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Treatment of the Insane: 1876

 The Treatment of the Insane: 1876

Editor’s Note: With the founding of the National Conference of Charities and Corrections in 1974, the subject of insanity received much attention. It was discussed by such experts as Dr. Bancroft, of New Hampshire; Dr. Pliny Earle and Dr. Nathan Allen, of Massachusetts; Dr. Stephen Smith and Dr. J. B. Chapin, of New York; Dr. Alice Bennett, of Pennsylvania; Dr. Richard Gundry, of Maryland; Dr. W. W. Godding, of Washington; Dr. Peter Bryce, of Alabama; Dr. A. B. Richardson, of Ohio; Dr. W. B. Fletcher and Dr. Joseph G. Rogers, of Indiana; Dr. R. S. Dewey, of Illinois; Dr. H. M. Hurd and Dr. E. H. Van Deusen, of Michigan; Dr. O. W. Archibald, of North Dakota; and Dr. E. T. Wilkins, of California….

The discussions were not limited to medical experts, but the laity also made contributions. Mr. F. B. Sanborn, of Massachusetts; Mr. William P. Letchworth, of New York; General R. Brinkerhoff, of Ohio; Secretary Fred H. Wines, of Illinois; and Messrs. Elmore, Vivian, Giles, and Wright, of Wisconsin, and many others took an active share in the discussion. At the first meeting of the Conference, in 1874, Dr. Chapin attacked vigorously the vicious system, then at its climax, of building hospitals for the insane at a cost of $1,500 to $3,000 per bed, while multitudes of insane, equally deserving, were left in miserable condition in poorhouses.

The Preface is from the Proceedings for the third Conference of Charities held at Saratoga, New York, September 6, 1876.  It is followed by a paper titled “The Treatment of the Insane” delivered paper by Dr. Nathan Allen, of Lowell, Mass. 

PREFACE

 The Conference of Charities at Saratoga was the third that has been held since May, 1874. It was found that the members of the various State Boards which deal with Public Charity in the United States were desirous of a better acquaintance with each other, and that they could not meet together and discuss the questions in which they had a common interest without mutual profit and encouragement. It also appeared that a considerable number of persons, some officially connected with public or private charities, and others not, were desirous of attending such a meeting, and were both competent and willing to join in its debates or to contribute papers which should be the fruit of special research, or of long experience. Therefore the Standing Committee of the Detroit Conference of 1875 (Messrs. Hoyt, Bagley and Croswell,) being authorized to do so, and having made the necessary arrangements, called the Conference of the present year in connection with the General Meeting of the American Social Science Association at Saratoga, on the 5th, 6th and 7th of September, 1876.

The sessions of the Conference were held in the Town Hall, and were opened by an address from Governor Tilden of New York, at which the president and many of the members of the Social Science Association were present. All such members were allowed to take part in the Conference, as well as those persons officially delegated or specially invited. In printing the debates, it has not been thought necessary to report remarks made by persons not belonging to one of those classes.

The papers and reports prepared by request of the Committee of Arrangements, or, of the Chairman of Standing Committees, are here printed in full, but of the discussions, in many cases only abstracts could be given. In some instances the speakers have been kind enough to write out an abstract of their remarks, and in all cases the editors have sought to give the substance of what was said. The same observation applies to the Reports from the State Boards…

AFTERNOON SESSION.  SEPTEMBER 6, 1876.

At the opening of the afternoon session, Theodore Roosevelt, of New York, in the chair, the following paper was read by Dr. Nathan Allen, of Lowell, Mass.

THE TREATMENT OF THE INSANE.

Among the numerous subjects that demand the attention of Boards of State Charities, no one is more important in its varied interest, or attended with greater difficulties, than that of insanity.

The question of expense, alone, is one of no small magnitude, since insanity involves far the largest expenditure that is made by the different states upon any one of the dependent classes. There is a wide range between extreme parsimony on the one hand, and on the other, needless extravagance.

