op PUBLIC IJTEHEST 
 
 THE 
 
 BY 
 
 EVENTS, JVI.D 
 
 Superintendent of the Cincinnati Sanitarium (A Private Hospital 
 
 for the Insane), Late Superintendent of the Indiana State 
 
 Hospital for the Insane, Member of the American 
 
 Medico-Psychological Society, etc., etc. 
 
 JRa.; befort the Hftotiasippi Valley Medical Association, Oct. 4, 1899,
 
 PROBLEMS OF PUBLIC INTEREST CONCERNING 
 THE INSANE. 
 
 ORPHEUS EVERTS, M.D., College Hill Station, Cincinnati, Ohio. 
 
 There are several problems of public interest involved in the 
 present relations of society to the insane. Among the more important 
 of these are questions of dependency, the curability of the insane, arid 
 the preventability of insanity. 
 
 Each of these questions presents two aspects for consideration 
 one appealing to whatever altruistic sentiment may have been devel- 
 oped with our growth, and the other to that selfish sentiment tbat is 
 common to the race. 
 
 That there is a large number of insane persons, increasing rather 
 than diminishing, in every civilized state, is a fact familiar to all intel- 
 ligent interested observers. 
 
 That the insane constitute a dependent class of society is equally 
 apparent. 
 
 Independence implies mental capabilities corresponding to im- 
 ^ pending necessities under any given circumstances. But few living 
 'V beings are superfluously endowed for the end indicated. A large 
 ^ proportion of animal, as well as vegetable, specializations entering 
 life upon terms of apparent equality, die prematurely because of in- 
 herent lack of capability to meet or resist the exigencies of environ- 
 ments. 
 
 The complex environments of civilized life require much greater 
 capability on the part of individuals to maintain independence than 
 are required by the more simple conditions of savagery. 
 
 Insanity implies mental impairment, hence lessened capability, 
 noticeable as contrasting previous conditions manifested by the per- 
 sons supposed to be insane. 
 
 Liability to become insane under ordinary provocation, is asso- 
 ciated, as a general rule, with inherent defects of organization charac- 
 teristic of a class of persons whose natural capabilities are below a 
 
 2151 5 1
 
 common level at, or even above, which independence implies con- 
 stant, anxious and often unsuccessful effort. A slight degree of im- 
 pairment, therefore, may be sufficient to reduce a self-supporting 
 person to a condition of dependency. 
 
 That exceptional persons of more than ordinary capability have 
 become insane under exceptional circumstances or that rare instances 
 of exaggerated capability associated with some degree of mental dis- 
 order, have been observed when properly considered should not dis- 
 credit the foregoing statement or inferences. 
 
 It is true if mental phenomena are sequential to cerebral activ- 
 ities, orderly and disorderly, and reflect cerebral conditions, sound 
 and unsound that it must be possible for whoever or whatever is 
 endowed with brains to become insane under sufficient provocation. 
 Fortunately for most of us, however, ordinary provocation is not 
 sufficient to seriously derange the mental mechanisms of a large 
 majority of mankind. 
 
 Neither should the fact that a considerable number of active, and 
 apparently capable, business men suffer and are destroyed by what is 
 now familiarly known as " paresis," affect the position taken unfavor- 
 ably." Clinically considered, in the sidelights of commemorative cir- 
 cumstances, these men are found to be not exceptional persons but 
 belonging to a class not only liable to become insane because of in- 
 herited peculiarities, but constitutionally prone to indulgence in prac- 
 tices more than ordinarily provocative of cerebral disease. 
 
 Degenerative impairment hence incapability of self-support on 
 the part of the insane being admitted, the question of public interest 
 is : What shall be done with and for them ? All savage peoples aid 
 and abet Nature in her methods of disposing of the defective and 
 incompetent, in all of her kingdoms, by neglects and practices quite 
 as cruel as her own. Our own ancestors were not exceptional in this 
 respect. 
 
