On the State of Lunacy and the Legal Provision for the Insane
TekstFrench writers coincide in these views. M. Parchappe assigns to an asylum containing 200 to 250 patients, a physician with an assistant, besides a dispenser; to one having 300 to 360 inmates, a physician, two assistants and a dispenser, besides a director to superintend the general administration, who in some institutions is also a medical man.
In Germany, and generally in Italy, the medical staff is still larger in proportion to the number of patients. Jacobi apportions to an asylum for 150 or 200 lunatics, a chief physician, a second, and an assistant, besides the dispenser. Roller coincides with this, and the asylum at Illenau under his superintendence, consisting of two divisions, one for recent, the other for chronic cases, and containing in all 414 patients, has three physicians besides two assistants or ‘internes.’ So at Leubus, in Silesia, there are three physicians, although the inmates are only 150 in number; and the rule is, in other German asylums, containing 100 inmates, to have two physicians, besides one or two internes and a dispenser (pharmacien).
Allowing the opinions and practice of the eminent men quoted, and which in truth are shared in by every asylum superintendent, their due weight, it would seem no extravagant arrangement to allot to an asylum accommodating from 150 to 200 patients (recent and chronic cases together), a physician superintendent and an assistant; and a similar medical staff to an institution for 300 or 350 inmates, all in a state of confirmed chronic insanity, imbecility, and dementia. If the population in an asylum for chronic cases is further augmented to 450 or 600, – the latter number we hold to represent the maximum which can economically and with a just regard to efficient government and supervision and to the interests of the patients, be brought together in one establishment, – the medical superintendent will require the aid of two assistants and a dispenser.
Such aggregations as of 1000 to 2000 insane people are unwieldy and unmanageable with the best appointed medical staff, unless this be so numerous as utterly to invalidate the plea of economy, the only one, fallacious as it is, that can be produced by the advocates for their existence. And not only are they unmanageable, but also hygienically wrong; for it is a well-recognized fact, that the accumulation of large numbers of human beings in one place, tends to engender endemic disease, uniformly deteriorates the health, and favours the onset, progress, and fatality of all disorders. The history of large asylums bears testimony to the truth of this; for cholera has scourged more than one most severely, and dysentery and chronic or obstinate diarrhœa are pretty constant visitants in their wards.
The contrast between the opinions and practice of the distinguished men referred to and those of some Committees of Visitors respecting the value of medical attendance on the insane, the nature of the duties to be performed, and the amount of labour the superintendent of an asylum may accomplish, is most remarkable. What those of the former are, is stated already; what those held by the latter are, we have an illustration in the administration of the Colney Hatch and of the Hanwell Asylums. In the latter establishment we find two medical men appointed to superintend 1020 insane inmates, besides nearly 200 persons employed about it. True, we are informed by the Committee, that the superintendent of the female department, who has the larger number, some 600, under his charge, is assisted by the matron; and we are sure he must be thankful for any assistance rendered him; yet it is the first time that we have been called upon to recognize a matron as an assistant medical officer. However, we must accept it as a fact, – gratefully we cannot, – but with a protest against placing a subordinate officer on such an independent footing, against entrusting her with duties incompatible with her education and position, and with the relations which should subsist between her and the superintendent, and against making her his equal in the remuneration for her services.
Did occasion offer, we might ponder over this new development of the matronly office; inquire respecting the medical qualifications demanded, and the manner in which the Hanwell Committee have ascertained them; and meditate at length on the notions which govern the Visiting Justices in organizing and directing an asylum; but for the present, we will, for further example’s sake, note some of their opinions and doings in the management of the sister ‘refuge for lunatics’ at Colney Hatch. We shall, for this purpose, appeal to the Report for 1856, and to make the quotations used intelligible, will premise, that the steward, at that date, had turned architect, and produced a plan for the extensive enlargement of the asylum as proposed by the Magistrates; and that, very naturally, when writing about it, he was intent to prove that his plan was the best, the cheapest and the most convenient even to the medical superintendents who would be called upon to officiate in it when completed. This much being premised, we will quote the steward’s own words.
