—^——-    fitfra.^—     'ill   —-—«.   ' I








THE  POPULAR FEELING  TOWARDS  HOSPI-





            TALS FOR THE INSANE.







                By I. RAY,  M.  D.





       Superintendent of Butler Hospital, Rhode Island. 
" On the best methods of saving our Hospitals for the Insan
  from the odium and scandal to which such Institutions at
  liable, and maintaining their place in the  popular estimi
  tion ; including the consideration of the question,  how fa
  is the community to be  allowed access to such Hospitals." 
   Within a few years past, no class of charities has ob-
 tained so strong a hold  on  the public sympathies as hos-
 pitals for the insane.  Most of the States  have endowed
 and fostered them with unusual liberality ; private  bene-
 ficence,  living and posthumous, has showered upon them
 its favors, and the time has come when no community
 among us is supposed to have discharged its obligations
 to this unfortunate class of our fellow-men,  that has.not '
 provided an establishment expressly for  their care and
 protection.   In the older  States  they are  crowded to
 their utmost capacity of accommodation, and  for  a con-
 siderable period, every year has witnessed the erection
 of a new, or the enlargement of an old one.  It is a cu-
 rious fact, however, that, in connection with this general
 current of public opinion, there is a strong under-current
 of a very different character.   None but those who have
 our opportunity of knowing, can have any adequate idea
 of the amount of bad feeling, gross misconception, scan-
 dalous gossip, and even fierce hostility, that quietly per-
vades the community, with the effect of circumscribing
 more or less their sphere of usefulness.  The most of us,
 fortunately, are so much concerned with  the increasing
pressure upon our means of accommodation, and intent,
 perhaps, on schemes of enlargement, as to make too little
account of this state of feeling and of its legitimate conse-
quences.  1 believe, however, it will be worth our while
to give  this subject  a thorough  consideraton — more
thorough than I find it within my power to give it at this
time.  My observations  must be very brief and general,
           1 
2
  rather calculated to suggest discussion than exhaust it,
  and while freely commenting on existing  defects and
  errors,  disclaiming all intention of a particular applica-
  tion.
    No hospital for the insane in this country,  or any other
  I  presume, has been  so fortunate as to be universally
  regarded, wherever known, as an honestly and kindly
  administered charity, fulfilling its mission of benevolence
  with as little drawback as possible on the score of human
  infirmity.  The separate counts of the indictment against
  them,  so to  speak, may be reduced  to a few general
  heads.   It is supposed that the patients are not treated
'  with invariable kindness; that the management is harsh
  and cruel; that obedience is enforced by blows or rough
  handling;  that refractory  conduct is  met by the disci-
  pline of shower-baths, or confinement in dark dungeons ;
  that they are neglected  when sick;  that they have im-
  proper and insufficient food; that their friends are not
  allowed to visit them ; and finally,  that to favor the
  schemes of interested relatives, persons are deprived of
  their liberty under  a mere pretence of insanity.  Besides
  all this, there exists a general and  indefinite prejudice
  that does not pretend to  any foundation in fact or reason,
  but none the less bitter on that account.
    Generally,  no doubt, these allegations are  entirely
  unfounded, and it  will not be difficult to explain their
  origin.   Some of it springs,  in  fact, from the ordinary
  principles and feelings  of our nature, and some  from
  causes of a special and peculiar character.    The se-
  clusion  to which patients are subjected, by withdraw-
  ing them from  constant observation,  involves the institu-
  tion in an  air of mystery which  stimulates the imagina-
  tion and excites the apprehensions of the ignorant and
  credulous.  Any appearance  of concealment very natu- 
3
 rally gives rise to the suspicion of something wrong, and
 thus the very measures designed to promote the restora-
 tion of the patient, are apt to be regarded as indications
 of a management that will not bear the light.  Co-ope-
 rating with this cause of ill-feeling, is the natural dispo-
 sition to attribute to others unworthy motives and  a rea-
 diness to abuse whatever power or confidence may be
 placed in them.
   The  most prolific  source of  this  distrust of  hospitals
 for the  insane, is, undoubtedly, the communications  of
 patients themselves,  the  more effective for falling, as
 they generally do, on willing ears.  We instinctively be-
 lieve whatever is seriously related,  and this  disposition
 is increased by every appearance of sincerity and plausi-
 bility.   That the stories of  the insane, as well  as  of
 some  who are  discharged from hospitals partially re-
 stored, exhibit these qualities in a remarkable degree, is
 well known to us, while it is equally well known that no
 moral traits are so common among the insane as a total
 disregard of veracity, and a feeling of hostility towards
 those who have had any part in controlling their  move-
 ments and thwarting their wishes.  It is not strange,
 therefore,  that they should abuse the  institution whose
 benefits they  enjoyed, nor is it more strange that such
 abuse should be received  as the honest and truthful ex-
 pression of a matter of fact.  It is not in human nature
 to listen to a coherent and circumstantial account of ill-
 treatment, without allowing it to  make the slightest im-
 pression, even though a very, large,  personal experience
 with the author of the narrative, may have shown him
 utterly unworthy of credit.  Such plain, deliberate, and
 touching statements are supposed, in spite of one's better
judgment,  to  have some shadow of foundation in fact,
 and thus many a friend or  relative gives a hesitating as- 
4
 sent to a  patient's  abuse of others, who would consider
 himself hardly dealt with, if a tithe of the same person's
 abuse of him were supposed to be true.  The friends of
 patients,  too, are apt  to be exacting and fault-finding,
 never satisfied that enough is done for the patient, though
 infinitely  more,  perhaps,  than they ever did themselves,
 and are restrained  by no feeling of delicacy or gratitude
 from free and frequent expressions of their dissatisfaction.
