Popular Science Monthly/Volume 43/October 1893/The Duty of the State to the Insane
By Dr. ANDREW MACFARLANE.
LUNACY legislation in the State of New York has been marked by two recent acts which are among the noblest monuments of the State's generosity, as well as witnesses of a scientific appreciation of the needs of the unfortunate class who are affected by them. These acts are:
1. The change in the titles of these State institutions from lunatic asylums to that of State hospitals.
2. The State care of the chronic insane.
The first is the natural outcome of modern ideas on the subject of insanity, which is now regarded not as a manifestation of the evil one, but as a disease of the brain, affecting it in the same way as pleurisy affects the pleura or peritonitis the peritoneum, and that those suffering from mental disease should be treated not as criminals or dangerous madmen but as very sick people.
The second is a grand philanthropic work, proving that the State cares for even the most unfortunate of her children, and seeks to soften as much as possible their sad lot.
The time is fortunately past when these measures required advocates, and to-day it is necessary to keep in view only what are the best means for carrying to a successful issue both of these measures, and to consider if in any way the one tends to render the other less successful.
The fact that it is thought the saddest affliction which can befall mankind, that it affects all grades of society, that three out of every thousand are its victims, makes the consideration of the care of the insane, from the purely scientific, the philanthropic, or the economic standpoint, a subject worthy of the most serious thought and of the deepest interest to all. To-day (May, 1893) there are in the State of New York 17,814 insane patients under legal certificates of commitment in thirty-two public or private asylums, whose buildings and equipments have cost $17,500,000, where 2,900 people are employed, and which are maintained at an annual cost of $3,500,000.
This huge creation is the work of less than fifty years, for in 1843 the Utica Asylum, the first State institution for the insane, was opened for the reception of patients. Bloomingdale Asylum, a private institution, had, however, been in successful operation for many years, and was then in receipt of an annual grant from the State, and the asylum on Blackwell's Island began in 1842 to care for the insane in New York city.
The erection of the Utica Asylum marked the first decided step in the humanitarian care of the insane by the State and the recognition of the obligation of the State to these unfortunates. It was designed that the Utica Asylum should receive all the recent cases of insanity. Those who, after a period of treatment, were deemed incurable were to be returned to the county houses, thus making room for all the recent cases. This condition lasted until 1865, when public opinion, shocked and horrified by the treatment in almshouses of the chronic insane, who then numbered 1,300, demanded that these, the most wretched of all God's creatures, should receive at least kindly care. The Willard Asylum was therefore established in 1865 for the care of the chronic insane, who were to be there maintained at the lowest rate conformable with a plain, simple diet and humane care. All the counties were required to send their chronic insane to the Willard Asylum except those which furnished suitable maintenance for them. Twenty counties, largely because of inadequacy of accommodations in State institutions, were accordingly temporarily exempted from the operation of this act. The State, however, continued to build State asylums: at Poughkeepsie in 1870; at Middletown in 1874; at Buffalo in 1880; at Binghamton, the State Inebriate Asylum, first used as a State asylum, in 1879; and the St. Lawrence Asylum in 1890.
The State asylum for insane criminals, formerly at Auburn, now at Matteawan, has not been considered in the following statistics, as the conditions there, on account of the character of the patients, are peculiar to itself and different from the other State hospitals.
The same general principle was carried into effect in their design—that is, the Utica, Poughkeepsie, Buffalo, and Middletown asylums were for the recent cases, while the chronic incurable cases were sent to the Willard and Binghamton asylums. The reason for this was the recognition of the difference in the requirements of these two classes of patients—the acute and the chronic insane. The acute insane are often dangerously sick, and should receive all the strictly medical care and attention which the character of their mental disease demands, the custodial supervision being here entirely secondary and kept as much as possible in the background. The chronic insane are incapable of living at home, and almost no hope of their recovery is entertained. These require custodial care, with incidental medical supervision. Their care is purely a question of sociology, of interest to the philanthropist rather than the physician. The supervising spirit, however, must always be medical, as only a scientifically trained mind can properly appreciate the influence of surroundings on their welfare, and can wisely and humanely classify them as their mental condition gradually changes. This difference, too, is most strikingly shown by the fact that the average weekly cost per patient in the acute asylums was $5.29, while in the Willard and Binghamton asylums for the chronic insane it was less than half that amount, or about $2.60. The ratio of physicians to patients in the acute asylums was 1 to 110, while in the chronic asylums it was 1 to 272. The recovery rate on average daily population was twenty per cent in the acute asylums, while in the chronic it was two per cent. The average recovery rate on admissions was about thirty-three per cent in acute asylums and about five per cent in chronic asylums.
