1846.] RAY ON HOSPITALS FOR THE INSANE. 393 always constituted itself a neutral ground upon which all may meet with that brotherly feeling fitting to be exhibited by the descendants of one common parent. With one exception, indeed, the reciprocal professional relations are as satisfactory as can be desired, and we need hardly state that the non-existence of an international copyright constitutes that exception. Its absence is far more injurious to the Americans than to ourselves. It is true that we are the pecuniary losers by it, and it can hardly be expected that a writer connected with a Journal, which, like ours, has been systematically pirated for years, can look at this element of the question with indifference; but the truly important aspect in which it should be regarded is the depressing effect which it exerts upon American medical literature. While numberless English works are reprinted on the other side of the Atlantic as soon as they appear, some two or three sterling productions are all our publishers, with equal facilities, have thought it worth their while to re-issue. And how can it be otherwise than that a nation which systematically relies for the supply of its literary food upon what it begs or filches from others, must be destitute of a stimulus and vigour necessary for producing it itself. Take away English re-prints and translations from French, and verily a small book-case will contain the productions of American medical (as indeed general) literature. Of the capabilities of American medical practitioners, none who have perused the original articles in their Journals, or the few good works they have published, can entertain any doubt. We there find the same practical sagacity which we are proud to say characterises the profession in our own country: but the results can never be exhibited in the form of good books, commanding an European reputation, until the vicious system of living upon the fruits of other person's labours has been discontinued. It is bad enough that no international copyright should exist between nations speaking different languages, but that it should be wanting amid people speaking the same tongue and boasting a common origin is indeed disgraceful. To return to Dr. Ray's Essay. He availed himself of one of those opportunities which so rarely fall to the lot of medical men-a few months' leisure-for the investigation of the condition of the principal insane establishments in England and France and some of those in Germany. For the information of his countrymen he has published the results of his tour in the very interesting and useful "Journal of Insanity," conducted by Dr. Brigham, and institutes a comparison between the institutions he had just visited, and those of his own country, assigning the following reason for so doing: 66 Presuming that the results of my observations may not be entirely devoid of interest to my professional brethren, and perhaps to some others, I am induced to offer them to the public, hoping that they may be productive of good in a department of philanthropy where much yet remains to be learned. If we would have our course in it characterised by progress, it will be better to dismiss all notions of superior excellence, learn what others are doing, and be willing to receive with a teachable disposition the lessons they offer us. I fear we have been too prone to believe that our institutions for the insane are far beyond those of any other country, and in a spirit of self-complacency, have gone on year after year copying one another-too often our faults and merits alike-scarcely evincing a suspicion that anything could be learned from abroad. We do not seem to have been aware that in Europe these institutions, for the last few years, have received a large share of public attention, and that intellectual effort and enlightened philanthropy have been devoted to their improvement, to a degree quite unparalleled in America. We should recollect that, there the greater control of the Government over all matters pertaining to the public good, and the greater wealth of the community of England, if no where else, give them an immense advantage over us in improving the condition of the public charities. Here the let-alone policy, which we have rejected in regard to trade, has been too much adopted in measures of philanthropy, which are thus abandoned to individuals whose zeal may not be according to knowledge, and whose pecuniary means are inadequate to carry out their undertakings in a generous and lofty style. Their steady, systematic, and intelligent mode of proceeding strongly contrasts with the fitfulness, irregularity, and lack of intelligence that characterise so many of our benevolent efforts, and produce an imperfect and disjointed result. It would not be strange then if it should appear that, in many respects, we have been outdone in a field of benevolent and scientific exertion where we have flattered ourselves that we shine without a rival." We shall notice the various heads under which Dr. Ray has classified the results of his observations. 1. The Visitation and Direction of Asylums.