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 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.
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 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 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.