 In point .of fact, however, I presume there can be no dif-
 ference of opinion among us on this subject, and  that all
 are ready to admit, that the charges above recited cannot
 be entirely attributed to these sources.   No one  will be
 bold enough to say that in no hospital in our country has
 there ever been an abuse of trust, or any arrangements
 of construction, direction, or discipline, calculated to de-
 feat the object in view, — the comfort and  restoration of
 the patients.  Instead of blinking the matter, it is better
 to admit the facts so far as they are true, ascertain their
 causes, and fix the responsibility  where it fairly belongs.
 If our attendants abuse their trust, let us acknowledge
 the fact and present it as a reason for  employing a better
 and more  expensive class of persons, consequently  es-
 tablishing a higher rate of payment  from the patients,
 If an incompetent or  time-serving building committee
has adopted a plan of construction which leads  to casu-
alties, and, in one way or another, prevents us from attain-
ing the highest practicable results, I see  no reason why
the fault should  nor be laid at the proper door.  When
the trustees  or directors, in order  to advance some politi-
 cal intrigue, are ready  to  strike a blow at the usefulness
of an institution, I am for letting  the  public  know how
their confidence is abused.  Admitting then the  general
 fact, that the ill-feeling  towards hospitals for the  insane,
 so prevalent in the  community, is not altogether  without 
5
 foundation, I proceed to consider those usages,  arrange-
 ments and events which are calculated to produce it.
   It cannot be  denied by  any candid person, that in
 some of our establishments there are arrangements of one
 kind or another,  that furnish legitimate grounds of com-
 plaint and  do much to weaken the  confidence  of the
 public.   They  indicate  a  misconception  of  the  true
 character of the insane and of the  exact objects  to be
 obtained in secluding them frOm their families and the
 world.   The buildings must necessarily present  some
 prison-like features, and the safety of the inmates forbids
 many of those provisions which long habit has associated
 with their  notions of domestic comfort.  This  must be
 regarded as a  necessary evil, but any degree of it not
 implicitly required by the circumstances of the case, is
 a justifiable ground of complaint.  Let me ask if our es-
 tablishments are faultless  in this respect; if everything
 has been done to make the  patient  feel as  little as pos-
 sible, the want  of domestic  comfort, the deprivation of
 liberty, the control of another's will, and the separation
from those who did whatever he would permit to gratify
 his wishes, to allay his irritation, and  minister to his in-
 firmities.    To this question, I apprehend that a hearty,
 unqualified affirmative cannot always be returned, and
 hence a fruitful occasion of distrust and aversion towards
 hospitals for the insane.
  Let us observe for a moment, the change  to which the
 patient is at first  subjected.   Against  his own will  pro-
 bably, and not without the use of some force, he is taken
 from his own home, — a home to which, notwithstanding
 his seeming disregard of all  its  claims and  proprieties,
he still retains some strong attachments,—and placed in
 an apartment of unusual size and form. It is  scantily pro-
 vided with furniture, and the walls are as bare and cheer- 
6
 less as unpapered and unpainted surface can make them
 A range of bed-rooms on each side shut out the  light
 and obstruct the view without. No open fire invites him
 to forget his troubles, for a moment, in the range of its
 genial rays, and a  crowd of persons,  by their strange
 looks and stranger conduct, appear to make a mock of
 his calamity.   At night, cries and other unaccountable
 noises disturb his rest, and fill him with  suspicion and
 fear.  Friends, while visiting him, hear a tale of wrongs
 and indignities, in the investigation of  which, unneces-
 sary annoyance may be brought to light, and the unfa-
 vorable impression strengthened by the screams of some
 excited patient, or the sight of one peculiarly repulsive
 and disagreeable. That such impressions would frequent-
 ly be made, under any system of  arrangements, I do not
 doubt, for the insane, as a class,  are wonderfully fault-
 finding and difficult  to please, in which qualities  they
 are frequently excelled by their  friends,  but I believe
 they would occur less often, if, in  some points, our estab-
 lishments were differently ordered.
  In the first place, in the plan and details of construc-
 tion, the single  consideration of cheapness has been too
 much allowed to prevail over that of perfect adapted-
 ness to the purpose.  The question that over-rides every
 other is, not how the proposed object can be best accom-
 plished, but how much it will cost. When the friends
 of humanity have presented to a State-Legislature a pro-
ject for establishing a hospital  for the insane, the voice
 which  rests the claims of this unfortunate  class  of our
 fellow-men, upon moral obligation, is feeble, compared
 with that which shows how cheap it can be done.  The
 estimate of cost is made far lower than it should be, an
 appropriation is voted,  and the gentlemen go home ex-
 ceedingly well pleased that so much good may be done 
7
for so little money.  Whether the end would not be bet-
ter  accomplished  by a more  liberal expenditure, is  a
question never asked.  In no single instance, I venture
to say, has any one been  bold enough to say to a State-
Legislature,—" The insane within your borders require
your aid; you are bound  by the  great law of humanity
and by every sense of obligation to give it, as  cheaply
as you can consistently with the perfect  accomplishment
of the object,  but cheap or dear,  it must be given to the
utmost extent which  the  progress of improvement has
shown to be possible."  The result has been that most
of our establishments  have wanted architectural  arrange-
ments that would have promoted  the comfort of their in-
mates and left less unfavorable impressions upon their
minds.   On this point  it  is high time  that our  views
should be definite and  well-settled,  because sooner or
later the country will look to us for instruction  on  all
subjects connected with our vocation.
  The  earliest  lunatic  hospitals  among us were con-
structed very  much after the fashion of the old establish-
ments of England, with this important difference, that
some of their  few  redeeming qualities were sacrificed to
economy, while the  loss was counterbalanced  by  no
compensating qualities.   The architectural construction
of our hospitals, thus bad in the  beginning, has  rather
deteriorated than improved, and  it is a mortifying fact
that while we have b,een satisfied with going from bad to
worse, in Great Britain  hospitals, better  than some, which
have been erected among us since this Association com-
menced its meetings, have been taken down  to make
room for others  comprising more perfect arrangements.
