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Abnormal psychology: clinical perspectives on psychological disorders (8th Ed.) Susan Krauss
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CHAPTER 1
Overview to Understanding Abnormal Behavior
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OUTLINE
Case Report: Rebecca Hasbrouck
What Is Abnormal Behavior?
The Social Impact of Psychological Disorders
Defining Abnormality
What’s in the DSM-5-TR: Definition of a Psychological Disorder
What Causes Abnormal Behavior?
Biological Contributions
Psychological Contributions
Sociocultural Contributions
The Biopsychosocial Perspective
Prominent Themes in Abnormal Psychology Throughout History
Spiritual Approach
Humanitarian Approach
Scientific Approach
Research Methods in Abnormal Psychology
Experimental Design
Correlational Design
You Be the Judge: Being Sane in Insane Places
Types of Research Studies
Survey
Laboratory Studies
The Case Study
Real Stories: Sir Elton John
Single Case Experimental Design
Research in Behavioral Genetics
Bringing It All Together: Clinical Perspectives
Return to the Case: Rebecca Hasbrouck
Summary
Key Terms
LEARNING OBJECTIVES
1.1 Distinguish between behavior that is unusual but normal and behavior that is unusual and abnormal.
1.2 Describe how explanations of abnormal behavior have changed through time.
1.3 Identify the strengths and weaknesses of research methods.
1.4 Describe types of research studies.
CASE REPORT: REBECCA HASBROUCK
Demographic Information:
18-year-old White bisexual cisgender woman. Rebecca’s pronouns are she/her/hers.
History of Present Illness:
Rebecca self-referred to the university counseling center. She is a first-year college student, living away from home for the first time. Following the first week of classes, Rebecca reports that she is having trouble falling and staying asleep, has difficulty concentrating in her classes, and often feels irritable. She reports she is frustrated by the difficulties of her coursework and worries that her grades are beginning to suffer. She also relays that she is having trouble making friends at school and that she has been feeling lonely because she has no close friends here with whom she can talk openly. Rebecca is very close to her boyfriend of 3 years, though they are attending college in different cities.
Rebecca was tearful throughout our first session, stating that, for the first time in her life, she feels overwhelmed by feelings of hopelessness. She reports that although the first week at school felt like “torture,” she is slowly growing accustomed to her new lifestyle, despite her struggles with missing her family and boyfriend, as well as her friends from high school.
Psychiatric History:
Rebecca has no prior history of depressive episodes or other mental health concerns, and she reports no known family history of psychological disorders. She shared that sometimes her mother tends to get “really stressed out,” though she has never received professional mental health treatment.
Current Symptoms:
Depressed mood, difficulty falling asleep (insomnia), difficulty concentrating on schoolwork. She described feelings of hopelessness but denies any thoughts of suicide or self-harm.
Risk Level:
Low risk. Rebecca has no current thought of suicide and no past history of suicidality or suicide attempts.
Case Formulation:
Although it appeared at first as though Rebecca was suffering from a major depressive episode, she did not meet the diagnostic criteria. While the age of onset for depression tends to be around Rebecca’s age, given her lack of a family history of depres sion and the fact that her symptoms were occurring in response to a major stressor, the clinician determined that Rebecca was
suffering from adjustment disorder with depressed mood.
Treatment Plan:
The counselor will refer Rebecca for weekly psychotherapy. Therapy should focus on improving her mood, and it also should allow her a supportive space to discuss her feelings surrounding the major changes that have been occurring in her life.
Sarah Tobin, PhD Clinician
Rebecca Hasbrouck’s case repor t summar izes the per tinent features that a clinician would include when f irst seeing a client af ter an initial evaluation. Each chapter of this book begins with a case repor t for a client whose character istics are related to the chapter’s topic. A f ictitious clinician, Dr. Sarah Tobin, who super vises a clinical setting that of fers a var iet y of ser vices, wr ites the case repor ts. In some inst ances, she provides the ser vices, and in others , she super vises the work of another psychologist. For each case, she provides a diagnosis using the of f icial manual adopted by the profession, known as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Text Revision (DSM-5-TR) (Amer ican Psychiatr ic Association, 2022).
At the end of this chapter, af ter you have developed a better underst anding of the client’s disorder, we will re tur n to Dr. Tobin’s descr iption of the treatment results and expected future outcomes for the client. We also include Dr. Tobin’s personal ref lections on the case to help you gain insight into the clinician’s exper ience in working with individuals with psychological disorders.
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The f ield of abnor mal psychology is f illed with countless fascinating stor ies of people who suf fer from psychological disorders. In this chapter, you will be able to get some sense of the realit y that psychological disturbance is cer t ain to touch ever yone, to some extent, at some point in life. As you prog ress through this course, you will almost cer t ainly develop a sense of the challenges peopl e associate with psychological problems. You will f ind yourself drawn into the many ways that ment al health problems af fect the lives of individuals, their families, and societ y. In addition to becoming more personally familiar with the emotional aspects of abnor mal psychology, you will lear n about the scientif ic and theoretical basis for underst anding and treating the people who suf fer from psycholog ical disorders.
1.1 What Is Abnormal Behavior?
It’s possible that you know someone ver y much like Rebecca, who is suf fer ing from more than the average deg ree of adjustment dif f iculties in college. Would you consider her psychologically disturbed? Would you consider giving her a diagnosis? What if she showed up at your door looking as if she were ready to har m herself?
This young woman’s apparent despair may be the symptoms of a psychological disorder
shisu ka/Shutterstock
At what point do you draw the line between someone who has a psychological disorder and someone who, like Rebecca, has an adjustment disorder? Is it even necessar y to give Rebecca any diagnosis at all? Questions about nor malit y and abnor malit y such as these are basic to advancing our underst anding of psychological disorders.
Perhaps you yourself are, or have been, unusually depressed, fear ful, or anxi ous. If not you, possibly someone you know has str ugg led with a psychological disorder or its symptoms. It may be that your father str ugg les with alcoholism, your mother has been hospit alized for severe depression, your sister has an eating disorder, or your brother has an ir rational fear. If you have not encountered a psychological disorder within your immediate family, you have ver y likely encountered one in your extended family or circle of fr iends. You may not have known the for mal psychiatr ic diagnosis for the problem, and you may not have understood its nature or cause, but you knew that something was wrong and recognized the need for professional help.
Until they are forced to face such problems, most people believe that “bad things” happen only
to other people. You may think that other people have car accidents, succumb to cancer, or, in the psychological realm, become dependent on opioids. We hope that reading this textbook will help you go beyond this “other people” syndrome. Psychological disorders are par t of the human exper ience, directly or indirectly touching the life of ever y person. However, they don’t have to destroy those lives. A s you read about these disorders and the people who suf fer from them, you will f ind that these problems can be treated, if not prevented.
1.2 The Social Impact of Psychological Disorders
Psychological disorders af fect both the individual and the other people in the individual’s social world. Put yourself in the following situation. You receive an urgent text from the mother of your best fr iend, Jeremy. You call her and f ind out he’s been admitted to a behavioral health unit of the local hospit al and wants to see you. According to Jeremy’s mother, only you can underst and what he is going through. The news comes out of the blue and is puzzling and distressing. You had no idea Jeremy had any psychological problems. You ponder what you will say to him when you see him. Jeremy is your closest fr iend, but now you wonder how your relationship will change. How much can you ask him about what he’s going through? How is it that you never saw it coming? Unsure about what to do when you get there, you wonder what kind of shape he’ll be in and whether he’ll even be able to communicate with you. What will it be like to see him in this setting? What will he expect of you, and what will this mean for the future of your fr iendship?
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Now imagine the same scenar io, but instead you receive news that Jeremy was just admitted to the emergency room of a general hospit al with acute appendicitis. You know exactly how to respond when you go to see him. You will ask him how he feels, what exactly is wrong with him, and when he will be well again. Even though you might not like hospit als ver y much, at least you have a prett y good idea about what hospit al patients are like. The appendectomy won’t seem like anything special, and you would probably not even consider whether you could be fr iends with Jeremy again af ter he is discharged. He’ll be as good as new in a few week s, and your relationship with him will resume unchanged.
Now that you ’ ve compared these two scenar ios, consider the fact that people with psychological disorders frequently face situations such as Jeremy’s in which even the people who care about them aren’t sure how to respond to their symptoms. Fur ther more, even af ter their symptoms are under control, individuals like Jeremy continue to exper ience profound and long-lasting emotional and social ef fects as t hey attempt to resume their for mer lives. Their disorder itself may also br ing about anguish and personal suf fer ing. Like Rebecca in our opening example, they must cope with feelings of loneliness and sadness.
Psychological disorders are almost inevit ably associated with stigma, a negative label that causes cer t ain people to be regarded as dif ferent, defective, and set apar t from mainstream members of societ y. This stigma exists even in today’s societ y, despite g reater awareness of the prevalence of ment al health issues. Social attitudes toward people with psychological disorders range from discomfor t to outr ight prejudice. Language, humor, and stereot ypes por tray psychological disorders in a negative light, and many people fear that those who have these disorders are violent and dangerous.
