1853 Legislative Council Report

Argus, Saturday 12 February 1853



The Committe appointed by the Legislative Council of Victoria to “enquire into the condition and management of the Yarra Bend Lunatic Asylum, and to take Evid- ence” have, after carefully weighing the voluminous evidence that has been taken before them, agreed to the following


First, as regards the unhappy lunatics themselves, your Committee find that these unfortunate creatures have, from the entire absence of any proper supervision (that has hitherto marked the superintendence of the Yarra Bend Asylum, being subjected to all the coercion and punishment usually had recourse to in madhouses at the will and caprice of the uncontrolled attendants; that the shower-bath which should only have been used as a means of improving the mental and physical health of the patients, has been turned into an engine of torture; and cases have been brought before your committee, in which patients with their clothes on have been locked in the bath, drenched with the shower, and then left for hours together, as one of the attendants described it “to get cool.” From this cause it is hardly to be wondered at that the shower bath should have lost its curative effects, and that looked upon only as an instrument of punishment, the use or rather the abuse of it, should have increased rather than allayed the sufferings of the patients; indeed, so great was the dread inspired by this cruelty, that one man made his escape from the Asylum immediately after enduring its infliction. In the same way the “strait jacket,’ the “handcuffs,” and the “gloves” have been applied it will by the attendants who, left to themselves the whole day, with the exception of a brief morning visit by the superintendent, seem to have had unlimited sway in the institution; and thus from gross
mismanagement and the total want of control over the attendants, the unhappy patients were much more likely to have their malady hopelessly confirmed, than to have a fair chance afforded them of being cured and restored to society. To one great evil in connection with this portion of the subject your committee would wish particularly to draw attention. The absence of all employment provided for the lunatics has been productive of the most baneful results. Left to roam about the yards to which they are contained during the day, without aim or object or the slightest occupation to interest or amuse them, and that too while in many instances unguarded by sane attendants: not only has the proverbial destructiveness of lunatics been called to play to such an extent as to endanger the lives both of patients and attendants, but practices of the filthiest, vilest, most immoral, and most sinful nature have been generated amongst them, and those to such an extent as to cause your committee to express their astonishment that they should have been so long allowed to exist. If any thing were wanting to show the necessity for providing constant but light and healthful employment for the patients, the facts now adverted to, and more fully detailed in the evidence taken before your committee, would at once set all doubt at rest.

By being constantly occupied, not only will the patient be kept from the mischievous and be kept from pondering constantly on the unhappy hallucinations which have usurped the place of reason; his mental as well as bodily health would be improved by the change from the present state of things, and he would also be enabled, as far as may be beneficial to himself, to contribute in some measure to the cost of his own maintenance.

In the rules for the management of the institution issued since the appointment of your Committee, there is one which you Committee would particularly notice, being the regulation providing for the celebration of Divine Service at the Asylum, at least once a week. Hitherto it appears this rule has not been acted upon, as from the limited accommodation provided by the Building there are no means of classifying the Patients ; and it can- not be too seriously or urgently impressed upon your Honorable house, that a great necessity exists for making immediate provision for some such classification, since the salutary influence of Religion upon the insane has long been acknowledged by those who have had experience in their treatment ; besides in all other respects, the beneficial results arising from judicious classification cannot be overrated. For this, as well as for many other reasons, the present building is ill adapted to the purposes of a lunatic asylum, and its extension calls for the immediate attention of your Honorable House.

Your Committee would next direct attention to the utter uselessness,-nay, they would go further and say the absolute injury that has resulted to the institution from the appointment of the present Visiting Justice. Naturally of an easy, unobservant disposition, the holder of this office, Mr. Smith, has by the arrangements for the in management of the institution, been thrown too much into the hands of the Colonial Surgeon and Superintendent, (these two officers forming with him the Board, by whose direction the Asylum has been solely regulated.) The result has been that his visits have been a mere form, and the decisions of the Board have equally, as a matter of course, received the signature of the Visiting Justice. To such an extent has this gone, that a female attendant (now Susan Heaver), then unmarried, has been in the family-way, has received leave of absence for her accouchement, and has been taken back to her previous employment, without the visiting magistrate having the slightest knowledge of the circumstance, although an entry was made of them in the ” Servants Book,” and although that book repeatedly bears the signature of Mr. Smith, as an attestation to the correctness of the entries. In fact, the grossest abuses have been shewn to have prevailed,-men and women, Asylum attendants, have left at night, and have returned at all hours, in a state of intoxication ; inebriety has been notoriously common, drinking has been carried on openly, the evils your Committee have already noticed have existed, and still the visiting justice, with a fatuity that is incomprehensible, expresses his opinion, ‘that there is not a better managed institution in Victoria.” The flocks of poultry, and the marketable pigs, that the superintendent had always on hand, never opened the eyes of Mr. Smith, or suggested to his mind the possibility that all those required feeding, and that something more than was purchased by Mr. Watson might go to them. The stud of the superintendent and his man Hiley never led him to think that amongst so many, it was probable the share falling to the one Government horse would be but small; your Committee will not say that Mr Smith wilfully shuts his eyes to all these glaring facts, that should have forced themselves upon him, but they would express an opinion that a gentleman of such limited powers of observation, is scarcely fitted for an officer of so much trust, and requiring so much energy and discernment as that of visiting magistrate of the only Lunatic Asylum in the Colony.

