THE RIGHTS OF THE INSANE, IN HOSPITALS. BY W. W. GODDING, M.D. Author of “ Two Hard Cases.” REPRINTED FOR THE Massachusetts Board of Health, Lunacy and Charity, BY PERMISSION OF THE AUTHOR. THE RIGHTS OF THE INSANE IN HOSPITALS.* BY W. W. GODDING, M. D. AUTHOR OF “TWO HARD OASES." In a preliminary article, which appeared in the April number of the “American Psychological Journal,” I indi- cated as a natural division of the subject, and the proper theme of this paper, the rights of the insane in places of detention. In addition to their rights in hospitals, I had then in mind to write of the outrages to which they are exposed in our city lock-ups, herded together with criminals, pend- ing the determination of the question of their insanity. Also, the wrongs which the chronic insane endure in county alms- houses and town asylums, which are, indeed, a twice-told tale in the reports made to the legislatures of a number of the States on the condition of the almshouses within their borders. But I find the theme too vast for my limits, and shall accordingly confine myself to the consideration of their rightsvin hospitals ; those establishments which, under com- petent medical supervision, are generally recognized as the proper places for the prolonged detention of the insane, since the right to confine them in almshouses is, at best, but doubtful, and certainly the prisons are no place for them. It does not seem to me that this age is in any danger of forgetting that the insane have rights in hospitals. Your * This paper, originally read before the Association of Superintendents of Ameri- can Institutions for the Insane, at their Annual Meeting at Newport, R. 1., in June, 1883, was afterwards printed in the “ American Psychological Journal.” , 2 W. W. Godding. average American hesitates a little over his Shorter Cate- chism, hut never a moment as to his bill of rights. Hardly more than a century removed from Jefferson and the Declar- ation of Independence, he must be a very insane man who, having been shut up in an American asylum in our day, fails to remind you that his inalienable rights are, “ life, liberty, and the pursuit of happiness.” And in regard to liberty, there are a great many outside who believe him ; notably the judges of the New York courts. In this era of philanthropic seeking after objects for an ostentatious sympathy, our insane neigh- bor is not likely to be left lying neglected by the roadside; on the other hand, he is in danger of being deluged by the oil and wine of a host of Good Samaritans, and set upon, if I may say it., by too many asses, who take him in, while, ostensibly, they are letting him out. I may state here that I realize how next to impossible it is for those of us who are entrusted with the care of hospitals for the insane to be unbiased in the consideration of ques- tions involving hospital inmates and their management, and though in everything else experience is consulted and de- ferred to, yet, in view of the wide-spread skepticism in regard to the wisdom of the present methods of caring for the insane, and the lessening faith in the reliability of expert opinion, it seems to me desirable that we should, for the purposes of this inquiry, forego the vantage-ground which, even if not accorded, eminent dignity and the pride of opinion is so apt to arrogate to itself; that for the nonce we shall be silent in regard to the “ Propositions” laid down by our Association thirty years ago, which, like the Koran, have been supposed to contain nothing superfluous and to omit nothing essential; that we shall try to forget even that we are hospital superintendents, and ask, Who is this insane man? just as if we had never had him under our control; and having found him, and decided that his disease requires for its treatment hospital care and restraint, put ourselves in his place and see how we should like it. “And as ye would that men should do to you, do ye also to them like- wise.” Rights of the Insane. 3 Having found our insane man meeting him on the road to the hospital the chances are ten to one that we shall overhear his friends say to him, that the imposing building to which they have come is a magnificent hotel, where they had better stop for some dinner that it is an old friend of theirs who keeps it. From such friends Heaven deliver me ! Once in the hospital, the insane man has a right to know, and to expect that he will be told, the truth. Falsehood, which walks hand in hand with him to the asylum gate, should leave him as he enters. The shallow lies of timid friends foolish as they are shallow, since they deceive nobody should find no place in that abode, which is now to become his home. Distrust plants itself soon enough in the insane mind, under the most favorable circumstances ; what right have the friends to include me in their refuge of lies? Why put enmity in his soul towards me on the very threshold of my care of him, believing, as he inevitably will, that lam privy to their deceit? Well said some forgotten sage whose memory be blessed “ Honesty is the best policy.” But another equally wise and alike forgotten sage has said, “ The truth is not to be spoken at all times.” Be- tween these two limits will be found the sum of wisdom in dealing wfith the insane in hospitals, for while even the truth is not to be spoken at all times, a lie should be spoken never. It is, perhaps, worth our while to take a moment to discuss the ethics of this matter. The commitment of an insane man to a hospital is legal; it not only conveys the right and the power, but it makes it our duty to hold him. Equally is it his right to know the facts, so far as he is capable of comprehending them. It would be pitiable if he could only attain that knowledge through a tissue of lies. Do I mean that he should be made acquainted with all the details of his case, including prog- nosis? Not at all. No more than any other sick man. Dr. Cowles, of Somerville, Mass., in his last report, has admi- rably condensed into a single sentence all that it is necessary to say to the insane on this subject: “You are sick ; you may get well.” If asked for the facts more in detail, give or 4 W. W. Grodding. withhold them as you think is best for the individual case, but do not lie ; it is not necessary. How is it when we tell the general paretic he may get well ? I think it is pur duty to say to the friends at the outset, that, in our experience, paretics