The only apology permissible for detaining lunatics in workhouses, is that
there is no asylum accommodation for them to be had; and the only one
attempted on behalf of the construction of colossal asylums is, that the
demands for admission and the existing numbers are so many, and the
majority of cases chronic and incurable, that the most economical means of
providing for them must be adopted, which means are (so it is supposed)
found in aggregating masses under one direction and one commissariat. Now,
whilst we have, on the one hand, contended that workhouses should be as
soon as possible disused as receptacles for the insane, we have, on the
other hand, endeavoured to prove that very large asylums are neither
economical nor desirable, especially if the cure of lunatics, and not
their custody only, is contemplated by their erection. Indeed the attempt
to keep pace in providing accommodation for the insane poor with their
multiplication by accumulation and positive increase or fresh additions,
has failed, according to the mode in which the attempt has hitherto been
made. New asylums have been built and old ones enlarged throughout the
country, and between 1843 and the end of 1857, the accommodation in them
had been increased threefold; whilst, at the same time, pauper lunatics
had so multiplied, that their number in licensed houses remained almost
the same, and the inmates of workhouses and chargeable imbeciles and
idiots residing with their friends or with strangers, had very largely
increased. The history of pauper lunacy in Middlesex furnishes one of the
most striking commentaries upon the system pursued to provide for its
accumulation, and on its failure. "When (we quote the 11th Report of the
Commissioners in Lunacy, 1857, p. 12), in 1831, Hanwell was built for 500
patients, it was supposed to be large enough to meet all the wants of the
county. But, two years later, it was full; after another two years, it was
reported to contain 100 patients more than it had been built for; after
another two years, it had to be enlarged for 300 more; and at this time
(Colney Hatch having been meanwhile constructed for the reception of 1200
lunatic paupers belonging to the same county) Hanwell contains upwards of
1000 patients. Colney Hatch was opened in 1851; within a period of less
than five years, it became necessary to appeal to the rate-payers for
further accommodation; and the latest returns show that, at the close of
1856, there were more than 1100 pauper lunatics belonging to the county
unprovided for in either of its asylums." At this conjuncture the
Commissioners proposed a third asylum, so that they might, "by a fresh
classification and redistribution of the patients, not only deal with
existing evils universally admitted, but guard against a recurrence of
evils exactly similar, by restoring to both asylums their proper functions
of treatment and care." However, instead of adopting this wise policy, the
Committee of Visitors insisted on following out their old scheme of adding
to the existing asylums, in the vain hope of meeting the requirements of
the county; and have proceeded to increase the accommodation of Hanwell to
upwards of 1600, and that of Colney Hatch Asylum to nearly 2100 beds. Yet
let them be assured they have taken a very false step, and that though
they heap story on story and add wing to wing, they will be unable to keep
pace with the demands of the pauper lunatics of the county; nor will they
succeed in the attempt, until they make the curative treatment of the
insane the first principle in their official attempts to put into
execution those lunacy laws confided to their administration by the
legislature.
Perceiving that this scheme of adding to asylums until they grow into
small towns defeats the object of such institutions as places of treatment
and cure, and that it will continue to fail, as it has hitherto failed, to
supply the demands for accommodation, the Commissioners remarked in their
last (12th) Report, that "a scheme of a far more comprehensive nature" is
called for to meet increasing events. They have not hinted in that Report
at any scheme, but we may gather from other similar documents, especially
from that of 1857, that one important plan they have in view is to remove
a large number of chronic, imbecile and idiotic patients from the
existing, expensively built and organized asylums, and to place them in
others erected, adapted and organized for their reception at a much less
cost. By this means they count both on rendering the asylums generally,
now in existence, available as curative institutions for the reception of
new cases as they arise, and on arresting the tendency and the need to
erect such enormous edifices as do discredit to the good sense of the
magistrates of the counties possessing them.
We agree with the Commissioners in the general features of the plan
advanced, and indeed, in our notice of the Reports of the Middlesex County
Asylums, in 1856 (Asylum Journal, vol. ii. p. 354 _et seq._), advocated
the establishment in that county of a third asylum especially for the
treatment of the recent cases as they occurred. Now the adoption of any
such plan implies the recognition of a principle which has been very much
discussed, viz. that of separating one portion of a number of insane
people from another, as less curable or incurable. However, the
Commissioners in Lunacy avoid discussion, and treat the matter in its
practical bearings; still a brief critical examination of it will not be
here misplaced.
§ _Separate Asylums for the more recent and for chronic cases._
The proposition of placing recent and chronic cases of lunacy in distinct
establishments is often so put as to beg the question. It is asked if any
one can undertake to say categorically that any case of insanity is
incurable, and thereupon to transfer it to an asylum for incurables? To
the question thus put every humane person will reply in the negative; he
will start at the idea of consigning an afflicted creature, conscious of
his fate, to an abode, which, like Dante's Inferno, bears over its portal
the sentence, "Abandon hope all ye who enter here." But a solution thus
extorted is in no way a reply to the question of the expediency or
inexpediency of making a distinction in place and arrangement for the
treatment of recent and of chronic cases of lunacy severally; for this is
a matter of classification, and one particularly and necessarily called
for, where the insane are aggregated in large numbers, and the conditions
of treatment required for the great mass of chronic cases are insufficient
for the well-being of the acute. The real practical questions are,--1,
Cannot the subjects of recent insanity be separated advantageously, and
with a view to their more effectual and successful treatment, from a
majority of the sufferers from chronic insanity, imbecility and fatuity,
and particularly so where the total number of the asylum inmates exceeds
the powers of the medical officer to study and treat them as individuals?
and, 2, Does not the separation of the very chronic, and according to all
probability, the incurable, afford the opportunity to provide suitably for
the care of that vast multitude of poor lunatics, at present denied asylum
accommodation; and to effect this at such an expenditure, as renders it
practicable to do so, and thereby to meet the present and future
requirements of the insane?
Several eminent psychologists have taken up the question of separating
recent and probably curable cases from others found in asylums, in an
abstract point of view, as if it were equivalent to forming an absolute
decision on the grand question of the curability or incurability of the
patients dealt with; and, as a matter of course, their adverse view of the
subject has found numerous abettors. The subject is, however, well
deserving of examination _de novo_, in the present juncture, when some
decided scheme must be agreed to for the future provision of the insane,
and for repairing the consequences of past errors.
In the first place, let us ask, are the harrowing descriptions of the deep
depression and despair felt by patients on their removal after one or two
or more years' residence in a curative asylum to another occupied by
chronic cases, true and sketched from nature? we think not. Writers have
rather portrayed the sensations they would themselves, in the possession
of full consciousness and of high sensibility, experience by a transfer to
an institution as hopelessly mad, and have overlooked both the state of
mental abasement and blunted sensibility which chronic insanity induces in
so many of its victims, and still more the fact that no such absolute and
universal separation of acute and chronic, as they picture to their minds,
is intended.
Indeed, we believe that, even among patients who retain the consciousness
and the powers of reflection to appreciate the transfer, no such lively
despair as authors depict is felt. In the course of our experience at St.
