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.
Mould[10] has 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 the {133} associated 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.
[Footnote 10: _Presidential 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 is
{134} plotting 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.[11] The 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.
[Footnote 11: An abstract of the various laws may be found in the
appendix to the American edition of Clouston's _Clinical 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,
{135} 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, {136} 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.
{137} Galvanism is sometimes useful, applied to the head, in cases of
mental torpor and stupor. That and the faradic current, used with
great care, act as powerful tonics to the general nervous and muscular
system.
Insomnia is often the chief manifestation of the insane taint, in
which case drugs are, for the most part, worse than useless. In all
forms of sleeplessness it is better to try malt, cod-liver oil, beer,
food, massage, baths, exercise, rest, etc. before resorting to
narcotics and sedatives. Camphor, hyoscyamus, cannabis indica, the
valerianates, bromides, codeia are much less objectionable than
chloral, morphine, and opium.
Where masturbation is simply an evidence of loss of self-control, it
is met best by constant watching, and gradually, as the mental state
improves, arranging the daily life so as to develop the feeling of
self-respect. Where it depends upon local paræsthesia, opium and
camphor and cold bathing are indicated.
Constipation is a troublesome symptom, especially in the states of
mental depression. When a full, laxative diet, cod-liver oil, and malt
do not correct it, small doses of laxatives given frequently act
better than the occasional use of purgatives.
There is a class of cases which are best treated by educating the
patients as one would educate a child.
In the general care of the insane it is the duty of the state to see
that they have all the rights of the citizen which are consistent with
their proper and safe treatment, including the benefits of property
and estate. There certainly should be in all countries, as in England,
officers whose duty it is to see that this is done. For a large number
of people with defective or diseased brains, who are now allowed to
wander about committing crimes and serving repeated sentences in
reformatories, houses of correction, and prisons, an enlightened
public policy would find the best, and in the end the cheapest,
treatment to consist in keeping them under supervision and control as
unsound members of society.
The more particular treatment of the insane differs in the various
mental diseases, varying as it necessarily must according to different
conditions. Its prevention is not an easy problem. Many of the
external causes of insanity seem inevitable in our complex
civilization: it would be impossible to widely regulate marriages,
even if we knew how; those people predisposed to insanity are usually
too self-confident and self-willed to receive advice; and moderation
in all things, healthful occupation, temperate habits, good digestion,
and, above all, out-of-door life, seem as much like a sarcasm if
suggested to many of the toilers as a waste of words if recommended to
the idle and luxurious, while the parents who have transmitted to
their children unstable or diseased brains generally impair what
chances they have in life by vicious training.
Where syphilis, drunkenness, and other marked sources of mental
degeneration do not obtain, simple food, plenty of sleep, avoidance of
extremes of heat and cold, plain dressing, baths, good digestion,
out-of-door life, fresh air, careful attention to slight disorders or
injuries of the brain and nervous system, guidance against too much
study and too much excitement or dissipation, development of character
and moral force, intellectual and physical training, avoidance of too
much emotional, sentimental, or even artistic culture, careful
watchfulness during the period of adolescence, occupation without
overwork, healthful recreation, a {138} contented or philosophical
mind, and suitable marriages, would produce the strong wills and
healthy organisms needed to combat the tendencies of modern life. Such
a course would undoubtedly make many a child with an hereditary
predisposition to insanity become a healthy parent of children in whom
the same treatment would soon eliminate the family taint. The
character should be strengthened to learn to overcome difficulties
rather than evade them. There are cases in which such a course can be
adopted, and where the physician's advice may be of untold benefit to
generations.
There are many crises in life when the mind totters and seems ready to
fall, which the physician is more likely to recognize than any other
person. Sometimes the odds are too heavy to fight against, but often
there is a transient mental disturbance in such critical cases, or an
incipient insanity, according as the indications are met with wisdom
and patience or with neglect, indifference, and lack of judgment. The
treatment called for is of the person rather than of the mental state,
and in all forms of mental disease success in treatment depends very
materially upon the personality of the physician, who must adapt
himself also to the personality of the patient.
