Recent progress in psychiatry

RECENT PRQGRESS

IN

PSYCHIATRY

By A.

AUSTRIXZESILO,

M.D.

Professor Emeritus of the University of Brazil, Presiden1 of the National Academy of Medicine, Rio de

Janeiro,

Br-axil

Among the many specialized disciplines making up the science of medicine, neuropsychiatry, because of the knowledge accumulated during recent years, occu-

pies

an important place. Psychiatry has apparently taken the lead because of the human understanding of its progress. In days gone by, mental pathology was on the same leve1 as clinical medicine generally, as it followed the same paths as the diseases of the body. One fact should, however, separate it from the other specialized subjects. The spirit of man is quite different from that of animals, and man% social interests make mental pathology follow paths quite different from other human nosology. We must begin by accepting a difference between Mental Hygiene and Psychical Therapeutics.

Before establishing the difference between these two branches, the psycho- somatic concepts dominating neuropsychiatry at present should be explained. Acting in the conventional dualism psychiatrists used to separate the spirit from the body more because of traditional ideas than through clinical or practica1 vision. Specialists restricted themselves to the nosography of mental diseases and they concerned themselves more with psychology than with the whole of human pathology.

Doctrinaires llave invariably agreed that medicine must take care of the whole human body. Yet when they studied individual diseases they would draw bound- aries and division lines between the various nosological branches. Fortunately such fundamentalists as De Giovanni, Benecke, Sigaud, Lombroso, Pende, Kret- schmer, Brauer, Viola, Quatrefages, Cormann, Rocha Vaz, Berardinelli and others established the relation between the body and the spirit to reach the philosophical and clinical concept of the psychosoma.

Edward Weiss in a comprehensive study “The Psychosomatic point of view in the practice of medicine” drew standards for the introduction of this guiding method in clinical medicine. Psychosomatic medicine is supremely unitarian. Spinoza% conception of universal pantheism may be applied to psychosomatic medicine, because the separation of the body and soul is simply conventional and obsolete. The unity of the living organism lies in the unity of its functions. Both the clinicians and the physiologists must comprehend vital harmony as a whole. Biotic unity is the undeniable principie which should guide medical reasoning.

Diagnostic problems of psychosomatic medicine are based above al1 on the separation of that which is organic and that which is functional. Clinical judg- ment supplemented by symptomatological tests constitutes the basis for the understanding of psychosomatic medicine. It is not always easy to separate the two. What is apparently simply functional may have organic roots, or vice-versa, what looks organic, might often be merely functional. A discerningclinical judg- ment applied to the symptomatology present may unravel the tangles. Physi- cians with large clienteles are apt to arrive at this discernment. As emphasized by Weiss and English the role of emotional problems in organic affections, in psychopathological conditions, in environmental influente on children, and the role of anxiety, obsessive or not, bring about many difficulties in the solution of clinical organo-neurotic problems. Both the mind and the organs show morbid manifestations which may be discovered and understood by an expericnced physi-

cian, even when already adapted to the reactions of the organs or systems of the body. Dunbar’s intuitive clinical research in the United States and Halliday’s in England, stressed the cure of disease rather than its knowledge. Man is not a mere physiological organism, guided by sheer instinct. In him there are im- portant psychological factors derived from his gregarious enviromnent and from civilization in which commotions, passions,mystical, political, patriotic and social struggles founded on egotism and the facts of life, remove him from common anatomophysiological conditions and make him a slave of the psychosoms, which is the human unit.

In the writer’s book on “Mental Analysis,” based on the bio-physiological and bio-pathological trinomial, Fumes, Libido, Ego, as symbols of nutrition, repro- duction and consciente, the unity of the psychosoma as indispensable to clinical understanding is affirmed. Starting with the principie that the basic act of life is nutrition conditioned by changes in environment, and reproduction is its corol- Iary; that improvement either through evolution or mutation brought about the most perfect species on earth, man, and as a result, the ego; it is asserted that al1 somatic or psychical pathology originates in changes in these three biotic human forces or principies n&ich make up the psychosoma. Any morbid manifestation affects the psychosoma, according to science and the best contemporary philo- sophical doctrine.