do not recover, while we say to the insane man, you may get well; for are we so infallible in diagnosis that we cannot make a mistake ? And though to our human appre- hension the man is dead when he says, “Never b-better in my life,” we have not omniscience, and so may not deny, though we cannot see through what healing touch, unknown to us and outside of our psychiatry, health may yet come back to those brain tissues, and an undoubted cure in gen- eral paresis occur. The question is, as of old, unanswer- able, “ Why should it be thought a thing incredible with you if God should raise the dead?” It is right to express the hope to invalids that they will be well soon. The dreary wastes of sickness, so long if con- templated ahead, shall seem but a little time when passed over, so only you keep up the sick one’s hope. When the insane man tells you he is to go home to-morrow, you are not called upon to contradict him. . If there is one thing of which, as a rule, the insane take less notice than another, it is of the lapse of time in a hospital. It is a merciful feature of this disease that, in their confinement, in the language of the great poet, “ To-morrow, and to-morrow, and to-morrow Creeps, in this petty pace, from day to day, To the last syllable of recorded time.” Time, little valued, is little noted by the insane, and they are going home soon, through all these years. Is the truth to be told the insane in regard to their dis- ordered fancies ? You cannot afford to lie. It is true the insane man cannot be reasoned with about his delusions ; your truth is falsehood to him, and may produce the very effect on his mind which you wish to avoid, in order to gain his confidence ; hence, the wise man will consider well be- fore he enters on the discussion. If the false belief is a Rights of the Insane. dangerous one, it is your duty to controvert it, if you say anything, but often it is best to say nothing. In a curable case it may be a matter of duty to combat these delusions, especially in melancholy, where oftentimes active dispute is better for the insane mind than silent brooding. In chronic, settled conditions of insanity the case is different, although I am aware that some consider it wrong to indulge any insane man in his delusions, but when those delusions are fixed and harmless, and the insanity is permanent, what is gained by contradiction? “In this thing pardon thy servant when I bow myself in the house of.Pimmon,” that I call this poor private “ General; ” saluting the good tailor as “ Mr. Presi- dent ; ” and fancy that their lives are happier for this harm- less recognition of their delusions ; indeed, I question if, after all, they have not quite as valid claim to their titles as many another out in the world that we salute, this one as “ Colonel; ” and that one as “ Doctor.” While speaking the truth to the insane at all times, when such speech is neces- sary, we should remember that in hospitals, as well as else- where, there is wisdom in the old adage, “ Speech is silver, but silence is golden.” The insane have a right to expect, and should find, in the hospital a home. What, this man, with whom, for months, there has been no possibility of living who has made his own home a hell will he settle down comfortably, and feel at home in a hospital ? Probably not; his right amounts only to this; that his surroundings there shall be such that were he capable of appreciating them, they would seem home- like. There are some people they call them sane, too in purple and fine linen, who have palatial advertisements of their wealth, which they mistake for homes, but which, so far as they make any home atmosphere about them, might as well be wigwams. The contented mind, the home that is within, you cannot make good the want of that by any sur- roundings. Nevertheless, the right of asylum, it is the right of refuge from the world and from one’s self; it entitles to a home, with all which that word implies. If it be said that the primary object of a hospital is to bring about a cure, not 6 W. W. Godding. to make a home, I admit it, but I deny that the two are in- compatible with each other; indeed, the content which the home feeling gives is most favorable to recovery ; the moral treatment, so called, is in a majority of cases more efficacious than medicine. But what would be home comfort for one would fall far short of that for another; with some points common to all, very diverse apartments must be provided if we are to have our hospitals in any considerable degree ap- proximate to such ideal asylum; something more than a stereotyped plan of unchanging wards would seem to be needed in shaping this house of many homes. The material, outward aspects of a home have, as a rule, been made a prominent feature in the public buildings pro- vided for the insane throughout the United States. Their architecture is, perhaps, something too palatial for the ideal of home comfort, but pardonable on the ground of State pride, which in these structures seems ostentatiously to say, “ The half of my goods I give to the poor,” though some- times, incongruously enough, the same State pride appears a little further on, in the hospital report, this time boasting that the support of these homes, including all expenses, costs less than fifty' cents per diem for each inmate ! But certainly these outward aspects, so far as they conduce to the home feeling, are much to be commended. The elevated .site, securing at the same time pure air, good drainage, and pleasant outlook, bespeaks the wisdom of its selection. The sunny bays, those windows which take in the whole landscape; the village, not too near, but which, being vis- ible, relieves from a sense of loneliness; the quiet lake, or river, adding the unspeakable charm of water to the peaceful outline of hill and grove, and meadow, while near at hand nature lifts her great branching trees, spreads her green lawns and blossoms her roses as if she had selected this for her home. This description will apply equally well to any one of a majority of the State hospitals of the United States— hospitals which so many of the insane have come to regard as their home. But while we do well to place our hospitals in the midst of Rights of the Insane. 