Mental Disorders
118 Art. XII.? :Author: JOHN CUIVWEN, M.D.
In examining the exciting causes of mental disorders, it is requisite to make a division into those which may be called moral, and those which are really physical. This distinction has been recognised from the earliest period and by the best writers, though in these latter days some have said that no such division should be made. It is claimed, by those who advocate that physical causes alone can produce mental disorder, that disease can only be produced by some physical cause acting on the organism, but this is most surely substituting effect for cause. It is useless to attempt to ignore the influence of moral causes, of the affections, passions, desires, and emotions in the production of derangements of the different organs of the body.
No one who has given attention to the reciprocal influence of mind and body can for a moment question the fact that joy and hope will exercise an active exhilarating influence on the func- tions of the different organs, while fear, terror, anxiety, fright, or any of the depressing passions, will cause a temporary sus- pension of some of the functions, or a cessation for a short period of the normal action of certain organs.
The nervous constitutions of individuals are so diverse one from another that the susceptibility to impressions arising from the action of the emotions, passions, etc. is of the most varied character, and the effects consequent on these impressions will necessarily influence the several organs of the body in a very different manner. Fright or the receipt of bad news will produce an entirely different effect on a number of persons who may experience the same fright or receive the same bad news at the same time ; just as exposure to severe cold or sudden change of temperature may produce in one an ordinary cold in the head, in another pneumonia, in a third enteritis, and some other severe affection in a fourth, depending entirely on the physical condition of the individual at the time of exposure.
It does not seem difficult to trace the connection between moral causes and physical disease. Fright in many persons exercises a paralysing or benumbing influence on the nervous system, and thus impairs the normal action of the heart and many of the other organs.
An address delivered before the Medical Socioty of the State of Pennsylvania. Anxiety will cause loss of appetite, inability to sleep, and other effects which gradually undermine the healthy action of the nervous system. Loss of property, business troubles, and all the kindred class of difficulties will occasion worry of mind, sleepless nights, and wearisome days, which, unless checked, will gradually deteriorate the integrity of the nervous system, and through it some of the vital organs, and thus produce in some bodily disease and in others mental disorder.
The direct chain of causation may be in this wise : a man meets with great reverses in business, and cannot perceive how he can meet his engagements and support his family. He broods over his condition, loses sleep at night, feels less able on the subsequent day to give his wonted attention to his affairs; his appetite fails ; the other functions of the system become disordered, he feels his bodily strength failing, and each suc- ceeding day he experiences greater difficulty in giving that thought to his business which he had done before ; and gradually he begins to look at things in a different light from that in which he had been accustomed to view them, and soon every- thing becomes changed to him, and his conduct and conver- sation attract the attention of his family, who now see that he is not what he formerly was, and his whole system is disordered.
Now it may be said that the disordered condition of system immediately antecedent to the outbreak of mental disorder, beiug a physical disease, was the cause of that mental disorder ; but surely that is merely substituting effect for cause, since that disorder is only the result of a cause tending, from the peculiar nervous constitution of the person, gradually to produce that particular diseased condition.
It is needless in this presence to cite a long series of cases giving evidence of the influence of the different emotions or passions in the production of disease. If the anxieties and terrors of the French Revolution of 1789 greatly increased the amount of cardiac disease in the French people, it as certainly very greatly increased the number of cases of mental disorder. If the fear and alarm caused by being told that the bedding in which he had slept had been previously used by a man who had died of cholera could produce in a man an attack of cholera, we can certainly have no great difficulty in believing that the fear or dread of some impending calamity may produce an attack of mental disorder in another.
It is a matter of historic record that any great social or political revolution in a community or State will cause a large number of cases of mental disorder. In I ranee, in each of the revolutions which have taken place within the last century, medical writers have remarked the great increase of mental 120 MENTAL DISORDERS. disorders consequent on those fearful changes. The breaking out of the war in 1870 was attended by a great and sudden increase for a few months of cases of mental disorder. It may also be noted as a remarkable fact that, while a great increase of mental disorder was noticeable at the commencement of the war, yet, after the attention of the country was fully engrossed in the prosecution of the war, and in all the cares and duties consequent on its continuance, mental disorders were less frequent than for several years previous, arising unquestionably from the fact that the public mind, as well as the minds of individuals, was fully occupied with the duties and obligations which the successful prosecution required and entailed.
Nothing need be assumed to account for these peculiar conditions, for they all proceed from the influence of certain fixed laws of the human economy, which we cannot ignore, if we would, and which are susceptible of definite explanation and positive proof.
As a large dose of poison may suddenly cause death, while smaller doses, administered gradually, may undermine the health and thus produce disease and death ; so certain passions and emotions act on some constitutions with such overwhelming power as to cause mental disorder quite suddenly; while in others the same passions and emotions, by their slow but con- tinued action, may exert such a deleterious influence on the nervous system, and thus so influence the functions of certain vital organs, as to impair the proper discharge of those func- tions, and thus gradually produce a condition which will cause loss of appetite and sleeplessness, and eventually such a derange- ment of the nervous system as to lead to some form of mental disorder. Everyone is familiar, from daily observation, with that state of worry or fret in many individuals which leads them continually to be on the look out for trouble or to lament over the past to such an extent as to cause sleepless nights and consequent irregular action of the stomach and bowels, and gradually leading on, unless corrected by proper treatment, to mental disorder. Whatever classification may be adopted of the moral powers, of the exciting or depressing passions, the cheerful or sorrowful emotions and desires, or the benevolent or malevolent affections, each and all may have an influence, singly or combined, in producing some form of mental disorder, and the particular form will be determined more by the pecu- liar constitution and temperament of the individual than by tlie special moral cause inducing it; and this difference and determining power will also be more perceptible in the female than in the male, from the fact that the female sex is more MENTAL DISORDERS.
impressionable, or more readily and more forcibly influenced by the emotions and affections.
It is a matter of general observation that, in the majority of cases of mental disorder, one or more causes combine to produce the unhealthy condition from which the trouble arises; and in cases where there is an hereditary predisposition to the disorder, moral causes will act much more readily, the faulty constitution yielding much more quickly to the strain or pressure brought to bear upon it.
