The more particular treatment of the insane differs in the various mental diseases, varying as it necessarily must according to different conditions. Its prevention is not an easy problem. Many of the external causes of insanity seem inevitable in our complex civilization: it would be impossible to widely regulate marriages, even if we knew how; those people predisposed to insanity are usually too self-confident and self-willed to receive advice; and moderation in all things, healthful occupation, temperate habits, good digestion, and, above all, out-of-door life, seem as much like a sarcasm if suggested to many of the toilers as a waste of words if recommended to the idle and luxurious, while the parents who have transmitted to their children unstable or diseased brains generally impair what chances they have in life by vicious training.
Where syphilis, drunkenness, and other marked sources of mental degeneration do not obtain, simple food, plenty of sleep, avoidance of extremes of heat and cold, plain dressing, baths, good digestion, out-of-door life, fresh air, careful attention to slight disorders or injuries of the brain and nervous system, guidance against too much study and too much excitement or dissipation, development of character and moral force, intellectual and physical training, avoidance of too much emotional, sentimental, or even artistic culture, careful watchfulness during the period of adolescence, occupation without overwork, healthful recreation, a contented or philosophical mind, and suitable marriages, would produce the strong wills and healthy organisms needed to combat the tendencies of modern life. Such a course would undoubtedly make many a child with an hereditary predisposition to insanity become a healthy parent of children in whom the same treatment would soon eliminate the family taint. The character should be strengthened to learn to overcome difficulties rather than evade them. There are cases in which such a course can be adopted, and where the physician's advice may be of untold benefit to generations.
There are many crises in life when the mind totters and seems ready to fall, which the physician is more likely to recognize than any other person. Sometimes the odds are too heavy to fight against, but often there is a transient mental disturbance in such critical cases, or an incipient insanity, according as the indications are met with wisdom and patience or with neglect, indifference, and lack of judgment. The treatment called for is of the person rather than of the mental state, and in all forms of mental disease success in treatment depends very materially upon the personality of the physician, who must adapt himself also to the personality of the patient.
In about one-fourth of the cases of insanity there is no hereditary predisposition to the disease, and its prevention can be most hopefully looked for in attention to the general laws of health, the observance of which tends to secure immunity from all diseases. In the remaining cases—three times as many, in round numbers—the most hopeful course is in abstaining from marriage altogether or in the avoidance of unwise marriages; and it is an encouraging fact that many people in the community now take that conscientious view of the matter, although if they decide what to do without competent advice they are liable to err in the opposite direction of exaggerating their morbid tendencies, and so increasing their unhealthy predisposition. There are certain groups of physical and mental manifestations which the experienced physician recognizes as signs of tendencies which only await favorable conditions—a sufficient exciting cause—in the indulgence in drink or other excesses, in the exclusive search for wealth or fame, in the absence of healthy occupation, in mental wear and worry, in over-excitement, in the various conditions of ill-health, to develop into actual insanity. This physiognomy of temperament suggests to the observant physician a warning against excess of all kinds, and a recommendation for that course in life which promises the greatest likelihood of preserving a quiet mind and a healthy body and of securing a rational employment. Too much work is less dangerous to most people than too little.
States of Mental Defect and Degeneration.12
12 Compare Moreau's La Psychologie morbide and Morel's Traité des Dégénérences physiques, intellectuelles, et morales de l'Éspèce humaine.
MICROCEPHALISM, CRETINISM, INTELLECTUAL IDIOCY, MORAL IDIOCY, INTELLECTUAL IMBECILITY, MORAL IMBECILITY (under which Westphal, Spitzka, and others place moral insanity) are really names for different degrees of similar defects, for the most part hereditary and congenital or resulting from disease or injury in infancy and early childhood, as distinguished from dementia, which is the result of later destructive mental or brain diseases. Idiots and the demented insane are sometimes so alike in their mental condition that, if young persons, they can be definitely distinguished one from the other only by a knowledge of the previous history of the case. Idiocy has its origin at or before birth or soon after, and terminal dementia seldom before puberty, commonly after maturity. In the United States census, where there is a doubt in the matter, the individual is classed as an idiot if the mental disorder occurred before the age of twelve in girls and fourteen in boys, and as insane (demented) if above that age.
The microcephalic brain may be as small as one-fifth the normal size, due chiefly to intra-uterine conditions for the most part unknown. Of course that means complete idiocy. The brains of other idiots differ in size and development. The mental condition in all is similar. Idiocy with the small or large or asymmetrical brain is classified, practically rather than scientifically, by Shuttleworth, as follows:
A. Congenital or Developmental13 Cases.—1, Microcephalic, with small heads: forehead and occiput defective; 2, hydrocephalic; 3, plagiocephalic, with distorted heads: features in an oblique plane; 4, scaphocephalic, with keel-like distortion of forehead; 5, scrofulous cases; 6, Mongol type; 7, cretinoid cases, with stunted bodies: irregularly expanded heads and enlarged thyroid glands; 8, syphilitic cases; 9, primary neurotic, with body well developed: signs of irregular nervous action; 10, sensorial idiocy, with two or more senses deficient (e.g. sight and hearing); 11, mixed cases.
13 Developmental conveniently includes those cases which, though of intra-uterine origin, become more pronounced as physical development proceeds.