HX64077608 RA982.B65 M386 The early history of 1ENTS of the writer. THE EARLY HISTORY McLEAN ASYLUM FOR THE INSANE. A CRITICISM OF THE REPORT OF THE MASSACHUSETTS STATE BOARD OF HEALTH FOR 1877. MORRILL WTMAN, M. D. [Reprinted from The Boston Medical and Surgical Journal, December 13, 1877.] CAMBRIDGE : $rinte& at tfje &te£itie $re££, 1877. RECAP RA^.Bfcf- M 386 Columbia (Hnitier^ftp mtijeCttpofUkttigork COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/earlyhistoryofmcOOwyma Ik W 0t2~ First Physician and Superintendent of the McLean Asylum for the Insane. at Woburn, Mass., 1778; D. at Roxbury, Mass., iE THE EARLY HISTORY OF THE MCLEAN ASYLUM FOR THE INSAKE. A CRITICISM OF THE REPORT OF THE STATE BOARD OF HEALTH FOR 1877. BY MORRILL WTMAN, M. D. The Report of the State Board of Health of Massachusetts for the present year contains an article, by Dr. Charles F. Folsom, secretary of the board, entitled Disease of the Mind. Its principal object, in the words of the general report of the board, is to show, " by citing well- known historical facts, that during the past century very great strides have been made in the treatment of mental disease." After quoting from the reports of Dr. Bell and of Dr. Earle, made in 1847 and 1848, with regard to the very few instances of personal re- straint of the insane under their care, Dr. Folsom makes the following statement. The paragraph is quoted entire. " With all this, the excited insane were found by a committee of our legislature in 1848 to be at the Worcester Asylum even in small rooms, ' having the least advantages for light, none for ventilation, unfavorably located, dark, dreary, damp, and uncomfortable to that extent as to aggravate rather than to assist the cure of the unfortunate beings placed there ; ' the male violent insane at the McLean Asylum, then considered one of the best, were kept in stone cells in the cellar ; and this simply indicates the general knowledge of the time. The position and condition of the more quiet of the insane in asylums were very much better of course ; but it was reserved for further study and experience to show that the most violent may be treated to a certain extent in a similar way." 1 Many persons, medical men and others, have received from this state- ment very erroneous impressions as to the apartments and treatment of the violent male insane at the McLean Asylum. If these impressions were well founded it would be a stain upon the reputation of those who instituted and continued such measures, and upon the board of trustees, for whose fidelity and judicious care of the asylum from its foundation it would be hard to find a parallel. 1 Board of Health Eeport for 1877, page 353. 2 The Early History of the McLean Asylum. I have therefore thought it best to correct the errors of statement in the above extract by a carefully prepared description, with drawings, of the building occupied by the violent male insane, and also to show what was the state of knowledge with regard to insanity and its treatment generally at the McLean previous to the period referred to. I am impelled to do this not only because the statement is a part of the report of the State Board of Health, and has been distributed as such, but also because it has been distributed in a separate pamphlet, with an authority which would not have attached to an individual writer. It may be here remarked that I have more than a general inter- est in correcting these errors. My father, Dr. Rufus Wyman, was appointed in 1818 the first physician and superintendent of the asylum ; in 1835, after seventeen years of service, his health failing under the care and anxiety inseparable from such an institution, he resigned. My early life and a part of my medical pupilage were spent there. I may therefore be presumed to know something of its history. When my father entered upon his duties he found buildings already erected. They consisted of a large and elegant house, the mansion of a gentleman of wealth, to which the trustees of the hospital had added two wings, each seventy-six feet in length by forty in breadth. The em- inence upon which these buildings stand is remarkable for its beauty, and although, in the words of the trustees, " the situation selected ap- pears to unite every practical advantage," it is much too small to admit of the proper arrangement of the buildings on the same level. The wings, as originally built, not differing materially in plan from hotels, are on a level several feet lower than the mansion. The buildings since added are necessarily on a still lower level. This abrupt slope, although it has some advantage and gives excellent opportunity for drainage, has compelled a crowding together of the different structures not desir- able, and no little skill and ingenuity have been required to obviate to the present extent this objection. " The male violent insane were kept in stone cells in the cellar." How far this statement correctly represents the facts it is now proposed to examine. The apartments occupied by the violent male insane in 1848, the rooms to which the report refers, are known at the asylum as the " strong rooms," and are four in number. They are in a brick build- ing, fifty-four feet by twenty-three feet, called the " lodge " or " re- treat; " it stands at the east of the mansion and quite detached from it. It was planned by my father and built under his direction in 1826. I have his original memoranda and manuscript plans, with a report to the trustees in March, 1825, on additions to be made to the asylum, of which this building was one. When the " lodge " was built, the McLean Asylum, which was the The Early History of the McLean Asylum. 