But besides the matter of expense, there are many other questions that require the most careful consideration of all individuals or boards which have, in any way, the care and oversight of public institutions, more especially of those provided for the insane. The question whether the insane shall be supported in town or city almshouses, in large or small hospitals; whether the harmless, chronic insane shall be separated from the acute cases; to what extent physical restraint is necessary, or how far personal freedom may be safely allowed; these, and other questions, constantly beset us. As the whole subject of providing for and treating the insane, has been, in a measure, experimental, open to change and improvement, new questions are continually springing up, the solution of which, in some cases, is easily determined by experience, while that of others requires the most careful consideration, and all the knowledge and wisdom that can be obtained. One object of these conferences of the State Boards of Charity is to bring together the results of experience and observation, and to see by comparison and discussion, what new light, what fresh information, we may obtain that will aid us in making improvements in the great work of administering public charity.

It is my purpose, in this paper, to bring before you a few of the more practical and important topics, in respect to the management and treatment of the insane, not so much to communicate information, as to suggest themes for inquiry and discussion. The first question that everywhere meets us is,

THE INCREASE OF INSANITY.

 In every state we find the lunatic hospitals not only full, but most of them crowded, notwithstanding new ones are constantly being built. Is this increase of insanity apparent or real? Is it made up of the residuum of those not cured, of that constantly accumulating class called the chronic insane? or is recent insanity increasing relatively faster than population? It is difficult to settle this question by exact figures for the census returns are very imperfect, and no other statistical researches have been made, that are sufficiently thorough or extensive. But it is, we believe, generally conceded now, by those most competent to judge, that there is an increase of insanity in a ratio greater than that of population, though this increase may vary in different localities, and at different periods.

The question naturally arises, what are the causes of this increase of insanity, and can nothing be done to check or prevent it? One thing is certain, the erection of lunatic hospitals, however numerous or well managed, will not prevent lunacy, though the greater the per centage of cures effected by means of these institutions, the more will they serve to diminish the number of the insane. To prevent insanity or its increase, its causes must be far better understood by the public generally than they now are. And no higher wisdom or more useful economy can the state or any official board exercise than in applying means and energies in this direction, aiming at “prevention rather than cure.”

Among the difficult questions relating to the insane that come before boards of charities, is that of

 THE PLACE AND MANNER OF SUPPORT.

We find the insane very much scattered — some in private famiilies, some in almshouses and others in hospitals — some faring well, and others suffering badly in body, and worse in mind. Passing by all cases in private families and private institutions, the almshouse and hospital constitute almost the only receptacles for this class. These almshouses may be located in city, county or town, may be large or small, but such are the condition, management, surroundings, and character of the inmates of many of them that these establishments are generally unfit places for the insane. It is true there is a portion of the harmless and chronic insane who may be very comfortably provided for here, in some places, and there are almshouses so located, and constructed and managed, as to afford all the accommodations for this class that could be desired. In certain localities, there has been of late great improvement in almshouses, especially in the internal arrangement for the care, comfort, and health of inmates, and occasionally in special provisions for insane paupers; but there is in the almshouses throughout the country, more or less ground of complaint for the gross neglect and bad treatment of this doubly helpless and dependent class.

The hospital makes different, and far better provision for the insane, than the almshouse. The primary object of the hospital is curative treatment, and, the secondary, to furnish a safe receptacle where the insane cannot injure themselves or others. But, for various reasons, we think the matter of cure does not receive the attention that it ought. It is unnecessary here to adduce arguments, either on the score of humanity or economy, to prove that the cure of the insane — treatment for this express purpose — should always be the first and paramount consideration. Friends of the insane should not, by dallying or because of prejudice, delay sending at once every acute case of insanity to the hospital, where all the experience, skill and appliances possible should be brought into requisition for the speedy cure of the patient. The first few weeks or months in the institution may decide the case for life.

