The Treatment of the Acutely Insane in General Hospitals BY / W. P. SPRATLING, M.D. FIRST ASSISTANT PHYSICIAN NEW JERSEY STATE ASYLUM FOR THE INSANE, MEMBER OF THE NEW YORK MEDICO-LEGAL SOCIETY Reprinted from the MEDICAL RECORD, June 28, 1890 NEW YORK TROW’S PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1890 ■' 4 * The Treatment of the Acutely m sane in General Hospitals.1 By W. P. SPRATLING, M.D., FIRST ASSISTANT PHVSICIAN NEW JERSEY STATE ASYLUM FOR THE INSANE, MEMBER OF THE NEW YORK MEDICO-LEGAL SOCIETY. Reprinted from the Medical Record, June 28, 1890. This is a question concerning the treatment of this es- pecial class of the insane that has lately sprung into prominence, and one that bids fair to create a general and liberal discussion, as its nature warrants and justifies. In no branch of medicine, or in any of the allied sciences that tend to promote the universal welfare of a people, have such marked advances been made in recent years as in the study and treatment of psycopathic disorders, and the very suggestion of any new feature that will have a tendency to place round about the insane such environ- ments or influences as will the better aid him to re- covery, or make his life during the term of confinement less burdensome, will meet at once with a candid and wholesome discussion at the hands of those whose lives have been spent in endeavoring to ameliorate the condi- tion of this unfortunate class. This question appeals alike to medical, scientific, and men of philanthropic ideas, for each one of these find in the insane man some especial interest, and something that claims the skill and sym- pathies of each. The primary consideration of this question by those who form the foremost rank and file of able and humane alienists of to-day will doubtless engender but one reply; * Read before the New York Medico-Legal Society, May 14, 1890. 2 and it would be difficult to convince these, with any argu- ment short of actual demonstration, that the acutely in- sane could be more successfully treated in general hos- pitals than in asylums as at present. On their part it would virtually be to disclaim the knowledge of insanity they had been acquiring all these years, and a renuncia- tion of progressive ideas, practical reforms, and methods instituted by themselves. It would be to acknowledge themselves as “latter-day drones,” so to speak, and, by their own assertions, unfit to work longer in this great field of labor. The present happy and increasing en- lightenment, great or little as it may be, that dawns more clearly upon us each day, throwing here a gleam, and flashing there a ray of light upon some hitherto dark and mysterious problem, springing from the diseased human brain, and the care of the individual possessing it, is due to those who have studied this malady in all its phases in the many great asylums now existing, so nobly founded by public charity, and whose internal management is so ably and humanely administered through the light of in- creasing knowledge. To bring about such a change in the custodial care and treatment of those afflicted with the acute types of insanity, can only be done by the sanc- tion, and with the authority, of the State’s law-makers. Legislation on this subject should not be hastily enacted ; for so radical a change, affecting, as it most assuredly would do, the character of all general hospitals into which insane cases might be admitted, and robbing existing asy- lums or hospitals for the insane of the very cases the State intended these institutions should receive, deserves a careful and extended consideration. At the January meeting of the New York Neurological Society of the present year, a committee, consisting of Dr. Frederick Peterson, Dr. Chas. L. Dana, and Dr. Ralph L. Parsons, was appointed to examine and report upon a revised code of lunacy laws, known as the Gallup Lunacy Bill. This bill, the year before, passed the New York Legislature, but failed to become a law on account of the Governor’s 3 opposition to it. Portions of this bill were favorably, and other portions unfavorably reported upon by the committee, and among other recommendations they made the following : “ A clause should be introduced into the bill providing that nothing in the lunacy laws of the State shall be construed to interfere with the reception and treatment of acute cases of insanity in chartered general hospitals, in the same manner and under the same condi- tions as patients suffering from other diseases are there received and treated, provided such hospitals have suit- able accommodations approved by the State Commission in Lunacy.” In the New York Medical Journal of February 22, 1890, appears an editorial in which is reviewed the work done by the committee appointed by the Society to ex- amine into the merits and demerits of the Gallup Lunacy Bill, and the writer of this article, in referring to the clause advising the reception of the acutely insane into general hospitals, says : “ In our opinion this is the most valuable portion of the committee’s report, for it suggests a step forward in the line of a great reform.” Then, at some length, the author comments upon the unsatisfactory form of treatment he assumes such cases to receive at the hands of those charged with this responsibility in our great asylums; and some of the criticisms embodied in this paper are unfair and unjust, being so clearly from the fact that the writer is evidently not well informed concerning the details of internal