplified, and revised for the routine determinations of the engineer and the laboratory technician, we are moved to discard most, but not all, of the claims to recognition in scientific research, where rigorous training, wide knowledge, shrewd hypothesis, the formulation of fresh problems, the control of conditions, and a productive interpretation of results are all marks of the researcher. Where the test is a technical and shorthand device, designed to contribute in a practical way to the clinical description of patients, it may be set down—along with the case-history, the routine physical examination, and the reports from urologist and hematologist—as a technological method. In all these matters, the test does often imply antecedent research of an experimental sort. This is as true of the psychological as of the physiological test. Whenever either subject proposes to aid psychiatry, whether by real research or by technological method, high standards of knowledge, procedure, and skill should be forthcoming. And it naturally follows that the applicability of tests and the wise utilization of research within psychiatry call for the same high qualities and abilities in the psychiatrist as in the contributing science. I t is natural that psychiatrists who are without adequate knowledge and training in psychology should look coldly upon methods and results which were not included in their formal professional preparation and which they are not competent to estimate; but it is quite as natural and suitable that sound method should fail in unskilled hands. The most elaborately planned and executed general attack ever undertaken upon the mental disorders by way of psychological experiment was made by Emil Kraepelin (1856-1926), widely recognized as the person chiefly responsible for system and scientific order in modern psychiatry. Moreover, it may be questioned whether any man has so thoroughly and competently known both the psychiatry and the experimental psychology of the period writes, "In my opinion, clinical psychology has far outgrown the measurement period. . . . I am undoubtedly prejudiced in favor of believing that clinical psychology can compare quite well in research with other aspects of psychology." He speaks of the volume cited as containing doctoral studies "dealing mainly with neurophysiological approaches to the problems of abnormal behavior," and he remarks that he and his colleagues are "making psychological studies of psychopathic patients by means of the psychogalvanic reflex, the chronaxie, the biochemical and the action current techniques." [290]

GENERAL AND EXPERIMENTAL PSYCHOLOGY 1890-1925. In view of the important accomplishments in his medical profession, derived in large measure by the use of psychological research, Kraepelin's work must be critically reviewed. We stand at an opportune time for such a review, because the labors of this man, extending through two-score years, have recently ended. As it is the fashion to decry his psychological studies and to question their importance for our understanding, it behooves the psychologist to scrutinize Kraepelin's elaborate program and its execution throughout a human generation. Here experimental psychology would seem to have been on trial so far as its psychiatrical usefulness was concerned when the studies were undertaken. Entering the first psychological laboratory to be established in Europe (Wundt, Leipzig, 1879), as one of its early students, Kraepelin began there in 1882 elaborate studies of the effects of drugs and medicaments upon the simpler mental processes. Ten years later he brought together his results in a long monograph,7 which was to be followed during the next thirty-five years by a hundred and more studies, nearly all of them based upon experiment,8 and all of them designed to illuminate the problems of psychiatry by drawing upon the knowledge, the training, and the discoveries of the psychologist. As a general subject of investigation, Kraepelin hit upon that integration of psychological functions called "mental employment," i.e., a consecutive human performance which includes perceiving, discriminating, remembering, reading, associating, understanding, and acting.9 In this field a seasoned methodology was at hand, chiefly contributed by the Leipzig laboratory. He regarded these psychological functions as fundamental to the everyday behavior of man and fundamental also to the mental diseases. 7 E. Kraepelin, Veber die Beeinflussung einfacher psychischer Vorgange durch einige Arzneimittel; experimentelle Untersuchungen, Jena, 1892. » Psychol. Arb., (E. Kraepelin, ed.), vols. 1-9, 1895-1927. 9 I t has been common to translate Kraepelin's functional term psychologische Arbeit into 'psychological work,' a conception into which has been injected the sterile parallelism which demands that the mind exert and perform as the muscles do in physical or bodily work. Such a conception was clearly not Kraepelin's. For him writing, computing, committing to memory, and the like, were total performances of a sustained character which could be factored and measured. Both in normal behavior and in the disorders the energetics of these performances were secondary matters. Here we find him in sharp contrast to 'dynamical' systems, old and new, which have created a libidinous, self-seeking, or instinctive soul endowed with powers akin to the older physical conception of active anthropomorphic 'forces.' [291]

THE PROBLEM OF MENTAL DISORDER Now in order to pass, under controlled experimentation, from the normal to the abnormal, Kraepelin created Pharmakopsychologie, which is the psychological study of derangements artificially produced by pharmacological agents. Here—so he reasoned— disorder could be induced by measurable dosages and described and measured in psychological terms. The program was worked out in a long series of brilliant and painstaking researches, brought to a formal end by Kraepelin's death, but nevertheless supplemented since by colleagues, students, and other psychologists. In these days when personality is regarded as the deranged entity in many, if not most, of the disorders, it is sometimes said that Kraepelin neglected the total man and dealt only with simple and analytical artifacts. Beyond noting that the term 'personality' is often a vague and undefined notion in current theories, taken from the language of the street, we must observe that Kraepelin was fully aware of the importance of deriving, so far as scientific knowledge permitted, the fundamental characteristics of the organism (Grundeigenschaften der Persbnlichkeit). These Grundeigenschaften he not only named; he derived expressions for several of them (improvability under practice, retention of practice-gains, resistance to fatigue, recovery from exhaustion, distractibility, habituation, etc.)10 as they were actually and experimentally factored out of his sustained employments of the active human being.11 While Kraepelin recognized the fact that many features and indicators of disorder which eluded—and still elude—the student of the brain were immediately accessible from a psychological approach, he never lost sight of the functioning organism and therefore encouraged every promising sort of morphological, physiological, and pathological research. As a result, his discoveries have been useful to the biological sciences and to pathology as well as to psychology itself. The studies of the effects of alcohol will illustrate the point to anyone who knows them at first hand and who has the knowledge of pharmacology, physi10 See Der psychologische Versuch in der Psychiatrie, Psychol. Arb., 1, 1896, 63-65, and Arbeitpsychologische Ausblicke, ibid., 8, 1925, 431-450. u Kraepelin's contributions to psychiatry were unlike those of his contemporary Freud in at least two important respects; he sought to establish his base-line within the normal by empirical means, and he sought to interrogate his patients by the methods and under the rules of the natural sciences rather than by a direct application of a speculative philosophy of mind to the disordered person. [292]

GENERAL AND EXPERIMENTAL PSYCHOLOGY ological chemistry, and psychology necessary to an estimation of their significance. Many have thought the outcome of Kraepelin's researches disappointing for psychiatry, and it has been said since his death that the whole program was ill-advised and unproductive. Before making generalizations of this sort, it would be useful to take an objective view of the main psychiatrical problems and issues in the period 1890-1925 and to discover what psychological researches, carried out during that time, were designed to accomplish in this field of application. The task suggested surpasses the knowledge and the abilities of the present writer, who will content himself with a few comments which appear to him to be appropriate and also to bear upon the present opportunities and limitations of experimental psychology as one of the supporting sciences. 1. The best experimental methodology at hand when Kraepelin entered the field was the product of Wundt's laboratory. I t chiefly bore upon (a) sensory phenomena and upon (b) the normal psychological functions combined and displayed in intellectual and voluntary tasks. In the disorders sensory facts must be regarded; but they are distinctly of secondary importance. Kraepelin wisely emphasized the description of the "sustained task," which is widely subject to disturbance of many kinds. The sustained task was not regarded as a routine response under the initiation and control of stimulus; but as an employment voluntarily laid out and governed by the organism itself. Loss of effective government, whether through drugs or in the psychoses, was then directly subjected to determination and measurement under his experimental control.12 2. The immediate accomplishment of the psychological studies was a notable increase in sound knowledge of fatigue and recovery, of practice and habituation, of incitement to work, of restpauses, memory, verbal associations, and sleep, as well as of the exact effects of morphine, alcohol, tea, hypnotics, chloroform, ether, amyl nitrate, and many other chemicals. Beyond the general influence of drugs and diseases, Kraepelin also collected a great deal of sound material upon individual differences in health and disorder. The extension of the laboratory methods of 12 That Kraepelin sometimes looked beyond psychology and psychiatry to the more general welfare of individuals and of peoples is suggested by his declaration that his ultimate end tended "zur inneren Gesundung und Befreiung unseres Volkes." Cf. Psychol. Arb., 8, 1925, 431-450. [293]

THE PROBLEM OF MENTAL DISORDER psychology to psychotic patients may be illustrated by his studies of the handwriting of manic-depressives in elation, depression, and remission; of perceiving, observing, and remembering in hebephrenics and paralytics; of the reactions of epileptics; and of the character and rate of ideational flow in maniacal states. These are samples taken from a long series. Many of these studies sound trite today because they suggest brief and routine clinical tests. But these tests were not selfcreated. They had to be preceded by long and difficult researches. According to Weygandt, one of Kraepelin's closest associates, Kraepelin was at the end indifferent to the judgment of the moment, for he reckoned that time alone would vindicate him and his methods. 3. By 1925 psychiatry had acquired many new features, as the range of the supporting sciences cited in this section bears witness. Kraepelin had then, and psychiatry of his sort has now, to compete with psychoanalysis, with the high pretensions of endocrinology, with many doctrines of constitutional type, with schools and dogmas of personality, with biological theories of abnormal function, and with a popular notion of the primacy of emotion and instinct in the disorders. Especially must we note that no one can make an intelligent comparison and estimation of psychiatry now and a generation ago without observing the tremendous socialization of the subject. Then the patient was an afflicted organism: now he is a disturbed, distorted, and unadjusted member of a family and a community; in this sense he is a disordered person. This shift in interest toward the social and private side of life is only symptomatic in psychiatry. Its range and expression are very wide in our European and American cultures. Man has at last become 'introspective' in the old sense that he is now thoroughly absorbed by the contemplation of his limitations, his sex, his health, his matrimonial vicissitudes, his dress and undress, and his private conduct. Schools of psychiatry have themselves multiplied, many of them no longer in sympathy with the Kraepelinian system even when they find difficulty in replacing it by a better organization of the facts. With this multiplication of interests, doctrines, and points of view, it is impossible that Kraepelin's experimental studies should retain their former status or their former prestige. The net outcome is neither a reproach to psychiatry nor a demonstration of the futility of Kraepelin's psychology. Kraepelin [294]

GENERAL AND EXPERIMENTAL PSYCHOLOGY attacked an extremely difficult and complicated task. He used chiefly as researchers immature students of medicine whom he had first to train and most of whom passed on after graduation to other fields. On the other hand, many of Kraepelin's critics have been psychiatrists who were wholly unprepared by training to understand and to use the results of experimental research. Moreover, they have often been disposed to accept and to promulgate methods and beliefs closer to the medical traditions in pathology and in psychiatry. 4. As a final comment we may express the opinion that this program of research, based upon the best psychological methodology of its time and carried through several decades with high competence and wide knowledge, deserves at the least a careful review by able and open-minded men in the light of new methods, new problems, and new interests in psychiatry and in psychology. Any new estimation and any new proposals for the extension of the experimental methods must consider that psychology has itself suffered material changes since the Wundtian psychology inspired Kraepelin. Today it is of the first importance that any serious student of the disorders who undertakes to value the ambiguous term 'psychology' should carefully distinguish three quite distinct references: (1) the psychological aids to diagnosis (tests, scales, questionaries, and the like), (2) the doctrines and practices of the psychoanalyst, and (3) the researches of the psychological laboratory, done with the training and in the method and spirit of all the natural sciences. This is not the place to attempt a comparative estimation of these three subjects indiscriminately called 'psychology'; but a sharp distinction of temper and method is decidedly relevant to the present review of the experimental proposals in this complicated subject. A careful examination of the more recent psychological (not psychoanalytical) studies, especially the American studies, shows that very many of them are of the superficial testing sort, frequently derived from Kraepelin's researches but done without knowledge of his fundamental methods and results. So far as they bear upon clinical routine only they may be neglected here, however high their pretensions to research and however useful they are as technical tools. Here belong also most of the applications of tests, scales, and questionaries to the 'traits' of personality and to the ' attitudes' of the insane and the neurotic. [295]

THE PROBLEM OF MENTAL DISORDER When we turn to the more fundamental and important researches now current in our field, we find, if we scan their whole range, a very great number of studies of this sort undertaken by the psychologist—or at least by an investigator psychologically trained—in order to advance our knowledge of the disorders. Practically all of the disorders and practically all of the more obvious signs and symptoms have been considered. This is not the appropriate place to make a catalogue of these studies. We list only a few convenient headings under which we briefly comment upon some of the more important and promising methods and results. I t will not require many headings to exemplify the diversity of interest and of problem. In this very diversity may rest a caution to the psychologist against diffusion and uneconomical dissipation of effort. 1. Sleep, Dreams, Hypnosis. Here experiment is commonly shared by psychologist and physiologist. The older studies of sleep-depth are of doubtful interpretation. Later studies bear more directly upon bodily motility and upon the organic and the outside conditions which govern it. The field is still cumbered by theory, which throws but a dim light upon the derangements of sleep in the disorders. Empirical and descriptive studies of dreams have provided a fair account of the psychological functions involved and their dependence upon certain healthy and disordered bodily processes. These studies lend but little support to the hypotheses of the psychoanalyst concerning the dream-mechanisms, although they do throw light upon the biographical histories of the well and the disturbed. I n the dreams we do find many plain variants from the usual waking course of the psychological functions and especially do we find that the sleeping state brings about important changes in government and control with a corresponding change in the dream-products of these functions. A very great deal may be expected of a sound psychological method which shall secure from trained observers an accurate report of the dream (not an emotional dream-story warped by psychoanalytic theory or the self-interest of the dreamer). When this report is referred to the functional resources of the sleeping organism and to the present and past government of these resources, the dream will supply much new information upon a multitude of disorders. Incidentally this new information will supply an important corrective to current speculations upon 'dreamsymbolism.' Recent experiments upon hypnotic and allied [296]

GENERAL AND EXPERIMENTAL PSYCHOLOGY states in man and other animals are distinctly promising for the student of certain neuroses.13 Long and painstaking experimentation would seem to be the most direct mode of advance beyond the extravagant theories of hypnosis and of certain neurotic disorders current for centuries. I t is high time that competent experimentation under respectable categories of psychology replaced the magical terms and beliefs and the superficial clinical and exhibitional methods of medicine. A good beginning would be made by expunging 'rapport,' 'suggestion,' 'suggestibility,' 'hypnotizer,' 'will power,' and a score of other medieval and magical terms. Animal subjects, notably the sheep, recently observed under experimental conditions, promise to supplement the studies with man. 2. Memory, Learning, and Habituation. Many recent experimental studies have sought to discover the result of various disorders (dementia praecox, epilepsy, general paralysis, anxious and confused states, etc.) upon those psychological functions which involve time and repetition. They are designed to uncover the effects of the earlier upon the later in function and to search out the historical origins of disorder. Here good methods are at hand (many of them set up by Kraepelin). The main requirements are to adapt them to deranged subjects —often a difficult task—and to derive a sober and empirical interpretation of the results. Too often short and superficial tests are made to confirm a psychiatrical theory of a disease.14 Here psychiatrist and psychologist should collaborate with patience and understanding and in the spirit of research—as, for example, at the Worcester State Hospital and the Psychiatric Hospital of the State University of Iowa—rather than by the routine clinical test. The three topics named touch the adjusted and the maladjusted life of man at vital points. What they need in the present context is more fundamental description under methods already in hand.15 13 A useful summary of topics and titles for hypnotism and suggestion will be found in P. C. Young, Psychol. Bull., 28, 1931, 367-391. The most competent exposition and review of experiment in this field is C. L. Hull, Hypnosis and Suggestibility, D. Appleton-Century, New York, 1933. 14 "Xhe general procedure," remarks Dr. J. M. Hunt in a review for the writer of a round hundred research titles in this border-line field, "is to explain the data by referring them to some theory, some doctrine, or to some conceptual mental entity." 15 Analyses of these topics, together with ample bibliographies, have lately been supplied by J. A. McGeoch, Psychol. Bull., 28, 1931, 413-466; 30,1933, 1-62. [297]

THE PROBLEM OF MENTAL DISORDER 3. Verbal Construction and Sequence. Much effort has been expended to turn to diagnostic use the sequence of words; especially the unmeaning sequence which appears in the uncontrolled or free arid the controlled or limited association of words and nonlinguistic (nonsense) sounds. One of the most constant and complicated products of social man is the vocal sound and its visual equivalent in verbal meaning. Man literally spouts words. Long ago Ebbinghaus found an experimental means for studying the connection, residue, and recital of verbal and nonsensical combinations. The experimental methods have been applied in a great number of directions.16 I n the psychiatrical direction two chief methods have been used. The first exploits the verbal repertory of the patient by paired associates. A word is presented with the instructions to respond with a synonym, an opposite, another noun, verb or adjective, and the like. Both the response-word and the time for its evocation are usually recorded. Here the association is controlled or limited. Certain kinds of preferred connection and certain delays and accelerations have been made out in several of the disorders. To establish the normal response to a large number of common words, Kent and Rosanoff in 1910 submitted a prepared list of one hundred words to one thousand subjects and wrote down the response-words obtained. By comparing the normal responses thus obtained with the responses of the disordered, they sought indications of the nature and cause of the malady.17 In the uncontrolled associative sequence (also called 'free association') the subject is asked to respond with the first word (of any kind) that occurs after the stimulus word is heard or seen. This method, long used in the psychologist's laboratory, was adopted by C. G. Jung, who regarded it as an indicator of emotive complexes. Again, both the time required for the response and the nature of the response were held to be significant. "Words are really something like condensed actions, situations and things," wrote Jung in defending his diagnostic use of this method. And again, " A n y psychic occurrence is never a thing in itself, but is always the resultant of the entire psychological past."18 Jung introduced critical words into his 16 A recent critical review has been done by J. A. McGeoch (Psychol. Bull., 27, 1930, 514-563). About two hundred titles are here cited. 17 See, for an example, G. Murphy, Types of word-association in dementia praecox, manic-depressives, and normal persons, Amer. J . Psychiat., 2, 1923, 539-571. 18 C. G. Jung, The association method, Amer. J . Psychol., 21, 1910, 223. [298]

GENERAL AND EXPERIMENTAL PSYCHOLOGY list, words to arouse emotion which displayed itself—as he maintained—in characteristic verbal times and responses. Here we see a notable attempt to add the divinatory process of psychoanalysis to the psychological research. Many attempts to develop the method as a diagnostic agent have been, on the whole, disappointing, as they have also been in criminology, where the intent has been to uncover the guilt or innocence of a suspected person. The art of psychoanalysis has drifted toward a much more informal attempt by the analyst to stir up emotion and then to interpret it for the existing disorder through the verbal confessions of the patient. Free association as a psychological method of research should not be confused with the context of the same term when used to denote the divinatory procedures of psychoanalysis.19 Any method which depends upon verbal sequences to supply diagnostic or descriptive material meets with many difficulties. The most obvious difficulties are (1) the linguistic limitations of the speaker, (2) the linguistic connections formed throughout years under imitation, reading, conversation, and many other conditions, (3) the determination by another of the exact significances intended in speech, (4) the multiplicity of memories and the problematical relation of them to a disorder, (5) the vast number of verbal associations which may be evoked by a given verbal hint, (6) the inadequacy of words to portray, without strict experimental control, the psychological functions as they run their course, and (7) the biographical significance of the words uttered. How far these difficulties are met and overcome 19 The currency of this confusion is illustrated by the remark of F. Alexander that "Psychology, as an empirical science of personality, began with the discovery of the method of free association by Freud" (The Medical Value of Psychoanalysis, 1932, 47). Everyone familiar with the history of the experimental study of memory and association knows that the method derives from Francis Galton and that it was described in 1879 (Psychometric experiments, Brain, 2, 1879-80, 149-162). Galton's object was " t o show how the whole of these associated ideas, though they are for the most part exceedingly fleeting and obscure, and barely cross the threshold of our consciousness, may be seized, dragged into daylight, and recorded" (150). His method was to allow "the mind to play freely for a very brief time." Besides measurable results carefully described, there came out the emotive memories, the biographical "unshared experiences," the backward references to boyhood, and an intimation of the "uncharted depths." Add transferences, mechanisms, and speculative theory —the objective and scientifically-minded Galton never would!—and you have the Freudian 'analysis.' Before 1890 a whole series of laboratory studies of free associations had been carried out in England and Germany (Cf. J. M. Cattell and S. Bryant, Mind, 14, 1889, 230-250). Alexander finds that "Between 1890 and 1895 Freud definitely gave up hypnosis and suggestion and discovered (sic) the method of free association." To him that hath! [299]

THE PROBLEM OF MENTAL DISORDER by forsaking the rules of experimentation and by the substitution of a procedure by which the patient is brought into rapport with the psychoanalyst is a matter of opinion. The theory of psychoanalysis and the methods which it encourages are so far removed from the practice of scientific control through experimentation that the associational methods do not seem likely to be notably fruitful while undergoing such distortion. I n general, the accomplishments of the strict associational methods in psychiatry are disappointing and the future of this type of research seems limited. A remote echo of these verbal procedures in the routine tests may have, in certain cases, as much value as many other diagnostic probings have; but here we leave the problems of research itself, substituting for the standards of experimentation the standards of the test-procedure.20 I t should be said in this connection, however, that the individual trained to observe under controlled conditions will often strike upon significant and illuminating facts in the most casual situation. Here familiarity with the expressions of disorder is usefully combined with psychological knowledge and training. I n the same manner does chemistry aid physiology and physics supplement the work of the historical geologist. 4. Methods of Registering Movement and Other Bodily Processes. Many attempts have been made to discover defect in the active muscular performances of the disordered. The ergograph, the tapping board, the reaction set-up, eye-movement records, Sommer's tridimensional analyzer, reflex recorders, and various steadiness devices are representative of the apparatus used. The first result that is relevant here is the discovery, in the disorders, of variations of muscular tonus, contraction, coordination, and output. One characteristic line of research, which physiologist and psychologist have for some time shared, concerns the reflexes. New methods of excitation and of record have been devised. The results have gone, in some cases, well beyond the diagnostic test. A large number of researches, e.g., upon the patellar tendon reflex, have thrown new light not only upon the simpler spinal arcs but also upon the higher and cerebral involvements of 20 Here essential differences are often overlooked because both experimentation and test treat their products by like statistical manipulation. The statistical treatment may, indeed, make the results more manageable and it should determine their reliability, but it does not alter the circumstances under which the primary observations were made. [300]

