LUNACY REFORM.—HISTORICAL CONSIDERATIONS E. C. SEGUIN', M.D. CLINICAL PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM ; ONE OF THE CONSULTING PHYSICIANS TO THE HUDSON RIVER STATE HOSPITAL FOR THE INSANE, ETC. [REPRINTED FROM “ARCHIVES OF MEDICINE,” OCTOBER, 1879.] NEW YORK G. P. PUTNAM’S SONS 182 FIFTH AVENUE 1879 LUNACY REFORM.—HISTORICAL CONSID- ERATIONS. At different times within the last one hundred years, Insane Asylums have been the subject of much anxious thought on the part of philanthropic physicians and laymert. This more or less expert study of asylums has usually grown out of a wave of strong popular feeling or prejudice against some points in the manage- ment of the insane. Three such periods of suspicion, of public enlightenment, and of consequent improvement in the lot of the insane, may be cited. i. The assault on the prison plan of asylum, as inaugurated at Bicetre in 1792. Pinel'was the embodiment, the executor of a large movement for human liberty acting in numerous directions. He used this great weapon to strike the manacles from insane patients, and did a great deal to assimilate their condition to that of patients in ordinary hospitals. 2. Charlesworth and Connolly in 1835-40 inaugurated another great reform which has gradually invaded country after country, our own very slowly we regret to say. This was the absolute abolition of all physical restraint upon violent patients, and the substitution of watchful kindness therefor. 3. Within the last ten or fifteen years in Europe, a decided re- vival of science has appeared in the medical staff of asylums ; or perhaps it is better to say that more scientific men and methods have appeared in this specialty. We may cite as examples Dr. 2 L UNA C V REFORM. Arndt, Profs. Meynert, Gudden, Westphal and Dr. Hitzig in Germany; Morel, Baillarger, Magnan in France ; Crichton Browne, Herbert Major, Mickle in England. These gentlemen, besides ad- ministering asylums in a satisfactory way, have made solid contri- butions to medical science, with respect to the anatomy of the brain, the study of its lesions in insanity, and points in therapeutics. In America no such movement has appeared, though in one asylum a costly and inefficient attempt at pathological study has been made. I have no hesitation in declaring that not one of the few American contributions to the scientific aspects of insanity has been meritorious, and has been quoted with praise by compe- tent critics. Indeed it is necessary to add that in the various European works on insanity, hardly an American physician’s name is cited except that of the celebrated Rush. Besides, no treatise on insanity, and no important monograph upon one of its forms has appeared in this country. The published studies of our alienists almost all relate to medico-legal topics which possess a practical (/. e., profitable ?) interest which scientific questions do not have. Not only there are no evidences of a scientific revival among asylum superintendents, but from conversation with these gentle- men, from reading the Proceedings of their Association, there is a widespread belief in the minds of many who have given attention to the subject, that our alienists are not scientifically trained men ; are not versed in the new anatomy of the brain ; do not believe in the growing physiological psychology of the present ; and that they are consequently incompetent to further the next progress in the treatment in the insane—a progress which is designated by all signs of the times as being in the direction of improved therapeu- tics based upon pathological anatomy and psychology. It would thus seem that the present scrutiny and criticism of asylums in this country is a part of a general movement tending to make the organization of hospitals for the insane more similar to that of hospitals for other patients. The chief points involved in such a reform will be detailed later on, in this and other editorials. Mingled with the professional E. C. SEGUIN. 3 criticism of the last few years, there has been a strong popular tide of ill-will and abuse directed against asylums, but on alto- gether different grounds. The public, even the educated public, would prefer, I suppose, to secure absolute kindness and humanity in asylums, rather than scientific and more successful treatment. This is, it seems to me, a natural feeling, but it is one which we cannot be expected to share. In the first place, we do not have faith in most of the stories told of asylum oppression, cruelty and wrongful imprisonment, because we know the peculiarities of monomaniacs, of patients with delusions of persecution, and the deceptive nature of remissions. In the second place, we believe that in the ordinary sense of the words, humanity and kindness now obtain in our asylums, and that there is no reason for calling in question the personal worth and kindliness of most of our superintendents. Therefore it is that in the various medical criticisms of New York asylums, the causes of complaint which have proved so interesting to enterprising newspapers are not referred to. The present movement is, we repeat, aimed at bringing about through public opinion, a more medical and scientific organiza- tion