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If the law were based on the modern conception of insanity as a disease, and not a crime, the procedure for commitment would take quite another aspect. As suggested by Professor Henderson, the Board of Inquiry composed of physicians would hold an inquest; the patient could not be detained in a jail, and the local authorities would be compelled to provide a proper place of detention. The method prevalent in most States of keeping the insane during the inquiry in the same place with criminals is not only outrageous but injurious. (140)

The detention of the insane is another matter when it is necessary to protect the interests at once of the community and of the inmates. It is a matter on which the inmates will usually differ in opinion from the superintendent of the institution, and it has not been found easy to work out rules that guarantee against all abuses. In the main, the right of correspondence should remain with the patients, the letters that they write being read by the superintendent or his representative, and any which are not forwarded being filed for the inspection of directors or other supervisors of the institution. (141)

Where the insane who are committed and detained are classified according as they or their relatives can or cannot pay for their support, the adjudication of this matter must usually rest with the overseers of the poor. There is likely to be a good deal of care exercised where the expense of maintenance is left to the towns and counties. Where the State maintains both the acute and the chronic insane, the drift is in the direction of giving free support to all insane persons, whether of the well-to-do classes or not.

Under the head of commitment and detention must be mentioned the matter of proper escort of the insane from the place of family residence to the hospital or asylum to which they are committed. In most States this matter is left to the sheriff, a relic of the time when only the legal aspects of the matter were considered by the courts. In other States the asylums are expected to send proper attendants to take the inmates to the institution, and a few provide that the county shall send a female attendant with every female patient, unless accompanied by her husband, father, brother, or son. The State Care Act of New York provides for female escort for females, and attaches a penalty for its non-observance.

The history of the treatment of the insane may be divided into four periods: the first, that of neglect, when the insane were only dealt with in case they were dangerous, and when they were treated as witches or wild animals; the second, the era of detention, when they were treated under such laws as the English Vagrancy Act; the third, the period of humanitarian and empirical treatment; and fourth, the period of scientific study, rational treatment, and preventive-medicine, when insanity is recognized as "a disease and not a doom." (142) In this country, during the early part of the present century, the English precedents were followed, and the precedents rather of the earlier than of the passing period. In New York, the law provided for the detention of the insane by chains if necessary. Dorothea Lynde Dix, who, in the middle of this century, visited a large number of places for the care of the insane, was compelled to tell a most grievous tale of abuse and barbarity. Even with the establishment of the State Boards of Charity in the more progressive States in the middle of the sixties and early seventies, the condition of things was hardly better. The reports of the early seventies, describing the condition of the insane in the town and county almshouses, give accounts of barbarities as hideous as any unearthed fifty years earlier in England, or described by Miss Dix in this country. Even as late as 1907 the State Board of Charities of Illinois, in making an inspection of the county almshouses of that State, found similar conditions and repeated the essential recommendations made by Miss Dix sixty years before. (143)

(143) Special Bulletin, April, 1907; see also Ellwood's Bulletin on Missouri Almshouses and discussion on pp. 197 ff., ante.

The history of the amelioration of the condition of the insane is marked chiefly by the decline of mechanical and medicinal restraint. Just after the French Revolution, Pinel inaugurated the movement in the great French hospitals for the insane and by 1837 mechanical restraint had been nominally abolished in England. English critics of American institutions claimed that our superintendents of institutions for the insane were far behind the times, because they would not commit themselves to the dogma of entire non-restraint; but careful foreign investigators who visited this country found that in the larger asylums there was as little restraint as obtained at the same time in England. Although the leading American alienists are agreed that restraint is useless as a curative measure, this, like other asylum abuses, was perpetuated in many asylums for the convenience of attendants, and encouraged by the manufacturer of "humane restraint apparatus." Except in the case of insane still remaining in almshouses, the grosser forms of restraint have disappeared, but "seclusion," that is, locking the insane person in a room by himself when he is troublesome and noisy, is still a very common practice. Dr. George A. Zeiler, superintendent of the Illinois Asylum for Incurable Insane, declares that mechanical restraint will infuriate and finally kill an insane patient by the interference with the normal functions of the body; but that seclusion brings on a condition of mind from which death is a welcome relief. Seclusion is even less justifiable than mechanical restraint, since it is done to relieve the attendants of trouble and responsibility. Medicinal restraint by narcotics is also fast disappearing from modern asylum practice, to be replaced by hydrotherapy, massage, and other non-medical agents. (144)