3 first in New England, had been open eight years; during this period it had received a larger proportion than ever since of patients from jails and almshouses, where they had no proper care. Some, neglected by those who had charge of them, were filthy and noisy ; treated for years like lower animals, they came to resemble them in many of their habits ; they had no proper rooms, and suffering from cold in winter were often confined in cellars ; their keepers, glad to be rid of them, sent them to the newly opened asylum. Subsequently, the earlier removal of the insane to asylums probably much diminished the number who fell into this dreadful condition. The " lodge " was originally of two stories, the upper intended for idiots and epileptics, those who were objectionable in their habits or subject to sudden outbreaks of frenzy. In this story the rooms were arranged as to warming, ventilation, and lighting as in the story below ; the floor was to be warmed by steam or hot air circulating in channels beneath it. These apartments, however, were never finished, the num- ber of patients requiring them having lessened. They were afterwards remodeled ancTfitted for a different class of persons. The rest of the " lodge " is in the main as originally built, with the exception of an upper story added by Dr. Bell in 1850. The lower story contains the " strong rooms." These are now as when first built, except the front walls, which were removed last year when the building was transferred to the steward's department. The class of boarders formerly occupying them is now in the " Bowditch ward " for excited cases. It should be distinctly understood that these rooms were exclusively for those unfortunate persons, some of whom are to be found in most large asylums, who at times are violent and noisy, who destroy their clothing, their bedding, even to the very mattresses on which they sleep, who defile their rooms in every possible way, — the most violent male insane. No others were ever placed in these rooms. Their number is small ; these four rooms were more than sufficient for one hundred and fifty male boarders at the McLean. Mr. Tyler, for more than thirty years con- nected with the asylum as attendant, supervisor, and steward, a highly valued officer, assures me that more than two rooms were never known to have been occupied at the same time. But small as the number is, even if it be but a single individual, he should be provided for in the manner best suited to his individual case. How this is to be done has been a difficult problem, and it is likely always will be. Reasoning and persuasion can avail nothing. They may be drugged with narcotics, but experience has decided against this plan for any length of time. Some would have them kept in apartments similar to those of the more quiet, and in their vicinity, holding and restraining them by sufficient manual force ; others think they should be secured and prevented from. 1 The Early History of the McLean Aaylum. doing mischief to themselves or others by means of manacles, strait- waistcoats, camisoles, muffs or mittens, as producing less desire for re- sistance than when opposed by manual strength. But neither of these plans prevents noise and filth, which render them utterly unfit compan- ions for the more quiet. Others, again, prefer to abolish all restraint upon the limbs, and while the paroxysm lasts leave these most unfortunate sufferers in proper apartments, where they can be made safe, and as far as possible comfortable, allowed the full exercise of their limbs, and where neither their noise nor their habits will disturb any one. This last is the method adopted by my father at the McLean. It was to carry out this method that he urged upon the trustees in 1825 the immediate erection of the " lodge." Its use was continued during the adminis- tration of Dr. Bell, who succeeded him at the asylum in 1836. In consequence of the formation of the ground, as above described, one side and one end of the lower story of the " lodge," for about one half its height, stands against a retaining wall. The other side (the front) and the other end opened upon an airing court fifty-seven by fifty; the floor of the " lodge " generally is two feet above the surface of the ground, the western end somewhat less, the ground falling off from the building in both these directions. On this floor, at this height above the surface of the ground, and in the front of the building, are the " strong rooms." Below the floors of these rooms is the cellar, about seven feet deep, ex- tending under the whole building. This cellar is well lighted with windows on the front and end, paved with bricks, well ventilated, and every part clean and whitened. Here is the furnace for heating the air for warming and ventilating the " strong rooms " above, and also the especial arrangement for warming their floors. These " strong rooms " nowhere come in contact with the external walls ; they are completely surrounded by corridors about five feet wide, properly ventilated and warmed, summer and winter. They are lighted by windows in the front wall, and also by smaller windows on the opposite side. The " strong rooms " are eleven feet by seven and a half on the floor, ten feet in height, the ceiling an elliptic arch, with a ventilating flue in the centre. They are entered by doors from the corridors, and lighted through un- glazed windows about two feet square, never closed in any way. Directly opposite these windows are the large windows, about three by five feet, in the front of the building, opening upon the airing court. In the cor- ridor are doors by which each room is completely separated from the others, and sound cut off as much as possible. Each room can be reached without passing any other. The walls, like those of other rooms in the asylum, are of brick plastered with Portland cement, made as smooth as possible ; the corners are rounded for cleanliness, as has re- cently been done for the new wards of the Massachusetts General Hos- pital. In one corner is a close-stool communicating with the corridor The Early History of the McLean Asylum. 