In spite of the fact that the State had built many new asylums, the number of insane patients in the State increased more rapidly than the accommodations provided for them. The counties also found it more economical to abuse, under the guise of care, many of their own chronic insane. The result, therefore, was that the number of these unfortunates in county houses had in 1889 increased to 2,200. Their condition was most pitiable, and the recital of what they were subjected to carries one back to the barbarities practiced in the middle ages and by savage tribes. The Charities Aid Association, President Craig of the State Board of Charities, and Dr. Stephen Smith, then State Commissioner in Lunacy, kept for three years nobly at the work of making public this disgrace and blot on our civilization. Finally, in 1890, the present State care act, the consummation of their endeavors and those of the present commission in lunacy created in 1889, became a law. This State care act calls for the removal of all the insane patients from county houses to State hospitals and their care therein. New York and Kings (Brooklyn) Counties are exempted from this act, as they are considered to furnish suitable accommodations distinct from their poorhouses for their insane. The State has been divided into districts, and each hospital has its own district, from which it draws all the patients, both acute and chronic, thus making all the State hospitals of the same character—that is, mixed hospitals for the care of both the acute and chronic insane, instead of hospitals for the acute cases and asylums for the chronic incurable cases.
In order to furnish accommodations for this large increase to the State hospital population, it has been designed and is now being carried out to erect cheap buildings as annexes to the present State hospitals on the hospital grounds at a cost of 8550 per patient. These buildings are intended for the more easily managed chronic cases, and will enable the State to care for the 2,200 insane patients who were inmates of county houses before this act went into effect. Each hospital is allowed $4.25 per week for the first three years of residence of each patient, and $2.50 per week for any period beyond three years. It is also intended that one assistant physician should be assigned to every two hundred patients.
The thought now arises, What kind of medical care do insane patients require, and what has and will be the effect of this huge influx of chronic incurable insane upon the true object of a State hospital, the cure of the insane?
The demand for and the recognition of the need of a more distinctively medical care for the insane is shown by the change in the titles of institutions for the insane from asylums, a place of refuge, to hospital, a place of cure; a movement which is so general as not to be due to any local cause or influence, and also in the recent pleas of some prominent alienists that the acute insane should receive the same kind of medical care as patients suffering from any other acute ailment. The latter go so far as to advise the establishment of a hospital for the acute insane on the same lines as those of any general hospital, with its visiting staff and thorough attention to all physical disorders in addition to the mental disease.
To-day the solution of this question lies either in a general hospital for the acute insane or in the hospitalizing of the old asylum or part of it. A general hospital for the acute insane would not, I believe, be advisable, and could not be properly conducted except in the large centers of population where there are many specialists in insanity. The duration of the illness, the need at certain stages of the disease of diversion or occupation, because there comes a time when such influences are most powerful for good, the difficulty of determining at once whether the disease is curable or not, thus tending to overcrowd such an institution or necessitating frequent changes; all these would make impracticable such an institution. Then, too, the fact that in our present State hospitals most of the patients come from small cities or the country, where there are poor or no hospital facilities and certainly no specialists, would necessitate the erection of many special small hospitals in these places or the transference of these patients to large cities with all the attendant ill effects—noise, excitement, and close quarters.
