The Commitment and Certification of the Insane
Boston Medical and Surgical Journal
jority of instances there is not, the slightest scrofulous element about the case. The trouble is that the original injury is usually of such a trifling nature that it is allowed to pass almost unheeded, and the patient goes about his ordinary business without thinking it worth while to do anything for it. If this man had had his hand almost half cut off, he would have been all right long ago, because he would have gone at once to a surgeon and had it properly attended to ; but the seeming "
... ut the seeming " Hibernianism," that " the less you are hurt the worse it is for you," often comes true in point of fact, on account of the time that is lost and the suffering that is endured before one finally recovers from the effects of an injury trivial in itself. The principles here laid down are applicable to all diseases of the joints. Only get a correct comprehension of the pathology in any case that may come under your care, and then, and then only, will you be able to treat it to advantage. But now as to the treatment to be adopted here. The muscles and tendons may have remained so long contracted in this case that they have become contractured, as it is called, or, in other words, structurally shortened. Such a marked deformity cannot be reduced in a moment, aud in treating it the important question first comes up, Can the contraction of the muscles and tendons be overcome by gradual traction, or will it be necessary to cut any of them ? On making joint-pressure here while the muscles are on the stretch, I find that no reflex contractions are produced by it, and this at once convinces me that with the aid of'gradual traction, maintained for a sufficient length of time, they can be fully restored to their original position ; whereas, if reflex contractions had thus been caused, such gradual traction would have been of no service whatever, aud we should have been obliged to use the knife. What we have to do, then, is to maintain extension and counter-extension, and at the same time keep the parts perfectly at rest. This can be most easily done by means of a piece of sole-leather about the width of half the circumference of the limb, and sufficiently long to reach from the upper part of the fore-arm to the extremities of the fingers, molded to the surface, and properly secured to the limb. Having cut the sole-leather the required shape, we dip it in cold water, and mold it accurately to the part, while the hand is extended in the position that overcomes the deformity to the greatest extent, after which we secure it by means of a roller. When the latter has been put on we should look carefully at the circulation of the finger ends, which should be left exposed, and if this is at all interfered with the bandage should immediately be taken off aud reapplied. This dressing having now been properly adjusted, we find that the patient is entirely free from pain. To-morrow, when the leather splint has become perfectly hard, it will be taken off, lined with adhesive plaster, which should lap a couple of inches or more, aud then bound again to the limb (extended as before), with the plaster against the fore-arm. In this way permanent extension and counter-extension will be maintained, and the diseased surfaces of the joint consequently kept from coming in contact with each other. In a few days later, when the deformity has become to a certain extent reduced, the splint can be taken off and remolded to the part ; and this can be repeated as often as necessary, until a cure has been effected. A tear has passed since the Board of Health, Lunacy, and Charity was established, and the new law relating to the commitment of the insane enacted. Some comments and suggestions relating to the operation of these measures may not be premature at the present time. There had been for several years a certain pressure in favor of a lunacy commission to which should be given the functions of the old Board of State Charities, relating to lunacy, with such new powers as might seem desirable. There had also been in 1878 a legislative attempt to consolidate the management of the state institutions of all kinds under one central board, for convenience and economy. In 1879 the political pressure for economical administration was great, and any measure likely to result in a saving of expense was welcome in the legislature. 1 am assured, however, that the union of the Board of Charities and the Board of Health with new functions relating to lunacy was advocated by Governor Talbot on purely administrative grounds, without any reference whatever to politics. It was believed that the Board of Health had accomplished a good work in the community at large in our own State, and an important missionary work in other States, and that it might now be properly called on to attend to the health interests of the state institutions. It was thought desirable that affairs relating to public health and public charities which run so nearly parallel, should be under the supervision of a single board, thus avoiding complications and possible conflict of authority. A separate commission of lunacy could also be avoided by giving this board the supervision of the insane. The result was our tripartite Board of Health, Lunacy, and Chanty. Many physicians, who had been proud of the good work achieved by our State Board of Health, regretted the loss of identity which seemed to result from its immersion in the new board. They also shared the fears of Dr. Bowditch in respect to its future usefulness. It is necessary, however, to accept this consolidation as an accomplished fact, and make the best of it. Time will prove or disprove the wisdom of the change. Meanwhile, the new board should have the cordial support of all physicians who desire to promote social and sanitary reform. If a separate or supplementary health report be annually issued, it will stand as evidence of the comparative independence and efficiency of the health department. Of the composition of the board I should not speak, except for the petition recently circulated to appoint one or more women in the place of two members of the lunacy department, whose terms soon expire. The functions of this department particularly should be exercised in the most purely judicial manner, and it should have the unquestioning confidence of the whole community and of the managers of our insane asylums also. It should no more be suspected of a hypercritical or hostile attitude towards asylums than of undue partiality towards them. Its action should always be based on the longest experience and most scientific information obtainable. If extremists are to be considered eligible to appointment, opposites should