GENERAL AND EXPERIMENTAL PSYCHOLOGY the controllable neuromuscular functions. Thus these reflex studies offer a new entrance to the more complex functions of the cord and brain. A series of investigations which has gone far beyond the reflexive functions has been in course many years by Jacobson, whose method of 'progressive relaxation' has made important contributions to the psychological and physiological functions, in health and disorder, of 'residual tension' in the skeletal muscles.21 Besides providing a therapeutic method which appears to have wide application, Dr. Jacobson's experiments have specifically borne upon the intimate relation between skeletal tonus and such psychological functions as understanding, thinking, and imagining. The experiments cannot be neglected by anyone who hopes to know the role of muscular tension and relaxation in the disorders. The instrumental refinements proposed are also important for the student of the "expressive' methods of registration. These methods of tonus, movement, and action should be retained in the repertory of the student of disorder. They are rapidly undergoing improvement and new application. One direction in which they are likely to be more and more useful is in psychological problems connected with neurological, pathological, and nutritional researches. Certainly no one can hope to understand the motor employments of the organism, whether in health or in maladjustment, when the psychological factors and functions are left out of the reckoning. One of the great aims of physiology and of psychology has been to secure accurate record, by way of bodily indicators, of various general organic changes. These indicators have commonly been referred to circulation, respiration, muscular tonus, tremor, and electrical potential, on the one side, and have been regarded as expressive of feeling, emotion, attention, voluntary arousal, and other things, on the other side. Familiar instruments used are pneumograph, sphygmograph, plethysmograph, electrocardiograph, galvanometer, and oscillograph. I n as much as these instruments tap the functions of the big organic systems which are commonly afflicted in the psychiatrical disorders, it is inevitable that they should be used also as indicators for the defective and aberrant functions of insanity and of the neuroses. A whole library of researches could here be collected. There is scarcely a disorder great or small that does not suggest a possible 21 See Dr. Jacobson's exposition above. [301]

THE PROBLEM OF MENTAL DISORDER involvement falling under this head. Opinions differ upon the usefulness to psychiatry of this kind of research. Much of it has been disappointing, partly because each new recording device easily arouses extravagant hopes of great discovery, and partly because the organic systems involved—blood-vessels, lungs, nervous system, musculature, and gland—are so intimately interlocked in function that the graphic records are usually impossible to interpret without ambiguity. Visual clarity of the record often hides the greatest obscurity of the functional cause. Great enthusiasm for these methods has of late been specifically directed toward certain variable electrical resistances found in the skin. The early designation 'psychogalvanic reflex' suggests the high hopes and pretentious claims of physiologist and psychologist alike. 'Psycho' and 'reflex' are plain misnomers, and 'galvanic' (like 'faradic') sounds both antiquated and incidental. The plain fact is that electrical changes at the body-surface are registerable and that these changes vary under a prodigious number of conditions. The belief that these methods specifically and differentially measure emotion was long ago questioned by critical psychologists and may now be definitely abandoned. More than forty years of research have greatly refined the instrumental procedures, but they have raised more problems than they have ever solved.22 Like the electrical currents referred to heart-beat, the skin-currents are doubtless delicate indicators of organic processes. Just what their significance is in the field of the abnormal is yet to be determined. Along with all the other ' expressive' methods of registration, they must be preserved and refined. Their primary utility in our field is bound to lie where the labors of physiologist, neurologist, endocrinologist, pharmacologist, and psychologist meet. I t is a good example of conjunctive research. Since the psychological functions are here openly involved, both in normal and in disordered organisms, the participation of the psychologist is clearly indicated. Most research laboratories of psychology have in course ' galvanic' and other 'expressive' studies. I n them much of the present refinement of technique has been learned, and their application in psychiatrical directions at least suggested. 22 A clear idea of the state of the expressive methods before the 'galvanic reflex' came in, may be gained from C. Fere's beautiful Sensation et mouvement: 6tud.es expfrimentales de psycho-me'canique, Paris, 1887. A recent bibliography for the 'galvanic' literature alone cites about 250 new books and articles for the period 1929-32; cf. C. Landis, Electrical phenomena of the skin (galvanic skin response), Psychol. Bull., 29, 1932, 693-752. [302]

GENERAL AND EXPERIMENTAL PSYCHOLOGY A similar collaboration is in course between psychologist and physiologist in the registration of action-potentials from brain and nerve. The method, which records, with high amplification, differences and changes of potential in neural tissue, has greatly extended our knowledge of receptorial functions, neural impulse in the nerve, and the action of neuromuscular mechanisms. Of late this type of research has been extended through the sensory tracts, notably the visual and acoustical tracts, to the central nervous system. Much of the fundamental investigation has come from the laboratory of the psychologist. Once within the brain the materials under scrutiny become so complex and the interpretation of the results so difficult that a long period of work upon the normal organism, human and animal, would seem to be necessary before a safe advance can be made into the abnormal and the pathological. Here lurks the danger of easy theorizing and rash conclusion which attends the rapid development of a new, delicate, and engaging method. Should these experimental approaches, just now in the focus of attention, succeed in revising present theories of cerebral functions, long current and wholly inadequate both in neurology and in psychology, that may be their first primary contribution to the study of the abnormal. If function patterns in the brain can be made out by means of action-potentials, and if, further, these patterns can be related in a significant way to the functions actually observed and distinguished by the psychologist, an epoch-making advance in psychiatry is bound to follow. A good illustration of combining an antequated or a defective psychology with unsound speculation about bodily functions is afforded by many recent studies of the emotions of normal and pathological subjects. While the implication of viscera, bloodvessels, glands, and autonomic nervous system, in certain of the more violent and obvious emotions, lias been made out by the employment of the registrational methods in their newer forms, we are still a long way from a descriptive account of the emotive functions themselves and from an accurate knowledge of the bodily resources involved. We have had here too much biological, physiological, and psychoanalytical theorizing and too little competent observation. No authentic account of emotional derangement and of the part it plays in the disorders is likely to be made until a competent description in psychological, as well as in physiological, terms has been secured. [303]

THE PROBLEM OF MENTAL DISORDER 5. The Solving of Psychological Tasks. Since the commonest defect encountered in the disorders, as the psychologist views them, lies in government or control of the psychological functions, it is of the greatest importance that the disordered organism be given problems to solve under carefully planned experimental conditions. Important because thus the psychologist can observe how the defective organism envisages and approaches the task set, how it carries out or avoids the task, what factors in government are deranged, and how the issues and products of the performance serve as indicators of defect and limitation in the patient. I n looking for tasks which may be most readily provided with an experimental setting, the obvious place to begin is to secure those which are primarily controlled by the circumstances of the moment, i.e., by the instructions which proceed from the words of the experimenter (formal instructions), from the situation placed before the subject (occasional instruction), and from the subject himself (self-instruction). An instance of the first kind of instruction is the command to add numbers, or to move rapidly upon a signal, or to respond orally to a stimulus-word. Where the trained and normal observer in the laboratory usually behaves in a steady and foreseen way under a formal instruction, the disordered subject may misunderstand, be inattentive, refuse to cooperate, delay, or respond in an illogical, contrary, or bizarre manner. An instance of the occasional instruction is the presentation of a series of objects of various values or of blocks which obviously fit together to form a pattern or picture. The objects presented themselves offer an occasion to the subject to perceive, construct, understand, and the like. That is to say, the occasion and the patient provide a task and initiate its performance without the intervention of the experimenter. The occasion may be made impersonal or it may be social. Often a difference of behavior on the ward and in the clinic is due to the two unlike occasions. The self-instruction, finally, is exemplified by the comments " I am too tired," " H e is tricking me," " I will make a good appearance," and so on. The test usually assumes a standard setting which is supposed to be the same for all human organisms. Thus it tends to overlook the dependence of performance upon the various kinds of instruction which control and govern the organic activities. I t is obvious, however, that the real task is the task as appre[304]

GENERAL AND EXPERIMENTAL PSYCHOLOGY hended by the subject or observer, not the test as formulated and understood by the tester or clinician. The experimental management of all forms of instruction, on the other side, is designed to discover the precise conditions of the moment under which the subject's organism is operating. The instructed task, in the sense just explained, has been widely used for the understanding of individual differences, of age-differences in children, and of the dependence of performance upon cultural mode and racial preference. While the method is newer in the field of the abnormal, the recent beginnings of its application are sufficient to approve it here. No acute observer of interrogator and patient in the clinic has failed to note that the behavior, tone, and attitude of the examiner lose their real significance, as a rule, unless the immediate context of the interview—as provided in our three forms of instruction—is carefully weighed and analyzed. Many a perfunctory director of a clinic who reveals himself to his professional fellows more clearly than he reveals his patient may profit by perfecting the art of control through instruction. Then he will know the exact dependence of his subject's performance upon (1) his own phraseology, manner, and intonation, upon (2) the occasion or setting, and upon (3) those hints, commands, cautions, and inhibitions which the subject himself provides to determine his behavior and the conduct of his own psychological functions. The skill of the psychologist will first be directed toward the independent variation of all the factors of instruction. I t will be directed secondly toward the choice of the particular formal, occasional, and self-instructions which are adapted to the disorder and to the competence and the distemper of the patient. The application of the method of task presupposes, therefore, a full preliminary knowledge of the patient and of his disordered behavior. Thus with a reclusive subject the psychologist is likely to avoid tasks which are principally set into commission by verbal request and comment and which require verbal answer. He will look instead for a suitable occasion to touch off the inhibited functions and then delve, by skillful soundings, into the self-instructions or their lack, searching at every turn in the method for the disordered springs of psychological functioning. Again, with a babbling and flighty verbigeration he may seek a combination of command and external situation which will enable the distracted subject to formulate a task and [305]

THE PROBLEM OF MENTAL DISORDER attempt its execution. Failure to solve is often as significant as success if only it gives a hint of the defective means of initiation and control. Where the method of tasks is competently managed it will protect the patient from the patter or the tenets of a theory and also from the attempt to substitute the foreign tasks of the experimenter for natural and spontaneous tasks set by the patient himself. No one knows better than the shrewd examiner the resources of many patients in circumventing his desires and, failing that, to reply to questions in the manner best designed to terminate the interview or to place the patient in a favorable light. The measure of accomplishment under variations of the task is often indicative of the source of bad government or of deficient function; but wherever possible the method calls for report by the subject. Frequent repetition of a task which interests the subject and is carried through with skill will often supply surprisingly rich material for understanding the disordered state and its antecedents. After exhausting the immediate antecedents, in this setting of simple tasks, the psychologist goes on to provide occasions which bear more directly upon the biographical history of the patient. The eliciting of verbal responses by the associative methods is an instance. Because of the abstract and ambiguous significance of words, however, it is better to substitute for words concrete and nonverbal situations (objects, pictures, motion pictures, and dramatic portrayal). The word is so ambiguous—especially when imbedded in the emotive matrix which is often provided by psychoanalysis—as to tempt the practitioner to interpret ad lib in terms of a preferred theory of narcissism, inferiority, incest, and the like. I t must be observed that the intimate pairing of patient and analyst, e.g., in the Freudian type of 'free association,' is quite different from the relation engendered between experimenter and subject. 6. Long-term Study of Individual Subjects is another procedure in psychological research to be commended for the study of the disordered. Here the laborious and concentrated method of psychoanalysis is suggestive. A detailed study of a few persons both for the observation of changes in the course of the disorder and for the matching of behavior day by day to antecendent history is of high value. The psychologist will make this intimate study exploratory and informative rather than therapeutic. He will, therefore, provide the detached atmosphere of research, and [306]

GENERAL AND EXPERIMENTAL PSYCHOLOGY prevent, so far as is possible, the highly socialized and highly polarized pairing in which the personal processes of transference are said to nourish. As the psychologist catches intimations of a defective function or of a source of mismanagement in government, he will try to relate these discoveries to the history of the organism under study. Here he will naturally call upon the principles of genetic psychology, avoiding speculative doctrines upon the nature of the soul or of the unconscious. The success of this method of long-term concentration upon the individual cannot be predicted. Since it moves within the lines of authentic research, however, it is worth a fair trial. 7. The Psychological Study of Children. Since many disorders are obviously prepared for, if not actually induced, in the early years, it is important that these years be carefully scrutinized, both for the facts and principles of development (biological and biographical) and for those agencies, means, and incidents which tend to disturb functional government. Just as inadequate diet, irregular elimination, and careless posture in the immature threaten the government of fundamental physiological functions, so do sour relations with parents, the shirking of responsibility, unrelieved fears, and flights from actuality threaten the government of the psychological functions. We may fill in the gap of these early and important years either by speculative theory (infantile sexuality, desire for power, conviction of inferiority, damnation through heredity, etc.) or by diligent research into the actual facts of development. Psychoanalysis has taken the former course, psychology prefers the latter. In this vast group of problems, psychology proceeds under its own principles of growth and change (e.g., the plan of gradual acquisition and expansion of the psychological functions and the successive phases of government and control); but it may well proceed through conjunctive research, in cooperation with students of diet, of the endocrines, of family interactions, of formal education, of social cultivation, and of the bodily diseases of infancy, childhood, and youth. An enormous amount of material lies at hand, with few able to organize it into a coherent account of the actual phasic changes undergone by the human organism between fertilization of the ovum and adulthood, and with few to translate the hazards of the young into plain scientific descriptions. [307]

THE PROBLEM OF MENTAL DISORDER I n a later study in this series Dr. Yerkes has proposed a plan of research upon the nonhuman primates which promises to extend in several directions our understanding of human disorders. Since the psychological functions of the ape stand much closer to those of the child than to those of the human adult, it is of great important that psychological and other studies of the child should run parallel to those of the gorilla and the chimpanzee, especially studies which bear upon the early occasions and agents which damage normal and adequate functions in the human young and in the anthropoid. I t is clear that no one of the seven topics just set down to illustrate psychological research is a psychiatrical topic. The methods cited have been developed in psychology and designed for psychological ends. Whatever usefulness they may have in psychiatry is therefore derived. This is as true here as it is in physiology, endocrinology, biochemistry, and anthropology. I t should be observed that many of the researches mentioned either call for cooperative labors with physiologist and neurologist or else receive their chief usefulness to psychiatry only when integrated with parallel studies carried out in other fields of research. Under present conditions the actual cooperation of psychologist and psychiatrist upon a common group of problems attacked with a common group of disordered subjects is highly desirable. An example is offered by the long-term program of research upon schizophrenia in course under the direction of Dr. R. G. Hoskins at the Worcester State Hospital in Massachusetts. The psychologist's participation in this important undertaking is here indicated by Mr. Shakow, who is in charge of that part of the cooperative undertaking. Psychological Avenues o f Approach t o Schizophrenia by david shakow, m.a., worcester The subjects of sensibility, perception, feeling, emotion, attention, memory, thought, social functions, and genetic history would all yield—as I believe—more or less significant results if experimentally attacked with the methods and equipment at hand. Because of the limited number of experimental psycholo[308]

PSYCHOLOGICAL APPROACH TO SCHIZOPHRENIA gists in the field of the abnormal, however, and even more because of the limited opportunities for investigation at the present time, some choice has to be made as to the avenue of approach and as to the selection of those specific experiments which seem to offer the greatest possibilities. In this statement are proposed certain experiments which are based upon the writer's experience with the abnormal. We may consider the contributions of the experimental psychologist in the field of psychopathology to lie in three directions. (1) In an accurate description of abnormal characteristics at the various developmental levels of the disorder or during the course of treatment. Such a description is diagnostically significant both from a nosological and a therapeutic point of view. (2) In a theoretical interpretation, based upon the descriptive material, of the factors involved in the abnormality, with implications for further psychological, therapeutic, and other researches. (3) In the development of better psychological procedures to be used by psychologists, psychiatrists, and others, in order to derive new facts and to revalue the existing material. When we say 'experimental' we intend to contrast it with empirical,' under which we should include 'clinical studies.' The testing methods are not discussed in this presentation, although we shall include certain types of controlled seminaturalistic methods. We roughly divide experimental procedures, for our purpose, into three classes: (a) controlled laboratory, (b) free laboratory, and (c) seminaturalistic. We consider all of them valuable and promising. At the present early stage of investigation in the field of mental disorders, all three procedures should certainly be employed. (1) Under the first group we include those experimental problems where the stimulus situations are, at a given time, fixed (so far as they can be fixed by the experimenter) and where the response is usually segmental and limited in its degree of freedom. The controls in this setting are to a large extent instrumental. Examples of such problems are studies of the patellar tendon reflex and studies with the prodmeter. (2) Under the second group we include problems where the stimuli are varied, the responses total (or at least multiple), and, in comparison with the previous group, less limited in the degree of freedom. Examples of this type are Luria's experiments and the 'interruption' experiment. (3) In the third group we include situations where [309]

THE PROBLEM OF MENTAL DISORDER the stimuli are varied, and practically unlimited freedom of response within the situation is permitted. The responses are total or partial responses, depending upon the subject. The controls in these situations are almost entirely of an observational nature supported by statistical analysis. An example of this type is Lewin's ' observation' experiment. I n all of these experimental approaches, the value of the psychologist's results would undoubtedly be greatly enhanced, both for practical and for theoretical uses, if as nearly simultaneous observations as possible were made in biochemistry, physiology, and psychiatry. Comparison, cross reference, and correlation could thus be made. The possibility of significant psychological generalizations would also be increased if temporally close observations of a psychological nature were arranged in order to provide similar analyses within the psychological field itself, e.g., between reaction-time and ' pursuit.' I t has been our experience that the temporal aspects of the investigation play a significant r61e in determining the validity and promise of the accumulated data. Included under this heading are the length of the individual experimental session and the period covered by the whole experiment. The continuous—as opposed to the discrete—method is the most promising in work with the mentally abnormal. As for the length of study, repeated observations with intervals seem to be necessary. In many investigations more would result from a few subjects studied periodically over a considerable time than from single brief observations of many subjects. Since the range of variability seems frequently to be wider in the abnormal than in the normal organism, generalizations based on single periods of observation are limited in value and subject to grave error. Crozier's1 study of variability in certain animals would seem to be useful here, despite the difficulties of its application to human problems. I t is important that the psychologist attack the problem at various levels of complexity. The simplest forms of behavior should be attacked as well as the very complex forms of thought and affective action, where, at least on direct observation, the main difficulties seem to lie. I t is in connection with the latter that the greatest difficulty in quantification enters. The 1 W. J. Crozier, The study of living organisms, in Foundations of Experimental Psychology, Clark University Press, Worcester, 1929, Chap. 2 (esp. pp. 86-92). [310]

PSYCHOLOGICAL APPROACH TO SCHIZOPHRENIA experimenter would probably go further if lie were satisfied, at this level, with qualitative studies instead of attempting a premature quantification. Only when he has exercised the necessary ingenuity—and much is needed—in these qualitative studies, should he attempt the additional refinements of measurement. The following are some of the specific projects which we have undertaken. 1. Experiments involving mainly neuromuscular coordination. Among these are our adaptations of the Koerth "pursuit" and the Miles " p r o d " problems. The results thus far obtained from the organization of the experiment on a long-time basis indicate certain fundamental distinctions between the responses of schizophrenics and normals and they also suggest differences among the types of schizophrenia. The observations were made at three-month intervals, with ten trials on the pursuitmeter or prodmeter at each session. We found significant differences between schizophrenic and normal subjects even when the factor of cooperation was held constant. I t was also found that the schizophrenics showed an improvement between the first two sessions—three months apart—not found in the normal group, a fairly unusual result in experimental learning. The classical types of schizophrenia tended to distinguish themselves, paranoids improving most and catatonics least, though this distinction disappeared in the third learning-period. There are here interesting implications for a general theory of learning in these experiments closely related to the discovery of Jenkins and Dallenbach2 when they interpolated a sleeping interval. 2. Experiments involving simple segmental behavior. An attempt was made in our study of the patellar tendon reflex to measure such simple psychophysiological responses as the latenttime and to correlate them with various physiological states and functions, e.g., with nutritional status, oxygen-consumption, and C02 production. These interfield correlations seem to hold great promise. Thus (the study is far from complete) fair correlations have been found between latent-time and the difference between venous and arterial CO2. The relatively high correlation usually found in normal subjects between height and latent-time seems to disappear in schizophrenics. 2 J. G. Jenkins and K. M. Dallenbach, Obliviscence during sleep and waking Amer. J. Psychol., 35, 1924, 605-612. [311]

THE PROBLEM OF MENTAL DISORDER Experiment at this comparatively simple level, while simultaneous studies of more complicated responses proceed, seems useful both because it yields quantitative measures and because of the possibility of intrafield correlations with the more complicated psychological functions. 3. Experiments involving the emotive aspects of personality. Here fall experiments by Lewin, which are likewise promising in psychopathology. The situations are simple, but they offer considerable opportunity for variety of response. Although they present difficulties in the way of quantification and exact interpretation, a competent experimenter will gain a great deal from their use because of the freedom with which the situations permit personal characteristics to appear. We have used the 'observation' and the 'interruption' methods.3 I n the former, the subject is placed in a Gesell observation room for a period of thirty minutes, where he is given the opportunity of occupying himself with a variety of interesting objects. A record of the activity of the individual during the period is made as accurately as possible; e.g., absence or presence of response, consistency of occupation with the object, and character of the performance. In the latter method, the individual is given an interesting task which is interrupted before completion. The interruption consists of a request to perform another, quite dissimilar, task. After completion of the interrupting task the subject is allowed a period of time to resume the original work. The purpose is to find out whether the subject spontaneously resumes the interrupted task, and, if he does, how soon. The significance of the results is interpreted in relation to the establishment and release of 'tensions.' Another variety of interruption is occasioned by 'substitution.' Here the interrupting and the interrupted tasks are quite similar. An analysis is made of the resumptions and the effect of these substitutive activities on the resumed performance. Another experiment in this group is from Luria.4 An attempt is made to study emotion by an analysis of the disturbance in voluntary and involuntary motor response when the response is given simultaneously with word-associations. The method is 3 K. Lewin, Filmaufnahmen tiber Trieb und Affektaiisserungen psychopathischen Kinder (vergleichen mit Normalen und Schwachsinnigen), Ztsch. f. Kinder-Forsch., 32, 1926, 414-447; M. Ovsiankina, Die Wiederaufnahmen unterbrochenen Handlungen, Psychol. Forsch., 11, 1928, 302-379. 4 A. R. Luria, The Nature of Human Conflicts, etc. (W. H. Gantt, trans.) Liveright, New York, 1932. [312]

PSYCHOLOGICAL APPROACH TO SCHIZOPHRENIA complicated, and it is conceivable that its main value will be found in a direction different from Luria's original intent, i.e., the discovery of ' complexes.' One of its most valuable aspects is its possibility of an extra control in the free-associational procedure. Our adaptation of the Miles pursuitmeter6 has been used by us to determine the ability of the individual to keep consistently at a simple task which is not seriously complicated by variation under learning. The task consists of adjusting a rheostathandle to keep a moving needle within fixed limits for thirty minutes. Early results point to much less efficient performance on the part of schizophrenics. Experimental work with abnormal individuals is exceedingly difficult. The control of attention, motivation, and the like, is much more taxing than it is with normal individuals. But ingenious experiment will go a long way toward removing these and other difficulties. 6 W. R. Miles, The pursuitmeter, J. Exper. Psychol., 14, 1931, 77-105.