of asylums. And to this end we ask all physicians to take up the question and study it from documents, and by frequent visits to the asylums near them. A complete study of all the questions involved in “ Asylum Reform ” is impossible in an article like this. I must restrict myself to the consideration of a few topics : I. Dr. Wilbur’s criticism in 1876. At the request of Governor Tilden and the N. Y. State Board of Charities, Dr. H. B. Wilbur, Superintendent of the State Asylums for Idiots at Syracuse, made an inspection of a number of British Asylums in the summer of 1875, and his report, chiefly statistical, was published by the Board of Charities in January, 1876. In 1877 Dr. Wilbur republished the pamphlet, with a preface in which he summarily dealt with a quibbling criticism of the report. In brief, it may be said that Dr. Wilbur visited asylums in Eng- 4 LUNACY REFORM. land, Scotland and Ireland containing nearly 15000 patients ; he took instant notes of what he saw, and made transcripts from the journals of the institutions, he conversed and corresponded with the eminent gentlemen who compose the Boards of Commissioners of Lunacy, and he met with the most cordial reception everywhere. Besides many comments on various matters connected with asylum management, Dr. Wilbur deals chiefly with these subjects : 1. The employment of patients. In this matter he found the most to praise in British asylums and the most to condemn in our institutions. The report contains tables giving the number of patients employed, and the kind of occupation in numerous asylums on the day of the visit. For example, in the West-Riding Lunatic Aslyum on July 26, 1875, out of 708 male patients, 532, or more than 75 per cent, were actually employed ; out of 699 females 485 were busy, or 69 per cent. Yet in 1876 Dr. Gray, by many considered the leading American superintendent, published the statement that not more than 25 per cent, of patients could be employed as six hour workers. Dr. Gray’s position with reference to the employment of the in- sane is clear enough, though his statistics are not easy to appreci- ate because he usually reckons the number of days’ work done in- stead of stating the percentage of patients employed. In his Report for 1876, he says, p. 63 : “I am well satisfied, from long and careful observation, that from twenty-two to twenty- five per cent, would be the highest estimate of six hour workers, who could be depended upon.” Again on p. 55 it is stated : “ We give them all the work they need.” In the Report for 1877 nothing is said of this important subject except that the amount of labor performed by patients was greater than in the preceding year. The same statistics of day’s labor are given. In the Report for the year 1878 the superintendent writes, p. 22 : “In my Report in 1876 I gave my views fully in regard to this question of occupation, and experience has only tended to confirm these views.” In other words, in Dr. Gray’s opinion, the E. C. SEGUIN. 5 percentage of labor in 1878 should be the same as that for 1876. Let us see If the annexed table bears this out: Utica Asylum. Year. Average Population. Male Patients. No. of Day’s Labor. 1876 615 19,9x1 1877 607 26,141 1878 600 34,9i5 Thus we see that two years, from 1876 to 1878, including the period when the force of Dr. Wilbur’s report was making itself felt, witnessed an enormous increase in the amount of labor done by Dr. Gray’s male patients, an increase of 43 per cent! But as the number of patients was less in 1878 than in 1876 by nearly 3 per cent., the increase in labor approximates 50 per cent. ! And yet in 1876 Dr. Gray tells us that he was obtaining all the labor that ought to be obtained from his insane patients : in 1878 he says that he has not changed his opinion ; yet his tables show that he has nearly doubled this labor ! Was Dr. Gray, in 1876, “ after twenty-six years of experience,” mistaken as to this ques- tion about which he expressed himself so dogmatically, or did he two years later overwork his patients ? Thus it appears that progress will be made even in the midst of protestations of conservatism. Dr. Wilbur’s statements in 1875-6 concerning the excellent system of employment in British Asylums have done thus much good. In all British asylums Dr. Wilbur found that great diligence was used to occupy patients in work proportionate to their strength, and that all the physicians looked upon occupation as positively useful in diminishing excitement and in preventing ennui. In connection with this let me beg any reader of the Archives to go to an asylum and see for himself the chronic insane and the con- valescents who are standing or sitting idle with despair and ennui written upon their faces. “ Something to do,” seems to be the only prescription called for. 6 L UNA C V REFORM. 