On the State of Lunacy and the Legal Provision for the Insane
TekstInasmuch as it is impossible, owing to their small number, for the Lunacy Commissioners, without totally neglecting their other duties, to make themselves acquainted with the condition of these pauper lunatics, scattered here and there over the country, in cottages and lodgings, we really possess, as before said, under the existing system, no information worth having, what that condition really is. Judging from the state in which workhouse lunatic inmates are found, the impression is unavoidable, that the pauper lunatics under notice must be in a worse one, since there is not only no sort of supervision over them equivalent to that provided in workhouses, but also the sums allowed towards their maintenance are most scanty, and, where they are lodged with strangers, no care and no sustenance beyond what is felt to be actually paid for, can be presumed to be given. Now and then a glimpse of the actual state of things is casually afforded by the Report of a County Asylum; and such are the glimpses we have got through this medium, that, except to arouse public attention by their recital, in order to bring about a reform, it were well, for the sake of the reputation of the country, that the revelations were unrecorded. Asylum superintendents could, indeed, more frequently raise the veil upon scenes of wretchedness and cruelty undergone by our lunatic poor in the habitations where parish officials place or keep them; but they generally forbear to do so in their Reports, although enough is shown by the description of the state in which patients are admitted into the asylums, and of the length of time that has been suffered to elapse since the commencement of their sad malady.
Dr. Hitchman, in the Reports of the Derby County Asylum, has more than once referred to the state of patients on admission from their homes or lodgings. Thus, in 1853, he narrates the case of a poor woman who had been demented for five years, and “kept at home until she fell into the fire and became extensively and severely burnt;” and not till after this accident was she taken to the asylum. A little way further on, in the same Report, he observes, – “Those only who have lived in public asylums know the misery, the wretchedness, and the wrong which are constantly inflicted upon lunatics in obscure places, even by their relatives and ‘friends,’ and which cease only with the life of the patient, unless he be conveyed to a well-conducted institution. It is, moreover, a remarkable phenomenon, that many individuals who perpetrate these enormities upon their kith and kin, who have habitually fastened them with cords, who have deprived them of a proper supply of clothing or of food, who have, in short, rendered them permanent cripples in body, as well as hopeless idiots in mind, have done so without malice, as a general rule, without passion, by slow degrees, and with no conception whatever of the present suffering or ultimate mischief effected by their proceedings. They affect no secrecy among their neighbours while these things are going on. Familiarity to the spectacle blinds their perceptions and blunts their feelings… Others there are, who, from penurious and selfish motives, inflict much wrong upon the lunatic. Of such a kind appears the following: – ‘T. G., removed from the custody of his relatives by the order of the magistrates. Has been insane thirty-eight years, under the management of his relatives, who have generally had him confined in an out-building.’ ‘He is stated to have been unclothed for many years. When brought into the asylum he was naked, except that around his pelvis were the remains of an article of dress; his hands were tightly bound to each other by ligatures passing around the wrists. When in the cart he was covered with a blanket, but this fell from him during his struggles on being removed. He roared hideously as he was being conveyed to the wards. He is a person of lofty stature and great size. His head and neck are very large; one side of his forehead is greatly disfigured by scars, and he has lost an eye. His ears have been deprived of their normal shape, and their lobes much thickened by the deposition of fibrine or other matter. His lips are large and pouting. His beard has been long unshaven, but has been recently cut with a pair of scissors. The bones and muscles of his arms are of great size; his lower extremities are red, swollen, and ‘pit,’ under pressure; one of his toes is deprived of its nail, and the whole foot appears to have suffered from the effects of cold. He walks with a stooping gait, and appears unable to retain the erect posture without support. He resists powerfully all attempts to clothe him, and appears to be entirely ignorant of the use of a bedstead. He whines after the manner of a dog that has lost its home. He dreads all who approach him; on being taken from his room in the evening, he hurried back to it with all the haste he could, and on all occasions he shrinks from observation. He is lost to every sense of decency; nakedness is congenial to him, but he will sometimes coil himself in a blanket for the sake of its warmth. He is guided by the lowest instincts only, and his whole appearance and manner, his fears, his whines, his peculiar skulking from observation, his bent gait, his straight hair, large lips, and gigantic fore-arm painfully remind one of the more sluggish of the Anthropoid Apes, and tell but too plainly to what sad depths the human being can sink under the combined influence of neglect and disease.’”
