§ _Magisterial interference. Excessive size of Asylums. Insufficient
medical supervision._
There are in too many asylums grave errors of construction, government,
and management, which detract from their utility, and damage the interests
of both superintendents and patients. In several there is too much
magisterial meddling, subversive of that unity of action and management
which should prevail in an asylum, as it must do in a ship, and
prejudicial to the position and authority of the superintendents, by
diminishing their responsibility, their self-respect and independence, and
their importance in the estimation of those under their direction. The
visiting justices of an asylum mistake their office when they descend from
matters of general administration and supervision to those of
superintendence and internal management. When they exchange their legal
position as occasional visitors of the wards for that of weekly or more
frequent inspectors; when they directly occupy themselves with the details
of the establishment, with the circumstances affecting the patients, with
their occupations and amusements, irrespective of the medical officer;
when they suffer themselves to be appealed to, and to act as referees in
matters of internal discipline; when they assume to themselves the hiring
and discharging of attendants; and when, without taking counsel with the
medical superintendent, they determine on alterations and additions to
their asylum,--they are most certainly pursuing a policy calculated to
disturb and destroy the government and the successful operation of the
establishment. A meddling policy is in all ways mischievous and bad; it
irritates honourable minds, and deters them in their praiseworthy and
noble endeavours to merit approval and reward; whilst it at the same time
acts as an incentive to apathy, indolence, and neglect: for freedom and
independence of action, a feeling of trust reposed, and of merit
appreciated, are necessary to the cheerful, energetic and efficient
performance of duties. So soon as the zeal of any man of ordinary moral
sensibility is doubted, so soon as his competency for his office is so far
questioned by the activity and interference of others in his particular
field of labour, so soon is a check given to his best endeavours in the
discharge of his duties, his interest in them abates, and a blow is
inflicted upon his feelings and self-respect. In short, it cannot be
disputed, that if an asylum have a duly qualified and trustworthy
superintendent, the less a committee of visitors interferes with its
internal organization and the direction of its details, the more
advantageous is it for the well-being of the institution.
Again, many asylums have grown to such a magnitude, that their general
management is unwieldy, and their due medical and moral care and
supervision an impossibility. They have grown into lunatic colonies of
eight or nine hundred, or even of a thousand or more inhabitants,
comfortably lodged and clothed, fed by a not illiberal commissariat,
watched and waited on by well-paid attendants, disciplined and drilled to
a well-ordered routine, gratified by entertainments, and employed where
practicable, and, on the whole, considered as paupers, very well off; but
in the character of patients, labouring under a malady very amenable to
treatment, if not too long neglected, far from receiving due consideration
and care.
Although the aggregation of large numbers of diseased persons, and of
lunatics among others, is to be deprecated on various grounds, hygienic
and others, yet the objections might be felt as of less weight, contrasted
with the presumed economical and administrative advantages accruing from
the proceeding, were the medical staff proportionately augmented, and the
mental malady of the inmates of a chronic and generally incurable
character. But, in the instance of the monster asylums referred to,
neither is the medical staff at all proportionate to the number of
patients, nor are their inmates exclusively chronic lunatics. The medical
officer is charged with the care and supervision of some three, four, or
five hundred insane people, among whom are cases of recent attack, and of
bodily disease of every degree of severity, and to whom a considerable
accession of fresh cases is annually made; and to his duties as physician
are added more or fewer details of administration, and all those of the
internal management of the institution, which bear upon the moral
treatment of its inmates, and are necessary even to an attempt at its
harmonious and successful working.
Now, little reflection is needed to beget the conviction, that a medical
man thus surcharged with duties cannot efficiently perform them; and the
greater will his insufficiency be, the larger the number of admissions,
and of recent or other cases demanding medical treatment. He may contrive,
indeed, to keep his asylum in good order, to secure cleanliness and
general quiet, to provide an ample general dietary, and such like, but he
will be unable to do all that he ought to do for the cure and relief of
the patients entrusted to him as a physician. To treat insane people
aright, they must be treated as individuals, and not _en masse_; they must
be individually known, studied, and attended to both morally and
medically. If recent insanity is to be treated, each case must be closely
watched in all its psychical and physical manifestations, and its
treatment be varied according to its changing conditions. Can a medical
man, surrounded by several hundred insane patients, single-handed, fulfil
his medical duties to them effectively, even had he no other duties to
perform, and were relieved from the general direction of the asylum? Can
he exercise a vigilant and efficient superintendence over the inmates? Can
he watch and personally inform himself of their mental, moral and bodily
condition, prescribe their appropriate treatment, diagnose disease and
detect its many variations; secure the due administration of medicines and
of external appliances; order the necessary food and regimen; feed those
who would starve themselves; attend to casualties and to sanitary
arrangements; judiciously arrange the classification, the employments and
recreations; keep the history of cases, make and record autopsies, and
watch the carrying out of his wishes by the attendants? Can, we repeat, an
asylum superintendent properly perform these, and those many other minor
duties of his office, conceivable to all those who experimentally
understand the matter, though not readily conveyed by description? Can any
person perform these duties, if they were separable, without injury to the
working of the institution, from the many details of general management
which the position of superintendent has attached to it? Can he be justly
held accountable, if the huge and complex machine goes wrong in any part?
Can he feel sure that his patients are well looked after, attended to
according to his wishes, and kindly treated? Can he do justice, lastly, as
a physician, to any one afflicted patient, whose restoration to health and
to society depends on the efficient exercise of his medical skill, and do
this without neglecting other patients and other duties? To these
questions, surely, every thinking, reasoning man will reply in the
negative.
The consequence is, that asylum superintendents, who thus find themselves
overburdened with multifarious and onerous duties, and feel the
hopelessness of a personal and efficient discharge of all of them, are
driven to a system of routine and general discipline, as the only one
whereby the huge machine in their charge can work, and look upon
recoveries as casual successes or undesigned coincidences (_see further_,
p. 119).
The inadequacy of the medical staff of most asylums is a consequence, in
part, of the conduct of superintendents themselves, and in part of the
notions of economy, and of the little value in which medical aid is held
by Visiting Justices in general. The contrast of a well-ordered asylum at
the present day, with the prison houses, the ill-usage and neglect of the
unhappy insane at a period so little removed from it, has produced so
striking an effect on mankind at large, that public attention is attracted
and riveted to those measures whereby the change has been brought about;
in other words, to the moral means of treatment,--to the liberty granted,
the comforts of life secured, the amusements contrived, and the useful
employment promoted,--all which can, to a greater or less extent, be
carried out equally by an unprofessional as by a professional man. It is
therefore not so surprising that the importance of a medical attendant is
little appreciated, and that the value of medical treatment is little
heeded.
