"How far a system of this kind, which virtually places in the hands of the

masters, many of whom are ignorant, and some of whom maybe capricious and

tyrannical, an almost absolute control over the personal liberty of so

many of their fellow men, is either warranted by law, or can be wholesome

in itself, are questions which seem open to considerable doubt. Probably

if the legality of the detention came to be contested before a judicial

tribunal in any individual case, the same considerations of necessity or

expediency which originally led to the practice, might be held to justify

the particular act, provided it were shown that the party complaining of

illegal detention could not be safely trusted at large, and that his

detention, therefore, though compulsory, instead of being a grievance, was

really for his benefit as well as that of the community."

Again, in the second place, the law, without direct legislation to that

effect, yet admits,--by the provisions it makes for pauper lunatics not in

asylums or licensed houses, and by the distinction it establishes between

persons proper to be sent to an asylum, and lunatics generally

so-called,--that insane patients may be detained elsewhere than in

asylums. For instance, by _sect._ lxvi. 16 & 17 Vict. cap. 97, 1853,

provision is made for a quarterly visit by the Union or Parish Medical

Officer to any Pauper Lunatic _not being_ in a Workhouse, Asylum,

Registered Hospital, or Licensed House, in order that he may ascertain how

the lunatic is treated, and whether he "may or may not properly remain out

of an asylum." So likewise by _sect._ lxiv. of the same Act, the clerk or

overseers are required to "make out and sign a true and faithful list of

all lunatics chargeable to the Union or Parish in the form in schedule

(D)." This form is tabular, and presents five columns, under the heading

of "where maintained," of which three are intended for the registry of the

numbers not confined in Asylums, Hospitals, and Licensed Houses, but who

are (1) in workhouses, (2) in lodgings, or boarding out, or (3) residing

with relatives.

Further, the law distinguishes, by implication, a class of lunatics as

specially standing in need of Asylum care, and as distinct from others. By

the Poor-Law Amendment Act (4 & 5 Will. IV. cap. 76. sect. 45), it is

ordered that nothing in that Act "shall authorize the detention in any

workhouse of any dangerous lunatic, insane person, or idiot for any longer

period than fourteen days; and every person wilfully detaining in any

workhouse any such lunatic, insane person, or idiot for more than fourteen

days, shall be deemed guilty of a misdemeanour." This section is still in

force, is constantly acted upon by the Poor-Law Board, and is legally so

read as if the word 'dangerous' were repeated before the three divisions

of mentally-disordered persons referred to, viz. lunatics, insane persons,

and idiots. So, likewise, by _sect._ lxvii. (16 & 17 Vict. cap. 97)--the

"Lunatic Asylums' Act, 1853," now in operation,--the transmission of an

insane individual to an asylum is contingent on the declaration that he is

"a lunatic and a _proper person to be sent to an asylum_."

Moreover, by _sect._ lxxix. of the same Act, it is competent to any three

Visitors of an asylum, or to any two in conjunction with the Medical

Officer of the asylum, to discharge on trial for a specified time "any

person detained in such asylum, whether such person be recovered or not;"

and by the following section (lxxx.) it is ordered, that, upon receipt of

the notice of such discharge, "the Overseers or Relieving Officers

respectively shall cause such lunatic to be forthwith _removed to_ their

parish, or to the _workhouse of the Union_." By the 79th section it is

further provided, that "in case any person so allowed to be absent on

trial for any period do not return at the expiration of such period, and a

medical certificate as to his state of mind, certifying that his detention

in an Asylum is no longer necessary, be not sent to the Visitors, he may,

at any time, within fourteen days after the expiration of such period, be

retaken, as herein provided in the case of an escape."

On the other hand, simple removal from an asylum is by the 77th section,

curiously enough interdicted except to another asylum, a Registered

Hospital, or a Licensed House. This intent, too, of the section is not

changed by the amendment, _sect._ viii. 18 & 19 Vict. cap. 105. Lastly, no

other place than an Asylum, Registered Hospital, or Licensed House, is

constituted lawful by _sect._ lxxii. for the reception of any person found

lunatic and under "order by a Justice or Justices, or by a Clergyman and

Overseer or Relieving Officer, to be dealt with as such." But this section

has to be read in connexion with preceding ones, for instance, with

_sect._ lvii., by which it is laid down that the Justices or other legal

authority must satisfy themselves not only that the individual is a

lunatic, but also that he is "a proper person to be sent to an asylum."

These quotations indicate the state of the law respecting the detention of

lunatics elsewhere than in asylums. This state cannot be held to be

satisfactory: it evidently allows the detention of lunatics in workhouses,

while at the same time it affords them little protection against false

imprisonment, and makes no arrangement for their due supervision and care,

except by means of the visits of the Lunacy Commissioners, which are only

made from time to time, not oftener than once a year, and rarely so often.

The alleged lunatics are for the most part placed and kept in confinement

without any legal document to sanction the proceeding; without a

certificate of their mental alienation, and without an order from a

magistrate. Within the workhouse, they are, unless infirm or sick, treated

like ordinary paupers, save in the deprivation of their liberty of exit;

they may be mechanically restrained, or placed in close seclusion by the

order of the master, who is likely enough to appreciate the sterner means

of discipline and repression, but not the moral treatment as pursued in

asylums; and, lastly, they live deprived of all those medical and general

measures of amelioration and recovery as here before sketched.

An extract from the 'Further Report' of the Commissioners in Lunacy will

form a fitting appendix to the observations just made. It occurs at p. 287

(_op. cit._), and stands thus:--

"It certainly appears to be a great anomaly, that while the law, in its

anxiety to guard the liberty of the subject, insists that no persons who

are insane--not even dangerous pauper lunatics--shall be placed or kept in

confinement in a lunatic asylum without orders and medical certificates in

a certain form, it should at the same time be permitted to the master of a

workhouse forcibly to detain in the house, and thus to deprive of personal

liberty, any inmate whom, upon his own sole judgment and responsibility,

he may pronounce to be a person of unsound mind, and therefore unfit to be

at large."

It is unsatisfactory that the law recognizes the distinction between

dangerous and other lunatics, designated as "harmless;" for we have

pointed out that no such rigid separation can be made; that it is with

very few exceptions impracticable to say with certainty what patients are

harmless and what not, inasmuch as their state is chiefly determined by

surrounding conditions, by the presence or absence of moral control and

treatment. It is likewise to be regretted that so much is left to the

discretion of relieving officers and overseers, in the determination of

the lunatics "proper to be sent to an asylum;" for those parish

functionaries nearly always display a proclivity, where relief is to be

afforded, to any plan which at first sight promises to be the most cheap;

and hence it is, as remarked in previous pages, they think to serve the

rate-payers best by keeping, if practicable, the insane in workhouses. The

expediency of asylum treatment for those who claim it, is surely not a

question to be determined by such officers. Yet the wording of the Act

(_sect._ lxvii.), that, if they have notice from the parish medical

officer of any pauper who "is, or is deemed to be a lunatic, and a proper

person to be sent to an asylum," or if they in any other manner gain

knowledge of a pauper "who is, or is deemed to be a lunatic, and a proper

person to be sent to an asylum, they shall within three days" give notice

thereof to a magistrate,--seems to put the solution of the question pretty

much in their hands. Although when they receive a notice of a pauper

lunatic from the union medical officer, they would appear by _sect._ lxx.