 Among civilized peoples it has come to be recognized as expedient 
 and dutiful for the strong of our kind to succor and sustain the weak, 
 no matter what the burden may be. Why this is or how it came to pass, 
 need not be discussed in this connection. Enough to say that it is an 
 " inevitable sequence of antecedent conditions; " that the duty is clear 
 and will nevermore be shirked while our people advance along the 
 lines of Christian civilization. It is our privilege, however, to consider 
 "ways and means" for the accomplishment of this end in a severely 
 practical light. The problem then is : how shall this recognized obli- 
 gation be discharged with the least expense to ourselves?
 
 This depends, of course, upon the kind of .provision for the de- 
 pendent insane demanded by our sense of duty enlightened by sym- 
 pathy as well as intelligence. What shall it be? Not such as was 
 extended to the insane of all Christian lands from the accession of 
 Roman ecclesiasticism in Europe to the close of the eighteenth century ! 
 O no! Not even such as was considered satisfactory in the earlier 
 decades of the present century ! Not by a long way ! Public senti- 
 ment now demands for the dependent insane not only custody and 
 treatment, but provision for all the privileges and comforts of life that 
 they are capable of enjoying. And this is right. Nothing could be 
 more just or humane; nothing easier of accomplishment: provided 
 the accomplishment be referred to agents sufficiently instructed and 
 informed of the various degrees and peculiarities of capability for 
 enjoyment of the different classes of the insane, instead of to the 
 conceited zeal of public ignorance, however well intended. Public 
 ignorance and mis-information respecting insanity and the insane, 
 have given rise to nearly, if not quite, all of the fadulent notions that 
 have made themselves known by endless clamor respecting public 
 provision for the insane of late years wearisome enough to well-in- 
 formed listeners, if not altogether unprofitable. 
 
 It has not been the purpose of the writer in preparing this paper 
 to renew or continue the discussion of definite "propositions" for the 
 proper care of the insane, including location, buildings, organization 
 and management, etc., of public hospitals or asylums, further than 
 to submit a brief resume of conclusions reached, or opinions enter- 
 tained, after the experiences of twenty-five years service as superin- 
 tendent of large and small, public and private, hospitals for the insane, 
 and interested studies of the characteristics, capabilities, and needs 
 of various classes of dependent persons. 
 
 These conditions have been summarized as follows: 
 
 (i.) Intelligent provision for the insane implies provision for 
 various classes, according to their capabilities of enjoyment, and the 
 exercise, under intelligent supervision, of variously impaired faculties. 
 
 (2.) Public provision for whatever class of insane persons 
 implies : housing, clothing, feeding, sanitary and moral discipline, 
 amusement and employment for such as are capable of being amused 
 or employed, and medical treatment for the sick: the essential features 
 of such provision being, so far as may be practicable under given cir- 
 cumstances, adaptability to the needs of each distinctive class. 
 
 (3. ) Great, expensive, architecturally-imposing palaces, providing 
 alike for all classes, however serviceable they may have been, aestheti-
 
 cally considered, in times past as they unquestionably were are no 
 longer necessary nor appropriate for the ends indicated. Yet, so the 
 insane are comfortably housed, each class according to its condition, 
 it is comparatively unimportant whether they be so in large or small 
 houses; cottages or palaces; connected or detached; high or low 
 buildings. 
 
 (4.) It is important that the insane of all classes be well fed 
 under careful supervision ; but whether in large or small dining rooms, 
 by groups, or aggregations, is of so little consequence that it should 
 be considered a matter of convenience rather than of principle. 
 
 (5.) It is important that public institutions for the insane -be 
 well organized and administered ; but whether by three or thirty trus- 
 tees is a matter of but little moment. Partisan or bi-partisan boards 
 of directors may be equally good or bad. The fewer statutory 
 details for the government of such institutions the better. Good 
 men will govern a hospital well under adverse statutes, and bad men 
 will manage to evade the wisest legislation. The usefulness and rep- 
 utation of a hospital for the insane will reflect the characteristics of 
 those who direct or administer its' affairs, rather than the laws by 
 which they are authorized to act, or the political party to which they 
 belong. 
 