There has, in fact, been a revulsion of popular feeling in favour of the
moral treatment and employment of the insane; and, as a popular sentiment
never wants advocates, so it has been with the one in question; and by the
laudation by physicians of the so-called moral means of treatment, and the
oblivion into which medical aid has been allowed to fall, magistrates,
like other mortals, have had their convictions strengthened, that medical
superintendents, considered in their professional capacity, are rather
ornamental than essential members of an asylum staff; very well in their
way in cases of casual sickness or injury, useful to legalize the exit of
the inmates from the world, and not bad scape-goats in misadventures and
unpleasant investigations into the management, and in general not worse
administrators, under the safeguard of their own magisterial oversight,
than would be members of most other occupations and professions.
As before remarked, the magnitude of an asylum, and the paucity of its
medical officers, are matters of much more serious import where recent
cases of insanity are under treatment. In a colossal refuge for the
insane, a patient may be said to lose his individuality, and to become a
member of a machine so put together as to move with precise regularity and
invariable routine;--a triumph of skill adapted to show how such
unpromising materials as crazy men and women may be drilled into order and
guided by rule, but not an apparatus calculated to restore their pristine
condition and their independent self-governing existence. In all cases
admitting of recovery, or of material amelioration, a gigantic asylum is a
gigantic evil, and, figuratively speaking, a manufactory of chronic
insanity. The medical attendant, as said before, is so distracted by
multitudinous duties, that the sufferer from the acute attack can claim
little more attention than his chronic neighbour, except at the sacrifice
of other duties. No frequent watching several times a day, and no special
interest in the individual case, can be looked for. There is such a thing
as a facility in observing and dealing with the phenomena of acute mental
disorder, acquired by experience; but it would be well nigh unjust to
expect it in a medical officer, in whose field of observation a case of
recent attack is the exception, and chronic insanity the rule, among the
hundreds around.
The practical result of this state of things is, that the recently
attacked patient almost inevitably obtains less attention than he needs
from the physician, who, from lack of sufficient personal observation,
must trust to the reports of others, to the diligence, skill and fidelity
of his attendants, and who, in fine, is compelled to repose work in
others' hands which should rightly fall into his own.
This being the case, the character of the attendants for experience,
knowledge, tact and honesty acquires importance directly proportionate to
the size of asylums, and the degree of inability of the medical
superintendents to perform his duties personally. Now, though we need
testify to the excellent qualities of some asylum attendants, yet,
notwithstanding any admissions of this sort, it is a serious question how
far such agents should be employed to supply the defects and omissions of
proper medical supervision and treatment. The class of society from which
they are usually derived; their common antecedents, as persons
unsuccessful or dissatisfied with their previous calling, or otherwise
tempted by the higher wages obtainable in asylums, are circumstances not
calculated to prepossess the feelings in favour of their employment in
that sort of attendance on the insane alluded to. They have no preliminary
instruction or training, but have to learn their duties in the exercise of
them. Many are their failures, many their faults, and often are they very
inefficient, as the records of every asylum testify; yet, on the whole,
considering their antecedents, and the nature of the duties imposed upon
them, their success is remarkable. However, whatever their character as a
body, as individuals they require the direct and ever-active oversight and
control of the superintendent. The institution of head-attendants is a
great relief to the labour of the latter, but rightly affords him no
opportunity to relax his own inspection and watchfulness.
In a large asylum there must be general routine: it can be conducted only
by routine; and the attendants are the immediate agents in carrying it
out. Their duties necessarily partake largely of a household character;
they are engaged in cleaning and polishing, in bed-making and dressing, in
fetching and carrying, and in serving meals. But along with these they are
entrusted with certain parts of the 'moral treatment' of the patients,--in
enforcing the regulations as to exercise, employment, amusement, the
distribution of meals, and the general cleanliness and order both of the
wards and their inmates; and in the exercise of these functions acquire
much knowledge respecting the character and habits of those under their
care. Yet withal, they are not fit and efficient persons to have medical
duties delegated to them. They are not qualified to observe and record the
symptoms of disease, to note its changes, nor, except under close
surveillance, to apply remedies externally or internally.
Such is the onset or the serious march of bodily sickness not
unfrequently, that even the experienced medical observer is prone to
overlook it. This is true where disease attacks those sound in mind, and
able to express their sufferings, and to lend the aid of their
intelligence towards the discovery of the nature and seat of their malady;
but the danger of oversight is increased tenfold when the insane are the
subjects of bodily lesion. Where the mind is enfeebled and sensibility
blunted, and where melancholy broods heavily over its victim, disease is
to be discovered only by a watchful and experienced practitioner of
medicine; for the unfortunate patient will make no complaint, and the
fatal malady may evince itself to the ordinary uninstructed observer by no
sufficient symptom to awaken attention; and even where the mind is not
imbecile, nor weighed down by its fears and profound apathy, yet the
features of its disorder will interfere, in most instances, with the
appreciation and interpretation of the symptoms which may reach the
knowledge of those about the sufferer, and thereby mask the disease from
the non-professional looker-on, and render its diagnosis even difficult to
the medical examiner.
With respect to the female attendants of asylums, it may also be observed,
that they are frequently young women without experience in disease, and
rarely qualified as nurses conversant with certain medical matters; and,
from our own observation, they are found to be often backward and shy in
reporting particulars respecting the female patients, and badly qualified
in administering to their wants when sick. Moreover, equally with the male
attendants, there is, by their education and training, no security for a
well-governed temper, for long suffering, patience and sympathy. Indeed,
the wages given in most asylums are not sufficient to induce a higher
class of young women to accept the onerous and often painful and
disagreeable duties of attendants on the insane, than that which furnishes
housemaids and kitchenmaids to respectable families. If, therefore, their
origin be only looked to, it would be contrary to experience to expect
from the nurses of asylums, as a body, the possession of high moral
principle and sensibility, of correct notions of duty, and of a hearty
interest in their duties. We make these remarks, with no intention to
censure the whole race of asylum nurses, among whom are many meritorious
women; but merely to enforce the opinion that something may be done to
improve their character and condition, and that, as a class, they are not
rightly chargeable with duties of the kind and to the extent we are
engaged in pointing out. On the contrary, their history, position, and
education conspire to make them servants in tone and character, unfit
often to exercise the discipline and authority entrusted to them; whilst
the general duties connected with the cleanliness and order of their wards
and rooms, and the observation of the universal routine of the asylum,
contribute to the same effect, and the more so in large establishments,
where the almost constant supervision of the superintendent is wanting,
where individual interest in patients is all but dead, and where their
number renders the inmates mere automatons, acted on in this or that
fashion according to the rules governing the great machine.