  The first step towards increasing the confidence of the
public in our hospitals, will be to deprive them,  as far as
possible, of their prison-like or peculiar features, and as- 
8
 similate them to domestic dwellings. Narrow, dark halls,
 low ceilings,  and bare walls,  should give way to more
 spacious and cheerful  apartments.   The monotonous
 ranges of windows, row above row, the long, blank wall,
 extending its  dieary monotony for many a rod, a style of
 building in short, which is no style at all, but that of pro-
 viding the greatest number of rooms at the smallest ex-
 pense, should be replaced by more pleasing forms of ar-
 chitecture, reminding us less of a jail or a factory, and
 more of  a comfortable and graceful private residence.
   There are many j articular arrangements quite com-
 mon among us, that tend more or less directly,  to create
 ill-feeling, and consequently must  be abandoned, if we
 would diminish this  evil.   First and foremost  among
 these objectionable points are the apartments for  the
 most violent and  refractory patients.   The only object
 which seems to have been sought for, in their construc-
 tion, is strength, without the  least attempt to conceal or
 soften down those obnoxious features which are always
 associated with mere- strength.  The patients  who are
 obliged to occupy  therr,  call them cells  or dungeons ;
 they regard them as  places of punishment or degrada-
 tion;  think of them  with an emotion of horror, and not
 all the benefits they have derived from the hospital can
 efface  the unfavorable impressions which these  rooms
 have stamped  upon their minds.   The friends are apt to
 imbibe the same impressions, and fortunate it may be for
 all  parties, if they are not led thereby to a precipitate
 removal of the patient.  Now, I  do not believe there is
any necessity for this.   Rooms may  be made  strong
without being made like a cell or a cage.  A  little  in-
genuity and a  little expense are only required, to render
them, apparently, like the other rooms  in the house.
The walls may be covered  with  an indestructible paint 
9
 or cement; the light may be admitted through windows
 out  of reach  or protected by iron netting;  hot air
 may be discharged by registers  at  the  upper part of
 the  room;  the door may  be  secured  by the ordinary
 lock; and a  close-stool may be  placed in a corner.
 discharging into a  soil-pipe connected  with tile  main
 drain.   These rooms may open  upon a hall arranged!
 in all essential  respects like the  others,  and provided,
 like them,  with dining-room, water-closet, bathing-room,
 clothes-closet,  &c.  Not only is the comfort of the patient
 thereby greatly enhanced, but the friends who sometimes
 insist on seeing his room, are shocked by  none of those
 disagreeable features  which now frequently meet tneir
 view.
  For the same as well  as  other reasons, these apart-
 ments should form a portion of the main building, or at
 least, not entirely separated from it.  I doubt if any ar-
 rangement in our hospitals  is  so  strongly calculated to
 excite dissatisfaction and hard feeling, as separate build-
 ings for this class of patients, and, judging from my own
 experience, with such  ample reason.  In  passing back
 and  forth, females are  necessarily  Exposed in a very un-
 seemly manner, sometimes it may b >,  to visitors on whom
 the sight will make a disagreeable impression. Although.
 of all classes of patients, that which needs the closest
 supervision of the officers, it is made the least accessible,
 and  consequently the least attended to.   If the plea of
 necessity could be urged in favor of this arrangement, or
if it  were chosen as the least of existing evils, it might
be tolerated, but I have been led to the conclusion, that
in no single respect, does it possess any advantage over
the other.   The principal, if not the only object supposed
to be gained by it, that of having the noise beyond the
hearing of the quiet patients, can as well, if not better be 
10
obtained in a different way.   By  a little  contrivance,
these apartments, though constituting a part of the main
building, may be so insulated from it by means of thick
partition-walls, entries and closets, that sound cannot be
easily propagated from one to the other.  In the Butler
Hospital, with an insulation of this kind, but much  less
perfect than it might have been  made, I can truly  say,
after an experience of over four years, that the annoy-
ance resulting from such proximity, is practically so little
as to be scarcely noticed by officers,  attendants or pa-
tients. When we consider the greater facility thus afford-
ed for removing patients, especially in the night, the less
danger of making  those disagreeable impressions which
such a transference is liable to occasion, and the greater
ease by which they may be inspected by the officers, the
question between the two arrangements is settled, I think,
beyond the reach of dispute.
  For a similar reason it is desirable that the house should
be amply provided with parlors well-warmed, lighted and
furnished, in which patients might forget, for a moment,
that they were not in a domestic dwelling, and lose some
of their acerbity of feeling which is cherished, if not pro-
voked by the peculiar aspect of the rooms and galleries.
Rooms should also be provided,  where patients  may
meet their friends,  so  arranged that the  former  may
not be exposed to the observation of visitors, and the lat-
ter may not be admitted into the galleries, to mingle  with
other patients and receive from them such impressions as
their  wayward fancies may happen to excite.
   To secure these objects,  it  is not only necessary that
hospitals for the insane  should be planned  by those who
know by personal experience  what architectural arrange-
ments are required, but such persons should superintend
(heir erection, from the digging  of the cellar to the last 
11
 finishing touch of the painter.  No plans nor specifica-
 tions can be so definite and minute, as to render such a
 supervision unnecessary.   In a great many  points, the
 fancy of the builder, or mere accident, becomes the guide,
 and, with the popular notions respecting the strength and
 appropriateness of materials, the result may be one, very
 likely, that jeopardizes  the reputation of the institution.
 A door or window-guard, so weak that a  vigorous blow
 leaves nothing between the patient and the open air, locks
 that may be opened by  the simplest contrivance, dust-
 flues large enough for the escape of patients, drains im-
 perfectly trapped, pipes placed where they never can be
 subsequently reached,—things like these may lead to ac-
 cidents calculated to impair the  confidence of the  com-
 munity in the very beginning, and I see no other way of
 preventing them,  but an intelligent supervision of every
 6tep and stage of the  construction.   The common prac-
 tice of entrusting the  erection of hospitals for the insane,
 whether with or without a suitable plan, exclusively to a
 board of commissioners, having no practical  acqaintance
 with the subject, cannot be too strongly condemned. To
 suppose that a person, because an eminent lawyer, or a
 successful merchant, or even a professed builder, is best
 fitted to superintend the building of an establishment so
 special as that of a hospital,for the  insane, is to ignore
 the universal experience of mankind.