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There seems to be something about a psychological disorder that makes people want to dist ance themselves from it as much as possible. The result is social discr imination, which
The families of individuals with psychological disorders face signif icant stress when their relatives must be hospit alized Ghislain & Marie David de Lossy/Cultura/Gett y Images
ser ves only to complicate the lives of the af f licted even more. Making matters worse, people exper iencing symptoms of a psychological disorder may not avail themselves of the help they could receive from treatment because they too have incor porated stigmatized views of ment al illness (Fir min et al., 2019). Some individuals are able to resist the stigma of psychological disorders due to their abilit y, for example, to def ine their identit y separate from their disorder and to reject the labels other people apply to them (O’Connor, Yanos, & Fir min, 2018).
In the chapters that follow, you will read about a wide range of disorders af fecting mood, anxiet y, subst ance use, sexualit y, and thought disturbance. Case descr iptions will give you a g limpse into the feelings and exper iences of real people who have these disorders, and you may f ind that some of them seem similar to you or to people you know. As you read about the disorders, put yourself in the place of the people who have these conditions. Consider how they feel and how they would like people to treat them. We hope you will realize that our discussion is not about the disorders but about the people who have them.
1.3 Defining Abnormality
There is a range of behaviors people consider nor mal. Where do you draw the line? Decide which of the following actions you regard as abnor mal.
Feeling jinxed when your “lucky” seat in an exam is already occupied when you get to class
Being unable to sleep, eat, study, or t alk to anyone else for days af ter your boyfr iend says, “It’s over between us ”
Breaking into a cold sweat at the thought of being trapped in an elevator
Swear ing, throwing pillows, and pounding f ists on the wall in the middle of an argument with a roommate
Refusing to eat solid food for days at a time in order to st ay thin
Engaging in a thorough hand-washing af ter coming home from a bike r ide
Protesting the r ising cost of college by joining a picket line outside the campus administration building
Being convinced that people are const antly being cr itical of ever ything you do
Dr inking a six-pack of beer a day in order to be “sociable” with fr iends
Playing video games for hours at a time, avoiding other study and work obligations
If you’re like most people, you probably found it sur pr ising ly dif f icult to decide which of these behaviors are nor mal and which are abnor mal. So many are par t of ever yday life. You can see now why ment al health professionals str ugg le to f ind an appropr iate def inition of abnor malit y. Yet cr iter ia need to exist so they can provide appropr iate treatment in their work with clients.
Looking back at this list of behaviors, think now about how you would rate each if you applied the f ive cr iter ia for a psychological disorder that ment al health professionals use. In realit y, no one would diagnose a psychological disorder on the basis of a sing le behavior, but using these cr iter ia can at least give you some insight into the process that clinicians use when deciding whether a given client has a disorder or not.
The f irst cr iter ion for a psychological disorder is clinical signif icance, meaning the behavior includes a measurable deg ree of impair ment that a clinician can obser ve. People who feel jinxed about not having a lucky seat available for an exam would f it this cr iter ion only if they could not concentrate on the exam at all unless they sat in that seat and this happened for ever y exam they t ake.
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Second, to be considered evidence of a psychological disorder, a behavior must ref lect a
dysfunction in a psychological, biological, or development al process. Concretely, this means that even if researchers do not know the cause of that dysfunction, they assume that it can one day be discovered.
The third cr iter ion for abnor malit y is that the behavior must be associated with signif icant distress or disabilit y in impor t ant realms of life. This may sound similar to clinical signif icance, but what distinguishes distress or disabilit y is that it applies to the way the individual feels or behaves, beyond a measurable ef fect the clinician can obser ve. The individual either feels negatively af fected by the behavior (“distress”) or suf fers negative consequences in life as a result (“disabilit y”). People may enjoy playing video games to a point, but if they exclude their other obligations, this will negatively af fect their lives. They may also feel distressed but unable to stop themselves from engaging in the behavior.
Four th, the individual’s behavior cannot simply be socially deviant as def ined in ter ms of religion, politics, or sexualit y. The person who refuses to eat meat for ideological reasons would not be considered to have a psychological disorder by this st andard. However, if that p erson restr icts all food int ake to the point that their health is in jeopardy, then that individual may meet one of the other cr iter ia for abnor malit y, such as clinical signif icance and/or the distress-disabilit y dimension.
The f if th and f inal cr iter ion for a psychological disorder is that it ref lects a dysfunction within the individual. A psychological disorder cannot ref lect a dif ference in politica l beliefs between citizens and their gover nments. Campus protesters who want to keep college costs down could not, according to this cr iter ion, be considered psychologically disordered, although they may be putting themselves at other kinds of r isk if they never attend a sing le class or are ar rested for trespassing on universit y proper t y.
This woman is distressed over her inabilit y to fall asleep, but does this mean she has a psychological disorder?
Tero Vesalainen/Shutterstock
As you can see, deciding which behaviors are nor mal and which are not is a dif f icult
proposition. Fur ther more, when it comes to making an actual diagnosis to assign to a client, the ment al health professional must also weigh the mer its of using a diagnostic label against the disadvant ages. The mer its are that the individual will receive treatment (and be able to receive insurance reimbursement), but a possible disadvant age is that the individual will be labeled with a psychological di sorder that becomes par t of his or her health records. At a later point in life, that diagnosis may make it dif f icult for the individual to qualify for cer t ain jobs.
For tunately, ment al health professionals have these cr iter ia to guide them, with extensive manuals that allow them to feel reasonably conf ident they are assigning diagnoses when appropr iate. These f ive cr iter ia, and the specif ic diagnoses for the many for ms of psychological disorders that can af fect people, for m the core content of this course.
The f ive cr iter ia we are using exist within a soci ocultural lens consistent with cur rent Wester n views on abnor malit y. It is impor t ant to acknowledge here that cultural lenses can inf luence the way abnor malit y is def ined, and throughout this course we will be outlining some specif ic inst ances of how dif ferent cultural lenses might frame what we might def ine as abnor mal.
WHAT’S IN THE DSM-5-TR
Definition of a Psychological
Disorder
Compare what you think constitutes abnormal behavior with the five criteria for a mental disorder described in the text. Which of these criteria were in your own definition of abnormal behavior? How would you determine whether an individual meets these criteria?
As you will learn in Chapter 2, the diagnostic manual known as the DSM-5-TR provides clinicians with considerable guidance in making the determination whether an in dividual’s behavior constitutes a psychological disorder.
1.4 What Causes Abnormal Behavior?
For the moment, we will leave behind the question of whether behavior is abnor mal or nor mal while we look at the potential factors that can lead individuals to exper ience a psychological disorder. As you will lear n, we can best conceptualize abnor mal behavior from multiple vant age points. From the biopsychosocial perspective, we see abnor mal behavior as ref lecting a combination of biological, psychological, and sociocultural factors as these evolve dur ing the individual’s g rowth and development over time.
Biological Contributions
We st ar t with the biological par t of the equation. The factors within the body that can contr ibute to abnor mal behavior include genetic abnor malities that, alone or in combination with the environment, inf luence the individual’s psychological functioning. Biological contr ibutions can also include physical changes that occur as par t of nor mal aging, illnesses an individual develops, and injur ies or har m caused to the body.
The most relevant genetic inf luences for our pur poses are inher ited factors that alter the functioning of the ner vous system. However, psychological disorders can also be produced by environment al inf luences alone if t hese af fect the brain or related organs of the body. For example, people with thyroid disturbances may exper ience wide f luctuations in mood. Brain injur y resulting from a head trauma can result in altered thoughts, memor y loss, and changes in mood.
Within the biopsychosocial perspective, we see social factors interacting with biological and psychological contr ibutions, in that environment al inf luences such as exposure to toxic subst ances or stressful living conditions can also lead individuals to exper ience psychological disorders. Environment al depr ivation caused by pover t y, malnutr ition, or social injustice can also place individuals at r isk for psychological disorders by causing adverse physiological outcomes.
Psychological Contributions
The idea that psychological disorders have psychological contr ibutions is probably not one that you believe requires a g reat deal of explanation. Within the biopsychosocial perspective, however, psychological causes are not viewed in isolation. They are seen as par t of a larger constellation of factors inf luenced by physiological alterations interacting with exposure to a cer t ain environment.
Psychological contr ibutions can include the result of par ticular exper iences within the individual’s life. For example, individuals may f ind themselves repeating distressing behaviors that are instilled through lear ning exper iences. They may also express emotional inst abilit y as the result of feeling that their parents or caret akers could not be relied on to watch over them.
Although there are n o purely psychological causes in the biopsychosocial perspective, we can think of those that ref lect lear ning, life exper iences, or exposure to key situations in life as ref lecting predominantly psychological inf luences. These can also include dif f icult y coping with stress, illogical fears, susceptibilit y to uncontrollable emotions, and a host of other dysfunctional thoughts, feelings, and behaviors t hat lead individuals to meet the cr iter ia for psychological disorder.