From the necessity of the case, the medical superintendent of a colossal
asylum is compelled mainly to trust to the observation of his attendants
to discover disease, and to report mishaps. He has his mile or upwards of
wards and offices to perambulate daily, and, to keep up some connexion
with their four or five hundred inmates, must adopt some general plan. For
instance, he refers to the attendant of each ward he enters, demands from
him if he has anything to report, wends his way through the apartment,
looks right and left, remarks if the floor and rooms are duly swept and
garnished; now and then inspects the bed and bedding, bids good morning to
more or fewer of the patients who may be present, and unless Brown or
Jones has something to report of any one of them, bids good day to all, to
recommence the same operation in the next ward. Now Brown or Jones might
have had something to report had they medical eyes, and information to
detect the first symptoms of disease in one of their patients; but as they
have not, the disorder has a fair opportunity to steal a march upon the
doctor, and possibly to take such firm possession of its victim before
this or that attendant is persuaded something is going wrong, that the
doctor only commences his professional operations against it in time to
render his certificate of death satisfactory, and the result explicable
without a coroner's inquest.
We do not blame the medical men for not doing more, but we deprecate the
system which places it out of their power to do so. No one can gainsay the
possibility, nay, the actual occurrence, of avoidable deaths in the large
asylums we condemn; and those who know the working of such institutions,
know also that the duties are performed much after the sketch delineated,
and could be got through in no greatly improved fashion.
But it must not be supposed, that it is only when disease exists or has to
be discovered, that the delegation of the principal part of the
supervision of patients to ordinary asylum attendants operates injuriously
to their well-being; far from it, for many are the cases which require the
presence of a more instructed and more sympathizing mind; of a person to
appreciate their moral and mental condition; to overrule by his official
position disorderly manifestations, to pacify the excitable, to encourage
and cheer the melancholy; to espy and anticipate the wants of all; to hear
the complaints of some, and to be the confidant of others; to mark the
mental changes of individuals, and to adapt surrounding circumstances,
their occupations and amusements accordingly. To give such
superintendence, or, in other words, to apply such moral and mental
treatment, the medical officer is the only fitting person; from him the
patients will and do naturally look for it. Let any one follow a medical
superintendent in his ordinary visits through the wards; and he will
observe how ardently the visit is anticipated by many; how numerous are
the little troubles and ailments they wish to disclose to the physician,
and only to him; how often he can arrest excitement and calm irritation,
only aggravated by the interposition of attendants; how often he can
recognize mental and bodily symptoms demanding attention, and, in general,
how largely he can supply those minutiæ of treatment, insignificant as
they appear, and unthought of as they are by others, whose moral feelings,
whose intellectual acumen, whose education and manners, and whose position
are deficient to conceive them, and insufficient to put them in force.
There is no question, it must be granted, but that whatever medical
supervision may be supplied, yet that the carrying out of most of the
details of management must always devolve upon the attendants; it becomes,
therefore, a matter of paramount importance to render that class of asylum
functionaries as efficient as possible. They need be encouraged by good
wages and good treatment; and, what is of great moment, these should be
sufficiently good, to induce persons of a better class than that which
usually furnishes attendants, to accept such posts. This idea will
probably be scouted by the stickler to "a due regard for economy," at
first sight; but we think his economical penchant might be gratified by
the plan of carrying out more fully in the wards the distinction of
attendants upon the insane and of household servants. For is it not
practicable to import the system adopted in the large London Hospitals,
where the office of 'sisters,' to nurse the patients, is separated from
that of under-nurse, to whom the cleanliness of the wards is committed? If
so, the immediate attendants on the insane might receive higher wages
without increasing the general expenditure of the asylum; for those
concerned in the cleaning of the wards would only earn the wages of common
household servants. We throw out this suggestion, in passing, for the
nature of our treatise forbids our enlarging upon such matters of asylum
organization; otherwise, much might be written respecting the duties and
the remuneration of attendants, and the advantages of pensions for them
after a certain term of faithful service.
To conclude this topic, we may remark that it would be easy, did the
subject stand in need of proof, to multiply illustrations, showing that,
to transfer the work of medical and moral supervision to attendants, in
any similar extent and measure to that which must of necessity prevail in
the excessively large asylums which County Magistrates rear in opposition
to the decided opinion of those best able to judge, is to frustrate the
object of those institutions as curative asylums, and to detract from
their advantages as refuges for the incurable.
The evils of overgrown asylums have not, as might be expected, escaped the
observation and reprobation of the Commissioners in Lunacy, who have
referred to them in several of their Annual Reports, but more at large in
that of 1857, wherein they detail their contest with the Middlesex
magistrates respecting the further enlargement of the enormous asylums of
Hanwell and Colney Hatch, and their strange defeat, the magistrates having
contrived to influence the Home Secretary in opposition to the decided
opinion of the Commissioners, though seconded by experience, by the
general assent of all asylum physicians, and by their position as the
referees appointed by the State in all matters touching the erection and
management of asylums. With this acquiescence in the erroneous scheme of a
County Magistracy in opposition to a Government Commission, we have at
present no immediate concern, and may content ourselves with reporting it
as an anomalous proceeding which ought never to have occurred: but to
revert to the sentiments of the Commissioners, they are expressed in the
following quotation from the Report mentioned.
