Insanity in The Middle States of America
939 Art. IV.? :Author: Edward C. Mann, M.D. Late Medical Superintendent State Emigrant Asylum, Ward’s Island, New York.
Insanity is, in the middle states, as in the other states, increasing disproportionately to the increase of population ; and it also seems to be appearing at an earlier age than formerly, which latter fact is probably due to hereditary influences, which have gradually become intensified by violation of physical laws in early life, want of proper training, or too high pressure in education. Next to hereditary predisposition, which is the first and great predisposing cause of insanity in the middle states, as elsewhere, comes the great mental activity and strain upon the nervous system that appertains to the present age and state of civilisation. This feverish haste and unrest which characterise us as a people, the undue predominance of the nervous temperament, and the want of proper recreation and sleep tend to a rapid decay of the nervous system and to insanity, as a necessary sequence. It is much to be deplored that intemperance is operating more and more, each succeeding year, as a formidable cause in the production of insanity. It is not too much to say that twenty-five per cent, of all cases of insanity admitted into the asylums of our middle states is due either proximately or remotely to intemperance, which has produced a permanently diseased state of the brain due to the interference in the nutrition, growth, and renovation of the brain tissue. The evil does not stop here; for the offspring of intemperate parents are growing up in our midst with weakened, if not actually diseased, nervous systems, and will inevitably, in time, become insane, diseased, or idiots. The relative increase in the proportion of the insane to the sane population is more favourable in the middle states than in some others. The census returns for 1870 of the United States show an increase of insanity of fifty-five per cent., while the increase of the general population has been only twenty-two per cent. The proportion of insane to sane population has increased from 1860, when it was shown that the entire popu- lation of the United States was 31,443,321, with an insane population of 23,999, or one insane person in every 1,310 of the whole population; up to 1875, inclusive, when, by bringing up the calculation at the same rate of increase for both , sane and insane population as obtained between 1860 and 1870, we find the former to be 42,115,896, and the latter or insane population 44,148, or one insane person in every 953 of the whole population of the United States. It may not be un- interesting to glance for a moment at the proportion of insane to sane population in other countries as compared with our own. In England there is one insane person to every 403 of the whole population, or more than double the proportionate number of the United States. In France there is an average of about one insane person to every 600 of the whole population. In Scotland there is one insane person to every 336 of the sane population, while in Ireland there is one insane person in every 302 of the population. In the United States, California ex- hibits the greatest proportion of insane to sane population, there being one in every 484. This is due to local causes.
Massachusetts shows the next greatest proportionate number of insane, while the New England States, as a whole, have a greater relative increase in the proportion of the insane to the sane population than is observable in either the middle, southern, or western states. In the care, the treatment, in finely appointed institutions, and in scientific investigations into the causes of insanity, the middle states hold a place of which they may be very justly proud.
NEW YORK.
In the year 1844, the state of New York erected the first Insane Asylum at Utica, which has accommodations for 600 patients. In 1867 the Willard Asylum for the chronic insane was erected at Ovid and provides accommodations for 1,100 patients. The state has three more institutions for the care and treatment of the insane : one at Poughkeepsie, one at Middletown, and one at Buffalo. These asylums will famish for the next few years ample and adequate provisions for the acute insane, while for the 1,300 or 1,500 of the chronic insane, now in county institutions, are needed asylums similar to the one in successful operation at Ovid. King’s county and New York county provide for their insane under special statutes. The former county provides for 800 or 1,000 insane and the latter for over 1,700. On Ward’s Island is situated the State Emigrant Insane Asylum, which provides for the insane emi- grants for the term of five years from the time of their landing in this country. This asylum furnishes accommodations for about 200 patients. The annual expense per patient in this institution is #150. The per capita cost of building, #1,138, and the total annual cost, #22,500. There are upward of 500 patients in private asylums; so that the insane population of New York state is probably not far from 7,000 or 8,000 at the present time. The census of June 30, 1870, enumerated 6,353 insane. The annual expense per patient at the State Asylum at Utica is $271. The per capita cost of building is estimated at $1,061, while the total annual cost of the asylum is $157,939. The state appropriates annually $15,000, and each county pays $5.42 per week for its own paupers. The annual expense per patient in the Willard Asylum is $174. The per capita cost of building, $942, while the total annual cost of the asylum is $181,542. Each county pays for its own paupers.