But, on account of the great aggregation of numbers in lunatic hospitals, and the multiplied duties and responsibilities of the superintendents, would not the individual treatment of a case be well-nigh impossible? Would not more cures be effected, and greater success follow treatment if the best medical skill and attendance could be brought to bear more directly and personally upon every patient? It is not easy to divide such labors or delegate to others such experience and skill. The truth of this position is manifest if we apply it to the treatment of other diseases, or to medical practice generally, or to the various departments of business, whose special knowledge and personal attention are found requisite for successful results. Besides, is it not a fact that the smaller hospitals have generally reported a larger per cent of cures? Also the report of the larger institutions do not show so great a percent of recoveries as they did twenty or thirty years ago, even of patients admitted from year to year, and under treatment. In explanation it is said the cases now sent to hospitals are of longer standing, have become chronic, and afford less chance for cure. It is said too, by some, that insanity as a disease has changed its type — has become more thoroughly fastened upon the brain, and, complicated with other nervous diseases, inasmuch as there has been decidedly a general increase of the nervous temperament. With changes of the body, and in the causes of insanity, we should naturally expect, as in other diseases, some changes in the type or features of insanity which might become more difficult and obstinate in treatment, and, perhaps, less hopeful, in recovery. If this be the case, it affords an argument in favor of the earliest, and most efficient means possible to cure the disease in its incipient stages. Since the hospital is generally regarded as the only proper place to cure insane patients, it should be so managed as to do this very work in the best possible manner.

In the private practice of medicine there are limits or bounds beyond which a physician cannot go, and, at the same time, do justice to all his patients. The same fact must, to some extent, hold good in hospital practice, though assistants may here more readily come to the relief of the principal. But the objection to a large number of patients does not apply wholly to the duties of the superintending physician, but, it has another side, in its effect upon the sick insane, causing an impression, if not frequently a conviction, in their minds, that but little (comparatively) is done for them, and that their individual case is of small or no consequence. We have heard this complaint repeatedly made not only by the insane, but by those who have recovered. Now with such a class of patients, that treatment which inspires the most personal interest, confidence and hope, is of all others, the most successful, and should be employed to the greatest extent. On this account,– small hospitals have altogether the advantage. In fact, if these institutions are to be regarded as hospitals expressly for the cure and treatment of the insane, they should be small. This was once the prevailing sentiment, and is still the opinion of some of the best judges, but, for various reasons, the general custom of late years has been to build large hospitals and, frequently, to make the small ones still larger. Among several topics involved in the question of small or large institutions, one of the most important is that of

CLASSIFICATION

This subject, if the lines are to be closely drawn, is attended with much difficulty. It involves the construction of the building, its internal arrangement, and whole management. For illustration: The criminal insane should be confined by themselves in safe quarters, constructed expressly for them, in an establishment by itself, or an appendage to a prison or some * other hospital. There is only one opinion on this point, but in respect to those made insane by intoxication, opinions may differ.

If the derangement or insanity is temporary, as it frequently is in the first attacks, and then repeated as often as the temptation is offered, there should be an asylum or hospital, expressly for this class of persons. As it now is, our lunatic hospitals are very much disturbed by the admission of large numbers, mentally deranged, sometimes dangerous and boisterous, from intoxicating liquors. As long as intemperance prevails to the extent that it now does, there should be asylums or places of confinement for inebriates, for temporary treatment, but, when such persons become more permanently deranged, and their insanity fixed, then the lunatic hospital is the best place for them.

There is another constantly increasing class that require special accommodations, viz: the epileptic insane. It might not be advisable to bring all these into a separate establishment, but there should be in every lunatic hospital, halls, rooms,’ etc., with furniture adapted to this particular class of persons. This should be done not merely for their comfort and safety, but for the benefit of other inmates.

Then there are the dangerous and suicidal insane. It has been found absolutely necessary to make special provision for this class, to some extent, in the construction and arrangement of rooms. Too much care and forethought cannot be exercised in making such provision, and this should be followed most rigidly (if not in lines of separation), with unceasing vigilance and watchfulness.

There are two other classes who should be cared for more of exclusively by themselves, viz: 1st. Those that are noisy, and, are disposed, either by some exciting cause, or by involuntary out-breaks of insanity, to disturb the quiet rest of others both by day and by night. The second class include those, who by reason of their habits or insanity, are uncleanly and filthy in their persons, or vulgar and obscene in their language. This latter fault is perhaps more common than the former, though not so easily detected; but more pains, we believe, should be taken to make special provision for both these classes.