management that pre- vail in most of our State institutions of to-day. More- over, it is not alone in this particular that a lack of in- formation is evident, but when, as the writer of this article says: “ The insane are no longer to be regarded in the light of insane criminals, and asylums are not always to bear the stigma of existing as a species of jail,” he shows the fact that this idea, at one time prevalent, but long ago discarded as barbaric by all men who studied the true cause and character of a man’s madness, is overlooked by him, and to-day, if there be a stigma affixed to any man’s 4 name who has ever been of unsound mind, it is by those who are untutored and ignorant regarding the inherent nature of this unfortunate malady. The admission into general hospitals of cases of acute insanity cannot be done under the confident expectation of having them regain their reason in from “ three weeks to three months,” as the writer says. Very true, many acute cases, which at the outset appear extremely unlikely to recover, get well in three months, or in a shorter period of time. But just in proportion as this number of favor- able cases, as regards an early recovery, will require ad- mission, a yet larger number will be admitted whose acute attack will not terminate in a few weeks or months, but pass into a chronic hopeless one, and in the course of time, for many apparent reasons, their removal to a regu- lar hospital for the insane becomes necessary. In the ar- ticle above referred to, it is stated that upon admission into an asylum “ a patient’s personality is entirely lost in the horde of from six hundred to two thousand mad peo- ple among whom he is placed.” It is true that some overcrowding in many of our hospitals for the insane ex- ists to-day, but it has been unavoidable, chiefly on account of the great increase in the number of insane. The evils of confining too large a number of insane under one roof has been ably shown by American alienists in late years, and the magnificent institutions that are being built to-day upon that most excellent and scientific plan known as the cottage system, is actual proof of their wise recom- mendations. But let us consider for a moment one of our ordinary State asylums, or hospitals for the insane, that has not many of the important improvements that institutions of a later growth enjoy; and let us go for a moment with a case of acute insanity, as he is sent from the reception- room to one of the hospital wards. Here he finds him- self one of a number of from twenty-five to twenty-eight patients on a ward that, in point of size, could comfort- ably accommodate from thirty-five to forty. Here he can 5 be provided with a single room, if it be deemed advis- able. Here he is seen twice daily by an assistant physi- cian, and the fact that he is on the hospital ward entitles him to the same physical treatment, as well as mental, that he might receive in any general hospital. In regard to the treatment or actual medication of the insane, the writer of this article, in speaking of acute cases in asy- lums, says, “ Does ne disturb others ? Then narcotize him. If that be impossible, put him into the pande- monium known as the back ward.” If we have not in our asylums to-day all known means of quieting the ma- niacal frenzy common to madmen, if it be best for him and those around him, then surely there is no potent charm or conquering influence that can be used as so happy a benefactor in any general hospital. Another most important consideration in regard to this proposed new method should not escape notice, and that is the effect of the admission of such cases upon the public character of a general hospital and the local reputation it enjoys. It cannot be denied that general hospitals, through the ever-increasing efficiency of the service they offer in caring for the bodily sick and injured, are coming daily into more popular favor, and a large number of such cases, by their own choice, are admitted into these hospi- tals for the purpose of being treated therein. Recogniz- ing, then, the indisputable fact, that general hospitals are steadily increasing in public patronage, it is fair to assume that a knowledge by patients, who, be they the subjects of public charity, or paying individually for what they re- ceive, are equally solicitous as to their surroiindings, and of the fact that madmen were being cared for under the same roof as themselves, would have upon them an unsal- utary effect. Public opinion on questions that have for their underlying principle the comfort and welfare of com- munities is an unmarketable article, and one that cannot be disposed of except in such a manner as will satisfy the greatest number entertaining such opinions. 