189

y Art. II.?ASYLUM SUPERVISION.* By NATHAN

Lowell, Massachusetts,

Commissioner in

ALLEN, M.D., Lunacy

LL.D.

to the Commonwealth of Massachusetts.

One of the most important questions in respect to public institutions is the proper supervision of Lunatic Hospitals. Boards of State Charities are especially interested in this subject. The members of these boards appointed from the different professions, and from all classes of business men, have the best means of knowing what is the present management of these hospitals, and whether there is need of better supervision. The greater the knowledge possessed on the subject, and the more thoroughly the matter is investigated, the stronger will be the conviction, we believe, that there is need of change or improvement in this direction. It is proposed to inquire briefly?First, what is the present management of such hospitals ; and secondly, what constitutes a proper supervision of them. As nearly all these institutions are built by appropriations from State treasuries, there is great similarity in their appointments and government. There are a few hospitals or asylums for the insane established by municipal authorities and private corporations; these are managed by officers or trustees appointed by very different bodies from those called State institutions. There is still another class of asylums or establishments for the insane, which are generally small, and in one sense strictly private, as they are owned and managed by individuals. It is the large hospitals owned by the State, and for the management of which the public are for this reason responsible, that come especially under our present inquiry. What, then, is the management of these institutions? The primary power is lodged with the Governor and Council. They appoint five or more trustees to each hospital, who choose a superintendent. The assistants and attendants are generally appointed by the superintendent, or nominated by him, subject to the approval of the trustees. All rules and regulations for the management of the officers and inmates of the institution are prepared by the superintendent and trustees, though in some instances they must be approved by the Governor and Council ?

Read before the National 1880.

July 2,

Conference of Charities at Cleveland,

Ohio,

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Thus the whole responsibility and power of government is placed in the hands of the superintendent and trustees. It is true there are powers lodged in other bodies, and provisions made for some oversight of these institutions, but they are so constituted that they are not often exercised or made available for purposes of improvement and reform. The law provides in most States that the Governor and Council should have a general oversight of public institutions, making regular The Legislatures in all the States not or occasional visits. only enact laws for the support of, and management of these establishments, but appoint committees from time to time But the oversight and visitation of both these to visit them. bodies are rather formal and ceremonious. Their visits are generally made at set times, in a body, with previous notice, and not unfrequently in a hurried manner. It is impossible for them to make a thorough examination into all the internal affairs of an institution, or into all the details concerning the condition and treatment of its inmates. Unless some charges of abuse or complaints have been made, these bodies never make special examinations, nor interfere with the government and management of hospitals. No great improvements or real reform can be expected from such oversight. There is another agency established in several States, intended to exercise some care and oversight of these institutions, viz. Boards of Charities. The original design in the establishment of these boards was a most wise and beneficent one. It was found by large experience and wise counsel that something was wanting in the management of institutions; that there was need of far greater watchfulness and more definite information and statistics, whereby comparisons could be made, extravagance checked, abuse prevented, and improvements of various kinds started. These boards have already done immense good, and with some modifications their usefulness may become more permanent and widely extended. But, as the organisation of these boards confine their duties wholly to visitation and report, with very limited powers, th^y cannot exercise that supervision over lunatic hospitals for improvement and reform which is absolutely necessary. The labours and reports of these boards have brought before the public such information, facts, and statistics, concerning these hospitals, as to show the great need of some changes or improvements for which legislation as yet has made

directly

adequate provision. What, then, is the kind or character of the supervision required ? It may be very properly designated a Lunacy no

Commission.

according

It should consist of

three

to the number of institutions

or

or

more

persons,

extent of the field.

