The Treatment and Prophy- 
laxis in Insanity. [Reprint from Thk Alienist and Neurologist, St. Louis, Jan., 1894.] 
The Treatment and Prophylaxis of 
Insanity* 
By John Punton, M. D., Kansas City, 
Professor of Nervous and Mental Diseases, University Medical College; Special 
Lecturer, Western Dental College; Neurologist to All-Saints, Scarritt, 
Bible and Training School and K. C., Ft. S. & M. R. R. Hospitals. 
I PRESUME it is unnecessary for me, at the outset, to 
say that I appreciate very highly the courteous invi- 
tation extended me by your committee, to read a paper 
before this very worthy society; and it is of special 
interest to me, because it was in this grand and philan- 
thropic State of Illinois that I received my first tuition 
in the department of medicine, which will form the theme 
of my remarks. 
In presenting the subject of “ The Treatment and Pro- 
phylaxis of Insanity,” it is not my intention to cover the 
entire field which the title of my paper would suggest, 
but simply direct your attention to a few facts connected 
with its most frequent and common forms, viz., melan- 
cholia. 
Melancholia, as its name implies, is characterized by a 
state of profound emotional perversion of a depressing 
and sorrowful nature, the same being the offspring of a 
disordered state of the brain. 
Of all the various forms of mental disease, states of 
mental depression are those that are nearest mental 
health, hence it appears as the sanest kind of insanity, 
which oftentimes renders its diagnosis the more difficult, 
especially in its incipiency. 
It presents itself in a number of different ways, with 
various psychological and clinical symptoms, which admits 
of its classification, there being, according to Clouston, 
no less than eight different distinct varieties. 
* Read before the Tri-State Medical Society, Peoria, Illinois, October 4th, 1893. Treatment and Prophylaxis of Insanity. 
3 
In its more simple forms, however, all authors are 
agreed that it is more frequent and common than any 
other variety of insanity, and as such, is a very manage- 
able and curable disease at home, not often requiring 
hospital or asylum treatment, and in this respect con- 
trasting greatly with all the other kinds of insanity. 
Its relative frequency renders its relation to the gen- 
eral practitioner of far greater importance than he is 
wont to allow,“and it was this very fact that led me more 
especially to select it for your thoughtful consideration. 
The department of medicine that has for its object 
the care and treatment of the insane is unfortunately, for 
itself, an exceedingly marked specialty, for when patients 
become insane they are invariably turned over to certain 
members of the profession, who devote their sole time 
and attention to this work. 
When we remember, however, that no less an author- 
ity than Guslain claims (and his experience has been 
verified by many other of the later authors) that nearly 
all forms of insanity are preceded by some form of men- 
tal depression, the importance of a thorough knowledge 
of this particular variety of mental disease to the general 
practitioner is very apparent. 
From an extended amount of practical observation 
and experience, covering a period of several years, I 
regret to state that this department of medicine receives 
less attention and its importance is more often ignored by 
the medical profession than any other branch of medical 
science. 
Now, I hold that the time has come when we, as 
members of a great and growing scientific body, must of 
necessity insist upon a more thorough knowledge of men- 
tal disease among medical men. 
It is surprising, as well as humiliating, to notice how 
many members of the' profession admit, both by their 
words and actions, that they have given this subject 
little or no study, and in this way excuse themselves 
from their lawful, responsible duties. John Punton. 
4 
In the earlier history of insanity, when mental dis- 
eases were confounded with superstition, and its etiology 
and pathology were still more or less imperfectly under- 
stood, no one could justly accuse the profession of being 
responsible for the rapid increase of the incurable insane, 
but to-day, with all the modern means of scientific 
research and a thorough knowledge of the brain and its 
functions, together with a more or less complete system 
of etiology and pathology of its diseased conditions, 
can we reasonably ask for such leniency or accept indif- 
ference as a sufficient plea for ignorance? 
The'present status of insanity should certainly demand 
the earnest attention of every individual medical practi- 
tioner of whatever school, and the public properly looks 
to us for practical aid in solving this most difficult 
problem. 