2. The removal of physical restraint. In this matter Dr. Wilbur found that remarkable progress had been made in Scotch and English asylums. In some institutions a system of open doors and gates for the majority of the patients prevailed, and nowhere were cribs, straight-jackets, etc. met with. At the colony of Gheel out of 1,300 patients only four were under restraint, and large numbers enjoyed almost perfect freedom. At the same time, 1875, that barbarous “ crib” was in use I be- lieve in all our asylums, and to-day I think it is still employed in some. It was banished from one large state institution only so late as last autumn. Straps and waiscoats are still freely employed in the best institutions, and when a visitor is shown around an asylum the medical officer carries a large bunch of keys, unlocks and locks innumerable doors, and does it in very much the same way that a keeper of convicts would do. And yet escapes from these well-locked, well-walled asylums are not unknown. In conclusion, it appears that by comparison there is a remains of last century repression of the insane in our State, while in Great Britain these unfortunates are more humanely treated year by year. 3. The relative frequency of accidental deaths and suicide. It is admitted that even in the best managed institution a deter- mined suicidal patient may carry out his plan. Still with equally good management there should not be great differences in the proportionate number of such occurrences in two countries. Yet Dr. Wilbur quotes from official reports as follows : “ In looking through the reports for 1874 of twenty British asy- lums, containing in the aggregate about 15,000 patients, I find that there were but seven accidental deaths, and these nearly all in the case of paralytics and epileptics, and only five suicides. “ In the annual report of the Commissioner of Lunacy of the State of New York for 1875, where are given the statistics of thir- teen institutions, containing in the aggregate about 3,500 insane persons, there is found the record of twelve suicides. Other casualties are not noted.” In the first instance the proportion of suicides to inmates is one-thirtieth of one per cent. E. C. SEGUIN'. 7 In the second instance the proportion is nearly one-third of one per cent. Thus in well-locked, well-watched New York asylums there were approximately ten times as many suicides as in the British institutions ! And who can tell about the accidental deaths not reported in our asylums ? 4. The inspection of asylums. As shown by Dr. Wilbur, this necessary supervision seems ad- mirably done in Great Britain by the various Boards of Lunacy. The members of these Boards really inspect, they look searchingly through asylums, using all possible sources of information, and they enter their conclusions truthfully and fearlessly upon a regis- ter kept at the asylums for that purpose, and make their judgment public by means of formal reports. In America the appointment of inspectors or commissioners was formally resisted by the Association of Superintendents as recently as 1876 (see p. 74 of second edition of Dr. Wilbur’s pamphlet) ; the resolution being passed by men who knew or ought to have known that government inspection of asylums had long been practiced in all the chief civilized nations with the best results, especially in Great Britain. And when a State Commis- sioner of Lunacy was appointed in the State of New York, of what advantage was it ? What serious criticisms or reforms followed his perfunctory execution of the high duties of his office ? A single ex- ample of what this official termed “ inspection” will suffice. I again quote Wilbur (p. 17): “In his (the Commissioner’s) report for 1875 he gave an unqualified indorsement of all the State asylums for the insane. He had visited from time to time the asylum for insane convicts at Auburn, and he commended the management of that directly and by implication. It occurred, however, that the “ Prison Commission” of last year (1876) made an investiga- tion of the management of that establishment, and I quote from the testimony in regard to it. “ Dr. McDonald, who was appointed Superintendent in the Spring of 1876, thus testified : 8 L UNA C Y REFORM. “ ‘ I found the institution in a decidedly unsanitary condition ; I think I never saw its equal in that respect, presenting an appear- ance of squalor and destitution beyond anything I have ever seen in any pauper establishment or poorhouse ; the bath-rooms and water-closets were a stench to the nostrils ; the beds were literally swarming with bugs; the food was badly cooked and badly served ; three-fourths of the patients were suffering from dys- pepsia and bad diet ; the bread was sour, the flour being of an inferior quality ; the cells dingy and dirty ; no provision for extra diet for the sick or feeble was made, except a weak tea ; there were few of the modern remedies used in asylums, about the only one was hydrate of chloral.’ (As to punishments.) “ ‘ Punishments were the order of the day when I came here ; I have a patient there to-day who has a pistol ball in his arm that was shot in by my predecessor, and another in the hip ; I found one patient with handcuffs upon his hands fas- tened behind him ; I am told patients were paddled ; one of my present attendants says he has seen my predecessor black the eye of a patient, and he did not think anything of doing it himself.’ ” One of the attendants testified to paddling patients ; handcuff- ing them ; and chaining a man up night and day for about two months. There were no records, medical or otherwise, kept of the daily life of the patients. And yet the State Commissioner of Lunacy in his various visits saw or learned nothing of all this ! He com- mended the management! After the exposure by the “ Prison Commission ” ought not the Commissioner of Lunacy to have resigned for very shame at his superficial and nominal performance of duty ? In another country would he not have been summarily removed ? This specimen of “ inspection ” in our state is amazing, but in connection with this barbarous asylum at Auburn a still more amazing thing occurred. At the very time when the above abuses were being perpetrated the Association of Superintendents held its annual meeting at Auburn, and after inspecting the prison asylum expressed themselves as follows : “ That their visit had been E. C. SEGUIN’. 9 peculiarly interesting as giving most obvious evidences of good management“ that it seems to us to demonstrate conclusively that even the most desperate convict, when bereft of reason, is treated like his fellow-men, only in a hospital specially provided for the purpose, with all the appliances that can contribute to his comfort and restoration.” The first sentence is clear and admira- bly illustrates the keen critical sense and special knowledge of the members of the Association ; the second, in view of the facts re- vealed a few months later, is sickly bosh and bathos. With this monstrous example of mismanagement, cruelty, and blindness existing in this State in this year 1875, the public are told that a searching inquiry into the management of all our asy- lums in 1879, as demanded of the Legislature by numerous peti- tioners is uncalled for, and is insulting to the Superintendents and the Commissioner of Lunacy ! Did these gentlemen invite the in- vestigation of Auburn asylum in 1876, or did they protest against it ? Who can tell but that a searching investigation to-day would not reveal the existence of numerous evils worth correcting, more or less after the Auburn type ? I have dwelt at length upon Dr. Wilbur’s critical report because it has never been replied to except by personal abuse, and partly because its publication has caused marked progress in one par- ticular, viz., the greater employment of chronic and convalescent insane. That it has had any effect upon the method of asylum inspection is doubtful, but Dr. Wilbur is not to blame for that. 11. The more medical and scientific criticisms of asy LUMS FOR THE INSANE. During the years 1878 several papers were read severely con- demning the management of asylums, the want of scientific knowledge in superintendents and their assistants, and the utter dearth of valuable contributions to the science of medi- cine from asylums. These papers were read before the New York Neurological and the New York Medico-Legal Societies, and many members took part in the discussions. L UNA C V REFORM. Dr. E. C. Spitzka’s contributions were the most important and the most acutely critical.* These essays and discussions have remained without reply, ex- cept the worn-out remarks that the attacks were personal, were made with a selfish aim in view, were insulting to the superintend- ents, were made by “ outsiders,” or by men who could not know anything of insanity, etc., etc. On a subsequent occasion reference may be made to the pecu- liar methods of “ reply ” employed by the asylum ring, embracing personal abuse, scornful but unsupported denials, warnings, and even threats of professional ruin to critics, etc. We have the documents for this accessory question, but postpone its presenta- tion, we hope indefinitely. 111. The petition of the Neurological Society to the Legislature in 1879. Out of the numerous discussions upon the pathology and treat- ment of various forms of insanity and upon asylum management in the New York Neurological Society, there grew up a demand for a formal investigation of asylums in our State. The only way in which this could be done was through a committee of the Legislature. Accordingly, at a meeting of the Society, held April 1, 1878, the following committee were appointed to draw up a form of petition to the Legislature embodying the chief points of complaint: Drs. T. A. Mcßride, (chairman), E. C. Harwood, E. C. Seguin, E. C. Spitzka, J. G. Kiernan, and Landon C. Gray. On October 7th, the committee presented their report in the shape of the following petition, which, after due consideration section by section, with a few alterations, was ac- cepted by the society, printed, and returned to the committee for the purpose of soliciting signatures. The committee was given power to elect additional members, and Drs. Hammond and Wm. J. Morton, were so added. *I. Reform in the Scientific Study of Psychiatry. Journal of Nervous arid Mental Diseases, April, 1878, p. 201. 2. Merits and Motives of the Movement for Asylum Reform. Ibid. Oct., 1878, p. 694. 3. Real Asylum Abuses. . Read before the N. Y. Medico-Legal Society, March, 1878. (Not published.) E. C. SEGUIN. 