   To these architectural defects, there is frequently added
 another evil well calculated to produce a disagreeable re-
 sult.  That niggardly economy which, in our State-Legis-
 latures, is swift to cripple any project or enterprize that has
 nothing to recommend it but its benevolent character, and
 grudges the necessary means for executing even the poor-
 est plan in a generous and liberal way,  has   frequently
led to the opening  of hospitals before their completion, 
12
and while wanting some important provisions.  A whole
wing perhaps, is left unfinished, and patients and attend-
ants of both sexes are placed in fearful proximity to one
another, the lamentable fruits of which constitute a page
in the history of our insane hospitals, which would deter
any body less reckless and irresponsible than a State-Le-
gislature, from marring an important project solely  for
the sake of saving the people's money.  Doors and win-
dows are left improperly secured, water is inadequately
supplied, and the danger of fire has been scarcely con-
sidered.  Solitaries for noisy patients have been left to be
provided at a more convenient season, and thus the noisy
and the quiet, the violent and the convalescent, are mixed
up together so as to disturb the peace of the day and the
slumbers of the night.  For  want of proper fences, in-
truders make their way to the windows, and the  grounds
are left in the rough, year after year; atone season covered
with pools of water and heaps of rubbish, and at another,
the scene of blasting operations that  involve the risk of
life and limb.   Any remonstrance upon the insufficiency
of such provisions for accomplishing the highest objects
of a hospital for the insane, is met by the usual reply:—
" We have already  spent considerable money,  and  the
people are anxious to see some result.   We do  not  ex-
pect you will accomplish as much as if the establishment
had that degree of completion we would wish to give it.
But we are prepared  to  make due allowances; all we
ask of you is to do the best you can, and at a future time
as our means increase, these deficiences shall  be sup-
plied."  All this sounds very fair and very reasonable,
but if any one  is  sufficiently verdant to be deceived by
it, I can assure him, on  the  strength of much personal
experience, in times long since gone by, that he will have
abundant opportunity  of learning how  far this promised 
13
allowance for his anticipated  short-comings will be en-
dorsed by the public, when the first murmur of complaint
shall reach its ears.   Were  this matter  rightly under-
stood, I am sure that no man with a proper regard for his
own reputation and peace of mind,  would embark in the
care of one of these unfinished establishments.

   The location of an insane hospital  is highly important
in regard to the points we are now considering, for  on
this it very much depends, how far its reputation will be
assailed by that kind of scandal and gossip which, in va-
rious degrees, is peculiarly incident to this class of insti-
tutions.  If placed in a rural district  and surrounded by
the usual neighborhood,  it is exposed to a prying obser-
vation and meddlesome interference  that are only in-
creased by any effort to restrain them.  The neighbors
assume the right  of coming on the grounds at their  plea-
sure, where they mingle with the attendants and patients,
exerting an influence that may be positively  bad, while
it is altogether beyond the  control of  the officers.  The
measures of  self-protection, to which  they resort finally
arouse a spirit of inveterate hostility that manifests  itself
in scandal and abuse.   No person can come within their
reach, especially if it be for the purpose  of  making in-
quiries respecting the institution, whose mind is not poi-
soned by this people's unscrupulous lies.  If he  have a
friend in it already,  favorable  prepossessions  however
well-founded, are replaced by the  most painful distrust
that sooner or later, perhaps, ends in  the removal of the
patient.  From this focus of ill-feeling, malign influences
are disseminated over the whole community which never
troubles  itself to inquire about their origin, and fortunate
is  the institution that is able to live down unfavorable im-
pressions thus created and maintained. 
14
   The proximity of a small town produces the same con-
 sequences.   In those little communities where business
 is never so pressing as to debar any man from making
 himself acquainted  with  every other  man's  concerns,
 those of so considerable an  establishment as an insane
 hospital,  furnish  inexhaustible  materials  for gossip.
 Every incident as it drops fresh from the lips of the vil-
 lage-butcher, or some prying neighbor, or some leaky at-
 tendant who finds a ready market for every thing of the
 kind he can carry, becomes the nine days' wonder, to be
 revolved in every circle until made to present some dam-
natory aspect.
  It has been a common practice to place our insane hos-
 pitals in the neighborhood of the Capitol, and of all the
 evils of a bad location, I do not hesitate to say, this is the
greatest.  The political vortex which is eternally boiling
and seething there, does not spare the hospital.   Its prox-
imity to the scenes  of political  intrigue and  aggrandize-
ment, is  enough to suggest the idea of making it an ele-
ment in every  scheme  of party-operations, and if the
purpose require it, detraction varied by every artifice of
a malignant ingenuity, is unscrupulously used.  The hos-
pital may thereby lose the confidence of the public, but
some needy camp-follower has  got his reward,  or  some
other equally commendable political end is obtained.
