Lunacy in the Commonwealth of Massachusetts
287 Art. XII.? In our last number we gave a few particulars relative to Insanity in Massachusetts, gathered chiefly from an imperfect report of the State Board. Through the courtesy of Dr Allen, Commissioner in Lunacy to the Commonwealth of Massachusetts, we have been favoured with the official report of the Com- missioners of Lunacy for that State, which appeared at the beginning of this year. At the present time there are 3,077 persons of unsound mind residing in Massachusetts, out of a population of 1,630,598, whereas in 1870, the population then being 1,457,351, the number of lunatics registered was 2,662, showing a difference of 415 in four years; and it appears to us that this increase of lunacy in the State is not compatible with the increase of the population. Between the years 1850 and 1870 there was an increase of 982 in the number of the insane, or 58*4 per cent. With regard to the increase of insanity, the Commissioners make the following remarks:? INCREASE OF INSANITY. That there would be an increase of insanity, corresponding to that of population, has been generally admitted; but that it is actually increasing in a ratio greater than that, has been considered very doubtful. On this point, however, there has been a difference of opinion among those who might be considered very good judges. Last year a distinguished lecturer, in Boston, declared, in a public address, ” that insanity is on the increase among us; ” to which a well-known writer upon this subject replied, saying, ” This is mere assumption.” Says one of our leading superintendents, in his Report for 1873, ” If mental disorders are not increased in a ratio greater than the increase of population, a proposition that has not,been proved, and the truth of which is exceedingly doubtful,” etc. The superintendent of another hospital, in his report for the same year, after stating that the average admissions for the last four years into his institution had been over 400 each year, against 243 average admissions annually for the four previous years, remarks: ” As something of the same advance, for years, has been observed in the other two State hospitals, we can hardly avoid the conclusion that there is a decided increase of insanity in our midst, an increase out of proportion to the natural growth of population.” A careful inspection of the constantly increasing number of admissions, for years, into our lunatic hospitals, would surely convey the impression that there was a decided increase of insanity in our 288 LUNACY m MASSACHUSETTS. State; but then, so many of these admissions are for a second or third time, while others are mere transfers, such an inspection would not afford very positive evidence in the matter. The fact that, for years, all our provisions for the insane, notwithstanding great enlargements from time to time, have been and are still very crowded, would seem to indicate that there must be a decided increase of insanity. A brief sketch of these changes or increased accommodations may aid us in Obtaining a better knowledge of this increase. In 1818 the McLean Asylum was established, and in 1832 con- tained G4 inmates, at which time the State Hospital at Worcester was built, for 120 patients. This was as large a number as it was then supposed would need such accommodation. In 183G-37 two wings were added, to accommodate one hundred more ; and in 1842 two more wings were added, to provide for another hundred. In 1851 the Worcester Hospital had 450 patients; the McLean, 200 ; the Boston City Lunatic Hospital, 204; the receptacles at Ipswich and Cambridge had 115 insane; besides these, many were confined in jails and almshouses. On account of the crowded state of these institutions, the Legislature, in May 1851, passed an Act to establish another hospital, which was opened at Taunton in 1854, with over 300 admissions the first year. Such was the pressure on the institutions that, in 1855, provision was made for another lunatic hospital. This was opened at Northampton in 1858; and these two hospitals, built near the same time, with pro- vision for 600 new patients, seemed to meet the demand for nearly ten years. In I860 (and for several years) the three State Hospitals were so crowded that an asylum, connected with the State Almshouse at Tewksbury, was opened for the chronic insane. This, ultimately, made provision for 300. For some years the Taunton Hospital has been so crowded that two large wings have just been added, making provision in all for 500 or GOO patients. Worcester, on account of its crowded state, and the pressure of the city upon its premises, is erecting a new hospital to accommodate 500 or 600. Besides these changes, the State is erecting at Danvers a large new hospital, making provision for 500 or more patients. And when all these accommodations are complete, providing for some 800 or 1,000 new patients, they will at once be all occupied, and more room will soon be demanded. From the extended provision made from time to time for the insane, it would certainly seem as though there had been a very decided increase in numbers, above the ratio that might have been expected. It is not the exact increase in numbers which we here aim to discover, but the relative increase of insanity compared ivith that of population. A definite enquiry made at the proper sources in all the cities and towns in the Commonwealth, as was done by the Lunacy Commission of 1854, might give us a very correct knowledge of the present number and distribution of the insane, though it would throw but little light on its increase or its causes, as connected with the changes of population. The census affords the only feasible medium of enquiry in this direction. The censuses are taken at different periods, under similar directions, conditions, and methods, and must yield results each time of comparatively equal value, the defects of each period being much the same in amount and kind. The value of their LUXACY IN MASSACHUSETTS. 