Luke's Hospital, we have seen many patients discharged 'uncured' after the
year's treatment in that institution, and transferred to an asylum,
without noting the painful and prejudicial effects on their mental
condition supposed. Disappointment too is felt by patients rather at
discovering that on their discharge from one asylum they are to be
transferred to another, instead of being set at liberty and returned to
their homes; for few of the insane recognize their malady, and they will
think much less about the character of the asylum they are in, than their
confinement and restricted liberty. Again, it is not at all necessary to
contrast the two institutions, by calling the one an asylum for curables,
and the other an asylum for incurables; indeed, such a class as incurables
should never be heard of, for we are not called upon to define it. The two
asylums might be spoken of as respectively intended for acute and for
chronic cases; or the one as an hospital, the other as an asylum for the
insane; or better still, perhaps, the one as the primary (for primary
treatment), and the other as the secondary institution.
The removal, and the date at which it should take place, should be left to
the discrimination of the medical officer. No period need be fixed at
which treatment in the primary institution should be given up; the nature,
the prospects, and the requirements of a case must determine when
treatment therein should be replaced by treatment in the secondary asylum.
Moreover, no barrier should be opposed to a reversed transfer; a trial in
another institution is often beneficial, and it would be an advantage to
have the opportunity of making it. In the removal from the hospital to the
asylum there would be no declaration that the patient was incurable, but
only that his case was such as not longer to require the special
appliances of the former, although it still needed the supervision of an
asylum, and a perseverance in a course of treatment and nursing fully and
particularly supplied by the resources of the latter.
The determination of the cases proper for the secondary asylum lodged in
the physician's hands would always enable him to retain those in the
primary one, whose state, though chronic, would in his opinion be
injuriously affected by a transfer, and any such others besides whose
presence in the wards he might deem an advantage in the management. We
mention the latter, because the opponents to separation insist on the
benefits to an asylum accruing from the admixture of recent and chronic
cases. And although we are not prepared to deny an opinion held by so many
eminent men, yet we are on the other side not at all persuaded that the
presence of old inmates is of any such real advantage, as supposed, to
newly-introduced ones. We can assert, from experience, that recent cases
can be very satisfactorily treated without the company of old ones; and we
must, moreover, confess to certain misgivings that the actual presence of
a long-standing case, often eloquent on the injustice of his detention, a
Job's comforter to the new-comer, by his remarks on the severity of his
disorder, with the assertion added, that there was nothing the matter
with the speaker's self when he came into the house; full of gossip about
all the mishaps of the place, and often exercising an annoying superiority
and authority assumed on account of his position as one of the oldest
inhabitants. To the statement of the value of their service in aiding the
attendants and in watching their neighbours, we rejoin, there should be
attendants enough to perform the duties of supervision; that many recent
are equally serviceable as chronic cases, and stand in need of being
encouraged by the attendants in taking part in those many minor details
which characterize life in the wards of an asylum.
However this question of the utility of mixing chronic and recent patients
together may be solved, we do not contemplate the existence of a primary
asylum without the presence of more or fewer chronic cases, retained in it
for the best medical and moral reasons. Likewise, on the other hand, the
secondary asylum will not so exclusively be the abode of incurables. The
lapse of time in a case of insanity most potently affects its chances of
recovery, but it is not an invariable obstacle to it; for experience
decidedly demonstrates that recovery may take place years after every hope
of it has passed away, and that patients rally from their affliction, not
after four or five years only, but even after ten and twenty;
consequently, among the large number of chronic patients under treatment,
there would doubtless be every year some restored to reason and to
liberty; and the dreaded foreboding of perpetual confinement and hopeless
incurability could not take possession of the minds even of those whose
perceptions rendered them conscious of their condition and position.
To arrive at a correct judgment on this matter, let us look into it from
another point of view, and compare the condition of a lunatic in the
proposed chronic asylum with that of one in a large county asylum,
conducted according to the prevailing system. Look to the fact, that in
some of the existing large curative (?) asylums, not more than from 7 to
12 per cent. of their six or eight hundred, or one thousand inmates, are
deemed curable, and say in what respect a patient introduced into an
establishment of the sort, surrounded on every side by crowds of chronic
lunatics, enjoys any superiority over one transmitted to a secondary
asylum of the description we contemplate. Call such an institution what we
may, announce it as a curative asylum, or as an hospital for curables, it
matters not; to a fresh-comer it has all the drawbacks of a chronic
asylum; for if he be alive to his condition, and can reflect on the
position and circumstances in which he is placed, he may well find grounds
for discouragement and despair on looking round the gigantic building,
overflowing with the victims of chronic insanity, many of appearance,
habits, and manners, repugnant to the higher and better feelings of any
thinking, reflecting mortal; who count their residence there by years and
even tens of years, with no prospect of release, and who, it may be in his
imagination, are not, or have never been, so afflicted as himself. Can
such a spectacle be otherwise than injurious to a recent case,
sufficiently well to perceive it on admission, or coming to appreciate it
during convalescence? and must not the recognition of his position by the
patient be most painful and discouraging as one of a multitude, eliciting
personally, except perhaps for the few first days, no more attention than
the most crazy old inmate near him; submitted to the same daily routine,
and having no superior with sufficient time on hand to hear at large his
tale of woe, to soothe his irritated spirit, or to encourage him in his
contest with his delusions and fears? If the case of the new-comer be
chronic, the conditions he finds himself placed in are sufficiently
distressing and annoying; but if it be recent and curable, they are
damaging to his chance of recovery.
The comparison just drawn tells in favour of the system of separation.
Recent cases would not, in the primary institution or hospital, find
themselves an insignificant few surrounded by a host of chronic patients,
and they would accordingly escape the evils of such a position; on the
contrary, they would be placed under the most favourable conditions for
recovery, be individually and efficiently attended to, and encouraged by
the many convalescents around them to hope and strive after their own
restoration to health and liberty.
The sketch presented of the evils of the companionship of long-disordered
inmates with new-comers, especially when those are melancholic, is not an
imaginary one, but drawn from experience. Often will a desponding patient
observe, 'I shall become like such or such moping, demented lunatic'; and
superintendents, if they would, might often record the ill-effects of
example of older inmates upon those newly admitted.
Attempts by means of classification somewhat mitigate, where made, the
evils of large asylums for recent cases, by keeping these to a certain
measure apart from most of the other lunatics; but nothing can do away
with the injurious impression on a mind sufficiently awake to receive it
(on such a one, in short, as the question of the place of treatment can
alone concern),--of being one member of many hundreds who have for years
and years known no other residence than the huge house of detention they
are in: and there is no compensation to be had for the loss of those
special appliances, and that individual treatment, which only a
properly-organized hospital can supply.
The last clause suggests another important argument for the treatment of
recent cases in a distinct establishment or in separate sections. It is,
that they require a peculiar provision made for them, involving greater
expense, a more complete medical staff, a physician accustomed to their
supervision and management, unfettered by that host of general duties
which the presence of a multitude of chronic patients entails, and a staff
of attendants disciplined to their care, and possessing many of the
qualifications of nurses. Moreover, the building itself for this class of
patients need be more expensively constructed and fitted than one for
chronic inmates.
