BRATTLEBORO — If we are familiar with the early warnings of mental disease, many a useful member of the community may be spared and perhaps years of suffering averted.
It is a well-known fact that the chances of recovery from mental disease are lessened in proportion to the length of time it is allowed to run without being brought under the influence of appropriate treatment.
“I think,” says Dr. Samuel Woodward, “it is not too much to assume that insanity in its incipient form, uncomplicated, is more curable than any other disease of equal severity; more likely to be cured than intermittent fever, pneumonia or rheumatism."
Experience proves that nine cases out of ten recover if placed under treatment within three months after the attack. It is, therefore, specially the duty of the general practitioner who is first called to such cases to familiarize himself with the early symptoms of this distressing malady, in order that he may arrest its progress at a time when curative measures are most effective.
In response to our inquiry, when patients are brought to us, we are often told that insanity came on suddenly, without previous warning; but upon investigation we find, almost without exception, that there was a long interval during which the patient exhibited peculiarities and committed strange acts.
Some authors go so far as to declare that the sudden onset of mental disease never takes place, and all agree that it is of the rarest possible occurrence.
The duration of the premonitory stage must, of course, depend greatly upon the intensity of the exciting cause and the strength of the predisposition, but it usually extends over a period of months, and sometimes for years before the final explosion takes place.
A young lady was recently placed under my care with a history of having been mentally unbalanced one month or possibly six weeks, but to me she confessed that for upwards of three years she had been greatly tormented by hallucinations against which she had waged a constant warfare, and from the influence of which she was enervated and considerably reduced.
I think no one, in these days, will question but that insanity is a manifestation of some physical derangement going on in the brain, or some distant part of the body affecting sympathetically the material organ of mind.
Dr. Andrew Wynter says: “The more the fact of the physical nature of insanity is acknowledged, the more it is recognized as an ailment which can be reached by physical agents, the greater will be the chance of its successful treatment.”
If a man shivers and feels depressed, he seeks the advice of his physician that he may meet the coming fever with the best resources of his art.
If a man feels his brain disturbed, if he feels the early warnings of which his friends as yet know nothing, would it not be equally wise of him to summon the aid of medicine before it is too late? If such a mystery were not made of mental disease, it would be deprived of half its terrors and half its evil consequences at the same time.
The idea of the mind being disordered independently of physical disease has no existence except in the imagination of those who willfully close their understandings to the reception of truth.
Eccentricity, natural or acquired, is perhaps the simplest form of deviation from ordinary mental standards, and does not specially concern us here further than to remind us, that individuals who occasionally go out of the beaten path cannot therefore be classed as walking the border line of insanity unless the singularities exhibited should gradually develop into actual delusions, as occasionally happens.
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It is not uncommon for delirium to be confounded with insanity; but the delirium of acute and sympathetic diseases is different from the disturbance of the intellectual faculties which charaterizes insanity.
Maniacal delirium is distinguished by the absence of fever, although there is sometimes an increased heat of the surface, yet it is usually confined to the scalp, or may be the result of violent muscular exertion.
In insanity there may be little or no disturbance, apparently, in the general constitution; the mind is occupied upon some fixed, assumed idea to the truth of which it will pertinaciously adhere, in opposition to the plainest evidence of its falsity; and the individual is always acting upon that false impression.
In insanity also, the mind is awake to the objects which are present. Then again, the illusions and hallucinations of delirium are often quickly dispelled by placing a bandage over the eyes, while those of insanity persist.
In judging of the existence of mental derangement we should be guided in our opinion by instituting a comparison between the manifestations which prevail at the time when the mind is supposed to be disordered and the previous mental condition of the individual in its natural state.
When a person of mild temper and gentle disposition becomes subject to fits of violent passion without adequate provocation, when a man naturally virtuous becomes gradually addicted to sensual gratifications, when the kind and indulgent father and husband neglects his family or perhaps treats them with utter indifference, when a man noted for his probity, temperance and business sagacity becomes the reverse, when an ingenuous person of sunny disposition becomes reversed, suspicions, peevish, quarrelsome, and perhaps forms an aversion to those he formerly held in high esteem, then you may be sure he is in the border land of insanity.
Dr. Philippe Pinel relates that a man who believed his wife to have been ill only six months, the period of invasion of furious delusions, agreed after a multiplicity of questions that the disease must have been going on for 15 years.
It is often easy to go back months or years in this way, and we finish by discovering that circumstances taken for causes, by friends, are frequently only the consequences of unobserved disease.
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One of the earliest and most important indications of approaching mental trouble, is insomnia and restlessness during the night; this is always present in incipient mania, but it should be remembered that these patients frequently declare that they sleep soundly and awake refreshed and in full vigor.
I hardly need say that this is only borrowed energy and portends speedy mischief. In incipient mania, the first alteration to attract the attention may be general exhilaration and high spirits; new ideas, propensities, and peculiarities are developed; there is an increased rapidity and expression of ideas, every faculty of the mind is exalted, and new ones are conceived never before given expression to.
Everything is done by impulse, nothing from reflection. Many things are begun with great enthusiasm, but few are carried out to completion. Short reveries are noted, there is great restlessness, and a constant desire to change; he gives expression to quick and hurried utterances, is blustering and authoritative, commanding and countermanding in the same breath; is passionate and irascible, scheming, ambitious, and extravagant.
All his business schemes come out far beyond his fondest anticipations; general agitation is noted with watchfulness, suspicion, and a propensity for drink, venery, etc.
