ON THE IMPORTANCE OF THE Early recognition and the Repression OF MENTAL DISEASE IN ITS INCIPIENT STAGES, INCLUDING THE CONSIDERATION O F MODERN NERVOUS DISEASES, BY EDWARD C. MANX, XL D„ OF NEW YORK, » Physician in Chiet to Sunnyside, a Private Hospital for Diseases of the Nervous System, Dipsomania, and the Opium Habit. REPRINT FROM THE “ PHILADELPHIA COLLEGE AND CLINICAL RECORD,” SEPTEMBER 15, 1881. ON THE IMPORTANCE OF THE EARLY RECOGNITION AND THE REPRESSION OF MENTAL DISEASE IN ITS INCIPIENT STAGES, INCLUDIN Grr HE CONSIDERATION OF MODERN NERVOUS DISEASES, BY EDWARD C. MANN, M. D„ OF NEW YORK, Physician in Chief to Sunnyside, a Private Hospital for Diseases of the Nervous System, Dipsomania, and the Opium Habit. Reprinted from the “PHILADELPHIA COLLEGE AND CLINICAL RECORD,” September 15, 1881. There exists in insanity, in common with other cerebral diseases, a stage of incuba- tion, in which the insanity is not yet char- acterized, and in which it commences with incomplete manifestations. It is an equiv- ocal state, differing but little from perfect sanity, but it is the earliest phase of mental alienation, and if recognized by the general practitioner and promptly treated in this incipient stage, subsequent trouble might be averted. As a primary proposition for the consideration of the general practition- er, who must, for the prevention of insan- ity, understand the principles which are the foundation of Psychological Medicine, we would say that in his relations with the young in the educational period, he should remember that precocity is a sign of bio- logical inferiority, and that the precocity of organisms and organs is in an inverse ratio to the extent of their evolution. Psycho-neuroses which attack an intact brain often commence in intellectual exer- tion of the exhausted brain, the exhaustion being induced by taking up too great a variety of subjects for study during the educational period of life. We have as a result a passive, dilatation of the blood vessels of the brain, connected with dis- turbances of nutrition, or an anaemia of the brain may produce grave nutritional disturbances in the ganglion cells of the cor- tex of the brain. We get, as a result of either of these states, habitual headache and a loss of intellectual tone. Perhaps these slight disturbances may not attract particular at- tention, or such cases may be dismissed with some simple prescription, but let it be remembered that one of the gravest and most incurable of nervous disorders, pro- gressive paralysis, commences in just this insidious manner, as a vaso-motor disturb- ance of nutrition of the cortical portion of the brain, where the vessels of the pia mater soon get into a state of passive dila- tation, and the disease thus established proceeds to its termination. Great atten- tion should, therefore, be paid to the very earliest indications of brain exhaustion, whether in school children or the young, during the whole educational period of life, or in those of more advanced age, where the earliest symptoms are those of nervous exhaustion, which if not checked rapidly lapses into actual mental disorder. The brain may not be intact, but may be pre- disposed to the acquisition of mental dis- ease by hereditary or acquired vices of conformation or nutrition, and then consti- tutional affective insanity, moral insanity, the monomanias, epileptic insanity, hyster- ical insanity, hypochondriacal insanity, and petiodical insanity, may appear, if ner- vous exhaustion should appear and run an unchecked course, or if the early symptoms of any of these states be disregarded as matters of slight importance. If a patient complains of general malaise, impaired nutrition and assimilation ; if we find muscular atonicity changing the 4 facial expression ; if neuralgia is present ; if we find cerebral anaemia, if our patient manifests mental depression, and above all, if he is sleepless, we have induced a rapid state of prostration which will soon precipitate the patient into active insanity, if these symptoms are not most effectively combated. Irritability and distrust are grave psychical symptoms in asthenic cases. If we have cerebral hyperaemia in our patient, headache may then be a prominent symptom. We must recognize these symp- toms as those of a grave, nervous prostra- tion, which, unchecked, lapses into actual insanity with great readiness. I never like to see neuralgia developing in such cases, as it is, when not malarial, very often a premonitory symptom of impending men- tal disturbance, when associated with other symptoms of nervous prostration. Profuse perspirations also are found in connection with nervous prostration, and occur at any hour of the day or night. A loss of the normal elasticity of the skin is another prominent symptom of disordered nervous action. Arsenic as a remedy in this latter class of cases is very valuable. In children, or young people from fifteen to twenty years, very grave psychical dis- orders may appear, which require the promptest treatment. The history of such patients will usually be, that during child- hood they have been excessively nervous, and have, perhaps, had convulsions in in- fancy. They have been very emotional children, suffering from night terrors. There are periods of marked mental inac- tivity, alternating with a hyper-activity of the mental functions, and such patients do not take or manifest a normal