STATE PROVISION FOR THE INSANE.1

STATE PROVISION FOR THE INSANE.¹

By C. H. Hughes, M.D.

We live in an age when every uttered sentiment of charity toward the insane is applauded to its remotest echo; an age in which the chains and locks and bars and dismal dungeon cells and flagellations and manifold tortures of the less humane and less enlightened past are justly abhorrent; an age which measures its magnificent philanthropy by munificent millions, bestowed without stint upon monumental mansions for the indwelling of the most pitiable and afflicted of the children of men, safe from the pitiless storms of adverse environment without which are so harshly violent to the morbidly sensitive and unstable insane mind; an age in which he who strikes a needless shackle from human form or heart, or removes a cause of human torture, psychical or physical, is regarded as a greater moral hero than he who, by storm or strategy of war taketh a resisting fortress; an age when the Chiarugis and Pinels, the Yorks and Tukes, of not remotely past history, and the Florence Nightingales and Dorothea Dixes of our own time, are enshrined in the hearts of a philanthropic world with greater than monumental memory.

Noble, Christlike sentiment of human charity! Let it be cherished and fostered still, toward the least of the children of affliction and misfortune, as man in his immortal aspirations moves nearer and nearer to the loving, charitable heart of God, imaging in his work the example of the divinely incarnate Master!

But let us always couple this exalted sentimentality with the stern logic of fact, and never misdirect or misapply it in any of our charitable work. Imperfect knowledge perverts the noblest sentiments; widened and perfected knowledge strengthens their power. A truly philanthropic sentiment is most potent for good in the power of knowledge, and may be made most powerful for evil through misconception of or inadequate comprehension of facts. As we grow in aspirations after the highest welfare of the insane, let us widen our knowledge of the real nature of insanity and the necessities for its amelioration, prevention, and cure.

It is a long time since Grotius wrote, "The study of the human mind is the noblest branch of medicine;" and we realize to-day that it is the noblest study of man, regardless of vocation. Aye! it is the imperative study of our generation and of those who are to follow us, if we would continue, as we wish to be, the conservators of the good and great, and promoters of advancing capability for great and good deeds in our humanity.

One known and acknowledged insane person to every five hundred sane persons, and among those are unreckoned numbers of unstably endowed and too mildly mannered lunatics to require public restraint, but none the less dangerous to the perpetuation of the mental stability of the race, is an appalling picture of fact for philanthropic conservators of the race to contemplate.

The insane temperament and its pathological twin brother, the neuropathic diathesis, roams at large unrestrained from without or that self-restraint which, bred of adequate self-knowledge, might come from within, and contaminates with neurotic and mental instability the innocent unborn, furnishing histogenic factors which the future will formulate in minds dethroned to become helpless wards of the state or family.

The insane temperament is more enduringly fatal to the welfare of humanity than the deadly comma bacillus which is supposed to convey the scourge of Asia to our shores. The latter comes at stated periods, and disappears after a season or two of devastation, in which the least fit to survive of our population, by reason of feeble organic resisting power, are destroyed; while resisting tolerance is established in the remainder. But this scourge is with us always, transmitting weakness unto coming generations.

It is the insanity in chronic form which escapes asylum care and custody except in its exacerbations; it is the insanity of organism which gives so much of the erratic and unstable to society, in its manifestations of mind and morals; it is the form of unstable mental organism which, like an unstrung instrument jangling out of tune and harsh, when touched in a manner to elicit in men of stable organisms only concord of sweet, harmonious sounds; it is the form of mental organism out of which, by slight exciting causes largely imaginary, the Guiteaus and Joan d'Arcs of history are made, the Hawisons and Passanantis and Freemans, and names innumerable, whose deeds of blood have stained the pages of history, and whose doings in our day contribute so largely to the awful calendar of crime which blackens and spreads with gore the pages of our public press.

We may cherish the sentiment that it were base cowardice to lay hand upon the lunatic save in kindness; and yet restrain him from himself and the community from him. We may couple his restraints with the largest liberty compatible with his welfare and ours; we may not always abolish the bolts and bars, indeed we cannot, either to his absolute personal liberty in asylums or to his entire moral freedom without their walls, yet we may keep them largely out of sight. Let him be manacled when he must and only when he must, and then only with silken cords bound by affectionate hands, and not by chains. We may not open all the doors, indeed we cannot, but we can and do, thanks to the humanitarian spirit of the age in which we live, open many of them and so shut them, when it must need be done, that they close for his welfare and ours only; that he may not feel that hope is gone or humanity barred out with the shutting of the door that separates him from the world.

We may not always swing the door of the lunatic as facilely outward as inward—the nature of his malady will not always admit of this—but we should do it whenever we can, and never, when we must, should we close it harshly. And while we must needs narrow his liberty among ourselves, we should enlarge it in the community to which his affliction assigns him, to the fullest extent permissible by the nature of his malady.

Liberty need not necessarily be denied him; and to the glory of our age it is not in the majority of American asylums for the insane, because the conditions under which he may safely enjoy liberty, to his own and the community's welfare, are changed by disease. The free sunlight and the fresh air belong as much to him in his changed mental estate as to you or me, and more, because his affliction needs their invigorating power, and the man who would chain, in this enlightened age, an insane man in a dungeon, because he is diseased and troublesome or dangerous, would be unworthy the name of human. Effective restraint may be employed without the use of either iron manacles or dismal light and air excluding dungeons.