It must also be distinctly recognised that the different depressing emotions and passions, and the malevolent affections, have a much greater influence in the production of mental disorders than those of the opposite character, from the un- doubted fact that they tend in a greater degree to impair the vital energy and diminish the power of resistance to disease, and seriously interfere with the elasticity of the other mental powers. Imagination has also a wonderful influence in the pro- duction of disordered conditions, and its effect in inducing disease, or as a prime factor in aiding in restoration, is so great and so fully acknowledged, that it is not requisite at this time and in this presence to enter into any detailed or extended statement respecting it. And as prevention is better than cure, it seems appropriate at this point to call the attention of every medical man to the propriety of inculcating, by every opportunity in his power, the urgent necessity of careful train- ing and restraint of the moral powers in the early years of childhood and maturity, in order to guard more assiduously against the evil results which may ensue from too great indul- gence of certain passions and emotions, or the too exclusive cultivation of certain desires and affections.
As in ordinary diseases it is usual to consider that the system of the patient is of a certain temperament which specially predisposes or renders more susceptible to a particular disease, so, as lias on a previous occasion been stated, there may be a special insane diathesis, or strong hereditary taint, which so weakens the nervous system that any cause, moral or physical, acts with special force, or much more promptly than in a really healthy or untainted constitution.
It will also be found in many cases that the mental disorder may be caused by reflex irritation, or the perverted action of other organs.
It is needless to attempt to give even a list of the many physical causes which may determine an attack of mental dis- order, for they may all be summed up in one short statement, that any disease, over-exertion, or excess which will greatly weaken the nervous system or interfere with its normal action will, in certain constitutions, and under certain circumstances, varying in character, degree, and intensity, be sure to be an ex- citing cause of mental disorder ; for it must be distinctly borne in mind that nearly every case of mental disorder which the pro- fession is called upon to treat in these days has an asthenic type. What the particular form which the mental disorder may be will be determined by a variety of conditions which are not by any means clearly defined or easily explained, and which, being of a speculative and not practical character, need not here be dwelt upon.
There has been, latterly, a great inclination to attempt a variety of classifications in mental disorders, and arrange the different forms under certain fanciful types or classes, which may answer very well for writers and theorists, or those who are fond of minute and careful distinctions, but in reality are of no essential value or assistance to the practitioner.
It will fully answer the object now in view, and very much simplify the whole subject, to take, as the basis of what it is desirable to say, the old division into mania, monomania, melan- cholia, and dementia,including under eacli the acute and chronic forms, with such variations as may arise from peculiar physical conditions or diseases.
In all cases of mental disorder there is a period of incuba- tion, varying with the character and intensity of the exciting cause from a few hours to many years. Certain causes may be so intense in their action that the interval between their im- pression and the development of the disease may be marked with very little appreciable extent; while cases are reported where a very long period has elapsed, and there may have been a combination of causes gradually inducing the disordered condition; and very great care should be exercised in the in- vestigation of these causes, in order to avoid as much as possible the error, into which friends and relations so frequently fall, of confounding effects with causes. A little patient inves- tigation will, however, serve to unravel, in the great majority of cases, the tangled web, and enable the physician to trace to one or two causes all the trouble he may be called upon to treat. Very frequently there will be observed in the commencement of the disorder a period of dulness and depression ; an inability or unwillingness to attend to the ordinary duties which have generally engaged the time and attention ; a disposition to shun company, and even the society of those with whom the person has been most familiar, or the members of the family ; a carelessness in dress or appearance foreign to the character ot the individual; a disregard of the many minor proprieties of lite ; an undue atten- tion to matters of small consequence, which would not, in health, have been thought of; an exaggeration of trifles, a perversion or unusual irritability of temper, and a deviation from the strict line of moral rectitude in conversation, or in ordinary dealings with others in the everyday transactions of life. These latter are especially to be looked for, as, in the great majority of cases, the first evidence of any disordered condition will be traced in the perversion of the moral powers and a change in the character, conduct, and conversation of the person. These deviations will gradually become more and more marked, until the whole conduct and character of the man has become changed, and he has passed the line which separates the normal from the abnormal state; and the form which the disorder will assume will be determined by causes or incidents, or the bodily condition which may exist at or immediately before the time at which the line is crossed.
Of course it must be understood that all these indications may not be presented in the same case, or in the order men- tioned ; but one or more will be found in every one, and the physician must be prepared to trace out the particular devia- tions from the correct course so clearly and distinctly as to satisfy himself and the family and friends that the deviation does actually exist, and the man has reached the point where medical interference is requisite for his own good and that of the family and neighbourhood.
A physician is called to see a man in regard to whom the friends feel uneasy, and unable or unwilling to say what is the matter with him. He finds him fretful, restless, at times quite irritable on the least opposition or contradiction; unable to attend to his business, or doing it in a way contrary to his former method. He ascertains that he is sleepless, sits up unusually late, or rises during the night or much earlier than usual in the morning; cannot fix his attention on what he is doing for any length of time, or has an unusual amount of business to attend to which requires him to be riding about or going from one place to another without regard to time or propriety; making bargains for tilings he has no use for, or at an extravagant price, or in unusual quantities ; talks a great deal more than is usual with him, is very positive and certain in all he says, is specially communicative to particular persons in a low tone or by drawing them to one side so that others may not hear; in many things manifests more than his usual shrewdness; is either too much occupied to sit down quietly and talk, or has a special desire to talk a great deal over what he is doing or proposes to do. His appetite will be capricious, eating very irregularly and scarcely sufficient to support his strength, or very voraciously and more frequently than usual. Added to these will be an indifference to outward appearances ; a dis- regard of the usual proprieties of social intercourse, finding fault with everybody and everything; he is distrustful, un- usually egotistic, and intensely selfish in thought, feeling, and expression.
If spoken to about his health, he was never better in his life ; be feels able to do any amount of work, and rejects with disdain any suggestion which may be made that he will suffer from loss of sleep or his great activity. In a short time he becomes more restless and excited, talks more rapidly, and manifests more incoherence in his ideas, or is full of plans and projects for doing all manner of business and making his fortune in an incredibly short period, or has a great desire to do some great exploit which will inure to the benefit of the community; or he will manifest an inclination to destroy or injure property of different kinds ; will exhibit a malignant or revengeful spirit, threatening or talking in a very insulting manner to those he meets ; jealous, suspicious of everything he may hear or see done, misconstruing and misinterpreting every expression, and acting as if he were determined to pick a quarrel with some one. He sleeps little or none, and moves about from place to place all night, or does something which disturbs the rest of the family and makes them fearful and anxious, and often abuses them for their interference in what he is doing or for the advice they offer him.