In about one-fourth of the cases of insanity there is no hereditary
predisposition to the disease, and its prevention can be most
hopefully looked for in attention to the general laws of health, the
observance of which tends to secure immunity from all diseases. In the
remaining cases—three times as many, in round numbers—the most hopeful
course is in abstaining from marriage altogether or in the avoidance
of unwise marriages; and it is an encouraging fact that many people in
the community now take that conscientious view of the matter, although
if they decide what to do without competent advice they are liable to
err in the opposite direction of exaggerating their morbid tendencies,
and so increasing their unhealthy predisposition. There are certain
groups of physical and mental manifestations which the experienced
physician recognizes as signs of tendencies which only await favorable
conditions—a sufficient exciting cause—in the indulgence in drink or
other excesses, in the exclusive search for wealth or fame, in the
absence of healthy occupation, in mental wear and worry, in
over-excitement, in the various conditions of ill-health, to develop
into actual insanity. This physiognomy of temperament suggests to the
observant physician a warning against excess of all kinds, and a
recommendation for that course in life which promises the greatest
likelihood of preserving a quiet mind and a healthy body and of
securing a rational employment. Too much work is less dangerous to
most people than too little.
States of Mental Defect and Degeneration.[12]
[Footnote 12: Compare Moreau's _La Psychologie morbide_ and Morel's
_Traité des Dégénérences physiques, intellectuelles, et morales de
l'Éspèce humaine_.]
MICROCEPHALISM, CRETINISM, INTELLECTUAL IDIOCY, MORAL IDIOCY,
INTELLECTUAL IMBECILITY, MORAL IMBECILITY (under which Westphal,
Spitzka, and others place moral insanity) are really names for
different degrees of similar defects, for the most part hereditary and
{139} congenital or resulting from disease or injury in infancy and
early childhood, as distinguished from dementia, which is the result
of later destructive mental or brain diseases. Idiots and the demented
insane are sometimes so alike in their mental condition that, if young
persons, they can be definitely distinguished one from the other only
by a knowledge of the previous history of the case. Idiocy has its
origin at or before birth or soon after, and terminal dementia seldom
before puberty, commonly after maturity. In the United States census,
where there is a doubt in the matter, the individual is classed as an
idiot if the mental disorder occurred before the age of twelve in
girls and fourteen in boys, and as insane (demented) if above that
age.
The microcephalic brain may be as small as one-fifth the normal size,
due chiefly to intra-uterine conditions for the most part unknown. Of
course that means complete idiocy. The brains of other idiots differ
in size and development. The mental condition in all is similar.
Idiocy with the small or large or asymmetrical brain is classified,
practically rather than scientifically, by Shuttleworth, as follows:
_A_. Congenital or Developmental[13] Cases.—1, Microcephalic, with
small heads: forehead and occiput defective; 2, hydrocephalic; 3,
plagiocephalic, with distorted heads: features in an oblique plane; 4,
scaphocephalic, with keel-like distortion of forehead; 5, scrofulous
cases; 6, Mongol type; 7, cretinoid cases, with stunted bodies:
irregularly expanded heads and enlarged thyroid glands; 8, syphilitic
cases; 9, primary neurotic, with body well developed: signs of
irregular nervous action; 10, sensorial idiocy, with two or more
senses deficient (_e.g._ sight and hearing); 11, mixed cases.
[Footnote 13: Developmental conveniently includes those cases which,
though of intra-uterine origin, become more pronounced as physical
development proceeds.]
_B_. Non-Congenital, Acquired, or Accidental.—1, Traumatic; 2,
post-febrile; 3, hydrocephalic; 4, hypertrophic, with large
square-built heads; 5, eclampsic; 6, epileptic; 7, paralytic; 8,
idiocy by deprivation: loss of two or more senses in infancy (_e.g._
sight and hearing); 9, emotional idiocy, with no bodily deformity:
shrinking, scared expression; 10, toxic idiocy, with no bodily
deformity: malnutrition.[14]
[Footnote 14: “The Physical Features of Idiocy,” _Liverpool
Medico-Chirurgical Journal_, July, 1883.]