On the State of Lunacy and the Legal Provision for the Insane

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.