to be bound to apprise a Justice of the matter, yet, in the absence of

such a notice, an equal power in determining on the case is lodged in

their hands as in those of the medical officer, by the phrase "is, or is

deemed to be a lunatic, and a proper person to be sent to an asylum;" for

this clause respecting the fitness of the case, reads with the parts of

the sentence as though it stood thus in full--'is a lunatic and a proper

person to be sent to an asylum, or is deemed a lunatic and a proper person

to be sent to an asylum;' and there is nothing in _sect._ lxx. to enforce,

under these circumstances, a notice being sent to a Justice. It is,

indeed, evidently left to the discretion of the overseer or relieving

officer to report a case of lunacy falling within his own knowledge to a

Justice, for he is empowered to assume the function of deciding whether it

is or is not a proper one for an asylum. Moreover, we cannot refrain from

thinking that a parochial medical officer is not always sufficiently

independent, as a paid _employé_, to certify to the propriety of asylum

care so often as he might do, where the guardians or other directors of

parish affairs are imbued with rigid notions of economy, and hold the

asylum cost for paupers in righteous abhorrence. In fine, were this

enactment for reporting pauper lunatics to County and Borough Justices, in

order to obtain a legal sanction for their detention, sufficiently clear

and rigidly enforced, there would not be so many lunatics in workhouses,

and none of those very unfit ones animadverted upon by the Commissioners

in Lunacy (see p. 25, and 11th Rep. C. L. 1857).

The first clause of _sect._ lxvii. is ambiguous; for though it is

evidently intended primarily to make the Union medical officer the vehicle

of communicating the knowledge of the existence of pauper lunatics in his

parish, yet it is neither made his business to inquire after such

persons, nor when he knows of their existence, to visit and ascertain

their condition. It is left open for him to act upon a report that such a

pauper "is deemed to be a lunatic, and a proper person to be sent to an

asylum," without seeing the individual; but generally he will officially

hear first of such patients through the channel of the relieving officer,

by receiving an order to visit them. Indeed, the relieving officer is

legally the first person to be informed of a pauper requiring medical or

other relief; and, as we have seen, it is competent for him to decide on

the question of asylum transmission or not for any case coming directly to

his knowledge. Hence, in the exercise of his wisdom, he may order the

lunatic forthwith into the Union-house, and call upon the medical officer

there to visit him. The consignment of the lunatic to the workhouse being

now an accomplished fact, it becomes a hazardous enterprise, and a

gratuitous task on the part of the medical officer (for no remuneration is

offered for his report), to give the relieving officer or overseer a

written notice that the poor patient should rightly be sent to the asylum,

when he knows that those parish authorities have made up their minds that

it is not a proper case to be sent there. In fact, the law makes no demand

of a notice from the medical officer of the Union necessary where the

knowledge of a lunatic pauper first reaches the relieving officer or

overseer, or where the patient is already in the workhouse; and no report

will be sought from him under such circumstances, unless the parochial

authorities decide that they will not take charge of the case in the

workhouse.

The object of the 67th and five following sections is evidently to promote

the discovery of pauper lunatics, and to ensure the early transmission of

all those amenable to treatment to County Asylums; but these advantages

are not attained, the legal machinery being defective. To fulfil the

intention, it should be made imperative on the part of the relatives or

friends to make known the occurrence of a case of lunacy at its first

appearance to a duly-appointed medical man, who should visit and register

it, and, with the concurrence of a magistrate, order detention in a

properly-constituted asylum. Such a medical officer would have a district

assigned to him; of his duties at large we shall have occasion hereafter

to speak; to allude further to them in this place will cause us to diverge

too widely from the subject under consideration.

The 67th section of the "Lunatic Asylums' Act," which has above been

submitted to criticism, we find referred to in the Lunacy Commissioners'

Eleventh Report, wherein it is spoken of as disregarded by parochial

authorities; its ambiguity and the loophole to a contravention of its

meaning being, however, unnoticed. The reference occurs in the following

passage (_op. cit._ p. 16), which censures a practice we have already

animadverted upon:--

"And here we take occasion to remark, that if the law were more strictly

carried out in one particular, the same temptation to a mistaken and

ill-judged economy would not so frequently present itself to Boards of

Guardians; nor could it so often occur to them as an advantage, that they

should themselves manage their insane poor by the resources at their own

disposal. A custom prevails, very generally, of sending all pauper

lunatics to the workhouses in the first instance, instead of at once

procuring an order for their transmission to an asylum; and nothing has

more contributed to the many recent and acute cases improperly so

detained. The practice, it is hardly necessary to say, is in direct

contravention of the law applicable to insane paupers. Assuming that they

come ordinarily at first under the care of the District Parish Surgeon, he

is bound to give notice (under the 67th section of the Lunatic Asylums'

Act) to the Relieving Officer, by whom communication is to be made to the

Magistrate, upon whose order they are to be conveyed to an Asylum; but in

effect these provisions are disregarded altogether. And thus it follows,

that the patient, if found to be manageable in the workhouse, is

permanently detained there; or even should he ultimately find his way to

an asylum, it is not until so much valuable time has been lost that his

chances of cure are infinitely lessened. For, although it is our

invariable habit, on the occasion of visiting workhouses, to recommend the

removal to asylums of all whom we consider as curable, or exposed to

treatment unsuited to their state, we find nothing so difficult as the

enforcement of such recommendations; and for the most part the Report of

the Medical Officer of the Union, to the effect that the patient is

'harmless,' is suffered to outweigh any opinion we can offer."

In this quotation, therefore, we have an official proof that the defective

and ambiguous legislation above commented upon is practically not without

its mischievous fruits to the well-being of the insane poor. To amend it,

some such scheme as we have sketched is called for to secure the reporting

of lunatics, their examination and registration, and the legal sanction to

their detention for the purposes of their own safety and that of others,

and of their treatment; and were it not that at the present moment asylum

accommodation cannot be afforded to all the pauper lunatics of the

kingdom, their confinement in workhouses ought to be at once rendered

illegal. Convinced as we are, that asylums for the insane could be

erected, fitted, organized, and maintained at a cost which would leave no

pecuniary advantage economically on the side of workhouses; and that, even

were the primary expenditure of the latter considerably less, they would

in the long run be more expensive on account of their unfitness for

lunatic patients, whatever the type of their malady, the injuries they

entail on the well-being of all, and the chronic insanity they produce and

foster,--it is with much reluctance we are forced to endorse the statement

made by the Commissioners in Lunacy, in their 11th Report (p. 17), that

workhouse "Lunatic Wards will have to be continued for some time longer,"

until, we may add, a more comprehensive, and withal a modified scheme be

brought into operation, to cherish, to succour, and to cure those

suffering under the double evil of poverty and insanity. Though a remedy

to meet the whole case must unfortunately be delayed, yet the Lunacy

Commissioners nevertheless need continue energetically to discourage the

plan of building special lunatic wards to workhouses, as one, according to

their own showing, indeed, fraught with very many evils to their inmates.