The same excellent physician reverts to these cases in his Fourth Report (1855), and laments the sad condition of health, and the horrible state of neglect of many patients on their admission. He says, “One or two patients had been confined by manacles in their own cottages until rescued by charitable interference, and were brought to the asylum with their wrists and ankles excoriated by the ligatures deemed necessary for their proper control.” One such case had been confined twenty-five years in his cottage-home.
These illustrations will suffice for our purpose. They indicate the existence of abuses and wrongs here in England, too similar, alas! to those the Special Lunacy Commission of Scotland brought to light by their well-known inquiry in 1855 (Report, Edinburgh, 1857), and such as the general description in their Report, and the particulars in Appendix K, too amply demonstrate. It is referred to as “the wretched state” of single patients living with their friends or others, and well merits the designation. They found these poor afflicted beings generally in a state of moral and physical degradation, ill-fed, ill-treated, ill-clothed, miserably lodged, shockingly dirty, abused, restrained by all sorts of mechanical contrivances of the coarser kind, or left to wander unheeded and uncared for; whilst among the imbecile or fatuous women, many were the instances where they had become the mothers of an illegitimate and often idiotic offspring. Judging from the specimens before us, we repeat, we have great misgivings lest a similar searching inquiry into the condition of pauper lunatics in England distributed in the homes of our cottagers and labouring classes, should reveal a state of things no less disgraceful to a civilized country.
To recall a conviction before expressed, additional legislative provision is demanded for this class of pauper insane. The quarterly visit of the hard-worked and underpaid Union Medical Officer or of his Assistant, affords no sufficient guarantee, even when regularly made, that they are duly taken care of, and not improperly deprived of the advantages of asylum treatment. But if we accept official statements, these visits are irregularly made and much neglected, and the reports of them far from properly attended to. In the Report of the Hants Asylum for 1856, the Committee took occasion to remark on the extended neglect and the inefficiency of these legal visits and reports; and though the Commissioners in Lunacy admit that of late matters have improved, yet they say that they are far from satisfactory. From these and other considerations adverted to, we have suggested that the inspection of the lunatic poor in question should be specially undertaken by the District Medical Officer, and that a report on them should after each visit be made to the Lunacy Commission, and, with advantage, also to the Poor-Law Board. This officer should be informed of every pauper or other lunatic living with friends or others, and should investigate, as said above, all the circumstances surrounding him, and decide whether or not a transference to an asylum would be for the better. It would consequently be for him to select and recommend the removal to an asylum of all such patients as afforded a prospect of recovery; and since good food and proper nursing improve not only the body, but also the mind and the moral feelings, and promote the lasting relief of the mental disorder, – it should also devolve upon him to signify the extent and mode of out-door relief to be afforded. Defective and faulty nutrition concurs powerfully to produce insanity, and, when it is induced, to make it permanent; the best policy must therefore be to nourish pauper lunatics sufficiently; – a policy, which we see, however, under existing circumstances, no prospect of being acted upon by the guardians of the poor.
The allowance made to out-door lunatic paupers differs much; for it may be intended to supply almost all the moderate wants of the recipient, or only a small part of them. It is always, however, very limited, and less than the calculated cost of in-door paupers per head, and can never suffice to procure the poor patient adequate nourishment and suitable attendance and clothing. Its amount, moreover, is regulated by no definite principles, but is left very much to the caprice of the relieving officers, and to the liberal or the opposite sentiments in the ascendant among the parochial guardians. It is contributed as a grant in aid to the relatives of the patient, and to those not related as a compensation for the outlay and trouble incurred on his account. The former are naturally liable to the maintenance of their lunatic kinsman, and no sufficient objection obtains to his being detained among them, provided his condition is not prejudiced by his exclusion from an asylum, and is duly watched over by competent medical officers, and that those relatives are able to afford him proper control, food and clothing, with or without parochial assistance. But the case is different in respect of those not related to the patient, who as strangers can have little interest in him; but who, on the contrary, have to make his detention serve their own purposes so far as possible, and cannot be expected to do or supply more than they are paid for. Now, as the weekly allowance from the parish is to be by rule kept as low as it can be, the lowest offers possess the highest recommendation for acceptance, and the comforts and well-being of the poor imbecile or idiotic people are almost necessarily sacrificed at the shrine of economy.