289 results consists not so mucli in absolute statements, as in enabling us to make comparisons as to the relation which the insane sustain at different periods to the changes in population. We cite the United States and State Census taken at five different periods?viz., 1850, 1855, 1860, 1865, and 1870. Included in this period there are two important phases?the late war, and foreign immigration?which call for special notice, not merely in their effect upon population, but in their relations to the insane. For the sake of convenience we present these tables together; and though taken by different agents, there are no marked discrepancies, but their results as a whole help to explain and confirm each other. The Commissioners state that tlie increase of insanity may arise from two sources:? First.?Looking at the foreign element, more especially the Irish, it may arise from the change in organisation and cha- racter, consequent upon migrating from the equable climate, outdoor exercise, pure air, and simple habits of life enjoyed in their native land. Here the not unfrequent disappointments, the different style of living, the increased habits of intemperance, working more indoors, living in tenements badly ventilated, etc., etc.?all these causes are peculiarly calculated to impair health, disturb the nervous system, and in many cases produce decided insanity. Moreover, this element in our population is largely increasing. Second.?A change from a vigorous, well-balanced organisa- tion to an undue predominance of the nervous temperament is gradually taking place in our New England people. The brain is being developed altogether too much at the expense of the body. The educational pressure on the young, to the neglect of physical exercise, the increasing artificial and unnatural habits of living, the great excitement and competition in business,? these and other causes are multiplying nervous diseases, especially of the brain, and disturbances of the mind, many of which must result in mental derangement. Then it must be borne in mind, that the evils resulting from the above-mentioned causes may be propagated by the laws of inheritance, in an aggravated and intensified form. The fact, that for twenty years there has been a decided increase of insanity in our State, disproportionate to the increase of population, is clearly demonstrated, we believe, by the tables and comparisons here presented; but neither time nor space will allow, at the present time, an enquiry in what particular classes this increased insanity has appeared, or what were the precise causes that produced it. Judging by the history of facts, and the various influences now in operation, we have reason to apprehend a still greater increase of insanity, unless 290 LUNACY IN MASSACHUSETTS. active measures are taken to arrest its progress by enlightening the public as to its causes. Some valuable remarks are made as to the difference between acute and chronic insanity. The causes are often complex and latent, and we are unable to determine when and how the disease originated, and consequently it is some- times a difficult thing to state whether we have an acute or chronic malady under our observation. The question naturally arises, at what period a disease may be considered to have passed from the acute to the chronic stage, and in no disease is this point more complicated than in insanity. When the disease has definitely settled into a chronic condition, it is almost hopeless to attempt a cure. Dr Alien says:?” If the proper treatment can be applied in its first attack or stage, it is estimated by some that, taking- all cases as they arise, from 70 to 80 per cent, can be cured, and others estimate the rate still higher; but if not treated at all, or attempted unsuccessfully, till the disease passes into a chronic state, it is found, as a general rule, that not more than 10 per cent, ever recover,” thus showing the great importance of treating the malady in the incubatory stage. This, we are sorry to say, in our own country is not always re- cognised ; the friends refusing to admit the real condition of the patient until the symptoms have become rapidly developed, and consequently, during the incubatory stage, no treatment has been adopted as a means of checking the rapid advances of the malady, and frequently the disease has assumed a chronic form before admission into an asylum. The chief recoveries occur in persons in whom the premonitory symptoms have been recognised, and active treatment immediately resorted to. One of the chief provisions required by the Lunacy Act in Massachusetts is that the Commissioners’ Report should give the various methods for treatment adopted in the State. This clause is an important one, and we regret there is no such provision in our own Act. We consider the remarks on treatment extremely valuable, and we here append them:? TREATMENT OF THE INSANE. The Act establishing this Commission enjoins upon it an enquiry into the treatment of the insane. This may be interpreted in different ways; it may refer to medical, sanitary, or personal treatment. In this enquiry it may not, perhaps, be out of place to notice briefly each of these topics. The administering of medicine constitutes a very important agency in the cure of the insane. By some the value o? this agency would be LUNACY IN MASSACHUSETTS. 