When the subject of insanity appears on the pro- 
gramme at our medical society meetings, the members 
invariably decline to take part in the discussion, and 
offer as an excuse, their inability to do so on account of 
their lack of knowledge, having given it no thought or 
study, while many are so indifferent and even discour- 
teous enough to leave the room, refusing to listen to such 
a dry and uninteresting topic, as they term it. Such 
conduct is a reflection on the boasted intelligence of the 
profession and should receive the censure it richly 
deserves. 
In view of the importance of the subject, it is also a 
lamentable fact that, even at this late period of enlight- 
enment, very few of our more reputable schools of medi- 
cine include the clinical study of insanity in their 
curriculum of studies, indeed, comparatively few teach it 
didactically, and when this is done, the whole subject is 
dismissed in about three abstract lectures. 
Now I hold that it is impossible to teach the princi- 
ples of this vast and intricate department of medicine in 
this crude manner, yet who can deny the truth of the 
assertion ? Treatment and Prophylaxis of Insanity. 
5 
In commenting on this, Clouston says : 
How can we know that which we do not study, and how can the 
family physician give advice and sign certificates about a disease which, 
as a medical student, he has never seen or had explained to him 
clinically ? 
As well might you ask a man to give you a life insurance certificate 
that a patient was free from heart disease, who had never listened to a 
cardiac murmur. 
The gross laxity of the college faculties in ignoring 
this important branch of study, is to a great extent 
responsible for the increased production of the more 
incurable forms of the disease, as well as the encourage- 
ment of indifference and ignorance among the members 
of the profession. A glance at statistics is sufficient to 
prove the grave responsibilities which rest upon us at 
the present time, and we are inexcusable, if we fail to 
furnish the means and measures which medical science 
and art place at our disposal for its speedy relief. In 
1880 this country had a population of 50,155,783, and a 
total number of insane estimated at 56,205. The late 
census, which was probably the most careful and pains- 
taking one ever made, furnishes me the following facts: 
With a population of 62,622,250, the total number of 
insane treated in both public and private institutions dur- 
ing the year 1889 was 97,535, which shows the marvel- 
ous increase in nine years of 41,330 or 73.53 per cent. 
In this connection it may prove interesting to note the 
number of insane treated in each of the three States 
represented by this society, during the same period, as 
follows : 
Illinois.—Jacksonville, treated (in the nine years) 3,340 
Elgin 1,612 
Anna. 2,154 
Kankakee 4,181 
Cook Co., Chicago 4,724 
Batavia (private) 277 
Oak Lawn, Jacksonville (private; for 2 years). 47 
Total for Illinois 16,335 6 
John Punton. 
Iowa.— Mt. Pleasant 3,659 
Independence 3,511 
Clarinda (for two years) 323 
Total in Iowa 7,493 
Missouri.—St. Joseph 1,769 
Nevada 484 
St. Louis 2,478 
Fulton (not given) 
St, Vincent’s (private) 1,390 
Total for Missouri 6,121 
Grand Total 29,949 
In order to have accurate statistics, I sent to the 
Census Bureau at Washington, and they kindly furnished 
me with a table showing the number of insane in each 
State of the Union in the year 1890. 
This I analyzed and compared with a similar one 
issued in 1880, and found that the relative number of 
population for each insane person in sixteen States was, 
as follows: 
New York 
1880. 
, 3G0, 
1890. 
330, 
INCREASE. 
8.3-10 
DECREASE. 
California .... 
a 
346, 
336, 
2.7-10 
Massachusetts.. 
a 
304, 
367, 
1.7-10 
Ohio 
n 
430, 
470, 
8.5-10 
Wisconsin 
a 
521, 
480, 
7.8-10 
Maine 
u 
421, 
508, 
17. 
Michigan 
u 
585, 
662, 
3.9-10 
Illinois 
a 
600, 
570, 
.5-10 
Iowa 
u 
639, 
590, 
7.6-10 
Minnesota 
a 
685, 
• 591, 
13.7-10 
Pennsylvania.. . 
u 
516, 
620, 
16. 
Indiana 
a 
560, 
663, 
15. 
Kentucky 
a 
602, 
681, 
25. 
Missouri 
u 
655, 
784, 
16.5-10 
Kansas , 
u 
1000, 
796, 
20. 
Nebraska 
u 
1005, 
1136, 
11.5-10 
This table shows that Illinois and Iowa have both 
increased, while Missouri has had the greatest decrease 
in any State of the Union in the ten years, with two Treatment and Prophylaxis of Insanity. 
