The first signs of insanity : their prevention and treatment

Front matter

LIBRARY

Walter E. Fernald State School

Waverley, Massachusetts

Preface

There are many excellent text-books on Insanity, but nearly all deal with the subject from the standpoint of the Asylum Superintendent, whose experience is chiefly with the advanced stages of the disease. This book has been written from a different point of view. It is the work of a physician who has made a special study of the signs and symptoms of the early phases of mental disorder, and their successful treatment. He contends that, although our asylums are model institutions, admirably conducted, and absolutely indispensable, yet, since nowadays we diagnose very mild and harmless cases, we require in addition to such institutions other facilities for treatment. In his opinion it is essential to the recovery of the patient that his treatment should not be delayed until he can be " certified " for an asylum, but should commence as soon as symptoms of mental disorder manifest themselves, and that such treatment must be individual, either in private care, or in an observation ward, or reception hospital.

The author's aim is to point out to all interested in the subject, whether medical practitioner, psychologist, sociologist, or general student, the fine distinctions between the normal and abnormal mind, rational and unsound thought, healthy and perverted feelings, and responsible and irresponsible conduct. For this purpose he has endeavoured to give — in Part I of the book — a description of the various mental powers which make up our mind and character, and showing their activity ; first of all under normal circumstances and secondly under the influence of disease. This description of normal and abnormal mental activity is so arranged as to

6 PREFACE

make the early manifestations of insanity easy to diagnose and therefore more accessible to treatment.

In Part II the author discusses the various causes of Insanity, including hereditary disposition, mental and moral causes, inebriety, toxines, etc. The problem of heredity, the drink problem, and the other questions involved in the causation of mental derangement are discussed from a common-sense point of view and from the author's own experience.

The author deals next — in Part III — with the prevention and treatment of mental infirmity and disease. He describes :

i. The precautionary methods that should be adopted by individuals in whose family there is a neurotic taint i and the methods of upbringing, of education, and of conduct in life that should be avoided where a man is handicapped by a bad heredity to unsoundness of mind or nervous disease.

2. The methods to be adopted by municipalities, whose

business it is to make provision for the ever-increasing mass of insane and feeble-minded.

3. He discusses the value of the various measures

which have been proposed for the improvement of the race, such as : restriction of marriage, sterilisation of the unfit, and the segregation of the incurable insane and feeble-minded in industrial colonies.

In Part IV the author gives a detailed description of the signs and symptoms of the various forms of insanity and weak-mindedness, which should prove of value to the medical practitioner and general student.

Lawyers will be interested in those forms of insanity in which there is a loss of control over the passions and conduct while the reasoning power as well as the judgment of what is right and wrong are preserved, rendering it difficult to distinguish between folly and iniquity, insanity and crime. The classification of the criminal tendencies of the insane (Chapter XXVII) should prove of practical value to them and to medical experts in determining whether a prisoner is insane and what is the particular variety of mental disorder from which he is suffering.

PREFACE 7

Since the subject is one likely to appeal not merely to medical men, but to a wide circle of readers, the author has endeavoured to express himself in popular language, and has avoided so far as possible such technical matters as are still subject to dispute amongst lunacy experts, his chief aim being to create a book of genuine practical utility.

As the work is one dealing with perhaps the most far-reaching and most dreaded of maladies to which mankind is heir, and the problem of providing for the weak-minded, insane, and otherwise degenerate is one which must seriously affect communities and the State, the author ventures to hope that the subject will receive due consideration by those who are in a position to influence public opinion. In view also of the evidence given before the Royal Commission on the Care and Control of the Feeble-minded, and the attempts which are to be made to obtain greater facilities for the treatment of incipient insanity, the time should be opportune for a book describing " The First Symptoms of Insanity — their Prevention and Treatment/ '

57, Wimpole Street, London, W April, 1912.

Introduction

It is difficult to get rid of antiquated notions on the subject of lunatics. The popular impression would seem to be that the insane are generally raving and desperate people, whose actions resemble those of beasts and whose language is that of Billingsgate ; that consequently they ought to be deprived of liberty and kept in specially built places of safety where they are protected from doing harm either to themselves or to others. This was the prevalent idea when asylums were first established, at a time when only the worst cases were admitted as insane. Even a century ago insane patients were still treated more like furious beasts than human beings. They were shown to the public on certain days of the week, like lions in a menagerie, at the charge of twopence. It was the custom for the ruffians of the town to jeer and mimic the demented inmates in order to excite them to rage. Refractory patients were heavily chained ; sometimes even those who were not violent were fastened like dogs to the wall. In another part of the house women were to be found locked in cells, naked and chained, lying on straw, with only one blanket for a covering. This, however, being the usual treatment at the time, did not strike horror to the public mind.