Sociocultural Contributions
The sociocultural perspective looks at the var ious circles of inf luence on the individual, ranging from close fr iends and family, to inst ances of discr imination (for example racism), to the institutions and policies of a countr y or the world as a whole. These inf luences interact in impor t ant ways with biological processes and with the psychological contr ibutions that occur through exposure to par ticular exper iences.
One impor t ant and unique sociocultural contr ibution to psychological disorders is discr imination, whether based on social class, income, race and ethnicit y, nationalit y, sexual or ient ation, or gender. Discr imination, as well as oppression that those in discr iminated g roups face, not only limits people’s abilit y to exper ience psychological well-being; it can also have direct ef fects on physical health and development. For example, people of color in the United St ates especially Black and Afr ican Amer ican people exper ience higher inst ances of oppression and violence due to systemic racism that has a ver y real impact in ter ms of increasing daily stress and anxiet y for these individuals. Dur i ng the COVID-19 pandemic, st atistics showed the dispropor tionate ef fect of the coronavir us on Black and Indigenous People of Color (BIPOC) in ter ms of vir us rates, economic impact, and mor t alit y. Another minor itized g roup that is of ten har med by systemic inequalit y is LGBTQ+ individuals, and it has been demonstrated that gender and sexual minor itized people of color, in par ticular, face higher rates of a range of ment al health issues, including suicidalit y and subst ance use, than their non-LGBTQ+ counter par ts.
And, as you lear ned earlier, people diagnosed with a psychological disorder are likely to be stigmatized as a result of their symptoms and diagnostic label. The stress of car r ying the stigma of ment al illness increases the emotional burden for these individuals and their loved ones. Because i t may prevent them from seeking badly needed help, it also per petuates a cycle
in which many people in need become increasing ly at r isk and hence develop more ser ious symptoms.
The stigma of psychological disorders seems to var y by ethnicit y and race. For example, among individuals with two for ms of disorders involving anxiet y, shame and stigma can become bar r iers to receiving treatment (Goetter et al., 2020). Var iations in the willingness to acknowledge ment al health issues also occurs across age and gender lines, with younger individuals and women more open to the exper ience of symptoms and therefore more willing to par ticipate in therapy and other psychological inter ventions.
The existence of multiple for ms of discr imination (such as racism, transphobia, and higher rates of violence and police br ut alit y against BIPOC) also means that individuals must cope not only with thei r symptoms and the stigma of their symptoms, but also with the negative attitudes toward their socially def ined g roup. This of ten means that individuals in need of ment al health treatment do not seek care. In some cases, as with transgender people (and par ticularly trans people of color), this reluct ance can stem from a perception that they will encounter transphobic attitudes and discr iminator y behav iors in the treatment setting. Clinicians working with individuals from discr iminated-against g roups are increasing ly lear ning the impor t ance of consider ing these factors in both diagnosis and treatment. We will lear n later in the book about the specif ic guidelines ment al health exper ts are developing to help ensure that clinicians receive adequate training in translating theor y into practice. Page 9
The Biopsychosocial Perspective
Table 1 summar izes the three categor ies of causes of psychological disorders just discussed. As you have seen, disturbances in any of these areas of human functioning can contr ibute to the development of a psychological disorder. Although this breakdown is helpful, keep in mind the many possible interactions among the three sets of inf luences.
TABLE 1 Causes of Abnormal Behavior
Biological
Psychological
Genetic inheritance
Physiological changes
Exposure to toxic substances
Past learning experiences
Maladaptive thought patterns
Sociocultural
Difficulties coping with stress
Social policies
Discrimination
Stigma
As you will see when reading about the conditions in this textbook , the deg ree of inf luence of each of these var iables dif fers among disorders. For some disorders, such as schizophrenia, biology seems to play a par ticularly dominant role. For other disorders, such as stress reactions, psychological factors predominate. Conditions such as post-traumatic stress disorder as a result of, for example, expe r iences under a ter ror ist regime or exposure to racial injustice have a pr imar ily sociocultural cause.
The biopsychosocial perspective also incor porates a development al viewpoint. This means we must underst and how these three sets of inf luences change over the course of an individual’s life. Some circumst ances endanger the individual more at cer t ain times than at others. Young children may be especially vulnerable to such factors as inadequate nutr ition, harsh parent al cr iticism, and neg lect. Protective factors, on the other hand, such as loving caregivers, adequate health care, and early life successes, can reduce an individual’s likelihood of developing a disorder. These early r isk-protective factors become par t of the individual’s susceptibilit y to developing a disorder, and they remain inf luent ial throughout life.
Later in life, r isk factors change in their specif ic for m and potential sever it y. Individuals who exper ience physical health problems due to a lifetime of poor diet ar y habits may be more likely to develop psychological symptoms related to altered cardiovascular functioning. On the other hand, if they have developed an extensive social suppor t network , this can somewhat of fset the r isk presented by their poor physical health.
At all ages, the biological, psychological, and sociocultural factors continue to interact and af fect the individual’s ment al health and well-being as well as the expression of a par ticular psychological disorder (Whitbour ne & Meeks, 2011). We can use the biopsychosocial framework to develop an underst anding of the causes of abnor malit y and, just as impor t a ntly, the basis for treatment.
1.5 Prominent Themes in Abnormal Psychology Throughout History
The g reatest thinkers of the world, from ancient times to the present, have attempted to explain the var ieties of human behavior that we now regard as evidence for a psychological disorder. Throughout histor y, three prominent themes seem to recur: the spir itual, the humanit ar ian, and the scientif ic.
Spir itual explanations regard abnor mal behavior as the product of possession by evil or demonic spir its. Humanit ar ian explanations view psychological disorders as the result of cr uelt y, stress, or poor living conditions. Scientif ic explanations look for causes we can objectively measure, such as biological alterations, fault y lear ning processes, or emotional stressors. Page 10
The Greeks sought advice from oracles, wise advisors who made pronouncements from the gods
ullstein bild Dtl /Gett y Images
Hieronymus Bosch’s Removal of the Stone of Folly, painted in the 1490s, depicted a medieval “doctor” cutting out the presumed source of madness from a patient’s sk ull The prevailing belief was that spir itual possession was the cause of psychological disorder
PAINTING/Alamy Stock Photo
We will follow the trajector ies of each of these perspectives throughout histor y. As you will see, each has had its per iod of major inf luence, but in some ways the issues are the same today as in ancient times in that the actual causes of psychological disorders remain unknown. The scientif ic approach will undoubtedly provide the key to discover ing what causes psychological disorders, but it will neve r theless be impor t ant for ment al health professionals to follow the pr inciples of the humanit ar ian approach. Spir itual explanations may never completely disappear from the hor izon, but the idea that psychological disorders can be understood will cer t ainly provide the best prospects for tur ning that underst anding into treatment.
Spiritual Approach
We begin with the oldest approach to psychological disorders, dating back to prehistor ic times. Archaeological evidence from about 8000 B C E suggests that the spir itual explanation of psychological disorders was then the most widely accepted. Sk ulls discovered in caves inhabited by prehistor ic peoples showed signs of trephining, in which holes were cut into the bone.
Archaeologists have found trephined sk ulls from many countr ies and cultures around the world, many of which reveal a sur pr ising deg ree of medical exper tise (Alf ier i et al., 2012). Trephining continued to be practiced throughout histor y and even into moder n times, but its use dur ing ancient times seems to be specif ically associated with beliefs that the individual exper iencing psychological symptoms was possessed by evil spir its.
A second manifest ation of belief in spir itual possession as the cause of psychological disorders is the r itual of exorcism. In this practice, a shaman, pr iest, or person entr usted with the t ask (such as a “medicine man”) car r ies out r ituals that put the individual under extreme physical and ment al duress in an ef for t to dr ive out devils. Exorcism continues to exist into the present day. For example, V ietnamese people with psychological symptoms are repor ted to seek exorcism and spir it-calling as for ms of healing at Buddhist temples (Nguyen, 2014).
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Dur ing the Middle A ges, people used a var iet y of magical r ituals to “cure” people with Witch-bur ning was a common practice in sixteenth-centur y Ger many, as shown in this render ing.
ZU 09/E+/Gett y Images
psychological disorders, but this treatment also took the for m of casting these individuals as sinners, witches, or personif ications of the devil. According ly, victims were severely punished. The view of af f licted individuals as possessed by evil spir its is apparent in the 1486 book Malleus Malef icar um, in which two Ger man Dominican monks justif ied their harsh punishment of “witches.” Depicting them a s heretics and devils whom the Church had to destroy in the interests of preser ving Chr istianit y, the book’s authors recommended “treatments” such as depor t ation, tor ture, and bur ning at the st ake.