“I must also remind the Committee,” he observes, “that some three years since it was with them a matter of serious deliberation, whether it was advisable that the male and female departments should be placed under the care of one medical superintendent, and, in fact, whether one medical officer should have the supervision and direction of 1250 inmates, and an extended range of building; or whether the two departments should continue, as they are at present, separate and distinct.” What an excellent insight does this revelation of the cogitations of the Committee-room of the Middlesex Magistrates afford us of the sentiments these gentlemen entertain of the requirement and value of medical skill in an asylum; of the capacity, bodily and mental, of a superintendent for work! But, without waiting to fill up a sketch of the wondrous virtues and faculties which the superintendent of the 1250 insane patients need to possess in order to know all, supervise them, direct them, and attend to the multitudinous duties of his office as a physician and director, we will by a further extract gather clearer notions of the extent of the work thought to be not too much for him. The gist of the ensuing paragraph is, that the steward strives to prove that by adding a new story here and there, besides spurs from the previous building, he will increase greatly the accommodation without much augmenting the ambulatory labours of the medical officer. And alluding to one, the male division of the establishment, he proceeds to argue, that “if it is considered feasible for one person to superintend 1250 patients of both sexes in a building extending from one extreme to the other, nearly two-thirds of a mile, would it not be equally feasible to superintend 840 patients in a building one half the extent [here Mr. Steward forgets to count the number of furlongs added by his proposed new wards], provided they are conveniently and safely located, although these patients are all males?”
To this we may be allowed to subjoin some remarks we penned in a critique published in the ‘Asylum Journal’ (vol. ii. p. 271) for 1856, and in which many of the observations contained in the present work were briefly sketched. “Who, we ask, can dispute the feasibility of a medical or of any other man superintending 840, 1250, or two or three thousand patients, collected in an asylum or in a town, in the capacity of a director or governor, if subordinate agents in sufficient number are allowed him? But we think the question in relation to asylums is not, how we can govern our insane population most easily and at the least possible cost, but by what means can we succeed in curing the largest number of cases of insanity as they arise, and thus permanently keep down expenditure and save the rates. These results are certainly not to be attained by persevering in the old scheme of congregating lunatics by tens of hundreds, but by making suitable provision for the immediate treatment of the pauper insane in asylums properly organized for it, and under the direction of a sufficient medical staff.”
How totally different, too, are the views of Jacobi to those of the Middlesex Magistrates concerning the office of superintendent, and the extent of work of which he is capable! In his treatise on Asylum Construction (Tuke’s Translation, p. 23), he presents the following sensible remarks: – “It is not that I should consider a more numerous family (than 200) incompatible with the right management of the farming and household economy, nor with the domestic care of the patients; both these might perhaps be organized in an establishment containing a number equal to the largest just named (four or six hundred), in such a manner as to leave nothing to be desired; but it is in regard to the higher government of the establishment, and the treatment of the patients as such, in its widest signification, which must rest upon the shoulders of a single individual, – the director of the establishment, – that I am convinced the number of patients should not exceed two hundred. For when it is considered that the duties of the governor embrace the control of all the economical and domestic arrangements, as well as of the whole body of officers and servants; that he must devote a great share of his time to the writing, correspondence, and consultations connected with his office; that as first physician, he is entrusted with the personal charge and medical treatment of every individual committed to his care; that he must daily and hourly determine, not only the general outlines, but the particular details of the best means for promoting the interests of the collective community, as well as of every separate person composing it; and that, besides all this, he is responsible to science for the results of his medical observations in the establishment over which he presides; nor less so for the promotion of his own advancement as a man and a philosopher; – it will be readily granted, that the given maximum of two hundred patients for a single establishment ought never to be exceeded. Indeed, a man of even extraordinary abilities would find himself unequal to the task of discharging these duties, in an establishment containing two hundred patients, were he not supported by such assistance as will hereafter be described; and were there not a great number amongst even this multitude of patients requiring not constant, or at least, a less degree of medical attention.”
Many writers on asylum organization, particularly those of the Continent, insist very strongly on so far limiting the size of asylums for the insane, that they may be superintended by one chief medical officer, aided indeed by assistants, but without colleagues of coordinate powers. The venerable Jacobi took this view, and desired that the director of an asylum should be the prime authority in all its details of management, and insisted that the institution should not by its size overmatch his powers to superintend it and its inmates as individuals. Thus, after reviewing the nature of the duties devolving on the chief physician, he observes (p. 192, Tuke’s translation), “It follows as a necessary consequence that one man must be placed at the head of the establishment,” … and that “his mind must pervade the whole establishment.” Likewise M. Parchappe joins in the same opinion; and after speaking (Des Principes, p. 43) of the impossibility of proper medical supervision in a very large asylum, observes, “that to divide the medical direction among two or more physicians is extremely detrimental to the superiority which the medical superintendent ought to hold in the general administration of asylums, and to that unity of purpose and opinions required in the interests of the patients.”