The treatment of the insane from a humanitarian point of view has advanced very much since those days. We do not now chain our lunatics to the floors, the walls, the tables, and the bedposts ; we do not keep them naked on straw, wallowing in their own filth ; or flog them periodically as a curative measure. Every kindness and consideration is shown to these unfortunate beings. Everything is done in asylums to render the lives of the inmates brighter and more pleasant. Fields and workshops afford facilities for work and wholesome recreation, and attendants are trained to a better understanding of their patients.

Yet in view of the fact that nowadays we recognise the earliest signs of insanity and have to treat these, as well as many borderland cases, it is surely a hardship that patients who are not in the least dangerous, and who are not likely to commit any folly, should have to be certified and imprisoned in an asylum. The Lunacy Law decrees — no matter how harmless and innocuous the form of insanity, how amenable to treatment in private care, or how mild the delusion, if any — that all persons of unsound mind shall be deprived of their liberty. Undoubtedly this is necessary in many cases, but in many others it retards, if it does not prevent, the recovery of the patient.

My experience of seeing patients in private practice and as out-patients, and in Continental Observation Clinics, has convinced me that there are a large number of cases which, with appropriate treatment, recover so rapidly that asylum residence becomes unnecessary. But if this period is neglected, and the case has reached a point where the patient must be certified, a much longer time is needed for recovery, and sometimes it is altogether too late to cure.

The intention of the law is of course to prevent patients from doing harm bodily, financially, or otherwise, to themselves or others, as well as to protect them from their own follies and the dishonesty of the unscrupulous. Hence all patients are put under the control of the Lunacy Commission. To secure this protection it is necessary under the present law to obtain a certificate of insanity, however slight the mental disorder of the patient, which certificate, unless the matter is urgent, must be signed by two doctors and confirmed by a Justice of the Peace, or Magistrate, who grants an order for the patient to be removed from his house, if necessary by force. He may then be put under lock and key in an asylum. The only exceptions are those patients who themselves desire to go into asylums as " voluntary boarders," and those patients whose relatives have the means to put them in " single '* care under the charge of some one directly responsible to the Commissioners of Lunacy.

In no other form of disease is " appropriate " treatment so tardily initiated and so difficult of attainment. Even the expert is hampered to an incredible extent. It is illegal to place any patient of unsound mind, even if he or she be under twenty-one years of age, under care and treatment for payment, direct or indirect, or even for residence only, unless the whole process of " certification " is gone through. The physician has to incur the responsibility that the patient, who in his judgment may be merely a borderland case and not certifiable, may be considered by the Lunacy Authorities to be insane ; in which case he would be prosecuted and have to pay, in addition to the costs of his defence, a considerable fine, even though he attended the patient gratuitously. True, prosecutions of physicians for not observing the Lunacy Laws are extremely rare. But this proves only that in the application of the laws there is less stringency than is in their wording, and that, provided the physician has acted " in good faith " and is of good repute, no public action will be taken.

If the relations of a rich man cannot procure treatment for him without certification, the case for the poor man is still worse. If a poor man breaks down, it is very difficult to procure treatment for him until he is bad enough to be sent to an asylum, though he may be wishful to place himself under care. He could not even be admitted to the County Asylum as a voluntary boarder. No hospital would take him because he had no organic disease, no asylum because he was not certifiable. Thus in the majority of instances the case is allowed to drift until overt acts of insanity appear. The Relieving Officer is then consulted, and the patient removed to the workhouse infirmary, where after a delay of a week or two the patient is certified, and subsequently transferred to the County Asylum. This procedure is unsatisfactory, and involves serious delay in employing effective treatment.

It is no exaggeration to say that in the great majority of cases the curable stages of insanity are not being treated, and that by the time asylum physicians see the patient, the disease has made such progress that the measures which could have been adopted in the early stages are of little avail.