  This is not the only nor the  smallest evil incident to the
connection in question.  The legislature is the foundation
of power, and its proximity renders it easy of access to
all however remotely connected with the hospital, who
have any fancied grievances to be redressed, or  are bent
on revenging some fancied wrong or slight.   The tale of
defamation finds eager listeners in men who,  like the an-
cient father, believe because it is impossible, and who
have no higher idea of public duty than that of raking 
15
among the sewers of village-scandal, for materials where-
with to depreciate the value of an institution and blacken
the character of its officers.  Of course, such wiseacres
have no difficulty in finding a mare's nest.  Without the
least idea how such  an institution should be administered,
neither knowing nor caring what may be even the mildest
consequences of their interference, they undertake to tear
away the veil that shields it from the public gaze, to lay
open to the inspection of the curious  a class of incidents
which the dullest sense of propriety would have withheld
any one from revealing, and sit in judgment on conduct
and measures which they are as little able to appreciate,
as they are to calculate the movements of the heavenly
bodies.  It is not impossible that some who  hear me may
be unable to conceive of a sufficient warrant for language
like this, but a  single fact may convince them that I am
not dealing with shadows.  Within the last ten years the.
legislature of an eastern State, has investigated its insane
hospital nearly every winter, on a vague charge of abuse,
by means of special committees  before whom have been
summoned domestics,  attendants and  even patients, to
testify whatever they might know, or were prompted to
know,  against the management.  In several  instances
neither the officers  nor directors received  notice of the
inquiry.  In two  instances the investigation was instiga-
ted by the representations of a discharged patient whose
statements betrayed the grossest delusions, and after nu-
merous meetings of the committee who were engaged in
listening to such testimony, a vote  of censure was de-
feated by a bare majority of the members.   The stream
of scandal was not confined to the committee-room, but
found its way to the chambers,, and in their printed de-
bates, was carried to the remotest sections of the State, fill-
ing the minds of all who had friends in the hospital, with 
16
 mortification and dismay.   And yet this establishment
 was under the control  of a  Board of Directors, honest,
 able and vigilant, who would have quietly investigated
 any alleged abuse, and applied an effectual remedy with-
 out proclaiming the facts to the public ear.  Such are the
 evils which result from the proximity of the Capitol, and
 I cannot see that they are accompanied by a single coun-
 terbalancing advantage.  Those institutions have  flour-
 ished best where the legislature has least interfered, and
 therefore it is better for both that they should be placed
 as far asunder as possible.
  After making  every reasonable allowance, however, I
 presume I only  utter  the common sentiment among us,
 when I say, that all our hospitals are liable to an indefi-
 nite amount of real abuse on the  part of those  who,  in
 one capacity or another, are employed in the care of the
 patients.  It is  this with which we as Superintendents,
 are chiefly  concerned in this inquiry, and if the import-
 ance of the subject implicitly requires plain speaking,  I
 trust I shall have the credit of doing it in a spirit of can-
 dot and friendliness of feeling.  Seeking nothing but the
 good of the cause, and disclaiming any intention to offend,
 I do not see how difference of opinion on this point more
 than on any other, should necessarily give offence.  I pre-
 sume no member of this Association will say that, to the
 best of his knowledge and belief, at no time, in  no way,
 has an instance of abuse on the part of attendants, occur-
 red in the institution under his charge—that nothing has
 ever been said or done by them calculated, if made known)
 to impair the confidence of the public.   The question, be
it observed, is not whether such abuses are inconsidera-
ble in comparison with the positive and unquestionable
benefits by which they are accompanied,  but  whether
they do not actually create disaffection towards these in- 
17
stitutions, and diminish  the amount of good they would
otherwise accomplish.   Unable as we are to ignore the
fact implied in the question, it becomes our duty to pro-
vide, as far as we can, the necessary remedy.
  When  we consider the moral and intellectual calibre
of the class  of persons  whom we employ as attendants,
in connexion with the traits of character which we require
in them, it is not suprising that improper practices should
sometimes occur.  They must manifest  patience under
the most trying emergencies, control of temper under the
strongest provocations, and a steady peiseverance in the
performance of duty, disagreeable and repulsive  as  it
often times is.  They must be kind and considerate, ever
ready to  sacrifice their own comfort to the welfare of their
charge, cleanly in all their ways,  and unsaving of any
pains necessary to render their charge  so also.  In all
respects, their deportment and demeanor must be precisely
such as refined and cultivated persons have indicated as
most appropriate  to the  management of the  insane.  In
short, they are expected to possess a combination of vir-
tues which,  in the ordinary walks of life, would render
their possessor one of the shining ornaments of the race.
Now, although there can be no objection to a high stand-
ard of excellence, that  man  can be little better than a
fool, who supposes it will be often reached by the persons
whom we employ as attendants.  They have been pre-
pared for this delicate and responsible duty, by no special
course of self-discipline, and, we know well enoOgh, are
seldom distinguished by the beauty or abundance of their
moral endowments.  They are in fact,  plain  every-day
men and women, with the common infirmities of the race,
losing their temper under extraordinary  irritations, and
sometimes guilty  of downright abuse of their trust.  This
is the truth, and there would be as little wisdom in deny-
                          3 
18
ing it, as in expecting that persons, on becoming attend-
ants upon the insane, are transformed by some mysterious
process, from ordinary men and women into angels.  In
this view of the case we might rest with tolerable satis-
faction, but there is much reason to fear that the future
will bring an additional  difficulty which cannot be con-
templated with quite so  much  philosophical composure.
Although in New-England, we are still able to secure the
services of a class of native Americans, possessing, for
the most part, some sterling qualities, it seems  as if we
should be driven ere long, like our brethren south of us,
to' the employment of foreigners.
  Relinquishing all idea of obtaining perfection out of im-
perfection, it is incumbent on us to circumscribe the
abuses of attendants within the narrowest limits, and this
can only be done by a suitable organization of the service.