The whole system, therefore, of boarding pauper lunatics in the homes of the poor unconnected with them by blood, as now pursued without restrictions or method, appears fraught with injury to those helpless beings. What sort of attention, food, and lodging can be expected for some 3 or 4 shillings a week? What sort of supervision and control can be looked for from a poor, illiterate labourer or artisan? Even a patient’s own relatives may and do grudge the cost and the trouble he puts them to, or they may be very imperfectly able to furnish in their cottage-home the means needed to ensure his protection and the conveniences and comforts of others, and be ill-adapted by character and education to act as his directors and guardians. But these difficulties and defects are augmented manifold when the patient becomes a dweller among strangers.
Only under very peculiar circumstances indeed would we tolerate the boarding of pauper lunatics with strangers; when, for instance, their comforts and safety are hedged round by legal provisions sufficiently ample, and by systematized arrangements to secure them. These ends are to be attained by taking the selection of the abode and the pecuniary details from the hands of parochial officers, and by entrusting them to some competent medical man, who should be responsible that the patients are properly cared for and treated. It should be for him to select the residence, and in so doing to seek out those who by character and condition are best fitted for the charge. If the law were so amended that asylum relief should be afforded to all on the appearance of their malady, the majority of those to be provided for in lodgings would come from the class of chronic, imbecile patients, accounted harmless, whose discharge from the asylum under proper surveillance might be recommended. Hence it would render the scheme more perfect and satisfactory, to retain these chronic lunatics in homes within a moderate distance of the County Asylum they were previously placed in, so that they might be under the supervision of the medical staff of that institution, and that the propriety of their prolonged absence from it, or of their return to it, might be therefore determinable by those best qualified to judge from past experience of their case.
Yet, in all probability, this restriction as to the district for receiving patients as boarders, would not always be practicable; and frequently, where the insane poor had near relatives capable and willing to receive them under their care, though at a distance from the asylum, it would not be desirable to sacrifice the advantages of the guardianship of friends to those obtainable by vicinity to the asylum; and, from these or other causes, many poor insane people would be found distributed here and there throughout a county under the charge of cottagers and others. In their cases we would make the District Medical Inspector the special protector and guardian of their interests and well-being provided by law, and require him to visit them at least twice a quarter, report on their condition, and on the fitness or unfitness of the persons boarding them. In all cases, he should as a preliminary proceeding inquire into the accommodation and general circumstances of the persons proposing to receive an individual of unsound mind into their family, and should reject the application of those who are unable to afford suitable conveniences and adequate management.
Could a properly-organized system of supervision and control be established, the disposal of poor insane persons in the homes of the industrious classes would not be open to the objections it is at present, when no adequate legal provision to ensure their inspection and welfare is in existence. Indeed, it would be an improvement and blessing to many of the chronic lunatics in our great asylums, could they so far be set at liberty, and have their original independence restored to them by a distribution in the cottage-homes of our country, where, under sufficient control, they could exercise useful employments, and relieve the rates of part of their cost. We have used the term ‘cottage-homes’ advisedly, because it is evident, that, except in very small towns, a town-residence would be most unsuitable.
The example of the great colony of insane persons at Gheel, in Belgium, has suggested this plan of boarding lunatics in the homes of the working classes, chiefly of agriculturists, to the minds of many English philanthropists desirous to ameliorate the condition of our pauper insane, and to lessen the large costs of asylum provision. The only attempt, however, as far as we are aware, partaking at all of the conditions calculated to render such a scheme satisfactory and successful, hitherto made, is that on a small scale at the Devon Asylum under the direction of Dr. Bucknill, and we are happy to find from this gentleman’s Report that the arrangement has hitherto worked well.
We shall return to this subject in a subsequent section, – “On the distribution of the chronic insane in cottage-homes.”
