A system of practical medicine. By American authors. Vol. 5

by Unknown

In some cases of insanity, with never anything like acute disease, where death occurs from the weakness of old age or some intercurrent malady, the brain does not present any recognizable difference from those of sane people whose brains have worn out with their bodies. In those forms of mental disease where changes are found, the most important and constant are in the cortex of the brain, especially in the fore, upper, and middle parts of the periphery, involving usually also the membranes. In beginning acute mania the condition of the blood affecting the brain or the pathological changes are probably as nearly identical with those in the acute stage of pneumonia, certain forms of typhoid fever, cerebro-spinal meningitis, and other diseases as the symptoms of the mania are now and then difficult to differentiate from those of the other diseases just mentioned. In rheumatism, syphilis, malarial poisoning, and Bright's disease with mania we find no distinctive pathological conditions to account for the maniacal symptoms.

If asked whether there is a fixed lesion of the brain or any of its parts corresponding to given psychological changes, we should be obliged to say no, except in the case of incurable dementia. If asked whether there are important morbid changes corresponding with all cases of insanity, we can only say yes, sooner or later, in the majority of cases, and that there are certain destructive lesions, chiefly inflammatory, atrophic, and degenerative, which invariably mean marked deterioration of the mind. As regards diseases of other organs than the brain, the insane, like the sane, die of all of them, and in especially large numbers of pulmonary consumption.

Insanity may, both in its acute and chronic form, be the result or symptom of simple anomalous excitation or nutrition of the brain or of inhibition of some of its portions, without any change in its gross appearance which can be detected by our present methods of research. In the majority of cases there are found diseased conditions which become more manifest the longer the duration of the disease, appearing for the most part in the blood-vessels, pia mater, and cortex of the brain, but also in the medullary portion, many of which are recognized only in their late stages. In the functional mental diseases there is no characteristic lesion of the brain as yet recognizable, even in the latest stages, more than is to be found in the brains of persons dying from other causes. When apparently local injuries or diseases cause insanity, they probably do so through a general disturbance of the brain or through diffuse disease resulting therefrom and for the most part affecting both hemispheres. The molecular, chemical, anatomical, physiological, pathological, or physical changes in the brain which give rise to insanity, and their relation to the grosser pathological conditions of the brain, are still not clearly made out.

In terminal dementia, especially in the last stage of paralytic dementia, nearly every tissue and organ of the body may be found to have undergone pathological changes, of which by far the greater portion is secondary to disease of the brain; and it is impossible to say how much of the brain lesions in these and other conditions of mental unsoundness is secondary to the disease or an accidental complication.

DIAGNOSIS.—In the diagnosis of insanity the physician assumes a responsibility for which he is liable under the common law. It is important, therefore, to avoid mistakes as far as possible. In the majority of cases the patient's unsoundness of mind is evident before he is brought to the doctor, but in not a few the symptoms are obscure, and they are often rendered more difficult of correct understanding and appreciation by the deception or reticence of the patient and by the prejudices of his friends.

First, before seeing the patient it is well to get from his family, friends, and physician a full knowledge of his natural state, all the facts known to them relating to strange behavior, delusions, etc., as they give most useful hints with regard to the method of examination. Apparent familiarity with an insane person's delusions will often secure their immediate acknowledgment. In a case of any obscurity or where there is doubt that other causes than insanity may have produced the unusual behavior, and particularly if any legal steps are to be taken regarding guardianship, restriction of liberty, commitment to an asylum, validity of wills and contracts, capacity to manage property, marriage, etc., it is imperative that both sides of the question be fully heard before any positive opinion is given. After the patient's confidence has been gained in general conversation, during which his appearance, manner, and mental condition as to intelligence, coherence, memory, judgment, perception, and capacity may be noted and compared with his normal standard, he should be examined carefully for any external evidence of lack of development or of injuries to the head. As in all other diseases, the condition of every organ of the body should be noted; a complete diagnosis should be made. The expression of the face often indicates such excessive excitement, gloom, stupor, suspicion, or fear as must be due to insanity alone.

Throughout the examination the questions and manner of the physician should be such as to avoid suggesting unpleasant ideas or associations to the patient. The matter of suicide should never be first mentioned by the questioner, and not seldom he does best who listens most and lets his patient disclose his morbid ideas and impulses, as he will frequently be led to do, if at all, by the manifestation of interest and sympathy, and of knowledge of the symptoms of the disease in hand, on the part of the physician. He often gets enough for his purpose without getting the whole story, upon which it sometimes does harm, or at least is not best, that the patient should dwell. In the diagnosis of mental disease, however, as well as in estimating responsibility, the fact must be borne in mind that a controlling delusion may be concealed for months or even years, and that the symptoms and mental condition of insane people vary so much at different times that it may be quite possible to get distinct evidence of unsoundness of mind at one time and not at another. The power of self-control is also liable to the same variation or alternation.

If the patient has no reason for simulation, it is commonly best to tell him the object of the examination. The family history should be learned from others, as questioning the patient on these points is apt to put him in a train of thought unfavorable to a hopeful view of his own case. After full personal questions concerning himself and his environment, one can usually tell whether there are unreasonable suspicions, violent impulses, perverted feelings with regard to his family, delusions, hallucinations, or illusions. A delusion's existence must often be accepted, however, from the behavior of the patient and from the statements of those about him. Hallucinations of hearing must sometimes be inferred from the attitude of listening to imagined voices; and prolonged observation under circumstances such that the patient does not know that he is watched will often settle the question of his insanity when other means have failed. A careful examination should, of course, be always made for the physical and rational signs of disease. In the differential diagnosis care must be used not to mistake for insanity the acute diseases typhoid fever, meningitis, smallpox before the period of eruption, pneumonia, cerebro-spinal meningitis, narcotism or delirium from drugs, and alcoholism—errors which have been made, and which can be avoided by deferring one's opinion for a sufficient time.