Without thorough organization, and the strictest discipline
under it, I am well assured that no amount of vigilance
will quite secure the object in view.  Different men will
have different ways, of course, of arriving at the same
result, but there are some ways so grossly defective, that
I see not how they  can be followed under any circum-
stances whatever.   Let us consider for a moment, what
used to be the practice,  and which, for any thing I know,
may still be found to some extent among us.  An attendant
is placed in charge of from ten to twenty patients, and,
with almost unlimited authority for certain purposes, he is
truly  " monarch of all he surveys, and his right there is
none to dispute."  He controls every movement, and by a
stricter rule than that by which the school-master governs
his pupils. He directs  their  uprising and  their down-
lying, their incoming and their outgoing, their meals, their
labors  and  amusements.  The refractory are made to
obey, and the turbulent are stilled in some way or another, 
19
or turned over to somebody else.  His will is law, and
no appeal lies from his decisions.  His orders are gene*
ral, and he is responsible to none but the chief.  If de-
sirous of farther orders, he leaves his charge to take care
of themselves, and goes in quest of the fountain of power;
and thus whether it be to call  the doctor, to procure a
dose of medicine, to  hunt up an articie of clothing, to
make a poultice, or to inquire  for his  letters,  he must
leave his gallery and go to the  centre-house, and if there
he happens to meet a female-attendant on a similar errand,
or encounters  any  one as  little in a  hurry as  himself,
where is the harm in   saying  "how d'ye do,"  and ex-
changing a little gossip ?  No one can  charge  him  with
neglect of duty.  He  has  reasons for being just where he
is, and if he says he came to the kitchen for hot water, it
will not be easy to prove that it was to make an appoint-
ment with one of the girls.  The radical fault in this way
of conducting the service, is the idea of the attendants
being directly controlled by the officers.  When we con*-
sider  how small a portion  of the twenty-four hours, any
officer, much less the Superintendent, can be in any partic-
ular gallery, nothing can be more preposterous than this
idea.   The truth is,  and it could not possibly be other-
wise, that, to a very great extent, the attendant does what
seemeth good to himself, and if any of it happens to be
wrong, his chief may find it out if he can, in spite of the
dust he can easily throw in his eyes.
  This  inevitable tendency to abuse  can  be checked,
and the  wishes of  the Superintendent thoroughly and
systematically enforced, only by means of a party who
shall  spend his time among the patients and attendants,
both  day and night, clothed with authority to which all
other  authority is subordinate.  In some institutions he is
called a supervisor, and the following may be considered 
20
as his principal duties. He is responsible for the manner
in which the service is performed, and the attendants are
directly responsible  to  him.  He  arranges and directs
their duties, meets every exigency as it occurs, knows
whatever is going  on in his department, and infuses or-
der and harmony in every branch of the service.  He is
the organ of communication between the wing and the
centre-house.   The attendants should never enter the
centre-house without express permission, and the  locks
should be so arranged that they could not if they would.
The supervisor administers  the medicine, attends  parti-
cularly  to  the sick,  watches the varying  humors and
phases of the  patients,  and  regulates the special atten
tions they may require.  He is responsible for the care
and custody of the clothing and other property of pa-
tients, and the furniture of the wing, and, the last  thing,
at night, makes a thorough  visitation of the galleries,
locks the outside-doors, and puts the keys in his pocket.
Thus, by his frequent presence, the delinquencies  of at-
tendants are  speedily discovered, the wants of patients
more readily  known  and supplied, and the  general ef-
fectiveness of the  service most certainly secured.  It fol-
lows of course, that the degree of  excellence which this
system will manifest in practice, must depend very  much
on the personal character of the supervisor.   If kind and
gentlemanly or lady-like in their demeanor, of a careful, vi-
gilant turn, jealous of their authority and capable of main-
taining it without giving offence, possessing a habit of or-
der and a  desire  to excel,  the institution in which they
serve, has one of the surest elements of success, and their
services are cheap at almost any price they choose to fix.
   My views of police also require that the  persons en-
gaged in the various branches of domestic service, should
never  enter the wings, except by  special  permission. 
21
Whatever reason  may  exist against the introduction of
visitors to the galleries,  may be urged with tenfold force
against the  admission of the domestics.  In short, I do
not see how the  peace and order of an establishment
can  be  maintained  a single day, if the employees of
every description are to  be constantly mixed up together,
to idle away their time, to circulate gossip, and partici-
pate in one another's bickerings and dissensions.
  In every institution, I presume, there may be  found
practices which are  connected with some peculiar views
or system of the  superintendent, that cannot  fairly be
tested by any conventional notions of  propriety.  There
may be, therefore, some reason for the somewhat preva-
lent practice of allowing patients, both male and female,
to leave the wing at  their pleasure, and have free access
to the centre-house and grounds, where they roam about at
will, but to me it seems to be subversive of all discipline, as
well as of that  privacy and seclusion which are supposed
to be necessary to the restoration of the disordered  mind,
as I am sure they are to the maintenance of that kind of
propriety which regards every unnecessary exposure of
the insane as an  unnecessary evil.  The only  benefit I
have ever heard claimed for the practice, that of making
patients more contented, because less restricted by locks
and  bolts, I have thought more fanciful than real, and at
best I doubt if  enough is gained by it to  compensate for
the real mischief that must arise  from it.  I see not how
we can pretend to rely on moral treatment in the work
of restoration,  while we expose  our patients every hour
to such  communications as  they  may receive from do-
mestics and visitors.
  There is another point in the administration of our es-
tablishments, of which  I venture to speak,  because it is
intimately  connected with the subject in hand.   The 
22
 same spirit of economy which has so mischievously pre-
 sided over their construction, has demanded a reduction
 of the price at which their benefits are to be  dispensed,
 to a very low figure.  The general desire  seems to be,
 not to raise the hospital to the highest possible degree of
 excellence, but to  reduce the rate of board to the mini-
 mum point, thereby making the merit of its administra-
 tion to consist, less  in the success  with which its pecu-
 liar  ends are promoted,  than  in  the small  amount of
 means by which it may be carried on.  How the very
 peculiar and  expensive attentions required by the insane,
 can be rendered at a price below  that of the humblest
 boarding-houses in the country, has never been very satis-
 factorily explained.  However that may be, the very low
 price of board in the most of our hospitals, has become a
 fixed fact, and the common impression now is that people
 may be maintained in a hospital for the insane for little
 or nothing. Persons who have occasion to place a friend
 or dependant in one of  them, are surprised and  dissatis-
 fied if required to pay  anything like an equivalent, while
 their owij domestic  economy may be indicative of abun-
 dance if not splendor.   By all means let the poor be re-
 ceived at the lowest possible point consistent with the
true objects of a hospital,  but I see no reason why the
 affluent, those who are  able to pay an equivalent for this
 as well as any other privilege, should be admitted on the
 same terms.  It never could have been intended that the
bounty of the  State or of individuals, should be devoted to
this class of persons. Charity does not consist in giving to
the rich.   But apart from this consideration, there is reason
to fear that the charges are sometimes too  low to make
the institution what  it should be to  any class of persons.
