CONCLUSION.
It has been my aim to conduct the preceding discussion in so plain and
direct a manner, that its lessons of instruction and warning, if it has
any, shall be readily appreciated by the reader. It will not, therefore,
be necessary to add chapters filled with specific directions how to avoid
insanity.
Some remarks, of a somewhat desultory character, concerning some branches
of the subject will comprise this closing chapter.
There are few diseases the conditions of whose existence are so clearly
and fully understood that they can in every case be avoided, and in
reference to the ultimate causes of many we know little or nothing. It is
true that, within a few years, we have more clearly recognized the
relations of hygiene to the prevalence of some forms of disease, and by
this means have done much toward limiting their progress, thus achieving
some of the grandest triumphs of medical science in recent times.
In doing this, however, we have not always, or even generally, known the
exact nature of the primary causes of these forms of disease, but have
simply learned, from observation, their relations to hygienic conditions;
but the knowledge of this relation has put society on vantage-ground in
all efforts to maintain the public health, so far as it relates to certain
forms of zymotic disease; and to the extent of our progress in
understanding these relations to most other forms of disease, shall we be
in a condition to avoid them.
The existence or the prevalence of insanity, however, does not depend on
any such conditions as relate to zymotic diseases, at least in the vast
majority of cases. Our study of its causes, therefore, has been in other
directions; and if our views of the influences which lead to degeneration
of nerve tissue are correct, these are even more easily appreciable than
are the causes of some other forms of disease, and consequently may be
avoided.
This must come largely, primarily, from the education of home and school
life, and from the regulation of daily conduct in its relation to the
brain; and, as the nervous system presides over and controls the body and
its several members in the discharge of their functions, an understanding
of its physiological action, at least in some degree, is of great
importance to everybody. While we cannot do much to lessen the amount of
brain-work or check the ambitions of adult life, as they have become so
intensified by modern modes of living and the requirements of business,
yet we may hope to do something by the judicious training and education of
the young.
That this may be effectually done, we must study the action of the brain
and nervous system when under the influence of different external
conditions and agencies. We have been accustomed to draw up long lists of
experiences and occurrences in the lives of those who have become insane,
as _causes_, such as _shock_, _grief_, _loss of friends_, _fever_, etc.,
etc. but it should be borne in mind that the vast majority of persons pass
through these or similar experiences, and yet do not become insane. It
becomes necessary, therefore, to go back of these experiences or
antecedents, and inquire as to the causation of that peculiar condition of
the nervous system which renders it susceptible of the effects of such
secondary causes.
This I have endeavored to do, more especially in the chapter on the Insane
Diathesis. I have sought particularly to draw attention to the delicacy
and great susceptibility of the brain while in childhood and youth to
external influences and impressions, and to show that if much in the way
of stimulation of any kind is added to its daily experiences, the effect
upon its future development and character may prove to be most
unfavorable. We have seen how at this early period of life it is moulded
and changed in no small degree by its experiences, and that if these are
of a disturbing character from any cause whatever, there can but result
such an influence on the brain-cells as will be incorporated into their
growth, and manifest itself in after-life in uncertainty and liability to
irregularity of brain-action.
Again, I have proceeded, in discussing the subject, on the supposition
that the nervous system is a unit; that, though the functions of the
several parts are of diverse character, such as motion, sensation, and
thought, yet the same laws of healthy activity pertain to all portions
alike; and that we could safely reason, in reference to the effects of
unfavorable influences, from the observed and known to the less known,
from the simple to the more complex processes of nerve-function; that what
is known to be injurious to the one must be so to the other. I have
endeavored to show that as too great or too little activity of the various
portions of the nervous system result in irregular activity or in failure
of activity, so, also, too much stimulation to the brain, as well as too
little exercise of function, both result in failure in some degree; that
through these two channels, and also from the effects of poisons acting on
the brain, comes the largest danger to its integrity of activity.
While some of the causes of insanity, however, are of such a character as
has been pointed out, and consequently preventable, yet it will readily be
perceived how difficult it will be to educate society so that it may be
avoided. The conditions of its existence pertain in many cases to all
classes of society, and ramify in the customs and habits alike of the rich
and the poor. In many other forms of disease there exists some degree of
unity in etiology, and we are able to discover their immediate hygienic
conditions with considerable certainty, and these conditions can in many
cases be avoided without much inconvenience; but those of insanity are so
multifarious, they are so interwoven with the very texture of our modern
civilization, that any warning which we can give, any words of help, or of
caution even, all are only too likely to fall on ears which are dull of
hearing. The ruling tendencies in our modes of living and of conducting
the great business enterprises of life, some of which are inherited, and
others learned in the years of early life, lie directly athwart its path.
