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Title: On the State of Lunacy and the Legal Provision for the Insane
Author: Arlidge, John T.
Language: English
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ON THE STATE OF LUNACY AND THE
LEGAL PROVISION FOR THE INSANE,
WITH OBSERVATIONS ON THE
CONSTRUCTION AND ORGANIZATION
OF ASYLUMS.
BY JOHN T. ARLIDGE, M.B., A.B. (LOND.),
LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS;
ASSOCIATE OF KING'S COLLEGE, LONDON; PHYSICIAN
TO THE WEST OF LONDON HOSPITAL; FORMERLY
MEDICAL SUPERINTENDENT OF ST. LUKE'S HOSPITAL,
AND PHYSICIAN TO THE SURREY DISPENSARY, ETC.
LONDON:
JOHN CHURCHILL, NEW BURLINGTON STREET.
1859.
PRINTED BY TAYLOR AND FRANCIS,
RED LION COURT, FLEET STREET.
TO THE RIGHT HONOURABLE
THE EARL OF SHAFTESBURY,
CHAIRMAN OF THE COMMISSION OF LUNACY,
WHOSE LONG-CONTINUED AND UNTIRING EFFORTS
IN BEHALF OF THE INSANE HAVE EARNED FOR
HIM THE HIGHEST ESTEEM AND ADMIRATION OF
ALL WHO FEEL INTERESTED IN THE WELFARE OF
THAT CLASS OF THE AFFLICTED,
THIS TREATISE IS, BY PERMISSION,
RESPECTFULLY DEDICATED BY HIS LORDSHIP'S
MOST OBEDIENT HUMBLE SERVANT,
THE AUTHOR.
PREFACE.
The writer of a book is usually expected to show cause for its
production,--a custom which, however commendable as a sort of homage to
his readers for challenging their attention to his lucubrations, must
often put the ingenuity of an author to the test. Indeed the writer of
this present treatise would feel some embarrassment in accounting for its
production, did he not entertain the conviction that he has, in however
imperfect a manner, supplied a work on several important subjects which
have never before been so placed before the public, and which, moreover,
occupy just now a most prominent position among the topics of the day.
In the last Parliament, up to the period of its dissolution, a Special
Committee of the House of Commons was engaged in examining into the
condition of lunatics and the laws of lunacy; and the present Government
has re-appointed the Committee, in order to resume the inquiry preparatory
to the introduction of new enactments into the Legislature. The subjects
treated of in the following pages relate to the same matters which have
engaged the attention of Parliament, and elicited the special inquiry
mentioned, viz. the present state of Lunacy and of the legal provision for
the Insane with reference to their future wants.
In order to a better appreciation of the existing provision for the
insane, and of its defects, the author has introduced certain preliminary
chapters on the number of the insane, on the increase of insanity, on the
inadequacy of the existing public provision for the insane, and on the
curability of insanity. In reviewing the character and extent of the
provisions for the insane, the course adopted has been to regard them in
reference to their effects on recovery, and to discover the conditions
inimical to it, whether without or within asylums. Hence the evils of
private treatment and of workhouse detention of lunatics, particularly of
the latter, have largely claimed attention. The condition of pauper
lunatics boarded with their friends or with strangers demanded special
notice, as did the long-complained-of evils of sending unfit cases to the
county asylums, often to the exclusion of recent and curable ones, which
might by proper treatment be restored to health and society. Turning to
the consideration of our public asylums, considered as curative
institutions, the disposition to extend them to an unmanageable size, and
to substitute routine for treatment, has called for animadversion, as an
error pregnant with numerous evils to their afflicted inmates. Another
error pointed out is that of appointing too small a medical staff to
asylums; and in proving this, as well as in estimating the proper size of
asylums, the experience and opinions of both English and foreign
physicians are copiously referred to.
The future provision for the insane forms an important chapter, which, in
order to consider the several schemes proposed, is divided into several
sections, viz. concerning the propriety of building separate asylums for
recent and for chronic cases--of constructing distinct sections--of
distributing certain patients in cottage homes--of erecting separate
institutions for epileptics and for idiots.
The registration of lunatics has appeared to the author's mind of so great
necessity and value that he has devoted several pages to unfold his views
and to meet probable objections; and, in order to render the plan
effectual, he has propounded as a complementary scheme the appointment of
District Medical Officers, and entered into detail respecting the duties
to be imposed upon them.
Viewing the Commission of Lunacy as the pivot upon which any system of
supervising and protecting all classes of lunatics must turn, it became
necessary to examine into the capability of the present Board for its
duties; and the result of that examination is, that this Board is
inadequate to the effectual performance of the duties at present allotted
to it, and that it would be rendered still more so by the adoption of any
scheme for a thoroughly complete inspection and guardianship of all
lunatics. This conclusion suggests the proposition to enlarge the
Commission, chiefly or wholly, by the appointment of Assistant
Commissioners, charged particularly with the duties of Inspectors.
The concluding chapter, on asylum construction, may be considered
supplementary. Its chief intent is to develope a principle generally
ignored, although (unless the arguments in support of it fail) one of
great importance if asylums are to serve, not as simple refuges for
lunatics, but as instruments for treating them.
This _résumé_ of the heads of subjects discussed in the ensuing pages
will, on the one hand, show that the present is not to be reckoned as a
medical treatise, but as one addressed to all who are interested either in
the legislation for Lunatics or in their well-being and treatment; and, on
the other, make good, it is trusted, the assertion that it occupies an
untrodden field in the literature of insanity, and that its matter is
good, even should its manner be thought not so.
Assuming the publication of the book to be justifiable, it only remains
for the author to add that he has not undertaken its composition without
bringing to the task thirteen years' study and practical experience among
the insane, treated in private houses, in licensed houses, and in public
asylums, together with the fruits of observation gathered from the
visitation of most of the principal asylums of France, Germany, and Italy.
In conclusion, he hopes that this small volume may in some measure
contribute towards the amelioration of the condition of the insane, who
have such especial claims on public sympathy and aid.
J. T. A.
Kensington, July 1859.
CONTENTS.
PRELIMINARY OBSERVATIONS.
Importance of an inquiry relative to the number of the Insane, and the
legal provision for them, 1.
CHAP. I.--OF THE NUMBER OF THE INSANE.
Official returns imperfect, 3.--Divergence of returns of Lunacy
Commissioners and of Poor-Law Board, 4.--Unreported 'private'
lunatics, 5.--Criminal lunatics in prisons, 6.--Inadequate estimate of
the number of the Insane, 7.--Illustration of the difficulty of
discovering the true statistics of Lunacy, 7.--Number of pauper
lunatics in workhouses, 9.--Paupers not enumerated in official
returns, 9.--Estimate of the total number of the insane on 1st of
January 1859, 10.--Causes of apparent increase, 10.
CHAP. II.--ON THE INCREASE OF INSANITY.
Materials for calculation unsatisfactory, 11.--Rate of accumulation of
the insane in asylums, 12.--Estimate of increase made by the
Commissioners, 12.--Table of number of lunatic paupers in workhouses,
13.--Calculation of their rate of increase, 14.--Increase of pauper
lunatics not in workhouses or asylums, 14.--Total increase and
accumulation of lunatics, 15.--Positive increase of insanity by new
cases, 15.--Table of admissions in four years, 16.--Total number of
new cases added yearly, 17.--Expenditure on account of the pauper
insane, 18.--Proportion of the insane to the population, 18.--Cause of
accumulation of the insane, 19.--Suggestions for obtaining improved
statistics of pauper lunatics, 19.
CHAP. III.--STATE OF THE PRESENT PROVISION FOR THE INSANE IN ASYLUMS.--ITS
INADEQUACY.
Commissioners' calculation of asylum accommodation wanted, 20.--Their
conclusion that the present provision is inadequate, 22.--On the
accuracy of the Commissioners' conclusions, 22.--Pauper lunatics
accommodated in workhouses, and boarded out, 23.--Their unsatisfactory
condition, 23.--Colony of insane at Gheel, in Belgium, 24.--Character
of lunatics in workhouses, 25.--Unfit cases of insanity in workhouses,
25.--Commissioners' estimate that one-half of lunatic inmates of
workhouses are improperly detained, 26.--Estimate of asylum
accommodation required, 26.
CHAP. IV.--ON THE CURABILITY OF INSANITY.
Insanity a very curable disorder, 27.--Experience of American
physicians, 27.--Exceptional circumstances in American asylums,
28.--Experience of St. Luke's Hospital, London, 28.--Experience of the
Derby County Asylum, 30.--Advantages of early treatment, 30.
CHAP. V.--ON THE CAUSES DIMINISHING THE CURABILITY OF INSANITY, AND
INVOLVING THE MULTIPLICATION OF CHRONIC
A. _Causes external to Asylums._
§ _Detention of Patients in their own homes._
Absence of all curative influences at home, 32.--Causes of delay in
submitting patients to treatment, 33.--Impediments to transmission to
county asylums, 34.--Evils of pauper test in public asylums,
34.--Characters of Continental asylums, 35.--Practice followed in
America, 36.--Scheme of assessment of means of those applying for
admission to public asylums, 36.--Failure of the pauper test to
protect the rate-payers, 37.--Its demoralizing and degrading effects,
38.--Suggestion as to conditions and mode of admission into county
asylums, 38.--Act in force to recover the costs of maintenance
objectionable and inefficient, 39.
§ _Detention of Patients in Workhouses._
Detention practised on economical considerations, 40.--Examination of
the value of such considerations, 41.--Estimated cost in asylums and
in workhouses includes different items in the two, 41.--Illustration
from the Devon Asylum Report, 42.--Children constitute above
two-thirds of workhouse inmates, 42.--Material effect of this on the
cost of maintenance, 42.--Inmates of asylums almost all adult,
42.--Fluctuations among inmates of workhouses greater than in asylums,
43.--Mode of estimating the rate per head of cost in workhouses,
43.--Population of workhouses, sane and insane mixed, 44;--that of
asylums of insane especially, 44.--Those insane who involve increased
cost rejected from workhouses, 44.--Remarks on this point by Dr.
Bucknill, 44.--Economy of workhouses for the insane doubtful,
45.--Cost of asylums contrasted with that of workhouses, 46.--System
of asylum structure hitherto adopted unnecessarily expensive,
47.--Workhouses and asylums not fairly comparable as to cost,
47.--Plan to diminish cost of asylums one-half, 48.--Chronic lunatics
can be provided with asylum accommodation at a rate not exceeding that
for workhouses, 48.--Internal cost of asylums and workhouses compared,
49.--Mistaken policy of constructing lunatic wards, 50.--Unfitness of
workhouses for insane patients, 51, 75.--Evils attending presence of
lunatics in workhouses, 52.--American experience in the matter,
52.--Workhouses unfit by structure and organization, 52,
75.--Workhouse detention especially prejudicial to recent cases, 53,
81.--Deficiency of medical care and of nursing in workhouses, 54,
78.--The dietary of workhouses insufficient for lunatics, 54,
77.--Injurious effects of workhouse wards upon lunatics, 56,
77.--Lunacy Commissioners' remarks thereon, 56.--Dr. Bucknill's
remarks on the same subject, 57.--Characters of the lunatic inmates of
workhouses, 58.--The majority of them imbecile and idiotic,
58.--Proportion especially claiming asylum care, 59.--Epileptics and
paralytics unfit inmates of workhouses, 59.--Old demented cases badly
provided for in workhouses, 59.--Imbecile patients are, as a rule,
unfit inmates, 60.--Idiots improperly detained in workhouses,
61.--None but a few imbeciles permissible in workhouses, 61.--On the
class of supposed 'harmless' lunatics, 61.--Remarks by Dr. Bucknill on
this class, 62.--Experience of the Surrey magistrates on transferring
'harmless' patients to workhouses, 63.--Degradation of the patients'
condition in workhouses, 64.--Legality of workhouse detention
examined, 65.--Remarks on this subject by the Lunacy Commissioners,
66.--Clauses of the Lunacy Asylums Act bearing on the subject,
66.--Defects of the law in protecting the pauper insane, 68.--Remarks
of the Lunacy Commissioners on the anomalies of the law,
68.--Objections to the powers conferred upon parochial officers,
68.--The law obscure, and open to evasion, 69.--Duties of the parish
medical officers ill-defined, 69.--Proposal of a district medical
officer, 70.--Contravention of the law by Boards of Guardians, 71,
81.--The further construction of lunatic wards should be stopped,
72.--Necessity for the supervision of the Lunacy Commissioners over
workhouses, 72.--Several amendments of the Lunacy Laws suggested,
73.--Proposed regulations for supervision of workhouses containing
lunatics, 73, 82.--Lunatics in workhouses should be under
certificates, 73.--Proposal to increase powers of Lunacy Commissioners
over workhouses, 74.--On the Supplement to the 'Twelfth Report' (1859)
'of the Commissioners in Lunacy,' on workhouses, 74.--Abstract of its
contents:--unfitness of workhouses for lunatics, 75.--Workhouses in
large towns most objectionable, 76.--Lunatic wards more objectionable
than the intermixture of the insane with the other inmates,
76.--Miserable state of the insane in lunatic wards, 76, 79.--No
efficient visitation of workhouse lunatics, 77.--Insufficiency of the
dietary for insane inmates, 77.--Medical treatment and nursing most
defective, 78.--Fearful abuse of mechanical restraint in workhouses,
78.--Wretched neglect and want in the internal arrangements for
lunatics in workhouses, 79.--Abuse of seclusion in workhouses,
80.--Varieties of mechanical restraint employed, 80.--Absence of all
means for exercise and occupation, 80.--Lunatics in workhouses
committed to gaol, 80.--Neglect and contravention of the law by parish
officers, 81.--Amendments in the law suggested by the Lunacy
Commissioners, 81.--Proposal to erect asylums for chronic cases, 82,
126.--Visiting Justices of Asylums to supervise workhouse lunatic
inmates, 73, 82.
§ _Pauper Lunatics living with relatives or strangers._
Number of such lunatics, 83.--Neglect of their condition,
83.--Question of insanity should be left to the district medical
officer, 84, 175.--This officer should visit and report on their
condition, 85, 87.--Indications of the unsatisfactory state of this
class of pauper lunatics, 85.--Evidence from Dr. Hitchman's Reports,
85.--Wretched state of 'single' pauper patients in Scotland,
87.--Neglect of Poor-law medical officers towards such patients,
87.--Objections to boarding pauper lunatics with strangers,
88.--District medical officer to select their residence, 89,
146.--Advantage of keeping them in lodgings near asylums, 89,
146.--Distribution of lunatics in cottage homes, 90, 145.--Notice of
the colony of insane at Gheel, 90, 145.
§ _Unfit cases sent to asylums.--Improper treatment prior to admission._
Recklessness and cruelty in transmitting patients, 91.--Non-lunatic
cases sent to asylums, 91.--Cases of very aged persons sent,
92.--Previous horrible neglect of patients, and their moribund state
on admission, 93.--Extracts from Reports of asylum superintendents
illustrative of the facts, 91-96.--Transfer of lunatics to asylums
must be committed to some competent and independent officer, 97.--Want
of instruction for medical men in insanity, 97;--Errors committed
owing to the want of it, 98.--Neglect of psychological medicine in
medical education, 98.--Law regulating transfer of weak cases to
asylums, 99.--An amendment of the law requisite, 99.
CHAP. VI.--CAUSES OPERATING WITHIN ASYLUMS TO DIMINISH THE CURABILITY OF
INSANITY, AND INVOLVING A MULTIPLICATION OF CHRONIC LUNATICS.
§ _Magisterial interference_ and § _Excessive size of asylums_.
Defective medical staff in large asylums, 102.--Efficient treatment
impossible, 102, 121.--Degeneration of management into routine,
103.--Exclusive estimation of so-called 'moral treatment,' 103.--A
very large asylum especially prejudicial to recent cases,
104.--Delegation of medical duties to attendants, 105.--Evils of
absence of medical supervision over individual patients, 105.--Evils
of large asylums upon character of attendants, 106.--Routine character
of medical visits, 107, 143.--Necessity of medical supervision being
complete, 107, 115, 121.--Distinction of asylum attendants into two
classes--attendants proper, or nurses, and cleaners, 108.--Objections
advanced by the Lunacy Commissioners to large lunatic asylums,
109.--The erection of large asylums supposed to be economical,
110.--The supposition fallacious, 110.--Commissioners' remarks on
these topics, 111.--Rate of maintenance higher in the largest asylums,
112.--Inadequate remuneration of medical superintendents, 113.--Lord
Shaftesbury's advocacy of improved salaries, 113.
§ _Limit to be fixed to the size of asylums._
Proper number to be accommodated in an asylum, 114, 137, _et
seq._--Estimate of American physicians, 115.--Estimate of French and
German physicians, 116.--Peculiar organization of German asylums, 117,
141.
§ _Increase of the medical staff of asylums._
Opinions of foreign physicians on the subject, 118.--Estimate of the
medical staff requisite, 118.--Erroneous views prevalent in some
asylums, 119.--Illustration furnished by the Middlesex asylums,
119.--Jacobi's views of asylum organization, 121.--Advantages of unity
in the organization of asylums, 122.--Appointment of a chief
physician, paramount in authority, 122.--Circumstances affecting the
selection of asylum superintendents, 123.
CHAP. VII.--ON THE FUTURE PROVISION FOR THE INSANE.
Rapid extension in the demand for accommodation, 125.--Illustrated by
reference to the Middlesex asylums, 125.
§ _Separate asylums for the more recent and for chronic cases._
Objections to such separate establishments, 126.--Examination of the
value of these objections, 127.--Cases to be transferred from one
institution to the other, how determined, 128.--Mixture of recent with
chronic cases undesirable, 128, 130.--Examination of the present
relative position of acute and chronic cases, 129.--Separate treatment
of recent cases desirable, 131.--Influence of distance on the utility
of an asylum as a place of treatment, 131.--Borough asylums,
131.--Many chronic cases removable from asylums, 132.--Less expensive
buildings needed for chronic cases, 132.--Views of the Lunacy
Commissioners on these points, 132.--Evidence of Lord Shaftesbury,
134.--French system of dividing asylums into 'quarters,'
135.--Permissive power of Lunacy Act to build distinct asylums for
chronic cases, 135.--On the powers of the Home Secretary to control
asylum construction, 136.--Amendment of present Act proposed, 136.--On
mixed asylums, for recent and chronic cases together,
137.--Conditions under which distinct institutions are desirable,
138.--Advantages of an hospital for recent cases, 138.--Number of
inmates proper in such an hospital, 139.--Regulations required in it,
139.--Organization of asylums for chronic cases, 140.--Union of
counties for the purpose of constructing joint asylums, 140.
§ _Construction of distinct sections to asylums._
German system of 'relative connexion' of asylums for recent and
chronic cases, 141.--Proposition of Lunacy Commissioners to place
industrial classes of patients in distinct wards, 142.--Advantages of
separate sections, 143.--Objections to a purely 'industrial
classification' of patients, 144.
§ _Distribution of the chronic insane in cottage homes._
Subdivision of asylums for chronic cases, 145.--Illustration of
cottage provision for the insane at Gheel, 145.--The system at Gheel
impracticable as a whole, 146.--The 'cottage system' deserving of
trial under proper restrictions, 146.--Suggestions as to the
arrangements required, 146.--'Cottage system' supplementary to
asylums, 147.--Economy of 'cottage system,' 147.
§ _Separate provision for epileptics and idiots._
Epileptics need separate provision, 148.--Idiots not fit inmates of
lunatic asylums, 148.--Idiots require special asylum provision,
149.--Removal of idiots from workhouses, 150.
CHAP. VIII.--REGISTRATION OF LUNATICS.
Necessity of registering the insane, 150.--Large number of insane at
present unprotected, 151.--Legal advantages of registration,
151.--Desirability of correct statistics of insanity, 152.--Lord
Shaftesbury's evidence on this point, 152.--Registration as a means of
discovering the existence and condition of lunatics,
152.--Registration would promote early treatment, 153.--Should be
accompanied by visitation, 153.--Enactment necessary to regulate the
sending of lunatics abroad, 153.--Practice pursued in Sardinia,
154.--Suggestions offered, 155.--All patients removed uncured from
asylums ought to have the place of their removal reported,
155.--Objections raised to registration, 156.--Their validity
examined, 156.--Principle of a compulsory registration and visitation
of all lunatics recognized in Belgium, 158.--English enactments
respecting 'single' patients, 159.--Their failure, 159.--Lunatics
secluded under the name of 'nervous' patients, 160.--Lord
Shaftesbury's observations on defects in the Lunacy Laws respecting
'single' cases, 161.--Clauses to Act, proposed by his Lordship, to
deal with 'nervous' patients, 161.--Clauses open to some objections,
162.--Lord Shaftesbury's proposal to report every 'nervous' patient,
163.--Compulsory powers of Lunacy Act defective, 164.--Suggestions
made, 164.--Proposition to report all lunatics to a district medical
officer, who should visit, 165.--Additional certificate granted by
this officer, 165.--Lunatics well protected, 165.--Modification of
present form of certificates of insanity, 166.--Objections to two
forms of certificates, 166.--Determination of the nature of
certificate to be given, 167.--Clause in Scotch Asylums Act respecting
'single' cases, 167.--Need of mitigated certificates and of
intermediate asylums for certain cases of mental disturbance, 168.
CHAP. IX.--APPOINTMENT OF DISTRICT MEDICAL OFFICERS.
District physicians appointed in Italy and Germany, 169.--Recognition
of principle of appointing district officers in England, in the
instance of sanitary medical officers, 169.--District medical officers
need to be independent, 170.--Extent of districts, 170.--Such officers
to register and visit reported cases of lunacy, 170.--Their reports of
cases valuable, 171.--Idiots also should be registered, 171.--District
officer might sign order for admission to an asylum, 171.--Better
qualified for the duty than magistrates, 171, 175.--Illustrations from
evidence of Lord Shaftesbury and Mr. Gaskell, 172.--Suggestions
respecting signature of orders, 172.--Objections to clergymen signing
orders, 173.--Magistrate's order not required for private patients,
174.--Remarks on proposition of Commissioners to leave selection of
cases in workhouses for asylum treatment to the Union medical officer,
175.--District officer best qualified for this duty, 175.--Additional
protection afforded to lunatics by the appointment of district medical
officers, 175.--District officer to inspect lunatics in workhouses,
176.--Regulations for his guidance, 176.--Lunatics in workhouses
should be under certificate, 176.--Medical officer best judge of the
wants of cases, 177.--No removal of lunatics from workhouses without
supervision, 177.--Committee of visiting magistrates for workhouses,
178.--Principles of action of the Lunacy Commission,
178.--Commissioners' recommendation of visiting committees,
179.--Workhouses licensed to receive lunatics, 179.--Lunatics in
workhouses reported by district officer, 180.--Visitation of pauper
lunatics by parish authorities, 180.--No such visitation of county
lunatics, 180.--Desirability that county lunatics should have a
visitor, 181.--Determination of question of lunatics chargeable best
left to district officer, 181.--Duties of district officer with
outdoor pauper lunatics, 182.--Need of inspection of singly-placed
lunatics, 182.--Cost of such inspection, 183.--District officer to
visit single cases in lodgings, &c., 183.--To visit private asylums as
the physician, joined in inspection with the magistrates,
183.--Position and remuneration of district officers, 184.--Such
officers to be met with, 184.--District officers engaged in
medico-legal inquiries, 185.--Such a class of officers much needed,
185.--Neglect of organization in State medical matters, 186.--A proper
organization not necessarily costly, 186.
CHAP. X.--ON THE LUNACY COMMISSION.
Centralization dreaded as an evil, 187.--Importance of a central and
independent body to the interests of the insane, 188, 192.--Want of
power in the hands of Commissioners, 188.--Reasons for a central
Board, 189.--More frequent visitation of asylums desired, 190.--Value
of Commissioners' opinion on lunatic cases, 190.--Inquiries of
Commissioners respecting the payment for patients, 190.--Divided
authority of Commissioners and Magistrates in the case of private
asylums, 191.--Anomaly of this state of things, 191.--Lunacy
Commissioners too few, 192.--Magistrates not effectual as asylum
visitors, 193.--Jurisdiction of the Commission should be the same
throughout the country, 193.--Licensing powers of magistrates,
194.--Duties of office of Masters in Lunacy, 194.--Commissioners
should visit all lunatics, whether Chancery or not, 195.--Proposed
division of Lunacy Commission, 195, 198.--Advantages of the division
proposed, 196.--Reasons for increasing Commission, 196.--Want of
Commissioners' supervision of lunatics in gaols, 197.--Inadequacy of
the present number of Commissioners, 197.--Appointment of Assistant
Commissioners, 198.
CHAP. XI.--OF SOME PRINCIPLES IN THE CONSTRUCTION OF PUBLIC LUNATIC
ASYLUMS.
Principles of construction in general use, 199.--Authorities on asylum
construction, 200.--Examination of the 'ward system,' 200.--Sketch of
the conditions of life in a 'ward,' 201.--Disadvantages of the
arrangements, 201.--The arrangements of a ward vary widely from those
of ordinary life, 202.--Day and night accommodation should be quite
separate, 203.--Advantages of this plan, 204.--Salubrity, warming, and
ventilation promoted, 205.--Economy resulting therefrom, 205.--Means
of communication facilitated, 206.--Supervision facilitated,
207.--Classification improved, 207.--Domestic arrangements
facilitated, 208.--Management facilitated, 209.--A smaller staff of
attendants required, 210.--The cost of construction diminished,
210.--Objections to a third story removed, 211.
THE STATE OE LUNACY, AND THE LEGAL PROVISION FOR THE INSANE.
PRELIMINARY OBSERVATIONS.
The number of the Insane, and the legal provision requisite for their
protection, care, and treatment, are subjects which will always recommend
themselves to public attention and demand the interest alike of the
political economist, the legislator, and the physician. To the first, the
great questions of the prevalence of Insanity in the community, its
increase or decrease, its hereditary character, and others of the same
kind, possess importance in relation to the general prosperity and advance
of the nation; to the second devolves the duty of devising measures to
secure the protection both of the public and the lunatic, with due regard
to the personal liberty, and the proper care and treatment, of the latter;
to the last belongs the practical application of many of the provisions of
the law, besides the exercise of professional skill in the management and
treatment of the insane.
Moreover it will not be denied that, owing to the intimate manner in which
he is concerned with all that relates to the lunatic, with all the details
of the laws regulating his custody and general treatment, as well as with
the institutions in which he is detained, with the features of his malady,
and with all his wants, the physician devoted to the care of the Insane is
well qualified to offer suggestions and recommendations to the legislator.
Hence the present pages, in which the aim is to examine the present state
of lunacy; the advantages to be gained by early treatment; and the
adequacy of the existing legal provision for the Insane; and to offer some
suggestions for improving the condition, and for amending the laws
relating to the care and treatment, of this afflicted class of our
fellow-creatures.
The whole subject of the efficiency of the Lunacy Laws and of their
administration, occupies just now a prominent place in public attention,
owing to the rapid multiplication of County Asylums and the constantly
augmenting charges entailed by them; to the prevalent impression that
Insanity is rapidly increasing; to recent agitation in our Law Courts
respecting the legal responsibility of the Insane and the conditions under
which they should be subjected to confinement, and still more to the
proposed legislation on the matter during the present Session of
Parliament. It would be a great desideratum could the Lunacy Laws be
consolidated, and an arrest take place in the almost annual additions and
amendments made to them by Parliament; but, perhaps, this is next to
impracticable, owing to the attempts at any systematic, effectual, and
satisfactory legislation for the Insane, being really of very recent date,
and on that account subject to revisions enforced by experience of its
defects and errors. However, the present time appears singularly suited to
make the attempt at consolidation, so far as practicable, inasmuch as the
appointment of a special committee of the House of Commons on the Lunacy
Laws, furnishes the means for a complete investigation into existing
defects, and for receiving information and suggestions from those
practically acquainted with the requirements of the Insane, and with the
operations of existing enactments.
To fulfil the objects taken in hand, and, in the first place, to sketch
the present state of Lunacy in this country, it will be necessary to
investigate the number of the Insane, and the annual rate of their
increase; then to examine the extent of the present provision for them in
asylums and of probable future wants. This done, after a brief essay on
the curability of insanity, as a means of judging what may be done to
mitigate the evil, we shall review the present provision for lunatics,
point out its defects, and suggest various remedial measures, calculated
in our opinion to improve the condition of the Insane, diminish the evil
of the accumulation of chronic cases, and render asylums more serviceable
and efficient.
In carrying out our design, we shall be found in some measure occupying
ground already taken up by the Commissioners in Lunacy, and by some able
essayists in the Medical Journals. We do not regret this, although it may
deprive us somewhat of the merit of originality of conception and
elucidation, as it will strengthen our positions and enhance the value of
our remarks. Fortunately, too, we coincide generally with the opinions
from time to time put forth by the Lunacy Commissioners, to whom so great
merit is due for their labours in the interests of the insane, and for the
character and position our County Asylums enjoy in the estimation of our
own people and of foreign nations.
To attempt the character of a reformer when the affairs of Lunacy and
Lunatic Asylums are in such good hands may be deemed somewhat ambitious;
yet as sometimes an ordinary looker-on may catch sight of a matter which
has eluded the diligent observer, and, as the views and suggestions
advanced are the result of mature and independent thought, aided by
experience of considerable length, and very varied, the undertaking may,
we trust, be received with favour.
At all events, we flatter ourselves that the representation of the state
of Lunacy in England and Wales; the estimate of its increase and of the
provision made for it; the evils of workhouses as primary or permanent
receptacles for the Insane; the ill consequences of large asylums, and
some of the legal amendments proposed, are in themselves subjects
calculated to enlist the attention of all interested in the general
welfare of our lunatic population, and in the administration of the laws
and institutions designed whether for its protection or for its care and
treatment.
CHAP. I.--OF THE NUMBER OF THE INSANE.
This inquiry must be preliminary to any consideration of the provision
made or to be made for the Insane. In carrying it out, we have chiefly to
rely upon the annual Reports of the Commissioners in Lunacy along with, so
far as pauper lunatics are concerned, those of the Poor-Law Board.
However, these reports do not furnish us with complete statistics, and the
total number of our insane population can be only approximately
ascertained. The Lunacy Commission is principally occupied with those
confined in public asylums and hospitals, and in Licensed Houses, and
publishes only occasional imperfect returns of patients detained in
workhouses or singly in private dwellings. On the other hand, the Poor-Law
Board charges itself simply with the enumeration of pauper lunatics
supported out of poor-rates, whether in asylums or workhouses, or living
with friends or elsewhere. Hence the returns of neither of these public
Boards represent the whole case; and hence, too, the chief apparent
discrepancies which occur when those returns are compared.
To show this, we may copy the tables presented in Appendix H of the Report
of the Commissioners in Lunacy for 1857, p. 81.
"Increase of Lunatics of all classes during the last
five years, according to Commissioners' Reports 3932
1852 1857
Paupers 12,982 16,657
Private Patients 4,430 4,687
------ ------
17,412 21,344
"According to returns published by Poor Law Board
during same period 6535
1852 1857
County and Borough Asylums 9,412 13,488
Licensed Houses 2,584 1,908
Workhouses 5,055 6,800
With friends or elsewhere 4,107 5,497
------ ------
21,158 27,693."
This very considerable difference of 2603 patients between the two
estimates is mainly due--as reference to the summary (at p. 53) proves--to
the omission, on the part of the Lunacy Commissioners, of those resident
in workhouses and "with friends, or elsewhere," reckoned in the Table of
the Poor-Law Board. This explanation, however, is only partial, for, after
allowing for it, the two estimates are found to diverge very considerably.
Thus, on adding the numbers in the categories last named, viz. 5055 + 4107
= 9162, in 1852,--and 6800 + 5497 = 12,297, in 1857 to the total given by
the Commissioners in each of those years, viz. to 17,412 and 21,344,
respectively, we obtain a total of 26,574 in 1852, and one of 33,641 in
1857; a variation of 5416 in the former, and of 5948 in the latter year,
from the results given in the Table presented by the Poor-Law Board. Much
of this wide difference is explicable by the Board last mentioned not
having reckoned the private patients, who amounted in 1852 to 4430, and in
1857 to 4687. Still, after all attempts to balance the two accounts, there
is a difference unaccounted for, of 986 in 1852, and of 1261 in 1857.
No clue is given in the official documents to the cause of this
discrepancy, and we are left in doubt which estimate of our lunatic
population is the more correct. The excess occurs in the Commissioners'
Returns; for on adding together, in each year in question, the numbers
reported by the Poor-Law Board, as detained in County and Borough Asylums
and in Licensed Houses, we find that the totals respectively are less
than the whole number of paupers as calculated by the Lunacy
Commissioners, by the precise difference we have made out, viz. 986 in
1852 and 1261 in 1857. Of the two returns before us, we accept that of the
Lunacy Commission, viz. that there were, including those in workhouses,
and with friends or elsewhere, 26,574 reported Lunatics in 1852, and
33,641 in 1857; and account for this larger total by the fact that the
Poor-Law Board Returns apply only to Unions and omit the lunacy statistics
of many single parishes, under local acts, and some rural parishes under
'Gilbert's Act,'--containing in them together above a million and a half
people more than are found in unions. Moreover, the Poor-Law Board returns
do not include County and Borough Patients. Looking to these facts, the
excess of 986 in 1852, and of 1261 in 1857, over and above the totals
quoted from the Summary of the Poor-Law Board, is not surprising; indeed,
taking the average usually allowed of one lunatic in every 700, the number
in one million and a half would be above 2000; that is, more than half as
many again as 1261; a result, which would indicate the Commissioners'
total to be within the truth.
We have just used the term 'reported lunatics,' for, besides those under
certificates and those returned as chargeable to parishes, comprised in
the foregoing numbers, there are very many of whom no public board has
cognizance. Most such are private patients supported by their own means,
disposed singly in the residences of private persons, throughout the
length and breadth of the country, and, with few exceptions, without the
supervision, in reference to their accommodation and treatment, of any
public officer. The Lunacy Commissioners justly deplore this state of
things; lament their inability, under existing Acts, to remedy it, and
confess that not a tithe of such patients is reported to them, according
to the intention of the law (16 & 17 Vict. cap. 96. sect. xvi.). It would
appear that less than 200 such cases are known to them; and it would not
be an extravagant or unwarrantable estimate to calculate their whole
number at about half that of the inmates of Licensed Houses, viz. at 2000.
This number would comprise those found lunatic by Inquisition, not
enumerated in the Commissioners' summary, although under the inspection of
the "Medical Visitors of Lunatics." According to the returns moved for by
Mr. Tite "of the total number of Lunatics in respect of whom Commissions
in Lunacy are now in force," there were, on the 27th July, 1858, 602 such
lunatics, and 295 of them were, according to the Commissioners' tables,
detained in asylums or Licensed Houses, leaving 347 not reckoned upon. In
addition to this class of the insane there is an unascertained small
number of persons of unsound mind in the horde of vagrant paupers, alluded
to occasionally in the Lunacy Commissioners' Reports.
The number of Criminal Lunatics in asylums is noted in the returns, but
that of those in jails is not reckoned. Although this is comparatively
small, owing to the usual custom of transferring prisoners, when insane,
to asylums, yet, at any one period, a proportion sufficient to figure in a
calculation of the whole insane population of the country will always be
found. Nay more, besides such scattered instances in County Prisons, there
is a very appreciable number in the Government Jails and Reformatories, as
appears from the returns presented to Parliament (Reports of the Directors
of Convict Prisons, 1858.)
The prisons included in these reports are:--Pentonville, Millbank,
Portland, Portsmouth, Dartmoor, Parkhurst, Chatham, Brixton, Fulham
Refuge, and Lewes. In the course of 1857, 216 persons of unsound mind were
confined, some for a longer or shorter period, others for the whole of the
year, in one or other of those prisons. Making allowance for those of the
216 who by removal from one prison to another (a transfer apparently of
common occurrence, the rationale of which we should find it difficult to
explain), might be reckoned twice, it may be safely stated that at least
150 were in the prison-infirmaries in question the whole year. In fact,
the Infirmary of Dartmoor Prison has wards specially appropriated to
insane patients, and actually constitutes a criminal asylum of no
insignificant magnitude. For instance, the report tells us that on the 1st
of January, 1857, there remained in that prison 102 cases; that 41 were
received during the year; 37 discharged (where, or how, we are not told,
except of 3, who were sent to Bethlem Hospital); and 106 remained on the
1st of January 1858.
It is also worth noting that in this Dartmoor Prison Infirmary, 38
epileptics remained on January 1st, 1857; 22 were admitted, 13 discharged,
and 47 remained on January 1st, 1858. The total of epileptics coming under
notice in the infirmaries of the several prisons in question, in the
course of 1857, amounted to 135. The remarks on some of these cases of
epilepsy by the medical officers, are sufficient to show that the
convulsive malady has seriously affected the mental health, and that they
might rightly be placed in the category of the insane.
However, having no wish to enhance the proportion of the subjects for
Lunatic Asylums, we will deal only with those enumerated as mentally
disordered. These amounted, according to the preceding calculations, in
the Government Prisons, to 150, and it would seem no exaggerated estimate
to assert that an equal number may be found in the various other prisons
and reformatories throughout the country. To put the matter in another
form, 300 lunatics are to be found in English prisons at any date that a
census may be taken. Consequently this sum of 300 must be added in
calculating the total of insane persons in this kingdom.
To establish still further the proposition with which we set out, that our
public statistics of Insanity are incomplete, the history of every County
Asylum might be adduced: for, notwithstanding very considerable pains have
been taken, on the proposition to build a new asylum, to ascertain the
probable number of claimants, and a wide margin over and above that
estimate has been allowed in fixing on the extent of accommodation
provided, yet no sooner has the institution got into operation, than its
doors have been besieged by unheard-of applicants for admission, and
within one-half or one-third of the estimated time, its wards have been
filled and an extension rendered imperative. Such is a _résumé_ of the
general history of English County Asylums, attested in the strongest
manner by that of the Middlesex, the Lancashire, and the Montgomery
Asylums; and confirmatory of the fact of the augmentation of insanity in
the country at a rate exceeding, more or less, that collected from county
returns and public statistics. It is, moreover, to be observed, that the
official statistics represent the total of lunatics existing on one
particular day, usually the first of January, in each year, and take no
account of those many who are admitted and discharged within the year, and
who rightly should be reckoned in an estimate of the total number of the
insane belonging to that period.
The average daily number resident in asylums would be a more correct
representation of their insane population than the total taken on any one
day, although it would fail to show the lunacy of the year.
Lastly, to illustrate the point discussed, to indicate how imperfect our
present estimate of the prevalence of insanity most probably is, and to
show the difficulties and defects of any ordinary census, we may appeal to
the experience of the special commission charged by the legislature of
Massachusetts to examine the statistics of Lunacy and the condition of
Asylums in that State, as recorded in their report, published in 1855.
"In 1848" (they write, p. 18), "a committee of the Legislature, appointed
to 'consider the whole subject connected with insanity within the
commonwealth,' ascertained and reported the number of insane in this State
to be 1512, of whom 291 were able to furnish the means of their own
support, and 1156 were unable to do so, and the pecuniary condition of 65
was not ascertained.
"In making that survey in 1848, the Commissioners addressed their letters
of inquiry 'to the municipal authorities of every city and town in the
commonwealth.'
"These public officers had direct means of knowing the number and
condition of the pauper insane, and probably this part of the report was
complete; but they had no other facilities of knowing the condition of
those lunatics who were in private families, and supported by their own
property or by their friends, than other men not in office, and could only
speak of those who were within their circle of personal acquaintance.
Consequently the report included only a part of the independent insane who
were then actually in, or belonged to, the State."
"In 1850 (p. 11), the marshals, the agents of the national government who
were appointed to take the census, visited every family; and, among other
items of information, they asked for the insane and idiots in the
household.
"By this personal and official inquiry, made of some responsible member of
every family, the marshals obtained the account of only 1680 insane
persons and 791 idiots, which is but little more than two-thirds of the
number ascertained by this Commission.
"Making all due allowance for the increase of population, and consequently
of the insane and idiots, these figures undoubtedly show far less than the
real amount of lunacy and idiotcy at that time, and render it extremely
probable that many concealed the facts that the law required them to state
to the marshals."
Thus the marshals discovered the number of insane to be in 1850 nearly
double that returned in 1848, and from their apparently searching inquiry,
it might have been presumed that they had made a near approximation to the
truth in the figures they published. However, the most pains-taking and
varied investigations of the Special Commissioners in 1854, prove the
marshals to have much underrated the number, for the result arrived at
was, that in the autumn of the year just named, there were 3719 lunatics,
of whom 1087 were idiots, in the State of Massachusetts.
The partial explanation of the divergence in numbers, viz.:--"that it is
probable that many of the families refused or neglected to report to the
marshals the insane and idiots who were in their households,"--is of
itself an indication of one of the impediments to a correct enumeration of
the insane members of a community, even when such is attempted under
favourable circumstances. It is one likewise which, however operative in
the United States, where the public asylums are open to, and resorted to
by, all classes of the community, must be still more so in this country,
where family pride endeavours in every way to ignore and keep secret the
mental affliction of a member, as though it were a plague spot. Besides
this, in no English census yet taken, has the enumeration of the insane
constituted a special subject of inquiry.
This illustration from American experience, coupled with the
considerations previously advanced, suffice to demonstrate that the
published statistics of insanity in England and Wales are incomplete and
erroneous, and that the machinery hitherto employed for collecting them
has been imperfect. The corollary to this conclusion is, that the number
of lunatics mentioned in the public official papers is much below the real
one. However, the facts and figures in hand justify the attempt to fix a
number which may be taken to represent _approximatively_ the total insane
population of this kingdom.
In their last Report (1858), the English Commissioners in Lunacy state
that, on January 1st, 1858, there were confined in asylums, hospitals, and
Licensed Houses, 17,572 pauper, and 4738 private patients, exhibiting an
increase of 915 pauper and of 51 private cases upon the returns of the
year preceding.
Pauper lunatics in workhouses are stated (10th Annual Report of the Poor
Law Board, 1858) to have numbered 6947, and those receiving out-door
relief 12,756; making a total of 20,703. By the kindness of Mr. Purdy, the
head of the Statistical Department of the Poor-Law Office, we are enabled
to explain that it is the custom of the office to reckon pauper lunatics
in Asylums and Licensed Houses among those receiving out-door relief;
consequently the sum of 12,756 comprises both those patients provided for
as just specified, and others boarded with their friends or elsewhere. We,
however, learn further, from the same excellent authority, that, owing to
the imperfection of the periodical returns, only a comparatively small
portion of the pauper insane confined in Asylums and Licensed Houses is
included in that total. Indeed, the fact of its being very much smaller
than that of the lunatics in Asylums and Licensed Houses, clearly enough
shows that the latter are not reckoned in it except partially.
Considering that the Poor Law Board obtain no record of the pauper
insanity in one million and a half of the population of England and Wales,
nor of the number of insane belonging to counties and boroughs,--for this
reason, that their cost of maintenance is not directly defrayed out of the
poor-rates, there must necessarily be a much greater number in workhouses
at large than the 6947 mentioned, and no inconsiderable proportion of poor
lunatics dispersed abroad in the country not enumerated in the 5500
counted as existing in January 1st, 1857. On these grounds, we assume 8000
as an approximative figure to represent the total of insane poor not under
confinement in Asylums and Workhouses, believing fully that it will be
found, on the publication of the returns for this year (1859), within the
mark.
Private patients not in Asylums, or Licensed Houses, often confined
without certificates, and the majority unknown to the Lunacy
Commissioners, we have put down, at a moderate estimate, at 2000. The
present state of the law does not enable the Commissioners or others to
discover these, often, we fear, neglected patients: and, on the other
hand, the operation of the laws regulating asylums, and the feeling evoked
by certain public trials of individuals confined in Licensed Houses, have,
together, combined to render them more numerous, by inducing friends to
keep them at home, to send them abroad to Continental institutions, or to
place them under the care of private persons or attendants in lodgings.
This completes our enumeration; and the figures stand thus, on the 1st of
January, 1858:--
_Pauper._ _Private._ _Total._
In Asylums and Licensed Houses 17,572 4,738 22,310
In Workhouses 6,947 ... 6,947
With Friends, or elsewhere 8,000 2,000 10,000
In Prisons, Vagrants, &c. 300 ... 300
------- ------- -------
32,819 6,738 39,557
To extend the estimate to the commencement of the present year (1859), we
require to add the gross increase of lunatics during 1858 to the total
just arrived at: 39,557. What this increase may be cannot be decisively
stated; but to anticipate the estimate of it, which we shall presently
arrive at, viz. 1600 per annum, the result is, that _on the 1st of
January_ 1859 there were in England and Wales, in round numbers, 41,000
persons of unsound mind, or, to employ the legal phraseology, lunatics and
idiots.
It perhaps should be explained, and more particularly with reference to
those detained in workhouses or supported by their parishes at their own
houses, that besides idiots, or those congenitally deficient, a very large
proportion of them is composed of weak and imbecile folk, who would, in
olden times, have been considered and called "fools," and not lunatics,
and been let mix with their fellow-men, serve as their sport or their
dupes, and exhibit their hatred and revenge by malicious mischief and
fiendish cruelty. But, thanks to modern civilization and benevolence,
these poor creatures are rightly looked upon as proper objects for the
supervision, tending and kindness of those whom Providence has favoured
with a higher degree of intelligence. This act of philanthropy, effected
at a great cost, elevates at the same time, very materially, the ratio of
insane persons to the population, and thereby gives cause of alarm at the
prevalence of mental disorder, and makes our sanitary statistics contrast
unfavourably with those of foreign lands, where the same class of the sick
poor has not been so diligently sought out and brought together with a
view to their moral and material well-being.
CHAP. II.--ON THE INCREASE OF INSANITY.
The only data at hand to calculate the gross increase of the insane in
this country, year by year, or over a series of years, are those contained
in the Official Reports of the Commissioners in Lunacy and of the Poor-Law
Board. These, as we have just shown in the preceding chapter, are
incomplete as records of the state of lunacy, since they take no notice of
numerous patients not in recognized asylums. Moreover, the annual summary
of the returns made by the Commissioners of insane patients confined in
Asylums and Licensed Houses, represents a compound quantity, made up of
the increment by accumulation in past years, and of the fresh cases
admitted in any particular year, and remaining at its close. The same is
true of the figures supplied by the Poor-Law Board. Now, though these
summaries are useful to show the rate of accumulation of the insane in the
various receptacles for them, annually or over any fixed period, they do
not tell us how many persons are attacked by madness in any year, or other
space of time; or, in other words, they do not inform us whether there is
an actual increase, or a decrease in the annual number of persons becoming
insane.
This question of the simple increase or decrease of insanity cannot be
correctly answered. It is elucidated in some measure, so far as licensed
institutions for the insane are concerned, by the tables of admission for
different years furnished by the Reports of the Lunacy Commissioners; and
it may be assumed to be partially answered by the returns of the number of
lunatics in workhouses published by the Poor-Law Board, after an allowance
made for the diminution caused by deaths which have taken place in the
twelvemonth; but no means whatever exist of discovering the number of
persons annually attacked with mental disorder, who do not fall under the
cognizance of the public boards.
With the materials in hand, let us in the first place examine the results
which follow from a comparison of the Lunacy statistics of the
Commissioners, instituted at intervals of more or fewer years. By this
course we shall attain, not indeed an estimate of the progressive increase
of our insane population, but a valuable comparative return of the number
of those enjoying the advantages of asylum care and management in
different years. The summary presented in each annual report shows that
there were in
_Males._ _Females._ _Total._
1843--Private patients 1,989 1,801 = 3,790 }
Pauper patients 3,532 3,950 = 7,482 } = 11,272
1853--Private patients 2,331 2,099 = 4,430 }
Pauper patients 5,916 7,066 = 12,982 } = 17,412
1858--Private patients 2,508 2,230 = 4,738 }
Pauper patients 7,985 9,587 = 17,572 } = 22,310
From these tables it therefore appears that the accumulation of insane
persons in Asylums in the ten years between 1843 and 1853, equalled 6140;
and in the five years between 1853 and 1858, 4898; or progressed at the
rate of 614 per annum in the ten years, and of 979·6 (or in round numbers
980) per annum in the five years under review, or upwards of 50 per cent.
faster in the latter space of time.
In their Twelfth Report (1858) the Commissioners in Lunacy attempt to
calculate the probable demands for asylum accommodation on the 1st of
January 1860, from the increased number of lunatics in the space of one
year, from January 1st, 1857, to January 1st, 1858, amounting to 915. But
as we have pointed out in a paper in the "Journal of Mental Science" (vol.
v. 1859, p. 249), the conclusion drawn from such data must be fallacious.
For instance, a calculation on the result of one year's statistics is
evidently worth little. There are many causes at work in asylums which
materially affect the relative number of admissions and discharges, and
consequently produce an inequality in the rate of increase viewed year by
year. Moreover, where the same plan of calculation has been adopted in
determining what asylum accommodation was necessary, experience has soon
exhibited the fallacy, and both the admissions and the demands for
admission have far exceeded the total reckoned upon. To arrive at a nearer
approximation to the truth, the augmentation in the number of lunatics
ought to be noted for a space of several years; and to make the deduction
more satisfactory, the increase of the general population, the conditions
of the period affecting the material prosperity of the people, and its
political aspects; and, lastly, the mere circumstance of the opening of
new asylums,--a circumstance always followed by an unexpected influx of
patients, need be taken into account.
In the preceding considerations only the returns of lunatics in Asylums,
Hospitals, and Licensed Houses are discussed; but, as we have seen, there
is an almost equally large number detained in workhouses, or boarded with
their relatives, or other persons, at the expense of their parishes, whose
increase or decrease is a matter of kindred importance. On reviewing the
returns of their numbers at periods when they have been taken cognizance
of by the Lunacy Commission, we find that there were in workhouses and
elsewhere, together, in
1843 9,339
_In Workhouses._ _With Friends
and elsewhere._
1847 4,490 3,465 = 7,955
1857 6,800 5,497 = 12,297
exhibiting an increase of 4342 in the ten years between 1847 and 1857, and
a decrease in the four between 1843 and 1847 of 1384, owing, doubtless, to
the opening of new asylums during that space of time. The returns of the
two classes of Pauper Lunatics together being both so infrequently made,
and, as before shown (p. 8), open to criticism on account of their
incompleteness, we shall attempt to arrive at a more correct estimate of
increase than that just made. In the first place, with respect to Union
Workhouses, the Summary of Indoor Paupers, published by the Poor Law
Commission (10th Report, p. 196), affords the necessary data. According to
this tabular statement, we find, that, there were on the 1st of January in
each of the ensuing years the following numbers of pauper lunatics:--
1847 4,490
1849 4,842
1850 4,659
1851 5,029
1852 4,744
1853 4,954
1854 5,459
1855 5,960
1856 6,480
1857 6,488
1858 6,947
These columns show, that since 1847 the minimum number of insane, at a
corresponding date in each year, occurred in 1850. Once indeed since, but
at a different period of the year, viz. on July 1st, 1851, the number fell
to 4574, or 75 less than at the date before named. Two or three years
excepted, the increment has been progressive; at one time, indeed, much
more rapidly so than at another. The fluctuations observable are, in the
first place, due to the opening of new, or the repletion of existing,
asylum accommodation; and in a lesser degree, to the rise or fall of
pauperism in the community at large, or to an increased mortality at
times, as, for example, in 1849, when cholera prevailed--an event which in
part, at least, explains the smaller figure of insane inmates in 1850.
But whatever the fluctuations observable year by year may be, there is a
most distinct increase in the space of any five or ten years selected
from the list, suggestive of the unwelcome fact that, notwithstanding the
very large augmentation of asylum accommodation and the reduction of
numbers by death, the rate of accumulation has proceeded in a ratio
exceeding both those causes of decrease of workhouse inmates combined.
Thus, to take the decennial period between 1847 and 1857, we discover an
increase of just 2000, or an average annual one of 200; and, what is
remarkable, as large a total increase, within a few units, is met with in
the quinquennial period between 1853 and 1858, and consequently the yearly
average on the decennial period is doubled; viz. 400 instead of 200. This
doubling of the average in the last five years would be a more serious
fact, were it not that in 1853 the number of workhouse inmates had been
reduced upon 1851, and had only slightly advanced above that of 1849.
Rejecting the maximum rate of accumulation, we will calculate the average
of the last three years cited, from 1855 to 1858, a period during which
there has been no notable cause of fluctuation, and no such increase of
population as materially to affect the result, and for these reasons
better suited to the purpose. In this space of time the increment equalled
987, or an average of 329 per annum; which may fairly be considered to
represent the rate of accumulation of lunatics in Union Workhouses at the
present time.
The absence of returns of lunatics in the workhouses of parishes under
local Acts, is an obstacle to a precise computation of them; however, on
the assumption that the proportion of lunatics in those workhouses to the
population (1,500,000) of the parishes they belong to, is equal to that of
those in Union Workhouses to the estimated population (18,075,000) of the
Unions, and that the average increase is proportionate in the two cases,
this increase should equal 1/12th of 329, or somewhat more than 27, per
annum; making the total average rate of accumulation in workhouses at
large 356 annually.
Unfortunately, no separate record is regularly kept of those poor insane
persons who are boarded with friends or others, and their number has been
only twice published, viz. in 1847 and 1857, when, as seen in a preceding
page, it was, respectively, 3465 and 5497. These two sums exhibit an
increase of 2032 to have accrued in the ten years included between those
dates, or an average one of 203 per annum.
We have, above, calculated the average annual increase on those in Union
Workhouses and those with friends, at 434 annually; and consequently that
of the latter being 203, the yearly increase of the former stands,
according to the returns employed, at 231. However, we have proved that
the average increase, in Union Workhouses, has reached in the last three
years the amount of 329, and in workhouses at large 356, which, added to
203, produces 559, or in round numbers, 560, as the sum-total of
accumulation of pauper lunatics not in Asylums, Hospitals, or Licensed
Houses. Adding the annual rate of increase of the insane in Asylums, viz.
980, to that among paupers, unprovided with asylum accommodation, 560, we
obtain the total accumulation per annum of 1540 lunatics reported to the
public boards. To this sum there should rightly be added the accumulative
increase among insane persons not known to those boards, and which, in the
absence of any means to ascertain its amount, may be not extravagantly
conceived to raise the total to 1600.
We come now to the second part of our present task, viz. to discover the
comparative number of new cases in several past years, so as to obtain an
answer to the question,--Has there been an increase of the annual number
of persons attacked with lunacy during that period? for previous figures
leave no doubt there is an augmented ratio of insane persons in the
population of the country. At the outset of this inquiry an insuperable
difficulty to a correct registration of the number arises from the
circumstance that, during any term of years we may select, the
accommodation for the insane has never, even for one year, been fixed, but
has been progressively increased by the erection of new, and the
enlargement of old asylums. This occurrence, necessarily, very materially
affects the returns made by the Commissioners of the number of admissions
into asylums and Licensed Houses. Even if the comparison of the annual
admissions into any one County Asylum only, were of value to our purpose,
the same difficulty would ensue by reason of the enlargement of the
institution from time to time, and of the circumstance that, as it
progressively filled with chronic cases, the number of admissions will
have grown smaller. Likewise, the farther that the inquiry is extended
back, the more considerable will this difficulty in the desired
computation be. In short, it may be stated generally, that the proportion
of admissions will vary almost directly according to the accommodation
afforded by asylums, and the inducements offered to obtain it.
On the other hand, the consequences of the variations in asylum
accommodation upon the total of admissions are to a certain extent
compensated for by the fluctuations they produce upon the number of
lunatics not provided for in asylums; for this reason, that where a County
Asylum opens for the reception of patients, the majority of these are
withdrawn from Licensed Houses and workhouses, and thereby a reduction is
effected in the number of inmates of those establishments.
After the above considerations, it is clear that an estimate of the
number of insane persons in any year, as gathered from the statistics of
those brought under treatment in asylums or elsewhere, can be only an
approach to the truth. Still it is worth while to see what results follow
from an examination of the Returns of Admissions, as collected by the
Commissioners in Lunacy. It would be of no service to extend the inquiry
far backward in time, on account of the rapidity with which asylum
accommodation has been enlarged; we will therefore compare the admissions
over the space of four years, viz. 1854, 1855, 1856, and 1857, during
which the changes in asylums have been less considerable.
_Table of Admissions._
1854--County and Borough Asylums 4,620
Hospitals 868
Licensed Houses 2,161
-----
Total 7,649
-----
1855--County and Borough Asylums 4,342
Hospitals 828
Licensed Houses 2,196
-----
Total 7,366
-----
1856--County and Borough Asylums 4,538
Hospitals 777
Licensed Houses 2,091
-----
Total 7,406
-----
1857--County and Borough Asylums 4,781
Hospitals 790
Licensed Houses 2,324
-----
Total 7,895
-----
There is a remarkable degree of uniformity in the sum of admissions in
each of these four years; and if each several sum could be taken to
represent the accession of new cases of insanity in the course of the
year, there would appear no actual progressive increase of the disease in
the community during the four years considered. The average of the
admissions for that period is 7579; those therefore of 1854 and 1857 are
in excess, and those of 1855 and 1856 are within it. The widest
difference is observed in 1857, when a sudden rise takes place, which, by
the way, is not explicable by the greater provision of asylum
accommodation in that year than in the three preceding. Yet this increase
is not so striking when viewed in relation to the totals of other years;
for it exceeds the average only by 316, a sum little greater than that
expressing the decrease of 1855 upon the total of 1854.
It is difficult to decide what value should be assigned to these results,
deducible from a comparison of the yearly admissions, in determining the
question of the increase of insanity, viewed simply as that of the
comparative number attacked year by year,--it would, however, seem a not
unreasonable deduction from them, that the proportion of persons attacked
by mental disorder advances annually at a rate little above what the
progressive increase of population is sufficient to explain. If this be
so, the increase by accumulation of chronic and incurable cases becomes so
much the more remarkable, and an investigation of the circumstances
promoting, and of those tending to lessen, that accumulation, so much the
more important.
There are, as heretofore remarked, very many insane persons who are not
sent to asylums or private houses, at least to those in this country, and
whose relative number yearly it is impossible, in the absence of all
specific information, to compute. Although the agitation of the public
mind respecting private asylums, and the facility and economy of removing
insane persons abroad, may have latterly multiplied the number of such
unregistered patients, yet there is no reason to assume that their yearly
positive increase is other than very small.
The pauper lunatics living in workhouses have as yet been omitted from the
present inquiry. Their yearly number is affected not only by the
introduction of fresh cases, but also by removals to asylums and by
deaths; or, in other words, it is a compound quantity of new inmates
received and of the accumulation of old. However, the returns above quoted
(p. 13) show that between 1855 and 1858 there was an increase of almost
exactly 1000, or, as before calculated, an average of 329 annually. The
Poor Law Board Report unfortunately gives no returns of the annual
admissions; hence we do not possess the means of discovering what
proportion of the growing increase observed is due year by year to the
accession of fresh inmates. The advancing growth in numbers of those
pauper insane receiving out-door relief is not clearly discoverable: from
the few data in possession, as before quoted (p. 14), about 200 are
annually added.
It appears pretty clearly, then, that there are at least 1600 reported
lunatics added to the insane population of the country yearly, and of
this increase only 60, or 1 in 26·66, are supported out of their own
resources in asylums; the remainder, with some few exceptions, falling
upon the rates for their entire maintenance.