Such erections ought, in fact, to be rendered illegal; the money spent on

them would secure proper accommodation in connexion with a duly organized

and managed asylum, as demonstrated in previous pages (p. 48), for all

those classes of pauper lunatics, which, under any sort of plea or

pretence, can be detained in workhouses. Lastly, we must look to the

Commissioners to maintain an active supervision over workhouse

inmates,--to hold, at least, an annual "jail delivery" of every

union-house, to order the immediate transfer of evidently improper

inmates, and to remove others, so to speak, for trial.

The "leading principles," as laid down by the Commissioners in 1847

(Report, p. 269), and to which, in subsequent Reports, they state their

continued adhesion, are as good as the present state of lunacy and lunatic

asylums permit to be enforced; but they can be enforced only by the

Commissioners themselves, or others possessing equal authority; for

workhouse officials will interpret them through the medium of their own

coloured vision; and if magistrates were entrusted with the task, we have

no confidence that it would be efficiently performed by them as

inexperienced, non-medical men, with whom economical considerations will

hold the first place. The principles referred to are expressed in the

following paragraph:--

"We have invariably maintained that the permanent detention in a workhouse

of any person of unsound mind, whether apparently dangerous or not, whose

case is of recent origin, or otherwise presents any hope of cure through

the timely application of judicious treatment, or who is noisy, violent,

and unmanageable, or filthy and disgusting in his habits, and must

therefore be a nuisance to the other inmates, is an act of cruelty and

injustice, as well as of great impolicy; and we have on all occasions

endeavoured, so far as our authority extends, to procure the speedy

removal of persons of that description to a lunatic asylum."

The following practical suggestions, calculated to improve the condition

of the insane poor, are deducible from the foregoing remarks on workhouses

considered as receptacles for lunatics.

1. The County Asylums should afford aid to all insane persons unable to

procure proper care and treatment in private asylums; and 2, such patients

should be directly transmitted to them; the circumstance of their entire

or partial liability to the poor-rates being, if necessary, subsequently

investigated. 3. As a corollary to the last suggestion, the primary

removal of patients to a workhouse should, save in very exceptional cases,

such as of distance from the asylum and unmanageable violence at home, be

rendered illegal; or, what is nearly tantamount to it, for the future no

alleged lunatic should be suffered to become an inmate of a workhouse,

except with the written authority of the District Medical Officer or

Inspector proposed to be appointed. 4. Without the sanction of this

officer, likewise, no lunatic should be permitted to be discharged or

removed from a workhouse. This is necessary for the patient's protection,

for securing him against confinement in any house or lodging under

disadvantages to his moral and physical well-being, to check improper

discharges, and to protect the asylum against the transfer to it of unfit

cases, a circumstance which will presently be shown to be of frequent

occurrence. 5. No person should be detained as a lunatic or idiot, or as a

person of unsound mind in a workhouse, except under a similar order as

that required in the case of asylum detention, and a medical certificate

to the fact of his insanity. 6. If workhouses need be used, whether as

temporary or as permanent receptacles for the insane, they should be

directly sanctioned by law, placed under proper regulations, and under

effective supervision, not only of the Lunacy Commissioners, but also of a

Committee of Visitors, and of the District Medical Officer, whose duty it

would be to watch over the welfare of the insane inmates, their treatment,

diet, occupation, and amusement. The Visitors should be other than

guardians or overseers of the poor of the union or parish in which the

workhouse is situated, although every union should be represented on the

Committee; and they might be selected from the magistrates, and from the

respectable classes among the rate-payers. If the county were large, it

might be advantageously divided into districts, a Committee of Visitors of

Workhouses being appointed in each district. 7. Every workhouse containing

lunatics should be licensed as a place of detention for them by the

Committee of Visitors, who should have authority to revoke the license.

This power of revoking the license should be also vested in the

Commissioners in Lunacy. 8. Every such workhouse, and the number of its

insane inmates, should be reported to the Lunacy Commissioners. According

to our scheme, the District Medical Officer would do this, as well as

report generally to the Lunacy Board, the condition and circumstances both

of the workhouse and of its insane inmates. 9. For the future, the

erection or the appropriation of distinct lunatic wards to workhouses

should be interdicted by law.

By the preceding suggestions reforms are, indeed, proposed to render

confinement in workhouses legal; to make it more satisfactory; to provide

for effectual supervision, and in general to assimilate the wards of

union-houses more closely to those of asylums. Yet all this is done only

on the ground of the necessity for some legislation on these matters, and

more particularly under the pressing circumstances of the time. The

present state of lunacy compels acquiescence in the Lunacy Commissioners'

statement, that workhouse-wards must for some time longer be used for the

detention of insane paupers; and this fact alone supplies an apology for

making suggestions to improve them. Moreover, apart from it, the workhouse

will at times necessarily be the temporary refuge for some few cases, and

may be occupied as a permanent dwelling by those rare instances of

imbecility of mind which can be allowed to intermingle with the other

inmates, and be usefully occupied; and for these reasons it need be

rendered both a legal and not unsuitable abode. At the same time, it is

most desirable that the Lunacy Commissioners should be able not only to

discourage, but also to veto the construction of lunatic-wards for the

future, on the grounds already so largely pointed out; and for this

reason, moreover, that where such wards exist, they are thought good

enough for their poor inmates, and are looked upon as asylums over which

the county institution has little preference. The existence, therefore, of

any specially erected or adapted ward, may always be urged against the

proposition for further expenditure in providing for pauper lunatics

elsewhere in suitable asylums;--a plea, which should consequently be set

aside by overturning the foundation whereon it rests.

Since the preceding observations on the detention of pauper lunatics in

workhouses were in print, a most important supplementary Report on the

subject has been put forth by the Commissioners in Lunacy (Supplement to

the Twelfth Report; ordered to be printed 15th of April, 1859). We have

read this Report with pleasure, so far as it confirms the views we have

taken, but with surprise and pain at the details it unfolds of practices

the most revolting to our better feelings, and, in general, of a state of

things discreditable to a civilized and christian country. By being

confirmatory of the opinions and statements advanced by us, it may be said

to give an official sanction to them; and as it is one of the most

important documents ever issued by the Board, we shall attempt an

analysis of its contents.

In the first place, the Commissioners resort to some recent corrected

returns of the Poor-Law Board, and discover that the number of pauper

lunatics in workhouses was, on the 1st of January, 1858, 7555, _i. e._

upwards of 500 above that returned in the Tenth Report of the same Board,

and referred to in the foregoing pages; and on the 1st of July in that

same year it amounted to 7666. They then proceed to describe the

"character and forms of insanity most prevalent in workhouses," and show

that their insane inmates all require protection and control; that "some,

reduced to poverty by their disease, are of superior habits to those of

ordinary paupers, and require better accommodation than a workhouse

affords. Many are weak in body, and require better diet. Many require

better nursing, better clothing, and better bedding; almost all (and

particularly those who are excitable) require more healthful exercise,

and, with rare exceptions, all require more tender care and more vigilant

superintendence than is given to them in any workhouse whatsoever."