-Under this head we find some well deserved censure upon the system which prevails among us. Who that has had an opportunity of witnessing the meddlesome inefficiency of visiting Justices of the Peace, and Governors of Subscription Asylums and Hospitals but must acknowledge the truth of this passage. "The small share of the individual in the general interest, is swallowed up in the more direct and personal interest that springs from his official relations. Most of them can have but a vague idea of the duties of their office, yet they are naturally pleased with the power which it confers, and especially that kind of it most pleasing to a certain class of minds-the power of patronage. Delegating no power which they can possibly exercise themselves, and constantly hampering those whom they have entrusted with any, it has come to pass that the English asylums have probably been directed with less intelligence and disregard of unworthy considerations than any on the Continent, or in America. The visiting Justices have been described by one who has seen much of them as 'on the subject of insanity profoundly ignorant, individually irresponsible, and collectively despotic.' Indications of the spirit in which they exercise their functions, may be gathered from the rules they have made; and it is a spirit which can form no higher opinion of the duties and characters of those who are charged with the care of the insane than by regarding them like those of the keepers of jails, workhouses and prisons. * * * * * * * * * * In some establishments the visiting justices even participate in the executive management, upon the idea that none can be trusted but themselves. At Hanwell, they furnish themselves with keys and enter the wards, changing attendants and patients from one gallery to another, and dispensing their orders with the utmost freedom. It is not strange, that under such management, this institution should have been filled with confusion and disorder: nor can we wonder at the remedy such persons adopted, to counteract the effect of their own mischievous interference. Conceiving that a little military discipline would meet the exigency of the case, they installed into the office of Superintendent, a half-pay military officer. Of course, this arrangement could not last long, but I could not learn that any wisdom was learned from such experience." When we consider the conduct of these meddling bodies we cannot but 1846.] VISITATION AND DIRECTION. 395 admire the tact with which Dr. Conolly managed to carry on his great experiment at Hanwell, and still more to wonder at the success which attended it. And yet, after all, he was obliged to retire from the management of an establishment in which it would be difficult to say whether the prevalence of vexatious opposition or injudicious co-operation has proved most detrimental to true progress. It becomes indeed a serious question whether the well-being of the insane is much longer to depend upon the remote contingency of men of common sense being elected on the Visiting Boards, who, after assuring themselves of the capacity of their Medical Superintendent, will be content to leave the absolute management of the patients in his hands. That we are far from this point many parts of Dr. Ray's Report too clearly exhibit. Even so apparently an essential power as the dismissal of servants improperly conducting themselves is not placed in the hands of the medical superintendent, and in more than one instance they have been retained, although protested against as unfitted for their situations! Dr. Ray, too, well observes, that the whole tenour of the regulations of most asylums implies a necessity of a scrutinizing surveillance of the conduct of the superior officers of these establishments exceedingly derogatory to them. Hence, a servant not liable to dismissal by the superintendent is supposed to be more at liberty to report any misconduct of the latter that may come under his cognizance. suspicion is never to be dismissed that these gentlemen are ready to take advantage of any opportunity to go wrong, and need to be hedged in by a system of checks and balances. The superintendent is very much regarded in the light of an upper-servant of some cleverness and honesty, rather than of a gentleman whose talents, moral worth, and scientfic attainments have raised him to a highly responsible, arduous, and honorable position in his profession." "The A rule is quoted from among those adopted at the Lincoln Asylum, and well characterised as mischievous in its tendency, as indicative of inconceivable meanness in those who made it. "Each patient discharged recovered shall be questioned by a deputation of the Board, not only with respect to the treatment of himself or herself, but also as to the treatment of the other patients." Those who know more of the medical institutions of the city of Lincoln than a casual visitor can, will feel surprised, not at this or any other absurdity being perpetrated, but that any improvement in the management of the insane should ever have been there first set on foot. In France, the medical officers are selected from a body whose preliminary training has thoroughly qualified them for their occupation. They are appointed by the Minister of the Interior from a list of three nominated by the General Council; and the chief medical officer of the establishment exercises a paramount authority in everything regarding the interests of the patients. 2. Officers. We quite agree with Dr. Ray that the distribution of duties is far more rational and efficient in America and Germany than in France and England. In the first-named country the Superintendent or Resident Physician is invested with paramount authority in everything which relates to the management of the patients, as also with the power of appointing and discharging the attendants. An assistant physician shares his labours and seconds his views. The duties of the Matron are limited to the management of house-keeping, and the superintendence of the work and clothing of the female patients. How different from this simple common-sense plan is our own. "There the officers are entrusted with less power, and that is more equally divided between them. Thus, responsibility is frittered away, and that unity of plan and purpose so necessary in maintaining the ordinary routine of service, not to speak of any higher end, is entirely wanting. In one of the largest establishments of the country I found that the officers themselves were not quite clear as to the exact limits of each other's responsibility. If the resident physician prescribed medicine, his prescription was liable to be countermanded by the visiting physician: if he moved a patient or attendant from one gallery to another, the matron might move them back again; and if the matron shut up a patient in her room, the visiting justices might, and probably