Insanity may, both in its acute and chronic form, be the result or symptom of simple anomalous excitation or nutrition of the brain or of inhibition of some of its portions, without any change in its gross appearance which can be detected by our present methods of research. In the majority of cases there are found diseased conditions which become more manifest the longer the duration of the disease, appearing for the most part in the blood-vessels, pia mater, and cortex of the brain, but also in the medullary portion, many of which are recognized only in their late stages. In the functional mental diseases there is no characteristic lesion of the brain as yet recognizable, even in the latest stages, more than is to be found in the brains of persons dying from other causes. When apparently local injuries or diseases cause insanity, they probably do so through a general disturbance of the brain or through diffuse disease resulting therefrom and for the most part affecting both hemispheres. The molecular, chemical, anatomical, physiological, pathological, or physical changes in the brain which give rise to insanity, and their relation to the grosser pathological conditions of the brain, are still not clearly made out.
In terminal dementia, especially in the last stage of paralytic dementia, nearly every tissue and organ of the body may be found to have undergone pathological changes, of which by far the greater portion is secondary to disease of the brain; and it is impossible to say how much of the brain lesions in these and other conditions of mental unsoundness is secondary to the disease or an accidental complication.
DIAGNOSIS.—In the diagnosis of insanity the physician assumes a responsibility for which he is liable under the common law. It is important, therefore, to avoid mistakes as far as possible. In the majority of cases the patient's unsoundness of mind is evident before he is brought to the doctor, but in not a few the symptoms are obscure, and they are often rendered more difficult of correct understanding and appreciation by the deception or reticence of the patient and by the prejudices of his friends.
First, before seeing the patient it is well to get from his family, friends, and physician a full knowledge of his natural state, all the facts known to them relating to strange behavior, delusions, etc., as they give most useful hints with regard to the method of examination. Apparent familiarity with an insane person's delusions will often secure their immediate acknowledgment. In a case of any obscurity or where there is doubt that other causes than insanity may have produced the unusual behavior, and particularly if any legal steps are to be taken regarding guardianship, restriction of liberty, commitment to an asylum, validity of wills and contracts, capacity to manage property, marriage, etc., it is imperative that both sides of the question be fully heard before any positive opinion is given. After the patient's confidence has been gained in general conversation, during which his appearance, manner, and mental condition as to intelligence, coherence, memory, judgment, perception, and capacity may be noted and compared with his normal standard, he should be examined carefully for any external evidence of lack of development or of injuries to the head. As in all other diseases, the condition of every organ of the body should be noted; a complete diagnosis should be made. The expression of the face often indicates such excessive excitement, gloom, stupor, suspicion, or fear as must be due to insanity alone.
Throughout the examination the questions and manner of the physician should be such as to avoid suggesting unpleasant ideas or associations to the patient. The matter of suicide should never be first mentioned by the questioner, and not seldom he does best who listens most and lets his patient disclose his morbid ideas and impulses, as he will frequently be led to do, if at all, by the manifestation of interest and sympathy, and of knowledge of the symptoms of the disease in hand, on the part of the physician. He often gets enough for his purpose without getting the whole story, upon which it sometimes does harm, or at least is not best, that the patient should dwell. In the diagnosis of mental disease, however, as well as in estimating responsibility, the fact must be borne in mind that a controlling delusion may be concealed for months or even years, and that the symptoms and mental condition of insane people vary so much at different times that it may be quite possible to get distinct evidence of unsoundness of mind at one time and not at another. The power of self-control is also liable to the same variation or alternation.
If the patient has no reason for simulation, it is commonly best to tell him the object of the examination. The family history should be learned from others, as questioning the patient on these points is apt to put him in a train of thought unfavorable to a hopeful view of his own case. After full personal questions concerning himself and his environment, one can usually tell whether there are unreasonable suspicions, violent impulses, perverted feelings with regard to his family, delusions, hallucinations, or illusions. A delusion's existence must often be accepted, however, from the behavior of the patient and from the statements of those about him. Hallucinations of hearing must sometimes be inferred from the attitude of listening to imagined voices; and prolonged observation under circumstances such that the patient does not know that he is watched will often settle the question of his insanity when other means have failed. A careful examination should, of course, be always made for the physical and rational signs of disease. In the differential diagnosis care must be used not to mistake for insanity the acute diseases typhoid fever, meningitis, smallpox before the period of eruption, pneumonia, cerebro-spinal meningitis, narcotism or delirium from drugs, and alcoholism—errors which have been made, and which can be avoided by deferring one's opinion for a sufficient time.