7 
exceptions, viz., Maine and Kentucky. Kansas on the 
other hand has lost her former low standard and increased 
twenty per cent., while Nebraska still retains the suprem- 
acy of having less insane to the population than any 
other State. 
Another important element in this connection- is the 
annual expectancy of insanity or the number of persons 
liable to become insane each year. It has been demon- 
strated conclusively that out of a given number of popu- 
lation a definite ratio will become insane annually, which 
varies in number in the different States of the Union. 
For instance, in Missouri, we expect out of a population 
of a little over two and one-half millions nearly six 
hundred persons will become insane this year. 
Applying this same rule to Illinois and Iowa, the 
former, out of a population of 3,826,351, can expect at 
least nine hundred new cases of insanity this year, while 
Iowa, with a population of 1,911,896, can look for about 
four hundred, which makes a grand total for the three 
States of at least 1,900 new cases of insanity liable to 
occur during the present year. All of these cases, there- 
fore, constitute the recent or acute, and therefore, pre- 
sumably curable cases of insanity. 
Now all authorities are agreed that at least fifty 
per cent, of recent insanity is curable, and insist that 
the most important law governing its incurability is a 
lack of appreciation, or delay in securing prompt and 
appropriate treatment in its incipiency. 
The great pathological law which holds good in 
other diseases, viz., the longer the duration of the dis- 
ease the less the chance of recovery, is even more 
potent in the treatment of insanity than in any other 
disease. 
Again, statistics prove that all the new cases of insan- 
ity rapidly fall into one of three classes, viz.: 
1. Those in which the violence of the disease proves 
speedily fatal. These constitute a very small proportion, 
about five or six per cent. 8 
John Punton. 
2. Those who recover their mental health under 
prompt and appropriate treatment. These comprise about 
one-half, or fifty per cent, of the original number. 
3. This leaves a little less than half or about forty- 
five per cent, of the new cases which arise annually to 
become chronic, the great majority of which are incur- 
able and hence become a burden to the State the remain- 
der of their lives. 
A proper treatment of the recognized curable forms 
of insanity is therefore a matter of serious import, not 
only to members of the medical profession, but to all 
parties concerned. 
Now, the treatment and prevention of insanity can be 
effective only in proportion as the causes are accurately 
ascertained and wisely avoided or removed. 
The etiology of all forms of mental disease, it seems 
to me, can readily be grouped into two great classes, 
viz.: 
1. Individual congenital defects. 
2. Individual acquired defects. 
The former comprises all those conditions pe'rtaining 
to ancestral inheritance, while the latter embraces those 
which arise in the life history of the patient. Both of 
these may co-exist and often do so, indeed, in by far 
the greater number, still there are many cases in which 
the causes are so directly the result of personal injury 
or self-abuse, that they must be solely regarded as suffi- 
cient in themselves to cause the morbid mental changes, 
irrespective of inherited taints. 
The chief cause of the congenital type and that which, 
in my judgment, underlies all the rest in producing and 
propagating states of mental depression, is the neurotic 
diathesis, or innate brain constitution of the individual. 
This manifests itself by nervous instability and defective 
innervation of the organic functions making itself felt by 
a constant tendency to degenerative changes in the nerve 
elements, rendering the subjects of it peculiarly liable to 
break down under certain stress of circumstances, which Treatment and Prophylaxis of Insanity. 
9 
would not specially affect another person inheriting a 
different constitution. . 
How this predisposition can be managed and modified 
is a very important practical question for us to solve. 
We may not, it is true, be able fully to explain its 
intricate pathology, but we do know that the number 
and diversity of inheritable deviations of structure and 
function are endless, and these are the problems we have 
to deal with in the treatment of melancholia. 
Outbreaks of insanity in persons inheriting a favorable 
predisposition seem to be in some manner connected with 
the growth and process of evolution of the individual, 
more especially at the physiological crises. These abnor- 
mal conditions of inheritance are often the result of 
imperfect growth, defective nutrition, incorrect habits, 
injudicious education and modes of life of the parents, 
the general effects of which tend to lower the normal 
standard of health. 