5 through the side of the room ; in two of the corners, are seats properly fastened to the wall. The floor is of granite slabs, eight or ten inches thick, smoothly hammered, and laid in cement. This floor is inclined towards one corner of the room, that next the corridor, where there is a proper outlet and waste-pipe. This secures the immediate draining away of water during the washing of the floor, of necessity frequently repeated with this class of patients. Notwithstanding the ample preparations for ventilation and wanning the air of the rooms and corridors, it was deemed essential that the floor also should be well warmed. To do this effectually and equably is a matter of no little difficulty. To be comfortable to those without cloth- ing it should have a temperature of about 100° ; this degree of warmth cannot be obtained from air fitted for respiration. In these " strong rooms" the difficulty is met by warming the stone floor by a fire be- neath. It had already been successfully tried in a room in the asylum (it was not of stone nor in a cellar) fitted up for patients of this class. The fuel was burned in a proper fire-place, and the heated gases, after circulating through the whole space beneath the floor of the rooms, es- caped by a chimney. The floors were thus warmed night and day, summer and winter, the thick slabs of granite keeping up an equable temperature hardly to be obtained in any other way. This method of warming is by no means new ; it is essentially that of the ancient hyp- ocaust, used two thousand years ago at Pompeii, as is fully shown by the excavations and also by the drawings upon the walls of the baths in this favorite watering-place of the Romans. In Pompeii the walls and ceilings also were hollow and warmed by the same fire. Adjoining the main corridor is the bath-room, and near that the room for clothing. The interior of the rooms is as plain as possible, but in other parts there is as much of architectural ornamentation as the use of the build- ing will allow. The room for the attendants is at the head of the stairs directly over the " strong rooms," where they can be within hearing of their charge and reach them at once either night or day. The drawings give in plan and section the details of the " lodge." It appears from this description, which I have endeavored to make accurate, that the " lodge " had an airing court fifty-seven by fifty for the use of the patients. That the strong rooms are quite open and above ground on two sides ; on the other sides they are partially belcw the surface ; on all sides they are surrounded by corridors well lighted, well warmed, and ventilated. They are themselves fully lighted and warmed by two methods, each independent of the other; they are nowhere within five feet of the external wall, and have below them a cellar seven feet deep, also well warmed, lighted, and ventilated. A room 6 The Early History of the McLean Asylum. so situated, having but one of its six sides of stone, can hardly be de- scribed with scientific exactness as a " stone cell in a cellar." Few- persons would suspect from the report of the board the true position and construction of these rooms, the amount of skill, thought, and ex- perience which have been bestowed upon them, nor the degree of safe custody and comfort, without restraint upon the limbs, that they have brought to those who occupied them. I am quite sure that on no other part of the asylum did the physician exercise more fully his great talent for contriving and executing accommodations for the insane than here. This his numerous plans, sketches, and memoranda clearly show. I am equally sure that no patients received more care, or were more con- stantly in his thoughts, than the unfortunate persons for whom it was designed. It cannot be said of these rooms, as is said in the report of 1848 of those in the Worcester Asylum, that they are " rooms having the least advantages of light, none for ventilation, unfavorably located, dark, dreary, damp, and uncomfortable." It may be interesting to know that when the report of the commit- tee of our legislature in 1848, just referred to, was made, new strong rooms for females were being erected at Worcester from money appro- priated by the State, and in 1850, these having been found good and well suited to their purpose, similar rooms were built for males ; they were substantially imitations of the strong rooms of the McLean. The idea that these rooms are in the cellar may have arisen from the fact that they may be reached in two ways : either by entering the left wing at the second story from the level of the ground of the centre house or mansion, and descending by the stairs to the level of the cellar of the wing ; or they may be entered directly from the airing courts, above which they are raised by the usual underpinning of two feet, as is clearly shown by the elevation and section. The lower story of the new Bowditch ward, for excited patients, may be reached by an under- ground passage descending from the floor of the " lodge " by seventeen steps, but it is also entered directly from its airing court, the floor of the two buildings being about equally raised above their respective courts. The new Worcester Asylum, now nearly finished, owing to a similar formation of the ground, has a retaining wall of about half the height of that at the McLean, against which the rooms for the excited patients are placed. By no proper use of language can either be said to be in a cellar. The size of the " strong rooms " as compared with rooms for excited patients in some other asylums deserves notice. At the Danvers State Asylum, now just finished, the rooms for excited patients, according to the official report, are seventy-two in number, each twelve feet long, eight feet wide, and eleven and one half feet high ; at the McLean they are eleven feet long, seven and one half feet wide, and ten feet The Early History of the McLean Asylum. 