291 estimated much higher than by others. In the establishment of hospitals the use of medicine has always assumed paramount im- portance. Formerly, medicine was deemed much more efficacious, and its use more essential, than of late years. It was regarded, in fact, as the chief agency in curing the insane; whereas of late, the moral, the sanitary and other outward agencies have assumed relatively greater importance. It is found that all those influences that appeal to the laws of the mind have a powerful tendency to the restoration of health. It is well known that there has been great improvement in the general practice of medicine as to the use of drugs, both in quality and quantity. It is to be presumed that all the most improved methods of compounding and administering medicine to the sick are to be found in our lunatic hospitals. But in examining the reports of these institutions,, and by enquiry of their superintendents, we find a great difference among them in the quantity of medicine used. In the item of ex- penditure for medicine in the various reports, it will be seen that for a series of years twice or three times as much medicine is purchased for the same number of patients by some institutions as by others. In one or two of the institutions this expenditure, as reported, is five or six times as large as in the others. It may be said, we are aware, that the item of expense is not a fair or correct criterion as to the wise ad- ministration of medicine, as the patients in the hospitals differ so widely. It is well known that, among the best physicians in private practice, a great difference exists in the quantity of medicine used. The same difference may exist in hospital practice. Here the medical attendants are sole judges, without interference on the part of patients or their friends. “Whether there is over medication, or a neglect in the efficient use of medicine in particular cases, are questions beyond the scope of our present enquiry. If medical skill and experience?if a wise discriminating use of drugs?if close attention to and watchfulness, of their effects?are required anywhere, it is surely in the medical treatment of insane persons. The highest skill, the best experience, and the greatest wisdom to be found in the profession should by all means here be brought into requisition. Connected with this topic the inquiry arises, Can a superintendent, with one or two assistants, treat properly four or five hundred sick people ? In private practice, a physician could not begin to do justice to a quarter part of this number. This constitutes a serious objection to large hospitals. In all these institutions, it is found that there must be one superintending mind; there must be in every department personal responsibility resting upon some one individual. If the superintendent is to act as steward,-?is to have charge of all the repairs, improvements, and finances of the institution,?is to have his mind charged with a multitude of other duties too numerous to mention, how can he properly examine, prescribe for, and carefully watch, from day to day, very many patients? It is true he may have good assistants, and there may be large numbers in our lunatic hospitals who really need no medical treatment; yet, with the cares, labours, and responsibilities put upon him, can he do justice to all such patients as are very sick, or in the first stages of the disease ? If there must be lack of attention or neglect of duty anywhere, it certainly should not be in the medical care of the insane. 292 LUNACY IN MASSACHUSETTS. Another agency in the treatment of the insane, in some respects more important than the use of drugs, certainly so to large numbers of them, is that of sanitary influences. Once the value and efficiency of these agencies were imperfectly understood; yet nowhere are they so important as in the case of the insane, Avhere great numbers, diseased both in body and mind, are brought into close CQntact. Good air, pure water, cleanliness, and proper exercise are here indispensable. Within a few years great improvements in these respects have been made in all our hospitals, but there is room for still more. Most serious defects, under these heads, might be pointed out in each of our institutions, in some more than others; but we cannot at the present time enter into detail. One single point should be mentioned. We found the lower halls at the Worcester Hospital, several in the older portions at Taunton and South Boston, badly ventilated ; but by the changes going on and in prospect, these evils, it is expected will be remedied. There is one other point, however, that calls for special notice?that is, the law of exercise, applicable to the mind as well as the body. As a curative agency for the insane, and a conservator of health, its value and importance cannot be overestimated. Much may be accomplished in this way within the walls of the institution, but more outside. Useful employment of various kinds may be found for a portion of the females within and about the establishment, while others should be made to seek exercise in verandahs and airing-courts, as well as in walks and rides. If the practice of gymnastics, with some of the more simple apparatus and appliances, could be employed by both sexes, it would conduce greatly to their physical and mental health. In the case of males, exercise can be provided to some extent within the institution, but far better and more wholesome without, in doing chores, in taking care of stock, in making repairs and improvements, in garden and farm work, &c. Though much has been effected in these directions, there is abundant room for further improvement. No kind of exercise is so wholesome as work in the garden or on the farm, and the more this can be extended the better. The introduction of some suitable mechanical work on a larger scale would, as it seems to us, prove an admirable addition to the remedial resources of such institu- tions. The utility or profit of the work would be a minor consideration, compared with its sanitary influence. Inasmuch as insanity is a disease affecting the mind, and inasmuch as all mental exercises have a powerful influence upon the physical system, it is found that, in order to treat insanity successfully, we must summon to our aid all those agencies that tend to produce a normal healthy action of the mind. Within ten or twenty years there has been great improvement in this respect. There is, among the insane, such an absorption or introversion of thought and feeling on themselves, such an overwhelming tendency for all their mental faculties to run in particular grooves or channels, accom- panied generally with great depression of spirits, that in order to break up this spell or incubus, and effect a change, there arises a necessity for resorting to those means, which serve to draw the mind away from itself and bring before it newscenes and objects. This is done in a great variety of ways, by amusements, such as billiards, games, plays, excursions, rides, LUNACY IN MASSACHUSETTS. 