 Such charges may procure the means of subsistence, but
 can they afford  all the  provisions for maintaining the 
23
health and comfort  of the patients, which  science or a
progressive philanthropy  have brought forward ?   Can
they give the institution the means of constant improve-
ment, and enable it to take an honorable  stand  by  the
side of others ?  We all  know that these questions must
be answered in the negative.  When an  institution is
warmed and ventilated in the most perfect manner; when
an ample  corps of attendants is employed, in one way or
another, in ministering to the comfort and gratification of
the inmates ; when  naked walls are covered with paint
and pictures ; wheh parlors and day-rooms, well-lighted,
warmed and furnished, present to the patient some of the
graces and refinements of a domestic residence; when
the grounds are tastefully planted, and offer every charm
that springs  from lawns, flower-beds and gravel-walks,
mounds and fountains,  in their most  pleasing combina-
tions ; then and not till then, should the weekly rate be
reduced to a sum just sufficient for the means of animal
subsistence.
   The only plea offered for these low rates, is  that the
pecuniary condition of  the community, does not admit of
higher, and that the establishment must be maintained at
these rates, or not at all.  The plea would be a strong
one, certainly, were it not founded on a fallacy too much
resorted to whenever the claims of humanity become im-
portunate.  There is in fact,  no  such public poverty as
the plea would imply.  On the contrary, such is our pros-
perity, that in every community within our  borders, the
taxes might be doubled and even quadrupled, and  then
be light when compared with the burdens of other nations.
Let the object be one which the people have strongly at
heart, any amount of taxation necessary to attain it, would
be cheerfully submitted to.  This perhaps would prove
nothing, were the object manifestly and confessedly of a 
24
 worthier character than that whose claims we are advo-
 cating.   But how seldom has this been  the case !  It is
 a true and mournful fact, that any  scheme of military
 achievement or territorial aggrandizement  in which the
 popular  feeling has embarked, has  ever been  pursued
 among us with supreme indifference respecting the cost.
 The Mexican war cost us more than enough to support all
 the insane of the country in hospitals of the highest charac-
 ter, through all coming time.  And yet who ever troubled
 himself about the cost of the Mexican war?   Let the
 country once feel that its true glory consists less in its
 powers of aggression, than in its institutions for promoting
 the cause of learning and  humanity, and then  we shall
 hear very little about the expense of the latter.
  Perhaps, as regards  individuals, this  plea of inability
 may have more foundation, but let us beware  how  we
 suffer this consideration to affect our prices.  Such is the
 general prosperity of our people, that most of those whose
 means may be called humble, are in the habitual use of
 certain indigencies regarded as essential to their com-
 fort, which cannot be afforded at our low rates of board*
 The peculiar attentions and privileges that constitute the
 merit of insane hospitals, can scarcely be appreciated by
 many who would be loud in their complaints on missing
 some animal  gratification which,  perhaps, they would
 better be without than with.   We do not find that parties
 who make the most urgent claims on our charity, for that
is essentially  charity  which is  dispensed for less than
cost, are disposed to make any sacrifice themselves. We
do not find (hem limiting their indulgence in rum  and
tobacco, silk and fine broadcloth,  on account of the do-
mestic misfortune.   If we are to have a very low rate in
our hospitals for the insane, let it be for the unquestiona-
bly destitute and friendless, but I firmly believe that the 
25
highest degree of success, and especially of public con-
fidence, requires for all others, a scale of charges that
will warrant the establishment in a generous indulgence
in whatever is calculated to  promote the comfort and
pleasure of its inmates.
   The question now remains to be considered, whether
the lree admission of the public into our hospitals for the
insane, would  raise  them  in  the  popular  estimation.
During the last and the early part of the present century,
they  were secluded from the public gaze, and people
were unable, without some difficulty,  to gain admission
within their walls.  Within a comparatively short period.
a very different practice has prevailed both in this coun-
try, and in France  and Great Britain.  Here the doors
have been thrown open and the public invited, if not so-
licited to enter, to converse with patients,  observe their
accommodations,  and learn as much as possible, of their
history  and treatment.  The object of this practice, if I
understand it rightly, is to increase the public  confidence
in these institutions, by making people  personally  ac-
quainted  with  their advantages  for  contributing to the
comfort and restoration of  the insane;  to substitute  for
the darkness and  mystery  which envelope them, an intel-
ligent appreciation of their merits, and awaken a sympa-
thy for that large class of our fellow-men whose disorder
is supposed to incapacitate them  for any farther partici-
pation in the decencies, not to say the humanities of life.
That this object has been obtained in some  degree, I arn
not  disposed to deny,  and it is quite probable that this
publicity has contributed to raise that interest in the pau-
per-insane,  which,  under God, has resulted in a great
work of humanity characteristic  of our times.  This, I
apprehend, is the only good it has effected.  Least of all
am 1  inclined to think it has increased that kind of confi-
                          4 
26
dence which we have supposed  to  be deficient.  We
must guard against misapprehension of the real sentiment
in question.   In that general estimation which is made up
of the views of all  humane, intelligent, reflecting men,
hospitals for the insane stand in the first rank of benevo-
lent institutions.  On the other hand, among those classes
whose intercourse with the world  has been too narrow to
impart any enlargement of mind,  and  whose education
has  been just enough to give them a  certain pride  of
opinion without increasing their capacity to think for them-
selves, or otherwise than wrong except by accident, there
is an under-current of distrust and aversion,  having no
other source  perhaps, than  some idle story that has floated
into their ears.  Now,  in  regard  to  the first mentioned
class, the proposed remedy is not required, because the
evil  does not exist; and in regard to  the latter, it is inad-
equate to accomplish the object in view.  They may pass
through the  halls of the quiet patients, for to them I sup-
pose the visits  of strangers would be confined, observe
them engage in various employments, and for the most
part, appearing like ordinary persons ;  they may  notice
the cleanliness of the house, and the  many indications of
neatness, good order and even kindness, but the real diffi-
culty is  not reached.  The feeling is,  that these traits
which make such  favorable impressions on the  casual
observer, may co-exist with a kind  of management unseen
by the world, which is marked by unkindness,   neglect
and even positive cruelty.   Shocking abuses are not prac-
tised before  spectators, but at times and occasions when
no eye can see, nor tongue proclaim the fact.  From any
thing seen, there is no guaranty that a patient would not
be neglected when  sick, shaken or beaten  when refrac-
tory, supplied with improper or insufficient  food,, or  in 
27
some way or other, treated without due  regard  to  the
proprieties of life, or the requirements of  humanity.