From the 1500s to the late 1600s, the major it y of individuals accused of witchcraf t were women. The bur ning and hanging of witches by the Pur it ans in the United St ates eventually ended af ter the infamous Sal em witchcraf t tr ials (1692–1693), when townspeople began to doubt the authenticit y of the charges against these women. Remnants of the oppression of women who practice indigenous methods of healing remain today in both Wester n and nonWester n cultures (Yakushko, 2018).
Although the spir itual approach is no longer the prevalent explanation for psychological disorders in Wester n culture, there are still pockets of believers who feel people with these disorders require spir itual “cleansing.” Across other cultures, those who enact the role of exorcists continue to practice, ref lecting longst anding cultural and religious beliefs.
Humanitarian Approach
The humanit ar ian approach to psychological disorders developed in par t as a reaction against the spir itual approach and its associated punishment of people with psychological disorders. The roots of the humanit ar ian approach can be traced to the Middle A ges, with the est ablishment of shelters to house these individuals, who of ten were ostracized by their families. The shelters were t ypically located within poorhouses and monaster ies.
Dorothea Dix was a Massachusetts refor mer who
sought to improve the treatment of people with psychological disorders in the mid-1800s.
Librar y of Congress Prints and Photographs Division [LC-USZ62-9797]
Although shelters could not of fer treatment, they initially provided some protection from a harsh outside world. However, they increasing ly became overcrowded and conditions within g rew intolerable. R ather than providing protection, shelters then became places of neg lect, abuse, and maltreatment. A widespread belief that people with psychological disorders lacked ordinar y sensor y capabilities led to s uch practices as not providing them with heat, clean living conditions, or appropr iate food.
Dur ing the sixteenth and seventeenth centur ies, views about medicine were generally uninfor med. Thus, like treatments for physical illness, the treatment of people with psychological disorders included bleeding, forced vomiting, and purging. However, with the newer sciences developing in the Renaissance, thera peutic healing based on compassionate suppor t began to emerge (Dreher, 2013).
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By the end of the eighteenth centur y, the humanit ar ian approach gained fur ther strength as a few courageous people working in hospit als in France, Scotland, and Eng land began to recognize the inhumanit y of the conditions in the poorhouses and monaster ies housing those with psychological disorders. The idea of moral treatment began to t ake hold based on the belief that people had a r ight to huma ne care and that they would benef it the most in their recover y from a quiet and restful environment. Institutions following this model used restraints only if absolutely necessar y, and even in those cases the patient’s comfor t came f irst.
Yet again, however, conditions in the institutions or iginally for med to protect patients began to worsen in the early 1800s due to overcrowding and the increasing us e of physical punishment as a means of control. In 1841, Boston schoolteacher Dorothea Dix (1802–1887) took up the cause of refor m. Hor r if ied by the overcrowding and appalling conditions in the asylums, Dix appealed to the Massachusetts legislature for more st ate-funded public hospit als to provide humane treatment for ment al patients. From Massachusetts, she then spread her message throughout Nor th Ame r ica and Europe.
Although deinstitutionalization was designed to enhance the qualit y of life for people who had been held for years in public psychiatr ic hospit als, many individuals left institutions only to f ind a life of pover t y and neg lect on the outside.
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Over the next 100 years, gover nments built scores of st ate hospit als throughout the United St ates following the humanit ar ian model or iginally advocated by Dix. Her work was car r ied for ward into the twentieth centur y by advocates of the mental hygiene movement, the goal of which was to improve the care and treatment of people living in ment al hospit als. Associated with the ment al hygiene movement was a n emphasis on preventing the development of psychological disorders through early inter vention (Toms, 2010).
Once again, however, it was only a matter of time before the hospit als became overcrowded and underst af fed. It simply was not possible to cure people by providing them with the wellintentioned but ultimately inef fective inter ventions proposed by moral treatment. Public outrage over the worseni ng situation in ment al hospit als eventually led to a more widespread realization that ment al health ser vices required dramatic changes.
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In 1963, the U.S. gover nment took emphatic action with the passage of g roundbreaking legislation. The Communit y Ment al Health Act of that year initiated a ser ies of changes that would af fect ment al health ser vices for decades to come. This legislation paved the way for the deinstitutionalization movement—which was the release of hundreds of thousands of patients from ment al hospit als st ar ting in the 1960s. The legislation mandated that people living in
ment al hospit als be moved into less restr ictive prog rams in the communit y, such as vocational rehabilit ation facilities, day hospit als, and psychiatr ic clinics. These facilities included halfway houses which are communit y treatment facilities designed for deinstitutionalized clients leaving a hospit al who are not ready for independent living.
Also making deinstitutionalization possible was the devel opment, in the 1950s, of phar macological treatments that could successfully control the symptoms of psychological disorders. Now patients could receive treatments that would allow them to live on their own outside psychiatr ic hospit als for extended per iods of time. By the mid-1970s, st ate ment al hospit als that once over f lowed with patients were practically deser ted. Hundreds of thousands of institution ally conf ined people were free to begin living with g reater dignit y and autonomy.
The deinstitutionalization movement did not completely fulf ill the dreams of its or iginators, however. R ather than eliminating inhumane treatment, it created another set of woes. Many of the promises and prog rams hailed as alter natives to institutionalization ultimately failed to mater ialize because of inadequate plannin g and insuf f icient funds. Patients were shuttled back and for th between hospit als, halfway houses, and shabby boarding homes, never gaining a sense of st abilit y or respect. A g reat number spend long per iods of time as homeless and marginalized members of societ y. Although the intention behind releasing patients from psychiatr ic hospit als was to restore basic human r ights to those with psychological disorders, the result may not have been as liberating as many had hoped.
Advocates of the humanit ar ian movement today suggest new for ms of compassionate treatment for people with psychological disorders. This latest approach encourages ment al health consumers to t ake an active role in choosing their treatment. Var ious advocacy g roups have worked tirelessly to change the way the public views people with psychological disorders and the way societ y deals with them in all settings. Pr imar y among these g roups is the U.S. National Alliance for the Ment ally Ill (NAMI) with its g rassroots-based local and regional chapters.
The humanit ar ian approach is also ref lected in the positive psychology movement, which emphasizes the potential for g rowth and change throughout life. The movement views psychological disorders as dif f iculties that inhibit the individual’s abilit y to achieve highly subjective well-being and feelings of fulf illment. In addition, the positive psychology movement emphasizes health over illness and prevention over inter vention.
Improvements in ment al health care from a human r ights perspective have become a central feature of the World Health Organization’s (WHO) Special Initiative for Men t al Health (2019–2023), intended to ensure access to high-qualit y and af fordable care for ment al health conditions at a g lobal level by the year 2023 (WHO, 2019b). Consistent with WHO’s Sust ainabilit y Development Goals (SDGs), this special initiative means to maximize human functioning by counter ing the human r ights violations, discr imination, and stigma associated
with psychological disorders. The wide-ranging prog ram is intended to directly benef it more than 100 million people living in 12 key countr ies, four of which have been identif ied as having what WHO refers to as fragile, conf lict, or vulnerable settings.
Scientific Approach
Looking next at the scientif ic approach, we now retur n to ancient times when it was the early Greek philosophers who f irst took a scientif ic approach to underst anding psychological disorders. Hippocrates (ca. 460–377 B C E ), considered the founder of moder n medicine, believed that ment al health depended on a balance of four so-called bodily “humors” based on the elements of air, water, f ire, and ear th. These physical qualities deter mined all behavior or iginating from the body. Although his theor y itself would eventually be proven wrong, Hippocrates was far ahead of his time in putting for th the notion that ment al health ref lected factors within the body rather than possession by evil spir its. Page 14
Positive psychology emphasizes personal g rowth through medit ation and other alter nate routes to self-discover y Prostock-Studio/iStock/Gett y Images
Several hundred years later, the Roman physician Claudius Galen (130–200 C E ) car r ied this view of bodily humors for ward, also expanding medical knowledge by conducting anatomical studies of the human body. This approach helped to advance the position that diseases had their source in abnor mal bodily functioning.
Dr Benjamin Rush, founder of Amer ican psychiatr y, was an ardent refor mer who promoted the scientif ic study of psychological disorders
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The scientif ic approach to psychological disorder receded for hundreds of years in favor of explanations rooted in the spir itual perspective. It next emerged in the wr itings of Dr. Benjamin Rush (1745–1813), the founder of U.S. psychiatr y and a signer of the Declaration of Independence. In 1783, Rush joined the medical st af f of Pennsylvania Hospit al. Appalled by the poor treatment of psychologically d isturbed patients there, Rush advocated for improvements such as placing patients in their own wards, giving them occupational therapy, and prohibiting hospit al visits by cur iosit y seekers looking for enter t ainment.
Ref lecting the prevailing methods of the times, though, Rush also suppor ted the use of bloodletting and purging in the treatment of psychological disorders, as well as the so-called tranqui lizer chair, intended to reduce blood f low to the brain by binding the patient’s head and limbs. Rush also recommended submerging patients in cold shower baths and fr ightening them with death threats. He thought that by inducing fear, he could counteract their sometimes violent behavior. However, even while advancing these seeming ly unscientif ic methods, Rush also advocated for the use of medicinal he rbs in treating psychological disorders (Forcen, 2017). These can be seen as precursors to moder n phar macological, scientif ically based inter ventions.
