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 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.
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, 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.