7 pleasant grounds, and keep the music of birds in their woods, and pour all the sunshine that we can into their picture- hung wards, neither the insane man, nor his friends, have any right to claim that he comes as a guest to a hotel, simply to find a quiet residence in the country. If that is what is sought, I would recommend the Ocean House, at Newport, or a farm house among the hills, as offering far superior in- ducements to summer boarders. No ; your dentist’s ante- room is full of vases, and pictures, and pleasant things, but you go there not to study art, but to be relieved of a villan- ous tooth. So with the insane man; he knows, or his friends know, that he is not in search of a watering-place, for he cannot be accommodated at their hotels, and as for a house in the country, it would not hold him. He goes to the hospital because he is insane, and this is the one central, important fact, to which all question of mere surroundings is but secondary. The impressions which the inmates retain of their hospital home depend very much upon the mental condition in which leave it. I would always be willing to entrust my dearest possession, my good name, to the keeping of my recovered patients. They would be only too tender of it. Their returning visits to the old wards are bright oases in the sterile wastes of imbecility which stretch wearily to the far horizons of hospital life. They come, like children, home, to tell you of their life away; their gratitude overflows'; what you believe were shortcomings, they oVerlook; they make your ears tingle with the words you feel you ought not to hear. On the other hand, depend upon patients go- ing away, only partially restored, to “to strip you of the robes of pride,” cure you of undue self-conceit, and half con- vince you if there is one man in the world meaner than another, you are that individual. The only consolation which you have is in the consciousness that you are neither better nor worse than before all this praise and blame were heaped upon you. I have been at considerable pain's to read a number of books written by persons who have been confined in asy- 8 W. W. Godding. loms, to try to inform myself of their grievances. Many of these appear to have had their origin in the mistaken notion of a hotel; their doors locked on the wrong side ; rooms are scantily furnished; instead of the customary notice that the proprietors have provided a safe at the office, where money and valuables can be placed, they are not even allowed the option of keeping them at their own risk, but these things are taken from them perforce, including even their penknives. The guests are tiresome ; conversation is at a low ebb; even at the table it is mostly confined to in- quiring, as the witty authoress of “Behind the Bars” puts it, after the health of the butter; the anxious query being, at each meal, “ How is the butter? ” Most of all, they com- plain of a constant system of espionage, that spares not even their letters. Unasked companionship is perpetually forced upon them ; out for exercise, an attendant dogs their foot- steps ; there is a night-watch, generally selected on account of her repulsive appearance, whose special mission seems to be to awaken them just falling into their first slumber, etc., etc. Would that all their complaints grew out of such mis- apprehension of the necessities of the situation ; but some of their charges of neglect and abuse, I fear, are well founded. Probably there is no hospital superintendent who has not discharged attendants for the ill-treatment of patients. While human nature remains what it is, such cases are liable to occur. In the multiplicity of persons seeking employment in a position that at the best can hardly be made attractive, there will always be some brutes often provided with the highest recommendations—who slip into places, and, with a wile worthy of their master, sometimes do much mischief before they are found out. To increase the difficulties of the situation, the insane often invent the most terrible tales of their sufferings. Sometimes these stories are born of their distempered imaginings ; more often they are the outgrowth of depraved moral propensities, the result of their mental disease. But while due allowance ought always to be made for this, the statement should never be disregarded simply because it is that of an insane man; it should be accepted or Rights of the Insane. 9 rejected on its credibility, taking into account all the known facts in the individual case. Humanity demands that the helpless insane shall be protected from the gross neglect and brutal violence of unfeeling nurses, by a sleepless vigilance on the part of those in charge. With proper precaution in the selection of supervisors and ward masters, and the con- stant, watchful care of the medical staff, such abuses should be rare. Of this lam sure : that no person fitted to be the superintendent of an asylum for the insane will fail to use his utmost endeavors to prevent such outrage and punish the offender. The patient has an unquestioned right to the care and attention of a kind and faithful nurse, who, in his turn, may claim due consideration and protection in the exercise of a proper authority and control over his charge. This is a work often difficult and thankless enough. Indeed, to patiently receive all which some of the insane are capable of saying; to be painstaking and untiring .in ministering to the careless and the helpless ; never to relax the silent vigi- lance against suicide; to have but one life to live, and to spend it among them, not in the passing visit of an hour, but month in and month out, —in the constant presence and contemplation of drivelling imbecility and demoniac faces, from which the original impress of the Creator’s image has gone out forever, such service implies a virtue but a “little lower than the angels’,” and deserves a recognition far beyond the pecuniary compensation which our hospitals afford. I hope there are palms growing somewhere for such as these. But whatever may be the virtues or shortcomings of at- tendants, it is certain that wrongs done to the insane from this quarter need but to be known to be righted. There is a wrong suffered by the insane in hospitals, far greater, in my opinion, than the occasional outrage at the hands of a brutal attendant, and, I am sorry to say, the medical super- intendents tolerate it; the public, with ears wide open to, and rightly indignant at, every reported instance of the abuse of the helpless insane, are silent or indifferent in regard to this. I refer to the over-crowding which exists, almost 10 W. W. Godding. without exception, in our State institutions for the insane. 