The detection of simulation is more difficult, especially as the insane sometimes feign insanity for a purpose, or, on the other hand, accuse themselves of wrong acts which they never committed. In general, it may be said that sane persons pretending to be insane very much overdo their part, do not make their symptoms conform to any recognized type of disease, and have a strong motive for their deception, as well as for the act for which they wish to be considered irresponsible. Their insanity first appears after the deed; they are exhausted by their efforts to seem mad, and appear quite sane if watched when they think that they are unobserved. A crime performed without accomplices, with no plan or a silly one for escape, and with no sane motive, is usually itself evidence of insanity. On the other hand, people partly demented by chronic insanity often commit crimes with all the method and motive of the criminal. In not a few cases, especially when the fact or not of impaired intellect cannot be decided by comparison with a previous condition, the question ofinsanity, or at least of responsibility, will be beyond human wisdom. A correct diagnosis can, of course, not be made without a familiarity with the various forms of mental disease; and insanity is now so well understood that a sufficient examination of an insane person should develop the clinical history of some known type of disease in nearly every case.
Little has been said of the physical evidences of insanity, because there is little to say. Conditions of mental torpor, depression, and excitement are associated with the physical manifestations which we would naturally expect in those mental states. Coarse brain disease with insanity or without may have identical physical signs; paralytic dementia is the only disease in which corporeal indications really assist in forming a diagnosis.
A family predisposition to mental disease does not materially affect the question of fact whether a given individual is insane or not, except that in a doubtful case it adds to the probability of insanity, and is thus far a factor of importance as corroborating other evidences of an unsound mind.
PROGNOSIS.—The prognosis in insanity depends first upon the type of disease, mania, melancholia, and some forms attended with confusion and stupor being the most curable; the forms attended with systematized delusions or with periodicity which is not dependent upon menstruation, folie circulaire, and moral insanity rarely so, and the organic brain diseases, congenital insanity, and confirmed primary delusional insanity (monomania) hopeless. The acute forms are far more curable than those of a subacute type: 60 per cent. of the cures in insanity occur in the first half year of treatment, 25 per cent. in the second half, and 2.5 per cent. in the second year, roughly speaking. In chronic cases a reported cure is most commonly only a remission, and after several years of existence insanity is generally incurable, although rare cases of cure in mania have been reported after even from six to fourteen years of treatment, and in melancholia after twelve years. So long as there is no permanent dementia and there are distinct intervals of mental clearness, no matter how short or how far apart, there is hope of final recovery in the curable mental diseases.
People of sound families, with insanity of an acute type arising from physical causes, often make such speedy and complete recovery as to justify their subsequent marrying if they wish, while those of unstable nervous organization recover more slowly and oftener relapse. Insanity from so-called moral causes, too, is of more unfavorable outlook than if from the physical causes, if we exclude organic brain disease. A person with good physical education, excellent mental training, and self-control is more likely to get well than one with a vicious bringing up. The ages of maturity and middle years are most favorable to complete recovery. In women there are more first cures and more relapses, according to Krafft-Ebing. In general, the mortality of the insane in asylums is about four times that of the sane of all ages, or approximately six times that of the sane at the ages when insanity prevails.
Prolonged stupor, profound incoherence, loss of memory, and moral debasement are unfavorable symptoms, unless quite acute, of short duration, or occurring after the rapid subsidence of acute symptoms. Hallucinations of hearing, and to a less extent of sight, impulses to violence, and especially systematized delusions, are grave indications. Paralysis,epilepsy, and convulsions usually mean chronicity or death. Extensive disease of the heart, kidneys, or lungs, confirmed dyspepsia, especially of alcoholic origin, and a previous history of syphilis, seriously affect the prospects of recovery. If there is actual cause for self-accusation, if the knowledge of wrong-doing is added to the morbid mental state, the period of convalescence is apt to be much retarded, or even recovery is prevented, by the difficulty of establishing a healthy reaction. Even an irresponsible act is often magnified into so depressing an influence as to prevent restoration to health, as in the case of those who have injured or killed members of their family.
Of 9689 persons admitted into the Worcester Insane Asylum8during fifty years ending September, 1881, of whom 1083 had been in other asylums, 35.49 per cent. were discharged well, 26.61 per cent. improved, 17.71 per cent. not improved, 0.5 per cent. not insane, and 14.85 per cent. died. Of those discharged, 25.41 per cent. were readmitted, and of 798 discharged recovered, with regard to whom inquiries were made, 156 were reported well at the time of replying, 197 as having died sane, 30 committed suicide, 162 relapsed and died, 94 relapsed and were alive, 30 were in hospitals or almshouses insane, and of 129 no information was got. Out of 798, there were 316, or 39.6 per cent., known to have become insane again or to have committed suicide. Of 1966 second admissions, 668 recovered; of 607 third, 263; of 261 fourth, 119; of 132 fifth, 70; of 70 sixth, 42; of 48 seventh, 30; of 37 eighth, 21; of 30 ninth, 19; of 26 tenth, 15; of 23 eleventh, 11; of 18 twelfth, 11; of 15 thirteenth, 10; of 12 fourteenth, 8; of 8 fifteenth, 5; of 4 sixteenth and seventeenth, 3; of 4 eighteenth, 2; of 2 nineteenth, 1, who was admitted and discharged well twenty-three times.