[313]

X V I . CLINICAL PSYCHOLOGY A N D T H E PSYCHONEUROSES By Joseph Jastrow, Ph.D., New Y o r k C i t t The interrelations of psychology and psychiatry need redefining. To psychiatry psychology owes the term clinical. I t derives from the bedside service an observational approach and a guidance by the clues and data thus supplied. There result both a psychology of the clinical symptoms and a generalized clinical attitude toward the entire factual range of a naturalistic psychology. The significance of the clinical view of psychic behavior is the theme of the present contribution. Psychiatry, long before it was established as a medical specialty, employed psychological concepts, however primitive and now outgrown. And today it is of the greatest importance that the psychiatrist should resort to psychology for an understanding of the sources of those disturbances which he describes in terms of symptoms in his case-histories. Mental disorder and mental order are of one origin; they arise from the assets and liabilities of the same constitution. An important principle of clinical psychology is that the abnormal is the exaggeration—it may be also the deficiency, and characteristically the distortion—of the normal; the normal harbors and presents the abnormal in miniature and under control.1 The psychology underlying the psychoneurosis is of maximal moment. The three seemingly innocent letters f. n. d. (functional nervous disorders) connote mountains of misery. For every pronounced 'mental' case, there are a score or a hundredvictims more or less disqualified. The clinical psychologist, bent upon analysis of the neurotic personality, and the psychiatrist seeking measures of relief, alike acknowledge their ignorance of the sources of these perplexing failings. True that compared to the ignorance of former generations, our knowledge is impressive; we at least avoid the tragic stupidities of the past. Dr. Core of Manchester makes hysteria the great regressive disorder and neurasthenia the great progressive disorder. There 1 For a fuller treatment of this principle, cf. J. Jastrow, Abnormal Psychology in the Cyclopedia of the Social Sciences, 1931. [314]

THE PSYCHONEUROSES thus emerges as a primary requisite for successful living the conviction that the crucial task of life is to mature, to grow, and to outgrow. Bodily growth under relatively simple conditions seems almost to take care of itself; complete mental growth requires cultivation. Immature heads on mature shoulders are dangerous. Puerilism—not infantilism, in the misleading Freudian sense—is responsible for a versatile repertory of friction, misery, folly, incompetence, and failure. Hysteria is of ancient recognition; it plays a considerable r61e in human history. The derivation of the word presents a plausible clinical misreading of its prevalence in women. Neurasthenia is a term so modern that its popularizer, Dr. Beard of New York, might still be living as a near-centenarian. But the liability which it labels is as ancient as the neopallium. An alternate name for the condition was Americanitis, a tribute to the devastating pace and pressure of the national tempo. Its popular name, nervous prostration, indicates the central symptom, which in turn points to a fault or flaw in the working of the fatigue mechanism, whose liabilities set the pace for the dance or run or walk or crawl of life. Its greater prevalence in men indicates that the neurasthenic way of breaking down is characteristically masculine, the hysterical way feminine, but with both so generically human as to cross sex lines freely. Hysteria is a source of action (sthenic), neurasthenia of inaction (asthenic). Their contrasted psychology is in many ways mutually enlightening. I cite hysteria and neurasthenia—the typical and lamentably widespread impairments, deviations, interferences, disqualifications in behavior—as salient examples of the analyses which clinical psychology aims to establish. Pronounced hysteria, including the classic major hysteria, may be construed as the end-term of a neurotic series of which the initial indications are observable in all sorts and conditions of men, women, and children. They confirm the cardinal principle above set forth. A functional nervous disorder may be considered as the exaggeration of a temperament; it develops congenially upon a favoring temperamental basis. I n all nervous disorders the temperamental basis is important. A temperament is a formula of nature for the make-up of a person; it appears as a marked tendency toward definite modes of response, including type-forms of abnormality or deviation. The intimate affiliations and [315]

THE PROBLEM OF MENTAL DISORDER indices of temperament are to be sought in all that is primary, early, fundamental in psychic life, in the instinctive, the emotional, and the organic. The temperamental trend and the somatic basis and the tendency i n petto toward what, when developed, becomes a major order of mental disqualification, are recognized in the notable contributions of Kretschmer. The interpretation is applied to the major disorders of psychoses, and combines the two classes of findings in a correlation between physique and psychique. The great orders of common psychoses are the manic-depressives, representative of the wide cycles of variation, and the schizophrenics, typical of the tendency to divided or fissured functioning. I n trend each of us more or less tends to either the cycloid or to the schizoid psychique. This finding strengthens the position that the entire range of mental disorders, including the 'functional' neuroses, have a somatic basis, intimately related to glandular balance. Our ignorance of its nature is no argument against its assumption. M y position as an hereditarian, as opposed to that of an environmentalist, shapes the perspective of my interpretation. As there are constitutional types of men, conveniently summarized in the physique, so also are there temperamental types, for which the word psychique should be available. M y physique is glaringly evident to all beholders; the photographic exposure of my features is so in a double sense. M y psychique is for most purposes fortunately veiled, though those favorably and those unfavorably disposed toward me have their own preferred readings of it. They infer it from my behavior, words, manner, and all the indices of 'character.' The clinical psychologist proposes to render a fair version of the intimate psychique; that is his metier, and to that end he aims to develop all valid techniques. He has no psychological camera, certainly not an x-ray apparatus to aid him (Freud to the contrary), in his intimate analysis. The problem of the 'psychoanalysis' of hysteria (in the catholic sense)2 is to locate the focal symptoms, which are equally evident in the temperamental traits and in the neurotic issue. The clue 2 It is most unfortunate that the term psychoanalysis has been appropriated by one specific method enmeshed in theory. It should apply to any mode of determining the psychological etiology of a psychosis or neurosis. I have proposed the term•psychodiagnosisto serve as a generic term. That indicates a purpose with no implication of adherence to any one principle or set of explanations. [316]

THE PSYCHONEUROSES to the answer is clinical. The hysterical mode of response as a temperamental trend is, to begin with, an explosive overemotionality. Emotions are specific; the typical emotion central in the hysterical picture is anger. Homo is furiens as well and long before and much more than he is sapiens. On the (onto) genetic side, the infantile proof is tantrums, a popular recognition of a clinical reality; on the (phylo)genetic side there is the wild, savage, untamed ancestral prototype and his survivor running amuck; on the clinical side, "anger is a brief madness," and mad means insane and angry for men and dogs alike. Anger is the ready outlet of the hysterical trend; any primitive emotion has its hysterical mode of expression. There are as well favorable, cultivated varieties of hysteria that serve to increase zest and provide thrills, such as football and baseball and other national manias, which are therapeutic so far as they drain off hysterical energy that if repressed might become dangerous. There are neutral hysterias and hysterias harboring handicaps and menaces. There are such varieties as war hysteria and Wall Street hysteria (note the unfeminine association); and there are in the complications of our social relations riots and torrents of emotion that get out of hand, which are of the family of hatred, violence, and fanaticism. The concept of hysteria leads to the consideration of that total hysterical syndrome, the complex. I use the word 'complex' in a more catholic and comprehensive sense than the Freudian. The hysterical complex is the composite group of behavior-trends typical of that deviation type. There are also specific complexes, limited sets of overemotionalized ideas, habits, taboos, compulsions, inhibitions, and beliefs regulating behavior, among them those recognizably Freudian. These are all clinical discoveries in Neurotica,3 the land where the neurotics live. Whatever our interest in complex-ridden humanity, the undercurrent of inquiry is insistent: why complexes ? And why just these ? The clinician may properly turn to the psychologist for reply. There seems no single clue to the derivation of all the symptoms of hysteria. A second group of phenomena has ever obtruded in the picture. Hysteria seems to be not a circle with a single center, but an ellipse with two conjugate foci. The other focus is the temperamental trait which, when developed, becomes or 3 The term is Mrs. Wembridge's. [317]

THE PROBLEM OF MENTAL DISORDER invites a trance state. A conspicuous instance, when it occurs, is somnambulism. All sleepwalkers are hysterical; obviously the reverse is not the case. Note that what is involved in this peculiar behavior (and the same holds in the relation of neurasthenia to the fatigue mechanism) relates to a fundamental of psychic living, sleep. We must sleep well and sleep adequately to keep mentally alive and fit. Irregular sleep indicates a failure in a vital mechanism; as such, insomnia of any variety suggests a tendency to neurosis. Somnambulism is an hysterical irregularity affecting the sleep-mechanism. A convenient name to cover all sleep-allied states is trance. At the beginning of the series there is the temperamental liability, the ready disposition to states of distraction or abstraction, including the common garden variety of absent-mindedness. This state of mind, habit of response, falls in turn under one of the great generalizing concepts of abnormal psychology: dissociation. One focus of the hysterical complex is the tendency to dissociation, the other being the tendency to emotional excess, to anger. The relation of hysteria and hypnosis exemplifies the trance factor saliently. I t entered into the picture with the striking observations of Charcot, which made Paris the Mecca of students of the hysterical complex, including Freud. The momentous Freudian system and the still more momentous Freudian era have their Urquelle in this phase of the problems presented by hysteria. Charcot found the most susceptible subjects for hypnosis among his hysterical patients at the Salpetriere; he did not recognize their equally marked suggestibility and capacity for simulation, with or without guile. The hypnotic condition is one of dissociation, an abnormal division between the privileges —assets and liabilities alike—of ordinary sleep and waking. I t is a wakeful sleep or a sleep-like wakefulness. That the trance may be the avenue to higher privileges, powers, or insights is an ancient belief and a recurrent hope; that it involves disqualification and leaves the personality partially bereft was established as soon as hypnosis was experimentally investigated, and not merely exploited for its sensational phenomena. Its limitation as a therapeutic resource is thereby conditioned. We are all variously subject to dissociation; the hysterical temperament is peculiarly so. Why or how hysteria comes to present these two foci from which the typical symptoms radiate, each contributing to the [318]

THE PSYCHONEUROSES total hysterical complex, or how they share the field between them,4 or what is their connecting bond; all that is the next step in analysis, which at present we can take only as a speculative guess, guided by clinical data. One may observe marked overemotionality with slight tendency to dissociation in one case, and the converse in another, even as in sisters, where there is a common inheritance. We have entered the tangled undergrowth of the hysterical jungle. The disqualifications inducible by hysteria became common knowledge on an unprecedented scale through the war neuroses, misleadingly called shell shock, because precipitated by an overpowering emotional strain associated with the bombardments of war; the actual assault was upon the fundamental emotions. The shock released latent tendencies to neuroses, as do likewise, though more gradually, the shocks, strains, tragedies, and psychic traumas of the incidents of so-called peaceful living. The warring emotions are the cause of the conflict, as Freud recognized in the psychic traumas which his analyses laid bare. The trauma exceeds the limit of endurable aggravation; it precipitates a dissociative eruption when the neural disposition provides that path of outlet or escape. The great majority of soldiers similarly exposed did not develop shell shock; and of those who succumbed, each did so in terms of his special liability. The greater tendency of officers to exhibit the more refined disqualifications of the neurasthenic type and of the privates to develop gross sensory and motor impairments is in accord with the principles of temperamental psychology and the issues of socially acquired control. Freud's insight traced in detail the sources of disability in the distressing incidents of life; he did not merely accept it as an unexplained issue. He came to his solution by carrying the explanation of Janet one state farther and that alone makes Freud important. Janet had spoken of subconscious ideas; he was aware that the clue to the somatic symptoms was to be sought in the psychic mechanisms. A half-century ago he recognized the abdominal distentions observable in some hysterics as 4 It is interesting to note that Shakespeare in delineating the two cases of hysteria whichfigurein his dramas, based one of them upon the anger tendency —Katherine in Taming of the Shrew—and the other on the trance tendency—the somnambulism of Lady Macbeth. The sleepwalking is evidently described from life, and the words put into the doctor's mouth, calling attention to the dissociation : that Lady Macbeth sees her own candle, but not those of the attendants who follow her, is a correct clinical observation. [319]

THE PROBLEM OF MENTAL DISORDER psychically determined; they disappeared under suggestion with or without hypnosis. So far as he interpreted them also as pregnancy fantasies, he had come upon the germ of the Freudian innovation. The inclusive concept which psychology has framed upon this and allied observations is that of the psychogenic origin of many symptoms. The older accounting of it all as imagination is shallow and at times naive; these symptoms are not fictitious nor feigned, with, however, a parallel mechanism at work. They respond positively and negatively to fear, hope, faith, and should be viewed with charity. The correct interpretation of symptoms in which the psychogenic5 factor plays a part, often the leading part, is a vital problem in the psychology of the neuroses. Freud added a neglected factor which is authentic, though in my opinion, limited in influence and often entirely absent. To construe all psychogenic action into the Freudian formulas of psychogenesis is precisely the logical error which makes so much of that doctrine extravagant and its application unsound, even pernicious. I t is the mechanism posited in these derivations, with their distortions of sex and symbolism, that forms the controversial arena.6 The clinical products of psychogenesis appear in the hysterical mimicries and in the nervous aggravations that accompany so many forms of somatic disturbance. The neurasthenic complex offers an additional opportunity for their discussion. The parallel analysis of neurasthenia begins with the fatigue system and its specific vulnerability. We shall not penetrate to the core of this inconceivably (to those who know it not) distressing neurosis until the nature of the fatigue mechanism gives up its secret to a neurological investigator. That we all manifest our neurotic weaknesses, whatever they may be, when tired— whether grouch-and-sulk inclined or snap-and-strike inclined—is disagreeably familiar. Most of us have somewhere a nerve weakness which is what neurasthenia literally means, but which is expressed as a psychic lack of resistance to the emotional 6 This symptom has so impressed one clinician, Babinsky, that he makes it a distinctive order of disorder, and calls it pithiatism, which, he holds, should be substituted for this phase if not for all hysteria. Pithiatism includes conditions that arise from suggestion and may be relieved by the same means; as that liability is itself to be psychologically accounted for, I see no advantage in detaching a type-symptom from the total picture in which it belongs. 61 have considered it in The Bouse That Freud Built, Greenberg, New York, 1932. [320]

THE PSYCHONEUROSES assaults of life, taking pitiless advantage of those who are down. We all have our neurasthenic liabilities; quite commonly they come forward as a complication in physical illness. The central emotion in the neurasthenic complex is fear, as primitive, as untaught, as devastating as anger. The night terrors of children are as characteristic as their tantrums. Crude physical fear is reflected in the bodily counterparts of starting, blanching, trembling, faintness, collapse. I t has a wide sympathetic reach, in that we fear with and for others and contagiously so, and a broad psychic spread in the form of dreads, anxieties, broodings, miseries. Anger is exciting, active, wasteful of energy. Fear inhibits, depresses, paralyzes; its affiliation is with the low dysphoric states; the depressions.7 Since rest and food are the restorative agencies of the fundamental cycle of living, their need is expressed in fatigue and hunger; and these conditions show their psychic consequences in the neurasthenic pictures; the hungry and the tired child behave similarly, and the adult retains this liability. I t is a typical datum of clinical psychology that, under the lowered resistance of a nervous system peculiarly disposed to overact and to react abnormally to the stresses of fatigue, the neurasthenic becomes subject to intense and harassing dreads and anxieties. They may center upon fear of illness, of death, of a nameless unknown; their assault is upon the most fundamental of all instincts, that of self-preservation. A reward as well as an index of health is courage, a readiness to face the assaults and trials of living. That euphoric condition extends to cheer, poise, and the summoning of the emotions favorable to the life abundant. We are all alike more courageous and more genial when well nourished, rested, and physically fit. The resulting picture of the complex of neurasthenia (and in slighter measure of the allied temperamental tendency) exhibits at least three sets of symptoms: exhaustion, fear, depression. They combine and vary indefinitely. They are presumably collateral effects of the same unknown types of disturbance in the fatigue mechanism. I t is equally characteristic that the symptoms of neurasthenia are subject to psychogenic influence. They fluctuate rapidly under psychic states, becoming relieved 7 This in no wise interferes with the hysterical (agitated) expression of what is fundamentally a depressive state, such as grief, guilt, remorse. Those who succumb to the prevalent financial depression, with its shock-like losses, show temperamental differences. I t paralyzes some, agitates others. [321]

THE PROBLEM OF MENTAL DISORDER under pleasant stimulation, and aggravated under trying, distressful, worrying conditions. To call them imaginary is a crude and ignorant and, in practice, an unjust misreading of the victim's responsibility. The neurasthenic has to fight for every inch of health and poise, and when he wins, deserves a hero medal, for he is a fighter under the unfairest handicap that could be imposed; he has the hardest task with the least energies to meet it. There arises the issue whether the more profitable mode of classifying (and treating) the several rather distinctive varieties of psychoneurosis is by accepting as the clue the dominant symptoms, or by tracing the complex (group, constellation, syndrome, total typical picture) to a unitary (or multiple) source. Following the first method, we arrive at such rubrics as anxiety neurosis, depression neurosis, fatigue neurosis, compulsion neurosis. The therapeutic efforts would then be directed to allaying, circumventing, 'abreacting' the anxiety-situations which develop so consciously as marked types of phobias (agoraphobias and claustrophobias, notably). Freud has gone so far as to select the anxiety neurosis as a specific 'disorder' with its origin invariably in sexual frustration. Viewed in the light of possible somatic (chemicophysiological) disturbances, it is conceivable that anxiety has one such (as yet unknown) basis, depression another. I t seems profitable to carry on all these problematic approaches, awaiting further knowledge. But the trend of my thesis favors the unified concepts and places the emphasis upon them. The psychodiagnosis favored by the principles of psychology applied to clinical material is that of such complexes as hysteria and neurasthenia. The malady is hysteria, compulsion a symptom; the malady is neurasthenia, anxiety a symptom. The search for completion and correction of the total psychological concept is in my opinion the promising route of clinical psychology. Part of my criticism of the Freudian position is its neglect of psychological, even of biological, fundamentals. The result is an unsupported, detached, and partial insight that none the less happens to be a most important one. The Freudian psychology is truly a clinical psychology; but, as I see it, wrongly carried out by reason of distorted premises and a hopelessly weak (logical) confirmation. I have used the hysterical complex to illustrate one group of principles of clinical psychology. I shall use neurasthenia simi[322]

THE PSYCHONEUROSES larly to illustrate other portions of the formidable chapter of human behavior or misbehavior that come to the fore in the f. n. d.'s. The 'functional' to most diagnosticians indicates the absence of an organic basis. That negative finding actually represents the limitations of our knowledge. I t does not imply that there are no processes within the organism responsible for the complex; that may be an x, but a very real unknown. I t is illogical for the psychoanalyst to find psychogenic causes everywhere ; it is even more so for the ' organic' diagnostician to ignore and repudiate the psychoneuroses, or dismiss them as evidence of culpable weakness and irrationality in his patient. A British pioneer in this field—in his day called psychological medicine— said very wisely that when a man is so ill as to believe he is ill when he is not ill, he is very ill indeed. The neurasthenic is often obscurely ill, the obscurity on the practitioner's side; to the patient the medley of symptoms, even though he can smile when they are referred to as his 'organ recital,' are the most realistic of distresses. The psychoclinician might well alter the classic saying to read varium et mutabile semper hysteria, while still recognizing the feminine version. I n contrast the neurasthenic presents a striking constancy (amid minor variations) of symptoms, some of them so distinctive as to serve as hall marks or tell-tales. An examiner in his initial interview with a neurasthenic patient can often establish a reputation for profound insight by anticipating or predicting these clue-symptoms before the patient has a chance to reveal them. These are somatic (not organic in the sense of an organ impaired) nor yet psychogenic in the hysterical sense. There is the intense pain in the back of the head (at the base of the brain). Few neurasthenics escape it; most of them never had it until their breakdown. There is the aggravation of the symptoms in the early morning; the afternoon is often better euphorically, and the evening decidedly so. The digestion is disturbed; the sleep is irregular, even to insomnia; in intense attacks there may be sweating of the palms; there may be tense feelings in the head, -a drawn scalp, twitchings, a sense of confusion. To suppose that these are wholly psychogenic, that they represent Freudian mechanisms of substitution for psychic situations which they cover or for which they offer escape, is about as logical as to conclude that there must have been held a convention of neurasthenics and that they adopted each of these [323]

THE PROBLEM OF MENTAL DISORDER symptoms as a plank in the neurasthenic party platform. Clinical psychology is not as simple as that; yet every one of these symptoms is definitely subject to fluctuations in terms of general states of mind. And this is something more than, though of the same nature as, the influence of those persons who rub us the wrong or the right way; and we are feline enough to bristle or purr accordingly. There are somatic clue-symptoms of hysteria likewise, such as the globus hystericus, long recognized; and by that route we reach the consideration of the glandular component as a possibly decisive factor. That hyperthyroid activity generates hysterical types of response is well known; the far greater incidence of such conditions among women is in line with the analysis. The glandular factor is definitely related to the autonomic nervous system; as are likewise many of the symptoms of the f. n. d.'s, so clearly so that the hypothesis that they are disorders of the autonomic is plausible. The point at the moment is to emphasize that symptoms subject to psychogenic influence may, indeed do, have somatic causes, whether we know what they are or not; the hope of their control may lie there. The contrasts of the hysterical and the neurasthenic disposition are important psychologically and therapeutically. Overaction and inaction; anger and fear; aggression and shy withdrawal; elation and depression; explosive and slowly cumulative reaction; impulsive and hesitant; childlike and mature; the neurasthenic always feeling more incapacitated than he is, the hysteric often unwilling to recognize that there is anything wrong; the neurasthenic male, the hysterical female; these contrasts are ordained in the nature of the liability but by no means universally; they are rules with many exceptions. Shaded down to temperamental proportions, the same type of picture, the same features remain. There is an hysterical laugh, even a sneeze, certainly a manner; there is the hysterical assertiveness and contentiousness, what the Germans call Rechtshaberei. There is hysterical exaggeration; but as the overdoing finds its outlet—this is the cultural factor— in one emotion or another, it changes its character. There arises overconscientiousness, distorted sympathies, extreme and perverse sensibilities, in which expression the Freudians find a strong support for the theory of substitutions for frustrated emotions, particularly in the sphere of sex. The Puritanic conscience, the antivivisection crusade, and a variety of devotions, rituals, [324]