11 The following is the petition, which, in March 1879, was pre- sented to the Legislature, supported by a large number of sig- natures, many of them by professional men of high standing and great influence : To the Legislature of the State of New York. The petition of the undersigned Physicians, Lawyers and other Citizens of the State of New York, represents as follozvs : There has lately sprung up a general and marked discontent in the public mind with regard to the management of our insane asylums. From the nature of the case, the internal mechanism of these institutions being more or less secluded from public scrutiny, it was not to be expected that the popular feeling could point to any special fault in the system as its cause. Like most popular movements, the agitation of the asylum question has, until quite recently, rested on isolated and flagrant instances of abuse, rather than on the great systemic defects of which these instances were but the outcome. But within the past few years, members of the medical profession, whose studies led them to investigate asylums, without bias or prejudice, purely in the interests of medical psychology and philan- thropy, have made public charges against the system of asylum supervision and asylum management in this State which are de- serving of notice. They merit special attention for the single reason, if there were no other reasons, that those now at the head of our asylums, have been either unable or unwilling to answer their arguments, or to disprove their allegations. Many of these defects, medical and administrative, have been admirably and fully set forth by Dr. H. B. Wilbur in his “ Report on the Management of the Insane in Great Britain,” published in 1876 and 1877. This writer institutes a comparison between the management of the insane in the two countries which is as humili- ating as it is instructive. The following points are among the most prominent features of the pending inquiry. Some of them rest upon exact evidence, others can be substantiated by responsible members of the medical profession, and regarding still others, strong circumstantial evidence can be adduced. It is the purpose of the projected investigation to discern how many of the questions herein set forth can be satis- 12 L UNA C V REFORM. factorily answered under oath. We also believe that the points referred to by these queries are of the highest importance for the welfare of the unfortunate insane. QUESTIONS RELATING TO THE MANAGEMENT OF ASYLUMS. i. How many days in the year is the Superintendent actually and really on duty in his office or in the wards ? 2. How many days in the year is the Superintendent away from his asylum engaged in private business, in medical or medico-legal consultations, attending upon courts without an order from the Attorney-General or other proper authority ? 3.'Does not the State (or city), in giving the Superintendent a fair or large salary, make a contract for the use of his whole time, usual vacation excepted ? 4. How often in a week does the Superintendent see and speak to every patient under his charge ? 5. How many patients in the asylum are seen only once a month, or less often, by the Superintendent ? 6. How frequently does the Superintent make unexpected visits to his wards ? How often does he make tours between midnight and morning, to observe the symptoms of some patients, and to see how nurses and watchmen perform their duties ? 7. How many patients are actually and really under the Super- intendent’s own medical treatment ? 8. Does the Superintendent see and examine every new case immediately after admission ; and is he responsible for the regis- tered diagnosis, and general treatment ? 9. Does the asylum possess, and do its medical officers really use such common instruments as the thermometer, ophthalmoscope, Eesthesiometer, dynamometer, sphygmograph, microscope, faradic and galvanic electrical batteries, the speculum, and uterine sound, chemicals for the analysis of the urine, etc. ? 10. Is feeding by force always done by a medical officer or in his presence, as it should be ? 11. Is the Superintendent consulted whenever forcible restraint is required ; and is the duration, manner and result of this me- chanical restraint duly recorded in a book kept for the inspection of the Commissioner of Lunacy and of the courts ? 12. How frequently does the Superintendent avail himself, for the benefit of his patients, of consultations with general physicians and surgeons, and gentlemen eminent in the several departments of medicine ? E. C. SEGUIN'. 13 13. Do you ever employ the barbarous and injurious means of restraint known as a “ crib ? ” 14. Are undergraduates in medicine ever employed in your asylum as assistant physicians, or acting assistant physicians ? QUESTIONS REFERRING TO THE INSPECTION OF ASYLUMS. x. Does the Commissioner of Lunacy give any notice of his coming to the officials of an asylum he is about to inspect ? 2. Has the Commissioner ever visited asylums at unusual hours, as in the middle of the night or in the very early morning, in order to determine the usual condition of their wards ? 3. Does the Commissioner ever go about an institution without company, or at any rate without a medical or other officer whose presence can prevent free speaking on the part of attendants and patients ? 4. How frequently are inspections made in the various asylums ; and how many days in the year is the Commissioner in Lunacy engaged in private business not legitimately appertaining todxis office ? 