It would therefore be difficult to exaggerate the importance of the
question of the provision for the insane poor in this country, both to the
political economist and to the legislator. There are certainly more than
1300 persons yearly so affected in mind as to be unfit or unable to take
care of themselves, and to obtain their own livelihood, and who, under
this distressing infliction of Providence, demand the care and charity of
their neighbours, and the succour of the State, properly to protect and
provide for them. To perform this duty at the least cost, compatible with
justice to these afflicted individuals, involves a tax upon the community
of which few persons have any adequate conception. Supposing, by way of
illustration, that the number mentioned required the accommodation of an
asylum, the cost of providing it, according to the system hitherto in
vogue, would nearly equal that incurred in the establishment and
maintenance of the Middlesex County Asylum at Colney Hatch, or a sum of
£300,000 for land, buildings, and fittings (equal, at 5 per cent. to a
yearly rental of £15,000), and an annual charge of £30,000 for
maintenance. The example of Colney Hatch, chosen for illustration, is a
very fair one, and the figures used in round numbers are actually within
the average expenditure in and for the establishment of County Asylums in
this country, as may be seen on reference to Appendix D. (Commissioners'
Report, 1854), and to the table of asylums in course of erection, printed
at p. 2 of their Twelfth Report (1858).
On applying these results to the total number of pauper lunatics in
Asylums, which, according to the return on the 1st of January 1858,
amounted to 15,000, the sum of £4,500,000 (not including interest) will
have been expended in providing them accommodation, and an annual charge
incurred of £450,000 for their care and maintenance. All this, too, is
independent of the cost on account of those maintained in Licensed Houses,
in workhouses, and in lodgings with friends or others, the amount of which
we do not possess sufficient information to determine.
The Commissioners in Lunacy, in their elaborate Report in 1844, took the
population of England and Wales at 16,480,082, and reckoned on the
existence of 20,893 lunatics on the 1st January of that year, of whom
16,542 were paupers. The latter, they calculated, stood in the proportion
of 1 to 1000 in the population, or, more correctly, 1 in 997; and the
total lunatics as 1 to 790. On the 1st of January 1857, they found the
pauper lunatics to be in the proportion of 1 in 701; whilst pauper and
private together equalled 1 in 600, to the estimated population,
19,408,364. Adopting the figures arrived at in the preceding discussion,
viz. that there are 41,000 insane persons in this country, and assuming
the population on the 1st of January, 1859, to have been 19,800,000, the
proportion of the insane would be as high as 1 in 483 persons.
This much-enlarged ratio of insanity to the population admits of several
explanations, without a resort to the belief that the disease is actually
and fearfully on the increase. As before said, we regard the accumulation
of chronic and incurable lunatics to be the chief element in raising the
total number, and this accumulation is favoured by all causes operating
against the cure of insanity; by the increased attention to the disease,
and by all those conditions improving the value of life of the insane,
supplied, at the present day, in accordance with the improved views
respecting their wants, and the necessity of placing them under conditions
favourable for their health, care and protection. On the operation of
these causes, favouring the multiplication of insane persons in the
community, we shall, however, not at present further enter, but proceed to
inquire how far the existing provision for the insane is adequate to their
requirements.
Before entering on this inquiry, a few words are wanting to convey a
suggestion or two respecting the collection of the statistics of pauper
lunatics. It is most desirable we should be able to discover, from the
official returns of the public boards, with precision, what number of
insane persons is wholly or partially chargeable to the Poor Rates, what
to Borough, and what to County Rates. The returns of the Poor-Law Office
ought not to be marred by the omission of the statistics of parishes,
which by local or special acts escape the direct jurisdiction of the
board. If the central board be denied a direct interference in their
parochial administration, it ought to be informed of the number of their
chargeable poor, including lunatics. It is equally unsatisfactory, that
the pauper registry kept by the Poor-Law Board is not rendered complete by
the record of all those chargeable to counties and boroughs, as this could
be so readily done by the clerks of county and borough magistrates.
An amendment, too, is desirable in the practice of the Poor-Law Office of
reckoning together in their tables pauper lunatics in asylums among the
recipients of out-door relief with those boarded with their friends or
elsewhere, whence it is impossible to gather the proportion of such class.
This technicality of considering workhouse inmates as the only recipients
of _in-door_ relief, to the exclusion of asylum patients who are in
reality receiving it in an equal degree, although in another building than
the workhouse, is an official peculiarity we can neither explain nor
approve; and it appears to us most desirable that lunatic paupers in
asylums should be arranged in a distinct column, and that the same should
be done with those living with their friends or others. By the adoption of
this plan the questions of the number of the pauper insane, of their
increase and decrease, whether in asylums or elsewhere, and of the
adequacy of accommodation for them, could be ascertained by a glance at
the tables. We would likewise desire to see those paupers belonging to
parishes not in union and under Local Acts, and those chargeable to
Counties and Boroughs, tabulated in a similar manner.
A practical suggestion, connected with the statistics of insanity, we owe
to Mr. Purdy, viz. that section 64 of the "Lunatic Asylums' Act, 1853" (16
& 17 Vict. cap. 97) should be amended by the insertion of a few words
requiring the clerks of unions to make the returns of the number of
chargeable lunatics on a specified day, as on the first of January in each
year. This practice was formerly enjoined, and probably its omission from
the Act now in force was accidental. The present enactment requires that
the clerks of unions "shall, on the first day of January in every year, or
as soon after as may be, make out and sign a true and faithful list of all
lunatics chargeable to the union or parish;" and the only alteration
required is the addition of two or three words at the end of this
paragraph, such as:--'on the first day of January of that year.' The want
of a fixed date of this kind, Mr. Purdy says, imposes great trouble in
getting the clerks to make their returns with reference to the same day in
the several unions and parishes.
CHAP. III.--STATE OF THE PRESENT PROVISION FOR THE INSANE IN ASYLUMS.--ITS
INADEQUACY.
In their Report for 1857, the Commissioners in Lunacy have presented us
with a memorandum of the present accommodation afforded in County Asylums,
and of that in course of being supplied, and have attempted further a
calculation of the probable requirements on the 1st of January 1860. The
former may be accepted as nearly correct, but the latter affords, as
before noticed, a rough, and not sufficiently accurate, estimate.
Their statement is, that on the 1st of January, 1858, 16,231 beds were
provided in public asylums; that, by the projected enlargement of existing
institutions, 2481 others would be obtained, and, by the completion of
eight asylums in course of erection, there would be added 2336 more--a
total of 4817, on or before January 1860. Of the increase in additional
buildings, 1000 beds, or thereabouts, would not be ready at so early a
date as that named; and in calculating existing provision, need be
deducted from the total of 2,336; consequently the accommodation in
County Asylums would, according to the Commissioners, in this year, 1859,
reach 20,000, and in 1860, 21,048.
The County Asylum accommodation on January 1st, 1858, expressed by the sum
of 16,231, exceeded the total of pauper lunatics returned as actually
partaking its advantages at that date, viz. 14,931, by the large number of
1300; showing a surplus to that amount, including beds, in infirmary
wards. What may be the precise number of the last, or, in other words, of
those generally inapplicable to ordinary cases, labouring under no
particular bodily infirmity, we cannot tell, but we feel sure that 1000 of
them would be available; in fact, the whole number by classification might
be rendered so. Be this so or not, the Commissioners have omitted any
reference to this present available accommodation, in calculating what may
be necessary in 1860.
On the other hand, they have rather over-estimated the future provision in
asylums, by adding together that in the Beds., Herts., and Hunts. Asylum
now in use, viz. 326, with that to be secured in the new one, viz. 504,
instead of counting on the difference only, 178, as representing the
actual increase obtained,--for the intention is to disuse the old
establishment as a county institution.
To proceed. The Commissioners calculate on an addition of 4817 beds to the
number provided in January 1858 (according to our correction, in round
numbers, 4500), and proceed to say, that "if to this estimate ... we apply
the ratio of increase in the numbers requiring accommodation observable
during the last year, some conclusion may be formed as to the period for
which these additional beds are likely to be found sufficient to meet the
constantly increasing wants of the country, and how far they will tend
towards the object we have sought most anxiously to promote ever since the
establishment of this Commission, namely, the ultimate closing of Licensed
Houses for pauper lunatics. On the 1st of January, 1857, the number of
pauper lunatics in County and Borough Asylums, Hospitals, and Licensed
Houses, amounted to 16,657. On the 1st of January, 1858, this number had
increased to 17,572, showing an increase during the year of 915 patients;
and of the total number 2467 were confined in the various metropolitan and
provincial Licensed Houses.
"Assuming, then, that during the next two years the progressive increase
in the number of pauper lunatics will be at least equal to that of the
year 1857, it follows, that on the 1st of January, 1860, accommodation for
1830 additional patients will be required; and if to this number be added
the 2467 patients who are now confined in Licensed Houses, there will
remain, to meet the wants of the ensuing year, only 520 vacant beds. It is
obvious, therefore, that if Licensed Houses are to be closed for the
reception of pauper lunatics, some scheme of a far more comprehensive
nature must be adopted in order to provide public accommodation for the
pauper lunatics of this country."
This conclusion must indeed be most unwelcome and discouraging to the
rate-payers, and to the magistracy, in whose hands the Government reposes
the duty of providing for the due care of pauper lunatics in County
Asylums. To the latter it must be most dispiriting, when we reflect on the
zeal and liberality which have generally marked their attempts to secure,
not merely the necessary accommodation, but that of the best sort, for the
insane poor of their several counties. It is, indeed, an astounding
statement for the tax-payer to hear, that, after the expenditure of one or
two millions sterling to secure the pauper lunatics of this country the
necessary protection, care, and treatment, and the annual burden for
maintenance, that a far more comprehensive scheme is demanded. No wonder
that the increase of insanity is viewed as so rapid and alarming; no
wonder that every presumed plan of saving expense by keeping patients out
of asylums should be readily resorted to.
The value of the conclusion, and of the facts whereon it rests, certainly
merit careful examination; and after the investigation made as to the
number of the insane, and their rate of increase and accumulation, such an
examination can be more readily accomplished.
To revert to the figures put forward by the Commissioners, of the number
of beds existing in asylums on the 1st of January, 1858, and of that to be
furnished by 1860. They reckoned on 16,231 beds at the former date, and on
the addition of 4817 by the year 1860, or a total of 21,048. We have,
however, shown, that in January 1858 there were 1300 vacant beds, and that
there was an over-estimate of the future increase by about 300, leaving,
without reckoning the number in progress, 1000 to meet coming claims. This
sum being therefore added, gives a total of 22,048 to supply the wants of
the pauper insane between the 1st of January, 1858, and the completion of
the new asylums in 1860. Using the average increase adopted by the
Commissioners, viz. 915 per annum, there would be at the commencement of
the year 1860, 1830 applicants for admission, to be added to the 2467
confined in Licensed Houses, whom the Lunacy Commissioners are so anxious
to transfer to county institutions, making in all 4297. But according to
our corrected valuation, there would be in the course of 1860, room for
5817 patients, that is, a surplus accommodation for 1520.
It must be admitted as incorrect on the part of the Commissioners, in the
Report just quoted, to calculate on the whole number of beds obtained by
new buildings, as available in January 1860, when, in all probability,
1000 of them will not be ready much before the close of the year; still,
after making allowance for the increased number of claimants accruing
between that date and the opening of the new asylums, there would,
according to the data used, remain vacancies for some thousand or more,
instead of the 520 reckoned upon by the Commissioners.
Our review, therefore, is thus far favourable, and suggestive of the
possibility of a breathing time before the necessity of a scheme of a "far
more comprehensive nature" need be adopted. But, alas! the inquiries
previously gone into concerning the number and increase of the insane
render any such hope fallacious, and prove that the Commissioners have
very much underestimated the number to be duly lodged and cared for in
asylums; unless indeed, after having secured the transfer of those now in
Licensed Houses to County Asylums, they should consider their exertions on
behalf of the unfortunate victims of mental disorder among the poor
brought to a close. Such an idea, however, is, we are persuaded, not
entertained by those gentlemen, who have, on the contrary, in their
Reports frequently advocated the provision of asylums for all the pauper
insane with few exceptions, and distinctly set forth the objections to
their detention in workhouses.
In fact, every well-wisher for the lunatic poor, is desirous to see
workhouses disused as receptacles for them, and it naturally appears more
important to transfer some of their inmates to proper asylums than to
dislodge those detained in Licensed Houses, where, most certainly, the
means of treatment and management available are superior to those existing
in workhouse wards.
But our efforts on behalf of the insane poor must not cease even when
those in workhouses are better cared for, since there then remains that
multitude of poor mentally disordered patients scattered among the
cottagers of the country, indifferently lodged, and not improbably,
indifferently treated, sustained on a mere pittance unwillingly doled out
by Poor-Law Guardians, and under no effectual supervision, either by the
parish medical officers or by the members of the Lunacy Board. Some
provision surely is necessary for this class of the insane; some effectual
watching over their welfare desirable; for the quarterly visits required
by law (16 & 17 Vict. cap. 97, sect. 66) to be made to them by the
overworked and underpaid Union Medical Officers cannot be deemed a
sufficient supervision of their wants and treatment. These visits, for
which the noble honorarium of 2_s._ 6_d._ is to be paid, whatever the
distance the medical officer may have to travel,--are intended by the
clause of the Act to qualify the visitor to certify "whether such lunatics
are or are not properly taken care of, and may or may not properly remain
out of an asylum;" but practically nothing further is attained by them
than a certificate that the pauper lunatic still exists as a burden upon
the parish funds; and even this much, as the Commissioners in Lunacy
testify, is not regularly and satisfactorily obtained. A proper inquiry
into the condition of the patient, the circumstances surrounding him, the
mode of management adopted, and into the means in use to employ or to
amuse him, cannot be expected from a parish medical officer at the
remuneration offered, engaged as he is in arduous duties; and, more
frequently than not, little acquainted with the features of mental
disease, or with the plans for its treatment, alleviation, or management.
Even in the village of Gheel in Belgium, which has for centuries served as
a receptacle for the insane, where there is a well-established system of
supervision by a physician and assistants, and where the villagers are
trained in their management, those visitors who have more closely looked
into its organization and working, have remarked numerous shortcomings and
irregularities. But compared with the plan of distributing poor demented
patients and idiots, as pursued in this country, in the homes of our
poorer classes and peasantry, unused to deal with them, too often
regarding them as the subjects of force rather than of persuasion and
kindness, and under merely nominal medical oversight four times a year,
Gheel is literally "a paradise of fools." Indeed a similar plan might with
great advantage be adopted, particularly in the immediate vicinity of our
large County Asylums.
But to return to the particular subject in question, viz. the proportion
of insane poor in workhouses and elsewhere who should rightly find
accommodation in asylums, a class of lunatics, as said before, not taken
into account by the Commissioners in their estimate of future
requirements.
We let pass the inquiry, what should be done for the 8000 poor imbecile
and idiotic paupers boarded in the homes of relatives or others, and
confine our observations to the 7947 inmates of workhouses. Now, although
we entertain a strong conviction of the evils of workhouses as receptacles
for the insane, with very few exceptions,--a conviction we shall presently
show good grounds for, yet, instead of employing our own estimate, we
shall endeavour to arrive at that formed by the Lunacy Commissioners, of
the proportion of lunatics living in them, for whom asylum accommodation
should be provided.
The principal and special Report on Workhouses, in relation to their
insane inmates, was published in 1847, and in it the Commissioners observe
(p. 274), that they believe they "are warranted in stating, as the result
of their experience, that of the entire number of lunatics in
workhouses,--two-thirds at the least--are persons in whom, as the mental
unsoundness or deficiency is a congenital defect, the malady is not
susceptible of cure, in the proper sense of the expression, and whose
removal to a curative Lunatic Asylum, except as a means of relieving the
workhouse from dangerous or offensive inmates, can be attended with little
or no benefit. A considerable portion of this numerous class, not less
perhaps than a fourth of the whole, are subject to gusts of passion and
violence, or are addicted to disgusting propensities, which render them
unfit to remain in the workhouse.... But although persons of this
description are seldom fit objects for a curative asylum, they are in
general capable of being greatly improved, both intellectually and
morally, by a judicious system of training and instruction; their dormant
or imperfect faculties may be stimulated and developed; they may be
gradually weaned from their disgusting propensities; habits of decency,
subordination, and self-command may be inculcated, and their whole
character as social beings may be essentially ameliorated."
In their Ninth Report (1855), speaking of those classed in the Workhouse
In-door Relief Lists, under the head of Lunatics or Idiots, they
observe:--"These terms, which are themselves vague and comprehensive, are
often applied with little discrimination, and in practice are made to
include every intermediate degree of mental unsoundness, from imbecility
on the one hand, to absolute lunacy or idiotcy on the other; and, in point
of fact, a very large proportion of the paupers so classed in workhouses,
especially in the rural districts, and perhaps four-fifths of the whole,
are persons who may be correctly described as harmless imbeciles, whose
mental deficiency is chronic or congenital, and who, if kept under a
slight degree of supervision, are capable of useful and regular
occupation. In the remainder, the infirmity of mind is for the most part
combined with and consequent upon epilepsy or paralysis, or is merely the
fatuity of superannuation and old age; and comparatively few come within
the description of lunatics or idiots, as the terms are popularly
understood."
Lastly, in the Eleventh Report (1857), the class of pauper insane, whose
detention in workhouses is allowable, is indicated in the following
paragraph:--"They (workhouses) are no longer restricted to such pauper
lunatics as requiring little more than the ordinary accommodation, and
being capable of associating with the other inmates, no very grave
objection rests against their receiving.... But these are now unhappily
the exceptional cases."
These extracts are certainly not precise enough to enable us to state,
except very approximatively, what may be the estimate of the Lunacy
Commissioners of the numbers who should be rightly placed in asylums. That
first quoted appears to set aside one-third as proper inmates of a
curative asylum, and amenable to treatment; and then to describe a fourth
of the remaining two-thirds, that is, one-sixth, as proper objects of
asylum care. On adding these quantities, viz. one-third to one-sixth, we
get as the result, one-half as the proportion of workhouse insane
considered to be fit subjects for asylums.
The second quotation by itself is of little use to our purpose, except in
conjunction with the third one and with the context, as printed in the
Report from which it is taken, relative to the general question of the
evils of workhouses as receptacles for the insane. So examined in
connection, the published statements and opinions of the Commission, lead
to the conclusion that the great majority of the insane in workhouses
should rightly enjoy the advantages of the supervision, general
management, nursing, and dietary of asylums.
However, to escape the possible charge of attempting to magnify the
deficiency of asylum accommodation, we will, for the time, assume that
only one-half of the lunatic inmates of workhouses require asylum
treatment; even then we had some 4000 to be provided with it at the
beginning of 1858, and should have at the least 4500 by January 1860.
Having now reduced the estimate of the demands for asylum care to figures,
it is practicable to calculate how far those demands can be met by the
existing provision in asylums and what may be its deficiency.
On the one side, there will be, at the most moderate computation, made as
far as possible from data furnished by the Reports of the Lunacy
Commissioners, 4500 inmates of workhouses, who should, on or before
January 1st, 1860, obtain asylum care and treatment. On the other, there
will be, as above shown, about 1000 beds unoccupied at the date mentioned,
after accommodation is afforded to the pauper residents in Licensed
Houses, and to the number of insane resulting from accumulation and
increase in the course of two years from January 1858. The consequence is,
that in January 1860, there will remain some 3500 pauper lunatics
unprovided for in proper asylums.
In the course of the preceding arguments, we have kept as closely as
possible to data furnished by the Lunacy Commissioners' Reports, and
withal have made out, satisfactorily we trust, that the provision supplied
by existing asylums and by those now in progress of erection, is
inadequate to the requirements of the insane population of this country.
The idea of its inadequacy would be very greatly enhanced by the
employment of the statistical conclusions we have arrived at respecting
the number of the insane and their rate of accumulation, and by the
reception of the views we entertain against their detention, with
comparatively few exceptions, in other receptacles than those specially
constructed and organized for their care and treatment. The truth of our
opinions we shall endeavour to establish in subsequent pages; and
respecting the rate of accumulation of pauper cases, we feel confident
that 1800 per annum is within the truth. To meet this increase, both the
asylums in existence and those in course of erection are undoubtedly
inadequate, and, as the necessary result, workhouse pauper inmates must
continue to multiply.
If the opinion were accepted that public asylum accommodation should be
provided for all the pauper poor, not many more than one-half are at
present found to be in possession of it, that is, 17,000 of the 33,000 in
the country. Hence it would be required, to more than double the present
provision in asylums for pauper lunatics, to give room for all and to meet
the rapid annual rate of accumulation.
CHAP. IV.--ON THE CURABILITY OF INSANITY.
An inquiry into the curability of insanity forms a natural pendent to that
concerning the provision required for the insane, and is at the same time
a fitting prelude to an investigation of the insufficiency and defects of
the present organization of asylums: for it is important to satisfy
ourselves as to what extent we may hope to serve the insane, by placing
them under the most advantageous circumstances for treatment, before
incurring the large expenditure for securing them.
Now it may be most confidently stated that insanity is a very curable
disorder, if only it be brought early under treatment. American physicians
go so far as to assert, that it is curable in the proportion of 90 per
cent., and appeal to their asylum statistics to establish the assertion.
The Lunacy Commission of the State of Massachusetts (_op. cit._ p. 69)
thus write:--"In recent cases the recoveries amount to the proportion of
75 to 90 per cent. of all that are submitted to the restorative process.
Yet it is an equally well-established fact, that these disorders of the
brain tend to fix themselves permanently in the organization, and that
they become more and more difficult to be removed with the lapse of time.
Although three-fourths to nine-tenths may be healed if taken within a year
after the first manifestation of the disorder, yet if this measure be
delayed another year, and the diseases are from one to two years'
standing, the cures would probably be less than one-half of that
proportion, even with the same restorative means; another and a third year
added to the disease diminishes the prospect of cure, and in a still
greater ratio than the second; and a fourth still more. The fifth reduces
it so low, as to seem to be nothing."
Dr. Kirkbride, Physician to the Pennsylvania Hospital for the Insane, in
his book "On the Construction and Organization of Hospitals for the
Insane," says (p. 2):--"Of recent cases of insanity, properly treated,
between 80 and 90 per cent. recover. Of those neglected or improperly
managed, very few get well."
This is certainly a very flattering estimate, and, inasmuch as it is
founded on experience, cannot fairly be questioned. However, before
comparing it with the results arrived at in this country, there are some
circumstances which call for remark. In the first place, American public
asylums are not branded with the appellation 'pauper,' they are called
'State Asylums,' and every facility is offered for the admission of cases,
and particularly of recent ones, whatever their previous civil condition.
Again, there is not in the United States the feeling of false pride, of
imaginary family dishonour or discredit, to the same extent which is
observed in this country, when it pleases Providence to visit a relative
with mental derangement,--to oppose the transmission to a place of
treatment. From these two causes it happens that in America the insane
ordinarily receive earlier attention than in this country. Lastly, the
United States' institutions, by being more accessible, admit a certain
proportion of cases of temporary delirium, the consequence of the abuse of
alcoholic drinks, of overwrought brain and general excitement,--causes
more active in that comparatively new, changing, and rapidly-developing
country than in ours. But such cases, which for the most part get well, do
not find their way into the asylums of this kingdom. Such are some of the
circumstances influencing favourably the ratio of cures in America, which
need be remembered when comparing it with that which is attained in our
own land.
The proportion of recoveries above stated, is calculated upon cases of
less than a year's duration. Let us see what can be effected in England
under conditions as similar as practicable, though not equally
advantageous. The most satisfactory results we can point to are those
obtained at St. Luke's Hospital, London, where the cures have averaged 62
per cent. upon the admissions during the last ten years. At this and
likewise at Bethlehem Hospital, the rules require that the disorder be not
of more than one year's duration at the time of application for admission,
and that it be not complicated with epilepsy or paralysis, maladies which
so seriously affect its curability. Such are the conditions favourable to
a high rate of recoveries enforced by rule. On the other hand, there are
at St. Luke's not a few circumstances in operation prejudicial to the
largest amount of success possible. Its locality is objectionable, its
general construction unfavourable, its grounds for exercise and amusement
very deficient, and the means of employment few. But apart from these
disadvantages, so prejudicial to its utility and efficiency, there are
other causes to explain its ratio of success being less than that
estimated by our American brethren to be practicable. Though the rule
excludes patients the benefit of the hospital if their disease be of more
than a year's duration, yet from the great difficulties attending in many
cases the inquiry respecting the first appearance of the insanity; its
sometimes insidious approach; the defect of observation, or the ignorance,
and sometimes the misrepresentations of friends, resorted to in order to
ensure success in their application to the charity, older cases gain
admission. Again, of those admitted in any year, there are always several
whose disorder is known to be of nine, ten, or eleven months' duration,
and at least a fourth in whom it is of six months' date and upwards.
Further, although the rules exclude epileptics and paralytics, yet at
times the history of fits is withheld by the patients' friends, or the
fits are conceived to be of a different character, or the paralysis is so
little developed as not to be very recognizable; and as in all ambiguous
cases,--whether it be the duration or the complication of the mental
disorder which is in doubt, the Committee of the Hospital give the benefit
of the doubt to the patient,--the consequence is, that several such
unfavourable cases are received annually. On referring to the statistical
tables of the institution, these "unfit" admissions are found to amount to
10 per cent.
We have thought these details desirable, on the one hand, to account for
the difference in the ratio of cures attained in St. Luke's compared with
that fixed by American writers; and on the other, to show that though the
rate of recoveries at that London Hospital is highly gratifying, it might
be rendered yet more so if certain impediments to success were removed,
and that similar benefits could be realized elsewhere if due provision
were made for the early and efficient treatment of the malady.
Were we at all singular in the assertion of the curability of insanity, we
should endeavour to establish it by an appeal to the statistics of
recoveries among recent cases in the different English asylums; but
instead of advancing a novel opinion, we are only bearing witness to a
well-recognized fact substantiated by general experience. This being so,
it would be fruitless to occupy time in quoting many illustrations from
Asylum Reports: one will answer our purpose.
At the Derby County Asylum, under the charge of Dr. Hitchman, a high rate
of cures has been reached. In the Third Report that able physician writes
(p. 5),--"It cannot be too often repeated, that the date of the patient's
illness at the time of admission is the chief circumstance which
determines whether four patients in a hundred, or seventy patients in a
hundred, shall be discharged cured. Of the 151 cases which have been
admitted into the asylum during the past year, eleven only have been
received within a week of the onset of their malady; of these eleven, ten
have been discharged cured,--the other has been but a short time under
treatment." In his Sixth Report (1857, p. 22), the same gentleman
observes,--"The cures during the past year have reached 60 per cent. upon
the admissions; but the most gratifying fact has been, that of twenty
patients, unafflicted with general paralysis, who were admitted within one
month of the primary attack of their maladies, sixteen have left the
asylum cured,--three are convalescent, and will probably be discharged at
the next meeting of the Committee, and the other one was in the last stage
of pulmonary consumption when she came to the asylum, and died in three
weeks after her admission."
After this review of what may be effected in restoring the subjects of
mental disorder to reason and society, to their homes and occupations, by
means of early treatment, it is discouraging to turn to the average result
of recoveries on admissions obtained in our County Asylums at large. This
average may be taken at 35 per cent., and therefore there will remain of
every 100 patients admitted, sixty-five, or, after deducting 10 per cent.
of deaths, fifty-five at the end of the year. This number, fifty-five,
might fairly be taken to represent the annual per centage of accumulation
of the insane in asylums, were the data employed sufficient and
satisfactory. But so far as we have yet examined the point, this
proportion is larger than a calculation made over a series of years, and
may be approximatively stated at 35 per cent. on the admissions.
How great would be the gain, alike to the poor lunatic and to those
chargeable with his maintenance, could this rapid rate of accumulation be
diminished, by raising that of recoveries, or, what is tantamount to it,
by securing to the insane prompt and efficient care and treatment! How
does it happen that this desideratum is not accomplished by the asylums in
existence? what are the impediments to success discoverable in their
organization and management, or in the history of their inmates prior to
admission? and what can be done to remedy discovered defects, and to
secure the insane the best chances of recovery? Such are some of the
questions to be next discussed.
CHAP. V.--ON THE CAUSES DIMINISHING THE CURABILITY OF INSANITY, AND
INVOLVING THE MULTIPLICATION OF CHRONIC LUNATICS.
In the preliminary chapters on the number and increase of the insane in
this country, we limited ourselves to determine what that number and that
increase were, and entered into no disquisition respecting the causes
which have operated in filling our asylums with so many thousands of
chronic and almost necessarily incurable patients. Nor shall we now
attempt an investigation of them generally, for this has been well done by
others, and particularly by the Lunacy Commissioners in their Ninth
Report, 1855; but shall restrict ourselves to intimate that the increase
of our lunatic population, mainly by accumulation, is due to neglect in
past years; to the alteration of the laws requiring the erection of County
Asylums for pauper lunatics generally; to the collection and discovery of
cases aforetime unthought of and unknown; to the extension of the
knowledge of the characters and requirements of the insane both among
professional men and the public; and, lastly, to the advantages themselves
of asylum accommodation which tend to prolong the lives of the inmates.
Such are among the principal causes of the astounding increase in the
number of the insane of late years, relatively to the population of the
country, some of which fortunately will in course of time be less
productive. Those, however, which we now desire to investigate, are such
as directly affect the curability of insanity, either by depriving its
victims of early and efficient treatment, or by lessening the efficiency
and usefulness of the public asylums.
The history of an insane patient is clearly divisible into three portions:
1st, that before admission into an asylum; 2nd, that of his residence in
an asylum; and 3rd, of that after his discharge from it. The last division
we have at present nothing to do with; and with reference to the causes
influencing his curability, these group themselves under two heads
parallel to the first two divisions of the patient's history; viz. 1,
those in operation external to, and 2, those prevailing in, asylums.
A. _Causes external to Asylums._
The chief cause belonging to this first class is that of delay in
submitting recent cases to asylum care and treatment. This delay, as we
have sufficiently proved, operates most seriously by diminishing the
curability of insanity, and thereby favours the accumulation of chronic
lunatics. It takes place in consequence either of the desire of friends to
keep their invalid relatives at their homes; or of the economical notions
of Poor-Law Officers, who, to avoid the greater cost of asylums, detain
pauper lunatics in workhouses. Other causes of incurability and of the
accumulation of incurables are found in injudicious management and
treatment before admission, and in the transmission of unfit cases to
asylums. To discuss the several points suggested in these considerations
will require this chapter to be subdivided; and first we may treat of the
Detention of Patients in their own homes.
§ _Detention of Patients in their own homes._
Although the immense importance of early treatment to recent cases of
insanity is a truth so well established and so often advocated, yet the
public generally fail to appreciate it, and from unfortunate notions of
family discredit, from false pride and wounded vanity, delay submitting
their afflicted relatives to efficient treatment. Unless the disorder
manifest itself by such maniacal symptoms that no one can be blind to its
real character, the wealthier classes especially will shut their eyes to
the fact they are so unwilling to recognize, and call the mental
aberration nervousness or eccentricity; and as they are unwilling to
acknowledge the disorder, so are they equally indisposed to subject it to
the most effectual treatment, by removing the patient from home, and the
exciting influence of friends and surrounding circumstances in general, to
a properly organized and managed asylum. Usually a patient with sufficient
resources at command, is kept at home as long as possible, at great cost
and trouble; and if he be too much for the control of his relatives and
servants, attendants are hired from some Licensed House to manage him; the
only notion prevailing in the minds of his friends being that means are
needed to subdue his excitement and to overcome his violence. There are,
in fact, no curative agencies at work around him, but on the contrary,
more or fewer conditions calculated to exalt his furor, to agitate and
disquiet his mind, and to aggravate his malady. The master of the house
finds himself checked in his will; disobeyed by his servants; an object of
curiosity, it may be, of wonder and alarm; and sadly curtailed in his
liberty of action. The strange attendants forced upon him are to be
yielded to only under passionate protests, and probably after a struggle.
In all ways the mental disorder is kept up if not aggravated, and every
day the chances of recovery are diminished. Perhaps matters may grow too
bad for continued residence at home, or the malady have lasted so long,
that the broken-up state of family and household can no longer be
tolerated, and a transfer from home is necessitated. Yet even then removal
to an asylum,--the only step which can hold out a fair prospect of
recovery, is either rejected as quite out of the question, or submitted to
usually after still longer delay,--a "trial" being made of a lodging with
a medical man or other person, probably with an asylum attendant. By this
plan certainly the patient is saved from the presence and excitement of
his family, and placed under altered conditions, calculated to exercise in
some respects a salutary influence on his mind; still many others are
wanting, and no guarantee is attainable of the manner in which he is
treated; for as a single patient, and as is usually the case, restrained
without certificates, he is almost invariably unknown to the
Commissioners, and virtually unprotected, even though a medical man be
paid to attend him occasionally. At last, however, except for a few, the
transfer to the asylum generally becomes inevitable, and too often too
late to restore the disordered reason; and years of unavailing regret fail
to atone for time and opportunity lost.
The same unwillingness to subject their insane friends to asylum care and
treatment pervades, moreover, the less wealthy classes, and even the
poorer grades of the middle class of society. Madness, to their
conceptions likewise, brings with it a stigma on the family, and its
occurrence must, it is felt, be kept a secret. Hence an asylum is viewed
as an evil to be staved off as long as possible, and only resorted to when
all other plans, or else the pecuniary means, are exhausted. If it be the
father of the family who is attacked, the hope is, that in a few days or
weeks he may resume his business or return to his office, as he might
after ordinary bodily illness, without such loss of time as shall endanger
his situation and prospects, and without the blemish of a report that he
has been the inmate of a madhouse. If it be the wife, the hope is similar,
that she will shortly be restored to her place and duties in her family.
Should progress be less evident than desired, a change away from home will
probably be suggested by the medical attendant, and at much expense and
trouble carried out. But too frequently, alas! the hopes are blighted and
the poor sufferer is at length removed with diminished chance of cure to
an asylum.
For the poorer members of the middle class, and for many moving in a
somewhat higher circle of society, whom the accession of mental disorder
impoverishes and cuts off from independence, there are, it is most deeply
to be regretted, few opportunities of obtaining proper asylum care and
treatment. In very many instances, the charges of even the cheapest
private asylum can be borne for only a limited period, and thus far, at
the cost of great personal sacrifices and self-denial. Sooner or later no
refuge remains except the County Asylum, where, it may be, from the
duration of his disorder, the patient may linger out the remainder of his
days. How happy for such a one is it--a person unacquainted with the
system of English County Asylums, might remark--that such an excellent
retreat is afforded! To this it may be replied, that the public asylum
ought not to be the _dernier ressort_ of those too poor to secure the best
treatment and care in a well-found private establishment, and yet too
respectable to be classed and dealt with as paupers entirely and
necessarily dependent on the poor's rate. Yet so it is under the operation
of the existing law and parochial usages, there is no intermediate
position, and to reap the benefits of the public asylum, the patient must
be classed with paupers and treated as one. His admission into it is
rendered as difficult, annoying, and degrading as it can be. His friends,
worn out and impoverished in their charitable endeavours to sustain him in
his independent position as a private patient, are obliged to plead their
poverty, and to sue as paupers the parish officials for the requisite
order to admit their afflicted relative to the benefits of the public
asylum as a Pauper Lunatic. In short, they have to pauperize him; to
announce to the world their own poverty, and to succumb to a proceeding
which robs them of their feelings of self-respect and independence, and by
which they lose caste in the eyes of their neighbours. As for the patient
himself, unless the nature and duration of his malady have sufficiently
dulled his perception and sensibilities, the consciousness of his position
as a registered pauper cannot fail to be prejudicial to his recovery;
opposed to the beneficial influences a well-regulated asylum is calculated
to exert, and to that mental calm and repose which the physician is
anxious to procure.
In the class of cases just sketched, we have presumed on the ability of
the friends to incur the cost of private treatment for a longer or shorter
period; but many are the persons among the middle classes, who if
overtaken by such a dire malady as insanity, are almost at once reduced to
the condition of paupers and compelled to be placed in the same category
with them. As with the class last spoken of, so with this one, the law
inflicts a like injury and social degradation, and at the same time
operates in impeding their access to proper treatment.
No one surely, who considers the question, and reflects on the necessary
consequences of the present legal requirement that, for a lunatic to enjoy
the advantages of a public asylum, towards which he may have for years
contributed, he must be formally declared chargeable to the rates as a
pauper,--can deny the conclusion that it is a provision which must entail
a social degradation upon the lunatic and his family, and act as a great
impediment to the transmission of numerous recent cases to the County
Asylum for early treatment.
It will be urged as an apology for it, that the test of pauperism rests on
a right basis; that it is contrived to save the rate-payer from the charge
of those occupying a sphere above the labouring classes, who fall, as a
matter of course, upon the parochial funds whenever work fails or illness
overtakes them. It is, in two words, a presumed economical scheme.
However, like many other such, it is productive of extravagance and loss,
and is practically inoperative as a barrier to the practice of imposition.
If it contributes to check the admission of cases at their outbreak into
asylums, as no one will doubt it does, it is productive of chronic
insanity and of permanent pauperism; and, therefore, besides the
individual injury inflicted, entails a charge upon the rates for the
remaining term of life of so many incurable lunatics.
If, on the contrary, our public asylums were not branded by the
appellation "Pauper;" if access to them were facilitated and the
pauperizing clause repealed, many unfortunate insane of the middle class
in question, would be transmitted to them for treatment; the public asylum
would not be regarded with the same misgivings and as an evil to be
avoided, but it would progressively acquire the character of an hospital,
and ought ultimately to be regarded as a place of cure, equivalent in
character to a general hospital, and as entailing no disgrace or discredit
on its occupant.
The Commissioners in Lunacy, in their Ninth Report (1855, p. 35), refer to
the admissions into County Asylums, of patients from the less rich classes
of society reduced to poverty by the occurrence of the mental malady, and
hint at their influence in swelling the number of the chronic insane,
owing to their transfer not taking place until after the failure of their
means and the persistence of their disorder for a more or less
considerable period. This very statement is an illustration in point; for
the circumstance deplored is the result of the indisposition on the part
of individuals to reduce their afflicted relatives to the level of paupers
by the preliminaries to, and by the act of, placing them in an asylum
blazoned to the world as the receptacle for paupers only; an act, whereby,
moreover, they advertise to all their own poverty, and their need to ask
parish aid for the support of their poor lunatic kindred.
On the continent of Europe and in the United States of America we obtain
ample evidence that the plan of pauperizing patients in order to render
them admissible to public asylums, is by no means necessary. Most
continental asylums are of a mixed character, receiving both paying and
non-paying inmates, and care is taken to investigate the means of every
applicant for admission, and those of his friends chargeable by law with
his maintenance. Those who are paid for are called "pensioners" or
boarders, and are divided into classes according to the sum paid, a
particular section of the asylum being assigned to each class. Besides
those pensioners who pay for their entire maintenance, there are others
whose means are inadequate to meet the entire cost, and who are assessed
to pay a larger or smaller share of it. Lowest in the scale of inmates are
those who are entirely chargeable to the departmental or provincial
revenue, being devoid of any direct or indirect means of support. Probably
the machinery of assessment in the continental states might not accord
with English notions and be too inquisitorial for adoption _in toto_; but
at all events, on throwing open public asylums for the reception of all
lunatics who may apply for it, without the brand of pauperism being
inflicted upon them, some scheme of fairly estimating the amount they
ought to contribute to their maintenance should be devised. For the richer
classes a plan of inquisition into their resources is provided, and there
seems no insuperable difficulty in contriving some machinery whereby those
less endowed with worldly goods might, at an almost nominal expense, have
their means duly examined and apportioned to their own support and that of
their families. Overseers and relieving officers are certainly not the
persons to be entrusted with any such scheme, nor would we advocate a
jury, for in such inquiries few should share; but would suggest it as
probably practicable that the amount of payment might be adjudged by two
or three of the Committee of Visitors of the Asylum with the Clerk of the
Guardians of the Union or Parish to which the lunatic belonged.
In the United States of America, every tax-payer and holder of property is
entitled as a tax-payer, when insane, to admission into the Asylum of the
State of which he is a citizen. He is considered as a contributor to the
erection and support of the institution, and as having therefore a claim
upon its aid if disease overtake him. The cost of his maintenance is borne
by the township or county to which he belongs, and the question of his
means to contribute towards it is determined by the county judge and a
jury. Most of the asylums of the Republic also receive boarders at fixed
terms, varying according to the accommodation desired; hence there are
very few private asylums in the States. In the State of New York there is
a special legal provision intended to encourage the early removal of
recent cases to the asylum; whereby persons not paupers, whose malady is
of less than one year's duration, are admitted without payment, upon the
order of a county judge, granted to an application made to him, setting
forth the recent origin of the attack and the limited resources of the
patient. Such patients are retained two years, at the end of which time
they are discharged, their friends being held responsible for the
removal. Their cost in the asylum is defrayed by the county or parish to
which they belong.
We have said above, that the requirement of the declaration of pauperism
is ineffectual in guarding the interests of the rate-payer against the
cost of improper applicants. Indeed, the proceeding adopted to carry it
out is both absurd and useless, besides being, as just pointed out,
mischievous in its effects.
In the interpretation clause of "the Lunatic Asylums' Act, 1853," it is
ordered that a "Pauper shall mean every person maintained wholly or in
part by, or chargeable to, any Parish, Union, or County." Hence when
insanity overtakes an unfortunate person who is not maintained by a parish
or union, it is required that he be made chargeable to one, or, as we have
briefly expressed the fact, that he be pauperized. To effect this object,
the rule is, that the patient shall reside at least a day and a night in a
workhouse. This proceeding, we repeat, carries absurdity on the face of
it. Either it may be a mere farce privately enacted between the parish
officers and the friends of the patient, to the complete frustration of
the law so far as the protection of the rate-payers is contemplated; or,
it may be made to inflict much pain and annoyance on the applicants by the
official obstructiveness, impertinent curiosity, obtuseness, and possible
ill-feeling of the parish functionaries in whose hands the law has
practically entrusted the principal administration of the details
regulating the access to our public asylums.
It is no secret among the superintendents of County Asylums, that by
private arrangements with the overseers or guardians of parishes, cases
gain admission contrary to the letter and spirit of the law, and to the
exclusion of those who have legally a prior and superior claim. We have,
indeed, the evidence of the Lunacy Commissioners, to substantiate this
assertion. In their Ninth Report (1855, p. 34) they observe,--"In some
districts a practice has sprung up, by which persons, who have never been
themselves in receipt of parochial relief, and who are not unfrequently
tradesmen, or thriving artisans, have been permitted to place lunatic
relations in the County Asylums, as pauper patients, under an arrangement
with the guardians for afterwards reimbursing to the parish the whole, or
part, of the charge for their maintenance. This course of proceeding is
stated to prevail to a considerable extent in the asylums of the
metropolitan counties, and its effect in occupying with patients, not
strictly or originally of the pauper class, the space and accommodations
which were designed for others who more properly belong to it, has more
than once been made the subject of complaint."
Desiring, as we do, to see our County Asylums thrown open to the insane
generally, by the abolition of the pauper qualification, it is rather a
subject of congratulation that cases of the class referred to do obtain
admission into them, even when contrary to the letter of the law. But we
advance the quotation and assertion above to show, that the pauperizing
provision of the Act is ineffective in the attainment of its object; and
to remark, that the opportunities at connivance it offers to parochial
officials, must exercise a demoralizing influence and be subversive of
good government. If private arrangements can be made between the
applicants for an assumed favour, and parish officers, who will undertake
to say that there shall not be bribery and corruption?
Sufficient, we trust, has been said to demonstrate the evils of the
present system of pauperizing patients to qualify them for admission into
County Asylums, and the desirability of opening those institutions to all
lunatics of the middle classes whose means are limited, and whose social
position as independent citizens is jeopardized by the existence of their
malady. This class of persons, as before said, calls especially for
commiseration and aid; being so placed, on the one hand, that their
limited means must soon fail to afford them the succour of a private
asylum; and on the other, with the door of the public institution closed
against them, except at the penalty of pauperism and social degradation.
What we would desire is, that every recent case of insanity should at once
obtain admission into the public asylum of the county or borough, if
furnished with the necessary medical certificates and with an order from a
justice who has either seen the patient or received satisfactory evidence
as to his condition (see remarks on duties of district medical officers),
and obtained from the relatives an undertaking to submit to the assessment
made by a commission as above proposed, or constituted in any other manner
thought better; or the speedy admission of recent cases might otherwise be
secured by prescribing their attendance and that of their friends before
the weekly Committee of the Visitors of the Asylum, by whom the order for
reception might be signed on the requisite medical certificates being
produced, and the examination for the assessment of the patient's
resources formally made, with the assistance possibly of some
representative of the parish interests,--such for instance as the Clerk to
the Board of Guardians.
In the County Courts the judges are daily in the habit of ordering
periodical payments to be made in discharge of debts upon evidence offered
to them of the earnings or trade returns of the debtor; and there seems no
_a priori_ reason against the investigation of the resources of a person
whose friends apply for his admission into a County Asylum. It is for
them to show cause why the parish or county should assume the whole or the
partial cost of the patient's maintenance, and this can be done before the
Committee of the Asylum or any private board of inquiry with little
annoyance or publicity. Rather than raise an obstacle to the admission of
the unfortunate sufferer, it would be better to receive him at once and to
settle pecuniary matters afterwards.
We must here content ourselves with this general indication of the
machinery available for apportioning the amount of payment to be made on
account of their maintenance by persons not paupers, or for determining
their claim upon the Asylum funds. Yet we cannot omit the opportunity to
remark that the proceedings as ordered by the existing statute with a
similar object are incomplete and unsatisfactory. These proceedings are
set forth in _sects._ xciv. and civ. (16 & 17 Vict. cap. 97). The one
section of the Act is a twin brother to the other, and it might be
imagined by one not "learned in the law," that one of the two sections
might with little alteration suffice. Be this as it may, it is enacted
that if it appear to two Justices (_sect._ xciv.) by whose order a patient
has been sent to an asylum, or (_sect._ civ.) "to any Justice or Justices
by this Act authorized to make any order for the payment of money for the
maintenance of any Lunatic, that such Lunatic" has property or income
available to reimburse the cost of his maintenance in the asylum, such
Justices (_sect._ xciv.) shall apply to the nearest known relative or
friend for payment, and if their notice be unattended to for one month,
they may authorize a relieving officer or overseer to seize the goods, &c.
of the patient, whether in the hands of a trustee or not, to the amount
set forth in their order. _Sect._ civ. makes no provision for applying to
relatives or friends in the first instance, but empowers the justice or
justices to proceed in a similar way to that prescribed by _sect._ xciv.,
to repay the patient's cost; with the additional proviso that, besides the
relieving officer or overseer, "the Treasurer or some other officer of the
County to which such Lunatic is chargeable, or in which any property of
the Lunatic may be, or an officer of the Asylum in which such Lunatic may
be," may proceed to recover the amount charged against him.
Concerning these legal provisions, we may observe, that the state of the
lunatic's pecuniary condition is left to accidental discovery. The
justices signing the order of admission (_sect._ xciv.) have no authority
given them to institute inquiries, although they may learn by report that
the patient for whom admission is solicited is not destitute of the means
of maintenance. Nor are the justices who make the order for payment
(_sect._ civ.) in any better position for ascertaining facts. There is,
in short, no authorized and regular process for investigating the
chargeability of those who are not actually in the receipt of parochial
relief on or before application for their admission into the County
Asylum, or who must necessarily be chargeable by their social position
when illness befalls them. Again, according to the literal reading of the
sections in question, no partial charge for maintenance can be proposed;
no proportion of the cost can be assessed, where the patient's resources
are unequal to meet the whole. Lastly, the summary process of seizing the
goods or property of any sort, entrusted to those who are most probably
the informers of the justices, namely overseers and relieving officers;
and, by _sect._ civ., carried out without any preliminary notice or
application, and without any investigation of the truth of the reports
which may reach the justices, is certainly a proceeding contrary to the
ordinary notions of equity and justice.
§ _Detention of Patients in Workhouses._
In the case of the insane poor, whose condition, circumstances, and social
position have been such that whenever any misfortune, want of work, or
sickness has overtaken them, the workhouse affords a ready refuge, the
requirement of pauperization to qualify for admission to the County Asylum
is in itself no hardship and no obstacle to their transmission to it.
Probably the prevailing tactics of parish officers may at times contribute
to delay the application for relief, but the great obstacle to bringing
insane paupers under early and satisfactory treatment in the authorized
receptacle for them--the County Asylum, is the prevalence of an economical
theory respecting the much greater cheapness of workhouse compared with
asylum detention. The practical result of this theory is, that generally
where a pauper lunatic can by any means be managed in a workhouse, he is
detained there. If troublesome, annoying, and expensive, he is referred to
the County Asylum; this is the leading test for the removal; the
consideration of the recent or chronic character of his malady is taken
little or no account of.
In fresh cases the flattering hope is that the patients will soon recover,
and that the presumed greater cost of asylum care can be saved; in old
ones the feeling is that they are sufficiently cared for, if treated like
the other pauper inmates, just that amount of precaution being attempted
which may probably save a public scandal or calamity.
To the prevalence of these economical notions and practice may be
attributed the large number of lunatics detained in workhouses (nearly
8000), and the equally large one living with their friends or others. Now
it is very desirable to inquire whether these theories of the superior
economy of workhouses compared with asylums as receptacles for the insane,
are true and founded on facts. This question is in itself twofold, and
leaves for investigation, first, that of the mere saving in money on
account of maintenance and curative appliances; and secondly, that of the
comparative fitness or unfitness, the advantages or disadvantages, the
profit or loss, of the two kinds of institutions in relation to the
welfare, the cure, and the relief of the poor patients placed in them.
These questions press for solution in connexion with the subject of the
accumulation of lunatics and the means to be adopted for its arrest, or,
what is equivalent to this, for promoting the curability of the insane.
On making a comparative estimate of charges, it is essential to know
whether the same elements of expenditure are included in the two cases; if
the calculated cost per head for maintenance in workhouses and asylums
respectively comprises the same items, and generally, if the conditions
and circumstances so far as they affect their charges are rightly
comparable. An examination we are confident, will prove that in no one of
these respects are they so.
In the first place, the rate of maintenance in an asylum is calculated on
the whole cost of board, clothing, bedding, linen, furniture, salaries,
and incidental expenditure; that is, on the total disbursements of the
establishment, exclusive only of the expenditure for building and repairs,
which is charged to the county. On the contrary, the "in-maintenance" in
workhouses comprises only the cost of food, clothing, and necessaries
supplied to the inmates (see Poor-Law Board Tenth Report, p. 144). The
other important items reckoned on in fixing the rate of cost per head in
asylums are charged to the "establishment" account of the workhouse, and
are omitted in the calculation of the rate of maintenance. Reference to
the Tables given in the Poor-Law Board Returns (Tenth Report, p. 61,
sub-column _e_ and a portion of _f_) will prove that the expenditure on
account of those other items must be nearly or quite equal to that
comprehended under the head of "in-maintenance" cost.
We have no means at hand to calculate with sufficient precision what sum
should be added to the "in-maintenance" cost of paupers per head in
workhouses, but it is quite clear that the figures usually employed to
represent it, cannot be rightly compared with those exhibiting the weekly
charge of lunatics in asylums. At the very least half as much again must
be added to a workhouse estimate before placing it in contrast with asylum
cost.
Since the preceding remarks were written, Dr. Bucknill has favoured us
with the Thirteenth Report of the Devon Asylum, in which he has discussed
this same question and illustrated it by a special instance. To arrive at
the actual cost of an adult sane pauper in a union-house, he gathered "the
following particulars relative to the house of the St. Thomas Union in
which this asylum is placed; a union, the population of which is 49,000,
and which has the reputation of being one of the best managed in the
kingdom. The cost of the maintenance of paupers in this union-house is
2_s._ 6_d._ per head, per week, namely, 2_s._ 2_d._ for food and 4_d._ for
clothing. The establishment charges are 1_s._ 0-1/2_d._ per head, per
week, making a total of 3_s._ 6-1/2_d._ for each inmate. The total number
of pauper inmates during the twelfth week of the present quarter was 246;
and of these 116 were infants and children, and 130 youths above sixteen
and adults. A gentleman intimately acquainted with these accounts, some
time since calculated for me that each adult pauper in the St. Thomas's
Union-house cost 5_s._ a week. Now the average cost of all patients in the
Devon Asylum at the present time is 7_s._ 7_d._, but of this at least
2_s._ must be set down to the extra wages, diet, and other expenses
needful in the treatment of the sick, and of violent and acute cases,
leaving the cost of the great body of chronic patients at not more than
5_s._ 7_d._ a week. Now if a sane adult pauper in a union-house costs even
4_s._ 6_d._ a week, is it probable that an insane one would cost less than
5_s._ 7_d._? For either extra cost must be incurred in his care, or he
must disturb the discipline of the establishment, and every such
disturbance is a source of expense."
This quotation is really a reiteration of Dr. Bucknill's conclusions as
advanced in 1857, in an excellent paper in the 'Asylum Journal' (vol. iv.
p. 460), and as a pendent to it the following extract from this paper is
appropriate; viz. "that the cost of a chronic lunatic properly cared for,
and supplied with a good dietary, in a County Asylum, is not greater than
that of a chronic lunatic supplied with a coarse and scanty dietary, and
detained in neglect and wretchedness as the inmate of a union workhouse."
Another most important circumstance to be borne in mind when the cost of
workhouses and asylums is contrasted, is that in the former establishments
more than two-thirds of the inmates are children. Thus the recipients of
in-door relief on the 1st of January, 1858, consisted, according to the
Poor-Law Returns, of 74,141 adults, and 50,836 children under sixteen
years of age. Now as the rate of maintenance is calculated on the whole
population of a workhouse, adults and children together, it necessarily
follows that it falls much within that of asylums, in which almost the
whole population is adult. This very material difference in the character
of the inmates of the two institutions may fairly be valued as equivalent
to a diminution of one-fourth of the expense of maintenance in favour of
workhouses; and without some such allowance, the comparison of the cost
per head in asylums and union-houses respectively is neither fair nor
correct.
Again, there is another difference between asylums and workhouses, which
tells in favour of the latter in an economical point of view, whilst it
proves that the expenditure of the two is not rightly comparable without
making due allowance for it along with the foregoing considerations. This
difference subsists in the character of the two institutions respectively;
namely, that in the asylum the movements of the population are slight,
whereas in the workhouse they are very considerable by the constant
ingress and egress of paupers; driven to it by some passing misfortune or
sickness, it may be for a week or two only or even less, and discharging
themselves so soon as the temporary evil ceases to operate or the disorder
is overcome: for the poor generally, except the old and decrepit who
cannot help themselves, both dread a lodging in the workhouse, and escape
from it as soon as possible; in fact, even when they have no roof of their
own to shelter them, they will often use the union accommodation only
partially, leaving it often by day and returning to it by night. All this
implies a large fluctuation of inmates frequently only partially relieved,
whether in the way of board or clothing; and consequently when the average
cost per head of in-door paupers is struck, it appears in a greater or
less degree lower than it would have done had the same constancy in
numbers and in the duration and extent of the relief afforded prevailed as
it does in asylums.
The effect of the fluctuations in population in union-houses ought, we
understand, to be slight, if the "Orders in Council" laid down to guide
parochial authorities in the calculation of the cost of their paupers,
were adhered to; viz. that for all those belonging to any one parish in
union, who may have received in-door relief during the year or for any
less period of time, an equivalent should be found representing the number
who have been inmates throughout the year; or the total extent of relief
be expressed by estimating it to be equal to the support of one
hypothetical individual for any number of years equivalent to the sum of
the portions of time the entire number of the paupers of the particular
parish received the benefits of the establishment. We do not feel sure
that these plans of calculating the cost per head are faithfully and fully
executed; the rough method of doing so, viz. by taking the whole cost of
"in-maintenance" at the end of the year and dividing it by the number of
its recipients, and assuming the quotient to represent the expenditure
for each. Whether this be the case or not, these daily changes among its
inmates, the frequent absence of many for a great part of the day and the
like, are to be enumerated among the circumstances which tend to keep down
expenditure of workhouses; and which are not found in asylums.
There is yet another feature about workhouses which distinguishes them
from asylums, and is of considerable moment in the question of the
comparative cost of maintenance in the two: this is, the circumstance of
the population of workhouses being of a mixed character, of which the
insane constitute merely a small section; while, on the contrary, that of
asylums is entirely special, and each of its members to be considered a
patient or invalid demanding particular care and special appliances.
Therefore, _a priori_, no comparison as to their expenditure can justly be
drawn between two institutions so dissimilar. Yet even this extent of
dissimilarity between them is not all that exists; for the union-house is
so constituted by law as to serve as a test of poverty; to offer no
inducements to pauperism, and to curtail the cost of maintenance as far as
possible. It has properly no organization for the detention, supervision,
moral treatment and control, nor for the nursing or medical care of the
insane; and when its establishment is attempted it is a step at variance
with its primary intention, and involves an extra expenditure.
Consequently, before overseers or guardians can with any propriety
contrast the workhouse charges of maintenance with those of asylums, it is
their business to estimate what an adult pauper lunatic costs them per
week, instead of, as usual, quoting the cost per head calculated on the
whole of the inmates, old and young, sane and insane.
Once more, even after a fair estimate of the cost of an adult insane
inmate of a workhouse is obtained, there is still another differential
circumstance favourable to a less rate than can be anticipated in asylums;
for this reason:--that in the former institutions the practice is to
reject all violent cases, the major portion of recent ones, and,
generally, all those who give particular annoyance and trouble; whilst the
latter is, as it rightly should be, regarded as the fitting receptacle for
all such patients;--that is, in other words, those classes of patients
which entail the greatest expense are got rid of by the workhouses and
undertaken by the asylums.
Dr. Bucknill has well expressed the same circumstances we have reviewed,
in the following paragraph (Report, Devon Asylum, 1858, p. 13):--"In
estimating the cost of lunatic paupers in asylums, the important
consideration must not be omitted, that the charge made for the care and
maintenance of lunatics in County Asylums is averaged upon those whose
actual cost is much greater, and those whose actual cost is less than the
mean; so that it would be unfair for the overseers of a parish to say of
any single patient that he could be maintained for a smaller sum than that
charged, when the probability is that there are or have been patients in
the asylum from the same parish, whose actual cost to the asylum has been
much greater than that charged to the parish. I have shown, that the
actual cost of chronic patients in an asylum exceeds that of adult paupers
in union-houses to a much smaller extent than has been stated: but if all
patients of this description were removed from the asylum, the inevitable
result must be that the average cost of those who remained would be
augmented, so that the pecuniary result to the parishes in the county
would be much the same. The actual cost of an individual patient, if all
things are taken into calculation, is often three or four times greater
than the average. Leaving out of consideration the welfare of the
patients, it would be obviously unfair to the community, that a parish
having four patients in the asylum, the actual cost of two of whom was
12_s._ a week, and of the other two only 4_s._ a week, should be allowed
to remove the two who cost the smaller sum, and be still permitted to
leave the other two at the average charge of 8_s._"
The conclusion of the whole matter is, that _cæteris paribus_, _i. e._
supposing workhouses to be equally fitting receptacles for the insane as
asylums, the differential cost of the two can only be estimated when it is
ascertained that the items of maintenance are alike in the two, and after
that an allowance is made for the different characters of their population
and of their original purpose; that is, in the instance of workhouses, for
the very large number of juvenile paupers; for the great fluctuations in
the residents; for the mixed character of their inmates, of sane and
insane together, and the small proportion of insane, and for the exclusion
of the most expensive classes of such patients. Let these matters be
fairly estimated, and we doubt much if, even _primâ facie_, it can be
shown that the workhouse detention of pauper lunatics is more economical
than that of properly constructed and organized asylums.
Should we even be so far successful as to make Poor-Law Guardians and
Overseers perceive that the common rough-and-ready mode of settling the
question of relative cost in asylums and workhouses, by contrasting the
calculated rate per head for in-door relief with that for asylum care, is
not satisfactory; we cannot cherish the flattering hope that they will be
brought to perceive that, simply in an economical point of view, no saving
at all is gained by the detention of the insane in workhouses. Those
Poor-Law officials generally are so accustomed to haggle about fractional
parts of a penny in voting relief, to look at an outlay of money only
with reference to the moment, forgetful of future retribution for false
economy, and to handle the figures representing in their estimate the
economical superiority of the workhouse for the insane, when they desire
to silence an opponent;--that the task of proving to them that their
theory and practice are wrong, is equivalent to the infelicitous endeavour
to convince men against their will.