" Certification " is an absolute and indispensable preliminary to treatment. Not that the certification itself is objectionable. It is the simplest and safest method of recording the medical opinion that the person is insane and a proper subject for detention and treatment. At the same time it must be remembered that it is very disastrous for a patient's future prospects to have it known that he has been certified and treated in an asylum. He is shunned, and perhaps feared by his friends, and possibly never again attains the status possessed before he was " certified/' Of course, the stigma to a great extent lies in the misfortune itself, and not in the red tape of the proceedings. Small wonder, then, that the public as well as many family physicians hesitate before they allow a patient to come under the ban of the Lunacy Laws and have him pronounced a " certified lunatic " ! To the expert this is merely playing with words, but it cannot be denied that to the general public it spells disgrace. It means loss of social and domestic rights, deprivation of all civil rights, separation from wife, family, and home, and if the patient does recover, he is for ever afterwards branded — " He was once a lunatic." It is the right which the certificate confers to remove a patient by force to an asylum who is still curable by other means that is objectionable to most people. If the patient is not bad enough for the asylum, the committal is apt to make him so. There may be resistance and a struggle at the time, or if transferred under a " ruse," the patient, on recognising where he has been placed, is apt to cause a scene, and become either violent or still more depressed, according to the nature of his mental trouble.

Imagine the misery of the patient who has any reason left when he finds he is a prisoner locked into a room by himself or, worse still, confined with other lunatics of all descriptions, generally more insane than himself. Let any one think what an asylum is, and what a sensitive person must feel at being imprisoned in it ! Let him realise also that many of its inhabitants have become insane simply because they are too sensitive. They cannot bear wrong and sorrow and disappointment, and resent what they believe to be an injustice. Imprisonment in an asylum is regarded by such patients as an additional wrong. They shrink from association with the mad people by whom they are surrounded. If perchance they lose the remembrance of old fears and anxieties, new and fresh ones soon accumulate in a place where they are so much dependent on others, and where discontent and despondency are the prevailing tones. There can be nothing more calculated to hinder their recovery than to limit the intercourse of the insane to those who are themselves insane, yet this is unavoidable in asylums, where the only rational persons with whom the patient regularly and freely associates are his attendants. Even the pleasures and exercises can only take place with numerous other fellows in misfortune, whose language and conduct would fill even less sensitive and timid people with alarm. The mere aggregation of so many distressed beings of different types under one roof is a disadvantage, as patients have to hear and share numberless griefs in addition to their own, and many painful delusions are suggested to them which might otherwise never have entered their own minds. The majority of new patients feel this acutely, and experience great difficulty in throwing off their mental troubles in consequence of the many depressing circumstances and incidents which surround them. The locked doors are a torture, and the scenes which are apt to occur when patients are forcibly fed exercise a bad influence on those who have never seen or imagined anything of the kind before. The monotony of existence, trying even to the staff, cannot fail to be something approaching absolute torture to those patients who have sufficient intelligence to note the passage of time. Even the sports and games in an asylum become wearisome to those who have nothing else to do. In the case of those unaccustomed to depend on books, the intelligence must also be starved when placed in circumstances where they can take little or no interest in the daily life around them, and their affections are killed by the unvarying, chilly, and even hostile influence of confinement.

The patients for whom lunatic asylums are particularly deleterious are those who display the milder forms of mental derangement, those who are capable of reasoning logically in regard to most of the circumstances presented to their minds, and are able to control themselves. Such persons feel very acutely the injustice and disgrace of incarceration. They know they are not dangerous to themselves or others, and the deprivation of their liberty they regard as cruel and uncalled for.

Moreover, there are a considerable number of persons who are certified as lunatics throughout the country who are simply suffering from temporary insanity, the result of, or associated with, some form of bodily disorder or toxic poisoning. Some of these people would have a much better chance of recovery in special wards of a general hospital than in a lunatic asylum.

I maintain that there are very many persons who are of unsound mind, but who have no right to be treated as lunatics, and I have no hesitation in stating that at the present day there are amongst those incarcerated in asylums a large number who could be well managed outside. I have proved this in numerous cases. I have, in many instances, been the means of obtaining the freedom from asylum supervision of those who, apparently, had there been no intervention, would have been there for their natural lives. I do not recollect one single case where the steps taken were not followed by good results.

It would be wrong, however, not to acknowledge that the British institutions for the insane are model institutions, well designed, perfectly governed, and admirably conducted. Nor will any one deny that there are cases — even in the early stages of insanity — where an asylum is useful, and others where it is indispensable. Just as we must have hospitals for the poorer classes, so we must have asylums for paupers, or for those living in wretched homes where they would be neither properly watched nor carefully fed ; but there are other cases for which the asylum is eminently unsuitable, and positively harmful. Circumstances may be such that some place where the lunatic can be kept in safety is absolutely requisite ; but it is not always necessary to confine him in an asylum, though it may be necessary to place him in such a situation as will secure his safety and, in all cases, where he will have careful nursing and skilled medical attendance.