1 wish I could feel that our superintendents were as little dis- posed to acquiesce in this as in abuses at the hands of un- faithful employees. We may say that this is the fault of the legislatures, which do not provide new hospitals for the accommodation of the increased number of the insane. This may be allowed to be the fact, and yet, as the superin- tendents are the ones to whom the community Ipok for opinions in regard to the proper care of the insane, I cannot relieve myself of the conviction that they are much to blame in this matter. I can say this with the more freedom be- cause I have never, during the years I have been in charge of hospitals, seen my wards other than over-crowded. Always building, I have never been able to get appropria- tions for that purpose fast enough to more than keep pace with the rapidly-increasing insane population. I say to friends who comp to me anxious to have me receive a pay patient, I cannot take him ; we have no room for him ; the law requires me to take free patients, but not private ones ; the hospital is over-crowded with these. They go away, and too often it is found, a little later, that they have discovered a way to get him in on the free list. They are much to blame for committing, so am I for receiving. My insufficient ex- cuse is, that the law which makes their admission impera- tive prescribes no limit of numbers. Against the injustice of such legislation we ought to protest, to enlighten the public, and create such a sentiment on the subject as to make it as impossible to over-crowd a hospital as to maltreat or abuse an insane man in any other way. It is a right of the insane, that is not to be ignored or trampled on, that they shall not have their lives endangered, or their chances recovery lessened, by being crowded into more straitened accommo- dations than are suited for the most humane care and enlight- ened treatment of their disease. It is the superintendent’s right, no less, and neither legal] enactment nor seeming necessity can properly take it away. If there is any omnibus whose door should be legally closed when it is full, it is an insane asylum. But the walls of the associate dormitory are, Rights of the Insane. 11 in a sense, elastic; the single room, constructed on a liberal plan, admits a second lodger; the cot-bed is easily folded away, by day, to be brought out on the corridor at night; the first step in a wrong direction necessitates another, and so on, until your home asylum is gone, and your pleasant wards have come to resemble the country hotel on the eve of a political convention, when the sofas of the parlors, the benches in the hall, the recesses of the attic, and the lofts of the stables, have been taxed to their utmost capacity to meet the urgent requirements of the delegates. But the political convention, which makes strange bed-fellows, breaks up to- morrow, while your crowded hospital never adjourns. Over-crowding destroys classification, renders double the amount of restraint necessary, creates discord and confusion where quiet and order are essential elements of successful treatment. It is the bane of all progress in and the humiliation of our American hospitals to-day. The insane have a right to protection from the world, when they leave it to enter a hospital. This right would hardly be questioned, but for the increasing clamor to have everything about asylums thrown open to the public, as a pro- tection against abuse. The days of general visiting of our in- stitutions for the insane impress observant foreigners oddly enough. In what other form of hospital would we tolerate so much idle curiosity, or deem it anything but a shame that the public should demand to have the misfortunes of human- ity and the loathsomeness of disease exhibited ? If insanity was a contagious disorder, like smallpox or yellow fever, how soon the hospital would be rid of the gaping crowd who now throng their wards, on visiting days, in search of a sensation, thinking, perchance, to witness an outbreak of mania, or spy an indecent exposure ! By all means protect the insane in asylums, with public inspection, but let it be the scientific examination of medical knowledge, and the in- telligent supervision of boards of philanthropic men and women, not the crowd which goes to-day to the morgue and to-morrow to the circus, those self-constituted inspectors, who have less idea of the proper management of the insane 12 W. W. Godding. than the dogs had of the therapeutics of their treatment of Lazarus. The insane have also the right to be protected in their cor- respondence. “ Let the doors be shut upon him, that he may play the fool only in his own house.” If we take care that their unguarded words may not here- after be repeated, to call up a blush, or cause a pang to their convalescence, how much more ought they to be protected in regard to the permanent record which their written pages may leave ! Yet the Belgian system of locked letter-boxes in asylum wards, from which letters can be posted the same as from any collection boxes, finds many advocates among our philanthropists, and it is considered by some the great- est outrage that the physician should examine the letters of his patients. He has an undoubted light to do this, in order that he may the better acquaint himself with the work- ings of a disordered mind; the same right that he has to inform himself of a disease of the liver or the kidneys, by examination of the secretions. The right to have unopened letters forwarded to a medical inspector, or commission higher than the hospital superintendent, is not here ques- tioned, but to indiscriminately mail the correspondence of the insane, without previous examination by the medical officer, is not a right, but a wrong of the insane. He must inspect, and if he be the true physician he should be, he will destroy some letters. How many secrets which come to the knowledge of the medical adviser, in general practice, are hidden in his breast, from all human eyes and will be buried with him ! Is the only sickness which has no power to pro- tect itself to be allowed no curtains to its privacy ?As a physician to the insane, I ask that the Hippocratic oath may be inscribed on my tombstone : “Whatever, I see, or hear, in the life of men, which ought not to be spoken of, I will not divulge.” In the name of the pure woman committed to my charge, whose physical derangement by its reflex influence, has filled her disordered mind with unclean imagery, while Hights of the Insane. 