Still, however unpromising our attempt may appear, it is not right to
yield whilst any legitimate arguments are at hand; and our repertory of
them, even of those suited to a contest concerning the pounds, shillings,
and pence of the matter, is not quite exhausted; for we are prepared to
prove, that asylum accommodation can be furnished to the lunatic poor at
an outlay little or not at all exceeding that for workhouses.
Now this point to be argued, the cost of asylum construction, is not, like
the foregoing considerations, chiefly the affair of Poor-Law Guardians and
Overseers, but concerns more particularly the County Magistrates, inasmuch
as it is defrayed out of the County instead of the Poor Rate. But although
this is the case, there is no doubt that the very great expense of
existing asylums has acted as an impediment to the construction of others,
and has seemed to justify, to a certain extent, the improper detention of
many insane persons in workhouses: for, on one side, asylums are found to
have cost for their construction and fittings, £150, £200, and upwards per
head, whilst on the other, workhouses are built at the small outlay, on an
average, of eighty-six such establishments, of £22 per head. The "Return"
made to the House of Commons, June 15, 1857, "of the cost of building
Workhouses in England and Wales, erected since 1840," shows indeed a very
wide variation of cost in different places, from £13 per head for the
Congleton Union House; £14 for the Erpingham; £16 for the Stockton and
Tenterden, to £47 for the Kensington; £50 for the Dulverton; £59 for the
City of London; £60 for St. Margaret Westminster; and £113 for the
Paddington. This enormous difference of expenditure on workhouse
lodging,--for, unlike asylum costs, it does not include fittings,
extending from £13 to £113 per inmate,--is really inexplicable, after
allowing for the varying ideas of parish authorities as to what a
workhouse should be, and for the slight differences in the cost of
building materials and labour in some parts of the country than in others.
Either some workhouses must be most miserable and defective habitations
even for paupers, or others must be very extravagant and needlessly
expensive in their structure.
There is this much to be said in explanation of the contrast of cost in
different workhouses, that in those belonging to large town populations,
infirmary accommodation becomes an item of importance and involves
increased expenditure, whilst in those situated in agricultural districts,
this element of expense is almost wanting. Moreover it is in town
workhouses generally that lunatic inmates are found, who, if not in the
infirmary, are lodged in special wards, often so constructed as to meet
their peculiar wants, and therefore more costly than the rest of the
institution occupied by the ordinary pauper inmates. This is the same with
saying that where workhouses are used as receptacles for the insane, it
greatly enhances the cost of their construction.
It will be evident to every thinking person that the costs of asylum and
of workhouse construction are not fairly comparable. The asylum is a
special building; an instrument of treatment; peculiarly arranged for an
invalid population, affording facilities for classification, recreation,
and amusements; and fitted with costly expedients for warming and
ventilation; whereas the workhouse is essentially a refuge for the
destitute, necessarily made not too inviting in its accommodation and
internal arrangements; suited to preserve the life of sound inmates who
need little more than the shelter of a roof and the rude conveniences the
majority of them have been accustomed to. Now these very characteristics
of workhouses are among the best arguments against the detention of
lunatics within these buildings; but of these hereafter.
There is doubtless a permissible pride in the ability to point to a
well-built asylum, commanding attention by its dimensions and
architectural merits, and we would be the last to decry the beauties and
benefits of architecture, and know too, that an ugly exterior may cost as
much or more than a meritorious one; yet we must confess to misgivings
that there has been an unnecessary and wasteful expenditure in this
direction. Nevertheless it is with asylums as with railways, the present
race of directors are reaping instruction from the extravagances and
errors its predecessors fell into.
The change of opinion among all classes respecting the character and wants
of the insane and their mode of treatment, is of itself so great, that
many of the structural adaptations and general dispositions formerly made
at great cost, are felt to be no longer necessary, and the very correct
and happy persuasion daily gains ground, that the less the insane are
dealt with as prisoners, and treated with apprehension and mistrust, the
more may their accommodation be assimilated to that of people in general,
and secured at a diminished outlay.
All this suggests the possibility of constructing asylums at a much less
cost than formerly, and of thereby lessening the force of one of the best
pleas for using workhouses as receptacles for the insane. The possibility
of so doing has been proved both theoretically and practically. In an
essay 'On the Construction of Public Asylums,' published in the "Asylum
Journal" for January 1858 (vol. iv. p. 188), we advocated the separation
of the day- from the night-accommodation of patients, and the abolition of
the system of corridors with day- and sleeping-rooms, or, as we briefly
termed it, "the ward-system," and showed that by so doing a third of the
cost of construction might be saved, whilst the management of the
institution would be facilitated, and the position of the patients
improved. By a careful estimate, made by a professional architect, with
the aid of the necessary drawings, for a building of considerable
architectural pretension, it was calculated that most satisfactory,
cheerful, and eligible accommodation could be secured, including
farm-buildings, and fittings for warming, ventilation, drainage, gas, &c.,
at the rate of £90 per head for patients of all classes, or at one-half of
the ordinary cost.
Experience has shown that chronic lunatics, at least, can be accommodated
in an asylum at a lower rate, in fact, at little more than half the
expense that we calculated upon.
Like other County Asylums, the Devon became filled with patients; still
they came, and after attempts to cram more into the original edifice, by
slight alterations, and by adding rooms here and there, it was at length
found necessary to make a considerable enlargement. Instead of adding
floors or wings to the old building, which would have called for a
repetition of the same original expensive construction of walls, and of
rooms and corridors, the Committee, with the advice of their excellent
physician, wisely determined to construct a detached building on a new
plan, which promised every necessary convenience and security with
wonderful cheapness; and, for once in a way, an architect's cheap estimate
was not exceeded. Instead of £200 or £250 per head, as of old,
accommodation was supplied at the rate of £38: 10_s._ per patient,
including fittings for all the rooms and a kitchen:--a marvel, certainly,
in asylum construction, and one which should have the effect of reviving
the hopes and wishes of justices, once at least so laudably entertained,
to provide in County Asylums for _all_ pauper lunatics of the county.
It is only fair to remark, that, as Dr. Bucknill informs us (Asylum
Journal, 1858, p. 323), this new section of the Devon Asylum is dependent
on the old institution for the residences of officers, for chapel,
dispensary, store-rooms, &c. "It is difficult," writes Dr. Bucknill, "to
estimate the proportion which these needful adjuncts to the wards of a
complete asylum bear to the expense of the old building; they can
scarcely, however, be estimated at so high a figure as one-eighth of the
whole." But, as a set-off against the increased cost per patient involved
in supplying the necessary offices described by Dr. Bucknill, we may
mention that there are twenty single sleeping-rooms provided in the
building, and that a greater cost was thereby entailed, than many would
think called for, where only chronic, and generally calm patients, were to
be lodged.
These illustrations of what may be done in the way of obtaining good
asylum accommodation for pauper lunatics at no greater rate, we are
persuaded, than that incurred in attempting to provide properly for them
in workhouses, furnish a most valid reason for discontinuing their
detention in the latter, and the more so, if, as can be demonstrated, they
are unfit receptacles for them.
The possibility of constructing cheap asylums being thus far proved, the
question might be put, whether the internal cost of such institutions
could not be lessened? We fear that there is not much room for reform in
this matter, if the patients in asylums are rightly and justly treated,
and the officers and attendants fairly remunerated. In producing power, an
asylum exceeds a workhouse, and therein derives an advantage in
diminishing expenditure and the cost of maintenance. On the other hand,
the expenditure of a workhouse is much less in salaries, particularly in
those given to its medical officer and servants, a form of economy which
will never repay, and, we trust, will never be tried in asylums. Warming,
ventilation, and lighting are less thought of, little attempted, and
therefore less expensive items in workhouse than in asylum accounts. With
respect to diet and clothing, workhouses ought to exhibit a considerable
saving; but this saving is rather apparent than real, and certainly in the
wrong direction; for lunatics of all sorts require a liberal dietary, warm
clothing, and, from their habits frequently, more changes than the
ordinary pauper inmates; yet these are provisions, which, except there is
actual sickness or marked infirmity, the insane living in a workhouse do
not enjoy; for they fare like the other inmates, are clothed the same, and
are tended or watched over by other paupers; the saving, therefore, is at
the cost of their material comfort and well-being. Excepting, therefore,
the gain to be got by the labours of the patients, there is no set-off in
favour of asylum charges; in short, in other respects none can be obtained
without inflicting injury and injustice. On the other hand, workhouse
expenditure need be raised if the requisite medical and general treatment,
nursing, dietary, employment, and recreation are to be afforded; which is
the same as saying, that workhouses, if receptacles for the insane at all,
should be assimilated to asylums,--a principle, which, if admitted and
acted upon, overturns at once the only argument for their use as such,
viz. its economy.
The perception on the part of parochial authorities, that something more
than the common lodging and attendance of the workhouse is called for by
the insane inmates, has led to the construction of "Lunatic Wards" for
their special accommodation, a scheme which may be characterized as an
extravagant mistake, whether viewed in reference to economical principles
or the welfare of the patients. If structurally adapted to their object,
they must cost as much as a suitable asylum need; and if properly
supervised and managed, if a sufficient dietary be allowed, and a proper
staff of attendants hired, no conceivable economical advantage over an
asylum can accrue. On the contrary, as Dr. Bucknill has remarked (Asylum
Journal, vol. iv. p. 460), any such attempts at an efficient management of
the insane in small and scattered asylums attached to Union Workhouses,
will necessarily increase their rate of maintenance above that charged in
a large central establishment, endowed with a more complete organization
and with peculiar resources for their management.
Dr. Bucknill returns to the discussion of this point in his just published
report (Rep. Devon Asylum, 1858, p. 11). He puts the question, "Would a
number of small asylums, under the denomination of lunatic wards, be more
economical than one central asylum?" and, thus proceeds to reply to
it:--"The great probability is that they would not be; 1st, on account of
the larger proportion of officials they would require; 2nd, on account of
the derangement they would occasion to the severe economy which is
required by the aim and purpose of union-houses as tests of destitution.
Where lunatics do exist in union-houses in consequence of the want of
accommodation in the County Asylum, the Commissioners in Lunacy insist
upon the provision of what they consider things essential to the proper
care of insane persons wherever they be placed. The following are the
requirements which they insisted upon as _essential_ in the Liverpool
Workhouse:--a sufficient staff of responsible paid nurses and attendants;
a fixed liberal dietary sanctioned by the Medical Superintendent of the
asylum; good and warm clothing and bedding; the rooms rendered much more
cheerful and better furnished; the flagged court-yards enlarged and
planted as gardens; the patients frequently sent to walk in the country
under proper care; regular daily medical visitation; and the use of the
official books kept according to law in asylums. If the direct cost of
such essentials be computed with the indirect cost of their influence upon
the proper union-house arrangements, it will require no argument to prove
that workhouse lunatic wards so conducted would effect no saving to the
ratepayers. The measures needed to provide in the union-house kitchen a
liberal dietary for the lunatic wards and a restricted one for the sane
remainder, to control the staff of paid attendants, to arrange frequent
walks into the country for part of the community, while the other part was
kept strictly within the walls;--these would be inevitable sources of
disturbance to the proper union-house discipline, which would entail an
amount of eventual expenditure not easily calculated."
If, on economical grounds, the system of Lunatic Wards has no evident
merit, none certainly can be claimed for it on the score of its adaptation
to their wants and welfare.
Indeed, the argument for workhouse accommodation, on the plea of economy,
loses all its weight when the well-being of the insane is balanced against
it. For, if there be any value in the universally accepted opinions of
enlightened men, of all countries in Europe, of the requirements of the
insane, of the desirability for them of a cheerful site, of ample space
for out-door exercise, occupation and amusement, of in-door arrangements
to while away the monotony of their confinement and cheer the mind, of
good air, food and regimen, of careful watching and kind nursing, of
active and constant medical supervision and control, or to sum up all in
two words, of efficient medical and moral treatment,--then assuredly the
wards of a workhouse do not furnish a fitting abode for them.
The unfitness of workhouses for the detention of the insane, and the evils
attendant upon it, have been repeatedly pointed out by the Commissioners
in Lunacy in their annual reports, and by several able writers. We were
also glad to see from the report of his speech, on introducing the Lunatic
Poor (Ireland) Bill into the House of Commons, that Lord Naas is strongly
opposed to the detention of the insane in workhouses, and therein agrees
with the Irish Special Lunacy Commissioners (1858, p. 18), who have placed
their opinion on record in these words:--"It appears to us that there can
be no more unsuitable place for the detention of insane persons than the
ordinary lunatic wards of the Union Workhouses." This is pretty nearly the
same language as that used by the English Commissioners in 1844, viz. "We
think that the detention in workhouses of not only dangerous lunatics, but
of all lunatics and idiots whatever, is highly objectionable."
To make good these general statements, we will, at the risk of some
repetition, enter into a few particulars. On the one hand, the presence of
lunatics in a workhouse is a source of annoyance, difficulty, and anxiety
to the official staff and to the inmates, and withal of increased expense
to the establishment. If some of them may be allowed to mix with the
ordinary inmates, there are others who cannot, and whose individual
liberty and comfort must be curtailed for the sake of the general order
and management, and of the security and comfort of the rest.
Some very pertinent observations occur in the Report of the Massachusetts
Lunacy Commission (_op. cit._ p. 166), on the mixing of the sane and
insane together in the State Almshouses, which correspond to our Union
Workhouses. They report that the superintendents "were unanimous in their
convictions that the mingling of the insane with the sane in these houses
operated badly, not only for both parties, but for the administration of
the whole institution." Further on, the Commissioners observe (p. 168),
"By this mingling the sane and insane together, both parties are more
disturbed and uncontrollable, and need more watchfulness and interference
on the part of the superintendent and other officers.... It has a
reciprocal evil effect in the management of both classes of inmates. The
evil is not limited to breaches of order; for there is no security against
violence from the attrition of the indiscreet and uneasy paupers with the
excitable and irresponsible lunatics and idiots. Most of the demented
insane, and many idiots, have eccentricities; they are easily excited and
disturbed; and nothing is more common than for inmates to tease, provoke,
and annoy them, in view of gratifying their sportive feelings and
propensities, by which they often become excited and enraged to a degree
to require confinement to ensure the safety of life.... The mingling of
the state paupers, sane and insane, makes the whole more difficult and
expensive to manage. It costs more labour, watchfulness, and anxiety to
take care of them together than it would to take care of them separately."
These sketches from America may be matched in our own country; and they
truthfully represent the reciprocal disadvantages of mixing the sane and
insane together in the same establishment.
Even supposing the presence of insane in workhouses involved, on the one
hand, no disadvantages to the institutions, or to the sane inmates; yet on
the other, the evils to the lunatic inhabitants would be condemnatory of
it; for the insane necessarily suffer in proportion as the workhouse
accommodation differs from that of asylums; or, inversely, as the
economical arrangements and management of a workhouse approach those of an
asylum. They suffer from many deficiencies and defects in locality and
organization, in medical supervision and proper nursing and watching, in
moral discipline, and in the means of classification, recreation, and
employment.
Workhouses are commonly town institutions; their locality often
objectionable; their structure indifferent and dull; their site and their
courts for exercise confined and small, and their means of recreation and
of occupation, especially out of doors, very limited. Petty officers of
Unions so often figure before the world, and have been so admirably
portrayed by Dickens and other delineators of character, on account of
their peculiarities of manner and practice, that no sketch from us is
needed to exhibit their unfitness as guardians and attendants upon the
insane. As to workhouse nurses, little certainly can be expected from
them, seeing that they are only pauper inmates pressed into the service;
if aged, feeble and inefficient; if young, not unlikely depraved or
weak-minded; always ignorant, and it may be often cruel; without
remuneration or training, and chosen with little or no regard to their
qualifications and fitness.
However satisfactory the structure of the ward and its supervision might
be rendered, its connexion with a Union Workhouse will be disadvantageous
to the good government and order of the establishment, as above noticed,
and detrimental to the welfare of the insane confined in it. Thus it must
be remembered that very many of the lunatic inmates have been reduced to
seek parochial aid solely on account of the distressing affliction which
has overtaken them; before its occurrence, they may have occupied an
honourable and respectable position in society, and, consequently, where
consciousness is not too much blunted, their position among paupers--too
often the subjects of moral degradation--must chafe and pain the
disordered mind and frustrate more or less all attempts at its
restoration. To many patients, therefore, the detention in a workhouse is
a punishment superadded to the many miseries their mental disorder
inflicts upon them; and consequently, when viewed only in this light,
ought not to be tolerated.
Of all cases of lunacy, the wards of a workhouse are least adapted to
recent ones, for they are deficient of satisfactory means of treatment,
whether medical or moral, and the only result of detention in them to be
anticipated, must be to render the malady chronic and incurable. Yet
although every asylum superintendent has reported against the folly and
injury of the proceeding, and notwithstanding the distinct and strong
condemnation of it by the Commissioners in Lunacy, the latter, in their
Report for 1857, have to lament an increasing disposition, on the part of
Union officers, to receive and keep recent cases in workhouses. Moral
treatment we hold to be impossible in an establishment where there are no
opportunities of classification, no proper supervision and attendance, and
no means for the amusement and employment of the mind; but where, on the
contrary, the place and organization are directly opposed to it, and the
prospects of medical treatment are scarcely less unfavourable. An
underpaid and overworked medical officer, in his hasty visits through the
wards of the workhouse daily, or perhaps only three or four times a week,
very frequently without any actual experience among the insane, cannot be
expected to give any special attention to the Pauper Lunatics, who are
mostly regarded as a nuisance in the establishment, to be meddled with as
little as possible, and of whose condition only unskilled, possibly old
and unfeeling pauper nurses, can give any account. Indeed, unless reported
to be sick, it scarcely falls into the routine of the Union medical
officer regularly to examine into the state and condition of the pauper
lunatics. These remarks are confirmed by the statement of the Lunacy
Commissioners, in their 'Further Report,' 1847 (p. 276), that pauper
inmates, "in their character of lunatics merely, are rarely the objects of
any special medical attention and care," and that it "was never found
(except perhaps in a few cases) that the medical officer had taken upon
himself to apply remedies specially directed to the alleviation or cure of
the mental disorder. Nor was this indeed to be expected, as the workhouse
never can be a proper place for the systematic treatment of insanity."
It would unnecessarily extend the subject to examine each point of
management and organization affecting the well-being of the insane in
detail, in order to show how unsuitable in all respects a workhouse must
be for their detention; yet it may be worth while to direct attention to
one or two other matters.
Except when some bodily ailment is apparent, the lunatic fare like the
ordinary inmates; that is, they are as cheaply fed as possible, without
regard to their condition as sufferers from disease, which, because
mental, obtains no special consideration. It is in the power of the
medical officer, on his visits, to order extra diet if he observes any
reason in the general health to call for it; but the dependent position of
this gentleman upon the parish authorities, and his knowledge that extra
diet and its extra cost will bring down upon him the charge of
extravagance and render his tenure of office precarious, are conditions
antagonistic to his better sentiments concerning the advantages of
superior nutriment to his insane patients.
Moreover, the cost of food is a principal item in that of the general
maintenance of paupers, and one wherein the guardians of the poor believe
they reap so great an economical advantage over asylums. But this very
gain, so esteemed by poor-law guardians, is scouted as a mistake and
proved an extravagance, _i. e._ if the life and well-being of the poor
lunatics are considered, by the able superintendents of County Asylums.
Dr. Bucknill has well argued this matter in a paper "On the Custody of the
Insane Poor" (Asylum Journal, vol. iv. p. 460), and in the course of his
remarks says,--"The insane cannot live on a low diet; and while they
continue to exist, their lives are rendered wretched by it, owing to the
irritability which accompanies mental disease. The assimilating functions
in chronic insanity are sluggish and imperfect, and a dietary upon which
sane people would retain good health, becomes in them the fruitful source
of dysentery and other forms of fatal disease."
In his just published Report, already quoted, the same excellent physician
remarks (p. 9),--"A good diet is essential to the tranquil condition of
many idiots and chronic lunatics, and is, without doubt, a principal
reason why idiots are easily manageable in this asylum, who have been
found to be unmanageable in union houses. The Royal Commission which has
recently reported on the Lunatic Asylums in Ireland states this fact
broadly, that 'the ordinary workhouse dietary is unsuited and insufficient
for any class of the insane.' It is therefore my opinion, founded upon the
above considerations, that neither the lunatics nor the idiots in the list
presented are likely to retain their present state of tranquillity, and to
be harmless to themselves and others, if they are placed in union houses,
unless they are provided with those means which are found by experience to
ensure the tranquillity of the chronic insane, and especially with a
sufficient number of trustworthy attendants, and with a dietary adapted to
their state of health. I have thought it desirable to ascertain the
practice of charitable institutions especially devoted to the training of
idiots, and I find that a fuller dietary is used in them than in this
asylum."
Until a recent date, it was the custom in workhouses, with few exceptions,
to allow most of their insane inmates to mingle with the ordinary pauper
inmates of the same age and sex, and in general to be very much on the
same footing with them "in everything that regards diet, occupation,
clothing, bedding, and other personal accommodation" (Report, 1847, p.
276).
This mingling of the sane and insane, having been found subversive of good
order and management, gave rise first to the plan of placing most of the
latter class in particular wards, many of them in the infirmary, and,
subsequently, owing to the advance of public opinion respecting the wants
of the insane, to the construction, in many unions, of special lunatic
wards, emulating more or less the character and purposes of asylums. The
false economy of this plan has been already exposed; and although the
Lunacy Commissioners have always set their faces against lunatic wards,
yet their construction has of late been so rapid as to call forth a more
energetic denunciation of it:--"Impressed strongly (the Commissioners
write, Report, 1857, p. 17) with a sense of their many evils, it became
our duty, during the past year, to address the Poor-Law Board against the
expediency of affording any encouragement or sanction to the further
construction, in connexion with Union Workhouses, of lunatic wards."
The evils of lunatic wards, alluded to in the last-quoted paragraph, are
thus enlarged upon in another page of the same Report (p. 15):--"It is
obvious that the state of the workhouses, as receptacles for the insane,
is becoming daily a subject of greater importance. They are no longer
restricted to such pauper lunatics as,--requiring little more than the
ordinary accommodation, and being capable of associating with the other
inmates,--no very grave objection rests against their receiving. Indeed it
will often happen that residence in a workhouse, under such conditions, is
beneficial to patients of this last-mentioned class; by the inducements
offered, from the example of those around them, to engage in ordinary
domestic duties and occupations, and so to acquire gradually the habit of
restraining and correcting themselves. But these are now unhappily the
exceptional cases. Many of the larger workhouses, having lunatic wards
containing from 40 to 120 inmates, are becoming practically lunatic
asylums in everything but the attendance and appliances which ensure the
proper treatment, and above all, in the supervision which forms the
principal safeguard of patients detained in asylums regularly constituted.
"The result is, that detention in workhouses not only deteriorates the
more harmless and imbecile cases to which originally they are not
unsuited, but has the tendency to render chronic and permanent such as
might have yielded to early care. The one class, no longer associating
with the other inmates, but congregated in separate wards, rapidly
degenerate into a condition requiring all the attendance and treatment to
be obtained only in a well-regulated asylum; and the others, presenting
originally every chance of recovery, but finding none of its appliances or
means, rapidly sink into that almost hopeless state which leaves them
generally for life a burthen on their parishes. Nor can a remedy be
suggested so long as this workhouse system continues. The attendants for
the most part are pauper inmates, totally unfitted for the charge imposed
upon them. The wards are gloomy, and unprovided with any means for
occupation, exercise, or amusement; and the diet, essential above all else
to the unhappy objects of mental disease, rarely in any cases exceeds that
allowed for the healthy and able-bodied inmates."
The subject had previously received their attention, and is thus referred
to in their Ninth Report (p. 38):--"They are very rarely provided with any
suitable occupation or amusement for the inmates. The means of healthful
exercise and labour out of doors are generally entirely wanting, and the
attendants (who are commonly themselves paupers) are either gratuitous, or
so badly organized and so poorly requited, that no reliance can be placed
on the efficiency of their services. In short, the wards become in fact
places for the reception and detention of lunatics, without possessing any
of the safeguards and appliances which a well-constructed and well-managed
lunatic asylum affords. Your Lordship, therefore, will not be surprised to
learn that while we have used our best endeavours to remedy their obvious
defects and to ameliorate as far as possible the condition of their
inmates, we have from the first uniformly abstained from giving any
official sanction or encouragement to their construction."
They further make this general observation:--"So far as the lunatic and
idiotic inmates are concerned, the condition of the workhouses which have
separate wards expressly appropriated to the use of that class, is
generally inferior to that of the smaller workhouses, and in some
instances extremely unsatisfactory."
Dr. Bucknill, whose excellent remarks on lunatic wards in their economical
aspect we have already quoted, has very ably canvassed the question of
their fitness as receptacles for the insane, and, in a paper in the
'Asylum Journal' (vol. iii. p. 497), thus treats on it:--"It is deserving
of consideration, whether the introduction of liberally-conducted lunatic
wards into a Union Workhouse would not interfere with the working of the
latter in its legitimate scope and object. A workhouse is the test of
destitution. To preserve its social utility, its economy must always be
conducted on a parsimonious scale. No luxuries must be permitted within
its sombre walls; even the comforts and conveniences of life must be
maintained in it below the average of those attainable by the industry of
the labouring poor. How can a liberally-conducted lunatic ward be
engrafted upon such a system? It would leaven the whole lump with the
taint of liberality, and the so-called pauper bastile would, in the eyes
of the unthrifty and indolent poor, be deprived of the reputation which
drives them from its portals."
There is a general concurrence among all persons competent to form any
opinion on the matter, that workhouses are most unfit places for the
reception of recent cases of insanity. On the other hand, there is a
prevalent belief that there is a certain class of the insane, considered
"harmless," for whom such abodes are not unsuitable. The Lunacy
Commissioners, in the extract from the Eleventh Report above quoted,
partake in this opinion: let us therefore endeavour to ascertain, as
precisely as we can, the class of patients intended, and the proportion
they bear to the usual lunatic inmates of Union Workhouses.
In their 'Further Report' for 1847, the Commissioners enter into a
particular examination of the characters of the lunatics found in
workhouses, and class them under three heads (p. 257):--1st, those who,
from birth, or from an early period of life, have exhibited a marked
deficiency of intellect as compared with the ordinary measure of
understanding among persons of the same age and station; 2ndly, those who
are demented or fatuous; that is to say, those whose faculties, not
originally defective, have been subsequently lost, or become greatly
impaired through the effects of age, accident, or disease; and 3rdly,
those who are deranged or disordered in mind, in other words, labouring
under positive mental derangement, or, as it is popularly termed,
"insanity." Those in whom epilepsy or paralysis is complicated with
unsoundness of mind, although their case requires a separate
consideration, do not in strictness constitute a fourth class, but may
properly be referred, according to the character of their malady and its
effects upon their mental condition, to one or other of these three
classes.
Further on in the Report, after remarking on the difficulties besetting
their inquiry, they write (p. 274):--
"We believe, however, we are warranted in stating, as the result of our
experience thus far, that of the entire number of lunatics in workhouses,
whom we have computed at 6020 or thereabouts, two-thirds at the least, or
upwards of 4000, would be properly placed in the first of the three
classes in the foregoing arrangement; or, in other words, are persons in
whom, as the mental unsoundness or deficiency is a congenital defect, the
malady is not susceptible of cure, in the proper sense of the expression;
and whose removal to a curative lunatic asylum, except as a means of
relieving the workhouse from dangerous or offensive inmates, can be
attended with little or no benefit.
"A considerable portion of this numerous class, not less, perhaps, than a
fourth of the whole, are subject to gusts of passion and violence, or are
addicted to disgusting propensities, which render them unfit to remain in
the workhouse; and it is the common practice, when accommodation can be
procured, to effect the removal of such persons to a lunatic asylum, where
their vicious propensities are kept under control, and where, if they
cannot be corrected, they at least cease to be offensive or dangerous. But
although persons of this description are seldom fit objects for a curative
asylum, they are in general capable of being greatly improved, both
intellectually and morally, by a judicious system of training and
instruction; their dormant or imperfect faculties may be stimulated and
developed; they may be gradually weaned from their disgusting
propensities; habits of decency, subordination, and self-command may be
inculcated, and their whole character as social beings may be essentially
ameliorated."
The conclusion to be deduced from these extracts is, that one-fourth or
two-thirds, that is, one-sixth of the whole number of occupants in
workhouses of unsound mind, found in 1846, were unfit for those
receptacles, and demanded the provision of institutions in which a moral
discipline could be carried out, and their whole condition, as social
beings, ameliorated and elevated. A further examination of the data
supplied in the same Report will establish the conviction that, besides
the proportion just arrived at, requiring removal to fitting asylums,
there is another one equally large demanding the same provision.
In this number are certainly to be placed all those of the third class
"labouring under positive mental derangement," and who, although reported
as "comparatively few" in 1846, have subsequently been largely multiplied,
according to the evidence of the 'Eleventh Report' (_ante_, p. 56). Those,
again, "in whom epilepsy or paralysis is complicated with unsoundness of
mind," are not suitable inmates for workhouse wards. No form of madness is
more terrible than the furor attendant on epileptic fits; none more
dangerous; and, even should the convulsive affection have so seriously
damaged the nervous centres that no violence need be dreaded, yet the
peril of the fits to the patient himself, and their painful features,
render him an unfit inmate of any other than an establishment provided
with proper appliances and proper attendants. As to the paralytic insane,
none call for more commiseration, or more careful tending and
nursing--conditions not commonly to be found in workhouses.
The Commissioners in Lunacy have not omitted the consideration of
workhouses as receptacles for epileptics and paralytics, and have arrived
at the following conclusions:--After treating, in the first place, of
epileptics whose fits are slight and infrequent, and the mental
disturbance mild and of short duration, they observe that, as such persons
"always require a certain amount of supervision, and as they are quite
incompetent, when the fits are upon them, to take care of themselves, and
generally become violent and dangerous, it would seem that the workhouse
can seldom be a suitable place for their reception, and that their
treatment and care would be more properly provided for in a chronic
hospital especially appropriated to the purpose."
Concerning paralytics, they state that they are far less numerous than
epileptics, and being for the most part helpless and bedridden, are
treated as sick patients in the infirmary of the workhouse. Their opinion
is, however, that a chronic hospital would be a more appropriate
receptacle for them,--a conclusion in which all must coincide, who know
how much can be done to prolong and render more tolerable their frail and
painful existence, by good diet and by assiduous and gentle nursing,--by
such means, in short, as are not to be looked for in establishments where
rigid economy must be enforced, and pauper life weighed against its cost.
To turn now to the second class of workhouse Lunatic Inmates, the demented
from age, accident, or disease: these, we do not hesitate to say, are not
suitably accommodated in workhouses, for, like the paralytic, they require
careful supervision, good diet and kind nursing; they are full-grown
children, unable to help or protect themselves, to control their habits
and tendencies; often feeble and tottering, irritable and foolish, and,
without the protection and kindness of others, the helpless subjects of
many ills. For such, the whole organization of the workhouse is unsuited;
even the infirmary is not a fitting refuge; for, on the one hand, they are
an annoyance to the other inmates, and, on the other, pauper nurses--whose
office is often thrust upon them without regard to their fitness for
it,--are not fitting guardians for them. In fine, where age, accident or
disease has so deteriorated the mental faculties, we have a complication
of physical and mental injury to disqualify the patient from partaking
with his fellow-paupers in the common accommodation, diet, and nursing.
In the reverse order which we have pursued, the first class of congenital,
imbecile, and idiotic inmates comes to be considered last. This happens by
the method of exclusion adopted in the argument; for the second and third
classes have been set aside as proper inmates of some other institution
than a workhouse, and it now remains to inquire, who among the
representatives of the first class are not improperly detained in
workhouses. This class includes, as already seen, some two-thirds of the
whole number of inmates mentally disordered; and among whom, we presume,
are to be found those individuals who may, in the Commissioners' opinion,
mix advantageously with the general residents of the establishment. The
number of the last cannot, we believe, be otherwise than very small; for
the very supposition that there is imbecility of mind, is a reason of
greater or less force, according to circumstances, for not exposing them
to the contact of an indiscriminate group of individuals, more especially
of that sort to be generally found in workhouses. The evils of mingling
the sane and insane in such establishments have already been insisted
upon; and besides these, such imbecile patients as are under review, lack
in workhouses those means of employment and diversion which modern
philanthropy has suggested to ameliorate and elevate their physical and
moral condition.
Lastly, if the remaining members of this class be considered, in whom the
imbecility amounts to idiocy, the propriety of removing them from the
workhouse will be questioned by few. Indeed, will any one now-a-days
advocate the "_laissez faire_" system in the case of idiots? Experience
has demonstrated that they are improveable, mentally, morally, and
physically; and if so, it is the duty of a christian community to provide
the means and opportunities for effecting such improvement. It cannot be
contended that the workhouse furnishes them; on the contrary, it is
thoroughly defective and objectionable by its character and arrangements,
and, as the Commissioners report, (_op. cit._ p. 259) a very unfit abode
for idiots.
On looking over the foregoing review of the several classes of lunatic
inmates of workhouses distinguished by the Commissioners in Lunacy, the
opinion to be collected clearly is, that only a very few partially
imbecile individuals among them are admissible into workhouses, if their
bodily health, their mental condition, their due supervision and their
needful comforts and conveniences are to be duly attended to and provided
for. In accordance with the views we entertain, as presently developed, of
the advantages of instituting asylums for confirmed chronic, quiet, and
imbecile patients, we should permit, if any at all, only such imbecile
individuals as residents in workhouses, who could pass muster among the
rest, without annoyance, prejudice or discomfort to themselves or others,
and be employed in the routine occupations of the establishment.
So much is heard among poor-law guardians and magistrates about a class of
"harmless patients" suitably disposed of in workhouses and rightly
removeable from asylums, that a few remarks are called for concerning
them. To the eye of a casual visitor of an asylum, there does certainly
appear a large number of patients, so quiet, so orderly, so useful and
industrious, that, although there is something evidently wrong about their
heads, yet the question crosses the mind, whether asylum detention is
called for in their case. The doubt is not entertained by the experienced
observer, for he knows well that the quiet, order, and industry observable
are the results of a well-organized system of management and control; and
that if this fails, the goodly results quickly vanish to be replaced by
the bitter fruits generated by disordered minds. The "harmless" patient of
the asylum ward becomes out of it a mischievous, disorderly, and probably
dangerous lunatic. In fact, the tranquillity of many asylum inmates is
subject to rude shocks and disturbances, even under the care and
discipline of the Institution; and the inoffensive-looking patient of
to-day may, by his changed condition, be a source of anxiety, and a
subject for all the special appliances it possesses, to-morrow.
Any Asylum Superintendent would be embarrassed to select a score of
patients from several hundred under his care whom he could deliberately
pronounce to be literally "harmless" if transferred to the workhouse. He
might be well able to certify that for months or years they have gone on
quietly and well under the surrounding influences and arrangements of the
asylum, but he could not guarantee that this tranquillity should be
undisturbed by the change to the wards of the workhouse; that untrained
attendants and undesirable associates should not rekindle the latent
tendency to injure and destroy; that defective organization and the
absence of regular and regulated means of employment and recreation should
not revive habits of idleness and disorder; or that a less ample dietary,
less watchfulness and less attention to the physical health, should not
aggravate the mental condition and engender those disgusting habits, which
a good diet and assiduous watching are known to be the best expedients to
remedy.
Dr. Bucknill has some very cogent remarks on this subject in his last
Report of the Devon Asylum (p. 6). "The term 'harmless patients,' or in
the words of the statute, those 'not dangerous to themselves or others'
(he writes), I believe to be inapplicable to any insane person who is not
helpless from bodily infirmity or total loss of mind: it can only with
propriety be used as a relative term, meaning that the patient is not so
dangerous as others are, or that he is not known to be refractory or
suicidal. It should not be forgotten, that the great majority of homicides
and suicides, committed by insane persons, have been committed by those
who had previously been considered harmless; and this is readily explained
by the fact, that those known to be dangerous or suicidal are usually
guarded in such a manner as to prevent the indulgence of their
propensities; whilst the so-called harmless lunatic or idiot has often
been left without the care which all lunatics require, until some mental
change has taken place, or some unusual source of irritation has been
experienced, causing a sudden and lamentable event. In an asylum such
patients may truly be described as not dangerous to themselves or others,
because they are constantly seen by medical men experienced in observing
the first symptoms of mental change or excitement, and in allaying them by
appropriate remedies; they are also placed under the constant watchfulness
and care of skilful attendants, and they are removed from many causes of
irritation and annoyance to which they would be exposed if at large, in
villages or union houses.
"It not unfrequently happens that idiots who have lived for many years in
union houses, and have always been considered harmless and docile, under
the influence of some sudden excitement, commit a serious overt act, and
are then sent to an asylum. One of the most placid and harmless patients
in this asylum, who is habitually entrusted with working tools, is a
criminal lunatic, of weak intellect, who committed a homicide on a boy,
who teased him while he was breaking stones on the road. If this is the
case with those suffering only from mental deficiency, it is evidently
more likely to occur in those suffering from any form of mental disease,
which is often liable to change its character, and to pass from the form
of depression to one of excitement. For these reasons I am convinced that
all lunatics, and many strong idiots, can only be considered as 'not
dangerous to themselves or others,' when they are placed under that amount
of superintendence and care which it has been found most desirable and
economical to provide for them in centralized establishments for the
purpose.
"For the above reasons, I am unable to express the opinion that any insane
patients who are not helpless from bodily infirmity or total loss of mind
are _unconditionally_ harmless to themselves and others. I have, however,
made out a list of sixty patients who are incurable, and who are likely,
_under proper care_, to be harmless to themselves and others.
"Of the patients in this list who are lunatic, only nine have sufficient
bodily strength to be engaged in industrial pursuits. The remaining
twenty-three are so far incapacitated by the infirmities of old age, or by
bodily disease, or by loss of mental power, that they are unable to be
employed, and require careful nursing and frequent medical attendance. The
patients who have sufficient bodily strength to be employed, are also with
the least degree of certainty to be pronounced harmless to themselves and
others. As the result of long training, they willingly and quietly
discharge certain routine employments under proper watch; but it is
probable, that if removed from their present position, any attempts made
to employ them by persons unaccustomed to the peculiarities of the insane,
will be the occasion of mental excitement and danger.
"The twenty-eight idiots have, with few exceptions, been sent to the
asylum from union houses, where it has been found undesirable to detain
them, on account either of their violent conduct, or of their dirty
habits, or some other peculiarity connected with their state of mental
deficiency; habits of noise or indecency for instance."
Probably the following extract from the Report of the Committee of the
Surrey Asylum (1856) may have more weight with some minds than any of the
arguments and illustrations previously adduced, to prove that the
detention of presumed "harmless patients" in workhouses will not answer.
The declaration against the plan on the part of the Surrey magistrates is
the more important, because they put it into practice with the persuasion
that it would work well. But to let them speak for themselves, they
write,--"The committee adverted at considerable length in their last
Annual Report to the circumstance of the asylum being frequently unequal
to the requirements of the County, and of their intention to attempt to
remedy the defect by discharging all those patients, who, being harmless
and inoffensive, it was considered might be properly taken care of in
their respective union houses.
"The plan has been tried, and has not been successful. Patients who, under
the liberal and gentle treatment they experience in the asylum, are quiet
and tractable, are not necessarily so under the stricter regulations of a
workhouse; indeed, so far as the experiment has been tried, the reverse
has been found to be the case; most of the patients so discharged having
been shortly afterwards returned to the asylum, or placed in some other
institution for the insane, in consequence of their having become, with
the inmates of the workhouse, 'a mutual annoyance to each other.' Any
arrangement, short of an entire separation from the other inmates of the
workhouse, will be found to be inefficient." This is the same as saying
that if lunatics are to reside in workhouses, a special asylum must be
instituted in the establishment for their care, and the comfort and safety
of the other inmates.
If the well-being of the insane were the only question to be settled, no
difficulty would attend the solution, for experience has most clearly
evidenced the vast advantages of asylums over workhouses as receptacles
for insane patients, whatever the form or degree of their malady. Dr.
Bucknill has some very forcible remarks in his paper on "The Custody of
the Insane Poor" (Asylum Journal, vol. iv. p. 460), with illustrative
cases; and in his Report last quoted, reverts to this subject of the
relative advantages of asylums and workhouses; but we forbear to quote, if
only from fear of being thought to enlarge unduly upon a question which
has been decided long ago by the observation and experience of all those
concerned in the management of the pauper insane; viz. that whatever the
type and degree of mental disorder and of fatuity, its sufferers become
improved in properly managed asylums, as intellectual, moral, and social
beings upon removal from workhouses; and by a reverse transfer, are
deteriorated in mind, and rendered more troublesome and more costly. To
the workhouse the lunatic ward is an excrescence, and its inmates an
annoyance: in its organization, there is an absence or deficiency of
almost all those means conducive to remedy or remove the mental infirmity,
and the very want of which contributes as much as positive neglect and
maltreatment to render the patient's condition worse, by lowering his
mental and moral character. But such deterioration or degradation is not
an isolated evil, or the mere negation of a better state; for it acts as a
positive energy in developing moral evil, and brings in its train
perverseness, destructiveness, loss of natural decency in habits,
conversation and conduct, and many other ills which render their subjects
painfully humiliating as human beings, and a source of trouble, annoyance,
and expense to all those concerned with them.
In a previous page we have sought to determine what was the proportion of
lunatic inmates found by the Lunacy Commissioners in workhouses considered
to be not improperly detained in them, and have estimated it at one-half
of the whole number. The foregoing examination, however, of the adaptation
of workhouses for the several classes of lunatics distinguishable, leads
to the conviction that a very much less proportion than one-half ought to
be found in those establishments. For our own part, we would wish to see
the proportion reduced by the exclusion of most of its component members,
reckoned as "harmless" patients; a reduction which would well nigh make
the proportion vanish altogether. What is to be done with the lunatics
removed from workhouses, is a question to be presently investigated.
But before proceeding further, some consideration of the legal bearings of
workhouse detention of lunatics is wanting, for it has been advanced by
some writers that such detention is illegal.
Now, in the first place, it must be admitted that a workhouse is not by
law, nor in its intent and purpose, a place of imprisonment or detention.
Its inmates are free to discharge themselves, and to leave it at will when
they no longer stand in need of its shelter and maintenance. Whilst in it,
they are subject to the general rules of workhouse-government, and to a
superior authority, empowered, if not by statute, yet by orders of the
Poor-Law Board, or by Bye-Laws of the Guardians, to exercise discipline by
the enforcement of penalties involving a certain measure of punishment.
Temporary seclusion in a room may be countenanced, although not positively
permitted by law; but prolonged confinement, the deprivation of liberty,
and a persistent denial of free egress from the house, are proceedings
opposed to the true principles of English law.
Yet it may be that a plea for their detention might be sustained in the
case of sick or invalid patients (with whom the insane would be numbered)
under certificate of the parochial medical officer, provided no friend
came forward to guarantee their proper care, or that they could not show
satisfactorily the means of obtaining it; for, of such cases, the
workhouse authorities may be considered the rightful and responsible
guardians, required in the absence of friends to undertake their charge
and maintenance. Upon such grounds, probably, cause might be shown for the
detention of the greater part of workhouse lunatic inmates, although there
is no Act of Parliament explicitly to sanction it. Should such a plea be
admitted, the notion, entertained by Dr. Bucknill, that an action would
lie for false imprisonment against the Master and Guardians of the
workhouse, would be found erroneous.
The Lunacy Commissioners presented some remarks on this question,
indicating a similar view to that just advanced in their 'Further Report,'
1847. For instance (p. 287, _op. cit._), they observed:--
"How far a system of this kind, which virtually places in the hands of the
masters, many of whom are ignorant, and some of whom maybe capricious and
tyrannical, an almost absolute control over the personal liberty of so
many of their fellow men, is either warranted by law, or can be wholesome
in itself, are questions which seem open to considerable doubt. Probably
if the legality of the detention came to be contested before a judicial
tribunal in any individual case, the same considerations of necessity or
expediency which originally led to the practice, might be held to justify
the particular act, provided it were shown that the party complaining of
illegal detention could not be safely trusted at large, and that his
detention, therefore, though compulsory, instead of being a grievance, was
really for his benefit as well as that of the community."
Again, in the second place, the law, without direct legislation to that
effect, yet admits,--by the provisions it makes for pauper lunatics not in
asylums or licensed houses, and by the distinction it establishes between
persons proper to be sent to an asylum, and lunatics generally
so-called,--that insane patients may be detained elsewhere than in
asylums. For instance, by _sect._ lxvi. 16 & 17 Vict. cap. 97, 1853,
provision is made for a quarterly visit by the Union or Parish Medical
Officer to any Pauper Lunatic _not being_ in a Workhouse, Asylum,
Registered Hospital, or Licensed House, in order that he may ascertain how
the lunatic is treated, and whether he "may or may not properly remain out
of an asylum." So likewise by _sect._ lxiv. of the same Act, the clerk or
overseers are required to "make out and sign a true and faithful list of
all lunatics chargeable to the Union or Parish in the form in schedule
(D)." This form is tabular, and presents five columns, under the heading
of "where maintained," of which three are intended for the registry of the
numbers not confined in Asylums, Hospitals, and Licensed Houses, but who
are (1) in workhouses, (2) in lodgings, or boarding out, or (3) residing
with relatives.
Further, the law distinguishes, by implication, a class of lunatics as
specially standing in need of Asylum care, and as distinct from others. By
the Poor-Law Amendment Act (4 & 5 Will. IV. cap. 76. sect. 45), it is
ordered that nothing in that Act "shall authorize the detention in any
workhouse of any dangerous lunatic, insane person, or idiot for any longer
period than fourteen days; and every person wilfully detaining in any
workhouse any such lunatic, insane person, or idiot for more than fourteen
days, shall be deemed guilty of a misdemeanour." This section is still in
force, is constantly acted upon by the Poor-Law Board, and is legally so
read as if the word 'dangerous' were repeated before the three divisions
of mentally-disordered persons referred to, viz. lunatics, insane persons,
and idiots. So, likewise, by _sect._ lxvii. (16 & 17 Vict. cap. 97)--the
"Lunatic Asylums' Act, 1853," now in operation,--the transmission of an
insane individual to an asylum is contingent on the declaration that he is
"a lunatic and a _proper person to be sent to an asylum_."
Moreover, by _sect._ lxxix. of the same Act, it is competent to any three
Visitors of an asylum, or to any two in conjunction with the Medical
Officer of the asylum, to discharge on trial for a specified time "any
person detained in such asylum, whether such person be recovered or not;"
and by the following section (lxxx.) it is ordered, that, upon receipt of
the notice of such discharge, "the Overseers or Relieving Officers
respectively shall cause such lunatic to be forthwith _removed to_ their
parish, or to the _workhouse of the Union_." By the 79th section it is
further provided, that "in case any person so allowed to be absent on
trial for any period do not return at the expiration of such period, and a
medical certificate as to his state of mind, certifying that his detention
in an Asylum is no longer necessary, be not sent to the Visitors, he may,
at any time, within fourteen days after the expiration of such period, be
retaken, as herein provided in the case of an escape."
On the other hand, simple removal from an asylum is by the 77th section,
curiously enough interdicted except to another asylum, a Registered
Hospital, or a Licensed House. This intent, too, of the section is not
changed by the amendment, _sect._ viii. 18 & 19 Vict. cap. 105. Lastly, no
other place than an Asylum, Registered Hospital, or Licensed House, is
constituted lawful by _sect._ lxxii. for the reception of any person found
lunatic and under "order by a Justice or Justices, or by a Clergyman and
Overseer or Relieving Officer, to be dealt with as such." But this section
has to be read in connexion with preceding ones, for instance, with
_sect._ lvii., by which it is laid down that the Justices or other legal
authority must satisfy themselves not only that the individual is a
lunatic, but also that he is "a proper person to be sent to an asylum."
These quotations indicate the state of the law respecting the detention of
lunatics elsewhere than in asylums. This state cannot be held to be
satisfactory: it evidently allows the detention of lunatics in workhouses,
while at the same time it affords them little protection against false
imprisonment, and makes no arrangement for their due supervision and care,
except by means of the visits of the Lunacy Commissioners, which are only
made from time to time, not oftener than once a year, and rarely so often.
The alleged lunatics are for the most part placed and kept in confinement
without any legal document to sanction the proceeding; without a
certificate of their mental alienation, and without an order from a
magistrate. Within the workhouse, they are, unless infirm or sick, treated
like ordinary paupers, save in the deprivation of their liberty of exit;
they may be mechanically restrained, or placed in close seclusion by the
order of the master, who is likely enough to appreciate the sterner means
of discipline and repression, but not the moral treatment as pursued in
asylums; and, lastly, they live deprived of all those medical and general
measures of amelioration and recovery as here before sketched.
An extract from the 'Further Report' of the Commissioners in Lunacy will
form a fitting appendix to the observations just made. It occurs at p. 287
(_op. cit._), and stands thus:--
"It certainly appears to be a great anomaly, that while the law, in its
anxiety to guard the liberty of the subject, insists that no persons who
are insane--not even dangerous pauper lunatics--shall be placed or kept in
confinement in a lunatic asylum without orders and medical certificates in
a certain form, it should at the same time be permitted to the master of a
workhouse forcibly to detain in the house, and thus to deprive of personal
liberty, any inmate whom, upon his own sole judgment and responsibility,
he may pronounce to be a person of unsound mind, and therefore unfit to be
at large."
It is unsatisfactory that the law recognizes the distinction between
dangerous and other lunatics, designated as "harmless;" for we have
pointed out that no such rigid separation can be made; that it is with
very few exceptions impracticable to say with certainty what patients are
harmless and what not, inasmuch as their state is chiefly determined by
surrounding conditions, by the presence or absence of moral control and
treatment. It is likewise to be regretted that so much is left to the
discretion of relieving officers and overseers, in the determination of
the lunatics "proper to be sent to an asylum;" for those parish
functionaries nearly always display a proclivity, where relief is to be
afforded, to any plan which at first sight promises to be the most cheap;
and hence it is, as remarked in previous pages, they think to serve the
rate-payers best by keeping, if practicable, the insane in workhouses. The
expediency of asylum treatment for those who claim it, is surely not a
question to be determined by such officers. Yet the wording of the Act
(_sect._ lxvii.), that, if they have notice from the parish medical
officer of any pauper who "is, or is deemed to be a lunatic, and a proper
person to be sent to an asylum," or if they in any other manner gain
knowledge of a pauper "who is, or is deemed to be a lunatic, and a proper
person to be sent to an asylum, they shall within three days" give notice
thereof to a magistrate,--seems to put the solution of the question pretty
much in their hands. Although when they receive a notice of a pauper
lunatic from the union medical officer, they would appear by _sect._ lxx.
to be bound to apprise a Justice of the matter, yet, in the absence of
such a notice, an equal power in determining on the case is lodged in
their hands as in those of the medical officer, by the phrase "is, or is
deemed to be a lunatic, and a proper person to be sent to an asylum;" for
this clause respecting the fitness of the case, reads with the parts of
the sentence as though it stood thus in full--'is a lunatic and a proper
person to be sent to an asylum, or is deemed a lunatic and a proper person
to be sent to an asylum;' and there is nothing in _sect._ lxx. to enforce,
under these circumstances, a notice being sent to a Justice. It is,
indeed, evidently left to the discretion of the overseer or relieving
officer to report a case of lunacy falling within his own knowledge to a
Justice, for he is empowered to assume the function of deciding whether it
is or is not a proper one for an asylum. Moreover, we cannot refrain from
thinking that a parochial medical officer is not always sufficiently
independent, as a paid _employé_, to certify to the propriety of asylum
care so often as he might do, where the guardians or other directors of
parish affairs are imbued with rigid notions of economy, and hold the
asylum cost for paupers in righteous abhorrence. In fine, were this
enactment for reporting pauper lunatics to County and Borough Justices, in
order to obtain a legal sanction for their detention, sufficiently clear
and rigidly enforced, there would not be so many lunatics in workhouses,
and none of those very unfit ones animadverted upon by the Commissioners
in Lunacy (see p. 25, and 11th Rep. C. L. 1857).
The first clause of _sect._ lxvii. is ambiguous; for though it is
evidently intended primarily to make the Union medical officer the vehicle
of communicating the knowledge of the existence of pauper lunatics in his
parish, yet it is neither made his business to inquire after such
persons, nor when he knows of their existence, to visit and ascertain
their condition. It is left open for him to act upon a report that such a
pauper "is deemed to be a lunatic, and a proper person to be sent to an
asylum," without seeing the individual; but generally he will officially
hear first of such patients through the channel of the relieving officer,
by receiving an order to visit them. Indeed, the relieving officer is
legally the first person to be informed of a pauper requiring medical or
other relief; and, as we have seen, it is competent for him to decide on
the question of asylum transmission or not for any case coming directly to
his knowledge. Hence, in the exercise of his wisdom, he may order the
lunatic forthwith into the Union-house, and call upon the medical officer
there to visit him. The consignment of the lunatic to the workhouse being
now an accomplished fact, it becomes a hazardous enterprise, and a
gratuitous task on the part of the medical officer (for no remuneration is
offered for his report), to give the relieving officer or overseer a
written notice that the poor patient should rightly be sent to the asylum,
when he knows that those parish authorities have made up their minds that
it is not a proper case to be sent there. In fact, the law makes no demand
of a notice from the medical officer of the Union necessary where the
knowledge of a lunatic pauper first reaches the relieving officer or
overseer, or where the patient is already in the workhouse; and no report
will be sought from him under such circumstances, unless the parochial
authorities decide that they will not take charge of the case in the
workhouse.
The object of the 67th and five following sections is evidently to promote
the discovery of pauper lunatics, and to ensure the early transmission of
all those amenable to treatment to County Asylums; but these advantages
are not attained, the legal machinery being defective. To fulfil the
intention, it should be made imperative on the part of the relatives or
friends to make known the occurrence of a case of lunacy at its first
appearance to a duly-appointed medical man, who should visit and register
it, and, with the concurrence of a magistrate, order detention in a
properly-constituted asylum. Such a medical officer would have a district
assigned to him; of his duties at large we shall have occasion hereafter
to speak; to allude further to them in this place will cause us to diverge
too widely from the subject under consideration.
The 67th section of the "Lunatic Asylums' Act," which has above been
submitted to criticism, we find referred to in the Lunacy Commissioners'
Eleventh Report, wherein it is spoken of as disregarded by parochial
authorities; its ambiguity and the loophole to a contravention of its
meaning being, however, unnoticed. The reference occurs in the following
passage (_op. cit._ p. 16), which censures a practice we have already
animadverted upon:--
"And here we take occasion to remark, that if the law were more strictly
carried out in one particular, the same temptation to a mistaken and
ill-judged economy would not so frequently present itself to Boards of
Guardians; nor could it so often occur to them as an advantage, that they
should themselves manage their insane poor by the resources at their own
disposal. A custom prevails, very generally, of sending all pauper
lunatics to the workhouses in the first instance, instead of at once
procuring an order for their transmission to an asylum; and nothing has
more contributed to the many recent and acute cases improperly so
detained. The practice, it is hardly necessary to say, is in direct
contravention of the law applicable to insane paupers. Assuming that they
come ordinarily at first under the care of the District Parish Surgeon, he
is bound to give notice (under the 67th section of the Lunatic Asylums'
Act) to the Relieving Officer, by whom communication is to be made to the
Magistrate, upon whose order they are to be conveyed to an Asylum; but in
effect these provisions are disregarded altogether. And thus it follows,
that the patient, if found to be manageable in the workhouse, is
permanently detained there; or even should he ultimately find his way to
an asylum, it is not until so much valuable time has been lost that his
chances of cure are infinitely lessened. For, although it is our
invariable habit, on the occasion of visiting workhouses, to recommend the
removal to asylums of all whom we consider as curable, or exposed to
treatment unsuited to their state, we find nothing so difficult as the
enforcement of such recommendations; and for the most part the Report of
the Medical Officer of the Union, to the effect that the patient is
'harmless,' is suffered to outweigh any opinion we can offer."
In this quotation, therefore, we have an official proof that the defective
and ambiguous legislation above commented upon is practically not without
its mischievous fruits to the well-being of the insane poor. To amend it,
some such scheme as we have sketched is called for to secure the reporting
of lunatics, their examination and registration, and the legal sanction to
their detention for the purposes of their own safety and that of others,
and of their treatment; and were it not that at the present moment asylum
accommodation cannot be afforded to all the pauper lunatics of the
kingdom, their confinement in workhouses ought to be at once rendered
illegal. Convinced as we are, that asylums for the insane could be
erected, fitted, organized, and maintained at a cost which would leave no
pecuniary advantage economically on the side of workhouses; and that, even
were the primary expenditure of the latter considerably less, they would
in the long run be more expensive on account of their unfitness for
lunatic patients, whatever the type of their malady, the injuries they
entail on the well-being of all, and the chronic insanity they produce and
foster,--it is with much reluctance we are forced to endorse the statement
made by the Commissioners in Lunacy, in their 11th Report (p. 17), that
workhouse "Lunatic Wards will have to be continued for some time longer,"
until, we may add, a more comprehensive, and withal a modified scheme be
brought into operation, to cherish, to succour, and to cure those
suffering under the double evil of poverty and insanity. Though a remedy
to meet the whole case must unfortunately be delayed, yet the Lunacy
Commissioners nevertheless need continue energetically to discourage the
plan of building special lunatic wards to workhouses, as one, according to
their own showing, indeed, fraught with very many evils to their inmates.
Such erections ought, in fact, to be rendered illegal; the money spent on
them would secure proper accommodation in connexion with a duly organized
and managed asylum, as demonstrated in previous pages (p. 48), for all
those classes of pauper lunatics, which, under any sort of plea or
pretence, can be detained in workhouses. Lastly, we must look to the
Commissioners to maintain an active supervision over workhouse
inmates,--to hold, at least, an annual "jail delivery" of every
union-house, to order the immediate transfer of evidently improper
inmates, and to remove others, so to speak, for trial.
The "leading principles," as laid down by the Commissioners in 1847
(Report, p. 269), and to which, in subsequent Reports, they state their
continued adhesion, are as good as the present state of lunacy and lunatic
asylums permit to be enforced; but they can be enforced only by the
Commissioners themselves, or others possessing equal authority; for
workhouse officials will interpret them through the medium of their own
coloured vision; and if magistrates were entrusted with the task, we have
no confidence that it would be efficiently performed by them as
inexperienced, non-medical men, with whom economical considerations will
hold the first place. The principles referred to are expressed in the
following paragraph:--
"We have invariably maintained that the permanent detention in a workhouse
of any person of unsound mind, whether apparently dangerous or not, whose
case is of recent origin, or otherwise presents any hope of cure through
the timely application of judicious treatment, or who is noisy, violent,
and unmanageable, or filthy and disgusting in his habits, and must
therefore be a nuisance to the other inmates, is an act of cruelty and
injustice, as well as of great impolicy; and we have on all occasions
endeavoured, so far as our authority extends, to procure the speedy
removal of persons of that description to a lunatic asylum."
The following practical suggestions, calculated to improve the condition
of the insane poor, are deducible from the foregoing remarks on workhouses
considered as receptacles for lunatics.
