CHAPTER XIIENDOCRINOLOGY AND PSYCHIATRY
The important influence exercised by the glandular structures on the human organism has long been recognized. Perhaps the earliest evidence of this is the study of alterations due to the removal of the sexual glands. Eunuchoidism was described by Larrey as early as 1812 in his well-known account of the Egyptian campaign. In 1845 Bouchardat advanced the theory that pancreatic lesions were responsible for the development of diabetic disorders. Thomas Addison in 1855 showed the existence of a very definite disease process caused by pathological conditions in the adrenals. Mongolianism was recognized as a distinct entity by Langdon-Down in 1866. Gigantism was studied very thoroughly by von Langer in 1872. The existence of the parathyroids was unknown until they were described by Sandström in 1880. Weiss in 1881 showed that the extirpation of the thyroid sometimes caused tetany. After myxedema had been studied clinically by Charcot and others the fact that it was clearly related to disturbances of the functions of the thyroid gland was demonstrated by Kocher and Reverdin in 1882. Adipositas Dolorosa was described by Dercum as a form of dysthyroidia in the same year. Acromegaly was originally defined by Pierre Marie in 1886 and its relation to the hypophysis was pointed out by him. In 1886 Möbius called attention to the part played by the ductless glands in Basedow's disease, Grawitz in 1888 showed the significance of thymic hyperplasia and Paltauf in the following year described the "lymphato-chloroticconstitution." The pancreatic origin of diabetes was elaborately outlined by von Mering and Minkowski in 1889. The influence exerted by glandular secretions on general metabolism was demonstrated by Brown-Sequard in the same year. Lemoine and Launois in 1891 reported the existence of sclerosis of the blood and lymph vessels in the pancreas and Laguerse in 1893 found that the Islands of Langerhans were often involved in diabetes. Thyroigenic obesity was reported by von Hertoghe in 1896. The isolation and chemical definition of adrenalin by Takamine in 1901 was a decided step in advance. Fröhlich in 1901 suggested that obesity, infantilism of the genitalia and myxedematous alterations of the skin pointed to tumors of the hypophysis. In the same year Neumann thoroughly reviewed the subject of growths in the epiphysis, submitting a study of twenty-two cases. The various types of dwarfism were first described by von Hansemann in 1902. Thyroplasia and myxedema were exhaustively studied by Pineles in 1910 and 1912. The literature on the subject of the ductless or so-called endocrine glands has grown enormously during the last two or three decades and is shown in full by Falta and Meyers.[106]
The endocrine syndromes as now understood have been briefly summarized by Blumgarten[107]in a very graphic form as follows:—
Thyroid Stigmata
Symptoms of So-called Hyperactivity
Symptoms of So-called Hyposecretion
Parathyroid Stigmata
Pituitary Stigmata
So-called Deficiency Symptoms
Adrenal Stigmata
So-called Deficiency Symptoms
Thymus Stigmata
Gonadal Stigmata
Symptoms of So-called Gonadal Hyperactivity
Symptoms of So-called Hyposecretion
Pineal Stigmata
(occur only in children)
Precocious sexual and mental development.
It will be noted that he associates manic symptoms, increased emotional irritability, ideas of reference and persecution with thyroid hyperactivity and speaks of a sluggish mentality in pituitary deficiency and gonadal stigmata. Blumgarten's summary of these conditions is very interesting: "The study of the various stigmata shows that many of these are present regularly in certain types of individuals. Consequently we may group individuals from an endocrine viewpoint into various types according to the prominent endocrine stigmata which they show. For example, the nervous, thin individual with tachycardia, rather prominent eyeballs, fine, delicate hair, suffering occasionally from gastric symptoms, suggeststhe thyroid type, as does also the clean-cut, alert individual, and the young woman suffering with amenorrhea and a tendency to obesity and lethargic mentality. On the other hand, the aggressive, energetic individual, with the history of an ancestry subject to vascular disease, with high blood pressure, with abundant, unusual distribution of hair and a tendency to pigmentation, suggests the adrenal type. And so does the tired, asthenic individual with low blood pressure and Sergent's white line, who may have had influenza or diphtheria and even may be suffering from tuberculosis. On the other hand, however, the heavily built individual with broad, large frame, wide intercostal angle, broad nose, prominent supra-orbital ridges, prominent lips, large, square fingers, suggests the pituitary type. These individuals are very fond of meats, are heavy eaters, and are constantly subject to diseases of a gouty nature, may have a history of syphilis, are often musical and, as a rule, are usually successful in their particular community."