There is yet another reason against largely extending the size of a county
asylum, and in favour of building, in the place of so doing, a distinct
structure. This reason is to be found in the influence of distance as an
obstacle to the transmission of the insane to an asylum for treatment, and
to the visits of their friends to them during their confinement. The
Lunacy Commissioners of the State of Massachusetts particularly remarked
the operation of distance in debarring insane patients from treatment, and
illustrated it by a table showing the numbers received from different
places within the district it served, and in relation to their population,
into the asylum. Likewise in this country, where the distance of the
asylum is considerable, it is a reason for delay on the part of the
parochial officers, who wish to avoid incurring the expense of removing
the case, if they can in any way manage it in the workhouse.
But the evil of remoteness operates more frequently, and with much
cruelty, against the visits of poor persons to see their afflicted
relatives in asylums. Many can neither undertake the cost, nor spare the
time required for the journey, notwithstanding the modern facilities of
travelling. The same evil is likewise an impediment to the visits of
parochial officers, who rightly possess a sort of legal guardianship over
their lunatic poor in asylums.
Lord Shaftesbury, in his evidence before the Select Committee, 1859, very
properly dwelt upon the advantages of visits from their friends to
lunatics in asylums, and even proposed to make their visits compulsory by
act of parliament. The Commissioners in Lunacy also, in their Twelfth
Report (1858), gave examples of the distress not unfrequently attending on
the separation of the patient in an asylum at a long distance from his
friends. Such distress operates to the disadvantage of the patient, and
increases the sorrow of his relatives.
Admitting there are advantages attending the multiplication of asylums
instead of aggregating lunatics in very large ones, it would appear the
correct policy for boroughs to build asylums for the refuge of their own
insane; or, where small, to unite with other boroughs in the county for
the same purpose, in place of contributing to the county-establishment,
and inducing the magistrates to extend its size injuriously. In a case
such as that of Middlesex, where the county asylums have attained such an
unwieldy size as to be past acting as curative institutions, it would seem
no improper extension of the law to make it imperative upon the large
metropolitan boroughs to build apart for their own pauper lunatics. Of
this we are persuaded, that it would soon be found to the profit of the
boroughs to undertake to provide for their own pauper insane.
We regret that, in advocating the separation of chronic from recent cases,
we place ourselves in antagonism to many distinguished men who have
devoted themselves to the care of the insane, and among others to our
former teacher and respected friend Dr. Conolly, from whose clinical
visits and lectures at the Hanwell Asylum, many years ago, we derived our
first lessons, in the management and treatment of the insane. But although
regretting some divergence of opinion on this point, we are confident of
his readiness to subscribe to that maxim of a liberal philosophy,
expressed by the Latin poet, "_nullius addictus jurare in verba
magistri_."
To return from this digression: there are two propositions to be
established, viz.--1. That there are many cases of chronic mental disorder
to be found in every county asylum, which encumber it, to the prejudice
and exclusion of recent cases, and which could, without mental pain or
damage, or any tangible disadvantage, be removed from the institution
considered as a curative one. 2. That less elaborate structural
adaptations, and a less expensive organization, would suffice for the
proper care and treatment of a large number of chronic cases. Let it be
understood, however, that neither in past nor future remarks is it our
intention to argue against the existence of mixed asylums altogether,--for
by careful classification in a moderately-sized establishment, a zealous
physician, properly assisted, may contrive to do his duty, both towards
the comparatively few acute, and the many chronic cases under his charge;
but against the pretence of admitting recent patients for curative
treatment in monster institutions filled with chronic cases, where
individual daily recognition is all but impracticable, efficient medical
supervision unattainable, and proper medical and moral treatment
impossible.
Deferring for the present the inquiry, under what conditions of the insane
population of a county should distinct asylums be constructed, let us see
what are the views of the Lunacy Board bearing upon the two propositions
put forth, and examine further into the means of providing for the future
wants of the insane. So long since as 1844, the then Metropolitan
Commissioners in Lunacy advised the institution of distinct asylums for
the more chronic cases of insanity (Report, p. 92), and thus expressed
themselves:--"It seems absolutely necessary that distinct places of refuge
should be provided for lunatic patients who have become incurable. The
great expenses of a lunatic hospital are unnecessary for incurable
patients: the medical staff, the number of attendants, the minute
classification, and the other requisites of a hospital for the cure of
disease, are not required to the same extent. An establishment, therefore,
upon a much less expensive scale would be sufficient."
An exception might be taken to the wording of this paragraph, as
assumptive of incurability being an absolute condition, and as
countenancing the scheme of a refuge distinctly provided for incurables;
both of them ideas repugnant to the humane mind, instructed by experience,
that insanity, at almost any lapse of time, and under most forms, is not
to be pronounced absolutely incurable, or beyond the hope of cure. The
scope of the argument adduced can, however, not be objected to, for it
will be generally admitted that less expensive institutions are needed for
very chronic cases in general, and that it is an important object to clear
the present curative asylums of such cases, so as to facilitate the
admission and the early treatment of recent patients. The present Lunacy
Board, in their Tenth Report, 1856, repeated these views, and pointed out
the importance of erecting detached buildings in connexion with the
offices used for the different occupations pursued in the establishment,
instead of adding new stories, or new wings, to the main building.
In the Report for the following year (1857), the Commissioners returned to
the subject, in connexion with the proposed enlargement of the Middlesex
County Asylums; and, having remarked on the rapid accumulation and
crowding of those refuges with chronic cases, so soon after that at Colney
Hatch was opened, thus write (p. 13):--"Manifestly the remedy now was, not
to exaggerate the mistake already committed, by additions on the same
costly scale for purposes to which they would be as inappropriate; but, by
a fresh classification and redistribution of the patients, not only to
deal with existing evils, universally admitted, but to guard against a
recurrence of evils exactly similar, by restoring to both asylums their
proper functions of treatment and care. It had become not more matter of
justice to the lunatics themselves, than of consideration for the
rate-payers, to urge, that the additional accommodation required being for
classes of patients, as to whom, for the most part, small hope of cure
remained, might be supplied in an asylum much better suited to them, and
of a far less costly character." At a subsequent page (p. 23), they recur
to the theme. After pointing out that the plan of placing chronic, and
presumed harmless patients taken out of asylums, in workhouses and "in
their private homes," had signally failed, they observe:--"We are,
therefore, brought back to the conclusion already stated ..., to which we
find all reasoning upon the subject necessarily converge, and which we
desire to impress as strongly as possible upon every one to whom the care
of the insane is committed, that a new, and less costly kind of provision
is now very generally required for large classes of pauper lunatics, to
whom the existing expensive structures are unsuited.