Fortunately, we can certainly declare that this predis- 
position is not a mysterious and necessarily fatal doom, 
certain at some time to overwhelm its victim. It is 
purely a physical defect which can be remedied and even 
cured, and loses half its horror when this is fully realized 
and understood. 
Next to heredity ts emotional excitement. It has been 
said that our emotions and affections are the mightiest 
factors in our lives, and they afford a vast field for the 
manifestation of nerve instability. “ It is in the regula- 
tion of our moral nature,” says Dr. Yellowlees, “by 
reason and duty and in controlling our fancies, impulses 
and passions that we tend to escape such penalties.” 
At this point we may pertinently inquire: From 
whom are the ranks of the insane mainly recruited ? 
The answer is certainly, “ From the men and women 
whose minds and hearts are untrained and ill-balanced, 
who are swayed by caprice and passion, and whose lives 
are ill-regulated and changeable. The access of insanity 
is often the ultimate wreck of a vessel without a helm. 10 
John Punton. 
Among the more prominent direct or acquired causes 
of insanity are the use and abuse.of certain agents, such 
as alcohol, opium, excesses of all kinds, mental and 
physical strains, overstudy, excessive grief, domestic 
infelicity, malformation, disturbances of circulation, acute 
diseases and injuries of all kinds. 
In most cases of insanity we are very apt to find several 
of these factors playing some part in inducing the mor- 
bid mental change, and the pathological phenomena so 
far discovered, all have for their basis some interference 
with the due nutrition, growth and renovation of the 
brain cells. While the true pathology of insanity is 
still in doubt, nevertheless, we are in possession of 
some facts which are essential aids in the treatment of 
the various forms. 
Meynert considers melancholia as a symptomatic 
disease, arising from trophic disturbances of the anterior 
lobes of the brain. This results in a dejected and 
saddened expression with decreased activity of mind 
and body due to the anaemic condition of the cortical 
cells. 
We are all aware that melancholia has for its chief 
symptoms mental depression, headache, and insomnia. 
Clouston says that mental depression is simply the 
functional expression of convolutional malnutrition. Cor- 
tical anaemia, therefore, is now recognized as being the 
chief pathological state we have to deal with in this, 
the most common form of insanity. 
Now, clinically, we are all aware that an abnormally 
anaemic condition of any organ practically means starva- 
tion and which, if long continued, results in degenera- 
tive changes which rapidly become incurable. 
Treatment.—The treatment of melancholia is there- 
fore directed to the correction and maintenance of a 
healthy and proper blood supply to the brain. 
Dr. Clouston says: 
If the brain and body conditions that accompany, do not cause 
states of morbid mental depression, if they are those of trophic defl- Treatment and Prophylaxis of Insanity. 
11 
ciency, as they undoubtedly are, then it necessarily follows that what 
will remedy those conditions is indicated, and all things that will aggra- 
vate them must necessarily be avoided. 
The means by which these ends may be secured, it 
seems to me, are fourfold: 
1. By moral persuasion. 
2. By the use of drugs. 
3. By hygienic measures. 
4. By mechanical appliances. 
I. Moral Treatment.—The underlying principle in the 
moral treatment of the insane is that the patient should 
be treated as a reasoning being, in other words, from the 
moment he comes under your care, it should be assumed 
that he will understand more or less correctly all that is 
said and done to and for him. 
He should, therefore, be treated as if you expected 
him to act rationally, and if he should fail, lead him by 
moral persuasion to do what you expect him to do. At the 
same time the fact of his being mentally deranged should 
be borne in mind. 
All moral treatment should have for its highest aim, 
therefore, the calling into normal exercise and use the 
rational part of the disordered mind. It should be 
assumed by both the physician and nurse that the patient 
is capable, to some degree at least, of understanding the 
fact that he is ill, and your conduct towards him should 
frankly and consistently show this. It must also be 
remembered that the normal functions of the brain may 
be only temporarily deranged, and that in most cases 
some degree of normal function remains. 
It seems beyond the comprehension of many persons 
that insanity deranges, rather than destroys the mind, in 
its incipient stages: Much therefore, depends upon your 
selection of a responsible nurse to carry out the 
principles herein enunciated. Another important step is 
the isolation of the patient whether treated at home or 
elsewhere: It is often with difficulty that the friends 
and relatives can be made to realize the necessity and 12 
John Punton. 
importance of this measure. But those of us who have 
devoted our time and attention to this study, know too 
well that the probabilities of recovery are much increased 
when the patient is committed to the care of strangers. 