One of the strongest arguments adduced in favor of large establishments is, that a more complete classification of the insane can be made by having a greater number of wings, halls and various other accommodations. While there may be much truth in this argument, still there are serious objections to the aggregation of great numbers of such people, who, must come in contact more or less, and exert, in a variety of ways, a powerful influence upon each other. In providing for so large numbers it is impossible to secure in a comfortable and wholesome manner, that amount of air, light, exercise, employment, recreation, freedom, and social intercourse with one another and with sane people, which are indispensable to promote their highest physical and mental welfare. If large numbers must be congregated together, there should be an abundance of land, and a portion of the buildings constructed in the pavillion style, or in small cottages where, to some extent, the family method of living can be adopted. There can be no question, but that the situation and prospects of many in these large hospitals might be greatly improved by transferring them to different quarters. This brings up a question which has been agitated for years, but, of late, has excited much interest, and is destined to create still more interest and discussion. We refer to the question of separate support and treatment of the class denominated

CHRONIC OR HARMLESS INSANE.

As this subject opens a large field for discussion, and many arguments may be advanced upon both sides, I shall confine my remarks to a few points. The fact is now well established by recent investigations, that a much larger proportion of the insane belong to this class than was formerly supposed. If we include the insane wherever found, it is safe to state that considerably more than one-half belong to it, and, if the test is applied to hospitals, we shall find in many cases, the proportion will amount to three-fourths or four-fifths, and, in some cases, nine-tenths. It is surprising, too, how rapidly this class increase in all lunatic hospitals, and notwithstanding a diminution of numbers by death, unless some positive means are provided for removing such patients, these institutions would in a short time become almost wholly filled with the chronic insane.

If a separation or division of this class is to be made, it becomes an important question upon what principle it shall take place, whether it shall include the most quiet and harmless, or the most demented and hopeless, or the healthiest and most serviceable. This must depend upon the particular objects had in view, as well as upon the character of the provision which has been made for them. In making a division of the chronic insane for support, there must be some distinction or classification. If the law of pauper settlement, or the claim of private support, should come into the account, these might determine each case, or direct where it must go, whether to an almshouse or to some private quarter. In the present state of the question it would be difficult to lay down any exact course or fixed principles upon which such separation should take place.

As the great majority of this class do not need hospital treatment, or its usual appliances and attendants, different accommodations should be provided in respect to land, buildings, and general management. A large amount of land, well adapted for cultivation, favorably located for health, easy of access, and with pleasant surroundings, should be the first object. The buildings in construction and all their parts, should be adapted to this class of persons, built in the pavilion style, not more than two stories high, with halls and rooms, well lighted and ventilated. The whole construction expense for each inmate should not exceed one thousand dollars, and, perhaps, might be provided for at considerably less than that sum. In this respect, it would differ radically from the present style of building lunatic hospitals where the out-lay or construction account averages from two to three thousand dollars for each patient.

As yet there has been no complete and fair experiment in our country of supporting the chronic insane by themselves. It may be said, that three trials of it are being made at the present time, but, have not been carried on long enough or under such favorable circumstances, as to ensure the success which is desirable,– certainly these would not claim to be considered as model institutions. It is only a few years since any movement of this kind commenced, and all the three experiments have been conducted under somewhat disadvantageous circumstances.

The oldest of these is in Massachusetts, called the Tewksbury Asylum for the chronic insane, started in 1866. It is connected with the state almshouse as a department, though in a separate building, but is a part of the same institution, under the same management and officers. It provides for about three hundred insane persons, all paupers.

The second experiment is in Rhode Island, called the ” State Asylum for the incurable insane,” located a few miles from Providence on a large farm, near other state institutions, though this is entirely separate, containing some one hundred and fifty inmates. It is wholly under the management of the board of state charities.

The third institution of this kind is the ” Willard Asylum for the insane,” located at Ovid, New York, and established in 1868. This asylum has about one thousand inmates, and is managed by a board of trustees, and a medical staff appointed expressly for the purpose. It is understood generally, we believe, that this institution during its eight years of operation, has met with much success, and, one of its greatest advantages is, the large amount of excellent land it possesses for cultivation. This introduces a subject of vast importance to this particular class of persons and demands careful consideration. We refer to

EMPLOYMENT FOR THE INSANE.

