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Vol. I.-No. 2. Subscription Price $1.00 per Year. WHEELING, W. VA,, OCTOBER, 1906. Single Copies 20 Cents Original Articles. WHAT CAN THE GENERAL PRAC- W. Holmes Yeakley, M.D., Davis, W.Va.* Read at meeting of Barbour-Randolph-Tucker Society. Mental disease appears in so many forms, is evinced by so many and so varied symptoms, that to discuss the subject very thoroughly in a single paper is next to an impossibility. I will, therefore, confine my remarks to a general summary of the more common forms of mental aberration, which the general practitioner should be prepared to recognize early, and should be able to do much toward preventing the progress of, and direct his professional skill toward curing the conditions already present. The observant practitioner of medicine sees many a case of psychosis, during his professional life, for which he is not consulted, until it is to sit upon a commission of lunacy, or is summoned as a witness to the criminal courts, to testify as to the sanity of the prisoner. There is usually a sensitiveness on the part of parents of weakminded children, which persuades them to keep an unhealthy silence as to any abnormal mental condition that may appear in the disposition of their offspring; and in * Dr. Yeakley has recently removed to Harrisonburg, Va. stead of seeking advice from an intelligent physician early, they are prone to put it off until it is too late for any method or amount of treatment to arrest the disease, and have at last to suffer separation from such child. by having it committed to a hospital for the insane; or, what is sometimes worse, suffer the remorse of having him placed behind prison bars. A correct classification of mental diseases is impossible, and though some classification is attempted by most of the authors of standard works on alienation, it is for the purpose of better discussion mainly, and is usually accompanied by an apology. The number of cases of mental disease seen by the general practitioner will depend largely upon the condition of society and the standard of civilization in his locality. Densely populated cities, poverty with its inadequate and improper food supply, business rush and worry, religious enthusiasm, alcoholism, drug habits, consanguinity, want of diversion from one line of work, excessive study, syphilitic troubles, prevalence of certain forms of acute diseases, constitute some of the conditions which tend to increase the percentage of mental-disease sufferers; and the physician whose field of practice lies in that locality where one or more of the above named conditions prevail, will certainly see more cases of mental abnormalities than his brother practitioner whose work is in the more favored communities. In England there is one insane person to every three hundred of the population, and it is equally as bad in many of our own states. It would be much easier to speak in general of the conditions which would lead us to make a diagnosis of mental disease, rather than attempt the difficult task of exactly defining it, and in the more recent works on psychiatry, a definition is often not given. But the title of this paper would seem to make it incumbent upon me to attempt some definition for mental disease; more particularly a differentiation between the medically insane and the legally insane. A definition which would probably satisfy us from a medical standpoint, would be as follows: A more or less prolonged departure from one's normal way of thinking and acting, usually accompanied by delusions, hallucinations and confusions, due to disease of the brain. This does not include the degenerative types of insanity. The courts recognize insanity in a broader sense, and have established the fact of insanity in cases which were not considered medically insane. The term "of unsound mind" is used by the courts, and is obviously much broader in its scope than that embraced by the medical definition given above. They try to establish whether or not the prisoner knew the quality and nature of the act-whether he believed the act was wrong, and whether he was impelled by stress of some abnormal condition of the brain at the time the act was committed. "The modern acceptance of the doctrine of criminal responsibility may be summed up as follows: 'Was the person whose act is in question able to understand its nature and to pass a fairly rational judgment on its consequences to himself and others, and was he free agent far as that act was concerned?" Ignorance of the law excuses no man, but there are a few persons who know the nature and quality of an act to be wrong, but are driven by imperative ideas so far as not to be free agents. It is hard in a general way to draw a sharp line of demarkation between the sane and the insane mind. For instance, we would not call the negro insane who believes he can safely plug the spirit of a deceased foe in a hole bored into a tree, and will, therefore, be free from sickness and "hants" as long as the plug remains secure; but such a belief in the edu a as cated white man no one will doubt would be, prima facie evidence of insanity; and we would not consider it abnormal in the nervous and impulsive man to be extremely demonstrative over a particular expression made which seemed to strike his fancy: but similar manifestations on the part of the even tempered man would arouse suspicion as to his mental equilibrium. The doctor is often called to pass judgment upon those with defective mental organization, and only in the case of the highclass idiot is such a decision difficult. In the examination of all cases, we should look carefully for physical deformities. In addition to the contour of the cranium, some of the more important marks of degeneration are the crumpled ear, absence of the lobes, the position of the ear to the head; the arched palate, projecting teeth, faulty articulation, clubbed fingers, the "crazy walk," etc. In considering the early general symptomatology of mental aberration, because of its relative importance to the general practitioner, I have chosen to take up briefly insanities of childhood