Rejecting all advice and every effort made to relieve this condition, he will soon experience an attack of acute mania, with unusual restlessness, constant noisy talking in an inco- herent strain on a great variety of subjects; destroying clothing, furniture, or anything which comes in his way ; using the most profane and obscene language; sometimes in good humour, more often cross, irritable, and abusive, but never con- tinuing in the same state any length of time.
The violence and intensity of the attack will depend on the peculiar temperament and physical condition of the patient, varying from the most extreme to the most gentle excitement; but in all partaking of the same general evidence of departure from healthy, normal action.
An examination of the physical symptoms will show a dry, harsh skin ; the hands clammy, or dry and rough; sometimes cold with a very languid circulation; the countenance with a peculiar heavy or very changeable appearance, the eyes lacking their natural lustre and expression, or with a strange, uneasy motion, so that he is unable to look steadily at any person or anything for more than a moment at a time ; the tongue coated; the mouth frequently dry from the constant talking ; the bowels constipated, and all the secretions more or less disordered; the pulse but slightly if at all excited when the patient will remain quiet for a few moments to give a fair opportunity to examine it; the head nearly natural as to temperature, and very rarely much heated.
There is, however, a form of acute mania which is very severe, often quite sudden in its access and very rapid in its course, which needs to be very carefully distinguished. The patient may feel dull and languid for several days, with very little to excite any apprehension; when suddenly he may become violently and even furiously excited, with the most intense rest- lessness, the most rapid and continuous utterance, or?to use the French expression?a tireless babel of the most incoherent language with scarcely three connected words, which it often seems impossible to interrupt; a quick weak pulse, running up to 120 or even 140; with little heat of the scalp, a dry skin, sometimes moist, however, from the excessive agitation; a great dryness of the mouth and tongue from the incessant chattering, which is so much beyond the patient’s control that he will not stop to take water to cool the mouth and tongue, or to answer a question, or even swallow the food when put to the mouth; and the countenance has a peculiar, distressed, and anxious expression. It is especially desirable to reach a correct diagnosis in such cases, as their duration rarely exceeds ten days, and if the proper treatment is not applied promptly and vigorously death will close the scene at the end of that period. There is also a form called transitory mania, lasting from a few hours to one or two days, during which the mind of the patient is very much disordered, and sometimes great excite- ment is found; the face is often red and flushed ; the eyes flashing, and with a peculiar restless expression, the look wild and often fierce; the skin moist; the pulse rather full and frequent; and the whole manner agitated as if in great fear or anxious to do something of a violent character, which, indeed, is often attempted and sometimes carried into execution. Such cases have been thought by some to arise from an error of diagnosis, but too many well-authenticated cases have been seen by careful and competent observers to render such an opinion tenable. Many physicians take the ground that these are simply developments of epilepsy, this peculiar condition taking the place of the regular convulsion, or being a more prominent expression of the masked form.
A monograph by Dr Edward Jarvis on this subject shows that one hundred cases at least are recorded, and an able paper on the same subject has been written by Dr Kraft Ebing of Germany. The diagnosis of this form is mainly important on account of the medico-legal questions which may arise, should the individual commit any violation of the law while suffering from it.
Another form will be met with, usually called recurrent mania, where the excitement varies in intensity from the mildest mischievous disposition, with constant foolish or extravagant talking and restless agitation, to the most violent form?noisy, boisterous, destructive of everything within reach, filthy and extremely careless in every way, continuing from a few weeks to many months, followed by a period of depression correspond- ing in duration and intensity with the previous excitement; then an interval of complete restoration; and after this restora- tion has continued for a certain period the excitement will return and the disease will follow the same course as in ‘the previous attack. Often these attacks will recur at the same period of the year, almost to a day, and will follow the same order as in the first attack, with scarcely any variation or change in the character of the disease. The length of time during which the excitement may continue will be of very variable duration, so that in some cases there may be two attacks in the course of the year; but most generally there is only one, and the extreme regularity of these attacks and the uniformity of the symptoms which characterise them has led the French to give the disease the name of circular insanity.
As a rule, it may be said that cases of acute mania will readily recover under proper treatment; but still it is wisest and best to give the prognosis with great caution, because in the earlier stages it is extremely difficult, nay, almost impos- sible, to say what form the disease may assume, and a great deal will also depend on the previous physical condition of the patient. If the constitution has been impaired by any previous bad habits or excesses, there will be great danger that the excitement will seriously undermine the system, and the recuperative powers may not be equal to the task of carrying the system over the period of depression, and the patient may sink from sheer exhaustion.
Then the physician must remember that the disease may assume the form of recurrent mania, and he must qualify his prognosis accordingly, for the general experience is that cases of this form of disease do not recover.
Unless the diagnosis of exhaustive mania is very clearly made out?and it is extremely difficult to do so satisfactorily? any statement of the ultimate result in cases of high maniacal excitement should be given with the greatest reserve and caution.
It may be proper in this place to call attention to a peculiar form of mania which within a few years has received the name of paresis, or general paralysis of the insane, in order that the practitioner may be on his guard, not only in reference to treatment, but particularly in regard to prognosis. It is cha- racterised by very exalted notions of personal importance or great wealth, or ability to perform great feats of strength or achieve great deeds which will inure to his own personal benefit or that of his personal friends. Some of these symptoms are also found in cases of ordinary acute mania; but with these exalted notions in paresis will also be found a difficulty in articulation, with a trembling of the tongue when the attempt is made to protrude it beyond the teeth, often a turning to one side and a general inability to use it freely, as if it were too lar^e for the mouth or too heavy for use, very flabby, and easily indented by the teeth ; a peculiar dragging of one of the feet or legs; added to these will be found a heavy, dull expression of countenance, and an unusual appearance of the eyes, and almost invariably an unequal contraction of the pupils. Careful observation will be required to detect these symptoms in the early stages, and cautious judicious treatment may relieve them temporarily ; but let not the medical man be too sanguine of success in restoring the patient, for when once the disease has been developed by the appearance of the symptoms above detailed, though the issue may be retarded by careful watching and cautious treatment, it will advance, occasionally by rapid strides, but most generally by very slow, insidious degrees, to paralysis of the tongue and limbs and continued enfeeblement of the mind.
These cases are rare except in cities or large towns, and are almost invariably confined to men.
