LUNACY COMMISSIONS.

BY EDWARD N. BRUSH, M. D.,

Physician-in-Chief and Superintendent Sheppard Asylum, Towson, Md.

It seems quite fitting and proper that at the fiftieth anniversary of this Association the subject of Lunacy Commissions should be discussed. It is almost fifty years ago that the first permanent Commission of Lunacy was established in England. It is just fifty years ago that Lord Ashley, better known by his later title, Lord Shaftesbury, in again urging the measure whose inception and successful operation will be inseparably connected with his name said: "The House possesses the means of applying a real and speedy remedy; these unhappy persons are outcasts from all the social and domestic affections of private life-nay, more, from all its cares and duties, and have no refuge but in the laws. You can prevent by the agency you shall appoint, as you have in many instances prevented, the recurrence of frightful cruelties; you can soothe the days of the incurable, and restore many sufferers to health and usefulness."

In the following year, August, 1845, the bills which he introduced received Royal sanction, and from that period date the labors and the glories of the English Lunacy Commission. These acts, as Tuke says in his "History of the Insane in the British Isles," have been well called the "Magna Charta of the liberties of the insane."

The subject of lunacy administration and the inspection of the insane under public and private care had been persistently agitated in the British Parliament from 1815 down to the passage of the act in 1845, but so indifferent were the law makers, and so thoroughly were the proprietors of private asylums and licensed houses intrenched that nothing was accomplished save the appointment of temporary commissions of inquiry, commissions with little or no power and but limited duties.

It is a curious feature of this whole subject and a sad commentary upon our humanity that the crying evils which attracted the attention and sympathy of philanthropic individuals were connected with the private care of the insane. There existed then, and there exist now, men who were willing and anxious to coin

money from the tears, blood, the groans and cries of their fellow beings.

In the earlier days of the agitation but few patients were in charge of public institutions, the pauper insane, when not neglected wholly and permitted to wander at large, were confined in jails and almshouses, where little was done to promote recovery, but what was done being under the direction and supervision of public officials seems to have been in a large measure free from the horrors which disgraced the private mad-houses of Great Britain.

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What a terrible indictment is contained in the words of Sir Andrew Halliday, who, in 1827, wrote in criticism of the act of 1774: "This act, the inadequacy of which has long been ascertained and fully exposed, is still the only law by which madhouses are licensed and regulated in England and Wales. That it has remained so long upon the statute book must hereafter excite astonishment; and that even now there should exist so much difficulty in having it altered and amended is a fact scarcely to be credited. Yet such is the fact; and thousands of our fellowmen have been hurried to an untimely grave in all the horrors of raving madness or helpless fatuity without its being possible to get their condition altered or amended merely because certain (we hope mistaken) prejudices were entertained by an exalted individual whose voice was long paramount in the Senate; and we had almost added through the influence of those who have realized immense fortunes as wholesale dealers and traffickers in this species of human misery." If this "exalted individual" were permitted to see the reforms which he delayed, if he were given a glimpse of the misery and suffering which his action maintained, I am sure those words must have given him many uncomfortable moments. And those others, whose influence, it is hinted, produced the prejudices which stood in the way of reform, surely they could not have grown so callous that they, too, were not made to blush with shame, and we hope feel some twinges of

remorse.

Lord Shaftesbury lived to see his reforms not only put under way, but for more than forty years directed, as Chairman of the English Lunacy Commission, its work and policy.

Upon the model of the English Lunacy Commission have been erected all the Commissions and Boards of Control or Inspection

that have been called into existence in this country and the purposes of these Commissions and Boards have been practically the same as those of their prototype, though happily the causes which necessitated their appointment have not been the flagrant abuses which the first Lunacy Commission of England had to correct.

These causes have had relation to the commitment, detention and treatment in asylums of insane persons or persons alleged to be insane; the management of asylums and hospitals for the insane; and covering both of the foregoing, the demand on the part of the public for wider knowledge and more exact information concerning these points.

In an inquiry concerning Commissions of Lunacy or a discussion of their work and function one naturally considers them with relation to their value:

1st. To the patients in asylums, and to the insane in general, whether in institutions or in private care as "single patients."

2d. To the institutions and their managers, medical officers and the nursing staff.

3d. To the public-both in the relation which the public bears to the patients in institutions or elsewhere-and in its relation to institutions through levies raised for their support.

When this subject was first presented to me I wrote to the legal members of three Boards of Lunacy suggesting the foregoing points for their consideration.