But that acute cases of insanity, however, need some kind of hospital treatment is evident. No less an authority than Dr. J. Batty Tuke has thus written: "The subjects of most of the insanities are very sick people indeed, for, in the first place, they are in danger of their lives; and, in a second, they are in imminent danger of lapsing into that living death, terminal dementia. Each case, under circumstances of curative rest and calm, requires special hospital treatment, conducted on identically the same principles as those that regulate practice in our general infirmaries, and conducted under similar conditions as regards rest, nursing, and therapeutic agents. The existing system of asylum structure, management, and treatment makes this almost unattainable. No class of cases requires the attention of trained nurses more than subjects of recent insanity."
Can the present State hospitals provide such accommodations and give such care as Dr. Tuke claims the acute insane for their proper treatment need? I believe they can, and also that the accommodation and care there provided could be made far better than any that might be furnished in an institution established exclusively on the lines of a general hospital.
Unfortunately, Dr. Tuke's charge that "the existing system of asylum structure, management, and treatment makes the medical care of the insane almost unattainable," is alas too true. The erection of palatial buildings, which would be grand and magnificent monuments to an architect's skill, a State's pride, or a physician's ambition, has too often predominated over modest, simple structures, which could be rendered homelike and natural to the inmates. The fact is that though millions of dollars have been appropriated for the care of the insane, and thousands of capable men have spent their lives in this line of work, very little has been discovered in America about the real nature of insanity, and to-day the whole subject is a terra incognita whose shores have scarcely been touched, and which furnishes a number of the most difficult but yet the most intensely interesting problems to be solved. This condition is the result not of a want of ability or investigating spirit among asylum physicians, but is the natural outcome of a system which so handicaps them with extraneous duties as to render long-continued original medical work almost impossible.
A physician has under his care on the average more than two hundred patients, both acute and chronic. The desire to get as many of these as possible engaged in suitable occupation, the wish to make the unhappy lot of the chronic insane a little brighter by entertainments of various kinds, the routine historywriting, the correspondence, the attention to the visits of the friends of this large number of patients—all of which, needful and necessary in their way, make so many demands on the physician's time that medical work becomes necessarily secondary and the administrative duties the more important work.
Though legislative enactment has made all asylums hospitals in name, it has not accomplished this in fact. To-day the tendency of the State care act, though noble and generous in its inception, has been to make the hospital treatment of the curable insane almost impossible, or at least most difficult. It has crowded all the State hospitals with a mass of patients for whom nothing medically can be done, thus essentially interfering with proper classification. It compels the placing of recent, curable, maniacal, and suicidal cases with old chronic patients who are violent, destructive, and filled with all kinds of delusions of persecution and various hallucinations. These tend not only to strengthen the newcomers in their own morbid ideas, but to implant many new ones. Their influence on the terrified, depressed, and deluded is especially pernicious. It is not necessary to paint a word-picture of the sad effect of such surroundings on these sufferers. Every asylum physician has been deeply touched by the descriptions by recovered patients of the shock upon them on admission of their surroundings; the shouts of their neighbors, the indescribable fear of other patients, the frightful thought, "This will be my fate," the baneful remarks of mischievous patients present in every institution who, with show of sympathy, say to the hypersensitive newcomer, "Such a one has been detained here these many years, and doubtless you will be."
These are not argument-made examples, but exist in every State hospital. They not only influence temporarily the imagination, but often do irremediable damage to the mind. The Pennsylvania State Lunacy Report, in considering this subject, says: "The acute are often heard to allude with horror to the condition of the chronic patients, dwelling most painfully upon the imminent probability of soon becoming hopelessly lost to home, friends, and society, and of passing the remainder of their lives in similar seclusion. Like begets like, and as the population of any hospital for the insane is chiefly chronic, there being relatively only a limited number of acute cases scattered through the various wards, this evil association must rob society of many a useful and productive citizen by placing him in daily contact with those who mar his chances for recovery." These are the mental and moral effects of such intercourse.