"It has always been the opinion of this Board that asylums beyond a
certain size are objectionable: they forfeit the advantage which nothing
can replace, whether in general management or the treatment of disease, of
individual and responsible supervision. To the cure or alleviation of
insanity, few aids are so important as those which may be derived from
vigilant observation of individual peculiarities; but where the patients
assembled are so numerous that no medical officer can bring them within
the range of his personal examination and judgment, such opportunities
are altogether lost, and amid the workings of a great machine, the
physician as well as the patient loses his individuality. When to this
also is added, what experience has of late years shown, that the absence
of a single and undivided responsibility is equally injurious to the
general management, and that the rate of maintenance for patients in the
larger buildings has a tendency to run higher than in buildings of a
smaller size, it would seem as if the only tenable plea for erecting them
ought to be abandoned. To the patients, undoubtedly, they bring no
corresponding benefit. The more extended they are, the more abridged
become their means of cure; and this, which should be the first object of
an asylum, and by which alone any check can be given to the present
gradual and steady increase in the number of pauper lunatics requiring
accommodation, is unhappily no longer the leading characteristic of Colney
Hatch or of Hanwell."
As may be supposed, the disposition to build huge asylums is due to the
same cause as that of the detention of insane persons in workhouses, viz.
to the plea of economy; a plea, which we believe to be about as fallacious
in the one case as in the other. The economy is supposed to arise from the
saving in commissariat matters and in the governing staff; and it is no
doubt proportionately cheaper to provision 1000 persons than 500, other
things being the same. But, on the one hand, very competent persons assert
that the cost of officers and servants for a population of 1000 insane is
more than double that for one of half that amount, when proportionately
compared. The multiplication of inferior officers beyond a certain point
entails that of superior ones in a higher ratio to overlook them; there is
not the same amount of productive labour considering the number employed.
The capability of the superintendent to supervise his attendants and the
patients stops at a certain point, and he need call to his aid a head
attendant at superior wages, and so add an extra person to the staff; if
the extent of his charge is farther increased by additional patients and
their necessary attendants, then an officer of a higher grade is called
for, and other overlookers of attendants and of the _régime_ of the house.
But figures showing the relative costs presently appealed to will do more
to convince the reader of the fact under notice than any 'aids to
reflection' we can supply.
There can be no question, that to build asylums for the insane above a
certain size is a fallacy when viewed even in an economical aspect; but
when regarded in relation to its ulterior consequences, the plan is not
only erroneous, but reprehensible. Were it really the case that a
pecuniary saving resulted from the aggregation of large masses of mentally
disordered folk, according to the figures in the ledger of the
institution, yet no positive gain could be boasted of until it was proved
that every case was placed in the most favourable conditions for recovery.
Can it be pretended that the very extensive asylums of this country, with
their present corps of medical officers, furnish such conditions?
Certainly not, if there be any truth in the account we have published of
their evils and defects. And if those conditions are not supplied, the
primary object of these institutions, _i. e._ the cure of the insane, is
frustrated, and chronic lunacy increased. Where, then, is the economy, if
patients, failing to receive the means of recovery, by reason of the
constitution of the asylum on so large a scale, fall into chronic disease,
and become permanent burdens on its funds? Where is the economy of a
system, which, by standing in the way of efficient treatment, reduces the
proportion per cent. of recoveries to twenty or thirty, when under
different arrangements that proportion may equal 60 per cent. or upwards?
It will be a happy day for the insane, and for the contributors to their
maintenance, when Visiting Justices arrive at the conviction, that they
have not done all they can on behalf of the poor disordered people under
their guardianship, when they have provided good lodging, board and
clothing for them, and such a system of routine and discipline as to check
the manifestation of their mental vagaries; and that it is not enough for
a recent case, to introduce it into an asylum and the companionship of
lunatics, with practically no positive provision for its medical
treatment. It will be well, too, for the insane, when the truth becomes
more generally assented to, that their malady is no mythical, spiritual
alteration, but the consequence of a material lesion of the brain, the
marvellous instrument, the subject and servant of the immortal soul, which
can by its divine essence know no disorder.
This is perhaps, strictly speaking, a digression from the subject; yet
erroneous ideas are the parents of erroneous practices, and those we have
hinted at form no exception to the rule. But, to return, we have some
excellent illustrative remarks on the fallacy of the belief in the economy
of very large asylums, contained both in the Report of the American and of
the English Lunacy Commissioners. The former thus write in their Report
(_op. cit._ p. 136):--
"The policy which has built large establishments for the insane is a
questionable one as applied to economy. After having built a house
sufficiently large, and gathered a sufficient number of patients for their
proper classification and for the employment of a competent corps of
officers and attendants, and allowing each to receive just as much
attention as his case requires, and providing no more, any increase of
numbers will either crowd the house, or create the necessity of building
more rooms; and their management must be either at the cost of that
attention which is due to others, or must create the necessity of
employing more persons to superintend and to watch them.
"If the house be crowded beyond the appropriate numbers, or if the needful
attention and the healing influences due to each individual are
diminished, the restorative process is retarded, and the recovery is
rendered more doubtful; and if additional provision, both of
accommodations and professional and subsidiary attendance, is made to meet
the increase of patients beyond the best standard, it would cost at least
as much per head as for the original number. Dr. Kirkbride thinks it would
cost more, and that the actual recoveries of the curable, and the
comfortable guardianship of the incurable, are not so easily attained in
large hospitals as in such as come within the description herein proposed.
'It might be supposed that institutions for a much larger number of
patients than has been recommended could be supported at a less relative
cost; but this is not found to be the case. There is always more
difficulty in superintending details in a very large hospital; there are
more sources of waste and loss; improvements are apt to be relatively more
costly; and, without great care on the part of the officers, the patients
will be less comfortable.'
"Besides the increased cost of maintaining and the diminished efficiency
of a large establishment, there is the strong objection of distance and
difficulty of access, which must limit the usefulness of a large hospital
in the country, and prevent its diffusing its benefits equally over any
considerable extent of territory to whose people it may open its doors."
Having pointed out the evils of large asylums to their inmates, the
English Commissioners, in their Eleventh Report (p. 11), remark, "that the
rate of maintenance for patients in the larger buildings has a tendency to
run higher than in buildings of a smaller size," ... and that it therefore
"would seem as if the only tenable plea for erecting them ought to be
abandoned." To substantiate this assertion, they appeal to the table of
weekly charges of the several county asylums, set forth in the Appendix
C.C. of the same Report, which certainly shows that the cost per head is
at its maximum in those which receive the largest number of patients. This
being so, surely no one can withhold assent to the just conclusion of the
Commissioners, that the system of erecting asylums above certain
dimensions ought to be abandoned, inasmuch as the only plea that can be
urged in its behalf, that, namely, of its economy,--a bad plea, by the
way, if the real interests of patients and ratepayers are concerned,--is
founded in error.