1. The County Asylums should afford aid to all insane persons unable to
procure proper care and treatment in private asylums; and 2, such patients
should be directly transmitted to them; the circumstance of their entire
or partial liability to the poor-rates being, if necessary, subsequently
investigated. 3. As a corollary to the last suggestion, the primary
removal of patients to a workhouse should, save in very exceptional cases,
such as of distance from the asylum and unmanageable violence at home, be
rendered illegal; or, what is nearly tantamount to it, for the future no
alleged lunatic should be suffered to become an inmate of a workhouse,
except with the written authority of the District Medical Officer or
Inspector proposed to be appointed. 4. Without the sanction of this
officer, likewise, no lunatic should be permitted to be discharged or
removed from a workhouse. This is necessary for the patient's protection,
for securing him against confinement in any house or lodging under
disadvantages to his moral and physical well-being, to check improper
discharges, and to protect the asylum against the transfer to it of unfit
cases, a circumstance which will presently be shown to be of frequent
occurrence. 5. No person should be detained as a lunatic or idiot, or as a
person of unsound mind in a workhouse, except under a similar order as
that required in the case of asylum detention, and a medical certificate
to the fact of his insanity. 6. If workhouses need be used, whether as
temporary or as permanent receptacles for the insane, they should be
directly sanctioned by law, placed under proper regulations, and under
effective supervision, not only of the Lunacy Commissioners, but also of a
Committee of Visitors, and of the District Medical Officer, whose duty it
would be to watch over the welfare of the insane inmates, their treatment,
diet, occupation, and amusement. The Visitors should be other than
guardians or overseers of the poor of the union or parish in which the
workhouse is situated, although every union should be represented on the
Committee; and they might be selected from the magistrates, and from the
respectable classes among the rate-payers. If the county were large, it
might be advantageously divided into districts, a Committee of Visitors of
Workhouses being appointed in each district. 7. Every workhouse containing
lunatics should be licensed as a place of detention for them by the
Committee of Visitors, who should have authority to revoke the license.
This power of revoking the license should be also vested in the
Commissioners in Lunacy. 8. Every such workhouse, and the number of its
insane inmates, should be reported to the Lunacy Commissioners. According
to our scheme, the District Medical Officer would do this, as well as
report generally to the Lunacy Board, the condition and circumstances both
of the workhouse and of its insane inmates. 9. For the future, the
erection or the appropriation of distinct lunatic wards to workhouses
should be interdicted by law.
By the preceding suggestions reforms are, indeed, proposed to render
confinement in workhouses legal; to make it more satisfactory; to provide
for effectual supervision, and in general to assimilate the wards of
union-houses more closely to those of asylums. Yet all this is done only
on the ground of the necessity for some legislation on these matters, and
more particularly under the pressing circumstances of the time. The
present state of lunacy compels acquiescence in the Lunacy Commissioners'
statement, that workhouse-wards must for some time longer be used for the
detention of insane paupers; and this fact alone supplies an apology for
making suggestions to improve them. Moreover, apart from it, the workhouse
will at times necessarily be the temporary refuge for some few cases, and
may be occupied as a permanent dwelling by those rare instances of
imbecility of mind which can be allowed to intermingle with the other
inmates, and be usefully occupied; and for these reasons it need be
rendered both a legal and not unsuitable abode. At the same time, it is
most desirable that the Lunacy Commissioners should be able not only to
discourage, but also to veto the construction of lunatic-wards for the
future, on the grounds already so largely pointed out; and for this
reason, moreover, that where such wards exist, they are thought good
enough for their poor inmates, and are looked upon as asylums over which
the county institution has little preference. The existence, therefore, of
any specially erected or adapted ward, may always be urged against the
proposition for further expenditure in providing for pauper lunatics
elsewhere in suitable asylums;--a plea, which should consequently be set
aside by overturning the foundation whereon it rests.
Since the preceding observations on the detention of pauper lunatics in
workhouses were in print, a most important supplementary Report on the
subject has been put forth by the Commissioners in Lunacy (Supplement to
the Twelfth Report; ordered to be printed 15th of April, 1859). We have
read this Report with pleasure, so far as it confirms the views we have
taken, but with surprise and pain at the details it unfolds of practices
the most revolting to our better feelings, and, in general, of a state of
things discreditable to a civilized and christian country. By being
confirmatory of the opinions and statements advanced by us, it may be said
to give an official sanction to them; and as it is one of the most
important documents ever issued by the Board, we shall attempt an
analysis of its contents.
In the first place, the Commissioners resort to some recent corrected
returns of the Poor-Law Board, and discover that the number of pauper
lunatics in workhouses was, on the 1st of January, 1858, 7555, _i. e._
upwards of 500 above that returned in the Tenth Report of the same Board,
and referred to in the foregoing pages; and on the 1st of July in that
same year it amounted to 7666. They then proceed to describe the
"character and forms of insanity most prevalent in workhouses," and show
that their insane inmates all require protection and control; that "some,
reduced to poverty by their disease, are of superior habits to those of
ordinary paupers, and require better accommodation than a workhouse
affords. Many are weak in body, and require better diet. Many require
better nursing, better clothing, and better bedding; almost all (and
particularly those who are excitable) require more healthful exercise,
and, with rare exceptions, all require more tender care and more vigilant
superintendence than is given to them in any workhouse whatsoever."
On turning to the "Design and Construction of Union Buildings," they
rightly point out that the stringent conditions to ensure economy, and to
check imposition and abuse, the "reduced diet, task labour, confinement
within the narrow limits of the workhouse premises," the plan of
separating the inmates into classes, the scanty means of out-door
exercise, &c., are inimical to the well-being of the insane residents. In
the "Modes of Workhouse Direction and Administration" there is great
unfitness. The rules under which the officers act "are mainly devised to
check disorderly conduct in ordinary paupers; and it is needless to say
with how much impropriety they are extended to the insane. Any increase of
excitement, or outbreak of violence, occurring in the cases of such
patients, instead of being regarded as a manifestation of diseased action
requiring medical or soothing treatment, has subjected the individual to
punishment, and in several instances led to his imprisonment in a jail. In
addition to these hardships, the lunatic patient is for the most part
precluded from leaving the workhouse at his own will. In effect he becomes
a prisoner there for life, incapable of asserting his rights, often of
signifying his wants, yet amenable to as much punishment as if he were
perfectly sane, and a willing offender against the laws or regulations of
the place. Nor, as will hereafter be seen, is his lot much bettered in the
particular cases where it is found convenient to the authorities to relax
those restrictions, and give him the power at will to discharge himself."
Rural workhouses of small size are generally preferable abodes for the
insane than those of larger dimensions, since their "arrangements have a
more homely and domestic character, and there are more means of occupation
and of free exercise in the open air;" and where their imbecile inmates
can be associated with the ordinary paupers, and regularly employed, their
condition is not unfavourable; "but these form only the exceptions."
Workhouses in the metropolis and in large towns generally, are for the
most part "of great size, old, badly constructed, and placed in the midst
of dense populations. The weak-minded and insane inmates are here
generally crowded into rooms of insufficient size, sometimes in an attic
or basement, which are nevertheless made to serve both for day and
sleeping accommodation. They have no opportunity of taking exercise; and,
from the want of space and means of separation, are sometimes associated
with the worst characters, are subjected unnecessarily to seclusion and
mechanical restraint, and are deprived of many of the requisites essential
to their well-being."
"Of the 655 workhouses in England and Wales, somewhat more than a tenth
part are provided with separate lunatic and idiot wards."
The "Objections to Intermixture of Inmates" are briefly stated. "There is
no mode of complying with suggestions for" the peculiar benefit of insane
inmates, "without disturbing the general economy of the house,--a fact
which shows how important it is that no lunatic or idiot should be
retained for whom any special arrangements are necessary." Separate
lunatic wards are declared to be more objectionable than the intermixture
of the pauper inmates. Only occasionally are such wards found at all
tolerable; and even then, the constant medical supervision, proper
attendants and nursing, sufficient diet, exercise, occupation, and other
needful provisions, are deficient. The majority are thus sketched:--"In
some of the wards attached to the old workhouses the rooms are crowded,
the ventilation imperfect, the yards small and surrounded by high walls;
and in the majority of instances the bed-rooms are used also as day-rooms.
In these rooms the patients are indiscriminately mixed together; and there
is no opportunity for classification. There is no separation where the
association is injurious; and no association where such would be
beneficial. In fact, patients of all varieties of character,--the weak,
the infirm, the quiet, the agitated, the violent and vociferous, the dirty
and epileptic,--are all mingled together, and the excitement or noise of
one or more injures and disturbs the others. The restless are often
confined to bed to prevent annoyance to the other patients, and the infirm
are thus disposed of for the want of suitable seats. Their condition when
visited in the daytime is obviously bad, and at night must be infinitely
worse. Even in workhouses where the wards are so constructed as to provide
day-rooms, these are often gloomy, much too small in size, and destitute
of ordinary comforts; while the furniture is so poor and insufficient,
that in some instances, there being no tables whatever, the patients are
compelled to take their meals upon their knees. Other cases to be
hereafter mentioned will indeed show that it is reserved for lunatic wards
of this description, and now happily for them only, to continue to exhibit
some portion of that disregard of humanity and decency, which at one time
was a prevailing characteristic in the treatment of insanity."
Not only, again, are there no sufficiently responsible authorities in the
house, and no qualified responsible attendants, but also no records of
restraint, of seclusion, of accident, or injury, or of medical or other
treatment. "Above all, there is no efficient and authoritative official
visitation. The Visiting Justices never inspect the lunatic wards in
workhouses, and our own visits are almost useless, except as enabling us
to detect the evil that exists at the time of our visit, and which, after
all, we have no power to remove." The "Results of Neglect in Deteriorating
the Condition of Patients" of all classes are ably portrayed. In the
absence of attentive and experienced persons to watch and to supply their
wants, many of the insane suffer unheeded and without complaint, to the
prejudice of their mental and bodily state; or become inattentive to
natural wants, and prone to violence and mischief. "In a very recent case
of semi-starvation at the Bath Union, when the frauds and thefts of some
of the attendants had, for a considerable time, systematically deprived
the patients of a full half of their ordinary allowance of food, the only
complaint made was by the wan and wasted looks of the inmates."
In the two next sections the Commissioners insist that the duty of
distinguishing the cases in workhouses to be classified as "Lunatics,
Insane Persons and Idiots," should be performed by the medical man
independently of the master; and that, without examination and sanction
from that officer, no person of weak mind should be discharged, or allowed
to discharge himself. Very ample cause for this latter proposition is
shown in the illustrations appended, particularly in the case of imbecile
females, who not unfrequently become, when at large, the prey to the
vicious, further burden the parish by their illegitimate offspring, and
often by an idiotic race.
"The diet necessary for the insane" is required to be more liberal than
for other inmates; yet the Commissioners have "in very numerous instances"
animadverted upon its inadequacy, both in quantity and quality, but
without result, except "in very few instances:" for, notwithstanding that
"the medical officer of a Union has full power" (by the Consolidated Order
207, art. No. 4) "to give directions, and make suggestions as to the diet,
classification and treatment of the sick paupers, and paupers of unsound
mind," yet, we are sorry to learn, that "the power thus given, although
backed by our constant recommendations, is rarely exercised by the medical
officer."
This circumstance is so far confirmatory of a view we have above taken,
that the medical officer of a parish or union is neither sufficiently
independent, as the paid _employé_ of the guardians, to carry out measures
that may be necessary for the alleviation of the condition of lunatics in
workhouses, where such means involve increased cost (we regret to
entertain the notion); nor always sufficiently acquainted with the wants
of the insane.
Considering the disadvantages of workhouses as receptacles for them, the
general statement follows naturally, that as a class of workhouse inmates,
the lunatics "are manifestly lower in health and condition than the same
class in asylums. Hence," add the Commissioners, "the patients' bodily
health and mental state decline upon removal from asylums to
workhouses--an effect chiefly due to the inferior diet." There are great
"variations in workhouse dietaries,"--from one spare meat dinner in the
week to a meat dinner daily. This latter provision is furnished "in a very
small number of houses." These dietaries are indeed much inferior to those
considered necessary for criminals in jails; a fact that affords a sad
comment on English consistency, which is thus found dealing with more
favour and consideration towards those who have transgressed the laws of
their country, than to those whose only crime is poverty, or poverty
complicated with disease or infirmity.
Medical treatment would, in truth, seem to be not legally provided at all
for lunatics in workhouses: no clause makes a visit of the union medical
officer to the lunatic-ward of a workhouse imperative. As examples of the
slight esteem in which medical supervision is held, the Leicester and the
Winchcombe houses are quoted. In the former, the visits of the medical
officer were only made quarterly; in the latter, by stipulation three
times a week, but in practice very irregularly. Attendance and nursing
are, as might be expected, on a par with medical treatment. Even imbeciles
have been found exercising the functions of nurses, and, generally
speaking, the selection of attendants is made from old and feeble people,
having no experience, no aptness for the duties, no particular qualities
of intellect or temper to recommend them, and receiving such a mere
pretence, if any at all, in the way of remuneration for their trouble,
that no painstaking efforts can be looked for from them. "Yet to such
individuals, strait waistcoats, straps, shackles, and other means of
restraining the person are not unfrequently entrusted; and they are,
moreover, possessed of the power of thwarting and punishing at all times,
for any acts of annoyance or irregular conduct, which, although arising
from disease, are nevertheless often sufficient to provoke punishment from
an impatient and irresponsible nurse."
The interior accommodation, fittings, and furniture are, if not abominably
bad, excessively defective: and on reaching this part of the Report, where
the details of internal fittings and management come under review, the
impression derivable from its perusal is akin to that gathered from the
revelations of madhouses made by the Parliamentary Committees of 1814 and
1815. The sketch of the evils suffered by lunatics in workhouses, which we
have ourselves attempted in past pages, tells a flattering tale compared
with the realities unfolded to us by the Commissioners, and adds a tenfold
force to the arguments against the detention of lunatics in such places.
To continue the practice would be to perpetuate a blot upon the internal
polity, the philanthropy and the Christianity of the country. Let those
who would know the whole case refer to the Report in question; it is
sufficient for our purpose to attempt a mere outline of its revelations.
Patients are frequently kept in bed because there are no suitable seats
for them; a tub at times answers the double purpose of a urinal and a
wash-basin; a privy is partitioned off in a small dormitory; baths are
almost unknown; a trough or sink common to all supplies the want of basins
for washing, and an outhouse or the open air furnishes the appropriate
place for personal ablutions. Clothing, again, is often ragged and
insufficient; in an unwarmed dormitory, a single blanket, or only a
coverlet, is all the covering afforded by night; loose straw in a trough
bedstead usually constitutes the bed for wet and dirty patients to nestle
in; and whether the bed be straw or not, the practice of using it night
after night, when "filthy with dirt, and often rotting from frequent
wetting, has been many times animadverted upon." In some workhouses two
male patients are constantly placed in the same bed; nor is the character
of the bedfellows much heeded; for a sane and insane, two idiots, one
clean and one dirty, and even two dirty inmates, have been found
associated together in the same bed, occasionally in a state of complete
nudity.
Further, the want of exercise and employment, the absence of supervision
and control, and the entrusting of means of coercion to irresponsible and
unfit attendants, lead to the most shocking abuse of restraint, and to
cruel seclusion.
"The requirement occasionally made by the Visiting Commissioner, that the
Master shall make a written record of such proceedings, is utterly
neglected. The dark, strong cells, constructed for the solitary
confinement of refractory paupers, are used for the punishment of the
insane, merely to prevent trouble; quiet helpless creatures, from whom no
violence could be apprehended, are kept in bed during the daytime, or
coerced; and even the dead-house has been made to serve the purpose of a
seclusion-room."
"The Examples of Restraint practised," as adduced in the Report, recall to
mind all those barbarities which civilized men of the present day are in
the habit of congratulating themselves as matters of the past, and the
subject of history. The catalogue of appliances for restraint reappears
once more on the scene; and we read of straps, leather muffs, leg-locks,
hobbles, chains and staples, strait-jackets, and other necessary
paraphernalia, as of yore, worn for days, or weeks, or months. Excellent
matter, indeed, in all this, to garnish a discourse on the advancement of
civilization, on the prevalence of improved notions respecting the
treatment of the insane, or on some similar topic addressed to the vanity
of the present generation!
But the chapter does not end here. "It would be difficult to select places
so entirely unfit for the purpose of exercise, or so prejudicial to the
mental or bodily state of the person confined," as the yards or spaces set
apart for it; and yet "of all the miseries undergone by this afflicted
class, under the manifold disadvantages before described, and of all the
various sources of irritation and discomfort to which we have shown that
they are exposed, there is probably none which has a worse effect than the
exclusion from all possibility of healthy movement. Nothing more
powerfully operates to promote tranquillity than the habit of extensive
exercise; and in its absence, the patients often become excited, and
commit acts of violence more or less grave, exposing them at once to
restraint or seclusion, and not unfrequently to punishment. In not a few
instances the outbreak has been looked upon as an offence or breach of
discipline, and as the act of a responsible person; and the patient has
been taken before a magistrate and committed to prison.
"A very grave injustice, it is hardly necessary to add, is thus committed,
in punishing by imprisonment individuals who are recognized and officially
returned as being of unsound mind. These persons in no respect differ from
the class of the insane usually met with in asylums, and are equally
entitled to the same protection, and the same exemption from punishment.
Instead of such protection, however, the patient is exposed to double
injury:--first, he is subjected to various sources of irritation while
confined in the workhouse, directly occasioning excitement; and, secondly,
the mental disturbance resulting therefrom is regarded as a crime, and is
punished by imprisonment."
The Commissioners in Lunacy next direct attention to the principal cause
of the evils described, which they discover in the neglect and evasion of
the duties imposed by the law on the officers of parishes and unions, in
the interests of the pauper insane. Thus, as remarked in previous
pages,--"Instead of causing the patient to be dealt with as directed by
the 67th and 68th sections of the Lunatic Asylums' Act, 1853, and
immediate steps to be taken for his direct removal to the asylum,
workhouses have been to a great extent made use of primarily as places for
the reception, and (in many instances) for the detention of recent cases
of insanity.
"The workhouse is thus illegally made to supply the place of a lunatic
establishment, and the asylum, with its attendant comforts and means of
cure, which the law has provided for the insane poor, is altogether
disregarded; or it comes into operation only when the patient, by long
neglect, has become almost hopelessly incurable. We should remark that
this occurs most frequently in the larger workhouses, and in those having
insane wards."
... "How totally unfit even workhouses having insane wards are for the
proper treatment of recent curable cases, we have endeavoured to exhibit
in some detail. Nevertheless, the practice of making use of them for all
classes of insane patients is rapidly increasing, and our efforts to check
it have proved hitherto quite ineffectual."
After further adverting to the influence of the neglect of the laws in
increasing pauper lunacy, they very briefly discuss the comparative cost
of lunatics in workhouses and in asylums, but their examination adds
nothing to what we have much more fully put forward on this subject.
Their "conclusion" contains some valuable suggestions, more or less
identical with those we have ourselves independently advanced, and which
may be briefly summed up as follows:--
"To remedy many of the evils adverted to would, in our opinion, be
impracticable, so long as insane patients are detained in workhouses,
whether mixed with other inmates or placed in distinct wards.
"The construction and management of workhouses present insurmountable
obstacles to the proper treatment of the disease of insanity; and
therefore the removal of the majority of the patients, and the adoption of
stringent measures to prevent the admission of others, have become
absolutely necessary."
The notions of parish authorities of the very great comparative economy of
workhouses over asylums rest, say the Commissioners, on a false basis; and
to place the question fairly before them, "it is essential that the mode
of keeping the accounts should be assimilated in each, and that in the
asylum only food and clothing should be charged to the parishes, and all
other expenses to the county. In such case, we believe it would be found
that the charges in each would be brought so nearly to a level, that there
would exist little or no inducement on the plea of economy to tempt the
guardians to keep their insane patients in workhouses, instead of sending
them at once to a county asylum."
To provide proper accommodation for the insane poor in workhouses,
inasmuch as many asylums are on "so large a scale as not to admit of the
necessary extension, whilst some are of a size much beyond that which is
compatible with their efficient working," the Commissioners propose "the
erection of inexpensive buildings, adapted for the residence of idiotic,
chronic, and harmless patients, in direct connexion with, or at a
convenient distance from, the existing institutions. These auxiliary
asylums, which should be under the management of the present visiting
justices, would be intermediate between union workhouses and the principal
curative asylums. The cost of building need not, in general, much exceed
one-half of that incurred in the erection of ordinary asylums; and the
establishment of officers and attendants would be upon a smaller and more
economical scale than those required in the principal asylums."
"Whether or not such additional institutions as we recommend be provided,
we think it essential that visiting justices of asylums should be invested
with full power, by themselves or their medical officers, to visit
workhouses, and to order the removal of insane inmates therefrom to
asylums at their discretion. They should also be empowered, upon the
report of the Commissioners, to order the removal into the asylum of
pauper patients boarded with strangers."
"And in the event of our obtaining your Lordship's approval of such
suggestions for legislative enactment, we would further recommend that it
should include the following provisions:--
"No lunatic, or alleged lunatic, to be received into or detained in a
workhouse, unless he shall have been duly taken before a justice or
officiating clergyman, and adjudged by him as not proper to be sent to an
asylum.
"In any case, however, wherein an order for a lunatic's reception into an
asylum shall be made by a justice or officiating clergyman, it shall be
competent to him, if, for special reasons to be set forth in his order, he
shall deem it expedient, to direct that such lunatic be taken, _pro
tempore_, to the workhouse, and there detained for such limited period,
not exceeding two clear days, as may be necessary, pending arrangements
for his removal to the asylum.
"A list of all inmates of unsound mind to be kept by the medical officer
of a workhouse, and left accessible to the Visiting Commissioners.
"The medical officer to specify, in such list, the forms of mental
disorder, and to indicate the patients whom he may deem curable, or
otherwise likely to benefit by, or in other respects proper for, removal
to an asylum.
"The Visiting Commissioner, and the Poor-Law Inspector, to be empowered to
order and direct the relieving officer to take any insane inmate before a
justice, under the provisions of the 67th Section of the Lunatic Asylums'
Act, 1853.
"In all cases of inmates of unsound mind temporarily detained in
workhouses, the medical officer to be invested with full powers as
respects classification, diet, employment, and medical and moral
treatment, and otherwise."
Of some of these suggestions we shall take a future opportunity to speak,
and at present pass from the consideration of the state and wants of
lunatics in workhouses to notice, briefly, the condition of those living
with their friends or elsewhere.
§ _Pauper Lunatics living with their relatives or with strangers._
In the previous chapter "On the state of the present provision for the
Insane," some remarks have been made on the class of lunatic poor living
with their relatives or strangers, calculated to arrest attention to their
numbers and their neglected position. The Commissioners in Lunacy have as
a rule, and in the absence of particular information, calculated that they
are about equal in number to those resident in workhouses. Considering the
imperfect nature of the statistical records of them, and the fact that
they escape official observation and inquiry to a much greater extent than
even the lunatic inmates of workhouses, we have assumed them to be more
numerous, and that there are 8000 so distributed in the homes of our
industrial classes.
Of these 8000, more or less, poor persons, dependent, on account of
distinct imbecility or idiocy, upon others for protection and support, no
one outside their abodes, it may be generally said, thoroughly knows their
condition, although a partial knowledge may be possessed by the parochial
authorities of the union or parish to which they are chargeable. To these
authorities, however, they possess no interest; they are regarded as
burdens upon the public purse, to be arranged for on the cheapest terms.
The only person at all responsible for their condition is the parish
medical officer, who is required by sect. 66 (16 & 17 Vic. cap. 97) to
visit them quarterly, and to certify "whether such lunatics are or are not
properly taken care of, and may or may not remain out of an asylum."
In the first place, the matter of deciding what pauper reported as insane,
imbecile, or idiotic is actually so, is not by law given to any parochial
officer; hence it frequently happens that differences of opinion and
divisions arise between the medical officer on the one hand, and the
poor-law guardians on the other, as to the chargeability of this and that
pauper to the parish as insane; and the decision acquires intensified
importance from the fact that one half-crown per quarter is at stake on
each pauper chattle in dispute; for if the medical man gain the day, just
that sum has to be squeezed out of the rate-payers to compensate him for
his quarterly call upon the admitted lunatic. We leave the reader to
imagine the battlings of the vestrymen on the knotty point; sane or not
insane, that is the question, the solution of which must cause the
consumption of much time and breath yearly to many an honourable board of
guardians, to animated discussions, bold definitions and fine-drawn
distinctions, lost to the _profanum vulgus_ enjoying no seat in the
conclave.
Here, then, appears a duty which, in our opinion, should be performed by a
duly appointed officer, such as a district medical inspector or examiner;
for we would deprive the guardians of the poor of all voice in deciding on
the sanity or insanity of any individual. The law might with equal or with
greater propriety leave the decision of the success or non-success of the
operation of vaccination to a vestry, as that of the question under
remark. Further, since many might argue, that to leave the determination
of the question to an officer like the parish medical man, directly
interested in settling it in one way, and who might saddle the parish with
an annual charge for every poor person in it who did not come up to his
standard of mental strength, would be unfair to the rate-payers; an
independent opinion, given by an officer in no way interested in the
decision of the point at issue, would seem to afford the very best means
of settling the point, and a sufficient guarantee against any supposable
irregularities. We would suggest, therefore, that the district inspector
should visit every poor person wholly or partially chargeable, or proposed
to be made chargeable to any parish, as being of unsound mind, and make a
return to the parochial authorities and to the Poor-Law Board, and that
the certificate of this officer should be held to be a sufficient proof of
the insanity of the individual.
But the duties of this officer, in relation to the lunatic poor under
consideration, would not stop here. In his visit we would require him to
investigate more narrowly than a Union medical officer can be expected to
do at the remuneration offered, and amid his many other arduous
engagements,--into the condition and the circumstances by which the poor
patient is surrounded, to report thereon to the Lunacy Board and to the
proper Union officials, and in general to state, in the words of the Act,
whether he is or is not properly taken care of, and is or is not a fit
subject for asylum care. The officer we propose, would approach the
inquiry independently of the parish authorities, and indifferent to their
censure, having no position and no pay to lose by his decision; whilst as
an experienced physician, understanding the varying features of mental
disorder, and the conditions necessary to its amelioration or cure, his
opinions would claim greater respect.
Inasmuch as it is impossible, owing to their small number, for the Lunacy
Commissioners, without totally neglecting their other duties, to make
themselves acquainted with the condition of these pauper lunatics,
scattered here and there over the country, in cottages and lodgings, we
really possess, as before said, under the existing system, no information
worth having, what that condition really is. Judging from the state in
which workhouse lunatic inmates are found, the impression is unavoidable,
that the pauper lunatics under notice must be in a worse one, since there
is not only no sort of supervision over them equivalent to that provided
in workhouses, but also the sums allowed towards their maintenance are
most scanty, and, where they are lodged with strangers, no care and no
sustenance beyond what is felt to be actually paid for, can be presumed to
be given. Now and then a glimpse of the actual state of things is casually
afforded by the Report of a County Asylum; and such are the glimpses we
have got through this medium, that, except to arouse public attention by
their recital, in order to bring about a reform, it were well, for the
sake of the reputation of the country, that the revelations were
unrecorded. Asylum superintendents could, indeed, more frequently raise
the veil upon scenes of wretchedness and cruelty undergone by our lunatic
poor in the habitations where parish officials place or keep them; but
they generally forbear to do so in their Reports, although enough is shown
by the description of the state in which patients are admitted into the
asylums, and of the length of time that has been suffered to elapse since
the commencement of their sad malady.
Dr. Hitchman, in the Reports of the Derby County Asylum, has more than
once referred to the state of patients on admission from their homes or
lodgings. Thus, in 1853, he narrates the case of a poor woman who had been
demented for five years, and "kept at home until she fell into the fire
and became extensively and severely burnt;" and not till after this
accident was she taken to the asylum. A little way further on, in the same
Report, he observes,--"Those only who have lived in public asylums know
the misery, the wretchedness, and the wrong which are constantly inflicted
upon lunatics in obscure places, even by their relatives and 'friends,'
and which cease only with the life of the patient, unless he be conveyed
to a well-conducted institution. It is, moreover, a remarkable phenomenon,
that many individuals who perpetrate these enormities upon their kith and
kin, who have habitually fastened them with cords, who have deprived them
of a proper supply of clothing or of food, who have, in short, rendered
them permanent cripples in body, as well as hopeless idiots in mind, have
done so without malice, as a general rule, without passion, by slow
degrees, and with no conception whatever of the present suffering or
ultimate mischief effected by their proceedings. They affect no secrecy
among their neighbours while these things are going on. Familiarity to the
spectacle blinds their perceptions and blunts their feelings.... Others
there are, who, from penurious and selfish motives, inflict much wrong
upon the lunatic. Of such a kind appears the following:--'T. G., removed
from the custody of his relatives by the order of the magistrates. Has
been insane thirty-eight years, under the management of his relatives, who
have generally had him confined in an out-building.' 'He is stated to have
been unclothed for many years. When brought into the asylum he was naked,
except that around his pelvis were the remains of an article of dress; his
hands were tightly bound to each other by ligatures passing around the
wrists. When in the cart he was covered with a blanket, but this fell from
him during his struggles on being removed. He roared hideously as he was
being conveyed to the wards. He is a person of lofty stature and great
size. His head and neck are very large; one side of his forehead is
greatly disfigured by scars, and he has lost an eye. His ears have been
deprived of their normal shape, and their lobes much thickened by the
deposition of fibrine or other matter. His lips are large and pouting. His
beard has been long unshaven, but has been recently cut with a pair of
scissors. The bones and muscles of his arms are of great size; his lower
extremities are red, swollen, and 'pit,' under pressure; one of his toes
is deprived of its nail, and the whole foot appears to have suffered from
the effects of cold. He walks with a stooping gait, and appears unable to
retain the erect posture without support. He resists powerfully all
attempts to clothe him, and appears to be entirely ignorant of the use of
a bedstead. He whines after the manner of a dog that has lost its home. He
dreads all who approach him; on being taken from his room in the evening,
he hurried back to it with all the haste he could, and on all occasions he
shrinks from observation. He is lost to every sense of decency; nakedness
is congenial to him, but he will sometimes coil himself in a blanket for
the sake of its warmth. He is guided by the lowest instincts only, and his
whole appearance and manner, his fears, his whines, his peculiar skulking
from observation, his bent gait, his straight hair, large lips, and
gigantic fore-arm painfully remind one of the more sluggish of the
Anthropoid Apes, and tell but too plainly to what sad depths the human
being can sink under the combined influence of neglect and disease.'"
The same excellent physician reverts to these cases in his Fourth Report
(1855), and laments the sad condition of health, and the horrible state of
neglect of many patients on their admission. He says, "One or two patients
had been confined by manacles in their own cottages until rescued by
charitable interference, and were brought to the asylum with their wrists
and ankles excoriated by the ligatures deemed necessary for their proper
control." One such case had been confined twenty-five years in his
cottage-home.
These illustrations will suffice for our purpose. They indicate the
existence of abuses and wrongs here in England, too similar, alas! to
those the Special Lunacy Commission of Scotland brought to light by their
well-known inquiry in 1855 (Report, Edinburgh, 1857), and such as the
general description in their Report, and the particulars in Appendix K,
too amply demonstrate. It is referred to as "the wretched state" of single
patients living with their friends or others, and well merits the
designation. They found these poor afflicted beings generally in a state
of moral and physical degradation, ill-fed, ill-treated, ill-clothed,
miserably lodged, shockingly dirty, abused, restrained by all sorts of
mechanical contrivances of the coarser kind, or left to wander unheeded
and uncared for; whilst among the imbecile or fatuous women, many were the
instances where they had become the mothers of an illegitimate and often
idiotic offspring. Judging from the specimens before us, we repeat, we
have great misgivings lest a similar searching inquiry into the condition
of pauper lunatics in England distributed in the homes of our cottagers
and labouring classes, should reveal a state of things no less disgraceful
to a civilized country.
To recall a conviction before expressed, additional legislative provision
is demanded for this class of pauper insane. The quarterly visit of the
hard-worked and underpaid Union Medical Officer or of his Assistant,
affords no sufficient guarantee, even when regularly made, that they are
duly taken care of, and not improperly deprived of the advantages of
asylum treatment. But if we accept official statements, these visits are
irregularly made and much neglected, and the reports of them far from
properly attended to. In the Report of the Hants Asylum for 1856, the
Committee took occasion to remark on the extended neglect and the
inefficiency of these legal visits and reports; and though the
Commissioners in Lunacy admit that of late matters have improved, yet they
say that they are far from satisfactory. From these and other
considerations adverted to, we have suggested that the inspection of the
lunatic poor in question should be specially undertaken by the District
Medical Officer, and that a report on them should after each visit be made
to the Lunacy Commission, and, with advantage, also to the Poor-Law Board.
This officer should be informed of every pauper or other lunatic living
with friends or others, and should investigate, as said above, all the
circumstances surrounding him, and decide whether or not a transference to
an asylum would be for the better. It would consequently be for him to
select and recommend the removal to an asylum of all such patients as
afforded a prospect of recovery; and since good food and proper nursing
improve not only the body, but also the mind and the moral feelings, and
promote the lasting relief of the mental disorder,--it should also devolve
upon him to signify the extent and mode of out-door relief to be afforded.
Defective and faulty nutrition concurs powerfully to produce insanity,
and, when it is induced, to make it permanent; the best policy must
therefore be to nourish pauper lunatics sufficiently;--a policy, which we
see, however, under existing circumstances, no prospect of being acted
upon by the guardians of the poor.
The allowance made to out-door lunatic paupers differs much; for it may be
intended to supply almost all the moderate wants of the recipient, or only
a small part of them. It is always, however, very limited, and less than
the calculated cost of in-door paupers per head, and can never suffice to
procure the poor patient adequate nourishment and suitable attendance and
clothing. Its amount, moreover, is regulated by no definite principles,
but is left very much to the caprice of the relieving officers, and to the
liberal or the opposite sentiments in the ascendant among the parochial
guardians. It is contributed as a grant in aid to the relatives of the
patient, and to those not related as a compensation for the outlay and
trouble incurred on his account. The former are naturally liable to the
maintenance of their lunatic kinsman, and no sufficient objection obtains
to his being detained among them, provided his condition is not prejudiced
by his exclusion from an asylum, and is duly watched over by competent
medical officers, and that those relatives are able to afford him proper
control, food and clothing, with or without parochial assistance. But the
case is different in respect of those not related to the patient, who as
strangers can have little interest in him; but who, on the contrary, have
to make his detention serve their own purposes so far as possible, and
cannot be expected to do or supply more than they are paid for. Now, as
the weekly allowance from the parish is to be by rule kept as low as it
can be, the lowest offers possess the highest recommendation for
acceptance, and the comforts and well-being of the poor imbecile or
idiotic people are almost necessarily sacrificed at the shrine of economy.
The whole system, therefore, of boarding pauper lunatics in the homes of
the poor unconnected with them by blood, as now pursued without
restrictions or method, appears fraught with injury to those helpless
beings. What sort of attention, food, and lodging can be expected for some
3 or 4 shillings a week? What sort of supervision and control can be
looked for from a poor, illiterate labourer or artisan? Even a patient's
own relatives may and do grudge the cost and the trouble he puts them to,
or they may be very imperfectly able to furnish in their cottage-home the
means needed to ensure his protection and the conveniences and comforts of
others, and be ill-adapted by character and education to act as his
directors and guardians. But these difficulties and defects are augmented
manifold when the patient becomes a dweller among strangers.
Only under very peculiar circumstances indeed would we tolerate the
boarding of pauper lunatics with strangers; when, for instance, their
comforts and safety are hedged round by legal provisions sufficiently
ample, and by systematized arrangements to secure them. These ends are to
be attained by taking the selection of the abode and the pecuniary details
from the hands of parochial officers, and by entrusting them to some
competent medical man, who should be responsible that the patients are
properly cared for and treated. It should be for him to select the
residence, and in so doing to seek out those who by character and
condition are best fitted for the charge. If the law were so amended that
asylum relief should be afforded to all on the appearance of their malady,
the majority of those to be provided for in lodgings would come from the
class of chronic, imbecile patients, accounted harmless, whose discharge
from the asylum under proper surveillance might be recommended. Hence it
would render the scheme more perfect and satisfactory, to retain these
chronic lunatics in homes within a moderate distance of the County Asylum
they were previously placed in, so that they might be under the
supervision of the medical staff of that institution, and that the
propriety of their prolonged absence from it, or of their return to it,
might be therefore determinable by those best qualified to judge from past
experience of their case.
Yet, in all probability, this restriction as to the district for
receiving patients as boarders, would not always be practicable; and
frequently, where the insane poor had near relatives capable and willing
to receive them under their care, though at a distance from the asylum, it
would not be desirable to sacrifice the advantages of the guardianship of
friends to those obtainable by vicinity to the asylum; and, from these or
other causes, many poor insane people would be found distributed here and
there throughout a county under the charge of cottagers and others. In
their cases we would make the District Medical Inspector the special
protector and guardian of their interests and well-being provided by law,
and require him to visit them at least twice a quarter, report on their
condition, and on the fitness or unfitness of the persons boarding them.
In all cases, he should as a preliminary proceeding inquire into the
accommodation and general circumstances of the persons proposing to
receive an individual of unsound mind into their family, and should reject
the application of those who are unable to afford suitable conveniences
and adequate management.
Could a properly-organized system of supervision and control be
established, the disposal of poor insane persons in the homes of the
industrious classes would not be open to the objections it is at present,
when no adequate legal provision to ensure their inspection and welfare is
in existence. Indeed, it would be an improvement and blessing to many of
the chronic lunatics in our great asylums, could they so far be set at
liberty, and have their original independence restored to them by a
distribution in the cottage-homes of our country, where, under sufficient
control, they could exercise useful employments, and relieve the rates of
part of their cost. We have used the term 'cottage-homes' advisedly,
because it is evident, that, except in very small towns, a town-residence
would be most unsuitable.
The example of the great colony of insane persons at Gheel, in Belgium,
has suggested this plan of boarding lunatics in the homes of the working
classes, chiefly of agriculturists, to the minds of many English
philanthropists desirous to ameliorate the condition of our pauper insane,
and to lessen the large costs of asylum provision. The only attempt,
however, as far as we are aware, partaking at all of the conditions
calculated to render such a scheme satisfactory and successful, hitherto
made, is that on a small scale at the Devon Asylum under the direction of
Dr. Bucknill, and we are happy to find from this gentleman's Report that
the arrangement has hitherto worked well.
We shall return to this subject in a subsequent section,--"On the
distribution of the chronic insane in cottage-homes."
§ _Transmission of unfit Cases to Asylums--improper Treatment prior to
Admission._
In preceding pages it has been remarked that the transfer of lunatics to
asylums is regulated not by the nature of their case, and its amenability
to treatment or amelioration, but by the circumstance of their being
refractory and troublesome, annoying by their habits, or so infirm and
sick as to require attentive nursing; or, in general, in such a state that
their residence involves an increased and unworkhouse-like cost. The
question of the recency of the attack is treated as of far less moment;
for if the poor sufferer have what are called harmless delusions, or if he
is only so melancholic that suicide is not constantly apprehended, then
under these and such similar conditions, the economical theory of the
establishment commonly preponderates over every consideration of the
desirability of treatment in the presumedly expensive asylum, and the
patient is retained. In course of time his malady becomes chronic, and in
all probability incurable, and his condition so deteriorated in all
respects by the absence of proper measures for his mental and moral
treatment, that sooner or later his physical health gives way, or his
habits grow inconveniently annoying and troublesome, and then it is that
workhouse officials discover that the County Asylum is his suitable abode.
By this system of 'clearance' the workhouses are relieved of their most
burdensome and costly inmates, who fall to the charge of asylums, in which
their presence necessarily keeps down the rate of recoveries, multiplies
the proportion of chronic lunatics, and increases the expenses and the
rate of mortality.
The Medical Superintendents of our Asylums bear witness to the
recklessness, and to the cruelty, at times, which often mark the doings of
workhouse authorities when they wish to rid themselves of the cost and
trouble of any of the lunatic poor in their keeping. The illustrations at
hand, obtained from County Asylum Reports, are so numerous, that we must
content ourselves with a selection of a few of the more striking.
Dr. Boyd, the distinguished physician of the Somerset County Asylum, makes
the following statement in his Sixth Report (1853):--"Several aged
persons, and many others in a feeble state, have been admitted during the
year, so that the mortality, although less than in the preceding year, has
still been considerable. For example, two cases have been recently
admitted: one that of a man with dropsy, and broken down in constitution,
who is reported to have been given to excess in drinking ardent spirits,
and to have been subject to epileptic fits; he was disappointed at not
being admitted into a general hospital, became violent, and was sent as a
patient here; he has been free from fits since his admission, is rational,
but apparently in the last stage of bodily disease. The other case is that
of a woman about seventy, paralysed, and unable to sit up in the arm-chair
without support. She was troublesome in the union workhouse, and was
reported _as dangerous_, and so was sent to the asylum. There have been
four males with paralysis recently sent in from being dirty in their
habits.... One female was improperly sent with _delirium_ attending on
_fever_: she died a fortnight after admission." In his Ninth Report, this
same Superintendent says,--"Some are sent to the asylum in a state of
paralysis, some are aged and in a state of fatuity, and others when they
become troublesome, or are in a diseased and feeble state of bodily
health, and require more nurse-tending than they receive in the
workhouses.... Under the existing arrangements, lunatic asylums are
gradually losing their proper character of hospitals for the recovery of
the insane, and sinking down to be mere auxiliaries to workhouses."
Out of eighty admissions at the Worcester County Asylum, fourteen were
between sixty and eighty years of age, and for the most part "the subjects
of organic disease of the brain, lungs, and heart, or suffered from
long-continued mental disease, or from the superannuation of old age, and
deficient nutrition of the brain and nervous centres. Four of them died
during the year.... During the early part of the year some correspondence
was entered into with several Unions, from which patients had been sent in
a dying or exhausted state; and the impropriety of such proceeding was
pointed out by your Committee.... It is not supposed that those
unfortunate cases are wilfully detained with improper intentions at their
homes or elsewhere, but from ignorance; and from want of the necessary
appliances, and the assistance of those accustomed to the insane, proper
measures cannot be adopted for their care and recovery," and various
injuries are inflicted.
The experienced Superintendent of the Beds., Herts., and Hunts. Asylum
reports, in 1856, that of 111, as many as twelve died within three months
of their being admitted; five did not survive a fortnight. "One male, an
epileptic seventy-nine years of age, and having been bedridden for years
from contracted limbs, and nearly exhausted from the journey, died on the
twelfth day. A female, aged sixty-eight, with disease of the heart, died
on the fourth day from exhaustion, having been some time without rest, and
having refused her food previous to admission. A female in the last stage
of pulmonary consumption, lived but seventeen days; and one very
distressing case of a female ... was brought to the asylum, who, worn out
from constant excitement, and having a large wound on the leg, with
ulcerations from ligatures on the wrists and ankles, sank on the
fourteenth day. The two last-mentioned patients were reported to have
refused food for nearly a week, but took every kind of nourishment offered
to them from the moment they were in the Asylum."
The Report of the Suffolk County Asylum records the admission of ten poor
persons in 1852 "nearly seventy years of age, nine over seventy, three
over eighty; sixteen in a state of bodily exhaustion; nine either idiots
from birth, or imbeciles for a very long period; one child with well-known
disease of the heart, and a woman, a cripple, scrofulous, blind and deaf."
"What," asks Dr. Kirkman, the venerable Superintendent, "can be done more
than good nursing to support a peevish mind in a patient eighty-four,
admitted only a few days ago?" He adds, "To give other instances, one man
was received some time back on a very qualified certificate, and upon
whose case a qualified certificate only could be given; and another
(somewhat experimentally) with the notice that his mania, if such it were,
existed only in the want of a slight resistance to a wayward will; and
another, a girl of sixteen, subsequently found not to be insane, but
suffering from aggravated cataleptic hysteria, supposed to have been
caused by fright, having spinal disease, and deformed throughout the
body."
Dr. Hitchman, whose Reports we have found so valuable in former sections
of this work, has repeatedly called attention to the subject now under
notice. In 1853 he writes:--"It is with feelings of deepest sorrow that
your physician is compelled to state, that patients continue to be sent to
the asylum in very advanced stages of bodily and mental disease.... So
long as no violent or overt act has been perpetrated; so long as the
sufferer can be 'managed' in the privacy of his miserable home, or by the
'cheap' resources of a workhouse, he is often detained from the lunatic
hospital. Disease, aggravated by neglect, continues its direful course,
the 'harmless' lunatic becomes very dirty in his habits, or very violent
in his conduct, windows are broken, clothes are torn, persons are injured,
and the strap, the strait-waistcoat, and the chain are brought into
service to control for a time the ravings and the mischief of the patient.
Steps are now taken for his removal--bound, bruised, dirty, and paralysed,
the poor creature is taken to an asylum. One glance is sufficient to
reveal to the experienced eye that _cure_ is hopeless; that while every
resource of the Institution will be needed to sustain the exhausted
energies of the patient--to preserve him from the sufferings consequent
upon the loss of his self-control over the excretions of his body, yet for
two or three years he may survive to swell the list of incurables--to
diminish the per-centage of cures--to crowd the hospital, and, worse than
all, to perpetuate this popular belief, and to encourage the pernicious
practice, which are now leading to the moral death and social extinction
of hundreds of our fellow-creatures."
Speaking of the admissions in 1854, he says:--"Several were in advanced
stages of bodily disease; thus, I. C. expired in eight hours after his
arrival at this hospital. He was removed from the vehicle in which he was
brought to his bed, where he remained tranquil until the moment of his
decease. The state of great prostration in which he was brought, forbade
the employment of the usual washing-bath; nor was he subjected to the
fatigue of being shaved (of which he stood in much need) in consequence of
his exhaustion. F. G., aged 76 years, admitted with the marks of restraint
round her wrists, survived eighteen days--only by the administration of
wine and warmth. S. C., brought bound by straps and a strait-waistcoat in
the afternoon of the 18th, was so convulsed and epileptic, that she died
on the morning of the 20th, having scarcely spoken during the time she was
in the asylum. Others were in advanced stages of dropsy, phthisis, and
general paralysis, and, although in a hopeless condition, lived on for
several weeks under the fostering care of the Institution. One poor girl,
admitted from Lincolnshire, in a perfectly helpless condition (the
delirium of fever having been mistaken for the ravings of insanity), was
conveyed from the vehicle to a water-bed, where she has remained in a
state of great suffering for upwards of twelve weeks, and is never likely
again to recover the use of her limbs."
The experience of the Kent Asylum is similar. The age of eleven persons
admitted in 1853 averaged 64, and twelve were from 72 to 75. "In many of
these the malady was simply decay of mind, or was due to apoplectic
seizures, and attended by palsy."
In the Report for 1857-1858, Dr. Huxley goes more at large into the
question of unfitness for asylum admission, and the vigour and clearness
of his remarks induces us to quote them at length. He observes:--"It seems
difficult to understand on what principle patients are sometimes sent. One
man, for an intemperate threat uttered under considerable provocation, is
hastened off to the asylum. He can then only be deemed insane in a
constructive sense, and in reliance on the undoubted good faith of the
whole proceedings for his removal. He is seen to be sane; he remains so,
and merely awaits the next discharging-day. In the interval he has had
time to reflect on the danger of uncontrolled speech; but perhaps he and
his family ought not to have incurred the reproach (as it is held) of
insanity in the blood. Perhaps, also, he ought not to have swelled the
list of persons insane, adding his mite to the evidence which supports the
general belief in an actual increase of disorders of the mind.
"Again, the facility with which a drunken prostitute finds admission and
re-admission is astonishing. The delirium, rather than insanity proper,
produced by excessive drinking, has, indeed, some alarming modes of
expression; but it is a different thing from true mental derangement, and
is transient, the patient being generally nearly all right again on
arrival. I confess to a feeling which grudges to such patients the
benefits of an asylum and association with the inmates who are truly
unfortunate. Their detention is wholly unsatisfactory; it leads to
nothing. Long or short, it proves no warning against a return to former
bad courses; whilst the presence of people (I do not call them patients)
of this sort seriously injures the interior comfort of the wards. Ought
such cases to swell the returns of lunacy? Then, in estimating the
supposed growth of insanity among the people, let the fact be remembered,
that here is one contributing element, which was not represented until of
late years. Once again, the extent to which strongly-marked senility is
now made the reason for admission to the asylum is, I think,
unprecedented. To grow childish, wilful, and intractable; to lose memory,
and forget the good habits of a life; to take no note of times and
seasons; to wake by night and be restless, and to become generally
incapable, are the rule rather than the exception at the close of an
extended life. I do not think these natural ills ought to be the cause so
frequently as they are found to be, for sending the subjects of them to an
asylum. Workhouses may not contain the little special accommodation
needful for such cases; but it would not be a good argument to hold, that
because they _do_ not, the asylum must be the proper receptacle.
"Poverty is, truly, the great evil; it has no friends able to help.
Persons in middle society do not put away their aged relatives because of
their infirmities, and I think it was not always the custom for worn-out
paupers to be sent to the asylum. May not this practice be justly regarded
as an abuse of the asylum? It is one more of the ways in which, at this
day, the apparent increase of insanity is sustained. It is not a real
increase, since the aged have ever been subject to this sort of
unsoundness.
"Decayed persons, once placed in an asylum, are ever after held to have
been rightfully deemed insane. If any of their descendants, therefore,
become mentally afflicted, the hereditary taint is straightway accounted
to them. This is, indeed, to show cause why all the world should be mad! I
hold it to be wrong to send persons to an asylum merely on account of
second childhood, and a wrong operating to general disparagement. In the
first place, the practice is only an indirect consequence of poverty;
next, it helps improperly to force asylums to a size inconsistent with
their best management; and thirdly, it is one amongst other apparent, but
not real grounds, for that increase of mental disorder, which is
apprehended with such general alarm.
"We received at least twelve persons, who, in my judgment, needed not, and
therefore ought not to have been sent, viz. seven aged, being of 70, 74,
76, 78, 79, 80, and 82 years; three children, of 6, 8, and 10 years; and
two adults. One of the children was not insane, but suffering from chorea
(St. Vitus's dance) affecting the whole body. This disorder had,
apparently, been mistaken for mania."
We will close these quotations by one from Dr. Bucknill's Report for
1854:--
"There can be little doubt that those asylums, the admission into which is
restricted by legal formalities alone, are not unfrequently made use of as
hospitals for the treatment of bodily disease and for the care of the
bodily infirm. To such asylums patients are sent suffering from serious
and troublesome bodily diseases, whose mental condition would never have
been considered a sufficient cause for removal had it existed alone. The
number of patients has not been small, who, from time to time, have been
admitted into the Devon Asylum with serious disease of the several organs
of the body, and with no greater amount of mental disturbance than is the
frequent result of such disease.
"Patients have been admitted suffering from heart disease, aneurism, and
cancer, with scarcely a greater amount of melancholy than might be
expected to take place in many sane persons at the near and certain
prospect of death. Some have been received in the last stages of
consumption, with that amount only of cerebral excitement so common in
this disorder; others have been received in the delirium or the stupor of
typhus; while in several cases the mental condition was totally unknown
after admission, and must have been unknown before, since the advanced
condition of bodily disease prevented speech, and the expression of
intelligence or emotion, either normal or morbid.
"These observations are made in no spirit of complaint. The capabilities
of these institutions to treat all ailments of mind or body are indeed
felt to be a source of satisfaction and pride. It ought, however, to be
known, that this County Asylum is, to some extent, made use of as a public
infirmary, and that the result of such employment must be expected in an
obituary somewhat lengthened, if not also in a list of cures somewhat
abbreviated."
Sufficient proofs are surely furnished in the above extracts, selected
from many similar ones, to establish the general statements advanced at
the beginning of the present subject, viz. that both recklessness and
cruelty not unfrequently mark the proceedings of workhouse officials in
their transmission of patients to the county asylums. They, moreover,
supply facts to prove that the neglect in transferring proper cases for
asylum treatment, and the inexcusable folly of sending to asylums the
victims of second childishness, the imbecile paralytics, the peevish and
perverse sufferers from chronic organic disease, such as poor
consumptives, whose days are measured by the shortest span, tend to
promote the accumulation of incurable inmates, to raise the mortality, and
to increase the expenditure of these institutions. In fact, the annual
returns of county asylum experience demonstrate that the transmission to
asylums is regulated by no rule, and is attended by great abuses.
The practical lesson deducible from this is, that the matter must be
placed in other hands, and guided according to some rational principles.
The insane poor must no longer be left to pine in neglect and misery in
their own homes, until their friends tire of the trouble of them, or some
casual circumstance class them, in a relieving officer's opinion, as
proper candidates for an asylum; nor must their presence in the workhouse
be, for the future, regulated by the mere circumstance of the care,
attention and expense they involve, in the estimation of workhouse
governors. There need be some specially appointed officer, whose business
it should be to know both the existence of every insane person in his
district and his condition and treatment, and to report those who require
the care of a curative asylum, those who only need the nursing and
supervision of a chronic one, and those who can be duly and efficiently
tended and cherished in the homes of their families. By the exertions of
such an officer, we should no longer read of the removal of dying
patients, only to die in the asylums; or of the victims of neglect and
wretchedness detained in workhouses or their homes, until the advance of
their mental malady, the complication of organic disease, or some
casualty, has rendered them hopelessly incurable, and burdensome in
cost,--a cause of a decreased rate of cures and of an augmentation of
deaths in the asylum.
But there is yet another lesson to be learned from the foregoing extracts,
confirmatory of our own experience, which we might well wish to ignore,
viz. the want of knowledge, both of the characters of insanity and of the
treatment it demands, among our professional brethren. Undoubtedly a vast
stride has been made of late years in diffusing correct views of insanity
and its treatment, yet much remains to be done; and it is humiliating to
read of cases of delirium from fever, or from organic disease, affecting
other organs than the brain; of patients afflicted with chorea; of others
delirious from exhaustion or from alcoholic drinks, sent to asylums as
cases of insanity. For it is to be remembered, that a medical certificate
is a necessary preliminary to the entrance of every person into an asylum;
and where the nature of the cases indicates no flagrant error of
diagnosis, it at all events exhibits a carelessness or recklessness of the
medical man, or his want of moral courage and of official independence,
where, for example, he acts as the agent in sending to asylums the aged
imbecile of fourscore years, or the poor restless, irritable victim of
consumption or other fatal organic bodily disease. Moreover, it speaks ill
of Union medical officers, who are entrusted with the supervision, medical
care and treatment, and with the dietary of the lunatic poor, to read of
the neglected and wretched state in which they are too often found, both
in workhouses and in their own homes, and of the condition in which they
sometimes are when received into asylums. The bonds and bands, the
physical exhaustion from want of food, are matters rightly placed, in a
greater or less measure, in their hands. The treatment by cupping,
leeches, general bleeding, blistering and purging, and by other depressing
means, lies wholly at their door; and such treatment, we regret to say, is
still, by some medical practitioners, deemed proper, although experience
has for years shown that madness is a disease of debility, and that to use
debilitating means is the most direct way to render it incurable.
There is yet another indication of the deficiency of information among
medical men in general, often noticed by asylum physicians, viz. their
inability to recognize the peculiar form of paralysis attended with
disordered mind, known as "general paralysis." Where, as at St. Luke's
Hospital, at Bethlem, and at Hanwell, under the recent regulation for
promoting the early treatment of recent cases, the existence of general
paralysis disqualifies an applicant from admission, the rejection of
patients, on the ground of its presence, often gives rise to
disappointment and to irritation on the part of the medical men signing
the certificates, who will stoutly deny the justice of the exclusion,
because they see no such loss of motion or sensation as they do in
hemiplegia or paraplegia, or those forms of palsy to which they are
accustomed to restrict the appellation.
This defective knowledge of insanity and its treatment ought not to be
found, were medical instruction complete. But whilst the medical
curricula make no requirement of instruction in mental disease necessary
to medical qualifications, they are expanded so as to comprehend almost
every branch of human knowledge, under the heads of 'Preliminary
Education' and of 'Collateral Sciences,' and yet ignore psychological
medicine, as though human beings were without minds, or, at least, without
minds subject to disorder. The consequence is, as facts above illustrate,
medical men enter into practice with no conception of the varied phenomena
of mental disorder; unable to diagnose it; unfit to treat it, and glad to
keep out of the way of its sufferers. Some, as before intimated, associate
it, in their views, with inflammatory or congestive disease, and treat it
accordingly, by blood-letting and the other parts of the so-called
antiphlogistic regimen, to the speedy destruction of the patient, by
increased maniacal excitement and concurrent exhaustion, or to his extreme
detriment in relation to his prospects of recovery. Let us hope that this
state of things may ere long be entirely amended, and that medical
practitioners may be required to understand disorders of the mind as
perfectly as those of the lungs.
Before quitting the subject of this section, a brief comment on the state
of the law regulating the transference of weak cases to asylums will not
be misplaced. According to _sect._ lxvii. 16 & 17 Vict. cap. 97, providing
for the examination of alleged lunatics prior to removal to an asylum, it
is enacted, "that in case any pauper deemed to be lunatic, cannot, on
account of his health or other cause, be conveniently taken before a
Justice, such pauper may be examined at his own abode;" and that, if found
lunatic, he shall be conveyed to an "Asylum, Hospital, or House...;
provided also, that if the physician, surgeon, or apothecary by whom any
such pauper shall be examined shall certify in writing that he is not in a
fit state to be removed, his removal shall be suspended until the same or
some other physician, surgeon, or apothecary shall certify in writing that
he is fit to be removed; and every such physician, surgeon, and apothecary
is required to give such last-mentioned certificate as soon as in his
judgment it ought to be given." A similar provision is made in the case of
"Lunatics wandering at large, not being properly taken care of, or being
cruelly treated" or neglected by their relatives, by the section next
following (_sect._ lxviii).
Further, by _sect._ lxxvii., empowering the Visitors of Asylums to remove
patients, it is provided "that no person shall be removed under any such
order without a medical certificate signed by the medical officer of the
asylum, or the medical practitioner, or one of the medical practitioners,
keeping, residing in, or visiting the hospital, or licensed house, from
which such person is ordered to be removed, certifying that he is in a
fit condition of bodily health to be removed in pursuance of such order."
From the clauses above quoted, it is evidently the intent of the law to
shield the unfortunate sufferers from mental disease, where prostrated by
exhaustion or by organic lesions, against hasty and injudicious removal
detrimental to their condition, or dangerous to life; yet, as already
seen, these provisions are inoperative in preventing the evil. Those,
indeed, regulating the transfer or removal of patients to or from an
asylum are to a certain extent obligatory, and are probably attended to;
but it is not so with those designed to protect lunatics from injurious
removals under the direction of parochial authorities, as enacted by
_sect._ lxvii. For by this section it is left to the discretion of the
medical practitioner called in, to examine the patient, and to certify, in
writing, to his unfitness for removal; but much too commonly, according to
the testimony of every asylum superintendent, the humane intentions of the
law are neglected. This 67th section need, therefore, to be assimilated to
the 77th, so far as to make it imperative on the part of the medical man
who examines the patient, to certify "that he is in a fit state of bodily
health to be removed."
This is but a slight amendment, but it might save many a poor creature in
a totally broken-down, exhausted, or moribund state, from being carried to
an asylum far away, only to pine away and die. It is hard to write against
the members of one's own profession, but the details put forth by asylum
physicians of the manner in which patients are conveyed to the public
institutions, and of the state in which they are received, demand, on the
score of humanity, a condemnation of the indifference and negligence which
sometimes mark the performance of duties rightly chargeable to parochial
medical officers. Partial excuses for these officers may be found in
abundance, on account of their usual wretched remuneration, and the too
dependent position they occupy in reference to the parish boards
appointing them; but no sufficient explanation appears for their
withholding a certificate allowed by law, which might prevent the removal
of a patient delirious with fever, of one perishing from heart disease or
consumption, or of one dying from the exhaustion of cerebral excitement
and defective nutrition.