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Its members should be compensated according to services rendered. They should be appointed for a series of years by the executive of each State, without regard to political party or personal favouritism. This appointment should be based solely on their qualifications, or fitness, or interest in such work. hold at the time no connection with any local should They institution. Their powers and duties should be co-extensive. They should have a general supervision, with full power, over everything concerning not only the management and government of the institution, but also the care and treatment of its inmates. A commission thus constituted might justly be held responsible to the public and to the higher powers of appointment. Its recommendation to legislatures, with respect to appropriaIts tions and the enactment of laws, would be valuable. reports would serve to enlighten the public in such matters, creating everywhere greater interest and confidence in such institutions. The question may be asked why lunatic hospitals require different or more supervision than other institutions ? The following may be given as some of the answers. The appropriations for this class are greater than for any other, and the expense upon each individual is larger. The insane are more dependent and helpless, and require different treatIt is not the body, mainly to be provided and cared ment. but mental disorder, which involves interests of a far for, higher nature, and more important in results. The rights of the insane in respect to personal liberty, family relations, and property are taken away under circumstances where there is danger of injustice and wrong doing; besides, they are brought together in large numbers, and confined in close quarters; placed under attendants where there is liability to abuse of various kinds. The difficulties and responsibilities attending the proper treatment of the insane are so great that they require constant watchfulness, and the most careful oversight. Experience proves this. Cases of improper committal and detention, of wrong treatment and abuse, are often brought to public notice, showing the need of constant vigilance, and the most careful oversight. The need and importance of such oversight is very clearly stated by the Eev. Dr. Bellows, of New York. Says Dr. B., " Insanity and Insane Asylums require far more inspection, study, and attention?far more publicity in all that touches their management?than they now receive in this State or county. The public is profoundly interested in being reassured by persons whose testimony is beyond suspicion, that this helpless and wretched class, the insane, are not neglected, abused

192

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and made worse instead of better, by our public institutions. They need and demand to know that persons of the highest character and enough of them to guarantee sound judgment, are incessantly busy, looking into the state, studying the complaints and protecting the rights of those who are incarcerated It is in the nature of things that abuses in public asylums. from pressure of call, from induration of sensibility, from force of routine, from pride of authority, from limited experience, from the inertia, of custom, should creep into asylums for the Eternal vigilance from the representatives of the insane. public anxiety, who have no interest except that of humanity, can alone keep either prisoners or asylums from degenerating, or from becoming stereotyped in effete prejudices of management." That we may have a better and clearer view of the subject, let us take different points of observation. There are four great interests or parties that require such supervision : In all large establishments 1. The institutions themselves. evils and abuses of some kind will spring up. The fault may not be directly on the part of the managers, but more with the sub-officers and attendants. The most effectual way to discover and correct these evils has been found by authorities outside, charged with such duties. Correction or reform seldom come from local officers. Besides, such is the peculiar relation of lunatic hospitals to the public that prejudices and distrust will prevail more or less in the community in respect to them unless provision is made for proper supervision. This distrust is not only exceedingly annoying to the officers of the hospital, but causes great injury to the public and the best interests of the insane. It frequently prevents persons in the first stage of insanity from being sent to the hospital, where they might be cured. It impairs the confidence of the insane in the physician and his treatment. Again: There is always room for some improvement in every institution. This is far less likely to come from persons constantly occupying the same point of view, and following day after day the same routine of duties, than from those looking from different and distant points of view, who can compare one institution with another, and make careful observations over a large field. Hence, the necessity in such management of more diversified experience, more general knowledge and larger observation than local officers usually have, whose labours and interest are almost wholly identified with one single establishment. In no other institutions or corporations in the country, are individuals charged with duties and responsibilities of such magnitude as the officers of lunatic hospitals, and nowhere else are counsel, skill and wisdom of the highest order, so much

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The lunatic hospitals of Great Britain are as here. provided with these advantages in a Commission of Lunacy. Superintendents, trustees and commissions all work harmoniously together for the best interests of the insane. The Lunacy Commission has been in operation in England over thirty years, and that in Scotland over twenty years. It is needed

on all sides that the most beneficial results have been about by the agency of these commissions in the imbrought proved management of hospitals and the better treatment of the insane. 2. But the class that need such supervision most, are the inmates of these hospitals, the unfortunate insane, the most helpless and dependent of all human beings. They are forcibly removed from home and friends. The law takes away from them their rights in respect to personal liberty and the use of their own property; it unsettles them in all business relations and in the duties they owe to their families ; it destroys the confidence which the public once reposed in them, and cuts them off in a great measure from intercourse and communication with their friends, as well as exposes them to personal abuse from attendants and others. Where such personal and fundamental rights are taken away or very much abridged, should not legislation make better provision for protection, defence and appeal than generally exist ? No proper provision is made by the courts that is available to them. They certainly cannot look to the Governor and Council at a great distance, nor to a Legislative Committee meeting once in a year or two, and making occasionally a formal visit to these hospitals. It should be a provision available and ready at hand, one in which they have confidence. It may be said the insane have always the superintendents and trustees for counsel and protection. This may be true to some extent, but, then, how frequently are the insane brought

admitted

to

hospitals by deception, cherishing strong prejudices against

these establishments as prisons, conscious that they are deprived of their rights, and look upon the hospital officials as their oppressors. Besides, such is frequently the type or nature of insanity, that it leads the insane to distrust those immediately about them, and to look elsewhere for aid and counsel. That the insane may recei re the full benefit of treatment, whatever the means may be, whether by medicine or other appliances, how important it is that they have confidence in these means, and in those having a constant oversight of them ! In the treatment of other diseases, this confidence is regarded as indispensable, and great pains are taken to secure it by counsel and in many other ways. In diseases of the mind, it is still more

important.