The annual expense per patient in the two New York county institutions is, in the New York City Asylum for the insane $92.89, and for the New York Lunatic Asylum on Blackwell’s Island $73.84. The annual expense per patient in the King’s County Lunatic Asylum, situated at Flatbush, L. I., is $120. The total annual cost for these three county institu- tions for the insane is as follows : New York City Asylum for the insane, Ward’s Island, $53,504; New York Lunatic Asylum, Blackwell’s Island, $89,420 ; King’s County Lunatic Asylum, Flatbush, $92,400. The annual expense for the Hudson River State Hospital for the insane at Poughkeepsie is $50,000 (ap- propriated by the state) and has capacity of 600 patients. It is built of brick and has* attached to it 333 acres of land. There are at present 207 patients occupying it. The Buffalo State Asylum for the insane is not yet completed. It is built of red sandstone and brick and has attached to it 200 acres of land. The State Asylum for insane criminals at Auburn, N. Y., was erected in 1859 at a cost of $125,000, and has 842 acres of land attached to it. The cost of subsequent additions has been $52,000, making the total cost of the present building $177,000. The per capita cost of the building is $1,222. The number of patients is 118, and the annual expense per patient is $208. The state appropriates annually $16,000 for this institution. The total annual cost of the institution is $24,544. The laws of New Icork relating to the commitment of the insane provide that no person shall be committed to, or confined as a patient in any asylum, public or private, except upon the certificate of two reputable physicians, under oath, after a personal examination ot the party alleged to be insane, setting forth the insanity of such person, said certificate to be approved by a judge or justice ot a court of record of the county or district in which the alleged lunatic resides. It would be very desirable that an addition to the laws of New York, and also to the laws relating to insanity in the other middle states, should be made, so as to guard, as far as possible, against the unfortu- nate results which are liable at any time to occur in the trials of the insane for homicide. It would seem very desirable, in order to secure society, to protect the legally and morally innocent, and to ensure the punishment of the legally and morally guilty, to have some improvement on the method now in use in criminal trials of the insane. There should be in each state a hoard of commissioners of lunacy, specially selected to investigate and testify in regard to these cases. Such a com- mission, appointed by the governor with the consent of the senate, and consisting of able and experienced alienists, could hardly fail to be of great benefit. They should visit the prisoner before his trial, or still better, the prisoner’s counsel if intending to advance the plea of insanity, should be re- quired to announce that fact to the district attorney, and the prisoner should then be committed to the state asylum for the investigation of his case. Being thus placed under the observa- tion of such a board of experts, they would be afforded a better opportunity for forming a correct judgment. They could then, it such was the case, announce that the prisoner was insane and unfit for trial, or in the event of a trial they could be called into court and give their evidence and professional opinion without being obliged to testify for either the prisoner or the district attorney. In this way perfect impartiality and fairness could be secured, and the jury would naturally attach great weight to such testimony and would be led to an unprejudiced and thoughtful view of the prisoner’s condition, which is of paramount importance in these cases. The jury would then with the aid of the commission of experts, decide whether the’ act in question was the offspring or product of mental disease ? whether he has sufficient mental power to control the sudden impulses of his disordered mind; whether or no there exists an inability to control mental action; whether the moral sense may not have been overborne by the superior force derived from disease, and other similar questions, the proper answers to which would do much to make the results of these trials more certain and satisfactory both to the legal and medical professions and to the general public.
NEW JERSEY.
The New Jersey State Lunatic Asylum at Trenton, N. J. was erected in 1848, and has attached to it 170 acres of land’ It has a capacity of 500 patients. The original cost of the building was ?100,000, and the cost of subsequent additions has been ?178,000, making a total cost of ?278,000. The per capita cost of building is estimated to be ?556. There are 710 patients, with an annual expense per patient of ?258, and a total annual cost of ?183,180. The state of New Jersey appro- priates annually $8,000 for the asylum. Five-sixths of the patients are paupers at $4.50 per week, paid by counties, while one-sixth are pay patients at $6 per week. Among the patients in this asylum are included the convict insane, numbering twenty- five, who have been transferred to the institution from the state prison, by virtue of the twelfth section of the act of the govern- ment and regulation of the state prison, approved March 26th, 1869. For this class separate provision is urgently needed, so that they can be separated from the other insane of the state. Of the 4,806 cases treated since the opening of the institution in 1848, 3,075 have been discharged improved or recovered, a state of affairs very creditable to the administration of the institution.
