[Footnote 1: Remarks following "Definition of Insanity,"
published in the October number of _The Alienist and
Neurologist_, and read before the Association of Charities and
Corrections at St. Louis, Oct. 15, 1884.]
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.
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