8Forty-ninth Annual Report, including tables by John G. Park, Medical Superintendent.
Thurnam's statistics, that one-half of the recent cases of insanity treated in asylums recover, and that of the recovered only two-fifths remain so, receive constant confirmation. There is a considerable proportion of the inmates of asylums whose brain-condition is so unstable that they come in and go out frequently. Their brains are unstable, too, in the little affairs of life, and many of the nominally cured remain comfortable only by being shielded from sources of physical wear and mental worry. It is impossible to get statistics of the curability of mental diseases properly treated outside of asylums, but the results would probably be more favorable than those just quoted, partly from the greater chances of cure in the mild cases and in those acute cases which can be kept at home, or at least do not require hospital treatment.
It is difficult to form an opinion as to the probability of subsequent attacks in those who have recovered from any of the curable forms of mental disease. The same constitution, of course, remains as that which predisposed the individual to the first attack, and no one can look far enough into the future to predict the influences which will be brought to bear upon any given person for a considerable period of time. If they are favorable for preserving mental health, the chances of escaping mental disorder in the future are very much greater than if the occupation which must be pursued and the life which must be led predispose to bodily exhaustion, anxiety, and brain-worry. If the disease first appeared under slight exciting causes, it will not often be possible toavoid similar conditions again, and some forms of insanity are characterized by relapses and recurrent attacks.
Of the persons reported recovered from mental disease, a large proportion fail to recover in the sense of being fully themselves again. There is left some change of character, no matter how slight, some moral perversion, irritability, instability, impaired will, lessened power of self-control, diminished mental capacity—some lowering of the intellectual or moral standard, some deterioration of some kind.
TREATMENT.—Not long after Leuret recommended and practised severe discipline in the treatment of the insane a case was reported at the Medical Congress in Naples (1845) where douches, setons, blisters, bleedings, internal medication, shocks, terror, harsh discipline—nothing succeeded in restoring to sanity a woman become insane three months after her confinement. There probably are places where similar methods are practised at the present day, and yet it is not unreasonable to suppose that the very treatment used is sufficient to render incurable patients who might otherwise get well. The modern management of mental disease by rest, diet, baths, fresh air, occupation, diversion, change of scene, no more medicine than is absolutely necessary, and the least restraint possible—in a word, improving the patient's general condition, meeting the indications of his disease, diverting his mind from its morbid thoughts, or putting the brain in a splint, so to speak, as each case demands—gives much better results, the value of which is much diminished by the enormous increase in the size of our asylums and the great aggregation in them of diseased persons in all stages of insanity.
In twenty American asylums, the statistics of which have been analyzed by Pliny Earle in his paper on theCurability of Insanity, the average diminution of reported recoveries for about twenty-five years has been from 46.08 to 34.26 per cent. annually of cases admitted, and in the Massachusetts State asylums from 25.95 to 22.25 per cent. of 3371 persons admitted from October, 1879, to October, 1882. The prospect of treatment of insanity does not, from these figures, look very hopeful, and it must be conceded that there is in the proportionate number of reported recoveries a decrease which it is important should be explained. It is undoubtedly true that a larger number of the chronic and quiet incurable insane are sent to the asylums now than formerly, thereby diminishing the curable proportion. The character of the asylums, too, has changed from being small, easily-managed institutions to overgrown affairs, crowded with so many incurables that the duties of the superintendents have become largely administrative, and the medical treatment of the sick has been driven to a subordinate position. Medical officers, too, are more cautious in using the word cured after experience has shown them how many reported cures are only remissions.