 (6.) It is wise to retain in orifice capable men, who have demon- 
 strated their fitness by successful management of affairs, so long as 
 their capability continues to be elastic ; but the displacement of offi- 
 cials whose ideas have become insoluble by competent and still grow- 
 ing men, with or without special training, should not be regarded with 
 alarm nor as of doubtful propriety. Capability without experience is 
 more valuable than experience without capability in any executive po- 
 sition. Whatever ills attend "rotation in office" in this country, a 
 custom essential to the vigor if not the existence of partisan organi- 
 zation, without which republican government would degenerate are 
 among the evils compensated by the good of almost unlimited free- 
 dom. The trend of human progress is not seriously deflected thereby. 
 
 ARE THE INSANE CURABLE? 
 
 That insane persons, in some instances, recover normal capabili- 
 ties after impairment and disorder, is not a question, but a fact. 
 Whether or not such persons are greatly, or to any extent, aided to 
 recover by what is done for them by public provisions for their treat- 
 ment, is a question. How shall it be answered? There is no exist- 
 ing source of. accurate information on the subject. Whatever answer
 
 5 
 
 is made must, therefore, be inferential and a matter of opinion only. 
 There is a prevalent notion, whether well or ill founded, that the 
 chance of recovery for an insane person is much enhanced by com- 
 mitment to a hospital for treatment. A notion that emanated, proba- 
 bly, from general practitioners of medicine, who, as a class, are only 
 too willing to escape the responsibility and annoyance of treating in- 
 sane persons under ordinary circumstances; and has been confirmed 
 by the claims of distinguished specialists administering the affairs of 
 stately institutions, by which their occupation and pretensions have 
 been greatly dignified. 
 
 As an economical problem it would be well to know more about 
 this matter than is now known. If any considerable number of in- 
 sane persons are curable or will recover under hospital treatment, that 
 would not recover otherwise, then it is a matter of economy on the 
 part of the state to provide for such treatment, at an expense to be 
 measured only by results. If the average life of a dependently im- 
 paired insane person is twelve years, and the average duration of dis- 
 ease of such as recover is one year, then the state can afford an 
 extraordinary expenditure for the cure of the curable, as each recovery 
 represents a saving of eleven years of maintenance of an unrecovered 
 person. It is not necessary to make more definite calculations; what 
 we need to know is that the insane are amenable to treatment. That 
 a large proportional number of insane persons are not curable, or re- 
 coverable under any known circumstances, can not now be denied 
 in the face of facts the significance of which admits of but little ques- 
 tion or modification. Men of experience and capability in the specialty 
 to-day smile interrogatively or with incredulity at the pretensions of cure 
 made by their not very remote predecessors in charge of hospitals for 
 the insane. Statistics of hospitals, inconclusive as they necessarily 
 are on most subjects requiring accurate and comprehensive informa- 
 tion, are particularly so in relation to the question under considera- 
 tion. Hospital authorities in bad repute because of their defects of 
 construction and administration, sometimes exhibit a larger percentage 
 of "cures" than do the most reputable. 
 
 My belief, based upon observed facts and rational inferences, is 
 that no insane person who is not spontaneously recoverable under 
 ordinarily favorable circumstances is curable by extrinsic influences 
 of any kind. No insane person whose mental impairment is se- 
 quential to structural changes of tissues immediately implicated in the 
 performance of mental functions, if of a pathological character, is 
 spontaneously recoverable under any circumstances. By recovery I
 
 mean perfect restoration of normal conditions ; not a partial restora- 
 tion that may pass for a " cure," that is after all, but repair. 
 
 Cicatricial tissues are always less complex, hence less capable, 
 than the tissues which they replace in the process of reparation. Tis- 
 sues by which lesions of continuity of skin or muscular fibers are re- 
 paired, are familiar examples of this law. It is not probable that 
 brain tissue is exceptional or exempt from so uniform a physiological 
 process. 
 
 Recoverability from insane conditions is, therefore, limited to 
 persons whose mental impairment is attributable to lesions of other 
 than cerebral structures, whereby the brain may be temporarily 
 deprived of its ordinary pabulum or supplied with vitiated nutriment, 
 without impairment of its structural integrity; and "curability," is 
 limited to such persons of this class as require the aid of more favor- 
 able circumstances than their ordinary environments supply or their 
 means may command, to enable them to resist or overcome these 
 conditions. 
 