CHAP. VI.--CAUSES DIMINISHING THE CURABILITY OF INSANITY, AND INVOLVING
THE MULTIPLICATION OF CHRONIC LUNATICS.
Other causes than those already examined are in existence, sending to
diminish the curability and to multiply the permanent sufferers of
insanity, to be found unfortunately in the character and constitution of
the very establishments constructed to afford requisite care and treatment
for our pauper lunatics. According to the division of our subject (p. 31),
these causes belong to the second head; or are--
B. _Causes in operation within Asylums._
§ _Magisterial interference. Excessive size of Asylums. Insufficient
medical supervision._
There are in too many asylums grave errors of construction, government,
and management, which detract from their utility, and damage the interests
of both superintendents and patients. In several there is too much
magisterial meddling, subversive of that unity of action and management
which should prevail in an asylum, as it must do in a ship, and
prejudicial to the position and authority of the superintendents, by
diminishing their responsibility, their self-respect and independence, and
their importance in the estimation of those under their direction. The
visiting justices of an asylum mistake their office when they descend from
matters of general administration and supervision to those of
superintendence and internal management. When they exchange their legal
position as occasional visitors of the wards for that of weekly or more
frequent inspectors; when they directly occupy themselves with the details
of the establishment, with the circumstances affecting the patients, with
their occupations and amusements, irrespective of the medical officer;
when they suffer themselves to be appealed to, and to act as referees in
matters of internal discipline; when they assume to themselves the hiring
and discharging of attendants; and when, without taking counsel with the
medical superintendent, they determine on alterations and additions to
their asylum,--they are most certainly pursuing a policy calculated to
disturb and destroy the government and the successful operation of the
establishment. A meddling policy is in all ways mischievous and bad; it
irritates honourable minds, and deters them in their praiseworthy and
noble endeavours to merit approval and reward; whilst it at the same time
acts as an incentive to apathy, indolence, and neglect: for freedom and
independence of action, a feeling of trust reposed, and of merit
appreciated, are necessary to the cheerful, energetic and efficient
performance of duties. So soon as the zeal of any man of ordinary moral
sensibility is doubted, so soon as his competency for his office is so far
questioned by the activity and interference of others in his particular
field of labour, so soon is a check given to his best endeavours in the
discharge of his duties, his interest in them abates, and a blow is
inflicted upon his feelings and self-respect. In short, it cannot be
disputed, that if an asylum have a duly qualified and trustworthy
superintendent, the less a committee of visitors interferes with its
internal organization and the direction of its details, the more
advantageous is it for the well-being of the institution.
Again, many asylums have grown to such a magnitude, that their general
management is unwieldy, and their due medical and moral care and
supervision an impossibility. They have grown into lunatic colonies of
eight or nine hundred, or even of a thousand or more inhabitants,
comfortably lodged and clothed, fed by a not illiberal commissariat,
watched and waited on by well-paid attendants, disciplined and drilled to
a well-ordered routine, gratified by entertainments, and employed where
practicable, and, on the whole, considered as paupers, very well off; but
in the character of patients, labouring under a malady very amenable to
treatment, if not too long neglected, far from receiving due consideration
and care.
Although the aggregation of large numbers of diseased persons, and of
lunatics among others, is to be deprecated on various grounds, hygienic
and others, yet the objections might be felt as of less weight, contrasted
with the presumed economical and administrative advantages accruing from
the proceeding, were the medical staff proportionately augmented, and the
mental malady of the inmates of a chronic and generally incurable
character. But, in the instance of the monster asylums referred to,
neither is the medical staff at all proportionate to the number of
patients, nor are their inmates exclusively chronic lunatics. The medical
officer is charged with the care and supervision of some three, four, or
five hundred insane people, among whom are cases of recent attack, and of
bodily disease of every degree of severity, and to whom a considerable
accession of fresh cases is annually made; and to his duties as physician
are added more or fewer details of administration, and all those of the
internal management of the institution, which bear upon the moral
treatment of its inmates, and are necessary even to an attempt at its
harmonious and successful working.
Now, little reflection is needed to beget the conviction, that a medical
man thus surcharged with duties cannot efficiently perform them; and the
greater will his insufficiency be, the larger the number of admissions,
and of recent or other cases demanding medical treatment. He may contrive,
indeed, to keep his asylum in good order, to secure cleanliness and
general quiet, to provide an ample general dietary, and such like, but he
will be unable to do all that he ought to do for the cure and relief of
the patients entrusted to him as a physician. To treat insane people
aright, they must be treated as individuals, and not _en masse_; they must
be individually known, studied, and attended to both morally and
medically. If recent insanity is to be treated, each case must be closely
watched in all its psychical and physical manifestations, and its
treatment be varied according to its changing conditions. Can a medical
man, surrounded by several hundred insane patients, single-handed, fulfil
his medical duties to them effectively, even had he no other duties to
perform, and were relieved from the general direction of the asylum? Can
he exercise a vigilant and efficient superintendence over the inmates? Can
he watch and personally inform himself of their mental, moral and bodily
condition, prescribe their appropriate treatment, diagnose disease and
detect its many variations; secure the due administration of medicines and
of external appliances; order the necessary food and regimen; feed those
who would starve themselves; attend to casualties and to sanitary
arrangements; judiciously arrange the classification, the employments and
recreations; keep the history of cases, make and record autopsies, and
watch the carrying out of his wishes by the attendants? Can, we repeat, an
asylum superintendent properly perform these, and those many other minor
duties of his office, conceivable to all those who experimentally
understand the matter, though not readily conveyed by description? Can any
person perform these duties, if they were separable, without injury to the
working of the institution, from the many details of general management
which the position of superintendent has attached to it? Can he be justly
held accountable, if the huge and complex machine goes wrong in any part?
Can he feel sure that his patients are well looked after, attended to
according to his wishes, and kindly treated? Can he do justice, lastly, as
a physician, to any one afflicted patient, whose restoration to health and
to society depends on the efficient exercise of his medical skill, and do
this without neglecting other patients and other duties? To these
questions, surely, every thinking, reasoning man will reply in the
negative.
The consequence is, that asylum superintendents, who thus find themselves
overburdened with multifarious and onerous duties, and feel the
hopelessness of a personal and efficient discharge of all of them, are
driven to a system of routine and general discipline, as the only one
whereby the huge machine in their charge can work, and look upon
recoveries as casual successes or undesigned coincidences (_see further_,
p. 119).
The inadequacy of the medical staff of most asylums is a consequence, in
part, of the conduct of superintendents themselves, and in part of the
notions of economy, and of the little value in which medical aid is held
by Visiting Justices in general. The contrast of a well-ordered asylum at
the present day, with the prison houses, the ill-usage and neglect of the
unhappy insane at a period so little removed from it, has produced so
striking an effect on mankind at large, that public attention is attracted
and riveted to those measures whereby the change has been brought about;
in other words, to the moral means of treatment,--to the liberty granted,
the comforts of life secured, the amusements contrived, and the useful
employment promoted,--all which can, to a greater or less extent, be
carried out equally by an unprofessional as by a professional man. It is
therefore not so surprising that the importance of a medical attendant is
little appreciated, and that the value of medical treatment is little
heeded.
There has, in fact, been a revulsion of popular feeling in favour of the
moral treatment and employment of the insane; and, as a popular sentiment
never wants advocates, so it has been with the one in question; and by the
laudation by physicians of the so-called moral means of treatment, and the
oblivion into which medical aid has been allowed to fall, magistrates,
like other mortals, have had their convictions strengthened, that medical
superintendents, considered in their professional capacity, are rather
ornamental than essential members of an asylum staff; very well in their
way in cases of casual sickness or injury, useful to legalize the exit of
the inmates from the world, and not bad scape-goats in misadventures and
unpleasant investigations into the management, and in general not worse
administrators, under the safeguard of their own magisterial oversight,
than would be members of most other occupations and professions.
As before remarked, the magnitude of an asylum, and the paucity of its
medical officers, are matters of much more serious import where recent
cases of insanity are under treatment. In a colossal refuge for the
insane, a patient may be said to lose his individuality, and to become a
member of a machine so put together as to move with precise regularity and
invariable routine;--a triumph of skill adapted to show how such
unpromising materials as crazy men and women may be drilled into order and
guided by rule, but not an apparatus calculated to restore their pristine
condition and their independent self-governing existence. In all cases
admitting of recovery, or of material amelioration, a gigantic asylum is a
gigantic evil, and, figuratively speaking, a manufactory of chronic
insanity. The medical attendant, as said before, is so distracted by
multitudinous duties, that the sufferer from the acute attack can claim
little more attention than his chronic neighbour, except at the sacrifice
of other duties. No frequent watching several times a day, and no special
interest in the individual case, can be looked for. There is such a thing
as a facility in observing and dealing with the phenomena of acute mental
disorder, acquired by experience; but it would be well nigh unjust to
expect it in a medical officer, in whose field of observation a case of
recent attack is the exception, and chronic insanity the rule, among the
hundreds around.
The practical result of this state of things is, that the recently
attacked patient almost inevitably obtains less attention than he needs
from the physician, who, from lack of sufficient personal observation,
must trust to the reports of others, to the diligence, skill and fidelity
of his attendants, and who, in fine, is compelled to repose work in
others' hands which should rightly fall into his own.
This being the case, the character of the attendants for experience,
knowledge, tact and honesty acquires importance directly proportionate to
the size of asylums, and the degree of inability of the medical
superintendents to perform his duties personally. Now, though we need
testify to the excellent qualities of some asylum attendants, yet,
notwithstanding any admissions of this sort, it is a serious question how
far such agents should be employed to supply the defects and omissions of
proper medical supervision and treatment. The class of society from which
they are usually derived; their common antecedents, as persons
unsuccessful or dissatisfied with their previous calling, or otherwise
tempted by the higher wages obtainable in asylums, are circumstances not
calculated to prepossess the feelings in favour of their employment in
that sort of attendance on the insane alluded to. They have no preliminary
instruction or training, but have to learn their duties in the exercise of
them. Many are their failures, many their faults, and often are they very
inefficient, as the records of every asylum testify; yet, on the whole,
considering their antecedents, and the nature of the duties imposed upon
them, their success is remarkable. However, whatever their character as a
body, as individuals they require the direct and ever-active oversight and
control of the superintendent. The institution of head-attendants is a
great relief to the labour of the latter, but rightly affords him no
opportunity to relax his own inspection and watchfulness.
In a large asylum there must be general routine: it can be conducted only
by routine; and the attendants are the immediate agents in carrying it
out. Their duties necessarily partake largely of a household character;
they are engaged in cleaning and polishing, in bed-making and dressing, in
fetching and carrying, and in serving meals. But along with these they are
entrusted with certain parts of the 'moral treatment' of the patients,--in
enforcing the regulations as to exercise, employment, amusement, the
distribution of meals, and the general cleanliness and order both of the
wards and their inmates; and in the exercise of these functions acquire
much knowledge respecting the character and habits of those under their
care. Yet withal, they are not fit and efficient persons to have medical
duties delegated to them. They are not qualified to observe and record the
symptoms of disease, to note its changes, nor, except under close
surveillance, to apply remedies externally or internally.
Such is the onset or the serious march of bodily sickness not
unfrequently, that even the experienced medical observer is prone to
overlook it. This is true where disease attacks those sound in mind, and
able to express their sufferings, and to lend the aid of their
intelligence towards the discovery of the nature and seat of their malady;
but the danger of oversight is increased tenfold when the insane are the
subjects of bodily lesion. Where the mind is enfeebled and sensibility
blunted, and where melancholy broods heavily over its victim, disease is
to be discovered only by a watchful and experienced practitioner of
medicine; for the unfortunate patient will make no complaint, and the
fatal malady may evince itself to the ordinary uninstructed observer by no
sufficient symptom to awaken attention; and even where the mind is not
imbecile, nor weighed down by its fears and profound apathy, yet the
features of its disorder will interfere, in most instances, with the
appreciation and interpretation of the symptoms which may reach the
knowledge of those about the sufferer, and thereby mask the disease from
the non-professional looker-on, and render its diagnosis even difficult to
the medical examiner.
With respect to the female attendants of asylums, it may also be observed,
that they are frequently young women without experience in disease, and
rarely qualified as nurses conversant with certain medical matters; and,
from our own observation, they are found to be often backward and shy in
reporting particulars respecting the female patients, and badly qualified
in administering to their wants when sick. Moreover, equally with the male
attendants, there is, by their education and training, no security for a
well-governed temper, for long suffering, patience and sympathy. Indeed,
the wages given in most asylums are not sufficient to induce a higher
class of young women to accept the onerous and often painful and
disagreeable duties of attendants on the insane, than that which furnishes
housemaids and kitchenmaids to respectable families. If, therefore, their
origin be only looked to, it would be contrary to experience to expect
from the nurses of asylums, as a body, the possession of high moral
principle and sensibility, of correct notions of duty, and of a hearty
interest in their duties. We make these remarks, with no intention to
censure the whole race of asylum nurses, among whom are many meritorious
women; but merely to enforce the opinion that something may be done to
improve their character and condition, and that, as a class, they are not
rightly chargeable with duties of the kind and to the extent we are
engaged in pointing out. On the contrary, their history, position, and
education conspire to make them servants in tone and character, unfit
often to exercise the discipline and authority entrusted to them; whilst
the general duties connected with the cleanliness and order of their wards
and rooms, and the observation of the universal routine of the asylum,
contribute to the same effect, and the more so in large establishments,
where the almost constant supervision of the superintendent is wanting,
where individual interest in patients is all but dead, and where their
number renders the inmates mere automatons, acted on in this or that
fashion according to the rules governing the great machine.
From the necessity of the case, the medical superintendent of a colossal
asylum is compelled mainly to trust to the observation of his attendants
to discover disease, and to report mishaps. He has his mile or upwards of
wards and offices to perambulate daily, and, to keep up some connexion
with their four or five hundred inmates, must adopt some general plan. For
instance, he refers to the attendant of each ward he enters, demands from
him if he has anything to report, wends his way through the apartment,
looks right and left, remarks if the floor and rooms are duly swept and
garnished; now and then inspects the bed and bedding, bids good morning to
more or fewer of the patients who may be present, and unless Brown or
Jones has something to report of any one of them, bids good day to all, to
recommence the same operation in the next ward. Now Brown or Jones might
have had something to report had they medical eyes, and information to
detect the first symptoms of disease in one of their patients; but as they
have not, the disorder has a fair opportunity to steal a march upon the
doctor, and possibly to take such firm possession of its victim before
this or that attendant is persuaded something is going wrong, that the
doctor only commences his professional operations against it in time to
render his certificate of death satisfactory, and the result explicable
without a coroner's inquest.
We do not blame the medical men for not doing more, but we deprecate the
system which places it out of their power to do so. No one can gainsay the
possibility, nay, the actual occurrence, of avoidable deaths in the large
asylums we condemn; and those who know the working of such institutions,
know also that the duties are performed much after the sketch delineated,
and could be got through in no greatly improved fashion.
But it must not be supposed, that it is only when disease exists or has to
be discovered, that the delegation of the principal part of the
supervision of patients to ordinary asylum attendants operates injuriously
to their well-being; far from it, for many are the cases which require the
presence of a more instructed and more sympathizing mind; of a person to
appreciate their moral and mental condition; to overrule by his official
position disorderly manifestations, to pacify the excitable, to encourage
and cheer the melancholy; to espy and anticipate the wants of all; to hear
the complaints of some, and to be the confidant of others; to mark the
mental changes of individuals, and to adapt surrounding circumstances,
their occupations and amusements accordingly. To give such
superintendence, or, in other words, to apply such moral and mental
treatment, the medical officer is the only fitting person; from him the
patients will and do naturally look for it. Let any one follow a medical
superintendent in his ordinary visits through the wards; and he will
observe how ardently the visit is anticipated by many; how numerous are
the little troubles and ailments they wish to disclose to the physician,
and only to him; how often he can arrest excitement and calm irritation,
only aggravated by the interposition of attendants; how often he can
recognize mental and bodily symptoms demanding attention, and, in general,
how largely he can supply those minutiæ of treatment, insignificant as
they appear, and unthought of as they are by others, whose moral feelings,
whose intellectual acumen, whose education and manners, and whose position
are deficient to conceive them, and insufficient to put them in force.
There is no question, it must be granted, but that whatever medical
supervision may be supplied, yet that the carrying out of most of the
details of management must always devolve upon the attendants; it becomes,
therefore, a matter of paramount importance to render that class of asylum
functionaries as efficient as possible. They need be encouraged by good
wages and good treatment; and, what is of great moment, these should be
sufficiently good, to induce persons of a better class than that which
usually furnishes attendants, to accept such posts. This idea will
probably be scouted by the stickler to "a due regard for economy," at
first sight; but we think his economical penchant might be gratified by
the plan of carrying out more fully in the wards the distinction of
attendants upon the insane and of household servants. For is it not
practicable to import the system adopted in the large London Hospitals,
where the office of 'sisters,' to nurse the patients, is separated from
that of under-nurse, to whom the cleanliness of the wards is committed? If
so, the immediate attendants on the insane might receive higher wages
without increasing the general expenditure of the asylum; for those
concerned in the cleaning of the wards would only earn the wages of common
household servants. We throw out this suggestion, in passing, for the
nature of our treatise forbids our enlarging upon such matters of asylum
organization; otherwise, much might be written respecting the duties and
the remuneration of attendants, and the advantages of pensions for them
after a certain term of faithful service.
To conclude this topic, we may remark that it would be easy, did the
subject stand in need of proof, to multiply illustrations, showing that,
to transfer the work of medical and moral supervision to attendants, in
any similar extent and measure to that which must of necessity prevail in
the excessively large asylums which County Magistrates rear in opposition
to the decided opinion of those best able to judge, is to frustrate the
object of those institutions as curative asylums, and to detract from
their advantages as refuges for the incurable.
The evils of overgrown asylums have not, as might be expected, escaped the
observation and reprobation of the Commissioners in Lunacy, who have
referred to them in several of their Annual Reports, but more at large in
that of 1857, wherein they detail their contest with the Middlesex
magistrates respecting the further enlargement of the enormous asylums of
Hanwell and Colney Hatch, and their strange defeat, the magistrates having
contrived to influence the Home Secretary in opposition to the decided
opinion of the Commissioners, though seconded by experience, by the
general assent of all asylum physicians, and by their position as the
referees appointed by the State in all matters touching the erection and
management of asylums. With this acquiescence in the erroneous scheme of a
County Magistracy in opposition to a Government Commission, we have at
present no immediate concern, and may content ourselves with reporting it
as an anomalous proceeding which ought never to have occurred: but to
revert to the sentiments of the Commissioners, they are expressed in the
following quotation from the Report mentioned.
"It has always been the opinion of this Board that asylums beyond a
certain size are objectionable: they forfeit the advantage which nothing
can replace, whether in general management or the treatment of disease, of
individual and responsible supervision. To the cure or alleviation of
insanity, few aids are so important as those which may be derived from
vigilant observation of individual peculiarities; but where the patients
assembled are so numerous that no medical officer can bring them within
the range of his personal examination and judgment, such opportunities
are altogether lost, and amid the workings of a great machine, the
physician as well as the patient loses his individuality. When to this
also is added, what experience has of late years shown, that the absence
of a single and undivided responsibility is equally injurious to the
general management, and that the rate of maintenance for patients in the
larger buildings has a tendency to run higher than in buildings of a
smaller size, it would seem as if the only tenable plea for erecting them
ought to be abandoned. To the patients, undoubtedly, they bring no
corresponding benefit. The more extended they are, the more abridged
become their means of cure; and this, which should be the first object of
an asylum, and by which alone any check can be given to the present
gradual and steady increase in the number of pauper lunatics requiring
accommodation, is unhappily no longer the leading characteristic of Colney
Hatch or of Hanwell."
As may be supposed, the disposition to build huge asylums is due to the
same cause as that of the detention of insane persons in workhouses, viz.
to the plea of economy; a plea, which we believe to be about as fallacious
in the one case as in the other. The economy is supposed to arise from the
saving in commissariat matters and in the governing staff; and it is no
doubt proportionately cheaper to provision 1000 persons than 500, other
things being the same. But, on the one hand, very competent persons assert
that the cost of officers and servants for a population of 1000 insane is
more than double that for one of half that amount, when proportionately
compared. The multiplication of inferior officers beyond a certain point
entails that of superior ones in a higher ratio to overlook them; there is
not the same amount of productive labour considering the number employed.
The capability of the superintendent to supervise his attendants and the
patients stops at a certain point, and he need call to his aid a head
attendant at superior wages, and so add an extra person to the staff; if
the extent of his charge is farther increased by additional patients and
their necessary attendants, then an officer of a higher grade is called
for, and other overlookers of attendants and of the _régime_ of the house.
But figures showing the relative costs presently appealed to will do more
to convince the reader of the fact under notice than any 'aids to
reflection' we can supply.
There can be no question, that to build asylums for the insane above a
certain size is a fallacy when viewed even in an economical aspect; but
when regarded in relation to its ulterior consequences, the plan is not
only erroneous, but reprehensible. Were it really the case that a
pecuniary saving resulted from the aggregation of large masses of mentally
disordered folk, according to the figures in the ledger of the
institution, yet no positive gain could be boasted of until it was proved
that every case was placed in the most favourable conditions for recovery.
Can it be pretended that the very extensive asylums of this country, with
their present corps of medical officers, furnish such conditions?
Certainly not, if there be any truth in the account we have published of
their evils and defects. And if those conditions are not supplied, the
primary object of these institutions, _i. e._ the cure of the insane, is
frustrated, and chronic lunacy increased. Where, then, is the economy, if
patients, failing to receive the means of recovery, by reason of the
constitution of the asylum on so large a scale, fall into chronic disease,
and become permanent burdens on its funds? Where is the economy of a
system, which, by standing in the way of efficient treatment, reduces the
proportion per cent. of recoveries to twenty or thirty, when under
different arrangements that proportion may equal 60 per cent. or upwards?
It will be a happy day for the insane, and for the contributors to their
maintenance, when Visiting Justices arrive at the conviction, that they
have not done all they can on behalf of the poor disordered people under
their guardianship, when they have provided good lodging, board and
clothing for them, and such a system of routine and discipline as to check
the manifestation of their mental vagaries; and that it is not enough for
a recent case, to introduce it into an asylum and the companionship of
lunatics, with practically no positive provision for its medical
treatment. It will be well, too, for the insane, when the truth becomes
more generally assented to, that their malady is no mythical, spiritual
alteration, but the consequence of a material lesion of the brain, the
marvellous instrument, the subject and servant of the immortal soul, which
can by its divine essence know no disorder.
This is perhaps, strictly speaking, a digression from the subject; yet
erroneous ideas are the parents of erroneous practices, and those we have
hinted at form no exception to the rule. But, to return, we have some
excellent illustrative remarks on the fallacy of the belief in the economy
of very large asylums, contained both in the Report of the American and of
the English Lunacy Commissioners. The former thus write in their Report
(_op. cit._ p. 136):--
"The policy which has built large establishments for the insane is a
questionable one as applied to economy. After having built a house
sufficiently large, and gathered a sufficient number of patients for their
proper classification and for the employment of a competent corps of
officers and attendants, and allowing each to receive just as much
attention as his case requires, and providing no more, any increase of
numbers will either crowd the house, or create the necessity of building
more rooms; and their management must be either at the cost of that
attention which is due to others, or must create the necessity of
employing more persons to superintend and to watch them.
"If the house be crowded beyond the appropriate numbers, or if the needful
attention and the healing influences due to each individual are
diminished, the restorative process is retarded, and the recovery is
rendered more doubtful; and if additional provision, both of
accommodations and professional and subsidiary attendance, is made to meet
the increase of patients beyond the best standard, it would cost at least
as much per head as for the original number. Dr. Kirkbride thinks it would
cost more, and that the actual recoveries of the curable, and the
comfortable guardianship of the incurable, are not so easily attained in
large hospitals as in such as come within the description herein proposed.
'It might be supposed that institutions for a much larger number of
patients than has been recommended could be supported at a less relative
cost; but this is not found to be the case. There is always more
difficulty in superintending details in a very large hospital; there are
more sources of waste and loss; improvements are apt to be relatively more
costly; and, without great care on the part of the officers, the patients
will be less comfortable.'
"Besides the increased cost of maintaining and the diminished efficiency
of a large establishment, there is the strong objection of distance and
difficulty of access, which must limit the usefulness of a large hospital
in the country, and prevent its diffusing its benefits equally over any
considerable extent of territory to whose people it may open its doors."
Having pointed out the evils of large asylums to their inmates, the
English Commissioners, in their Eleventh Report (p. 11), remark, "that the
rate of maintenance for patients in the larger buildings has a tendency to
run higher than in buildings of a smaller size," ... and that it therefore
"would seem as if the only tenable plea for erecting them ought to be
abandoned." To substantiate this assertion, they appeal to the table of
weekly charges of the several county asylums, set forth in the Appendix
C.C. of the same Report, which certainly shows that the cost per head is
at its maximum in those which receive the largest number of patients. This
being so, surely no one can withhold assent to the just conclusion of the
Commissioners, that the system of erecting asylums above certain
dimensions ought to be abandoned, inasmuch as the only plea that can be
urged in its behalf, that, namely, of its economy,--a bad plea, by the
way, if the real interests of patients and ratepayers are concerned,--is
founded in error.
One more topic needs a few words, viz. the very inadequate remuneration of
the medical superintendents in some asylums,--a circumstance, confirmatory
of the small value assigned by their Committees of Visitors to
professional qualifications. The worst instances of underpayment are, in
fact, met with in those very asylums where the number of inmates attains
its maximum, and the medical provision for their care is at its minimum;
where the administrative power of the medical men is the most limited and
most interfered with, and their ability to discharge their duties
conscientiously and efficiently, utterly crippled by the multitude of
claimants upon their attention surrounding them; and where, in fine, they
are merely accessory officials, useful in cases of sickness and accident.
It must, indeed, be gratifying to the advocates of the rights of women to
know, that in one asylum, at least, female labour is rated as equal to
male professional labour; that the matron is as well paid as the medical
officers, and more valued in the estimation of the Committee of Visitors.
But, however this circumstance may be viewed by the partisans of the
interests of the fair sex, we venture to believe that to most people it
will appear a gross anomaly. For our own part, we consider also that it
would be to the interests both of patients and rate-payers to elevate the
position of the medical superintendents of asylums, and to pay them
liberally.
As this section of our work is passing through the press, we have got the
Report, just printed, "from the Select Committee on Lunatics," and are
most happy in being able to extract from its pages a very decided opinion
expressed by the Earl of Shaftesbury respecting the scanty salaries of
medical superintendents. His Lordship, in reply to the question (765),
"Have you any other remedies to apply to county asylums?" said,--"I do not
know whether it is a matter that could be introduced into the Bill, but I
think the attention of the public should be very much drawn to the state
of the medical superintendents in these asylums. It is perfectly clear,
that to the greater proportion of the medical superintendents in these
asylums, very much larger salaries should be given; and unless you do
that, you cannot possibly secure the very best service.... The great
object must be to raise the status and character of the superintendents to
the highest possible point." In the course of further examination on this
subject, his Lordship repeats and adds to the opinion just recorded. For
instance, he remarks,--"One of the great defects of the present system is,
that the salaries of the medical officers are much too low for the service
they perform. I think that the county ought to secure the very best talent
and responsibility that can be found, and they ought to raise their
salaries higher. I believe in some of the asylums the salaries are higher,
but I hardly know one where the salary is adequate to the work done.... I
cannot think that any superintendent ought to receive much less than from
£500 to £600 a year, besides a house and allowances."
In this matter, we hope the liberal views of the noble Chairman of the
Lunacy Commission will sooner or later be reciprocated by the Visitors of
Asylums; in the mean time, the thanks of the medical profession are
heartily due to his Lordship for his able advocacy of its just claims.
§ _Limit to be fixed to the size of Asylums._
One remedy against extending the evil consequences of large asylums, is to
restrict the size of future buildings within certain limits. We do not
hope to persuade the advocates of gigantic asylums, by any representation
we can offer of their ill-effects to the patients and their false economy,
to abandon their notions; but we do hope that there will be a
parliamentary interdiction to their perpetuation, or that the
Commissioners in Lunacy will have sufficient authority lodged in their
hands to limit the size of future asylums.
Although all persons conversant with the treatment and requirements of the
insane concur in condemning such huge asylums as Hanwell and Colney Hatch,
yet there is some difference in opinion, of no very great extent indeed,
among them with regard to the number of patients who should be assigned to
the care of a single superintendent. Moreover, the number who may be
treated in the same building and by one physician, will differ according
to the nature of the cases--whether all acute, or all chronic, or mixed,
acute and chronic together. In this country all the asylums are of a mixed
character, but, excepting two or three hospitals for the insane, contain a
large preponderance of chronic cases. They are, moreover, all spoken of by
the Lunacy Commissioners as Curative Asylums.
Let us now examine the opinions of some of the best authorities upon the
subject, so that a tolerably accurate judgment may be formed of the limits
within which the size of asylums should be restricted.
In 1844, the Metropolitan Commissioners in Lunacy laid it down as a rule
that "no asylum for curable lunatics should contain more than 250
patients, and 200 is, perhaps, as large a number as can be managed with
the most benefit to themselves and the public in one
establishment."--Report, 1844, p. 23. The present Commissioners have
expressed similar views, which also were clearly stated before the Special
Committee of the House of Commons this year, by the noble Chairman, the
Earl of Shaftesbury.
If we look to American opinion, we find (Rep. Commiss. Massachus. 1855, p.
135) that "it is the unanimous opinion of the American Association of
Medical Superintendents of Insane Asylums that not more than 250 patients
should be gathered into one establishment, and that 200 is a better
number. When this matter was discussed, there was no dissent as to the
maximum; yet those who had the charge of the largest hospitals, and knew
the disadvantages of large numbers, thought that a lower number should be
adopted.
"Taking the average of the patients that now present themselves in
Massachusetts, of whom 80 per cent. are supposed to be curable, and need
active treatment, and 82 per cent. incurable, and require principally
general management and soothing custodial guardianship, and having 'due
regard to the comfort and improvement of the patients,' this limit of 250
should not be exceeded.
"The principal physician is the responsible manager of every case, and
should therefore be personally acquainted with the character and condition
of his patients, the peculiarities of the diseased mind, as manifested in
each one, and the sources of trouble and depression, or exaltation and
perversity. This knowledge is necessary, in order that he should be able
to adapt his means of medical or of moral influence with the best hope of
success."
Dr. Kirkbride, in his special treatise on the Construction and
Organization of Asylums, thus expresses his views (p. 10):--"Whatever
differences of opinion may have formerly existed on this point (the size
of the Institution), I believe there are none at present. All the best
authorities agree that the number of insane confined in one hospital,
should not exceed 250, and it is very important that at no time should a
larger number be admitted than the building is calculated to accommodate
comfortably, as a crowded institution cannot fail to exercise an
unfavourable influence on the welfare of its patients. The precise number
that may be properly taken care of in a single institution, will vary
somewhat, according to the ratio of acute cases received, and of course to
the amount of personal attention required from the chief medical officer.
In State Institutions, when full, at least one half of all the cases will
commonly be of a chronic character, and require little medical treatment.
Even when thus proportioned, 250 will be found to be as many as the
medical superintendent can visit properly every day, in addition to the
performance of his other duties. When the proportion of acute or recent
cases is likely to be much greater than that just referred to, the number
of patients should be proportionately reduced, and 200 will then be found
to be a preferable maximum. While no more patients should be received
into any hospital than can be visited daily by the chief medical officer,
it is desirable that the number should be sufficiently large to give an
agreeable company to each class, and to permit a variety of occupations
and amusements that would prove too costly for a small institution, unless
filled with patients paying a very high rate of board, or possessed of
some permanent endowment. It might be supposed that institutions for a
much larger number of patients than has been recommended, could be
supported at a less relative cost; but this is not found to be the case.
There is always more difficulty in superintending details in a very large
hospital--there are more sources of waste and loss; improvements are apt
to be relatively more costly; and without great care on the part of the
officers, the patients will be less comfortable.
"Whenever an existing State Institution built for 250 patients, contains
that number, and does not meet the wants of the community, instead of
crowding it, and thereby rendering all its inmates uncomfortable, or
materially enlarging its capacity by putting up additional buildings, it
will be found much better at once to erect an entirely new institution in
another section of the State; for under any circumstances, the transfer of
acute cases from a great distance, is an evil of serious magnitude, and
constantly deplored by those who have the care of the insane."
French authorities take the same views. M. Ferrus, who wrote so long back
as 1834, and is now one of the Inspectors of Asylums in France, says, in
his book, 'Des Aliénés,' that an asylum for the treatment of mental
disorder ought not to contain above 150, or at most 250 patients; but that
one having a mixed population of cases requiring treatment of incurables
and idiots, may receive 400 or even 500 such inmates, provided the
physician is afforded sufficient medical assistance. However, his brother
inspector, M. Parchappe, whose able work, 'Des principes à suivre dans la
fondation et la construction des Asiles d'Aliénés' (published so recently
as 1853), forms the most valuable treatise on those subjects, does not
approve so large a number of inmates to be collected in an asylum as M.
Ferrus would sanction. He writes:--"After taking every consideration into
account, I think the minimum of patients ought to be fixed at 200, and the
maximum at 400. Below 200, the economical advantages decline rapidly
without a compensatory benefit; above 400, although the economical
advantages augment, it is at the detriment of the utility of the
institution in its medical character."
M. Guislain, the eminent Belgian physician, in his grand work on Insanity,
remarks (vol. iii. p. 347), "It would be absurd to attempt to bring
together in the same place a very large population; it would tend to
foster an injurious degree of excitement; would render the management
difficult or impossible; would destroy the unity of plan, and neutralize
all scientific effort. The maximum ought not to exceed 300 or 350 insane
persons. This limit cannot be exceeded without injury to the well-being of
the inmates; but unfortunately this has been but too often disregarded,
under the plea of certain views of organization or of economy."
Jacobi placed the maximum of asylum population at 200 (Ueber die Anlegung
und Errichtung von Irren-Heil-anstalten, p. 24); Roller expressed his
opinion (Grundsätze für Errichtung neuer Irren-anstalten, p. 84) that one
instituted for the treatment of cases (Heil-anstalt) should not at the
most receive above 200; but that an asylum for chronic cases
(Pflege-anstalt), connected with the other, may admit from 250 to 300,
making a total population, under the same general direction, of 450 or
500; and Damerow (Ueber die Relative Verbindung der Irren-Heil-und
Pflege-anstalten) unites in the same opinion.
It would be useless to multiply quotations; for, in short, there is
complete unanimity among all those concerned in the direction of asylums,
that such institutions, when of large size, are prejudicial to their
inmates and withal not economical. There is likewise a very near
coincidence of opinion perceptible with reference to the question of the
number of patients which ought to be placed in the same building.
Supposing the asylum to be specially devoted to the reception of recent
cases, it is agreed that it ought to accommodate not more than 200, and
that the smaller number of 150 inmates would be preferable. If a
receptacle for both acute and chronic mental disease, some would limit the
population to 250, whilst others would extend it to 400, provided the
medical officers were increased in proportion.
The example of the German asylums under the direction of Damerow and
Roller is peculiar; for the curable and chronic cases are not mixed, but
placed separately in two sections or two institutions under a general
medical direction within the same area. This is the system of 'relative
connexion' of the "Heil-anstalt,"--institution for treatment, or the
Hospital, and the "Pflege-anstalt," the 'nursing' institution, or the
asylum; to the former they would allot 200, and to the latter 300 as a
maximum, making a total of 500 inmates under the same physician in chief
and the same general administration, but each division separately served
by its own staff and specially organized.
§ _Increase of the Medical Staff of Asylums._
In the next place, the medical staff of an asylum should be large enough
to secure daily medical observation and attendance for each individual
patient, along with a complete supervision of his moral condition, his
amusements and employment. We have said that this provision is deficient
in many English asylums, a statement amply confirmed by the opinions of
others.
Dr. Kirkbride (_op. cit._ p. 44) lays it down as a rule, that "where there
are 250 patients, especially if there is a large proportion of recent
cases, besides the chief physician, two assistant physicians will be
required, one of whom should perform the duties of apothecary. In some
institutions, one assistant physician and an apothecary will be
sufficient. If the full time of two assistant physicians, however, is
taken up by their other duties among the patients, an apothecary may still
be usefully employed in addition; and to him, other duties among the male
patients may with propriety be assigned."
French writers coincide in these views. M. Parchappe assigns to an asylum
containing 200 to 250 patients, a physician with an assistant, besides a
dispenser; to one having 300 to 360 inmates, a physician, two assistants
and a dispenser, besides a director to superintend the general
administration, who in some institutions is also a medical man.
In Germany, and generally in Italy, the medical staff is still larger in
proportion to the number of patients. Jacobi apportions to an asylum for
150 or 200 lunatics, a chief physician, a second, and an assistant,
besides the dispenser. Roller coincides with this, and the asylum at
Illenau under his superintendence, consisting of two divisions, one for
recent, the other for chronic cases, and containing in all 414 patients,
has three physicians besides two assistants or 'internes.' So at Leubus,
in Silesia, there are three physicians, although the inmates are only 150
in number; and the rule is, in other German asylums, containing 100
inmates, to have two physicians, besides one or two internes and a
dispenser (pharmacien).
Allowing the opinions and practice of the eminent men quoted, and which in
truth are shared in by every asylum superintendent, their due weight, it
would seem no extravagant arrangement to allot to an asylum accommodating
from 150 to 200 patients (recent and chronic cases together), a physician
superintendent and an assistant; and a similar medical staff to an
institution for 300 or 350 inmates, all in a state of confirmed chronic
insanity, imbecility, and dementia. If the population in an asylum for
chronic cases is further augmented to 450 or 600,--the latter number we
hold to represent the maximum which can economically and with a just
regard to efficient government and supervision and to the interests of the
patients, be brought together in one establishment,--the medical
superintendent will require the aid of two assistants and a dispenser.
Such aggregations as of 1000 to 2000 insane people are unwieldy and
unmanageable with the best appointed medical staff, unless this be so
numerous as utterly to invalidate the plea of economy, the only one,
fallacious as it is, that can be produced by the advocates for their
existence. And not only are they unmanageable, but also hygienically
wrong; for it is a well-recognized fact, that the accumulation of large
numbers of human beings in one place, tends to engender endemic disease,
uniformly deteriorates the health, and favours the onset, progress, and
fatality of all disorders. The history of large asylums bears testimony to
the truth of this; for cholera has scourged more than one most severely,
and dysentery and chronic or obstinate diarrhoea are pretty constant
visitants in their wards.
The contrast between the opinions and practice of the distinguished men
referred to and those of some Committees of Visitors respecting the value
of medical attendance on the insane, the nature of the duties to be
performed, and the amount of labour the superintendent of an asylum may
accomplish, is most remarkable. What those of the former are, is stated
already; what those held by the latter are, we have an illustration in the
administration of the Colney Hatch and of the Hanwell Asylums. In the
latter establishment we find two medical men appointed to superintend 1020
insane inmates, besides nearly 200 persons employed about it. True, we are
informed by the Committee, that the superintendent of the female
department, who has the larger number, some 600, under his charge, is
_assisted_ by the _matron_; and we are sure he must be thankful for any
assistance rendered him; yet it is the first time that we have been called
upon to recognize a matron as an assistant medical officer. However, we
must accept it as a fact,--gratefully we cannot,--but with a protest
against placing a subordinate officer on such an independent footing,
against entrusting her with duties incompatible with her education and
position, and with the relations which should subsist between her and the
superintendent, and against making her his equal in the remuneration for
her services.
Did occasion offer, we might ponder over this new development of the
matronly office; inquire respecting the medical qualifications demanded,
and the manner in which the Hanwell Committee have ascertained them; and
meditate at length on the notions which govern the Visiting Justices in
organizing and directing an asylum; but for the present, we will, for
further example's sake, note some of their opinions and doings in the
management of the sister 'refuge for lunatics' at Colney Hatch. We shall,
for this purpose, appeal to the Report for 1856, and to make the
quotations used intelligible, will premise, that the steward, at that
date, had turned architect, and produced a plan for the extensive
enlargement of the asylum as proposed by the Magistrates; and that, very
naturally, when writing about it, he was intent to prove that his plan was
the best, the cheapest and the most convenient even to the medical
superintendents who would be called upon to officiate in it when
completed. This much being premised, we will quote the steward's own
words.
"I must also remind the Committee," he observes, "that some three years
since it was with them a matter of serious deliberation, whether it was
advisable that the male and female departments should be placed under the
care of one medical superintendent, and, in fact, whether _one medical
officer_ should have the _supervision and direction of 1250 inmates_, and
an extended range of building; or whether the two departments should
continue, as they are at present, separate and distinct." What an
excellent insight does this revelation of the cogitations of the
Committee-room of the Middlesex Magistrates afford us of the sentiments
these gentlemen entertain of the requirement and value of medical skill in
an asylum; of the capacity, bodily and mental, of a superintendent for
work! But, without waiting to fill up a sketch of the wondrous virtues and
faculties which the superintendent of the 1250 insane patients need to
possess in order to know all, supervise them, direct them, and attend to
the multitudinous duties of his office as a physician and director, we
will by a further extract gather clearer notions of the extent of the work
thought to be not too much for him. The gist of the ensuing paragraph is,
that the steward strives to prove that by adding a new story here and
there, besides spurs from the previous building, he will increase greatly
the accommodation without much augmenting the ambulatory labours of the
medical officer. And alluding to one, the male division of the
establishment, he proceeds to argue, that "if it is considered feasible
for one person to superintend 1250 patients of both sexes in a _building
extending_ from one extreme to the other, _nearly two-thirds of a mile_,
would it not be equally feasible to superintend 840 patients in a building
one half the extent [here Mr. Steward forgets to count the number of
furlongs added by his proposed new wards], provided they are conveniently
and safely located, although these patients are all males?"
To this we may be allowed to subjoin some remarks we penned in a critique
published in the 'Asylum Journal' (vol. ii. p. 271) for 1856, and in which
many of the observations contained in the present work were briefly
sketched. "Who, we ask, can dispute the feasibility of a medical or of any
other man superintending 840, 1250, or two or three thousand patients,
collected in an asylum or in a town, in the capacity of a director or
governor, if subordinate agents in sufficient number are allowed him? But
we think the question in relation to asylums is not, how we can govern our
insane population most easily and at the least possible cost, but by what
means can we succeed in curing the largest number of cases of insanity as
they arise, and thus permanently keep down expenditure and save the rates.
These results are certainly not to be attained by persevering in the old
scheme of congregating lunatics by tens of hundreds, but by making
suitable provision for the immediate treatment of the pauper insane in
asylums properly organized for it, and under the direction of a sufficient
medical staff."
How totally different, too, are the views of Jacobi to those of the
Middlesex Magistrates concerning the office of superintendent, and the
extent of work of which he is capable! In his treatise on Asylum
Construction (Tuke's Translation, p. 23), he presents the following
sensible remarks:--"It is not that I should consider a more numerous
family (than 200) incompatible with the right management of the farming
and household economy, nor with the domestic care of the patients; both
these might perhaps be organized in an establishment containing a number
equal to the largest just named (four or six hundred), in such a manner as
to leave nothing to be desired; but it is in regard to the higher
government of the establishment, and the treatment of the patients as
such, in its widest signification, which must rest upon the shoulders of a
single individual,--the director of the establishment,--that I am
convinced the number of patients should not exceed two hundred. For when
it is considered that the duties of the governor embrace the control of
all the economical and domestic arrangements, as well as of the whole body
of officers and servants; that he must devote a great share of his time to
the writing, correspondence, and consultations connected with his office;
that as first physician, he is entrusted with the personal charge and
medical treatment of every individual committed to his care; that he must
daily and hourly determine, not only the general outlines, but the
particular details of the best means for promoting the interests of the
collective community, as well as of every separate person composing it;
and that, besides all this, he is responsible to science for the results
of his medical observations in the establishment over which he presides;
nor less so for the promotion of his own advancement as a man and a
philosopher;--it will be readily granted, that the given maximum of two
hundred patients for a single establishment ought never to be exceeded.
Indeed, a man of even extraordinary abilities would find himself unequal
to the task of discharging these duties, in an establishment containing
two hundred patients, were he not supported by such assistance as will
hereafter be described; and were there not a great number amongst even
this multitude of patients requiring not constant, or at least, a less
degree of medical attention."
Many writers on asylum organization, particularly those of the Continent,
insist very strongly on so far limiting the size of asylums for the
insane, that they may be superintended by one chief medical officer, aided
indeed by assistants, but without colleagues of coordinate powers. The
venerable Jacobi took this view, and desired that the director of an
asylum should be the prime authority in all its details of management, and
insisted that the institution should not by its size overmatch his powers
to superintend it and its inmates as individuals. Thus, after reviewing
the nature of the duties devolving on the chief physician, he observes (p.
192, Tuke's translation), "It follows as a necessary consequence that one
man must be placed at the head of the establishment," ... and that "his
mind must pervade the whole establishment." Likewise M. Parchappe joins in
the same opinion; and after speaking (Des Principes, p. 43) of the
impossibility of proper medical supervision in a very large asylum,
observes, "that to divide the medical direction among two or more
physicians is extremely detrimental to the superiority which the medical
superintendent ought to hold in the general administration of asylums, and
to that unity of purpose and opinions required in the interests of the
patients."
Without citing other foreign writers to substantiate the view under
consideration, we may call attention to the fact, that the Lunacy
Commissioners, who have always so stoutly advocated the position of the
medical officer as the superintendent of an asylum, likewise appear to
accept the same principle; for in their Eleventh Report (p. 11), they
remark, that besides the direct injury inflicted upon patients when
congregated in excessive numbers in the same institution, "experience has
of late years shown, that the absence of a single and undivided
responsibility is equally injurious to the general management."
Lastly, the Committee of Visitors of the Surrey County Asylum
appear,--judging from their recent appointment of a chief physician to
their institution, paramount to the medical officers of the divisions, and
invested with full powers as director,--to have arrived at the just
conviction that there must be unity and uniformity in the management of an
institution. However, we regret to say that this conviction is
unaccompanied by that other which Jacobi and Parchappe would associate
with it, viz. that the size of the asylum should be no larger than will
admit of the chief physician acquainting himself with every case
individually, and treating it accordingly. Whilst, indeed, by their
proceeding, they constitute the chief physician a governor of a large
establishment, and the director of the household and of its economy, they
at the same time deprive him of his professional character by removing the
opportunities of exhibiting it beyond his reach, both by the relations
they place him in to the other medical officers, and by the enormous
aggregation of patients they surround him with.
Few objections, we presume, are to be found to the principle of having a
chief medical officer paramount to all others engaged in the work of an
asylum; and although, considered as a _medical superintendent_, his
professional qualities are not in much requisition in so large an
institution as the Surrey County Asylum, yet we regard such an appointment
as most desirable, and as preferable to the system of dividing the
management between two medical officers, as pursued in the Middlesex
County Asylums. Indeed, the value of the principle of concentrating power
in the hands of a chief officer, under the name of governor, or of some
equivalent term, is recognized by its adoption in large institutions of
every sort in the country. Such enormous asylums as those referred to,
partake rather of the nature of industrial than of medical establishments.
Their primary object is to utilize the population as far as practicable,
and this end can be attained in a large majority of the inmates;
consequently an able director is of more consequence than a skilful
physician; for the latter is needed by a very small minority, by such a
section, in fact, as is represented by the inmates of a workhouse
infirmary only compared with its entire population. Therefore, since the
enormous asylums in existence are not to be got rid of, it is desirable to
give them an organization as perfect as practicable; and it is under this
aspect that we approve the plan of the Surrey Magistrates in appointing a
director paramount to every other officer. The approval of this
proceeding, however, does not minish aught from our objections to such
enormous institutions, considered as curative asylums for the insane. As a
refuge for chronic lunatics, an asylum so organized and superintended as
is the Surrey, may subserve a useful purpose; but we hold it to be an
unsuitable place for recent cases demanding treatment as individuals
suffering from a curable disease, and requiring the exercise of the skill
and experience of a _medical_ man _specially_ directed to it.
While the system of congregating so many hundreds of lunatics in one
establishment, and the magisterial principle of providing for the care and
maintenance and of non-intervention in the individual treatment of the
insane prevail, no objection can be taken to the practice of Committees
of Visitors in according the first merit when candidates come forward for
the office of medical superintendent of an asylum, to qualifications for
the routine government of large masses, for the allotment of labour, for
the regulation of the domestic economy of a house, for the profitable
management of the farm; in short, for qualities desirable in a governor of
a reformatory-school or prison. Indeed, they are right in so doing, when
they wish to have a well-disciplined and profitably worked asylum; and
when their institution attains the dignity of a lunatic colony, it is the
best course they can adopt, for medical qualifications in such an
establishment sink into insignificance amidst the varied details of
general administration, which fall to the lot of the superintendent. But
the case would be materially changed were the primary object of an asylum
the successful treatment of its inmates, and were its dimensions within
the limit to afford its superintendent the opportunity to know all, and to
treat all its patients as individuals to be benefited by his professional
skill. In selecting the physician of such an asylum, the administrative
and agricultural qualifications he might possess, though far from being
unnecessary or unimportant, should occupy a secondary place in the
estimation of Committees of Visitors; and the primary requirement should
be the possession of properly certified medical skill, of experience in
the nature and treatment of insanity, in the wants and management of the
insane, and of asylums for them; of evident interest and zeal in his work,
and of those intellectual and moral endowments adapted to minister to the
mind diseased, to rule by kindness and forbearance, and at the same time
with the firmness of authority.
CHAP. VII.--ON THE FUTURE PROVISION FOR THE INSANE.
The only apology permissible for detaining lunatics in workhouses, is that
there is no asylum accommodation for them to be had; and the only one
attempted on behalf of the construction of colossal asylums is, that the
demands for admission and the existing numbers are so many, and the
majority of cases chronic and incurable, that the most economical means of
providing for them must be adopted, which means are (so it is supposed)
found in aggregating masses under one direction and one commissariat. Now,
whilst we have, on the one hand, contended that workhouses should be as
soon as possible disused as receptacles for the insane, we have, on the
other hand, endeavoured to prove that very large asylums are neither
economical nor desirable, especially if the cure of lunatics, and not
their custody only, is contemplated by their erection. Indeed the attempt
to keep pace in providing accommodation for the insane poor with their
multiplication by accumulation and positive increase or fresh additions,
has failed, according to the mode in which the attempt has hitherto been
made. New asylums have been built and old ones enlarged throughout the
country, and between 1843 and the end of 1857, the accommodation in them
had been increased threefold; whilst, at the same time, pauper lunatics
had so multiplied, that their number in licensed houses remained almost
the same, and the inmates of workhouses and chargeable imbeciles and
idiots residing with their friends or with strangers, had very largely
increased. The history of pauper lunacy in Middlesex furnishes one of the
most striking commentaries upon the system pursued to provide for its
accumulation, and on its failure. "When (we quote the 11th Report of the
Commissioners in Lunacy, 1857, p. 12), in 1831, Hanwell was built for 500
patients, it was supposed to be large enough to meet all the wants of the
county. But, two years later, it was full; after another two years, it was
reported to contain 100 patients more than it had been built for; after
another two years, it had to be enlarged for 300 more; and at this time
(Colney Hatch having been meanwhile constructed for the reception of 1200
lunatic paupers belonging to the same county) Hanwell contains upwards of
1000 patients. Colney Hatch was opened in 1851; within a period of less
than five years, it became necessary to appeal to the rate-payers for
further accommodation; and the latest returns show that, at the close of
1856, there were more than 1100 pauper lunatics belonging to the county
unprovided for in either of its asylums." At this conjuncture the
Commissioners proposed a third asylum, so that they might, "by a fresh
classification and redistribution of the patients, not only deal with
existing evils universally admitted, but guard against a recurrence of
evils exactly similar, by restoring to both asylums their proper functions
of treatment and care." However, instead of adopting this wise policy, the
Committee of Visitors insisted on following out their old scheme of adding
to the existing asylums, in the vain hope of meeting the requirements of
the county; and have proceeded to increase the accommodation of Hanwell to
upwards of 1600, and that of Colney Hatch Asylum to nearly 2100 beds. Yet
let them be assured they have taken a very false step, and that though
they heap story on story and add wing to wing, they will be unable to keep
pace with the demands of the pauper lunatics of the county; nor will they
succeed in the attempt, until they make the curative treatment of the
insane the first principle in their official attempts to put into
execution those lunacy laws confided to their administration by the
legislature.
Perceiving that this scheme of adding to asylums until they grow into
small towns defeats the object of such institutions as places of treatment
and cure, and that it will continue to fail, as it has hitherto failed, to
supply the demands for accommodation, the Commissioners remarked in their
last (12th) Report, that "a scheme of a far more comprehensive nature" is
called for to meet increasing events. They have not hinted in that Report
at any scheme, but we may gather from other similar documents, especially
from that of 1857, that one important plan they have in view is to remove
a large number of chronic, imbecile and idiotic patients from the
existing, expensively built and organized asylums, and to place them in
others erected, adapted and organized for their reception at a much less
cost. By this means they count both on rendering the asylums generally,
now in existence, available as curative institutions for the reception of
new cases as they arise, and on arresting the tendency and the need to
erect such enormous edifices as do discredit to the good sense of the
magistrates of the counties possessing them.
We agree with the Commissioners in the general features of the plan
advanced, and indeed, in our notice of the Reports of the Middlesex County
Asylums, in 1856 (Asylum Journal, vol. ii. p. 354 _et seq._), advocated
the establishment in that county of a third asylum especially for the
treatment of the recent cases as they occurred. Now the adoption of any
such plan implies the recognition of a principle which has been very much
discussed, viz. that of separating one portion of a number of insane
people from another, as less curable or incurable. However, the
Commissioners in Lunacy avoid discussion, and treat the matter in its
practical bearings; still a brief critical examination of it will not be
here misplaced.
§ _Separate Asylums for the more recent and for chronic cases._
The proposition of placing recent and chronic cases of lunacy in distinct
establishments is often so put as to beg the question. It is asked if any
one can undertake to say categorically that any case of insanity is
incurable, and thereupon to transfer it to an asylum for incurables? To
the question thus put every humane person will reply in the negative; he
will start at the idea of consigning an afflicted creature, conscious of
his fate, to an abode, which, like Dante's Inferno, bears over its portal
the sentence, "Abandon hope all ye who enter here." But a solution thus
extorted is in no way a reply to the question of the expediency or
inexpediency of making a distinction in place and arrangement for the
treatment of recent and of chronic cases of lunacy severally; for this is
a matter of classification, and one particularly and necessarily called
for, where the insane are aggregated in large numbers, and the conditions
of treatment required for the great mass of chronic cases are insufficient
for the well-being of the acute. The real practical questions are,--1,
Cannot the subjects of recent insanity be separated advantageously, and
with a view to their more effectual and successful treatment, from a
majority of the sufferers from chronic insanity, imbecility and fatuity,
and particularly so where the total number of the asylum inmates exceeds
the powers of the medical officer to study and treat them as individuals?
and, 2, Does not the separation of the very chronic, and according to all
probability, the incurable, afford the opportunity to provide suitably for
the care of that vast multitude of poor lunatics, at present denied asylum
accommodation; and to effect this at such an expenditure, as renders it
practicable to do so, and thereby to meet the present and future
requirements of the insane?
Several eminent psychologists have taken up the question of separating
recent and probably curable cases from others found in asylums, in an
abstract point of view, as if it were equivalent to forming an absolute
decision on the grand question of the curability or incurability of the
patients dealt with; and, as a matter of course, their adverse view of the
subject has found numerous abettors. The subject is, however, well
deserving of examination _de novo_, in the present juncture, when some
decided scheme must be agreed to for the future provision of the insane,
and for repairing the consequences of past errors.
In the first place, let us ask, are the harrowing descriptions of the deep
depression and despair felt by patients on their removal after one or two
or more years' residence in a curative asylum to another occupied by
chronic cases, true and sketched from nature? we think not. Writers have
rather portrayed the sensations they would themselves, in the possession
of full consciousness and of high sensibility, experience by a transfer to
an institution as hopelessly mad, and have overlooked both the state of
mental abasement and blunted sensibility which chronic insanity induces in
so many of its victims, and still more the fact that no such absolute and
universal separation of acute and chronic, as they picture to their minds,
is intended.
Indeed, we believe that, even among patients who retain the consciousness
and the powers of reflection to appreciate the transfer, no such lively
despair as authors depict is felt. In the course of our experience at St.
Luke's Hospital, we have seen many patients discharged 'uncured' after the
year's treatment in that institution, and transferred to an asylum,
without noting the painful and prejudicial effects on their mental
condition supposed. Disappointment too is felt by patients rather at
discovering that on their discharge from one asylum they are to be
transferred to another, instead of being set at liberty and returned to
their homes; for few of the insane recognize their malady, and they will
think much less about the character of the asylum they are in, than their
confinement and restricted liberty. Again, it is not at all necessary to
contrast the two institutions, by calling the one an asylum for curables,
and the other an asylum for incurables; indeed, such a class as incurables
should never be heard of, for we are not called upon to define it. The two
asylums might be spoken of as respectively intended for acute and for
chronic cases; or the one as an hospital, the other as an asylum for the
insane; or better still, perhaps, the one as the primary (for primary
treatment), and the other as the secondary institution.
The removal, and the date at which it should take place, should be left to
the discrimination of the medical officer. No period need be fixed at
which treatment in the primary institution should be given up; the nature,
the prospects, and the requirements of a case must determine when
treatment therein should be replaced by treatment in the secondary asylum.
Moreover, no barrier should be opposed to a reversed transfer; a trial in
another institution is often beneficial, and it would be an advantage to
have the opportunity of making it. In the removal from the hospital to the
asylum there would be no declaration that the patient was incurable, but
only that his case was such as not longer to require the special
appliances of the former, although it still needed the supervision of an
asylum, and a perseverance in a course of treatment and nursing fully and
particularly supplied by the resources of the latter.
The determination of the cases proper for the secondary asylum lodged in
the physician's hands would always enable him to retain those in the
primary one, whose state, though chronic, would in his opinion be
injuriously affected by a transfer, and any such others besides whose
presence in the wards he might deem an advantage in the management. We
mention the latter, because the opponents to separation insist on the
benefits to an asylum accruing from the admixture of recent and chronic
cases. And although we are not prepared to deny an opinion held by so many
eminent men, yet we are on the other side not at all persuaded that the
presence of old inmates is of any such real advantage, as supposed, to
newly-introduced ones. We can assert, from experience, that recent cases
can be very satisfactorily treated without the company of old ones; and we
must, moreover, confess to certain misgivings that the actual presence of
a long-standing case, often eloquent on the injustice of his detention, a
Job's comforter to the new-comer, by his remarks on the severity of his
disorder, with the assertion added, that there was nothing the matter
with the speaker's self when he came into the house; full of gossip about
all the mishaps of the place, and often exercising an annoying superiority
and authority assumed on account of his position as one of the oldest
inhabitants. To the statement of the value of their service in aiding the
attendants and in watching their neighbours, we rejoin, there should be
attendants enough to perform the duties of supervision; that many recent
are equally serviceable as chronic cases, and stand in need of being
encouraged by the attendants in taking part in those many minor details
which characterize life in the wards of an asylum.
However this question of the utility of mixing chronic and recent patients
together may be solved, we do not contemplate the existence of a primary
asylum without the presence of more or fewer chronic cases, retained in it
for the best medical and moral reasons. Likewise, on the other hand, the
secondary asylum will not so exclusively be the abode of incurables. The
lapse of time in a case of insanity most potently affects its chances of
recovery, but it is not an invariable obstacle to it; for experience
decidedly demonstrates that recovery may take place years after every hope
of it has passed away, and that patients rally from their affliction, not
after four or five years only, but even after ten and twenty;
consequently, among the large number of chronic patients under treatment,
there would doubtless be every year some restored to reason and to
liberty; and the dreaded foreboding of perpetual confinement and hopeless
incurability could not take possession of the minds even of those whose
perceptions rendered them conscious of their condition and position.