The next major advance in the scientif ic approach occur red in 1844, when a g roup of 13 ment al hospit al administrators for med the Association of Medical Super intendents of Amer ican Institutions for the Insane. This organization eventually changed its name to the Amer ican Psychiatr ic Association and is now a leading inter nationally recognized scientif ic and professional societ y.
In 1845, the scientif ic approach received another impetus with the publication by Ger man psychiatr ist Wilhelm Gr iesinger of The Pathology and Therapy of Mental Disorders. Gr iesinger proposed that “neuropathologies” were the cause of psychological disorders, and in so doing, he recognized the role of the ner vous system in abnor mal behavior. Fur ther advances occur red when Ger man psychiatr ist Emil Kraepe lin (1856–1926) promoted a classif ication system for psychological disorders that paralleled those applied to medical diseases, focusing on documenting the patter ns of symptoms associated with specif ic disorders. Ultimately, this work provided the scientif ic basis for cur rent diagnostic systems.
While these advances in medical science and psychiatr y were t aking place, the or igins of a psychological app roach to abnor malit y began to emerge in the early 1800s, when European physicians exper imented with hypnosis for the treatment of people showing symptoms of psychological disorders. Eventually, these ef for ts led to the g roundbreaking work of V iennese neurologist Sigmund Freud (1856–1939), who in the early 1900s developed psychoanalysis, a theor y and system of practice based or iginally in neurology but ultimately becoming focused on the concepts of the unconscious mind, inhibited sexual impulses, and early development.
Throughout the twentieth centur y, psychologists continued to develop models based on obser vations of the behavior of laborator y animals. The work of Russian physiologist Ivan Pavlov (1849–1936), known for his discover y of classical conditioning, became the basis for the behavior ist movement begun in the United St ates by John B. Watson (1878–1958). B. F. Skinner (1904–1990) for mulated a systematic approach to operant conditioning, specifying the t ypes and nature of reinforcement and its use as a way to modify behavior. In the twentieth centur y, these models continued to evolve into theor ies that would have more direct relevance to psychological disorders, including those of Alber t Bandura (1925–), A aron Beck (1921–), and Alber t Ellis (1913–2007).
Page 15
These newer models, along with integ rative models that t ake a biopsychosocial approach, are leading to promising empir ical (evidence-based) ways to underst and the causes of psychological disorder. Although not all may prove useful, they will help ensure that our application of the scientif ic perspective results in treatments that are both humane and scientif ically based.
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Allemani and Gratia attribute the disease to the absorption of the first milk (colostrum), and there are several considerations that strongly favor this hypothesis. The disease sets in always in connection with the parturient development and congestion of the udder and the secretion of the first milk. In exceptional cases it may even appear just before parturition. Even upon the calf the colostrum operates as an irritant and purgative. Is it wonderful that, in the parturient cow, with a high state of plethora, a highly susceptible state of the nervous system, and the various concurrent conditions already referred to above, a direct poisoning of the nerve centres should appear? It is worthy of notice that the absorption from the mammæ takes place without any metabolic change, such as occurs in the stomach and liver in the case of materials digested. It is to be presumed that the hypothetical mammary poison is delivered in the brain in its pristine condition and possessed of its full force.
The doctrine is corroborated even more strongly by the successful results of treatment by the injection of a solution of potassium iodide into the udder. The iodide solution may presumably act in one or more of several ways. It is unquestionably an antiseptic, and would tend to arrest or control microbian growth and activity, thus preventing the further formation of toxins. It has a potent deobstruent action on glandular tissue, tending not only to dry up the milk, but to hold in check the leucocytic function of producing dangerous leucomaines. There is reason to believe that with regard to some poisonous ptomaines iodine acts as a direct antidote, probably uniting with these and forming new and comparatively harmless compounds. It manifestly acts in this way in the case of cryptogamic diuresis, and in cerebral congestions arising from spoilt fodder. The iodide tends further to act as a calmative to the nerve centres, and as a diuretic, serving to eliminate the poison that may be present in the blood.
Microbian Infection or Intoxication. The doctrine has been advanced that the disease is either a microbian infection of the nerve centres or a process of poisoning by the absorbed toxins of microbes. Of the two hypothesis the latter is the more acceptable, in view of the fact, that cows in a condition of coma will sometimes recover with extraordinary rapidity. This is more likely to occur in connection with the elimination or exhaustion of a transient narcotic poison,
than with a deadly microbe colonized in the brain. This hypothesis is in full accord with the acknowledged success of the iodide injections; with the observation of Bissauge, which I can endorse, that certain villages and hamlets habitually furnish cases of parturition fever, while neighboring ones, with the same breeds and apparently the same management escape; and with the observations of Russell and Wortley Axe, that the malady will sometimes be suddenly prevented in a herd, by the simple expedient of having the cows moved to a new and previously unoccupied stable, for calving and the first nine days thereafter.
In support of the doctrine of a microbian origin is recalled the fact that the disease almost invariably follows parturition, which opened the way for the introduction of bacteria by the genital passages. This is somewhat invalidated by the fact that it follows the easy parturition, in which there was no chance for the introduction of germs on hands or instruments, and does not follow dystokia in which, without question, germs have been planted abundantly in the interior of the womb. Undue weight should not be given to this objection, as the essential accessory conditions of plethora, etc., are usually largely modified in cases of dystokia.
The microbiology of the affection leaves much to be desired. Coureur and Pottiez and later Van de Velde found a streptococcus in the blood. Trinchera, Nocard, and Cozette found the common pus cocci (staphylococcus pyogenes aureus, citreus and albus) a streptococcus and a colon bacillus in the liquid squeezed from the cotyledons, and in the liquid debris on the uterine mucosa. These microbes were not found in other organs. They grew readily in artificial cultures, but we lack the final proof of a successful inoculation on a susceptible parturient subject. The whole subject is therefore still a plausible theory.
We are not however limited to the womb as the only possible field of a pathogenic microbian growth. The frequent presence of microbes in the sphincter of the teat, in the galactophorous sinus, and in the milk ducts inside the mammæ is absolutely proved. Guillebeau found on the mucosa in cases of mammitis three forms of bacillus, to which he attributed the disease. In the New York State Veterinary College we have found mammitis usually associated with a streptococcus in the milk. In one cow in the University herd which
gave abundance of good milk, and rarely showed any sign of congestion, streptococcus was constantly present. In cows producing “gassy” curd, V. A. Moore and A. R. Ward found in the milk a bacillus which morphologically and in cultures resembled the colon bacillus (evidently one of the colon group). In the milk and mammary gland tissue got from other (slaughtered) cows, a micrococcus growing in yellow or buff-colored colonies predominated. (Moore and Ward). That the colon bacillus, so constant in the intestines and manure, is not always found in the milk ducts, would show that in its normal condition it is not adapted to this habitat, but when a variety appears that is so fitted, it appears to be able to maintain its place indefinitely.
With such facts before us, we must allow the possibility of poisoning by toxins of bacteria in the udder, or by compounds formed by the synthesis of such toxins and the leucomaines of the expanding udder, or by the union of the udder toxins with those from the womb. The whole subject of microbian and leucocytic causation of parturient fever is still hypothetical, yet enough is known to show the high probability of such source, and to demand a thorough investigation which will place the subject on a substantial and assured basis.
Nature. Theories of the nature of this disease are numerous and varied, and are largely based upon some restricted or one-sided view of phenomena and lesions. Coutamine considers it as the reaction of the surplus of nerve force, which was not used up in the easy parturition. The theory is somewhat fantastic as an explanation of the rapidly developing asthenia and paralysis. Billings explains the cerebral anæmia as due to vaso-constriction of the nervous capillaries produced by the exaggerated excitability of the uterine nerves. But with the easy parturition, and delivery, and the moderate contraction of the womb, without violence or spasm, the theory seems rather insubstantial. Trasbot looks on the affection as a congestion of the myelon, apparently shutting his eyes to the far more prominent encephalic symptoms. Haubner considers it as a cerebral anæmia induced by the vaso-dilatation in the portal system and abdominal viscera generally, the result in its turn of the vacuity of the abdomen, from the expulsion of the fœtus and its connections. But the womb is often found contracted and comparatively
exsanguine, the plethoric condition of the cow, suddenly increased by the great mass of blood from the uterine vessels, maintains a marked general blood tension, and finally, the closed box of the cranium cannot have its blood so completely drained from it as can a part outside such a cavity. Stockfleth attributed the malady to a metro-peritonitis, and the absorption of the morbid products and poisoning, but neither a metritis nor peritonitis is a common accompaniment of the affection.