As the laws of physiology have become, of late years, better understood, together with the causes of disease, physical exercise has assumed, as a remedial agency, more and more importance. Especially is this the case in all kinds of chronic disease. Insanity is a disease of the brain and the nervous system, and in its acute stages, requires, like other diseases, medication, and the appliances of a hospital, but, when it has passed into a chronic state, there should be added to or combined with this treatment, a strict observance of the principles of hygiene and sanitary laws. The symptoms of insanity in its acute stage, are generally distinctly marked so that medical treatment can be brought to bear directly upon it, but, when it has settled into a chronic state, the indications of disease become more obscure and complicated, so that the exact pathological condition of the system-cannot be so easily understood. Here comes in the law of exercise. Amusements and recreations, of various kinds, are provided for diverting the mind. These are good in their place; we would have more of them rather than less. Airing courts are good in their way, so are the exercises of walking and riding, all these have a most beneficial influence upon both body and the mind. But work – active employment of some kind, is more important than all other treatment to the chronic insane. It develops muscle and gives strength; improves the appetite and digestion; increases all the vital forces of the system; occupies and diverts the mind; has a strong tendency to give self-control and bring into exercise all the mental faculties in harmony with the laws of the body. It has a decided tendency to prevent not only slight attacks of mental derangement, but also momentary out-breaks of insanity. It would often obviate the necessity of physical restraint and seclusion.

This employment should be suited to the need, and taste of the insane. Farm-work and gardening afford the greatest variety and most wholesome kinds of occupation. They call into exercise all parts of the body, surround one with pure air and plenty of sunlight, and at the same time, occupy pleasantly the higher and better faculties of the mind. Among a large body of men, many may prefer trades, or some kind of mechanical business – perhaps have had experience in these, or can learn some one of them. While a plenty of good land, connected with a large institution, may furnish a great variety of work, other kinds of occupation and business can easily be introduced, if desired.

In the treatment of the insane formerly very little account was made of work or exercise, and even at the present day, it is considered by many persons of small consequence. Once it was thought that diseases could be cured by medicine alone, but, the better we understand the laws of the human system and the causes of disease, the less dependence we find upon medicine, but the greater upon the necessity of a strict observance of the laws of nature. Most emphatically is this true, in diseases of long standing, involving the nervous system and mental soundness. Accordingly we find in all asylums for the insane, that where wholesome exercise of body and mind has been most systematically and extensively introduced in these institutions, there has been found the most successful treatment of the insane, the best health, the least mortality, and the most recoveries. Of course, the measure of success varies, and is exhibited in different ways.

There are several institutions in Scotland and England where employment has been made particularly within a few years, a primary object, and this has been followed with the most beneficial results. It is believed, we have some such institutions in this country, among the foremost of which, may be mentioned the Northampton Lunatic Hospital in Mass., and the Willard asylum in New York. If wholesome exercise of body and mind as a law of nature, as a remedial agency, is an indispensable condition, upon which depend general health and soundness of mind, it should certainly be resorted to, under the most favorable circumstances, and to the greatest extent. By the use of such means, success and not failure, must inevitably follow. Not only experience and observation confirm this position, but such a course of treatment harmonizes with the established laws of physiology, both in a normal and morbid condition. Many illustrations could be given where health of body and sanity of mind have thus been restored, after much medication and long hospital treatment. Most intimately connected with this subject of employment is another that vitally affects the interests of the insane, that of

 PERSONAL FREEDOM.

Ever since Dr. Conolly broke open the prison doors, and knocked off the chains from the bodies of the insane, the question of freedom, restraint, seclusion, etc., has been the occasion of controversy. Since that period the whole history of the treatment of the insane shows that there has been a steady improvement, more liberty and freedom, less confinement and restraint. All must admit that cases of insanity occasionally occur of such violence and danger to human life, that restraints of some kind are indispensable. There can be but one opinion, that occasionally there may be an insane person so violent and dangerous as to render the use of force absolutely necessary for safety, and even a resort to bolts and bars, but how far, or to what extent, this shall be carried, there is difference of opinion. But because force or seclusion may occasionally be necessary, it does not follow that all insane persons must be connned by locks, bolts and bars, great improvement has recently been made in this respect in several asylums in Scotland and England. The buildings have been changed or constructed with particular reference to making these experiments. The leading features of this reform are thus characterized: first, unlocked doors; second, great amount of general freedom; third, the large numbers on parole; and fourth, the special attention given to the occupation of patients. No locks or keys are used except o small wards or parts of the hospital where but few paents are confined. The insane are so taught, trained and treated that they are not disposed to make trouble or escape. Their apartments are constructed and arranged as though designed for individual boarders or private families.