In treating insanity, even more than any other disease, the fact must be borne in mind that one is treating a diseased person; and indeed it is often necessary to treat a whole family of persons predisposed to insanity in giving directions for one actually insane. There probably has been no time during the last quarter of a century when there was more uncertainty in the minds of the medical profession regarding the best treatment for patients suffering from curable mental diseases than at present. Twenty-five years ago the almost universally-accepted practice was to sendthem to an insane asylum with as little delay as possible, without much regard to the character and duration of their disease. Twenty years ago, in the medical school the professor of obstetrics advised sending all well-marked cases of puerperal insanity early to the hospitals for the insane, and only a few years later Godding, then superintendent of the asylum at Taunton, advised that patients with puerperal insanity be kept at home until every available resource but the asylum had been tried without success.9Meynert lectures to his classes in Vienna that in every case there is a disadvantage in sending curable insane persons to asylums, although it is often a necessity to do so. Maudsley thinks that a large proportion of the curable insane can be treated to best advantage either at home or in small private asylums or houses; while Bucknill says that by home treatment more cases would be cured than with our present methods. The late Isaac Ray summed up his vast experience in the treatment of the insane by saying that it cannot be shown that the introduction of insane asylums has added anything to the curability of insanity, much as they are to be praised from the humanitarian point of view. According to the statistics of Pliny Earle—to which the only objection we can make is that they are so exhaustive and conclusive that we cannot controvert them—the permanent curability of mental diseases in asylums for the insane is not only small, but decreasing.
9Boston Medical and Surgical Journal, vol. xci. p. 317.
Part of the results obtained by Earle may be due to the fact that curable cases are more treated at home now than formerly, that the degenerative types of insanity are more common, and that in our cleaning up and civilizing processes we are not only driving out filth diseases, but letting in disorders due to greater efforts and more intense struggles for the kind of existence which modern life demands. But it is also true that in enlarging our asylums, as we have been compelled to do, we have lost something in personal care of patients, and that we have increased the depressing influences of large masses of sick people to such an extent as to involve serious disadvantages in their treatment. It is a matter of common observation that some insane people do well at home, others away from home, and others in asylums—that some do badly in asylums, and quickly get well if discharged, and that others, after continually going down at home, immediately improve upon being sent to an asylum. There seems, however, to be no fixed rule in individuals, and certainly there is very far from unanimity of opinion among alienists generally as to the conditions for home treatment or removal from home or sequestration in asylums, except, of course, that few men of experience would take the responsibility of keeping out of asylums persons with alcoholic insanity or with delusions of persecution, or cases of violence and delirium, or any insane patients under conditions involving danger to the community or to individuals, although it is often a matter of extreme difficulty to decide when restraint becomes necessary or justifiable.
I have selected from a large number a few cases where I have acted contrary to the usually accepted views as to indications for removal from home, and with such success that I am led more and more each year to rather widen than narrow the lines within which home treatment seems to me desirable.
Case I.—Mr. ——, age 20, of sound constitution and withoutmarked hereditary tendency to disease, although several members of his family are people of very little force. The patient had masturbated in college, as many boys do, and was compelled to give up his studies upon his father's failure in business. An attack of slowly-advancing melancholia developed, for which he was sent to the farm of a relative in the South without improvement, so that he returned home at the end of a year in pronounced acute melancholia. He secreted himself in a marsh not far from home, where he was by accident found bleeding freely from the radial artery, which he had cut to kill himself. He had the usual delusions of the disease. He thought the world was all wrong, that he had committed great crimes—the unpardonable sin—and that there was nothing but destruction before him and his family. He was desperately suicidal. The circumstances giving rise to his disease and the associations of his delusions were entirely connected with his home and members of his family. His people could not afford to hire a nurse, but his three brothers and one cousin were only partly employed, and they agreed to take care of him. The treatment was tonic and supporting, with plenty of sleep, food and outdoor exercise, with careful attention to daily details of life, arranging it as to amusements, occupation, etc. etc. from day to day to suit his condition, and with absolute watchfulness day and night to prevent suicide. He remained in the home where his disease arose, and he was taken care of by the people most actively associated with his delusions. He made a rapid and perfect recovery, and is now very successful in his work as a professional man.
Case II.—Miss ——, age 35, a sound, healthy woman, without any known hereditary predisposition to disease. Without any assignable cause, except a moderate amount of overwork and steady home-life without sufficient recreation, she became very ill with acute melancholia, much mental confusion, very varied delusions that the world was all wrong, her friends distorted and changed, and herself so great a sinner that she could not escape everlasting damnation. Her most constant and distressing delusion was that people were constantly lying in wait to kill her and her mother and her sisters. When I saw her she was taking large quantities of hydrate of chloral and bromide of potassium, which were at once stopped. With plenty of food, fresh air, exercise, rest, malt, and cod-liver oil she slept well. She was first put under the care of a professional nurse, who was not liked by the family, and I then decided to let the mother and sisters assume full charge. She was watched with unremitting care day and night, and yet managed to make three attempts at suicide, which of course were not successful. She made a rapid and most perfect recovery, and is still perfectly well.
