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

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.