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But tlie distrust cherished by the insane of hospital officials does not arise wholly from prejudice, or a diseased mind, but, from this fact, they find by experience and a variety of circumstances that everything affecting their interests is virtually placed in the hands of one body or one man. It is true there are local trustees, having care and oversight of the hospital and its officers, but as a general thing they know very little about insanity or the treatment of individual patients, making short and formal visits, depending almost wholly upon the superinHe is moreover appointed by the tendent for information. trustees, and is their executive officer. The interests, business and reputation of both parties are so closely identified that they constitute really one governing body. Such is the interpretation placed upon it, not only by the insane but by large numbers outside of the hospitals. Though a wide difference may be found in different hospitals as to the relations and doings existing between these two parties, the impression prevails very generally, that the power, in its controlling influence, is virtually exercised by the executive officer. It is needless to dwell here upon the objections to a one man power. Two years since, an English gentleman, who had been a Government Inspector over twenty years in Great Britain, and whose constant business was to visit hospitals and workhouses, came to the United States to obtain certain information about After inspecting carefully several our public institutions. lunatic hospitals, he remarked that he was struck with the different appearance and conduct of the insane in hospitals here and that in England; that among the insane he saw here there was a constant restlessness, a complaining spirit, seeking protection and counsel of every one passing, as though there was something wrong or wanting; whereas, in the British hospitals, there was a quiet contentment, every intelligent insane person feeling and knowing that their rights were protected by Government, and wrongs and abuses could not exist without being exposed and corrected. This was proved to them by frequent visits of the Commissioners in Lunacy, hearing their complaints and settling difficulties. Cannot a Republican Government make some similar provision for the most unfortunate of all its subjects, suffering more or less daily for the want There are other points wherein the insane need of it ? this outside supervision, such as personal liberty, mechanical restraint, seclusion, correspondence, detention, ill-treatment of any kind, real or imaginary, etc. In case, even, were there no wrongs or abuses, what a relief would it bring to their mind in a suspicious and disturbed state to know and be assured that their individual cases are all looked after, and that no real harm can befall them ?

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The English gentleman referred to before, after inquiring into the management or provisions made for the government of our hospitals, remarked that it was very different in Great Britain, that the rights and interests of the insane there were more carefully guarded, that every insane person knew he had influence and power at headquarters, and that the Government was his friend. In a Government made "by the people and for the people," cannot the rights of its feeblest and most needy subjects be protected ? Can neither democracy nor republicanism do it ? Most assuredly, it can and will as soon as the means and ways are understood. No intelligent or thoughtful community will always rest easy in such a state of things, or be satisfied with present legislation on this subject. 3. The third party demanding this supervision, is very numerous, including the friends of the insane and the public at large. These hospitals sustain a most intimate and important relation to the community, different from any other institution. Every member of society, every man and woman, must feel an interest in them. Who is not liable to be insane or have a friend thus affected ? Every voter and taxpayer should feel an

them, inasmuch as the money for building them directly from taxes, and was appropriated by legislatures representing individual voters. Besides, the moneys constantly used for defraying the expenses of running these hospitals and paying the salaries of the officers in charge of them, come mainly from taxpayers, however small these taxes may be. While superintendents and trustees have the immediate charge and control of these institutions, they do not own them, neither were they built or are they run for their emolument. In one sense they are masters, but in another, from a higher and broader view, they are servants. While they have their rights, and their opinions are to be respected, there are parties inside and outside of hospitals who also have rights therein, and whose opinions are entitled to consideration. The claims and interests of the latter parties are vastly greater and more important than those of the former. In fact, the. real interests of those in charge of these hospitals are trifling and insignificant compared with those of the insane and their friends. On the side of the latter not only far greater numbers are concerned,

interest in comes

but the healths and lives of multitudes are more or less involved Under these circumstances, it would seem that the insane should have the wisest and best supervision that can possibly be provided?that the principles of humanity, of justice and common sense, demand it. Such supervision has been found in the Lunacy Commissions of Great Britain and Scotland.

in the issue.