Again, in many other forms of disease, we approach toward their nature and
causes by examination of the secretions and excretions of the body; we use
our chemical tests; we percuss and auscultate; we reason from the
pathological conditions existing after death, to those which must have
existed prior to death; but in cases of insanity, these modes of procedure
have so far availed us very little. While we find slight degrees of
difference in the secretions of the insane at times, yet these changes do
not appear to be pathognomonic. They may be found to exist equally with
the sane and insane, and therefore avail little or not at all in
determining any change which has taken place in the brain. Nor can we
determine the nature of those vibratory movements which are supposed to
take place during the processes of reasoning or the experiences of
sensation.
In examinations after death of the brains of those who have died while
insane, we find certain morbid changes in the cells and connective tissues
in many cases, and a few years since we were indulging large expectations
that we had at length arrived on solid ground, and thenceforth could
proceed to more perfect knowledge and definite results. But, so far, there
has very little of positive value, in determining the "_fons et origo_" of
insanity, been brought to light through pathological researches. The
changes in brain tissue found after death in the insane are degenerations
in various stages of progress, and in no essential respect differ from
those which may be found in some cases after death from injury and
disease, where no insanity has existed.
Indeed, if we ever should be able to definitely determine the connections
between morbid changes in the brain and the various modifications of
thought and action among the insane, while we should be in a position to
frame more perfect classifications of the insaniae, yet it is not easy to
perceive how we should be much the gainers in our appreciation of the
ultimate causes of insanity, or in its treatment.
Notwithstanding all these and other difficulties, however, we may hope for
progress in the future in our ability to appreciate at least some of the
causes of insanity more fully and be able to avoid them.
A few sentences in the form of a recapitulation will serve to recall some
of the more important points embraced in our discussion, and indicate
through what channels we may anticipate successful effort in the
prevention of insanity.
I.--_In Improved Methods of Education._
1. A larger appreciation of the importance of _individuality_ in giving
instruction. The teacher will have a fewer number of pupils, and find it
necessary to study the peculiarities and tendencies, both physical and
mental, of each one. Instead of having all together pass through a regular
routine of education, with little or no reference to mental constitution,
the system will be, in some measure, adapted to the present, and what may
appear to be the future, requirements of each scholar.
2. There will be less importance given to education of the brain by means
of books only, for all children, and a larger importance to _industrial
education_. Inasmuch as the large majority of the members of society must
obtain the requirements of living by industrial operations, society will
appreciate more fully the importance, not only to itself, but especially
to the individual, of so educating each person, that he may be
self-supporting, and consequently less liable to become a diseased and
dependent member of it.
3. A larger importance will be given, in methods of education at home, to
inculcating and enforcing obedience to laws and regulations. This is
essential, not only to the interests of society, but especially to those
of the individual in his relations to the laws of health. Man is endowed
not only with intellect, but with a will in the direction and use of it,
and it becomes his duty and essential to his interests to find out those
courses of conduct which will lead to health. In a considerable degree he
is capable of regulating his conduct so as to be in harmony with such
regulations. If, however, he is not taught the necessity of obedience
while young, and how to obey easily, the lesson becomes one very difficult
to learn in later life, and he is in great danger of never learning it.
4. A larger degree of importance will be given to education in relation to
physiology and heredity, especially so far as they relate to the
institution of the family. As the well-being of both society and the
individual depends so largely on that of the family, a knowledge of the
laws of heredity will be considered as essential to all persons who enter
into the relation of marriage, so that tendencies toward diseases may be,
at least in some measure, avoided.
II.--_In Reference to Certain Habits and Customs of Living._
1. One of the most important of these will relate to the use of alcohol,
in its various forms, as a beverage. Its stimulating and deteriorating
influence upon the brain will be more fully understood and avoided,
thereby removing one of the largest factors in the causation of insanity.