13 her white soul is as untouched in its chastity as the lady in “ Comus,” when beset by the lascivious whisperings of de- mons, I protest against the mistaken philanthropy which, under the plea of protection, will put misery in all her after life, by disclosing to eyes other than her physician’s the stained pages which a passing frenzy soils. The insane have important rights in regard to classification and association, which should be respected in hospitals. True, insanity itself is a great leveller of distinctions. Under its sway the polite man is surly, the fastidious are boorish, the philosopher becomes a fool. The thin veneer- ings of culture, the insignia wherewith society distinguishes its ranks, fall away, leaving the animal instincts in their bare repulsiveness. But some men do not lay aside all gen- tlemanly impulses on becoming insane. Sometimes these outward wrappings of a finer clay are the last to go, and now and then, in some poor, withered branch of the F.F.V’s, or imbecile descendant of the Mayflower, where the blood has been kept too pure, I have seen a faded gentility outlive the mind, touching in its old-time chivalry, and worthy to be deemed a “ survival of the fittest.” It is proper that such social distinctions, where they exist, should find recognition in hospitals. The insane soldier is happy in barrack associa- tions ; the boorish son of the soil has no use for his napkin; cauliflower, is the only floral table decoration which he appreciates; but I confess to a tender sympathy with the lunatic, who in the height of his ravings, objects to roller towels and protests against a community in hair-brushes. Even in “ the last infirmity of noble minds ” such a man is entitled to a single room, hot and cold water, with all the modern conveniences. Has wealth a right to demand that a distinction should be made in its favor in public asylums ? I think not; our pub- lic institutions are State charities, which should be for all alike. It is eminently proper that suitable provision should be made in private or corporate establishments for those of the insane whose means enable them to command the luxu- ries, and surroundings which would be out of place in a hos- 14 W. W. Godding. pital supported by the State. In these places they should be allowed to pay for and receive all the indulgences and attentions which their abundant means or the extravagance of friends may permit to be lavished upon them. But the first care of the State should be for those who have no means to care for themselves, or if her provision for the insane is so ample that all can share it, then mental condition, not wealth, should decide the classification. No ten or twenty dollars a week should confer the right to send the drivelling, imbecile scions of shoddy, or vulgar, gold-bedizened women in mania, to trample like swine through all the pleasant places of the quiet wards, simply because, being wealthy, they must be endured in rooms and society from which the conditions of their insanity would otherwise exclude them. The returning reason of honest indigence has rights that are sacred, and not to be thus ruthlessly invaded. “These wards are for your pay patients ? ” is the oft-repeated ques- tion of visitors; it is a pleasure to be able to answer, they are for those whose mental condition accords with the sur- roundings, without regard to their pecuniary circumstances. Natural delicacy should be respected, and the insane spared unnecessary humiliation while under care and treat- ment in hospitals. In the- case of persons of refinement, with feelings rendered morbidly sensitive by their insanity, it is a difficult thing to exercise a watchful care at all times, and at the same time recognize the natural rights of privacy. Here, as everywhere else, the golden rule is the safe guide. Where the delusions are harmless, there need be nothing in hospital care which should wound the sensibilities ; but where the delusions are actively homicidal or suicidal, the custo- dian’s right implies the protection of his patient at any sacri- fice. Delicacy must not be permitted to stand in the way of this, any more than in the operations of the surgeon on the body; for “is not the life more than meat, and the body than raiment?” Yes, the oversight of constant presence and sleepless vigilance, we must have all this ; but let it be done delicately; there is such a difference in the two ways of doing the same thing; and, above all, those careless Rights of the Insane. 15 words, which cut into sensitive natures like knives, spare us those, doing to others as we would that they should do to us. As a rule, the classification of the patients, and distinction by wards, is not close enough in our hospitals. This is, in part, the fault of the over-crowding and consequent neces- sities of the situation. Many of the insane are fearfully profane ; but that is no reason why the ears of those who are not should be shocked by such utterances. Especially should epileptics be assigned to distinct sections, or better yet, have detached buildings devoted to their use. Usage familiarizes us with their aspect and their convulsions, until we hardly mind them ; but consider what a reception it must be to a sensitive lady in melancholia, on entering the ward which is to be her home, tq hear, as the first sound of wel- come, that piercing cry, at which, with all our familiarity with it, we instinctively shudder; and then to see at the next instant the victim, unless caught by the watchful nurse, fall, quivering like the felled ox, with lips frothing and struggling limbs. I fear the pleasant home pictures on the wall will lose their charm in the presence of such a realistic picture as this. Call it the sacred disease, as the ancients did, and sacredly screen it from the eyes of all novices in asylum wards. Nor is it well to make chorea and idiocy familiar sights to the recent insane; the ‘ ‘ chambers of imagery ” in their brains are demon-beset enough already. Honest citizens stricken down with insanity have a right to protection from the association, in hospitals, with convicts overtaken by the same affliction. This would not be ques- tioned in regard to any other form of disease. Humanity requires, and the State provides