7 high ; at the new Worcester State Asylum, nearly finished, they are ten feet long, eight and one half feet wide, and eight feet and eight inches high ; the cubic space for each patient at the Danvers is the greatest, the McLean next, and the Worcester least. The materials of which the walls of the several rooms in these three asylums are constructed are substantially the same : in all they are of brick ; at Danvers and the McLean, plastered with Portland cement in the neatest and smoothest manner ; at Worcester, of bricks painted, without plaster. The McLean is the only one with rounded corners. The floors at Danvers and Worcester are of wood, not warmed ; those at the McLean are of stone, warmed. The McLean " strong room " was provided with a comfortable mat- tress, or, if this were destroyed, with the best materials as a substitute that could be found. It had seats and a close-stool. By a strict rule of the asylum these rooms were the first visited in the morning. Every morning before breakfast the patient was bathed and placed in a similar adjoining room. Everything which had become soiled was removed, the room well washed, and the walls and floor carefully cleaned with transparent lime-water, which left the walls free from odor and visible lime deposit. The warm stone floor, besides the comfort it gives, must, in a sanitary point of view, be considered the best. It does not absorb offensive matter of any kind, — a very important fact if faecal matter is the source of so much " germ disease," as sanitarians now assert ; it is quickly dried, and again fit for use. If really better than wood it should not be rejected because of its apparent harshness, and it would not be if we consider for a moment the condition of the pa- tients. They have been accommodated elsewhere as long as possible. They are violent and raving in their excitement or delirium, pay little attention to their surroundings, and are so wanting in regard to the common decencies of life that, for the quiet and comfort of others as well as of themselves, their temporary seclusion has become a neces- sity. As to the floor itself, it is practically no harder than a hard pine floor ; neither yields to the pressure of the body. Dr. Bell, in his report for 1839, after more than ten years' experience, says of these patients : " There are, it is true, certain cases where the mind is so frenzied and chaotic that the individual is reckless and uncon- scious of what he does ; here the provision of a suitable lodge room with stone floor, warmed by steam or hot air below, without glass or mov- able furniture, is the best and kindest appliance which can be adopted for a few days until medical and soothing treatment can place the suf- ferer in a condition to be operated upon by moral means. We never have had occasion, since the institution has been under my care, to use strong rooms as places of permanent detention, a few weeks being the extent of time which they have ever been occupied by a single person." 8 The Early History of the McLean Asylum. The following letter from the eminent alienist, Dr. Isaac Ray, gives his opinion of the " strong rooms," and their fitness for those who occu- pied them : — My dear Sir, — I recollect perfectly the rooms of the violent and excited patients at the McLean Asylum, to which you refer. They were in the basement story, and constructed very much like other patients' rooms. They opened upon a common corridor, some four or five feet wide, which was lighted by ordinary windows in the wall. This light passed into the rooms through an unglazed window by the side of the door. The floors were made of stone slabs, which were heated by a fire beneath, and thus the air was warmed by heat radiated from the floors. I always thought them very well fitted for their allotted purpose, that of keeping violent, raving patients, and I never saw them occupied by any others. They were justly regarded, I think, consid- erably in advance of any other existing means for keeping that descrip- tion of patients. Of course improvements have followed the increase of means. The rooms now used for that purpose look out by a glazed window into a yard, the walls are smoothly plastered, the use of steam has led to a better method of warming, and the doors open upon a long, broad hall, tastefully wainscoted and painted. All these were very desirable, as anything is which gives a more cheerful aspect to the patient's surroundings. But they add little or nothing to the essential requisites of a strong-room, — freedom of movement, perfect cleanliness, good warmth, and ventilation, — and in these particulars the old lodge rooms have never been surpassed, to my knowledge. Dr. Folsom speaks of the strong rooms at Worcester and at the McLean in the same breath, and in such a manner that an incautious reader might suppose there was little to choose between them. It would not be worth while now to describe the former. It is enough to say that they were destitute of the prime requisites just mentioned, while their surroundings were of the most repulsive character. You are at liberty to make any use of this letter which will serve your purpose. Yours truly, I. Ray. Dr. Wtman. 