Asylums we must have, and for some patients there is no better place ; but there are others for whom we require new institutions, more in the nature of hospitals, and extended powers for private treatment. (See Chapter XIV.)

I do not think I am wrong in saying that in view of the powers of the Lunacy Commission some medical practitioners have a wholesome dread of being in any way mixed up with the certification of an insane person or even of attending him privately. Another reason for this reluctance on the part of the family physician, and why insanity is neglected in the early stages, is that a good many medical practitioners feel that they are not sufficiently competent to treat an insane patient. The treatment of insanity requires an intimate knowledge of the structure and functions of the brain, of normal and abnormal mind and character, and special experience of the practical affairs of life ; but the subject has, up to a few years ago, not been included in the medical curriculum, so that the vast majority of the older practitioners have had no opportunity whatj ever of acquiring a systematic knowledge of it. And even now, though the study of insanity has been made compulsory to medical students, it occupies a comparatively insignificant position, so that a mere smattering of knowledge of the subject is all that can be acquired. Hence the first signs of insanity of ten fail to be recognised, not only by the public at large, but also by medical practitioners, or, if recognised, are under-estimated.

Another reason for the delay in treatment is that, unfortunately, the public believe that most specialists own private asylums, or are sleeping partners in such concerns, or are in some friendly relation to their proprietors. Hence there is a fear, though absolutely unjustified, that patients who consult these specialists may be sent too readily to their institutions when other measures may still be adopted. So great is this fear of being sent to an asylum as the result of consulting a lunacy specialist, that the public avoids a visit until compelled by dire necessity. It is only in the last resort, when all other means are exhausted and the mental breakdown is complete, that an alienist is consulted. This undesirable state of affairs will continue so long as consulting lunacyphysicians are allowed to have financial interests in private asylums, and until the public is made aware that the specialist has some definite treatment to propose besides certification and confinement within locked doors and barred windows.

What the insane require, notwithstanding their insanity, is association with healthy minds. And this is out of the question in an asylum. The patient, if not inclined to work or play, is left to indulge in his fixed ideas and delusions, which therefore tend to become more fixed than ever.

Whatever curative influence the asylum may possess, the one thing that could have saved the patient it cannot supply, and that is " individual ': treatment. For what personal attention can a patient receive in an asylum, even when there is a so-called hospital annexe, when a thousand or more patients have to be visited by the superintendent and two or three assistant medical officers. No one can deny that the majority of asylum physicians are able men, but I do not think it possible for any man, however clever and however eminent in his profession, to treat a thousand patients as he would wish to treat them.

The insane, like ordinary men, have their bodily ailments, and the treatment of these must take up a good deal of the physician's time. Further, in such vast concerns, the mere clerical work is very considerable, not to speak of the keeping of medical records and attention to correspondence. The medical superintendent is not only a doctor, but he is the head of a great establishment embracing gardens and a farm, as well as the staff and buildings of the asylum itself. Of course, " where there's a will, there's a way," and it is not true of all asylum medical officers that they have no time for scientific work because of their administration duties. Those who have achieved the most in the speciality have not always been those who have leisure, but the busy, the willing, and the determined. Although hindered often by imperfect structural arrangements, overcrowding, and inability to divide the patients into small enough groups, efforts have been made to classify them in accordance with various specific needs. In recent years more tangible provisions for classification may be seen in special buildings for the study of the new cases, and for the treatment of the more acute conditions, which have been added at many institutions, in special wards or buildings for general hospital purposes equipped for the treatment of those suffering from acute physical illnesses and surgical conditions, and in infirmaries for the feeble and bed-fast. For the better personal care and nursing of the patients, training-schools for nurses have been established. Still, the managing committee value the superintendent for the sake of his qualities as a manager, administrator, and organiser, and only secondarily as a skilled physician.