According to Kaplan[108]"such states as lack of courage, melancholy, suicidal tendencies, dementia praecox, precocious adolescence, and immature senility, sadism and masochism; all of these are possible manifestations in a gonadotrop individual." Garretson[109]is of the opinion that the "large group of patients generally misunderstood and frequently classed in civil life as neurasthenics, psychasthenics, hysterics, cyclothymics, and hypochondriacs, is now capable of an intelligent analysis and rational therapy, if one will concede that these are the victims of an endocrinic asthenia."
As an evidence of the influence of the endocrine glands on psychical functions, Falta[110]refers to "the alterationin character that is almost always associated with the development of Basedow's disease; to the psychical irritability, the inclination to irascibility, the manic-euphoristic attitude of patients with Basedow's disease; to the apathy and lack of interest of the myxedematous; to the characteristic quiet mental attitude in hypophysial dystrophy, and the feeling of mental want of strength in those suffering with Addison's disease; to the depressive attitude of the tetany patient, and finally to the profound influence that the ripening of the sexual glands at the time of puberty or the loss of function of the sexual glands in castrates exercises on the psyche." Going into this subject more in detail Falta gives the following mental symptoms as associated with Basedow's disease: abnormal irritability, "immotivated" gaiety, hasty speech, rapid flow of thoughts, a suggestion of flight of ideas, changeable moods and terrifying dreams. He also finds an alteration in the personality as shown by suspiciousness, capriciousness, irritability and either euphoric or depressed tendencies. Möbius compares this with a condition of mild intoxication associated with maniacal periods alternating with depression. Occasional attacks of delirium with confusion and hallucinations terminating in coma have been described. Sattler, who has analyzed 150 of these cases as reported in current literature, classifies over seventy as cases of manic-depressive insanity. Boinet, Parhan and others have shown that depression with suicidal inclinations may follow the ingestion of large amounts of thyroidin. Conditions of excitement have also been reported in thyroidism, and, according to Falta, are not uncommon. Brunet has expressed the opinion that in such cases Basedow's disease acts only as a precipitating factor in an individual predisposed to a psychosis.
The English Myxedema Commission found the apathy characteristic of that disease present in all but threeof 109 cases. This condition develops early and may manifest itself in the form of a mild mental dulness. Intellectual activities are often markedly diminished and there is a slow, monotonous form of speech. Deterioration may be well developed and memory seriously impaired. The commission in its investigations found illusions in eighteen cases, hallucinations in sixteen and psychoses in sixteen. These took the form usually of a depression with occasional excitements. The symptoms, in some cases at least, disappeared after thyroid treatment was instituted.
The psychic changes in cretinism have been made the subject of considerable study. The usual mental state is, of course, one of feeblemindedness. Perception has been shown to be disturbed, memory is impaired and there is a marked emotional deterioration and instability.
In the parathyroid form of tetany von Frankl-Hochwart found depressions and confused states with hallucinations. Depressions were reported by him in fourteen of thirty-seven cases examined. Excitements were also noted in some instances. Falta refers to "a characteristic apathy, a want of initiative, and a slowing of speech" in acromegaly. In rare cases he has also noted mental exaltation. Oppenheim (1914) has called attention to cases of acromegaly presenting the picture of general paresis but due to an alteration of glandular functions and not syphilitic in origin.
