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 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 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.
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. Mould10 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 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.
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.