On the State of Lunacy and the Legal Provision for the Insane
TekstThese sketches from America may be matched in our own country; and they truthfully represent the reciprocal disadvantages of mixing the sane and insane together in the same establishment.
Even supposing the presence of insane in workhouses involved, on the one hand, no disadvantages to the institutions, or to the sane inmates; yet on the other, the evils to the lunatic inhabitants would be condemnatory of it; for the insane necessarily suffer in proportion as the workhouse accommodation differs from that of asylums; or, inversely, as the economical arrangements and management of a workhouse approach those of an asylum. They suffer from many deficiencies and defects in locality and organization, in medical supervision and proper nursing and watching, in moral discipline, and in the means of classification, recreation, and employment.
Workhouses are commonly town institutions; their locality often objectionable; their structure indifferent and dull; their site and their courts for exercise confined and small, and their means of recreation and of occupation, especially out of doors, very limited. Petty officers of Unions so often figure before the world, and have been so admirably portrayed by Dickens and other delineators of character, on account of their peculiarities of manner and practice, that no sketch from us is needed to exhibit their unfitness as guardians and attendants upon the insane. As to workhouse nurses, little certainly can be expected from them, seeing that they are only pauper inmates pressed into the service; if aged, feeble and inefficient; if young, not unlikely depraved or weak-minded; always ignorant, and it may be often cruel; without remuneration or training, and chosen with little or no regard to their qualifications and fitness.
However satisfactory the structure of the ward and its supervision might be rendered, its connexion with a Union Workhouse will be disadvantageous to the good government and order of the establishment, as above noticed, and detrimental to the welfare of the insane confined in it. Thus it must be remembered that very many of the lunatic inmates have been reduced to seek parochial aid solely on account of the distressing affliction which has overtaken them; before its occurrence, they may have occupied an honourable and respectable position in society, and, consequently, where consciousness is not too much blunted, their position among paupers – too often the subjects of moral degradation – must chafe and pain the disordered mind and frustrate more or less all attempts at its restoration. To many patients, therefore, the detention in a workhouse is a punishment superadded to the many miseries their mental disorder inflicts upon them; and consequently, when viewed only in this light, ought not to be tolerated.
Of all cases of lunacy, the wards of a workhouse are least adapted to recent ones, for they are deficient of satisfactory means of treatment, whether medical or moral, and the only result of detention in them to be anticipated, must be to render the malady chronic and incurable. Yet although every asylum superintendent has reported against the folly and injury of the proceeding, and notwithstanding the distinct and strong condemnation of it by the Commissioners in Lunacy, the latter, in their Report for 1857, have to lament an increasing disposition, on the part of Union officers, to receive and keep recent cases in workhouses. Moral treatment we hold to be impossible in an establishment where there are no opportunities of classification, no proper supervision and attendance, and no means for the amusement and employment of the mind; but where, on the contrary, the place and organization are directly opposed to it, and the prospects of medical treatment are scarcely less unfavourable. An underpaid and overworked medical officer, in his hasty visits through the wards of the workhouse daily, or perhaps only three or four times a week, very frequently without any actual experience among the insane, cannot be expected to give any special attention to the Pauper Lunatics, who are mostly regarded as a nuisance in the establishment, to be meddled with as little as possible, and of whose condition only unskilled, possibly old and unfeeling pauper nurses, can give any account. Indeed, unless reported to be sick, it scarcely falls into the routine of the Union medical officer regularly to examine into the state and condition of the pauper lunatics. These remarks are confirmed by the statement of the Lunacy Commissioners, in their ‘Further Report,’ 1847 (p. 276), that pauper inmates, “in their character of lunatics merely, are rarely the objects of any special medical attention and care,” and that it “was never found (except perhaps in a few cases) that the medical officer had taken upon himself to apply remedies specially directed to the alleviation or cure of the mental disorder. Nor was this indeed to be expected, as the workhouse never can be a proper place for the systematic treatment of insanity.”
It would unnecessarily extend the subject to examine each point of management and organization affecting the well-being of the insane in detail, in order to show how unsuitable in all respects a workhouse must be for their detention; yet it may be worth while to direct attention to one or two other matters.
Except when some bodily ailment is apparent, the lunatic fare like the ordinary inmates; that is, they are as cheaply fed as possible, without regard to their condition as sufferers from disease, which, because mental, obtains no special consideration. It is in the power of the medical officer, on his visits, to order extra diet if he observes any reason in the general health to call for it; but the dependent position of this gentleman upon the parish authorities, and his knowledge that extra diet and its extra cost will bring down upon him the charge of extravagance and render his tenure of office precarious, are conditions antagonistic to his better sentiments concerning the advantages of superior nutriment to his insane patients.