Much more might be said under this heading, but I 
hurry on to speak of the use of drugs in the treatment 
of melancholia. 
2. Use of Drugs.—If mental depression is the func- 
tional expression of convolutional malnutrition, as I 
believe it is, then every therapeutic agent which tends to 
restore the healthy action of the brain is indicated. My 
friend and teacher, Dr. L. C. Gray, of New York, advises 
the use of opium in his late work for the direct treat- 
ment of melancholia. 
Clouston says he performed a series of elaborate 
experiments with it in melancholia, and it always caused 
a loss of appetite and loss of weight in every case, and 
Dr. Mickle has confirmed these results. 
In my own practice I seldom use it, as I believe it 
interferes with two of the most important functions for 
its speedy relief, viz., digestion and assimilation. Then 
again, often when called in consultation, I find many 
practitioners prescribe indiscriminately the bromides and 
chloral for the relief of insomnia, which is nearly always 
a troublesome symptom. If before using these drugs 
they would remember the pathological condition pres- 
ent, I am sure they would not employ them, for this 
purpose, in the treatment of melancholia. 
Fortunately, we have at our command to-day many 
agents which are preferable to either of these for induc- 
ing sleep. Sulphonal is by far the best drug for this 
purpose. • . 
The majority of melancholiacs are much below par in 
body weight, indeed this seems to be of more diagnostic 
importance than would at first appear, as there seems to 
be a marked relation between the two. Such remedies 
as tend to increase body weight are therefore urgently 
needed, as in my experience the physical improvement Treatment and Prophylaxis of Insanity. 
13 
precedes the mental. For this purpose I use quinine, 
iron, strychnia, phosphorus, arsenic, cod liver oil, mineral 
acids, vegetable bitters, hypophosphates, laxatives, whisky, 
malt preparations, etc., besides food of all kinds, especially 
milk and eggs. In many cases milk is my sheet anchor. 
I have given as much as three quarts a day for months 
at a time beside six eggs daily. 
Blood enriching tonics and fattening diet are the 
most potent remedies for the relief of morbid mental 
depression, while the various hypnotics, such as sulphonal 
in doses of from ten to forty grains, paraldehyde from 
one-half to two drachms dissolved in chloric ether or 
cinnamon water, chloralamide from twenty to forty grains, 
somnal from one-half to one drachm, and very occa- 
sionally chloral are in my judgment the best agents to 
produce artificial sleep. 
In the more restless forms of the disease sedatives 
are called for, and among the best of these are hyoscine 
in doses of one-hundred-and-fiftieth of a grain to one- 
eightieth of a grain, used either hypodermically or 
by the mouth; cannabis indica, lupulin and conium are 
also valuable agents. 
All medicines that tend to lessen the appetite and 
impair digestion and nutrition are contra-indicated in 
this disease. The nervous diathesis at best does not 
put on fat naturally. We must, therefore, combat the ten- 
dency to innutrition by scientific dieting and appropriate 
therapeutics. Next in importance is proper hygienic 
measures. 
3. Hygienic Measures.—In my experience moderate 
and suitable daily out-door exercise is indispensable in 
the treatment of melancholia. I make it a rule to keep 
fmy patients in the fresh air as much as possible. 
It is the best hunger and sleep producer I know of. 
Without this all other means fail. In some cases the 
rest and change that belongs to a sea voyage is prefer- 
able, but in others it is directly harmful; absolute change 
in habits and surroundings, rest from all mental labor, 14 
John Punton. 
judicious use of baths, pleasant and cheerful society, 
moderate and agreeable occupation and the substitution 
of pleasurable feelings for painful ones are the principal 
features to be aimed at in the hygienic treatment of the 
case. 
4. Mechanical Appliances.—In the care and manage- 
ment of the insane, the enforcement of kind but firm 
discipline is essential for the best results. It must ever 
be borne in mind that you have an irresponsible being 
to deal with, therefore, you yourself must do the reason- 
ing until such time as your patient is mentally respon- 
sible. 