To arrive at a correct judgment on this matter, let us look into it from
another point of view, and compare the condition of a lunatic in the
proposed chronic asylum with that of one in a large county asylum,
conducted according to the prevailing system. Look to the fact, that in
some of the existing large curative (?) asylums, not more than from 7 to
12 per cent. of their six or eight hundred, or one thousand inmates, are
deemed curable, and say in what respect a patient introduced into an
establishment of the sort, surrounded on every side by crowds of chronic
lunatics, enjoys any superiority over one transmitted to a secondary
asylum of the description we contemplate. Call such an institution what we
may, announce it as a curative asylum, or as an hospital for curables, it
matters not; to a fresh-comer it has all the drawbacks of a chronic
asylum; for if he be alive to his condition, and can reflect on the
position and circumstances in which he is placed, he may well find grounds
for discouragement and despair on looking round the gigantic building,
overflowing with the victims of chronic insanity, many of appearance,
habits, and manners, repugnant to the higher and better feelings of any
thinking, reflecting mortal; who count their residence there by years and
even tens of years, with no prospect of release, and who, it may be in his
imagination, are not, or have never been, so afflicted as himself. Can
such a spectacle be otherwise than injurious to a recent case,
sufficiently well to perceive it on admission, or coming to appreciate it
during convalescence? and must not the recognition of his position by the
patient be most painful and discouraging as one of a multitude, eliciting
personally, except perhaps for the few first days, no more attention than
the most crazy old inmate near him; submitted to the same daily routine,
and having no superior with sufficient time on hand to hear at large his
tale of woe, to soothe his irritated spirit, or to encourage him in his
contest with his delusions and fears? If the case of the new-comer be
chronic, the conditions he finds himself placed in are sufficiently
distressing and annoying; but if it be recent and curable, they are
damaging to his chance of recovery.
The comparison just drawn tells in favour of the system of separation.
Recent cases would not, in the primary institution or hospital, find
themselves an insignificant few surrounded by a host of chronic patients,
and they would accordingly escape the evils of such a position; on the
contrary, they would be placed under the most favourable conditions for
recovery, be individually and efficiently attended to, and encouraged by
the many convalescents around them to hope and strive after their own
restoration to health and liberty.
The sketch presented of the evils of the companionship of long-disordered
inmates with new-comers, especially when those are melancholic, is not an
imaginary one, but drawn from experience. Often will a desponding patient
observe, 'I shall become like such or such moping, demented lunatic'; and
superintendents, if they would, might often record the ill-effects of
example of older inmates upon those newly admitted.
Attempts by means of classification somewhat mitigate, where made, the
evils of large asylums for recent cases, by keeping these to a certain
measure apart from most of the other lunatics; but nothing can do away
with the injurious impression on a mind sufficiently awake to receive it
(on such a one, in short, as the question of the place of treatment can
alone concern),--of being one member of many hundreds who have for years
and years known no other residence than the huge house of detention they
are in: and there is no compensation to be had for the loss of those
special appliances, and that individual treatment, which only a
properly-organized hospital can supply.
The last clause suggests another important argument for the treatment of
recent cases in a distinct establishment or in separate sections. It is,
that they require a peculiar provision made for them, involving greater
expense, a more complete medical staff, a physician accustomed to their
supervision and management, unfettered by that host of general duties
which the presence of a multitude of chronic patients entails, and a staff
of attendants disciplined to their care, and possessing many of the
qualifications of nurses. Moreover, the building itself for this class of
patients need be more expensively constructed and fitted than one for
chronic inmates.
There is yet another reason against largely extending the size of a county
asylum, and in favour of building, in the place of so doing, a distinct
structure. This reason is to be found in the influence of distance as an
obstacle to the transmission of the insane to an asylum for treatment, and
to the visits of their friends to them during their confinement. The
Lunacy Commissioners of the State of Massachusetts particularly remarked
the operation of distance in debarring insane patients from treatment, and
illustrated it by a table showing the numbers received from different
places within the district it served, and in relation to their population,
into the asylum. Likewise in this country, where the distance of the
asylum is considerable, it is a reason for delay on the part of the
parochial officers, who wish to avoid incurring the expense of removing
the case, if they can in any way manage it in the workhouse.
But the evil of remoteness operates more frequently, and with much
cruelty, against the visits of poor persons to see their afflicted
relatives in asylums. Many can neither undertake the cost, nor spare the
time required for the journey, notwithstanding the modern facilities of
travelling. The same evil is likewise an impediment to the visits of
parochial officers, who rightly possess a sort of legal guardianship over
their lunatic poor in asylums.
Lord Shaftesbury, in his evidence before the Select Committee, 1859, very
properly dwelt upon the advantages of visits from their friends to
lunatics in asylums, and even proposed to make their visits compulsory by
act of parliament. The Commissioners in Lunacy also, in their Twelfth
Report (1858), gave examples of the distress not unfrequently attending on
the separation of the patient in an asylum at a long distance from his
friends. Such distress operates to the disadvantage of the patient, and
increases the sorrow of his relatives.
Admitting there are advantages attending the multiplication of asylums
instead of aggregating lunatics in very large ones, it would appear the
correct policy for boroughs to build asylums for the refuge of their own
insane; or, where small, to unite with other boroughs in the county for
the same purpose, in place of contributing to the county-establishment,
and inducing the magistrates to extend its size injuriously. In a case
such as that of Middlesex, where the county asylums have attained such an
unwieldy size as to be past acting as curative institutions, it would seem
no improper extension of the law to make it imperative upon the large
metropolitan boroughs to build apart for their own pauper lunatics. Of
this we are persuaded, that it would soon be found to the profit of the
boroughs to undertake to provide for their own pauper insane.
We regret that, in advocating the separation of chronic from recent cases,
we place ourselves in antagonism to many distinguished men who have
devoted themselves to the care of the insane, and among others to our
former teacher and respected friend Dr. Conolly, from whose clinical
visits and lectures at the Hanwell Asylum, many years ago, we derived our
first lessons, in the management and treatment of the insane. But although
regretting some divergence of opinion on this point, we are confident of
his readiness to subscribe to that maxim of a liberal philosophy,
expressed by the Latin poet, "_nullius addictus jurare in verba
magistri_."
To return from this digression: there are two propositions to be
established, viz.--1. That there are many cases of chronic mental disorder
to be found in every county asylum, which encumber it, to the prejudice
and exclusion of recent cases, and which could, without mental pain or
damage, or any tangible disadvantage, be removed from the institution
considered as a curative one. 2. That less elaborate structural
adaptations, and a less expensive organization, would suffice for the
proper care and treatment of a large number of chronic cases. Let it be
understood, however, that neither in past nor future remarks is it our
intention to argue against the existence of mixed asylums altogether,--for
by careful classification in a moderately-sized establishment, a zealous
physician, properly assisted, may contrive to do his duty, both towards
the comparatively few acute, and the many chronic cases under his charge;
but against the pretence of admitting recent patients for curative
treatment in monster institutions filled with chronic cases, where
individual daily recognition is all but impracticable, efficient medical
supervision unattainable, and proper medical and moral treatment
impossible.
Deferring for the present the inquiry, under what conditions of the insane
population of a county should distinct asylums be constructed, let us see
what are the views of the Lunacy Board bearing upon the two propositions
put forth, and examine further into the means of providing for the future
wants of the insane. So long since as 1844, the then Metropolitan
Commissioners in Lunacy advised the institution of distinct asylums for
the more chronic cases of insanity (Report, p. 92), and thus expressed
themselves:--"It seems absolutely necessary that distinct places of refuge
should be provided for lunatic patients who have become incurable. The
great expenses of a lunatic hospital are unnecessary for incurable
patients: the medical staff, the number of attendants, the minute
classification, and the other requisites of a hospital for the cure of
disease, are not required to the same extent. An establishment, therefore,
upon a much less expensive scale would be sufficient."
An exception might be taken to the wording of this paragraph, as
assumptive of incurability being an absolute condition, and as
countenancing the scheme of a refuge distinctly provided for incurables;
both of them ideas repugnant to the humane mind, instructed by experience,
that insanity, at almost any lapse of time, and under most forms, is not
to be pronounced absolutely incurable, or beyond the hope of cure. The
scope of the argument adduced can, however, not be objected to, for it
will be generally admitted that less expensive institutions are needed for
very chronic cases in general, and that it is an important object to clear
the present curative asylums of such cases, so as to facilitate the
admission and the early treatment of recent patients. The present Lunacy
Board, in their Tenth Report, 1856, repeated these views, and pointed out
the importance of erecting detached buildings in connexion with the
offices used for the different occupations pursued in the establishment,
instead of adding new stories, or new wings, to the main building.
In the Report for the following year (1857), the Commissioners returned to
the subject, in connexion with the proposed enlargement of the Middlesex
County Asylums; and, having remarked on the rapid accumulation and
crowding of those refuges with chronic cases, so soon after that at Colney
Hatch was opened, thus write (p. 13):--"Manifestly the remedy now was, not
to exaggerate the mistake already committed, by additions on the same
costly scale for purposes to which they would be as inappropriate; but, by
a fresh classification and redistribution of the patients, not only to
deal with existing evils, universally admitted, but to guard against a
recurrence of evils exactly similar, by restoring to both asylums their
proper functions of treatment and care. It had become not more matter of
justice to the lunatics themselves, than of consideration for the
rate-payers, to urge, that the additional accommodation required being for
classes of patients, as to whom, for the most part, small hope of cure
remained, might be supplied in an asylum much better suited to them, and
of a far less costly character." At a subsequent page (p. 23), they recur
to the theme. After pointing out that the plan of placing chronic, and
presumed harmless patients taken out of asylums, in workhouses and "in
their private homes," had signally failed, they observe:--"We are,
therefore, brought back to the conclusion already stated ..., to which we
find all reasoning upon the subject necessarily converge, and which we
desire to impress as strongly as possible upon every one to whom the care
of the insane is committed, that a new, and less costly kind of provision
is now very generally required for large classes of pauper lunatics, to
whom the existing expensive structures are unsuited.
"Our last Report directed attention to the fact, that in providing, not
merely for the harmless and demented, but for the more orderly and
convalescing, the most suitable was also the least expensive mode; that
they might satisfactorily be placed in buildings more simple in character,
and far more economically constructed; and that therefore it was
advisable, wherever the necessity for enlarging one of the existing
asylums presented itself, that the question should be considered in
reference to these two kinds of patients. And whether the mode adopted may
be, for the convalescing, by simple and cheerful apartments detached from
the main building, and with opportunity for association with the officials
engaged in industrial pursuits; or, for harmless and chronic cases, by
auxiliary rooms near the out-buildings, of plain or ordinary structure,
without wide corridors or extensive airing-court walls, and simply warmed
and ventilated; it is, we think, become manifest that some such changes of
structure must be substituted for the system now pursued, if it be desired
to retain the present buildings in their efficiency, and to justify the
outlay upon them by their continued employment as really curative
establishments. In this way only, as it seems to us, can justice be done
to the rate-payer as well as to the pauper."
Lastly, in their Supplementary Report on Lunatics in Workhouses (1859),
they repeat their recommendations to erect distinct inexpensive buildings
for chronic cases. The paragraph containing their suggestion has already
been quoted (p. 82), and need not be repeated here.
The noble chairman of the Lunacy Board, according to his valuable evidence
given before the Special Committee of Lunatics, just printed, appears to
have been an early and constant advocate for constructing distinct
receptacles for chronic and acute cases. In reply to query, No. 664, his
lordship has more particularly enlarged upon the utility of the plan, and
referred to the distinct proposition of the Board in 1845, that it should
be carried out by the Committees of Asylums. The scheme of separately
providing for many chronic lunatics has also received the valued support
of Dr. Boyd (Seventh Report, Somerset Asylum, p. 10), who appears to
contemplate the erection of the proposed building contiguous to the
existing asylum, so as to make use of the patients' labour "in preparing
stone and lime, and in doing all the heavy part of the work," and to unite
the two establishments under a common administration and commissariat, as
a plan attended with considerable economical advantages.
We do not deem it necessary to quote other authorities at large, in
support of the system advocated; otherwise we might adduce many
continental writers, especially among the Germans. It is fair to add,
however, that in France generally "mixed asylums" are the rule, and that a
few of these contain five or six hundred inmates, but none, we are happy
to say, have acquired the prodigious dimensions of several of our English
asylums. Moreover, the French system is to erect a number of detached
buildings, or sections within the general area of the establishment,
adapted to the different classes of the insane, according to the character
of their disease, or to their condition as pensioners or paupers. We
cannot here discuss the advantages or disadvantages of this plan, but it
certainly obviates some of the evils of aggregation evidenced in English
asylums, consisting of one continuous structure. It has just been said,
that in no French asylum are so many lunatics congregated as in some
English institutions; yet it is true, that the great Parisian hospices
contain similar numbers; for instance, La Salpêtrière holds as many as
1300; but in this case the arrangement is such, that each of the five
sections it is divided into, constitutes practically a distinct hospital
for the insane, structurally separated, or quite detached; with
subordinate quarters or sections, to provide for a proper classification
of the inmates, and having its own grounds for exercise, &c., and its own
medical staff. Thus, to the 1300 patients there are five physicians,
having equal power and privileges, each one the head of his own section.
We would not in any way adduce this extensive Parisian hospice as an
example to follow, either in structure or organization; and have alluded
to it in so many words only to show, that though equally large in its
population, it is comparable in no other respect to the huge receptacles
for the insane to be found in this country. Of the prevailing system in
Germany we shall presently find occasion to speak.
Lastly, the 8th & 9th Vict. cap. 126, gave express powers to provide for
the chronic insane in distinct establishments; in order, according to the
marginal abstract to sect. xxvii., "to prevent exclusion from asylums of
curable lunatics; separate provision to be made for chronic lunatics."
The chronic asylums were again referred to in sect. xlii. and in sect.
lvi., which conferred the necessary powers on the visitors to remove the
patients from one asylum to another. It is not worth while to repeat the
clauses referred to, since the Act was repealed by the 16th & 17th Vict.
cap. 97, and no re-enactment of them took place. Nevertheless, it is to be
observed, that the last quoted Act contemplated the provision of asylum
accommodation for the whole of the lunatics of each county, and with this
object, by sect. xxx., empowered the justices, at any general or quarter
sessions, to cause, or to direct the Committee of Visitors of the County
Asylum to erect an additional asylum, or to enlarge the existing building,
to supply the requisite accommodation; and further, put it into the power
of a Secretary of State, "upon the Report of the Commissioners in Lunacy,"
to call upon the magistrates of any county or borough to do the same.
This enactment may be enforced by the Lunacy Board so far as the Secretary
of State can prevail with a body of magistrates to accede to it, "in such
manner as the said Secretary of State may see fit, and direct." But this
high official has no direct power to compel a Committee of Visitors under
any sort of penalty. "It shall be lawful for such Secretary of State,"
says the clause, "to require" such additional asylum alteration or
enlargement; but the history of the contest between that public officer
and the Middlesex 'Committee of Visitors' appears to prove that his
requisition may be neglected and set aside. "He found" (as Lord
Shaftesbury tells us in his evidence, Rep. Select Comm., Query, No. 799),
"that the passive resistance offered was beyond his power." We coincide
with his lordship, that this ought never to have happened, and think, that
the Secretary of State, acting under the representations and advice of the
Lunacy Commissioners, ought to be armed with full powers to enforce the
provision for pauper lunatics in asylums being rendered equal to the
demand for it, according to some plan agreed to by them, in every county,
in harmony with the true intent and purpose of the Act now in force.
In order to facilitate the carrying out of this design, and to limit the
scope for the passive resistance and attempted delay of some county
magistrates, the re-enactment of the sections of the 8th & 9th Vict. sect.
126, as quoted, appears desirable, viz. to sanction and promote the
erection of distinct retreats for chronic cases. We are, indeed, glad to
find, that in this recommendation we are also in accord with the noble
lord at the head of the Lunacy Commission.
Looking at the matter in a general point of view, therefore, we appear to
find, in the plan of separating the more chronic and most unpromising
cases of lunacy from the recent and hopeful, so as to leave these in
smaller numbers for the purpose of more direct and effectual treatment,
one mode of improving and extending the future provision of the insane.
However, to elucidate the scheme, we need go into further detail, so as to
define more particularly the classes to be separately accommodated, and
the extent to which the separation should be carried.
The grand distinction, above employed, in discussing the question of
separation, has been that of recent and chronic cases, and it has been
sought to ignore that of curable and incurable, as not only undesirable,
but actually mischievous. By recent cases, we understand all those where
the malady is of less than one year's duration, which form a class that
demands the more active and constant attention and treatment of the
physician, more purely medical care, more consideration and watching from
the attendants, ampler measures for moral treatment, and for exercising
salutary impressions on the mind; and withal, special arrangements and
fittings in the asylum building itself. All these particular conditions
for treatment and management are not to be obtained by recent cases of
insanity, as we have insisted on throughout this chapter, in asylums which
have grown beyond the size which a chief medical officer can personally
supervise in all its details, and, so to speak, animate the whole machine.
If this be admitted, and if the cure of the insane be treated as the
primary and essential object of asylum detention, then surely the
necessity of special provision for recent cases will be recognized.
In moderately sized asylums acute and chronic cases may be, as said
before, received and treated together; for instance, in such as
accommodate from 250 to 450 patients, provided that the
physician-superintendent is properly assisted, for the proportion returned
"as deemed curable" in the English county asylums,--a proportion which
represents pretty nearly that of the recent cases, rarely exceeding 10 or
12 per cent.; consequently, the 40 or 50 demanding special supervision and
medical care may be undertaken by the superintendent, if he be
sufficiently assisted in the management of the chronic cases and in the
carrying out of the general details of the establishment. On the other
hand, a small, and perfectly distinct asylum for 40 or 50 patients could
not be established or conducted so advantageously, and still less so
economically; a circumstance, which will always avail to perpetuate the
system of mixed asylums for acute and chronic cases together.
Nevertheless, it must be borne in mind, that the 40 or 50 patients in the
population of 300 or 400, do not constitute the whole number of recently
attacked cases which may be admitted for treatment, but, so to say, the
residue at a particular date; for instance, the first day of the year.
Moreover, if the improvements in the law, and in its administration,
suggested, are carried out, and the admission of patients immediately on
the occurrence of their malady be facilitated, then, as a matter of
course, the proportion of those "deemed curable" would be immensely
increased; so much so, that it would be a very moderate estimate to reckon
on 100 recent, to every 500 chronic cases; or, what is equivalent to this
statement, the plan of placing patients under immediate treatment would
cause the progressive decrease of chronic cases, and raise the standard of
the asylum as a curative institution; a happy result, which, whilst it
would necessitate a more complete medical staff, would at the same time
well repay its cost.
Passing now to asylums which exceed the limits assigned as falling within
the compass of the abilities of any physician to superintend effectually
for the greatest benefit to its inmates, we hold the opinion, that where
these amount to 600 or 900, the most just and humane, and in the end the
most economical policy, is, to divide the establishment. Yet even here,
according to the present system regulating admissions, and the natural
consequence of this, the small per-centage of acute cases under care at
any one time, viz. from about 7 to 10 per cent. in the whole population,
would perhaps be held to furnish too small a number to justify the cost of
erection and maintenance of a wholly distinct hospital for their
treatment. Still we are confident that, if in any county where the pauper
lunatics in asylums attained the number mentioned, a distinct institution
for the reception of recently afflicted persons were erected, and the
admission of such patients were promoted, if that institution were free as
a public one for the insane other than paupers, such as those from among
the middle classes, unable to meet the costs of a proper private
asylum--it would secure to itself the number of patients needed to warrant
its establishment as a distinct institution, succeed even as an economical
arrangement, and confer an immense boon both on pauper lunatics and their
more unfortunate fellows in affliction, who are too rich for the "Pauper,"
and too poor for the "Private" Asylum.
Lastly, we come to the consideration of those overgrown establishments
where from 1000 to 2000 lunatics are congregated under one roof. Such
monstrosities ought never to have been constructed; they are nevertheless
looked upon by their promoters with admiration, and spoken of with pride,
though there is nothing in them to admire besides their magnitude and
pseudo-military discipline, and no more in them to be proud of as county
institutions than in enormous prisons; for as the latter indicate the
neglected morality of the county, so do the vauntedly large asylums prove
the neglected treatment of insanity. However, as the erection of these
unmanageable structures is an accomplished fact, nothing is left than to
deplore the fatal mistake; to take care that it is not repeated in other
instances, and to insist on the construction of distinct hospitals for
recent cases. The very existence of such an hospital would invite resort
to it, and bring within its agency many cases which do not find their way
into the existing institutions until, most probably, all hope of cure is
well nigh gone. Moreover, just as mentioned above in reference to a
proposed county hospital for lunatics, the law should intervene to secure
the early transmission of all cases for treatment, and admission be
granted to others besides paupers, under certain stipulations, by the
payment of more or less of their cost.
In counties with a population of lunatics of the extent named, the
difficulty of placing the chronic and recent cases of insanity in separate
asylums vanishes; for the latter will always be forthcoming in sufficient
number to justify a distinct institution for their treatment both on
medical and economical grounds; and the former, we apprehend, will always
be found numerous enough to occupy the accommodation provided. As refuges
for old cases, the evils of the existing gigantic establishments would
happily be mitigated, although not removed, by appropriating them solely
to the use of long-standing cases of lunacy.
Where the construction of a distinct hospital for recent cases of lunacy
is decided on as necessary, it should certainly accommodate not more than
300. All patients should be admitted whose disease is of less than one
year's duration; but this limitation should not be so absolute as to
prevent the physician to admit, after the lapse of a longer period, any
cases which might appear to him amenable to successful treatment;--a point
in prognosis, taught, and only taught, by experience in dealing with
recent insanity. Although the great majority of the insane who recover, do
so within the first year of their attack, yet statistics show that about
10 per cent. are restored in the course of the second year of treatment;
it would therefore seem that two years would constitute a fair and
sufficient period for the duration of residence in the primary asylum.
Here again the knowledge and experience of the physicians must be allowed
scope, both to discharge certain cases within the period named, and to
retain others beyond it. We should not consider it expedient to reject all
cases of epilepsy and general paralysis forthwith upon their application,
although insanity so complicated is generally very hopeless; for an asylum
with special appliances for treatment would at least be desirable to the
victims of those sad maladies in their early stages.
It is unnecessary to define the classes of lunatics who would occupy the
secondary asylums. As said before, we do not contemplate these
institutions as mere places of refuge; we do not consider the attempt and
the hope of cure relinquished in their wards, but that the means of
treatment are diligently persevered with. We would have them to be neither
hopeless retreats for patients, nor institutions calculated to encourage
supineness or apathy on the part of their medical officers. Indeed a
slender objection we have met with against the separation of the recent
from chronic patients, involves a slur upon the medical profession in
supposing a lack of interest and energy as incumbent upon the
superintendent of an asylum for chronic lunatics;--a supposition, which
reflects unfairly upon, and is untrue with respect to many superintendents
of asylums actually in existence. Are not interest and zeal, we may ask,
exercised for the benefit of those deemed incurable; are they not
exercised on account of idiots even, for whom their absence might be
esteemed not surprising? If cure is not attainable, the physician to the
insane, unless unfit for his calling, seeks and finds his reward in
ameliorating their condition; in elevating their mental and moral, and in
improving their physical being.
In those counties in which the number of the insane and the prevalence of
insanity are not sufficiently extended as to justify the institution of a
distinct curative asylum, the plan of the union of counties, as followed
for the provision of the ordinary asylums, suggests itself to the mind.
Practically, however, we believe, it is a plan which would not answer,
since it would render arrangements between counties in possession of
asylums difficult, and their accounts complicated. The only way in which
it could be made feasible would be by the levying of a general rate
throughout the country for the maintenance of lunatics, and by dividing
the country into districts, as is the practice in Scotland and Ireland,
apportioned in size to the population, to each of which an asylum for
chronic, and one for recent cases of insanity, might be assigned. Such a
scheme of a general rate, however, we do not expect to see realized,
although many arguments are adducible in support of it. Sir Charles Wood,
when Chancellor of the Exchequer, made the proposition to contribute on
behalf of the maintenance of asylums a portion of the proceeds of the
general taxation of the country; but the scheme met with little favour,
and was dropped. The principal objections advanced against it were, that
it was wrong in principle, a novel and uncalled for attempt to interfere
with local government, and no more to be justified than would be a
contribution from the revenue of the country towards providing for the
relief of any other form of disease. Respecting the last objection, it is
worth noting, that District Dispensaries throughout Ireland are partially
supported by Parliamentary grants; surely, therefore, if the principle of
subsidizing hospitals or dispensaries is admitted in one part of the
United Kingdom, there can be nothing unreasonable in a proposition to
extend it to another.
Where to provide for the lunatic population of a county considerably
exceeds the legitimate dimensions of a single asylum, and yet the
proportion of recent cases is too small to warrant the construction of a
distinct institution for them, we have proposed the establishment of two
asylums, each of a mixed character. Under such circumstances, and likewise
where a single asylum threatens to outgrow a manageable size, there are
certain very advantageous arrangements to be made, adapted to secure much
more efficient treatment, particularly of recent cases, than is usually
provided under the present system of aggregating all under one roof to be
subjected to one course of routine and discipline. These arrangements are
effected by the
§ _Construction of distinct Sections to Asylums._
The French system of asylum construction, as before noticed, is to divide
the building into several, more or less, sometimes quite distinct
sections, having a general administration and offices in common. The
number of sections and the character of their residents is a matter of
medical classification, and in each one there is a mixture of acute and
chronic cases, just as in our asylum wards; the combination being
regulated by the similarity in the phases of their malady, as, for
instance, if refractory; if epileptic; if clean and orderly; or demented,
paralytic and dirty. In Germany, on the contrary, although this same
medical classification is carried out, there is a primary separation of
the insane of the province or state into acute and chronic. But in the
mode of providing for the treatment of the two classes apart, two plans
are pursued, one termed that of "absolute separation," and the other of
"relative connexion" (relativ verbindung); the former consists in placing
recent and chronic cases in buildings completely detached; each one having
its own staff, organization and management; the latter, whilst keeping the
chronic and recent cases apart, possesses a common medical and general
administration in a building composed of two principal sections, either
forming parts of the same structure (as at Illenau, in Baden), or
detached, but within the same area (as at Halle, in Saxon Prussia).
Damerow is the most able advocate of the system of relative connexion, on
which he has largely written, and it is one which appears to be gaining
ground in Germany.
Now, except in the case of the overgrown Middlesex Asylums, where the
Lunacy Commissioners distinctly recommended a third asylum to be erected,
the plans propounded by that Board for affording additional accommodation
in institutions already large enough, are in principle much that of the
"relative connexion" system as proposed by the Germans. The reports above
quoted, in connexion with the question of separating recent from chronic
cases, show generally what the plans of the Commissioners are. They would
erect "detached day-rooms and associated dormitories near the wash-houses
on the women's side, and the workshops and farm-buildings on the men's
side." (10th Report, 1856, p. 27.) To prove the advantages of the plan,
they go on to say, "In making our visitations to the larger County
Asylums, we have repeatedly observed that a considerable portion of time
is occupied by the servants, who have charge of the wash-house and
workshop department, in merely collecting the patients in the wards, and
in conducting them to and from their respective places of employment. In
one asylum, we ascertained by minute inquiries that not less than one hour
and a half was thus every day wasted by the servants, and was passed
unprofitably and unpleasantly by the patients themselves.
"In addition to the saving of cost and time obtained by adopting the plan
we now recommend, we have the best reason for believing that the patients
derived a direct benefit, in many ways, from residing in cheerful airy
apartments detached from the main building, and associated with officials
engaged in conducting industrial pursuits. A consciousness that he is
useful, and thought worthy of confidence, is necessarily induced in the
mind of every patient, by removal from the ordinary wards, where certain
restrictions are enforced, into a department where he enjoys a comparative
degree of freedom; and this necessarily promotes self-respect and
self-control, and proves highly salutary in forwarding the patient's
restoration. As a means of treatment, we consider this species of separate
residence of the utmost importance, constituting in fact a probationary
system for patients who are convalescing; giving them greater liberty of
action, extended exercise, with facilities for occupation; and thus
generating self-confidence, and becoming not only excellent tests of the
sanity of the patient, but operating powerfully to promote a satisfactory
cure.
"The want of such an intermediate place of residence is always much felt;
and it often happens, that a patient just recovered from an attack of
insanity, and sent into the world direct from a large asylum, is found so
unprepared to meet the trials he has to undergo, by any previous use of
his mental faculties, that he soon relapses, and is under the necessity of
being again returned within its walls." (P. 27, Rep. 1856.)
The proposition of the Commissioners has been carried out to a certain
extent in several large asylums; for instance, at the Leicester, the
Wakefield, and the Devon. At the last it has been most fully developed in
the construction of a detached building for 100 patients; respecting the
excellence and cheapness of which, we have spoken in a previous page (p.
48).
The views of the Commissioners will meet with general approval. The
prevalent system in France of breaking up an asylum into sections, more or
less detached, we hold as preferable to the close aggregation of wards
under one roof, with continuous corridors, seen in the majority of English
Asylums. The correct principle to be pursued in an asylum is, to
assimilate its character and arrangements as far as possible to those of
the homes of the classes of persons detained in them. Can this be effected
in a large building constructed as much unlike ordinary houses as it well
can be; recalling in its general character that of an extensive factory,
workhouse, or barrack, of somewhat more ornate architecture indeed, and
with better "belongings" within and without, where the patients live by
day in long corridors, and sleep by night in boxes opening out of the
same, and where perhaps they are mustered and marched in great force into
a great hall to eat their meals? Certainly all this is not home-like,
however excellent to the lovers of routine or the admirers of military
discipline. But the separation into sections greatly lessens this
objectionable state of things; the population becomes thereby divided, so
to speak, into families, overlooked and controllable as such. The
advantage of transferring an improving patient from one ward to another is
considerable; but it would be much more so, if the transfer were from one
section to another; for the construction of separate sections admits of
the architectural arrangements, the fittings, &c., being varied to a much
greater extent than they can be in the case of wards, forming mere
apartments of one large building, constructed, as it must be, on a nearly
uniform plan.
From the same grounds likewise follow the economical advantages of
distinct sections; for the more expensive building arrangements required
for acute cases need not be repeated in the section for quiet, orderly,
chronic, or for convalescent patients, where accommodation may be
beneficially made to accord as nearly as possible with that of their
cottage homes. If detached sections were adopted, the elaborate,
complicated and costly systems of warming and ventilation would not be
needed; there would be less to cherish the feeling of imprisonment; and,
lastly, to recal the valuable observation of the Commissioners before
quoted (p. 142), this species of separate residence would be a means of
treatment "of the utmost importance, constituting in fact a probationary
system," and a most excellent addition to the means of 'moral treatment'
now in operation. There is one subsidiary recommendation made by the
Lunacy Commissioners, which we cannot so freely subscribe to, that, viz.
of classifying the patients in sections according to their occupations.
Those of the same trade or employment must, as a matter of course, be
associated together, during the hours of labour; but at the expiration of
those hours we would wish to see that association broken up. The
congregation of the same mentally disordered persons always together is
not desirable; the insane are selfish enough--absorbed in self, from the
effects of their malady; and it should always be a point in treatment, to
disturb this condition, to arouse the attention to others, and to other
things; an effort which would be the more difficult in a small knot of
people always accustomed to meet together, knowing each other's ways and
whims, and each thinking the other mad, though not himself. Again, if the
workers are entirely separated from the drones in the hive, the latter are
likely to remain drones still: they lose the benefit of example, which
operates, as among children, so strongly with the insane.
To apply these observations to one class of workers, for example, to the
laundresses: it seems to us scarcely merciful to keep these poor patients
to the wash-tub all day; at the close of their labour to turn them into an
adjoining room, and at night consign them to sleep over it. Instead of
being thus scarcely allowed to escape the sphere and atmosphere of their
toil, they should have their condition varied as far as possible, be
brought into new scenes, mixed with others who have been otherwise
engaged, and made to feel themselves patients in an asylum, and not
washer-women. Is it, in short, not a radical error in the direction of an
asylum, to place the inmates in such a position and under such
circumstances, as to make them feel themselves workmen under compulsion,
regularly employed, dealt with only as labourers and artisans, by being
kept all day in their workshops, and in the evening and night brought
together, because they are workers, and unlike the other residents of the
asylum, who will in their opinion come to be regarded, as unlike
themselves,--as the fitting occupants, and the only patients? Treated
apart in the manner under notice, there would be nothing in the position
or circumstances around the industrious inmate to suggest to him that he
was a patient, except in name, as called so by the officials. We are,
therefore, opposed to this _industrial system_ of classification, and
regard medical classification as the only proper one.
The division into quarters or sections is a plan more applicable to an
asylum for chronic than to one for acute cases. In the latter, patients
are to be treated specially and individually; and as sufferers from acute
disease must be classified medically rather than with reference to any
matters of management, occupation, and discipline, and are on the whole
less conformable to general orders and plans: yet certain principal
sections are wanted in them; as, for example, for the refractory and
violent, for the quiet and orderly, and the convalescent. To some of the
last named, a separate section, of a home-like character, regulated less
as an asylum than as a family residence, and where the highest amount of
liberty compatible with safety and order is the rule, would afford a most
valuable means of treatment.
§ _Distribution of the Chronic Insane in Cottage Homes._
The subdivision of an asylum for chronic cases could be carried very far.
Not only might sections be appropriated specially to idiots, to
epileptics, to imbeciles, and to the very aged and infirm in an infirmary,
but also to several classes of the chronic insane not falling under either
of those categories, distinguishable by the greater or less amount of
trust to be reposed in them, by their dispositions and tendencies, and by
their industrious and moral habits. However, there must be at some point a
limit to the utility of subdividing an establishment necessitated by the
requirements of its administration and of an effective and easy
supervision; and as yet, in this country, the system of aggregation
prevails most largely over that of segregation. English asylums have, some
of them, detached wards and a few farm-buildings, affording lodging to
patients engaged in industrial pursuits; but the plan of segregating their
residents has not been pushed farther, except to a small extent by Dr.
Bucknill, who has placed some selected pauper lunatics in the homes of
cottagers living in the vicinity of the county asylum; for we cannot call
the boarding out of the imbecile poor--scattered, as it were, broad-cast
over the country, disposed of in cottages, according to the notions of the
inferior parochial officers, and watched over only nominally,--a system of
providing for them. If system at all, it is merely one for putting them
out of the way, of escaping responsibility, and of hiding them from
observation.
The colony of insane at Gheel, in Belgium, is the only one where the
segregation of the insane has been systematically carried out. It presents
most of the elements of success in its constitution and government. It has
an organized medical staff; it is a naturally secluded locality; its sane
inhabitants have been for ages accustomed to act as the guardians and
nurses of the insane, and to receive them as boarders into their families.
Yet, notwithstanding the eulogiums of many visitors to this village,
others who have more minutely examined into it have detected many
irregularities, and pointed out weighty objections against its management.
The questions may be fairly put,--Are the irregularities inevitable? Are
the objections inseparable from the system? To discuss these points in
detail would carry us far beyond the limits we must observe; but we may
express our belief in the value of the system, considered as such,
although we do not see how or where it can be applied to a similar extent
as found at Gheel. The irregularities which have been remarked are
remediable, and the objections generally removeable. It is a defect at
Gheel, that there is no central establishment of the character of an
asylum and infirmary, and it is a mistake to undertake the charge of
recent and violent cases, and of epileptics for the most part, and
likewise of paralytics, in cottages under cottagers' supervision only.
Other classes of patients might be pointed out as unfit residents in
peasants' families. The system, in short, is pushed to an extreme in this
place; but this error does not invalidate it as a system. Objectionable
cases for the cottage home could be collected in a central establishment,
and there would be plenty left to partake of the "air libre et la vie de
famille," which a recent physician of the colony of Gheel, M. Parigot,
commended in his _brochure_ addressed to the consideration of the friends
of the insane.
Many who have become acquainted with the system pursued at Gheel have been
enraptured by its many apparent advantages, the liberty it affords, and
the great cheapness of its management, and have wished to import it as a
whole into this country. Such a scheme we regard as both impracticable and
undesirable; yet we at the same time believe something may be attempted in
the same direction most beneficially (see p. 89). The attempt should first
be made in connexion with some of our county asylums of a moderate size. A
similar secluded district as that of the commune of Gheel is, thanks to
Providence, not to be found perhaps in England; but this is of no such
primary importance: a moderate distance from considerable towns, or from
large villages, is all that is strictly requisite, and several asylums are
so situated. The difficulty of place being encountered, a more serious one
appears, viz. that of finding suitable cottagers to undertake the charge
of patients. At first, a suitable class could not be reckoned on; but,
according to the laws of supply and demand, it would only require time to
form such a class. Sufficient inducements only are wanting, and probably
those supplied would be found so. It is an advantage to a cottager to have
a constant lodger, to receive a certain weekly payment; and it would
constitute a greater one to have as an inmate one who could assist in
certain labours of the house and garden. We might hope to see old
attendants of the asylum settled around, after retirement from their
employment, with a pension; and to the care of such two or three, or even
more, selected patients might be entrusted. If the land belonging to the
asylum were of sufficient extent, the patients boarding around might still
be employed upon it; or, if they were artisans, they might daily resort to
its workshops, its bakehouse or brewhouse, just as the ordinary peasant
labourer goes to and fro to his place of employment. The asylum would thus
still reap the benefit of the patients' labour, and this arrangement, we
believe, would work better than one providing for their employment with
strangers at a distance from the institution.
By limiting the area inhabited by patients in lodgings to that immediately
surrounding the asylum, a satisfactory supervision could be exercised by
the authorities; and on the occurrence of illness, or a change in the
mental condition, a transfer to the asylum could be speedily accomplished.
Again, by keeping the insane within a moderate range of the asylum, and by
retaining them as labourers on its grounds, the advantages of a central
general administration would be found in the provision and distribution of
food and clothing.
In previous pages we have advocated, under certain conditions, the
erection of distinct asylums for chronic cases of insanity; to this plan
the system just developed, of boarding out a certain number in cottages,
must be held as supplementary. A chronic, or a moderate, manageable-sized,
mixed asylum must form the nucleus of the 'cottage system' of providing
for the insane. The cases must be selected from the asylum-residents, and
the selection be left with the medical superintendent. The persons
receiving patients must be held responsible to the superintendent, and to
the members of the Lunacy Board, for their proper care and management, and
they must enter into some sort of covenant with the Visitors of the
asylum. To carry out the scheme under notice, many matters of detail are
required, but these it would be out of place here to enter upon.
There is this evident general and economical advantage about this 'cottage
system,' that it would obviate the necessity of constructing large asylums
for chronic lunatics at an inevitably heavy outlay, and also of
instituting so large a staff of officers and servants as is called for to
govern and conduct an expensive special establishment. In country
districts, agricultural labourers and other small householders might be
found willing to board, lodge, and look after patients for 7 or 8
shillings per week each; or, according to the plan we prefer, the asylum
would provide board, and receive the benefit of the patients' labour, and
only some small sum would be payable for his lodging and care.
Having only in view at the time the amelioration of the present condition
of the insane boarded out with friends or strangers, we have proposed in a
preceding page (p. 87), their frequent supervision, and the arrangements
necessary to their welfare, being entrusted to a distinct medical officer
under the central control of the Lunacy Board. This plan would still hold
good with reference to all those lunatics not living within the fixed
radius around the asylum; within which the superintendent would be the
directing authority, the supervisor and protector. Moreover, as we have
remarked (p. 89), residence with their immediate relatives would be
frequently preferable to their severance from them in order to be brought
within the sphere of the asylum; and such patients would derive benefit
from the inspection proposed.
§ _Separate Provision for Epileptics and Idiots._
The extent to which the separation of epileptics and idiots, but more
particularly of the former, from other classes of mentally disordered
persons should be carried, is a matter much discussed. The rule is to have
epileptic wards in large asylums, although there are some epileptics in
whom violence and dementia are such prominent features, as to justify
their position severally with the refractory or with the demented.
However, the painful features of their malady, the special provisions
needed in the apartments occupied by epileptics, and the precautionary
measures to be observed in their clothing and food, the ill effects of the
sight of their paroxysms upon others, and other reasons well known to
medical men, constitute sufficient grounds for the ordinary practice
pursued of keeping epileptic lunatics generally in particular wards. This
plan answers well in moderately-sized asylums; where their number is
considerable, as in large establishments, we should prefer their location
in a distinct section; and if the county possessed one asylum for recent,
and another for chronic cases, the majority of the epileptics should be
residents in a section of the latter.
Of the great value of separate provision for idiots we think there can be
no doubt. Indeed, the association of idiots with lunatics is an accident
of legal origin rather than a proceeding dictated by science and medicine.
The law places together idiots and lunatics under similar protection, and
treats them as nearly in the same position socially. Hence it has come to
pass that their legal claim to care and protection has brought them within
the walls of the County Asylums. Their presence there, however, we regard
as a mistake prejudicial to their own welfare and an onus upon the asylum
authorities. Of old, all that was considered necessary for idiots, was to
provide food and lodging for them, and to keep them out of harm's way.
But, thanks to modern philanthropy, the prospects of the idiot are much
improved; the amelioration of his condition is attempted; his moral,
mental and physical powers are found to be improveable, and it is sought
to elevate his status as a social being, and to foster his capacity for
amusement and for useful employment.
Contrasted with previous neglect, the care and management afforded in an
asylum render the poor idiots an infinite service; yet withal a lunatic
asylum is not the proper abode for them. Within its walls they are unfit
associates for the rest of the inmates, and it is therefore felt to be
necessary to place them in a special ward. Too frequently this ward is in
the worst placed and most forgotten section of the building, sometimes
with little open space about it, and devoid of those conditions calculated
to evolve the little cerebral power possessed. Whatever their claims upon
the attention of the medical superintendent, and however zealous he may be
to discharge all his duties, yet amidst the multifarious occupations
pressing upon him, and specially occupied as he is in treating insanity,
that officer finds himself unable to do more than watch over the health of
the idiotic inmates, and attend to the improvement of their habits: he is
not in a position, and has not the opportunities to superintend the
education of idiots; and we are certain that every asylum-physician would
rejoice, both for his own sake and for the interests of the idiots
themselves, to see them removed to a special institution, or to a section
of the asylum specially organized for their care.
Not only are idiots in the way in a lunatic asylum, and their ward an
excrescence upon it, but the organization and arrangements are not adapted
for them. Idiots require a schoolmaster as much as a doctor; the latter
can see that all those means are provided for them to improve their habits
and their physical condition; but it must devolve on a patient instructor
to operate more immediately upon the relic of mental power which is
accorded to them. The sooner they are brought under the teacher's care the
better: experience shows that much more may be effected with idiots during
their childhood than when they have arrived at a more mature age, and the
developmental changes in the brain have so far ceased, that an increased
production of nervous power can be scarcely looked for.
This is a theme we cannot further enter upon; and to conclude this
section, we may remark, that the number of idiots is so large as to
justify the erection of several distinct institutions for their care and
improvement. Several counties might unite in the establishment of an idiot
asylum, the parishes being charged for the number belonging to them in it;
an arrangement, which would no more complicate parochial accounts, than
where one charge has to be met (as often is the case at present) for the
maintenance of a certain number of lunatics in the county asylum; a second
for that of another portion in a licensed house; and a third for some
others in the workhouse wards.
There is another matter worth noting. The county asylums for the most part
being filled to the exclusion of recent cases of insanity, and the
condition of idiots being held in still less importance than that of the
insane by workhouse authorities, it is not to be wondered at that, on the
one hand, the admission of idiots into asylums is not promoted, and that,
on the other, so many idiotic paupers are found in workhouses. To provide,
therefore, cheaply for idiots in distinct institutions, and to facilitate
and enforce their transfer to them, will be a means of ridding
union-houses of a portion of their inmates, for which they are so entirely
unfitted. To the genuine philanthropist and the truly humane, no
hesitation would arise as to securing every necessary provision, and the
best means for ameliorating the fate of any sufferers, and particularly
that of the poor helpless idiots. But to the majority of mankind the
question of cost is preliminary to the exercise of philanthropy; and some
perhaps think it enough to feed and clothe, to watch and keep clean the
miserable drivelling idiot, since all the money that could be spent upon
one would only produce after all a poor, weak-minded creature, of little
or no service in the world. This argument cannot be gain-said, though it
must be condemned by every Christian animated by the leading principle of
his religion, that of "love."
To the sticklers for economy, the proposition may be propounded for
consideration, whether, on the adoption of the plan of erecting distinct
asylums for the chronic insane, the idiots could be less expensively
provided for in a section or "quarter" of such an asylum, properly
furnished with the means of improving their condition, than in an
establishment reared specially for the purpose? We content ourselves with
putting the question.
CHAP. VIII.--REGISTRATION OF LUNATICS.
We are fain to look upon a complete registration as a remedy to many
admitted evils affecting the welfare of lunatics, and we may add, of
idiots also.
Lunacy may be regarded as a form of "civil death;" it deprives its
sufferer of his rights as a citizen; subjects him to the loss or
restriction of liberty; disqualifies him from many civil privileges, and
invalidates his powers of dealing with property and of executing legal
documents. Yet not unfrequently are lunatics, particularly among the more
wealthy classes, placed under the penalties of their condition without
the knowledge and authority of the Officers of the State, by whom alone
can such penalties be legally enforced. An individual, we say, is often
deprived of his liberty and of the control over his affairs, at the hands
of relatives or friends, and often indeed transferred to the house of a
stranger, and there subjected to surveillance and repression; and all this
done against his will, and, what is more, against the principles of
English law and English freedom.
Elaborate provision is made and still further attempted to prevent the
unnecessary detention of persons in asylums, whose cases have been
regularly reported to the public authorities; but no steps have as yet
been taken to discover unreported cases of alleged lunacy or private cases
treated singly; no enactment contrived to bring within the knowledge of
any Government-board the number of persons, year by year attacked with
insanity, and thereby, for a longer or shorter period, disqualified from
the exercise of their civil rights. To our mind, this state of things
proves a grievous defect in the law of lunacy. Every person has an
inherent right to the protection of the law; yet practically, if insane,
he does not at all, as a matter of course, obtain it: his malady and
position may very probably be unknown, and he may be helpless, or
otherwise debarred from making it known. Were a machinery contrived to
report it to legally constituted authorities, the sufferer would have the
satisfaction of feeling that he was dealt with according to law in the
process of the treatment he was subjected to.
Were each case of lunacy systematically registered, it would, we believe,
frequently save legal contests. Documents dealing with property are often
matters of litigation, on the plea of the insanity of the person executing
them, and enormous costs are incurred on the one side to substantiate, and
on the other to overthrow the plea. Evidence collateral and direct is
hunted up, probably years after the date of the alleged state of insanity;
and often enough it comes out, or is decided by the jury, that the
individual was once insane, or was so at the date of executing the
document in dispute. Now, in such a case, had the insanity which has been
so laboriously, tediously and expensively established as having occurred,
been registered in a public office at the time of its occurrence, how
great would have been the gain to the feelings, the interests, and the
convenience of every person concerned in the suit! If the document had
been executed during the period the individual was registered as of
unsound mind, the production of the register alone would have availed in
proof of its invalidity. The whole litigation, indeed, might have been
prevented by a search of the register before the action was begun.
In the introductory chapters on the statistics of insanity, we have
remarked on the very incomplete records of the prevalence of the disease,
and on the consequent impossibility of discovering the actual number of
the insane, and of determining the question of their increase in the
community. Yet it will be granted that such statistics are of great
importance in a civilized country, and have bearings upon several
questions in social economy.
The Earl of Shaftesbury, in his valuable evidence before the 'Select
Committee on Lunatics' (1859), observes, in answer to query 263, "I think
it would be very desirable if we could have proper statistics upon
insanity drawn up and put upon a good footing. It would require great
trouble and expense; but I think it would be worth the trouble and
expense, if it could be put in the hands of some competent persons; and I
have no doubt that some remarkable results would be brought out." Every
one, who knows how defective are the existing statistics of the disease,
will cheerfully second his Lordship's wish. This, however, does not go so
far as our own; for Lord Shaftesbury appears, as far as we can judge from
his words, solicitous only to take a sort of census of the insane and to
deduce from it certain facts; whereas we desire not only an accurate
census at present, but also a well-arranged scheme for keeping up the
correctness of the statistics of the insane for the future, by making
every instance of insanity returnable to the Lunacy Board. Our desire, in
short, is to bring every lunatic in the kingdom within the cognizance of
the Commissioners in Lunacy, either directly or by some recognized agent
acting in their place, so that protection and proper care may be assured
to every such afflicted individual. A necessary supplementary provision to
placing a name on the register would be required for removing it on
certified recovery; the return of which should be made through the same
channels as the report of the attack.
Should the registration proposed be enforced by law,--as it must be to
render it at all perfect, under a penalty,--it would afford a remedy
against the wide-spread plan of placing lunatics where they are unheard
of, and unknown to all except those concerned in their detention. It would
make the Commissioners acquainted with all those very numerous patients
who often drag on a painful and neglected existence in lodgings, under the
control of persons of all sorts, with many of whom, it is to be
apprehended, the gain to be got by their detention is the ruling motive in
their actions.
Another advantage obtainable by a system of registration, so conducted as
to ensure the reporting of cases immediately, or almost so, on their
occurrence, is, that it would prepare the way for early treatment, more
particularly so perhaps in the case of pauper lunatics. In the instance of
the last-named class of insane, the law might render their removal to an
asylum imperative, on the report of the onset of their disorder, by
refusing their friends the attendance of the parochial medical officer on
the patient at home as well as parochial relief, and by holding them
responsible on the ground of culpable neglect for anything untoward that
may happen to the patient or others. We anticipate that such an arbitrary
interference of the law would be but very seldom required, for the poor
mostly would be only too happy to rid themselves of a troublesome and
useless member of the family.
Moreover, in the case of those raised above poverty and competent to
provide for their insane relatives, it would be no undue stretch of legal
authority to require them to satisfy some duly appointed and experienced
officer, that the provisions contemplated or furnished by them for the
patient were of a satisfactory character and calculated to favour
recovery. The existing law, indeed, goes so far as to interfere with the
friends of a lunatic and to deprive them of his care, if there be evidence
to show that he is cruelly treated or neglected. It moreover imposes upon
the friends all costs incurred on behalf of the patient. The section cited
is _sect._ lxviii. 16 and 17 Vict. cap. 97, and the suggestion we offer is
but an amendment of this, so far as to require the friends of every insane
person not placed in a licensed house or asylum, to show that such lunatic
is properly treated and taken care of.
The registration must be accompanied by visitation. The appointed medical
registrar must be a witness to the fact he is called upon to register; and
a case once registered should be visited at least once in three months,
until recovery or death takes place, when in either case the return of the
patient as a lunatic would be cancelled under a certificate to the fact
supplied by the registrar. These remarks apply specially where patients
are placed out singly. This plan of registration, coupled with that of
visitation, would not only give security that the patient was properly
treated, but would also prevent secret removals to lodgings or other
uncertified receptacles for lunatics, or to a foreign country.
With reference to the last-named proceeding, there ought assuredly to be
some stringent legal provisions, if not to prevent it entirely, at least
to place it under great restrictions. The Lunacy Law in its intent and
administration is both stringent and minute where it deals with asylum
provision for the insane in this country; but it is impotent if the
friends of a lunatic choose to send him out of the country. The act cuts
him off from all protection of the laws he was born under and has never
forfeited. Certainly it must be granted, that in every civilized country
of the world lunacy laws are enacted for the protection of the insane; yet
even where those laws are good, we know of no realm, and we believe there
is none, where the interests of the insane are so well watched over and so
adequately provided for, as in our own. This opinion we assert as the
result of personal observation in most of the countries of Europe, and the
perusal of the reports on the state of the insane in those countries.
Where English lunatics are transferred to foreign public asylums--and
there are many sent to such, particularly to those in France--there is
often very excellent treatment and moderate State supervision; but it must
be borne in mind, that the poor patients are thrust among strangers by
nation, by habits, and by laws; there is no security against their being
placed among the lowest classes of pensioners, who are less tenderly dealt
with than our asylum paupers; and they are besides entirely at the mercy
of their relatives or friends, who may as far as possible ignore their
existence, prey upon their substance at home, and allow only some pittance
for their maintenance in the foreign land.
We are persuaded that the allusion to this defect in the laws of lunacy is
sufficient to extort attention to it, and obtain its redress. The project
of the law of lunacy for Sardinia, which we translated for the pages of
the 'Journal of Psychological Medicine' (vol. x. p. 818), contained the
two following clauses:--"Art. 21. It shall be incumbent on all individuals
who shall place an insane person in a foreign asylum, to present, every
thirty days, to the Minister of the Interior a precise report of the
physical and mental condition of the patient, prepared by the physician of
the asylum. Art. 22. It shall be in the power of the Minister of the
Interior, by previous concert with his colleague for foreign affairs, to
cause any patient confined in a foreign asylum to be brought back to his
own country, provided that this can be done without injury to the patient,
and that he can be readily provided for in his own family, and is in
possession of sufficient pecuniary means for his maintenance."
Some such clauses need be added to any new Act of Parliament for the care
and treatment of lunatics in this kingdom. The Commissioners in Lunacy
would be the right persons to move first in the matter by calling upon
friends for information respecting their lunatic relatives abroad; and the
Foreign Minister, acting upon their recommendation, would, we presume, be
the proper official to arrange with the authorities abroad for the
transfer of the patient to his own country.
It may not be possible so to limit individual liberty as to interdict the
removal of lunatics from their native country; but it is undoubtedly
consonant with English law, and a matter of justice to the poor lunatic,
when so dealt with by his friends as a commodity to barter about, that the
legal protection due to him in his own land should be so far extended to
him in a foreign state, that some public authority should be satisfied
that he is duly cared for, and treated in the asylum he occupies, and has
that allowance set aside for his maintenance, which his pecuniary means
will justify. Likewise, it would be no illegal stretch of power to call
upon the friends of a lunatic, whose condition abroad was unsatisfactory,
to bring him back to his native country; or, in case of their refusing to
do so, to have the order carried out by others, and its costs levied upon
the recusant friends.
After all, however, before any such law could be effectual, the
opportunities of ascertaining the existence of lunatics must be gained by
the adoption of the system of registration; for, otherwise, the
Commissioners could derive no knowledge of the cases sent abroad, even of
such as might have at one time been under their jurisdiction in licensed
asylums.
This remark leads us to notice another default in the lunacy code, viz.
that of not enforcing a return in the case of all patients removed from
asylums uncured, of the place to which they are removed. At present it is
possible for the friends of a lunatic in an asylum or licensed house, to
order his discharge, and to remove him where they please, to some spot
unknown, if they so choose, to any but themselves. The superintendents of
the asylums make a return to the Lunacy Commissioners that such a patient
has been discharged by order of the relative or friend who authorized his
admission, and that he has gone out uncured or relieved, but no
information is required of the place and manner in which the lunatic is to
be disposed of for the future. This circumstance is true of all cases of
lunacy not found so by inquisition; that is, all except those put under
the jurisdiction of the Lord Chancellor, or of his representatives in
lunacy affairs, the Masters in Lunacy. For these so-called 'Chancery
lunatics' the sanction of the Masters is required, both to the removal, to
the locality, and to the persons proposed for the patient's reception.
Similar protection should be extended to all insane persons. The power of
removal cannot be taken out of the hands of a lunatic's immediate
relatives, but it may be hedged about by the restriction, that the removal
of an uncured patient shall be reported to the Commissioners in Lunacy,
who shall, after acquainting themselves with the place, the persons, and
the provisions intended for the welfare of the patient, have the power to
permit or to refuse it.
The registration of all lunatics, particularly on the accession of their
malady, is exposed to certain objections, none of which, however, are, in
our opinion, of sufficient weight to militate against the plan. One great
impediment to its adoption, among most persons above the condition of
paupers, and in some degree among the poor also, is the desire of secrecy
on the part of friends, who endeavour in every way to restrict the
knowledge of their relative's mental disorder to the circle of his own
family, and, if possible, to ignore its being actual insanity. On the one
hand, the insanity is treated as if it brought discredit on all related to
the afflicted person; and on the other, relations dread its recognition by
any public authority, and set themselves in array against any inquiry
which seems to trench on their private affairs. The self-same feelings and
prejudices, as before shown (p. 32), operate against the early and
successful treatment of private patients; and as obstacles to registration
they are equally to be regretted. The attempt to keep secret an attack of
insanity is virtually impracticable; and though it is, in truth, a dire
misfortune to both patient and family, yet is an attack of mental disorder
a less discredit than one of gout, which our forefathers, in their folly,
courted as a pledge of good manners and good breeding. The mischief of
these notions, however, is, that they operate inimically to the interests
of the patient: they stand in the way of early and appropriate treatment,
and thereby tend to prolong the malady, or to render it inveterate. Could
the friends bring themselves boldly to face the whole truth, and admit the
fact that their relative was insane, and were they encouraged by their
medical man to take this true view of the matter, and to act upon it, by
submitting the patient to the necessary treatment, they would very often
escape the evil of exposure they dread, and soon have their relative
restored to them again, instead of having, by various subterfuges, to hide
his condition, and to account for his long disappearance from society and
from home. Besides, the hollowness of the pretences or excuses for absence
must some day be found out, when the impression upon acquaintances will be
the more profound, and the self-respect of the relatives suffer the wound
inflicted by the exposure of the vain deception they have essayed to
practise.
Again, the recording of the occurrence of insanity in a member of a
family, which we hold to be as important to the patient and his friends as
to the State, need not be regarded as an inquisitorial proceeding. It can
be effected with every attention to secrecy;--the registrar would be sworn
to secrecy, and the register in the central office would be a sealed book,
except under certain conditions authorized by the Courts of Law. There is
no public declaration of the fact of the insanity involved by its being
recorded in the books of an office under the security of its
functionaries.
Allowing that family prejudices and pride were of more moment than we are
willing to admit, yet they should not suspend the enforcement of
registration; for it must be remembered that the insane stand in a
different class to patients suffering from any bodily infirmity. They
forfeit by their malady the power to act in their own affairs; or their
actions, if their mental disorder has been as far as possible concealed,
are at any time during their life or after their death, liable to be
called in question on the plea of insanity. It is undoubtedly, then, the
province of the law to interpose on their behalf for the interests both of
themselves and of others. The law is remiss if it permit a mentally
unsound person to act on his own behalf, or others to act for him, without
its sanction; and is it, we ask, consonant with English jurisprudence to
detain a man against his will, in other words, to imprison him, even in
his own house, and under the authority of his own immediate relatives? As
soon as insanity has declared itself, so soon, we maintain, should both
the person and the property of the sufferer come under the protection of
the law; and this protection ought to be promptly and cheaply afforded.
Interference with a mentally disordered individual had better be premature
than be delayed until by some actions his interests, his property, or his
condition suffer. It is better for him to be found a lunatic, or, to avoid
a painful and objectionable term, be adjudged to be unable properly to
take care of himself and his affairs, and to be deprived for a time of
liberty of action,--than that he should be treated as a sound man, and be
suffered to damage his own prospects and property, and to expose himself
or family to future litigation on account of his actions.
When a violent or sudden death, or a suicide occurs, be it in whatever
class of society it may, there is no escaping the requirement of the law,
however painful be the circumstances the inquiry evokes; the coroner must
hold an inquest, and the whole matter be publicly investigated before a
jury. Family pride and prejudice, however much they may be offended, are
not allowed to stay the inquiry. Why should they then be suffered to stand
in the way of a simple recognition, made not through the intervention of a
public court, but as secretly as possible, of a disorder, which places the
sufferer in a state of social and civil death, and perhaps more seriously
deranges his pecuniary affairs than even natural death itself?