5. Does not the State, in paying the Commissioner a fair salary, make a contract for his whole time, customary vacation excepted ? 6. Was the present Commissioner appointed in strict accord- ance with the law which requires the candidate for this position to have been a “ physician of experience ? ” Besides, your petitioners believe the following statements to be well founded. They refer to more strictly medical matters than the above recited questions, yet we consider that if these evils exist, the State and the patients in our asylums are highly inter- ested in their eradication. 1. Superintendents of insane asylums are, nearly without excep- tion, not chosen from among medical men who have pursued special studies in neurology at home and abroad, and who are well-trained physicians, but from among assistant physicians of asylums who, after having been badly chosen {vide infra), have passed a number of years immured in an institution. 2. Assistant physicians of asylums (future candidates for the position of superintendent) are nearly always men just issued from our too elementary medical schools ; men who have not served in civil hospitals (which can be entered only by severe competitive 14 LUNACY REFORM. examination) ; their qualifications are not submitted to any test ; when in the institution they are not furnished with means of study (medical journals, books and instruments) ; and, inevitably, as years go by. they forget what general medicine they knew on graduating. 3. Assistant physicians, moreover, are overworked, and wretch- edly paid. Their time is taken up by visiting too many patients, by writing interminable, useless histories of cases, and by various “ official ” duties, such as talking by the hour with friends of patients, receiving visitors, etc. The largest asylum under State management (in this State) has only four assistant physicians for between six and seven hundred patients. In a general hospital, like Bellevue or the New York Hospital, every division of from forty to eighty patients is officered by one attending physician (who really sees his patients daily) and three assistants, all grad- uates, selected from among a crowd of the best men by a severe competitive examination. And it must be borne in mind that in general hospitals there are, as in insane asylums, very many chronic cases requiring a minimum of care. From this compara- tive statement it is at once evident that in spite of enormous out- lays of money our insane asylums are indifferently officered. 4. Superintendents and their assistants, with hardly an excep- tion, are not versed in the new anatomy and physiology of the nervous system, the part chiefly concerned in insanity. 5. Superintendents and their assistants, with hardly an excep- tion, are not believed to be skilled in the modern methods of diag- nosis and of post-mortem examination. Few of them are able to read in the original the invaluable contributions to insanity and its treatment which we owe to German and French scientific phy- sicians for the insane. 6. The little pathological work which has been done in our asylums at enormous cost has been of the most elementary sort, and has been ridiculed at home and abroad. With the liberal aid it receives from the State, the pathological laboratory in one of our asylums did not furnish the materials for successful competi- tion for the great Tuke prize, for the best essay on the pathological anatomy of insanity, offered in England last year. 7. In some of our asylums the pernicious practice of allowing undergraduates, accepted without bona fide examination, to act as assistant physicians, is tolerated. This is highly unjust to the pa- tients, who have a right to medical attendance in the legal sense, and also to practitioners outside. The lunacy laws of 1874 pro- 15 E. C. SEGUIN. vide that no practitioner can certify to the lunacy of a patient un- less he have been three years in the practice of his profession ; and it thus happens that this experienced physician’s diagnosis and certificate are in a measure subjected to the revision and control of men who have not yet obtained their degree, or of others who have just passed from the benches of the medical school to the asylum. In view of the above numerous reasons for believing that there exists gross mismanagement in the medical administration of in- sane asylums in this State, your petitioners respectfully request that your honorale body appoint a committee for the examination of the management of all institutions, for the care of the insane of the State of New York. And your petitioners will always pray, etc. The way in which the petition was received, the farcial manner in which the committee conducted an “investigation,” and the triumphant manner in which New York State asylums for the insane were pronounced perfect, will be related in the next numbers of the Archives. In subsequent numbers there will also appear other critical articles studying in detail certain points in the petition. Person- alities will be carefully excluded from these columns, but the nu- merous faults of omission and of commission in asylums must be unsparingly exposed. E. C. Seguin. M.D.