hospital accommodation within the prison enclosure for the criminal breaking down with tubercular or other disease, but never for one moment contemplates sending him to associate with the fading lives of the Consumptives’ Home, or to be treated in a general hospital for the community at large. Insanity being a mis- fortune, and not a crime, the two ought never to be con- founded. The convict insane should be cared for apart, in 16 W. W. Godding. detached buildings, separately enclosed, or, if their num- bers justify the outlay, in a distinct hospital for this class. I say convict insane, meaning only those who have become insane undergoing sentence for crime. Criminal insane is a broader term, and while it includes the convict class, it is also understood to mean those who, in an insane mental condition, have committed acts which, done by sane persons, would have been crimes. The rights here are purely those of classification; in a majority of cases they do not come from the criminal class of society. Their instincts are not necessarily depraved; the fatal act is not likely to have been in any way different, except in the results from the sudden violence so often seen in mania. Still, public senti- ment in regard to the sacredness of human life, if there was no other reason, would point to the necessity of a somewhat more careful seclusion and prolonged detention of one who, in an insane frenzy has committed a homicide, even though it be the mother with puerperal mania, whose brain disease, if it exists, is only functional; who to-day has taken the life of her darling of yesterday, and who, when the blood has returned to its accustomed channels and the brain has cleared, would give, for its restoration, her own life to-morrow. This woman is no criminal; here is a horror, as of night- mare, but no crime. The insane have a right to have discrimination used in their custody and treatment, based upon the varying types of their disease. We build our hospitals with walls like prisons, bar the windows and strengthen the bolts—why? To provide against the escape of a few dangerous lunatics for whom even that provision is hardly strong enough; for the public have a right to demand such protection against this handful of homicidal maniacs as shall make their elope- ment well-nigh impossible ; for their presence in a community is a perpectual menace to innocent life. There should be a sec- tion of the hospital built especially for these. But how often do we see those with timid melancholia and harmless demen- tia, that have no other home and would not run away if they could, looking out with wistful faces through the same heavy Rights of the Insane. 17 grating, and hearing the bolts clash at every opening of the door. They certainly have the right to such classification as will set their windows wide open and let them go forth at will in the air and sunshine of the hospital grounds, which are, and will always remain, their world; whose walls are their life’s horizon ! Three-fourths of the chronic insane in our hospitals require supervision rather than custody; kept busy, they are content. Their right is to be employed, but you cannot always induce them to exercise that right. The modern philanthropist is making a mistake in supposing he has found in labor the universal treatment for insanity. No panacea has yet been discovered for insanity, any more than for any other ill. The conditions of brain disease make it utterly impossible to employ some of the insane, who stand as in a cataleptic trance, or sit silent, or creep about with drooping heads, never saying a word. They are like auto- mata with their works run down; they eat and sleep, and the listless morning and the vacant evening make their day; dynamite could not rouse their ideas, for they have none ; soul and body apparently parted company years ago; they simply exist, they do not really live. But there is a grade of chronic insanity something above this, where occupation suited to individual needs and capacities is of real hygienic value, and is the greatest boon the hospital can give. Per- haps such labor can be made moderately remunerative, but the right is one of treatment, and not a question of finance. There are cases where it will be found, at first to cause excitement, and will require to be suspended ; and there will be now and then a case where it will have to be given up en- tirely. In this, as in everything else, the insane have a right to treatment in accordance with the varying phases of each individual case; and those conditions are to be determined, not by theory, but under intelligent medical supervision, that prescribes at one time labor, at another, rest or di- version. Then there is the question of parole, a delicate one, involving the rights of the insane and the custodian. Some deny that the insane in hospitals can have any right of 18 W. W. Godding. parole, claiming that the very idea of custody precludes it. But the primary object of hospitals is cure ; and, homicidal and suicidal cases aside, the question of custody is wholly secondary to that. For myself, I believe in the right of the insane to a parole ; I think that I have often seen recovery hastened by it; that there are times in the history of very many cases when that confidence reposed, that trust in the unimpaired integrity of an innate manhood, has been to the struggling reason like the grasp of a hand stretched out in the darkness, leading at last to the light. But here, again, as in every other delicate question in the management of the insane, you must study the individual case. 1 allow that a parole may increase the responsibility of the superintendent, which would seem already to be heavy enough; but a true man in that position will never shrink from responsibility where the welfare of his patient is involved. The subject of paroles is a very wide one, too wide for exhaustive dis- cussion here. As I have said in another paper, it is too late in the history of the treatment of the insane to claim that you have done all you can for an insane man when you have locked him up. Sometimes the best curative treatment you can give him is to open his door, not indiscriminately ; each individual case must be determined by itself, remem- bering that you alone are responsible ; that you take a risk when you open the door; that you take a risk also, for which you are none the less responsible, when you close it upon his hope. Which suggests the right that we demand for the insane that the hospital superintendent shall be a physician and not a politician. But for the regular rotation of the incumbents of these offices, in some of our States, on the accession to power of a different political party, I should have supposed this right a self-evident one. Has the scientist fallen to a level with the ward politician ? It is beginning to be regarded as doubtful whether the medical superintendent can be stew- ard, engineer, architect, farmer, florist, landscape gardener and financier, and still be able to give the proper professional care to his patients, though no one has been found ready to liights of the Insane. 