The asylum or hospital is regarded by the insane as a home not a prison or penitentiary. Acting on the motto, ” the more you trust, the more you may,” appeals to the self-respect and the self-government even of the insane which is found to exert a wonderful influence upon them. Under such treatment, it is surprising how rapidly they improve and how few attempt or want to leave the institution. The effects of such management are found to be first greater contentment and general happiness; second, better conduct in everyone, less excitement; third, the preservation of the individuality of each patient; fourth, less degradation; and fifth, greater vigilance and care on the part of the attendants. Special pains are taken that every insane person shall have some work – something to do, to occupy his time and attention. Under such treatment, it is seldom found necessary to resort to restraint or seclusion of any kind, though increased care, watchfulness, and fidelity, may become requisite.

The description here given is no fancy sketch, but a simple statement of facts — the results of experiments, commenced, carried on and approved by the highest medical authorities in such matters. And why should not such treatment of the insane be successful, and be approved? — Does it not harmonize with those laws which govern both the body and the mind?

On no one point are we so sensitive as on that of personal liberty. The idea of having our liberty — our freedom forcibly taken away — of being confined by bolts and bars, shocks our sensibilities. This is perfectly natural; it accords with our best instincts of self-respect and self-government. In case of the insane surrendering up their personal rights — their liberties — may not the change in many instances aggravate or increase their derangement, and, serve as a powerful hindrance to the restoration of health and sanity? If certain muscles, limbs, or organs of the body have become weak and reduced in vitality, it is exercise free and voluntary — continued and persevered in for a long time — that gives strength and health. The individual must do this for himself, and, if need be, encouraged and urged to do it. Those means and appliances must be used to give strength and cure disease which nature or the laws of pathology have adapted to the purpose.

So of the laws of mind. The love of liberty, of freedom, of voluntary exercise is here the first law. Our best instincts the governing faculties of the mind — self-will, self-respect, self-government — all tend in this direction, and should be encouraged. All moral, civil and social provisions and agencies must have a powerful influence to improve both physically and mentally the chronic insane. And just as long as they are treated as criminals, as prisoners, as dangerous persons who must be confined, placed under guardianship and constantly watched, just so long will their physical energies suffer and be cramped, and their spirits languish and be depressed.

There are, of course, many individuals among the insane who have become so demented, so lost to all self-respect, and sense of their rights, as to be incapable of appreciating such treatment or being influenced by it. At the same time, there are large numbers among the chronic insane, if they could have the same kind treatment, and useful employment, the same confidence and freedom as are accorded to sane people, what a surprising change it would soon make in their conduct and character. It would not only improve their health and spirits, making them more contented and happy, but would doubtless restore some of them to sanity, usefulness and self-support. Such a boon we believe, will yet come to many of the chronic, insane. The discoveries and applications of modern science everywhere favor health and human improvement, and the best instincts of humanity, guided by the higher mental faculties, are pretty sure to move in an onward and upward direction. Wherever the rights and liberties, and the interests of any class of persons are invaded or are suffering, whether inside or outside of an institution, such a state of things cannot always continue. Reform sometime must and will come. Another point, involving the rights and personal freedom of the insane (if not sometimes of the sane), should receive far greater attention than it has received, we refer to the

 COMMITTAL OF THE INSANE.