The insane man is one of our comrades who has fallen mentally maimed in the battle of life. It may be our turn next to follow him to the rear; but because we must carry him from the battlefield, where he may have fought even more valiantly than ourselves, we need not forget or neglect him. The duty is all the more imperative that we care for him, and in such a manner that he may, if possible, be restored. Simple sequestration of the insane man is an outrage upon him and upon our humanity. "Whatsoever ye would that men should do unto you, do ye even so to them," is the divine precept, which, if we follow it as we ought, will lead us to search for our fallen comrades in the alms-houses and penal institutions and reformatories, and sometimes in the outhouses or cellars of private homes, to our shame, where errors of judgment or cruelty have placed them, and to transfer them to places of larger liberty and hopes of happiness and recovery. The chronic insane are entitled to our care, not to our neglect, and to all the comforts they earned while battling with us, when in their best mental estate, for their common welfare and ours.

Almshouses and neglected outhouses are not proper places for them. They are entitled to our protection and to be so cared for, if we cannot cure them, as that they may not do those things, to their own harm or the harm of the race, which they would not do if they were sound in mind. Society must be protected against the spread of hereditary insanity, hence such kindly surveillance, coupled with the largest possible liberty, should be exercised over them as will save posterity, so far as practicable, from the entailment of a heritage more fatal than cancer or consumption.

The insane man is a changed man, and his life is more or less delusional. In view of this fact, we should endeavor always to so surround him that his environments may not augment the morbid change in him and intensify his perverted, delusioned character.

Realizing the fact that mind in insanity is rather perverted than lost, we should so deport ourselves toward the victims of this disease as in no wise to intensify or augment the malady, but always, if possible, so as to ameliorate or remove it.

Realizing that the insane man in his best estate may have walked the earth a king, and in this free country of ours have been an honored sovereign weighted with the welfare of his people, and contributing of his substance toward our charities, we should, with unstinting hand, cater to his comfort when this affliction comes upon him.

We should give him a home worthy of our own sovereign selves, and such as would suit us were we providing for ourselves, with the knowledge we have of the needs of this affliction, pending its approach to us.

That his home should be as unirritating and restful to him as possible it should be unprison-like always, and only be an imprisonment when the violent phases of his malady imperatively demand restraint. An hour of maniacal excitement does not justify a month of chains. Mechanical restraint is a remedy of easy resort, but the fettered man frets away strength essential to his recovery. Outside of asylums direct restraint is often a stern necessity. It is sometimes so in them, but in many of them and outside of all of them it may be greatly diminished, and asylums may be so constructed as to make the reduction of direct restraint practicable to the smallest minimum. Direct mechanical restraint for the insane, save to avert an act of violence not otherwise preventable, is never justifiable. The hand should never be manacled if the head can be so influenced as to stay it, and we should try to stay the hand through steadying the head.

Every place for these unfortunates should provide for them ample room and congenial employment, whether profitable to the State or not, and the labor should be induced, not enforced, and always timed and suited to their malady. A variety of interesting occupations tends to divert from delusional introspection.

Most institutions attempt to give their patients some occupation, but State policy should be liberal in this direction.

Deductions are obvious: Every insane community of mixed recent and long standing cases, or of chronic cases exclusively, should be a home, and not a mere place of detention. It should be as unprison-like and attractive as any residence for the non-criminal. It should have for any considerable number of insane persons at least a section (640 acres) of ground. It should be in the country, of course, but accessible to the supplies of a large city. It should have a central main building, as architecturally beautiful and substantial as the State may choose to make it, provided with places of security for such as require them in times of excitement, with a chapel, amusement hall, and hospital in easy covered reach of the feeble and decrepit, and accessible, without risk to health, in bad weather.

Outhouses should be built with rooms attached, and set apart from the residence of trustworthy patients, for farmer, gardener, dairyman, herdsman, shepherd, and engineer, that those who desired to be employed with them, and might safely be intrusted, and were physically able, could have opportunity of work.

Cottages should be scattered about the ground for the use and benefit of such as might enjoy a segregate life, which could be used for isolation in case of epidemic visitation. Recreation, games, drives, and walks should be liberally provided.

A perfect, but not direct and offensive, surveillance should be exercised over all the patients, with a view to securing them the largest possible liberty compatible with the singular nature of their malady.

In short, the hospital home for the chronic insane, or when acute and chronic insane are domiciled together, should be a colonial home, with the living arrangements as nearly those which would be most congenial to a large body of sane people as the condition of the insane, changed by disease, will allow.

It is as obvious as that experience demonstrates it, that the reigning head or heads of such a community should be medical, and not that medical mediocrity either which covets and accepts political preferment without medical qualifications.

The largest personal liberty to the chronic insane may be best secured to them by provision for the sexes in widely separated establishments.

It is plain that the whole duty of man is not discharged toward his fallen insane brother when he has accomplished his sequestration from society at large, or fed and housed him well. The study of the needs of the insane and of the duty of the State in regard to them is as important and imperative a study as any subject of political economy.