19 maintain the converse of the proposition, that it would be better that the superintendent should not be a medical man. But certainly there is no time for him, in addition to all these other duties, to attend the political caucus. “ Fye on’t! O fye ! ’tis an unweeded garden That grows to seed : things rank and gross in nature Possess it merely.” Science dwells in a world that should be as inviolate of poli- tics as if they had no existence. When the offices of a lunatic asylum are held only as the rewards of party services, a new horror will be added to the outrages on the insane. Philan- thropists should lift up their voices against it; the scientific experts in insanity, without regard to their positions, should be a unit on this question ; and the superintendents them- selves should protest, in the name of humanity, against such prostitution of their high office, casting it into the mire of political spoils. The insane in places of detention everywhere have a right to ask that there shall be in each State, above local trustees, overseers or superintendents, a power behind the throne, in the shape of a Board of Commissioners of Lunacy, who shall stand between them and wrong, political or other; a Board which should never degenerate into a political organization. Created by executive- appointment, it should be placed above party, and conducted solely in the interest of the insane. A well-recognized philanthropist, not of the pseudo kind,—with qualities, both of heart and brain, fitting him for the work; a lawyer and a physician, both eminent in their professions, and of a standing to be known and respected throughout their State. This triumvirate should have full powers of inspection everywhere, with ad- visory powers in all matters pertaining to lunacy, includ- ing regular reports, with their recommendations, to legisla- tures, on the subject of public and private provision for the insane, their condition and treatment. As a Court of Ap- peal in regard to discharge from custody in hospitals or alms- houses, or transfer from one institution to another, their 20 W. W. Godding. power should be absolute. To remove them as far as possi- ble from political influences, they should receive the salaries of Judges of the Supreme Court of the State, should be ap- pointed for ten years, subject to impeachment and removal only for cause. Such a Commission would mean something and, I believe, would be welcomed by hospitals and their superintendents, who would demand, as their right, only that those places should be tilled by well-informed, scientific men of broad views, interested in no particular system, dis- tinguished by their philanthropy and non-partisanship, in- tent only upon serving the best interests of the insane and the State. The insane have a right, that is also ours, to the courage of our convictions in regard to detention or discharge. The hospital superintendent, when he takes the insane man into his care, assumes an obligation to him and to the community, which he must sacredly keep. He can never for a moment afford to be false to his convictions. If, in his opinion, care- fully weighing all the circumstances, the time has come for discharge, no matter how much friends may desire his longer detention, the man must go. But more often it is the patient, and perhaps his friends, clamoring for his release. Decide whether, under the circumstances, he is likely to recover as soon or sooner at home than by remaining in the hospital, and what would be the risk of such removal. If not likely to recover anywhere, would he injure himself or others if at large. Decide all these points on your conscience, and hav- ing decided, stand. What, as against a writ of habeas cor- pus, and before a New York judge? Bead Dr. Talcott’s last report of the hospital at Middletown, N. Y. ; note his case of cranial concussion subsequent to judicial discharge, and see, in cases of insanity, what judicial wisdom in New York means.* lam proud to say that the judiciary before which my writs of habeas corpus come is not elective. Doing * Dr. Talcott says of two patients discharged by habeas corpus in 1882, one was locked up in jail afterwards for threatening to kill his mother. The other was given up to the District Attorney of New York City, because, becoming unmanageable, “he had engaged in the unnatural diversion of beating the heads of bis helpless little children against the walls of the house where he resided,” Rights of the Insane. 21 only our duty to society as well as the individual, what have we to fear from habeas corpus? When it comes, the medical man with life passed among the insane should remember that, though, presumably, he knows very little about law, he knows, or should know, more about the insanity of his patient than any judge on the bench, however eminent. But we will say the case is a chronic one, with long periods of lucid interval, and will appear sane ? None the less make your return; state the facts as impartially as if you were yourself on the bench, and abide the result. You know, however well the man may seem to-day, that the mania, with its homicidal impulse, will inevitably return, if he lives long enough. If his Honor thinks that, in your anxiety to shield the community, you have given too little consideration to the right of your patient to personal liberty, he may discharge him. From that moment he takes your place as custodian of the man and guardian of the public safety. There is nothing for you or for him but to abide the result. The newspapers will have it, the next morning— “ Another sane man released from a lunatic hospital.” A few months later should the same papers have occasion which God forbid to record one of those ghastly occurrences