 The problem of public interest in this connection then is : has 
 public provision for the insane furnished can it be made to supply 
 essentially more favorable conditions for the recovery of the recover- 
 able, than, as a rule, they otherwise enjoy? 
 
 That this question should be answered affirmatively I have no 
 doubt. 
 
 Concentrated efforts, therefore, should be made, backed by 
 liberal expenditures intelligently directed toward the creation of 
 environments in every way conducive to the recovery of the recover- 
 able ; while provision for all other classes should be made with refer- 
 ence to their individual welfare and the utilization of such remnants 
 of capability as they may be still possessed of, at the least, reasonable, 
 expense. 
 
 It may be inferred from the foregoing that the writer does not 
 estimate medicine as the most important factor in the problem of 
 curative conditions for the insane. If by medicine is meant the 
 administration of drugs or chemicals, the inference is a fair one. The 
 insane can be medicated elsewhere as well as they can be in hospitals 
 or asylums. 
 
 Hospital physicians have no mysterious knowledge of medicine 
 no specific no secret remedies. 
 
 Hospitals for the insane under the exclusive control of Doctors 
 of Homeopathy, claim larger percentages of cure than do similar in- 
 stitutions administered by Doctors of Medicine.
 
 The administration of medicine or the appearance of medicine, 
 may still be wise, being responsive to the necessities of the multitudes 
 who have not yet fully emerged from the shadows of primitive super- 
 stitions, nor so far departed from ancestral types as to be uninfluenced 
 by the fetisch feeling that is common to the race, forever suggesting 
 supernatural beings, designs, powers, activities and virtues in associa- 
 tion with natural objects in explication of natural phenomena. There 
 are material medicines, also, that are neither poisonous nor inert, that 
 in the hands of skillful physicians contribute, unquestionably, to con- 
 ditions essential to recovery, as above indicated medicines that can 
 not well be omitted in the treatment of the insane under the most 
 favorable circumstances. But these are not, or need not be, many 
 nor should too much dependence be placed upon their efficacy to the 
 neglect of other and more important measures. 
 
 There are other uses, also, to which medicines are now being 
 liberally appropriated in the treatment of the insane, that if not cura- 
 tive of those to whom the medicines are administered, are comforting 
 to others with whom they may be necessarily associated securing for 
 the time-being silence and languor instead of raving and violence ; 
 and at the same time enabling the management to assure an admiring 
 public of the fact that all restraints have been abolished from the hos- 
 pital under their control, and the greatest reformation of the age has 
 been accomplished by their benevolence and sagacity ! 
 
 There may be wisdom in such an appropriation of means ; knock- 
 ing the insane down with chemical clubs and paralyzing them with 
 poisons instead of limiting their movements by camisoles or protection 
 beds; but if so, it is wisdom of a kind unknown to my philosophy. 
 There may be virtue in the practice but if so, it must be of that kind 
 that is said to be its own reward ! 
 
 If the conditions favorable to the recovery of the recoverable 
 insane do not consist of special medication or mysterious methods of 
 treatment peculiar to hospitals for the insane of what then do they 
 consist ? 
 
 They consist, in the first place, of the authority vested in or as- 
 sumed by such institutions to control the conduct and prescribe the 
 modes of living of the insane committed to them for custody and 
 treatment. Secondly notwithstanding the fad of the foolish that 
 hospitals for the insane should be made as "home-like" as possible 
 they consist of better sanitary surroundings, appurtenances and ob- 
 servances in but few respects " home-like " to the greater number of 
 dependent insane persons to be benefited thereby.
 
 8 
 
 Third not greater skill in medicine, but more knowledge of the 
 insane on the part of doctors and nurses than is common to the pro- 
 fession hence more rational treatment. 
 
 This is all ! But indeed this is much when considered in contrast 
 with the ordinary home surroundings, modes of living and methods 
 of dealing with the insane, characteristic of the population from 
 which the insane are, for the most part, derivable. 
 