293 together with lectures, music, pictures, reading, religious exercises, etc. All these measures, when properly employed, have a powerful tendency to restore the mind to a normal and healthy action. They operate in harmony with the laws both of mind and body; and the most skilful and success- ful managers of the insane resort more and more to these agencies. It is found that the more constantly the minds of the insane can be occu- pied with agreeable and pleasant employments and associations, the greater are their chances of recovery. In no one way, nor in any de- partment for treating the insane, has so great improvement been made as in the use of these agencies. And the more correctly and thoroughly Ave understand the laws of mind as based upon the functions of the brain, both in a normal and abnormal state, the more successfully will they be applied to cure the derangements both of body and mind. But it is almost superfluous to say that, as in the past there has been con- stant improvement in the use and adjustment of such appliances and remedies, there is yet room for and hope of still greater. THE QUESTION OF PERSONAL TREATMENT possesses points of great interest. It is unnecessary to discuss the impor- tance of kind gentle treatment to persons in health ; but its influence upon the insane is so powerful that we cannot find language strong enough to express its value. The very nature of their disease makes them morbidly sensitive and generally suspicious. They are governed very much by first impressions and outside influences. While deprived of reason, or the use of those higher faculties designed for our guidance, they yield readily to the impulses of will, feeling, taste, fancy, etc., as affected by persons or circumstances around them. Now in this mor- bid, sensitive, uncontrolled state of mind, the manner, talk, gesture, or smile of those especially in charge of the insane has a powerful in- fluence. It may do more, in many cases, to break up and cure their derangement than it is possible lor medicine or any sanitary agency to do. Hence the importance that all having charge of the insane, whether physicians, attendants, or nurses, should at all times take special pains to treat them with great kindness and tenderness. No assistant or attendant should ever be employed, without he possesses qualifications particularly adapted to this business. To discharge successfully the duties here incumbent requires a peculiar combination of qualities. Among these may be mentioned an inexhaustible share of patience and goodnature, a cultivated, well-balanced mind, firm and decided, without harshness or severity, always cheerful and persevering. Considering the importance of this subject in hospital treatment, we believe persons should be trained expressly for this business, and should receive such compensation as will render the situations more permanent than they usually are. In this way far more good might be accomplished, and less complaint would be heard from patients or their friends. Lunatic hospitals have probably suffered in reputation more from this source than from any other. Perhaps under the head of ” Treatment of the Insane,” the question of ” Diet,” specified in the law creating this Commission, should receive 294 LUNACY IN MASSACHUSETTS. some notice. Much might be said on this subject; but to do it justice, one should visit the hospitals at meal-hours, and carefully examine into the kinds, qualities, quantity of food, manner of cooking, etc., and en - quire whether each inmate obtained sufficient food, or what was best adapted to his wants. All this would require far more time and labour than our prescribed limits allow. Each of the hospitals has a regular *l Diet Table,” which is followed, we are informed, with much uniformity. Those tables have been prepared with great care, and improved, from time to time, as experience and observation dictated. Each of these tables specifies meat always in some form at dinner, and about half the time at breakfast. A great variety of food is presented in these tables, not intended, of course, for every meal or day, but extending through the week. The general character of the diet would seem to be plain, nutri- tious, wholesome,and substantial, interspersed with pastry, dessert, condi- ments, fruit, milk, etc. The sick have a prescribed diet adapted to their wants. Judging by these tables, it would seem as though the inmates of these hospitals could have no just ground of complaint for the want of variety in their food; and it is generally understood that the cooking in all our large institutions is superintended by experienced persons. Whatever other complaints have been made against our lunatic hospitals, scarce any have come to our knowledge on the ground of insufficient or unwholesome food. It has been maintained that the insane, on account of the excited and disturbed state of the brain and nervous system, require more nutritious food than other people ; and from extended observation and enquiry, we are satisfied that the dependent class, particularly of the insane in our public institutions, fare