One of the astonishing facts which confronts the student of sociology, is
the unaccountable indifference, which has existed hitherto in society to
the vast evils of intemperance. When, however, the young become more
generally educated in reference to the physiological effects of alcohol,
and more fully appreciate the fact that they do not cease with those
primarily concerned, but pass over from the individual to his family and
to society; that the amount of disease and suffering to both, from this
evil, are so much greater than from any other--nay, I had almost written
from all others together,--extending in the family to the third and fourth
generations frequently in the forms of insanity and idiocy, and in society
to ignorance, poverty, crime, and a larger expenditure of charity than for
all other forms of evil,--why, it seems certain I shall be justified in my
prophecy, that the day cannot be far distant when society will proscribe
and limit the ravages of this enemy of human society.
2. The second refers to the excessive use of tobacco, especially by the
young, before the system attains to the maturity of its growth.
3. The importance of less stimulating and exhausting methods of conducting
business avocations in large towns and cities. A more full recognition of
the fact, that every brain is limited to its unit of power in activity--so
much and no more,--and that length of days and fulness of strength can be
expected only by the judicious care and expenditure of brain-force.
4. A more full recognition of the importance to the brain of _change_ and
longer periods of rest, both for adult persons when engaged in the usual
avocations of life, and especially for children in relation to the hours
of sleep.
5. The importance of improved sanitary conditions for all houses occupied
by the poor, especially in cities, and of all shops and manufacturing
establishments.
The kinds of avocations followed in-doors are not likely to be much
changed or lessened; indeed, I think they are likely to become even more
common; that larger numbers will be engaged in such occupations in the
future than in the present; but it is quite possible to realize more fully
the fact that the brain requires the effects of pure air, if it is to
remain in a condition of health, and that it is practicable to introduce
this to all places so occupied.
As will readily be perceived, the tendencies of the preceding pages have
served to point toward the importance of systematic preventive measures
concerning insanity. _Prevention_ is the watchword which is being
signalled along the line of the medical profession, at the present time,
concerning the management of disease. The importance of State Boards of
Health in many of the larger States has become so generally recognized,
that they are yearly appointed, and make regular reports, with more or
less full accounts as to the results of observations in reference to the
public health and the prevention of disease, which prove to be of the
highest value.
I would suggest the importance of appointing on such Boards one or more
physicians who are qualified for such a position, whose special duty it
shall be to ascertain and make public reports upon the prevalence of such
conditions as conduce to the production of mental disease. They should be
appointed by the State, so that they may have influence with school
teachers and school boards. In this way they may be able to point out the
dangers which lie in methods of educating and preparing the young for the
duties and responsibilities of life. Such persons should be able to wisely
direct in laying the broadest and most secure foundations on which to rear
the fabric of vigorous mental health.
That physicians appointed by the State, and operating in conjunction with
superintendents of public institutions and with teachers, would be able to
accomplish a most valuable work, in reference to the conduct of education,
and in instructing the public concerning those habits of life which are at
variance with mental health, I have no doubt. I may add that there can be
no question that a generous expenditure of money for such a purpose would
save many minds from the suffering and ruin which result from disease,
and, in the end, prove to be the wisest economy.
THE END.
FOOTNOTES:
[1] The whole number was 31,782.
[2] "The Past in the Present: What is Civilization?" by Arthur Mitchell,
M.D., LL.D., ed. 1880, p. 227.
[3] From "An Address delivered before the Graduating Class in the Medical
Department of Yale College," by the Author, 1875. Tuttle & Morehouse, New
Haven, Ct.
[4] As an example of what is required of young pupils, in addition to the
usual study hours in school, I herewith subjoin a list of what a lad,
twelve years of age, brought home from school, by direction of the
teacher, to learn during the evening:
1--_a._ From what incident is the phrase "passed the Rubicon" derived?
_b._ Why is the Archipelago southeast of Greece sometimes called the AEgean
Sea?
_c._ What poet is sometimes called the Ettrick Shepherd?
_d._ What is the largest bell in the world, and how much does it weigh?
_e._ What was the debt of the United States at the close of the
Revolution?
2.--Spell the following words and give the definition of them (being
prepared to write both the spelling and definition as they are announced
by the teacher):
Clarify, Pyrenees, judgment, leguminous, critique, pistachio, deceit,
scissors, superficies, idiom, anodyne, filigree, monody, cartouch,
committee, tobacco.
3.--Work out and hand in on paper solutions of the following problems:
_a._ What number is that from which if you take 8/14, the remainder will
be 1/3?
_b._ What number is that to which if you add 4/9 of 11, the sum will be
44-3/5?
_c._ What number multiplied by 11 will give 44-3/5 for a product?
_d._ What number divided by 4-2/7 will give 243/324 for a quotient?
