Mental Diseases and Dentistry

By JOHN L. KENDRICK, D. D. S.

Providence, R. I.

            The physically-minded practitioner will perhaps be partial to the idea of focal infection which a few years ago captivated the medical world. The teaching that abscessed teeth, infected tonsils, inflamed appendices and gall bladders constitute a potential and sometimes an actual danger to their possessors and therefore should be adequately treated.

It is, undoubtedly, a decided contribution to good hygiene and prophylaxis. But it was made the starting point of a system, according to which, all mental difficulties are said to be rooted in some focal physical disturbance. Such an attitude would, if generally accepted, tend to do away with the desire to study the personalities of abnormally reacting individuals, making psychiatry superfluous and leave behavior disorders entirely to the surgeon’s knife and the dentist’s forceps.

The call for prompt recognition and treatment of locally circumscribed areas of infection with their possible effects on the total organism,, should not make one develop an amnesia for a large variety of other and often much more potent factors.

The slogan of focal infection has recently been losing a great deal of its original appeal. But the physician who feels under obligation to explain all human activity in terms of diseased organs, is given another choice. In myxedema and cretinism, with striking defect in the development of the mental faculties, the glands of internal secretion were found to be of considerable etiologic significance.

The Psychic Glands

The psychic accompaniments of exophthalmic goiter are well known to every physician. The study of endocrinology has furnished us with data, the theoretical as well as practical importance of which is inestimable. But here again, the undoubted need of including these facts in one’s occupation with the human being has led certain enthusiasts to proclaim the ductless glands and their products as the one and only unrivaled source of all functions of man.

They have been presented to the public as the “glands regulating personality” and the “glands of destiny”. Most of this, says Lurie, is fiction, or at best a gross exaggeration of facts. We find that disturbances in the function of the ductless glands may produce changes in the personality makeup of the individual of such nature as to prevent him from making normal adjustment to his environment.

In the child, a physiological fluctuation of endocrine functions, that there are wide individual variations within the limits of the normal, and that slight deviations from the average may at times be causative or contributing factors in the etiology of faulty adjustment. At any rate, the assignment of a monarchic role to the endocrinopathies in dealing with complex human performances must appear to the objective investigator as one-sided as the idea of an infected tooth or a supposedly guilty sigmoid.

Every present-day discussion of the cause of epilepsy should begin with the confession that it is unknown and end with the logical phrase, not proved. the condition generally beings in early life. Most of the cases develop before or at puberty and the vast majority before the age of twenty. Direct hereditary probably plays a definite role in about 24 per cent of the cases. And yet many epileptic persons have normal children while entirely healthy parents my give birth to epileptic progeny.

Heredity Mental States

Alcoholism in the parents, especially if the child is begotten during a debauch, may lead to the convulsive state in the offspring, in addition to other mental defects. Most observers insist on the vague term of “neuropathic diathesis” as a cause of epilepsy, or at least as a fertile soil for the development of the convulsive state. That parental syphilis may give rise to various congenital cerebral defects in children and is the cause of infantile or juvenile syphilis of the brain, all of which may be accompanied by convulsions, is, of course, well known. But it is a question whether the epileptic state is the direct result of congenital lues.

The fact that less than 2 per cent of epileptic children show a positive Wassermann reaction does not militate against syphilis as a cause, because it is well known that a negative serology is extremely common in congenital syphilitics. But if syphilis does give rise to convulsions in the offspring, the specific pathology in those cases excludes from the syndrome under discussion.

The question of the influence of the mother’s health on the intra-uterine life of the fetus is very obscure; but it is certain that embryologic, pathologic, and other prenatal influences can give rise to minor or major cerebral defects which may be the causes of subsequent epilepsy.

That mental defectiveness, which is not the result of the epilepsy, is frequently associated with convulsions is well known. It is quite possible that the same factors are responsible for both. But a special mental or psychic make-up is said to characterize the individual destined to become an epileptic. Clark believes that hypersensitiveness, egocentricity, and emotional poverty, together with stubbornness and unsociability, antedate for a long time the advent of epilepsy.

Many patients undoubtedly manifest this personality defect; as a matter of fact, it is more characteristic of the dementia praecox group. While it does argue for a psychopathic trend, many children with that make-up never develop either the one or the other disease.

Trauma to the head during childbirth with all the possible cerebral complications (asphyxia, hemorrhage, etc.) is a very important factor in the development of convulsions. It is very doubtful whether psychic trauma alone, such as severe fright or shock, can cause convulsions. Although convulsions in infants do occur in the course of dentition and the various infectious diseases it is altogether unlikely that they alone can cause epilepsy.

Millions of children suffer those conditions and never develop the illness. As a rule it is a question of coincidence; and the most that one can says is, that the infectious disease may have sensitized a nervous system already destined for convulsions.

The same may be said of rickets. However, if by chance encephalitis, meningitis or a vascular accident occurs during the course of an acute infectious disease, epilepsy may subsequently develop. The question of reflex epilepsy may be dismissed with a word: it is highly fanciful. In any case we know little or nothing about it.

Various authors speak of scars of nerves or of the skin, of phimosis, intestinal parasites, impacted tooth, diseased organs, and a host of other fortuitous conditions. Peripheral reflexogenous zones, irritation of which can precipitate an attack, are variously mentioned but of course are not usually accepted.