"Our last Report directed attention to the fact, that in providing, not
merely for the harmless and demented, but for the more orderly and
convalescing, the most suitable was also the least expensive mode; that
they might satisfactorily be placed in buildings more simple in character,
and far more economically constructed; and that therefore it was
advisable, wherever the necessity for enlarging one of the existing
asylums presented itself, that the question should be considered in
reference to these two kinds of patients. And whether the mode adopted may
be, for the convalescing, by simple and cheerful apartments detached from
the main building, and with opportunity for association with the officials
engaged in industrial pursuits; or, for harmless and chronic cases, by
auxiliary rooms near the out-buildings, of plain or ordinary structure,
without wide corridors or extensive airing-court walls, and simply warmed
and ventilated; it is, we think, become manifest that some such changes of
structure must be substituted for the system now pursued, if it be desired
to retain the present buildings in their efficiency, and to justify the
outlay upon them by their continued employment as really curative
establishments. In this way only, as it seems to us, can justice be done
to the rate-payer as well as to the pauper."
Lastly, in their Supplementary Report on Lunatics in Workhouses (1859),
they repeat their recommendations to erect distinct inexpensive buildings
for chronic cases. The paragraph containing their suggestion has already
been quoted (p. 82), and need not be repeated here.
The noble chairman of the Lunacy Board, according to his valuable evidence
given before the Special Committee of Lunatics, just printed, appears to
have been an early and constant advocate for constructing distinct
receptacles for chronic and acute cases. In reply to query, No. 664, his
lordship has more particularly enlarged upon the utility of the plan, and
referred to the distinct proposition of the Board in 1845, that it should
be carried out by the Committees of Asylums. The scheme of separately
providing for many chronic lunatics has also received the valued support
of Dr. Boyd (Seventh Report, Somerset Asylum, p. 10), who appears to
contemplate the erection of the proposed building contiguous to the
existing asylum, so as to make use of the patients' labour "in preparing
stone and lime, and in doing all the heavy part of the work," and to unite
the two establishments under a common administration and commissariat, as
a plan attended with considerable economical advantages.
We do not deem it necessary to quote other authorities at large, in
support of the system advocated; otherwise we might adduce many
continental writers, especially among the Germans. It is fair to add,
however, that in France generally "mixed asylums" are the rule, and that a
few of these contain five or six hundred inmates, but none, we are happy
to say, have acquired the prodigious dimensions of several of our English
asylums. Moreover, the French system is to erect a number of detached
buildings, or sections within the general area of the establishment,
adapted to the different classes of the insane, according to the character
of their disease, or to their condition as pensioners or paupers. We
cannot here discuss the advantages or disadvantages of this plan, but it
certainly obviates some of the evils of aggregation evidenced in English
asylums, consisting of one continuous structure. It has just been said,
that in no French asylum are so many lunatics congregated as in some
English institutions; yet it is true, that the great Parisian hospices
contain similar numbers; for instance, La Salpêtrière holds as many as
1300; but in this case the arrangement is such, that each of the five
sections it is divided into, constitutes practically a distinct hospital
for the insane, structurally separated, or quite detached; with
subordinate quarters or sections, to provide for a proper classification
of the inmates, and having its own grounds for exercise, &c., and its own
medical staff. Thus, to the 1300 patients there are five physicians,
having equal power and privileges, each one the head of his own section.
We would not in any way adduce this extensive Parisian hospice as an
example to follow, either in structure or organization; and have alluded
to it in so many words only to show, that though equally large in its
population, it is comparable in no other respect to the huge receptacles
for the insane to be found in this country. Of the prevailing system in
Germany we shall presently find occasion to speak.
Lastly, the 8th & 9th Vict. cap. 126, gave express powers to provide for
the chronic insane in distinct establishments; in order, according to the
marginal abstract to sect. xxvii., "to prevent exclusion from asylums of
curable lunatics; separate provision to be made for chronic lunatics."
The chronic asylums were again referred to in sect. xlii. and in sect.
lvi., which conferred the necessary powers on the visitors to remove the
patients from one asylum to another. It is not worth while to repeat the
clauses referred to, since the Act was repealed by the 16th & 17th Vict.
cap. 97, and no re-enactment of them took place. Nevertheless, it is to be
observed, that the last quoted Act contemplated the provision of asylum
accommodation for the whole of the lunatics of each county, and with this
object, by sect. xxx., empowered the justices, at any general or quarter
sessions, to cause, or to direct the Committee of Visitors of the County
Asylum to erect an additional asylum, or to enlarge the existing building,
to supply the requisite accommodation; and further, put it into the power
of a Secretary of State, "upon the Report of the Commissioners in Lunacy,"
to call upon the magistrates of any county or borough to do the same.
This enactment may be enforced by the Lunacy Board so far as the Secretary
of State can prevail with a body of magistrates to accede to it, "in such
manner as the said Secretary of State may see fit, and direct." But this
high official has no direct power to compel a Committee of Visitors under
any sort of penalty. "It shall be lawful for such Secretary of State,"
says the clause, "to require" such additional asylum alteration or
enlargement; but the history of the contest between that public officer
and the Middlesex 'Committee of Visitors' appears to prove that his
requisition may be neglected and set aside. "He found" (as Lord
Shaftesbury tells us in his evidence, Rep. Select Comm., Query, No. 799),
"that the passive resistance offered was beyond his power." We coincide
with his lordship, that this ought never to have happened, and think, that
the Secretary of State, acting under the representations and advice of the
Lunacy Commissioners, ought to be armed with full powers to enforce the
provision for pauper lunatics in asylums being rendered equal to the
demand for it, according to some plan agreed to by them, in every county,
in harmony with the true intent and purpose of the Act now in force.
In order to facilitate the carrying out of this design, and to limit the
scope for the passive resistance and attempted delay of some county
magistrates, the re-enactment of the sections of the 8th & 9th Vict. sect.
126, as quoted, appears desirable, viz. to sanction and promote the
erection of distinct retreats for chronic cases. We are, indeed, glad to
find, that in this recommendation we are also in accord with the noble
lord at the head of the Lunacy Commission.
Looking at the matter in a general point of view, therefore, we appear to
find, in the plan of separating the more chronic and most unpromising
cases of lunacy from the recent and hopeful, so as to leave these in
smaller numbers for the purpose of more direct and effectual treatment,
one mode of improving and extending the future provision of the insane.
However, to elucidate the scheme, we need go into further detail, so as to
define more particularly the classes to be separately accommodated, and
the extent to which the separation should be carried.
The grand distinction, above employed, in discussing the question of
separation, has been that of recent and chronic cases, and it has been
sought to ignore that of curable and incurable, as not only undesirable,
but actually mischievous. By recent cases, we understand all those where
the malady is of less than one year's duration, which form a class that
demands the more active and constant attention and treatment of the
physician, more purely medical care, more consideration and watching from
the attendants, ampler measures for moral treatment, and for exercising
salutary impressions on the mind; and withal, special arrangements and
fittings in the asylum building itself. All these particular conditions
for treatment and management are not to be obtained by recent cases of
insanity, as we have insisted on throughout this chapter, in asylums which
have grown beyond the size which a chief medical officer can personally
supervise in all its details, and, so to speak, animate the whole machine.
If this be admitted, and if the cure of the insane be treated as the
primary and essential object of asylum detention, then surely the
necessity of special provision for recent cases will be recognized.
