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, {126} 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 Asylum[8] during
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.
[Footnote 8: _Forty-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 to {127} avoid 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 the _Curability 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 send {128} them 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.[9] Meynert 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.
[Footnote 9: _Boston 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 without {129} marked
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. His {130} surroundings 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 may {131} have 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 inheritance {132} of 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.