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By JOHN P. GRAY, M. D., of Oneida County.
Read November 19, 1884.

To prevent the occurrence of disease in communities is not only a matter of prudence, but a measure authorized and enforced by supreme law. Modern science has suggested medical healthboards, and legislatures have created them in States and Counties. Such boards exist in the State of New York, and they are approved by the people. These boards are authorized to proclaim rules and regulations of hygiene, and are clothed with adequate power to enforce them. Appropriations of money are made to execute the work. This extends over all parts of the State. They exercise inspection and control of roads, streets, buildings, whether public or private-even the houses and premises of residents, as well as factories, workshops, and all places where men or women are congregated. In the case of certain infectious or contagious diseases, they even exercise a controlling power so far as to isolate persons from their families, to remove them to buildings at a distance from their homes, and to provide for their care by medical men under public appointment. The law goes even further, in ordering compulsory vaccination of persons attending the public schools, which is, perhaps, the most extreme measure adopted for the prevention of disease. All these things are authorized and done for the general public health and safety, and all this under the constituted civil authorities of States and

Counties. All these precautionary measures are at the behest of medical science. It is a great advance made when a government has thus practically extended its protection over its citizens, forcibly, if need be, alike over the rich and poor, so that neither ignorance nor indifference shall be the means of evil to communities, when that evil can be prevented or even measurably controlled.

It is true, with regard to all ordinary diseases, that the individual is left to his own discretion where negligence, indifference, ignorance, or superstition can affect only himself injuriously. But even here he is obliged, under the health-laws, to exercise that measure of care which will secure others against offensiveness or danger.

Insanity is a disease of frequency, and is among the most serious disorders which can afflict individuals or communities. There is no disease, perhaps, which is so largely within the purview of legal enactments. To a greater extent than in any other, the law authorizes the control, treatment, and protection of the victims of this disease. There are elements of danger as well as helplessness in it, which make such legal measures necessary, wise, and humane, both for the individual and for communities. The law not only interferes forcibly to secure to the insane safety against themselves as well as others, but also to secure treatment and to extend guardianship over their property; and the law at every step appeals to medical science and the services of the profession.

More than twelve thousand persons thus under the control and protection of law, now in the hospitals and other institutions in the State of New York, attest the importance of this subject to the medical profession; and, when it is remembered. that no one can be placed under control and treatment as insane unless he be so adjudged by medical men, we must see our responsibility and our intimate relations to this form of human affliction. That we recognize its existence as disease, and the necessity of measures of treatment, is well. But an equally, if not more important point, is whether there be anything we can do in the way of prevention; anything efficiently, in this direc

tion, to lessen its frequency. To this question I shall direct what little I have to say.

To prevent the occurrence of any disease in any individual is a blessing, and the graver the disease, the greater the blessing. Preventive measures in connection with insanity open a wide field, which begins with the growth, development, and education of the child up to maturity. It takes in the habits of body and mind, the feelings, the passions, the griefs, the troubles, the worries, the toil, the accidents, and the dissipations of life. This is only to say, however, in a general way, that good health, mental culture, the control of the emotions and passions, and the exercise of morality, are safeguards against insanity in any form. The old adage, “A sound mind in a sound body," is true; but the converse is, fortunately, not true that an unsound body should necessarily produce an unsound mind. But it is universally admitted that insanity means sickness of body, producing disturbance of mental action, and that it can not occur except as the result of bodily illness. Bodily illness or disease, then, is occasionally of such a character as to develop insanity; but this is so occasional and exceptional that, in all of the various illnesses medical men are called upon to treat, insanity is the last outcome they anticipate or think of. Medical men of large experience, both in cities and in the country, have told me that they very rarely have a case of insanity in their own practice; that is, among their own personal patients. One of the most distinguished medical men in western New York, with a large practice both direct and consulting, told me some years ago, when in consultation with him in a case, that he had seen so little of insanity in his own practice that he did not feel like undertaking the treatment of the case. The case was one of profound melancholia. When I said to him: "You must have had cases of depression to treat in so large and varied a practice?" "Oh, yes," he replied, "hundreds of them." "What do you do with them?" "Get them to quit work, to stop talking of themselves, and stuff them with food."

This case was a tired-out business man who, under perplexities and worry, had lost sleep and appetite and, consequently,

strength, had passed through a stage of depression, though continuing at his business, and finally had melancholia with intent of suicide. Until this point had been reached, neither he nor his family had applied to a physician, but, on the contrary, they had exercised a vigilant secrecy.

In 1879, one of the most careful and prominent practitioners of New York city told me that, among the great number of women he had attended in confinement, he was surprised, in looking over the past, to see how few had suffered from puerperal insanity or from the melancholia which is said to come on with change of life. Repeating this to a general practitioner whose practice was largely among the wealthy, he, also, said that this was his own experience.

I cite only these instances out of a great many that I have heard from those with whom I have talked upon the subject of the cases of insanity in their own individual experiences. I had observed many years before, that a very large proportion of the patients brought to the hospital at Utica were really without family physicians-persons who called in medical men only in extremities, dosing themselves ordinarily with known or patent remedies, or those who called indifferently and indiscriminately for medical services when they desired them. I have thought that I could see the reason for the fact of so little insanity existing among the many suffering from all kinds of depressing affections under careful practitioners. They did not let them become ill enough to become insane. They anticipated the morbid conditions of body, and any morbid drift of mental action likely to lead, if neglected, to insanity. They looked after the younger members of the family in whom defects of health appeared. All this certainly is in the nature of preventive measures of the most useful character.

Among the most important of anticipatory measures, is the early recognition of fagging of the brain, and the fact that such fagging is simply a depressed physiological state, whether found in children, youths, or adults, whether among the wise or the ignorant, the high or the low. In such conditions, we must recognize the absolute necessity of sustaining and restoring the

energies by rest and nutritive food, whether there be appetite or not, and the value of blood-enriching tonics. These are the methods of relief which should be applied, instead of advising traveling, varied scenes, and social life, to divert the thoughts, or the administration of hypnotics or narcotics to quiet the system. Persons in such conditions are usually restless, more or less sleepless, with a variable appetite, and, while willing and anxious to talk about themselves, they are not inclined to social life, amusements, or traveling. These things, valuable, ordinarily, as recreation, are to them weariness of the flesh and, still further, exhaustion of the strength. It is true that the persistent plea of such patients is generally for remedies that will give comfort and ease, and especially sleep; and they may secure by exercise a degree of weariness that will lessen restlessness, and they may secure sleep from sedatives and narcotics. Still, this class of remedies, while giving temporary comfort by tranquilizing the nervous system, at the same time is apt to disorder nutrition and assimilation, and is likely to do more harm than good. The prevention here comes, in recognizing the true condition as brain-fag, and in resisting the plea for sedatives1 and substituting food and rest. Few practitioners of experience can fail to recall instances of mistaken treatment or no treatment which gradually carried the patient into hypochondria, and from that into melancholia, and from that into mental failure and dementia. This is especially true with regard to business men who suffer with mental worry, and women suffering from domestic griefs and over-toil, who at the same time lessen sleep and also the quantity and quality of their food, and withdraw themselves largely from the air and sunlight. Many such cases end in suicide, unexpectedly, both to the family and the physician. I have been consulted in many such cases both by physicians, after wearying transitions in the patient for months from better to worse, and by persons who have resorted to patent medicines for nervous disorders, debility, etc., as they have seen them advertised; and, no matter what be the intelligence of the

1 These remarks have reference to the common abuse of bromides, etc. Their great value as remedies can not be questioned.

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