The laws in the various states differ materially as to the process of committing an insane person to a lunatic hospital. As the medical testimony affords the principal evidence, it is highly important that this should be correct and properly presented. Sometimes the courts take an active and leading part, but more generally their course is formal and approbative, and not unfrequently judges decide without seeing the person or knowing anything of the merits of the case, except from the medical testimony and representations of interested parties. In some states the certificate of one physician only is necessary, but more generally the law requires the sworn testimony of two “respectable physicians.” Neither the courts nor the laws make much discrimination in the qualifications, or the character of the physicians, further than that they shall be ” reputable ” or of ” respectable standing in the community.” It is an’easy thing of course to find such physicians everywhere. Trouble comes, not so much from bribery or any self-interest, as from the fact that these certificates are too hastily signed, and a mere formal opinion sworn to, without such careful examination, and such reasons given, as the merits of the case demand. No judge decides so important a case, or pronounces a sentence on an individual without giving his reasons. For a physician to declare publicly that a person is insane, and to make oath to a document which consigns the individual to a lunatic hospital, is to assume a vast responsibility. It deprives the person at once of his rights and privileges; it cuts him off from all business relations, and from the legal disposition of his property; it discharges him virtually from the duties he owes to society and to his family; it renders him no longer responsible for his acts, and subjects his person to the control of others. But this is not all; there is the moral effect — the stigma — the sense of degradation and humiliation of being forcibly removed from a position of freedom and independence, to one of confinement, and unpleasant associations; this sudden change has not unfrequently a crushing effect, from which the individual never fully recovers.

In the preparation and completion of a document that makes such changes in the rights, situation and prospects of an individual, the greatest pains possible should be taken, and no examination can be too careful, or thorough, lest some wrong or injury be done. The law stipulates that the vagrant and the criminal cannot be punished without a trial by a judge or jury; he is commonly provided with counsel; the evidence and the facts must be clearly set forth, and spread out before the public. Should the law provide greater safeguards and stronger defenses for the vicious and the criminal than for the innocent and unprotected insane? It is true, in most of the states, that the laws do provide for trial and appeal to the courts in behalf of the insane, but how seldom is this protection resorted to? In most cases, this part of the law is a mere form, in fact, a dead letter to the insane. In the medical certificate declaring a person insane, the law should require that the reasons be stated. In some states, the statutes direct the wording of certificates thus, that the person is ” dangerous to the community,” or is “furiously mad;” but in many of the states, it allows the certificate to say that the person is a ” fit subject” for a lunatic hospital, and this opinion must be based upon ” personal examination and inquiry.” It will be seen at once how easy it is to sign such a certificate upon very slight examination.

Suppose now the law required that the reasons, the facts, the evidence should be stated in the certificate clearly and distinctly, upon which this opinion is based, and it were understood that the document was to be subjected to rigid criticism, and if found incorrect or imperfect, to be returned for revision, would not such a procedure compel a more thorough examination, and a better knowledge of the symptoms of insanity, as well as a higher appreciation of the nature and results of this legal process? Once in the practice of medicine, mere opinions, without explanations or reasons, might have answered, but at the present day, where the rights, the interests, and character of a patient are involved, something more than a medical opinion should be demanded; the grounds or reasons for this opinion should also be stated, not only for the information and protection of the patient, but for the satisfaction of his friends and the public. Besides, such a statement may be turned to most valuable account by the physcian who is afterwards to treat this same patient. Two other important advantages would be secured by such a course. Some persons now consigned to a lunatic hospital would never be sent there. It would lead to a better understanding of the symptoms and causes of insanity, on the part of all physicians making such examinations.

In Great Britain where far more attention has been given to the treatment of the insane than in our country — especially in all legal proceedings — the medical certificates of committal require that the reasons be definitely stated, not what he, the witness, thinks, or believes, or hears, but the specific facts which he himself as a medical man has observed before or at the time of signing. The law goes further; it has a second provision. The physician must state what facts or evidence indicating insanity in the patient, he has derived from others, giving names and describing definitely the nature and character of these facts. Every blank certificate has a wide, open space for each of these heads or provisions to be filled out. If by design or negligence these facts are not properly stated, the physician is made liable by law for damages to the insane person thus committed. After long experience and much legislation in Great Britain, these careful and wise provisions in the medical certificate for the committal of the insane have been found not only expedient but to work well for all parties concerned. Now why should not a similar course be pursued in our country? New York is the only state where any such legislation has taken place. Here the law requires in the certificate, not merely an opinion, but that the reasons — the grounds upon which an opinion is based, should be clearly and definitely stated. This law has been in operation only about two years, encountering at first some opposition but the longer it is tried and the better it is understood, the more favorably is it received by all parties. The state is indebted for this law, to a ” commission of lunacy,” which leads us, in concluding this paper, to offer a few remarks on that subject under the head of

 MANAGEMENT OF LUNATIC HOSPITALS.

