Who is insane!

Front matter

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BOUGHT WITH THE INCOME OF THE

SAGE ENDOWMENT FUND

Foreword

IN the year 1882 I was appointed the State Commissioner in Lunacy of New York by Gov. Alonzo B. Cornell. On assuming the duties of the office the Governor informed me there was a popular and growing belief that many inmates of the Asylums for the Insane were sane but have never had an opportunity to relate their grievances except to officers who gave little or no credence to the patients' statements. Therefore, he advised me to keep constantly in mind when visiting an Asylum the question, "Who is Insane?" In carrying out his Instructions I became quite obsessed with these three words and hence the title of this Book.

The insane of the State of New York, in custody, were at that time about 12,000 in number and were confined in State Asylums, in County Asylums, in Poor Houses and in private institutions. They were found in every condition hitherto known in the history of this unfortunate class from that of the pauper of the County Alms House, in filthy cells and stalls, shackled hands and feet, and fed like swine, to the kindly care, good food, clean, sanitary dormitories and freedom from cruel forms of restraint, of those in the palatial State Asylums.

The most important reforms effected by my service were: 1. The introduction of the Training School for Attendants; 2. The creation of a State Commission in Lunacy; 3. The removal of the insane from County to State care. The Training School raised the grade of qualification of attendants and has become a permanent feature of State institutions for the insane. The Commission in Lunacy has so reorganized the service of the former State Institutions for the Insane as to change them from Custodial "Asylums" to Curative "State Hospitals." The "State Care Act" permanently removed the insane from the beastly quarters and care of the "Poor-Houses" to the humane treatment of the State.

These three reforms have raised the standard of care and treatment of the insane in the State of New York to the highest grade yet attained. Nor is this reform limited to the "State Hospitals" of this State, but fortunately, their example is being copied so widely as to give the assurance that the time is not distant when the institutions for the insane in this country will take the first rank.

This Book is a commentary on my experiences as an official visitor of the Institutions for the Insane and the Charities and Reformatories of the State. Its intent and purpose are to illustrate with as few technicalities as possible the illusive nature of insanity, its origin in the

WHO IS INSANE J derangement of the functions of the brain-cells, the extreme impressibility of these cells and our power to increase or repress their activities. In these facts, which modern science has developed, are found the scientific principles on which the prevention of insanity, and its successful treatment, must be based. The same principles are shown to be applicable to the education of the mentally defective classes and to the reform of criminals.

This Book should prove helpful in the prevention of insanity at the different periods of life and hopeful of the time when biology shall be able to completely unfold the mysterious mechanism of the brain, physiology to explain the function of every nerve centre and psychology to interpret the significance of all mental phenomena. The Author.

January, 1916.

PART ONE Who is Insane and What is Insanity?

Chapter Page

I. Who is Insane? 17

II. Is There Any Sure Sign of Insanity? 31 III. The Diagnosis of Insanity at Sight. . 41

rV. What is Insanity? 59

y. How We Become Insane 71

PART TWO Critical Periods of Life Predisposing TO Insanity

VI. Childhood 95

VII. Adolescence 107

yill. Mid-Life 119

IX. Climacter 127

X. Old Age 137

CONTENTS— Continued

Chapter Page

XI. The Prevention of Insanity 147

XII. The Susceptibility of the Insane to

Curative Measures 153

PART THREE Care and Treatment of the Insane

XIII. Mechanical Restraint 171

XIV. Custodial Care 177

XV. Curative Treatment 183

XVI. Cure the Curable 193

XVII. Use the Usable 199

XVIII. Voices from the Asylums 209

XIX. State Care of the Insane 219

CONTENTS— Continued

PART FOUR The Lesson Applied to the Feeble-Minded AND Criminal

Chapter Page

XX. Extend Curative Methods to all the

Dependent Classes 233

XXI. Teach the Idiot and Feeble-Minded

Self-Care and Self-Support 239

XXII. The Treatment of the Criminal.... 249

PART FIVE A New Institution — The Dawn of a Better Day

XXIII. A New Institution 271

XXIV. Eugenics 283

PART ONE Who Is Insane and What Is Insanity? I

Who Is Insane?