better than they would do outside. RESTRAINT OF THE INSANE, FREEDOM ALLOWED, ETC. On no one point are people so sensitive as on that of personal liberty. The idea of being confined by bolts and bars shocks one’s sensibilities. The thought that liberty is to be taken from us?that the freedom, the control of our own persons must be surrendered to others?produces anything but agreeable or pleasant impressions. This is perfectly natural; it accords with our best instincts of self- respect and self-government. And in the case of the insane the effect of such a change may aggravate or increase the very derangement out of which grew this necessity, and also serve as a most grievous hindrance to the restoration of health and sanity. On account of this great change in surrendering up one’s personal rights to which the insane must submit, special pains should be taken, that this confine- ment and restraint should at first, and all through the treatment, be as light and inoffensive as possible ; and all the freedom compatible with safety to the patient and others should, at all times and on all occasions, be allowed. In respect to this matter of the personal liberty of the insane, great changes for the better have been made within a short period, both in Europe and our own country. The insane in our lunatic hospitals are obtaining every year more and more freedom by use of halls, yards, courts, and by outdoor exercises. But whenever there is danger or positive evidence that a patient will injure himself, LUNACY IN MASSACHUSETTS. 295 or others, lie must be confined in a room by himself, or in some way his limbs or person be restrained so as to prevent such injury. Both in the manner and frequency of employing this confinement or restraint, great care and discrimination should be exercised. Neither should such confinement or restraint be continued longer than is absolutely necessary. No pain or suffering should by this means be inflicted upon the body. Special care, too, should be taken that no injury occurs by this confinement to the health, and that it should interfere as little as possible with any of those agencies intended for the permanent recovery of the insane. In all our large lunatic hospitals cases are constantly occurring where seclusion or restraint is absolutely necessary,?some- times temporarily, and at others more permanently. In our visits to these institutions we have made careful enquiry on this point, and have been surprised that these cases of confinement or restraint were so few, and that it was applied with so little apparent injury to body or mind. By actual count, the number thus confined or restrained on our visits ranged between five and ten. To all the insane who can go outside of the walls of the institu- tion, freedom should be allowed as far as possible. Let them go, for work or pleasure, in small or large companies; let them ride or walk ; they should by all means be encouraged and urged to go. In these outside exercises let them be put upon their honour?upon their good behaviour. Should one occasionally escape, it does but little injury; whereas great numbers are essentially benefited, and, perhaps, cured for life. There are, however, two modes of using force or restraint which demand special notice. First.?In case an insane person is dis- obedient or disorderly, and requires correcting by the laying on of hands, this correction should always be performed without harshness or violence, or showing ill-temper. Many complaints have been made by patients against attendants in lunatic hospitals for rough and abusive treatment of their persons, and Ave apprehend that, in some instances, just grounds have existed for such complaints. Second.?The other mode of using force is in confining the insane, as a mode of correction or punishment for some misconduct, or for refusing to work, etc., in cells or rooms, sometimes dark, cold, and unwholesome, and keeping them in the meantime upon scanty fare. We question whether this mode of correcting the insane can be justified by any principles of justice, or by any advantages that may accrue from such a course. In fact, it is a violation of the laws of the State. Several cases, where parties refusing to work were confined, for a shorter or longer time, in cells, lately occurred in one institution: but as, upon expostulation, the procedure was immediately stopped, with the assurance that it should not be repeated, any further comment is deemed unnecessary. Our special attention is drawn to the evil resulting from allowing patients to be too frequently visited by their friends and relations. The physician has no motive in pro- hibiting their visits. He is perfectly aware of the great mischief so often following an injudicious visit made to a person suffering from acute insanity. If, however, the friends 296 LUNACY IN MASSACHUSETTS. are obstinate, and still insist on seeing the inmate, all responsi- bility will rest with them for any aggravation of the disease. We are told that several hundred cases of insanity in workhouses and private families, are really only fit for asylums. There are at the present time five Private Asylums in the State. The oldest of these was established thirty years ago; but with the yearly increase of insanity, more accommodation will soon have to be provided, the remainder of the lunatics being at present confined in hospitals. “We regret very much to find that, according to the present Lunacy Law, no provision is made for an official visitation of Private Asylums. Dr Allen makes various suggestions for the management and improvement of hospitals, and we congratulate him upon his earnest labours in the field of Psychology. Notwithstanding his having been deprived of the valuable services of his coad- jutor, W. Phillips, Esq., he has given us a most valuable Eeport.
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