Falta includes the following in his description of the symptomatology of Addison's disease: "Almost always the disease manifests itself in ready fatigability, disinclination for work, and apathy; to these symptoms are sometimes added headaches, poor sleep, sometimes obstinate insomnia, psychical ill humor and depression, often too, abnormal irritability; further, diminution in memory, noises in the ears, vertigo and commonly fainting attacks, singultus, and rheumatoid pains in the backand in the extremities, sometimes, also epileptiform convulsions. Extremely stormy manifestations on the part of the nervous system may, especially in the later stages, make their appearance—violent delirium, acute confusion, convulsions, deep stupor, and coma."
Raeder[111]has made an analysis of glandular involvements found in the study of one hundred cases of feeblemindedness at autopsy. He classifies these as 1, extreme changes—in which three or four glands were involved and where there were marked anomalies of growth, underdevelopment, disproportion of the body parts, etc.; 2, marked changes—in which at least two glands were involved and where there were distinct changes in growth and anomalous development; 3, moderate changes—in which one or two glands were involved; and 4, cases where no glandular involvement was found. He noted extreme changes in ten per cent of the series, marked changes in eleven per cent, moderate changes in fifty-three per cent and none at all in twenty-six per cent. Sixty per cent of these individuals showed deviation from the normal in size, fifty-one per cent were undersized and nine per cent were above the average height, while thirty-eight per cent were normal. The pituitary was found to be involved in forty per cent of the one hundred cases, the thyroid in nineteen per cent, the suprarenal in twenty-seven per cent, the sex glands in thirty-eight per cent, the thymus in twelve per cent and other glands in six per cent. He frequently found several involved: "Pituitary with gonads in nine cases, was the most common dual adenosis, though there were combinations of sex and thyroid in four instances, sex and suprarenal in four cases, and in three cases the thyroids, pituitary and gonads were affected in triple involvement. Furthermore, there were six cases in which the gonads werecombined with three other glands; two included the gonads, thyroid, pituitary and suprarenal; two, gonads, thyroid, pituitary and thymus." Further investigation only can accurately determine the exact relation which exists between disturbance of these glands and the presence of mental deficiency.
Attention was called some time since to the fact that the injection of adrenalin leads to an increase in blood pressure. This has been discussed by Falta, Newburgh, Nobel and others. Neubürger[112]made a study of thirty-nine cases, seven of which were normal, the others including alcoholism, neurasthenia, manic-depressive, etc., but not dementia praecox. A fairly well marked rise of blood pressure followed adrenalin injection very quickly, reaching its maximum in from six to twelve minutes. He found the reaction diminished or absent in eighty per cent of the sixty-three cases of dementia praecox which he examined, but does not advance the claim that this can be utilized for diagnostic purposes. Walter and Krumbach[113]found an increased pressure in sixty per cent of normal control cases and obtained similar reactions in dementia praecox. Schmidt, on the other hand, confirmed the findings of Neubürger. Emerson[114]found status lymphaticus in over twenty-nine per cent of his cases of dementia praecox and Davis[115]found the same condition in twenty-four per cent of war neuroses in a series of over one hundred cases. These findings, however, lack confirmation by other observers. Straus[116]includes asmental symptoms in thyroidal disbalance: sluggish mental reactions alternating with sparkling wit, irritability, general moodiness and depression, difficulty in thought with inability to concentrate, forgetfulness, fatigability and somnolence.
Turro[117]has shown that all of the physical evidences of fright—pallor, dilatation of the pupils, rapid pulse, cutis anserinus, perspiration, etc., can be produced experimentally by the injection of epinephrin in certain cases. Knauer and Billigheimer[118]have called attention to the striking similarity between the functional changes to be found in disturbances of the vegetative (sympathetic) nervous system and certain manifestations associated with fear neuroses. They attribute these disturbances to congenital inferiority, toxic sources, emotional shock or fatigue.