Franck who accounts for the asthenia by an anæmic condition of the brain, explains the anæmia by a pre-existing congestion and œdema of the rete mirabile at the base of the brain. He claims that sows which have also a rete mirabile in this situation sometimes suffer from parturient fever. He fails to adduce cases in the sheep and goat which also have retia mirabilia. The pregnant sheep may die of an asthenic affection, but usually before parturition. Franck’s theory is plausibly based on the anatomical and physiological conditions, for the elaborate network of vessels at the base of the brain, undergoes great distention under increased arterial tension, and with the serous effusion, compresses the brain and drives out its blood.
Palsy of the ganglionic system has been invoked, with succeeding congestion of the myelon and encephalon (Barlow, Kohne, Carsten Harms, etc.). Explanation is made that the supposed excess of nervous force fails of distribution through a lack of conductility of the nerves, and the nerve centres suffer. Binz has even found the spinal roots of the sympathetic surrounded by a thick gelatinoid exudate. The theory is, however, essentially speculative and fails to explain the origin of the disease or its connection with the recognized conditions of its occurrence.
Plethora with Arterial tension and all conditions contributing to this, as already set forth under causes must be allowed a prominent place in considering the nature of the disease. The blood globules in my experience are somewhat smaller than normal, implying the density of the plasma, and implying a direct influence on trophic and metabolic processes. Under these influences the congestion of the encephalic circulation, and notably of the rete mirabile, and a serous effusion, tend first to prostrate the nerve force, and second to render the other intracranial structures anæmic.
The direct action of a narcotic poison, leucocytic or microbian, though as yet a hypothesis merely, has much in its favor, on considerations drawn from the observed immunity in particular buildings, the sudden prostration, the promptitude of certain recoveries and the favorable results of the iodine mammary injections. The presence of sugar in the urine, most abundantly in the worst cases, implies a profound disorder in glycogenic centres (medulla, liver), and primarily no doubt in the bulb.
Lesions. These are exceedingly variable in successive cases. Congestion and effusion in the meninges, cerebral or spinal, in the rete mirabile and choroid plexus have been often noticed, and exceptionally clots of extravasated blood. In certain cases congestion and pink discoloration of portions of the brain substance (cerebral convolutions, bulb, ganglia) with marked puncta vasculosa, are found, while in others the greater part or the whole of the encephalon is anæmic. The puncta in such cases, large and dark, on the surface of the section, promptly enlarge until they may form distinct drops.
In the lungs areas of collapse, and of dark red congestion and infiltration are common, mostly as the result of the entrance of alimentary or medicinal matters into the bronchia owing to palsy of the pharynx. Such materials can be found in the bronchial tubes.
The third stomach and the large intestine may be impacted, the contents more or less baked and glossy on the surface, and coincident congestions of the mucosa are not uncommon. In some instances, however, the contents are soft and pultaceous and the absence of mucous congestions is remarkable.
The womb rarely shows characters differing from the condition which is normal to the first few days after parturition.
The blackness and thickness of the blood has been noted by practically all observers. This is partly the result of its density, but doubtless also of the undetermined toxins which are operative in the disease.
Yellowish gelatinoid exudates have been found in the subdorsal and sublumbar regions, as well as the cranium and spinal canal.
Glucose appears to be constantly present in the urine, and in excess in the more violent and fatal cases: from 1.19 grm. per litre in
slight cases to 41.8 grms. in a fatal one (Nocard). Albumen may be present, though probably only when local inflammation has supervened.
Symptoms. The conditions of the attack should be noted. This is a disease of the first six days after parturition, rarely seen in the second week, and never after the fourteenth day. It is very exceptional before parturition, yet Müller quotes 47 cases in 1107 births. The breed, condition, milking qualities, plethora, feeding, etc., of the patient are, as already noted important data in diagnosis. The onset is sudden without premonitory symptoms.
Two very distinct types are met with, the comatose and violent or spasmodic, which, however, merge into each other by insensible gradations, and may follow each other.
From twelve to seventy hours after an easy parturition there suddenly appear signs of discomfort. Feeding and rumination cease, the calf is neglected, there may be plaintive moaning, the eyes seem dull and clouded, the eyelids drooped, the conjunctiva red, the pulse normal for parturition, sometimes extra strong, the breathing excited often with moans or grunts. The senses are dulled, the walk is unsteady, the feet being abducted and planted like clumps, or the legs sway, perhaps cross each other, remain semi-bent, and soon give way leaving the animal prostrate, resting on the sternum and abdomen, or later on the ribs, with head extended. Attempts may still be made to rise, but this is rarely accomplished unless when improvement sets in. This is the condition in which the patient is usually found, being the first to be noticed by the owner. The bowels are torpid, the urine retained in the bladder, and the animal may remain thus in a drowsy condition, without changing from the sterno-ventral decubitus, or dropping the head on the ground until improvement sets in. The head rests on the shoulder or upper flank. If held outward or forward the upper border of the neck has an S shaped outline.
More commonly the somnolence increases, passing into a complete torpor and insensibility, the eye may be touched without causing winking, pricking or other injury causes no further response, the patient turns upon its side, with its head extended on the ground. She may lie in this condition with no sign of vital activity save pulsation and breathing, and the latter is liable to be slow and
stertorous by reason of the paralysis of soft palate and larynx. The jugulars usually show a venous pulse. Fermentations in the inactive paunch cause the evolution of gas with tympany, which still further obstructs the breathing, and reacts injuriously on the nerve centres. The normal eructations from the rumen may continue, with liquids and floating solids, and in the paralytic state of the throat these too often pass in part into the bronchia, causing septic bronchitis and pneumonia. The same is liable to follow the administration of liquids, the irritant drugs passing into the larynx, trachea and lungs. The pulse becomes soft, small and finally almost imperceptible. It may be 50, 60 and upward.
In favorable cases, defecation may still occur, or the rectum once emptied may fill again through the continuance of peristalsis, the milk continues to be secreted, and in one to four days, spontaneous defecation and micturition may be resumed, and the patient may get on its limbs and commence feeding. There is usually at first a little weakness of the limbs, but this is transient and health is restored in a very short time. The suddenness of the improvement is often as marked as of the attack. The patient is left prostrate and insensible, without giving any response when the eyeball is touched and in two or three hours it is found on its feet, eating, with eyes bright and clear.
Some patients, however, are restored to ordinary sensation, intelligence and appetite, while the hind limbs remain paralytic, or paretic, and the station and gait both weak and uncertain for days or even weeks. In such cases there have been presumably structural changes in the nerve centres, which require time for repair.
In fatal cases, death may occur quietly from apoplexy, cerebral compression, or narcotism, or it may be preceded by a period of marked excitement or disorderly muscular movements. Lifting of the head, throwing it alternately on the shoulder and on the ground, trembling of head, members and body, cramps or jerking of the limbs or of other parts, drawing the hind limbs up against the abdomen, and again extending them, rolling of the eyes, loud, noisy, irregular, embarrassed breathing and a running down pulse are often marked features.
The temperature range is peculiar. At the start there may be some hyperthermia 103° or 104°; with the advance of the disease it tends
to become lower, 98°, 96°, or 94°. When improvement sets in, it rises again promptly to the normal.
Cadeac describes a special form which is ushered in by great restlessness, bellowing, throwing the head to right and left, grinding the teeth, sucking the tongue, salivation, licking of certain parts of the body, spasms in the neck, back or limbs, and prompt recovery, or lapse into the comatose condition as above described. It proved less fatal than the ordinary comatose type, but seems to depend on similar conditions.
Prognosis. Mortality. The disease is very deadly, the mortality in time past having reached 40, 50 or even 60 per cent., the gravity increasing as the disease set in nearer to parturition. Cases occurring on the first or second day were mostly fatal, those at the end of the first week were hopeful, and those occurring during the second week were very hopeful. With the Schmidt (iodine) treatment the mortality is claimed to be reduced to 16 or 17 per cent.
Prevention. Measures directed toward the lessening of plethora tend to remove one of the most fruitful causes of the disease and though not invariably successful, are yet of great value. The most direct is the abstraction of blood in the last fortnight of pregnancy, to the extent of 6 or 8 quarts. This tends to secure a lessening of the blood tension, and blood density, but there is the drawback of a created tendency to a subsequent increase in blood formation to make up the loss. This measure should be reserved for cows that are very plethoric, extra heavy milkers and such as have already suffered from the disease.
Purgatives will measurably secure the same end without the same degree of danger. One to two pounds of Epsom or Glauber salts in the last week of gestation, or at latest when labor pains set in, tend not only to remove solid or impacted masses from the first and third stomachs, and inspissated contents from the large intestines, but to secure a free depletion from the portal system. If not before, this should always be given immediately after parturition to cows in extra high condition, heavy milkers, and that have had a short and easy delivery.
Restriction of food for a week before and as long after parturition is of equal importance. A very limited supply of aqueous, easily
digested, and laxative food (roots, sloppy bran mashes, fresh grass, ensilage) will meet the demand.
Exercise in the open air is of great value in giving tone to the muscles, and especially the nervous system, and in stimulating the emunctories and other functions.