The chronic insane by the mere force of numbers also influence too much the character of the management of a State hospital and turn it from its true work, the cure of the insane. They constitute more than nine tenths of the entire number of patients in every mixed asylum, and receive more attention and care than the character of their condition demands, thus depriving the curable insane, who are less than one tenth the number, of much of what the hopefulness and acuteness of their sickness needs and requires. In justice, it must be said that every asylum physician seeks to give the acute cases the larger part of his time, but the press of other matters, non-medical, so encroach upon his time that he usually finds that he has neglected, or at least has not done as much for them as he might have accomplished under other circumstances. What, then, are these other circumstances, and how can a State hospital take better care of acute cases than a general hospital?
Let us take, for example, a State hospital of one thousand patients. The staff would consist of a medical superintendent, five assistant physicians, and a woman physician. In a hospital of that capacity there would never be more than one hundred patients who would be considered curable, and the number would probably not exceed sixty. More than nine hundred patients would be hopelessly incurable, for the most part the wrecks of past disease, who practically need nothing but kindly custodial care with incidental medical treatment. Two, or at most three, physicians could easily do all that a humanitarian spirit might deem necessary for such a number of this class of patients. Three or four physicians would thus be left to devote themselves to the curable patients. Instead of constructing annexes for the harmless patients, let these be lodged and cared for in the huge barracks-like main buildings, the creation and legacy of a former generation. Then erect at suitable distances from the main building three or four houses for the treatment of the curable patients. These should be built simply and comfortably, so constructed as to do away with the huge institutional feeling and to give them a homelike appearance, and so furnished as to take away as much as possible all indications of confinement and restraint. They should contain no wards, but plainly furnished single rooms with sitting-rooms, thus permitting the utmost privacy, with the opportunity of intercourse when deemed beneficial.
Here the real medical work of the hospital should be done, and no labor should be spared which would in any way tend to the recovery of a patient or help to solve any of the unknown problems of insanity.
Electricity, massage, baths of all kinds, thorough examination of the blood and the various excretions, the use of the sphygmograph and ophthalmoscope, together with a very thorough physical examination would easily and most profitably keep employed the number of physicians assigned to the acute cases. For it is in this acute and presumably curable period that the case should have everything that medical skill and unremitting attention under the most favorable circumstances can confer. The disease must be arrested in this beginning stage if it be in our power to arrest it.
The nurses, too, should be especially selected for this service among the curable insane. Those who have, by work among the chronic insane, shown that they possess the aptitude and tact necessary to care intelligently for such patients could easily be selected for this special work. Then with these nurses could be placed several nurses who have had general hospital training and who would therefore be more apt to regard insane patients from the purely medical side. The number of nurses, too, should depend upon the need of each case; if necessary, a single nurse should be assigned to a patient, though this, probably, would rarely be required. The criterion, however, should be. What will be most helpful in a curative way to the patient? The nurses would thus feel the great importance of the work they were doing, because every case would be considered as a curable case, and there is no greater incentive to good work than the feeling that the work is of great value. By a slight increase in the wages in addition to the importance attached to the work, the very best nurses employed in the hospital could be secured for this work, and easily made most enthusiastic about it. The effect also upon the medical staff would be most beneficial. Any one who has seen the tendency to the undermining of the medical spirit in talented, brilliant, and ambitious physicians who have accepted State hospital positions, will appreciate the importance of anything that would increase the medical spirit in State hospitals.
In a discussion before the British Medico-Psychological Society on the subject How can the medical spirit best be kept up in asylums for the insane? the following means were most strongly dwelt upon:
1. Classification—that is, separation of the curable from the incurable asylum population.
Such purely medical treatment of the curable insane can be best carried out in annexes to the present State hospitals and under the same management. The State in each State hospital has a most valuable plant, with large, handsome grounds, conveniently situated to the section of country from which it receives its patients. They are in charge of well-equipped and competent medical officers who have given their lives to this work, and especially appreciate the needs of this class of patients. Then, too, there is the body of trained nurses from whom the special nurses could be selected. There are also in existence various industries and means of amusement, which, though hurtful in certain stages for some, might be and are used with great advantage in the
convalescing period when the acute insane are not so susceptible to morbid influences. But most important, because of the difficulty of determining at once in some cases the curability of the disease, is the possibility of keeping under observation doubtful cases until the character of their disease can be determined and they can be correctly classified. Transferences from the chronic to the acute buildings could also easily be made if any supposed chronic case should manifest signs of mental improvement.