The special history of the disease, with a discussion of the different points on which a diversity of opinion still exists, and probably will continue to exist, will be found in various monographs which have been written within the past few years. Puerperal mania may arise during the course of gestation, but more generally is developed after delivery, and will vary in the intensity of the symptoms and the duration of the attack from a slight confusion of mind, continuing during a few days, to the most violent excitement, extending through many months. As this disease depends on the peculiar condition of the system and arises from that condition, there will generally be no great difficulty in the diagnosis.
Mania arising from the continuance of epilepsy has this striking peculiarity, that its development is most decided after one or more convulsions. How long a person may be subject to epileptic attacks before any symptom of mental alienation is noticed is a matter which does not appear to have received careful attention. In a majority of cases it will depend in great measure, no doubt, on the particular form of the epilepsy, on the impairment of the integrity of the nervous system by hereditary transmission of nervous disease, on the general physical condition of the individual, and on the manner of life which he may lead, whether cautious and systematic in the ?U<ro-anCe 3rreoularities and excitement, or careless and indifferent, and inclined to indulgence in excesses of various kinds.
llie form which the mental disorder will assume will also vary very greatly in different cases. In some there will be simply restlessness, confusion of mind, and inability to attend to anything, or complete stupidity ; in others a dogged sullen- ness, with a fierce scowl on the countenance, and the whole manner and bearing such as to suggest the greatest caution to prevent a violent outbreak; while in others, an excitement will burst forth, perfectly blind and furious, impelling to acts of a desperate character, regardless of everybody and everythino-, often leading the person to attack anyone who may approach him ; a fierce wild expression of countenance, as if some fearful sight were present to the view, and gesticulation and movements of the body corresponding to the excitement of the mind. These conditions will continue from an hour, or even less to some days, when the individual will sink into a deep sleep, con- tinuing often for hours, and sometimes for a day or two’ and arouse from it with all the excitement gone, and only a dulness of mind and feeling of general debility.
It is a singular and striking fact that the peculiar ideas actions, and manner which are noticed in the first attack of ex- citement will almost invariably be found to characterise all the subsequent attacks, in the same order though not always in the same degree, and these often extend to the premonitory symp- toms ; so that, by carefully watching these and using precau- tionary medical means, the violence of the attack may be mitigated. The variation in different cases, however, will be so great that it is impossible to give in detail any description which will apply to all; but a careful observation will soon enable anyone to discover the special symptoms of each case and take measures accordingly.
Another fact which is proper to be carefully borne in mind is, that what occurs during a paroxysm will be recollected in all its details during a subsequent paroxysm but not during the interval, and what occurs in the interval will not be present to the mind during the paroxysm. There may be exceptions to this, but they are so rare that they only tend to confirm the rule.
As attempts are often made, from a variety of motives, to imitate the epileptic seizure, it may be proper to state the diagnostic symptoms, so as to avoid confounding- the true disease with the counterfeit presentment. The first appearance of the attack will be manifested by different indications in almost every case. Some will have a very distinct aura rising from some part of the body to the head, some will utter a loud and piercing cry, and almost every case will have something peculiar which, to those who have seen an attack in that individual, will give warning of what will occur. Many invariably fall forward, striking the forehead or some part of the face; others will stagger a moment and then fall to one side, mostly to the right; while others again may quietly settle down on the floor; but the variations will be as great as the persons. There will be a deathly pallor of the face and lips, and for a few seconds after the fall there will be no convulsive movements ; but then the muscles of one side of the face and the corresponding side of the body will begin to work, and the contortions will be fright- ful, with suffusion of the face, distension of all the blood-vessels, closure of the eyelids, a peculiar stertorous breathing, and, as the fit progresses, frothing or foaming at the mouth, often mixed with blood from biting the tongue. When the patient falls to one side the first movement is a convulsive drawing up of the knees and a turning over on the face, and when turned on the back there may appear a convulsive movement of the muscles of both sides; but the severity of the convulsions will be con- fined to the muscles of the side opposite to that on which the patient fell, and the limbs quickly straighten out. The same unilateral character of the convulsions will also be noticed when the patient falls on the face or settles down quietly. After con- tinuing for a few moments these frightful contortions subside, the patient will draw a deep sigh, try to raise himself to a sitting posture, will fall back as if completely exhausted, and lie in a dull stupid state for some time. If the eyelids, which are closely shut, are carefully opened during the convulsion, it will be found that the pupils are widely dilated and insensible to light. If the hands are examined it will be noticed that the thumbs are bent on themselves, and also bent in a peculiar manner rigidly in the palms of the hands and the fingers over them, and on the side most convulsed there will be more or less spasmodic action of the thumbs during the convulsion. The face and body will often be covered with profuse perspiration from the violent action. One symptom is uniform in all cases from the earliest period of the attack, a complete unconscious- ness of all surrounding objects and impressions.
Sometimes, in place of the convulsion, the individual will manifest unusual irritability of temper, inclination to find fault and quarrel with everybody and everything, or have violent bursts of passion which are really uncontrollable, and frequently lead to deeds of violence ; and all these, with similar symptoms, are simply developments of the disease in a different form, ancl must be treated accordingly.
But while these attacks are readily noticed, and can be dis- tinctly recognised, there is another form much more obscure, and on that account more necessary to be carefully observed and traced out in its history and development. This is the petit mat of the French writers or the masked epilepsy of some later authors, and it is much more fatal to the mental integrity than the more violent form, and often exists for years before the patient or any one else really suspects the true nature of the case. It may be noticed in a momentary suspension of con- sciousness ; a fulness of the head, or, as the phrase is, a rush of blood to the head; a feeling of vertigo ; a slight confusion of mind; a vacant stare; and a stopping for an instant in conver- sation, with sometimes a singular movement of the hands and movement of the head or the muscles of the mouth ; and, after a time, a failure of memory; an extreme irritability of temper, flying into a passion without any provocation; a per- verseness of conduct; and at times a sudden and unnatural obstinacy in trifling matters, with a disposition to annoy others and do things with the apparent purpose of giving trouble, all of these being frequently classed under the significant but inapplicable term, devilish.
Often the masked epilepsy occurs only at night, which adds to the obscurity of the case and the difficulty of detection. After continuing for a variable period, the disease will develop most generally into true epilepsy, and even in this form may exist longer than the friends are at first willing to believe, from the continued occurrence at night, and the attack not being sufficiently severe to leave very distinct evidences; and, when the conviction is forced upon the mind by evidence which can- not be gainsaid, the friends will insist very often that the attack which had been brought prominently to their notice is really the first which the patient has had.