In the cold season protection against cold draughts and chills must be seen to, and in the hot season the avoidance of an excess of solar heat and above all of the confined impure air of the barns.
At midsummer and later, there is often great danger in the rich clover and alfalfa pasture, or soiling crop, with which the cow will dangerously load her stomach, and the only safe course is to remove predisposed animals and shut them up in a bare yard or box-stall. Under such simple precautions herds that had formerly suffered severely, have had the disease virtually put a stop to.
In individual cases other measures are indicated. When the udder has reached an enormous size and development, and is gorged with milk, days before parturition, it should be systematically milked. The irritation in the gorged gland is quite as likely to induce premature parturition, as is milking, and, at the worst, the result is not so bad as an attack of parturition fever.
Basing his advice on the fact that parturition fever does not follow a case of severe dystokia, Cagny applies sinapisms on the loins, croup and thighs of a fleshy, plethoric, heavy milking, parturient cow. Proof of their efficacy is not obtainable.
Félizet advises leaving the calf with its dam for one week. Kohne doses the cow with nux vomica: Harms, with tartar emetic.
In view of the probability of a bacterial infection the cow should be taken to a clean, pure, well-aired stable a day or two before calving, having been first cleansed from adherent filth, and sponged all over with a 4 per cent. solution of carbolic acid.
To prevent diffusion of infection Bournay recommends antiseptic injection of the womb immediately after calving. Bissauge adds that the stable should be disinfected after every case of parturition fever, the manure carefully removed and the ground scraped and well watered with a disinfectant.
For fleshy, plethoric, predisposed cows, the iodine injection of the udder should be applied immediately after calving. A measure of this
kind which is so successful as a curative agent, and which brings such circumstantial evidence of the production of a poison (leucomaine or ptomaine) in the mammary gland, can hardly fail to be even more effective as a prophylactic than as a therapeutic resort.
Treatment. With the state of plethora and congestion about the head in the early stages the question of bleeding at once arises. If early enough while there is a full bounding pulse, and as yet no sign of great loss of muscular control it is often very beneficial, as much as 6 quarts or more being withdrawn. It is well however to avoid cording the neck, which must increase the vascular tension in the brain, and to trust rather to digital compression of the vein. The blood should be drawn from a large opening in a full free stream, and may be stopped when the pulse softens. In the more advanced condition, with paralysis and more or less dulling of the senses, or coma, bleeding may be dangerous rather than useful. There is then serious pressure on the brain, with serous effusion, and perhaps blood extravasation, and in any case anæmia, and this latter may be dangerously or even fatally increased by the lessening of the blood pressure, without any compensating advantage in the way of reabsorption of the effusion. In such cases eliminating agents are a safer resort.
Purgatives commend themselves, but with the drawback of a too tardy action. Now however with the peristaltic stimulants given hypodermically this objection is largely obviated. Pilocarpin 1½ gr., and eserine 3 grs. will often secure a noticeable movement of the bowels in the course of fifteen minutes, implying a corresponding motion onward in the bowels more anteriorly, and even of the contents of the gastric cavities. If there is already palsy of the muscles of deglutition, this may be repeated several times at intervals of four or five hours. If however deglutition is still well performed a purgative of one or two pounds Epsom salts, with 10 drops croton oil, and 1 oz. oil of turpentine may be given by the mouth. Should this operate, it will supplement and carry on even more effectively the work of the hypodermic agents, and even lessen the density, plasticity and tension of the blood and act as a potent derivative from the brain.
A compromise may be made by giving aloes 2 ozs., croton oil 20 drops in bolus; or 1 to 2 ozs. sulphate of soda in solution may be
injected subcutem.
In any case oil of turpentine or other antiseptic is of great value in the stomach in preventing fermentation and tympany, and thereby obviating a whole series of troubles such as: cerebral disturbance by nervous shock and blood pressure; impaired respiration and hæmatosis by pressure on the diaphragm; and eructations of food to the pharynx and its inhalation or gravitation into the lungs.
It is always well to clear out the rectum by injections, when if there is any indication of pharyngeal paralysis most of the remedies may be given by this channel.
Stimulants (ammonia carbonate, alcohol, anise, fennel, ether, nux, etc.) have been largely employed by the mouth and may be by the rectum. In the absence of spasms I have relied largely on nux or strychnia.
When the skin chills, some have sought to heat it by enveloping the posterior half of the body in cotton or wool soaked in turpentine, by applying sinapisms, or by moving over the surface a warming-pan containing red hot charcoal.
More generally cold in the shape of cold water, ice or snow has been applied to the cranium and spine. Theoretically the anæmic brain might be thought to forbid this, but clinically it often operates well, possibly by inducing a sympathetic contraction of the vessels in and around the nerve centres and thus indirectly favoring the resumption of active circulation and the reabsorption of effusions.
An elevated position of the head is no less important. It favors the return of blood from the brain by gravitation, and in this way improves the intracranial circulation, and the resumption of normal function. A halter, or a rope around the horns, may be tied to a beam overhead, or the head may be laid on thick bundles of straw which will keep it up to or above the level of the chest, and in this way not only is gravitation ensured, but the brain is protected against the violent blows and concussions, which come from dashing the head on the ground.
Frequent rubbing of the udder and drawing of the milk, is an excellent means of depletion, a removal of a source of irritation, and presumably an extraction of part of the offending poison. It should
never be neglected. But of all known methods of treatment the iodine injection furnishes the greatest hope of success.
Injection of the mammæ with Iodine. Iodide of potassium 100 grains (200 grs. in the case of a very large udder) are dissolved in a quart of water which has been boiled for 15 minutes, the solution cooled to 104° F. and injected in equal parts into the four quarters, which have been just milked out clean. The glands are then manipulated so as to work the solution into all the recesses of the milk tubes and follicles. If the patient does not get on its legs at the end of twelve hours, the glands may be milked out and injected anew. In nearly 2000 cases the recoveries reached an average of nearly 83 per cent. In serious or advanced cases with structural changes of a grave nature, a good result cannot be hoped for. The injection does not forbid the concurrent use of other approved measures.
The injection is easily made with a caoutchouc tube of five feet long fitted to a teat tube at one end and to a funnel at the other. The tube is inserted in the teat, and the funnel at a height of five feet receives the liquid, which readily passes into the teat. When ready to pass the tube from one teat to another, an assistant pinches the caoutchouc tube just below the funnel, until the insertion has been made. Every precaution must be taken against sepsis. The udder, teats and hands, must be washed with soap, and treated with a 3 per cent. solution of lysol. The teat tube and funnel are boiled. The caoutchouc tube is washed and irrigated with a solution of mercuric chloride (1:1000), and then with one of boric acid (3:100).
DISEASES OF THE EYE.
DESIRABLE FEATURES IN THE EYE.
The eye in the physiognomy. Broad forehead. Full eyes. Both eyes alike. Iris smooth, lustrous. Media translucent. Pupil sensitive to light. Convexity median, uniform. Pupil black in ordinary light. Lids open and mobile. Sclera light pink. Tears clear, limpid without overflow. Lids thin, delicate, margins evenly curved. Whole eye responsive to moving objects. Defects: small eye: semi-closed, thick, sluggish lids; convex cornea: sunken eye: projecting eye: weeping eye: blear eye: watch eye: irresponsive iris: dilated pupil: unequal eyes: flat cornea; ovoid cornea.
Much of the expression of the face depends upon the eyes, and in animals as in man it is difficult to find compensations for a forbidding countenance. Perfect, sound, intelligent eyes are always pleasing; imperfect, defective, sunken or lifeless eyes mar the whole expression. The following points may be specially noted:
1st. Ample breadth between the orbits. This is of great importance in the horse, in which we seek for intelligence, courage and indomitable energy. This confirmation does not indicate the size of brain, as the cranium is situated higher up, but by placing the eyes well outward, it indicates a wider range of vision, and usually implies large, clear eyes, and since interdependent parts tend to correspond in development and quality, this commanding vision bespeaks a large, active brain, intelligence, docility and activity.
2d. Full, prominent eyes. This may be excessive, either through primary conformation or disease. Abnormal convexity of the cornea implies myopia. But within normal limits the prominent eye suggests good health, condition and vigor, with ample cushions of fat under the bulb and a sound, well-developed condition of the eyeball and its muscles.
3d. Both eyes equal in all respects. Any variation in size, shape, color, fullness, clearness or in any other respect is at best unsightly, and implies not only defect but often disease as well.
4th. The iris should be lustrous, uniform in color and even in surface. Whether dark brown as in the horse, or yellow as in the dog, it should be brilliant. Any part that lacks lustre, being lighter brown, or yellow and dull like a dead leaf, usually indicates previous disease and a tendency to further trouble. Albinos and those in which the pigment is congenitally absent in patches must be considered as exceptions, yet, even in them, the peculiarity cannot be held to add to the beauty.
5th. All the Media (Cornea, aqueous humor, lens and vitreous) must be perfectly clear and translucent. The slightest cloudiness or opacity in any of these is a serious blemish and usually indicates disease, past or present.