All ordinary occupations are executed in a more hurried and less perfect manner, or are wholly forgotten; and there is great confusion of mind, though no positive delusion, hallucination or delirium be yet declared.
He has more or less pain in the head, with throbbing at the temples, giddiness and buzzing in the ears. The digestive function is altered, the appetite is capricious, sometimes increased, sometimes diminished; the complexion changes,
The secretions and excretions are gradually impeded and vitiated and the patient grows thin. These symptoms may continue the same for some time, but by degrees they all become aggravated, or fresh ones intrude before positive delirium is developed.
If these symptoms are suffered to proceed, there is a sense of fullness or distension, or constriction like a band around the head. Noises in the ears become louder, great acuteness of hearing, but attention transitory.
There is vertigo; redness and unusual brilliancy of the eyes; volubility and an exaggerated emotional state.
These are a few of the more prominent symptoms found in the incipient stage of mania, and as the active or confirmed stage is so patent to all, I will pass to a consideration of the symptoms of impending melancholia.
This disorder usually has a protracted period of incubation during which the symptoms do not differ essentially from those in other varieties of insanity, except that mental depression is more pronounced and the patient is tormented by groundless apprehensions which are seldom found in mania.
Soon the characteristic change in the patient's general appearance and attitude takes place. There is often marked diminution of nerve energy, accompanied with lassitude and general inertia.
The muscular system is relaxed, the gait is unsteady, movements are made slowly and only when necessary. The voice becomes notably subdued, and there is a disinclination to talk. At the same time his habits and mode of thought are observed to undergo a change.
He becomes dejected, peevish, suspicious, and is disposed to connect everything bad with himself. He shuns the society of those with whom he formerly took pleasure - and often fancies that his family are lacking in proper respect, or that they may be maltreating him.
Everything about him is negative, nothing affords pleasure, he is self-conscious, discontented, and ill at ease. He is usually aware that a change has taken place in his moral nature and seeks solitude to hide his infirmity. If he reads, he selects stories of a gloomy cast and is apt to search the Scriptures for passages that confirm his morbid fancies.
He sleeps but little and is annoyed by frightful dreams. There is a sense of weight and oppression about the stomach, accompanied with indigestion, flatulence, offensive eructations [belching], loss of appetite, constipation, etc.
The habit of biting the nails is common, also picking the fingers or any pimple or abrasion of the skin until the parts are sore and sensitive, though the pain is unheeded.
He becomes irritable and oftentimes flies into a passion upon slight provocation.
Some melancholiacs are always discontented and nothing pleases them; others are utterly indifferent, because their attention is completely absorbed in the contemplation of their own misfortune; and others maintain that everything is too good for them.
In all cases of melancholia it is our first duty to carefully investigate the general condition of health of the patient.
Hepatic, gastric, or intestinal disease will almost invariably be found, and if promptly removed by appropriate treatment, mental health may, in some cases, be soon restored. It is impossible here to do justice to the broad and important subject of general paresis [mental impairment caused by syphilis]. I will therefore state briefly that the early symptoms are so common to other mental disorders that a diagnosis can seldom be made with certainty until the later characteristic symptoms are declared.
Insomnia and mental depression with more or less hypochondria are always present in the incipient stage, but the opposite condition of exhilaration and great exuberance of feelings soon follows and continues to the end, with the exception of short intervals of depression, which distinguish a case now and then.
Failure of the memory is one of the earliest indications; he forgets his appointments and often is unable to call old friends by name. In writing he occasionally skips important words. Slowly and insidiously, a complete change is wrought in his moral nature, he becomes irritable, fretful, moody, and gives way to excesses and dissipations of various kinds.
His friends will tell you that for some time past he has been guilty of small, dishonest acts, one of the most common of which is theft; and it is noteworthy that he steals openly, and appropriates articles which are of no value to himself or anyone else. He speculates foolishly and squanders his money in a most lavish way, is filled with schemes for achieving the impossible, has unlimited self-confidence and is quite blind to his glaring limitations.
All these symptoms, in an intelligent person, may be exhibited in a semi-plausible manner, and his friends do not, as a rule, consider him deranged, though they recognize that an unaccountable change has taken place in his character.
The practitioner seldom sees a case in this early stage, but a little later on, when the characteristic tremor of the tongue and lips, clipping of words, disturbances of coordination, bracing gait, irregular pupils, and grandiloquent delusions make their appearance, the diagnosis becomes easy.
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It should never be forgotten that in the earliest stages of mental disturbance, patients are as a rule morbidly suspicious and keen to observe.
The greatest amount of tact and judgment is therefore demanded on the part of the physician to so conduct his examination as not to convey the belief that mental derangement is suspected; for in committing this error, we at once end our own usefulness and perhaps seriously complicate that of others.
Regarding the treatment of incipient mental derangement, I shall say nothing further than to remark, that there is no “Royal Road” to cure, and the characteristics of each case must be carefully studied and fought upon general principles.
It is our duty to improve every opportunity to educate the public in this matter, and to correct the deplorable custom, which is everywhere prevalent, of ignoring the early indications of mental diseases, and trumping up excuses for slight departures from the habits and modes of thinking common to the individual, until he has drifted far beyond the borderland, and becomes so violently excited or dangerous in his impulses, as to compel the friends at last to acknowledge the truth.
“If,” says Dr. Andrew Combe, “an acquaintance with the philosophy of mind were common among educated persons, and the patient had confidence enough in the knowledge and discretion of his friends, to reveal to them the first approach he felt of losing his command of his own faculties, the development of insanity might often be prevented; and in fact, its attacks are in many instances, just so many punishments for our ignorance and neglect.”