A uniform defective development of the physical and mental personality of the individual has been designated by Lasègue as infantilismus. As described by Di Gaspero and de Sanctis the mental status of these cases belongs to the domain of feeblemindedness and in some instances to imbecility. According to Kraepelin[119]the attention is easily attracted and as easily distracted. These individuals are inquisitive and flighty. Apprehension is defective. What they hear and see can only be related in a fragmentary and unreliable manner. They often learn readily and forget as quickly. Pende described the mental development as only one-third of the normal. Memory gaps are supplied by exaggeration and fabrication, as influenced by emotion or suggestion. DiGaspero found falsification of memory in twenty per cent of his cases. Imagination is very active with a tendency to dreamlike unrealities, wonderful tales of adventure, etc. Mental processes are inadequate, vague and uncertain. The real and the unreal are not clearly differentiated. Explanations and descriptions are inaccurate and indefinite. Standards of value, size or time are vague. The store of ideas is impoverished and associations are poor. Calculations are slow and faulty. These persons are illogical, impractical and credulous. They are swayed by prejudices, catchwords and hasty judgment. Their range of thought is narrow and their viewpoint of life childish. The emotional and volitional content is immature. They are cheerful but lack earnestness, and are often ambitious and boastful. At other times they are likely to be despondent, timid, anxious, fearful and lacking in self-confidence. The mood is exceedingly variable. They are not industrious, cannot apply themselves constantly to any line of work, and tire easily. Their conduct is very uncertain and unreliable. Some have criminal tendencies. Occasionally hysterical symptoms appear. Evidences of an absence of physical development manifest themselves in all varieties of immaturity. These defects, according to Falta, are shown especially in the genitalia and the lymphatic apparatus, with a delay in the closure of the epiphysis and the retention of a childish physique generally. The skeletal framework shows a failure of development, the lower length of the body exceeds the upper slightly, if at all, the head is relatively large, the bones slender and the pelvis infantile in type. The sexual organs and the "vita sexualis" are those of a child. The blood shows a large lymphocyte count and a definite status lymphaticus is sometimes found to be present. The hairy development of the pubis and axillary surface is slight. The internal organs are normal. Trueinfantilism, according to Falta, is not due to a glandular disturbance. He also maintains that the mind, while that of a child, is normal otherwise and shows no defects. Juvenile myxedema, hypophysial dystrophy and eunuchoidism, Falta would not include with the infantilismus group. Infantilism has been ascribed to syphilis, tuberculosis, alcoholism, etc., of the parents. Brissaud in 1907 advanced the theory that it was a hypothyroid symptom. His views have been supported by various other writers, although not shared by either Falta or Kraepelin. The latter has also described mental conditions more or less suggesting feeblemindedness and associated with lesions of the hypophysis, the pineal gland, the adrenals, the sexual glands and the thymus.
Lesions in the anterior lobe of the pituitary result in gigantism or acromegaly, with a childish mentality most marked in the emotional sphere. These persons are usually indifferent, good-natured and boastful, and at the same time clumsy and inactive. A diminished activity of the glandular portion of the hypophysis means dwarfism. Lesions of the posterior or "nervous" lobe may cause "dystrophia adiposo genitalis," the "adipositas dolorosa" of Dercum. The mental status in this condition Kraepelin compares to that described in acromegaly—apathy and indifference, with occasional restless or excited types. The intellectual capacity may be normal, mediocre or somewhat deficient.
The pineal gland is spoken of as having a very definite relation to sexual development. Extirpation is said to lead to rapid development of the body, the accumulation of fat and early sexual development,—a condition described by Pellizzi as "makro-genitosomia praecoce." Schüller in fifty-one cases with pineal involvements found ten occurring during the first decade of life. Death usually takes place within a few months or years. Similar conditions result from hyperactivity of the adrenalcortex,—rapid development of the body, and particularly of the sexual organs, obesity and overgrowth of the hair and beard. Wiesel described as a "suprarenal genital symptom complex" cases of pseudo-hermaphrodism in women.