In brief, the body and the mind make a physio-pathological unit. The clinician should always keep in mind that organic diseases have psychical roots, as organic elements are often found in functional troubles. Wise physicians and symptoma- tologists, well armed with the latest knowledge, should understand thoroughly that it is better to cure the sick than systematiae the diseases.

Electro-encephalography.-In spite of the fact that this subject does not quite belong to Psychiatry, some referente should be made to the new diagnostic method which through Lennox’ teachings is beginning to be used in neuro-psychiatric practice. The operation of the electro-encephalograph is easy and requires only experience on the part of the person handling it. The graphic records show the rhythm or lack of rhythm in the patient and permit the diagnosis of epilepsy in the hidden, latent, or apparent stages. It also helps in prognosis and it may be applied to various illnesses such as schizophrenia, mar&-depressive psychosis and others. The infallibility of the method cannot be vouched for as yet, but it can be stated that neuro-psychiatric symptomatology has taken great strides forward with this new weapon. Berger who devoted much time to the matter demon- strated the existence of two kinds of brain waves, Alpha and Beta. At present observers concede the presente of another wave, Gamma and also Delta, which may be observed while the patient is asleep or under narcosis. Electro-encepha- lographical work by Ameritan physicians has brought out previously entirely un- known facts. These observations were made in persons apparently normal, pa- tients suffering from mental and nervous disturbances, and in soldiers, sailors and officers who had been injured physically or mentally in the war. In many cases electro-encephalography demonstrated a sometimes healthy and sometimes dis- turbed encephalic rhythm. Electro-encephalographyrecords the electric currents which cross the cerebral cortex, the rhythm of the currents through their uni- formity, retardation or acceleration serving therefore as a relative indicator in cases of excitement, of regular function or varied abnormalities of the cortical functions. The best indications and practica1 results are in epilepsy. The method is already used to some extent in Argentina and Brasil.

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PAN AMERICAN SANITARY BUREAU [December romantic, doctrinary and philosophical period is over. Present science leads to efficient and not merely speculative pragmatism. Years ago mental hygiene aimed at adopting the classical rules given in psychiatric text-books, namely, to prevent hereditary infectious factors and others, the so-called exogenous causes of mental disturbances. It is quite diñerent today. The principal idea is to fit the man to his environment, taking into account individual and public interests in order that his personal qualities may be useful to the social or human group. In Brazil the efforts of Professors Henrique Roxo, Adauto Botelho, Heitor Carrilho, Pernambuco, in Rio de Janeiro, and Pacheco e Silva and coworkers in Sáo Paulo, have done much towards developinp mental hygiene. Unfortunately the prob- lems cannot be solved by a few men alone, but demand general thought on the part of the governments and peoples. At present the only people who may effi- ciently face the solution of the problem are the North Americans.

There are various points to be taken into consideration, and among them are pedagogic principies, the specifically human family attitudes; the attitude of the people towards social principies; the ideas on psycho-pathological inheritance. Al1 these points merit detailed explanations.

Mental hygiene is a very serious administrative subject. It does not include merely psyohiatric problems. It is fundamentally social, according to the present extent of knowledge, or rather one of securing the optimum efficiency of man in the environment where he lives and works.

PSYCHIATRY

1095

develop shynèss, malingering, hypocrisy, daydreaming, habitual lying, trickerp or even misdemeanors covered by the criminal codes.

The psychotechnique much in vogue in the United States and so favored by professor Emilio Mira, is an undeniably proper measure in Child education and at the same time means a great step forward in mental hygiene. Its basis lies in applying proper methods to the study of social problems. Modern psychiatry finds its most beautiful conceptions in this field.

Man% social function is his most important and worthy purpose, which may only be secured on a basis of perfect educational training in its pragmatic sense, that is, efficient, useful, productive, social, patriotic and humane education in the strongest sense of the Word. A precise and productive apprenticeship; the essen- tial study of technique; the formation of persons of balanced minds, who will cooperate with their environment and with humanity; an exact understanding of that which is useful and indispensable to professional knowledge; due use of natural talents; a social and human sense of cooperation; the distribution of mental and professional work in accordance with the individual’s psychosomatic conditions; rest, social interchange, amusements which produce true psycho- somatic pleasure; a complete understanding of duty; and Cnally everything that may make an intelligent and useful machine for the family, country and humanity.