The new state asylum is situated at Morristown, N. J., and has been erected at a projected cost of $2,250,000, and is one of the finest institutions in this country, if not in the world. The site is admirably selected and covers about 400 acres of land, which cost $80,000. The asylum has a capacity of 800 patients. The per capita cost of building is estimated at $2,802. The waterworks cost $20,000, and the water supply is said to be four times enough to meet the ordinary wants of the institution. It is expected that the reception of patients will be accomplished very soon. The building has a frontage of 1,250 feet, and it is a mile and a quarter around it, outside of the foundation line. It is a four-storey, semi-gothic structure, built of Syenitic granite, quarried on the grounds. All the main materials for the building were also obtained on the ground?the stone, the clay for bricks, etc. Brick has been made at the rate of 80,000 per day, about 15,000,000 having been used in the construction. The law relating to the committal of the insane in New Jersey requires the certificate of one physician, under oath, setting forth the insanity of the patients, said certificate to be sworn to before, and approved by, a judge of the state and county where the person resides.
PENNSYLVANIA.
Pennsylvania has four state hospitals for the insane, each of which provides accommodations for 500 patients, and it is ex- pected that another will be erected in Philadelphia. There is also a Friend’s Hospital at Frankford, Pa. Previous to 1845, there was no provision for the pauper insane who were confined in county almshouses. Public sentiment has appreciated the necessity and the wisdom of providing for the pauper insane the best treatment possible. If I am not mistaken, the city of Philadelphia is entitled to the credit for making the first regular INSANITY IN THE MIDDLE STATES OF AMERICA. 237 provision for the insane ever made in America. In the year 1751, the Pennsylvania hospital at Philadelphia was incor- porated by the provincial assembly, for the purpose of providing for the indigent sick and for the care and cure of the insan<? The first patient ever placed for treatment for insanity in an American institution was admitted to that hospital on February 11, 1752. The second institution for the care of the insane established in the United States was the asylum at Williams- burg, Virginia, which was opened for the reception of patients in 1773. At the present day we have in operation, or nearly ready for occupancy, in the United States, seventy-six hospitals for the insane, which will accommodate 29,000 patients. Since the establishment in 1751 of the Pennsylvania hospital, with its sound declaration of principles, which even at that time recognised insanity as a physical disease capable of cure in 1805, when Dr Benjamin Rush delivered lectures on insanity with clinical instruction in his wards?and down to the present year, the one hundred and twenty-sixth since the hospital was founded, and which is at present presided over by one of the ablest and most distinguished of specialists in this department of medicine, Dr Thomas S. Kirkbride, Pennsylvania has main- tained a position in the application of state medicine to the treatment of insanity of which she may be justly proud. The law relating to the committal of the insane in Pennsyl- vania requires the certificate of the patient’s insanity from two physicians of acknowledged respectability who shall have ex- amined the patient within six days of its date, and this certifi- cate must be sworn to before some magistrate, or judicial officer in conformance with the law approved April 20, 1869. The’ annual expense of maintaining of patients in the three asylums at Harrisburg, Dixmont, and Danville is respectively $250, $251, and $234. The per capita cost of building was, for the asylum at Harrisburg, $750, and at Dixmont, $1,375. The total annual cost of the Harrisburg asylum is estimated at $104,000, of the Dixmont asylum $129,000, and of the Dan- ville asylum $57,000. There is a strong necessity for further accommodation for the insane of Pennsylvania, and it is to be hoped that another year will see that the bills which were reported for the appropriation of funds for the completion of the extension of the hospital at Danville, and for the new insane hospital at Warren, will become laws, thus providing for the insane now jn almshouses, jails, or in their own homes, with their restoration to health indefinitely postponed for lack of proper treatment. It has been very wisely determined, by the commission appointed by the legislature to inquire into the condition of the criminal insane, that a separate institution is needed for this class, and they have recommended that such an institution be erected in a central and easily accessible portion of Pennsylvania. It is estimated that this will costal 50,000, and that it will accommodate 100 patients. It is estimated that about one person in 3,986 of the population of Pennsylvania annually becomes insane. I he increase of the insane population of 18/3 over that of 1864 was 36*04 per cent., while the increase of the sane population for the same period was only 18*88 per cent. The census of the insane in Pennsylvania on June 30, 1870 was 3,895. It is estimated by the Board of Public Charities at Pennsylvania that, on June 30, 1873, there were 4,318, making an increase of 423. It is also estimated that, at the present rate of increase of insanity in Pennsylvania, there will be deve- loped in ten years from 1873, 10,419 cases of insanity, which, added to the number remaining insane in 1873 will make an aggregate of 14,737. Of this number it is estimated that 5,064 will be cured and 3,583 will die, leaving in June 1883 6 093 insane persons living under the present system of treatment. On the other hand, if, as will be shown in a subsequent part of this paper, the chronic insane were to be placed in asylums adapted to their needs, it would leave the hospitals free for the necessary care and treatment of recent and curable cases who are now deprived of the early treatment so essential to recovery.
