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

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.