Most of the asylums and hospitals for the insane are managed by a superintendent and board of trustees, who have the sole charge. In some states, there may be a committee or board of charities, whose duty is, chiefly, if not wholly, that of visitation and counsel. While the executive in each state or some private corporation, has the appointment of these trustees, and the legislature the enactment of laws for their government, seldom if ever does either the executive or the legislature interfere directly with the management of these institutions. Thus the whole responsibility and power of government is placed in the hands of the superintendent and trustees who are virtually one body. No thoughtful person can often visit these hospitals and make much observation, without seeing the importance of having more careful and discriminating supervision over them, and a more thorough investigation into the whole subject of insanity than exists at present. There are three great interests or parties that require such a supervision.

First: The institutions themselves. Evils and abuses will spring up in these establishments; and, the most effectual way to correct or prevent them, is by suitable authorities outside, charged in part, with such duties. Correction or reform will seldom come from local officers. Besides, until some such provision is made, prejudice and distrust will exist, more or less, in reference to those institutions, causing injury not only to the officers and their management, but, indirectly, far greater injury to the public.

Again: There is always room for some improvement in every such institution; and, 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 labors and interest, are almost wholly identified with one establishment.

The second party interested is the insane, their friends and the public at large. These justly demand that they should, in some way, be represented in such inspection and management. The law takes away the right of the insane in respect to their liberty and property; it unsettles them in all business relations, and in the duties they owe to their families; it cuts them off, in a great measure, from communication with their friends, and exposes them to personal abuse from attendants, etc. Where such personal and fundamental rights are either taken away or abridged, should not legislation make some better provision, for protection, defense and appeal, than now exists? Not only the insane and their friends are concerned in this question, but every member of society, every man and woman, should feel an interest in it. For who is not liable to be insane, or have a friend thus affected. No intelligent or thoughtful community will always rest easy with such a state of things, or be satisfied with present legislation on this subject. Reform is only the work of time.

The third party interested, is Humanity itself aspiring to a higher civilization. Every generation owes something to its successor. 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 true healthy civilization. To check the evil, its causes must be better understood, the public must be instructed and enlightened on the subject. It is the duty of every state to do something in this direction. It is not wise to build great institutions and make large appropriations for carrying them on, without doing something to remove the causes which necessitate such measures. There should be in every state, a permanent commission, consisting of one or more persons, whose duty it should be, to investigate this whole subject of insanity, in all its bearings, relations and causes, and make, from time to time, reports to the public. But no such investigations and reports will ever be made without some express legislation in relation to it. If a hundredth or a thousandth part of the means now expended upon this unfortunate class, should be expended for the objects here set forth, it would be difficult to estimate, either upon the score of humanity or on that of economy, the amount of good that would in time be thus accomplished.

The chairman, Mr. Theodore Roosevelt, had not observed any special mention with regard to the occupations given to the insane. He called attention to the fact because in the city insane asylums of New York they have no occupation of any kind whatever. They wander about the galleries, and in some cases in a ward containing fifty but one nurse will be detailed as a guardian. Consequently they are not able to have the ordinary physical exercise which they require.

Dr. Allen thought that if the general principle of giving occupation to the insane were adopted, there would be no trouble in applying it. He had mentioned farm work as specially wholesome and favorable, but many trades and indoor occupations might also be adopted.

Mr. Dexter of England said that the employment system in England is not as good as it used to be. The county justices unfortunately rule the finances and manage to so thoroughly economize in the conduct of asylums that they cut down allowances-to a few paltry hundred dollars. So employment is not so general as it used to be.

Source: Proceedings of the Conference Of Charities, Held In Connection With The General Meeting of the American Social Science Association At Saratoga, September, 1876. Pp. 35-54. — National Conference on Social Welfare Proceedings (1874-1982) http://www.hti.umich.edu/n/ncosw/

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