DELAWAEE.
The insane in Delaware are scattered all over the state in almshouses, jails, etc., and many of them are provided for in the Pennsylvania hospital. Accurate statistics could not be obtained respecting the number in the state.
PEO VISION FOE THE CIIEONIC INSANE.
From a thorough and extended examination of the reports of our insane asylums?and these remarks cover not only the middle states but apply equally as well to all of the states it seems to be very evident that we are building large, expensive institutions, fitted up with all the appurtenances demanded by modern science for the treatment and cure of insanity, and that as soon as such institutions are opened for the reception of patients they become filled up with a class of cases, three- fourths of whom are chronic and hopelessly insane patients. It is no less evident that if proper provision is not made for this class of the insane, each state must build, every few years, a very expensive institution, for which every city and town must he heavily taxed. What are we going to do to relieve this rapidly increasing difficulty? If this class of the chronic insane are well taken care of, they are going to live in this hopelessly insane state?from which at the utmost not more than 10 per cent, will ever recover?for years, costing for their maintenance not less than $3.50 per week. It is a fact that every medical superintendent of an institution for the insane must have noticed that the presence of this incurable class of patients exercises a very depressing and unfavourable effect upon the minds of the recent and acute cases. If a patient perceives, upon admission, that the population is made up principally of patients who have been inmates for years, and for whom no hope of cure is entertained by the medical officers, and that few patients go out restored to health, the moral effect must neces- sarily be depressing and disastrous upon the mind of such a patient, and tend to retard his own recovery. At present, many large, fine institutions, instead of being?as they were originally intended to be?hospitals for the treatment and cure of the insane, are merely asylums and receptacles for the retention of patients at an enormous expenditure of money for architectural display. The overcrowding of such institutions by the reten- tion of the chronic insane precludes the possibility of proper classification or proper ventilation. By transferring this class of the chronic insane, and leaving the class of recent and curable insane, we derive many advantages. First and foremost, the patients understand that they are in a hospital, that they come to be cured of a physical disease, and that by submitting to the treatment and discipline of the institution, they will be cured. Secondly, we have at our disposal ample room for proper classi- fication, good ventilation, amusements, and recreation. The present system of asylum management is defective and expen- sive beyond the ability of the state to meet the demand, and tends directly to increase the number of the chronic insane, as ninety per cent, of the capacity of all of our state institutions is occupied by the chronic insane to the exclusion of recent and curable cases. This class of cases often become chronic and incurable cases before they can obtain the proper curative hos- pital treatment, which, if applied in time, would have resulted in a speedy cure and restoration to their families, and a saving of their productive power to the commonwealth. From an exami- nation of the statistics of the state insane asylums in the United States in 1875, it is seen that the total cost of 55 of these insti- tutions is not far from $29,879,258. This makes an average cost for each of these institutions of $543,259, and an average per capita cost of $1,074 for each of the asylums in our country. Now, I maintain that no state can afford to provide for the chronic insane at such a per capita cost of hospital construction, when they can be provided for at a per capita cost of construc- tion of $300, by providing for them plain, substantial buildings. It would be very easy and practicable to erect such buildings, accommodating 50 patients, each for $15,000 each, while no hospital accommodating the number that four such colleges or buildings would provide for could be built for less than $200,000.