Case III.—A letter-carrier about 25 years old, without known hereditary tendency to disease, under-fed, over-tired, and worried, broke down with pronounced mania of the simple type, without marked delirium or delusions. He was much exhilarated, often excited, rarely noisy, and, as he had no delusions, he was not dangerous. He was somewhat troublesome, and I feared that his disease might become more active, and so I recommended his removal to an asylum, to which his friends fortunately refused to consent. He became progressively worse, but still not maniacal or delirious. He had no specific insane delusions, but he had a generally exalted notion about all the events of life and his own affairs. Hissurroundings were not conducive to quiet, as he lived in the noisy part of the city, and his associations were those under the influence of which his disease appeared. But he made a most excellent recovery, and resumed his work with only a year's interruption.
Case IV.—A healthy young woman, without hereditary predisposition to insanity, confined with her first child. Her delivery was not attended with any especial difficulty, and she made rapid progress toward health and strength until the beginning of the third week, when a slight change of character was noticed which soon developed into active mania. She was delirious, profane, obscene, filthy in her habits, and filled with delusions regarding herself, her family, and her surroundings. She had a great aversion to her infant, and often did not know the several members of her household. Hers was as violent a case of puerperal mania as I have ever seen in an insane asylum. She was naturally not very strong, however, and people could always be near enough at hand to prevent her doing any harm to herself or others. Her infant was kept out of her sight most of the time for five months, and all of the time for many weeks. The usual treatment was adopted, an excellent recovery was made in six months, at the end of a year strength was restored, and the patient remains quite well now.
Case V. was quite similar to the last, except that the disease was melancholia, and that the patient had tried to kill herself and her infant before I saw her. She made a complete recovery. Both cases were taken care of in their own homes, and for the most part by members of their own families.
I have reported these cases with as little detail as possible to illustrate the point which I have insisted upon for several years, that many cases at least of mental disease are to be treated precisely like typhoid fever or rheumatism or a broken leg, so far as removal from home is concerned, and that home-associations are no more harmful in properly-selected cases than in pneumonia or phthisis. I do not mean, however, that the patient should not be under the most careful treatment. On the contrary, the little details of medical care are fully as important as in early Pott's disease or beginning inflammation of the hip-joint. But it is often difficult to decide what cases should be best treated at home, what by slow travel or removal to other places than home, and what in asylums.
The objections to asylum treatment, when it is not absolutely necessary, are very great. On the other hand, the advantages that asylums possess for supervision and control are so obvious that they must continue by far the best means of treating the vast majority of cases of incurable insanity, and a large proportion of those in which a cure may be reasonably expected. The exigencies of many cases demand them. If, however, it can be shown that the aggregation of invalids in them is unfavorable to the best chances of recovery, and if, as I think is the case, many of the restraints and restrictions now common in them are unnecessary—for many of the patients, to say the least—the deduction is clear that a change must be made in asylum construction and management to correspond to these views. A common depressing influence in the treatment of mental disease is the fact that the patient remembers some member of the family who has had to go to an insane asylum, and fears the same fate for himself, or after one commitment and recovery fears that he mayhave a relapse and be obliged to enter an asylum again. I am quite sure that a considerable number of the recovered patients of insane asylums who commit suicide do so from this dread; which is not altogether unnatural, as the tendency there is downward, so that the patient, as he in the progress of his disease more and more loses self-control and power of decent behavior, is progressively dropped into lower wards, with more disorderly or demented patients, at a time when all the surrounding influences should be, on the contrary, of a tendency to lift up. On the other hand, many who recognize their infirmity wish to be taken away from old friends and associations, and prefer the seclusion of an asylum, which is their best home.
The more acute the disease, the more likely it is to be of not long duration, and, as a rule, the easier it is to treat it without removal from home, except in cases of great violence. The question whether home-influences are benefiting or injuring an individual patient must often be settled by experiment. It is a great comfort to many of the insane to see their friends, no matter how seldom, at times when they feel that they need their support and influence; and this is impossible unless the friends are near at hand. There are cases in which familiar scenes and faces and voices reassure the patient when delirium subsides, and during a short interval of comparative mental clearness their sedative influence is great as compared with the confusion and worry of trying to understand the new surroundings of a hospital ward or the sight of strange people and the sound of unknown voices. The mere fact of delusions being connected with the home-surroundings and members of the family is not so important as the character of the delusions; and the influence of the relatives is often most salutary, even when the patient has most distressing thoughts concerning them or even when he is too insane to be always sure of their identity. If the insanity arises in a violent emotional shock, and home sights and surroundings recall and arouse the mental pain, as is the rule in such cases, recovery usually depends upon removal from home. The matter of suicide where there are means of proper watching does not influence me in my decision, as I think that the dangers of self-destruction are fully as great in asylums as outside with sufficient care, whereas the stimulus to the patient to kill himself from both insane and sane motives is greater the more he is surrounded with depressing influences. On the other hand, it not seldom happens that the diversity of sights in the hospital, the routine, the varied events of the day, the amusements, the walks, the drives, even the discomforts and annoyances, serve to distract the patient's mind from his delusions better than the same result can be accomplished under the pleasant influences at home, while a natural feeling of self-respect prevents those who have power of self-control from giving way to their impulses before strangers, especially when they know that such conduct will take them to a lower ward with less agreeable associates.