6th. The pupil should promptly and freely respond to light and darkness by contraction and expansion. Absence or tardiness of movement indicates impaired vision, from disease of the eye, its nerves, or their nerve centres.
7th. Each cornea should have a median convexity, uniform in all directions implying the absence of myopia, preshyopia and astigmatism. Any deviation from this will interfere with the perfection of sight, and endanger shying and other troubles.
8th. Under ordinary light the pupil should appear black throughout. In the larger animals such dilation of the pupil as to expose the tapetum lucidum under such circumstances implies impaired vision (amblyopia, amaurosis), inflammation of the iris or undue intraocular pressure. A white color or spot shows cataract.
9th. The lids must be open and mobile without excessive dilation. Tardily moving or semi-closed lids, distorted by scar or angle, everted or inverted, are unattractive and usually imply disease in the eye, nerves or brain.
10th. The unpigmented portion of the sclera should be light pink. The dark red of congestion and the pallor of anæmia are equally objectionable.
11th. The tears must be clear, limpid and confined within the lower lid. Any milkiness, flocculency or overflow is indicative of disease.
12th. The eyelids must be thin, delicate, evenly and uniformly curved along the borders, and fringed by an abundance of strong, prominent and well directed lashes. Puffiness or swelling betrays inflammation, dropsy, anæmia, parasitism or other disorder, angularity of the upper lid an internal ophthalmia, and depilation or wrong direction of the lashes, local disease.
13th. The eye should respond instantly, by movement, to new objects and noises, without showing undue irritability or restlessness. The intelligent apprehension of the objects will introduce an aspect of calmness and docility.
DEFECTS, BLEMISHES AND ABNORMALITIES OF THE HORSE’S EYE.
Some of these may be present in the absence of actual disease, and yet prove so objectionable that they disqualify the animal for any use, in which style or æsthetic appearance is demanded. Among such sources of disqualification may be noted:
1st. The small eye. One or both eyes may appear small because of internal pain and retraction within their sockets, or from actual atrophy or contraction of the eyeball, the result of deep seated disease, or the organ may be congenitally small, and deep seated in the orbit, and the thick tardy eyelids may have a narrow opening through which they can only be partially seen. This last condition usually implies a dull lymphatic constitution, low breeding and a lack of intelligence, docility and vigor.
2d. The semi-closed eye with thick, coarse, sluggish lids. In this case the bulb may be not unduly small, yet as it is not freely exposed it conveys the same general expression to the observer. Like the small eye it indicates low breeding, lack of intelligence or docility and often stubbornness or even vice.
3d. The convex eye. In this the transparent cornea describes the arc of an unduly small circle, suggesting a conical form and projecting unduly beyond the margins of the lids. It implies imperfect vision, myopia, and, it is alleged, low breeding and lack of alertness.
4th. The sunken eye. This has been already referred to under the small eye. The eyelids are usually flaccid, the upper being drawn in by its levator so as to form an angle, and the edges of the orbit are somewhat prominent. It is seen in old, worn out animals, which have lost the pads of fat in the depth of the orbit, and more
commonly in animals that have suffered several attacks of recurrent ophthalmia.
5th. The projecting eye. In this case the lids are unduly contracted and the eye protrudes between them so as to show a large amount of sclerotic around the transparent cornea. This may be due to nervous strain and suffering but, however produced it is decidedly unsightly and objectionable.
6th. The weeping eye. This is always a condition of disease. It may be due to irritant gases, or solid particles, to inturned cilia, everted lids, conjunctivitis or a variety of other conditions. A careful examination may show whether it is only a transient and remediable fault of a good eye or a permanent and irremediable defect.
7th. The blear eye. With swelling and scabbing of the edges of the lids and Meibomian glands, and congestion of the adjacent conjunctiva, there is usually some blurring of the surface of the transparent cornea. The trouble is mostly chronic and constitutes a serious objection.
8th. The watch eye. In this, as in the albino, there is a lack of pigment, so that the iris and sclerotic are white or bluish white in part or in whole. Such an eye may be good and durable, but not beautiful nor attractive.
9th. Blindness of one or both eyes. In all such cases the pupil remains fixed and immovable, showing no accommodation to light and darkness, and there is a lack of prompt responsiveness on the part of the eye to sounds and objects. In amaurosis, glaucoma and cataract especially, the pupil remains widely open, and alert movements of the ears are employed to make up for the lack of sight. The condition often comes from internal ophthalmia, such as the recurrent form, and is associated with atrophy of the bulb.
10th. Eyes of unequal size. This usually implies serious disease in one, not infrequently recurring ophthalmia.
11th. Too flat corneal surface. In this case there is a manifest lack of the normal projection, the anterior surface of the cornea describing the arc of a larger circle, the visual rays coming from a distance alone converge on the retina and presbyopia occurs. In this as in myopia and other visual imperfections a horse is liable to stumble and, if nervous, to shy.
12th. Ovoid Cornea. In such cases the front of the transparent cornea has an ovoid outline the arc formed by it in one direction being that of a greater circle, than the arc which crosses this at right angles. In consequence of this, the rays impinging on the outer portions of these respective arcs do not converge to the same point on the retina and a blurred and imperfect image results. This astigmatism causes the subject to stumble and, if nervous, to shy.
SYSTEMATIC INSPECTION OF THE EYE.
System in Examination. Eyelids: cilia: lachryneal puncta: mucosa, light pink, brick red, yellow, puffy, dropsical: Ciliary vessels deep, immovable; nictitans; transparent cornea equally smooth, glossy, with clear image at all points: foreign body on cornea: corneal ulcer: opacities in aqueous humor: iris and pupil: corpora nigra: changes in passing from darkness to light: pupillary membrane: adhesions of iris: intraocular pressure: contracted pupil: hole in iris. Oblique focal illumination of cornea, aqueous humor, iris, lens, Purkinje-Sanson images.
In examining animals for soundness and especially the horse or dog, the condition of the eye must be made one of the most important subjects of inquiry, as a disease or defect may render the animal altogether unsuited to the object to which it is destined. As in every other field of diagnosis thoroughness is largely dependent on the adoption of a system which will stand in the way of any flaw being too hastily overlooked. Many of the points to be noted will be decided at a glance, yet this does not obviate the necessity of turning over in the mind, in succession, the different points of inquiry, and directing the necessary attention, however hastily, to each in turn. The following points should be observed:
1st. Are the eyelids swollen, hypertrophied or faulty in form, position or movements. Faults as thus indicated may imply any one of a great variety of disorders which should be followed out to their accurate diagnosis. It may be bruises, lacerations, punctures, parasites, conjunctivitis, keratitis, dropsy, anæmia, hepatic or intestinal parasitism, nephritis, paresis, entropion, ectropion, etc.
2d. Inspect the cilia as regards form, size and direction. Absence or wrong direction may imply disease of the Meibomian glands, infective inflammation, demodex or other acarian infesting, or turning in or out in inflammatory conditions.
3d. See that the lachrymal puncta are open and that there is no overdistension of the sac. The overflow of tears and the swelling of the caruncle and of the area beneath it will often indicate such trouble. In its turn it may imply inflammation of the duct, and obstruction by the tenacious muco-purulent product, or it may imply merely obstruction of its lower end by a dried scab. This last may be seen in the horse, on the floor of the false nostril at the line of junction of the skin and mucosa, and in the ass, higher up on the inner side of the ala nasi. In exceptional cases it may be desirable to pass a stilet through the canal from the puncta downward or from below upward to determine whether it is pervious.
4th. Determine the vascularity of the conjunctiva. When free from pigment as it habitually is in pigs and birds this is easily done, while in animals like the horse, in which the bulbar portion, which covers the sclerotic, is largely pigmented, we can scrutinize only the pigment free parts. In health there should be only a few, fine, pink vessels which move with the mucosa when pressed aside on the bulb. In congestion the surface may appear brick red, and the vessels are irregular, large, tortuous and are seen to anastomose at frequent intervals. These move on the bulb when pressed. The congestion is usually deepest on the palpebral mucosa and in the cul de sac, and may be whitened for an instant by pressure through the eyelid. To expose the conjunctiva the right fore finger and thumb may be pressed on the upper and lower lids respectively of the left eye, and the left finger and thumb for the right, allowing them to slide backward above and below the eyeball. Another method is to seize the cilia and edge of the upper eyelid between the finger and thumb, and draw it downward and outward from the bulb, and then deftly invert it over the tip of the finger. In the old the unpigmented conjunctiva may appear yellow from the presence of subconjunctival fat, or this may appear at any age from hepatic disease (distomatosis) or icterus. It is swollen, or dropsical in anæmia, distomatosis, etc.
5th. Examine the ciliary vessels whether they are congested or not. These are distinguished from the conjunctival vessels in that they radiate in straight lines outward from the margin of the transparent cornea and do not move on the sclerotic under pressure. They are enlarged and very red in congestion of the ciliary circle and in iritis. In eyes devoid of pigment over the sclerotic, there