The modern psychiatrist must be a psychologist before being a clinician. Mental hygiene should always precede the clinical work, as prophylaxis should come before pathology. Unfortunately mankind is not ready for the therapeutic axiom that prevention is better than cure.

Recent Progress in Psychiatry.-The classical mental pathology was based on a nosographic description of neuro-psychic diseases. It was made of what special- ists were able to observe and reason out. The French school with Pinel, Esquirol, Morel, Delasieauve, Magnan and others built the classical structure of psychiatry, which was continued and completed by Germans, such as Schuele, Griesinger, Kraft-Ebbing and especially Krapelin, mho introduced something new into the nosology of mental pathology. The psychological concept of present psychiatric knowledge is undoubtedly the contribution of Breuler and Kretschmer.

The idea of the constitution, the temperament and the character, while not being new, served to bring together many scattered ideas of mental pathology and subordinate them to elements more useful for the prevention and treatment of mental disease (Adolph Meyer, Nolan P. Lewis, Samuel Jellife, the Menninger brothers). In a recent paper Professor E. Mouchet, of Buenos Aires, stressed the latest advances in psychiatry. In my opinion the best progress lies in placing the present conception of the insane or lunatic on more rational and solid psychologi- cal bases. Unfortunately practically the whole subject of medicine was derived from clinical empirism. Psychiatry could not be an exception to the general rule. Al1 contemporary advances in mental pathology have been made by secular obser- vations, until some cIever or perceptive individual brings the clinical novelty into therapeutics.

Among recent advances in the therapeutic field first place belongs to Freud’s psychoanalysis, through his study of the subconscious, also called the deep or abysmal analysis. In our opinion, the value of the method lies in disclosing to psychology the precocious development of sexual life in childhood and of dis- carding the old ideas as to the important r8le psychopathic heredity plays in the origin of many mental diseases. As a fact, many mental disturbances are due to mistakes in pedagogic education, social inadaptation, neglected individual temperament, rather than to the genetic factor.

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PAN AMERICAN SANITARY BUREAU [December that usually epilepsy is not inherited but acquired. Many cases of epilepsy in children are due to neuro-virus diseases contracted in childhood, even though in many cases observed by Lennox, electro-encephalographic dysrhythmias were not aecompanied by the seizures which generally constitute the most evident clinical symptoms of epilepsy.

The trouble with psychoanalysis is in its creator’s exclusiveness. Deep analy- sis of the subconscious does not always bring about clinical cure. The objections dealt with Freud’s inflexibility. Stekel, Adler, Young, Jellife, Brill and the author disagreed with Freud because they considered his ideas clinically unsound. For a while psychoanalysis was in its mystic phase, and to disagree with Freud was a sacrilege. Fortunately clinical truth moved slowly to a point at which mental analysis has dealt, as the case may be, with the subconscious, the conscious, the condition of the individual, whether social, affective or mixed and eomplex. Contemporary psychotherapy must be based on mental analysis to find out emotional or functional causes of psychic pathology in order to eliminate them from the patient’s mind. Questioning must be patient and thorough in order to be beneficial. Mere affirmative answers are Worth little when there are causes for moral suffering. Psychotherapy often gives good results in psychoneuroses and in some psychotic conditions. The alienist knows that each demanda differ- ent clinical treatment according to psychic manifestations. The treatment of obsessions, which appear as phobias, anxiety, or complexes, are tedious jobs for psychotherapy. Sometimes mental analysis finds or reveals the road to Damas- tus, and sometimes it does not. It is not unusual to discover that obsessive neurosis, miscalled psychasthenia, constitutes the clinical expression of manic- depressive psychosis in its melancholic form, or of schizophrenia in its early or frustrate forms or schizophrenic reactions, or a manifestation or equivalent of epilepsy, that the clinical history or electro-encephalography may disclose. It is therefore readily seen that psychotherapy cannot be uniform in every case.