'This very fact is undoubtedly responsible for the removal from the 6 city of one of the best known and most thoroughly equipped asylums in this country. Again, we find in this article the assertion that, if the acutely insane were admitted into general hospitals under the same conditions precisely as other patients are received, it would lead to a “ vast improvement ” in the early and efficient treatment of the nutritive disorder of brain. I must confess that I am unable to realize how the creation of this vast improvement is to be brought about, and what the method of its application is to be. A person sick in a crowded city, with even a physical dis- order that has been created more from the monotonous routine of his form of business and social life, the ever- recurring daily scenes and the constant excitement of busy traffic, is advised by his physician to seek some secluded spot, some remote abiding place in the country or on the sea-shore, where nature can substitute the charm of her inspiring impressions upon his tired senses for those fa- tiguing scenes and confining occupations that have well- nigh made him a physical wreck. Why not let the un- fortunate and penniless poor of the city who may fall a victim to some acute mental disorder be taken from such surroundings and placed out in the country in suitable homes provided for them, where wholesome winds blow and the noise of traffic is unheard. Concerning the recep- tion-houses in New South Wales and Queensland, and of lunacy wards in Victoria for the treatment of insanity in its early stages, nothing can at this experimental period of their existence be said in favor of such methods that would justify their adoption in this country. The con- struction of a psycopathic hospital that is about to occur in London is indeed a noble conception, and one em bodying, as it will, every known scientific method and means that present knowledge can devise in the treatment of the insane, will doubtless bring incomparable good to all who must partake of the beneficent and scientific skill that is to be found within its walls. Yet at the head of the internal management of this hospital is to be placed a 7 “ resident medical officer of asylum experience,” and with him he carries, as his chief qualification for this high of- fice, the very knowledge of insanity previously acquired in asylums with which he must have been connected. For some time past an undercurrent opinion, generated in the minds of some of the most progressive and ablest psy- chologists in this country, has been in existence, in which the idea embodied is the abolition of the word asylum, as it is applied to places in which the insane are treated. In the third annual report of the St. Lawrence State Asy- lum for the Insane at Ogdensburg, N. Y., Dr. P. M. Wise, the Superintendent, says : “ I would further recommend at this time a change of the present title of the asylum to the St. Lawrence State Hospital, to accord with the higher function of the institution, as herein set forth. The pa- tients in an institution are confronted with the name at all times, and it has an influence in creating impressions greater than is generally known.” For suitable reasons he furthermore says: “ Neither is it necessary to attach the word ‘ lunatic ’ or ‘ insane ’ to the title.” The managers of that institution concurred with Dr. Wise in his opinion, and by an act of the Legislature recently the name was changed to the St. Lawrence State Hospital. Dr. Edward Cowles, Superintendent of the McLean Asylum, near Boston, also refers to this subject in his last annual report. In speaking of a new building that is to be erected at Belmont for the inmates of McLean Asy- lum, he says, “ It is not a new asylum we want; it is a new hospital.” Dr. G. Alder Blumer, Superintendent of the State Lunatic Asylum at Utica, N. Y., in his last annual report, writes at some length upon the “ Hospital Idea,” in the course of which he says : “ In my last annual report I ven- tured the suggestion that a change of the name of our State Lunatic Asylum to State Hospital would be desirable, as better showing the character of the institution, and serving to impress upon the public the fact, so continu- ously ignored, of the physical basis of insanity, and all 8 that that simple doctrine implies.” Among all the desir- able changes that present and future conceived enlighten- ment on the subject of insanity brings to us to-day, none seems of more vital importance than the abolition of the word asylum, and with it, if possible, its linked associ- ates “ lunatic ” and “ insane.” These words, I doubt not, have in some instances, isolated though they be, been the Gibraltars upon which the feeble hope of some over- sensitive minds, distorted by disease, have been dashed to their death. To me it seems a matter of most vital im- portance, for I believe it to constitute a rational and hu- mane step forward in the line of a truly great reform. Worcester defines asylum as a “ sanctuary, a place of refuge, a place of retreat and security; a shelter, origin- ally applied to places in which criminals and debtors were secure from arrest.” Webster defines asylum to be “ a sanctuary; or place of refuge and protection, where crim- inals and debtors were secure from arrest; and from which they could not be taken without sacrilege. In later times Christian churches were regarded as asylums in the same sense. So sacred was the church to some that it had the right of an asylum or sanctuary.” In the dark ages this might have been a suitable definition for a place in which those were confined who were thought to “ be possessed of an evil spirit,” but to-day science, cou- pled with liberal knowledge and truly humane ambition, should seek to abolish this misnomer, and not relax its efforts until it has accomplished its great aim. In view of the foregoing, Mr. President, I beg to offer this resolution : Whereas, Insanity is now generally conceded to be a physical disease, and, as such, a malady for medicinal treatment, as much so as inflammation or fever ; Resolved, That this Society commend the adoption of the term “ hospital ” in place of “ asylum,” for institu- tions having the care of the insane. Morris Plains, May 20, 1890.