On turning to the "Design and Construction of Union Buildings," they

rightly point out that the stringent conditions to ensure economy, and to

check imposition and abuse, the "reduced diet, task labour, confinement

within the narrow limits of the workhouse premises," the plan of

separating the inmates into classes, the scanty means of out-door

exercise, &c., are inimical to the well-being of the insane residents. In

the "Modes of Workhouse Direction and Administration" there is great

unfitness. The rules under which the officers act "are mainly devised to

check disorderly conduct in ordinary paupers; and it is needless to say

with how much impropriety they are extended to the insane. Any increase of

excitement, or outbreak of violence, occurring in the cases of such

patients, instead of being regarded as a manifestation of diseased action

requiring medical or soothing treatment, has subjected the individual to

punishment, and in several instances led to his imprisonment in a jail. In

addition to these hardships, the lunatic patient is for the most part

precluded from leaving the workhouse at his own will. In effect he becomes

a prisoner there for life, incapable of asserting his rights, often of

signifying his wants, yet amenable to as much punishment as if he were

perfectly sane, and a willing offender against the laws or regulations of

the place. Nor, as will hereafter be seen, is his lot much bettered in the

particular cases where it is found convenient to the authorities to relax

those restrictions, and give him the power at will to discharge himself."

Rural workhouses of small size are generally preferable abodes for the

insane than those of larger dimensions, since their "arrangements have a

more homely and domestic character, and there are more means of occupation

and of free exercise in the open air;" and where their imbecile inmates

can be associated with the ordinary paupers, and regularly employed, their

condition is not unfavourable; "but these form only the exceptions."

Workhouses in the metropolis and in large towns generally, are for the

most part "of great size, old, badly constructed, and placed in the midst

of dense populations. The weak-minded and insane inmates are here

generally crowded into rooms of insufficient size, sometimes in an attic

or basement, which are nevertheless made to serve both for day and

sleeping accommodation. They have no opportunity of taking exercise; and,

from the want of space and means of separation, are sometimes associated

with the worst characters, are subjected unnecessarily to seclusion and

mechanical restraint, and are deprived of many of the requisites essential

to their well-being."

"Of the 655 workhouses in England and Wales, somewhat more than a tenth

part are provided with separate lunatic and idiot wards."

The "Objections to Intermixture of Inmates" are briefly stated. "There is

no mode of complying with suggestions for" the peculiar benefit of insane

inmates, "without disturbing the general economy of the house,--a fact

which shows how important it is that no lunatic or idiot should be

retained for whom any special arrangements are necessary." Separate

lunatic wards are declared to be more objectionable than the intermixture

of the pauper inmates. Only occasionally are such wards found at all

tolerable; and even then, the constant medical supervision, proper

attendants and nursing, sufficient diet, exercise, occupation, and other

needful provisions, are deficient. The majority are thus sketched:--"In

some of the wards attached to the old workhouses the rooms are crowded,

the ventilation imperfect, the yards small and surrounded by high walls;

and in the majority of instances the bed-rooms are used also as day-rooms.

In these rooms the patients are indiscriminately mixed together; and there

is no opportunity for classification. There is no separation where the

association is injurious; and no association where such would be

beneficial. In fact, patients of all varieties of character,--the weak,

the infirm, the quiet, the agitated, the violent and vociferous, the dirty

and epileptic,--are all mingled together, and the excitement or noise of

one or more injures and disturbs the others. The restless are often

confined to bed to prevent annoyance to the other patients, and the infirm

are thus disposed of for the want of suitable seats. Their condition when

visited in the daytime is obviously bad, and at night must be infinitely

worse. Even in workhouses where the wards are so constructed as to provide

day-rooms, these are often gloomy, much too small in size, and destitute

of ordinary comforts; while the furniture is so poor and insufficient,

that in some instances, there being no tables whatever, the patients are

compelled to take their meals upon their knees. Other cases to be

hereafter mentioned will indeed show that it is reserved for lunatic wards

of this description, and now happily for them only, to continue to exhibit

some portion of that disregard of humanity and decency, which at one time

was a prevailing characteristic in the treatment of insanity."

Not only, again, are there no sufficiently responsible authorities in the

house, and no qualified responsible attendants, but also no records of

restraint, of seclusion, of accident, or injury, or of medical or other

treatment. "Above all, there is no efficient and authoritative official

visitation. The Visiting Justices never inspect the lunatic wards in

workhouses, and our own visits are almost useless, except as enabling us

to detect the evil that exists at the time of our visit, and which, after

all, we have no power to remove." The "Results of Neglect in Deteriorating

the Condition of Patients" of all classes are ably portrayed. In the

absence of attentive and experienced persons to watch and to supply their

wants, many of the insane suffer unheeded and without complaint, to the

prejudice of their mental and bodily state; or become inattentive to

natural wants, and prone to violence and mischief. "In a very recent case

of semi-starvation at the Bath Union, when the frauds and thefts of some

of the attendants had, for a considerable time, systematically deprived

the patients of a full half of their ordinary allowance of food, the only

complaint made was by the wan and wasted looks of the inmates."

In the two next sections the Commissioners insist that the duty of

distinguishing the cases in workhouses to be classified as "Lunatics,

Insane Persons and Idiots," should be performed by the medical man

independently of the master; and that, without examination and sanction

from that officer, no person of weak mind should be discharged, or allowed

to discharge himself. Very ample cause for this latter proposition is

shown in the illustrations appended, particularly in the case of imbecile

females, who not unfrequently become, when at large, the prey to the

vicious, further burden the parish by their illegitimate offspring, and

often by an idiotic race.

"The diet necessary for the insane" is required to be more liberal than

for other inmates; yet the Commissioners have "in very numerous instances"

animadverted upon its inadequacy, both in quantity and quality, but

without result, except "in very few instances:" for, notwithstanding that

"the medical officer of a Union has full power" (by the Consolidated Order

207, art. No. 4) "to give directions, and make suggestions as to the diet,

classification and treatment of the sick paupers, and paupers of unsound

mind," yet, we are sorry to learn, that "the power thus given, although

backed by our constant recommendations, is rarely exercised by the medical

officer."

This circumstance is so far confirmatory of a view we have above taken,

that the medical officer of a parish or union is neither sufficiently

independent, as the paid _employé_ of the guardians, to carry out measures

that may be necessary for the alleviation of the condition of lunatics in

workhouses, where such means involve increased cost (we regret to

entertain the notion); nor always sufficiently acquainted with the wants

of the insane.

Considering the disadvantages of workhouses as receptacles for them, the

general statement follows naturally, that as a class of workhouse inmates,

the lunatics "are manifestly lower in health and condition than the same

class in asylums. Hence," add the Commissioners, "the patients' bodily

health and mental state decline upon removal from asylums to

workhouses--an effect chiefly due to the inferior diet." There are great

"variations in workhouse dietaries,"--from one spare meat dinner in the

week to a meat dinner daily. This latter provision is furnished "in a very

small number of houses." These dietaries are indeed much inferior to those

considered necessary for criminals in jails; a fact that affords a sad

comment on English consistency, which is thus found dealing with more

favour and consideration towards those who have transgressed the laws of

their country, than to those whose only crime is poverty, or poverty

complicated with disease or infirmity.