Mental analysis, an expression used by the writer instead of psychoanalysis, is at present based on more logical and precise data, from the study of the psycho- soma up to a more accurate knowledge of the constitution, the temperament, and the character which also revea1 the functional morbid factors in the patient.

Rational and Emplrical Therapeutics of Mental Diseases.-The historical phase of the problem will be laid aside to take up the subject matter itself. Ma- larial therapy in cerebral parenchymatous syphilis, and especially general paraly- sis of the insane must be mentioned. Even though it is no novelty, it may be stated that Wagner von Jauregg’s discovery is one of the most sensational con- quests in psychiatry. In fact, those who work with the mentally ill or manage public or private asylums for the insane are obliged to pay special homage to t,he Viennese physician, because of the clinical cures secured through the use of malaria1 therapy. Although it is not free from danger, 1 may state from my own personal observations that malaria1 therapy is far better than al1 the bio-therapic methods used in mental medicine. This must be well known by al1 psychiatrists as the method has long been used in their specialty.

19.44

achizophrenia became known to the effect that dementia is neither the initial nor the terminal factor. According to his psychological conception, the main features of schizophrenia are found in the cleavage of the personality of the patient who withdraws from the outer world into himself, to create a state of autism, or psychological self-centering. According to Kretschmer’s classification, such pa- tients are former schizothymics mho with comparative facility may fall into schizoidism and show schizophrenic reactions aecording to endogenic or exterior excitants until reaching true schizophrenia withall its pathological characteristics. The individuals become asyntonic, true introverts, because they are interested almost exclusively in the inner world. In these psychological conditions they be- come ambivalents or ambitendents and are dominated by a hesitation in thought, sentiment or action. Autism, ambivalente and asyntony separate men from the emotional trials and interests which characterize the human species, especially during puberty, adolescente, and youth and the pre-maturity state in general. Self-centering, asyntony, ambivalente, emotional deviation, as a rule paradoxieal, make the scbizothymic or even the schizoid become schizophrenic. This rarely occurs with rapidity. The process develops slowly, in preparatory stages, being noticed by the family or teachers, who first remark the changed attitude toward the individual% social environment.

On the proper psychic symptomatology, through polydiiensional diagnosis, the clinician bases his diagnosis of sehizoidism, true schizophrenia or true schi- zophrenic reactions. Modern methods of clinical cure are advisable although their results are still accepted with reserve by experienced psyohiatrists.

Through experience in private practice, especially in the Botafogo Sanitarium during two decades, the author may say that in the case of schizoidism and schizo-, phrenic reactions the curative (clinical) results are incontestable. In cor&rmed cases of schizophrenia, improvement is at times a fact, though regressions usually develop.

Shock cure methods shall now be analyzed. It can be stated that never before was any other therapeutic method so rapidly spread in psychiatry. Kraepelin’s dementia praecox and Bleuler’s schizophrenia, considered as incurable diseases, were attacked with these new curative processes. Everywhere in the world the neuro-psychiatric centers tried long and widely various kinds, both chemical and physical shocks. Their use was extended to various mental and nervous func- tional disturbances, especially depressive, obsessive or confused conditions. Very soon many cases were cured at least temporarily, some incompletely. The enthusiasm resembled that shown in the case of sulfa drugs and penicillin. Let us take a closer view of the methods and processes.

Sakel’s method.-This method had its inception in clinical empirism. The Viennese author, through actual experience, tried to relieve his patients, and especially anxiety and depression cases, by means of insulin. He had noticed that when an exgss of medication caused a comatose condition, patients would

