§ _Detention of Patients in their own homes._
Absence of all curative influences at home, 32.--Causes of delay in
submitting patients to treatment, 33.--Impediments to transmission to
county asylums, 34.--Evils of pauper test in public asylums,
34.--Characters of Continental asylums, 35.--Practice followed in
America, 36.--Scheme of assessment of means of those applying for
admission to public asylums, 36.--Failure of the pauper test to
protect the rate-payers, 37.--Its demoralizing and degrading effects,
38.--Suggestion as to conditions and mode of admission into county
asylums, 38.--Act in force to recover the costs of maintenance
objectionable and inefficient, 39.
§ _Detention of Patients in Workhouses._
Detention practised on economical considerations, 40.--Examination of
the value of such considerations, 41.--Estimated cost in asylums and
in workhouses includes different items in the two, 41.--Illustration
from the Devon Asylum Report, 42.--Children constitute above
two-thirds of workhouse inmates, 42.--Material effect of this on the
cost of maintenance, 42.--Inmates of asylums almost all adult,
42.--Fluctuations among inmates of workhouses greater than in asylums,
43.--Mode of estimating the rate per head of cost in workhouses,
43.--Population of workhouses, sane and insane mixed, 44;--that of
asylums of insane especially, 44.--Those insane who involve increased
cost rejected from workhouses, 44.--Remarks on this point by Dr.
Bucknill, 44.--Economy of workhouses for the insane doubtful,
45.--Cost of asylums contrasted with that of workhouses, 46.--System
of asylum structure hitherto adopted unnecessarily expensive,
47.--Workhouses and asylums not fairly comparable as to cost,
47.--Plan to diminish cost of asylums one-half, 48.--Chronic lunatics
can be provided with asylum accommodation at a rate not exceeding that
for workhouses, 48.--Internal cost of asylums and workhouses compared,
49.--Mistaken policy of constructing lunatic wards, 50.--Unfitness of
workhouses for insane patients, 51, 75.--Evils attending presence of
lunatics in workhouses, 52.--American experience in the matter,
52.--Workhouses unfit by structure and organization, 52,
75.--Workhouse detention especially prejudicial to recent cases, 53,
81.--Deficiency of medical care and of nursing in workhouses, 54,
78.--The dietary of workhouses insufficient for lunatics, 54,
77.--Injurious effects of workhouse wards upon lunatics, 56,
77.--Lunacy Commissioners' remarks thereon, 56.--Dr. Bucknill's
remarks on the same subject, 57.--Characters of the lunatic inmates of
workhouses, 58.--The majority of them imbecile and idiotic,
58.--Proportion especially claiming asylum care, 59.--Epileptics and
paralytics unfit inmates of workhouses, 59.--Old demented cases badly
provided for in workhouses, 59.--Imbecile patients are, as a rule,
unfit inmates, 60.--Idiots improperly detained in workhouses,
61.--None but a few imbeciles permissible in workhouses, 61.--On the
class of supposed 'harmless' lunatics, 61.--Remarks by Dr. Bucknill on
this class, 62.--Experience of the Surrey magistrates on transferring
'harmless' patients to workhouses, 63.--Degradation of the patients'
condition in workhouses, 64.--Legality of workhouse detention
examined, 65.--Remarks on this subject by the Lunacy Commissioners,
66.--Clauses of the Lunacy Asylums Act bearing on the subject,
66.--Defects of the law in protecting the pauper insane, 68.--Remarks
of the Lunacy Commissioners on the anomalies of the law,
68.--Objections to the powers conferred upon parochial officers,
68.--The law obscure, and open to evasion, 69.--Duties of the parish
medical officers ill-defined, 69.--Proposal of a district medical
officer, 70.--Contravention of the law by Boards of Guardians, 71,
81.--The further construction of lunatic wards should be stopped,
72.--Necessity for the supervision of the Lunacy Commissioners over
workhouses, 72.--Several amendments of the Lunacy Laws suggested,
73.--Proposed regulations for supervision of workhouses containing
lunatics, 73, 82.--Lunatics in workhouses should be under
certificates, 73.--Proposal to increase powers of Lunacy Commissioners
over workhouses, 74.--On the Supplement to the 'Twelfth Report' (1859)
'of the Commissioners in Lunacy,' on workhouses, 74.--Abstract of its
contents:--unfitness of workhouses for lunatics, 75.--Workhouses in
large towns most objectionable, 76.--Lunatic wards more objectionable
than the intermixture of the insane with the other inmates,
76.--Miserable state of the insane in lunatic wards, 76, 79.--No
efficient visitation of workhouse lunatics, 77.--Insufficiency of the
dietary for insane inmates, 77.--Medical treatment and nursing most
defective, 78.--Fearful abuse of mechanical restraint in workhouses,
78.--Wretched neglect and want in the internal arrangements for
lunatics in workhouses, 79.--Abuse of seclusion in workhouses,
80.--Varieties of mechanical restraint employed, 80.--Absence of all
means for exercise and occupation, 80.--Lunatics in workhouses
committed to gaol, 80.--Neglect and contravention of the law by parish
officers, 81.--Amendments in the law suggested by the Lunacy
Commissioners, 81.--Proposal to erect asylums for chronic cases, 82,
126.--Visiting Justices of Asylums to supervise workhouse lunatic
inmates, 73, 82.
