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greater portion of the idiot's early training, and can best be accomplished in our institutions by making their daily lives conform as nearly as possible to that of the normal child, especially as regards diet, exercise, diversion, and sleep, all of which must be persistently directed and diligently guided from without, because of a lack of inherent stimulus to incite and will or inhibition to guide, the automatic movements especially being controlled, and this energy directed along normal lines.
And here I wish to lay special stress on two mutually interdependent processes, namely: first, proper physical exercise, realizing how persistently inactive or pervertedly active idiots often are, when allowed to follow their own tendencies, and how thoroughly active are normal children during their waking hours; and, second, proper sleep, which some one has beautifully called “ ure's anæsthetic, through virtue of which the animal economy is for a certain portion of each day placed wholly in her hands for the reception of her remedial and restorative agents.” These processes when normalized are two most potent factors in the production of sound physical health : the former, physical exercise, tending as it does to bring about normal circulation of blood and lymph, thereby tending to create a normal appetite and prepare the gastro-intestinal tract and digestive organs for the proper reception and digestion of food (here proper feeding and mastication should not be neglected, these contributing toward normal assimilation and excretion, the final result of all being normalized nutrition, growth, and development); and the latter, sleep, tending to render normal the proportion between destruction and construction metamorphosis of tissue, which, during the period of most active growth, with longer hours of sleeping than waking, gives us a balance on the side of construction.
This routine should be based on a study of the daily lives of normal children, paying special heed to their family constitution and disposition, both in the study of the normal children and in the application of the results of such study to the training of the idiot.
In special cases of disease and faulty development, notably in the myxedematous types and deformities resulting from muscular contractures, improper innervation, etc., special treatment will be necessary, of which dietetic, medicinal, and surgical will constitute only a part, electricity, hydropathy, and massage being valuable
adjuvants, not only for their local but also for their constitutional effects.
This mode of procedure will necessitate our ascertaining as completely as possible the family history and the past history of the patient (for such we may truly call the idiot) and directly following admission, making a thorough physical and mental examination and recording the condition of all organs and parts and the bodily and constitutional condition as a whole. This may all be richly supplemented by photographs.
Following this, after they have become accustomed to their new environment, another complete physical and mental examination should be made for purposes of comparison, this change of environment alone, with no special treatment or training, often producing marked physical and mental improvement.
All the physiological processes should be closely watched, and their condition with the physical and mental regularly recorded at stated intervals. These records will be of great value, not alone because of their direct bearing in the case at hand, but also because they will show us how closely physical and mental improvements are allied, and will be valuable data from which to deduce statistics and for consultation and comparison in future work.
And thus, through efforts directed toward the production of sound physical health, our idiot has arrived at that stage in his development where he is ready for manual and intellectual training, especially the former, his moral training having begun much earlier, and which must with his physical training still keep pace with all other training.
Now, as we improve these processes of growth and development in the child, we must broaden his capacity for mental training, not alone because we have increased the physiological activity of the brain and receptive capacity of the mind, but also, by improving his physical and mental state, we have likewise broadened his horizon by rendering him competent to a limited extent to commingle with society, a training and educational factor not without its bearing even upon the life of the idiot.
6. METHOD OF SECURING HEALTH OF INSANE
BY H. E. ALLISON, MEDICAL SUPERINTENDENT MATTEAWAN STATE
HOSPITAL, FISHKILL-ON-HUDSON, N.Y.
[Read Wednesday evening. ]
The treatment and care of the insane require an intimate knowledge of the mental and physical condition of the person afflicted. He is suffering from disease, and needs the help of a physician.