3509 Baring Street, Philadelphia, September, 1877. Having corrected the errors of statement as to the rooms for the vio- lent insane, I will now consider the state of knowledge with regard to insanity generally and its treatment at the McLean. The report of the board assures us that the state of things which it assumes to have existed at the McLean in 1848 "simply indicated the general knowledge of the time," — a somewhat sweeping conclusion and not very precise in its meaning. It is reasonable to conclude, how- ever, that whatever else was intended by the expression it means that the state of knowledge at that time was at a low ebb. It is possible, The Early History of the McLean Asylum. 9 too, that the generalization was first made in the interest of progress, and in seeking for facts in support of this statement the selection of the McLean is not quite happy. However this may be, as the McLean has been selected it is now proposed to show from memoranda and the report of its physician in 18*25 the knowledge with regard to the treat- ment of the insane then existing. There is no reason to believe that this knowledge was less in 1848. The report to the trustees from which the following extracts are made •is dated March, 1825: — " In constructing buildings for lunatics, their comfort, happiness, and cure should be regarded as the ultimate and all-important objects. Other objects contributing to the accomplishment of these great ends are of almost equal importance. Among these are provisions for the attendants conveniently to manage the patients and to execute the orders and directions of those to whom is confided the general superin- tendence of the institution. Upon the care, fidelity, and experience of the attendants, the quiet conduct and the eventual recovery of the boarders greatly depend. Suitable attendants cannot be procured un- less their convenience in the discharge of their duties be duly regarded, or if procured must be often changed, and consequently they will never acquire the requisite experience." " Few persons who are qualified to have the oversight and to be the companions of the boarders will be willing to perform the menial services. Indeed, these services degrade the attendant in the opinion of those under his care, and render them less submissive and respectful in their deportment. He should therefore have an assistant. The attendant would be likely to remain in the asylum a long time, and the often changing of the assistant, if necessary, would be attended with little in- convenience." At this time the attendants, many of whom had been school-teachers, were selected with great care, usually on the recommendation of their clergymen. The principal attendants were required to keep journals recording the condition of those under their care and other matters per- taining to the administration of their office. This was done not only for the inspection of the physicians, but also to secure vigilance and close observation on the part of the attendants. " The feelings and opinions of relatives and friends of lunatics must be consulted, for they are to select the residence of those under their care." " The public also must be consulted, for the institution, in a great de- gree, depends upon the charities of the public for its support, especially for the funds to defray the expenses of erecting its buildings. These contributions are to be expended with the greatest caution. Every measure and every plan should be well digested before any attempt to execute it." 10 The Early History of the McLean Asylum. " The first great object presented is a proper classification of the subjects of a lunatic asylum. The evils to be avoided by an entire sep- aration of males from females are so apparent that no arguments are needed to show its propriety. A further division of lunatics of either sex into distinct classes or families is not to be disputed. But the dif- ficulties attending a suitable division are very great. These difficulties are various according to the form of government, the laws and customs of the country, and habits of the lunatics. In all cases the quiet are to be separated from the noisy and violent, the clean from the dirty, the clothed from the naked, and the latter from each other, that one patient should in the least possible degree disturb or offend another. Each division should form a little family, producing the greatest degree of comfort and happiness of which its members are susceptible. Some individuals who are much disturbed by noise require the most perfect seclusion and solitude ; for these two rooms are so constructed and so situated that they may be suitably accommodated. They will also an- swer for ordinary sleeping rooms." " There are lunatic males who are generally tranquil, harmless, sus- ceptible of much enjoyment, capable of walking abroad without an at- tendant, and in fact requiring little or no restraint. Their friends find it necessary to send such persons from home. They desire for them large, handsome, and convenient apartments, and sometimes accommo- dations for a servant. They are willing to pay in proportion to the accommodations required. Such boarders may constitute a single family, called house boarders, and have apartments in the connecting wings and front part of the centre house." One or more boarders were always at the physician's table, had rooms in the mansion house, and mingled with his family, went to Boston and elsewhere, and always without an attendant. The more quiet also passed their evenings in the physician's family, and always appeared and were treated like other gentlemen. Some occupied themselves for months together as teachers of the physician's children, with advantage to both. " Class I. Other lunatics, whose friends may wish for them hand- some rooms and galleries, and have the means of paying the necessary expenses, still require to be restrained, and their rooms and airing courts must be so constructed that they cannot easily escape. These may constitute the first class, occupy one wing, and be divided into three families, each living in a single story. The convalescents and most tranquil may take the upper story, the most noisy and turbulent may take the basement story, and the remainder may take the middle story." " Class II. A second class, requiring to be restrained, may occupy the other wing. Neither their habits of life nor their pecuniary means will The Early History of the McLean Asylum. 