One more topic needs a few words, viz. the very inadequate remuneration of
the medical superintendents in some asylums,--a circumstance, confirmatory
of the small value assigned by their Committees of Visitors to
professional qualifications. The worst instances of underpayment are, in
fact, met with in those very asylums where the number of inmates attains
its maximum, and the medical provision for their care is at its minimum;
where the administrative power of the medical men is the most limited and
most interfered with, and their ability to discharge their duties
conscientiously and efficiently, utterly crippled by the multitude of
claimants upon their attention surrounding them; and where, in fine, they
are merely accessory officials, useful in cases of sickness and accident.
It must, indeed, be gratifying to the advocates of the rights of women to
know, that in one asylum, at least, female labour is rated as equal to
male professional labour; that the matron is as well paid as the medical
officers, and more valued in the estimation of the Committee of Visitors.
But, however this circumstance may be viewed by the partisans of the
interests of the fair sex, we venture to believe that to most people it
will appear a gross anomaly. For our own part, we consider also that it
would be to the interests both of patients and rate-payers to elevate the
position of the medical superintendents of asylums, and to pay them
liberally.
As this section of our work is passing through the press, we have got the
Report, just printed, "from the Select Committee on Lunatics," and are
most happy in being able to extract from its pages a very decided opinion
expressed by the Earl of Shaftesbury respecting the scanty salaries of
medical superintendents. His Lordship, in reply to the question (765),
"Have you any other remedies to apply to county asylums?" said,--"I do not
know whether it is a matter that could be introduced into the Bill, but I
think the attention of the public should be very much drawn to the state
of the medical superintendents in these asylums. It is perfectly clear,
that to the greater proportion of the medical superintendents in these
asylums, very much larger salaries should be given; and unless you do
that, you cannot possibly secure the very best service.... The great
object must be to raise the status and character of the superintendents to
the highest possible point." In the course of further examination on this
subject, his Lordship repeats and adds to the opinion just recorded. For
instance, he remarks,--"One of the great defects of the present system is,
that the salaries of the medical officers are much too low for the service
they perform. I think that the county ought to secure the very best talent
and responsibility that can be found, and they ought to raise their
salaries higher. I believe in some of the asylums the salaries are higher,
but I hardly know one where the salary is adequate to the work done.... I
cannot think that any superintendent ought to receive much less than from
£500 to £600 a year, besides a house and allowances."
In this matter, we hope the liberal views of the noble Chairman of the
Lunacy Commission will sooner or later be reciprocated by the Visitors of
Asylums; in the mean time, the thanks of the medical profession are
heartily due to his Lordship for his able advocacy of its just claims.
§ _Limit to be fixed to the size of Asylums._
One remedy against extending the evil consequences of large asylums, is to
restrict the size of future buildings within certain limits. We do not
hope to persuade the advocates of gigantic asylums, by any representation
we can offer of their ill-effects to the patients and their false economy,
to abandon their notions; but we do hope that there will be a
parliamentary interdiction to their perpetuation, or that the
Commissioners in Lunacy will have sufficient authority lodged in their
hands to limit the size of future asylums.
Although all persons conversant with the treatment and requirements of the
insane concur in condemning such huge asylums as Hanwell and Colney Hatch,
yet there is some difference in opinion, of no very great extent indeed,
among them with regard to the number of patients who should be assigned to
the care of a single superintendent. Moreover, the number who may be
treated in the same building and by one physician, will differ according
to the nature of the cases--whether all acute, or all chronic, or mixed,
acute and chronic together. In this country all the asylums are of a mixed
character, but, excepting two or three hospitals for the insane, contain a
large preponderance of chronic cases. They are, moreover, all spoken of by
the Lunacy Commissioners as Curative Asylums.
Let us now examine the opinions of some of the best authorities upon the
subject, so that a tolerably accurate judgment may be formed of the limits
within which the size of asylums should be restricted.
In 1844, the Metropolitan Commissioners in Lunacy laid it down as a rule
that "no asylum for curable lunatics should contain more than 250
patients, and 200 is, perhaps, as large a number as can be managed with
the most benefit to themselves and the public in one
establishment."--Report, 1844, p. 23. The present Commissioners have
expressed similar views, which also were clearly stated before the Special
Committee of the House of Commons this year, by the noble Chairman, the
Earl of Shaftesbury.
If we look to American opinion, we find (Rep. Commiss. Massachus. 1855, p.
135) that "it is the unanimous opinion of the American Association of
Medical Superintendents of Insane Asylums that not more than 250 patients
should be gathered into one establishment, and that 200 is a better
number. When this matter was discussed, there was no dissent as to the
maximum; yet those who had the charge of the largest hospitals, and knew
the disadvantages of large numbers, thought that a lower number should be
adopted.
"Taking the average of the patients that now present themselves in
Massachusetts, of whom 80 per cent. are supposed to be curable, and need
active treatment, and 82 per cent. incurable, and require principally
general management and soothing custodial guardianship, and having 'due
regard to the comfort and improvement of the patients,' this limit of 250
should not be exceeded.
"The principal physician is the responsible manager of every case, and
should therefore be personally acquainted with the character and condition
of his patients, the peculiarities of the diseased mind, as manifested in
each one, and the sources of trouble and depression, or exaltation and
perversity. This knowledge is necessary, in order that he should be able
to adapt his means of medical or of moral influence with the best hope of
success."
Dr. Kirkbride, in his special treatise on the Construction and
Organization of Asylums, thus expresses his views (p. 10):--"Whatever
differences of opinion may have formerly existed on this point (the size
of the Institution), I believe there are none at present. All the best
authorities agree that the number of insane confined in one hospital,
should not exceed 250, and it is very important that at no time should a
larger number be admitted than the building is calculated to accommodate
comfortably, as a crowded institution cannot fail to exercise an
unfavourable influence on the welfare of its patients. The precise number
that may be properly taken care of in a single institution, will vary
somewhat, according to the ratio of acute cases received, and of course to
the amount of personal attention required from the chief medical officer.
In State Institutions, when full, at least one half of all the cases will
commonly be of a chronic character, and require little medical treatment.