Who Is Insane?

|H0 is insane? No one, or every one, according to the persons questioned. No one in an asylum will admit that he or she is insane. Each in turn would resent such an insinuation. Certainly no one out of an asylum will assent to the charge of being insane. And yet the sane and insane readily rec- No One or ognize the insanity of others. An Every One intelligent old lady, once the head of a Ladies' Seminary, wished to be discharged from an asylum alleging that all the patients in the Hall believed her sane. Seven women were privately asked their opinion as to her sanity, and all declared she was very insane, while asserting their own sanity. When informed of the result of the test, the old lady accurately described the special peculiarities of each of her accusers, but could not realize her own condition.

So it is in every community. The private gos- 17 sip is much concerned about those who are called "strange," "peculiar," "deranged," "unbalanced," "light-headed," "a-httle-off," "out-of gear," "wrong-in-the-upper-story," "cranks." Few, if any, escape for a life-time one or the other of these epithets. Without, as within the asylum, no one recognizes his or her own mental deviations, but readily detects the aberrations of others. It is an apt illustration of the old precept, "Let me pull out the mote out of thine eye, — and, behold, a beam is in thine own eye."

N the world at large, every advanced thinker,

enthusiastic reformer and popular teacher is

almost certain to be classed with the insane.

The friends of the Master said: "He is beside

himself"; St. Paul was declared "mad" by the

highest judicial tribunal; Advanced Thinkers Luther was charged with Classed as Insane hallucinations; Napoleon

had his guiding star; Byron was "erratic"; Wilberforce and Garrison were "fanatics." "Genius is a neurosis," says a French authority, and Dryden wrote, "Great wits are sure to madness near allied."

"The popular judgment of the insane is largelj' based on unjust prejudices," said an eminent alienist. It is true, whatever may be the explanation, that we have an instinctive dread of the insane, and shrink from contact or association with them. The sudden discovery that our companion, with whom we may have had an agreeable and profitable conversation, has an illusion, delusion or hallucination, however harmless, gives us at once an undefinable sense of discomfort, or, perhaps, of insecurity. We wish to escape his presence. His sane and sensible opinions on all current topics weigh nothing in our estimation. Failing in one particular mental function, we cannot believe that his judgment is reliable on any subject.

WHILE this feeling on our part is apparently instinctive because so universal, yet with many it has been intensified in childhood by that terror of the neighborhood, a crazy man or woman, whom the friends persist in retaining at home, confined in a garret

or other out-of-the-way Popular Prejudice place. "Run, boys, old Je- Against the Insane rusha is coming," was the

frequent signal of alarm in our boyhood days when one of our number saw the truly frightful figure of a woman, roaming in the fields, her outer dress thrown over her head, and a butcher's knife thrust under a belt about her waist. She proved to be a "terror by night" to all of the children of that vicinity during their lives, for she appeared ever after in all of their disturbed dreams.

Many have their fear and dread of the insane intensified by the occasional horrible crimes which they commit. Without reason we are disposed to accept the one act of a single person as characteristic of the reliability of ten thousand of that class.

When, however, we are brought into more familiar contact with the insane, and become interested in their special peculiarities of thought and action, a strange fascination may take the place of fear, giving rise to an intense desire to analyze and interpret their mental operations. Even "Old Jerusha" ceased to be a terror when we became more familiar with her history.

Personally, I came to be greatly interested in her visits to our home, though these visits were often made at midnight. She was very fond of my mother, and her tap on the door with the handle of her knife awakened me to a sense of security, rather than fear. Mother always cheerfully responded to her knock, invited her to come in, prepared a cup of tea, and, together, they discussed current neighborhood events. It was only when the course of their conversation brought to her thoughts her betrayer that Jerusha showed any considerable mental disturbance. At the thought of him, she would seize her knife, and, brandishing it over her head, excitedly exclaim: "If I ever meet him I'll bathe this blade in his heart's blood!" A touch of my mother's finger upon her arm, and a deprecating glance at the bedroom of the children, brought a humble apology and an immediate return of the knife to her belt.

