CURABILITY OF THE INSANE IN MASSACHUSETTS. another purpose, equally noble and humane, in furnishing homes and ministering to the needs of the insane, who otherwise would often be friendless and neglected." The physician of the women's department in the same hospital, Dr. Margaret A. Cleaves, who has had, in Iowa and in Pennsylvania, greater experience among insane patients than any physician of her sex in the United States, makes these remarks in the same report: "We do not believe that such systematic treatment as we have introduced here, and which we believe should be carried on in every hospital where insane women are kept, will greatly increase the percentage of recoveries. There are too many factors at work in the production and perpetuation of insanity for the removal of any one cause or condition, without that of others, to bring about such a result. A large proportion of those who become insane have the seeds of mental disorder inherent at their birth. And it is because of this fact, that the same special diseased conditions do not operate alike upon all women. It is in the work of prevention therefore, rather than cure, that the greatest good is to be accomplished. The individual once insane is exceptionally the same as before, and the seeds of mental disease or tendencies to disordered nervous action, may lie dormant for the lifetime of the individual, to awaken with renewed life and vigor in the offspring." We certainly believe it possible to increase the percentage of recoveries above the small number which are now found in many of our hospitals; but whether these recoveries can be greatly increased is doubtful. And little change for the better can be hoped for so long as our hospitals for recent cases are encumbered with so large a population of chronic and incurable patients. It would be well, therefore, in building a new hospital for the insane in Massachusetts, whether at public or private expense, to provide specially for the recent and curable cases. There are too many such cases in Massachusetts to be received in any one hospital; but a considerable portion of them could have better medical care at such a special hospital than is possible in the crowded wards of a mixed asylum. Further classification of the chronic cases could be made by devoting one asylum wholly to women, who now outnumber the men in our hospitals and asylums by nearly 300, DIFFICULTIES IN THE CARE OF THE INSANE. and who accumulate faster than the men. A change of this kind would allow one establishment to be occupied wholly by women, and another wholly by men, thus avoiding some of the difficulties which now exist in caring for both sexes in different portions of the same building. The chronic insane capable of out-door labor might be transferred to this special asylum for men, which should have connected with it a farm and some workshops suitable for their employment. This proposed classification might be carried still farther as opportunity should offer, and so long as each step resulted in an improvement of the general condition of our insane. Measures should also be taken looking toward an earlier treatment of incipient insanity, and to the prevention of insanity wherever possible. Unavoidable Difficulties in the Care of the Insane. After all that can be done to improve the classification and treatment of the insane, however, there will remain certain inherent difficulties in dealing with them. The lack of classification just mentioned is but one of these difficulties which beset the physicians and other persons occupied with the treatment of this unfortunate class. We have heard so much of late concerning the neglects and abuses in our lunatic hospitals, that the public are in danger of overlooking the other side of the question, and of underrating the obstacles which are found, and must be found, in treating the insane. It is to be remembered that the care of any class of the public dependants is difficult; that persons deprived of their reason are all the more difficult to care for; that the restraint and treatment which they need are oftentimes the very things to which they most unreasonably object; that they are seldom capable of forming a sound opinion concerning their own condition, and oftentimes are violent and perverse in a wrong opinion. This violence and perversity, though the direct result of disease, cannot fail to be very provoking to the persons who have the care of them; and it is a constant surprise and pleasure to find that there are so many competent persons who will undertake this care, either as physicians or attendants, and who perform their duties, DIFFICULTIES IN THE CARE OF THE INSANE. upon the whole, so well. Instances of neglect, ill judgment, ill temper, and occasional abuse, no doubt, occur, and lead to the resignation or discharge of the attendants and other persons in fault. It is found very difficult, almost impossible at some seasons of the year, to obtain a sufficient number of well-qualified attendants to take charge of the women's wards in some of the hospitals; even the physical strength necessary to control excited and violent patients not being easily attainable in case of women. This difficulty often compels the superintendents to employ persons less competent than they could wish. Nor has it always been easy to obtain the services of well-qualified young physicians for medical assistants, especially since the increase in the size of our hospitals has made the duties of a medical assistant so much harder to perform. The duties of a superintendent have also been greatly increased by the change in the size of our hospitals; while, from this and other circumstances, the medical care of the insane, as a specialty of the profession, has become less attractive than formerly, and the number of persons qualified to serve as superintendents of our State hospitals is not found to be very large. The constant criticism of lunatic hospitals here and in other States by writers in the magazines and newspapers, seldom very intelligent and often quite unjust, does not tend to make the position of superintendent attractive to persons otherwise qualified; especially when the public are asked to rely on the statements of discharged patients in regard to matters of which they could not possibly have had a clear knowledge. PRESENT NUMBER AND LOCATION OF THE INSANE. In order to complete this chapter, we present here a statement (Table B) showing the number, sex, and classification, with respect to support, of all the insane persons in hospitals and asylums on the 1st of January, 1882: PART THIRD. PUBLIC CHARITY. PART THIRD. PUBLIC CHARITY. I. THE IN-DOOR AND OUT-DOOR POOR. BEFORE taking up in detail the relief of the poor, it may be proper here to state, in a general way, what are the relations of the Commonwealth to the persons aided by public charity, and those other classes temporarily dependent or needing supervision, with whom the duties of the Board bring its members and officers in contact. The most numerous of all these classes, and containing, originally or ultimately, nearly all the public dependants of Massachusetts, are those whom we call, for brevity, the Poor; that is, persons who require aid or support, or State supervision, either for themselves, or for their destitute or insane relatives or children. This large and constantly varying class of persons may again be divided for convenience into the in-door and out-door poor; and these classes again include, first, the in-door and out-door poor of the State, and, second, the in-door and out-door poor of the cities and towns. All these classes and persons come generally under the observation of the Inspector of Charities, and many of them also come under the observation and practical administration of the two Superintendents of Indoor and of Out-door Poor. The two Departments of the Board which deal practically with these two classes of the State poor, in establishments, and in the towns of their residence, present in their statistical tables in the Appendix the important facts concerning them, in addition to such as may be found reported by the Inspector of Charities in the socalled "Pauper Abstract." These statistics also include those of immigration, which is under the direct supervision of the N |