Insanity

The term “insanity” denotes a mental disorder which incapacitates the individual for a free life among his fellows. It also suggests the wisdom of segregating and treating “insane” persons. The medical word “psychosis” has a similar designation, although it refers rather to behavior and mental condition, than to legal and social status. The word “psychoneurosis” is frequently used in medicine to indicate disorders which fall short of complete disorientation and incapacity but still imply mal-adjustive condition.

 

 

Hysteria

Common forms of psychoneurosis are hysteria and states of morbid fear and anxiety. Still milder disorders without number are to be found in the unstable, the incorrigible, the lawless, the queer, the irascible, the anxious, the suspicious, the cruel, the naughty, the moody, the erratic, the reclusive, and the ungoverned. So many and so various are the forms and the issues of mental disorder and disability that the problems of recognition, description and care, touch upon many subjects.

The committing of a member to the hospital for the insane disturbs the family and community much more deeply and seriously than does a temporary absence for bodily ills. In the second place, the mentally disturbed and ungoverned outside the hospitals probably exceed the hospitalized cases. No one knows the numerical relation between the hospitalized and the ambulatory, because no reliable means of enumeration has yet been discovered.

Among the afflicted who are abroad in society and who are almost invariably working mischief in the family and in the neighborhood, we must include not only the neurotic and the psychoneurotic, who are under the care of the advice of physicians, psychoanalysts, healer, magicians, cult leaders, quacks, astrologers, radio advisers, and the like. We must included also a great number of the queer, the vagrant, the flighty, the incorrigible, the suspicious, the irrascible, the unstable and the reclusive.

Two Branches of Psychiatry

In the realm of disease and morbid anatomy, medicine has no rival. Its reluctance to admit a class of “functional” disorders revealing no pathological agent or lesion. The clinically inclined physician tends to accept this class, while the pathologist maintains “functional” is only a concession to ignorance, to be removed of course as soon as we penetrate further into the anatomical and organic mysteries of disease.

The contention that all disease must rest upon pathological damage to the body, has made all mental, private, and social factors merely incidental. The result has been to produce every shade of compromise from two extreme positions. The one extreme declares the disorder to be not merely mental symptoms and indicators, but a disease of the mind; the other extreme maintains that disease must imply pathology and that pathology always appears in bodily tissue.

The practical outcome of this confused state has been to produce two branches of psychiatry, the one calling itself “psychological” and the other “neurological”; the one tending to modify diseases for a real mental variety of it, the other maintaining a more traditional and restricted view, which look always and hopefully for mental lesions.

The psychiatrist prefers the examination many cases, while the neurologist is opt to be a laboratory man making detailed studies of the individual case and consorting with the anatomist and the histologist.

The doctors of mental medicine have been cut across by outside influences by the increasing prestige of biochemistry, endocrinology, genetics, and the like, and more fundamentally by inroads from sociology, anthropology, psychology, a popular hygiene, and psycho-analytical theory and practice. These lather influences have threatened to alienate a certain part of the regular medical practice and secondly, because they have challenged the term “diseases” as the final and fundamental concept underlying the disorders.

Personality and Environment

The fundamental problem of the psychiatrist is the disturbances of the adaptation of the personality, to the total situation of the environment. The personality means the individual in action, with his behavior and his beliefs. It includes all the partial functions which may be studied in other disciplines; it includes all the chemical changes; it includes all the physiological activities as well as all the overt reactions, all the thoughts and emotions and strivings of the individual.

It is these functions by means of which man adapts himself to his environment, the special derangements of these functions, and the special stresses and strains which the environment lays upon the personal that the material with which the psychiatrist work.

The psychiatrist deals with disordered individuals, and his primary task is to understand the individual and his deranged condition.

Since man is a socialized individual, he becomes and remains socialized only by exercise of his psychological functions within self, others, social criticisms, judgments and aspirations, and not his physiological functions which preserve the integrity of the body. It is primarily upon this difference between bodily disease and psychological disorder one must differentiate.

A great number of diseases which begin as strictly problems of internal medicine soon overflow into the channels of psychiatry and vice versa. One need but mention the deliria of typhoid, pneumonia and other infectious diseases; the mental states associated with lead and the metallic poisons; the various mental accompaniments of syphilis and alcoholism; of arterio-sclerosis and old age, and the effects of well known endocrine diseases on the functions of the mind. But all this is only a very small portion of the whole reason why one should cultivate that attitude which comes from some knowledge of mental diseases and which might be termed the psychiatric point of view.

With the psychiatric point of view comes the ability to deal efficiently and successfully with difficulties and obstacles every one encounters in the daily round of his professional duties: the ability to treat not only the physical symptoms of the patient, but also his whims and peculiarities, his personality, his mind and in fact the entire patient.

The psychiatric point of view will be an asset which will pay continuous dividends in the shape of greater efficiency, greater success and greater service to mankind.

References

            Wechsler, O. S., M.D.: A Text-book of Clinical Neurology.

W. B. Saunders. 1927.

Strecker & Ebaugh; Clinical Psychiatry. P. Blakiston’s Sons & Co. Inc. 1931.

Bently & Cowdry: The Problem of Mental Disorder. McGraw-Hill Book Co. Inc. 1934