WHEN, instead of observing the life of a single insane person, our duties lead us to study them isolated in a community, as they are found in asylums, a new and altogether different impression is made upon The Insane us, which not only supplants all in Asylum* fear or dread of contact with them, but gives every phase of their lives an interest of marvelous intensity. We seem to be among a people so like ourselves in many respects, and so unlike in others, that at first we experience a degree of mental confusion quite disturbing.

If the visitor to an asylum is an official, who is required to converse with every one who desires to speak with him, apart from officers and attendants, the impression that is made upon his mind becomes so pronounced that he cannot possibly escape the conviction that there can be no hard and fast lines drawn between large numbers of the sane and insane. He discovers that he is in a community of people quite as full of mental activities as the one he left in the outside world. Here he finds the same passions, emotions, conceptions and themes of conversation that occupy the people of the town. One is loitering along the hall like a man of leisure, another walks rapidly with knitted brow as if intent on business, a third is reserved or even morose, as if laboring under a disappointment, a fourth is talkative and mirthful, and laughs at every unusual event. Evidently each one has a special subject of interest to him or her alone, which occupies the thoughts to the exclusion of everything else. On this one topic the individual speaks freely and earnestly, and, whether correctly or incorrectly, certainly with entire candor.

My impression of the insane in asylums was, therefore, that they form a community not very unlike the ordinary village. There are in each the quiet, sober, thoughtful; the active, restless, excitable; the queer, peculiar, nondescript.

nPHE mental impression which a stranger to A the insane experiences, after a day spent in constant conversation with the inmates of an asylum as he meets them under varying conditions, is peculiarly confusing. For my own part I could not divest mj'self of Every One the impulse to regard and

Seemed Insane treat every one whom I met in the outside world as insane. Whether walking along the public street.

or entering a passing car, or stopping at a hotel, I could not escape the conviction that I was still among the insane. Involuntarily, I endeavored to determine from what form of insanity everyone with whom I conversed was suffering.

The more rational they appeared to be, the more closely 1 questioned them, in the constant expectation of discovering the carefully concealed clue to their mental deHnquencies. As never before, though quite unconsciously at the moment, I studied the peculiarities of each stranger and strove to detect in his or her features, dress, manner or acts, the latent evidences of an unsound mind. And it is true, I met many persons in the outside world, active in its affairs, who, on careful scrutiny, exhibited mental aberrations quite as distinct as did many of the inmates of the asylum. Especially was this true of perversions of the senses, as of seeing, hearing, smelhng, tasting, touching. WTiile in large numbers of cases the evidences of mental disturbance were readily recognized, in other cases the most careful and painstaking inquiry elicited no positive proof of a deranged mind.

BUT though I had become so inquisitive as to the insanity of others, I was altogether unprepared for the discovery that I was about to have my own sanity tested by an inmate of an asylum. "Who is insane, you or I?" was the

starthng question put to me

Who Is Insane, as I walked along the Hall,

You or I? pencil and paper in hand. I

was intently studying the peculiarities of others to determine the special features of their mental aberrations, but it had not occurred to me that, from the view-point of the inmates of an asylum, I might myself be a "suspect." I was not surprised at the first part of the question, "Who is Insane?" for that was constantly uppermost in my own mind. It was the entirely unexpected application of the inquiry to myself that created momentary mental confusion.

My querist was a young lady who had been a prominent teacher in a seminary for young ladies. Her mobile features, quick movements, excited manner and rapid speech indicated a highly organized nervous system. The mincing manner of her approach, the sarcastic smile and the attitude of expectancy which she assumed, her head being poised on the tip of her finger resting on her cheek, showed that she anticipated the embarrassment which her question might create. Other patients, who heard the question, quickly gathered about us, all evidently intent on hearing my answer.