THE PSYCHONEUROSES scruples, idiosyncrasies, all in a measure creditable, may still present an hysterical factor. That there are compensations in all temperaments is apparent. The hysterical source of energy, though hollow, is in many respects better than its lack, and youth will and should have its fling. The compensations of neurasthenia are many: sensitiveness, deeper and richer emotional ranges, originality. The neurotics represent a deviation from the more usual and normal formula; the f. n. d.'s are the variants, and in them there is hope for the race. The dull levels of mediocrity are safer; the farthest flight of the arrow strains the bow to near the breaking point, increasing the danger of its snapping. The overlapping symptoms are likewise significant; pure types are few; the run of clinical cases is mixed. This finding falls in with the temperamental basis and the glandular emphasis. Precisely because the masculine make-up favors the neurasthenic way of breakdown will hysteria in the male be modified by i t ; neurasthenia in women will be altered by the concomitant hysterical trends. The sexes, clinically considered, are as plainly psychological ultimates as they are culturally, emotionally, occupationally, or otherwise. The greater susceptibility of men to a disorder characterized by fear-complex implies no lesser courage in the protecting male; it may mean that he carries the energy output more readily to the extreme, has a lesser protection in the fatigue symptoms; it may be affected by the culturally reenforced notion that a loss of courage is a greater defect in masculinity and thus involves greater concern. The greater irascibility of the female of the species, which is in so many ways deadlier than the male, appears in the feminine gender of the word shrew itself; its genetic bearing is presumably its major meaning, namely, a greater tendency in women to regression, a lesser shift and change in attaining maturity. All of which is merely suggestive, a truth within limits, and a corroboration of the general clinical analyses, but misleading when carried too far or applied indiscriminately. I have chosen to use my space to illustrate by specific analyses the relations of clinical psychology to psychiatry. I t is the mStier of the clinical psychologist to set forth as a chapter in psychology the data that appear in a clinical survey. Logically he precedes the psychiatrist, who both follows and supplies the clues; for in practice nature presents only personalities and situations, normal and otherwise. [325]

THE PROBLEM OF MENTAL DISORDER There are compensations in the neurotic temperament. But I cannot agree with those who find in them either goals or inevitable sequences. Normality is the desirable goal and in this relation the ideal that sets the norm is balance. I t is the instability of both temperaments—hysterical and neurasthenic—that is their handicap. The therapeutic ideal is poise, control; that is indispensable to the wise pursuit of many of life's important callings. We do not desire in any sense a neurotic world; there are altogether too many approximations to it. Calm, judicious, though vital and integrated judgments are the true assets of civilization. To indicate what measures of therapy are favored by the approach of clinical psychology falls beyond my present purpose, however clearly we all recognize that the direction of effort— employing the joint resources of science and art—is the prevention, cure, and control of psychoneurotic deficits and the allaying of the disasters which they entail. I present clinical psychology as a research department—one of several—of every psychiatric foundation. I regard as the leading purpose of clinical psychology the analysis of neurotic symptoms, and wish it were possible to ignore the all too abundant literature of recent years and restore the word psychoanalysis in just this meaning. The application (of whatever principles of clinical psychology and psychiatry one professes) to individual cases is psychodiagnosis. The Freudian psychoanalysis is just one form of psychodiagnosis, and should be so recognized. I t proceeds upon an analysis which in my opinion is at once so speculative and unnatural as to invite if not to require its rejection. Yet the Freudian therapy —in turn speculative and doctrinaire—follows upon the assumptive analysis. Clinical psychology forms a basic psychiatric resource. The common meeting ground is the study of personality. The modern view of personality is fundamentally modified and enriched not only by the inclusion but also by the directive guidance of psychopathic personalities in interpreting normal personalities. Humanity may be regarded as a clinic in a novel and profitable sense. The training of the psychiatrist must include an expert interest and a professional competence in the problems of clinical psychology.

[326]

X V I I . T H E COMPARATIVE PSYCHOPATHOLOGY OF I N F R A H U M A N PRIMATES

By Robert M. Yerkes, Ph.D., and Ada W. Yerkes, Ph.D., New Haven and Orange Park The purpose of this summary report is to consider the possible usefulness of primates other than man, and particularly the monkeys and anthropoid apes, in the experimental study of the nature, causation, relations, and control of nervous and mental defects and disorders. The point of view and presuppositions of the writers are those of the comparative psychobiologist— objective, biocentric, genetical.1 I t is assumed that every psychosis has its neurosis and that neuropathology, logically viewed as science of function and of structure, is inclusive of psychopathology. There are obvious practical reasons for the current distinction, and both terms will be used throughout this report. I n the literature on the nervous and mental disorders of infrahuman animals which constitutes the factual basis of this report, the perennial dispute concerning animal consciousness appears. The argument runs thus: lacking mind an animal cannot be insane, since insanity is, by definition, a disease of the mind. Of authors who in the past hundred years have contributed voluminously to our subject, Pierquin de Gembloux (1839),Lindsay (1880),3 Dexler (numerous publications since 1900),4 Hutyra and Marek (1905-1906),5 Frohner and Zwick (1915),6 1 Comparative psychobiology, as herein used, designates the study of the behavior of the organism whether or not conscious or self-conscious. It is primarily objective, equally concerned with the behavior of man and other organisms, and seeks phylogenetic and ontogenetic information as well as knowledge of the conditions and principles of organic behavior. 2 Pierquin de Gembloux, TraitS de la folie des animaux, et ses rapports avec celle de Vhomme et les legislations actuelles (2 vols.), Paris, 1839. 3 TV. L. Lindsay, Mind in the Lower Animals in Health and Disease (2 vols.), vol. 2, Mind in Disease, New York, 1880. 4 H. Dexler, Pathologie und pathogenic Anatomie des Nervensystems und der Sinnesorgane'der Haustetische, Ergebn. vonLubarsch-Ostertag, 1900-1901,401-505; Die Hauptsymptome der psychotischen Erkrankungen der Tiere, Prag. med. Wochnschr., 33, 1908, 523, 535, 547, 562, 572, 587, 602, 614, 628, 663, 677, 691, 707, 723, 740, 757, 790; 34, 1909, 5, 19, 30. 6 Hutyra and Marek, Pathologie und Therapie (3 vols.), vol. 3 (6th ed.), 1922, 266-281, Jena. 6 E. Frbhner and W. Zwick, Lehrbuch der speziellen Pathologie und Therapie der Haustiere, Stuttgart, 1915. [327]

THE PROBLEM OF MENTAL DISORDER and Frohner (1923),7 the earlier confidently assume the existence of mind in animals, whereas contemporary authorities, in much more critical and conservative spirit, in some instances admit and in others question or deny its presence. This dispute is relatively immaterial to the comparative psychobiologist, because he is concerned primarily with behavioral phenomena and a priori neither affirms nor denies the existence of consciousness or mind in any organism except himself. In the present connection, we assume as a working hypothesis the presence of consciousness in other organisms precisely as for our fellow men. We must insist, however, that this assumption is needless in the objective and comparative study of neural and mental diseases. Epilepsy designates a more or less variable assemblage of neurological, physiological, and behavioral phenomena. The totality constitutes the disease. This is true likewise for the hysterias, manias, and dementias. As consistent objectivists we may describe the disease, whether or not it be known as mental, in terms of directly observable and measurable constituent features, many of which are recognized as symptoms, some as differentiae. The presence of consciousness or mind in connection with the disease is not a matter for ex-cathedra and dogmatic affirmation or denial, but instead for discovery and proof. Meanwhile behavioral description should be relied upon in psychiatry as in physiology and psychobiology. Infraprimate Animals. Survey of the literature on the neuroand psycho-pathology of vertebrates reveals almost negligibly significant information for fishes, amphibians, and reptiles; notably more data and theoretical discussion for birds, because certain of them are kept as domestic pets, and much more abundant and valuable contributions for mammals. As a matter of course, far more attention has been given to the diseases and disabilities of domestic animals, especially dog and horse, than to any other except man. For the moment we defer consideration of the infrahuman primates. Among the nervous or mental symptoms, defects, or diseases which have been attributed to one or another of the domestic quadrupeds, the following are found. We assume no responsibility for correctness of diagnosis. Vertigo, rotation, tetany, birth convulsions, catalepsy, eclampsia, St. Vitus' dance, muscu7 E. Frohner, Pathologie und Therapie, 1904; Lehrbuch der klinischen Vntersuchungsmethoden filr Tierarzle, Stuttgart, 1923.

[328]

PSYCHOPATHOLOGY OF PRIMATES lar spasms of various kinds, chorea, puerperal paresis, exophthalmic goiter, toxicoses, hydrocephalus, tumors of the nervous system, concussions, encephalitis and paralysis of several sorts; moronity, imbecility, idiocy; hysteria, melancholia, mania; senile, traumatic, and affective dementia; and, finally, variously described neuroses and psychoses. With certain conspicuous exceptions, contributions to the neuro- and psycho-pathology of the vertebrates, exclusive of the primates, must be ranked relatively low in scientific quality and value. Thoroughgoing case-studies, characterized by specificity, detail, completeness, reliability, and accuracy of description, are rare by comparison with casual and obviously incomplete and inadequate reports. Nevertheless, the literature abundantly indicates the existence of highly significant phenomena and of relatively neglected opportunities for fruitful research. Critical examination of the evidences has wholly convinced us that neurology and psychiatry have at least as much to gain from intelligent and persistent study of pertinent aspects and conditions of the structure and behavior of infrahuman animals as have physiology and psychobiology. Hitherto the domestic animals, and with a few exceptions even the laboratory animals, have been used relatively little for experimental studies in psychiatry. I t appears that this is delaying the progress of the subject as science and art, and that it requires small gift of prophecy to foresee rich returns from the further development of neuro- and psychopathology and psychiatry as experimental and comparative disciplines. Infrahuman Primates. Information on the diseases of primates is widely scattered and extremely difficult to assemble and evaluate. Prior to the present century there appeared few contributions of any considerable scientific importance. Experience in zoological gardens, menageries, medical and other biological laboratories, however, indicates that the monkeys and apes are subject to many of the diseases which appear in domestic animals. On the basis of extensive experience Dr. A. Calmette,8 of the Pasteur Institute of Paris, states: It seems that all microbic maladies of the human race can be transmitted to chimpanzees, and that many of them are transmissible to the 8 A. Calmette, Sur l'utilisation des singes en medecine experimentale (Le Laboratoire Pasteur de Kindia, Guinee Fransaise), Bull. Soc. Path, exotique, Paris, 17, 1924, 10-19. [329]

THE PROBLEM OF MENTAL DISORDER monkeys. This is true for syphilis, typhoid fever, cholera, bacillic and amoebic dysenteries, exanthematous and recurrent typhus, yellow fever, pestilence, acute poliomyelitis, measles, scarlet fever, small pox, trachoma, pneumonia, grippe. It is equally true for maladies produced by protozoa or by parasites: trypanosomiasis, leishmaniosis, bilharziosis.9 From observations made by veterinarians and pathologists in various zoological gardens of the world, in the laboratories of the Pasteur Institute both in Africa and in France, the Russian laboratories for scientific use of the primates in Sukhum, Caucasus, the Rockefeller Institute for Medical Research, and the Laboratories of Comparative Psychobiology of Yale University, to mention a few signally important sources, the Calmette inventory of diseases of apes might be extended to include yet other nervous and mental symptoms and disorders which generally have been considered characteristically human. Almost certainly man's nearest of kin in neuro- and psychopathology, as also in general pathology, is one of the anthropoid apes, probably chimpanzee or gorilla. With recognition of their relatively intimate relationship to man, within a few years infrahuman primates have come to be used extensively in medical research. In the laboratories of the Pasteur Institute, during the past ten years, various African primates have served as experimental subjects for investigation of tuberculosis, cancer, encephalitis lethargica, poliomyelitis, and several other diseases which are of grave import to man. We have not found any systematic review or digest of the literature on primate neuro- and psycho-pathology. Significant contributions, apart from such experimental studies of specific diseases as have recently been made in laboratories for medical research, are rare. There are numerous brief descriptive references to symptoms or symptom-complexes and a few case-studies. I t may be inferred either that diseases which concern neurologist and psychiatrist are much less frequent in other primates than in man, or that they have been overlooked so far as scientific record is concerned. Favoring relative infrequency of occurrence are the absence of syphilis in wild primates and the probability that these animals exist in a cultural environment which is much less exacting and fatiguing, both relatively and absolutely, than that of man. 9 Calmette, op. cil., pp. 18-19. [330]

PSYCHOPATHOLOGY OF PRIMATES Our experience indicates that an overexacting environment tends to induce in chimpanzee either drowsiness, sleep, the neglect or, if possible, the avoidance of the annoying situation, or, instead, increasing excitement and evident resentment until an emotional explosion occurs and the animal temporarily becomes violent. The thought inevitably comes to one that human civilization, with its present extraordinary demands on the nervous system, is responsible for not a few of the prevalent forms and relatively high frequencies of nervous disorders. Varying degrees of resistance and of behavioral adaptivity undoubtedly exist in man, and demands which one nervous system can meet adequately may produce neuroses in another. Evidently it is possible to lay too great stress on the control of the human nervous system and too little on adjustment of environment or mode of life to the functional characteristics and limitations of the individual. No better material for the experimental study of problems suggested by these reflections is likely to be found than the chimpanzee. With it, opportunity offers to test experimentally the effect on the nervous system of so modifying the environment as markedly to increase or diminish the difficulty of adaptation and the consequent fatigue. Relevancy of the Comparative Study of Normal Behavior. In its behavioral aspects, comparative psychopathology is a relatively neglected area of comparative psychobiology. Apart from their historical interest the meager findings are significant chiefly as indicating the possibility of important research. Students of comparative and genetic psychology, or, as we prefer to say, of psychobiology, hitherto have devoted themselves in the main to analysis and description of normal or typical behavior and to discovery of its causes, conditions, relations, and controls. Such work, properly done, should be basic to the study of abnormal behavior and should contribute to the scientific foundation of comparative psychopathology. I t is unnecessary to argue that abnormalities of behavior can as little be successfully characterized except by contrast with the normal as can pathological structures. Behavioral norms and standards of reference and comparison, knowledge of optimal as well as extreme forms of activity, are essential to the progress of neurology and psychiatry. Thus it would appear that comparative psychobiology, in its concern with normal behavior, should contribute notably to these sciences. Improved methods of [331]

THE PROBLEM OF MENTAL DISORDER observing, measuring, and describing behavior are constantly being demanded and sought by the physician, and not least it would appear by neurologist and psychiatrist. Such demands should be met and unquestionably can be met increasingly by psychobiological advances. The history of biological science suggests that conspicuous aids to those aspects of research, diagnosis, and descriptive pathology which are primarily behavioral are more likely to derive from the psychobiological study of other mammals than from the corresponding study of man himself. Notable as exhibits of behavioral studies relevant to psychiatric need are data on receptivity, affectivity, adaptivity, organic rhythms, sexual and other forms of reproductive behavior, and response to insoluble or difficultly soluble environmental problems. Information of these sorts has become available for several of the mammals and notably in recent years for chimpanzee. I n general, the work has been limited to normal or typical forms of response, but its extension to the abnormal is entirely practicable. Support of this statement is to be found in the accidental discovery of Pavlov10 and his associates of the production of neuroses in the dog. The writers have observed comparable phenomena in monkey and chimpanzee. I t is of peculiar interest to note here that nearly a century ago Pierquin de Gembloux11 remarked, in his treatise on insanity in animals, that attempts to train them beyond their capacity prepare for an explosion of insanity. Whereas it rarely is practicable to employ human subjects in the experimental study of induced psychopathic conditions, it is reasonably certain that chimpanzee can be used to extraordinary advantage. Yet, for such work, thoroughgoing knowledge of normal behavior is absolutely essential. Chimpanzee and Man; the Argument from Similarity. We wish to maintain that comparative psychobiology and the infrahuman primates, although actually significant in the history of psychiatric progress, are potentially vastly more significant. The stock argument is pertinent that, other things being equal, the closer the resemblance of an experimental animal to man, the more valuable the immediate results of inquiry in connection with 101. P. Pavlov, Conditioned Reflexes; an investigation of the physiological activity of the cerebral cortex (G. V. Anrep, trans, and ed.), Oxford University Press, London, 1927. 11 See above, note 2. [332]

PSYCHOPATHOLOGY OF PRIMATES the solution of human problems. In fundamental, as distinguished from applicational, research, this argument does not necessarily apply, since important discoveries may be made irrespective of the type of organism studied. That the monkeys and anthropoid apes are genetically more closely related to man, both in structure and in function, than are any other existing animals is certain. Critically searching evidences have rapidly accumulated in the last two or three decades that the anthropoid apes, exclusive of gibbon and siamang, are even more manlike than has hitherto been supposed. From normal anatomy, from pathology, parasitology, bacteriology, immunology, physiology, and psychobiology, have come definite evidences of marked similarity between one or another of the existing great apes— gorilla, orang-outan and chimpanzee—and man. As Calmette12 has indicated, they, far more than any other known animals, exhibit susceptibility to diseases which hitherto have been studied only in man and which generally have been considered characteristic of man. The expression 'almost human,' as applied to the great apes, is-no exaggeration when characteristics of sense, habit-formation, emotional expression, social behavior, diseases, and disabilities are under consideration. Indeed the varied information now available to us fully justifies the prophecy that neuro- and psycho-pathology are likely during the coming decades to be more signally advanced by wise and ingenious experimental uses of the infrahuman primates, and probably of the great apes, than in any other way. Obviously this would not be the case should it become feasible to experiment freely and without restrictions with human subjects. Chimpanzee. Present knowledge of the structural and functional neurology, the psychobiology, and the sociology of chimpanzee justifies the assumption that this creature is the best available substitute for man in the investigation of problems of normal as well as of deranged behavior. The writers express themselves with assurance, because their familiarity with the relevant literature is supplemented by many years of intimate acquaintance with both monkeys and apes as objects of naturalistic and experimental inquiry. The traits of chimpanzees in many instances so closely parallel those of man that one who regularly works with them comes to treat them virtually as children, and to expect of them much that would be expected of a 12 See above, note 8. [333]

THE PROBLEM OF MENTAL DISORDER fellow man. For instance, intercommunication between apes and between ape and man may be highly developed, although seldom does it depend primarily upon speech. Instead, bodily attitude, gesture, and movement tend richly to supplement, when they do not actually replace, sounds. Systematic use of chimpanzee for the experimental study of varied problems of neuro- and psycho-pathology is dictated also by availability, economy, control, practicability of intimate and thoroughgoing knowledge of ancestry, life-history, and experimental history. Granted that this animal is nearest to man genetically and that the neurological and psychobiological, if not also the psychiatrical, relationship is very close, it would seem natural that investigators should immediately undertake to supplement their limited and sadly restricted opportunities for experimental studies of man by systematic use of the chimpanzee. We dwell on chimpanzee in this connection simply because, all things considered, it appears to be the most serviceable material for the extension of neurological and psychobiological science into psychopathology. Other primates certainly can and doubtless will be used to increasing advantage, but whereas chimpanzee is one step removed from man in its neural constitution, behavioral characteristics, social development, any primate other than a great ape is two or more steps removed. This is peculiarly significant when it is admitted that the greater the disparity of function, the less probable that logical inferences will hold from type to type. General or naturalistic observation of the behavior of monkeys and apes and experimental procedures are equally feasible and profitable. The former indeed is necessary as providing acquaintance with normal activity, its variations and adaptations, while the latter may be employed for the production, modification, or control of neural and behavioral defects and disturbances identical or analogous with those which appear in man. In general, naturalistic study should provide basic informational background, and experimentation should lead to the solution of specific problems. Prerequisite to the effective use of chimpanzee or any other subhuman primate in psychopathological research is intimate and thoroughgoing acquaintance with its behavioral characteristics as individual and species. Ancestry, life-history, and experimental history must be accurately known, and the investigator should be thoroughly [334]

PSYCHOPATHOLOGY OF PRIMATES acquainted also with the behavioral traits and capacities of his individual subject. The neurologist or psychiatrist who presumes to undertake to use a colony of chimpanzees with the degree of preparedness which ordinarily obtains for similar uses of laboratory animals might better use his time otherwise. Possible Psychobiological Approaches to Problems of Psychopathology. Psychiatry is one of the branches of medicine whose practical development has far outrun the growth of its scientific foundation. Whether as report of subjective examination, psychoanalysis, mental testing; or general observation of behavioral characteristics and personality traits, it is ultrapragmatic and in almost every direction devoid of serviceable norms and adequate standards of judgment and comparison. Among the many experimental approaches to highly important problems, the following are at once practicable and especially promising in the light of recent progress within the other divisions of biological sciences. 1. Observation of the effects on neural function and behavioral expression of various drugs which chance to be peculiarly significant in human life, and also other chemical agencies as indicated in the study of specific problems and in the search for means of bringing about certain types of alteration of function. Such work might be thought of as biochemical, pharmacological, and psychobiological, for it should bring to bear upon the problems of psychiatry the major resources of these divisions of science. 2. Investigation of the structural and functional status of the glands of internal secretion and of their products, experimentally and otherwise, in their relations to normal behavior and to its pathological deviations. The method of such inquiries might be operative, genetical, or pedagogical, but in any event it would inevitably link the resources of endocrinology with those of comparative psychobiology. 3. Study of the functional relations of neural structure and behavior. This might proceed logically from general observation of behavioral characteristics in normal and in deranged animals to an examination of the histology, cytology, and chemistry of the nervous system—and that, it is important to note, without awaiting the end of the natural life-span as is necessary in man. Or, by contrast, procedure might from the start be surgical or otherwise manipulative. Herein both structural and functional [335]

THE PROBLEM OF MENTAL DISORDER neurology should be supplemented by the methodological resources of psychobiology. 4. Systematic use of the type of physiological training commonly designated by such terms as conditioning, training, dressur, for the experimental reenforcement, inhibition, or other distortional modification of behavior, and for the production or alteration of atypical, maladapted, or definitely pathological conditions of neural function and of behavior or conduct. The linkage thus of physiological training with the procedures of comparative psychobiology in the interests of psychopathology is .relatively new and has been inadequately tested to permit an estimate of its importance. We are inclined to expect much of it. 5. Systematic study of the influence of educational procedures in the production of behavioral adaptations. Thus, for the study of either normal or abnormal habits, or other modes of adjustment to material and social factors in environment, many of the procedures of experimental education, particularly as developed in the study of the behavior of infrahuman organisms, should be intensified in value by association with the informational background and techniques of the comparative psychobiologist. This particular category of inquiry differs from the former in that it is pedagogical and outward-looking, as contrasted with physiological and inward-looking. As in the previous case, it is noteworthy that the varied resources of "animal education," so-called, as available through comparative psychobiology, have been used to a negligible extent in psychiatric research. This is difficult to understand and still more so to justify. 6. Investigation of affective phenomena, their nature and relations to neural conditions. As a matter of course, affective aspects of behavior should be included in many, if not all, of the categories of inquiry previously listed. I n this instance, however, it is a matter of specialization of interest and attention. Manifestly, the relations between the special study of affects and search for neurological correlates of behavior, as indicated in paragraph 3, are peculiarly intimate; for there are present indications that the neural mechanisms of affective response have been located by physiological experiment and that it remains for the several functional sciences to study minutely the characteristics of these mechanisms and their modes of operation in the production and regulation of affects. Inasmuch as disturbances of affectivity are conspicuously important in neuro- and psycho-pathology, the significance of this general line of research requires no emphasis. [336]

PSYCHOPATHOLOGY OF PRIMATES 7. The observation of social response, its conditions, relations, and modifications, is peculiarly important, since with chimpanzee as contrasted with man such phenomena may be controlled for experimental purposes to the limit of human ingenuity and need. Probably in no existing creatures can social life and response be studied to so great advantage under natural and under controlled conditions and with definitely and adequately known subjects as with chimpanzee. The values of social stimuli, the characteristics and significance of social conflict, inhibition, repression, inadequacy of response, and maladjustment, in their relations to neuro- and psycho-pathological phenomena, may be determined as problem-solution requires. I t is not necessary, as in man, to await nature's experiment, for with chimpanzee the investigator need not consider the welfare of his experimental subject aside from humane treatment and justifiable use, nor need he be influenced by its natural life-span. In no field of behavioral research are prospects of important discoveries and practical assistance for psychopathology better than in that of the experimental study of social phenomena and their neurological relations. Ordinarily one would choose to suggest specific problems or assemblages of problem rather than general methodological approaches to the fields of inquiry. We have chosen the latter alternative because it is evident that psychiatry especially needs new avenues of approach to old problems and the reformulation of certain problems to permit of other than the conventional modes of attack. Heretofore, because of the nature of its human materials, the subject has been clinical and descriptive. I t should by contrast become experimental and genetically explanatory through the utilization of infrahuman primates as experimental materials. To say that the subject requires rebirth within the sciences, even if true, would not distinguish it from many other divisions of biology. I t appears that even now comparative psychobiology has a body of information and a variety of techniques pertinent to the infrahuman primates which, if effectively utilized, should speedily help to carry psychopathology to new levels of insight and therapeutic success. In the past fifty years experimentation with infrahuman animals has given powerful impetus and varied methodological and informational assistance to experimental education. I t now appears that psychobiological study of the monkeys and great apes may be made similarly to advance psychiatry by help[337]

THE PROBLEM OF MENTAL DISORDER ing to provide applicable methods, fruitful extensions of knowledge of behavior and its principles, and, most precious of all, a variety of experimental procedures, including many methods of behavioral measurement which have not heretofore been utilized in psychiatric research. We have written thus optimistically and prophetically from our own experience and with historical orientation, confident that psychobiology, as herein defined, can importantly aid and supplement psychiatry, and that the chimpanzee is the best possible substitute for man in many psychiatric investigations.