healthy in- terest in their surroundings. If hysterical girls, they may neither eat nor sleep for some days at a time. There are no suicidal or homicididal tendencies in these cases, but a disposition to recurrent mania. In the menstrual psychoses of young girls and women, the psychic disorders which come on at these times in many of them are, I think, more than a natural exagger- ation of the nervous excitability which we may naturally expect in a female at this period. It is a true periodic insanity in many cases, an acute psychosis, with the intellectual centres involved. They are vaso-motor neuroses with recurrent cere- bral hyperaemia. We find this form of periodical insanity at any expoch of sexual life, and there is marked physical and men- tal prostration in the intervals between the paroxysms, and we should combat these states by every means in our power. I re- move uterine trouble, if any exist ; use the constant current of electricity to the cen- tral nervous system, to improve its nu- trition, and give sodium bromide and ergot, in combination. The mono-bro- mide of camphor, in Clin’s capsules, of four grains each, is also very valuable in some of these cases. I also, for one week pieceding the appearance of the menses, in such women, employ cerebral electriza- tion daily, using the constant current, which possesses the power of combating and perfectly antagonizing the various congestive states, which, unchecked, lead to insanity. Of all the cases in which I am accustomed to use electrization of the brain, none give more gratifying results than these periodic menstrual psychoses in women. A marked tendency to sleep, even in cases which have been sleepless for days, follows these applications. I have never seen any evil results from the use of moderately strong currents judiciously ap- plied, and on the contrary, I have more than once prevented the access of insanity by this means. Certainly, I know that in many cases where there had been a recur- rent periodical menstrual psychosis, or mania, this treatment has resulted in my hand in the complete cure of the patient, when conjoined with the proper medicinal treatment, so that I most earnestly, and from experience, advocate its use. In a paper in the ‘New York Medical Gazette I have given my views at length on this sub- ject, of the value of the constant current of electricity as an application to antago- nize cerebral hyperaemia and ward off im- pending mental disease. I would insist upon the point that in young ladies, especially, their mental fu- ture depends very largely upon the nervous and physical strength which they attain before the age of twenty-one. Many pa- tints are brought to me suffering from ner- vous prostration and protracted headaches, during the monthly menstrual epoch, all on account of too great intellectual exer- tion, inducing a very nervous and hyster- ical condition. We too often sacrifice the constitution to what we deem educational ne- cessities. I deem the necessity in a young girl to have plenty of bone, blood and muscle, and to be well developed, with an accurate balance between the physique and the ner- vous system, and if something has to be sacrificed, let it be some of her education, and not some of her mental and physical health. 5 Insanity will just as surely follow neg- lect of mental hygiene as the zymotic diseases follow neglect of sani.ary pre- cautions, and we too often forget this fact, for the reason that the incubating stage of insanity may be, and often is, long and insidious, and easily over- looked by one who is not a student of psy- chological medicine. It is very easy to ruin the delicate tissue of the brain by overstraining it when exhausted. There are too many young brains not strong and vigorous, but unstable and subject to irreg- ular and uncertain action, which have been rendered so by an entirely false system of education. There is a great deal of brain fatigue among professional and business men, re- sulting from a preponderance of waste over repair,which induces grave nervous prostra- tion. Such patients complain of a loss of physical and mental power, and of an ina- bility to do what they could do when well ; and these same patients exhibit exagger- ated sensibility, being very easily affected by trivial impressions. Such patients suf- fer much from vertigo and confusion of mind, owing to an impaired nutrition of the brain and spinal cord, and a diminution of vascular tonus. One very important set of symptoms to early recognize and combat are those char- acteristic of cerebral syphilis. In these cases we have a deep-seated headache of extraordinary intensity, with nocturnal exa- cerbations, and of long duration. The head- ache is the premonitory symptom of very grave cerebral mischief, which we may ward off if we recognize its significance. As the results of the cerebral congestion of specific origin, we have vertigo and mental dullness, temporary disorders of the special senses and momentary impairment of the intellect. These symptoms, at first transi- tory, may become permanent by inatten- tion. Congestive attacks of greater in- tensity, even attaining the grade of apo- plectic fits, may now occur. In the gravest forms of specific cerebral disease, an apoplectiform seizure, followed by fatal coma, may usher in the attack with no premonitory symptoms. Epilepsy, if commencing after twenty years of age, is