From two of these gentlemen I have received replies which show a broad and liberal comprehension of the subject and from those replies I shall quote during the course of my remarks.

Upon the first point one of these gentlemen, the efficient legal member of the Pennsylvania Board, prefaces what he has to say with such wise and appreciative remarks, that I cannot pass them without quotation. He says: "Treatment has become allied

with care and detention and thus it is that Courts of Law are coming to recognize treatment as a principle, that out of the asylum has merged the hospital. The old rigid rule that no person can be legally restrained of liberty, in an institution for the insane, unless dangerous to himself or the community is being relaxed. Lunatics who are neither dangerous to themselves nor to the community are being sent or remanded to hospitals for treatment. *** Now it is proper that commitments should be made upon the authority of medical examiners and it is impossible to prevent occasional sensa

tional publications, therefore the solution of the problem how to secure and retain the confidence of the public in our institutions and to remove groundless fear as to their internal management, becomes of the deepest concern to all who are associated with the care and treatment of the insane. When entire public confidence is secured, the number of voluntary commitments will increase and the prevalent hesitation in early commitments of curable cases will pass away. 'Home care' will as effectually disappear as has disappeared home treatment of capital and important surgical cases.

Continuing, this gentleman says: "I believe the answer to the problem I have suggested has been found. It has been found in my view in the establishment of supervisory public bodies called Committees or Commissions of Lunacy, Boards of Control and the like."

I am confident that the body of my hearers will agree with this gentleman. The patients in asylums have in such bodies a court of appeal which reaches their complaints of improper commitment or detention or of unjust or harsh treatment without the delay and publicity incident to courts of law.

As the Honorable Attorney General of the State of Maryland, ex officio one of the members of the Lunacy Commission of the State, says in a letter to me on the subject: "An intelligent supervision by an official body authorized to make a thorough inspection from time to time at their pleasure must be frequently most beneficial to patients. They may discover cases where the patients are the victims of gross error or worse in being confined at all and may be the instruments of securing their release. They may find that patients are being detained who are sufficiently cured to be discharged. They may in conversation with them ascertain that all is not being done for them that should be and may suggest different and improved treatment *** They may have opportunity to hear and inquire into complaints, which, but for their visititations, would never be heard or inquired into."*

A scrutiny into the papers upon which patients are committed, an inquiry into the propriety of commitment or of further detention,

*The reference to gross error or worse "which may be discovered in the commitment of patients should not I think be passed without quoting the remark of Lord Shaftesbury who, in his long experience extending as I have said over forty years, never found a case which showed any evidence of ulterior motive in the commitment of a patient, which is also the testimony of Dr. Ordronaux and his successor Dr. Stephen Smith in N. Y. State, and the legal member of the Penna. Board who says "I have never known a case of fraudulent commitment."

an examination into the treatment pursued and a careful investigation of all causes of complaint comprise the personal service which a commission may and should render patients to these be added, as from these would flow in a measure, a constant attempt to instill into the mind of the patient confidence in and respect for those having him in charge and directing his

may

treatment.

But there are large numbers of insane not in charge of institutions, patients in family care, or residing as single patients, occasionally in larger numbers with physicians, in retreats or sanitariums, who do not commonly come under observation of commissioners or inspectors. In this field there remains a great work. The commission in Pennsylvania has found numerous instances of neglect and abuse of patients thus cared for, and will doubtless discover others. It should be as much a violation of law to restrict a patient of his liberty in a private house or in a sanitarium as in an asylum or hospital and the facts are that in these instances the patient's liberty is much more curtailed than in institutions. Every Asylum Board is in itself a Commission of Lunacy and its powers of discharge, of redressing wrong, of correcting improper treatment are really larger than a Commission of Lunacy which is, or should be, supervisory and inspectory in its work, making all its orders operative through local boards of Managers or Trustees.

The patient in private care has nothing of this kind to rely upon. His own family, with the best intentions but through ignorance of a better way, may shut him in a garret or out-house or immure him in a cellar and there is none to whom he may appeal. It is very firmly my opinion that as the State reserves the right to, through its courts of law, administer the property of those declared insane by judicial process, it should, through other proper officers, see that the persons of all these unfortunates, whether in public institutions or private charge, whether cared for for hire or maintained at home, are protected from indignity and that a certain proper standard of care commensurate with the means and position of the patient be maintained.

I am not an advocate of paternalism in governmental affairs, but the insane have something not in common with the rest of mankind—a something, which according to John Stuart Mill, should everywhere make them proper objects of the care of the State. That something, as Bucknill puts it, is their helplessness,