Your Committee have now to consider how the onerous duties imposed upon the Colonial Surgeon, in connection with the Asylum, have been performed. With infinite pain have your Committee listened to the evidence which has been brought before them, and which has so seriously, and so unmistakeably implicated an old and responsible officer of the Government in charges of an extremely flagrant nature.

The care of Susan Heaver, referred to by more than one witness and already alluded to, in this report (although the charge of immoral conduct, made against the Colonial Surgeon, has not been, made out), still presents many features that are worthy of comment, and many circumstances that appear, to say the least, of them, exceedingly strange. A young woman when by her own account, had been only four months in the Colony, is engaged without the regular reference to the Superintendent, by the Colonial Surgeon ; a few months afterwards she is found to be in the family-way, and as the period of her accouchment arrives, she receives from, the Colonial Surgeon six weeks leave of absence. Having received injury from a patient, a premature delivery of a still-born child is followed by a dangerous hæmmorrhage and, in the hour of danger, she sends for the assistance of the Colonial Surgeon from the other end of the town. Subsequently, this women is taken back and against the distinctly expressed opinion of the Superintendent. She proves, a notorious, drunkard, absenting herself from the Asylum and returning at late in a state of stupid inebriety. She is allowed to neglect the ward to which she is appointed, and to leave the patients to themselves for hours together; and at the very time the committee was sitting she is allowed to have her husband (for she is married now) living and sleeping in the asylum, at the expense of the institution, for three weeks at a time; indeed, privileges and immunities are permitted her to which the other attendants are strangers; in addition to all this, and despite her debauched habits, she is in the receipt of a higher rate of wages than any other attendant or than is paid to a woman who has been longer in the institution than herself, and whose conduct, so far as this enquiry has shown, is irreproachable. Under such circumstances, your committee have considered that the Colonial Surgeon has at all events, acted with great impropriety in thus making a protegée of a woman of so worthless a character. It is with regret that your Committee have now to refer to facts which tell in a more positive manner against the Colonial Surgeon, and which have led to disorder in the institution and to injury to the public service. Your Committee advert to the contemptuous and insulting treatment received by the resident Medical Officer, Dr Embling, at the hands of the Colonial Surgeon. So openly was this done and to such an extent was it carried, that the efficiency of the Resident Surgeon was completely destroyed, and the attendants only too ready to take their cue from their superiors, refused to obey that gentleman’s orders. The ill-advised and unprofessional interference of the Colonial Surgeon with cases under the treatment of Dr Embling without the semblance of previous consultation with that gentleman, and the repeated attempts to take from him all control over the patients resulted in the office of Resident Surgeon (for which you office the salary had been voted by your Honorable House) being trans- formed into that of a mere dispenser, whilst the moral control of the patients so necessary to give effect to the medical treatment, was handed over entirely to the Superintendent, who in his turn, again most improperly delegated this power to the attendants. The un- bridled length to which the insulting conduct of the Colonial Surgeon was carried, was such that, at least on one occasion, language the lowest and most ungentleman-like, becoming a public officer, was used by him to Dr. Embling ; and the unseemly exhibition of temper and unguarded language on the subject, of the same gentleman, in the presence of your Committee, will speak for themselves on this point.

A charge of a much more serious nature has now to be remarked upon by your Committee. It appears from the evidence that a female patient named Hastings was removed from the gaol to the Yarra Bend Asylum, where, on the 3rd day after her arrival, she died. The woman at the time of leaving the gaol was in a dying state and both Dr. Embling and Mr. Watson, on her reception into the institution, expressed their surprise that one almost in articulo mortis should have been sent on such a journey, half clothed, and in an open cart; and both agreed that her removal from the Gaol to the Asylum took away any small chance that might have previously existed of her recovery. But the worst remained to be told. Knowing the opinion of both the Resident Surgeon and Superintendent, the Colonial Surgeon refused to allow any Inquest to be held on the body, and thus this officer, who, from his position, ought to be the medical protector of the public, and the one upon whom it would fall to demand an enquiry into doubtful causes of death, was the person, on the contrary, who stifled enquiry and prevented publicity. Had she remained in the gaol, the stringent regulations of that establishment would have defied concealment, and would have rendered an inquest absolutely necessary. With such a case as this before them, your Committee feel called upon to declare, that all confidence in the Colonial Surgeon must vanish when the evidence respecting it is made public, and that they look upon this direct infringement of the law as a most dangerous precedent, and one that ought to be met by the strongest reprobation of your Honorable House.