[338]

X V I I I . PSYCHOTIC SYMPTOMS A N D SOCIAL BACKGROUNDS By M a n d e l Sherman, M.D., and Irene C. Sherman, M.D., Chicago Psychiatrists have begun to recognize that a definite relationship exists between the symptoms of mental disease and the cultural background of the individual patient. Indeed some anthropologists and sociologists believe that the culture of a group influences the qualitative and quantitative components of the normal personality and intelligence. In a study of mountaineers living in hollows of varying isolation such relationships were observed. I n these hollows the growth of intelligence becomes less rapid at a given chronological age in some sections and at another chronological age in other sections of the mountains. This leveling out of intelligence as measured by tests appears to be due to the requirements made upon the individual by the community. I n one of the regions the tests showed an average intelligence of approximately eight years, whereas in another region it was approximately eleven years. As the social organization of these communities increased in complexity, necessitating wider contacts and more difficult adjustments, the number and complexity of personality traits also increased. The traditional attitudes, superstitions, and fears of the mountaineers also appeared to be closely related to their cultural conditions. In one of the hollows of low social organization, for example, superstitions and fears about the weather and the elements generally were the most frequent, whereas in one of the hollows of higher social organization, superstition and fear regarding agriculture and personal conditions were the most common. Fears of bodily illness were fairly frequent in one of the hollows of higher cultural development but were practically absent in one of the hollows of lower social organization. Thus we may infer that the culture determines to a large extent the attitudes and fears of a group. The influence of cultural background upon the development of the neuroses was clearly demonstrated in the mountain hollows. The mountaineers living in the community of simplest social [339]

THE PROBLEM OF MENTAL DISORDER organization had few symptoms of neuroses, but as the complexity of the social organization increased, these symptoms became more prevalent. With the increase in number and complexity of social problems, there was a corresponding increase in the number of individual conflicts, as well as a change in type of conflict with the change in type of problems to be solved. Presumably this increase in frequency of conflicts and this change in the characteristic type of conflict are directly related also to the increased frequency of neurotic symptoms in communities of a more complex cultural order. I t is more difficult to estimate the r61e of culture in mental disease in highly socialized communities than in sparsely populated mountain hollows of relatively simple culture. Yet an approach to this problem is possible by means of a quantitative study of the hospital records of the mentally ill. When a large number of such records are examined, it is clear that a relation exists between the type and frequency of symptoms of mental disease and such cultural factors as race, education, nationality, occupation, and religion. That the various factors in the cultural background are important as determinants of the symptoms of the 'functional' insanities is evident in the therapeutic procedures of every psychiatrist. Before psychotherapy is undertaken with a patient, a detailed history is obtained of his previous experiences; his difficulties and frustrations, his early training, desires, and ambitions, unusual emotional traumata, and incidents involving conflict between the requirements of his cultural traditions and his desires. Thus an attempt is made to localize the origin of the observed conflicts. The recognition of the role of individual conflict is further implied in the current belief that the symptoms of the functional insanities cannot be grouped into definite diagnostic categories, and that variation in symptoms indicates variation in past experience. A study in progress by the writers is an attempt to discover common and differential factors in this determination of the symptoms of the insane. Thus far the records of approximately five hundred adult white and four hundred adult negro patients have been examined, particularly with respect to hallucinations, delusions, and paranoid ideas. A few examples of the relationships discovered and their implications for future investigations will be discussed. [340]

SYMPTOMS AND SOCIAL BACKGROUNDS Men are more given to delusions of grandeur than women. As our culture is constituted, this might be expected. The social contacts of men are, as a rule, more numerous than those of women, and their social problems more serious and profound. In his attempts to solve his conflicts the male is therefore more likely than the female to compensate for his failures of adjustment by developing ideas of his superiority. Grandiose delusions probably give us a greater insight than any other symptom into previous frustrations. Grandiose delusions are fairly easily analyzed and their symbolic content is less complicated than other symptomatology. Grandiose delusions are probably among the most simple forms of escape from, and compensation for, difficulties and frustrations which the individual is unable to overcome. In the ordinary daydreams of children and adults, and in their planning for the future, we see the mechanism of grandiose delusions, but it is under control. Grandiose delusions also give us insight into the ideals of the individual, and into the goals set by the cultural situation. Among those Americans, for example, who measure success in terms of money, grandiose delusions most commonly have to do with the possession of great wealth, whereas foreign-born are more subject to grandiose delusions pertaining to literary and other artistic pursuits. While there is wide variation in type of grandiose delusions in white individuals, so far as sex is concerned, differences are slight in the negroes, who diverge markedly from the white group in the type of grandiose delusions. The largest factor for both male and female negroes is the religious delusion, which comprised almost half of the total number. On the other hand, over a third of the delusions of grandeur of white males concerned financial power. None of the white females of the group had such delusions. Religious delusions were much more frequent in the white female than in the white male. The negro female also exceeded the negro male; but the excess of the negro female is very much smaller than that of the white female. Lacking many social contacts and responsibilities of men and not greatly involved in masculine problems, women are possibly more prone to turn to religion as a compensation for difficulties and disappointments. The slight difference in the percentage of religious delusions between male and female negroes compared [341]

THE PROBLEM OF MENTAL DISORDER to the predominance of these delusions in the white female over the white male may be evidence of the relative social similarity of negro men and women as compared to the whites. The possession of great wealth is the second most prominent type of delusion of grandeur in negroes; third place is taken by aspirations and delusions of superiority in literary and educational fields. This type of delusion was not often found in the white group. Often these delusions of grandeur regarding educational and literary achievement are intricately interwoven with religious delusions. The following excerpts are typical. One subject is a male negro of thirty-two years of age, a laborer and gospel worker, with two years of college, a resident of Cook County seven years but born in Arkansas. Diagnosis: dementia precox. The patient believes that he has two articles in the Associated Press. Those two articles [he says] . . . are the solution of the race problem. . . . I have a speech memorized for the World's Fair. . . . What is good society and social duties? Christ tells me, 'You shall know the truth and the truth will make you free.' I have been studying metaphysics for eight years. . . . Yes, nurse, you are dumb, don't you see I have all the intelligence there is to have, see ? A negro woman of forty-five with fifth-grade schooling declared, " I ' v e got some poetry in the papers, and it's the best ever was; and yet they all think I'm Dumb Dora." In many instances the negroes' delusions of grandeur based on the possession of money have an educational aim for the benefit of their race. One man believed he had two thousand dollars invested with Hoover, and when it reached a million he was going to use it to build schools for the negro. I t is also of interest that none of the negroes' delusions of grandeur having a racial connotation referred directly to any racial conflict or racial competition. This is illustrated in the case of a man who believed he was head of a great negro steamship company and of the woman who proclaimed herself the chief of missionaries to the people of Africa. While women are less inclined than men to develop delusions of grandeur, the white woman is more subject than the white man to paranoid trends. The reverse is true of negroes. The white woman, in other words, is more inclined than the white man to blame others for her failures, whereas the male resorts to overcompensation as a defense of his deficiencies. We do not [342]

SYMPTOMS AND SOCIAL BACKGROUNDS venture to suggest a reason for this difference, or for the fact that the negro male is more likely to develop paranoid ideas than the negro female. Females, both white and negro, exceed the males in hallucinations, although the percentage of this type of abnormality among all negroes far exceeds that among whites. Somatic delusions are as common among white as among negro males, but considerably commoner among white than negro females. They are far commoner among white females than among any other group. A number of hypotheses may be offered for the relative frequencies of hallucinations and somatic delusions in the mentally diseased. The negro, living under relatively less complex social conditions than the white, is perhaps more likely to develop hallucinations than other types of abnormality in his escapes and rationalizations. The negro is notably superstitious and prone to believe in visions and other manifestations of supernatural powers; and possibly the white woman is more subject to such beliefs than the white man. As we have suggested, the status of the negro woman is much nearer that of the man than is the corresponding status of the white woman. Her social contacts and problems are relatively little differentiated from those of the negro man. I n consequence she is less likely to develop somatic delusions than the white woman. The latter, because she has fewer significant social problems than the white man, may be likely to turn her attention to herself in the effort to find a system of rationalization, and so to utilize various bodily symptoms as justification for, and escape from, her failures and disappointments. The hallucinations of many psychotic individuals are religious in character. This is particularly true of the Protestant group. More than half of their hallucinations were found to pertain to religious subjects. Only about a quarter of the hallucinations of those of Catholic faith, however, were of this type, and not one Jewish individual in the group studied had a religious hallucination. I t is well known that Catholics and Jews tend to accept their religion without criticism, whereas Protestants are much more prone to view certain aspects of their religion with some doubt. Consequently they are likely to have conflicts about religion, and possibly such conflicts are factors in their psychoses. [343]

THE PROBLEM OF MENTAL DISORDER Birthplace, like religion, appears to be related to the characteristic symptoms of the psychoses. The foreign-born white have the largest percentage of paranoid ideas; the native white are second, and the negroes from the South least subject to this type of idea. Paranoid ideas are much more frequent in the northern than the southern negro. The factor of social and economic competition is no doubt of significance in this relationship. The northern negro lives in a far more competitive society than the southern negro. As a rule, the foreign-born individual in America also has more obstacles to meet than the native citizen. In the event of failure, or seeming failure, and unable to accept defeat, he may tend to blame others for his assumed deficiencies. Hallucinations also are much more frequent in the southern negro than in the northern. Education also appears to be correlated to some extent with the kind of symptoms a psychotic individual displays. Paranoid trends, for example, are most common in patients who have had relatively little education. Here again struggle in a competitive environment may be a determining factor. Grandiose delusions are most frequent in those who have attended college, and somatic delusions most frequent in white patients with little education. As a rule, an individual who has had academic training meets with more social and intellectual problems than one who has had little schooling. Obviously a person able to attain but little formal education, either because of an intellectual defect or a circumstantial hindrance, is likely to have little acquaintance with the wide range of problems with which other individuals are acquainted. As a result, his fantasies and rationalizations tend to concern his own bodily condition. The foregoing illustrations indicate the procedure which may be followed profitably in interpreting the large mass of factual data in the files of institutions for the insane. Much improvement in record-keeping must be made, however, to promote an intelligent investigation of the large number of factors undoubtedly involved in this problem. One subtle factor was illustrated when a comparison was made of the number of admissions of negro patients to the psychopathic hospital with various indices of social disorganization in the residential zones of Chicago. Utilizing sociological data at hand upon the relative number of charity cases, of unmarried mothers, and of juvenile delinquency, in the seven negro zones of Chicago, the rates of negro admissions were [344]

SYMPTOMS AND SOCIAL BACKGROUNDS calculated. The rate decreased from Zone 1 to Zone 7, that is, from the economically and socially poorest to the best, corresponding with a similar decrease in the rates of the indices mentioned. Perhaps the same processes which tend to produce social disorganization in the negro also produce functional mental disorder. In any event, the prevalence of insanity seems to be an index of social disorganization in this urban population.

[345]

X I X . CULTURAL ANTHROPOLOGY By A. L. Kroebek, Ph. D., B e r k e l e y The mutual relations of anthropology and psychiatric science are still relatively undeveloped, but they bid fair to become of some importance in time. On the face of things, cultural anthropology would seem capable of but little relation to psychiatry, because culture in its very nature is a social product, and psychiatric phenomena are manifested in the individual. The actual condition, however, is much less schematic. The culture of every community is never quite identical in any two members of that community. Again, in every psychiatric, or for that matter psychological, situation, environment plays a part, and this again is culturally conditioned. One outstanding fact of obvious importance has never been wholly explained, perhaps just because it involves both disciplines. All cultures which we commonly call primitive or backward contain as an important constituent the element of magic or related beliefs in certain supernatural efficacies. To a considerable but lessening degree these elements continue into the more advanced cultures. Ordinarily we designate peoples as civilized in proportion as they have sloughed off magical beliefs and practices. There is of course a subjective element in all such labelings; first because activities in which rationality does not participate importantly—aesthetic activities, for instance— also enter into higher civilization; and secondly, because everyone is biased to see the magico-irrational attitudes of his own culture as rational. Still, it can hardly be denied that in a broad sense the proposition holds. I t is equally obvious that a reversion to belief in magical cause and effect is one of the outstanding phenomena of psychotic delusions. A patient believes that another person has entered his body; that he feels that person's sight boring into his body from a distance; that he is shattered by waves or emanations sent out by an enemy in a cave in Jerusalem; that his food is poisoned by machinations or passes, without even the putting of material substances into it; that the pain in his chest is due to his [346]

CULTURAL ANTHROPOLOGY own breaking of a moral rule; and so on endlessly. Such convictions in a normal civilized person are prima facie evidence, if coupled with distress, of psychopathological derangement. But they are of a type of, and often specifically identical with, the beliefs of all normal members of most uncivilized societies. Here is a case. An elderly Neapolitan cobbler comes to a hospital clinic with a rambling story told in broken English. His account wanders from headaches and listlessness to an old woman who has made him sick. He is referred to the neuropsychiatric department with the comment: "Question of psychosis." Examination brings out little more than irrelevant detail about the enemy and how long she has wished him ill, and why, and how she makes his head hurt. There is all the first indication of a persecutory delusion. The man is told to come back with an interpreter. He returns with a fluent Italian-American, who expounds apologetically that the old man is illiterate and believes the woman is a witch and has cast the evil eye on him. The apparent delusion dissolves into a bit of superstition typical generally of the lower orders of Naples society. What is a normal belief there is a psychotic symptom in one of our hospitals. If the writer or reader of these lines were to harbor the same conviction as this Neapolitan, it would be prima facie evidence of mental derangement. The norm of one culture is a sign of nervous pathology in the other. Several inferences follow. 1. Psychiatric diagnosis cannot be made without regard to cultural environment. If this principle has not been more explicitly recognized, it is because most psychiatrists draw all their professional experience from within one cultural group)— often from not more than a subgroup or class. 2. I n general, it is the lower culture some of whose normal belief-content is recognized as delusionally abnormal in the higher. The concepts of higher and lower have of late years been taboo to most anthropologists, or at least avoided by them as being qualitative and subjective, likely to be egocentrically founded, and incapable of precise definition. These criticisms may all be granted; but yet our inference remains unshaken that the psychiatric-anthropological comparative finding coincides with the popular unscientific ranking of cultures. Evidently there is a certain validity in the popular judgment; and anthropology may find in the psychiatric criterion the beginning of a [347]

THE PROBLEM OF MENTAL DISORDER gauge for dealing with this problem which so far it has increasingly viewed askance. 3. The psychiatrist may also draw his own conclusion from the observation. At least it may help him to understand psychotic delusions and perhaps hallucinations somewhat more completely in their character of regressions. 4. I n this connection, it is probably of significance that the following anthropological finding also has its psychiatric parallel. Magic is ordinarily employed only in situations of magnitude, importance, difficulty, danger, or strain, or when the involved causality is complex or obscure. The same primitive who pins faith on shamanistic procedures in serious illness will tie up a cut finger in the same matter-of-fact manner as we. A weapon or a canoe on whose strength or seaworthiness one's life may depend is likely to have a spell spoken over it before use; but not so a pole for knocking acorns off a tree or a mousetrap. I n the innumerable minor activities of life the savage is likely to be as ' practical' or as 'rational' as we; to assume, apparently, the same mechanical causality as we, put side by side with the magical causality which he is equally convinced operates in the bigger affairs of uncertain outcome. The psychiatric equivalent of this compartmenting is the usual persistence in the insane of many normal activities and reasonings alongside fixed delusional systems. There is certainly warrant for considering the magico-religious systems of primitives as being essentially close cultural equivalents of such psychopathological systems in individuals. But there are always large parts of the culture, and areas of the personality, respectively, which remain 'normal.' And it seems to be something akin to what for want of a more precise term may be called strain, that brings on the 'abnormalities' in both cases. These are points on which there have been some reflections and observations, but which no one seems as yet to have thought through very far. Obviously, too, the analogies pointed out must not be pressed too far. On the other hand, they appear to be more than mere analogies, and to contain a real connection which is not yet very well understood, but which may be of much significance when it becomes clearer. The older anthropologists, as exemplified, e.g., by Frazer, were very specially interested in the field of magic, taboo, and symbolic ritual; also in such social 'aberrations' as totemism and exogamy. In fact Frazer deals with little else, except incidentally. Environ[348]

CULTURAL ANTHROPOLOGY ment and its influences, the whole subsistence basis of life, the economic structure reared on this, are virtually passed over by him. There is no sociological search for laws or dynamic processes, nor, on the other hand, any serious interest in major historical continuities, nor the modern ethnographer's preoccupation with distributions which may throw light on the sequence of cultural events. Frazer's endless dealing with "survivals' is not in contradiction to this statement, because a survival is after all essentially a persistence outside its original cultural context—a sort of fixation. Frazer's real interest, in short, is not in the normal processes of culture nor in the sequence of its developments, but in its pathology. I t is for this reason, perhaps, as much as on stricter methodological grounds, that ethnologists of the present generation have turned away almost to the point of ignoring him. An allied but somewhat different interest in the pathological element in culture is found in the recent work of Reo Fortune on the Melanesians of Dobu. Here there is not the endless heaping up of historically unconnected items to show how widespread and persistent the aberrations of magic and taboo are, but a vivid, intensive, functional picture of how such elements affect a single primitive culture. A strange set of institutions, centering around alternate yearly residence of both husband and wife in each other's natal groups, represents a remarkable compromise between the conflicting impulses of kin ties and marital ties, and is further interwoven deeply with economic and magico-religious practices which reflect another compromise-formation between the business of sane practical living and a mass of wish and fear fantasies. The whole cultural situation parallels strikingly a clinical picture of a violent neurosis, if not a psychosis. I t may fairly be questioned whether Dobu society is truly, in comparison with most others, as pathological as Fortune describes it. Conceivably his picture is colored by a special interest in the abnormal which makes him pass lightly over the normal factors in the culture. Some checking seems to be indicated on this point. But whether he exaggerates or not, Fortune has shown, more strikingly than probably anyone before him, that whole cultures may be permeated, and possibly distorted, by trends outwardly quite similar to those which warp the lives of psychopathic individuals. That cultures do differ in this respect, at least nearly as much as personalities, is clear at once when Eskimo [349]

THE PROBLEM OF MENTAL DISORDER society is set alongside Dobuan. Allowing for all possible overemphasis by Fortune, the undoubted fact remains that the whole system of peculiar Dobu institutions has only slight Eskimo parallels or equivalents. Of course, normal cultures are as important as abnormal, and perhaps more numerous. The frequency-relation, the transitional forms, the varieties of abnormality, all remain to be worked out. But at any rate we have here a fairly clear indication of differences which promise to be genuinely important to the student of culture in introducing an angle of concrete psychological approach; and the psychological approach is one in which ethnologists have made little progress, in fact have pretty thoroughly left alone in the generation between Frazer and Malinowski. Psychiatrists in their turn can presumably also profit in understanding by becoming more aware of the fact that phenomena familiar to them, or at least very analogous phenomena, occur also on the superindividual cultural level. Of course, none of these considerations are wholly new. Historians who are not too professionally factual have long since recognized that certain civilizations could be construed as 'sickly' in some of their basic attitudes and trends; the Middle Ages, for instance, as compared with classic Greece. India as compared with China probably provides another example. In general, historians have not pressed such findings very far, and have left them incidental, often tenuous. And it would no doubt be unfortunate if historians in the mass were to abandon their well-traveled important paths to indulge in wanderings in historical psychologizing. But there is room, as well as need, for a psychological interpretation of major historical phenomena —which are cultural phenomena—in addition; always provided the approach be in terms not of popular introspective-intuitional but of scientific psychology. And in such an approach there is the warrant of precedent for believing that the fruitful first attack in some cases is likely to be on the abnormal elements. After all, the greatest significance of these elements lies in the clearer definition and deeper insight which they yield on the normal, which it is hard not to take for granted instead of investigating. Freud's Totem and Taboo is an attempt to re-use the data of Frazer in a psychoanalytic explanation. Ethnologically this volume has no standing whatever. I t accounts for the birth of [350]