No wonder that the recovery rate of the present day in the most comfortable and luxurious palaces for the insane and under the most humane treatment is no greater than in the days when strait-jackets and rough treatment were freely used in badly furnished asylums. The surroundings, the comfort, and the care of the patient do affect his behaviour and modify his symptoms, but they have no effect on the disease itself. Mental disorders, once they have reached the acute stage, will run their course, and whether they end in recovery, or become chronic, or end in death, does not depend on any treatment in an asylum which a hospital or an efficiently organised private home could not supply just as well. On the other hand, for the majority of inmates, chronic and incurable cases that no treatment will ever improve, the palatial character of the building in which they are immured affords no delight, and the elaborate and expensive organisation is entirely thrown away.

The operation of the Lunacy Laws has made it necessary to herd lunatics together in special institutions where they can be more easily visited and accounted for by the authorities. The result of this is that there has grown up a body of men who are directly responsible to these authorities for the confinement and detention of the insane.

It is a feature of the Asylum Medical Service that men enter it early in life, and grow up subject to its conditions. Men, just qualified, are chosen as junior officers, and are gradually promoted, either in the same asylum or some other in which an opening may occur. No one is chosen as a senior officer, whatever his qualifications for the treatment of mental disease, unless he has had asylum experience. In other words, the future superintendent must not only have been put into the groove early in life, but he must have remained there. Dr. Conolly was the only physician, to my knowledge, who was ever chosen as superintendent without such experience, and it was he who abolished at Han well Asylum the employment of mechanical restraint, of fetters and shackles for the insane — an example which has been universally followed.

With the constantly increasing size of asylums it is no doubt essential that only such medical officers should be selected who have experience in the routine work of these large establishments, and it is entirely to their credit that of late years much valuable work has been done, especially in those asylums which are provided with laboratories. We have learned more about the structure and pathology of the brain during the last twenty or twenty-five years than in the hundred years that had gone before. Whatever may be said against the asylum system, it must be admitted that the conductors of them are disinterested and many of them brilliant men, and that they are the first to admit the advantages of early treatment of the insane. The only difference of opinion is that some desire an extension in the organisation of asylums to that effect, and others are in favour of special hospitals and observation wards.

As regards private asylums, one serious grievance is that their owners can refuse admission to the consultant who comes to see whether the patient is well enough to be removed to more favourable surroundings. If the visit does not suit the proprietor, he can respond that there is no occasion for such interference, or that the patient will probably get worse from the visit. Or else the proprietor may suggest the name of some friendly expert, if not the actual sleeping partner of the concern, in place of the doctor proposed by the patient's friends. Perhaps this is seldom done, but it can be done, and that it should be possible is against the public interest and the intention of the Lunacy Law. After all, the proprietors of private asylums are human beings, with the same defects as the rest of mankind, and a " licensed " house for mental cases is as much a mercenary speculation as an hotel or large boarding-house. That there is little or no scandal with reference to them shows that they are as a rule well conducted, and that no person is detained unjustly, yet even the suspicion of such an occurrence should be made impossible.

Of course, there are doctors and " doctors/' and the proprietors of private asylums may plead that they refuse admission only to " cranks " and men disliked by their own colleagues. All the same, it would be more satisfactory if it were made compulsory on asylum superintendents to admit any qualified physician selected by the trustee or relative of a patient to visit him and report as to his personal condition, and that of his surroundings and treatment.

But, it will be said, have we not Lunacy Commissioners to inspect these places and visit each patient ? Certainly ! And it is surprising the amount of work they do, and how efficiently they do it. We must remember, however, that half a dozen commissioners — in January this year increased to eighth — have to visit and report upon 133,000 lunatics in England and Wales in the course of a year, and that many of these have to be reported upon after personal inspection several times during the year. In 1845, when the Lunacy Commission was established, and its paid members were, as until recently, six in number, they had to visit only about 25,000 lunatics. It is a wonder the work is done so ably, and it speaks volumes for their indefatigable industry and solicitude. When one is personally acquainted with their work and has the highest esteem for every one individually, one is reluctant to say anything at all by way of criticism. But they themselves will acknowledge that some have only had legal training, and even those who are medical men have only been chosen for the post because of their asylum training, and that supervision of a hundred and thirty-three thousand insane, even if the number of Commissioners were increased by half, would be impossible if the insane were not gathered together in large herds, but were in private or family care.

The Commission was originally formed for the purpose of doing away with the possibility of illegal detention of persons who were not insane, and to prevent cruelty to persons so detained. But as regards public (county and borough) asylums, they only go once a year to see the general appearance of the patients and their relative contentment with their lot, and whether the place is clean and fairly decorated. Beyond that, there is no independent view, so that the individual patient cannot receive that attention which was originally intended, certainly not as much as if he was in private care.