At a loss for an explanation which would not offend so sensitive an audience, I hesitated a moment, and then replied: "Why you, of course, are insane." She slowly and thoughtfully repeated my words, and added in the same strain, "You, of course! Why, 'of course?' Do you see insanity in my features?" Taking a small mirror from a stand, she moved it before her face, saying: "WiU you be so kind as to teach me how to examine a person's face and discover what may be his mental condition?" She placed herself in different attitudes, holding the mirror in different positions, and making ludricous grimances, greatly to the amusement of the by-standers. She continued: "If you will teach me your occult art, I should be delighted to be able to say to anyone I meet: 'Why, of course, you are insane.' If I become as expert as you think you are, and had your assurance, I might even say to you, 'Why, you, of course, are insane.' "

The interview was becoming decidedly personal, and the patients gathered around us were excited by the shrewd turn of her remarks, and boisterously applauded the points which she made against me. I attempted to bring the colloquy to a close, but she spoke so rapidly that I could not interrupt her, until I turned away, when she apologized for what she said I might regard as rudeness, but which she felt was the proper improvement of a rare opportunity to express her opinions.

"You altogether mistook the meaning of my reply to your question," I said, with as much composure as I could command. "I did not and could not decide as to your sanity or insanity by any peculiarity of your features, nor for anything noticeable in your personal appearance, for, in these respects, I see no difference between you and many whom I meet in the streets. It occurred to me, at the moment, that I should make no mistake in my answer if I said 'You, of course, are insane,' for this reason, the law provides that only insane persons shall be confined in asylums for the insane, while the sane are rigidly excluded. Now, as between you and me, you are legally confined in this asylum, and I am legally excluded; therefore, when you called upon me for a decision as to 'Who is insane, you or I,' I could promptly and truthfully say, 'Why you, of course, are insane.' "

"Ah, I see how you work the problem," she said. "In an asylum, insane; out of an asylum, sane; it's the same old story of the ins and outs, with this difference, that the ins are anxious to get out and the outs are anxious not to get in."

Assuming a defiant attitude, she sneeringly said: "This whole business of locking people in these prisons for life, because some fool of a doctor says they are insane, is a contemptible and transparent fraud. You admit that if you had met me in the street, or in the cars, or in a hotel, you would have declared me sane, but happening to meet me in this asylum you promptly and audaciously pronounce me insane. On what a slender thread hangs our destiny!"

With a graceful wave of her hand and a low bow she withdrew to her room, leaving me to my reflections.

She had propounded one of the most profound questions known to science and had made a declaration of immense social significance. "Who is insane, you or I?" is a question which confronts us whenever we look into the eyes of our fellows. And, truly, on what a slender thread hangs our destiny, when we may be committed to an asylum for a lifetime because we differ in thought, word or action from another, whose mental integrity has never been gauged by any absolutely correct standard !

II. Is There Any Sure Sign of Insanity?

n

Is There Any Sure Sign of Insanity?

STUDENT of the famous alienist, Esquirol, inquired of him, "Is there any sure sign by which the insane can be distinguished?" He repHed, "Please dine with me to-morrow at six o'clock." The student complied. Two other guests were present, one of whom was elegantly dressed and apparently highly educated, while the other Apparent Insanity was rather uncouth, noisy of Balzac and extremely conceited.

After dinner the pupil rose to take leave, and as he shook hands with his teacher he remarked: "The problem is very simple after all; the quiet, well dressed gentleman is certainly distinguished in some line, but the other is as certainly a lunatic and ought at once to be locked up." "You are wrong, my friend," replied Esquirol with a smile. "That quiet, well dressed man who talks so rationally has for years labored under the delusion that he is God, the Father; whereas the other man, whose exuberance and selfconceit have surprised you, is M. Honore de Balzac, the greatest French writer of the day."

A MORE remarkable misadventure, recorded on the authority of the distinguished writer, Aurelien SchoU, befell not a student but a shining light of medical science, Legrand du Saule, one of the acknowledged authorities on mental diseases in The Case of Paris. A well-known man of let-

Renan ters, feeling uneasy about a

daughter who showed some signs of eccentricity, was anxious to get the opinion of this specialist without arousing her suspicions. For this purpose he concluded to give a dinner to which de Saule and several other celebrities were invited. It was a feast of reason and the flow of soul was full and free. Legrand du Saule took little part in the conversation, but listened attentively and used his highly trained powers of observation.

