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

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.”