Even when thus proportioned, 250 will be found to be as many as the
medical superintendent can visit properly every day, in addition to the
performance of his other duties. When the proportion of acute or recent
cases is likely to be much greater than that just referred to, the number
of patients should be proportionately reduced, and 200 will then be found
to be a preferable maximum. While no more patients should be received
into any hospital than can be visited daily by the chief medical officer,
it is desirable that the number should be sufficiently large to give an
agreeable company to each class, and to permit a variety of occupations
and amusements that would prove too costly for a small institution, unless
filled with patients paying a very high rate of board, or possessed of
some permanent endowment. It might be supposed that institutions for a
much larger number of patients than has been recommended, could be
supported at a less relative cost; but this is not found to be the case.
There is always more difficulty in superintending details in a very large
hospital--there are more sources of waste and loss; improvements are apt
to be relatively more costly; and without great care on the part of the
officers, the patients will be less comfortable.
"Whenever an existing State Institution built for 250 patients, contains
that number, and does not meet the wants of the community, instead of
crowding it, and thereby rendering all its inmates uncomfortable, or
materially enlarging its capacity by putting up additional buildings, it
will be found much better at once to erect an entirely new institution in
another section of the State; for under any circumstances, the transfer of
acute cases from a great distance, is an evil of serious magnitude, and
constantly deplored by those who have the care of the insane."
French authorities take the same views. M. Ferrus, who wrote so long back
as 1834, and is now one of the Inspectors of Asylums in France, says, in
his book, 'Des Aliénés,' that an asylum for the treatment of mental
disorder ought not to contain above 150, or at most 250 patients; but that
one having a mixed population of cases requiring treatment of incurables
and idiots, may receive 400 or even 500 such inmates, provided the
physician is afforded sufficient medical assistance. However, his brother
inspector, M. Parchappe, whose able work, 'Des principes à suivre dans la
fondation et la construction des Asiles d'Aliénés' (published so recently
as 1853), forms the most valuable treatise on those subjects, does not
approve so large a number of inmates to be collected in an asylum as M.
Ferrus would sanction. He writes:--"After taking every consideration into
account, I think the minimum of patients ought to be fixed at 200, and the
maximum at 400. Below 200, the economical advantages decline rapidly
without a compensatory benefit; above 400, although the economical
advantages augment, it is at the detriment of the utility of the
institution in its medical character."
M. Guislain, the eminent Belgian physician, in his grand work on Insanity,
remarks (vol. iii. p. 347), "It would be absurd to attempt to bring
together in the same place a very large population; it would tend to
foster an injurious degree of excitement; would render the management
difficult or impossible; would destroy the unity of plan, and neutralize
all scientific effort. The maximum ought not to exceed 300 or 350 insane
persons. This limit cannot be exceeded without injury to the well-being of
the inmates; but unfortunately this has been but too often disregarded,
under the plea of certain views of organization or of economy."
Jacobi placed the maximum of asylum population at 200 (Ueber die Anlegung
und Errichtung von Irren-Heil-anstalten, p. 24); Roller expressed his
opinion (Grundsätze für Errichtung neuer Irren-anstalten, p. 84) that one
instituted for the treatment of cases (Heil-anstalt) should not at the
most receive above 200; but that an asylum for chronic cases
(Pflege-anstalt), connected with the other, may admit from 250 to 300,
making a total population, under the same general direction, of 450 or
500; and Damerow (Ueber die Relative Verbindung der Irren-Heil-und
Pflege-anstalten) unites in the same opinion.
It would be useless to multiply quotations; for, in short, there is
complete unanimity among all those concerned in the direction of asylums,
that such institutions, when of large size, are prejudicial to their
inmates and withal not economical. There is likewise a very near
coincidence of opinion perceptible with reference to the question of the
number of patients which ought to be placed in the same building.
Supposing the asylum to be specially devoted to the reception of recent
cases, it is agreed that it ought to accommodate not more than 200, and
that the smaller number of 150 inmates would be preferable. If a
receptacle for both acute and chronic mental disease, some would limit the
population to 250, whilst others would extend it to 400, provided the
medical officers were increased in proportion.
The example of the German asylums under the direction of Damerow and
Roller is peculiar; for the curable and chronic cases are not mixed, but
placed separately in two sections or two institutions under a general
medical direction within the same area. This is the system of 'relative
connexion' of the "Heil-anstalt,"--institution for treatment, or the
Hospital, and the "Pflege-anstalt," the 'nursing' institution, or the
asylum; to the former they would allot 200, and to the latter 300 as a
maximum, making a total of 500 inmates under the same physician in chief
and the same general administration, but each division separately served
by its own staff and specially organized.
§ _Increase of the Medical Staff of Asylums._
In the next place, the medical staff of an asylum should be large enough
to secure daily medical observation and attendance for each individual
patient, along with a complete supervision of his moral condition, his
amusements and employment. We have said that this provision is deficient
in many English asylums, a statement amply confirmed by the opinions of
others.
Dr. Kirkbride (_op. cit._ p. 44) lays it down as a rule, that "where there
are 250 patients, especially if there is a large proportion of recent
cases, besides the chief physician, two assistant physicians will be
required, one of whom should perform the duties of apothecary. In some
institutions, one assistant physician and an apothecary will be
sufficient. If the full time of two assistant physicians, however, is
taken up by their other duties among the patients, an apothecary may still
be usefully employed in addition; and to him, other duties among the male
patients may with propriety be assigned."
French writers coincide in these views. M. Parchappe assigns to an asylum
containing 200 to 250 patients, a physician with an assistant, besides a
dispenser; to one having 300 to 360 inmates, a physician, two assistants
and a dispenser, besides a director to superintend the general
administration, who in some institutions is also a medical man.
In Germany, and generally in Italy, the medical staff is still larger in
proportion to the number of patients. Jacobi apportions to an asylum for
150 or 200 lunatics, a chief physician, a second, and an assistant,
besides the dispenser. Roller coincides with this, and the asylum at
Illenau under his superintendence, consisting of two divisions, one for
recent, the other for chronic cases, and containing in all 414 patients,
has three physicians besides two assistants or 'internes.' So at Leubus,
in Silesia, there are three physicians, although the inmates are only 150
in number; and the rule is, in other German asylums, containing 100
inmates, to have two physicians, besides one or two internes and a
dispenser (pharmacien).