Moreover, the cost of food is a principal item in that of the general maintenance of paupers, and one wherein the guardians of the poor believe they reap so great an economical advantage over asylums. But this very gain, so esteemed by poor-law guardians, is scouted as a mistake and proved an extravagance, i. e. if the life and well-being of the poor lunatics are considered, by the able superintendents of County Asylums. Dr. Bucknill has well argued this matter in a paper “On the Custody of the Insane Poor” (Asylum Journal, vol. iv. p. 460), and in the course of his remarks says, – “The insane cannot live on a low diet; and while they continue to exist, their lives are rendered wretched by it, owing to the irritability which accompanies mental disease. The assimilating functions in chronic insanity are sluggish and imperfect, and a dietary upon which sane people would retain good health, becomes in them the fruitful source of dysentery and other forms of fatal disease.”
In his just published Report, already quoted, the same excellent physician remarks (p. 9), – “A good diet is essential to the tranquil condition of many idiots and chronic lunatics, and is, without doubt, a principal reason why idiots are easily manageable in this asylum, who have been found to be unmanageable in union houses. The Royal Commission which has recently reported on the Lunatic Asylums in Ireland states this fact broadly, that ‘the ordinary workhouse dietary is unsuited and insufficient for any class of the insane.’ It is therefore my opinion, founded upon the above considerations, that neither the lunatics nor the idiots in the list presented are likely to retain their present state of tranquillity, and to be harmless to themselves and others, if they are placed in union houses, unless they are provided with those means which are found by experience to ensure the tranquillity of the chronic insane, and especially with a sufficient number of trustworthy attendants, and with a dietary adapted to their state of health. I have thought it desirable to ascertain the practice of charitable institutions especially devoted to the training of idiots, and I find that a fuller dietary is used in them than in this asylum.”
Until a recent date, it was the custom in workhouses, with few exceptions, to allow most of their insane inmates to mingle with the ordinary pauper inmates of the same age and sex, and in general to be very much on the same footing with them “in everything that regards diet, occupation, clothing, bedding, and other personal accommodation” (Report, 1847, p. 276).
This mingling of the sane and insane, having been found subversive of good order and management, gave rise first to the plan of placing most of the latter class in particular wards, many of them in the infirmary, and, subsequently, owing to the advance of public opinion respecting the wants of the insane, to the construction, in many unions, of special lunatic wards, emulating more or less the character and purposes of asylums. The false economy of this plan has been already exposed; and although the Lunacy Commissioners have always set their faces against lunatic wards, yet their construction has of late been so rapid as to call forth a more energetic denunciation of it: – “Impressed strongly (the Commissioners write, Report, 1857, p. 17) with a sense of their many evils, it became our duty, during the past year, to address the Poor-Law Board against the expediency of affording any encouragement or sanction to the further construction, in connexion with Union Workhouses, of lunatic wards.”
The evils of lunatic wards, alluded to in the last-quoted paragraph, are thus enlarged upon in another page of the same Report (p. 15): – “It is obvious that the state of the workhouses, as receptacles for the insane, is becoming daily a subject of greater importance. They are no longer restricted to such pauper lunatics as, – requiring little more than the ordinary accommodation, and being capable of associating with the other inmates, – no very grave objection rests against their receiving. Indeed it will often happen that residence in a workhouse, under such conditions, is beneficial to patients of this last-mentioned class; by the inducements offered, from the example of those around them, to engage in ordinary domestic duties and occupations, and so to acquire gradually the habit of restraining and correcting themselves. But these are now unhappily the exceptional cases. Many of the larger workhouses, having lunatic wards containing from 40 to 120 inmates, are becoming practically lunatic asylums in everything but the attendance and appliances which ensure the proper treatment, and above all, in the supervision which forms the principal safeguard of patients detained in asylums regularly constituted.
“The result is, that detention in workhouses not only deteriorates the more harmless and imbecile cases to which originally they are not unsuited, but has the tendency to render chronic and permanent such as might have yielded to early care. The one class, no longer associating with the other inmates, but congregated in separate wards, rapidly degenerate into a condition requiring all the attendance and treatment to be obtained only in a well-regulated asylum; and the others, presenting originally every chance of recovery, but finding none of its appliances or means, rapidly sink into that almost hopeless state which leaves them generally for life a burthen on their parishes. Nor can a remedy be suggested so long as this workhouse system continues. The attendants for the most part are pauper inmates, totally unfitted for the charge imposed upon them. The wards are gloomy, and unprovided with any means for occupation, exercise, or amusement; and the diet, essential above all else to the unhappy objects of mental disease, rarely in any cases exceeds that allowed for the healthy and able-bodied inmates.”