In moderately sized asylums acute and chronic cases may be, as said
before, received and treated together; for instance, in such as
accommodate from 250 to 450 patients, provided that the
physician-superintendent is properly assisted, for the proportion returned
"as deemed curable" in the English county asylums,--a proportion which
represents pretty nearly that of the recent cases, rarely exceeding 10 or
12 per cent.; consequently, the 40 or 50 demanding special supervision and
medical care may be undertaken by the superintendent, if he be
sufficiently assisted in the management of the chronic cases and in the
carrying out of the general details of the establishment. On the other
hand, a small, and perfectly distinct asylum for 40 or 50 patients could
not be established or conducted so advantageously, and still less so
economically; a circumstance, which will always avail to perpetuate the
system of mixed asylums for acute and chronic cases together.
Nevertheless, it must be borne in mind, that the 40 or 50 patients in the
population of 300 or 400, do not constitute the whole number of recently
attacked cases which may be admitted for treatment, but, so to say, the
residue at a particular date; for instance, the first day of the year.
Moreover, if the improvements in the law, and in its administration,
suggested, are carried out, and the admission of patients immediately on
the occurrence of their malady be facilitated, then, as a matter of
course, the proportion of those "deemed curable" would be immensely
increased; so much so, that it would be a very moderate estimate to reckon
on 100 recent, to every 500 chronic cases; or, what is equivalent to this
statement, the plan of placing patients under immediate treatment would
cause the progressive decrease of chronic cases, and raise the standard of
the asylum as a curative institution; a happy result, which, whilst it
would necessitate a more complete medical staff, would at the same time
well repay its cost.
Passing now to asylums which exceed the limits assigned as falling within
the compass of the abilities of any physician to superintend effectually
for the greatest benefit to its inmates, we hold the opinion, that where
these amount to 600 or 900, the most just and humane, and in the end the
most economical policy, is, to divide the establishment. Yet even here,
according to the present system regulating admissions, and the natural
consequence of this, the small per-centage of acute cases under care at
any one time, viz. from about 7 to 10 per cent. in the whole population,
would perhaps be held to furnish too small a number to justify the cost of
erection and maintenance of a wholly distinct hospital for their
treatment. Still we are confident that, if in any county where the pauper
lunatics in asylums attained the number mentioned, a distinct institution
for the reception of recently afflicted persons were erected, and the
admission of such patients were promoted, if that institution were free as
a public one for the insane other than paupers, such as those from among
the middle classes, unable to meet the costs of a proper private
asylum--it would secure to itself the number of patients needed to warrant
its establishment as a distinct institution, succeed even as an economical
arrangement, and confer an immense boon both on pauper lunatics and their
more unfortunate fellows in affliction, who are too rich for the "Pauper,"
and too poor for the "Private" Asylum.
Lastly, we come to the consideration of those overgrown establishments
where from 1000 to 2000 lunatics are congregated under one roof. Such
monstrosities ought never to have been constructed; they are nevertheless
looked upon by their promoters with admiration, and spoken of with pride,
though there is nothing in them to admire besides their magnitude and
pseudo-military discipline, and no more in them to be proud of as county
institutions than in enormous prisons; for as the latter indicate the
neglected morality of the county, so do the vauntedly large asylums prove
the neglected treatment of insanity. However, as the erection of these
unmanageable structures is an accomplished fact, nothing is left than to
deplore the fatal mistake; to take care that it is not repeated in other
instances, and to insist on the construction of distinct hospitals for
recent cases. The very existence of such an hospital would invite resort
to it, and bring within its agency many cases which do not find their way
into the existing institutions until, most probably, all hope of cure is
well nigh gone. Moreover, just as mentioned above in reference to a
proposed county hospital for lunatics, the law should intervene to secure
the early transmission of all cases for treatment, and admission be
granted to others besides paupers, under certain stipulations, by the
payment of more or less of their cost.
In counties with a population of lunatics of the extent named, the
difficulty of placing the chronic and recent cases of insanity in separate
asylums vanishes; for the latter will always be forthcoming in sufficient
number to justify a distinct institution for their treatment both on
medical and economical grounds; and the former, we apprehend, will always
be found numerous enough to occupy the accommodation provided. As refuges
for old cases, the evils of the existing gigantic establishments would
happily be mitigated, although not removed, by appropriating them solely
to the use of long-standing cases of lunacy.
Where the construction of a distinct hospital for recent cases of lunacy
is decided on as necessary, it should certainly accommodate not more than
300. All patients should be admitted whose disease is of less than one
year's duration; but this limitation should not be so absolute as to
prevent the physician to admit, after the lapse of a longer period, any
cases which might appear to him amenable to successful treatment;--a point
in prognosis, taught, and only taught, by experience in dealing with
recent insanity. Although the great majority of the insane who recover, do
so within the first year of their attack, yet statistics show that about
10 per cent. are restored in the course of the second year of treatment;
it would therefore seem that two years would constitute a fair and
sufficient period for the duration of residence in the primary asylum.
Here again the knowledge and experience of the physicians must be allowed
scope, both to discharge certain cases within the period named, and to
retain others beyond it. We should not consider it expedient to reject all
cases of epilepsy and general paralysis forthwith upon their application,
although insanity so complicated is generally very hopeless; for an asylum
with special appliances for treatment would at least be desirable to the
victims of those sad maladies in their early stages.
It is unnecessary to define the classes of lunatics who would occupy the
secondary asylums. As said before, we do not contemplate these
institutions as mere places of refuge; we do not consider the attempt and
the hope of cure relinquished in their wards, but that the means of
treatment are diligently persevered with. We would have them to be neither
hopeless retreats for patients, nor institutions calculated to encourage
supineness or apathy on the part of their medical officers. Indeed a
slender objection we have met with against the separation of the recent
from chronic patients, involves a slur upon the medical profession in
supposing a lack of interest and energy as incumbent upon the
superintendent of an asylum for chronic lunatics;--a supposition, which
reflects unfairly upon, and is untrue with respect to many superintendents
of asylums actually in existence. Are not interest and zeal, we may ask,
exercised for the benefit of those deemed incurable; are they not
exercised on account of idiots even, for whom their absence might be
esteemed not surprising? If cure is not attainable, the physician to the
insane, unless unfit for his calling, seeks and finds his reward in
ameliorating their condition; in elevating their mental and moral, and in
improving their physical being.
In those counties in which the number of the insane and the prevalence of
insanity are not sufficiently extended as to justify the institution of a
distinct curative asylum, the plan of the union of counties, as followed
for the provision of the ordinary asylums, suggests itself to the mind.
Practically, however, we believe, it is a plan which would not answer,
since it would render arrangements between counties in possession of
asylums difficult, and their accounts complicated. The only way in which
it could be made feasible would be by the levying of a general rate
throughout the country for the maintenance of lunatics, and by dividing
the country into districts, as is the practice in Scotland and Ireland,
apportioned in size to the population, to each of which an asylum for
chronic, and one for recent cases of insanity, might be assigned. Such a
scheme of a general rate, however, we do not expect to see realized,
although many arguments are adducible in support of it. Sir Charles Wood,
when Chancellor of the Exchequer, made the proposition to contribute on
behalf of the maintenance of asylums a portion of the proceeds of the
general taxation of the country; but the scheme met with little favour,
and was dropped. The principal objections advanced against it were, that
it was wrong in principle, a novel and uncalled for attempt to interfere
with local government, and no more to be justified than would be a
contribution from the revenue of the country towards providing for the
relief of any other form of disease. Respecting the last objection, it is
worth noting, that District Dispensaries throughout Ireland are partially
supported by Parliamentary grants; surely, therefore, if the principle of
subsidizing hospitals or dispensaries is admitted in one part of the
United Kingdom, there can be nothing unreasonable in a proposition to
extend it to another.