Lesions of the adrenal, as studies of Addison's disease show, have, according to Kraepelin,[120]the following symptoms: weakness of memory, apathy, dulness, inactivity and inhibition of growth. He also calls attention to the fact that in anencephaly, hemicephaly and microcephaly defective development of the adrenals is very common. "Eunuchoidismus" and "viriginität" with mental symptoms due to defective development of the sex glands are also described. The physical manifestations include defective secondary sexual characteristics, in men in the growth of the beard and change of the voice, and in women in the development of the mammary glands, the fat deposits and the curve of the hips. There is a failure of sexual development and absence of menses, as well as defective physical growth. Eunuchoidismus may manifest itself in a giantism somewhat suggesting that resulting from lesions of the pituitary or in a dwarflike physical development. The former variety is characterized by an unusual height with long arms and legs. The forehead is receding, with a low hair line. The external genitals are very small and there is little pubic or axillary hair. Ossification is delayed. In the second form (dwarfs) the body, arms and legs are short and thick. The head is large and the neck short. The genitals are small and the penis is short and button-shaped. Hair formation is slight. The mental condition in either case is characterized by an intellectual defect with timidity, emotional instability, helplessness and weakness of will, sometimes with an active imagination. Kraepelin also describes endocrine conditions resultingfrom thymic lesions—thymic idiocy, status thymolymphaticus—and mentions the pancreatic infantilismus referred to by Brownell, Basedow's disease, acromegaly, pluriglandular insufficiency and other conditions already mentioned. Kraepelin has encountered only seven "dysadenoid" forms in a study of 244 cases. Bourneville has reported 104 cases of persistent thymus.
One of the most interesting contributions to the literature of endocrinology is Mott's[121]suggestion that dementia praecox is due to a combination of degenerative changes in the cortical neurones and the generative organs. As a result of the study of twenty-two cases of dementia praecox he found that more marked pathological changes were found in the testes than were observed in cases of manic-depressive insanity, alcoholic psychoses, epilepsy or paranoia. The characteristic findings consisted in regressive changes in the seminal tubules and abnormal staining reactions in the spermatozoa. He found more evidences of virility in a senile individual of eighty than in any of his cases of dementia praecox. His theory as to the pathogenesis of the disease is based on the fact that the changes in the neurones are of the same character—a degeneration of the nuclear elements. These findings have not at this time been confirmed by other observers.
Timme[122]has described a psychic makeup due to subinvolution of the thymus. "The mental picture presented by these subinvoluted thymic states is also of great importance, for analogous to their structural lack of differentiation is their psychic makeup. They remain child-like in their character, so that they are self-centered; simple in their mental processes and imitative; looking for protection and care, and more or less unfitted forthe active struggles of life. They are obstinate and negativistic; if, however, an efficient compensation takes place, then, although the mental development may have been delayed, it nevertheless seems finally to reach complete maturity; and these individuals are among the brightest and most intelligent of their community." In cases of precocious involution of the thymus he finds the mental condition to be of chief interest. "They are precocious, with much initiative, are easily aroused to anger and are resentful. They have cruel instincts and show little inhibition. Although they seem far advanced for their years while still young, yet they never seem thoroughly to mature, and become blocked in early adolescence. They seem to retain their impulsive, unreasoning characteristics, brook no restraint and remain constantly a prey to their easily aroused anger." Of thyroid insufficiency he says: "Mentally, the patient is dull, sluggish and with little initiative. He moves slowly and thinks slowly, is extremely forgetful and his lethargy is occasionally disturbed by outbursts of anger due probably to his maladjustment to the more quickly moving world about him." In his summary of the hyperthyroid makeup, Timme says: "Both mind and body are everlastingly busy. And not only with present problems, but anticipatory of tomorrow's as well. The patient shows no rest or relaxation. His mind, filled with echoes of the day's troubles, prevents his falling to sleep until long after he retires, and he is again awake and immediately on the "qui vive" as soon as daylight comes." Statistics on endocrine conditions are unfortunately not available as yet.