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PAN AMlZRICAN SANITARY BUREAU [Decembor fits reaulting from Sakel’s method which may only be summarized here aa each ease demands individual treatment, taking into consideration age and organic condition especially in the circulatory and respiratory systems. It is preferable to use the method on an empty stomach, in the morning, after ascertaining the adequacy of the organs and systems. At the beginning 10 units are used, to be inereased daily until hypoglycemic symptoms appear, such as prostration, alight tremor, sweats, nervousness, sleepineas, a certain degree of anxiety, and a few other symptoms which vary from person to person. After determining the dosage required, this is repeated daily until coma develops. The number of shocks varies, though there should be a minimum on which the authors have not as yet agreed. The dose to secure the insulinic effect is variable, from 10 to over 200 units. There are patients who need very high doses to go into a coma. The manifestations of the method, at times, as stated, are dramatic but while dangerous they are not as fatal as might seem at first sight. This insulin coma lasts on an average two to three hours, but the time varies according to the clinical circumstances of the case. The number of shocks is from 10 to 20. One fact is indisputable: the earlier the method is used the more efficient it proves. While the physician is familiar with the distressing symptoms caused by the insulin shock, he should always be on guard for any unusual symptom. If necessary, he should bring the coma to an end by means of a drink of sweetened water or by an injection of glucose solu- tion. In specialized services such risks are less likely. Medical experience re- moves from the threatening picture of insulin coma many of its dangers and conse- quently threats to the patient’s life.

Many Brazilian psychiatrists have had much experience in shock therapy. As they reslise Sakel’s method is very exacting, it has been increasingly substituted by cardiazol and electric shock which will be taken up elsewhere. Convulsion therapy as recommended by Meduna has spread faster than the insulin coma method. Camphor is the drug used to produce convulsions, especially by means of intravenous cardiazol. It has been more than 35 years since the writer, while doing general practice as physician of the Association of Commercial Employees in Rio de Janeiro, discovered that when the patients were given bromated camphor to ease the pain and cramps in acute gonococcic infection, they developed epilepti- form convulsiona which he called “camphor epilepsy.” At that time 1 publiahed a paper in Brasil-Mé&co under the title of “Epileptiform spasma produced by the use of Bromated Camphor,” and severa1 colleagues sent similar reports. The Brasilian medical profession then became aware that camphor was a highly con- vulsant drug. Unfortunately no opportunity was had to apply it in a single mental case; the doses of camphor preparations were somewhat more restricted. In clinical practice 1 had recognized that patients with obsessions and anxiety conditions improved when having epileptic seizures and 1 had established a rela- tionship between epilepsy and obsessional neurosis or psychasthenia. Meduna, who carne to Rio de Janeiro, where he lectured severa1 times on his method, fol- lowed the clinical reasoning based on the antagonism between epilepsy and schizo- phrenia. Thus convulsion therapy for mental disturbances and in psychoneurosis was originated.

1944

occur, aome of these quite serious. Fortunately in our practice at the Botafogo Sanitarium such accidents did not happen. Serious accidente are more frequent and more dangerous in the insulin coma than in von Meduna’s convulsion therapy. The convulsibility threshold varies considerably. The drug is given until the convulsive condition develops, this being quite different in each patient. Some Brazilian clinicians stop the cardiaaol before seizures develop, especially in pa- tients with miopragic organs. From 10 to 20 shocks ora few more, as a rule, are enough for a clinical cure. Experienced physicians are on the alert against un- toward accidents, even t.hough these are uncommon. Usually patients, after cardiazol shocks fa11 into a state of anxiety, and frequently feel quite uncom- fortable, so that after improving they do not want to try the method again. As a rule, patients do improve. Regressions may, however, occur. In many patients the results are negative. Some, but not many physicians are skeptical as to the value of this method.

The electric shock has substituted von Meduna’s cardiazol method and in nearly al1 clinics is replacing the latter. Cerletti and his coworker Bini, in Italy, used for the first time the electric shock as a convulsant instead of cardiarol. The tendency at the present time among Brazilian alienists is to replace cardiazol shock by the electric shock, which while perhaps less efficient it ís less risky and easier to apply. At the present time in the Botafogo Sanitarium the electric shoek is preferred and we usually apply 10 to 20 shocks. Both the scientific bases and the physio-therapeutic mechanism of the cures or improvements secured by the shocks are unknown. Meduna himself put forth some hypotheses but without endorsing any of them. Scientific doubt still holds.