Allowing the opinions and practice of the eminent men quoted, and which in
truth are shared in by every asylum superintendent, their due weight, it
would seem no extravagant arrangement to allot to an asylum accommodating
from 150 to 200 patients (recent and chronic cases together), a physician
superintendent and an assistant; and a similar medical staff to an
institution for 300 or 350 inmates, all in a state of confirmed chronic
insanity, imbecility, and dementia. If the population in an asylum for
chronic cases is further augmented to 450 or 600,--the latter number we
hold to represent the maximum which can economically and with a just
regard to efficient government and supervision and to the interests of the
patients, be brought together in one establishment,--the medical
superintendent will require the aid of two assistants and a dispenser.
Such aggregations as of 1000 to 2000 insane people are unwieldy and
unmanageable with the best appointed medical staff, unless this be so
numerous as utterly to invalidate the plea of economy, the only one,
fallacious as it is, that can be produced by the advocates for their
existence. And not only are they unmanageable, but also hygienically
wrong; for it is a well-recognized fact, that the accumulation of large
numbers of human beings in one place, tends to engender endemic disease,
uniformly deteriorates the health, and favours the onset, progress, and
fatality of all disorders. The history of large asylums bears testimony to
the truth of this; for cholera has scourged more than one most severely,
and dysentery and chronic or obstinate diarrhoea are pretty constant
visitants in their wards.
The contrast between the opinions and practice of the distinguished men
referred to and those of some Committees of Visitors respecting the value
of medical attendance on the insane, the nature of the duties to be
performed, and the amount of labour the superintendent of an asylum may
accomplish, is most remarkable. What those of the former are, is stated
already; what those held by the latter are, we have an illustration in the
administration of the Colney Hatch and of the Hanwell Asylums. In the
latter establishment we find two medical men appointed to superintend 1020
insane inmates, besides nearly 200 persons employed about it. True, we are
informed by the Committee, that the superintendent of the female
department, who has the larger number, some 600, under his charge, is
_assisted_ by the _matron_; and we are sure he must be thankful for any
assistance rendered him; yet it is the first time that we have been called
upon to recognize a matron as an assistant medical officer. However, we
must accept it as a fact,--gratefully we cannot,--but with a protest
against placing a subordinate officer on such an independent footing,
against entrusting her with duties incompatible with her education and
position, and with the relations which should subsist between her and the
superintendent, and against making her his equal in the remuneration for
her services.
Did occasion offer, we might ponder over this new development of the
matronly office; inquire respecting the medical qualifications demanded,
and the manner in which the Hanwell Committee have ascertained them; and
meditate at length on the notions which govern the Visiting Justices in
organizing and directing an asylum; but for the present, we will, for
further example's sake, note some of their opinions and doings in the
management of the sister 'refuge for lunatics' at Colney Hatch. We shall,
for this purpose, appeal to the Report for 1856, and to make the
quotations used intelligible, will premise, that the steward, at that
date, had turned architect, and produced a plan for the extensive
enlargement of the asylum as proposed by the Magistrates; and that, very
naturally, when writing about it, he was intent to prove that his plan was
the best, the cheapest and the most convenient even to the medical
superintendents who would be called upon to officiate in it when
completed. This much being premised, we will quote the steward's own
words.
"I must also remind the Committee," he observes, "that some three years
since it was with them a matter of serious deliberation, whether it was
advisable that the male and female departments should be placed under the
care of one medical superintendent, and, in fact, whether _one medical
officer_ should have the _supervision and direction of 1250 inmates_, and
an extended range of building; or whether the two departments should
continue, as they are at present, separate and distinct." What an
excellent insight does this revelation of the cogitations of the
Committee-room of the Middlesex Magistrates afford us of the sentiments
these gentlemen entertain of the requirement and value of medical skill in
an asylum; of the capacity, bodily and mental, of a superintendent for
work! But, without waiting to fill up a sketch of the wondrous virtues and
faculties which the superintendent of the 1250 insane patients need to
possess in order to know all, supervise them, direct them, and attend to
the multitudinous duties of his office as a physician and director, we
will by a further extract gather clearer notions of the extent of the work
thought to be not too much for him. The gist of the ensuing paragraph is,
that the steward strives to prove that by adding a new story here and
there, besides spurs from the previous building, he will increase greatly
the accommodation without much augmenting the ambulatory labours of the
medical officer. And alluding to one, the male division of the
establishment, he proceeds to argue, that "if it is considered feasible
for one person to superintend 1250 patients of both sexes in a _building
extending_ from one extreme to the other, _nearly two-thirds of a mile_,
would it not be equally feasible to superintend 840 patients in a building
one half the extent [here Mr. Steward forgets to count the number of
furlongs added by his proposed new wards], provided they are conveniently
and safely located, although these patients are all males?"
To this we may be allowed to subjoin some remarks we penned in a critique
published in the 'Asylum Journal' (vol. ii. p. 271) for 1856, and in which
many of the observations contained in the present work were briefly
sketched. "Who, we ask, can dispute the feasibility of a medical or of any
other man superintending 840, 1250, or two or three thousand patients,
collected in an asylum or in a town, in the capacity of a director or
governor, if subordinate agents in sufficient number are allowed him? But
we think the question in relation to asylums is not, how we can govern our
insane population most easily and at the least possible cost, but by what
means can we succeed in curing the largest number of cases of insanity as
they arise, and thus permanently keep down expenditure and save the rates.
These results are certainly not to be attained by persevering in the old
scheme of congregating lunatics by tens of hundreds, but by making
suitable provision for the immediate treatment of the pauper insane in
asylums properly organized for it, and under the direction of a sufficient
medical staff."
How totally different, too, are the views of Jacobi to those of the
Middlesex Magistrates concerning the office of superintendent, and the
extent of work of which he is capable! In his treatise on Asylum
Construction (Tuke's Translation, p. 23), he presents the following
sensible remarks:--"It is not that I should consider a more numerous
family (than 200) incompatible with the right management of the farming
and household economy, nor with the domestic care of the patients; both
these might perhaps be organized in an establishment containing a number
equal to the largest just named (four or six hundred), in such a manner as
to leave nothing to be desired; but it is in regard to the higher
government of the establishment, and the treatment of the patients as
such, in its widest signification, which must rest upon the shoulders of a
single individual,--the director of the establishment,--that I am
convinced the number of patients should not exceed two hundred. For when
it is considered that the duties of the governor embrace the control of
all the economical and domestic arrangements, as well as of the whole body
of officers and servants; that he must devote a great share of his time to
the writing, correspondence, and consultations connected with his office;
that as first physician, he is entrusted with the personal charge and
medical treatment of every individual committed to his care; that he must
daily and hourly determine, not only the general outlines, but the
particular details of the best means for promoting the interests of the
collective community, as well as of every separate person composing it;
and that, besides all this, he is responsible to science for the results
of his medical observations in the establishment over which he presides;
nor less so for the promotion of his own advancement as a man and a
philosopher;--it will be readily granted, that the given maximum of two
hundred patients for a single establishment ought never to be exceeded.