Medical treatment would, in truth, seem to be not legally provided at all

for lunatics in workhouses: no clause makes a visit of the union medical

officer to the lunatic-ward of a workhouse imperative. As examples of the

slight esteem in which medical supervision is held, the Leicester and the

Winchcombe houses are quoted. In the former, the visits of the medical

officer were only made quarterly; in the latter, by stipulation three

times a week, but in practice very irregularly. Attendance and nursing

are, as might be expected, on a par with medical treatment. Even imbeciles

have been found exercising the functions of nurses, and, generally

speaking, the selection of attendants is made from old and feeble people,

having no experience, no aptness for the duties, no particular qualities

of intellect or temper to recommend them, and receiving such a mere

pretence, if any at all, in the way of remuneration for their trouble,

that no painstaking efforts can be looked for from them. "Yet to such

individuals, strait waistcoats, straps, shackles, and other means of

restraining the person are not unfrequently entrusted; and they are,

moreover, possessed of the power of thwarting and punishing at all times,

for any acts of annoyance or irregular conduct, which, although arising

from disease, are nevertheless often sufficient to provoke punishment from

an impatient and irresponsible nurse."

The interior accommodation, fittings, and furniture are, if not abominably

bad, excessively defective: and on reaching this part of the Report, where

the details of internal fittings and management come under review, the

impression derivable from its perusal is akin to that gathered from the

revelations of madhouses made by the Parliamentary Committees of 1814 and

1815. The sketch of the evils suffered by lunatics in workhouses, which we

have ourselves attempted in past pages, tells a flattering tale compared

with the realities unfolded to us by the Commissioners, and adds a tenfold

force to the arguments against the detention of lunatics in such places.

To continue the practice would be to perpetuate a blot upon the internal

polity, the philanthropy and the Christianity of the country. Let those

who would know the whole case refer to the Report in question; it is

sufficient for our purpose to attempt a mere outline of its revelations.

Patients are frequently kept in bed because there are no suitable seats

for them; a tub at times answers the double purpose of a urinal and a

wash-basin; a privy is partitioned off in a small dormitory; baths are

almost unknown; a trough or sink common to all supplies the want of basins

for washing, and an outhouse or the open air furnishes the appropriate

place for personal ablutions. Clothing, again, is often ragged and

insufficient; in an unwarmed dormitory, a single blanket, or only a

coverlet, is all the covering afforded by night; loose straw in a trough

bedstead usually constitutes the bed for wet and dirty patients to nestle

in; and whether the bed be straw or not, the practice of using it night

after night, when "filthy with dirt, and often rotting from frequent

wetting, has been many times animadverted upon." In some workhouses two

male patients are constantly placed in the same bed; nor is the character

of the bedfellows much heeded; for a sane and insane, two idiots, one

clean and one dirty, and even two dirty inmates, have been found

associated together in the same bed, occasionally in a state of complete

nudity.

Further, the want of exercise and employment, the absence of supervision

and control, and the entrusting of means of coercion to irresponsible and

unfit attendants, lead to the most shocking abuse of restraint, and to

cruel seclusion.

"The requirement occasionally made by the Visiting Commissioner, that the

Master shall make a written record of such proceedings, is utterly

neglected. The dark, strong cells, constructed for the solitary

confinement of refractory paupers, are used for the punishment of the

insane, merely to prevent trouble; quiet helpless creatures, from whom no

violence could be apprehended, are kept in bed during the daytime, or

coerced; and even the dead-house has been made to serve the purpose of a

seclusion-room."

"The Examples of Restraint practised," as adduced in the Report, recall to

mind all those barbarities which civilized men of the present day are in

the habit of congratulating themselves as matters of the past, and the

subject of history. The catalogue of appliances for restraint reappears

once more on the scene; and we read of straps, leather muffs, leg-locks,

hobbles, chains and staples, strait-jackets, and other necessary

paraphernalia, as of yore, worn for days, or weeks, or months. Excellent

matter, indeed, in all this, to garnish a discourse on the advancement of

civilization, on the prevalence of improved notions respecting the

treatment of the insane, or on some similar topic addressed to the vanity

of the present generation!

But the chapter does not end here. "It would be difficult to select places

so entirely unfit for the purpose of exercise, or so prejudicial to the

mental or bodily state of the person confined," as the yards or spaces set

apart for it; and yet "of all the miseries undergone by this afflicted

class, under the manifold disadvantages before described, and of all the

various sources of irritation and discomfort to which we have shown that

they are exposed, there is probably none which has a worse effect than the

exclusion from all possibility of healthy movement. Nothing more

powerfully operates to promote tranquillity than the habit of extensive

exercise; and in its absence, the patients often become excited, and

commit acts of violence more or less grave, exposing them at once to

restraint or seclusion, and not unfrequently to punishment. In not a few

instances the outbreak has been looked upon as an offence or breach of

discipline, and as the act of a responsible person; and the patient has

been taken before a magistrate and committed to prison.

"A very grave injustice, it is hardly necessary to add, is thus committed,

in punishing by imprisonment individuals who are recognized and officially

returned as being of unsound mind. These persons in no respect differ from

the class of the insane usually met with in asylums, and are equally

entitled to the same protection, and the same exemption from punishment.

Instead of such protection, however, the patient is exposed to double

injury:--first, he is subjected to various sources of irritation while

confined in the workhouse, directly occasioning excitement; and, secondly,

the mental disturbance resulting therefrom is regarded as a crime, and is

punished by imprisonment."

The Commissioners in Lunacy next direct attention to the principal cause

of the evils described, which they discover in the neglect and evasion of

the duties imposed by the law on the officers of parishes and unions, in

the interests of the pauper insane. Thus, as remarked in previous

pages,--"Instead of causing the patient to be dealt with as directed by

the 67th and 68th sections of the Lunatic Asylums' Act, 1853, and

immediate steps to be taken for his direct removal to the asylum,

workhouses have been to a great extent made use of primarily as places for

the reception, and (in many instances) for the detention of recent cases

of insanity.

"The workhouse is thus illegally made to supply the place of a lunatic

establishment, and the asylum, with its attendant comforts and means of

cure, which the law has provided for the insane poor, is altogether

disregarded; or it comes into operation only when the patient, by long

neglect, has become almost hopelessly incurable. We should remark that

this occurs most frequently in the larger workhouses, and in those having

insane wards."

... "How totally unfit even workhouses having insane wards are for the

proper treatment of recent curable cases, we have endeavoured to exhibit

in some detail. Nevertheless, the practice of making use of them for all

classes of insane patients is rapidly increasing, and our efforts to check

it have proved hitherto quite ineffectual."

After further adverting to the influence of the neglect of the laws in

increasing pauper lunacy, they very briefly discuss the comparative cost

of lunatics in workhouses and in asylums, but their examination adds

nothing to what we have much more fully put forward on this subject.

Their "conclusion" contains some valuable suggestions, more or less

identical with those we have ourselves independently advanced, and which

may be briefly summed up as follows:--

"To remedy many of the evils adverted to would, in our opinion, be

impracticable, so long as insane patients are detained in workhouses,

whether mixed with other inmates or placed in distinct wards.

"The construction and management of workhouses present insurmountable

obstacles to the proper treatment of the disease of insanity; and

therefore the removal of the majority of the patients, and the adoption of

stringent measures to prevent the admission of others, have become

absolutely necessary."

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.

We shall return to this subject in a subsequent section,--"On the

distribution of the chronic insane in cottage-homes."