Numerous other and minor charges appear to be fully established against Dr Sullivan, by the evidence given before your Committee, making in the aggregate a sum of official delinquency such as your Committee had never expected to find, even under the worst management

The uniform adherance to the interests of the Superintendent, and boldly- attempted justification of his peculations; the connivance at the employment of a discharged patient (Mrs Walters) as a domestic servant the Superintendent,-this woman having been for months lodged, fed and clothed at the expense of the Asylum, at a time when the Institution was declared to be so crowded that lunatics were left in our watch-houses and gaols; the attempt to cajole the witness, Miller, by offering to provide him with a situation at Geelong, though represented by himself and the Superintendent to be a man of the worst character, and many other circumstances which your Committee do not feel themselves called upon to enter into at length, all justify your Committee in coming to the conclusion that the public service is not benefitted by having such an officer in its employment

Of Mr. Watson, the late Superintendent of the Asylum, your Committee would willingly say but little since his connection with the in- stitution has ceased; but his proceedings whilst attached to the institution have been of such a nature as imperatively to call for remark from your Committee. Improving upon the example set him by the Colonial Surgeon, his constant opposition to the Resident Surgeon led to scenes, of the most unbecoming character; and, by the licence it gave to the attendants and other servants of the Institution, tended materially to bring that gentleman into contempt but pass ing over this conduct, disgraceful as it may have been in any officer of the Government, your Committee have to deal with facts of another description. Not contented with the by no means limited advantages he enjoyed, in having residence and rations provided for himself and wife, in addition to their joint annual stipend, Mr. Watson has evidently added materially to his income, by turning the Yarra Bend Lunatic Asylum into an extensive poultry farm, maintaining, according to the evidence, no less than between two or three hundred head of poultry of various kinds judiciously supplemented by a few store pigs ; that the provisions of the lunatics but to often went to feed these fowls and pigs your Committee can have little doubt, whilst there is very distinct evidence that the rations of the Government horse suffered for the same purpose. The attempt made by Mr. Watson to show that he bad purchased grain for his poultry led to a, most lamentable exhibition of insincerity by himself, and to downright falsehood by the witness Hiley. In the case of all public officers, employed away from town, your Committee conceive that there can be no objection to a small stock of poultry being kept for table use by those officers; but, in yielding this right, your Committee are of opinion that great care should be used in all cases when those officers are the responsible distributors of Government rations, lest it glide into abuse, and lest, as in the instance now before them, that which was granted as an addition to comfort should be turned into a source of profit, and ultimately degenerate into peculation itself. To such an extent was this model farming carried, that fowls were sold by dozens and the poultry merchants, in times of scarcity, looked to the Yarra Bend Asylum to supply the market, and found it worth their while to go out to the institution to make their purchases. This, alone would have been manifestly improper, but when joined to the fact that the rations of the Institution were used to support the live-stock whose price made so im- portant an item in his revenue, your Committee cannot too strongly express their utter disapproval of Mr. Watson’s conduct. Nor, in his capacity of Superintendent, do your Committee find the least redeeming point to weigh against the accusations that have been so clearly substantiated. Inattention to his duties, carelessness of the wants of the patients, and heedlessness of their welfare, and disregard of their comfort, seem to have been the prevailing features of the Superintendent’s inattention to his duties in leaving the distribution of the rations entirely in the hands of the cook, whereby the patients have been deprived of their fair share of food, and the attendants rendered discontested : carelessness of the wants of the patients in not making more careful, more attentive, and more frequent visits to the yards and dormitories of the Institution; headlessness of their welfare–in entrusting the charge of them so much to the attendants, one ward being constantly left to the sole charge of a lunatic attendant (Donovan) the other attendant having been a regularly withdrawn, by Mr. Watson’s consent, as to cause him to say, in answer to question as to how his word was conducted, that he had no opportunities of judging in permitting an unfortunate female patient to go at large in the grounds of the Institution not watched, after the patient had previously, by such disgraceful neglect, been allowed to become pregnant while an inmate of the Institution ; and for not providing some efficient check for the immorality and crime which he knew to exist; and disregard for their comforts, in allowing the patients to be turned out into the yards for the day in all weathers, and there leaving them, in too many instances, to take care of themselves, so that it has been a frequent occurrence that women have roamed about in the yards, unheeded by the attendants, for hours together, in a state of perfect nudity; and is suffering the unrestricted use of coercion and of punishment by the attendants who were much more likely to be guided in the measure of such means by their own angry impulses, than by the good likely to rest?? to the unfortunate lunatics. Your Committee also consider that the Superintendant has been guilty of the greatest impropriety, in permitting the services of the male attendants being called into requisition in the female wards. They have been regularly called upon to bring the hot water for the women’s bath and one witness declared that he had actually been present when the female patients were stripped for the bath; they have also been employed to put the strait jacket upon refractory patients, when scenes of the most disgusting character invariably occurred: the impropriety being still further added to by the obscenity of the lunatic attendant (Donovan), previously referred to, who, it appears, always endeavoured to render the proceedings as immoral as possible. The evidence of abuse, impropriety, obscenity, and crime that has come before your Committee, in the course of their lengthened and pained enquiry, all of which might have been materially checked, if not altogether prevented, by ordinary attention to his duties by Mr. Watson, has been such, that your Committee cannot as well from the nature of the subject as from the length of the details it would require, enter into them more fully than they have done; but that Mr. Watson has been grossly negligent, as well as highly culpable, there can be no doubt in the mind of any one who will as carefully note the evidence as your Committee have done.