11 require or permit the rooms of this class to be finished or furnished in a style so expensive as those of the first class. They may, however, be provided with every comfort and convenience to be found in the apartments of the other class, and have everything adapted to their habits and feelings. This class will also be divided into three families, to be distributed in the several stories as is contemplated for the first class. Provision is made for a further and temporary division of apart- ments whenever any particular boarders are found to have aversions to each other." " The wings thus improved would contain accommodations for the quiet, the sick, and those who are not excessively noisy." " Class III. The very noisy, dirty, and violent patients will form a third class. They may possibly be kept in the wing for the second class. But it is believed a distinct building is to be preferred. Apart- ments may be provided in the same building for idiots and epileptics. The principal objection to this separation is that the worst patients being far removed would be likely to be neglected. But the comfort and tranquillity of the other patients require the removal, and the neg- lect must be prevented by increased vigilance." We here see some of the reasons for the selection of the site for the " lodge " for this class. It is as closely connected with the wing as possible, and yet detached ; the four rooms, which were more than suffi- cient for their accommodation, were upon that side farthest removed from the other buildings, so that noise and shoutings could not be heard in them ; this allowed the free opening of the windows of the lodge at all times. " The proper situation of the day rooms (or parlors) is a subject on which competent judges entertain different opinions. In several well- approved institutions all the day rooms are on the first or first and sec- ond stories. Under this arrangement those who occupy the upper story are during the day removed far from their sleeping rooms. It is true they have a more easy access to their airing courts, and the attendants who keep in the day rooms can more readily afford assistance to each other as it may be needed. But when the sleeping rooms join the gal- leries and are immediately connected with the day rooms, the members of the family occupying the same are under less restraint and have a gx-eater variety of accommodations. If sitting in the day room become unpleasant, the gallery is at hand for walking, and the airing court is sufficiently easy of access. If a patient be feeble or wearied, and desir- ous of passing an hour upon his bed, or if he prefer to write or read without the presence of others, his room is near and within the hear- ing and call of his attendant. These reasons seem to be conclusive for placing the sleeping rooms, day rooms, and galleries contiguous to each other and in the same story." 12 The Early History of the McLean Asylum. " The principal objections likely to be urged against this plan are that the classes will be too numerous for quiet or safety, and will re- quire the day rooms (parlors) to be too large. These objections do not appear to me to be valid or in any way proportional to the advantages gained." Great differences of opinion have existed among those in charge of the insane as to the extent to which classification should be carried. The plan here given and adopted approached individualization. Dr. Bell thought it was carried too far. Of late the opinion has been gain- ing ground, especially in Europe, that a " strictly individual treatment " is needed. This cannot be approached without a classification at least as detailed as that adopted here more than half a century ago. " The centre of each wing may be carried up so as to form large halls for the exercise of the boarders in the winter and in stormy weather. Work rooms may be here constructed in which the exercise of some mechanic arts will not disturb the patients in the lower sto- ries." " The committees and the board of trustees may hold their meetings • 1 in the mansion house, some part of which may be used for the chapel." The physician was descended of a Puritan stock ; he believed in the stated religious observance of the Sabbath; he had written in its defense, and believed what he wrote. The patients who were able attended divine service in the neighboring churches. .Religious services were also held m the wings Sunday evenings ; during which the physician read a ser- mon to those who were well enough and desired to attend. " Each family is also provided with dining and work rooms, a separate airing court, and has access to it by separate stairs, that the members of different families may not mix together. The courts are so arranged that patients in an improved state of mind will not see those who are in a worse condition." " Two rooms are provided for those who need inspection during the night." " The present garden for the exercise of the male boarders would be contiguous to their airing courts, but the boarders of one sex could not see those of the other during their exercise or amusements. The hill to be formed in glacis for walks, ornamented with trees and shrubbery." " In front of each connecting wing is a small court and a low building which is designed for house boarders who may be sick and cannot be re- moved to either wing or retained in the centre house. Small buildings of one story may be erected in the rear and front yards, as shown in the plans. Their height will not obstruct the view from other houses. This is a want which ought not to be overlooked." We have here a plan of small, detached, one-story hospital buildings, much after that now so strongly advocated, and within a few years The Early History of the McLean Asylum. 