The subject had previously received their attention, and is thus referred to in their Ninth Report (p. 38): – “They are very rarely provided with any suitable occupation or amusement for the inmates. The means of healthful exercise and labour out of doors are generally entirely wanting, and the attendants (who are commonly themselves paupers) are either gratuitous, or so badly organized and so poorly requited, that no reliance can be placed on the efficiency of their services. In short, the wards become in fact places for the reception and detention of lunatics, without possessing any of the safeguards and appliances which a well-constructed and well-managed lunatic asylum affords. Your Lordship, therefore, will not be surprised to learn that while we have used our best endeavours to remedy their obvious defects and to ameliorate as far as possible the condition of their inmates, we have from the first uniformly abstained from giving any official sanction or encouragement to their construction.”
They further make this general observation: – “So far as the lunatic and idiotic inmates are concerned, the condition of the workhouses which have separate wards expressly appropriated to the use of that class, is generally inferior to that of the smaller workhouses, and in some instances extremely unsatisfactory.”
Dr. Bucknill, whose excellent remarks on lunatic wards in their economical aspect we have already quoted, has very ably canvassed the question of their fitness as receptacles for the insane, and, in a paper in the ‘Asylum Journal’ (vol. iii. p. 497), thus treats on it: – “It is deserving of consideration, whether the introduction of liberally-conducted lunatic wards into a Union Workhouse would not interfere with the working of the latter in its legitimate scope and object. A workhouse is the test of destitution. To preserve its social utility, its economy must always be conducted on a parsimonious scale. No luxuries must be permitted within its sombre walls; even the comforts and conveniences of life must be maintained in it below the average of those attainable by the industry of the labouring poor. How can a liberally-conducted lunatic ward be engrafted upon such a system? It would leaven the whole lump with the taint of liberality, and the so-called pauper bastile would, in the eyes of the unthrifty and indolent poor, be deprived of the reputation which drives them from its portals.”
There is a general concurrence among all persons competent to form any opinion on the matter, that workhouses are most unfit places for the reception of recent cases of insanity. On the other hand, there is a prevalent belief that there is a certain class of the insane, considered “harmless,” for whom such abodes are not unsuitable. The Lunacy Commissioners, in the extract from the Eleventh Report above quoted, partake in this opinion: let us therefore endeavour to ascertain, as precisely as we can, the class of patients intended, and the proportion they bear to the usual lunatic inmates of Union Workhouses.
In their ‘Further Report’ for 1847, the Commissioners enter into a particular examination of the characters of the lunatics found in workhouses, and class them under three heads (p. 257): – 1st, those who, from birth, or from an early period of life, have exhibited a marked deficiency of intellect as compared with the ordinary measure of understanding among persons of the same age and station; 2ndly, those who are demented or fatuous; that is to say, those whose faculties, not originally defective, have been subsequently lost, or become greatly impaired through the effects of age, accident, or disease; and 3rdly, those who are deranged or disordered in mind, in other words, labouring under positive mental derangement, or, as it is popularly termed, “insanity.” Those in whom epilepsy or paralysis is complicated with unsoundness of mind, although their case requires a separate consideration, do not in strictness constitute a fourth class, but may properly be referred, according to the character of their malady and its effects upon their mental condition, to one or other of these three classes.
Further on in the Report, after remarking on the difficulties besetting their inquiry, they write (p. 274): —
“We believe, however, we are warranted in stating, as the result of our experience thus far, that of the entire number of lunatics in workhouses, whom we have computed at 6020 or thereabouts, two-thirds at the least, or upwards of 4000, would be properly placed in the first of the three classes in the foregoing arrangement; or, in other words, are persons in whom, as the mental unsoundness or deficiency is a congenital defect, the malady is not susceptible of cure, in the proper sense of the expression; and whose removal to a curative lunatic asylum, except as a means of relieving the workhouse from dangerous or offensive inmates, can be attended with little or no benefit.
“A considerable portion of this numerous class, not less, perhaps, than a fourth of the whole, are subject to gusts of passion and violence, or are addicted to disgusting propensities, which render them unfit to remain in the workhouse; and it is the common practice, when accommodation can be procured, to effect the removal of such persons to a lunatic asylum, where their vicious propensities are kept under control, and where, if they cannot be corrected, they at least cease to be offensive or dangerous. But although persons of this description are seldom fit objects for a curative asylum, they are in general capable of being greatly improved, both intellectually and morally, by a judicious system of training and instruction; their dormant or imperfect faculties may be stimulated and developed; they may be gradually weaned from their disgusting propensities; habits of decency, subordination, and self-command may be inculcated, and their whole character as social beings may be essentially ameliorated.”