would order her to be enlarged. Thus each one was constantly interfering with somebody else, and preparing for some fresh jealousy or heart-burning, disorder or dissatisfaction. * * * * * * * * It was not perceived that there should be a radical difference between the management required for patients labouring under diseases of the body, and that most suitable for persons smitten with disorders of the mind. "To this cause is chiefly to be attributed the slow progress which institutions for the insane have made in the way of improvement. The officer in the immediate charge of the patients had the least power to minister to their moral necessities, even if capable of perceiving and appreciating them, while the one who had the power could see nothing in his hasty and infrequent visits to call for its exercise. Even after the gross abuses that resulted from this management were unfolded, it was attempted to remedy them, not by cutting off the source of the evil, by putting the establishment into the charge of men possessing moral and scientific qualifications of a high order, and invested with the necessary power for carrying their views into effect, but by making stricter rules and a more searching espionage." In nearly all the English establishments there is indeed a resident officer of some kind, but there is also one a mere visiting physician, and the respective duties of these officers are very loosely defined and very different in different institutions. "In some, the visiting physician seems intended for ornament rather than use, his visits being a mere matter of form, while the resident medical officer is the real chief. In others, the visiting physician is the fountain of all power the Justices have not kept to themselves, and directs the whole management, the duties of the resident medical officer being confined to the execution of his orders, which may be so general that the former reap all the credit of their success, and avoid any responsibility that may be incurred by their failure. In the rules of the Lincoln Asylum the House-Surgeon is expressly forbidden to enter the galleries of the female patients without the attendance of the matron or some responsible female!!" In a note, Dr. Ray furnishes from the pen of a friend a graphic account of the ludicrous farce performed at a weekly visitation of the physician of St. Luke's, during which patients were prescribed for at the rate of about fifteen per hour, the peculiarities, habits, &c., of those unfortunate individuals being enquired into in their presence, and in that of their comrades in misfortune. The Matron is oftentimes a too important, and even a mischievous person, in the English asylum. "In some establishments she is the principal 1846.] SITE AND CONSTRUCTION-DORMITORIES. 397 member of the government on the female side of the house, completely controlling the same, and yielding to the physician only in the matter of medical treatment." No one can doubt the great utility of female influence in the management of the insane, but, for this end, it must act implicitly under the superintendence and control of the medical officer, and never in contravention to his commands. How seldom it is the case that a matron will consent to this, all who know much of our public asylums must be aware. Immense benefit would often accrue from appointing the wife of the medical superintendent to the office. In France, the chief medical officer possesses paramount power, but is not resident. He passes a much longer period smong the patients than the visiting physician does in England. His non-residence is however a very serious defect. Generally speaking, the officers of European asylums are not so well remunerated as are those of the establishments in America. 3. Site of European Asylums.-Dr. Ray speaks with great and welldeserved admiration of the site of many of our county-asylums, and the tastefulness with which the grounds surrounding them are laid out. By far the most beautiful establishment, however, that he had the opportunity of visiting was, that of MM. Falret and Voison at Vanves, near Paris, situated in the midst of 100 acres, laid out in the finest style of landscape gardening. The Americans, notwithstanding their unlimited command of land, are far less liberal in their devotion of it to the purposes of asylums. While gladly acknowledging the admirable situations and external arrangements of our country asylums; we must not forget the pitiable state, in this respect, of various other establishments. We allude to private and public institutions situated in London and other towns, nearly, and in some cases totally, destitute of the means of affording the patient, not a fine prospect, for the circumstances of the locality may generally render that impossible, but even more room for exercise than a wild beast possesses in a menagerie. It is notorious that this is the case with several establishments, and it surely would be no injustice to compel those proprietors who are unable to furnish the requisite accommodation in this vitally important respect either to discontinue their occupation or to remove to more convenient localities. 4. Construction.-Dr. Ray admires the more recently constructed asylums in Britain, both for their convenience and appearance, especially those, such as the Surrey and Glasgow, which are erected in the TudorGothic style. He considers that it is far better to extend the erections for the obtaining the requisite room than to raise them above two stories in height. The interior of the asylums he visited favourably contrasted with those in America in their greater amplitude, the width of the halls and corridors, the height of the ceilings, the spaciousness of the dayrooms, and in their light and cheerful aspect. The rooms are, with few exceptions, placed only on one side of the galleries, while in America the vicious plan of constructing them on both sides prevails. 5. Sleeping-Rooms and Dormitories.-The pauper sleeping-rooms in the No. 106. 27 |