§ _Pauper Lunatics living with relatives or strangers._
Number of such lunatics, 83.--Neglect of their condition,
83.--Question of insanity should be left to the district medical
officer, 84, 175.--This officer should visit and report on their
condition, 85, 87.--Indications of the unsatisfactory state of this
class of pauper lunatics, 85.--Evidence from Dr. Hitchman's Reports,
85.--Wretched state of 'single' pauper patients in Scotland,
87.--Neglect of Poor-law medical officers towards such patients,
87.--Objections to boarding pauper lunatics with strangers,
88.--District medical officer to select their residence, 89,
146.--Advantage of keeping them in lodgings near asylums, 89,
146.--Distribution of lunatics in cottage homes, 90, 145.--Notice of
the colony of insane at Gheel, 90, 145.
§ _Unfit cases sent to asylums.--Improper treatment prior to admission._
Recklessness and cruelty in transmitting patients, 91.--Non-lunatic
cases sent to asylums, 91.--Cases of very aged persons sent,
92.--Previous horrible neglect of patients, and their moribund state
on admission, 93.--Extracts from Reports of asylum superintendents
illustrative of the facts, 91-96.--Transfer of lunatics to asylums
must be committed to some competent and independent officer, 97.--Want
of instruction for medical men in insanity, 97;--Errors committed
owing to the want of it, 98.--Neglect of psychological medicine in
medical education, 98.--Law regulating transfer of weak cases to
asylums, 99.--An amendment of the law requisite, 99.
CHAP. VI.--CAUSES OPERATING WITHIN ASYLUMS TO DIMINISH THE CURABILITY OF
INSANITY, AND INVOLVING A MULTIPLICATION OF CHRONIC LUNATICS.
§ _Magisterial interference_ and § _Excessive size of asylums_.
Defective medical staff in large asylums, 102.--Efficient treatment
impossible, 102, 121.--Degeneration of management into routine,
103.--Exclusive estimation of so-called 'moral treatment,' 103.--A
very large asylum especially prejudicial to recent cases,
104.--Delegation of medical duties to attendants, 105.--Evils of
absence of medical supervision over individual patients, 105.--Evils
of large asylums upon character of attendants, 106.--Routine character
of medical visits, 107, 143.--Necessity of medical supervision being
complete, 107, 115, 121.--Distinction of asylum attendants into two
classes--attendants proper, or nurses, and cleaners, 108.--Objections
advanced by the Lunacy Commissioners to large lunatic asylums,
109.--The erection of large asylums supposed to be economical,
110.--The supposition fallacious, 110.--Commissioners' remarks on
these topics, 111.--Rate of maintenance higher in the largest asylums,
112.--Inadequate remuneration of medical superintendents, 113.--Lord
Shaftesbury's advocacy of improved salaries, 113.
§ _Limit to be fixed to the size of asylums._
Proper number to be accommodated in an asylum, 114, 137, _et
seq._--Estimate of American physicians, 115.--Estimate of French and
German physicians, 116.--Peculiar organization of German asylums, 117,
141.
§ _Increase of the medical staff of asylums._
Opinions of foreign physicians on the subject, 118.--Estimate of the
medical staff requisite, 118.--Erroneous views prevalent in some
asylums, 119.--Illustration furnished by the Middlesex asylums,
119.--Jacobi's views of asylum organization, 121.--Advantages of unity
in the organization of asylums, 122.--Appointment of a chief
physician, paramount in authority, 122.--Circumstances affecting the
selection of asylum superintendents, 123.