§ _Transmission of unfit Cases to Asylums--improper Treatment prior to

Admission._

In preceding pages it has been remarked that the transfer of lunatics to

asylums is regulated not by the nature of their case, and its amenability

to treatment or amelioration, but by the circumstance of their being

refractory and troublesome, annoying by their habits, or so infirm and

sick as to require attentive nursing; or, in general, in such a state that

their residence involves an increased and unworkhouse-like cost. The

question of the recency of the attack is treated as of far less moment;

for if the poor sufferer have what are called harmless delusions, or if he

is only so melancholic that suicide is not constantly apprehended, then

under these and such similar conditions, the economical theory of the

establishment commonly preponderates over every consideration of the

desirability of treatment in the presumedly expensive asylum, and the

patient is retained. In course of time his malady becomes chronic, and in

all probability incurable, and his condition so deteriorated in all

respects by the absence of proper measures for his mental and moral

treatment, that sooner or later his physical health gives way, or his

habits grow inconveniently annoying and troublesome, and then it is that

workhouse officials discover that the County Asylum is his suitable abode.

By this system of 'clearance' the workhouses are relieved of their most

burdensome and costly inmates, who fall to the charge of asylums, in which

their presence necessarily keeps down the rate of recoveries, multiplies

the proportion of chronic lunatics, and increases the expenses and the

rate of mortality.

The Medical Superintendents of our Asylums bear witness to the

recklessness, and to the cruelty, at times, which often mark the doings of

workhouse authorities when they wish to rid themselves of the cost and

trouble of any of the lunatic poor in their keeping. The illustrations at

hand, obtained from County Asylum Reports, are so numerous, that we must

content ourselves with a selection of a few of the more striking.

Dr. Boyd, the distinguished physician of the Somerset County Asylum, makes

the following statement in his Sixth Report (1853):--"Several aged

persons, and many others in a feeble state, have been admitted during the

year, so that the mortality, although less than in the preceding year, has

still been considerable. For example, two cases have been recently

admitted: one that of a man with dropsy, and broken down in constitution,

who is reported to have been given to excess in drinking ardent spirits,

and to have been subject to epileptic fits; he was disappointed at not

being admitted into a general hospital, became violent, and was sent as a

patient here; he has been free from fits since his admission, is rational,

but apparently in the last stage of bodily disease. The other case is that

of a woman about seventy, paralysed, and unable to sit up in the arm-chair

without support. She was troublesome in the union workhouse, and was

reported _as dangerous_, and so was sent to the asylum. There have been

four males with paralysis recently sent in from being dirty in their

habits.... One female was improperly sent with _delirium_ attending on

_fever_: she died a fortnight after admission." In his Ninth Report, this

same Superintendent says,--"Some are sent to the asylum in a state of

paralysis, some are aged and in a state of fatuity, and others when they

become troublesome, or are in a diseased and feeble state of bodily

health, and require more nurse-tending than they receive in the

workhouses.... Under the existing arrangements, lunatic asylums are

gradually losing their proper character of hospitals for the recovery of

the insane, and sinking down to be mere auxiliaries to workhouses."

Out of eighty admissions at the Worcester County Asylum, fourteen were

between sixty and eighty years of age, and for the most part "the subjects

of organic disease of the brain, lungs, and heart, or suffered from

long-continued mental disease, or from the superannuation of old age, and

deficient nutrition of the brain and nervous centres. Four of them died

during the year.... During the early part of the year some correspondence

was entered into with several Unions, from which patients had been sent in

a dying or exhausted state; and the impropriety of such proceeding was

pointed out by your Committee.... It is not supposed that those

unfortunate cases are wilfully detained with improper intentions at their

homes or elsewhere, but from ignorance; and from want of the necessary

appliances, and the assistance of those accustomed to the insane, proper

measures cannot be adopted for their care and recovery," and various

injuries are inflicted.

The experienced Superintendent of the Beds., Herts., and Hunts. Asylum

reports, in 1856, that of 111, as many as twelve died within three months

of their being admitted; five did not survive a fortnight. "One male, an

epileptic seventy-nine years of age, and having been bedridden for years

from contracted limbs, and nearly exhausted from the journey, died on the

twelfth day. A female, aged sixty-eight, with disease of the heart, died

on the fourth day from exhaustion, having been some time without rest, and

having refused her food previous to admission. A female in the last stage

of pulmonary consumption, lived but seventeen days; and one very

distressing case of a female ... was brought to the asylum, who, worn out

from constant excitement, and having a large wound on the leg, with

ulcerations from ligatures on the wrists and ankles, sank on the

fourteenth day. The two last-mentioned patients were reported to have

refused food for nearly a week, but took every kind of nourishment offered

to them from the moment they were in the Asylum."

The Report of the Suffolk County Asylum records the admission of ten poor

persons in 1852 "nearly seventy years of age, nine over seventy, three

over eighty; sixteen in a state of bodily exhaustion; nine either idiots

from birth, or imbeciles for a very long period; one child with well-known

disease of the heart, and a woman, a cripple, scrofulous, blind and deaf."

"What," asks Dr. Kirkman, the venerable Superintendent, "can be done more

than good nursing to support a peevish mind in a patient eighty-four,

admitted only a few days ago?" He adds, "To give other instances, one man

was received some time back on a very qualified certificate, and upon

whose case a qualified certificate only could be given; and another

(somewhat experimentally) with the notice that his mania, if such it were,

existed only in the want of a slight resistance to a wayward will; and

another, a girl of sixteen, subsequently found not to be insane, but

suffering from aggravated cataleptic hysteria, supposed to have been

caused by fright, having spinal disease, and deformed throughout the

body."

Dr. Hitchman, whose Reports we have found so valuable in former sections

of this work, has repeatedly called attention to the subject now under

notice. In 1853 he writes:--"It is with feelings of deepest sorrow that

your physician is compelled to state, that patients continue to be sent to

the asylum in very advanced stages of bodily and mental disease.... So

long as no violent or overt act has been perpetrated; so long as the

sufferer can be 'managed' in the privacy of his miserable home, or by the

'cheap' resources of a workhouse, he is often detained from the lunatic

hospital. Disease, aggravated by neglect, continues its direful course,

the 'harmless' lunatic becomes very dirty in his habits, or very violent

in his conduct, windows are broken, clothes are torn, persons are injured,

and the strap, the strait-waistcoat, and the chain are brought into

service to control for a time the ravings and the mischief of the patient.

Steps are now taken for his removal--bound, bruised, dirty, and paralysed,

the poor creature is taken to an asylum. One glance is sufficient to

reveal to the experienced eye that _cure_ is hopeless; that while every

resource of the Institution will be needed to sustain the exhausted

energies of the patient--to preserve him from the sufferings consequent

upon the loss of his self-control over the excretions of his body, yet for

two or three years he may survive to swell the list of incurables--to

diminish the per-centage of cures--to crowd the hospital, and, worse than

all, to perpetuate this popular belief, and to encourage the pernicious

practice, which are now leading to the moral death and social extinction

of hundreds of our fellow-creatures."