In no class of mental disorders is more difficulty experienced in reaching a clear and satisfactory diagnosis than in cases of monomania, and this difficulty arises in great part from the very gradual approach of the disease and the slight change apparent in the conduct and conversation of the patient in the earlier stages, and an unwillingness to talk about their views and feelings. The only sure guide to a correct and clear decision in any given case will be found in a thorough and searching examination into the whole history of the individual, his opinions, habits, and conduct, comparing him as he may be at the time of the examination with what he had been at a previous period of his life when really himself, and thus tracing out as far as may be done the deviation from the healthy condition. This will require patient and painstaking labour ; for, if Lord Erskine, with all his great tact, ingenuity, and skill in cross- examination, could not obtain the clue to a delusion of the most extravagant character after hours of close examination, it may fairly be allowed to men of less skill and ability to require a much longer period and the most thorough investigation.
Many men are very ready to talk on the subject of their delusion, and will very readily give all the information desired, but there are those who are very reticent, who do not feel free to talk about their peculiar ideas, and from these it is much more difficult, if not impossible, to obtain such information as will enable the physician to pronounce a decided opinion. There will be noticed a peculiarity in the manner of the patient, a reticence in his conversation, an abstraction of mind, a disposi- tion to avoid others, with other deviations from the natural disposition, long before anything may be said about the peculiar delusion which engrosses the mind, and often the delusion will only be ascertained from the letters which the patient may write and the persons to whom they may be addressed.
Many of this class are very shrewd in all their business arrangements, and in many cases their abilities seem sharpened by disease, so that to the ordinary observer they appear quite sound and free from any mental obliquity; but in all these cases there is a change of conduct, a perverseness of the moral nature, and a bearing and manner towards the members of their own family, and a disposition to find fault with all they do, which clearly indicate the mental disorder. The delusions of many of this class are of a harmless character and give no trouble or annoyance to any one, but a very large number have such a tendency as to render their possessors very troublesome, and often dangerous to their families and to the members of the community at large.
The most dangerous of these forms are those which take the homicidal tendency, where the patient may be quiet and plea- sant for the greater part of the time, but will suddenly start up and rush on any one near with anything which may come to his hand, and in a few moments the paroxysm passes off, and no one is more penitent for what may be done or attempted to be done; but the impulse urging to the act is irresistible, and such persons need on this account to be carefully watched to prevent serious consequences during such paroxysms.
Many persons will give warning of the feeling which prompts the impulse, and ask to be restrained until it has passed away, but in the majority no such warning will be given, though to those accustomed to their manner, something in the expression of the countenance and in the conduct will give notice of what is to be apprehended.
Authors give a variety of names to other symptoms of the disease, according to the form which it may manifest, but being only names for variations of the same disease, or species of the same genus, they need only be referred to as manifestations in various forms of a disease which requires carefully to be inves- tigated, and when once recognised as disease to be properly treated, and from the tendencies manifested such treatment is generally only practicable in some hospital for the insane. Another form is what is usually called moral insanity.
Though the abuse of the term has rendered its use of question- able propriety, yet it must be admitted, there is a disorder of the moral powers which cannot be classed as simple wickedness, however great, or inclination to evil, but is clearly and unmistakably the result of disease, for the plain reason that it is not a steady advance from one degree of wickedness to another, but is a change in the man’s moral nature, rendering him just the reverse of what he had previously been. A man is attacked with some fever or other severe disease which greatly disorders his nervous system, and it is noticed that, as he begins to recover, his views of his relations to his family and friends have changed ; he is morose, regardless of truth and honour, suspicious of all his family, profane and abusive in language, profligate and addicted to a variety of evil habits and practices ; in fact, he is the exact counterpart of what he was before the attack of the disease, but, so far as can be discovered, no de- cided intellectual disorder exists. It is claimed by some that this cannot be classed as insanity, because the intellectual faculties appear to act properly ; but as the mind has two classes of faculties, moral and intellectual, is it not reasonable to infer that the moral can be affected and disordered without any appreciable disorder of the intellectual ?
The relations of the two classes are so intimate, that one class must be more or less affected by the disorder of the other, but in the disease under consideration, the intellectual dis- order is so slight in the early stages as not readily to be traced, and often the disease will continue for a long time without any distinct delusion, even when the most persistent efforts are made to discover it.
It lias, however, always seemed to me, that the very fact, that the man was not able to recognise the manifest incon- sistency in his life and conduct with his professions, and the total change in all his views and feelings which he is so ready to ascribe to changes in others while it really exists in himself, must be evidence of the weakening of the intellectual powers, and the consequent inability to discover the correct relations of things. Unfortunately the disease manifests itself so insidiously, and the indications are shown so often only to the man’s own family, whom he annoys and torments by every imaginable device, and by many devices unimaginable except to a disordered mind, and appears so well before strangers, that it is extremely difficult in most cases to detect the disorder in its early stages, and it runs on until all hope of curative treatment has passed.
In some cases the disease which has blunted the moral has sharpened some of the intellectual powers, and there is a sharp- ness and shrewdness, combined often with a malignity of evil, which renders the person the very incarnation of mischief and hate, and enables him dexterously to hide, under a very plausible exterior, his own defects, and depict in the most glowing colours those of others. While it may be suspected that such persons have intellectual delusions, it will defy the sharpest examiner to bring them clearly and distinctly to the apprehension of others, and the simple assertion of a belief in their existence will not satisfy those who demand proof positive of the fact.
The case must be treated and judged by what is clearly to be seen and traced out by unmistakable symptoms, and not by what may be supposed to exist, for no sane mind, not even the most gifted of those who have been longest engaged in the treatment of the insane, can imagine what extragavant vagary may lie concealed behind the shadowy veil of the man’s out- ward conduct and deportment.
The symptoms of melancholy are generally so clear and positive that it does not seem worth while to give a detailed statement of them ; but there are certain antecedent conditions leading to the diseaseclaimsh claim attention in order, if possible, to avert the impending trouble.