13 adopted by the other branch of the Massachusetts General Hospital in Boston. " Near the broad steps of the stairs are holes through which the gal- leries and day rooms may be inspected ; similar holes are in the walls of the dining-rooms for viewing the tables, etc. ; as a like provision is made in each story, the whole wing may be inspected without the knowledge of the boarders or attendants. Through these apertures the friends of a patient may see him without exposing him to the dan- gers of a visit." Unceasing vigilance is the safety of the insane. These conveniences for the unexpected inspection of the boarders by their friends are a part of a plan. When the boarders were in the airing courts they were seen by their friends from the mansion house through a fine telescope mounted for the purpose. Few better arrangements could be devised for giving friends confidence in the treatment pursued. There may be objection to patients seeing their friends, but none to the friends seeing the patients. The influence of such a system upon all connected with the institution is obvious. The report is accompanied by detailed plans, in accordance with which the buildings were soon after erected. As has already been stated, some of the boarders were quite at liberty to come and go as they pleased. These found their own occupation and amusement ; one was a frequent visitor at the reading-room of the Boston Athenaeum, and might have been seen daily among the literary gentlemen who associated there. A constant effort was made to in- crease the means of occupation and amusement for all. Walking in the airing courts or in the country with attendants, going to church on Sunday, visiting places of interest on other days, were the most com- mon, or riding in open wagons in pleasant weather. Soon afterwards the physician was " authorized to procure a carriage and pair of horses to be used at the McLean Asylum for the insane, for the purpose of giving air and exercise to the boarders." 1 These rides were then, as now, taken in the neighboring country. They were of necessity con- fined to those who were comparatively quiet and well behaved. But there were others who needed air and exercise even more than these ; for such a carriage-way of nearly half a mile in circuit was made round the garden, where they could ride and where neither their noise nor their appearance would disturb any. A row-boat upon Charles River, then attractive and unpolluted, was in frequent use, affording an amuse- ment particularly relished by those who had been sailors, of whom the asylum usually contained several. In summer, excursions in the harbor in large boats gave a pleasant sail, a run upon the islands, a chowder on board, and all the enjoyment 1 Bowditch's History of the Massachusetts General Hospital, page 84. 14 The Early History of the McLean Asylum. of a day from home. There was bowling, gardening, the exercise of the mechanic arts, books, papers, and various games. Chess was a favorite with some ; the physician was an excellent player, and not unfrequently met with a worthy antagonist among his boarders. Such was the state of knowledge and such the condition of the several classes of boarders at the McLean fifty years ago, widely different from what is intended to be conveyed by the report of the Board of Health. " The position and condition of the more quiet of the insane w^ere much better of course," says the report of the board, " but it was re- served for further study and experience to show that the most violent may be treated to a certain extent in a similar way." In expressing this opinion it is to be regretted that we have no account of this improved treatment. Indeed, very little is said, either directly or by the corre- spondents with regard to the " most violent." We read much — and very pleasant reading it is — of those in England and Scotland whose occupa- tions and treatment seem to be much like that just described as existing here, but I fail to find a satisfactory description of the other class, of their treatment and apartments, either here or abroad. The study and experience of a Scotch physician as late as 1875 1 have convinced him that seclusion is the best for " those who use coarseness of language " and for the " destructive ; " of these last two or three cases have occurred in his asylum in a year. To what extent seclusion is carried we have no means of knowing, nor have we any means of knowing if any destroy their clothing and bedding. There are probably such cases in Europe ; we certainly have them in Massachusetts. The report gives us no in- timation of the proportion of such cases nor of their treatment, either here or abroad ; instead of " well-known historic facts " from which to judge of the progress in treating the " most violent " like the more quiet, we have an opinion. But in estimating the value of this opinion we must remember that the point of comparison, the " stone cells in the cel- lar," is proved not to exist ; indeed the whole spirit of the sentence, so far as the McLean Asylum is concerned, fails to show a just apprecia- tion of the knowledge and practice of the two physicians who had charge of it through the first half of its existence. A more ornamental architecture may have been devised, and, it may be, some minor advantageous changes in details, in the hope of '•' hiding by their comfortable and cheerful arrangements the necessities of re- straint," but other than these, from my own observation, I do not believe that in either of the two asylums now being built at the expense of the State the arrangements for lighting, warming, and ventilating the apart- ments for the treatment and safe custody of the " most violent " insane are material improvements over those in use at the McLean fifty years age. The Bowditch excited ward is for another class of patients, as ^Keport, page 367. The Early History of the McLean Asylum. 