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The most beneficial results have followed the labours and reports of these Commissions, which may be best described in the language of one who was superintendent for a long time of the largest lunatic hospital of New England, and who has visited those abroad. This gentleman, Dr. M. Bemis, of Worcester, from his own large experience and personal knowledge, is abundantly capable of forming opinions and making comparisons. In answer to the inquiry what improvements have been made in the lunatic hospitals of Great Britain, and what relation does the Lunacy Commission hold to these institutions, makes this statement: " The improvements are many. They have supplemented and modified this system to such an extent, that while it bears some resemblance to the past, the present is studded all over with new features. The improvements for ventilation, cleanliness, classification, for freedom, both outside and inside, are most noteworthy. Their advances, in the direction of labour among the patients, in the immunity from physical restraint and seclusion, in the granting of innocent indulgence to trustworthy patients, are far beyond what is now practised in any American hospital. The Lunacy Commission has done much, and its continued operation is of incalculable benefit, not only to the insane, but also to the officers of the institutions. They have improved the condition of the insane in many ways, and have rendered a residence in a lunatic asylum less irksome and hopeless to those who are obliged to submit to the restraint and treatment in a public institution. They have removed the hard and forbidding cruel fixtures for restraint and seclusion. They have well nigh emancipated the insane from the use of mechanical restraint; have quite abolished every kind of punishment and task ; have raised and improved the quality of food and clothing. They have opened the apartments of the furious and filthy to the sun and air, and opened the doors, that all may enjoy, in some degree, the freedom of the several establishments. More than this, they constantly act as guardians for the insane, and then strongly support and strengthen those who conduct faithfully the affairs of the asylums. They have a systematic correwith spondence every institution, and by reports of officers of each, they know, not so much the economies of each, but what is better, they have an understanding of the commitments to such an extent that they can easily tell the justice and propriety of any questionable case. They are made to know of all cases of restraint and seclusion, and they interest themselves in every case of hardship, and thus lighten the burdens of the insane, without in any way increasing the cares of the officers. From their frequent inspection of the several institutions, and from

ASYLUM

the

SUPERVISION.

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of facts gathered by their correspondence, they publish every year a valuable report of their labours, with plans, suggestions, and histories of cases of hardship, abuse and suffering." When the great advantages, as here described, arising from a Lunacy Commission, are considered, it would not seem possible that the superintendent of any hospital would or could oppose such a supervision. The insane are not the only parties benefited, but the hands of the trustees and superintendents are supported ; much of the prejudice existing against these institutions and their managers would disappear; less complaints would be heard from the insane and their friends, and far greater confidence would be placed in these hospitals by all classes in the community. But what is the attitude in which superintendents place themselves in respect to such supervision ? Some years since, as a body, they passed a resolution affirming that " the appointment of Lunacy Commissioners with a view to official visits or any supervision of State institutions for the insane, is to be deprecated, as not only wholly unnecessary, but injurious, and subversive of the present efficient system of control by trustees appointed by the State executive." It may be said that this resolution was adopted by a convention of superintendents years ago, and that the sentiment is not generally endorsed by them at the present day. It is gratifying to know that here and there a superintendent is taking a more charitable, a more liberal and enlightened view of things: but, at the same time, the adoption of a Lunacy Commission has been bitterly opposed for years, and that, too, in a variety of ways, by hospital officials; in fact, the chief opposition comes from this particular quarter. In confirmation of this statement we might recite some facts and circumstances which occurred this very year in New York and Massachusetts. When it is considered that a Lunacy Commission, properly conducted, is calculated above all other agencies not only to inspire public confidence in these hospitals, and improve the condition and treatment of their inmates, but also to stay up the hands of superintendents and strengthen their administration, it is surprising that they should ever oppose it. In fact, they should be the last to oppose it and the first to welcome it. But great advances have been made within a few years in public opinion on this subject. It is being found out that people have rights, and, when more generally understood, will maintain them. The world moves?the progress of science is always forward. Reform is only the work of time. Again, in these large establishments questions frequently arise, the settlement of which need just the advice and counsel which such a commission can give. Differences of opinion mass

