Prophylaxis Of Insanity
32 Art, II.? :Author: J. M. “WINN, M.D., M.R.C.P., Consulting Physician to St. George’s and St. James’s Dispensary, &c., formerly Resident Physician of Sussex House Lunatic Asylum.
In the following remarks we propose to treat only of insanity in its hereditary character. It is admitted by the highest authorities in psychological medicine, that about one-half of the cases which have come under their care could be traced back to some insane or half-insane ancestor. If, however, it can be proved, as I have before now contended, that not only insanity, but every form of hereditary disease may, by a conservation of morbid energy, give rise to insanity, the cases which owe their origin, without predisposition, solely to moral causes and vicious habits, must be reduced to a small minority.
In 1869 I published a treatise on The Nature and Treatment of Hereditary Disease, with reference to a correlation of Morbific Force * in which I remarked that if any medical man, conversant with the treatment of insanity, and who has opportunities of knowing intimately the connections of his patients, will make careful inquiries into their history, he could scarcely fail to discover evidence of some form of hereditary disease, in one or other member of the same family. If he has not detected the existence of decided insanity, for friends and relatives generally endeavour to conceal such fact, he would probably ascertain that few have escaped some constitutional taint, in the form of scrofula, phthisis, epilepsy, &c; for how few of us can boast of an ancestry entirely free from hereditary disease. To substantiate this theory of a correlation of morbific force, I published in the treatise referred to, clinical cases, showing how skin diseases correlate with mania; epilepsy and phthisis with acute mania; scrofula with melancholia, &c. On May 21, 1870, I sent a letter to The Medical Times and Gazette, in which I gave additional facts in confirmation of my theory. Since my treatise appeared, the tendency of thought amongst medical men has been in the direction of my theory. Nine months after its publication Mr. Jonathan Hutchinson read a paper at a meeting of the Hunterian Society on Some of the principal Diatheses, and their mutual Relation, in which he argued that gout, syphilis, scrofula, cancer, bronchocele, dartrous affections, &c., have common properties. This group (although syphilis is mentioned, which I do not include in my category, and insanity is omitted) bears a very close resemblance to mine. Mr. Hutchinson classifies these diseases under the head of diathesis, which he considers different from dyscrasia or
Published by David Bogue, 3 St. Martin’s Place, W.C.
temperament; but all these words are vague, and do not convey to the mind the same clear idea that is expressed in the term, correlation of force.
In 1878, in a paper on The Brain in Health and Disease, by Dr Edward C. Mann, late of the New York State Em. Insane Asylum, the writer, in referring to the connexion between phthisis and insanity, recognises my theory, but does not mention my name. He observes: ” I also believe there is a correlation of morbific force, which renders these diseases mutually convertible”?using my very words. Again, in 1880, Dr Walter Kempster, in his annual report of The Northern Hospital for the Insane of the State of Wisconsin * gives instances of the mutual convertibility of different forms of hereditary disease, without any reference to my researches twelve years previously.
My attention has recently been called afresh to the subject of this paper, by some remarks made by Dr Greorge M. Beard, in the prospectus of a National Association for the Protection of the Insane and the Prevention of Insanity, in the United States. He observes: “The subject of insanity is greater than insanity itself, since all the diseases of the brain and the nervous system, by whatsoever names known, are related to each other, run into each other, and take each other’s place. The man who only knows insanity,- does not know even that; all the diseases of the nervous system are members, one of another, and are to be studied as parts of a great whole and in relation to each other.” This is all very well as far as it goes, but the induction is only partial, and is included in my broader generalisation. The expression, ” diseases of the brain and nervous system,” has nevertheless a wide application. Who can say in what medical disease (not zymotic) some disturbance in the nervous system is not the fons et origo of all the mischief ? It is now admitted that in diabetes the nervous system plays an important part, and the most rational theory of ” catching cold ” is that which attributes it to an impression made on the nervous tracks by a low temperature.
To establish a correlation of force it is necessary to prove a mutual convertibility. It is not sufficient to give instances of one disease passing into another; we must demonstrate a see-saw sort of action; and I gave instances in my treatise of diseases passing backwards and forwards, either in the same individual, or in various members of different generations of the same family. That some sort of force is active in insanity cannot be doubted?force is in operation everywhere; as Carlyle said,
Published in Part I. Vol. IV. of the Journal of Psychological Medicine.
Now Series.
there is force in a rotting apple. One case in particular, in which the insane force manifested itself, is indelibly impressed on my memory. I have mentioned it before, but, it will bear repetition. The patient, a highly educated gentleman about 40 years of age, and of unexceptional moral character, was subject to attacks of acute mania of the most violent character. During the intervals between the attacks, his mental and bodily condition were those of a person perfectly free from disease, and formed a striking contrast to his maniacal state. The paroxysms were marked by outbursts of uncontrolled passion, violent gestures, and the use of obscene and blasphemous language. After the lapse of a few weeks this terrible commotion would subside, leaving the patient calm and rational. It was like the clearing of the atmosphere by a thunder-storm, and supports my theory that there were latent morbific forces in the system which became developed by some exciting cause, leading to a disturbance of the nervous molecules. No one can doubt that this was an expenditure of force, and in every sense of the word we may term this energy morbific. An ordinary attack of epilepsy bears a close resemblance to a recurrent case of acute mania?in it we perceive the same expenditure of energy.
