SECTION ON STATE MEDICINE AND PUBLIC HYGIENE. 1. Incipient Insanity, Diagnosis and Treatment. John Punton, M. D., Kansas City, Mo. 2. The Relation of the Public Schools to the Medical Profession. Prof. Arthur Lefevre, Austin. 3. The Prophylaxis of Tuberculosis. William S. Carter, M. D., Galveston. 4. Tuberculosis in Our Public Institutions. Jas. F. Greenwood, M. D., San Antonio. INCIPIENT INSANITY, DIAGNOSIS AND TREATMENT. JOHN PUNTON, M. D., KANSAS CITY, MO. The mildly insane appeal, as a class, more often to the general practitioner than the alienist. Not until some serious complication has arisen in connection with the case is it found necessary to consult the medical psychologist. My remarks will purposely be restricted to those varieties of insanity with which the general medical practitioner is more liable to come in contact; emphasize those features which relate to their incipient manifestations, as well as diagnosis and treatment. Considered from whatever standpoint, it is clear that no other symptom or disease can be compared with this demon of the intellect, in the terror it inspires, in the deep distress to relatives and friends, in the utter helplessness to the sufferer, as well as the serious havoc it creates in all business relations and social ties. The diagnosis and treatment of insanity should, therefore, claim our most earnest and constant attention. In view of the susceptibility to critical argument, no attempt will be made to burden you with a strictly technical definition of insanity, but if it is, as I believe it to be, an expression of some derangement of function or stricture of the brain, or both those combined, by virtue of which the normal mental attributes of an individual are so affected as to lessen the power of controlling thought, speech and conduct, then it would seem that the symptoms accompanying these changes are the most essential clinical elements for the physician to not only recognize, but correctly interpret, as these are nothing more or less than the tangible expression of the underlying pathological process. When, therefore, we are called to minister to a case presenting symptoms of insanity, and this principle is applied, we find that its chief clinical feature represents one of three great psychological states, viz.: first, mental depression; second, mental exaltation or delirious excitement, and third, mental weakness or enfeeblement. Now, upon analysis, you will observe that these correspond to the three most common varieties of insanity, viz.: Melancholia, mania and dementia. It is, therefore, extremely important that we familiarize ourselves with not only the psychological, but also the accompanying corporeal changes with which these are associated. Dementia does not properly come within the scope of my subject, and I shall purposely omit its consideration, confining my remarks to the study of melancholia and mania. At the present time a remarkable change is taking place in reference to our former knowledge of insanity, characterized by a marked disposition toward more strict accuracy and simplification in its classification, diagnosis and treatment. For centuries it has been the prevailing custom to classify insanity from either its etiologic, symptomologic, pathologic or psychological standpoint, so that those of us who learned our psychiatry fifteen years or more ago know full well how these views of insanity were handed down from generation to generation, and how they still cling to our memory, thereby moulding our forms of thought in classifying the more common types. It is only within the past few years, however, that we in America have fully realized their faulty consideration, and that, as the result of modern critical investigation, such views are now known to be wholly inaccurate and misleading, as the newer and more correct views recognize these common psychoses as belonging to and forming a part of the same pathological process. Moreover, the newer conceptions of insanity recognize that in the study of these mental disorders, one group or class of cases tend toward recovery, while still another class have a characteristic proneness to rapidly merge into dementia. Upon this clinical fact, therefore, depends the future welfare of our patient. Hence, in every case of incipient insanity, we now look, from the outset, for the prognosis, as in the former case a favorable opinion can be ventured, while in the latter class the final outcome is beset with serious misgivings. The trend of modern psychiatry is therefore toward simplification in classification, whereby a simple species of insanity takes the place of several under the older teaching. Hence the modern term, manic-depressive insanity, is now being used for both mania. and melancholia, which not only expresses their true pathological association, but also furnishes more correct rules for their diagnosis, prognosis and treatment. All authorities agree that incipient insanity, in the vast majority of cases, is preceded by varying degrees of mental depression, and various theories have been advanced to account for its presence, but it must be confessed that up to this date its true pathogenesis is not well understood. Mercier1 declares "that the depression of spirits has for its physical basis a low ebb of tension of nervous energy, and that this condition has its physical effect in producing an undue lack of activity in all the bodily organs." Clouston2 claims "that depression is simply the functional expression of convolutional malnutrition.” I heard Turner3 read a paper before the British Medical Association, in which he claimed "that melancholia was due to an interruption of the path of afferent impulses, thus affecting the sensory reflex arc, producing characteristic cell changes, which, he thought, formed the physical basis of melancholia. The consensus of opinion, however, by those most competent to judge, declares that melancholia is a disorder of cerebral nutrition, due to failure or defect of normal cellular metabolism, either in the way of anemia or congestion, with defective elimination of products that give rise to ischemic conditions and molecular disturbances in the cerebral gray matter. The exact mechanism of these changes, as before remarked, are not fully understood, but it is certain that they seriously affect the visceral and nutritive functions of the nervous system, as well as the higher mental attributes, all of which is expressed in the form of strain or fatigue of their normal processes. Hence, we find an impaired appetite, constipation, loss of body weight, general weakness or exhaustion, insomnia and a distressed mental state, or feeling of pain in the head, which Clouston terms psychalgia, and which is usually referred to the occiput as belonging to and forming part of the clinical syndrome of incipient melancholia. Moreover, accompanying these is a disordered emotional state which leads the patient to accuse himself of wrong-doing, or as being unworthy, and while appreciating the unreasonableness of his feelings, yet he continues to worry about his condition to such a degree as to cause him to lose all interest in his family and business associations, until finally the morbid self-introspection culminates in a true insane delusion, which at once carries him beyond the province of incipient melancholia, and places him among the more complicated types of the disorder. In the diagnosis, therefore, of incipient melancholia, all important is the absence of delusions, as their presence always indicate a more serious and advanced state of the disease. We must also remember the important rôle heredity plays in its production. Peterson claims that this is encountered in fully one-half the cases, and that heredity, physical ill health and mental stress together form a triad of factors which are responsible for most cases of melancholia. Some innate weakness or defective brain constitution is, however, the recognized hereditary etiological factor of incipient melancholia, and, when an individual possessing such a birthright is exposed to the common causes of insanity, the symptoms of incipient melancholia may be readily induced. The strenuous life incident to business, commercial and professional careers, as well as the various trades and other professions, all tend to induce nervous weakness or exhaustion, and nervous irritability, both of which constitute the cardinal symptoms of neurasthenia, which, according to Chapin," is the most important factor in the production of insanity. He, therefore, fitly styles it as the soil out of which insanity develops. To aid you in detecting this most common variety of insanity, the diagnostic criteria consist of the following symptoms, viz.: |