Without citing other foreign writers to substantiate the view under consideration, we may call attention to the fact, that the Lunacy Commissioners, who have always so stoutly advocated the position of the medical officer as the superintendent of an asylum, likewise appear to accept the same principle; for in their Eleventh Report (p. 11), they remark, that besides the direct injury inflicted upon patients when congregated in excessive numbers in the same institution, “experience has of late years shown, that the absence of a single and undivided responsibility is equally injurious to the general management.”
Lastly, the Committee of Visitors of the Surrey County Asylum appear, – judging from their recent appointment of a chief physician to their institution, paramount to the medical officers of the divisions, and invested with full powers as director, – to have arrived at the just conviction that there must be unity and uniformity in the management of an institution. However, we regret to say that this conviction is unaccompanied by that other which Jacobi and Parchappe would associate with it, viz. that the size of the asylum should be no larger than will admit of the chief physician acquainting himself with every case individually, and treating it accordingly. Whilst, indeed, by their proceeding, they constitute the chief physician a governor of a large establishment, and the director of the household and of its economy, they at the same time deprive him of his professional character by removing the opportunities of exhibiting it beyond his reach, both by the relations they place him in to the other medical officers, and by the enormous aggregation of patients they surround him with.
Few objections, we presume, are to be found to the principle of having a chief medical officer paramount to all others engaged in the work of an asylum; and although, considered as a medical superintendent, his professional qualities are not in much requisition in so large an institution as the Surrey County Asylum, yet we regard such an appointment as most desirable, and as preferable to the system of dividing the management between two medical officers, as pursued in the Middlesex County Asylums. Indeed, the value of the principle of concentrating power in the hands of a chief officer, under the name of governor, or of some equivalent term, is recognized by its adoption in large institutions of every sort in the country. Such enormous asylums as those referred to, partake rather of the nature of industrial than of medical establishments. Their primary object is to utilize the population as far as practicable, and this end can be attained in a large majority of the inmates; consequently an able director is of more consequence than a skilful physician; for the latter is needed by a very small minority, by such a section, in fact, as is represented by the inmates of a workhouse infirmary only compared with its entire population. Therefore, since the enormous asylums in existence are not to be got rid of, it is desirable to give them an organization as perfect as practicable; and it is under this aspect that we approve the plan of the Surrey Magistrates in appointing a director paramount to every other officer. The approval of this proceeding, however, does not minish aught from our objections to such enormous institutions, considered as curative asylums for the insane. As a refuge for chronic lunatics, an asylum so organized and superintended as is the Surrey, may subserve a useful purpose; but we hold it to be an unsuitable place for recent cases demanding treatment as individuals suffering from a curable disease, and requiring the exercise of the skill and experience of a medical man specially directed to it.
While the system of congregating so many hundreds of lunatics in one establishment, and the magisterial principle of providing for the care and maintenance and of non-intervention in the individual treatment of the insane prevail, no objection can be taken to the practice of Committees of Visitors in according the first merit when candidates come forward for the office of medical superintendent of an asylum, to qualifications for the routine government of large masses, for the allotment of labour, for the regulation of the domestic economy of a house, for the profitable management of the farm; in short, for qualities desirable in a governor of a reformatory-school or prison. Indeed, they are right in so doing, when they wish to have a well-disciplined and profitably worked asylum; and when their institution attains the dignity of a lunatic colony, it is the best course they can adopt, for medical qualifications in such an establishment sink into insignificance amidst the varied details of general administration, which fall to the lot of the superintendent. But the case would be materially changed were the primary object of an asylum the successful treatment of its inmates, and were its dimensions within the limit to afford its superintendent the opportunity to know all, and to treat all its patients as individuals to be benefited by his professional skill. In selecting the physician of such an asylum, the administrative and agricultural qualifications he might possess, though far from being unnecessary or unimportant, should occupy a secondary place in the estimation of Committees of Visitors; and the primary requirement should be the possession of properly certified medical skill, of experience in the nature and treatment of insanity, in the wants and management of the insane, and of asylums for them; of evident interest and zeal in his work, and of those intellectual and moral endowments adapted to minister to the mind diseased, to rule by kindness and forbearance, and at the same time with the firmness of authority.
Chap. VII. – on the future provision for the insane
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.