The rules which govern most penal institutions are very general, and largely disciplinary in their character. They apply to numbers more than to individuals, and are framed to control sane men. The inmates are sentenced for definite terms, which may be reduced to shorter periods of imprisonment by good conduct, which is a negative quality, and simply implies nonviolation of rules applying equally to all. On admission to prison the convict's record is briefly tabulated as to his crime, length of sentence, previous convictions, and a short personal history; and he becomes a part of a mass of humanity, in which his individuality is very largely lost. In institutions where the reformatory system is in vogue, and to which youths are committed for indeterminate periods, much has been done to remedy this evil. There the inmate is expected to earn his discharge by individual effort in positive work. He must achieve something. Still, even in reformatories, general rules are made applicable to classes and to grades rather than to persons. No exceptions are made to favor those mentally weak. Organization, I presume, requires this; and perhaps it fits the majority. Still, it is our belief that the courts and the prisons will ultimately come to consider the individual more carefully than they do at present. The danger from the man will be weighed rather than the danger from the crime. Progress will be made in the direction of more thorough sifting, weeding, and differentiation of the various units which compose the mass of criminals. The treatment of insane
convicts comes within the province of medicine; and, like the care of all disease, it requires the most painstaking knowledge of each individual case. All varieties of insanity are found among convicts. Their delusions, hallucinations, and conduct are modified and very strongly marked by their criminal habits. For this reason they constitute a less tractable and more dangerous class than the ordinary lunatic. Like all the insane, they are in constant need of medical care and treatment, not necessarily active dosing in every case, but each requires at least some daily observation. The best method of securing to the insane convict good health varies with the nature and cause of the disease; but he primarily requires hospital treatment, which cannot be adequately given within the limits of the prison.
The origin of insanity among convicts may be classified : first, as arising, outside of prison life, from factors of ill-health which leads to the commission of some insane act, in itself a criminal offence; second, from causes mainly due to conditions within the prison, attendant upon confinement and constant reflection upon the consequences of crime; third, from mixed causes dependent upon influences both outside and inside prison walls. The members of the first division, properly speaking, are not criminals, although convicted and sentenced. This class consists of persons who, by some insane act, have broken the law, and have been improperly convicted therefor. They enjoy, as a rule, a good degree of physical health, and possess a large share of mental development. On the average, they are well endowed intellectually. They are not naturally inclined to criminal acts, and may be termed accidental criminals. Their crime is the result of disease. Among them may be included cases of chronic mania, paranoia, toxic insanity from alcoholism and the abuse of drugs, paresis in its early stages, melancholia, some forms of epilepsy, cases of dementia; in fact, all varieties of insanity. The foreign element of our population enters largely into this class, wherein, from the difficulties of language, insanity is not recognized during trial. In some cases, even among the nativeborn, the existence of mental disease is not suspected; and convictions are had, and sentences passed upon insane men whose true state has not been apparent at the time, even to their own counsel. The majority of such convictions, however, are found in cases wherein the plea of insanity has been raised as a defense, and failed. In these instances the derangement of the mind
becomes evident after confinement. Such convicts in New York State are
soon transferred from prison to the Matteawan State Hospital. As a rule, they are not encouraging cases for treatment. Paresis is generally recognized in the present state of our knowledge to be a progressive and fatal disease; and paranoia, chronic mania, and epilepsy are usually intractable. Melancholia and some cases of confusional insanity, especially among foreigners, and the toxic insanities, such as alcoholism and cocainism, offer the best chances of cure. Many persons who are utterly unable on admission to give a coherent account of themselves, upon convalescence often disclose their history and identity. Five such were returned to foreign countries last year from the Matteawan State Hospital, and three to their homes and friends in other States. While confinement has no causative relation to the production of insanity in the examples to which we have alluded, yet the surroundings intensify the disease; and the prison offers no proper facilities for treatment. The crimes committed by them are mostly directed against the person. Their acts are often homicidal in their nature, by reason of delusions of persecution ; or they may become noisy, maniacal, and threatening. So long as they have the liberty of the prison yard or corridors, they are a menace to the safety of other inmates, or, if excitable, may disturb several tiers of convicts by their clamorous outcries, and injure the discipline of the prison. Their proper place is in a special hospital for the care of insane convicts under the treatment of a physician. The conviction of persons who were insane at the time the act was committed is an injustice to them, and their confinement as felons increases their mental derangement. The removal from prison to a hospital exercises a beneficial effect upon them. They may be dangerous, but they are not criminal. They are dangerous by reason of their insane delusions, which impel them to acts injurious or destructive to property or life; but they are not morally depraved. It is important that every facility should be given to effect recovery. A hospital for the treatment of such cases should be an adjunct, in a collective sense, to all the penal institutions of a State. It may be in proximity, but should not be attached to any prison; and its management should be an independent one on the plan of a hospital, and under a medical superintendent who should be the responsible head. One such hospital could receive all cases of insanity from several penal institutions, and so might care for all insane convicts in the State.