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HOSPITAL TREATMENT]
617
INSANITY

like instances could be cited, but the interesting point to be borne in mind is, that with a general tendency to improvement in the condition of imbeciles upon public charge, idiots and insane persons came gradually to be separated from criminals and other paupers, and to be segregated. The process of segregation was, however, very slow. Even after it had been accomplished in the larger centres of civilization, the condition of these unfortunates in provincial districts remained the same. Furthermore, the transfer to asylums provided especially for them was not followed by any immediate improvement in the patients.

Twenty-five years after Pinel had, in 1792, struck the chains from the lunatics huddled in the Salpétrière and Bicêtre of Paris, and called upon the world to realize the horrible injustice done to this wretched and suffering class of humanity, a pupil of Pinel, Esquirol, wrote of the insane in France and all Europe: “These unfortunate people are treated worse than criminals, reduced to a condition worse than that of animals. I have seen them naked, covered with rags, and having only straw to protect them against the cold moisture and the hard stones they lie upon; deprived of air, of water to quench thirst, and all the necessaries of life; given up to mere gaolers and left to their surveillance. I have seen them in their narrow and filthy cells, without light and air, fastened with chains in these dens in which one would not keep wild beasts. This I have seen in France, and the insane are everywhere in Europe treated in the same way.” It was not until 1838 that the insane in France were all transferred from small houses of detention, workhouses and prisons to asylums specially constructed for this purpose.

In Belgium, in the middle ages, the public executioner was ordered to expel from the towns, by flogging, the poor lunatics who were wandering about the streets. In 1804 the Code Napoleon “punished those who allowed the insane and mad criminals to run about free.” In 1841 an investigation showed in Belgium thirty-seven establishments for the insane, only six of which were in good order. In fourteen of them chains and irons were still being used. In Germany, England and America, in 1841, the condition of the insane was practically the same as in Belgium and France.

These facts show that no great advance in the humane and scientific care of the insane was made till towards the middle of the 19th century. Only then did the actual metamorphosis of asylums for detention into hospitals for treatment begin to take place. Hand in hand with this progress there has grown, and still is growing, a tendency to subdivision and specialization of hospitals for this purpose. There are now hospitals for the acutely insane, others for the chronic insane, asylums for the criminal insane, institutions for the feeble-minded and idiots, and colonies for epileptics. There are public institutions for the poor, and well-appointed private retreats and homes for the rich. All these are presided over by the best of medical authorities, supervised by unsalaried boards of trustees or managers, and carefully inspected by Government lunacy commissioners, or boards of charities—a contrast, indeed, to the gaols, shrines, holy wells, chains, tortures, monkish exorcisms, &c., of the past!

The statistics of insanity have been fairly well established. The ratio of insane to normal population is about 1 to 300 among civilized peoples. This proportion varies within narrow limits in different races and countries. It is probable that intemperance in the use of alcohol and drugs, the spread of venereal diseases, and the over-stimulation in many directions induced by modern social conditions, have caused an increase of insanity in the 19th as compared with past centuries. The amount of such increase is probably very small, but on superficial examination might seem to be large, owing to the accumulation of the chronic insane and the constant upbuilding of asylums in new communities. The imperfections of census-taking in the past must also be taken into account.

The modern hospital for the insane does credit to latter-day civilization. Physical restraint is no longer practised. The day of chains—even of wristlets, covered cribs and strait-jackets—is past. Neat dormitories, cosy single rooms, and sitting- and dining-rooms please the eye. In the place of bare walls and floors and curtainless windows, are pictures, plants, rugs, birds, curtains, and in many asylums even the barred windows have been abolished. Some of the wards for milder patients have unlocked doors. Many patients are trusted alone about the grounds and on visits to neighbouring towns. An air of busy occupation is observed in sewing-rooms, schools, shops, in the fields and gardens, employment contributing not only to economy in administration, but to improvement in mental and physical conditions. The general progress of medical science in all directions has been manifested in the department of psychiatry by improved methods of treatment, in the way of sleep-producing and alleviating drugs, dietetics, physical culture, hydrotherapy and the like. There are few asylums now without pathological and clinical laboratories. While it is a far cry from the prisons and monasteries of the past to the modern hospital for the insane, it is still possible to trace a resemblance in many of our older asylums to their ancient prototypes, particularly in those asylums built upon the so-called corridor plan. Though each generation contributed something new, antecedent models were more or less adhered to. Progress in asylum architecture has hence advanced more slowly in countries where monasteries and cloisters abounded than in countries where fixed models did not exist. Architects have had a freer hand in America, Australia and Germany, and even in Great Britain, than in the Catholic countries of Europe.

Germany approaches nearest to an ideal standard of provision for the insane. The highest and best idea which has yet been attained is that of small hospitals for the acutely insane in all cities of more than 50,000 inhabitants, and of colonies for the chronic insane in the rural districts adjacent to centres of population. The psychopathic hospital in the city gives easy and speedy access to persons taken suddenly ill with mental disease, aids in early diagnosis, places the patients within reach of the best specialists in all departments of medicine, and associated, as it should be, with a medical school or university, affords facilities not otherwise available for scientific research and for instruction in an important branch of medical learning. A feature of the psychopathic hospital should be the reception of patients for a reasonable period of time, as sufferers from disease, without the formality of legal commitment papers. Such papers are naturally required for the detention and restraint of the insane for long periods of time, but in the earlier stages they should be spared the stigma, delay and complicated procedure of commitment for at least ten days or two weeks, since in that time many may convalesce or recover, and in this way escape the public record of their infirmities, unavoidable by present judicial procedures.

There should be associated with such hospitals for the acutely insane in cities out-door departments or dispensaries, to which patients may be brought in still earlier stages of mental disorder, at a period when early diagnosis and preventive therapeutics may have their best opportunities to attain good results. In Germany a psychopathic hospital now exists in every university town, under the name of Psychiatrische Klinik.

Colonies for the chronic insane are established in the country, but in the neighbourhood of the cities having psychopathic hospitals, to receive the overflow of the latter when the acute stage has passed. The true colony is constructed on the principle of a farming hamlet, without barracks, corridored buildings, or pavilions. It is similar in most respects to any agricultural community. The question here is one of humane care and economical administration. Humane care includes medical supervision, agreeable home-life, recreation, and, above all things, regular manual and out-of-door occupation in garden, farm and dairy, in the quarry, clay-pit or well-ventilated shop. Employment for the patients is of immense remedial importance, and of great value from the standpoint of economical administration. In the colony system the small cottage homes of the patients are grouped about the centres of industry. The workers in the farmstead live in small families about the farmstead group of buildings; the tillers of the soil adjacent to the fields,