There is no doubt, however, that home-treatment of the insane in the majority of cases is synonymous with neglect of all those minute attentions to details that make the difference between recovery and chronic mental disease. Home-associations often act upon the insane mind like frequent passive motion to a diseased or fractured hip; the relatives of the insane patient oftener than not share with him a common inheritanceof an unstable mental organization, and will not be judicious in their treatment of him, or they cannot be subjected to the risk of becoming insane themselves in taking care of an insane brother or parent; and it is seldom that a private house away from home can be converted into a hospital, as it must be for the treatment of an insane person. One of the greatest difficulties in the home-treatment of the insane is during the many months of slow convalescence, when it is difficult to prevent a too early resumption of cares or work or methods of life prejudicial to complete restoration to health; so that in that stage of the disease, if in no other, removal from the familiar and usual surroundings of the patient will usually be quite necessary. The small private hospitals, with all their many and obvious advantages, always have been, and inevitably must be, chiefly devoted to wealthy patients who wish for a home where they can have medical supervision, rather than curative institutions for any large number of persons; and there is not enough going on in them to sufficiently occupy the attention of certain curable patients who must be removed from home, although they are well adapted to those who need quiet and seclusion chiefly. The larger hospitals, with their large staff of skilled officers and nurses, and with all their appliances for recreation or rest, amusements or occupation, discipline or gentle support, must be our chief means for treating the insane. They are indispensable for a large number of the insane who are of such unstable mental equilibrium that a little over-exertion or a trifling deviation from a carefully regulated routine throws them off their balance; and they must be used, temporarily at least, for many of the incurable or partially curable insane who need a place and an opportunity to learn self-control and self-management. Enormous advances have been made in the construction and management of hospitals for the insane, more especially in the last fifteen years. We see it everywhere. But the greatest need, of opportunities to combine advantages of the asylum treatment with the benefits of home-comforts, to place sick people where the influences surrounding them will be healthy, and where there are not so many harmful as well as useless restrictions upon liberty, and so many morbid associations, is as yet entirely unfilled in this country. The question of the best, or even of an improved, organization for our insane asylums is too wide a subject to be discussed here. That our present system tends to make the medical staff narrow if they are appointed to their duties without previous broad training and experience or for political reasons, is a self-evident proposition; and yet there are manifest objections to just such a visiting staff as is customary in general hospitals.
As Maudsley says, squalor in an attic with liberty is better than being locked up in a palace with luxury. Many of the insane share that feeling with their sane brothers. To not a few it makes the difference between recovering their mental health and lapsing into incurable dementia. Many would voluntarily consent to remain in places less distasteful to them. If we could separate them into classes, as Mr. Mould10has done in England by buying or hiring ordinary dwellings one or two miles even from his asylum, we could have separate houses with open doors or shut, as the case demands, for those who require them, and reserve theassociated halls and large buildings for a different class. Mr. Mould has not applied his own system to those cases which need it the most, the curable insane, except to a very moderate degree.
10Presidential Address at the Annual Meeting of the British Medico-Psychological Society, October, 1880.
It is not often that the physician is called, or his advice heeded if given, in the early stages of mental disease, and the first symptoms are by no means easy to differentiate from the less harmful results of mental strain. If there be, however, sufficient loss of equilibrium to suggest the question of beginning insanity, it is of course better to take the safer way and recommend removal of all sources of irritation, and to advise rest, sleep, simple food, attention to the general laws of health, outdoor life, and change of scene for a sufficient length of time to restore the mental poise, avoiding narcotics and sedatives as far as possible, and keeping the patient with a safe adviser or within easy reach of one. In many cases, especially of young persons, this may involve a radical change in their choice of a profession and whole plans of life. If the question of marriage comes up in these cases before the physician as to preventing further developments of threatened disorder, it can only be said that what may be well for the individual is not always best for society. A few years' delay will usually give time for the question to settle itself.