In these times, when the violent and sudden changes in values, and the fluctuations consequent on these changes, require the constant and earnest attention of men of business, there is a large class who feel sensibly the effect of this great and continued strain on their nervous system. The constant anxiety, the close and continuous effort of mind required to prevent the injurious effect on their own daily transactions, of the many rapid changes which occur in the course of business with the strong desire to maintain their own credit, and keep their families happy and comfortable, act on many men by causing sleepless nights, a gradual diminution of appetite with a consequent feeling of languor and inability to give that close thought and application to their duties which hitherto they have been in the habit of doing, a depression of spirits and a constant foreboding and apprehension of evil.
A single step only in almost all these cases is requisite to carry the man across the border line into melancholy, though many men sever the vital cord by some violent means just while lingering near the line, and before the family and friends can summon up courage to realise the situation and take the proper steps to prevent such an act.
These antecedent conditions require all the caution, skill, and tact of the physician so to adapt the means for their relief that the progress of the disease may be stayed, and the man turned back in health and soundness to his family and to society. The means to be used are absolute rest and change of scene, if it can be had, but, if not, relaxation from the severe strain to as great an extent as can be secured, the application of the appropriate means to secure regular and abundant sleep, with the use of the remedies most conducive to strengthen and improve the condition of the nervous system and correct the errors of digestion. These means will, of course, vary with the condition of the patient, his peculiar temperament and idiosyn- crasy, and the necessity for greater or less promptness in the administration of the proper remedies; one thing must, how- ever, be steadily kept in view, the avoidance of stimulants of every kind, for though they may act more promptly and give relief more speedily, the great danger must be considered of leading the man into a habit which may bind him with bonds he may not be able to break, and cause greater distress and trouble to his family than an attack of mental disorder. In cases of melancholy the delusions and hallucinations are all sad and distressing, either of some great and unpardonable sin committed, some duty neglected, some injury inflicted on others ; the exaggeration of some slight action, trifling thought, or hasty expression into a fearful offence against their fellow men ; the apprehension of great torture or punishment to be inflicted on the person himself or his family, with constant self-accusation ; avoiding the society of others and brooding in seclusion over the condition into which each one imagines these things to have brought him. With this distress of mind is almost always associated a depressed state of all the physical powers, loss of appetite, great inability to sleep, and sluggish- ness of all the different functions of the body. The condition most to be dreaded in all these cases is when the suicidal disposition is strongly manifested, for, while the idea is present to tlie mind in all cases, it is developed with fearful force and power in others, and then the greatest possible precaution and vigilance will be required at all times. When the disease has assumed the form of religious melancholy, and the patient believes himself forsaken of God, having com- mitted the unpardonable sin, or in some other unaccountable manner lost the favour of God and man, this suicidal propensity haunts the mind with fearful force, and to the same mind the singular inconsistency is constantly manifested of the constant fear of death and the torments they believe they will suffer after death, and the continual effort to rush into that very state they so much dread.
It is very often stated, when inquiry is made into the cause of melancholy, that the condition has been induced by too great reading of religious books, or too constant attendance on reli- gious services. Careful observation in these cases will show that this is rather a hasty assumption, and that the reading of religious books, or attendance on religious meetings, is an effect, not a cause, of the state of mind which immediately precedes the positive manifestation of mental disorder. The person, without understanding the cause, and being unwilling to say anything to his friends on the subject, feels miserable and un- comfortable ; the mind is depressed and filled with gloomy apprehensions, and the resort is to the Bible or other religious books, in the hope of finding something which will afford comfort and consolation, and thus bring relief; but as the mind is confused and troubled, the effect desired is not obtained in the manner expected, and the more the person reads, the more confused and troubled be becomes. Some active medication to relieve the disordered system, and something to give sound sleep for several successive nights, would sooner dissipate all the fears and clear the mind and enable the person to see things clearly.
Very many cases of religious melancholy occur in those who have led most correct and religious lives, who are scrupulously exact in the discharge of all their duties, and in whom no one could trace any irregularity of life or conduct, but in whom the nervous system has been weakened by some physical disease or unusual strain, and the person hopes by more strict attention to religious matters to relieve the uncomfortable condition, when, in reality, what is particularly needed is rest and nourish- ment.
There is a form of acute melancholy which is not common, but on that account, and also because of its rapid course, needs to be more carefully examined. In connection with the dis- tressed ideas and great depression of mind, there is a peculiar duskiness of tlie countenance, often a suffused condition of the eyes, and frequent disposition to weep ; a frequent and languid pulse, and a languid capillary circulation; a clamminess of the hands and surface of the body, in contrast with the dry and harsh skin in ordinary cases of melancholy; loss of appetite and great physical debility, which give warning of a tendency to pulmonary troubles, and unless proper attention is given in the early stages to such cases, they very rapidly run into pul- monary consumption.
It may not be amiss here to state that in many cases of melancholy phthisis is developed in a very insidious manner, so that, before any one suspects the true nature of the case, the disease has assumed a most positive and dangerous form, and has passed beyond the reach of any restorative means. There is often a disposition on the part of some people to make light of all the troubles which persons labouring under melancholy experience, saying they are all imaginary, and attempting to reason with or ridicule them on account of these fears and anxieties. But it is utterly useless to attempt to reason against or ridicule them, for they are as fixed in the patient’s mind as the bodily ailment which causes them, and as to their imaginary character, I know no better answer than that given by an elderly lady, ” They say all these notions and pains are only imaginary, but they are all real to me, and I suffer just as much from them.” What they need will be a few words of kindly sympathy, pleasantly and cheerily expressed, and the assurance that everything will be done to relieve them and make them more comfortable.
Though dementia is usually regarded as the termination of every class of mental disorders which does not yield to restora- tive treatment, there is an acute form of the disease which requires attention and careful treatment. This will be mani- fested by apparent obliteration of all the mental faculties ; entire stupidity, so as not to take notice of anything transpiring around, or even speaking in any way ; standing for hours in the same posture with scarce a movement; great carelessness in every respect; coldness and lividity of the whole capillary circulation, with great languor of the whole arterial circulation, and every function of the body in full sympathy with this extremely depressed condition. It is proper also to call attention to the great periodicity so frequently noticed in cases of mental disorder, so that in certain classes nearly every case will partake of this character and render it extremely difficult to form an opinion as to the ultimate result of the case, for, while this periodicity complicates the case and leads to the belief that no restoration will be effected, there are those in whom this condition gradually wears off and the patient recovers entirely. The lesson to be drawn from these facts is to exercise extreme caution in expressing a positive prognosis in any given case, for it has been the experience of every superintendent of a hospital for the insane to have had his predictions frequently falsified both in regard to restorations promised and unfavourable results anticipated.