  But even if this kind of publicity had the effect of turn-
ing the popular undercurrent against hospitals for the in-
sane, I am not sure we should  be justified in incurring
the numberless evils  by which it is always accompanied.
The promiscuous admission of visitors to the galleries, is
inconsistent with that seclusion which they are supposed
to afford, and for the  sake  of which many  patients are
expressly  placed there.   To expose them therefore, in
this manner, to public  observation,  is  equivalent  to  a
breach of trust.   No  degree of precaution will entirely
prevent some unpleasant exhibition which  is reported
abroad, until under the magnifying process of repeated
transmission, it is fitted for a nine days'  wonder.  It is
painful to many, and annoying to all, to have the beha-
vior of those whom they love, made the theme of village
gossip, and,  at some  future day perhaps,  brought to the
notice of the patients  themselves, to cover them with
shame and mortification.   We all  know  that  even the
simplest remark from the lips of a  spectator,  respecting
the appearance or conduct of a certain patient, is apt to
be so distorted, in the course of its circulation, as to reach
the ears of friends, in a shape well-calculated  to excite
their apprehensions and disturb their peace.   For these
reasons I cannot think that the free admission of the pub-
lic into our hospitals would prove  a remedy for the evil
in question, even if it were not forbidden by a proper re-
gard for the rights of the insane and of their friends.
  The only kind of  supervision  which ought to secure
the public confidence,  is  that which is exercised by a
board of. Directors or Trustees possessing the qualities
necessary  for the  successful performance of their trust.
The success of an insane hospital is so dependent upon 
28
the character of this board, that it is to be regretted that
it should so often  be constituted with  little or no refer-
ence to the special duties that are required.  A Director
should be free, in that capacity, from all political or other
unworthy biasses, strongly anxious to promote the cause
of humanity, and  without  any object whatever but the
highest welfare of the institution.   He should possess
habits of business in order that he may perform his duty
with that promptitude, precision  and correctness  which
are expected in other business, and  sufficient discretion
to meet the perplexities of his position.   He should  cheer-
fully bestow the time and pains which the. office requires,
and his social and moral position should  place him beyond
the reach of the arts, the passions and  the prejudices of
others.  Especially should he be of a liberal turn of mind,
to meet the questions frequently coming up, of improve-
ment and change, and of that generous and elevated spirit
which places  a man beyond  the temptation of doing a
mean thing, and allies him to truth and justice.  I know
of no better guaranty for  the proper  management of a
hospital, than the  frequent and  thorough visitations of
such men as this, and I  believe  that no better could be
reasonably wished.  True, special instances  of abuse
would seldom meet their notice, because such things are
not done before company, however common they may be
under other circumstances: but with such opportunities,
careful and intelligent observers could  not fail to discern
the general spirit which pervades the establishment and
characterizes its  moral management.   If  an institution
can bear creditably such inspections,  once a week, we
may be  quite sure that it cannot  be very  remiss any in-
termediate day.  The most labored  attempt to give it a
character on these occasions, not properly belonging to it, 
29
 could not prevent its prevalent spirit and habitual usages
 from sometimes making their appearance.
 ^ An institution of this kind should always find in  its
 board of Directors a tower of strength on which it can
 rely for support in the day  of adversity and trial, and
 that kind of moral credit  necessary to  ensure the confi-
 dence of the public.   But what benefit can  it derive
 from the kind of men that are often placed in this  posi-
 tion,— retired  or  broken-down  politicians to whom the
 office is tendered as a cheap recognition of past services,
 or an inducement to continued fidelity; country doctors
 or lawyers to whom the pay and mileage becomes a very
 acceptable addition to their professional income; small
 shopkeepers  and  traders  who  covet the place for the
 sake of driving profitable bargains with the hospital;  to-
 gether with a numerous class who have no other thought
 in regard to the office but the little consequence which it
 is supposed to confer.  Such men have been the  occasion
 of much mischief to our hospitals for the insane.  I be-
 lieve if they had  uniformly been under the direction of
 honorable, intelligent and  high-minded men  selected
 solely on account  of these qualities, they would have se-
 cured a far higher degree of public favor than that which
 they actually possess.
   To ensure the  success of a  hospital  for the insane,
 there is another requisite  more  important perhaps than
 all others, of which it  may be expected that  I should
 speak.  I refer to  the personal  character of the superin-
 tendent.   My own limits, if not the occasion, will forbid
 my dwelling upon this point.  I  must therefore confine
 myself to the simple statement, that unless he  possess
 the talents necessary to command the respect of intelli-
 gent men, that devotion  to his profession which will lead
him  to spare no pains to qualify himself in the most per- 
30
feet manner for the performance of its duties, that tem-
per and disposition that will establish something stronger
and dearer than a merely professional relation between
himself and the  objects of his  charge,  and that] moral
and  intellectual  elevation which is  only satisfied with
high aims and  substantial results, — unless he possess
these traits, he has much  reason  to believe that  he has
mistaken his calling and  that he  will fail to obtain that
public confidence which ought to  be as the] very  breath
of his nostrils.
Wm.  Saunderson, Printet.