 These conditions well provided for, all the rest minor matters 
 about which so much babble has been heard, of mere " annise and 
 cummin " importance in hospital affairs however interesting to per- 
 sons incapable of appreciating weightier matters may safely be per- 
 mitted to take care of themselves. 
 
 IS INSANITY PREVENTABLE? 
 
 Theoretically yes! Practically no! Theoretically, insanity is 
 preventable because so many of the so-called "exciting causes" of 
 insanity, in an ideal state of society would either not obtain or would 
 be prevented. Practically, insanity is not preventable because, 
 human nature being as it is, an ideal state of society can not be ef- 
 fected by any means at our command ; nor otherwise than by the slow, 
 however continuous, process of growth. 
 
 There are persons it is true, many and worthy in their way, who 
 think otherwise and devote their energies persistently to the accom- 
 plishment of such ends. Persons who seem to be exceedingly sensi- 
 tive to special objects but oblivious to the great fact of a Universe. 
 Persons who interest themselves deeply in special subjects but fail to 
 recognize the more important relations of parts to aggregates, or of 
 generals to particulars, without which knowledge is of but little value. 
 Persons who think, if at all, of the Universe as of a limited domain, 
 governed by personal decrees of limited applicability, and special 
 providences to meet contingent emergencies as they arise. Persons 
 who think of mankind as degenerate beings fallen from a high estate, 
 moving upon a down-grade toward inevitable disaster helpless of 
 themselves, but for an arrest of whose downward progress they seem 
 to think it only necessary to secure the enactment of some kind of a 
 law, prohibitory or other, whereby the race may be restored to primi- 
 tive conditions of innocence and happiness. These persons have 
 their uses and play their parts in the great drama of human progress 
 failing of accomplishment, however, because the movements of 
 mankind along the lines of civilization are not determined nor de- 
 terminable by human prudence, wisdom or design, nor to be arrested
 
 or greatly modified by whatever protest, persuasion or statutory en- 
 actment, not in harmony therewith. 
 
 To prevent insanity, the fact is conspicuous that the antecedent 
 conditions essential to its development must be so modified as to 
 change the sequence. 
 
 What are the antecedent conditions essential to the manifestation 
 of insanity ? 
 
 (a.) An inherent, consequently inheritable, peculiarity of or- 
 ganization, not common to the race but characteristic of a defective 
 class of persons, and recognized properly, as a structural "poten- 
 tiality of insanity." 
 
 (b.) Certain lesions of nutrition whether from deprivation or 
 excess inanition, indigestion, intoxication, or inherited dyscrasias of 
 various kinds. 
 
 (c.} Exhaustion of organic energy transmutable by cerebral 
 activities into mental force, by unusual or excessive expenditure in 
 work or dissipation. 
 
 (d.) Physiological limitations determined by germinal or sper- 
 matic conditions, by which structural types, growths, activities and 
 longevities, of individuals are dominated through every stage of exist- 
 ence, however influenced by external relations. 
 
 Of these antecedent conditions, some of which are essential to 
 the development of insanity, it will be seen at a glance that not one 
 of them can be successfully eliminated from present conditions ot 
 society, although there may be an ideal remedy for each. 
 
 The first mentioned, for example that of inherited defect ot 
 organization might be eliminated in time by counter-marching the 
 column of civilization and returning to primitive, or savage, con- 
 ditions of society, in which the defective drop out of the procession 
 early in life because of their original incompetency to continue the 
 effort required for existence, if not aided and abetted thereto by 
 naturally instructed or instigated kindred, leaving only the more per- 
 fect to survive. But this we will not do; for whatever may be said 
 or sung of the wisdom of nature and the beauty of things natural, no 
 people having once reached a high plane of civilization by spontaneous 
 effort has been known to return to barbarism or savagery. Disap- 
 pointed and dissatisfied individuals occasionally seek the wilderness 
 hoping to escape the exactions of good society, morally and otherwise, 
 but they represent exceptional characteristics. 
 
