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THE PRESIDENT: I see present a gentleman who has had not only a cursory acquaintance with English and Scotch hospitals for the insane, but who has lived in those countries and knows about the management from their own point of view. He is now connected with one of our largest hospitals. I call on Dr. Goldsmith, Superintendent of the Danvers State Lunatic Hospital.
DR. GOLDSMITH: The care of the insane in different countries, as Great Britain and this country, differs chiefly in matters of detail, concerning which it is difficult for me to speak intelligibly here. I may say, however, that it is my belief that equally faithful, zealous and wise men have worked at the problem in each country, and that the resulting systems are somewhat different is, in my opinion, largely due to the fact that the conditions under which they have worked have been different.
The general condition of our civil service here has exercised a very injurious influence on the treatment of the insane. In many of our western States I am well informed that party politics now exercise such a direct and decided influence on the appointment of officers and managers as to render a continuous good administration impossible, and everywhere there is a feeling of insecurity of reputation, if not position, which prompts asylum superintendents to feel more anxiety about the popular repute of their hospitals than about the quality of professional work accomplished. They know that the only official criticism to which they are subjected is nonexpert and often injudicious, and they fear that the quiet performance of duty may not prove a security against ignorant or malicious attack, and the temptation always exists, whether yielded to or not, to ward off popular criticism and attract popular admiration in ways that make the judicious grieve. I mention this as a point of difference because the same cause of anxiety hardly has an existence in Great Britain. Partly for this reason I think expert governmental inspection very desirable. It would substitute, if the inspectors were properly selected, intelligent official criticism. for unintelligent, and should prove a safeguard to those who do good work and a discloser of quackery. It would also render safe a variety of provision for the insane which I consider desirable, and which is entirely unsafe without it; as without it there is no sufficient security for the proper treatment of insane persons under private care, unless the capital involved is sufficient to secure the services of an educated physician who has social and professional standing at stake; and the home or private house treatment, which is, in my opinion, best for quite a large number of properly selected cases, is liable to very grave abuses. In the asylum treatment of the two countries there are three points of decided difference. Mechanical restraint is used hardly at all in Great Britain; a larger proportion of patients are employed, and
the per capita expense is much less. In regard to the expense, I may say that it is the practice here to treat dependent patients in State hospitals in a much more liberal way in the matter of diet, rooms and furniture than is the case there, and of course it costs more. It also costs more to accomplish the same result here than there because of different climate, greater demand for labor, etc. There has been a lavishness of outlay on buildings in some localities here which is unknown there, and which is now generally recognized to be a mistake. Having to care for the insane at a rate at all satisfactory to the public in structures thus expensively designed and equipped, adds many otherwise avoidable difficulties to the work of some of us. In the matter of employment of patients, I think them unquestionably ahead of us, and regard it as the most important point of difference in the practice of the two countries, considering simply the effect on the patients; for the direct pecuniary profit derived from the work of the insane is not much increased by the employment of those who do not possess fair intelligence and self-control. The fact that our climate denies us the full use of the best employment-agriculture during about half the year, increases our difficulty, and there are others which I need not mention, but which I believe will grow less numerous rapidly if we devote ourselves with a will to surmounting them. I may say that private patients are not employed to any extent in either country. One feature of practice there, which I believe to have a sound psycological support, and which helps them much in securing effective work and in doing without mechanical restraint, is the greater accountability to which they are accustomed to hold patients. The shield of irresponsibility is not allowed to defend all the irregular and wayward and violent actions of asylum patients, and lawlessness is lessened, general comfort increased, and the weakened inhibitory power of the individual stimulated and supported. I believe that a mistaken kindness and sensitiveness to criticism have inclined us to lessen the sense of responsibility and coddle our patients into a comfortable dementis. In regard to the use of mechanical restraints, I have no hesitancy in saying that I think the British practice, as a whole, better than ours, but I do not think it better in all cases. I have watched the cases of several patients treated abroad without restraint who. I think, would have been more humanely, comfortably and successfully treated with it, and I even had a British superintendent say to me at an autopsy, I cannot see why your American practice of restraint would not have saved this woman's life;" nor could I, and I should hardly have felt justified in its omission. These cases constitute, however, but a small portion of those who are restrained in the majority of American asylums. The fact is that attendants, having no restraint to resort to in troublesome cases, are prompted to exercise watchfulness, attention and tact to a degree that I have not seen equalled otherwise; and I do not believe it possible to train a stað of atter 3
ants to the best exercise of these qualities with as free access to restraining apparatus as has been the custom to allow in the United States. They also try to furnish an orderly means for expression of abnormal motor activity to a greater extent than we, and, though they employ very few patients who would be restrained in a good hospital here, they by means of employment relieve themselves of an excitable and exciting element which is sure to produce trouble among others. By these means they succeed, as I believe, in quite largely reducing the number of cases where physical force must oppose physical force, and in that fact rests all the merit of non-restraint as a system. For among the very small number of cases where something better cannot be substituted, and force is still requisite, I think restraint is often as good, and sometimes better, than the means adopted there. For instance: they give patients who are maniacal and disposed to destroy clothing, almost indestructible very uncomfortable bedding and leave them at night; and one who has seen such patients rolling uncovered about the floor in the not very torrid atmosphere of an English asylum in winter may be pardoned for thinking the protection of restraint not undesirable. In some of their asylums there is quite a large use of chemical restraint, as it is termed, but I hardly think it greater than here, and the smallest use of sedative drugs that I have ever seen in asylum practice was in an institution where no restraint was used. There are some cases where intense maniacal excitement is accompanied by great physical exhaustion, and they are decidedly more frequent here than there, in which I think a judicious use of mechanical restraint gives a better chance for recovery than any other form of treatment. The difficulties in the way of substituting something better for restraint and of securing an efficient service generally, are much greater in this country than in Great Britain; chiefly because of the difficulty experienced in keeping desirable attendants sufficiently long (where the duties are disagreeable) to train an efficient staff. This difficulty exists in the institution with which I am connected, where the changes are now so rapid as to render the best sort of service impossible.