_e._ What divisor will give 4-2/7 for a quotient, 66 being the dividend?
_f._ What number is that 8/14 of which exceeds 1/2 by 4-2/7?
_g._ What number is that to which if 8/14 of itself be added, the sum will
be 66?
_h._ What number is that from which if 1/3 of itself be subtracted, the
remainder will be 11?
I call attention: 1st, to the amount of labor and time it will require
simply to do the work of the above lesson, even supposing that a class of
children from eleven to thirteen years of age have the ability, and after
five hours in the school-room during the day; and 2d, to the character of
some of the requirements.
[5] Before this patient left the Retreat she gave me the following
schedule of her daily duties and mode of life while in school:--
"Breakfast at 7 A.M. From 7-1/2 to 8-1/2, did work. Studied from 8.30 to
8.55. From 9 till 1-1/2 o'clock P.M., studied and recited. Dined at 2, and
after dinner worked until 3. Then 1/2 hour for recreation. From 3-1/2 till
5-1/2 o'clock, study hours. From 5-1/2 to 6, turns were taken by the
pupils in preparing supper. Supper at 6. From 6-1/2 to 7, recreations.
From 7-1/4 to 9, Latin recitations and study."
Other pupils need not have studied so much by 1-1/2 hours.
Comment on the above is unnecessary.
[6] D. H. Tuke: "Insanity and its Prevention."
[7] Quoted by Dr. Tuke.
[8] Since writing the above, the following, in a newspaper published in
Chicago, Ill., has come to my attention:
"The chief cause of the 'lumping' system is that, owing to the
disappearance of apprentices, a good workman in any trade is becoming a
rarity. This leads to the lumping system in two ways: first, there are few
workmen who know how to do more than one or two things; second, a vast
army of inferior workmen are drifting about who cannot command good wages,
and consequently have to work upon the cheapest class of work, and these
are the only men whom the sub-contractor can afford to employ. According
to old master-carpenters and masons, the disappearance of apprentices
accounts for the new state of affairs. One of the best carpenters in the
city, who owns a shop and does a large business, said: 'It is scarcely an
exaggeration to say that the race of good workmen is dying out, and that
were it not for the immigration of foreign workmen we should be at a loss
for men to do even the commonest jobs. The best foreign workmen do not
come here at all, finding enough to do at home, so that those we do find
are not such workmen as we had twenty years ago; but at least they are
better than the men who have failed to learn a trade here. The newspapers
say that men do not know their trades nowadays because there is no such
thing as apprenticeship. There is no such thing as a legal apprenticeship
bond between a boy more than sixteen years of age and an employer;
consequently a boy who is taught something useful in a shop, will learn
where he can get half a dollar more a week in some other place. A boy will
not stay in a shop more than a year without pay; we have to pay them for
allowing themselves to be taught a trade. As boys are usually not worth
their salt in a carpenter shop, we do without them. The consequence is
that boys pick up a trade in a superficial way instead of learning it.'"
[9] "Heredity: A Psychological Study of its Phenomena, Laws, Causes and
Consequences," p. 1. Th. Ribot, 1875.
[10] Quoted by Ribot.
[11] "Illustrations of Heredity," by J. R. Dunlap.
[12] Quoted by Ribot.
[13] Ribot on "Heredity," pp. 86, 87.
[14] _Journal of Mental Science_, January, 1881.
[15] Dr. McGraw, "Address on Heredity and Marriage," pp. 12 and 15, quoted
by Dr. Miles.
[16] Quoted from "Diseases of Modern Life," by B. W. Richardson, M.D. D.
Appleton & Co., 1877, pp. 213 and 214.
[17] "A Sober View of Temperance," by Rev. Daniel Merriam, Bibliotheca
Sacra, Oct., 1831.
[18] "Diseases of Modern Life," by B. W. Richardson, M.D. pp. 228 and 229.
[19] The writer is here describing a personal experience.
[20] "After a short time the products of tobacco find a ready exit out of
the system. They are thrown out by the three great eliminatories--the
lungs, the skin, and the kidneys. The volatile matters exhale by the
lungs; * * * while both (nicotine and the bitter extracts), I believe,
are carried off by the kidney, the grand eliminator of all poisons of the
soluble type."--"Diseases of Modern Life," by B. W. Richardson, M.D., pp.
283 and 285.
[21] Quoted by John Lizars--"The Use and Abuse of Tobacco," New York,
1880, p. 21.