Indeed, a man of even extraordinary abilities would find himself unequal
to the task of discharging these duties, in an establishment containing
two hundred patients, were he not supported by such assistance as will
hereafter be described; and were there not a great number amongst even
this multitude of patients requiring not constant, or at least, a less
degree of medical attention."
Many writers on asylum organization, particularly those of the Continent,
insist very strongly on so far limiting the size of asylums for the
insane, that they may be superintended by one chief medical officer, aided
indeed by assistants, but without colleagues of coordinate powers. The
venerable Jacobi took this view, and desired that the director of an
asylum should be the prime authority in all its details of management, and
insisted that the institution should not by its size overmatch his powers
to superintend it and its inmates as individuals. Thus, after reviewing
the nature of the duties devolving on the chief physician, he observes (p.
192, Tuke's translation), "It follows as a necessary consequence that one
man must be placed at the head of the establishment," ... and that "his
mind must pervade the whole establishment." Likewise M. Parchappe joins in
the same opinion; and after speaking (Des Principes, p. 43) of the
impossibility of proper medical supervision in a very large asylum,
observes, "that to divide the medical direction among two or more
physicians is extremely detrimental to the superiority which the medical
superintendent ought to hold in the general administration of asylums, and
to that unity of purpose and opinions required in the interests of the
patients."
Without citing other foreign writers to substantiate the view under
consideration, we may call attention to the fact, that the Lunacy
Commissioners, who have always so stoutly advocated the position of the
medical officer as the superintendent of an asylum, likewise appear to
accept the same principle; for in their Eleventh Report (p. 11), they
remark, that besides the direct injury inflicted upon patients when
congregated in excessive numbers in the same institution, "experience has
of late years shown, that the absence of a single and undivided
responsibility is equally injurious to the general management."
Lastly, the Committee of Visitors of the Surrey County Asylum
appear,--judging from their recent appointment of a chief physician to
their institution, paramount to the medical officers of the divisions, and
invested with full powers as director,--to have arrived at the just
conviction that there must be unity and uniformity in the management of an
institution. However, we regret to say that this conviction is
unaccompanied by that other which Jacobi and Parchappe would associate
with it, viz. that the size of the asylum should be no larger than will
admit of the chief physician acquainting himself with every case
individually, and treating it accordingly. Whilst, indeed, by their
proceeding, they constitute the chief physician a governor of a large
establishment, and the director of the household and of its economy, they
at the same time deprive him of his professional character by removing the
opportunities of exhibiting it beyond his reach, both by the relations
they place him in to the other medical officers, and by the enormous
aggregation of patients they surround him with.
Few objections, we presume, are to be found to the principle of having a
chief medical officer paramount to all others engaged in the work of an
asylum; and although, considered as a _medical superintendent_, his
professional qualities are not in much requisition in so large an
institution as the Surrey County Asylum, yet we regard such an appointment
as most desirable, and as preferable to the system of dividing the
management between two medical officers, as pursued in the Middlesex
County Asylums. Indeed, the value of the principle of concentrating power
in the hands of a chief officer, under the name of governor, or of some
equivalent term, is recognized by its adoption in large institutions of
every sort in the country. Such enormous asylums as those referred to,
partake rather of the nature of industrial than of medical establishments.
Their primary object is to utilize the population as far as practicable,
and this end can be attained in a large majority of the inmates;
consequently an able director is of more consequence than a skilful
physician; for the latter is needed by a very small minority, by such a
section, in fact, as is represented by the inmates of a workhouse
infirmary only compared with its entire population. Therefore, since the
enormous asylums in existence are not to be got rid of, it is desirable to
give them an organization as perfect as practicable; and it is under this
aspect that we approve the plan of the Surrey Magistrates in appointing a
director paramount to every other officer. The approval of this
proceeding, however, does not minish aught from our objections to such
enormous institutions, considered as curative asylums for the insane. As a
refuge for chronic lunatics, an asylum so organized and superintended as
is the Surrey, may subserve a useful purpose; but we hold it to be an
unsuitable place for recent cases demanding treatment as individuals
suffering from a curable disease, and requiring the exercise of the skill
and experience of a _medical_ man _specially_ directed to it.
While the system of congregating so many hundreds of lunatics in one
establishment, and the magisterial principle of providing for the care and
maintenance and of non-intervention in the individual treatment of the
insane prevail, no objection can be taken to the practice of Committees
of Visitors in according the first merit when candidates come forward for
the office of medical superintendent of an asylum, to qualifications for
the routine government of large masses, for the allotment of labour, for
the regulation of the domestic economy of a house, for the profitable
management of the farm; in short, for qualities desirable in a governor of
a reformatory-school or prison. Indeed, they are right in so doing, when
they wish to have a well-disciplined and profitably worked asylum; and
when their institution attains the dignity of a lunatic colony, it is the
best course they can adopt, for medical qualifications in such an
establishment sink into insignificance amidst the varied details of
general administration, which fall to the lot of the superintendent. But
the case would be materially changed were the primary object of an asylum
the successful treatment of its inmates, and were its dimensions within
the limit to afford its superintendent the opportunity to know all, and to
treat all its patients as individuals to be benefited by his professional
skill. In selecting the physician of such an asylum, the administrative
and agricultural qualifications he might possess, though far from being
unnecessary or unimportant, should occupy a secondary place in the
estimation of Committees of Visitors; and the primary requirement should
be the possession of properly certified medical skill, of experience in
the nature and treatment of insanity, in the wants and management of the
insane, and of asylums for them; of evident interest and zeal in his work,
and of those intellectual and moral endowments adapted to minister to the
mind diseased, to rule by kindness and forbearance, and at the same time
with the firmness of authority.