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

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 —

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.