 Asexualization of the recognizably defective and constitutionally 
 vicious, criminal, and otherwise offensive and unfit members of society
 
 by surgical interference, now safely practicable, would do this business 
 in time. But however patent the fact may be that we are breeding 
 criminals and lunatics and paupers and prostitutes at a constantly in- 
 creasing ratio, as an inevitable sequence of our acts of benevolence 
 and humanity and that a compulsory solution of the problem will 
 some day be made it will require more than one " campaign of edu- 
 cation " to secure the adoption of so effectual, rational and beneficent 
 a measure. Meantime it is a waste of energy to talk about prohibit- 
 ing the legalization of marriages between defective parties as a remedy, 
 as all obstructive marriage laws contribute only to an increase ot 
 bastardy, feticide and kindred vices. The uniform demands of or- 
 ganic appetence will not be satisfied nor held in abeyance, effectu- 
 ally, or to any considerable degree, by statutory enactments. Comets 
 have never been deflected from their courses by papal bulls ; nor can 
 the imperious sentiment of sex in man be suppressed by ordinances. 
 
 Many worthy persons now believe that the second conditions 
 mentioned so far at least as they may be incidental to alcoholic in- 
 toxication can be corrected by law. But, however commendable 
 their motives, or valuable their work consistent with such belief, the 
 advocates of " prohibitory laws " for the elimination of alcoholic in- 
 temperance from society must admit that the end is still far from ac- 
 complishment with but little probability of success in the near future. 
 
 There are other poisons, also, that are more efficient than alcohol 
 as ordinarily used, in the provocation of insanity poisons that are 
 developed within the body the presence of which is neither voluntary, 
 nor recognized as vicious in a moral sense by unskilled observers, 
 but none the less indicative of depravity of organization, manifested 
 by depravity of functions to which such poisoning is attributable. 
 Neither men nor women not even Doctors of Medicine have ever 
 been persuaded or compelled to live rationally at the expense of 
 natural or acquired inclinations or appetites, or in violation of the 
 decrees of Fashion. 
 
 Conditions (c] or the undue expenditure of organic energy, 
 whether by overwork or the indulgence of exciting passions, can not 
 be interfered with to any considerable extent without encroaching upon 
 the "inalienable rights" of persons to an intolerable degree. Ambi- 
 tious men and necessitous women will continue to exhaust their ener- 
 gies by untimely toil. Gamblers of all grades of respectability, will 
 strain their faculties to utmost tension in their efforts to exchange 
 nothing for something whether it be to effect a "corner in wheat" 
 or beat a faro-bank. The libidinous will not cease to pursue their
 
 pleasures, sacrificing sleep at the shrine of Venus; and anxious wives 
 and mothers with saddened brows \vill still keep vigils awaiting. the 
 return of recreant husbands and undutiful or prodigal sons. These 
 are things that can not be controlled by law, nor rapidly modified by 
 education. 
 
 Conditions (d] of unquestionable force and importance pre- 
 ceding, and probably involving all. subsequent conditions incidental 
 to constitutional evolution, are not sufficiently within the scope of 
 present knowledge to be corrected by any known method of inter- 
 ference. 
 
 Insanity is, therefore, not only not .preventable, but increasing 
 and certain to increase with the progress of civilization, that by its arts 
 and charities stays the relentless and remorseless hand of Nature 
 from weeding her garden of humanity of the defective, superfluous, 
 and unprovided for. 
 
 Is this a gloomy outlook for the future of humanity ? Not for 
 him who has come to recognize humanity as a part and parcel of the 
 universe, harmonious in its co-relations, responsive to its own neces- 
 sities under all of the varying conditions of its historic development. 
 To such only as in their egotistic infidelity and short-sightedness think 
 that the conduct of the universe depends upon their action, and ap- 
 prehend immediate disaster should their schemes fail of accomplish- 
 ment, is the future ever beclouded. 
 
 Thus far the strong have been strengthened by bearing the 
 burden of the weak. When the burden shall have increased beyond 
 certain limitations there will be a response to impending necessities, 
 the character of which we need not now anticipate. Our duties are 
 immediate, and pertain to whatever is nearest to be done. What we 
 do constitutes the antecedents of sequences that we call the future; 
 to differ widely from results anticipated or predicted by those who 
 are the conspicuous actors of any given present time or generation. 
 
 215151
 
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