Speaking of the admissions in 1854, he says:--"Several were in advanced

stages of bodily disease; thus, I. C. expired in eight hours after his

arrival at this hospital. He was removed from the vehicle in which he was

brought to his bed, where he remained tranquil until the moment of his

decease. The state of great prostration in which he was brought, forbade

the employment of the usual washing-bath; nor was he subjected to the

fatigue of being shaved (of which he stood in much need) in consequence of

his exhaustion. F. G., aged 76 years, admitted with the marks of restraint

round her wrists, survived eighteen days--only by the administration of

wine and warmth. S. C., brought bound by straps and a strait-waistcoat in

the afternoon of the 18th, was so convulsed and epileptic, that she died

on the morning of the 20th, having scarcely spoken during the time she was

in the asylum. Others were in advanced stages of dropsy, phthisis, and

general paralysis, and, although in a hopeless condition, lived on for

several weeks under the fostering care of the Institution. One poor girl,

admitted from Lincolnshire, in a perfectly helpless condition (the

delirium of fever having been mistaken for the ravings of insanity), was

conveyed from the vehicle to a water-bed, where she has remained in a

state of great suffering for upwards of twelve weeks, and is never likely

again to recover the use of her limbs."

The experience of the Kent Asylum is similar. The age of eleven persons

admitted in 1853 averaged 64, and twelve were from 72 to 75. "In many of

these the malady was simply decay of mind, or was due to apoplectic

seizures, and attended by palsy."

In the Report for 1857-1858, Dr. Huxley goes more at large into the

question of unfitness for asylum admission, and the vigour and clearness

of his remarks induces us to quote them at length. He observes:--"It seems

difficult to understand on what principle patients are sometimes sent. One

man, for an intemperate threat uttered under considerable provocation, is

hastened off to the asylum. He can then only be deemed insane in a

constructive sense, and in reliance on the undoubted good faith of the

whole proceedings for his removal. He is seen to be sane; he remains so,

and merely awaits the next discharging-day. In the interval he has had

time to reflect on the danger of uncontrolled speech; but perhaps he and

his family ought not to have incurred the reproach (as it is held) of

insanity in the blood. Perhaps, also, he ought not to have swelled the

list of persons insane, adding his mite to the evidence which supports the

general belief in an actual increase of disorders of the mind.

"Again, the facility with which a drunken prostitute finds admission and

re-admission is astonishing. The delirium, rather than insanity proper,

produced by excessive drinking, has, indeed, some alarming modes of

expression; but it is a different thing from true mental derangement, and

is transient, the patient being generally nearly all right again on

arrival. I confess to a feeling which grudges to such patients the

benefits of an asylum and association with the inmates who are truly

unfortunate. Their detention is wholly unsatisfactory; it leads to

nothing. Long or short, it proves no warning against a return to former

bad courses; whilst the presence of people (I do not call them patients)

of this sort seriously injures the interior comfort of the wards. Ought

such cases to swell the returns of lunacy? Then, in estimating the

supposed growth of insanity among the people, let the fact be remembered,

that here is one contributing element, which was not represented until of

late years. Once again, the extent to which strongly-marked senility is

now made the reason for admission to the asylum is, I think,

unprecedented. To grow childish, wilful, and intractable; to lose memory,

and forget the good habits of a life; to take no note of times and

seasons; to wake by night and be restless, and to become generally

incapable, are the rule rather than the exception at the close of an

extended life. I do not think these natural ills ought to be the cause so

frequently as they are found to be, for sending the subjects of them to an

asylum. Workhouses may not contain the little special accommodation

needful for such cases; but it would not be a good argument to hold, that

because they _do_ not, the asylum must be the proper receptacle.

"Poverty is, truly, the great evil; it has no friends able to help.

Persons in middle society do not put away their aged relatives because of

their infirmities, and I think it was not always the custom for worn-out

paupers to be sent to the asylum. May not this practice be justly regarded

as an abuse of the asylum? It is one more of the ways in which, at this

day, the apparent increase of insanity is sustained. It is not a real

increase, since the aged have ever been subject to this sort of

unsoundness.

"Decayed persons, once placed in an asylum, are ever after held to have

been rightfully deemed insane. If any of their descendants, therefore,

become mentally afflicted, the hereditary taint is straightway accounted

to them. This is, indeed, to show cause why all the world should be mad! I

hold it to be wrong to send persons to an asylum merely on account of

second childhood, and a wrong operating to general disparagement. In the

first place, the practice is only an indirect consequence of poverty;

next, it helps improperly to force asylums to a size inconsistent with

their best management; and thirdly, it is one amongst other apparent, but

not real grounds, for that increase of mental disorder, which is

apprehended with such general alarm.

"We received at least twelve persons, who, in my judgment, needed not, and

therefore ought not to have been sent, viz. seven aged, being of 70, 74,

76, 78, 79, 80, and 82 years; three children, of 6, 8, and 10 years; and

two adults. One of the children was not insane, but suffering from chorea

(St. Vitus's dance) affecting the whole body. This disorder had,

apparently, been mistaken for mania."

We will close these quotations by one from Dr. Bucknill's Report for

1854:--

"There can be little doubt that those asylums, the admission into which is

restricted by legal formalities alone, are not unfrequently made use of as

hospitals for the treatment of bodily disease and for the care of the

bodily infirm. To such asylums patients are sent suffering from serious

and troublesome bodily diseases, whose mental condition would never have

been considered a sufficient cause for removal had it existed alone. The

number of patients has not been small, who, from time to time, have been

admitted into the Devon Asylum with serious disease of the several organs

of the body, and with no greater amount of mental disturbance than is the

frequent result of such disease.

"Patients have been admitted suffering from heart disease, aneurism, and

cancer, with scarcely a greater amount of melancholy than might be

expected to take place in many sane persons at the near and certain

prospect of death. Some have been received in the last stages of

consumption, with that amount only of cerebral excitement so common in

this disorder; others have been received in the delirium or the stupor of

typhus; while in several cases the mental condition was totally unknown

after admission, and must have been unknown before, since the advanced

condition of bodily disease prevented speech, and the expression of

intelligence or emotion, either normal or morbid.

"These observations are made in no spirit of complaint. The capabilities

of these institutions to treat all ailments of mind or body are indeed

felt to be a source of satisfaction and pride. It ought, however, to be

known, that this County Asylum is, to some extent, made use of as a public

infirmary, and that the result of such employment must be expected in an

obituary somewhat lengthened, if not also in a list of cures somewhat

abbreviated."

Sufficient proofs are surely furnished in the above extracts, selected

from many similar ones, to establish the general statements advanced at

the beginning of the present subject, viz. that both recklessness and

cruelty not unfrequently mark the proceedings of workhouse officials in

their transmission of patients to the county asylums. They, moreover,

supply facts to prove that the neglect in transferring proper cases for

asylum treatment, and the inexcusable folly of sending to asylums the

victims of second childishness, the imbecile paralytics, the peevish and

perverse sufferers from chronic organic disease, such as poor

consumptives, whose days are measured by the shortest span, tend to

promote the accumulation of incurable inmates, to raise the mortality, and

to increase the expenditure of these institutions. In fact, the annual

returns of county asylum experience demonstrate that the transmission to

asylums is regulated by no rule, and is attended by great abuses.

The practical lesson deducible from this is, that the matter must be

placed in other hands, and guided according to some rational principles.