No class of cases require more tact and skill to prop- 
erly manage than the more simple varieties of insanity, 
and the less they ]are removed from true sanity the 
more difficult the task. 
Every precaution must be taken to guard against 
suicide, for in many instances they will resort to every 
conceivable method to accomplish such a purpose. Many 
refuse to eat or take medicine in the hope of termi- 
nating their lives by starvation. The use of the stomach 
or nasal tube is therefore indicated. If they are obsti- 
nate and pugnacious the temporary use of the strait- 
jacket is warrantable. 
In referring to this, I am aware that many regard 
the use of mechanical restraint as cruel and unnecessary, 
but, after many years of observation and practical experi- 
ence with the insane, I am compelled to state that I 
believe its judicious use to be not only necessary but 
humane. 
The extra amount of help and appliances to be found 
in every well-equipped asylum is not often available in 
private practice, hence we are compelled to do the best* 
we can with limited means and measures. 
There are many other points which could be profit- 
ably referred to here, but my paper is now altogether 
too bulky, and before closing I desire to say a few 
words on prophylaxis. Treatment and Prophylaxis of Insanity. 
15 
Prophylaxis.—Insanity is a strictly physical disease, 
and as such, comes eminently within the range of pre- 
ventive medicine. 
No greater progress has been made during the pres- 
ent century in any department of philanthropy and 
science than in the direction of the better care of the 
insane. But a greater work remains to be done, a work 
that is even greater than cure or kindly care. It is that 
of prevention. The great question before us to-day is, 
not only what can be done for the chronic insane, but 
how can we prevent insanity ? 
We are all compelled to accept the science of pre- 
vention as a higher and greater power than the science 
of remedy. In order for this to be effective, it must 
necessarily reach back to the family life, the school life 
and even the nursery and cradle of the child. 
The science of prevention, therefore, must be looked 
for outside the wards of a hospital. 
The general practitioner, of all others, says Dr. Mann, 
is in a position to check the sources of insanity at their 
very beginnings : 
By carefully directing the mental and physical life of a pregnant 
woman, he may form the future mental complexion of the unborn child. 
He may watch over the child’s brain during the early formative period 
of infancy and childhood, and so advise the parents, that they may guide 
the children in the paths which lead to mental stability. 
He may recognize the insane or neurotic diathesis and by intelli- 
gently recognizing that such a person is more liable than others to men- 
tal disease, may apply a wise culture to the erring emotions and 
discipline to the conduct in the early years of life, while they are yet 
applicable and the fearful heritage may oftentimes be avoided. 
Especially is the preventive aspect most important in the 
dieting, occupation, habits, education and general careers 
of such persons. 
Too often an indifference is displayed by the family 
physician to give such advice and counsel as is neces- 
sary. Yet he is derelict in his duty if he fails to sound 
the alarm. Another important feature which comes within 
the province of the family physician is to guard against 16 
John Punton. 
a relapse in those who have already suffered from melan- 
cholia. From an extended amount of observation and 
experience in this direction, I do not hesitate to affirm 
that many cases could be saved from the wards of an 
asylum were this law more fully understood and obeyed, 
by both the physician and friends of the patient. 
Bearing in mind the pathology of the disease and the 
loss of body weight which accompanies it, I advise all 
my recovered patients to weigh themselves at least once 
a month. 
If there be the slightest loss from the normal stand- 
ard I advise them to be on the alert and not be satisfied 
until it be regained; a loss of a few pounds in weight 
may be the first real warning of the disease returning, 
even though they may feel as well as usual. In addition 
to this I advise them to lead quiet, routine, systematic 
lives, taking regular periods of rest and repose as well 
as much out-of-door air and exercise, interspersed with 
suitable employment of both mind and body. 
Self-control and prudence in observing the laws of 
health, watchfulness in avoiding excitements of all kinds 
and the cultivation of right and just views of life, consti- 
tute the strongest security against the return of the 
dreadful malady. 
To sum up the whole matter, the treatment and pro- 
phylaxis of insanity consist, as Dr. Mann wisely says, in 
a proper recognition of known physiological, mental and 
moral laws, which when properly understood and obeyed 
result, not only in the highest development of the race, 
but in the highest type of civilization.