CULTURAL ANTHROPOLOGY culture by a single cardinal act occurring at a wholly unknown time in an undesignated place among an unspecified population. This fundamental act was the killing and eating, by a band of brothers, of their father who out of jealousy had driven them from their mothers and sisters; and their immediate remorse, culminating in their ritually honoring their slain father with a taboo as their totem. Even without its ancillary hypotheses this interpretation is of course only pure fantasy as history. So unhistorical-minded is Freud that it is not even clear whether he believes the central act to have occurred literally only once in time and space or as a recurrent determinant phenomenon. Probably he and his followers feel that such a point does not matter. They have with one stroke of insight solved the Gordian knot of the origin of culture at which historians and anthropologists have vainly picked at so long. Nevertheless, while Freud's work is only an appropriation of the data of prescientific anthropology for the embellishment of his fabric of speculative psychology, and not ethnology at all, it cannot be dismissed as wholly negligible. I t does suggestively illuminate one point on which ethnologists remain hung up; the fact of the universality of prohibitions against incest. So exceptionless are incest-taboos in all societies of which we have any knowledge, that we must assume them, by all precedent, to be an utterly ancient, primal 'invention.' We can hardly construe them as a precultural hereditary equipment from the subhuman period because even the most advanced primates seem to lack all trace of such taboos. But incest-taboos differ from practically all other 'inventions,' that is, cultural products, in that these, whether of greater or less antiquity, are not universal; here and there, often in many places, they have become altered, reversed, lost; or they failed to be diffused or transmitted. The universality of the occurrence of incest-prohibitions therefore stamps them as something different from ordinary cultural phenomena. They are, as it were, cultural phenomena which are not products of culture; which is, by assumed definition, in modern rigorous ethnology, a contradiction in terms. Nevertheless, it seems a fact; and this fact of something cultural derivable perhaps directly from a purely psychic root, is what Freud has touched on with his penetrating—if fantastic and sometimes perverse—insight. His attempt as such no anthropologist can accept as a solution. But in his attempt there may be some [351]

THE PROBLEM OF MENTAL DISORDER adumbration to a genuinely scientific truth, which if laid bare might go far to explain many other basic problems of cultural origins. When it is remembered that Freud's explanation is essentially in terms of the Oedipus mechanism, the pertinence of these problems to fundamental psychiatric interest is evident. A recent endeavor by Benedict to define cultural proclivities in terms of psychiatric or personality tendencies is also of interest, although her designation of them as culture "configurations'— evidently an influence from Gestalt psychology—is in itself somewhat ambiguous. She analyzes several native American cultures to find that their respective sets are Apollonian, Dionysian, and paranoidal or megalomaniac in character. To the present author the analyses seem penetrating and essentially sound; but it has been argued that they remain highly subjective and open to contrary opinion. Her approach is too new, and too little thought through by others, to render a sure judgment of its validity possible at present. But the approach is stimulating and may be important, and in any event is of psychiatric interest. I t is likely to bear also on another set of problems; those of inherent race-psychology; not so much the old vicious circle of argument on the intelligence and capacity of races as their trends stated as qualifications of personality. This is a subject anthropologists have increasingly shied off from, perhaps because they felt that their critical equipment sadly hampered them in competition with amateur laymen. There is, however, no sound reason to expect anything else but that races which differ anatomically also differ in some degree physiologically and psychologically. And the facts that culture-conditioning and inherent race-traits are so completely interwoven that their critical segregation is extremely difficult, and that the overlaps between races are presumably greater than their differences, are no grounds for denying that there are likely to be genuine differences. This set of problems necessitates for its ultimate solution more than psychiatrists and anthropologists can supply. Geneticists, physiologists, psychologists, physical as well as cultural anthropologists, will all have to participate. But if Benedict is right in supposing that cultures, as such and independently of their carriers, also have their particular psychic qualities definable in terms of personality-trends, the race-problem becomes correspondingly more complicated still, because the 'culture person[352]

CULTURAL ANTHROPOLOGY ality' will have to be dissociated from the 'race personality,' which is expressible only in the same terms in the present state of knowledge. These considerations may serve to give some notion of the existing and especially the possible relations of the two disciplines. What psychiatry may have to gain from deeper understanding along these lines is for psychiatrists to judge; anthropology will unquestionably profit.

[353]

X X . EDUCATION By Leta S. H o l l i n g w o r t h , Ph.D., New Y o r k In the present state of knowledge, there is no assignable organic cause for mental disorder in a majority of persons who are brought for advice and care.1 These are, therefore, classified as functional cases. I t is with the members of this majority that the present study proposes to deal. Although all mental disorders may be ultimately comprehended from the standpoint of neurology alone, this hypothesis does not bear destructively upon anything that will be said in our discussion of education. If it should be ultimately proved that mental life is based on the nervous system (and not upon electrical phenomena, the chemique of the body, or some factor as yet wholly unsuspected) it would still remain true that the mechanism works according to the way it is handled.2 I t has been shown to work predictably. The learning process would not cease to be explanatory of mental disorder, simply because the latter were neurologically based, for the learning process is based also, in theory, upon the nervous system.3 For about a quarter of a century the idea has been gaining headway that insane behavior may arise as a product of learning. This point of view integrates mental disorder with systematic psychology. Insanity thus ceases to be a phenomenon outside of nature, since its symptoms are understood as resulting from the operation of the very laws that govern all mental life. From the point of view thus taken, there is no psychological difference between sane and insane behaviors. There is no telling, in psychological terms, where sanity ends and insanity begins. The definition of insanity, where commitment is in question, is in fact drawn up in terms of end results, which are social and economic. An insane person is one who "is liable 1 Cf. L. F. Barker, The nature, causes and prevention of nervous breakdowns, Addr. Roy. Canad. Instit., Toronto, Jan. 10, 1925, and E. S. Abbott, Prev ntable forms of mental disease and how to prevent them, Boston Med. and Surg. J., 1916, 555-563. 2 C. S. Sherrington, The Integrative Action of the Nervous System, Silliman Lectures, Yale University, 1906. 3 A. I. Gates, Psychology for Students of Education, The Macmillan Company, New York, 1930. [354]

EDUCATION to harm himself or others." The distinction is not in the origin of conduct, but in its consequences. This recent insight into mental disorder as learned has crept into the literature of the subject from various sources. Janet's concept of hysteria as a way out of emotional conflict was introduced in 1904.4 I n 1908 Adolf Meyer suggested that the sets of symptoms ordinarily classified under the caption of dementia precox are nothing more nor less than sets of habits, formed under conditions which he tentatively specified.5 Freud and Breuer opened the area of discussion known as psychoanalytic theory by proposing that abnormal behavior originates in infantile experience. Then and subsequently Freud erected an elaborate vocabulary of neologisms and a series of speculative interpretations of these childish experiences and their sequels which are irreconcilable with systematic psychology. The point of interest for us here is simply the fact that these practitioners recognized disordered conduct as of common origin with ordered conduct, namely, as originating in experience. These citations by no means constitute an exhaustive account of the history of the psychological concept of insanity; but they do serve to establish the fact that there has been for some time such a concept in many reflective and expert minds. Behavior of a Puzzled Creature. I n 1898 Thorndike supplied to this stream of developing theory a contribution of fact established by experimental method. He set up experiments to determine how animals learn; and from these experiments laws of learning were derived, which can be used to induce in animals predicted conduct. The experimental psychologist can set up a design for behavior and work it out in an animal, by following the laws of learning, within the limits prescribed by the creature's capacities. As Thorndike expresses it, "Any response of which an organism is capable may become attached to any stimulus to which it is sensitive" by adhering to these known laws.6 These laws may be illustrated by the hiragry kitten, which, when placed in a cage with food outside, will strive to emerge. We say that the creature is ready to eat, and that he takes a 'set' or attitude toward the restraint experienced. 1 P. Janet and F. Raymond, NSvroses et idles fixes, Paris, 1904-1908; The Major Symptoms of Hysteria, The Macmillan Company, New York, 1918. 5 A. Meyer, What do histories of cases of insanity teach us concerning preventive mental hygiene during the years of school life? Psychol. Clin., 1908, 90-101. 6 E. L. Thorndike, Animal intelligence, Psychol. Rev. Monog. Suppl., 2, 1898, 109. [355]

THE PROBLEM OF MENTAL DISORDER Being caged, he becomes puzzled as to how his hunger may be satisfied. We note that the kitten strives blindly, in an uninformed manner. He performs nearly every action of which he is capable. He jumps up, jumps down, bares his claws, bites the bars, emits vocal sounds, sits, paces, licks his whiskers, and so forth. He is thus driven by his hunger into a trial-and-error activity. His action is not single and direct. It is multiple and miscellaneous, and we can see, though he cannot, that most of it is irrelevant. He is impelled now by this, now by that, detail of the situation. Noticing now how impulsion arises from details, we observe that the kitten does not respond quite equally to every element in his puzzle. Some elements have more power over him than others have. Such details as the color of the cage, facing of the cage north or south, and the day of the week, have little or no value as determinants of his activity. On the other hand, such a factor as the bars of the cage or the position of the stimulating food outside has great potency as a determinant. The activity of the organism is, therefore, not wholly random, even at first. It is partial and selective, rather than quite confused. Why are some elements 'prepotent' over others? The explanation lies partly in original nature and partly in previous learnings. A few stimuli (and their analogues) are prepotent the first time they are met. A new-born kitten will fasten directly to a nipple or to anything closely resembling a nipple. Most prepotencies arise, however, from past experiences. An organism responds in a new situation as it has already learned in previous experience to respond satisfactorily in situations analogous to it. That is to say, an organism will react similarly toward things that are alike; will behave by analogy with previous learnings. For example, a cat which has already learned to get out of one cage by striking a knob with his paw, will, when placed in another cage, go about pawing anything that resembles a protuberance. Furthermore, anything that has once been brought in as a part of the situation being experienced may come to be responded to as if it were the whole original situation, no matter how irrelevant, accidental or intrinsically uninteresting it may have been when introduced. Thus, the words, "Kitty, Kitty, Kitty" (at first matters of complete indifference) spoken in a certain tone, over and over again, when food is brought, will eventually elicit by themselves the same action as that elicited when food also was in the situation. This is called 'associative shifting' (referred to also as 'conditioning'); and it is especially clear in the formation of emotional habits.7 The laws of learning state first t h a t an animal must desire before i t will learn anything. I t must be ready, and desire alone induces readiness. Being ready, i t takes an attitude or set toward the attainment of desire. I f the direct way to fulfillment be blocked, multiple activity ensues, in the course of which the creature's behavior follows analogy, grows gradually more and more partial to some details over others, and shifts w i t h association. This leads finally to an outcome. The t o t a l course of events is influenced by a more general principle, which Thorndike 7 M. C. Jones, Emotional development, Handbook of Child Psychology. (C. Murchison, ed.), Clark University Press, 1933. [356]

EDUCATION calls the Law of Effect. This states that an organism yields to whatever satisfies craving, neglects whatever brings neither satisfaction nor annoyance, and avoids whatever brings positive annoyances. A puzzled creature is likely to repeat, in less time than he took at first, whatever brings release from craving. Repeating the successful act, he learns eventually to do i t readily, thus illustrating the Law of Exercise. The caged kitten w i l l eventually learn to perform any act, within its capacities, that will bring relief from hunger. Since Thorndike's formulation of the laws of learning, additional interpretations have from time to time been suggested. It is held, for instance, that the German school of Gestalt psychology has some new insight to offer, in stating that all psychological reactions are in terms of 'configuration.'8 When considered closely, however, it does not become evident that configurations arise by means essentially different in any respect from those analyzed out from total behavior in Thorndike's laws. An effort has again been made to synthesize the various aspects of the learning process under one single formula, embodied in the principle of redintegration. This formula states that "learning is cue reduction." We may call what precedes the response the 'antecedent' or 'stimulus' for this response. Although the response remains the same from day to day, there is a notable change in the stimulus. An act that once required a fairly elaborate antecedent comes in time to be touched off by a very slight feature of this antecedent. Learning is seen therefore to consist in a reduction of the stimulus required to produce a given act.9 The formula of redintegration in no way invalidates or supersedes the laws of learning, as Thorndike originally stated them. The former represents an advance in thinking about the subject, in that it synthesizes the total behavior of a learning process into a single concept, while the latter analyze the process into its main components. These laws of habit-formation hold throughout animal nature, and are fundamentally the same for man and beast.10 Human beings when puzzled follow the same laws of learning which have been illustrated in the case of the trapped kitten. This fact has often been demonstrated in laboratories of psychology. Learning to Be Insane. I n his early experiments, Thorndike observed that the laws of learning are no respectors of end results. A hungry monkey might learn to open a cage door and 8 K. Koffka, Beitrdge zur Psychologie der Gestalt, Barth, Leipzig, 1919; W. Kohler, Gestalt Psychology, Liveright, Inc., New York, 1929, 10, 403. 8 H. L. Hollingworth, Educational Psychology, D. Appleton-Century Company, New York, 1933. 10 E. L. Thorndike, Animal Intelligence; Experimental Studies, The Macmillan Company, New York, 1911. [357]

THE PROBLEM OP MENTAL DISORDER get his food in an orderly, sane, and socially applauded manner. Or he might with about equal ease learn to run away from the food and hang grimacing at the top of his cage when the food-dish was placed in sight. Either set of behavior was producible by exactly the same techniques, and to the experimentalist the one was no more insane than the other. But, to the naive observer, one monkey was wise and well adjusted, while the other was mysteriously perverse, maladjusted, and likely foolishly to starve. The skilled psychologist can experimentally produce insane or perverted habits in an animal, if he will simply wait repeatedly until the animal acts irrelevantly (which is sure to occur in the course of its prolonged multiple activity) and will inevitably seize that moment to release the animal from craving, by presenting the food. Thus any act of which a puzzled animal is capable may become the response to any stimulus to which it is sensitive, if only appetite be in a measure eased by the attachment. In the same way, situations in which severe suffering has been undergone will come to be avoided; and by the laws of analogy and of partial (selective) activity, any part of such a situation will tend to be shunned as though it were the whole. With this brief resume of the learning process, we may turn to the particular case of human beings. I t inheres in life that every person must be caught time and again in an emotional trap, where the way out is blocked, and the satisfier of appetite cannot be reached. The person is thus involved in a puzzle (sometimes called an emotional conflict). Trapped and craving, he goes through the same process witnessed in the case of the caged animal. An actual example from daily life, showing a child's efforts at escape, will illustrate what happens.11 A child of six came with her mother into a strange household, where the mother had obtained employment as housekeeper. The child had been told many times that her mother's employment depended on the child's good behavior. The alternative to obedience was well understood to be separation from her mother and placement in a home for children. Now this child had been warned by her mother not to touch thefloorplugs for electric lights; but one evening she began to tamper with one of the plugs, thrusting a nail into it. A fuse was thus blown out, plunging the house instantly into darkness. When the accident happened, the child's proximity to thefloorplug was marked and the cause wasfixedimmediately. 11 L. S. Hollingworth, Helping the Nervous Child, Lincoln School of Teachers College, Columbia University, New York, 1927. [358]

EDUCATION The child was now in a 'trap situation.' An emotional panic arose. Escape from the facts of the situation began instantly to be sought by the blind method of trial-and-error. The self-defense of the child is most interesting to analyze. Shefirstsaid, with forced gaiety, "Oh! it doesn't matter. He's laughing! He doesn't care!" (referring to the owner of the house). The owner, occupied with ladders and fuses, however said, "Yes, he does care. It makes trouble for us all. I am not laughing." The child then burst into weeping and danced about as though on hot bricks. In a moment she cried, " I t doesn't matter, because it's my house. This is my own house! I paid nine dollars for it." The falsity of this escape was also firmly rejected by the household. The genuine ownership of the house was stated firmly and convincingly. The child then began to shriek, "Oh! look! I got dirty! I got all dirty!" and she held up her sleeve, dripping with some liquid into which she had evidently dipped it. The adults concerned were not diverted. They continued to speak of the floor plug and obedience. The child was at this point taken to sit with her mother in the dark till repairs could be completed. Soon she said, "I'm glad the house is dark. Everybody likes it here in the nice dark." This evasion of the real was also denied uncompromisingly by the household. Finally, left to herself, she came forward after a considerable time, and said, "I'm sorry I did it. I won't ever do it again.'' This constructive attitude was cheerfully accepted by all concerned as a genuine escape, and the promise was kept without a lapse. Suppose the child's mother to have shielded the child, to have championed one of the various pretenses so desperately attempted. "She didn't mean to." " I t doesn't matter." "Yes, yes, of course this is your house, darling." These are typical modes of 'spoiling,' and of setting the child's feet on the road to habitual disorder. In another case, a child thirty months old, who preferred sweet desserts to all other foods, began to lay his hand upon his abdomen when his vegetables were placed before him, and to say, "Danny feels so sick! Can't eat carrots. Can eat dessert." At these remarks, the mother looked at him without sympathy, and said "Oh! pifHe!" Whereupon the child soon ate his meal, as usual. Repeatedly, when his meal was brought, he would say he was sick and must have dessert at once. His mother invariably met the escape with the word "piffle" and the attitudes which accompany it. Finally, one day the mother was preoccupied when the child made his bid for dessert and forgot to say "piffle." The boy watched her for a few seconds; then said "piffle" himself and started without further trouble to eat his vegetables. This was the end of this particular attempt at escape. M e n t a l Disorder Regarded as Escape. The transcriptions just presented from the psychology of young children t y p i f y the unreal kinds of 'ways o u t ' which the human mind is able to find in seeking release from emotional predicaments. The moment a lessening of tension is felt the action that gave relief is adopted. [359]

THE PROBLEM OF MENTAL DISORDER The child, or the average man, does not, of course, have insight into what is in process. He cannot verbalize his actions. Many of the so-called "psychological mechanisms" which are commonly found to afford release have been identified and named by thinkers in the field. They have been variously called 'parataxes of defense,' 'make-believes,' 'escape mechanisms,' 'mechanisms of evasion,' and have been interestingly described.12 Among the mechanisms most easily recognized by the general listener is the sour-grapes defense, in which escape from admission of personal inadequacy is found by claiming that the object sought was not worth striving for. Commonly recognized also is the mechanism of symbolism, in which a thing that is like something forbidden but desired, or which is part of a whole that has passed away, stands for the forbidden or the lost and elicits the responses belonging emotionally to those things. The mechanism of capitalization is seen in those who "need the status of a physically impaired person"13 in order to get out of some disagreeable responsibility. Some trifling impairment or remembered ill is thus adopted in the emotional life as seriously incapacitating. Projection is the name applied to the escape from remorse or self-contempt, which is found by blaming our failures and faults on other people. Compensation describes the assumption of a witty manner by a person who suffers a chronic disappointment, and the crabbed manners of one who is at heart unduly inclined to kill people with kindness. I t cannot become our purpose here to describe all of these ways out, but merely to exemplify them and to add that they are learned as kinds of habit which people form when trapped and puzzled. They are formed irrationally, without much if any insight.14 The average man explains his own failure by believing that "the boss had it in for h i m " for the same reason that the hungry kitten scratches his ear; each has found release from tension in that way. In a world differently constituted these ways might be really effective and thus gain social approval. However, as things are, the end results are not likely to be good. 12 F. L. Wells, Mental Adjustment, D. Appleton & Company, New York, 1916; R. S. Woodworth, Dynamic Psychology, Columbia University Press, New York, 1917; T. V. Moore, Dynamic Psychology, J. P. Lippincott Company, Philadelphia, 1924. 13 G. V. Hamilton, Objective Psychopathology, Mosby, St. Louis, 1925. 14 F. H. Lund, The psychology of belief, etc., J . Abn. and Soc. Psychol., 20, 1925, 63-81, 174-196. [360]

EDUCATION The kitten's ear-scratching will not get him food in the world at large, but only from a certain special keeper (who may sell him or may die). The man's projection of his faults upon others will make of him an intolerable nuisance to everybody, even to those who let him be comforted in that way when he was young. These ways out are bad, mad ways only because of the end results. When carried to extremes in unstable persons, wholly without insight, they are called 'delusions,' 'hallucinations,' ' obsessions,' and so forth, and lead to segregation as intolerable. Hart has shown with extraordinary clearness how these everyday irrationalities differ in degree only from the symptoms of insanity.15 We have seen in the cases of the two children already mentioned how early in development these mechanisms can be utilized by the mind. Suppose the mother of the baby with the escape stomach-ache to foster the escape by that route. Instead of the matter-of-fact, disbelieving "piffle!" suppose her to become filled with sympathy, and to adopt the attitude that vegetables hurt the baby's stomach, so that he has to live on apple sauce and sweet desserts. Many a mother has been heard talking in this manner, educating her child to be mentally disordered. A child reared thus, by acquiescence in his escape mechanisms, is ordinarily called "spoiled.' Spoiled for what? Obviously, for living and working in a world organized on an impersonal basis, without special sentiment in regard to him. Mental Disorder as Unrevised Habit. I t is not enough, however, for the maintenance of mental order to form habits serviceable at a given time. There must be a constant process of habit-breaking, as well as of habit-making, if a person is to function adequately in society till he dies. This necessity for progressive habit-breaking arises chiefly from two causes: (1) from the biological fact that no individual can himself remain static, since development and decline are natural phenomena, and (2) from the fact that the external conditions of life constantly change, because of invention, discovery, and the evolution of that intangible called 'public taste.' What is useful today is gone tomorrow. What was admired in one's girlhood is the butt of jokes in one's maturity. These phenomena of change are based on the flow of time, over which man has absolutely no control. Disregard of time leads to the formation of many a trap of 15 B. Hart, The Psychology of Insanity, Cambridge University Press, 1920. [361]

