ON THE IMPORTANCE OF THE EARLY RECOGNITION AND THE REPRESSION . OF M E N TA l. DIS E A IK ITS INCIPI}:NTS/AGh>. U 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 COLLEGE AND CLINICAL RECORD, September 15, 1881. There exists in insanity, in common with other cerebral diseases, a stage of incubation, in which the insanity is not yet characterized, and in which it commences with incomplete manifestations. It is an equivocal state, differ- ing but little from perfect sanity, but it is the earliest phase of mental alienation, and if re- cognized by the general practitioner and promptly treated in this incipient stage, subse- quent trouble might be averted. As a primary proposition for the consideration of the gener- al practitioner, who must, for the prevention of insanity, 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 biological inferiority, and that the precocity of organisms and or- gans is in an inverse ratio to the extent of their evolution. Psycho-neuroses which attack an intact brain often commence in intellectual exertion 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 disturb- ances in the ganglion cells of the cortex 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 attention, or such cases may be dis- missed with some simple prescription, but let it be remembered that one of the greatest and most incurable of nervous disorders, progres- sive paralysis, commences in just this insidious manner, as a vaso-motor disturbance of nutri- tion of the cortical portion of the brain, where the vessels of the pia mater soon get into a state of passive dilatation, and the disease thus established proceeds to its termination. Great attention should, therefore, be paid to the very earliest indications of brain exhaustion, whether in school children or the young, dur- ing the whole educational period of life, or in those of more advanced age, where the ear- liest 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 predisposed to the acquisi- tion of mental disease by hereditary or ac- quired vices of conformation or nutrition, and then constitutional affective insanity, moral insanity, the monomanias, epileptic insanity, hysterical insanity, hypochondriacal insanity, and periodical insanity, may appear, if nervous exhaustion should appear and run an un- checked 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 facial expres- sion ; if neuralgia is present; if we find cere- bral 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 in- 2 sanity, if these symptoms are not most effect- ively combated. Irritability and distrust are grave psychical symptoms in asthenic cases. If we have cerebral hypenemia in our patient, headache may then be a prominent symptom. We must recognize these symptoms as those of a grave nervous prostration, 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 mental 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 elas-’ ticity of the skin is another prominent symp- tom 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 disorders may appear, which require the promptest treatment. The history of such patients will usually be, that during childhood they have been exces- sively nervous, and have, perhaps, had convul- sions in infancy. They have been very emo- tional children, suffering from night terrors. There are periods of marked mental inactivity, alternating with a hyper-activity of the mental functions, and such patients do not take or manifest a normal healthy interest in their sur- roundings. If hysterical girls, they may neither eat nor sleep for some days at a time. There are no suicidal or homicidal 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 thart a natural exaggeration of the nerv- ous 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 cerebral hyperaemia. We find this form of periodical insanity at any epoch of sexual life, and there is marked physical and mental prostration in the intervals between the paroxysms, and we should combat these states by every means in our power. I remove uterine trouble, if any exist; use the constant current of electricity to the central nervous system, to improve its nu- trition, and give sodium bromide and ergot, in combination. The monobromide of camphor, in Clin’s capsules, of four grains each, is also very valuable in some of these cases. I also, for one week preceding the appearance of the menses, in such women, employ cerebral elec- trization 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 grati- fying results than these periodic menstrual psy- choses 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 applied, and on the contrary, 1 have more than once prevented the access of insanity by this means. Certainly, I know that in many cases where there had been a recurrent 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 subject, of the value of the constant current of electricity as an ap- plication to antagonize cerebral hypenemia and ward off impending mental disease. I would insist upon the point that in young ladies, especially, their mental future depends very largely upon the nervous and physical strength which they attain before the age of twenty-one. Many patients are brought to me suffering from nervous prostration and pro- tracted headaches, during the monthly men- strual epoch, all on account of too great intel- lectual exertion, inducing a very nervous and hysterical condition. We too often sacrifice the constitution to what we deem educational necessities. 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 nervous system, and if something has to be sacrificed, let it be some of her education, and not some of her mental and physical health. Insanity will just as surely follow neglect of mental hygiene, as the zymotic diseases follow neglect of sanitary precautions, and we too often forget this fact, for the reason that the incu- bating stage of insanity may be, and often is, long and insidious, and easily overlooked by one who is not a student of psychological medi- cine. 