due, probably, to specific brain disease, and is often preceded by the premonitory headache of whiph I have spoken. In these cases I al- ways put a patient immediately on ener- getic anti-syphilitic treatment, as I care little about the history. The epilepsy is to me evidence of the existence of the dis- ease. The mental symptoms, when insan- ity appears, are those of exaltation, delir- ium and mania. The gravest forms of this disorder yield rapidly to appropriate treat- ment. If we find in a patient, a male more particularly, persistent mental dullness and muscular feebleness, existing as vague, un- defined symptoms, it is always well to ex- amine that patient’s history pretty thor- oughly, and a specific course of treatment may, very likely, prevent in such a patient the invasion of insanity. We must not promise perfect recovery in these cases of cerebral syphilis, for some never recover, and there may be incomplete recoveries. In a certain proportion of cases, however, we may get a rapid and brilliant cure. Cold douches are very valuable in cerebral syphilis, as an adjuvant to specific treat- ment, and should never be omitted. I am more inclined to think that syphilitic brain disease is overlooked, than* that it is so very rare as some authors claim. I have detailed the symptoms of the gradual breaking down of the nervous sys tern, causing nervous prostration and in- cipient insanity, and would now briefly state my treatment of such states : We must secure for our patient good, re- freshing sleep, and take him away for a time from business cares and anxieties, and if a woman, give her rest. If the condition is as asthenic, alcoholic stimulants are in- dicated, to ward off the cerebral anaemia, which if not relieved will bringon an attack of mania. Strychnia is also indicated in these anaemic states. I usually use the citrate of iron, quinine and strychnia, rest, massage and electricity, together with a milk punch three times a day. If there is a condition of cerebral congestion, I em- ploy, as I have said, the constant current of electricity to the brain, to antagonize the congestive states. The bromide of zinc, commencing with one-quarter to one grain doses,and the hydrobromate of quinine, are both useful in cerebral congestion, but we are more apt to have an anaemic and asthe- nic state of the system, especially in wo- men. In these conditions, quinine is one of the best nerve tonics, and may be given in one or two grain doses before each meal. Arsenic is also very valuable indeed. By appropriate and judicious treatment we may get a perfect cure in the incipient stages of insanity, and generally with no fear of a relapse. MODERN NERVOUS DISEASES. Observant physicians know that neuro- tic affections are increasing and multiply- ing. We have to-day, as Americans, a morbid nervousness, which I consider to be an entirely new state of the system, de- veloping itself in modern society, and making itself manifest by neuralgia, sick- headache, dyspepsia, hay-fever, neurasthe- nia, or nervous exhaustion. This unprece- dented nervousness, when it does not pass into actual disease, is also indicated by our increased sensitiveness to heat and cold, and a greatly augmented susceptibility to the action of stimulants and narcotics. Fat persons are less numerous and thin persons more numerous in the well-fed classes of society than was formerly the case. The increasing nervousness of this country is most clearly evinced by the connection with and influence of the nervous system on other diseases not pro perly nervous. Thus, in diabetes, the nervous system is in intimate relation with the disease ; and I consider that it is often induced by mental anxiety and distress, or by sudden fear and shock. It seems to me to be advancing, pari passu, with the increase of nervous diseases. It is a disease decid- edly more common than it used to be. I attribute its greater prevalence to our pre- sent state of civilization. Bright’s disease of the kidneys, nephri- tis, and granular kidney, are also caused and aggravated by mental worry and anx- iety. Heart diseases are also increasing steadily, particularly those of neurotic origin and nature. Rheumatism and gout, in both of which there is a neurotic ele- ment, are more severe than they were years ago. Life, even though it be not shortened, is often rendered miserable by so-called mild nervous disorders, such as hysteria, herpes zoster, urticaria, writers’ cramp, and sick headache. Premature baldness and early decay of the teeth are both far more frequent than they used to be, while our leading druggists can bear witness to the truth of my state- ments by testifying as to the greatly in- creased consumption of neurotic remedies, such as morphia, hyoscyamus, conium, chloral, the bromides, arsenic, strychnia, and gelseminum. The consumption of tea, coffee and tobacco is also largely on the increase ; the two former neurotic beverages and the latter a great nerve sed- ative. The neurotic circle in society is in- creasing out of proportion to the increase of population, as well as the distinctly in- sane circle of society. The causes of all this nervousness are due, first, to the increasing complexity of the nervous system ; and secondly, the in- creased complexity of life. The brain, I consider, is increasing in size in the Ameri- can people, and this affects its functional activity immensely. Even though