Two principles must be constantly kept in mind in the treatment of the different forms of mental disorder, as well as in all nervous diseases: to secure ample rest and to administer carefully and systematically proper nourishment. It has been usual to recommend to persons suffering from mental disorder to take a greater amount of bodily exercise than they have generally seemed inclined to do, and those afflicted with various nervous diseases are often urged to take more exercise in order to become stronger. The natural inclination in many persons so afflicted and suffering from languor, lassi- tude, and a feeling of general debility is to keep quiet and do as little as possible, and this indication of nature for rest ought to be more respected than it usually has been. It would seem that a little consideration would show the fallacy and injury in recommending exercise in such cases. The nervous system has been injured by overstrain of some kind, and what is essentially requisite to enable it to regain its healthy action is rest, absolute rest for a time, and then alternating with exercise very care- fully graduated and regulated.
Every one will admit, that in order to relieve and restore speedily a sprained limb, it should be kept quiet as possible; if the eye is injured by too steady work too long continued, or by the effect of too great light, it should have rest and protection, and the same principle must be applied where the mind is suffering from great disorder of the nervous system. It is an acknow- ledged fact that every physical act of the system is accom- panied with loss of power and waste of substance, muscular and nervous, so that in any system already enfeebled, and where the nerve power is so much injured as to show decided symptoms of disease, it is only reasonable and right to enforce rest, so that the loss of power and the waste may be reduced to the minimum.
The same principle must also be insisted on in regard to the mind when in any way or from any cause disordered in its action ; constant exercise of any kind will only tend to increase the condition on which the disorder depends, for as every act of the mind involves the waste and decay of the cells of the brain by which the manifestations are made known to us, it must be clear that in a part already weakened, continued exercise will only further impair its power, and the more positive the enforce- ment of rest, the less will be the loss of power and the better the prospect of restoration.
Then having insisted on and practised rest, it is as needful that the loss of power and the waste be supplied by the regular and systematic administration of good substantial nourish- ment, and, if the powers of assimilation are much impaired, the proper remedies must be given to restore them to their normal action.
It is too common to give weak broths and such dilutions to persons suffering from languor and lassitude, or even to those in a more excited state. What is really needed is some more positive food which can be readily acted on, and give a larger amount of nutritive matter for the quantity taken, and the great majority of persons have such a strong dislike and even repug- nance for such watery extracts, that their taste and their strength would both be better consulted by such food as eggs, egg and milk, bread, meat, tender and well-cooked and free from grease, with such vegetables as are agreeable. It is preferable and desirable to insist on the rule, a little and often, than to keep on filling the stomach with a quantity of watery material with an almost infinitesimal amount of nutritive matter in it.
In cases of acute mania, as a rule, the appetite is good and often ravenous to supply the demand consequent on the great physical exercise ; but in those suffering from melancholy, the desire for food is often, and indeed generally, very slight, and they require to be carefully watched to prevent their neglect and refusal of such food as may be really needed for their support.
The primary indication in the treatment of mental disorders is to correct the diseased or disordered condition on which the irregular action depends. The causes inducing that disordered action may have been very various, and their removal will claim the earliest attention, but the treatment of the condition consequent on their action must be carefully investigated and conducted so that the nervous system may be placed in the most favourable state for the process of repair and renovation. The loss of sleep is one of those conditions almost invariably found in the commencement of all cases of mental disorders which tends to great deterioration of the nervous power, and consequent irregular action of the more important viscera. Belonging to the class of middle age physic, cautious and con- servative, I have never yet been able to see the force of the reasoning which would discard the discreet and moderate use of calomel, and I am confident that, in many persons, the disease lias been shortened and restoration more promptly promoted than if it had not been used. I do not profess to explain its physiological action, but from an experience of a third of a century, confidence in its therapeutic benefit is strengthened, not diminished.
Commencing the treatment with six grains of calomel and ten grains of Dover’s powder at night, followed by castor oil, or some other medicine calculated to produce a free but not exhausting catharsis, the system is prepared for whatever treatment may be most clearly indicated by the symptoms presented.
Every case must be carefully studied by itself, and no system of treatment can be laid down which will meet all the varying symptoms presented by different cases; but a little care and caution will soon enable the practitioner to ascertain what will be best adapted to the particular case in hand. In acute mania the clear and positive indication is to induce rest and quiet, and that is usually best secured by some of the preparations of opium. Of course the idiosyncrasies of patients in reference to the use of these preparations must be carefully watched, and often when one preparation will not agree another may be tried and then another, and, given in combination with extract, byoscyami, some one of the prepara- tions will often be more readily borne, and appear to act more satisfactorily than by itself.
If there is decided contraction of the pupils, with a dry and parched condition of the tongue and fauces, the medicine does not agree, and must be stopped, but often there is a very dry state of the tongue, caused by constant talking, and little effect 011 the pupils, and this state may readily be removed by drink- ing some water.
O ? ? The regular administration of the preparations of opium has a tendency in many persons to produce constipation, which must be guarded against and relieved by such means as will act most gently. Some writers, who claim to be authority, declaim against the use of opium on account of its supposed tendency to injure the brain and render mental disorders chronic. Such has not been my experience, and I fear that those who have had such experience have been very careless in the administration of the drug, and very inattentive to the general treatment. Many physicians rely 011 bromide of potassium to produce sleep, but except in large doses it lias very little beneficial effect in cases of insomnia accompanying mental disorders, and the large doses required often derange the stomach and produce bromisin, the effects of which are very depressing and troublesome to relieve.
Convinced that chloral hydrate is a remedy which requires to be used in a very cautious manner, and that the bad effects attributed to it arise from the large doses in which it is often given, it will naturally be inferred that I would recommend its use only in moderate doses of fifteen to twenty grains, repeated if required at intervals of two hours, until the desired effect is produced.
The combination of chloral hydrate and bromide of potas- sium is often found beneficial in cases of great restlessness and fretfulness; and when a more permanent effect is desired a small amount of morphia may be added to the mixture, or given with either separately, thus prolonging the sedative influence. As a matter of practical experience, it may be stated that it is safest and best not to adhere to one preparation of any class of medicine for a length of time, but to change it for another. If one preparation of opium has been used for a time, substitute another; or if one preparation of iron has been given, it would be found most advantageous to change it for another after a few weeks’ use, and not continue the use of any one form more than a few weeks at a time.