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 ir- regular and uncertain action, which have been rendered so by an entirely false system of edu- cation. There is a great deal of brain fatigue among professional and business men, resulting from a preponderance of waste over repair, which in- 3 duces grave nervous prostration. Such patients complain of a loss of physical and mental power, and of an inability to do what they could do when well; and these same patients exhibit exaggerated sensibility, being very easily affected by trivial impressions. Such pa- tients suffer 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 characteristic of cerebral syphilis. In these cases we have a deep-seated headache, of extraordinary intensity, with nocturnal exacer- bations, and of long duration. The headache 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 transitory, may become permanent by inattention. Congestive attacks of greater in- tensity, even attaining the grade of apoplectic 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 which I have spoken. In these cases I always put a patient immediately on energetic anti-syphilitic treatment, as I care little about the history. The epilepsy is to me evidence of the existence of the disease. The mental symptQms, when insanity appears, are those of exaltation, delirium and mania. The gravest forms of this disorder yield rapidly to appropri- ate treatment. 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 examine that patient’s history pretty thoroughly, and a specific course of treatment may, very likely, prevent in such a patient the invasion of in- sanity. We must not promise perfect recov- eries in these cases of cerebral syphilis, for some never recover, and there may be incom- plete recoveries. In a certain proportion of cases, however, we may get a rapid and bril- liant cure. Cold douches are very valuable in cerebral syphilis, as an adjuvant to specific treatment, 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 system, causing nervous prostration and incipient insanity, and would now briefly state my treatment of such states. We must secure-for our patient good, refreshing 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- thenic', alcoholic stimulants are indicated, to ward off the cerebral anaemia, which if not relieved will bring on 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, to- gether with a milk punch three times a day. If there is a condition of cerebral congestion, I employ, as I have said, the constant current of electricity to the brain, to antagonize the congestive states. The bromide of zinc, com- mencing with one-quarter to one grain doses, and the hydrobromate of quinine, are both use- ful in cerebral congestion, but we are more apt to have an anaemic and asthenic state of the sys- tem, especially in women. 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 in- deed. 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 are rapidly increas- ing and multiplying, and our morbid nervous- ness which is developing itself in modern so- ciety is making itself manifest by a great in- crease in neuralgia, sick headache, dyspepsia, and nervous exhaustion. The increasing ner- vousness of this country is most clearly evinced by the connection with and influence of the nervous system on other diseases not properly 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 would appear to be advancing pari passu with the increase of nervous diseases. It is a disease decidedly more common than it used to be, and there can be no doubt but that its greater prevalence is due to our present state of civilization. Bright’s disease of the kidneys, nephritis, and granular kidney are also caused and aggravated by mental worry and anxiety. Heart diseases are also increasing steadily, particularly those of neurotic origin and nature. The neurotic circle in society is increasing out of proportion to the increase of population, as well as the distinctly insane circle of society. The causes of all this nervousness are due, first, to the increasing complexity of the nervous system; and, secondly, the increased com- plexity of life. There is an elaboration in brain 4 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 com- plex and excitable nervous systems, cause our increased nervous disease, and even mental disease itself. As 1 have said in the beginning of this paper, modern systems of education are also influential in promoting nervousness and in contributing to the increase of mental and nervous diseases, and there are serious dangers lurking in our present teaching processes. In many of my patients I have traced sleepless- ness, night terrors, somnambulism, epilepsy, hy- drocephalus and other troubles, to educational pressure unwisely applied to delicate chil- dren. It is a point of importance to under- stand that brain tissue degenerations and mental diseases may be separated by long inter- vals of time from the too premature and intense stimulation of the brain which causes these nervous diseases. Hydrocephalus, however, is a nervous disease which shows itself at once, from overstimulation of the brain in the young, and of late years the increase in deaths from this disease has not been among infants, but among children and young people from five to twenty years, in the educational period of life. This is a very significant fact. More remotely, as a cause of overstimulating the brain by education, we meet with the prepon- derance of nervous diseases in the refined and cultivated classes. The functional activity of the brain is established at different epochs and perfected at different rates. By cautious stimu- lation of the brain we bring it to its highest development. Ry 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 impressions made on the sensory centres of the brain when they are un- dergoing development. We must aim, there- fore, in our system of education, at a harmonious development of body, brain and mind alike, and we shall then attain progress with health combined. 28 JV. joth St., New York.