The essential matter in the care of the insane is not the adherence to or rejection of any particular system; for I believe that most plans that are always adopted or always refrained from in the care of the sick are often unwisely adopted and unwisely omitted. But it is essential, as Dr. Bancroft has pointed out, that the asylum officer study carefully the symptoms of each individual, and adapt the treatment to the special indications. If sufficient opportunity and encouragement for this are given, I think the details of treatment will be satisfactorily adjusted.
As regards the separation of the sexes, I personally consider the plan a bad one. I think the aim should be to have the hospitallife sacrifice as few of the pleasant features of home-life as possible, and many sources of pleasure are taken away by the separation of
Neither do I see any reason why men and women cannot be associated as physicians in the care of the insane; and I think it desirable, if a good appointment can be made, that one of the physicians in a State hospital be a woman.
The Minnesota State Lunacy Commission was formed in 1879 to weed out the idiots from the insane asylums, and put them into an experimental school, which proved so much of a success that our last legislature made an appropriation to build an Idiot Asylum. The commission being reappointed, the question came up what it was to do. The Governor was very earnest in the matter, thinking there was need of suggestion which it was our province to make. We hope that our commission, at the end of the next two years, will have a report to make that will be of some interest.
With regard to our hospitals, our patients there are well cared for, and there is a great interest in the State that they should be. Our legislature has made all necessary appropriations, and I have no doubt that the next legislature will further improve the laws concerning lunacy, so that we shall be in very good circumstances. It is our intention to establish a Board of Charities, and there is a prospect that action in that direction may be taken at the next meeting of the Legislature.
VERMONT. BY DR. ALLEN.
Dr. S. J. ALLEN, Supervisor of the Insane of Vermont, said: I came here at the request of the Governor of Vermont, though, as to the condition of the charities of Vermont, I am afraid I cannot enlighten you. I am one of the State Supervisors of the Insane, and, of course, know more about matters connected with them than any others. So far as the care of the insane in the State of Vermont is concerned, I am sorry to say they are rather poorly provided for at present. There is no State hospital; there is a private institution at Brattleboro', where the State boards its insane, making yearly appropriation for that purpose of about $13,000. This hospital, at the present time, contains about 460 patients, and the building is somewhat over-crowded. As to the management I have no fault to find. It is good, so far as we have the means, but we require a different structure. About all the patients are cared for under one roof. We hope, some time in the near future, to have in Vermont a State asylum, built upon the village or cottage plan, where we can better care for our insane, of whom there are in the State about 700. In addition to the insane in the Brattleboro' Asylum, there are about fifty idiots boarded there; persons in a state of chronic dementia, who may have been violently insane when admitted, but who are now simply demented. I took occasion at the last meeting of our supervisors
to call up the subject of discharging a portion of this class of inmates. Any pauper insane person, who has no residence in any particular town, is cared for by the State. If they are sent to the hospital from a town, that town is responsible for their care, and pays $3.58 a week. As I understand it, superintendents of hospitals in Vermont have not the right or power legally to discharge a patient until cured. To be sure you can let out certain cases on trial, with the understanding that if they are not proper subjects for freedom they must be returned. It has seemed to me that asylums of the character of the one at Brattleboro', ought not to be made boarding-houses for paupers, or for patients who require no treatment, and no restraint (restraint coming under the head of treatment), but shelter, clothing, and food only. At our last visit we ordered the discharge of ten patients belonging to that class. Some of the towns found no fault, but in several cases where the State patients were discharged, the towns to which they were sent objected and questioned the right of the supervisors, under the law, to discharge such cases. Nevertheless, they have the right to recommit, and the supervisors will then exercise the right to redischarge.
Mrs. SPENCER, of Washington: I wish to make an enquiry. In all the discussions, I have listened in vain to hear even a suggestion as to the causes of insanity. While our institutions deal with percentages of admission and discharge, I am eager to know why the evil is perpetually increasing, and how to check the tide. It was stated this morning that insanity has doubled in Massachusetts within the last twenty years. Now there is one cause of insanity which no one will dispute, a vicious, profligate life. I have also learned that insanity among the young is fearfully on the increase, even among persons under fifteen years of age. I believe that the increase of insanity among young people, born from fourteen to twenty years ago, is due to the effect of the civil war on the fathers and mothers. If that is so, that percentage will decrease. But the other cause, profligacy, is one with which citizens and philanthropists have to deal. I had hoped for light on this subject.
Mr. EVANS, of Philadelphia, differed from Mrs. Spencer in regard to the cause of insanity; he thought it was not so much attributable to the late war as to our public school system. His experience in Philadelphia, in connection with the public schools, led him to this conclusion. The mere scholastic education that children received there did not fit them to go back to the world in which they must live. They left the public schools with many inflated ideas and notions, which in few cases could be carried out.
Rev. F. H. WINES, of Illinois, said, referring to the remarks of