Where to provide for the lunatic population of a county considerably
exceeds the legitimate dimensions of a single asylum, and yet the
proportion of recent cases is too small to warrant the construction of a
distinct institution for them, we have proposed the establishment of two
asylums, each of a mixed character. Under such circumstances, and likewise
where a single asylum threatens to outgrow a manageable size, there are
certain very advantageous arrangements to be made, adapted to secure much
more efficient treatment, particularly of recent cases, than is usually
provided under the present system of aggregating all under one roof to be
subjected to one course of routine and discipline. These arrangements are
effected by the
§ _Construction of distinct Sections to Asylums._
The French system of asylum construction, as before noticed, is to divide
the building into several, more or less, sometimes quite distinct
sections, having a general administration and offices in common. The
number of sections and the character of their residents is a matter of
medical classification, and in each one there is a mixture of acute and
chronic cases, just as in our asylum wards; the combination being
regulated by the similarity in the phases of their malady, as, for
instance, if refractory; if epileptic; if clean and orderly; or demented,
paralytic and dirty. In Germany, on the contrary, although this same
medical classification is carried out, there is a primary separation of
the insane of the province or state into acute and chronic. But in the
mode of providing for the treatment of the two classes apart, two plans
are pursued, one termed that of "absolute separation," and the other of
"relative connexion" (relativ verbindung); the former consists in placing
recent and chronic cases in buildings completely detached; each one having
its own staff, organization and management; the latter, whilst keeping the
chronic and recent cases apart, possesses a common medical and general
administration in a building composed of two principal sections, either
forming parts of the same structure (as at Illenau, in Baden), or
detached, but within the same area (as at Halle, in Saxon Prussia).
Damerow is the most able advocate of the system of relative connexion, on
which he has largely written, and it is one which appears to be gaining
ground in Germany.
Now, except in the case of the overgrown Middlesex Asylums, where the
Lunacy Commissioners distinctly recommended a third asylum to be erected,
the plans propounded by that Board for affording additional accommodation
in institutions already large enough, are in principle much that of the
"relative connexion" system as proposed by the Germans. The reports above
quoted, in connexion with the question of separating recent from chronic
cases, show generally what the plans of the Commissioners are. They would
erect "detached day-rooms and associated dormitories near the wash-houses
on the women's side, and the workshops and farm-buildings on the men's
side." (10th Report, 1856, p. 27.) To prove the advantages of the plan,
they go on to say, "In making our visitations to the larger County
Asylums, we have repeatedly observed that a considerable portion of time
is occupied by the servants, who have charge of the wash-house and
workshop department, in merely collecting the patients in the wards, and
in conducting them to and from their respective places of employment. In
one asylum, we ascertained by minute inquiries that not less than one hour
and a half was thus every day wasted by the servants, and was passed
unprofitably and unpleasantly by the patients themselves.
"In addition to the saving of cost and time obtained by adopting the plan
we now recommend, we have the best reason for believing that the patients
derived a direct benefit, in many ways, from residing in cheerful airy
apartments detached from the main building, and associated with officials
engaged in conducting industrial pursuits. A consciousness that he is
useful, and thought worthy of confidence, is necessarily induced in the
mind of every patient, by removal from the ordinary wards, where certain
restrictions are enforced, into a department where he enjoys a comparative
degree of freedom; and this necessarily promotes self-respect and
self-control, and proves highly salutary in forwarding the patient's
restoration. As a means of treatment, we consider this species of separate
residence of the utmost importance, constituting in fact a probationary
system for patients who are convalescing; giving them greater liberty of
action, extended exercise, with facilities for occupation; and thus
generating self-confidence, and becoming not only excellent tests of the
sanity of the patient, but operating powerfully to promote a satisfactory
cure.
"The want of such an intermediate place of residence is always much felt;
and it often happens, that a patient just recovered from an attack of
insanity, and sent into the world direct from a large asylum, is found so
unprepared to meet the trials he has to undergo, by any previous use of
his mental faculties, that he soon relapses, and is under the necessity of
being again returned within its walls." (P. 27, Rep. 1856.)
The proposition of the Commissioners has been carried out to a certain
extent in several large asylums; for instance, at the Leicester, the
Wakefield, and the Devon. At the last it has been most fully developed in
the construction of a detached building for 100 patients; respecting the
excellence and cheapness of which, we have spoken in a previous page (p.
48).
The views of the Commissioners will meet with general approval. The
prevalent system in France of breaking up an asylum into sections, more or
less detached, we hold as preferable to the close aggregation of wards
under one roof, with continuous corridors, seen in the majority of English
Asylums. The correct principle to be pursued in an asylum is, to
assimilate its character and arrangements as far as possible to those of
the homes of the classes of persons detained in them. Can this be effected
in a large building constructed as much unlike ordinary houses as it well
can be; recalling in its general character that of an extensive factory,
workhouse, or barrack, of somewhat more ornate architecture indeed, and
with better "belongings" within and without, where the patients live by
day in long corridors, and sleep by night in boxes opening out of the
same, and where perhaps they are mustered and marched in great force into
a great hall to eat their meals? Certainly all this is not home-like,
however excellent to the lovers of routine or the admirers of military
discipline. But the separation into sections greatly lessens this
objectionable state of things; the population becomes thereby divided, so
to speak, into families, overlooked and controllable as such. The
advantage of transferring an improving patient from one ward to another is
considerable; but it would be much more so, if the transfer were from one
section to another; for the construction of separate sections admits of
the architectural arrangements, the fittings, &c., being varied to a much
greater extent than they can be in the case of wards, forming mere
apartments of one large building, constructed, as it must be, on a nearly
uniform plan.
From the same grounds likewise follow the economical advantages of
distinct sections; for the more expensive building arrangements required
for acute cases need not be repeated in the section for quiet, orderly,
chronic, or for convalescent patients, where accommodation may be
beneficially made to accord as nearly as possible with that of their
cottage homes. If detached sections were adopted, the elaborate,
complicated and costly systems of warming and ventilation would not be
needed; there would be less to cherish the feeling of imprisonment; and,
lastly, to recal the valuable observation of the Commissioners before
quoted (p. 142), this species of separate residence would be a means of
treatment "of the utmost importance, constituting in fact a probationary
system," and a most excellent addition to the means of 'moral treatment'
now in operation. There is one subsidiary recommendation made by the
Lunacy Commissioners, which we cannot so freely subscribe to, that, viz.
of classifying the patients in sections according to their occupations.