When insanity has actually appeared the same rules should govern its management as in other diseases. If, like smallpox and diphtheria, it is a great source of danger to others, the patient should be put in a safe place; if, like typhoid fever arising from bad drainage, its cure depends upon the removal of a given cause, the patient must leave the infected locality or have the cause displaced; if, like rheumatism in a damp cellar, it can be treated successfully only under different conditions, the patient must be removed; and if poverty or other conditions prevent the best possible treatment, the next best practicable plan must be followed.
The first question which comes up in the care of the insane is with regard to removal from home and commitment to an asylum; and here a great many points must be taken into consideration. It is not always that a home can be accommodated to the use of an insane member of the family. There are not many in which there can be proper quiet and seclusion without depriving the patient of that abundance of fresh air and outdoor exercise which is so often required in treatment. Frequently those nearest to him irritate him to the last degree, or he has some aversion or delusion in regard to them rendering their presence injurious. If the delusions and impulses of a patient are not such as to endanger the lives of the household, his violence and excitement and uneasiness or melancholia may make life simply intolerable to his relatives, or his exactions may be exhausting to their strength and his constant presence a means of making still others insane. His noise may disturb a whole neighborhood. His vagaries may require control, his indecencies concealment, his enfeeblement help more than can be sufficiently given outside of a hospital, his general condition more judicious care than his friends can command, and his example may have a pernicious effect upon children growing up with an insane diathesis. In many people a long time insane much of their vicious conduct is due to habit or to tendencies which they cannot or will not control without the steady, kind discipline which cannot be got at home.
A man with delusions by virtue of which he thinks that some one isplotting to ruin or kill him is apt to commit murder; a mother who believes that the world is going to ruin and her children to torture may be expected to put herself and them out of misery; a demented woman chops off her infant's head because its cries disturb her; and the maniac's delirium or epileptic's fury drives him into any horrible act. Such people need to be watched always by some person or persons fully able to prevent their doing harm, which in many cases can only be done, with any reasonable degree of liberty to the patient, in a hospital for the insane. If the danger is obviated by removal of certain persons—children, for instance—or if watching by nurses serves the purpose, and there are no Other objections to such a course, there are cases in which the chances of cure are more if the patient remains at home whenever the disease pursues an acute course. Most of the insane, however, have passed the curable stage; the majority need the moral support and freedom from responsibility or the regular life and regimen of a hospital; and a large proportion of the cases following a subacute or chronic course must be removed from home. The expense attendant upon the safe treatment of mental disease in a private house is entirely beyond the means of most families, just as they cannot send their consumptives to Colorado or France, and so the hospital becomes a necessity. Except in dangerous cases, however, the hospital should never be hastily decided upon. A little delay does not diminish the patient's chances of recovery, and may show that the attack is only transient, whereas removal to a strange place might aggravate the disease and increase its duration. It is particularly important not to choose an unfavorable time to commit an insane person to an asylum, and thereby add to discouraging conditions already existing an additional source of despair at a time when every influence should be as elevating and cheering as possible. In most cases, especially if there is a suicidal or homicidal tendency, it is best, when removal to an asylum has been decided to be necessary, not to argue the question with the patient, but to explain why it must be done, and then do it without delay.
The law provides the methods of commitment to asylums. They are so different in the different States that they cannot be discussed here.11The one rule holds good everywhere, however—that it is far better to use force than deception in sending the insane from home to asylums, and that the cases are very few in treating the insane in or out of asylums where deception is either justifiable or wise. A second safe rule is that a person of unsound mind is always a source, immediate or remote, of more or less danger.
11An abstract of the various laws may be found in the appendix to the American edition of Clouston'sClinical Lectures on Mental Diseases.
Commitment to an asylum means so much that safeguards against improper action should provide careful examination of the case by competent physicians, as little restraint as is required by safety, good medical treatment in the hospital, thorough supervision by experienced persons on the part of the state, safe-keeping of the dangerous patients, and easy removal of those who have recovered or who may be sent out to their own advantage. In too many States confinement in an asylum means that two physicians, or even one, who may know little or much of insanity, think it best, and removal depends upon the word of one man,the superintendent. Once in the asylum, the best practice of the present day should be followed—namely, to allow free communication and visits from friends until it is shown that they do harm, to multiply cheerful and natural influences to the last degree, to furnish rest, exercise, occupation, or recreation as each case requires, and to remove all that is morbid and disagreeable so far as that can be done. A permanent removal from the hospital should be insisted upon as soon as it is safe to complete the convalescence at home or elsewhere, and an abundance of fresh air, indoors and out, should be supplied as the best curative agent from first to last. Arguing, moralizing, cheering up, rigid restraint, disciplining, sedative drugs simply for quieting patients, and still more bleeding and blistering, are for the most part things of the past. Mechanical restraint is all but abolished in the best hospitals, and is used only so far as it is considered the best medical treatment. A prison-like appearance of the wards has been found to be not only quite unnecessary, but harmful.