The insane poor must no longer be left to pine in neglect and misery in

their own homes, until their friends tire of the trouble of them, or some

casual circumstance class them, in a relieving officer's opinion, as

proper candidates for an asylum; nor must their presence in the workhouse

be, for the future, regulated by the mere circumstance of the care,

attention and expense they involve, in the estimation of workhouse

governors. There need be some specially appointed officer, whose business

it should be to know both the existence of every insane person in his

district and his condition and treatment, and to report those who require

the care of a curative asylum, those who only need the nursing and

supervision of a chronic one, and those who can be duly and efficiently

tended and cherished in the homes of their families. By the exertions of

such an officer, we should no longer read of the removal of dying

patients, only to die in the asylums; or of the victims of neglect and

wretchedness detained in workhouses or their homes, until the advance of

their mental malady, the complication of organic disease, or some

casualty, has rendered them hopelessly incurable, and burdensome in

cost,--a cause of a decreased rate of cures and of an augmentation of

deaths in the asylum.

But there is yet another lesson to be learned from the foregoing extracts,

confirmatory of our own experience, which we might well wish to ignore,

viz. the want of knowledge, both of the characters of insanity and of the

treatment it demands, among our professional brethren. Undoubtedly a vast

stride has been made of late years in diffusing correct views of insanity

and its treatment, yet much remains to be done; and it is humiliating to

read of cases of delirium from fever, or from organic disease, affecting

other organs than the brain; of patients afflicted with chorea; of others

delirious from exhaustion or from alcoholic drinks, sent to asylums as

cases of insanity. For it is to be remembered, that a medical certificate

is a necessary preliminary to the entrance of every person into an asylum;

and where the nature of the cases indicates no flagrant error of

diagnosis, it at all events exhibits a carelessness or recklessness of the

medical man, or his want of moral courage and of official independence,

where, for example, he acts as the agent in sending to asylums the aged

imbecile of fourscore years, or the poor restless, irritable victim of

consumption or other fatal organic bodily disease. Moreover, it speaks ill

of Union medical officers, who are entrusted with the supervision, medical

care and treatment, and with the dietary of the lunatic poor, to read of

the neglected and wretched state in which they are too often found, both

in workhouses and in their own homes, and of the condition in which they

sometimes are when received into asylums. The bonds and bands, the

physical exhaustion from want of food, are matters rightly placed, in a

greater or less measure, in their hands. The treatment by cupping,

leeches, general bleeding, blistering and purging, and by other depressing

means, lies wholly at their door; and such treatment, we regret to say, is

still, by some medical practitioners, deemed proper, although experience

has for years shown that madness is a disease of debility, and that to use

debilitating means is the most direct way to render it incurable.

There is yet another indication of the deficiency of information among

medical men in general, often noticed by asylum physicians, viz. their

inability to recognize the peculiar form of paralysis attended with

disordered mind, known as "general paralysis." Where, as at St. Luke's

Hospital, at Bethlem, and at Hanwell, under the recent regulation for

promoting the early treatment of recent cases, the existence of general

paralysis disqualifies an applicant from admission, the rejection of

patients, on the ground of its presence, often gives rise to

disappointment and to irritation on the part of the medical men signing

the certificates, who will stoutly deny the justice of the exclusion,

because they see no such loss of motion or sensation as they do in

hemiplegia or paraplegia, or those forms of palsy to which they are

accustomed to restrict the appellation.

This defective knowledge of insanity and its treatment ought not to be

found, were medical instruction complete. But whilst the medical

curricula make no requirement of instruction in mental disease necessary

to medical qualifications, they are expanded so as to comprehend almost

every branch of human knowledge, under the heads of 'Preliminary

Education' and of 'Collateral Sciences,' and yet ignore psychological

medicine, as though human beings were without minds, or, at least, without

minds subject to disorder. The consequence is, as facts above illustrate,

medical men enter into practice with no conception of the varied phenomena

of mental disorder; unable to diagnose it; unfit to treat it, and glad to

keep out of the way of its sufferers. Some, as before intimated, associate

it, in their views, with inflammatory or congestive disease, and treat it

accordingly, by blood-letting and the other parts of the so-called

antiphlogistic regimen, to the speedy destruction of the patient, by

increased maniacal excitement and concurrent exhaustion, or to his extreme

detriment in relation to his prospects of recovery. Let us hope that this

state of things may ere long be entirely amended, and that medical

practitioners may be required to understand disorders of the mind as

perfectly as those of the lungs.

Before quitting the subject of this section, a brief comment on the state

of the law regulating the transference of weak cases to asylums will not

be misplaced. According to _sect._ lxvii. 16 & 17 Vict. cap. 97, providing

for the examination of alleged lunatics prior to removal to an asylum, it

is enacted, "that in case any pauper deemed to be lunatic, cannot, on

account of his health or other cause, be conveniently taken before a

Justice, such pauper may be examined at his own abode;" and that, if found

lunatic, he shall be conveyed to an "Asylum, Hospital, or House...;

provided also, that if the physician, surgeon, or apothecary by whom any

such pauper shall be examined shall certify in writing that he is not in a

fit state to be removed, his removal shall be suspended until the same or

some other physician, surgeon, or apothecary shall certify in writing that

he is fit to be removed; and every such physician, surgeon, and apothecary

is required to give such last-mentioned certificate as soon as in his

judgment it ought to be given." A similar provision is made in the case of

"Lunatics wandering at large, not being properly taken care of, or being

cruelly treated" or neglected by their relatives, by the section next

following (_sect._ lxviii).

Further, by _sect._ lxxvii., empowering the Visitors of Asylums to remove

patients, it is provided "that no person shall be removed under any such

order without a medical certificate signed by the medical officer of the

asylum, or the medical practitioner, or one of the medical practitioners,

keeping, residing in, or visiting the hospital, or licensed house, from

which such person is ordered to be removed, certifying that he is in a

fit condition of bodily health to be removed in pursuance of such order."

From the clauses above quoted, it is evidently the intent of the law to

shield the unfortunate sufferers from mental disease, where prostrated by

exhaustion or by organic lesions, against hasty and injudicious removal

detrimental to their condition, or dangerous to life; yet, as already

seen, these provisions are inoperative in preventing the evil. Those,

indeed, regulating the transfer or removal of patients to or from an

asylum are to a certain extent obligatory, and are probably attended to;

but it is not so with those designed to protect lunatics from injurious

removals under the direction of parochial authorities, as enacted by

_sect._ lxvii. For by this section it is left to the discretion of the

medical practitioner called in, to examine the patient, and to certify, in

writing, to his unfitness for removal; but much too commonly, according to

the testimony of every asylum superintendent, the humane intentions of the

law are neglected. This 67th section need, therefore, to be assimilated to

the 77th, so far as to make it imperative on the part of the medical man

who examines the patient, to certify "that he is in a fit state of bodily

health to be removed."

This is but a slight amendment, but it might save many a poor creature in

a totally broken-down, exhausted, or moribund state, from being carried to

an asylum far away, only to pine away and die. It is hard to write against

the members of one's own profession, but the details put forth by asylum

physicians of the manner in which patients are conveyed to the public

institutions, and of the state in which they are received, demand, on the

score of humanity, a condemnation of the indifference and negligence which

sometimes mark the performance of duties rightly chargeable to parochial

medical officers. Partial excuses for these officers may be found in

abundance, on account of their usual wretched remuneration, and the too

dependent position they occupy in reference to the parish boards

appointing them; but no sufficient explanation appears for their

withholding a certificate allowed by law, which might prevent the removal

of a patient delirious with fever, of one perishing from heart disease or

consumption, or of one dying from the exhaustion of cerebral excitement

and defective nutrition.

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--