THE PROBLEM OF MENTAL DISORDER unrevised habit. There is profound truth in the inscription on the old English sun-dial, " I t is later than you think." I t follows that a basic principle of mental stability lies in habit-revision. Social efficiency, whether of an individual, of a family, or of a whole nation, depends on ability first to make habits, and then to break them, as time advances. "When a nation is under consideration in this connection, sociologists speak of " breaking up the cake of custom."16 For anation that cannot break its "cake of custom" the penalty is backwardness, obsolescence, and the loss of national independence. Such a nation will be taken eventually, either formally or informally, under a mandate. For an individual who cannot revise habits, much the same penalties are involved. A person who cannot change his ways of thinking and acting as his life elapses becomes more or less of a social-economic liability and as such is in danger of breakdown. We may illustrate these remarks most strikingly from the area of cradle-habits, or, as Watson has called them, "nest-habits."17 Educators constantly detect among their pupils those who retain habits appropriate to the cradle, but wholly inappropriate to the school. Such habits often pertain to creature comforts, like food, clothing, and sleep. Extreme examples are those in which a mother or nurse appears at school, at the lunch hour, to put food into the mouth of a healthy, intelligent six-year-old child. Occasionally a teacher will be astonished to see a nurse appear at the noon hour with a nursing bottle of milk for a healthy six-year-old pupil. The most extreme instance within the knowledge of the present writer has been reported from the Ozark Mountains, by a teacher having a prolonged struggle with a mother who came to school at noon to feed her ten-year-old daughter from the breast. This mother had several younger children, among them an infant. The eldest had been hard to wean from the breast, and so the mother had continued through inertia, feeding the child thus. When the school demanded that this habit be revised, a 'nervous breakdown' ensued, which lasted for about three weeks. The child had violent emotional explosions, claimed she was dying, refused all food, and behaved in such a fashion that she would have been segregated in a sanitarium had she been twenty-five, instead of ten, years old. What has been said of cradle-habit applies with equal force to habits formed at any period of life. All habits must be held open 16 W. Bagehot, Physics and Politics, D. Appleton & Company, New York, 1902. 17 J. B. Watson, Psychology from the Standpoint of a Behaviorist, J. P. Lippincott Company, Philadelphia, 1919. [362]

EDUCATION to necessary revision, except perhaps those of extremest old age. Some nervous breakdowns are based on unrevised adolescence rather than on unrevised infancy; or on unrevised motherhood; or on unrevised middle age. I n accordance with our knowledge of the laws of learning, we may say that whatever period of a person's life has been most gratifying will tend strongly to cast its habits forward over the rest of life. Emotional habits growing out of great agreeableness will be hard to revise. Thus one has seen many a woman who was greatly admired in her adolescence (say, in the eighteen-nineties) as a lovely girl, adhering while her years advanced to all the habits which secured such admiration at that period. The artificial manners, the coyness before men, the accomplishments, the need for chaperonage after dark, even the modes of dress of the eighteen-nineties, were embalmed in the habit-system, because they had once brought her intense satisfaction. Gradually, of course, all these habits became less and less serviceable to such a woman, and to society at large. She grew elderly, and the world changed rapidly. No one now admires a woman of fifty who wears ruffles, smiles coyly over a fan, and demands chaperonage when going to the house next door after dark. The nervous breakdown ultimately occurring had its origin in the failure to revise adolescent habits. The particular form of disorder which results from failure of habit-revision is emotional depression. Misinterpretations of the environment, as by delusions, hallucinations, and the like, may in some cases be indirectly motivated as escapes from the conflicts involved. But the chief disorder, directly generated by obsolescence of the personality, is profound melancholy; a despair, either chronic or acute, which incapacitates the individual for effective living and may even lead to the longing for death as an escape from misery. An excellent example of this melancholy is found in homesickness, in which the individual cannot go on with his life in a normal manner because of unprogressive emotional habits. Unrevised emotional habits may lead to absurd involvements. There exist women of seventy who fear rape. There are men of seventy who spend energy trying to win the affections of girls in their teens. Middle age is 'the dangerous age,' because it is then that the trap of unrevised habit closes around the person who has spent [363]

THE PROBLEM OF MENTAL DISORDER too much of his total life-span in the grip of habits appropriate only to earlier stages of development. I t follows that the avoidance of such traps is an educational problem, the problem of constantly continuing education. Mental Disorder as Persistent Childishness. The discussion of persistent childishness is, in a sense, merely a ramification of the discussion of habit-revision, and yet it is not exactly the same thing. Habit-revision as a principle of mental order applies to all ages, while certain phenomena normal to childhood only call for special mention, as peculiar mixtures of the developmental and the learned. The normal psychology of childhood involves behavior which, when it appears in an adult, is abnormal. No exhaustive discussion of these phases can be undertaken here, but we may offer a few illustrations of what is meant. Irrational negativism is a normal phase of child psychology, and it is also a symptom of insanity. Reynolds18 and Rust19 have made precise observations of this phase in young children. The general conclusions are that negativism is normally very marked at about two years of age and declines thereafter till at five years it should be reduced to a point where the child is no longer markedly under its sway. Extreme negativism in an adult is a developmental anomaly which may be shown to bear relationships to educational procedures. The neologism as a feature of insane behavior is paralleled by the neologisms of the child. Thus one child developed the word 'lalabuma,' to denote soft, round, and delicious. Another invented ' boobalumksis,' meaning the place where socks end. Normally, such neologisms cease to be uttered as the child grows older. Among the interesting psychological products of childhood is the imaginary playmate. This is a figment which has been somewhat studied.20 I t should normally disappear by the time a child is twelve years old, if nothing happens to fix it. To persist beyond that period is to become an anomaly. The child answers the voices of his imaginary companions, hears them speak, sees 18 M. M. Reynolds, Negativism of pre-school children, Teachers College, Columbia University, Contrib. to Ediic., no. 288, 1928. 19 M. M. Rust, The effect of resistance on the intelligence test scores of young children, Child Devel. Monog., no. 6, Teachers College, Columbia University, 1931. 20 N. S. Harvey, Imaginary Playmates, State Normal College of Ypsilanti, Michigan, 1918. [364]

EDUCATION them, and makes allowances for them, as by asking that they have seats at table, and so forth. When found in an adult, this behavior amounts to a symptom of insanity. A great many more of these parallelisms between phenomena of normal child psychology and the classical symptoms of insanity could be drawn. To the observer who is familiar both with normal children and with the adult insane, the conviction comes that the condition of the latter is in many cases simply one of persistent childishness.21

The concept of infantilism has, in fact, become established in psychiatry in recent years. In connection with it, the term regression has come into use to describe the mental disorders of adults.22 The thought here embodied is that a person who has genuinely progressed to a psychological level beyond the childish later doubles back on the developmental career and acts as would be acceptable only at earlier stages. A truer insight would probably reject the word 'regression, and would state that progress had never really been made in the first place. Apparent progress had been achieved, in that the individual had dressed, spoken, and acted like a person of his age; but crisis had proved his adulthood to be spurious. In such cases, where the person is merely an imitation of an adult, the essentially undeveloped character manifests itself when props are removed (as by the death of a sustaining relative or mate), and the fundamentally childish attitudes emerge in overt conduct. These failures to develop progressively through and away from the various normal phases of childhood are problems for educational consideration. In each instance, hindering circumstances are likely present which function as traps for the immature person to arrest and block his progress. Fumbling, without insight, the child takes the easiest way. He stays with his familiar satisfactions, in the environment as it is. New learning does not take place without desire. As long as a child is entirely comfortable as he is, he will not move on to form habits at advanced levels. Children do, in fact, differ greatly among themselves in their attitudes toward growing up. Some of them fear to grow up, and even exert themselves actively against doing so. Some of them can verbalize their attitudes by the time 21 A. Rosanoff, A theory of personality types based mainly on psychiatric experience, Psyckol. Bull., 17, 1920, 281-299. 22 F. L. Wells, Mental regression; its conception and types, Psychiat. Bull., 9, 1916, 445-492. [365]

THE PROBLEM OP MENTAL DISORDER they are ten or twelve years old. As one boy has said: " I t is better to be a baby. You get more service."23 Ideally a scientific educational psychology would first determine by research what are the normal phenomena of immaturity. I t would then appraise the status of each child from time to time to find whether the normal course was being followed, age by age. Where unfortunate deviations were detected, educational procedures would be experimentally instituted to correct the anomaly. These would be based upon the laws of learning. The nature of the emotional trap would be investigated, and the way out would be planned and provided wherever possible. A way would be provided for the child to grow up. To grow up emotionally is to form habits at ever higher and higher levels of self-control (fortitude being the criterion of adequate adulthood). Individual Differences in Capacity. I n the preceding discussion, it has been suggested repeatedly that not all children learn with equal readiness. There is, indeed, a literally enormous range of difference among individuals in the ease with which they can learn a given process. This is true of motor skills, of intellectual feats, and of emotional management. We have stated that fortitude as a form of emotional expression must be learned for adequacy as an adult. There are great differences among children in the learning of fortitude, and these are present from the beginning of life. Constitutionally, infants differ in their emotional stability. Among the interesting early experiments to obtain quantitative statements as to individual differences among young children in this respect are those of Marston.24 Marston confronted fifty-six young children of preschool ages with situations experimentally devised to give them neglect, frustration, and difficulty. He then classified the children under five or six degrees of stability of response (which might as well be called fortitude). For instance, he supplied each one with a puzzle-box which was too difficult, allowing three minutes for effort. Each child was told he would find something desirable inside, if he could open the box. Responses ranged all the way from those of a few children who made immediate, constructive attack upon the problem, and worked at the box the whole time without complaining or calling 23 H. P. Taussig, Talks on mental hygiene to classes of grammar school children, Amer. J. Orthopsychiat., 1931, 184-192. 24 L. R. Marston, The emotions of young children, Univ. of Iowa Stud., 3,1925, no. 3. [366]

EDUCATION for help, to those of children who would not even undertake the task and fled in timidity from the box. The typical response of this group was to work at the puzzle with complaints and requests for help. Several 'breakdowns' occurred, by way of emotional explosions, blaming the failure upon the box, upon imaginary sore fingers, and so forth. Among other important findings of a test character are those of Collmann, who demonstrated the wide range of dermal galvanic response of eleven-year-old children to various kinds of exciting stimuli.25 A significant aspect of his findings deals with the relationship between intelligence and the electrical phenomena of the skin. The greatest excitability was found among children of mediocre intelligence. The feeble-minded, on the one hand, and the very bright, on the other, yielded comparatively small deflections as groups. There was, however, much overlapping among children of different degrees of intelligence in the magnitude of the skin potential. The findings of Collmann fit in well with the results of tests made on psychoneurotic soldiers during the World War. I t has been shown26 that men suffering nervous breakdown under stress of war clustered below the general run of military draft in intelligence. They were, as a group, dull but not feeble-minded. Collmann did not include among his experimental groups any group clustering between 80 and 90 I.Q. He did, however, find by further analysis of data that of the mediocre children (clustering between 90 and 110 I.Q.), those falling into the lower half of the group yielded the greatest excitability of all studied.27 This is consistent with the situation found earlier among soldiers, in that minimal stability occurs where intelligence is somewhat (but not much) below average. Collmann points out that the feeble-minded children had not sufficient associative power to derive maximal stimulation from the situations offered; while the very bright had such associative wealth that they reassured themselves automatically. The mediocre had sufficient associative capacity to be excited, but not enough to be automatically stabilized by such items as would guarantee confidence in the matter as a whole. Hollingworth 26 R. D. Collmann, Psychogalvanic reactions of normal and exceptional children, Teachers College, Columbia University, Contrib. to Educ, no. 469, 1931. 25 H. L. Hollingworth, Psychology of the Functional Neuroses, D. Appleton & Company, New York, 1920. 27 R. D. Collmann, private communication, 1933. [367]

THE PROBLEM OF MENTAL DISORDER uses the word 'scope' to designate this associative power. Apparently, there is an area of intelligence where, other things being equal, 'scope' is such as to favor instability.28 This is not to say that mental disorder is limited in occurrence to the dull and the mediocre. Incidence is probably greatest there, the world being as it is; but instability and mental disorder are found in persons of every degree of intelligence. In thinking of insanity as learned, it is therefore of primary importance to consider that children differ enormously by original nature in the readiness with which they can learn. Some learn fortitude much more easily than others do. A few cannot learn it at all. Education of the Emotions. From the point of view which we are clarifying here, it follows that the prevention or the correction of mental disorder is a problem of the education of the emotions. More especially it is a problem of education of the emotions from earliest years. I n the present stage of knowledge, procedures to this end must be regarded as experimental. This is not to say that nothing is established, that no plans can be suggested. We are supplied already with the basic and verifiable laws of learning. The next step is to make our design for behavior. Do we know what sort of conduct we wish to produce in human beings ? Presumably our design will be one for keeping people out of hospitals and under their own supervision. I t can be determined what kinds of emotional habits enable people to be and remain tolerable in adult society. There is already general agreement as to what the signs of sanity are.29 I n the first place, education might prevent people from building their own emotional traps of unrevised habit. If somehow it should be made possible to bring about that every human being would be led or forced to keep his habits up to date, one source of mental disorder would be obviated by education. Again, if children could be consistently taught to solve their emotional predicaments instead of escaping from them by the parataxes of defense into an unreal world, generalized habits of mental integrity might be formed. Such transfer of training might be effected, through instance after instance of concrete conflict thus met and solved, that it would become habitual to 28 H. L. Hollingworth, Abnormal Psychology, D. Appletou & Company, New York, 1930. 29 S. Paton, Signs of Sanity, Charles Scribner's Sons, New York, 1922. [368]

EDUCATION face emotional problems on the basis of hard fact rather than on the shifting sands of wishful thinking. A child might be so brought up that pretense would annoy rather than satisfy him. We have spoken of insight as a preventive. By this is meant that intelligent persons might learn to understand their own mechanisms of escape and to recognize their own failures of integrity. In this way self-correction would be rendered possible. Multiple activity without insight would be reduced to a minimum, thus reducing the amount of irrational behavior at present witnessed. Insight could be given by teaching what the learning process is. Such teaching is, indeed, largely what is aimed at in psychoanalysis. The person is led to recognize his own mental processes. The quarrel with psychoanalysis would merely be that it does not teach the verifiable laws of systematic psychology. In the study of psychoneurotic soldiers it was observed that "understanding' was an aid to them. Hollingworth calls this "cortical redintegration."30 Ideally and theoretically, most persons might thus learn to be sane by a complete and consistent application of educational techniques. I n practical life, however, completeness and consistency are not feasible. To secure these, human beings would have to be under the guidance of firm, impersonally interested experts, from birth to maturity, as animals in an experimental laboratory are. No one pretends that this is possible. I t is not to be supposed that the essential education can be carried on by mere verbal instruction. Children and adults may be told what to do, but they will not do it unless they can be strongly motivated. No one will move who is filled with creature-comfort where he is. To tell him that he will not be comfortable there ten years thence makes no impression, save in a few exceptional cases. Progressive development can be secured in typical cases only by making it more satisfying to move on than to remain static. To form progressive habits means quite literally to take pains. Education for the prevention of mental disorder is therefore not a paper-and-ink affair, but an affair of actual deeds that favor progress toward adequacy in the future. 30 H. L. Hollingworth, Psychology of the Functional Neuroses, D. Appleton & Company, New York, 1920. [369]

THE PROBLEM OF MENTAL DISORDER I n speaking of the adequate adult we have mentioned fortitude as an educational goal. This is not because fortitude is good in itself, but because the nature of the world demands it for an independent life. I t is 'good' for keeping people out of sanitaria and under their own supervision. Thus in aiming at mental disorder, education must aim at fortitude. This has been recognized as the primary goal of emotional training ever since the days of savagery.31 I t holds and must hold as long as man has so little control over life and death. Where fortitude has not been built up by education, nervous breakdown is imminent. An excellent example of the undisciplined person, brought into sudden and inevitable contact with the unyielding world at large, is that contained in the autobiography of a hospital patient.32 The modern experimental approach to education as a means of preventing mental disorder is seen currently in two lines: (1) in laboratories of comparative psychology, and (2) in progressive schools. Since it is not ethical to undertake the experimental production of abnormality in children, the infrahuman animals are being studied. Exhaustive references cannot be given here, but the recent works of Warden, Jenkins, and Lorge may be cited.33 Warden and Jenkins have severally shown how sexual perversions come about through the learning process. Lorge has produced eccentric and irrelevant behavior at will, in white rats, by application of the laws of learning. I n the progressive schools much attention is being given to emotional habit-formation. The attempt is to teach sane habits and to report upon character, as well as upon intellect and skill. A t present, too many of these schools lay stress on wish fulfillment, rather than upon fortitude, as the means to their goal. Is there any likelihood that, through education, mental disorder might be prevented altogether? No; for several reasons. In the first place, some infants are constitutionally so unstable that no education could build the necessary habits into them. I n the second place, the complete control of condi31 W. D. Hambly, Origins of Education among Primitive People, Macmillan & Co., Ltd., London, 1926. 32 J. Hillyer, Reluctantly Told, The Macmillan Company, New York, 1926. 33 C. J. Warden, The relative strength of the primary drives in the white rat, J. Genet. Psychol., 1932, 16-36; M. Jenkins, The effects of segregation on the sex behavior of the white rat as measured by the obstruction method, Genet. Psychol. Monog., 1928, 457-571; I. Lorge, Learning of irrelevant acts (unpublished). [370]

EDUCATION tions which the scientist can exercise in his laboratory is not feasible in society at large. Furthermore, those disorders which rest on organic bases, in the ordinary sense, such as arteriosclerosis, syphilis, and so forth, would not be prevented by education as we are speaking of it here. There will still be mental disorder, even when education shall have done its best. But it is reasonable to believe that the frequency of mental disorder might be greatly reduced if what is even now known in educational psychology could be more widely applied. I n this connection two observations may be added. With further understanding of these matters, the well-trained teacher is likely to be the person who will first recognize the child who is incapable of profiting by the normal educational routines and who will suggest the desirability of special diagnosis. Secondly, children of this type who are placed under special care may in many cases be educated, at least to the degree that they will be less unhappy themselves and less of a burden to society

[371]

SUMMARY Let us now review in a large way our scientific support as it is represented by these studies; review it to discover, first, what this support promises for our problem of the disorders, and to discover, secondly, what the defects and limitations of the support are. Consider first the articles bearing upon the nervous system and its functions. The first impression made by the neurological articles is that a recent change in the face of these sciences is little less than revolutionary, revolutionary not in the sense that the sciences supply a finished neurology (taking that term in the broad sense of all the subjects here represented) but rather in the sense that they present a point of view, an envisagement of neural functions, a grasp of fundamental problems, and a prescription for new research that indicate, in a striking way, the inadequacies and the defects of what we may now regard as the more traditional neurologies of the textbooks. The second impression is gained by a comparison of these fresh writings with the current concepts in neuropathologies, upon which the present psychiatrical theories and practices are chiefly based. This impression is that these neuropathologies reflect much more strongly the older, traditional knowledge than the newer. The first impression—that of revolutionary change—may be specifically sustained by reference to the temper of our neurological writings (I to V I I I ) . First, we have the frank opinion, gained by various lines of research upon the brain, that a great gap of ignorance yawns between psychiatry and these foundational sciences (Cobb). Secondly, we have the firm conviction of a neurophysiologist that there is still no functional account of the central nervous system which affords anything like a coherent description of central processes that has been made to match the normal (not to say the disordered!) psychological activities and functions (Bishop). This is a state of affairs long commented on by psychologists, but rarely faced by the physiologist of the nervous system. Thirdly, it is made clear that an extremely important relation obtains between both normal and [372]

THE SUPPORTING SCIENCES disordered psychological events, on the one hand, and neuromuscular states of tension and relaxation, on the other (Jacobson). Fourthly, a physiological approach to the nerve-cell enables us to see clearly that fundamental processes here are approachable by new methods which promise a command of cerebral processes of great significance to psychiatry (Cowdry). Fifthly, chemistry is now in a position to extend its methods to a description of substances and metabolic processes in the brain without which the adequate and the disturbed operations of that complicated organ cannot be understood (Page). Sixthly, a concise review of the evolutional history of nerve and muscle has given a perspective absolutely necessary to an intelligent understanding of human behavior and its defects in the disorders (Parker). Seventhly, a statement of the integrative functions— the more fixed and the more labile—has clearly revealed the fallacies and the inadequacies of older views based upon the assumption of simple reflex-like structures, combined in an additive way, to account for neural control of the organism and of behavior (Herrick). The second impression—that of the relevancy to psychiatry of all this scientific investigation—is supported by a reference to the psychiatrical points of view (Section I I ) , where new scientific help is urged in many places, and to the statement of the neuropathologist himself (Penfield). Wanting an appropriate and dependable physiology of the nervous system (and of the organism at large), it seems clear that theories of the ' seat of consciousness,' of 'local seats of function in the cortex,' and of a 'universal pathology' wherever behavior is disturbed or nonadaptive to the conditions of living are no longer adequate to the facts in hand—not adequate either to disordered states or to normal activities. The second group of articles (IX and X) supports both of these impressions. The clear statement of the part played in behavior by the factor of stock (determination through the nuclear genes), the throwing out of the old confusion between stock and familial or connate characters and defects, and an enumeration of the difficulties of inferring directly from plant and animal genetics at large to human functions and disorders (Jennings) should temper the common belief that those disorders which are not easily referable to environment are to be straightway set down as 'hereditary.' This caution is further sustained by the critical [373]

THE PROBLEM OF MENTAL DISORDER review of theories of 'pathological constitutions' which have until now been supported by a slender foundation in fact (Freeman). While the third group ( X I to X I V ) has pointed the way to a critical assessment of the part played in disorder by glandular, viral, nutritional, and pharmacal agents, the authors issue a warning against all those intemperate theories which profess to find in any one of these four factors the master-key to the main problems of psychiatry. On the positive side, they suggest many avenues of research through which the important rdles played by these agents may be determined. No part-problem stands in greater need of clarification than the establishment of a suitable—and workable—relation between psychiatry and psychology (XV to X V I I ) . Were it profitable to seek causes for the present unsatisfactory state of this relation, we should easily find them; the contentions of rival schools in both fields, lack of responsibility among psychologists for supplying a sound basis for psychiatrical application, unsound training of the psychiatrist, the confusion of speculation with scientific method, an attitude of self-sufficient priority in medicine, and a hopeless medley of psychology, clinical testing, therapy, casestudy, mental hygiene, and philosophical romancing. But causes are now less important than an intelligent attempt at cooperation. The most important part for psychology to play is clearly the part to be played by the other supporting sciences; i.e., a contribution of fact, principle, and mode of research. Scarcely less important, however, is the psychological aid to description and classification. The psychiatrist deals with disordered individuals. His primary task is to understand the individual and his deranged condition. This task has commonly involved what may be called a psychological delineation of the active organism. After a good many decades of medical history, it can hardly be said that the branch called ' psychiatry' has notably succeeded at this task. I t is no easier to describe in this way without adequate knowledge and training than it is in physiology and chemistry. There, too, medicine has not succeeded when it has made its own selection of borrowed facts or has offered its own substitute for a standard physiology or a standard chemistry. On the other side, psychology must do its part. Here no less a revolution is called for than in neurology and biochemistry. Much that psychiatry needs in all these fields [374]

THE SUPPORTING SCIENCES is still not at hand either in psychology, in psychobiology, in physiology, or in the field of pure chemistry. But the new habit of referring thence for support is rapidly augmenting the scientific resources themselves. As for the psychiatrist's account of the disorders, the issue bears mainly upon the physiological and the psychological functions of the organism and upon their control and government. The one kind of function and the one sort of control are as important for the understanding of the disorders as the other. Neither calls for a general biological, medical, or philosophical theory. Both call for factual descriptions by trained men. The demands properly to be made upon psychology touch the psychoneurotic defects and the lesser and milder disorders quite as much as they touch the major psychoses. Besides the general field of experimentation, they will make heavy drafts also upon social, ethnic, and animal (especially primate) psychologies; and it begins to appear that the sociologist and the cultural anthropologist as well ( X V I I I and X I X ) will presently be in a position to contribute both facts and principles of great importance. The ultimate reason why social psychology, sociology, and anthropology now assume important roles is that disorder directly touches the socialized individual. Campbell, Meyer, Bentley, and others have emphasized the fact that the student of the disorders is not simply dealing with an organism, where "organism' means merely the living body. At least half of the objects surveyed and valued by man are social', i.e., they are self, others, social groups, communal occupations, social criticisms, judgments, and aspirations. Precisely herein does disorder lodge. The object of study then is socialized man; and man becomes and remains socialized only by exercise of his psychological functions—not his physiological functions, which preserve the integrity of the body. I t is primarily the insistence upon this difference between bodily disease and psychological disorder that the ambiguous and uncritical terms 'person' and 'personality' are designed, by some psychiatrists, to express. Finally (XX), it clearly appears that education may, through its intimate association with the child and the youth, detect and describe many early delinquencies and obliquities in the young, which will lead inevitably—unless checked in school and in society—to a great variety of disorders in the adolescent and [375]

THE PROBLEM OF MENTAL DISORDER in the adult. How many disorders and how many disordered persons were first misdirected by bad conduct and misgovernment in childhood, no one knows; but certainly so many have been that the very best methods and the soundest principles of development which the sciences can command should be brought into requisition for the discovery of these early origins of disorder and derangement.