With regard to the appointment of the lunatic Donovan, another protege of the Colonial Surgeon and reflecting as little credit on his discrimination as the one previously referred to, your Committee are clearly of opinion that to this cause many of the immoralities alluded to may be traced; shewn by most of the witnesses to be a man of the foulest conversation, of the most disgusting habits, and of the most libidinous propensities, he is rendered still more unfitted for so responsible a charge by his habits of intemperance, and his reckless conduct when in a state of intoxication, giving liquor to his fellow patients, and creating confusion and excitement where good order and peace are so much required.

To the Colonial Surgeon must be attributed the evils that have resulted from Donovan’s appointment, for although Dr. Sullivan has endeavored to screen himself from the responsi- bility he has thus incurred, by alleging that it was by order of His Excellency the Lieutenant-Governor that Donovan was so employed, still your Committee cannot believe that His Excellency would ever have given his consent to any such proceeding, but at the instigation and on the recommendation of the Colonial Surgeon.

Your Committee now turn to the Resident Medical Officer, Dr. Embling, and it is with extreme regret that they observe that the efforts of that gentleman to promote the efficieny of a valuable institution, and to check the abuses that so seriously affected its usefulness, have been rewarded with oontumely by his superior officer; with neglect by the Visiting Justice; with insult by the Superintendent; with disobedience by the servants of the establishment, and with suspension from office by the Government. The voluminous evidence taken before your Committee shows not one tittle of a charge as being even so much as hinted at against Dr. Embling; and his whole offence so far as your Committee can perceive, has been that he possessed too much conscientiousness and that he wished to make himself too useful to the public, thereby interfering with their privileges which although unwarranted in themselves, had been so long enjoyed that they had come to be looked upon by those most interested in their preservation as just and vested rights.

With the evils and abuses that have been shown to exist, your Committee would now leave your Honorable House to deal, satisfied in the conviction, that by exposing them they have taken the best possible means of ensuring their being remedied.

Your Committee cannot conclude their Report, without offering two distinct recommendations which have suggested themselves in the course of this inquiry.

First, with respect to Visiting Justices. The number of years that Mr. Smith his acted in this capacity, have left him quite as ignorant of the mode in which the affairs of this Institution are conducted, as he was on the first day of assuming office, and to prevent a recurrence or continuance of similar abuses in other departments, from the incapacity, inertness, or want of observation in the Visiting Justice, your Committee would recommend the introduction of a system of rotation, by which the Visiting Justice who has attended at one Institution during one year, should be appointed to the supervision of some other institution for the year succeeding. By this means the probability of the discovery of abuses would be greatly increased, whilst there would be a certainty that they will not be allowed to continue for so long a period as they have done at Yarra Bend Asylum.

And second, with regard to evidence taken before Select Committees of your Honorable House appointed to enquire into Government Departments, your Committee have found that the grossest falsehoods have been told, the most glaring misstatements have been made by two witnesses in particular, in order to deceive your Committee, and their experience has shown them, that in Government departments, when enquiry is necessary, there will always be the risk that evil-disposed men may be sought and found, ready to bolster up their Patrons with any evidence that may be required.

Your Committee would therefore recommend that an Act be passed by your Honorable House making all persons guilty of Perjury, and subject to the punishment prescribed by Law for that offence, who may give false evidence before any Committee appointed by your Honorable House to enquire into any department of the Public Service, or into the conduct of any officer of the Government.




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