Those of the same trade or employment must, as a matter of course, be
associated together, during the hours of labour; but at the expiration of
those hours we would wish to see that association broken up. The
congregation of the same mentally disordered persons always together is
not desirable; the insane are selfish enough--absorbed in self, from the
effects of their malady; and it should always be a point in treatment, to
disturb this condition, to arouse the attention to others, and to other
things; an effort which would be the more difficult in a small knot of
people always accustomed to meet together, knowing each other's ways and
whims, and each thinking the other mad, though not himself. Again, if the
workers are entirely separated from the drones in the hive, the latter are
likely to remain drones still: they lose the benefit of example, which
operates, as among children, so strongly with the insane.
To apply these observations to one class of workers, for example, to the
laundresses: it seems to us scarcely merciful to keep these poor patients
to the wash-tub all day; at the close of their labour to turn them into an
adjoining room, and at night consign them to sleep over it. Instead of
being thus scarcely allowed to escape the sphere and atmosphere of their
toil, they should have their condition varied as far as possible, be
brought into new scenes, mixed with others who have been otherwise
engaged, and made to feel themselves patients in an asylum, and not
washer-women. Is it, in short, not a radical error in the direction of an
asylum, to place the inmates in such a position and under such
circumstances, as to make them feel themselves workmen under compulsion,
regularly employed, dealt with only as labourers and artisans, by being
kept all day in their workshops, and in the evening and night brought
together, because they are workers, and unlike the other residents of the
asylum, who will in their opinion come to be regarded, as unlike
themselves,--as the fitting occupants, and the only patients? Treated
apart in the manner under notice, there would be nothing in the position
or circumstances around the industrious inmate to suggest to him that he
was a patient, except in name, as called so by the officials. We are,
therefore, opposed to this _industrial system_ of classification, and
regard medical classification as the only proper one.
The division into quarters or sections is a plan more applicable to an
asylum for chronic than to one for acute cases. In the latter, patients
are to be treated specially and individually; and as sufferers from acute
disease must be classified medically rather than with reference to any
matters of management, occupation, and discipline, and are on the whole
less conformable to general orders and plans: yet certain principal
sections are wanted in them; as, for example, for the refractory and
violent, for the quiet and orderly, and the convalescent. To some of the
last named, a separate section, of a home-like character, regulated less
as an asylum than as a family residence, and where the highest amount of
liberty compatible with safety and order is the rule, would afford a most
valuable means of treatment.
§ _Distribution of the Chronic Insane in Cottage Homes._
The subdivision of an asylum for chronic cases could be carried very far.
Not only might sections be appropriated specially to idiots, to
epileptics, to imbeciles, and to the very aged and infirm in an infirmary,
but also to several classes of the chronic insane not falling under either
of those categories, distinguishable by the greater or less amount of
trust to be reposed in them, by their dispositions and tendencies, and by
their industrious and moral habits. However, there must be at some point a
limit to the utility of subdividing an establishment necessitated by the
requirements of its administration and of an effective and easy
supervision; and as yet, in this country, the system of aggregation
prevails most largely over that of segregation. English asylums have, some
of them, detached wards and a few farm-buildings, affording lodging to
patients engaged in industrial pursuits; but the plan of segregating their
residents has not been pushed farther, except to a small extent by Dr.
Bucknill, who has placed some selected pauper lunatics in the homes of
cottagers living in the vicinity of the county asylum; for we cannot call
the boarding out of the imbecile poor--scattered, as it were, broad-cast
over the country, disposed of in cottages, according to the notions of the
inferior parochial officers, and watched over only nominally,--a system of
providing for them. If system at all, it is merely one for putting them
out of the way, of escaping responsibility, and of hiding them from
observation.
The colony of insane at Gheel, in Belgium, is the only one where the
segregation of the insane has been systematically carried out. It presents
most of the elements of success in its constitution and government. It has
an organized medical staff; it is a naturally secluded locality; its sane
inhabitants have been for ages accustomed to act as the guardians and
nurses of the insane, and to receive them as boarders into their families.
Yet, notwithstanding the eulogiums of many visitors to this village,
others who have more minutely examined into it have detected many
irregularities, and pointed out weighty objections against its management.
The questions may be fairly put,--Are the irregularities inevitable? Are
the objections inseparable from the system? To discuss these points in
detail would carry us far beyond the limits we must observe; but we may
express our belief in the value of the system, considered as such,
although we do not see how or where it can be applied to a similar extent
as found at Gheel. The irregularities which have been remarked are
remediable, and the objections generally removeable. It is a defect at
Gheel, that there is no central establishment of the character of an
asylum and infirmary, and it is a mistake to undertake the charge of
recent and violent cases, and of epileptics for the most part, and
likewise of paralytics, in cottages under cottagers' supervision only.
Other classes of patients might be pointed out as unfit residents in
peasants' families. The system, in short, is pushed to an extreme in this
place; but this error does not invalidate it as a system. Objectionable
cases for the cottage home could be collected in a central establishment,
and there would be plenty left to partake of the "air libre et la vie de
famille," which a recent physician of the colony of Gheel, M. Parigot,
commended in his _brochure_ addressed to the consideration of the friends
of the insane.
Many who have become acquainted with the system pursued at Gheel have been
enraptured by its many apparent advantages, the liberty it affords, and
the great cheapness of its management, and have wished to import it as a
whole into this country. Such a scheme we regard as both impracticable and
undesirable; yet we at the same time believe something may be attempted in
the same direction most beneficially (see p. 89). The attempt should first
be made in connexion with some of our county asylums of a moderate size. A
similar secluded district as that of the commune of Gheel is, thanks to
Providence, not to be found perhaps in England; but this is of no such
primary importance: a moderate distance from considerable towns, or from
large villages, is all that is strictly requisite, and several asylums are
so situated. The difficulty of place being encountered, a more serious one
appears, viz. that of finding suitable cottagers to undertake the charge
of patients. At first, a suitable class could not be reckoned on; but,
according to the laws of supply and demand, it would only require time to
form such a class. Sufficient inducements only are wanting, and probably
those supplied would be found so. It is an advantage to a cottager to have
a constant lodger, to receive a certain weekly payment; and it would
constitute a greater one to have as an inmate one who could assist in
certain labours of the house and garden. We might hope to see old
attendants of the asylum settled around, after retirement from their
employment, with a pension; and to the care of such two or three, or even
more, selected patients might be entrusted. If the land belonging to the
asylum were of sufficient extent, the patients boarding around might still
be employed upon it; or, if they were artisans, they might daily resort to
its workshops, its bakehouse or brewhouse, just as the ordinary peasant
labourer goes to and fro to his place of employment. The asylum would thus
still reap the benefit of the patients' labour, and this arrangement, we
believe, would work better than one providing for their employment with
strangers at a distance from the institution.
By limiting the area inhabited by patients in lodgings to that immediately
surrounding the asylum, a satisfactory supervision could be exercised by
the authorities; and on the occurrence of illness, or a change in the
mental condition, a transfer to the asylum could be speedily accomplished.
Again, by keeping the insane within a moderate range of the asylum, and by
retaining them as labourers on its grounds, the advantages of a central
general administration would be found in the provision and distribution of
food and clothing.