its size may not be increased, there is a great elab- oration in structure and in the way of a finer architecture of our brains, new phases of intelligence, and new proclivities to nervous disease. Our brains are finer in structure and more subtle in mechanism, but instability is the result. The conditions of modern life, which act on our complex and excitable nervous sys- tems, cause our increased nervous disease, and even mental disease itself. Modern systems of education are also influential in promoting nervousness, and in contributing to the increase of mental and nervous dis- eases. The general tendency of modern education on the young is to increase the activity and susceptibility of the nervous system by modifying the nutrition of the brain centres and stimulating their growth, and in fragile, sickly, or badly nourished children, inducing brain exhaustion and organic disease. There is a great increase in habitual headaches, which I attribute to the ex- hausting effects of excessive and ill-direct- ed brain work in our modern schools. There are serious dangers lurking in our present teaching processes. I have traced sleep- lessness, night terrors, somnambulism, epi- lepsy, hydrocephalus, hallucinations, and other troubles to educational pressure un- wisely applied to delicate children. The great trouble is to make persons under- stand that brain tissue degenerations and mental diseases may be separated by long intervals of time from the too premature and intense stimulation of the brain which cause these nervous diseases. Hydroce- phalus, however, is a nervous disease, which shows itself at once from over-stimulation of the brain in the young, and of 'late years the increase in deaths from this dis- ease has not been among infants, but among children and young people from five to twenty years in the educational 7 period of life. This is a very significant fact. More remotely, as a cause of over-stimu- lating the brain by education, we meet with the preponderance of nervous diseases in the refined and cultivated classes. If by premature and stimulating processes of education we force an elaboration of cereb- ral structure, hastening the functional ac- tivity of the brain, with no due regard to the law of evolutional precedence—which nature observes in her elaboration of the brain in infancy, childhood, and adult age respectively—we upset the whole equi- librium of the brain, and serious nerv- ous disease will necessarily follow. Growth must precede function, and if, while the child is so young or delicate that func- tional activity is still feeble, we apply un- due exercise or stimulation, the brain will never be brought to the highest develop- ment of which it is capable. The cerebral centres, if never properly exercised, never develop correctly ; but if we over-exercise or over-strain the brain centres at their nascent period, we dwarf and weaken them, disturbing the balance of mind by serious- ly interfering with the natural sequence of the evolution of the brain centres. The functional activity of the brain is established at different epochs and perfect- ed at different rates. By cautious stimula- tion of the brain we bring it to its highest development. By undue haste we ruin its functional activity forever, and can never have a sound and vigorous brain. The whole future complexion of mental life is, in a great part, determined by the impres- sions made on the sensory centres of the brain when they are undergoing develop- ment. We must aim in our system of education at a harmonious development* of body, brain, and mind alike, and we shall then attain progress, with health combined. We must resist the inroads of nervous and mental disease by a due attention to the regulation of the emotional elements by disciplining the natural forces of character, and by placing before ourselves high ideals. We must remember to work wisely, with- out haste, as well as with proper rest, in our different vocations of life. Sleep is essential to mental health, as during sleep our brain cells derive their nutritive renovation almost entirely, and brain-workers need much sleep. Meals, to be digested, must be eaten slowly, not has- tily, for we are rapidly becoming a nation of dyspeptics, from too rapid eating, and vertigo and giddiness are often due to tem- porary derangement of the digestive organs. We may enjoy constitutional vigor and a well-balanced development of parts, or by carelessness and neglect, we may suffer from constitutional debility and an irregu- lar development of pnrts. To avoid the numerous modern nervous diseases I would finally caution the edu- cated and reading and thinking portion of society to be careful not to violate those laws, the observance of which is indispen- sable to the well-being of the brain. The two states of wakefulness and restlessness which often occur in men of over-worked brains are to be promptly met by leaving one’s business and getting away for a time with complete change of scene for a month or more. The diet should be carefully regulated at the same time. An over- worked business or professional man will, in a month, return home well and able to go on with his regular daily round of dutv, when, by neglect of this simple precaution, the over-tasked brain gives way, and men- tal disease ensues. Edward C. Mann, M.D. io-i2 o’clock, 28 West 30th St., New York. j-o’clock, 481 Franklin Ave., Brooklyn.