For the chronic and harmless insane we do not need so many attendants or such costly accommodations, as for acute and recent cases. For the chronic insane we need plain but substantial buildings, which should, I think, be located on a large farm, so that the patients could all be employed out-of- doors. In this way these patients could be made producers and could be supported at comparatively little expense to the state, and at the same time they would have the benefit accruing from a good, plain, country style of living, with an abundance of fresh air, sunlight, and regular and systematic occupation. By such a course of treatment many would improve in general health and some would probably recover, who never would have been benefited if they had been confined in an asylum. Of the thousand patients admitted to the asylum for the chronic insane at Tewksbury, Mass., during the eight years of its exist- ence, about one hundred have recovered or improved from out- door work, and the experiment is regarded as a decided success. The expense has averaged, I believe, not far from $100 a year for each inmate, and it is stated by competent authority that the patients are as well cared for as they were previous to their admission. The establishment, in 1869, of the Butler Asylum for the chronic insane, in Rhode Island, was found to be a very successful experiment. It is a well managed institution, and the trustees say regarding it, that ” its result is to enlarge the capacity of the hospital for the treatment of recent cases of insanity, and thereby to increase its beneficial agency as a curative institution.” Quite a number of patients have re- covered through the agency of the out-door work, and it is stated that the patients are better cared for than before coming to this institution. The annual saving to the state of Ehode Island is stated to be over $12,000, while the amount saved annually to the state of Massachusetts, by the establishment of the Tewksbury Asylum, is stated to be $25,000 or over $200,000 since its establishment. The Willard Asylum for the chronic insane at Ovid, in New York, regarded by many as an experiment of doubtful expediency, to say the least, has proved, under the skilful management of its able medical super- intendent, Dr John B. Chapin, to be a highly successful measure. The trustees say in their last report, ” The idea heretofore promulgated that the chronic insane could not be so well cared for in a separate asylum, and that it was better to retain them in a hospital with recent and acute cases, has proved on trial here to be a fallacy.” That other institutions are beginning to appreciate the difficulties arising from treating the recent and chronic insane in the same institution will be seen from the following: In the last annual report of the medical superintendent of the lunatic asylum at Charlottetown, Prince Edward Island, 1 find these remarks :
” Of the sixty-four patients who remain in the asylum at present, nine-tenths are cases of chronic mania, from twenty- five years’ standing down, and of whose recovery, or even material improvement, no hope can be entertained.” No remedy, however, is suggested in this report for this state of affairs. I believe all will agree with me in thinking that the remaining one-tenth of the inmates, supposing them to be recent and curable cases, are to be sincerely pitied for their depressing surroundings. In the last annual report of the medical superintendent of the asylum at Prestwich in England, I find the following remarks: ” From the returns of the cJerks to the boards of guardians, it would appear that up to the end of last year there were 6,000 pauper lunatics in this county, while the increase for the past three years has been at the rate of nearly 200 per annum. To deal with this steadily increas- ing mass of lunacy is a problem which, as time goes on, becomes by its magnitude more and more difficult of solution. There can be no doubt that the only way of checking the growth of lunacy is by treating, in properly organised hospitals, the recent cases as they occur, and that cannot be effectively done until our presnt asylums are eased of some of the dead weight of chronic insanity which fills their wards and hampers their curative powers.” The great objection which has been urged by those opposed to the separation of the recent chronic insane has been, that the latter, in institutions designed for them alone, would be neglected and abused, and that they would not receive proper medical attention and care. The results thus far obtained have not confirmed these fears. I hold that under all circumstances such an institution should be presided over by a medical superintendent of equal ability and capacity to those at the head of hospitals for the recent insane, and that no attempt should be made to put such patients on a poor, meagre, or insufficient diet, and that they should never be neglected or abused. By having these asylums located on large farms, we secure to the patients, as I have previously remarked, occupation, fresh air and sunlight, and a good nourishing country style of living, and if there are any possi- bilities for recovery in any of the patients, such a plan of treatment will develop them.
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