That a morbific element may lie dormant during a whole generation need not surprise us, when we see how the terrible poison of rabies may be latent for an indefinite period. I have dwelt thus long on the etiology of insanity before discussing its prophylaxis, as a rational mode of treatment of any disease cannot be devised until we have ascertained its cause; and if there be but one cause for the existence of all hereditary diseases, as we have given grounds for believing, it follows that there must necessarily be one general plan of treatment, more or less applicable to the whole. The prophylaxis of hereditary disease involves the to important questions of hygiene and marriage.
Hygiene.?Hygienic treatment cannot begin too early. Where hereditary taint is feared it should commence with the earliest period of life. Constitutional disease is often manifested soon after birth in the form of convulsions. The nourishment of the infant must be the first care. The food which nature supplies is the best; and even if the mother belongs to a family in which there is hereditary disease, I do not think it an objection to her nursing, provided she be strong and has plenty of milk, for there is no ground for believing that the class of hereditary diseases to which I have referred can be transmitted, like syphilis, through the secretions of the mother. The three other requisites for an infant’s health are air, warmth, and bathing. Its moral education should begin in infancy. Firmness must be combined with tenderness. A lengthened discussion on education would be out of place here, but a few words are requisite on the danger of overstimulating the brain by too great a variety of studies. Precocious children are often scrofulous, and parents take a foolish pride in the exhibition of their talents, and are disposed to keep them at their tasks, when they should be romping with their playmates.
The most critical period of life is the interval between fifteen and twenty-five. This fact shows the necessity of controlling the sexual passions at this period.
There can be no doubt that a large class of those disposed to hereditary maladies might have escaped disease had they chosen a suitable profession or vocation.
Regular exercise in the open air is a most powerful therapeutical agent. An empiric once gained great reputation for *the cure of epilepsy. His plan was simply to order his patients to walk a considerable number of miles daily. Whilst on the subject of the treatment of hereditary disease, we must not forget the great value of cod-liver oil. It bears a similar relation to hereditary that quinine does to zymotic disease. Issues, once so much in vogue, should not be overlooked. Marriage.?This subject demands the most earnest attention. I have generally found it useless, when consulted by young people as to the advisability of their marrying, to say?don’t. There can be no doubt as to the danger of two individuals marrying when there is hereditary taint on both sides. It is not necessary, if the views I have inculcated be right, that the form of hereditary disease should be the same.
The general rule of transmission is from parents uninterruptedly to the children, and from them to the grandchildren, frequently with an interruption, from the grandparents to the grandchildren. Sometimes the taint is derived from collateral branches.
Some time since I drew up the following rules for the guidance of those who have consulted me as to the advisability of their marriage into any family of which one or more members have suffered from constitutional disease. They were published in my treatise On the Nature and Treatment of Hereditary Diseojse. As I am not aware that anyone else has drawn up rules of a similar character, and as they have an approximative value, I will repeat them: ?
1. If there be a constitutional taint of any kind in either father or mother on both sides of the contracting parties, the risk is so great as almost to amount to a certainty, that their offspring would inherit some form of disease belonging to the class to which these investigations refer. . 2. If the constitutional disease is only on one side, either directly, or collaterally through uncles or aunts, and the contracting parties are both in good bodily health, the risk is diminished one-half, and healthy offspring may be the issue of the marriage.
3. If there have been no signs of constitutional disease for a whole generation, we can scarcely consider the risk materially lessened, as it so frequently reappears, after being in abeyance for a whole generation.
4. If two whole generations have escaped any symptoms of hereditary disease, we may fairly hope that the danger has passed, and that the morbific force has expended itself. We now arrive at the vexed question of consanguine marriages. Perhaps the true reason why the intermarriage of blood relations is so generally considered to be a fruitful source of disease, is that, if there be any latent morbific force in both parties (both of whom are derived from the same ancestor), it is likely to be more intensified by their union than if there were no consanguinity. Nevertheless, if both parties are in good health, and free from ancestral contamination, there can be no reasonable objection to the marriage of cousins. It may be argued that it is of little avail to give prudential rules respecting marriage where the affections are strongly engaged, and that the stamping out of hereditary disease is a Utopian notion; but medical science should aim at the highest ideal, and it is the province of the physician and sanitary reformer to point out the best means of preventing physical evils, as it is that of the moral philosopher to exhibit the disastrous consequences of a violation of moral laws. Whether the rules I have suggested concerning marriage be adopted or not, there can be no doubt that hygienic means have done much to arrest and alleviate hereditary disease. A medical man is often rewarded for his care and attention by seeing delicate children grow up strong and healthy men and women, the morbific force either expending itself or continuing latent. Sometimes if disease cannot be eradicated, a favourable change of type occurs ; a grave malady being transmuted into one of a less fatal character. One case of this kind especially recurs to me?that of a professional man who was very delicate in his youth, and liable to haemoptysis. In after years he became subject to attacks of gout. When in his ninetieth year, he was able to ride on horseback and attend to business, although still occasionally laid up with gout.
We must also take heart from the new doctrine of dissipation of energy. If this be true, we can look forward to the dissipation of morbific force. The vital force of an individual is exhausted in a few years, why then may we not hope for a similar termination of hereditary evil ?
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