[376]

SECTION IV COMMENTS AND REFLECTIONS Our limited survey of the problem of the disorders has tended to show that this problem is urgent. Adequate understanding of the disorders and adequate therapy are both wanting. The survey has also confirmed the general conviction that, while the problem is very complex, it may readily be resolved into many part-problems. While these part-problems all call for consideration and for solution, this study has suggested that some of them are primary and that their solution promises to advance the solution of others. We have accordingly first set forth, from various points of view, the main business of the psychiatrist; for no complicated subject can be intelligently approached without a clear statement of its character and locus. All of these presentations tend to emphasize the medical aspect, not only with respect to treatment and relief but also with respect to the concept of disease, which commonly implies a pathological state of bodily tissue. Some writers, to be sure, speak of really mental pathologies, and some stand for mental causes of certain (called 'pathogenic') diseases. With the exception of the psychoanalytic point of view, all stress lesions in the central nervous system. The field of the disorders laid out, the sciences of life have been asked to suggest what each is in a position to contribute by way of research. Taken all together the scientific materials at hand considerably exceed the actual use thus far made of them in psychiatry. There naturally arises the question of ways and means of enriching our central field of the disorders from these foundational sources. I t is probable that advance is to be made here by an approach from both directions; i.e., by encouraging the most promising researches, on the one hand, and by increasing, on the other, the demand for scientific products within psychiatry itself. Here increase in production without a correlative extension of use would lead to nothing more practical than a dead storage [377]

THE PROBLEM OF MENTAL DISORDER of knowledge. Without question the more difficult side of this problem is the psychiatrical side. That involves in many quarters both a shift in outlook, which would compel men to value facts above doctrines and new insight above tradition, and also a correction in education and training which would enhance the desire for fresh knowledge. This is a task to which some psychiatrists are now devoting themselves, whether by advocating changes in psychiatrical education or by emphasizing the need for a closer alliance with fundamental knowledge. While the task is to be referred in part to psychiatry itself and to its organizations, we must not lose sight of the great accomplishments of that profession in other directions; for example, in attempting maintenance and care well beyond the actual provisions made by public and private grants, in ministering to an incredibly great number of patients, and in solving difficult problems of administration and operation. In a period of criticism which is zealous to improve and to reform, it is important that due credit should be given to the existing means and agencies. On the side of scientific support, it is not likely that any single individual or single association would be able to assess all claims or to maintain a just perspective in all the subjects. I t may be possible, however, to formulate two or three general measures of support and advance, as indicated by our scientific writers. Let us observe, first, that the disorders, more than any other aspect of life, impress us with our scanty knowledge of the normal, natural, and adequate processes and performances of human living. The first cause of our defective understanding of disorder rests in this scanty knowledge of the normal functions, both physiological and psychological. We demand theories and doctrines where we lack fundamental facts, and even when these facts appear, inertia and tradition—firmly built into our professions and our institutions—keep us in the old ways. Nevertheless, informed readers of the preceding section will agree that the last years have so enriched our understanding of the normal processes of life that the study of the abnormal may now profit in a new way by this rapidly increasing knowledge of the organism and of its physiological and psychological modes of operation and means of government. [378]

COMMENTS AND REFLECTIONS Accurate knowledge of cerebral physiology is still woefully inadequate. I t now definitely appears that no doctrine of bundled reflexes, of parallel and intertwined conducting systems, and of local seats for sensation, association, attention, learning, and intelligence can be depended upon to describe the central neural processes. At last we are ready to admit that we know practically nothing of the fundamental bodily processes which initiate and sustain perceiving, remembering, desiring, acting, resolving, fearing, understanding, observing, and thinking. Until we know the essential modus operandi in each of these and many other normal performances, it is neither impressive nor satisfying to assert that doubtless brain changes of 'a pathological character' underlie the delusions of the paranoid, the stupid remoteness of the hebephrenic, the wild excitement of the maniac, and the self-accusations voiced in dementia praecox. Certainly nothing is more to the point, then, than to encourage anyone, whether chemist, cytologist, psychologist, comparative neurologist, or physiologist, who is on the track of this fundamental knowledge. I t is to be observed that a very large part of the researches in the last section bear upon this very problem. If we are to keep an open mind toward all new discoveries here, we must not prejudice the hearing of the new facts by insisting that they sustain some cherished theory, as that old conflicts are harbored in the unconscious or that the reclusiveness of the schizophrenic and the anxiety of the neurotic 'must be' based upon a brain disease. Nor need we slip into Bishop's non sequitur that the absence of pathological lesion argues for a belief in 'purely mental' causes. Another advantage of the scientific anchorage of psychiatry is to free the subject from various vices and virtues of the times. The recent swing from intellectualism toward the affective and the nonrational in life has fortunately directed attention toward the subcortical structures, the viscera, the glands, and the autonomic system. But it also tends toward extravagance, supporting such things as instinctual forces, mysterious drives, and unconscious mechanisms. Intellect and raw feeling are only abstractions, the one no more than the other representing the concrete business of living and behaving. I t seems likely that a better balance within these views will issue from a broad and unprejudiced examination of the entire central nervous [379]

THE PROBLEM OF MENTAL DISORDER system as it is functionally integrated with all the other great systems of the body. Another and related tendency which will repay critical scrutiny is the popular tendency to extol wholes and totalities. This is a useful reaction against the method of analysis into final and atomic units, traditional in physics and chemistry and carried over into anatomy, physiology, and psychology. The cell, the reflex function, and the sensation are products, in these three fields, of this lust for analysis. Now the pendulum returns. Synthesis, integration, organismal wholes, Gestalt, total organism, entire personality, and the like, are new and modish terms. The correction has again been wholesome. But again we stand at a critical turn ready to strike a balance in the descriptive sciences. We now begin to see—and to see for psychiatry as well as for the supporting sciences—that 'total organism' may be an exaggeration for 'organism-at-large,' 'Gestalt' only one aspect of functional products, and 'personality' only a gross shorthand term to refer to the functions and functional issues of the socialized organism. There are few places where a proper balance, initiated from the sciences of life, between whole and part, text and context, the integer and the integrated, will be more serviceable than in the tangled network of the disorders. The hopeful sum of these comments is that the relevant sciences stand at the present moment in a position to contribute much, by way of new facts, exact principles, and seasoned methods, to the understanding and the relief of the disorders. Beyond our own materials and beyond our own primary objects lie many part-problems calling for solution and calling for adequate support. To mention again some of the most urgent of these will suffice for the present context. The first is the creation of a method of inventory for all classes of disorder. This will demand a satisfactory working classification or catalogue raisonne of kinds and types and a mode of censustaking for hospitalized and ambulatory incidence. Such a census might well include topographical, ethnographical, dietary, social, and economic factors, which should throw light upon inciting causes and conditions and upon exacerbating and relieving circumstances. A companion study would bear upon the comparative value of our existing systems of care and treatment; upon all forms of housing, doctoring, medication, special [380]

COMMENTS AND REFLECTIONS therapies, and cultish cures. Without such a study the contention of schools, parties, and doctrines bids fair to go on indefinitely. The present trial by argument and advertising is both primitive and wasteful. No studies of the sort here indicated could hope to approach a solution of our general problem did they not also make a determined search for the untoward conditions, physical, physiological, psychological, social, and economic, which breed and multiply the disorders. Here cure is only palliative. The only real solution will be preventive and prophylactic. Whether men can and will discover and practice a cultural mode and an art of living in which the psychological disorders will be brought under effective control remains to be seen. Our time and our temper seem appropriate for a saner and wiser attack upon this great human problem than has yet been made.

[381]

I N D E X

Acid-base equilibrium, 101, 150/. Acting, 283, 379 Action-potential, 99, 128, 141/., 303 Adaptative mechanisms, 20 Adrian, 116, 146 Alcoholism, 26 Alexander, 89, 299 American Psychiatric Association, 93 Anatomy, comparative, 207 Anger, 317 Anthropology, 2, 27, 44, 94, 109, 375 cultural, 346 Apes, 108, 329 Arteriosclerosis, 267 Association, free, 76/., 298/. verbal, 298/., 312 Asthenic, 105, 227 Astrocytes, 181 Athletic, 105, 227 Autonomic, 303 Axis cylinder, 106 B Behavior, labile, 213 patterns, 103 rigid, 213 sexual, 14 Bensley, 151 Bentley, 107, 275, 375 Biochemistry, 23, 27, 94, 310, 374 Biography, 74, 76 Biological energies, 284 Biology, 104 Bishop, 98, 120, 372, 379 Blasthophoria, 36 Body-build, 106 Body-mind, 280 Body-mind-soul, 280

Bonding powers, 284 Borna disease, 247 Bound water, 165

Calcium, 258/. metabolism, 157 Campbell, 9, 14, 91, 94, 375 Cannon, 116 Carbohydrates, 169 Carlson, 106, 238 Carotene, 169 Castration, 85 Catalepsy, 271 Cellular oxidation, 101 Cerebral anatomy, 97, 111 Cerebral chemistry, 106 Cerebral circulation, 117/. Cerebral histology, 113 Cerebrosides, 166 Cerebrospinal, 44 Cerebrospinal fluid, 23, 97, 118 Chambers, 151 Charcot, 39 Chemical, 17, 19, 21 Chemistry, 97, 101, 118, 162, 379 Chemotherapy, 253/. Chen, 107, 266 Childishness, 364 Chimpanzees, 108, 331-335 Cholesterol, 166 Chromosomes, 104 Cobb, 97, 111, 372 Coghill, 203/., 215 Colloidal dispersion, 101, 148 Compensation, 360 Comprehending, 283 Conditioning, 19, 24, 97, 115, 206 Conflict, 93, 368 Conklin, 279

[383]

THE PROBLEM OP MENTAL DISORDER Constitution, 24, 72, 83, 97, 104/., 108, 225, 227, 233, 294, 374 Cowdry, 100, 146, 373 Crozier, 310 Cultural, 97 Culture and mental disease, 340/. Cyclothymia, 135, 234 Cytologist, 379 D Dallenbach, 311 Davis, 116 Delusions, 341/. Dementia praecox, 30, 135 Development, 110 Diagnosis, 30/. Diet, 102 Dietary deficiency, 106, 258/. Disorder and disease, 281, 375 Dispositions, innate, 284 Dissociation, 318 Dreams, 296/. Dream-symbolism, 296 Drives, 284 Drug-addiction, 268 Drugs, 293 Dynamic equilibrium, 104

E Ebbinghaus, 298 Education, 97, 109/., 354, 375 medical, 5 psychiatrical, 6, 61 Effectors, 184 Ego, 86/. Elaborative thinking, 283 Elation, 272 Electrical, 99, 133 Electrical impulse, 143 Electrical measurement, 99 Electrical potential, 128, 148, 302 Electrical responses, 130 Electrocardiograph, 301 Electromyogram, 142/. Electrophysiology, 98, 120 Emotion, 10, 15, 21, 41, 47, 77/., 93, 110, 294, 299, 303, 312, 336, 363,

Emoving, 283 Encephalitis, 106, 156, 241, 248/. Endocrines, 97, 105, 116, 240 Endocrinology, 2, 105, 232, 234, 294, 302, 307 Endocrinopathies, 236 Energy-charge, 84 Environment, 35, 219/. Enzymes, 102, 171, 218 Epilepsy, 26, 36, 181, 267, 294, 328 Ergasia, 11, 55 Erlanger, 146 Escape, 359/. Excitement, 133 Expressive methods, 302

Fantasy, 78 Fatigue, 133 Fearing, 379 Feeble-mindedness, 36/., 219, 367 Fisher, 279 Forbes, 116, 140 Fortune, 349 Franz, 113 Freeman, 105, 147, 152, 227, 374 Freud, 40, 276, 319, 350/., 355 Functional, 1, 25, 32/., 40, 97, 111, 113/., 323 Functional neuroses, 316 Functional psychoses, 234 G

Galvanometer, 140, 301 General biology, 216 Genes, 104, 216, 284 Genetics, 2, 46, 104, 216, 352, 373 Gerard, 192 Gersh, 149 Gesell, 312 Gestalt, 114 Glycerides, 166 Goodpasture, 106, 241 Government, 375 extraorganic, 285 historical, 287 organic, 286 [384]

INDEX H Habit, 361 Habituation, 297/. Hallucination, 22, 81, 109, 343/., 361 Head, 211 Hebephrenic, 294 Hereditary, 97, 104 Heredity, 35, 46, 231, 316, 373 Herpes simplex, 242/. Herrick, 103, 197, 373 History, biographical, 287 biological, 287 Holergasia, 11 Hollingworth, 110, 354 Homeostasis, 97, 116 Hormone, 21, 218, 238, 240 Hoskins, 105, 234, 308 Hull, 297 Humoral agents, 97 Hypertension, 137 Hypnosis, 26, 296/., 318 Hypnotics, 269/., 293 Hypothyroidism, 239 Hysteria, 108, 315/.

Id, 86/. Imagining, 283 Immunity, 253 Infantile sexuality, 307 Inferiority complex, 15, 234, 307 Inhibition, 115 Inorganic salts, 164 Insanity, 8, 14, 92, 161, 332, 368 Inspecting, 283 Instincts, 47, 284, 294 Instinctual, 74, 86/., 379 Integration, 380 cerebral, 104 psychological, 17 Irritability, 133

Jackson, Hughlings, 182 Jacobson, 99, 133, 286, 301, 373 Janet, 319, 355

Jastrow, 108, 314 Jenkins, 311 Jennings, 35, 56, 104, 216, 373 Jung, 298 K Kakergasia, 11 Keilin, 151 Kraepelin, 30, 134, 290/. Kretschmer, 32, 105, 229, 235 Kroeber, 109, 121, 346 Kubie, 12, 71, 91, 93

Lashley, 113, 202 Learning, 110, 297/., 357/. Libido, 34 Lipids, 102, 166 Localization, 114/., 131, 211 Luria, 312 M

McCollum, 259 MacCurdy, 279 McDougall, 279 Magic, 109, 346 Malinowski, 350 Manic-depressive, 30, 135, 143, 157, 229, 231, 271, 294, 316 Mechanism, 91 associative, 114 neural, 97 psychic, 13, 82/., 85 Medical sciences, 94 Melancholia, 234 Memory, 297/. Mental activity, 122/. Mental hygiene, 5, 69, 374 Metabolism, 20, 101, 162 chemical, 102 Meyer, 11, 51, 91, 93, 215, 355, 375 Microvoltage, 143/. Mineral constituents, 101, 153 Minot, 35, 106, 255 Muller, 218 [385]

T H E PROBLEM OP M E N T A L DISORDER Paranoid trends, 344 Parathyroids, 239 Parergasia, 11 N Paresis, 28, 120, 266/. Narcotics, 173 Parker, 103, 184, 205, 373 Nerve impulse, 97, 128 Partial pattern, 204 Nerve-net, 185/. Pathergasia, 11 Nervous organs, vertebrate, 189/. Pathogenesis, 106, 241 Nervous system, origin of, 184 Pathology, 97 Neural disorder, 103, 197 Pavlov, 24, 40, 45, 80, 115, 123, 211, Neural impulse, 303 332 Neural integration, 103, 197, 204 Pellagra, 29, 112, 261 Penfield, 102, 178, 373 Neurasthenia, 108, 133, 315/., 320/. Perceiving, 283, 379 Neuro-anatomy, 207 Person, 11, 54, 62 Neurobiotaxis, 190 Neurocytology, 100, 146 Personality, 9, 13, 16/., 24, 30, 43, 55, Neurocytotropic, 106, 241 63 92/., 106, 110, 232, 292, 294, Neurohumoral, 103 312, 318, 375 Pharmacal, 105/., 374 Neurohumoralism, 193/. Pharmacal agents, 97 Neurologist, 2, 39, 41 Pharmacodynamic, 232 Neurology, comparative, 379 Pharmacology, 23, 107, 266, 302 Neuromuscular, 373 Pharmacopsychology, 292 Neuromuscular mechanisms, 303 Phosphatides, 166 Neuromuscular patterns, 286 Physiology, 17, 27 Neurone, types of, 187/. Neuropathology, 102, 106, 178, 373 cerebral, 379 Neurophysiology, 98, 120, 123, 125 comparative, 200 Neuropil, 209 Pierquin de Gembloux, 332 Neurosurgeon, 178 Piper, 140 Nitrogen compounds, 170/. Plethysmograph, 301 Noble, 5 Pneumograph, 301 Nosology, 24 Policard, 154 Nutrition, 18, 97, 255, 374 Poliomyelitis, 106, 156, 241, 247 Potentials, 99 o in muscle, 100 Observing, 379 Primates, 97, 108, 308, 327 Oedipus, 85 Primitive search, 283 Oligergasia, 11 Projection, 360 Oligodendroglia, 181 Proteins, 101, 149 Organic, 33, 40, 97, 113/. Psyche, 86 Organicist, 2, 41 Psychiatrical education, 378 Organismal, 12, 282, 380 Psychiatry, 96, 374 Organism-at-large, 380 clinical, 7, 14 Oscillograph, 127, 212, 301 medical, 7, 28 Oxidation, 102, 151, 174 neurological, 2, 7 orthodox, 74, 92 psychoanalytical, 7, 82 Page, 101, 162, 259, 373 psychobiological, 7 Paralysis agitans, 111, 268 psychological, 2 [386] Myers, 276 Myerson, 9, 28, 91, 93, 215, 279

INDEX Psychic causes, 93 Psychic determination, 71 Psychic trauma, 319 Psychoanalysis, 45, 71, 89, 92, 107, 122, 276, 294, 316, 377 Psychoanalyst, 71, 87, 91 Psychoanalytic Society, 88 Psychoanalytical, 2, 12, 104 Psychobiological, 11, 51, 66, 92, 282, 327 Psychochemistry, 233 Psychogenic, 283, 320, 377 Psychological, 44/., 94, 373, 379 Psychological functions, 107, 307, 375 Psychological government, 284 Psychological instruction, 304jf. Psychological study of children, 307 Psychological tasks, 304Jf. Psychology, 2, 27, 50, 60, 68, 97/., 107, 213, 275, 374/. clinical, 108, 314 experimental, 275$'. genetic, 277 social, 277, 375 Psychoneuroses, 8, 14, 40, 72, 97, 108, 143, 314 Psychoneurotic, 4, 367 Psychopathology, 10, 15, 39, 43, 92, 108, 327jf. Psychoses, 14, 40, 97 drug, 273 major, 269/., 375 minor, 268 organic, 26, 234 Psychosexual, 83 Psychotherapy, 92 Psychotic symptoms, 109, 339 Purpose, 284 Pursuitmeter, 313 Pyknic, 105, 227

Remembering, 283, 379 Repression, 75 Resolving, 379 Rivers, 242

Schizophrenia, 30, 153, 234, 236, 269, 308/., 316, 379 Schizophrenic, 26, 31, 105, 229, 231 Scott, 154 Self-object, 288 socialized, 285 Senile dementia, 156 Sexual perversion, 370 Shakow, 308 Sherman, 109, 264, 339 Sherrington, 116, 146 Sleep, 296/. Social, 42, 48, 94, 109, 122, 307 Social backgrounds, 339 Social response, 337 Social science, 109 Socialization, 294 Socialized objects, 285 Sociological, 25, 44, 278 Sociology, 2, 27, 38, 67, 375 Sodium amytal, 269 Somatic, 25 Somatist, 41 Soul, 43 Sphygmograph, 301 Stimulus-word, 304 Study of individual subjects, 306/. Superego, 86Jf. Supporting sciences, 96jf., 110 Sympathetic, 116 Sympathicotonic, 232 Symptomatology, 25 Synaptic, 191

R Rabies, 106, 156, 241, 247 Racial, 97 Receptor, 99 Regression, 365 Relaxation, 136jf., 301, 373 Relaxation-time, 143

Temperament, 108, 316 neurotic, 326 Tension, 100, 135, 140, 301, 373 Tests, mental, 300 Theiler, 246 Thinking, 379 [387]

T H E PROBLEM OF M E N T A L DISORDER Thorndike, 355 Thudichum, 162 Thymolymphatic, 235 Thyroid, 21, 112, 232, 237 Tonus, 140, 301 Total pattern, 204 Training, psychiatrical, 87Jf. Trance, 318 Twins, 217, 234 U Unconscious, 13, 73, 77, 91, 281 Unconscious forces, 284 Unconscious mechanisms, 379 Understanding, 379

V Vagotonic, 232 Vegetative, 44, 106, 238 Virus, 97, 105, 241, 374 Vitamins, 102, 106, 168/., 259-263 W Wagner-Jauregg, 29 Water balance, 101, 150 Wechsler, 10, 39, 91, 93 Wertham, 235 Wever, 116

Yellow fever, 246 Yerkes, 108, 308, 327

[388]