In previous pages we have advocated, under certain conditions, the
erection of distinct asylums for chronic cases of insanity; to this plan
the system just developed, of boarding out a certain number in cottages,
must be held as supplementary. A chronic, or a moderate, manageable-sized,
mixed asylum must form the nucleus of the 'cottage system' of providing
for the insane. The cases must be selected from the asylum-residents, and
the selection be left with the medical superintendent. The persons
receiving patients must be held responsible to the superintendent, and to
the members of the Lunacy Board, for their proper care and management, and
they must enter into some sort of covenant with the Visitors of the
asylum. To carry out the scheme under notice, many matters of detail are
required, but these it would be out of place here to enter upon.
There is this evident general and economical advantage about this 'cottage
system,' that it would obviate the necessity of constructing large asylums
for chronic lunatics at an inevitably heavy outlay, and also of
instituting so large a staff of officers and servants as is called for to
govern and conduct an expensive special establishment. In country
districts, agricultural labourers and other small householders might be
found willing to board, lodge, and look after patients for 7 or 8
shillings per week each; or, according to the plan we prefer, the asylum
would provide board, and receive the benefit of the patients' labour, and
only some small sum would be payable for his lodging and care.
Having only in view at the time the amelioration of the present condition
of the insane boarded out with friends or strangers, we have proposed in a
preceding page (p. 87), their frequent supervision, and the arrangements
necessary to their welfare, being entrusted to a distinct medical officer
under the central control of the Lunacy Board. This plan would still hold
good with reference to all those lunatics not living within the fixed
radius around the asylum; within which the superintendent would be the
directing authority, the supervisor and protector. Moreover, as we have
remarked (p. 89), residence with their immediate relatives would be
frequently preferable to their severance from them in order to be brought
within the sphere of the asylum; and such patients would derive benefit
from the inspection proposed.
§ _Separate Provision for Epileptics and Idiots._
The extent to which the separation of epileptics and idiots, but more
particularly of the former, from other classes of mentally disordered
persons should be carried, is a matter much discussed. The rule is to have
epileptic wards in large asylums, although there are some epileptics in
whom violence and dementia are such prominent features, as to justify
their position severally with the refractory or with the demented.
However, the painful features of their malady, the special provisions
needed in the apartments occupied by epileptics, and the precautionary
measures to be observed in their clothing and food, the ill effects of the
sight of their paroxysms upon others, and other reasons well known to
medical men, constitute sufficient grounds for the ordinary practice
pursued of keeping epileptic lunatics generally in particular wards. This
plan answers well in moderately-sized asylums; where their number is
considerable, as in large establishments, we should prefer their location
in a distinct section; and if the county possessed one asylum for recent,
and another for chronic cases, the majority of the epileptics should be
residents in a section of the latter.
Of the great value of separate provision for idiots we think there can be
no doubt. Indeed, the association of idiots with lunatics is an accident
of legal origin rather than a proceeding dictated by science and medicine.
The law places together idiots and lunatics under similar protection, and
treats them as nearly in the same position socially. Hence it has come to
pass that their legal claim to care and protection has brought them within
the walls of the County Asylums. Their presence there, however, we regard
as a mistake prejudicial to their own welfare and an onus upon the asylum
authorities. Of old, all that was considered necessary for idiots, was to
provide food and lodging for them, and to keep them out of harm's way.
But, thanks to modern philanthropy, the prospects of the idiot are much
improved; the amelioration of his condition is attempted; his moral,
mental and physical powers are found to be improveable, and it is sought
to elevate his status as a social being, and to foster his capacity for
amusement and for useful employment.
Contrasted with previous neglect, the care and management afforded in an
asylum render the poor idiots an infinite service; yet withal a lunatic
asylum is not the proper abode for them. Within its walls they are unfit
associates for the rest of the inmates, and it is therefore felt to be
necessary to place them in a special ward. Too frequently this ward is in
the worst placed and most forgotten section of the building, sometimes
with little open space about it, and devoid of those conditions calculated
to evolve the little cerebral power possessed. Whatever their claims upon
the attention of the medical superintendent, and however zealous he may be
to discharge all his duties, yet amidst the multifarious occupations
pressing upon him, and specially occupied as he is in treating insanity,
that officer finds himself unable to do more than watch over the health of
the idiotic inmates, and attend to the improvement of their habits: he is
not in a position, and has not the opportunities to superintend the
education of idiots; and we are certain that every asylum-physician would
rejoice, both for his own sake and for the interests of the idiots
themselves, to see them removed to a special institution, or to a section
of the asylum specially organized for their care.
Not only are idiots in the way in a lunatic asylum, and their ward an
excrescence upon it, but the organization and arrangements are not adapted
for them. Idiots require a schoolmaster as much as a doctor; the latter
can see that all those means are provided for them to improve their habits
and their physical condition; but it must devolve on a patient instructor
to operate more immediately upon the relic of mental power which is
accorded to them. The sooner they are brought under the teacher's care the
better: experience shows that much more may be effected with idiots during
their childhood than when they have arrived at a more mature age, and the
developmental changes in the brain have so far ceased, that an increased
production of nervous power can be scarcely looked for.
This is a theme we cannot further enter upon; and to conclude this
section, we may remark, that the number of idiots is so large as to
justify the erection of several distinct institutions for their care and
improvement. Several counties might unite in the establishment of an idiot
asylum, the parishes being charged for the number belonging to them in it;
an arrangement, which would no more complicate parochial accounts, than
where one charge has to be met (as often is the case at present) for the
maintenance of a certain number of lunatics in the county asylum; a second
for that of another portion in a licensed house; and a third for some
others in the workhouse wards.
There is another matter worth noting. The county asylums for the most part
being filled to the exclusion of recent cases of insanity, and the
condition of idiots being held in still less importance than that of the
insane by workhouse authorities, it is not to be wondered at that, on the
one hand, the admission of idiots into asylums is not promoted, and that,
on the other, so many idiotic paupers are found in workhouses. To provide,
therefore, cheaply for idiots in distinct institutions, and to facilitate
and enforce their transfer to them, will be a means of ridding
union-houses of a portion of their inmates, for which they are so entirely
unfitted. To the genuine philanthropist and the truly humane, no
hesitation would arise as to securing every necessary provision, and the
best means for ameliorating the fate of any sufferers, and particularly
that of the poor helpless idiots. But to the majority of mankind the
question of cost is preliminary to the exercise of philanthropy; and some
perhaps think it enough to feed and clothe, to watch and keep clean the
miserable drivelling idiot, since all the money that could be spent upon
one would only produce after all a poor, weak-minded creature, of little
or no service in the world. This argument cannot be gain-said, though it
must be condemned by every Christian animated by the leading principle of
his religion, that of "love."
To the sticklers for economy, the proposition may be propounded for
consideration, whether, on the adoption of the plan of erecting distinct
asylums for the chronic insane, the idiots could be less expensively
provided for in a section or "quarter" of such an asylum, properly
furnished with the means of improving their condition, than in an
establishment reared specially for the purpose? We content ourselves with
putting the question.