The conclusion to be deduced from these extracts is, that one-fourth or two-thirds, that is, one-sixth of the whole number of occupants in workhouses of unsound mind, found in 1846, were unfit for those receptacles, and demanded the provision of institutions in which a moral discipline could be carried out, and their whole condition, as social beings, ameliorated and elevated. A further examination of the data supplied in the same Report will establish the conviction that, besides the proportion just arrived at, requiring removal to fitting asylums, there is another one equally large demanding the same provision.
In this number are certainly to be placed all those of the third class “labouring under positive mental derangement,” and who, although reported as “comparatively few” in 1846, have subsequently been largely multiplied, according to the evidence of the ‘Eleventh Report’ (ante, p. 56). Those, again, “in whom epilepsy or paralysis is complicated with unsoundness of mind,” are not suitable inmates for workhouse wards. No form of madness is more terrible than the furor attendant on epileptic fits; none more dangerous; and, even should the convulsive affection have so seriously damaged the nervous centres that no violence need be dreaded, yet the peril of the fits to the patient himself, and their painful features, render him an unfit inmate of any other than an establishment provided with proper appliances and proper attendants. As to the paralytic insane, none call for more commiseration, or more careful tending and nursing – conditions not commonly to be found in workhouses.
The Commissioners in Lunacy have not omitted the consideration of workhouses as receptacles for epileptics and paralytics, and have arrived at the following conclusions: – After treating, in the first place, of epileptics whose fits are slight and infrequent, and the mental disturbance mild and of short duration, they observe that, as such persons “always require a certain amount of supervision, and as they are quite incompetent, when the fits are upon them, to take care of themselves, and generally become violent and dangerous, it would seem that the workhouse can seldom be a suitable place for their reception, and that their treatment and care would be more properly provided for in a chronic hospital especially appropriated to the purpose.”
Concerning paralytics, they state that they are far less numerous than epileptics, and being for the most part helpless and bedridden, are treated as sick patients in the infirmary of the workhouse. Their opinion is, however, that a chronic hospital would be a more appropriate receptacle for them, – a conclusion in which all must coincide, who know how much can be done to prolong and render more tolerable their frail and painful existence, by good diet and by assiduous and gentle nursing, – by such means, in short, as are not to be looked for in establishments where rigid economy must be enforced, and pauper life weighed against its cost.
To turn now to the second class of workhouse Lunatic Inmates, the demented from age, accident, or disease: these, we do not hesitate to say, are not suitably accommodated in workhouses, for, like the paralytic, they require careful supervision, good diet and kind nursing; they are full-grown children, unable to help or protect themselves, to control their habits and tendencies; often feeble and tottering, irritable and foolish, and, without the protection and kindness of others, the helpless subjects of many ills. For such, the whole organization of the workhouse is unsuited; even the infirmary is not a fitting refuge; for, on the one hand, they are an annoyance to the other inmates, and, on the other, pauper nurses – whose office is often thrust upon them without regard to their fitness for it, – are not fitting guardians for them. In fine, where age, accident or disease has so deteriorated the mental faculties, we have a complication of physical and mental injury to disqualify the patient from partaking with his fellow-paupers in the common accommodation, diet, and nursing.
In the reverse order which we have pursued, the first class of congenital, imbecile, and idiotic inmates comes to be considered last. This happens by the method of exclusion adopted in the argument; for the second and third classes have been set aside as proper inmates of some other institution than a workhouse, and it now remains to inquire, who among the representatives of the first class are not improperly detained in workhouses. This class includes, as already seen, some two-thirds of the whole number of inmates mentally disordered; and among whom, we presume, are to be found those individuals who may, in the Commissioners’ opinion, mix advantageously with the general residents of the establishment. The number of the last cannot, we believe, be otherwise than very small; for the very supposition that there is imbecility of mind, is a reason of greater or less force, according to circumstances, for not exposing them to the contact of an indiscriminate group of individuals, more especially of that sort to be generally found in workhouses. The evils of mingling the sane and insane in such establishments have already been insisted upon; and besides these, such imbecile patients as are under review, lack in workhouses those means of employment and diversion which modern philanthropy has suggested to ameliorate and elevate their physical and moral condition.
Lastly, if the remaining members of this class be considered, in whom the imbecility amounts to idiocy, the propriety of removing them from the workhouse will be questioned by few. Indeed, will any one now-a-days advocate the “laissez faire” system in the case of idiots? Experience has demonstrated that they are improveable, mentally, morally, and physically; and if so, it is the duty of a christian community to provide the means and opportunities for effecting such improvement. It cannot be contended that the workhouse furnishes them; on the contrary, it is thoroughly defective and objectionable by its character and arrangements, and, as the Commissioners report, (op. cit. p. 259) a very unfit abode for idiots.