that have of late been too common, there will be a brief editorial reflecting on asylum superintendents, for the premature discharge from their institutions of lunatics with homicidal propensities. No, let it be his Honor, not me, who gives that order of discharge. Much as I respect his position, I can better afford his censure now, than that in the after years some pale face should put aside the curtains of my sleep, to say, “ Let me sit heavy on thy soul to-morrow.” But the detail of rights grows endless, while this paper has already exceeded its limits. Much which remains, as of treatment with drugs, of mechanical and non-restraint, of night service, of nursing, of companionship, of female phy- sicians, of intelligent medical supervision, that is progressive rather than stationary, may be merged in the one paramount right to such treatment as will effect a cure, a right to which all others are in abeyance. It is for this that hospitals 22 W. W. Godding. were established. Achieving this, we shall be excused for our method or want of method. In the management of the insane here in America we are in a transition period. The propositions of the Association of 1851 and 1853 no longer fill the whole horizon; the enthusiastic admirer of every- thing from beyond the water hastens to espouse the system of non-restraint, in its entirety, and makes a holocaust of his camisoles, while the conservative believer in the old still laces his ideas in a strait-jacket. There is much to be said in favor of both; yet, between the two, we are steadily drifting away from old moorings, never to return. Drifting ever towards the right, why make haste to anchor to any system, however praiseworthy? We may recognize the good in all, and, without attaching ourselves to any, pro- claim the American idea to be to intelligently study, and scientifically treat, not insanity as a disease in the concrete, but individual cases as they occur, believing that the man is more than the system, and that over and above and beyond all else in merit, stands the cure. The insane man has a right to demand that, in his care and treatment, his own individual case shall be regarded; he is not interested in insanity as an abstraction; he is sick, and as against getting well, the legalized methods, the rubbish of eminent authority, the ponderous dulness of philanthropic boards, shall weigh but as the veriest dust in the balance. And the responsible medical officer in charge has the undoubted, inalienable right, as his medical attendant, to prescribe for him, as, being a physician, he would have for any other form of dis- ease ; not at the dictate of any board of commissioners or inspector of lunacy, however clothed in authority, for these officers can never share with him the responsibility of that man’s life or restoration to reason. And in regard to those steps to be taken in the crisis of the disease, steps which the physician’s conscience dictates, no board sitting in author- ity away from the bedside, where alone is the individual responsibility, has any moral right to say him yea or nay. Commissioners of lunacy may have a wide field of useful- ness in many directions, but not here. If your medical Rights of the Insane. 23 superintendent is not tit to be trusted in this, change him, until you get one who can be, but do not endeavor to tie his hands in any individual case with preconceived notions. To the true man, in an emergency, where the life of his patient is at stake, those dried formulas wherewith you fain would bind him will be no more than the green withes by which they vainly strove to capture Manoah’s son. In the treatment of the insane the procrustean is worse than the crib bed. There is too much fashion in psychiatry, as in other medicine. When treatment crystallizes into ste- reotyped methods be sure that some unfortunate individuals are crushed between the angles of that crystallization. We cannot allow this mania to pass into dementia under the most orthodox method of restraint or non-restraint, leaving any- thing else undone to avert it. It will not do to let this man go down in obedience to some dead man’s dictum, for if he dies, it is in our hands. We are not called upon to offer hecatombs to the manes of great names, however famous, founders though they may have been of whatever systems. We have the right, nay, ours is the necessity, of individual responsibility, and we are morally bound to leave nothing nnattempted to save the life, to restore the mind. New remedies, mechanical restraint, the pack, the douche, the merits or demerits of all systems, are not to be decided for us by popular clamor. A howl is neither science nor argument, and in the line of his duty, a brave man will not allow himself to hear it. Let us not forget what Dr. Ham- mond has said of the cruelty of keeping congested brains in the horizontal position by means of a crib bed, and at the same time, let us remember that there is a mania depending upon anaemia of the brain, which, in the stage of exhaustion, demands the horizontal position, if the life is to be saved. We are not to delegate our responsibility, or hide behind any great man’s shadow. Not that we claim to be better judges of insanity, or wiser, or abler in any respect, than they ; but that in the individual case before us judgment has come to us ; it is our opportunity, and, regardless of what another, 24 W: IV. Godding. in our place, might think or do, we must stand in our lot, “ Doing the right, as God gives us to see that right.” They boast of the Belgian, the French, the English, the German, the American systems in the care of the insane. There is good in all systems ; there is evil also. “ Our little systems have their day; They have their day and cease to be.” True science is never divided against itself. There is one right way, but only in eternity may we know it; yet even now, in our time, in every land and under all systems, in this noblest service of humanity, honest endeavor, integ- rity of purpose, and self-denying devotion, are doing their work and finding their reward, transcending the system to save the man. In the temple of psychiatry, to-day, modern philanthropy writes over all, this inscription: “He opened their doors; He broke their chains,” and says there is no higher line than that. But the humanity of another age will write above it: “ And they brought unto Him those who were lunatic, and He healed them.”