The State has always recognized the principle that curable patients required more and better care and attention than the chronic cases. This was formerly shown by the greater sums per patient given to the hospitals for the acute insane. The same fact underlies the present allowance of $4.25 per week for the first three years of hospital residence, the presumably curable period, and $2.50 per week for the remaining time, when the patient would be regarded as chronic. This is an exceedingly poor, though probably under the circumstances the best, way to meet this problem, the difference in the character of the care required by the curable and the chronic patients. Only sixty per cent of the admissions are curable cases; the others can be diagnosed as incurable at the first meeting, and require only the simple care which chronic patients should receive. As the hospitals are now constituted, the acute cases are placed among the chronic, and of necessity can receive little more than the average care of the hospital. We have here a double injustice: first, greater sums are given for some patients (those whose recovery is hopeless from admission) than the character of care for their disease demands; second, many (those who are curable at admission) do not receive the extra care which their illness demands, and to which the increased sum ($4.25) entitles them. It practically means, therefore, that the increased sums received from the recent cases go to elevate the general standard of care of all the patients rather than to be expended exclusively on the acute cases for whom this increased amount is given. Thus the chronic cases get more care than it was designed that they should have, or than they really need, and the acute patients are deprived of the better care and attention which it was intended they should receive.
"The duty of the State is such provision as to accomplish the largest result in the restoration to health of curable cases, the element of expense being here a subordinate one, and for the remainder such comfortable provision as shall insure safety to the community and humane care to the sufferer."
The medical superintendent could determine on the admission of patients which were incurable and which gave hope of cure. The State should then appropriate such moderate sum per person for all incurable patients, whether of recent admission or of longstanding disease, as to enable these sufferers to receive kindly care and a few of the pleasures of life. For the curable cases in the hospital annexes no reasonable expense should be spared. This is true economy regarded either from the philanthropic, economic, or scientific point of view. The curable patients come entirely from the strong people who have earned their own livelihood, and have done their part in the world until, loaded down by ill-health, trouble, or care, they break down and go to a State hospital for treatment. The mental weaklings, the victims of the degeneracy of their ancestors, the last step before the extinction in them of the species—these, who have always been a burden on the community, are all to be found in the incurable class.
It has been estimated that the average duration of life of a chronic insane person is twelve years. This represents in money expended for care and in lost productiveness about five thousand dollars. The economic importance, therefore, of saving every patient possible from lapsing into chronic insanity becomes apparent. It is reasonable also to suppose that with such hospital care the duration of sickness in curable cases would be lessened, and that many would more quickly resume their former occupations.
The moral effect, too, upon the general public would be marvelous, and the strictly medical aspect of insanity would be appreciated by the lay mind. It is an accepted scientific fact that insanity, in curable cases, is curable directly in proportion to its early medical treatment away from home associations. The public, when the character of the hospital annex for recent cases and the importance of early treatment were understood, would not regard a State hospital as a place of living death, only to be resorted to when all other means fail, and often after all hope of recovery or possibility of accomplishing any curative measure is past.
The cost per patient in the hospital annex would not be more than is now expended in any good general hospital, and would not exceed nine or ten dollars per week for such patient. Such a method would not be any more expensive than the present system, and when the permanent effects are considered would give the best results and would also be a positive saving. The average weekly cost under the present conditions per patient is three dollars and a half, or $3,500 for a State hospital of one thousand patients. Under the separate plan of treatment, the curable patients, numbering not more that eighty, could be maintained at a weekly cost of ten dollars per patient, or $800; the nine hundred and twenty chronic incurable patients could be humanely and kindly cared for at three dollars per week for each person, or $2,760, thus making the total cost of treatment, under probably the best conditions, 83,500.
This mode of treatment of the insane, far from being Utopian, is at present in successful operation in Strasburg and Heidelberg, and is about to be carried into effect in some of the Scotch asylums. The most eminent alienists in Great Britain and America have strongly advocated it.