On looking over the foregoing review of the several classes of lunatic inmates of workhouses distinguished by the Commissioners in Lunacy, the opinion to be collected clearly is, that only a very few partially imbecile individuals among them are admissible into workhouses, if their bodily health, their mental condition, their due supervision and their needful comforts and conveniences are to be duly attended to and provided for. In accordance with the views we entertain, as presently developed, of the advantages of instituting asylums for confirmed chronic, quiet, and imbecile patients, we should permit, if any at all, only such imbecile individuals as residents in workhouses, who could pass muster among the rest, without annoyance, prejudice or discomfort to themselves or others, and be employed in the routine occupations of the establishment.
So much is heard among poor-law guardians and magistrates about a class of “harmless patients” suitably disposed of in workhouses and rightly removeable from asylums, that a few remarks are called for concerning them. To the eye of a casual visitor of an asylum, there does certainly appear a large number of patients, so quiet, so orderly, so useful and industrious, that, although there is something evidently wrong about their heads, yet the question crosses the mind, whether asylum detention is called for in their case. The doubt is not entertained by the experienced observer, for he knows well that the quiet, order, and industry observable are the results of a well-organized system of management and control; and that if this fails, the goodly results quickly vanish to be replaced by the bitter fruits generated by disordered minds. The “harmless” patient of the asylum ward becomes out of it a mischievous, disorderly, and probably dangerous lunatic. In fact, the tranquillity of many asylum inmates is subject to rude shocks and disturbances, even under the care and discipline of the Institution; and the inoffensive-looking patient of to-day may, by his changed condition, be a source of anxiety, and a subject for all the special appliances it possesses, to-morrow.
Any Asylum Superintendent would be embarrassed to select a score of patients from several hundred under his care whom he could deliberately pronounce to be literally “harmless” if transferred to the workhouse. He might be well able to certify that for months or years they have gone on quietly and well under the surrounding influences and arrangements of the asylum, but he could not guarantee that this tranquillity should be undisturbed by the change to the wards of the workhouse; that untrained attendants and undesirable associates should not rekindle the latent tendency to injure and destroy; that defective organization and the absence of regular and regulated means of employment and recreation should not revive habits of idleness and disorder; or that a less ample dietary, less watchfulness and less attention to the physical health, should not aggravate the mental condition and engender those disgusting habits, which a good diet and assiduous watching are known to be the best expedients to remedy.
Dr. Bucknill has some very cogent remarks on this subject in his last Report of the Devon Asylum (p. 6). “The term ‘harmless patients,’ or in the words of the statute, those ‘not dangerous to themselves or others’ (he writes), I believe to be inapplicable to any insane person who is not helpless from bodily infirmity or total loss of mind: it can only with propriety be used as a relative term, meaning that the patient is not so dangerous as others are, or that he is not known to be refractory or suicidal. It should not be forgotten, that the great majority of homicides and suicides, committed by insane persons, have been committed by those who had previously been considered harmless; and this is readily explained by the fact, that those known to be dangerous or suicidal are usually guarded in such a manner as to prevent the indulgence of their propensities; whilst the so-called harmless lunatic or idiot has often been left without the care which all lunatics require, until some mental change has taken place, or some unusual source of irritation has been experienced, causing a sudden and lamentable event. In an asylum such patients may truly be described as not dangerous to themselves or others, because they are constantly seen by medical men experienced in observing the first symptoms of mental change or excitement, and in allaying them by appropriate remedies; they are also placed under the constant watchfulness and care of skilful attendants, and they are removed from many causes of irritation and annoyance to which they would be exposed if at large, in villages or union houses.
“It not unfrequently happens that idiots who have lived for many years in union houses, and have always been considered harmless and docile, under the influence of some sudden excitement, commit a serious overt act, and are then sent to an asylum. One of the most placid and harmless patients in this asylum, who is habitually entrusted with working tools, is a criminal lunatic, of weak intellect, who committed a homicide on a boy, who teased him while he was breaking stones on the road. If this is the case with those suffering only from mental deficiency, it is evidently more likely to occur in those suffering from any form of mental disease, which is often liable to change its character, and to pass from the form of depression to one of excitement. For these reasons I am convinced that all lunatics, and many strong idiots, can only be considered as ‘not dangerous to themselves or others,’ when they are placed under that amount of superintendence and care which it has been found most desirable and economical to provide for them in centralized establishments for the purpose.