There are certain cases of high maniacal excitement, par- ticularly in asthenic cases, where none of the usual anodynes appear to do any good, and where sleep can be readily induced and kept up for several hours by the administration of half an ounce or an ounce of pure old rye whiskey, according to the severity of the excitement, combined occasionally with a small dose of morphia. It must, however, be remembered that the effect of such doses must be carefully watched, and the whiskey with- drawn as soon as it can possibly be done, so as not to induce the habit of drinking. It is always best to give whiskey mixed with some carminative, so as to hide the taste and not allow the patient to know what lie is taking. In conjunction with the medical means, strict attention must be given to the regular and systematic administration of food, so as to support the strength and prevent exhaustion from the excitement.
In cases of exhaustive mania, the safest and best treatment after the preliminary course recommended, will be the exhibition of half-ounce or ounce doses, according to the violence of the symptoms, of pure old rye whiskey, witli milk and the most nutritious diet which can be given, and the confinement of the patient to the horizontal position. I have found it necessary in some such cases to give an ounce of whiskey every two hours for nearly a day, thus reducing the pulse from 120 to 80, and bringing on quiet refreshing sleep, and ultimate restoration. In epileptic mania, the only medicine which seems to control the high nervous excitement is bromide ol potassium, regularly and perseveringly given in small doses from day to day, and from month to month, with special care to prevent constipation, and, if possible, a milk diet morning and evening and a small quantity of meat with bread and vegetables for dinner. The danger in epileptic mania arises after the convulsion, or when unusual irritability takes the place of the convulsion ; but any one who will carefully watch the case can generally ascertain by certain changes of manner and conduct, or certain methods of expression peculiar to the patient, when the excitement is coming on; and when these appearances are observed, renewed vigilance must be exercised to prevent any violent demonstra- tion. There is such an infinite diversity in the appearances and conduct that no rule can be laid down for particular guidance, but the physician must study each case by itself and learn how to meet the indications presented.
The most troublesome symptom in melancholia is sleepless- ness, and to remove this will require all the tact and ability of the physician in the administration of the different form of narcotics witli at the same time such a course of tonic treatment as will bring up the system to the normal standard. The most annoying and perplexing symptom in this form of disease is the disposition to suicide, and the only resource is unceasing watch- fulness at all times and under all circumstances. Such cases can never be trusted for a single moment where the propensity is active, and are most to be suspected when they protest most positively that they have given Tip all idea of such a thing and ask to be left alone; and many cases succeed in their plans by some plausible pretext by which they throw the attendant entirely off his guard.
Cases of monomania have generally assumed such a character when the family are willing to consult the physician that medical treatment cannot be attempted with any hopes of success, and the physician’s only duty then is to sign the certifi- cates required by law to secure admission to a hospital. The treatment of puerperal mania in the earliest stages is so clearly marked out by the symptoms presented that every physician will know what is required in the case, and it is only when the disease has assumed a violent form, or has become intractable and troublesome to the family, that the necessity arises for removing the patient from the family to the care of a hospital.
In acute dementia the difficulty of administering food and medicine is so great, and the care in other respects so trying and wearinf, that the friends soon see the necessity of placing the patient in some hospital for the insane.
It is a duty incumbent on the physician to impress upon the minds of every family in which he may be called to treat an insane person the fact that mental disorders will, as a rule, require considerable time in the treatment before any decided improvement will be noticed; that very few persons really regain their full mental integrity in less than six months ; and that in melancholy the course of treatment will be quite pro- longed, generally from nine months to a year and more. Some attacks of acute mania will pass off in a few weeks, but these are very exceptional cases, and it is always to be apprehended where the attack passes off suddenly that another outbreak of greater violence and longer continuance will follow in a few weeks.
Every physician should impress on those who have occasion to place a member of the family in a hospital for the insane, that, having shown confidence in the physician of the hospital by placing the patient under his care, they should be willing to continue that confidence, and be guided by his judgment as to the proper time at which the patient may be removed. Never encourage the family to be trying experiments to ascertain whether a change of scene might not be of benefit and hasten restoration, for in a mind weakened by disease the most careful and cautious management will be required to prevent the injurious effects of certain scenes and associations. Every physician of a hospital for the insane who has had many years’ experience can count scores of cases where irreparable injury has been done, and the disorder rendered chronic and incurable, by these efforts to try change of scene and associations during the convalescent period. The patient himself will urge the change in the very strongest manner, and make a most pitiful appeal to the friends by persuasion, threats, promises, and com- plaints, and the mode in which this is done ought to convince the friends that the man lias not regained his healthy mental action, and at this critical juncture, the calm and dispassionate opinion of the physician ought to be more potent in enabling them to reach a correct conclusion than the passionate appeals of one just recovering from a serious disorder, and whose brain and nervous system have not yet acquired their full healthy operation.
The question of the removal of a patient from home and friends to a hospital and the care of strangers is surrounded with so many considerations involving the welfare and happi- ness of the patient and the family, that it is almost impossible to lay down any rules to which many exceptions may not be taken; but when the necessity does arise?and that period is generally much earlier than the friends are willing to act?the sooner the decision is reached and carried into effect the better for the patient and the family. It is always far better to be frank and honest with a patient when it has been decided to send him to a hospital, and tell him the plain truth of what has been thought best to be done, and not deceive him by a variety of tales which he will soon find to be false, and which will rankle in his mind, cause ill-feeling-, and often bitter dislike to those who deceived him, and interfere in many cases with successtul treatment and restoration; for it intensifies the distrust already existing in his mind, and renders it extremely difficult for the officers of the hospital to disabuse his mind and acquire his confidence. It is difficult under the most favourable circumstances to acquire the confidence of the insane, and when they have been deceived in being brought to the hospital, their distrust is intensified, and they consider all in the hospital in league against them, and the difficulty of treatment is greatly enhanced. The physician should also impress upon the minds of the family the very great importance of early treat- ment, and the continuance of that treatment in the hospital until restoration is fully effected, and the physician of the hospital can recommend the removal with safety. At the same time he should endeavour to disabuse their minds ot the prejudices entertained by so many against hospitals, and impress upon their mind as strongly as possible the idea that the treatment in all well-regulated hospitals at the present day is conducted on the principles of kindness, forbearance, good- will, and charity in its noblest and most expansive expression.
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