To repeat, the law is bound to watch over the interests of the insane, by
seeing that they are properly provided for, whether in their own houses or
elsewhere. No difference of opinion will occur to the proposition where
the insane are placed with those who are directly or indirectly advantaged
by their detention. To meet the case of such, indeed, an attempt to secure
a legal recognition and protection has been made by 16 and 17 Vict. cap.
96. But the same unanimity will be wanting when it is proposed to demand a
return, and to sanction the supervision by public functionaries, of
patients residing in their own homes: and although we have endeavoured to
show good reasons why such a requirement should be made,--and the
arguments could be enforced by illustrations proving that, both among rich
and poor, insane persons are not satisfactorily, nay more, not even kindly
treated by their own relatives,--yet Lord Shaftesbury stated it to be his
persuasion (Evid. of Com. p. 35) that public opinion is not ripe to
introduce a new power to enter domestic establishments. Nevertheless, if
public opinion be not ripe for such an innovation, "it would seem (to
employ Sir Erskine Perry's query, No. 304, as an affirmation) that
whenever a person is put under surveillance, it is not too much for the
legislature to require information of that fact;" that is to say, if
"domestic rights" must yet for a time be allowed to hide domestic wrongs
to the helpless victims of mental disease, by denying them the protection
of the law they live under, they should not avail against their being
reported or registered.
However, in the case of those who are obliged to seek for parochial aid,
the domestic impediments to the institution of a public officer to inspect
the condition of their lunatic relatives, could not be suffered to
operate.
Now the principle of requiring a compulsory return and visitation of all
insane persons confined in their own homes or in lodgings, is not new. The
Belgian Lunacy Commissioners recommended in their Report on the
amelioration of the Lunacy Laws, in 1842, that no person should be
confined in his own home, excepting after an examination by two
physicians, and a certificate from them of the necessity of the restraint
upon his liberty. The certificate was to be handed to the "juge de paix,"
who might order other visits; and if dissatisfied with the arrangements
for the care and treatment of the patient, might require others to be
entered into. The family medical man was likewise charged, under a penalty
for non-performance, to send in a quarterly report of the state and
condition of the patient.
With the same object in view of obviating abuses in the domiciliary
treatment of the insane, M. Bonacossa, the chief physician of the Turin
Asylum, proposed the following clause to the Sardinian Lunacy
Code:--"That, as patients are often kept in confinement in their own homes
or in the houses of private persons to their detriment, it shall be made
imperative on all individuals retaining an insane person in their house,
to report the fact to the syndic of the commune, or to the intendant of
the province."
The British legislature has taken some steps in the same direction, but
the fear of encroachment upon individual liberty has conspired to render
its comparatively feeble attempts to provide for the due protection of
single patients nugatory. By the Act of 1829, every medical man who had
been in charge of a private patient for eleven months was required to send
the name of the patient, under a sealed cover, to the Lunacy Commission;
but this document could only be opened upon application to the Lord
Chancellor. Moreover, the fixing of the period of eleven months led to the
transfer of the poor lunatics from one person to another within that
period, so as to render the requirement of notice of his existence and
detention null and void. By the 8 and 9 Vict. cap. 100, this enactment was
repealed, and by _sect._ xc. it was ordered that no person, except one who
derived "no profit from the charge, or a committee appointed by the Lord
Chancellor," should receive a lunatic into his house, to board or lodge,
without the legal order and medical certificates, as required for
admission into a registered house or asylum; and that within seven days
after the reception of a lunatic, the person receiving him should transmit
to the Commissioners copies of the order and medical certificates,
together with a notice of the situation of the house, and the name both of
the occupier and of the person taking charge of the patient. It further
ordered that every such patient should be visited at least once in every
two weeks, by a duly qualified medical man, who should also enter a
statement after each visit of the state of the patient's health, both
bodily and mental, and of the condition of the house. With a view to
secrecy, the same Act ordained (_sect._ lxxxix.) the institution of a
private committee of three of the Lunacy Commissioners,--to whom alone the
register (_sect._ xci.) of such patients was to be submitted for
inspection,--who should visit those registered single lunatics, report
upon them in a private book (_sect._ xcii.), and, if desirable, send this
report to the Lord Chancellor, who could order the removal of the patient
elsewhere (_sect._ xciii.), if his state was proved to be unsatisfactory.
This legal apparatus completely failed to attain the desired object: it
was left open for the person receiving the patient to consider him a
lunatic or not, and to report him or not at discretion; for no penalty
hung over his head for disobedience to the Act. So, again, the three
members of the "Private Committee" could neither derive official knowledge
of the single patients they ought to visit, nor find time or opportunity
to carry out the visitation of those reported to them, living as they did
scattered throughout the country.
The last-named Act, having thus failed in its objects, was much varied by
that of 1853 (16 and 17 Vict. cap. 96), the last enacted, which was less
ambitious in its endeavours to deal with the single private lunatics. By
this Act the private Committee was abolished, and any member of the Lunacy
Commission was empowered to visit those single cases reported to the
Board; at least one visit a year being required. But the provisions under
this Act are very ineffectual, both for the discovery and for the
protection of the patients. The Commissioners are directed to visit those
only who are placed under certificate and known to them; and although
every person taking charge of a lunatic or an alleged lunatic is required
(by _sect._ viii.), before receiving the patient, to be furnished with the
usual order and medical certificates, and (by _sect._ xvi.) to make an
annual report of his mental and bodily condition to the Commissioners
during his residence in his house, yet there are, in the first place, no
means provided for discovering the existence of the lunatic unless the
person receiving him choose to report it; and again, the requirement as to
the certificates and order may be complied with, but no copy be sent to
the Commissioners; and lastly, it is left to the will and pleasure, or to
the honesty of the individual receiving the case, whether it is to be
considered as one of lunacy or not.
It is needless to attempt to prove that a law so loosely framed must be
inoperative. No person who has given a thought to the subject but knows
that there are many hundred, nay, in all probability some two thousand--as
we have surmised in our estimate (p. 5), single private (not pauper)
patients in England: yet, as Lord Shaftesbury acquaints us in his evidence
(Committee on Lunatics, p. 34), only 124 such patients are known to the
Lunacy Board. Some few of the many others may be under certificates,
though unreported; still the great majority are, there is no doubt,
detained without attention to any legal formalities or legal sanction, and
for the most part treated as "nervous patients," and as therefore not
amenable to the Commissioners in Lunacy. The existence of the lunacy is
thus disguised under the term of 'nervousness,' and the patients robbed of
the protection which the law has rightly intended, and yet signally failed
to afford.
The noble chairman of the Lunacy Commission, in the course of his able
evidence before the "Committee on Lunatics" (1859), has given some
admirable suggestions for the amendment of the law in order to bring the
so-called "nervous patients" under the cognizance of the Commission, and
to obtain a more complete knowledge of the number and position of the many
lunatics detained in private houses.
According to the existing law (Evid. Comm. p. 33), it is only, says Lord
Shaftesbury, "where a patient is put out to board with some person who is
benefited by the circumstance that the Commissioners can, upon application
to the Chancellor, obtain access to a house where they have reasonable
ground to believe there is a patient restrained, and who ought to be under
certificate. But not only, in the first place, is it difficult to
ascertain where such patients are, but it is also difficult afterwards, as
we must have good testimony to induce the Chancellor to give us a right to
enter a private house, and make an examination accordingly." In reply to
queries 303, 304, 315, 318, 320 and 325, his Lordship insists on the
necessity of the law interposing to compel persons who receive any
patients whatever for profit, whether styled nervous or epileptic
patients, to give notice of their reception to the Commissioners in
Lunacy, who should have the power to visit and ascertain their state of
mind, and determine whether they should or should not be put under
certificate as lunatic. If they were found to be only 'nervous' persons,
the Commissioners would have nothing to do with them.
To give these suggestions a legal force, his Lordship produced the
following clauses as additions to the Lunacy Act (Evid. Comm. query 432,
p. 43):--
"Whereas many persons suffer from nervous disorders and other mental
affections of a nature and to an extent to incapacitate them from the due
management of themselves and their affairs, but not to render them proper
persons to be taken charge of, and detained under care and treatment as
insane; and whereas such persons are frequently conscious of their mental
infirmity, and desirous of submitting themselves to medical care and
supervision, and it is expedient to legalize and facilitate voluntary
arrangements for that object, so far as may be compatible with the free
agency of the persons so affected, be it enacted, as follows:--
"Subject to the provisions hereinafter contained, it shall be lawful for
any duly-qualified medical practitioner or other person, by his direction,
to receive and entertain as a boarder or patient any person suffering from
a nervous disorder, or other mental affection requiring medical care and
supervision, but not such as to justify his being taken charge of and
detained as a person of unsound mind. No person shall be received without
the written request in the form, Schedule --., to this Act, of a relative
or friend who derives no profit from the arrangement, and his own consent,
in writing, in the form in the same schedule, the signatures to which
request and consent respectively shall be witnessed by some inhabitant
householder.
"The person receiving such patient shall, within two days after his
reception, give notice thereof to the Commissioners in Lunacy, and shall
at the same time transmit to the Commissioners a copy of the request and
consent aforesaid. It shall be lawful for one or more Commissioners, at
any time after the receipt of such notice aforesaid, and from time to
time, to visit and examine such patient, with a view to ascertain his
mental state and freedom of action; and the visiting Commissioner or
Commissioners shall report to the Board the result of their examination
and inquiries. No such patient shall be received into a licensed house."
Lord Shaftesbury proceeds to say that by this plan "every person,
professional or not, who receives a patient into his house, or attends a
patient in such circumstances, should notify it to the Commissioners; but
we should not require them to notify it until after three months should
have elapsed, because a patient might be suffering from brain fever, or a
temporary disorder; but I would say that any person accepting or attending
a patient in these circumstances should notify it to the Commissioners,
after three months shall have elapsed from the beginning of the
treatment."
In the after part of his evidence (Query 921, p. 100), his Lordship
desired to supply an omission in the preceding clause, viz. to make it
compulsory on a medical man attending a nervous patient, and not only the
person receiving one, to communicate the fact to the Commissioners, so
that they might go and see him, and form their own judgment whether he
should or should not be placed under certificate.
There is much that is excellent in the clauses suggested, yet some
improvement is needed in their wording. Thus it is provided that a medical
practitioner, or a person under his direction, may receive a 'nervous'
patient, and the subsequent provisions are made in accordance with this
principle, as though only medical men could receive such patients, or that
they alone were amenable to the laws regulating their detention. Sir
Erskine Perry detected this oversight (Query 434), and Lord Shaftesbury
admitted the want of sufficient technicality in the drawing up of the
clause.
Again, we do not conceive there is adequate reason for postponing the
report of a case until three months after the commencement of the
treatment; a delay, not imposed, indeed, under the clause as propounded,
but implied in his Lordship's subsequent remarks. To refer to the class of
patients mentioned as properly exempt from a return to the Lunacy
Commission until after three months have elapsed:--a case of so-called
'brain fever' is not likely to be sent from home to board with a medical
man or other person during the existence of the acute malady commonly
known under that term. On the other hand, genuine cases of acute mania get
called by the same name, and such certainly ought to be reported to the
Commissioners before the expiration of three months. Besides, the delay to
notify 'temporary disorder' for so long a time is likely to be injurious
and to defeat the object of the clause. Delirium or mental aberration
lasting for three months is something more than a symptom of any one
commonly recognized bodily disease, and rightly deserves the designation
of madness; and, if this be the case, it also claims the supervision of
the Commissioners or other duly appointed officers over its management,
particularly when this is undertaken, with the object of profit to the
person treating it. Moreover, the delay proposed involves an idea not
flattering to the discernment and the powers of diagnosis of the members
of the medical profession; for its intent, we take it, is solely to
prevent giving unnecessary trouble and distress to all concerned, in
having to send a notification of the disorder, while yet unconfirmed, to
the Commissioners: an annoyance which ought never to happen; for every
medical man should be able to distinguish the delirium of fever, of
drinking, or of other corporeal conditions it is sometimes linked with,
from insanity; and it would be very discreditable to the medical skill of
any one not to find out the true nature of the case long before the
expiration of three months. Further, for the sake of promoting early and
efficient treatment, the notification of disorder, whether called
'nervous' or mental, should be given before the end of three months. The
change from home to board with a medical man may be all that is desired
for a 'nervous' patient; but if it be a case of recent insanity, something
more than solitary treatment at home or in a private lodging is essential.
The evils of the last-named plan are largely illustrated in the evidence
of Lord Shaftesbury himself, and of other witnesses before the Select
Committee. It is consequently desirable to have cases, under what
designation soever they are received, reported before the close of three
months, so that the Commissioners may see them and determine whether or
not the conditions under which they are placed are conducive to their
well-being and recovery, and may give their recommendations accordingly.
The proposition appended by the noble Earl, to the effect that every
medical man attending a 'nervous' patient should communicate the fact to
the Lunacy Commissioners, is most important, and in its scope approaches
that of enforcing a registration, as advocated by ourselves: for we
presume that his Lordship would desire the paragraph to be so worded, that
the notice should be demanded from the medical attendant, as well in the
case of a lunatic or alleged lunatic as in that of a so-called 'nervous'
patient.
A similar defect attaches to the clauses proposed as to those actually in
force under existing Acts; that is to say, the want of means of enforcing
them. By the Act 8th and 9th Vict. cap. 100, _sect._ xlv., it is made a
misdemeanour to receive or detain a person in a house without a legal
order and medical certificates; and by _sect._ xliv. it is declared a
misdemeanour to receive two or more lunatics into any unlicensed house.
These clauses are, however, valueless in preventing the abuses they aim at
checking; for, as so often said before, alleged and undoubted lunatics are
perpetually received by persons into their private houses as 'nervous'
patients, mostly without certificates, or, if under certificates,
unreported to the Commissioners.
No solid argument is conceivable, why a person having two lunatics under
charge should be liable to punishment for a misdemeanour, whilst another
may detain one with impunity. The penalty should be similar in each case.
The same legal infliction, too, should, we think, be visited alike upon
the friends putting away a relative under private care and upon the
individual receiving him. It might also be rendered competent for any
relative or friend to call upon those concerned in secluding, or in
removing the patient from home under restraint, to show cause for so
doing; and the production of the medical certificates and of a copy of the
notification sent to the Commissioners, with or without a certificate from
such an officer as we propose as a district medical inspector, should
serve to stay proceedings. The detention or the seclusion of a person,
whether at home or elsewhere, contrary to his will, and at the sacrifice
of his individual liberties and civil rights, appears to us tantamount to
false imprisonment, and an act opposed to the principles of English
liberty, whether it be perpetrated by relatives or strangers, if done
without the knowledge and sanction of the law and of its administrators.
But whatever amendments be introduced, we hold them to be secondary to a
complete system of registration of lunatics and 'nervous' patients
rendered compulsory upon the medical men attending them, or taking them
under their charge, and likewise upon the relatives, or, in the case of
paupers, upon the relieving officers or overseers of their parish. The
family medical attendant appears the most fitting person to make a return
of the sort: his professional knowledge must be called in to testify to,
or to decide on, the nature of the disease, and the fact can be best
communicated by him in his medical capacity. The Lunacy Commissioners of
Massachusetts had recourse to the physicians living in every town and
village of the State; and it was only by so doing that they were enabled
to arrive at an accurate knowledge of the number of the insane, and to
correct the statistics gathered through other channels, which might, at
first sight, have appeared ample to their discovery.
Further, as already noted, we advocate another step in conjunction with
registration; for we would convey the notification of the existence of the
alleged insane or nervous patient primarily to the district medical
officer, and then call upon this gentleman to visit the patient, with
every deference to family sensitiveness and necessary privacy, in order
that he may make a report on the nature and character of the malady, and
the conditions surrounding the patient, to the Commissioners in Lunacy.
The immediate visitation of a reported case by such a skilled officer
would be of advantage to the patient, to his friends, and to the
Commissioners. Without overruling or controlling the medical attendant or
others, his advice on the wants of the case would be useful, and he could
fulfil one purpose proposed to be effected by a visit from the
Commissioners, viz. that of signifying whether the patient should be
placed under certificates or not; his opinion being subject to revision by
the visiting Commissioners, should the nature of his report appear to them
to call for their personal examination of the case. If, again, medical
certificates were required, these might be countersigned by the district
officer in question, after a separate examination, and an additional
protection be thus applied against illegality in the legal documents
required to sanction the patient's restriction or detention. This plan
would likewise afford a check to the transmission to the Lunacy Board of
those insufficient certificates which at the present time involve such
frequent trouble. But, although the district officer's signature or
certificate might by its presence be held to increase the validity of the
evidence for a patient's insanity, yet its absence, where his opinion
differed from that of the medical men called in to sign the legal
certificates, should not operate as a bar to dealing with the alleged
lunatic as such, until an examination by one of the Board of Commissioners
could be had; and therefore the registrar should be bound to transmit the
order and certificates, when properly filled up, accompanied by his own
report of the case.
Supposing these provisions just sketched to be carried out, and that an
individual is found lunatic by his immediate medical attendants, by the
official registrar, a perfectly disinterested person, and, sooner or later
by the Commissioners, there certainly appears no reason why the lunatic
himself, or any officious friend or sharp lawyer in search of business,
should be able to challenge by legal proceedings a decision so cautiously
arrived at by so many competent persons. The determination of a trial by
jury we hold to be less satisfactory, and less likely to be in accordance
with fact; so easy is it in some instances for a clever counsel to
frighten witnesses, to get fallacious evidence, and to represent his
client's cause, and appeal to the passions of the jurors of very
miscellaneous mental calibre, often with more feeling than judgment, and
generally to use all those arts which are thought legitimate by the
practitioners of the law to win a verdict.
There is one subject well deserving notice; one which acts as a
stumbling-block to the treatment of mentally disordered persons, and will
also do so, more or less, to registration; viz. the present legal
necessity of placing all in the category of lunatics. The practical
questions are, whether this proceeding is necessary, and if not, whether
the present form of the order and medical certificates cannot be so
modified, as to lessen the objections of friends to place their suffering
relatives under the protection of the law and its officers; we should add,
to remove the objections of patients themselves; for it is irritating to
the minds of certain classes of the insane to know that they are accounted
lunatics by law equally with the most degraded victims of mental disorder
with whom they may find themselves associated; and it offers an impediment
at times, as those conversant with the management of asylums know, to
patients voluntarily submitting themselves to treatment.
The adoption of two forms of certificate, one for persons found to be of
unsound mind, and the other for the class of 'nervous' patients, would
undoubtedly involve some disadvantages. It would be the aim of all those
in a position to influence opinion, to obtain the registration of their
insane friends under the ambiguous appellation of 'nervous' patients; and
this could be met only by placing it in the power of an officer attached
to the Lunacy Commission to make the decision, after an examination of the
patient, respecting the nature of the certificate required. Perhaps the
examination to be made by a Commissioner, according to the scheme
propounded by Lord Shaftesbury (p. 161), is intended, though not said to
be so, to serve the purpose referred to; otherwise it would be a defect in
his Lordship's plan, that no person is empowered to discriminate the
individuals he would legislate for as 'nervous' patients not properly the
subjects for asylum treatment, from those mentally disordered persons who
are so.
Although the introduction of a modified or mitigated form of certificate
of mental unsoundness, besides the one now in use, may be open to the
objection mentioned, and to others conceivable, yet it would, on the other
hand, possess certain advantages, and would, among others, be certainly
an improvement upon the present state of things, by promoting the
registration of numerous cases now unknown to the administrators of the
Lunacy Laws.
It would be impossible to draw the line rigidly between really insane
persons and those suffering from temporary delirium, or 'nervousness.' No
ready cut and dried definitions of insanity would serve the purpose, and
the discrimination of cases in order to their return as 'lunatic,' or as
'nervous,' must within certain limits rest upon definitions imposed by
law, and beyond these to common sense and professional experience. With
such criteria to guide, no sufferers from the delirium of fever, of
alcoholism, or other kindred morbid state, and no eccentric personages
whose peculiarities are not necessarily injurious to themselves, to
others, or to their property, should be brought within the operation of
the laws contrived to protect positive mental disorder. They would not
occupy the same legal position as those classes proposed to be under one
or other form of certificate; for, in our humble opinion, all those under
certificate, whether as insane or as 'nervous' patients, should be under
like legal disabilities in the management of themselves and their affairs,
and partake of equal legal protection. In the preamble to the clauses
suggested by Lord Shaftesbury, the nervous disorder or other mental
affection is very properly supposed to be of a nature and extent to
incapacitate the sufferers from the due management of themselves and their
affairs; that is, that they are to be rightly placed under similar civil
disabilities with the insane;--a position, which could, moreover, not be
relaxed even in favour of those voluntarily placing themselves under
treatment, without giving rise to much legal perplexity and quibbling. But
this last-named result we have some apprehension might ensue, if the next
sentence of the clause to those quoted were retained: forasmuch as,
farther to define the class of persons to be legislated for, this sentence
requires that their disorder shall not render them proper persons to be
taken charge of and detained under care and treatment as insane; a
condition, which seems to exclude them from the catalogue of insane
persons in the eye of the law, and therefore to relieve them from the
legal disabilities attaching to lunatics; but, perhaps, it is from
ignorance of law that we cannot conceive how it is proposed to provide for
the care and official supervision of persons alleged to be incapacitated
from the management of themselves and their affairs, and at the same time
to pronounce them unfit to be dealt with as insane.
The Scotch Asylums Act (1857) contains a clause (41st) to authorize the
detention of persons labouring under mental aberration, in its earlier
stages, in private houses, under a form of certificate set forth in
Schedule G, wherein the medical man certifies that the individual in
question is suffering from some form of mental disorder, not as yet
confirmed, and that it is expedient to remove him from his home for
temporary residence in a private house (not an asylum), with a view to his
recovery. This plan of disposing of a patient is permitted to continue for
six months only. By some such scheme as this, it seems possible to bring
the sufferers from disordered mental power within the cognizance of the
public authorities appointed to watch over their interests, and at the
same time to rescue them from being classed with the inmates of lunatic
asylums, and from the frequently painful impression, in their own minds,
that they are publicly considered to be lunatics. To avoid disputes and
litigation, however, such patients should, even when under that amount of
surveillance intimated, be debarred from executing any acts in reference
to property, which might be subsequently called into question on the plea
of their insanity.
According to the present state of the law, there is no intermediate
position for a person suffering from any form of cerebral agitation or of
mental disturbance; he must be declared by certificate a lunatic, or his
insanity must be called 'nervousness.' Under the latter designation of his
malady, he cannot receive treatment in an Asylum or Licensed House; and
yet, all his acts in behalf of his own affairs, that is, where his friends
do not arbitrarily assume the power to act for him, may at any future time
be disputed as those of a lunatic. Yet, as noticed more than once before,
all the probable disadvantages of this anomalous position are risked in
very many cases, and the best chances of recovery thrown away, because the
friends (and the patient too very often) are unwilling to have him
certified as a lunatic. An alteration, therefore, of the law seems much
required in this matter. The Earl of Shaftesbury has met this want
partially by the clause he has proposed in favour of 'nervous' patients,
and his Lordship, in a preceding portion of his evidence (Queries
191-192), expressed himself in favour of mitigating the wording of the
medical certificates required. We have also heard Dr. Forbes Winslow
express sentiments to a similar effect, that the law ought to recognise
the legality of placing certain patients suffering from some varieties of
mental disturbance under treatment in licensed houses, and especially
those who will voluntarily submit themselves to it, without insisting on
their being certified as lunatics.
This is not an improper place in our remarks to direct attention to the
proposition to legalize the establishment of intermediate institutions, of
a character standing midway, so to speak, between the self-control and
liberty of home and the discipline of the licensed asylum or house, to
afford accommodation and treatment for those who would be claimants for
them under the mitigated certificates above considered. Such institutions
would be very valuable to the so-called 'nervous patients,' and to the
wretched victims of 'dipsomania'--the furor for intoxicating drinks; for
there are many advantages attending the treatment of these, as of insane
patients, in well-ordered and specially arranged establishments, over
those which can be afforded in private houses. It may likewise be added,
that the facilities of supervision by the appointed public functionaries
are augmented, and greater security given to the patients when so
associated in suitable establishments. We add this because, although the
certificates are mitigated in their case, and they are not accounted
lunatics, yet we regard that degree of visitation by the Commissioners,
indicated by Lord Shaftesbury, to be in every way desirable.
It is not within the compass of this work to enter into the details for
establishing and organizing these retreats: they have been discussed by
several physicians, and more particularly in Scotland, where, it would
seem, examples of drunken mania are more common than in England.
CHAP. IX.--APPOINTMENT OF DISTRICT MEDICAL OFFICERS.
Throughout the preceding portion of this book we have pointed out numerous
instances wherein the legal provision for the insane fails in its object
from the want of duly-appointed agents, possessing both special experience
and an independence of local and parochial authorities; and we have many
times referred to a district medical officer, inspector or examiner, as a
public functionary much needed in any systematic scheme to secure the
necessary supervision and protection of the insane, particularly of such
as are paupers. We will now endeavour to specify somewhat more precisely
the position and duties of that proposed officer; but, before doing so, we
may state that the appointment of district medical officers is not without
a parallel in most of the Continental States. In Italy there are
provincial physicians, and in Germany Kreis-Artzte, or
District-physicians, who exercise supervision over the insane within their
circle, besides acting in all public medico-legal and sanitary questions.
In our humble opinion, the institution of a similar class of officers
would be an immense improvement in our public medical and social system.
The want of public medical officers to watch over the health and the
general sanitary conditions of our large towns has been recognised and
provided for; although the machinery for supplying it is much less perfect
than could be wished: for to entrust the sanitary oversight and regulation
of populous districts to medical men engaged in large general practice,
often holding Union medical appointments, and rarely independent of parish
authorities, is not a plan the best calculated to secure the effectual
performance of the duties imposed; for, as a natural result, those duties
must rank next after the private practice of the medical officer, and
constitute an extraneous employment.
In the establishment of a class of district medical officers,--chiefly for
the examination, supervision and registration of all lunatics or alleged
lunatics and 'nervous' patients not in asylums, but placed, or proposed to
be placed, under surveillance, accompanied with deprivation of their
ordinary civil and social rights,--we would protest against the commission
of such an error in selecting them, as has, in our opinion, occurred in
the appointment of sanitary medical officers generally: for the
performance of the duties which would devolve on the district medical
officer, it would indeed be essential that he should be perfectly
independent of local authorities, that he should not hold his appointment
subject to them, and that his position among his professional brethren
should be such as to disarm all sentiments of rivalry or jealousy among
those with whom his official duties would bring him in contact. What
should be his position and character will, however, be better estimated
after the objects of his appointment are known.
The extent of the district assigned to this official would necessarily
vary according to the density of population; so that some counties would
constitute a single district, and others be divided into several. In the
instance of a county so small as Rutland, the services of a separate
district medical officer would hardly be required, and the county might be
advantageously connected with an adjoining one.
One principal purpose of his office would be to receive notice of every
case of insanity, of idiocy, or of 'nervousness' (as provided for by Lord
Shaftesbury's proposal), and to register it; the notice to be sent to him
by the medical attendant upon the patient. Upon receiving such notice, he
should forthwith, except under certain contingences hereafter indicated,
visit the case, and determine whether it should be rightly placed under
certificates as one of lunacy, or as one of 'nervous' disorder, amenable
to treatment without the seclusion of an asylum; and should transmit the
result of his examination and the report of the case to the Lunacy Board.
It might supply an additional protection to the lunatic, and be
satisfactory otherwise, if the signature of this officer were required to
the original certificates (see p. 165) before their transmission to the
central office in London.
The return made by the district medical officer to the Commissioners in
Lunacy would be of much service to them in determining their future course
with reference to the visitation of the patient (in carrying out Lord
Shaftesbury's proposal, p. 161), supposing him to be detained at home, or
in lodgings with strangers, instead of being transferred to an asylum or
licensed house. So again, if the patient were removed to an asylum, he
would furnish a report of his history and condition to the physician or
proprietor, and thereby render a valuable service, particularly in the
case of paupers, of whom next to nothing can frequently be learnt from the
relieving officers who superintend their removal to the County Asylum. The
want of a medical report of cases on admission is, in fact, much felt and
deplored by medical superintendents; and, since it is proposed that the
district officer should visit the patient at his own home, or, in
exceptional cases, elsewhere, and inquire into his mental and bodily
state, and into the history of his disorder, before his removal to the
asylum, and as soon as possible after the onset of the attack, he would be
well-qualified to render a full account of his case.
We have spoken of a notice of idiots within his district being sent to the
district inspector, and of his duty to register them. This matter we
regard as certainly calling for attention, for, as remarked in a previous
page (p. 149), idiots need be submitted to appropriate educational and
medical means at an early age to derive the full benefits of those
measures; and among the poor, they certainly should not be left uncared
for and unnurtured in the indifferent and needy homes of their friends,
until, probably, their condition is almost past amelioration.
Again, with reference to the transmission of pauper lunatics to county
asylums, we are disposed to recommend that the order for it be signed by
the district medical officer, without recourse to a justice, in those
cases where he can visit them, and in comparison of which indeed others
ought to be exceptional. Where, for instance, by reason of the remoteness
of the patient's home, or of the workhouse or other building wherein he is
temporarily detained, the district medical officer's visit could not be
specially made except at great cost, the removal of the patient to the
asylum might be carried out under the order of a magistrate, and the
examination made by the district officer, as soon after his reception as
possible; or better, at his own residence, which ought to be in a town not
far from the county asylum.
We advocate the delegation of the authority to the district officer to
make an order in lieu of a justice, on the production of the legal medical
certificate required, because we consider him much better qualified to
administer that portion of the lunacy law, particularly as that law at
present stands, which puts it in the power of a justice to impede the
transmission of a lunatic for treatment, if, in his opinion, the patient's
malady do not require asylum care: and it is a fact, that the clause
permitting a justice this influence over a patient's future condition is
often exercised; at times, contrary to the decided advice of medical men,
and to the detriment of the poor patient. Lord Shaftesbury refers to such
an occurrence in his evidence (_op. cit._, query 846). Having in view
private patients especially, his Lordship remarks that nothing could be
worse than to take them before a magistrate: "there would be a degree of
publicity about it that would be most painful ..., and to have the matter
determined by him whether the patient should or should not be put under
medical treatment. In ninety-nine cases out of one hundred, the magistrate
knows little or nothing about the matter. A case occurred the other day of
a poor man who was taken before a magistrate, and he refused to certify,
because the man was not in an infuriated state. 'A quiet person like him,'
he said, 'ought not to be put into an asylum; take him back.' He was in a
low, desponding state, and if he had been sent to a curative asylum, he
might have been cured and restored to society."
Mr. Gaskell also adds his evidence to that of the noble chairman of the
Board, in reply to query 1385 (_op. cit._ p. 133) put by Sir George
Grey:--"Is the magistrate to be quite satisfied on the evidence that the
pauper is a proper person to be taken charge of in the county asylum?" Mr.
Gaskell replies, "Yes, as I said, on the medical gentleman giving a
certificate. Then it is his duty to make an order, and if he is not
satisfied by his own examination, or the medical evidence is not
sufficient to justify the order, he declines. I am sorry to say that they
frequently do."
It is also to be remembered that the existing law allows the justice's
order to be dispensed with, if it cannot be readily obtained, or if the
patient cannot be conveniently taken before him, and admits as a
substitute an order signed by an officiating clergyman and an overseer or
a relieving officer, upon the production of a medical certificate.
Moreover, by the interpretation clause, the chaplain of a workhouse is to
be deemed an officiating clergyman within the meaning of the Act. Now,
these conditions seem to us to frustrate the undoubted intent of the law
in requiring a magistrate's order, viz. to guard against the unnecessary
detention of an alleged lunatic; for they place the liberty of the pauper
entirely in the hands of parish officers and paid servants, who will
naturally act in concert; and it is conceivable that workhouse authorities
might be anxious to get rid of a refractory pauper, and could together
with the relieving officer influence in a certain degree the opinions and
sentiments of the salaried chaplain and medical officer, in order to
sanction his removal to the county asylum.
We have, indeed, in previous pages (p. 91, _et seq._), shown that unfit
and occasionally non-lunatic patients are sent to asylums; but, even did
such an event never happen, we should still hold that the protection to
the alleged lunatic intended by the requirement of an order signed by the
officials designated, is very little worth, and would be advantageously
replaced by the order of a district medical officer appointed and
authorized by the scheme we propose. It is also worthy of note, that
patients sent to asylums under the order of the chaplain and relieving
officer feel themselves sometimes much aggrieved that no magistrate or
other independent authority has had a voice in the matter. They regard the
relieving officer or the overseer, as the case may be, to be directly
interested in their committal to the asylum, and only look upon the
chaplain of the union as a paid officer, almost bound to append his
signature to any document matured at the Board of Guardians, when called
upon to do so. Moreover, they can recognise in him, in his professional
capacity as a clergyman, no especial qualifications for deciding on the
question whether they are proper persons to be confined on the ground of
their insanity. This remark, too, extends to every other clergyman called
upon to act in the matter. Nay, more, there is another more potent
objection at times to a clergyman signing the order; viz. when the patient
is of a different faith, or when perhaps animated by strong prejudices
against the clergy of the English Church, and when, consequently, it is
possible for him to imagine himself the victim of religious persecution or
of intolerance.
Even Lord Shaftesbury, who is so identified with the interests of religion
and of its ministers, manifests no disposition to entrust to the clergy
the interests of the insane. In reply to the query (No. 838, Evid. Com.),
whether he would desire ministers of religion to pronounce on the fitness
or unfitness of persons for confinement as of unsound mind, he replies, "I
should have more distrust of the religious gentleman than I should have of
the medical man; and I say that with the deepest respect for the ministers
of religion. The difficulty of it would be incalculable, if you were to
throw the duty on the parochial clergy in the neighbourhood, who are
already overburdened."
In truth, there is no more reason for assigning to the clergy the
determination of the question of sanity or insanity of an alleged lunatic,
than for entrusting it to any other respectable and educated class of
society. We have seen that magistrates sometimes exercise their privilege
of deciding the question in an arbitrary and injudicious manner, and it is
permissible to suppose the clergy not to be always in the right in
exercising the same function. Indeed, we have at least one instance on
record that they are not, in the Supplement to the Twelfth Report of the
Commissioners in Lunacy; viz. in the case of an epileptic woman, subject
to paroxysms of dangerous violence and destructiveness,--such as are
common to the epileptic insane in asylums, and reported by the master of
the workhouse "as unsafe to be associated with the other inmates. For
these offences she had been subjected to low diet, restraint, and
seclusion, and on three occasions had been sent to prison. The medical
officer of the workhouse considered her of unsound mind, not fit to be
retained in the workhouse, and improperly treated by being sent to prison.
In March 1856, and February 1857, he had given certificates to this
effect, and steps were taken to remove her to the asylum. When taken on
those occasions, however, before the vicar of the parish, he refused to
sign the order, and she was consequently treated as refractory, and sent
to prison."
Taking the foregoing remarks into consideration, the only circumstances
under which we would call upon an officiating clergyman, not being the
chaplain of the Union, to make the order, would be where no magistrate
resided in the neighbourhood, and where, from the remoteness of the
locality, the district medical examiner could scarcely be expected to
visit the individual case,--an event that would be of rare occurrence in
this country.
There are indeed cases, such as of acute mania, where the justification of
the confinement of a lunatic, by the order of a magistrate or clergyman,
is a mere formality, and might be altogether dispensed with, and all legal
protection guaranteed by the medical certificate, and an order signed by a
parish officer to authorize the asylum authorities to receive the patient
at the charge of the parish sending him. But if this were objected to,
then assuredly the examination of the lunatic immediately upon or just
before his admission into the asylum by the district medical officer,
would supply every desideratum in the interests of the patient, and such
an examination would, according to our scheme, be always made at this
stage of the patient's history.
Lastly, let it be remembered that a magistrate's order is not required for
the admission of a private patient into an asylum or licensed house. A
relative or friend may sign the order and statement, and the alleged
lunatic is thought to be sufficiently protected by the two medical
certificates. Now, were a magistrate's or a clergyman's order any real
security against the commission of a wrong to an individual, it would be
much more necessary in the instance of private patients possessing
property, and whose confinement might serve the interests of others, than
in the case of paupers, for whose confinement in an asylum no inducement,
but rather the contrary feeling, exists. In fact, the confirmation given
to the propriety of placing a pauper lunatic in an asylum by the district
medical officer, as proposed, might be considered supererogatory,
considering that a certificate is required from the superintendent of the
asylum shortly after admission, had it no other purpose in view.
According to the proposition advanced by us, an experienced opinion by an
independent authority would be obtained in lieu of one formed by an
inexperienced magistrate (who would generally prefer escaping an interview
with a madman, mostly act upon the medical opinion set forth, or if not,
be very likely to make a blunder in the case), or of one certified by two
inexperienced, paid, and therefore not sufficiently independent, workhouse
functionaries.
The clause proposed by the Commissioners (Supp. Rep. 1859, p. 37), "that
the medical officer of the workhouse shall specify, in the list of lunatic
inmates kept by him, the forms of mental disorder, and indicate the
patients whom he may deem curable, or otherwise likely to benefit by, or
be in other respects proper for, removal to an asylum," is virtually
unobjectionable; but, with due submission, we would advocate that, whether
with or without this list and those expressions of opinion, the District
Medical Officer's Report should be considered the more important document
whereon to act. The evidence given before the late Committee of the House
of Commons (1859) shows that we must not expect much book-keeping or
reporting from the parochial medical officers, and that many
misconceptions and erroneous views prevail, and will damage results
collected from them. The Union medical officer will necessarily have his
own opinions respecting the nature and prospects of the lunatics under his
observation, and no great objection can be taken to his recording them, if
thought worth while: yet they would be sure to be given, even without any
legal requisition; and might often help, when privately expressed, the
District Examiner in his inquiries; and it would, besides, be better to
avoid the chances of collision between the written opinions of two
officers who should work together harmoniously.
Also, in the instance of private patients to be placed in an asylum,
licensed house, or elsewhere with strangers, we look upon the visitation
and examination of such a medical officer as we suggest as a valuable
additional protection and security to them. He would constitute an
authority in no way interested in the detention, and, by the nature of his
office, bring to bear upon any doubtful cases an unusual amount of special
knowledge and experience. We cannot help thinking that such a functionary
would be much more efficient and useful than a magistrate (to whom some
have proposed an appeal), as a referee to determine on the expediency of
placing a person under certificate as of unsound mind.
Another class of duties to devolve on a district medical officer comprises
those required to watch over the interests and welfare of pauper lunatics
sent to, or resident in, workhouses. At p. 73, we have advanced the
proposition, that, in future, no alleged lunatics should be removed to a
workhouse, except as a temporary expedient under particular conditions,
such as of long distance from the asylum or unmanageable violence at home;
and that in all cases a certificate to authorize any length of detention
in a workhouse should emanate from the district medical officer. The
object of this proposal is to prevent the introduction of new, and
particularly of acute cases of insanity, into workhouses; for, as we have
shown in the section 'on the Detention of Patients in Workhouses' (p. 40,
_et seq._), the tendency is, when they are once received, to keep them
there. According to our scheme, the district officer would receive notice
of all fresh cases from the medical practitioner in attendance upon them,
and, in general, visit them at their homes before removal to the workhouse
or elsewhere. With respect to the actual inmates of the workhouse, it
would be equally his duty to ascertain their mental and bodily state, to
suggest measures to ameliorate their condition, and to report on those
whom he might consider fit for removal either to the County Asylum or to
lodgings out of the Union-house. He would make his report both to the
Committee of Visitors of the workhouse, hereafter spoken of, and to the
Lunacy Commissioners. It should devolve primarily upon the Committee to
act upon the reports, or, on their omission so to do, the Commissioners in
Lunacy, either with or without a special examination made by one or more
of their number, should be empowered to enforce those changes which might
in their opinion be absolutely necessary.
Again, by Suggestion 5 (p. 73), we provide that no person shall be
detained as a lunatic or idiot, or as a person of unsound or weak mind,
except under an order and a medical certificate to the existence of mental
derangement, just such as is needed to legalize confinement in an asylum.
The order would best come from the District Medical Examiner, whilst the
certificate would, as usual, be signed by the Union medical officer.
Now, by one of the propositions contained in the Supplementary Report of
the Commissioners in Lunacy (1859, p. 37), it is sought to render a
similar protection by another expedient; viz. that the alleged lunatic
"shall be taken before a justice or officiating clergyman, and adjudged by
him as not proper to be sent to an asylum." By the next paragraph, it is
further proposed that, "In any case wherein an order for a lunatic's
reception into an asylum shall be made by a Justice or officiating
clergyman, it shall be competent for him, if, for special reasons, to be
set forth in his order, he shall deem it expedient, to direct that such
lunatic be taken, _pro tempore_, to the workhouse, and there detained for
such limited period, not exceeding two clear days, as may be necessary,
pending arrangements for his removal to the asylum."
Now, with all becoming deference to the position and experience of the
Commissioners, we must confess to a predilection for our own plan, which,
indeed, was drawn out before the appearance of the Supplemental Report.
This preference we entertain for the reasons shown when speaking of the
relative qualifications of magistrates and clergymen to make the order for
admission into asylums; viz. that on the one hand there are no à priori
grounds for supposing their discrimination of insanity, and of its wants
and requisite treatment, to be better than that of other people; that some
direct objections attach to clergymen, and that experience proves that
neither Justices nor clergymen have hitherto so performed the duty as to
afford any inducement to increase its extent; and, on the other, that in
the district medical officer we have an independent and skilled person to
accomplish the work.
Nevertheless the suggestion offered by the Commissioners is a great
improvement upon the practice in vogue, which leaves the determination of
the place and means of treatment, and of the capability of a patient to be
discharged or removed, to the parish authorities. On this matter we have
commented in previous pages, and illustrated at large in the history of
the condition of the insane in workhouses, or boarded with their friends
outside.
By suggestion 4 (p. 73), we propose that no lunatic or other person of
unsound mind in a workhouse should be allowed to be discharged or removed
without the sanction of the district medical officer. This proposition we
regard as of great importance; for we have seen (p. 90, _et seq._) with
what recklessness, contempt of common sense, and cruelty, poor lunatics
are removed from workhouses to asylums under the operation of existing
arrangements. Again, some directing, experienced and independent authority
is needed (p. 89) to overrule the removal of imbecile and other inmates to
the houses of their relatives or of strangers; to indicate the cases to be
sent, and to examine the accommodation, and ascertain the character and
fitness of the persons offering to receive them. These functions also we
would delegate to the district medical officer. Once more, imbecile,
partially idiotic, and occasionally patients more rightly called lunatic,
are sent away, or allowed to discharge themselves from, the workhouse,
with the sanction of the authorities of the House and of the Guardians.
The terrible evils of this proceeding are alluded to at p. 77, and more
fully entered into in the Commissioners' Supplementary Report (1859), and
in the evidence before the Committee on Lunatics (1859, Queries
1594-1596). The district medical officer would here again come into
requisition, and, under a distinct enactment of the law, resist the
discharge, unless satisfied that the relatives of the disordered or
imbecile paupers, particularly when females, could afford proper
supervision and accommodation, and exercise due control over them.
The sixth suggestion we have made (p. 73) contemplates the visitation of
lunatics in workhouses, not only by the Lunacy Commissioners, as
heretofore, but also by a Committee of Magistrates, and the district
medical officer.
The powers committed to the Lunacy Commissioners by existing Acts to
inspect workhouses are very inadequate and unsatisfactory; for, as the
Commissioners observe, they can make recommendations, but have no
authority to enforce attention to them, and the only course open to them
is, to get their views represented through the medium of the Poor Law
Board; and, although this Board co-operates most readily in their
recommendations, yet it has no positive power to enforce them. The result
is, the Commissioners find that the circuitous and troublesome proceeding
to which they are restricted renders their endeavours in behalf of
workhouse lunatics almost nugatory.
To rectify this objectionable state of things, the first principle to be
recognised is, that the Lunacy Board shall be charged with the custody of
all lunatics, whose interests it shall watch over and have the necessary
power to promote, however and wherever they may be found. It should not
have to exercise its authority, to enforce its orders and regulations,
through the medium or by the agency of any other Board. No competing
authority should exist. All lunatics should be reported to the
Commissioners; all should be subject to their visitation, or to that of
any assistants appointed under them; and the power of release should be
lodged in their hands in respect of all classes of patients when they see
reason to exercise it. In the instance of pauper lunatics in workhouses,
they should be able to interpose in their behalf, to require every
necessary precaution to be taken for their security, and due accommodation
and treatment provided.
The district medical officer would be their local representative; would
make frequent inspections, and report to them and act under their
direction. He would indeed be responsible to them in all duties connected
with the interests of the insane.
We have (p. 73) proposed a Committee of Visitors of Workhouses, for each
county or for each division of the county, selected from the magistrates
and from the respectable classes of ratepayers, not being guardians or
overseers, although chosen with a view to represent parochial interests.
This Committee should visit, at least once a quarter, every workhouse
containing a person of unsound mind or an idiot, in the district under its
jurisdiction; and it would be desirable that the district medical
inspector should visit in company with the Committee, besides making other
visits by himself at other times.
We are happy to find that this suggestion tallies in general with one made
by the Commissioners in Lunacy in their recent Supplementary Report, as
well as with the views of Dr. Bucknill. But we conceive it rather a defect
in the Commissioners' scheme that they propose that "the Visiting
Commissioner and the Poor Law Inspector be empowered to order and direct
the relieving officer to take any insane inmate before a Justice, under
the provision of the 67th Section of the Lunatic Asylums Act, 1853." For,
according to the principle enunciated in the last page, the Lunacy
Commissioners, as the special guardians of the insane, should alone be
concerned in the direct administration of the Laws of Lunacy, and on this
ground we object to the power proposed to be conferred on the Poor Law
Inspectors; and we take a further objection to their being called upon to
form an opinion respecting the lunatics who require Asylum treatment, and
those who do not. There is truly no impediment, in the abstract, to their
forming an opinion; yet, on the other hand, we would not have them to act
upon it, but desire them to report the circumstances falling under their
notice to the Lunacy Commissioners, who would thereupon examine into them,
and decide on the steps to be taken. By the plan, however, which we have
drawn out, and by the functions proposed to be entrusted to the district
medical officer, the whole clause last discussed would be rendered
superfluous.
The seventh suggestion (p. 73) submitted to consideration is, that every
workhouse containing lunatics should, under certain necessary regulations,
be licensed as a place of detention for them, by the Committees of
Visitors of Workhouses when situated in the provinces, and by the Lunacy
Commissioners when in the metropolitan district, and that the licence
should be revoked by the Committees, after reference to the Lunacy Board,
in the case of workhouses licensed by them, and by the Commissioners
solely in the instance of any workhouse whatever. This plan confers the
requisite power on the Commissioners to control the accommodation and
management of workhouse wards for lunatics, and resembles the one pursued
at present with regard to asylums. It would likewise permit them to order
the closure of lunatic wards, and the removal of all lunatics from a
workhouse, when they were persuaded that proper Asylum or other
accommodation was available for the insane inmates.
Whatever course they adopted, or whatever decision they arrived at on such
matters, they would be chiefly guided by the results of the inspection and
the reports thereon made by the district medical officer, and further
established by their own visitation. The present number of Commissioners
is far too small for them to visit each workhouse even once a year; and,
if our views respecting the necessity of a complete examination of every
one of such institutions, at least four times a year, be correct, it would
still be impossible to get this work done by them, even though their
number was trebled; therefore, as just said, the inspection made by the
district medical officer would afford the chief materials for their
guidance in dealing with workhouse lunatics, and save them an immense
amount of labour.
Our eighth suggestion (p. 73) is to the effect that all lunatics in
workhouses should be reported to the Lunacy Commissioners, and that this
should be done by the district medical officer (p. 97). The number, age,
sex, form and duration of malady, previous condition in life and
occupation, and all particulars touching the mental and bodily condition
of the patients, would be thus duly registered. The advantages of such a
system of reporting are obvious, and, as this branch of the district
officer's work has partially come under notice before, it need not be
enlarged upon here.
The law provides for the occasional visitation of pauper lunatics in
asylums chargeable to parishes, by a certain number of the officers, and
among them the medical officer of the parish to which, as paupers, they
are chargeable; and something, by way of remuneration for their trouble,
is allowed out of the funds of the union or parish. This arrangement keeps
up a connexion between a parish and the lunatics chargeable to it in the
county asylum, which in various respects is desirable, and probably
satisfactory to the ratepayers. But the lunatic inmates of an asylum
chargeable to the county do not receive the benefit of any such wise
provision: when once in the asylum, they find none interested in their
condition save the staff of the asylum, its visitors, and the
Commissioners. The last-named, in their annual visit, can have no time to
consider them apart,--not even to discover and distinguish them from the
rest. Very many of them are foreigners, and their condition is
consequently more deserving commiseration, as being, most likely, without
friends, to interest themselves in their behalf. If the inquiry were made
of the superintendents of county asylums, we believe it would be found
that the omission of the law in providing for the more immediate watching
of these poor lunatics is attended with disadvantages and injuries to
them. To supply this want, we are disposed to recommend the district
medical inspector as their special visitor; for he would be identified, on
the one hand, with the county in which his duties lie, and, on the other,
with the Lunacy Board, in such a manner as to be able to lay before it, in
the readiest and best manner, any circumstances respecting these county
pauper lunatics which it might seem desirable to report, and, when they
were foreigners, to bring about a communication with the Foreign Office,
and secure their removal to their own country.
The visitation of these lunatics would rightly entitle the district
officer to remuneration, which might be the same as that now paid per head
for the visitation of out-door pauper lunatics, viz. half-a-crown per
quarter. This amount would be payable by the county to which the patients
were chargeable, and would add to the fund applicable for the general
purposes of the Lunacy Board.
The Supplementary Report of the Lunacy Commissioners (1859, p. 13-14)
contains some observations relative to the decision, in the instance of
workhouse inmates, of the question who among them are to be reckoned as
"Lunatics, Insane Persons, and Idiots" on the parish books? It is at
present a task left to the guardians, the master, or to the parish medical
officer; but the Commissioners rightly recommend that it should be
entrusted to the last-named officer. However, we should prefer to see the
duty delegated to the district medical inspector, as better qualified, in
general, by experience, and, what would be of more importance, as being
independent of parochial functionaries: for the duty is a delicate and
responsible one; and, the disposition of guardians being economical where
money is to be expended on the poor, they always desire to escape the
heavier charge entailed by lunatics, and, where they can manage it, are
pleased to witness the discharge of imbecile paupers, and of others more
correctly called insane, whom they may choose for the time to consider as
sane enough to be at large. The difficulties besetting this question of
determining what paupers are to be considered insane, and what not, is
remarked upon by the Scotch Lunacy Commissioners in their
recently-published First Report (1859), and was referred to in the English
Commissioners' Report for 1847 (p. 239 & p. 257). The enormous evils
attending the present loose mode of deciding the question are sketched in
the Supplementary Report quoted, and in previous pages of this book.
We now come to the duties of the district medical officer in reference to
the pauper insane not in workhouses or asylums, but boarded with
relatives or strangers: as, however, we have, treated of them at some
length in the section on the condition of those lunatics (p. 83, _et
seq._), we will refer the reader back to that portion of the book. Suffice
it here to say, that the district medical officer is very much needed as
an independent and competent functionary to supervise and regulate the
state and circumstances of this class of poor patients. He should visit
every poor person wholly or partially chargeable, or proposed to be made
chargeable, to the parish, as being of unsound mind (p. 84), and make a
quarterly return to the parochial authorities and to the Lunacy Board (p.
87). He should also take in hand the selection of the residence and the
examination into the circumstances surrounding the patient (p. 89).
If the scheme of boarding the pauper insane in the vicinity of the county
asylums, in cottage-homes (see p. 90, and p. 145), were carried out, the
extent of the duties of the district inspector would be much curtailed,
inasmuch as a majority of such lunatics would fall within the sphere of
the asylum superintendents in all matters of supervision.
The subsequent publication of the "Evidence before the Select Committee on
Lunatics," 1859, enables us to refer the reader to other illustrations of
much weight, to show the pressing demand for an efficient inspection of
single cases, and for securing satisfactory returns of their condition,
particularly when paupers. The necessity for inspection is proved by Lord
Shaftesbury's exposure of the wretched state of single patients (at p. 33,
_et seq._), and the want of returns by the evidence of Mr. Gaskell (p.
134, _et seq._). The passages bearing on these points are too long for
quotation at this part of our work, and are very accessible (Blue Book
above-mentioned) to every reader desirous of seeing other evidence than
that adduced in preceding pages.
The appointment of the district medical officer would have this further
benefit with reference to out-door pauper lunatics, that it would set
aside discussions respecting the persons who should receive relief as
such; a circumstance, upon which turns, as noticed before (p. 84), the
question of the quarterly payment of two shillings and sixpence for each
lunatic visited. The district officer would possess an entire independence
of parish officials, and could not be suspected of any interested motive
in making his decision. In undertaking the inspection of this class of
pauper lunatics, he would certainly displace the parish medical officers,
and the small fee payable to these last would fall into the treasury of
the Lunacy Board; yet the loss to an individual union medical officer
would be scarcely appreciable; for the number of lunatics boarded out in
any one parish or portion of a parish coming under his care, would, in
every case, be very small; whilst, on the other hand, the sum in the
aggregate paid into the hands of the Commissioners, on account of all such
patients in the kingdom, would,--supposing, for example, our estimate of
8000 to be tolerably correct,--form a not inconsiderable sum; taking the
number mentioned, it would amount to £4000 per annum,--a useful
contribution to the fund for meeting the expenses of district medical
inspectors, and sufficient to pay the salary of eight such officers. But
the fee might be doubled without being burdensome to any parish.
Although the Commissioners in Lunacy might occasionally visit private
lunatics in their own homes, and more especially those boarded with
strangers, yet it would be impossible for them, even if their number were
doubled, to exercise that degree of supervision which is called for. This
would particularly be the case, were the system of registration, or of
reporting all persons under restraint on account of mental disorder or
mental weakness, carried out; and the only plan that appears for securing
the desired inspection of their condition, and of the circumstances and
propriety of their detention, is that of imposing the duty upon the
district medical officer. We have already suggested that this officer
should see all such cases when first registered; by so doing, he would be
brought into contact with the patients and their families, and would, as a
county physician, also constitute a less objectionable inspector than even
the Commissioners themselves in their character as strangers and as
members of a public Board.
The medical inspector's visit should be made at least four times a year,
and a moderate fee be paid on account of it to the general fund of the
Lunacy Board. If it were only half-a-guinea per quarter for each patient,
it would produce a considerable sum available for the purposes of the
Commission.
There is yet one other duty we would delegate to the district medical
officer, viz. that of visiting the private asylums not in the metropolitan
district, in company with the Committee of Visiting Justices, who,
according to the requirement of the present law, must join with themselves
a physician, in making their statutory visits. We conceive that the
assistance of such a physician as we would wish appointed in the capacity
of district medical officer, would render the magisterial visits more
satisfactory, and establish a desirable connexion between the Visiting
Justices and the Lunacy Board. We do hear, at times, of a species of
rivalry or of opposition between the visitors of private asylums and the
Commissioners, to the detriment of proprietors. If such an evil prevails,
one means of checking it would, we believe, be found in the position and
authority of the district medical officer when called on, as suggested, to
act as the visiting physician with the magistracy as well as the local
representative of the Commissioners in Lunacy.
On reviewing the duties to be undertaken by a district medical officer,
the propriety of the remarks with which we began this chapter will
appear:--viz. that he should occupy as independent a position as possible;
that, as a medical man, he should be free from all sentiments of rivalry,
and therefore not be engaged in practice,--or at least not in general
practice. It would be much better that he should not practise at all on
his own account, but should be so remunerated that he might devote all his
time and attention to the duties of his office.
He should receive a fixed annual stipend, and not be dependent on fees. By
this course, he could not be accused of having any interest in the
seclusion of the insane under his supervision. So, again, in order to
confer on him the necessary independence in the discharge of his duties,
his appointment should be made by the Lunacy Board with the concurrence of
the Home Secretary or of the Lord Chancellor,--not by the magistrates, nor
by any parochial authorities. It should also be a permanent appointment,
held during good behaviour, and revocable by the Commissioners only, after
an investigation of any charges of misconduct, and upon conviction.
The acquisition of the services of suitable and competent medical men
might be started as a difficulty in carrying out our scheme; yet it is
really of so little moment that it scarcely needs discussion. The
development of the country perpetually opens up new offices and creates a
demand for fitting men to fill them; but, by the law of political economy,
that where there is a demand there will be a supply, individuals rapidly
come forward who are adapted, or soon become adapted, to the new class of
duties. And so it would be on instituting the post of district medical
officer in each county or division of a county; for it is to be remembered
that the rapid extension of asylums has raised up a class of medical
practitioners specially conversant with the insane; so that, when a
vacancy occurs in any one such institution, qualified candidates spring up
by the dozen, and the difficulty is, not to find a suitable man, but to
decide which of many very suitable applicants is the most so. Moreover,
the anxiety, the mental wear and tear, and the greater or less seclusion
of an asylum superintendent's life, are such, that his retirement after
some fifteen or twenty years' service is most desirable, although his age
itself may not be so far advanced but that many years of active usefulness
are before him: to many such a retired superintendent, the post of
district medical inspector, even at a very moderate salary, would be
acceptable, whilst its duties would be most competently performed by him.
Our business has been to point out wherein a necessity appears for the
appointment of a district medical officer in the interests of the insane,
and to indicate, in general, the duties which would devolve upon him in
regard to them; but we may be allowed to hint at another set of duties
which, we are of opinion, might most advantageously be allotted to him,
and afford an additional argument in favour of creating him a public
servant, so paid as legitimately to demand his withdrawal from private
medical practice. The duties we mean are in connexion with medico-legal
investigations in cases of sudden and of violent death, of criminal
injuries, and of alleged lunacy; duties, by the way, which are exercised
by the district or provincial physicians in Continental States. We should,
by such an arrangement, obtain the services of a medical man expert in all
those inquiries and trials which come before the coroner's court and the
higher courts of law; we should obtain a skilled and experienced
physician, occupying a position perfectly independent of either side, in
any trial or investigation where a medical opinion or the result of
medical observation was called for. Medical witnesses, in a legal inquiry,
are not unfrequently blamed, and still oftener criticized, and perhaps
unfairly so, by their professional brethren, respecting the manner in
which they may have made an autopsy, or conducted the examination in other
ways, touching the cause of death, or an act of criminal violence; and
they are always exposed to the rivalry of their neighbours; and wishes
that some skilled individual had been sent for in their stead to conduct
the investigation, find their way into the public papers. Again, it should
be remembered that a medico-legal inquiry is an exceptional event in the
practice of most medical men: they bring to it no particular experience,
and generally they would much prefer to escape such investigations
altogether, as they seriously interfere with their ordinary avocations,
and obtain for them no adequate remuneration. Yet withal, the plan
proposed would far from entirely prevent their being engaged in the
subjects comprehended in the term 'Medical Jurisprudence,' or deprive them
of fees. As the actual practitioners of the country and always near at
hand, they would be the first sent for in any case, the history or
termination of which might involve a judicial inquiry; whilst, on the
other hand, the district medical officer would have to be summoned and
would act in the case only as the representative of the public interests
and of the public security. Lastly, the district medical officer in the
discharge of his duties would not render the services of special medical
jurists unnecessary; the chemist, for instance, would be as important in
his special calling as he is at the present time, wherever death by
poisoning was suspected.
It would be beside our purpose in this treatise to enlarge upon the
medico-legal duties which would devolve on the district medical officer in
the position in which we would place him, or on the benefits that would
accrue from his labour to public justice, and to the interests of the
State. Reflection upon the plan will, we believe, convince any reader, who
knows how matters now are, that it would lead to an immense improvement.