Besides the above-mentioned therapy we also use a combination of curative methods such as : insulin and cardiazol which consists in applying cardiazol during the coma or during the “moist” insulin crisis; cardiazol with picrotoxin, also a convulsant, the dose being 2 to 3 co. of a 1% solution. About 20 minutes Iater according to symptoms observed, the cardiazol is applied in the usual manner, the dose being reduced to half the standard one, because of the convulsant action of picrotoxin. At the Botafogo Sanitarium, when the desired results are not achieved, Dr. Alipio Pessoa uses cardiazol, insulin and a pyretogenic substance such as milk, pyrifer, etc., obtaining encouraging results sometimes. It must be added that with insulin, coma occasionally does not follow but only a moist or wet shock condition with abundant and prolonged sweating which clinically proves suflicient.

A strict therapeutic procedure cannot be prescribed for the three shock meth- ods, as they vary according to the patient’s clinical condition.

Penicillin in Neuro-Psychotic Diseases.-The recent discovery of sucha miracu- lous drug as penicillin attracted the attention of neuro-psychiatrists. It has been more widely used for neuro-virus conditions, epidemic cerebro-spinal meningitis, by the intra-spinal route, and neurosyphilis, especially in general paralysis. We do not have to go into the work done by workers in the United States in this matter. We wish only to report the work done here in the Hospital for Neuro- Syphilis, by Drs. Matiaa Costa and D. Araujo, in dementia paralytica and that reported to the Brazilian Society for Neurology and Psychiatry. At the begin- ning the doses are high, 3 million units, 70,000 every three hours. The workers recorded improvement in cases where malaria1 therapy had failed and in others in which malaria had not been tried. In all the patients there was active improve- ment. Dr. Flavio de Souza also found improvement in his cases.

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PAN AMERICAN SANITARY RUREAU [December 19.461 Monis, Professor of Neurological Clinic in the University of Lisbon, devised the brain operation which he called prefrontal leukotomy or psyeho-surgery, for the relief or cure of chronic and incurable psychotic conditions. Thia eminent Portuguese neurologist described at first his method as experimental operations for the treatment of certain psychoses. Impetus was given to his work because oE the lack of a radical treatment for chronic psychoses, some of which were then considered incurable. At the London Congress, in a session devoted to the study of the frontal lobe, Egas Monis outlined a theory for psyeho-surgcry. “In certain pathological conditions some groups of connections may lose their normal lability, beeome more constant and acquire much prevalence over al1 the others; and any stimulus may set them into motion. The persistence of some psychic morbid manifestat.ions must correspond to this fixation of the connections estab- lished between certain ce11 aggregations.” From this theoretical point of view he performed prefrontal leukotomies on various patients. While results were not invariably favorable the percentage obtained seemed quite encouraging to the Portuguese neurologist. The first applications were made on 20 patients, with the following results: 7 clinical cures; 7 improvements; 6 appreciable beneficial results; no deaths. It is to be noticed that in the successful cases, the patients could have improved or been cured with other therapeutic processes. Among paraphrenia and schizophrenia patients only two improved and five showed no appreciable therapeutic resulta. Egas Moniz’s work spread to various countries and the method was used in Italy, the Scnndinavian countries, Spain, the United States and Brazil. It is true that curative methods for chronic psyehoses are very few, although efforts on behalf of the sufferers are continuing.

Modern tendencies in the treatment of mental patients favor specific ergo- ’ therapy. The ideal would be mental hygiene, but this is still in the far future. As mental prevention is not available to all peoples because of la& of funds, social culture, efhcient education, once the acute psychotic stage is over, the in- sane or psychopathic should be placed in agricultura1 colonies, or work shops for voluntary ergotherapy. The pntients’ actual working capacity will be deter- mined by psychotechnique. Finding the work to which the patient is adapted is the ideal ergotherapy. There must be therefore a group or corps of experta for the selection and placing of patients. There is little use in sending men to work in the field and the women to sewing or emhroidery shops. This procedure is obsolete. Psychotechnics should be applied to the well and to the si&.

Idealista believe that insane asylums still embody the old mistakes. The ideal aolution would be to employ mental preventive measures and integrate man through psychotechnics with his social environment, in other words, to anticipate the individual% capacity for social intercourse in order to prevent mental OP

emotional crises. _1

For Referentes list see Portuguese original, p. 1070.