15 its name indicates ; it has no room peculiarly fitted for the comfort of the most violent. It must not be supposed that I deny a steady amelioration in the treatment of the insane generally during the past fifty years ; that would be unjust to the talented and devoted laborers in this field. Of the experiments which have been tried here with a reasonable hope of success, some have led to important changes in treatment ; some have been repeated abroad, and after a short trial accounts of them reach us as novelties. Dr. Bell in his final report, after twenty years' service, has some instructive remarks on this subject. It is now demonstrated : (1.) That the report has not fairly represented the apartments of the violent male insane at the McLean, nor their treatment during the first thirty years of its existence. (2.) That the report has not fairly represented the state of knowl- edge at the McLean with regard to insanity, nor the treatment there of the insane generally during the same period. The report has been written, printed, and distributed at the expense of the State ; it bears the seal of the Commonwealth ; it goes forth to the people for whom it is written as a historical state document, and takes its place in public libraries bearing an authority which belongs to no individual ; its statements, therefore, should be cautiously made and care- fully verified. It is to be hoped, inasmuch as the board has elsewhere been pleased to make favorable mention of my father's services, that the facts here presented under a sense of filial duty will also induce it to correct any errors prejudicial to his merits into which it may have fallen. As the first physician of the McLean he laid well and deep the foundation of a class of public charities before unknown in New England; he devoted himself to the one great object of his life with an untiring energy and fidelity scarcely to be equaled ; the evidence of the operations of his mind are still obvious in the mechanical and architect- ural arrangements and in the moral regime and internal system of most of the institutions for the insane in the land. Such services I would not have forgotten or undervalued in a history of insanity by an official board of his native State. Cambridge, December, 1877. Note to Page 13. The following extracts indicate the principles of treatment adopted at the McLean by its first physician. "A knowledge of the mental functions in health can be derived only from the history of mental operations. This history of facts, with the laws and princi- ples deduced therefrom by the aid of a sound logic, is called the philosophy of mind. Mental philosophy, then, is an indispensable study of an accomplished physician." " The treatment of insanity chiefly depends upon the connexion between the mind and body. If there be inflammation of the brain, or its membranes, it is to be treated as inflammation of those parts. If there be other organic disease, whether of structure or of function, in any part of the body, medical treatment will be required. But in mental disorders, without symptoms of organic disease, a judicious moral management is more successful. It should afford agreeable occupation. It should engage the mind, and exercise the body; as swinging, riding, walking, sewing, embroidery, bowling, gardening, mechanic arts; to which may be added reading, writing, conversation, &c, the whole to be per- formed with order and regularity. Even the taking of food, retiring to bed, rising in the morning, &c, at stated times, and conforming to stated rules in almost everything, is a most salutary discipline. It requires, however, constant attention and vigilance, with the greatest kindness in the attendants upon a lunatic. Moral treatment is indispensable, even in cases arising from organic disease. In regard to medical treatment, I believe, that purging, bleeding, low diet, &c, have been adopted with little discrimination. They are to be resorted to only when there is organic disease, which requires the 'reducing plan.'' But these remedies, especially in debilitated subjects, are seldom useful in relieving mental disease. They are usually injurious, and frequently fatal. It is undoubtedly true, that impressions upon the alimentary canal by purging or vomiting, and upon the skin of the extremities by blistering, are useful in chronic cases of mental disorders. But these remedies must be suited to the strength and general health of the patient." A discourse on Mental Philosophy, as connected with Mental Disease, delivered before the Massachusetts Medical Society, June 2, 1830, by Rufus Wyman, M. D. Kate I . !^ 40 V/o fyo 4^ 4 2 1 Building] Proposed Ma rich IS 2 5" % The HfenoTOEPrcmiuoCG. 220 Eevohskike St. Bostoh Plate!!. The HeiiothsPhihtihgCo. 220 Dexqhshibe St. Boston Plate III * T THEHELionKPRiHTmoCo. 220 Dexqhshue St.Bostok \ ""7"'* J — 1 [ _r i i \ l i I i / :it. h > -r CI u J •■'"cr 4> i. 4*tf/. 'J 1 r ^ > ^ "%. IV ; 5 £ P - C :n R S^cr-Ja. B.W.JJ.' CHl