later. In making the first examination of all cases of psychoneuroses, we should learn in what way the patient has changed. Has cheerfulness changed to melancholia, neatness given place to slovenliness, the sober suddenly become alcoholic, the miser developed into a spendthrift, the even tempered. man given way to sudden outbursts of anger; has the imagination become dull, perception faulty, does the patient answer questions sluggishly, have there developed morbid fears, are there present any of the cardinal symptoms of insanity-delusions, hallucinations and confusions? The delusions may be fixed or evanescent. In short, a thorough examination should be made of the patient's present condition, his past history from the cradle to the present time, and his family history carefully studied through the last three generations; for it is a peculiar fact that mental disease will often miss one generation and appear in the next with unabated severity. It is hard to tell just what part heredity plays in the etiology of insanity. It has been variously estimated at from sixteen to forty per cent.. but my own experience with the insane leads me to believe that a much larger percentage than the maximum given may be directly or indirectly traced to heredity. A careful analysis should always be made of the urine, because it often acts as a valuable guide to some of the most important forms of neuroses. In acute manias, for instance, the amount is diminished, the salts are increased, albuminuria present, which may be unaccompanied by any kidney lesion. Valuable symptoms may often be found in the disturbance of the motor system. Increased or diminished tendon reflexes, ptosis, corrugation of the brow, atrophy of the small muscles of the mouth, and peculiarity of the gait. Spastic contraction of single muscles or groups of muscles, in the absence of trauma, is strongly indicative of approaching organic disease of the brain. The sensory system comes in for its share of disturbance, and is manifest in a number of psychoses. The hyperesthesias are of more importance to us than the anesthesias, as the latter occur in the late stages of insanity, and are not the cause of so much anxiety on the part of the patient. Hyperesthesias of the nerves of special sense are frequent accompaniments in the early stages of mania, hysteria, and alcoholism. Abnormal acuteness of sight and hearing lead to many false perceptions, and often drive the victims to acts of violence, by fallacies of perception being perverted by a cloudy intelligence into acts of persecution by former friends or their agents. Peripheral neuralgias are frequent in the depressed, and add intensity to their painful delusions. Some vaso-motor disturbance is usually present, and is especially marked in melancholia, paresis, as shown in the small slow pulse, dry skin, fragile nails and dead-looking hair. The examiner should ever keep in mind the fact that he is not dealing with a destroyed but perverted mentality, and should avoid all comparisons with sane individuals. Every case of mental disease will be complex or simple as the patient is educated or uneducated. We would not expect to find in the perverted mentality of the uneducated farmer, whose knowledge of the world and its works was confined to the growth of his crops and domestic animals, the occasional reading of a weekly newspaper, with a chapter from the Bible thrown in on Sunday, as complex and varied delusions as we would look for in the educated man, whose life had been broadened by study and travel. It is not infrequently the case that the examining physician finds it difficult to discover the particular channel through which the perverted mind is straying; and only after persistent questioning, and many methods of attack tried, will he sometimes be able to find the special form of mental weakness. I recollect well one case, examined by a specialist, who succeeded in concealing every concealing every evidence of insanity through a most severe examination for probably thirty minutes; but at last when he was addressed as "Jesus," he responded, "I am He❞—which subsequent examination proved to be a fixed delusion and the man was unmistakably insane. The insanities of childhood and puberty are of the degenerative and inherited types, and though they are not of common occurrence, it can be safely said they are of the greatest importance to the general practitioner, for in these cases he can probably accomplish more good than in any other department of psychiatry. Far too little attention has been given to the care and protection of this class of psychoses by both the medical profession and the state. By wise legislation and diligence on the part of the doctor, many cases of permanent mental breakdown could be prevented. Rarely is mental disease seen in the very young children except in the purely degenerative type-idiocy and imbecility. But we have all observed the child who before puberty gave promise of becoming a bright, intelligent adult. He learned rapidly, was interested in all the sports which make the life of the normal boy so full; but as puberty came on would show signs of mental weakness as if the body were growing at the expense of the brain-"the over-grown boy." He becomes sluggish in learning and seems to have lost all interest in his surroundings. He is especially dull in mathematics and those branches which require study in the abstract. Instead of being able to take a prominent place in the world, as he had given promise, he is fitted only for some subordinate position. Dr. Burr believes we are all a little crazy at this period of life, but that the children born of good healthy stock soon overcome the weakness and go on to the development of excellent manhood, while those who are born with the stigma upon them from weak or diseased parents, show at this time the primary symptoms which will result later in permanent mental breakdown-the chronic manias and dementias so often developing in the mentally weak. It is not uncommon to find among negroes the brightest children at three to six years of age, but one only has to observe them through three or four |