In many cases of insanity I make the question of removal to a large hospital one of circumstances and of money. If separation from the influences under which the disease occurs is necessary, and that cannot be secured at home, I usually select, as the case demands and opportunity is afforded, a private house with good nurses, a small private hospital, or an insane asylum where the general influences are the healthiest, where the medical treatment is in accordance with the best modern principles, and where the construction of the hospital is most nearly adapted to the requirements of the present day. Accessibility to visits of friends and the family physician where they help in the cure, and remoteness from them when they do harm, are also points to be considered. In many cases where the illness is of long duration a change of scene and association will prove of great service, even from one hospital to another. The permanent settling down into the routine of hospitalism is especially to be avoided. Of course there are cases, or rather conditions, in which a change would be detrimental to the last degree.
The associations, surroundings, and influences brought to bear upon the patient—what has been called the moral treatment—are of the first importance in the treatment of mental disease, and diet and hygiene come next. Medicines are of use in properly selected cases. The appetite must often be stimulated, the digestion regulated, and various painful symptoms must be relieved, so far as possible, without a resort to internal sedatives and narcotics. Rest and sleep are essential to recovery, but every effort should be made to obtain them by judicious regulation of outdoor exercise and of quiet as each case requires, abundant non-stimulating food frequently given, fresh air, tonics, baths, and removal of sources of irritation. Stimulants will sometimes be needed to prevent excessive exhaustion. Seclusion in a room darkened or not is useful in some conditions of excitement, and not seldom distressing symptoms are relieved by the simple presence of another person or by the absence of certain individuals.
Drugs of sufficient strength and in such quantity as to produce quiet or sleep should be used only when absolutely necessary, and then for as short a time as possible. Their prolonged use is open to many manifest objections in all persons, and particularly in those suffering from mental disorders, inasmuch as with them large doses, if any, are commonly given,and it is very difficult often, in the impaired state of mind of the patient, to get indications of symptoms which contraindicate the use of a particular drug or to learn when it is producing harmful effects. Tonics are often indicated, but should be used with discrimination, as some of them, especially those affecting the cerebral circulation, frequently produce disagreeable results.
After apparent recovery there should be a long period of after-treatment, which in most cases will be best met in rest or travel.
In the various forms of mental disease, through concentration of the mind on various delusions and by excess or deficiency in mental activity, the ordinary symptoms of physical disturbance or disease, independent of the insanity, are so much modified as to be often overlooked. It goes without saying that intercurrent diseases and distressing symptoms should be treated on the principles generally applicable to those conditions, so far as that can be done without aggravating the insanity. The usual treatment of pneumonia, for instance, may in an insane person provoke such determined opposition or so excite or aggravate delusions that, so far as the disease of the lungs is concerned, it may be better to let it take its chance, with good general care, including food, warmth, etc.
The conditions of cerebral hyperæmia require cold applications to the head, the wet pack, prolonged warm baths, a non-stimulating diet, and quiet. If the condition is acute and of short duration, rest in bed is useful, provided it can be secured without force. For prolonged mental excitement from cerebral hyperæmia it will be usually better to equalize the circulation by that motor activity which is characteristic of the disease, and to allow free exercise in the open air, keeping within the limits of exhaustion. My experience has not justified the use of bleeding, except, possibly, in acute delirium (mania peracuta). It is difficult to limit the action of blisters, and they often irritate the patient so much as to do more harm than good. Persistent refusal of food is usually due to delirium or delusions, and should be met with a resort to feeding with the stomach-tube before the point of exhaustion is reached if the tact of a skilled nurse fails of success. Mechanical restraint increases the cerebral hyperæmia, and there are few homes or general hospitals where it must not be used if there is excessive violence or delirium, making the insane asylum in those cases a necessity. Objectionable as it is, however, mechanical restraint is less harmful than the continued use of large doses of sedative drugs, as is so often the practice, in order to keep patients quiet enough to remain at home.
Ergot, hydrate of chloral, and opiates, which sometimes must be given by the rectum or stomach-tube, are sometimes advisable for a short time, but must be used with great caution. Milder sedatives, especially the bromides, serve a temporary use in the less violent cases; but less sleep will often serve if secured by quiet, abundant liquid food, and general measures, and in exhaustion by alcoholic stimulants.
Menorrhagia is very common in the maniacal states. It usually requires no special treatment, unless so great as to produce exhaustion. Amenorrhœa is commonly conservative, and then demands only general treatment; if it causes evident disturbance of the cerebral circulation, the ordinary methods, including electricity, massage, and local use of leeches, should be used.