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between the friends of a patient and the to treatment, or how long the person must remain in the hospital, or when he can return safely to his home; also, differences arise between the overseers of the poor of cities and towns and the hospital officials as to the removal of pauper insane persons to almshouses or other places of sapport. In such cases the intervention of a third party is very sometimes

occur

superintendent

as

necessary. Then the question of a more complete classification of the insane, both on the score of humanity and economy, should receive far greater attention than it has hitherto. Instead of building palatial residences at immense cost, and herding together such large numbers of the insane, let the chronic class, comprising fully two-thirds or three-fourths of the patients in hospitals, be provided for at less expense in asylums or other establishments or homes, furnishing advantages better adapted to these persons than large and costly hospitals. In every point of view this question is one of vast importance, and requires all the consideration and wisdom that any kind of Board or Commission could give to it. Another question closely connected with the above, is the great increase of expense for the insane. This class is increasing relatively; not only faster than population, but also faster than either of the other dependent classes. The support of the insane is becoming really burdensome in every State, and is likely to become more and more so every year. A careful review of the provisions made for the insane shows that much of this expenditure has been needless and extravagant, particularly in the construction of buildings. The opinion, moreover, seems to be pretty well established that the present management of our lunatic hospitals and the treatment of the insane, are in many respects far behind those in Grreat Britain. This is the testimony of foreign alienists who have visited our institutions, and are capable of making comparisons. It is very evident that some improvements or reforms are greatly needed among us. Are these likely to come from experts in one thing, from head officers of our institution or from members of legislatures constantly changing ? Do we not need men of large and diversified experience, of special fitness and qualifications for such business; men who can devote time, labour, and thought to the work ; in other words, a good Lunacy Commission ? Again, it is obvious after all that the advantages growing out of such a commission must depend almost wholly upon the character of the persons placed upon it. It must be composed of men thoroughly posted in these matters, men heartily interested in the work, men who have the confidence of the public,

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and especially of the advocates of reform. The community, as well as the cause itself, demand something more than the mere name of a Board or Commission of Lunacy. Such is the interest and intelligence accumulating on this subject that no well-informed people will always rest satisfied with the present order of things, nor remain content unless executive and legislative bodies take some advanced steps for improvement in this direction. How much better is it for the hospitals and all parties concerned that this interest and intelligence should be wisely directed, and result in some permanent good, rather than that it should be wasted in excitement, in sensational reports, in exposures and attacks on our hospitals ? Superintendents and trustees, in their reports and through other channels, complain that this fault-finding and prejudice against them and the hospitals, are very annoying, and when the complaints become somewhat bitter and personal, they feel as though they were abused and insulted. Bat who is to blame? Are there no causes or reasons for it ? When it is considered that a large number of persons are deprived of their rights without adequate means of protection, are confined in close quarters, not accessible to their friends, where it is understood abuses and wrongs are sometimes perpetrated?so reported by the press and individuals that have experienced them?is it strange that the friends of the insane should express uneasiness and anxiety, and that the community should join with them in sympathy and complaint ? One of the special duties of the English Lunacy Commission is to exercise a careful oversight of the hospitals with reference to abuses, wrongs, accidents, &c., preventing and correcting them as far as possible, and making reports upon them whenever they occur. This course satisfies the demands of the public and creates confidence in these establishments. The fourth party interested is the future or humanity itself, aspiring to a broader and higher civilisation. Its aim is ' equal rights. Its practical application is the golden rule.' Its design -is to do the largest amount of good?to enlist the best possible agencies. We have here a great evil, insanity, constantly increasing, occasioning immense expense and an untold amount of suffering. This evil is the result of violated law, physical and mental; it is abnormal, no part of a tiue, healthy civilisation. To check the evil, its causes must be better understood, the public must be instructed and enlightened on the subject. As prevention is better than cure, it is our duty to do something in this direction. It is not wise to build great establishments and make large appropriations for carrying them on, without doing something to remove the causes which necessitate such measures.

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Within a few years great advances have been made in a better understanding of the causes of disease and the laws of health. Special pains have been taken by means of boards of health, books, journals, lectures, &c., to diffuse a knowledge of hygiene and sanitary agencies. The fact is fully established that, by a proper application of these means, one-third of the sickness and premature mortality may be prevented. But how is it with insanity ? What have hospitals and legislatures done to preIf a very small portion of the means now employed vent it ? in the construction of

buildings

and the support of the insane

expended in different ways to prevent insanity?in cutting off the supplies?what a vast difference it would make in the It should be the settled policy of all expense ! legislative were

bodies and the executive officers of every State to carry on some systematic measures of this kind, and unless such provision is made by legislative action, the work will certainly not be done While there is need of improvements in the at present. management of hospitals and in the better treatment of the insane, something should be done at the same time to prevent the increase of this great evil. The claims of humanity and economy demand it. And in no other way, and by no other means can these objects be so well secured as by the establishment of a good Lunacy Commission.

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