Lord Shaftesbury, before a select committee of the House of Commons in 1887, thus explained the intention of the promoters of the early lunacy laws: "The asylum was to be divided into two; there was to be the principal asylum, which was for the acute cases; and there was to be a chronic asylum alongside of it, which was for old, chronic, incurable cases. All the recent cases were to be sent to the principal asylum, which was to have a full medical staff, and everything which could be necessary for treatment and cure."
Dr. J. Wigglesworth, superintendent of an English asylum, in the discussion on The Future Provision for the Chronic Insane before the British Medico-Psychological Society, said: "A more important question than the care of the chronic insane was whether they could not make a more determined effort to do more for the cure of the recent cases. To do this they must hospitalize asylums more. They must have small buildings properly officered and equipped, to which all recent cases should first be sent. The increased knowledge thus obtained would without doubt in time bring about an increase of the recovery rate."
Dr. H. Hayes Newington, in his presidential address delivered at the annual meeting of the Medico-Psychological Society of Great Britain in 1890, advocated the hospital annex for curable cases within easy distance of the main building. He stated that, in a hospital of one thousand patients, not more than sixty on an average would need such treatment.
Dr. D. Hack Tuke, in discussing the above address, said: "There should be means of treating acute cases in a separate hospital block, one in the construction of which no reasonable expense should be spared; or there should be a hospital at some distance from the asylum, on the lines laid down by Dr. Newington."
Dr. E. B. Whitcomb, in his presidential address before the British Medico-Psychological Society in 1801, stated: "The hospital treatment of the acute insane would insure the separation of acute from chronic insanity, sustain and encourage the more rational treatment of insanity as a symptom of physical derangement; but above these a well-constituted hospital would be the means of promoting to a greater extent and in a more elaborate manner than at present exists a scientific and wider knowledge of the disease. Such a hospital should be administered on the most liberal principles, not as you see at the present time in a competing spirit as to the smallest cost, but having a due regard to frugality in its truest and most economical aspect—the cure of the insane."
Mr. William P. Letchworth, formerly President of the New York State Board of Charities, in a scholarly and careful résumé in his admirable work. The Insane in Foreign Countries, advocates thorough remedial measures in small hospitals, no matter how expensive, for the acute insane, as not only more humane, but in the end more economical.
Dr. Chapin, Superintendent of the Pennsylvania Hospital for the Insane, in his presidential address before the superintendents of institutions for the insane, said: "Every hospital should have a special organization for the medical treatment of its recent curable cases. Is it the better way to continue our recent cases in the wards of large hospitals in constant contact with hundreds of chronics? To this serious and important interrogatory I must enter an emphatic negative answer, and believe it is not too soon to sound a note of warning. The needs of the recent and acute cases may be best met by the erection in connection with our State asylums of small and well-appointed hospital wards for the strictly medical treatment of such cases."
The late Dr. Bancroft, Superintendent of the New Hampshire State Asylum, thus wrote on this subject: "I have little doubt that moderate-sized hospitals constituted and operated either independently or as annexes would return increased ratios of recovery while adding vastly to the comfort and happiness of patients during hospital residence. Such adjustment would diminish routine, secure the largest degree of personal freedom and indulgence, and guarantee to each individual the best remedial influences as well as protection from such as are both distasteful and detrimental."
Dr. Godding, in an address before the National Conference of Charities and Corrections, thus spoke on this question: "The provision, then, should include one building, or preferably one group of buildings, designed especially for the acute and curable cases. No detail in construction should be omitted, no liberality of arrangement curtailed, that may be held to in any way assist in the treatment and cure of these cases."
The last fifty years have witnessed a work of which we have reason to be proud: the evolution of the care and treatment of the insane out of the mist and darkness of superstition and ignorance, when the insane were chained, beaten, and burned, to the present kindly care which seeks to treat them as very sick people. The future, however, presents also a grand work to be accomplished: the elevation of this specialty to the highest scientific and philanthropic plane.
The duty of the State to the insane may, therefore, be summed up in—
1. The separate treatment of the curable and incurable insane under the same medical executive.