Toward the end of the dinner he leaned toward his host and whispered : "You may make your mind easy about your daughter. She is suffering from nothing more serious than a trifling nervousness which will pass off. But I think it right to tell you that there is one of your guests whose mental condition is distinctly alarming, and, I fear, hopeless." Being asked who this was, the oracle said : "That stout gentleman yonder, with the look of a canon, who is laughing so heartily." The man who was thus enjoying himself, all unconscious of the doom pronounced upon him, was Ernest Renan.

LORD Erskine, who as Lord High Chancellor of England, had supervision of the insane, received several letters from an inmate of an asylum, alleging false commitment. The letters were so well written that the Chancellor requested the superintendent of Insane on the asylum to bring this patient One Subject to him for his personal examination. The patient proved to be a very gentlemanly person, and in conversation on a great variety of subjects showed unusual intelligence. Turning to the superintendent, the Chancellor expressed his surprise at the detention of a gentleman whose mind was so well balanced and so free from delusions. The superintendent requested the Chancellor to ask his visitor, "Who is the King of England?" On putting this question, the conduct and attitude of the man suddenly changed, and, rising and assuming a proud air, he placed his hand over his heart, saying: "I am the King of England, and you are my Lord Chancellor." I conversed with a man who spoke readily and very intelligently on a variety of subjects. I could detect no defect in his views on whatever topic we discussed. Noticing that in the intervals of our conversation he looked at a tree-top and smiled, I asked him if he saw anything in the tree. "Why, certainly," he replied, "don't you see the two women in the tree, one above the other, and both smiling at us?" I confessed my inability to see them, though at his suggestion I took different positions. He ceased to converse, but in sotto voce declared "everybody is in the conspiracy."

A SUPERINTENDENT requested me to examine a certain patient and inform him as to the man's sanity. I spent an hour or more in conversation with him and we discussed a great variety of subjects. He was very intelligent, humorous and inquisitive. The Effect and I could discover no sign of of a Word mental confusion or disturbance. On reporting the fact to the superintendent he suggested that while conversing with him I should incidentally say, "Telephone." On the following day, while passing through the hall in which this patient was confined, he came to me and we again entered into conversation, the topic which most interested him being current political events. In an interval I spoke the word, "Telephone," at which he became excited and declared that I was one of the conspirators. On inquiry I learned that he never showed any signs of mental disturbance except when that word was spoken in his hearing. He had been employed in an establishment in the constant use of a telephone, then a new and novel instrument.

On visiting a county asylum one hot summer day, I found a very efficient man in charge. The patients were all in the field and he was alone. The little isolated asylum building for the insane was in excellent condition in every part and I spent some time with the attendant conversing on matters relating to inmates and the management of the almshouse, about which he was very well informed.

On finishing my inspection he invited me to his room, and on entering he locked the door and put the key in his pocket. To my inquiry as to his training for his present position, which he seemed to fill so acceptably, he replied, with marked emphasis, that God was his only instructor; that he was in immediate communication with Him and never took any advice from man or woman, but always followed His instructions. I asked if God should instruct him to punish one of the inmates would he do so without consulting the superintendent. "Certainly," he replied, and raising the cover of his desk he showed me a whip, a sharp pointed knife and a pistol.

Looking at my watch, I arose, expressed my surprise that it was so near train-time and moved towards the door, complimenting him meantime effusively on his devotion to his duties and his reliance on God. I was immensely relieved when he took the key from his pocket, opened the door and gave me free access to the outer world. For years this man continued to do excellent work as an attendant, and it was only when allusion was made to this one matter of his source of instruction that he showed any symptom of insanity.

THE preceding illustrations seem to prove that there is no sure sign by which the insane can readily be detected. "While the grosser forms of insanity are easily diagnosed, there are vast numbers of cases that require the most careful and prolonged ob- No Sure Sign servation to determine the speof Insanity cial phase of aberration. In some cases only allusion to a certain thing, subject, or person will cause the insane to reveal their illusions, delusions, or hallucinations.

