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