It appears to be a feature of our countrymen, both in public and private
affairs, that they will avoid, as long as possible, recourse to a system
or to a plan of organization; they seem to prefer letting matters go on as
long as they will in their own way, and only awake to a consciousness that
something is wanting when errors and grievances have reached their
culminating point, and a continuation in the old course becomes
practically impossible. Then, when the evil has attained gigantic
dimensions, when much injury has been inflicted, and an enormous waste in
time and money has occurred, committees of inquiry and special
commissioners are hastily appointed, a sort of revelry indulged in the
revelations of past misadventures and past folly and neglect; and some
scheme is seen to be imperatively necessary, the costliness of which must
be endured; and, perhaps, the conviction all at once arises, that the cost
of the needed plan of organization, which can be estimated, is in fact
much less than what has been submitted to, without attempting an estimate,
for a long time before.
We lag behind most countries on the Continent in our state medical
organization; our individual instruments are better, yet they are not
co-ordinated in any general system. We trust that this has been in some
measure shown in the preceding pages, and that it has been made out, that
if the insane, and more particularly those in private houses and those who
are paupers, are to be efficiently looked after, and their protection from
injuries and their proper care and treatment secured, some such scheme as
we have indicated is now called for. Surely evils have sufficiently
culminated, when at least one-half of the insane inhabitants of this
country have either no direct legal protection, are unknown to the
publicly-appointed authorities under whose care they ought to be, or are
so situated that their protection and their interests are most
inadequately provided for.
Did not a necessity for an improved and extended organization on behalf of
the interests of the insane exist, the plea of its cost would probably
defeat an attempt to establish it, notwithstanding the plainest proofs of
its contingent advantages, and of the fact that sooner or later its
adoption would be imperative. But, looking at the question merely with
reference to the cost entailed, we believe, that this would not be
considerable, and that, as a new burden, it would indeed be very small:
for, as we have pointed out, there are certain moneys now paid under Acts
of Parliament, which would, by the organization advocated, become
available towards defraying its expenses. For instance, the fee of ten
shillings per annum, payable for the quarterly visits to every pauper
lunatic not in asylums, would revert to the district officers; as likewise
would the fee payable to the physician called upon by the visitors to the
licensed houses in every county. We have also proposed a fee to be paid
for a quarterly visit to all county patients in lunatic asylums, and to
all private patients provided for singly, and are of opinion that a
payment should be made for each lunatic or 'nervous' patient, when
registered as such, whether pauper or not; the sum, in the case of a
pauper, however, of a smaller amount than that for a private lunatic.
Considering the character and extent of the supervision and attention
proposed to be rendered, and the numerous advantages, direct and indirect,
which would necessarily accrue from the establishment of the organization
suggested, there are certainly good grounds for enforcing payment for
services rendered, so as to make the whole scheme nearly, or quite,
self-supporting. To repeat one observation before concluding this
chapter,--it should be so ordered, that all moneys levied on account of
the visits of district medical officers, and of registration, should be
paid to the credit of the Lunacy Board, through the medium of which those
officers would receive their salaries.
CHAP. X.--ON THE LUNACY COMMISSION.
We put forward our remarks upon this subject with all becoming deference;
yet it was impossible to take a review of the state of Lunacy and of the
legal provision for the insane without referring to it. Indeed, in
previous pages several observations have fallen respecting the duties and
position of the Commission of Lunacy, and the operation and powers of this
Board have also formed the topic of many remarks and discussions in other
books, as well as in journals, and elsewhere.
There appears to be in the English character such an aversion to
centralization as to constitute a real impediment to systematic
government. Various questions in social science are allowed, as it were,
to work out their own solution, and are not aided and guided towards a
correct one by an attempt at system or organization. Confusion, errors,
and miseries must prevail for a time, until by general consent an
endeavour to allay them is agreed upon, and a long-procrastinated scheme
of direction and control is submitted to, and slowly recognized as a
long-deferred good. Such is the history of the care and treatment of the
insane. After ages of neglect, evils had so accumulated and so loudly
cried for redress, that some plan of conveying relief became imperative;
and it is only within our own era, that the first systematic attempt at
legislation for the insane was inaugurated. From time to time experience
has shown the existence of defects, and almost every Parliament has been
called upon to amend or to repeal old measures, and to enact new ones, to
improve and extend the legal organization for the care and treatment of
lunatics and of their property.
One most important part of this organization was the establishment of the
Lunacy Commission, which has given cohesion and efficacy to the whole. To
the energy and activity of this Board are mainly due the immense
improvements in the treatment of the insane which characterize the present
time, and contrast so forcibly with the state of things that prevailed
before this central authority was called into power. The official
visitation by its members of all the asylums of the country has imparted a
beneficial impulse to every superintendent; the Commissioners have gone
from place to place, uprooting local prejudices, overturning false
impressions, and transplanting the results of their wide experience and
observation on the construction and organization of asylums, and on the
treatment of the insane, by means of their written and unwritten
recommendations, and by their official reports, which form the
depositories of each year's experience.
An attempt to show the manifold advantages of this central Board would be
here out of place; but we may, for example's sake, adduce the recent
investigation into the condition of lunatics in workhouses, as one of many
excellent illustrations of the benefits derived from an independent
central authority. But, whilst illustrating how much and how long the
supervision of independent visitors has been, and, in fact, still is
needed over lunatics in those receptacles, it also proves that the
existing staff is inadequate to fulfil the task. We have, indeed,
suggested the appointment of a class of district medical officers who
would relieve the Commissioners from the greatest part of the labour of
inspecting workhouse lunatic wards, but we would not thereby entirely
absolve them from this duty. An annual visit from one Commissioner to each
Union-house containing more than a given number of lunatics would not be
too much; and, to make this visit effectual, the Commissioner should be
armed with such plenary powers as to make his recommendations all but
equivalent to commands, though subject to appeal. At present the Lunacy
Commissioners are practically powerless; the law orders their visits to be
made, and sanctions their recommendations, but gives neither to them nor
to the officers of the Poor Law Board the power to insist on their advice
being attended to if no reasonable grounds to the contrary can be shown.
In this matter, therefore, a reform of the law is called for. The court of
appeal from the views of the Commissioners might be formed of a certain
number of the members of the Poor Law Board and of the Lunacy Commission,
combined for the purpose when occasion required.
The proposition has been made (p. 179) to institute a Committee of
Visitors of Workhouses, chiefly selected from the county magistracy; and
it is one that will no doubt be generally approved. But to the further
proposition, that the supervision of workhouse lunatics should be entirely
entrusted to these Committees, and that the Commissioners in Lunacy should
not be at all concerned in it, we do not agree; for, in the first place,
we wish to see the Lunacy Commissioners directly interested in every
lunatic in the kingdom, and acquainted with each one by their own
inspection or by that of special officers acting immediately under their
authority; and, in the second place, we desire to retain the visitation of
the members of the Commission in the capacity of independent and
experienced inspectors. The advantages of an independent body of visitors,
as stated in the Commissioners' 'Further Report,' 1847 (p. 93), chiefly
with reference to asylums (see p. 192), have much the same force when
applied to the visitors of workhouses,--that is, if the insane in these
latter receptacles are to be placed on an equality, as far as regards
public protection and supervision, with their more fortunate brethren in
affliction detained in asylums. But, besides the arguments based on the
advantages accruing from an independent and experienced body of visitors,
there is yet another to be gathered from the past history of workhouses
and their official managers: for among the members of Boards of Guardians,
to whom the interests of the poor in workhouses are confided, are to be
found, in a large number of parishes, magistrates holding the position of
ordinary or of honorary guardians; and, notwithstanding this infusion of
the magisterial element, we find that almost incredible catalogue of
miseries revealed to us by the Lunacy Commissioners to be endured by the
greater number of lunatics in workhouses. In fact, to assign the entire
supervision of workhouse lunatic inmates to a committee of visiting
Justices is merely to transfer the task to another body of visitors, who
have little further recommendations for the office than the Boards of
Guardians as at present constituted. From these and other considerations,
we advocate not only the visitation of lunatics in workhouses by the
district medical officers proposed, but also, at longer intervals, by one
or more of the Commissioners or of their assistants; and, if this idea is
to be realized, an increase of the Commission will be necessary, at least
until Union-houses are evacuated of their insane inmates.
The beneficial results flowing from the visitation of asylums by the
Lunacy Commissioners is a matter of general assent; and the opinion is
probably as widely shared, that this visitation should be rendered more
frequent. A greater frequency of visits would allay many public suspicions
and prejudices regarding private asylums, and would, we believe, be
cheerfully acquiesced in by asylum proprietors, who usually desire to meet
with the countenance and encouragement of the Commissioners in those
arrangements which they contrive for the benefit of their patients. The
proceeding in question would, likewise, furnish the Commissioners with
opportunities for that more thorough and repeated examination of cases,
particularly of those which are not unlikely to become the subject of
judicial inquiries. The ability to do this might, indeed, often save
painful and troublesome law processes; for, surely, the careful and
repeated examinations of the Commissioners, skilled in such inquiries,
when terminating in the conclusion that the patient is of unsound mind,
and rightly secluded, should be accounted a sufficient justification of
the confinement, and save both the sufferer and his friends from a public
investigation of the case.
The decision of the Lunacy Commissioners, we are of opinion, should be
held equivalent to that of a public court, and should not be set aside
except upon appeal to a higher court, and on evidence being shown that
there are good reasons for supposing the original decision to be in some
measure faulty. Is not, it may be asked, the verdict of a competent,
unprejudiced body of gentlemen, skilled in investigating Lunacy cases, of
more value than that of a number of perhaps indifferently-instructed men,
of no experience in such matters, under the influence of powerful appeals
to their feelings by ingenious counsel, and confounded by the multiplicity
and diversity of evidence of numerous witnesses, scared or ensnared by
cross-examination in its enunciation?
Again, the more frequent visitation of the insane by the Commissioners
would be productive of the further benefit of obviating the imputation
that patients are improperly detained after recovery; and it would also,
in some cases, be salutary to the minds of patients, fretting under the
impression of their unnecessary seclusion; for the inmates of asylums
naturally look to the Commissioners for release, anticipate their visits
with hope, and regret the long interval of two, three, or more months,
before they can obtain a chance of making their wants known, particularly
since they are conscious how many affairs are to be transacted during the
visit, and that only one or two of their number can expect to obtain
special consideration.
There is, moreover, a new set of duties the Commissioners propose to
charge themselves with, involved in the clause of the Bill introduced in
the last session of Parliament (clause 26), requiring information to be
given them of the payment made for patients in asylums, in order to their
being able to satisfy themselves that the accommodation provided is
equivalent to the charges paid. This task will necessarily entail
increased labour on the Commission, and lead, not only to inquiries
touching the provision made for the care and comfort of the patients
within the asylum, but also to others concerning the means in the
possession of their friends, and the fair proportion which ought to be
alloted for their use. In short, we cannot help thinking that the duties
proposed will frequently lead the Commissioners to take the initiative in
a course of inquiries respecting the property of lunatics available for
their maintenance.
According to present arrangements, although every asylum in the country is
under the jurisdiction of the Commissioners in Lunacy, yet, beyond the
metropolitan district, their jurisdiction is divided, and the county
magistrates share in it. Indeed, provincial asylums are placed especially
under the jurisdiction of the magistrates, by whom the plans of licensed
houses are approved, licences granted or revoked, and four visitations
made in the course of each year; whilst the Commissioners, although they
can, by appeal to the Chancellor, revoke licences in the provinces, are
not concerned in granting them, and make only two visits yearly to each
licensed house beyond the metropolitan district. This variety in the
extent of the jurisdiction of the Lunacy Board in town and country, is, to
our mind, anomalous, and without any practical advantage. If the
magisterial authority is valuable in the regulation of asylums at one
portion of the country, it must be equally so at another; the
'non-professional element' (Evid. Com., Query 126), if of importance in
the country, must be equally so in the neighbourhood of the metropolis. We
do not argue against the introduction of magisterial visitation of
asylums, but against the anomaly of requiring it in the country and not in
town, and against treating provincial asylums as not equally in need of
the supervision of the Central Board with the metropolitan. We perceive a
distinction made, but cannot recognize a difference. There is a single
jurisdiction in the instance of one set of asylums, and a divided one in
that of another; and yet the circumstances are alike in the two.
The real explanation of this anomaly in the public supervision and control
of asylums, is, we believe, to be found in the fact of the inadequacy of
the Lunacy Commission to undertake the entire work. The superiority of the
Commissioners, as more efficient, experienced, and independent visitors,
will be generally admitted; but they are too few in number to carry out
the same inspection of all the private asylums in the country, as they do
of those in the metropolitan district. The Commissioners are free from
local prejudices, unmixed in county politics, and constitute a permanent,
unfluctuating board of inspection and reference; whereas county and
borough magistrates owe their appointment usually to political
considerations and influence: politics are a subject of bitter warfare
among them in most counties; local and personal prejudices and dislikes
are more prone to affect them as local men; and, withal, the Committees of
Visiting Justices are liable to perpetual change, and, out of the entire
number elected on a committee, the actual work is undertaken only by a
few, who therefore wield all the legal powers entrusted to the whole body.
A passage from the 'Further Report' of the Lunacy Commissioners (1847)
recently referred to (p. 189) may be serviceably quoted in this place.
Speaking of the extracts selected by them for publication in the Report,
"to show that occasions are continually arising, where the intervention of
authority is beneficial," the Commissioners proceed to remark that "the
defects adverted to in the extracts may sometimes appear to be not very
important; but they are considerable in point of number, and, taken
altogether, the aggregate amount of benefit derived by the patients from
their amendment, and from the amendment of many other defects only
verbally noticed by the Commissioners, has been very great. It is most
desirable that no defect, however small, which can interfere with the
comfort of the patient, should at any time escape remark. A careful and
frequent scrutiny has been found to contribute more than anything else to
ensure cleanliness and comfort in lunatic establishments, and good
treatment to the insane. These facts will tend to show how advantageous,
and indeed how necessary, is the frequent visitation of all asylums. It is
indispensable that powers of supervision should exist in every case; that
they should be vested in persons totally unconnected with the
establishment; and that the visitations should not be limited in point of
number, and should be uncertain in point of time: for it is most important
to the patients that every proprietor and superintendent should always be
kept in expectation of a visit, and should thus be compelled to maintain
his establishment and its inmates in such a state of cleanliness and
comfort as to exempt him from the probability of censure. We are
satisfied, from our experience, that, if the power of visitation were
withdrawn, all or most of the abuses that the Parliamentary Investigations
of 1815, 1816, and 1827 brought to light, would speedily revive, and that
the condition of the lunatic would be again rendered as miserable as
heretofore."
We have in past pages referred to magisterial authority in relation with
the pauper insane, as frequently exercised prejudicially, and with
reference to asylum construction and organization, as sometimes placed in
antagonism to acknowledged principles and universal practice, much to the
injury of the afflicted inmates. Its operation is not more satisfactory
when extended to the duties of inspection. We have heard complaints made
that magistrates sometimes act very arbitrarily in their capacity of
visitors to asylums, and that it is not uncommon for them, instead of
acting in concert with the Commissioners in Lunacy, to place themselves in
opposition to their views. In fact, the Annual Reports of the
Commissioners testify to the not unfrequent want of harmony between the
visiting magistrates and the Commissioners in Lunacy; and the very facts,
that the latter have to make special yearly reports to the Lord Chancellor
on the neglect or unfitness of certain private houses, and that they have
sometimes to apply to him to revoke licences, demonstrate that the
magisterial authorities are at times backward and negligent in their
duties. Indeed, the impression to be gathered from the annual reports of
the Commission is, that almost the only efficient supervision and control
of provincial asylums are exercised by the Lunacy Commissioners.
The publication of the evidence before the Select Committee (1859) adds
fresh proofs that magistrates make but indifferent visitors of asylums,
and but imperfectly protect the interests of the insane; and that an
extension of the jurisdiction and of the inspection by the Lunacy
Commissioners is much needed. We would refer for particulars to queries
and answers numbered from 2582 to 2605, and from 2788 to 2789.
We have commented in previous pages on the manner in which the Visiting
Justices of public asylums perform their duties, and need not repeat the
statements already made; yet we may here remark that the visitation of the
wards of county asylums is often so very carelessly made, that it has
little or no value, and that it is frequently difficult to get the quorum
of two Justices to make it, the majority objecting on personal and other
grounds.
From the foregoing considerations we would advocate the extension of the
Commissioners' jurisdiction, and its assimilation to that in force within
the metropolitan district. To extend it merely to thirty miles around the
metropolis, as some have proposed, would be only to increase the anomaly
complained of. The lunatics, and those in whose charge they live, in every
district in England, should be under one uniform jurisdiction, with the
authority and protection of one set of public officers and one code of
rules. If magisterial supervision have a real value, let it be superadded
to a complete scheme of inspection and control exercised by the Lunacy
Commissioners; and if it exist anywhere, let no district be exempt from
it; for the existence of any such exemption furnishes a standing argument
against the value attributed to its presence. For instance, it may be
fairly asked,--Are the metropolitan licensed houses any the worse for the
absence of magisterial authority, or, otherwise, are the provincial any
better for its presence?
According to Lord Shaftesbury's evidence,--and his Lordship is favourable
to the authority of the Justices being perpetuated,--the system of
licensing provincial houses is sometimes loosely conducted; the house is
only known to the licensing magistrates by the plan presented, and its
internal arrangements must be virtually unknown, inasmuch as no inspection
is made of the premises. This furnishes an argument for handing over the
licensing power to the Commissioners in Lunacy, who exercise this portion
of their duties with the greatest care and after the most minute
examination. But, besides this, the position of a magistrate does not
afford in itself any guarantee of capacity for estimating what the
requirements of the insane ought to be, or of judging of the fitness of a
house for their reception. The act of licensing should certainly be
conducted upon one uniform system and set of regulations; and the
revocation of licences should likewise be in the hands of one body. No
division of opinion should arise between a public Board and a Committee of
Justices respecting the circumstances which should regulate the granting
or the refusing, the continuation or the revocation of a licence. A
divided, and therefore jarring jurisdiction, cannot be beneficial; and the
arguments for the introduction of the magisterial element depend on the
popular plea for the liberty of local government,--a liberty, which too
often tends to the annihilation of all effectual administration.
If our views are correct, and if the jurisdiction of the Commissioners in
Lunacy ought to be increased, then, as a result, the number of
Commissioners must also be augmented. In the need of this increase, very
many, indeed the large majority of persons acquainted with the legal
provisions made for the care and treatment of lunatics, concur; and
reasons for it will still further appear upon a review of the other
functions assigned to the Commissioners, and of those with which we would
charge them.
By existing arrangements there are two State authorities concerned with
lunatics, one particularly charged with their persons, whether rich or
poor,--the Lunacy Commission;--the other with their estates, and
therefore, with those only who have more or less property,--the office of
the Masters in Lunacy. Here, then, is another instance of divided
jurisdiction, although it is one wherein there are no cross-purposes, the
distinction of powers and duties being accurately defined in most
respects. Perhaps the separation of the two authorities is too distinct
and too wide, and a united jurisdiction might work better; but on this
point we forbear to speak, not having the knowledge of the laws of
property and of their administration necessary to guide us to a correct
conclusion. Yet we may thus far express an opinion, that the visitation of
lunatics, whether found so by inquisition or not, should devolve on the
members of the Lunacy Commission. We can perceive no reason for having
distinct medical visitors to Chancery lunatics; as it is, a large number
of such lunatics is found in asylums and licensed houses, and comes
therefore under the inspection of the Commissioners. Thus, according to
the returns moved for by Mr. Tite (1859), it appears there are 602
lunatics, in respect of whom a Commission of Lunacy is in force, and of
these, 300 are inmates of asylums; therefore one-half of the entire number
of such lunatics is regularly inspected by the Lunacy Commissioners, and
the visits of the "Medical Visitors of Lunatics" are nothing else than
formal; we would therefore suggest that two Assistant Commissioners should
be added to the Lunacy Board, who should receive the salaries now payable
to the Chancery lunatics' medical visitors, be disallowed practice, and be
entirely engaged as medical inspectors under the direction of the Board;
or that, in other words, the moneys derived from the Lunacy Masters'
office should be paid over to the Commission for its general purposes,
upon its undertaking to provide for the efficient protection and
visitation of all lunatics, so found on inquisition.
The plan of bringing all lunatics and all so-called 'nervous' patients,
whether placed out singly or detained in asylums of any sort under the
cognizance and care of the Commission, as enlarged upon in previous pages,
would materially augment the labours of the central office; and, in our
humble opinion, a greater division of labour than has hitherto marked the
proceedings of the Commission would greatly facilitate the work to be
done. At present, the members of the Commission perform a threefold
function; viz. of inspectors, reporters, and judges. The task of
inspecting asylums and their insane inmates, of ascertaining the treatment
pursued and examining the hygienic measures provided, is peculiarly one
falling within the province of medical men, and should be chiefly
performed by medical Commissioners. On the other hand, the business of the
Board, in its corporate capacity, is only indirectly and partially
medical. Lord Shaftesbury, indeed, goes so far as to say (query 14, Evid.
Com.) "that the business transacted at the Board is entirely civil in
ninety-nine cases out of one hundred. A purely medical case does not come
before us once in twenty Boards." These considerations certainly appear to
indicate a natural and necessary division of the Board into a deliberative
central body, sitting _en permanence_, once, twice, or oftener in the
week, if necessary, and a corps of visitors and reporters to examine the
state of asylums and the insane throughout the country. This division of
the Commission would obviate the chief objection to an increase of the
number of members; viz. that a larger number of Commissioners than at
present would render the Board unwieldy, and rather impede than facilitate
its business as a deliberative assembly. We entertain, moreover, the
opinion that it would be more satisfactory to those who sought
instructions, or whose affairs or conduct were in any way the subject of
investigation, to have to deal with such a permanent deliberative or
judicial body as proposed, than with one combining, like the members of
the present Board, the various functions of inspectors, reporters, and
judges; a condition, whereby any question agitated must, to a certain
extent, be prejudged by the official reports of the very same persons
called upon to examine it.
Again, if this proposed division of the Lunacy Board took place, it would
furnish a better justification for increasing certain of its powers, as
these would be wielded by a permanent deliberative body, instead of, as at
present, by a Commission exercising mingled functions. The value of the
Board would be increased as a court of reference in all matters, such as
the construction and the size of asylums, where the authority of the
State, by duly ordered channels, is called for to overrule the decisions
of local administrative bodies. Lastly, this arrangement would facilitate
the amalgamation, proposed by some persons, of the office of the Masters
with the Commission in Lunacy; or it would, at least, render the
co-operation and combined action of the two offices more simple and easy.
There are other reasons for an increase of the staff of the Lunacy
Commission, following from the amount of work which, by any revision of
existing statutes, must fall within the compass of its operations. For
instance, we regard the suggestion that we have made, that no uncured
lunatic or 'nervous' patient should be removed from an asylum or other
establishment, without the sanction of the Commissioners and their
approval of the place and conditions to which the removal is intended,--as
very important for the protection of the insane. To carry out this duty
will involve a certain amount of labour, particularly as it would often
require some member of the Commission to examine the patient and the
locality in which it is proposed to place him, and to report on the
expediency of his removal. Often, perhaps, this business might be
entrusted to the district medical officer, particularly in the country. On
the other hand, in the metropolitan district, the work of district medical
officers might be advantageously performed,--at least in all that concerns
the insane,--by a couple of the Assistant Commissioners hereafter spoken
of, in addition to their other duties elsewhere.
Another piece of evidence, to our apprehension, that the present
Commission is inadequate to the multifarious duties imposed upon it, is,
that the Commissioners have never hitherto effectually inspected gaols,
nor succeeded in getting imbecile and lunatic criminals reported to them
with the least approach to accuracy. The inspection of workhouses proved
that it did not suffice to receive the reports of workhouse officials
respecting the existence and number of insane inmates, but that, to
ascertain these facts, personal examination by the Commissioners was
necessary; and there is no satisfactory reason for supposing the
discrimination of insane prisoners to be much better effected than that of
workhouse lunatics, in the many prisons distributed over the country. It
comes out, in the course of the evidence before the Select Committee,
1859, that the Commissioners know little about the insane inmates of
gaols, and that reports of the presence of such inmates are but rarely
supplied them. The law requires the Commissioners to visit gaols where any
lunatics are reported to them to exist; but the duty of reporting is made
the business of no particular individual, and therefore, as a natural
consequence, no one attends to it. In the evidence referred to, the case
of ten alleged lunatics, committed to York Castle and imprisoned there for
a series of years, as criminals acquitted on the ground of insanity,
elicited much attention, and Lord Shaftesbury alluded to the interference
of the Lunacy Commission on behalf of several lunatics in different
prisons. The fact we have brought to light from one Government report, as
stated at p. 6 of this treatise, is of much moment in discussing the
present subject; viz. that there were as many as 216 persons of unsound
mind in the ten convict prisons under the immediate control of the
Government, in the course of one year, and that of these the Dartmoor
Prison wards contained as many as 106 such inmates. There is no allusion,
in the Commissioners' reports or in the printed evidence of the Select
Committee, to show that these insane prisoners were visited by, or known
to, any members of the Lunacy Board. But, besides these insane inmates
thus distinctly made known to us to exist in so few prisons, there must be
many more detained in the numerous houses of detention throughout the
kingdom. These facts render it an obvious duty on the part of the
Commission of Lunacy to ascertaining the number and condition of this
unhappy class of lunatics, and to order suitable provision to be made for
them. There is a disposition on the part of some visitors of gaols to
erect, or set apart, special wards for lunatic prisoners; a system to be
much more deprecated than even the establishment of lunatic wards in
connexion with workhouses, and one which will require the active
interposition of the Lunacy Board to discourage and arrest.
It were easy to take up the duties of the Commissioners in Lunacy in
detail, and to show that they cannot be efficiently performed by the
existing staff; but the fact will be patent to any attentive reader of
this chapter and of the foregoing dissertations on the provisions
necessary for the care and supervision of lunatics in general. The scheme
which we have, with all due deference to established authorities, sketched
in outline, to increase the jurisdiction and usefulness of the Lunacy
Commission, provides for a division of its staff; in the first place, by
altering to a greater or less extent the character and position of the
present Board, so as to constitute it a fixed central Commission or
Council, chiefly charged with adjudging and determining questions put
before it; with superintending the public arrangements for the interests
of the insane generally, and with providing for the good and regular
management, organization, and construction of lunatic asylums; and in the
next place, by instituting, in connexion with this head deliberative body
(which need not, by the way, consist of so many members as the present
Commission), a corps of Assistant Commissioners, specially charged with
the duties of visitation, inspection, and reporting, and with the carrying
out of the resolutions determined on by the deliberative council. At the
same time, the power of visiting and reporting might still be left with
some Commissioners under certain circumstances, as well as in making
special investigations, and in examining matters of dispute raised upon
the reports of the Assistants.
Though differing from so high an authority as the noble chairman of the
Lunacy Board, we must say that we cannot conceive of it as at all a
necessary consequence, that, if the work of visitation to asylums and
lunatics is performed by a class of inspectors or Assistant Commissioners,
and not by the present members of the Commission, it must be indifferently
done, and prove a source of dissatisfaction:--that is, we have no such
apprehensions, provided always that proper men are appointed, and that
their official status is made what it ought to be, both in remuneration
and in independence of position. Nor can we agree to the giving up of the
proposed plan on the score of its expense. If the whole of the lunatic and
'nervous' people suffering confinement in this country are to be brought
within the knowledge and under the supervision of the Lunacy
Commissioners, if the enlarged provisions of the law necessary for their
proper care and treatment,--and even those only among them proposed by the
Commissioners themselves are to be carried into effect,--the Commission
must be increased. And, instead of adding new Commissioners on the same
footing and salary as the existing ones, we believe the public would be
better served by the appointment of Assistant Commissioners with the
duties we have proposed,--two of whom could be remunerated at the same
outlay as one full Commissioner. Moreover, we have proposed that the sum
payable out of the Masters' office to medical visitors be devoted to the
purposes of the Commission; and, if our notion of a central deliberative
body were accepted, one legal and one medical member of the present
Commission could well be spared to undertake more especially the duties of
visiting Commissioners.
Lastly, if the jurisdiction and powers of the Commission were extended to
all lunatics living singly and to so-called 'nervous patients,' a
considerable addition to the treasury would be obtained, even by a small
tax, or per-centage on income. Probably six Assistant Commissioners,
constantly employed in the work of inspection, with the aid of two
visiting chief Commissioners from the present Board, would suffice for the
discharge of the duties to be entrusted to them. If so, the cost of six
such additional officers would be very trifling, covered as it would be by
increased funds passing into the hands of the central office in the
administration of the improved legislation.
If precedent be a recommendation to a plan, it can be found in favour of
appointing Assistant Commissioners in the example of the Scotch Lunacy
Commission, and in the constitution of the Poor Law Board, which has a
distinct class of officers known as inspectors. In fact, every other
Government Board or Commission, except that of Lunacy, has a staff of
Assistants or of Inspectors.
CHAP. XI.--ON SOME PRINCIPLES IN THE CONSTRUCTION OF PUBLIC LUNATIC
ASYLUMS.
In the preceding pages of this book we have had occasion to discuss many
important points respecting the organization of public asylums; and, as we
entertain some views at variance with the prevalent system of asylum
construction, a supplementary chapter to elucidate them cannot be
misplaced. The substance of the following remarks formed the subject of a
chapter on Asylum Construction published by us in the 'Asylum Journal'
(vol. iv. 1858, p. 188) above a year since, and, as we then remarked, the
principles put forward had been adopted by us some five or six years
previously, and were strengthened and confirmed by the extended
observations we had personally made more recently on the plans and
organization of most of the principal asylums of France, Germany, and
Italy.
All the public asylums of this country are, with slight variations,
constructed after one model, in which a corridor, having sleeping-rooms
along one side, and one or more day-rooms at one end,--or a recess (a
sort of dilatation or offset of the corridor at one spot), in lieu of a
room, constituting a section or apartment fitted for constant occupation,
day and night, forms--to use the term in vogue--a 'ward.' An asylum
consists of a larger or smaller number of these wards, united together on
the same level, and also superposed in one, two, three, and occasionally
four stories. There are, indeed, variations observed in different asylums,
consisting chiefly in the manner in which the wards are juxtaposed and
disposed in reference to the block and ground plans, or in the
introduction of accessory rooms, sometimes on the opposite side of the
corridor to the general row of small chambers, to be used as dormitories
or otherwise; but these variations do not involve a departure from the
principle of construction adopted.
Those who have perambulated the corridors of monastic establishments will
recognize in the 'ward-system' a repetition of the same general
arrangements,--a similarity doubtless due in part to the fact of ancient
monasteries having been often appropriated to the residence of the insane,
and in part to the old notions of treatment required by the insane, as
ferocious individuals, to be shut apart from their fellow-men.
Whilst the ideas of treatment just alluded to prevailed, there was good
reason for building corridors and rows of single rooms or cells; but,
since they have been exploded, and a humane system of treating the insane
established in their place, the perpetuation of the 'ward-system' has been
an anomaly and a disastrous mistake. The explanation of the error is to be
found in the facts,--that medical men in England, engaged in the care of
the insane, have contented themselves with suggesting modifications of the
prevailing system,--than which indeed they found no other models in their
own country; and that the usual course has been, to seek plans from
architects, who, having no personal acquaintance with the requirements of
the insane, and the necessary arrangements of asylums, have been compelled
to become copyists of the generally-approved principle of construction,
which they have only ventured to depart from in non-essential details, and
in matters of style and ornamentation.
The literature of asylum architecture in this country evidences the little
attention which has been paid to the subject. The only indigenous work on
asylum-building--for the few pages on construction in Tuke's introduction
to his translation of Jacobi's book, and the still fewer pages in Dr.
Brown's book on asylums, published above twenty years ago, do not assume
the character of treatises--is the small one by Dr. Conolly, and even this
is actually more occupied by a description of internal arrangements in
connexion with the management of lunatics, than by an examination of the
principles and plans of construction. This bald state of English
literature on the subject of construction contrasts strongly with the
numerous publications produced on the Continent, and chiefly by asylum
physicians, the best-qualified judges of what an asylum ought to be in
structure and arrangements.
However, to resume the consideration of the 'ward-system' as it exists,
let us briefly examine it in its relations to the wants and the treatment
of the insane. Every day adds conviction to the impression, that the less
the insane are treated as exceptional beings, the better is it both for
their interests and for those who superintend them. In other words, the
grand object to be kept in view when providing for the accommodation of
the insane, is to assimilate their condition and the circumstances
surrounding them as closely as possible to those of ordinary life. Now,
though it is clearly impracticable to repeat all the conditions of
existence prevailing in the homes of the poorer middle and pauper classes
of society who constitute the inmates of our public asylums, when these
persons are brought together to form a large community for their better
treatment and management, yet we may say of the 'ward-system,' that it is
about as wide a departure from those conditions as can well be conceived.
It is an inversion of those social and domestic arrangements under which
English people habitually live.
The new-comer into the asylum is ushered into a long passage or corridor,
with a series of small doors on one side, and a row of
peculiarly-constructed windows on the other; he finds himself mingled with
a number of eccentric beings, pacing singly up and down the corridor, or
perhaps collected in unsocial groups in a room opening out of it, or in a
nondescript sort of space formed by a bulging-out of its wall at one spot,
duly lighted, and furnished with tables, benches, and chairs, but withal
not a room within the meaning of the term, and in the patient's
apprehension. Presently, he will be introduced through one of the many
little doors around him into his single sleeping-room, or will find
himself lodged in a dormitory with several others, and by degrees will
learn that another little door admits him to a lavatory, another to a
bath, another to a scullery or store-closet, another to a water-closet
(with which probably he has never been before in such close relation),
another to a _sanctum sanctorum_--the attendant's room, within which he
must not enter. Within this curiously constructed and arranged place he
will discover his lot to be cast for all the purposes of life, excepting
when out-door exercise or employment in a workroom calls him away: within
it he will have to take his meals, to find his private occupation or
amusement, or join in intercourse with his fellow-inmates, to take indoor
exercise, and seek repose in sleep; he will breathe the same air, occupy
the same space, and be surrounded by the same objects, night and day.
This sketch may suffice to illustrate the relations of a ward as a place
of abode for patients, and to exhibit how widely different are all the
arrangements from those they have been accustomed to. Let us now notice
briefly the relations of the ward-system to the treatment required for
insane inmates. The monotonous existence is unfavourable: the same
apartment and objects night and day, and the same arrangements and
routine, necessitated by living in a ward, are not conducive to the relief
of the disordered mind. Where access to the sleeping-rooms is permitted by
day, the torpid and indolent, the melancholic, the morose and the
mischievous, will find occasion and inducement to indulge in their several
humours; opportunity is afforded them to elude the eye of the attendants,
to indulge in reverie, and to cherish their morbid sentiments. When the
rules of the institution forbid resort to their rooms by day, the idea of
being hardly dealt with by the refusal will probably arise in their minds,
since the inducement to use them is suggested by their contiguity; the
doors, close at hand, will ever create the desire to indulge in the
withheld gratification of entering them. How many insane are animated with
a desire to lounge, to mope unseen, and to lie in bed, needs not to be
told to those conversant with their peculiarities; and, surely, the
removal of the temptation to indulge would be a boon both to physician and
patients.
Again, the corridor and its suite of rooms present obstacles to
ventilation and warming, and, as the former in general serves, besides the
purpose of a covered promenade, that of a passage of communication between
adjoining wards, it is less fitted for the general purposes of daily life,
and the passage to and fro of persons through it is a source of
disturbance to its occupants, and often objectionable to the passer-by. As
a place of indoor exercise, the corridor has little real value, especially
when considered in relation to the other objects it has to serve. Those
who desire to sit still, to read, to amuse or to employ themselves, feel
it an annoyance to have one or more individuals walking up and down, and
often disposed to vagaries of various sorts; few of the whole number care
for perambulating it if they can get out of doors for exercise (and there
are not many days when they cannot), and, as far as concerns the health of
those few who use the corridor for exercise, it would be better to
encourage them to walk in the grounds, than, by having such a space within
doors, to induce their remaining there.
When casual sickness or temporary indisposition overtakes a patient, and a
removal to the infirmary ward is not needed, though repose is required, it
is a great disadvantage to have an exercising corridor in such immediate
contiguity with the bedroom, and to have the room open into the corridor;
for it is an arrangement more or less destructive of quiet, and exposes
the poor sufferer to the intrusion of the other inmates of the ward,
unless the room-door be locked,--a proceeding rarely advisable under the
circumstances supposed.
The introduction of the plan of building an open recess in a corridor as a
sitting apartment instead of an ordinary room was a consequence of the
difficulties experienced in exercising an efficient supervision of the
inmates when dispersed, some in the corridor, and others in the day or
dining rooms. Yet, although the plan in question partially removes these
difficulties, no one could wish to exchange the advantages in comfort and
appearance of a sitting-room with the greater approximation it affords to
the ordinary structure of a house, for a recess in a corridor, if
effectual supervision could in any other way be attained. But the plan of
a corridor with an offset in lieu of a room does not secure a completely
effective oversight, control, and regulation of the occupants, since it
presents many opportunities, in its large space, and by the disposition of
its parts, for those to mope who may be so disposed, and for the
disorderly to annoy their neighbours, without arresting the attention of
the one or two attendants.
In the construction and arrangements of a ward, it is necessary to provide
for all the wants of the inmates both by day and night, to supply the
fittings and furniture needed by the little community inhabiting it; and
all such arrangements and conveniences have consequently to be repeated in
every one of the many wards found in the asylum, at a very large cost.
Again, by the ward-system, the patients are lodged on each floor of the
building, and therefore the service of the asylum becomes more difficult,
just in proportion to the number of stories above the ground-floor, or the
basement, where the kitchen and other general offices are situated. It is
chiefly to obviate this difficulty that the elevation of our public
asylums has been limited to two stories, and a greater expenditure thereby
incurred for their extension over a larger area. (See p. 212.)
From whatever point of view the ward-system may be regarded, there is in
it, to our view, an absence of all those domestic and social arrangements
and provisions which give a charm to the homes of English people. The
peculiar combination of day and night accommodation is without analogy in
any house; whilst the sitting, working, or reading, and, occasionally, the
taking of meals, in a corridor, a place used also for exercise, and for
the passage of persons from one part of the asylum to another, represent
conditions of life without parallel among the domestic arrangements of any
classes of the community.
The principle of construction we contend for is, the separation, as far as
practicable, of the day from the night accommodation. Instead of building
wards fitted for the constant habitation of their inmates, we propose to
construct a series of sitting or day rooms on the ground-floor, and to
devote the stories above entirely to bedroom accommodation. Not that we
would have none to sleep on the ground-floor, for we recognise the utility
of supplying accommodation there, both by night and day, for certain
classes of patients, such, for instance, as the aged and infirm, who can
with difficulty mount or descend stairs; the paralytics; some epileptics,
and others of dirty habits, and the most refractory and noisy patients.
The last-named are, in our opinion, best lodged in a detached wing,
particularly during their paroxysms of noise and fury, according to the
plan adopted in several French asylums. And we may, by the way, remark,
that if such patients were so disposed of, one reason assigned for
internal corridors as places requisite for indoor exercise, would be set
aside, inasmuch as these are supposed practically to be most useful to
that class of asylum inmates.
In our paper on construction in the 'Asylum Journal,' before referred to,
we illustrated (_op. cit._ p. 194) our views by reference to a rough
outline of a part of a plan for a public asylum we had some years before
designed; but it seems unnecessary to reproduce that special plan here,
since, if the principle advocated be accepted, it becomes a mere matter of
detail to arrange the disposition, the relative dimensions, and such like
particulars, whether of the day-rooms below or of the chambers above.
There is this much, however, worth noting, that, by the construction of
adjoining capacious sitting-rooms, it is easy so to order it, that any
two, or even three, may, by means of folding-doors, be thrown into one,
and a suite of rooms obtained suited for public occasions, for dancing,
for lectures, or theatricals. So again, even in the case of those who may
be placed together in the same section of the establishment, and who join
at meals, the construction of two or more contiguous sitting-rooms affords
an opportunity for a more careful classification, in consideration of
their different tastes, and of their capability for association, for
employment, or for amusement.
However, without delaying to point out the advantages accruing in minor
details of internal arrangements when the principle is carried out, let us
briefly examine its merits abstractedly, and in relation to the system in
vogue.
1. It assimilates the condition of the patients to that of ordinary life,
as far as can be done in a public institution. They are brought together
by day into a series of sitting-rooms adapted to the particular class
inhabiting them, and varied in fittings and furniture according to the
particular use to which they are applied,--as, for instance, for taking
meals, or for the lighter sorts of work, indoor amusements, and reading.
For the sections, indeed, inhabited by the more refractory and the
epileptic, a single day-room would suffice. When thus brought together in
rooms, instead of being distributed along a corridor and its divergent
apartments, association between the several patients can be more readily
promoted; and this is a matter worth promoting, for the insane are
morbidly selfish and exclusive. Likewise, it becomes more easy for the
attendants to direct and watch them in their amusements or occupations,
and to give special attention or encouragement to some one or more of
their number without overlooking the rest. Besides this, rooms admit of
being arranged and furnished as such apartments should be; whilst,
whatever money may be laid out in furnishing and ornamenting corridors,
they can never be rendered like any sort of apartment to be met with in
the homes of English people. The separation of the sleeping-rooms from the
day accommodation also has the similar advantage of meeting the wishes and
habits of our countrymen, who always strive to secure themselves a sitting
and a bed room apart: and, altogether, it may be said, that in a suite of
day-rooms disposed after the plan advocated, and in the perfectly
separated bedroom accommodation, there is, to use a peculiarly English
word, a _comfort_ completely unattainable by the ward-system, however
thoroughly developed.
2. Greater salubrity and greater facilities for warming and ventilation
are secured. It will be universally conceded that sleeping-rooms are more
healthy when placed above the ground-floor, so as to escape the constant
humidity and exhalations from the earth, particularly at night. The system
suggested secures this greater salubrity for the majority of the
population, who occupy the upper floors during the night; those only being
excepted, whom, for some sufficient reason, it is desirable not to move up
and down stairs, or not to lodge at night in the immediate vicinity of the
rest of the patients. Again, the separation of the apartments for use by
day from those occupied at night favours the health of the establishment
by rendering ventilation more easy and complete. In a ward occupied all
day and all night, the air is subject to perpetual vitiation, and, whilst
patients are present, it is, especially in bad weather, difficult or quite
unadvisable to attempt thorough ventilation by the natural means of
opening windows and doors,--a means which we believe to be preferable to
all the schemes of artificial ventilation of all the ingenious engineers
who have attempted to make the currents of air and the law of diffusion of
gases obedient to their behests. But "the wind bloweth where it listeth,"
and all the traps set to catch the foul exhalations, and all the jets of
prepared fresh air sent in from other quarters, will not serve their
bidding: the airy currents will disport themselves pretty much as they
please, and intermingle in spite of the solicitations of opposing flues to
draw them different ways. But if, on our plan, the apartments for day use
are kept completely distinct from those used by night, each set being
emptied alternately, a most thorough renewal of air may be obtained by
every aperture communicating with the external atmosphere.
The actual construction of a ward creates an impediment to the perfect
ventilation of all its apartments. There is a wide corridor, and along one
side a series of small chambers, the windows of which are necessarily
small, and sometimes high up; the windows, too, both in rooms and
corridor, must be peculiarly constructed, and the openings in them for
ventilation small. Although it is easy in this arrangement to get a free
circulation of air along the corridor, it is not so to obtain it for each
room opening out of it. By the scheme of construction we propose, these
difficulties are mostly removed. The day-rooms on the ground-floor need no
corridor alongside, and, as a single series or line of apartments, are
permeated by a current of air traversing them from side to side. But if,
for the convenience of the service of the house, some passage were thought
necessary, it would be external to the rooms, and in designing the asylum
it should be an object to prevent such corridors of communication
interfering with the introduction of windows on the opposite sides of each
sitting-room. On the bedroom-floor above, a corridor, where necessary,
would not be a wide space for exercise, such as is required for a ward,
but merely a passage, giving access from one part of the building to
another. So, with respect to the windows, except those in the single
bedrooms, it would be perfectly compatible with security to construct them
much after the usual style adopted in ordinary houses, and thereby allow
large openings for the free circulation of air.
Further, when the patients inhabit ordinarily-constructed sitting-rooms,
the warming of these may be effected by the common open fires, which are
dear to the sight and feelings of every Englishman, and impart a cheerful
and home-like character. Likewise, there would be no need of keeping the
whole building constantly heated at an enormous expense; for only one half
of it would be occupied at a time, nor would those most costly and
complicated systems of heating be at all required. The saving in large
public asylums would be something very large in this one item,--that of
fuel to burn, without counting the expenditure which is generally incurred
for the heating apparatus, flues, furnaces, and shafts. As with the
warming, so with the lighting of an institution constructed on our
model,--only one-half would require illumination at the same time, and
much gas-fitting would be saved by the diminution of the number of small
apartments, repeated, after the prevailing model, in every ward, and
requiring to be lighted.
3. Access to the airing courts, offices, workshops, &c., becomes easier to
all the inmates. According to the established system of construction, the
half, or upwards, of the patients have to descend from the wards on the
upper floors for exercise or for work, and to ascend again to them for
their meals, or to retire to rest. This ascent and descent of stairs may
have to be repeated several times daily; and it must be remembered that it
cannot take place without the risk of various inconveniences and dangers
necessarily dependent on stairs, and that it must frequently entail
trouble and anxiety upon the attendants, particularly in mischievous and
in feeble cases. The plan advocated obviates all these evils, so far as
practicable. The patients would have to go up and down stairs only once
a-day, and the attendants, therefore, escape much of the constantly
occurring trouble of helping the feeble, or of inducing the unwilling to
undertake the repeated ascent and descent,--a task ever likely to be
neglected, and to lead to patients being deprived, to a greater or less
extent, of out-door exercise and amusement.
4. It facilitates supervision. Supervision, both by the medical officers
and by the attendants, becomes much more easy and effectual when the
patients are collected in rooms, affording them no corners or
hiding-places for moping and indulging in their mental vagaries, their
selfishness and moroseness. When the medical officer enters the day-room,
all the inmates come at once under his observation, and this affords him
the best opportunity of noting their cases, and of discovering their
condition and progress. By the attendants similar advantages are to be
gained; the patients will be more immediately and constantly under their
eye than when distributed in a corridor and connected rooms; their
requirements will be sooner perceived, and more readily supplied; their
peculiarities better detected and provided against; their insane
tendencies more easily controlled and directed; whilst, at the same time,
the degree and mode of association will call forth feelings of interest
and attachment between the two.
Just as supervision becomes more easy by day, so does watching by night;
for almost the whole staff of attendants would sleep on the same floor
with the patients, and thereby a more immediate communication between them
be established, and a salutary check on the conduct of the latter, from
the knowledge of the attendants being close at hand, more fully attained.
Perhaps these advantages will appear more clear when it is understood that
the subdivision of the bed-room floor into several distinct wards, cut
off from each other by doors, stair-landings, &c., would not be at all
necessary on the principle of construction recommended. The comparatively
few noisy patients in a well-regulated asylum would occupy the
sleeping-rooms of the ground-floor wings, if not placed in a distinct
section; and therefore, the inhabitants of the floor above being all quiet
patients, no partitions need separate their section of the building into
distinct portions or wards, and act as impediments to the freedom of
communication and ventilation.
This matter of the partitions needed is, however, a point of detail, which
would have to be determined pretty much by the general design adopted.
5. Classification is more perfect. Owing to the sleeping apartments being
quite distinct from those occupied by day, the rule usually observed in a
ward, as a matter of necessary convenience, of keeping the same group of
occupants in it both night and day, need not at all be followed. On
retiring from their sitting-rooms, where they have been placed according
to the principles of classification pursued, the day association would be
broken up, and their distribution in the sleeping-rooms might be regulated
according to their peculiar requirements at night. This valuable idea, of
arranging patients differently by day and by night, was put forward by Dr.
Sankey, of Hanwell ('Asylum Journal,' vol. ii. 1856, p. 473), in the
following paragraph:--"Whatever the basis of the classification, it will
not hold good throughout the twenty-four hours: why, therefore, should it
be attempted to make it do so? At night the classification should be based
on the requirement of the patient during the night; and during the day,
the patient should be placed where he can be best attended during the
day." Let us add, that the more perfectly Dr. Sankey's principle could be
carried out, the more easy would supervision be rendered.
Since mechanical restraint has been set aside, seclusion in a
specially-constructed chamber, or in the patient's own room, has in some
measure taken its place, and been frequently abused; for it is more
difficult to control the employment of seclusion than of instrumental
restraint, and in a ward there is almost a temptation to employ it where a
patient is inconveniently troublesome to the attendant; the single room is
close at hand, and it is a simple matter to thrust the patient into it,
and an easy one to release him if the footstep of the superintendent is
heard approaching. The plan of construction we would substitute for the
ward-system would almost of itself cure the evil alluded to. Furthermore,
since sitting-rooms and other apartments to meet the exigencies of daily
use are excluded from the upper floors, it would become easier for the
architect to dispose the single rooms and dormitories, and more
especially the attendants' rooms, with a view to the most effectual
supervision. We may, in fine, state under the two last heads, generally,
that access to the patients, their quiet and comfort, their watching and
tending and their classification will be more readily and also more
efficiently secured by the arrangement pointed out, than by the system of
construction hitherto pursued in this country.
6. Domestic arrangements will be facilitated in various ways.--The
patients, in the first place, will be less disturbed by the necessary
operations of cleaning, which every superintendent knows are apt to be a
source of irritation and annoyance, both to patients and attendants. The
ground-floor may be prepared for the day's use before the patients leave
their bedrooms; and in the same way the latter may be cleaned during the
occupation of the ground-floor. By the present constitution of a ward for
use both night and day, considerable inconvenience, and many
irregularities in management constantly result. The cleaning has to be
hurried over, or to be done at awkward hours, to avoid alike the
interruption of patients, or the being interrupted by them; and, at the
best, it will from time to time happen that patients are excluded from
their day or their bedrooms, or from the corridors, during the operation.
Another advantage will accrue from the system proposed. The amount of
cleaning will be much diminished, for the two floors will be used only
alternately, and not only the wear and tear of the entire building, but
also the exposure to dirt will be greatly lessened; above all, the small
extent of corridor will make an immense difference in the labour of the
attendants in cleaning, compared with that which now falls to their lot.
Again, the drying of floors after they have been washed is always a
difficulty, particularly in winter, and is the more felt in the case of
the bedrooms, which have, when single-bedded or small, but a slight
current of air through them, and consequently dry slowly. This difficulty
is augmented, when, as it often happens, it is necessary for them to be
kept locked, to prevent the intrusion of their occupants or of others. The
ill effects of frequently wetted floors in apartments constantly occupied,
and therefore dried during occupation, have been fully recognized and
admitted by hospital surgeons, and have impressed some so strongly, that,
to escape them, they have substituted dry rubbing and polished floors to
avoid the pail and scrubbing-brush. By the arrangements submitted,
however, this difficulty in washing the floors is removed, since there is
no constant occupancy of the rooms, and therefore ample time for drying
permitted.
Further, by the plan in question, the distribution of food, of medicine,
and of stores, becomes more easy and rapid; the collection, and the
serving of the patients at meals, are greatly simplified and expedited. A
regularity of management in many minor details will likewise be promoted.
As the majority of the patients are quite removed from proximity to their
sleeping-rooms, the temptation and inducement to indulge in bed by day, or
before the appointed hour at night, will be removed, as will also the
irregularity frequently seen in wards some time before the hour of bed, of
patients prematurely stowed away in their beds, and of others disrobing,
whilst the remainder of the population is indulging in its amusements, its
gossips, or in the 'quiet pipe,' before turning in.
7. Management facilitated.--Our own experience convinces us that there is
no plan so effectual for keeping otherwise restless and refractory
patients in order as that of bringing them together into a room, under the
immediate influence and control of an attendant, who will do his best to
divert or employ them. We are, let it be understood, only now speaking of
their management when necessarily in-doors; for, where there is no
impediment to it, there is nothing so salutary to such patients as
out-door exercise, amusement, and employment. On the contrary, to turn
refractory patients loose into a large corridor, we hold to be generally
objectionable. Its dimensions suggest movement; the patient will walk
fast, run, jump, or dance about, and will, under the spur of his activity,
meddle with others, or with furniture, and the like; and if an attendant
follow or interfere, irritation will often ensue. But in a room with an
attendant at hand, there are neither the same inducements nor similar
opportunities for such irregularities. Some would say, such a patient is
well placed in a corridor, for he there works off his superabundant
activity. But we cannot subscribe to this doctrine; for we believe the
undue activity may be first called forth by his being placed in a
corridor; and that it is besides rare that a patient, particularly if his
attack be recent, has any actual strength to waste in such constant
abnormal activity as the existence of a space to exercise it in
encourages. And, lastly, it is better to restrict the exhibition of such
perverted movement to the exercising grounds, or better still to divert it
to some useful purpose by occupation; for in a ward such exhibitions are
contagious.
These remarks bear upon the question of the purpose and utility of
corridors as places for exercise, concerning which we have previously
expressed ourselves as having a poor opinion, and have throughout treated
corridors mainly as passages or means of communication.
8. A less staff of attendants required.--If the foregoing propositions,
relative to the advantages of the system propounded, be admitted, the
corollary, that a less staff of attendants will suffice, must likewise be
granted, and needs not a separate demonstration. There is this much,
however, to be said, that the proposition made in a former page to
distinguish attendants upon the insane from the cleaners or those more
immediately concerned in the domestic work of the house, would be an
easier matter when the construction followed the principles recommended.
The attendants upon the occupants of the sitting-rooms need be but few,
for their attention would not be distracted from their patients by
domestic details; for the cleaners would prepare the apartments ready for
occupation, would be engaged in fetching and carrying meals, fuel, and
other things necessary for use, and the attendants would thereby be
deprived of numerous excuses for absence from their rooms, and for
irregularities occurring during their occupation with household duties.
9. The actual cost of construction of an asylum on the plan set forth
would be greatly diminished.--It has just been shown that the proposed
plan will ensure a more ready and economical management; and if structural
details could be here entered upon, in connexion with an estimate of costs
for work and materials, it could without difficulty be proved, that the
cost of accommodation per head, for the patients, would fall much under
that entailed by the plan of building generally followed. The professional
architect who assisted us made a most careful estimate of the cost of
carrying out the particular plan we prepared (designed to accommodate 220
patients), and calculated that every expense of construction, including
drainage of the site, gas apparatus, farm-buildings, &c., would be covered
by £19,000, _i. e._ at the rate of less than £90 (£87) per head.
That a considerable saving must attend the system propounded will be
evident from the fact, that, instead of a corridor, on the first floor, at
least twelve feet wide, as constructed on the prevailing plan, one of six
feet, or less, simply as a passage for communication, is all that is
required, and thus a saving of about that number of feet in the thickness
or depth of the building, in each story above the ground-floor, is at once
gained. A similar, though smaller, economical advantage is likewise
obtained on the ground-floor, for the corridor there need be nothing more
than an external appendage, and of little cost to construct.
A further saving would attend the construction of an asylum on the plan
set forth, both from the concentration of the several parts for night and
day use respectively, and generally from the rejection of the ward-system.
The construction of almost all the sleeping accommodation on one floor
would render many provisions for safety and convenience unnecessary,--for
instance, in the construction of the windows. So the substitution of what
may be termed divisions, or quarters in lieu of wards, would do away with
the necessity of many arrangements requisite for apartments, when intended
for use, both by night and day. As constructed commonly, each ward is a
complete residence in itself, replete with all the requisites for
every-day life, except indeed in the cooking department; and the
consequence is, there is a great repetition throughout the institution of
similar conveniences and appurtenances. Indeed, in the plan we designed,
the influence of example or general usage led us to introduce many
repetitions of several accessory apartments, which were, in fact, uncalled
for, and added much to the estimate. For instance, we assigned a bath-room
to each division, although we consider that a room, well-placed, to
contain several baths (_i. e._ in French phrase, a 'salle des bains'),
would more conveniently serve the purpose of the whole ground-floor
inmates, and be much cheaper to construct and to supply. Yet, if this
notion of a 'bath-house' be unacceptable to English Asylum
Superintendents, a smaller number of bath-rooms than was either provided
in the particular plan alluded to, or is usually apportioned to asylums,
would assuredly suffice. The same may be said of the lavatories,
sculleries, and store-rooms.
10. The plan removes most of the objections to the erection of a
second-floor or third-story.
These objections generally owe their force to the difficulty of assuring
the inmates of a third-story their due amount of attention, and their fair
share of out-door exercise, and of much indoor amusement, without
entailing such trouble upon all parties concerned, that a frequent
dereliction or negligence of duty is almost a necessary consequence.
Dr. Bucknill ('Asylum Journal,' vol. iii., 1857, p. 387, _et seq._) has
well argued against the erection of a third-story, on economical grounds;
and remarks that "practically, in asylums built with a multiplicity of
stories, the patients who live aloft, are, to a considerable extent,
removed from the enjoyment of air and exercise, and the care and sympathy
of their fellow-men. They are less visited by the asylum officers, and
they less frequently and fully enjoy the blessings of out-door recreation
and exercise. Those below will have many a half-hour's run from which they
are debarred; the half-hours of sunshine on rainy days, the half-hours
following meals, and many of the scraps of time, which are idly, but not
uselessly spent, in breathing the fresh air."
The foregoing considerations are certainly sufficient to condemn the
appropriation of a third story for the day and night uses of patients,
according to the 'ward-system' in operation; but they have no weight when
the floor is occupied only for sleeping. We must confess we cannot
appreciate the chief objection of Dr. Bucknill (_op. cit._ pp. 388, 389,)
to the use of a third floor for sleeping-rooms only, for we do not see the
reason why "the use of a whole story for sleeping-rooms renders the
single-room arrangement exceedingly inconvenient;" for surely, on the
common plan of construction, a row of single rooms might extend the whole
length of a third floor on one side of a corridor, equally well as on the
floors beneath.
Without desiring to enter on the question of the relative merits of
single-room and of dormitory accommodation, to examine which is the
special object of the paper quoted, we may remark, that the addition of a
third story, when the plan we have advocated is carried out, obviates the
generally admitted objections to such a proceeding. The same arrangement
of apartments may obtain in it as on the bedroom-floor below, and the
proportion of single rooms to dormitories, viz. one-third of the whole
sleeping accommodation to the former, insisted upon by Dr. Bucknill, can
be readily supplied. Attention would only be required to allow in the plan
sufficient day-room space on the ground-floor,--a requirement to be met
without difficulty.
The existence of a third story is no necessary feature to an asylum
constructed on the principle discussed, and we have adverted to it for the
sole purpose of showing that the ordinary objections to it are invalid,
when the arrangement and purposes of its accommodation are rendered
conformable to the general principles of construction advocated in this
chapter.
A hint from Dr. Bucknill's excellent remarks on the advantage of being
able to utilize spare half-hours must not be lost. Two flights of stairs,
he well states, constitute a great obstacle to a frequent and ready access
to the open air, and we are sure he would allow even one to be a
considerable impediment to it; and, consequently, that an asylum with no
stairs interposing between the patients and their pleasure-grounds would
possess the advantage of facilitating their enjoyment of them.
These remarks on the advantages of the principle of construction we advise
for adoption would admit of extension, but sufficient has been advanced,
we trust, to make good our views. We have taken in hand to write a chapter
on some principles in the construction of public asylums, but we must stop
at the point we have now reached; for it would grow into a treatise, did
we attempt to examine the many principles propounded, and entirely surpass
the end and aim of this present work.
THE END.
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