The explanation of the apparent anomaly, that there is no sure sign of insanity, is found in the following facts : — The brain being a complicated mechanism, as will be shown in a subsequent chapter, any one of the innumerable parts may become deranged in its action. The effect of such derangement may be hmited to a change in the function of that part chiefly, or it may involve a change in the action of many parts closely allied in physiological activities.

It follows, as in any mechanism, that the evidences of mental derangement will be more or less obscure or pronounced according to the functional relations of the part in which the disturbance began. We may derange the striking apparatus of a clock without affecting it as a correct time-piece; but if we change the action of the pendulum, we can no longer rely upon the clock as a measurer of time. So, in the action of the brain (though in a much larger sense owing to the enormous number and intricate connection of its parts), the speaking of a certain word may be the only method of eliciting the derangement. The entire mental operations may be deranged by the entrance of a poison into the blood, which would affect large sections of the brain.

m

The Diagnosis of Insanity at Sight

Ill

The Diagnosis of Insanity at Sight

REMARKABLE exception to the preceding proofs of the difficulty of diagnosis of insanity occurred in my personal experience and is worthy of record in this connection. That an insane person may be recognized at sight by an expert was demonstrated in the famous trial of William Freeman, the murderer. I happened to be a witness of the A Dramaticincident, which was highly dra- Episode matic in all of its details. In an instant and without warning the large gathering of excited spectators, all intent on the question at issue, the insanity of the prisoner, found the issue shifted to itself by the demand of the prosecution that the learned expert witness on the stand should point out an insane person in the audience. The trial was at Auburn, New York, and it happened that I attended the court at that critical period.

"What ! Do you affirm that you can diagnose insanity at sight?"

"I do," was the calm, dignified, but emphatic response.

THIS question was put by John Van Buren, Esq., at that time Attorney-General of the

State of New York, and was answered by

Dr. Amariah Brigham, Superintendent of the

Utica Asylum for the Insane. The incident was

remarkable for the intense pop-

The Freeman ular interest in the results of the

Case trial, the scientific questions in-

volved, and the eminence of the now historical personages engaged in its management. This occasion was the trial of William Freeman, a negro, for the murder of the Van Ness family in the vicinity of Auburn, Cayuga county, New York, on the night of the 12th of March, 1846. The frightful tragedy was thus described in a local paper :

"William Freeman, a negro, a native of Auburn, who has recently been discharged after five years' confinement in the States Prison, having provided himself with weapons, proceeded to the house of John G. Van Ness, in the suburbs of Auburn, and there, without notice and without any apparent motive, slew Mr. Van Ness, a wealthy and worthy citizen, Mrs. Van Ness, her sleeping infant, and her aged mother, and wounded mortally, it is believed, the laboring man who dwelt with them, leaving only the maid servant of the family, and she had only been spared because he had been disabled in the affray."

The murderer was arrested and confessed the perpetration of the crime, but showed no signs of regret; on the contrary, he freely described the incidents of the murder, and laughed continually during the recital. The incensed and excited pubUc saw in his strange acts and unaccountable conduct, together with the entire absence of motive for the crime, grounds for the behef that he might escape punishment on the plea of some wily lawyer that the prisoner was insane. Crowds of excited people gathered about the jail determined to seize the prisoner and lynch him, but the sheriff adopted such precautions that no serious effort was made at a rescue. But popular feeling now took another form. It was determined to resist to the last any effort that might be made to secure the escape of the criminal under cover of alleged insanity. The greatest vigilance was maintained over every movement in the legal proceedings in order to prevent that issue. What made the apprehension that this question would be raised more decisive was the circumstance that only a month previously a murderer had escaped the lawful punishment of his crime through the plea of insanity interposed by his counsel, William H. Seward, Esq. Tljere was, indeed, a wide-spread belief that the criminal in the Van Ness tragedy was emboldened to perpetrate murder owing to the results of the recent trial. The excitement of the public was in some measure allayed by the remark of a prominent Judge that the prisoner would not escape conviction by any plea or defense of Seward.