§ Transmission of unfit Cases to Asylums – improper Treatment prior to Admission
In preceding pages it has been remarked that the transfer of lunatics to asylums is regulated not by the nature of their case, and its amenability to treatment or amelioration, but by the circumstance of their being refractory and troublesome, annoying by their habits, or so infirm and sick as to require attentive nursing; or, in general, in such a state that their residence involves an increased and unworkhouse-like cost. The question of the recency of the attack is treated as of far less moment; for if the poor sufferer have what are called harmless delusions, or if he is only so melancholic that suicide is not constantly apprehended, then under these and such similar conditions, the economical theory of the establishment commonly preponderates over every consideration of the desirability of treatment in the presumedly expensive asylum, and the patient is retained. In course of time his malady becomes chronic, and in all probability incurable, and his condition so deteriorated in all respects by the absence of proper measures for his mental and moral treatment, that sooner or later his physical health gives way, or his habits grow inconveniently annoying and troublesome, and then it is that workhouse officials discover that the County Asylum is his suitable abode.
By this system of ‘clearance’ the workhouses are relieved of their most burdensome and costly inmates, who fall to the charge of asylums, in which their presence necessarily keeps down the rate of recoveries, multiplies the proportion of chronic lunatics, and increases the expenses and the rate of mortality.
The Medical Superintendents of our Asylums bear witness to the recklessness, and to the cruelty, at times, which often mark the doings of workhouse authorities when they wish to rid themselves of the cost and trouble of any of the lunatic poor in their keeping. The illustrations at hand, obtained from County Asylum Reports, are so numerous, that we must content ourselves with a selection of a few of the more striking.
Dr. Boyd, the distinguished physician of the Somerset County Asylum, makes the following statement in his Sixth Report (1853): – “Several aged persons, and many others in a feeble state, have been admitted during the year, so that the mortality, although less than in the preceding year, has still been considerable. For example, two cases have been recently admitted: one that of a man with dropsy, and broken down in constitution, who is reported to have been given to excess in drinking ardent spirits, and to have been subject to epileptic fits; he was disappointed at not being admitted into a general hospital, became violent, and was sent as a patient here; he has been free from fits since his admission, is rational, but apparently in the last stage of bodily disease. The other case is that of a woman about seventy, paralysed, and unable to sit up in the arm-chair without support. She was troublesome in the union workhouse, and was reported as dangerous, and so was sent to the asylum. There have been four males with paralysis recently sent in from being dirty in their habits… One female was improperly sent with delirium attending on fever: she died a fortnight after admission.” In his Ninth Report, this same Superintendent says, – “Some are sent to the asylum in a state of paralysis, some are aged and in a state of fatuity, and others when they become troublesome, or are in a diseased and feeble state of bodily health, and require more nurse-tending than they receive in the workhouses… Under the existing arrangements, lunatic asylums are gradually losing their proper character of hospitals for the recovery of the insane, and sinking down to be mere auxiliaries to workhouses.”
Out of eighty admissions at the Worcester County Asylum, fourteen were between sixty and eighty years of age, and for the most part “the subjects of organic disease of the brain, lungs, and heart, or suffered from long-continued mental disease, or from the superannuation of old age, and deficient nutrition of the brain and nervous centres. Four of them died during the year… During the early part of the year some correspondence was entered into with several Unions, from which patients had been sent in a dying or exhausted state; and the impropriety of such proceeding was pointed out by your Committee… It is not supposed that those unfortunate cases are wilfully detained with improper intentions at their homes or elsewhere, but from ignorance; and from want of the necessary appliances, and the assistance of those accustomed to the insane, proper measures cannot be adopted for their care and recovery,” and various injuries are inflicted.
The experienced Superintendent of the Beds., Herts., and Hunts. Asylum reports, in 1856, that of 111, as many as twelve died within three months of their being admitted; five did not survive a fortnight. “One male, an epileptic seventy-nine years of age, and having been bedridden for years from contracted limbs, and nearly exhausted from the journey, died on the twelfth day. A female, aged sixty-eight, with disease of the heart, died on the fourth day from exhaustion, having been some time without rest, and having refused her food previous to admission. A female in the last stage of pulmonary consumption, lived but seventeen days; and one very distressing case of a female … was brought to the asylum, who, worn out from constant excitement, and having a large wound on the leg, with ulcerations from ligatures on the wrists and ankles, sank on the fourteenth day. The two last-mentioned patients were reported to have refused food for nearly a week, but took every kind of nourishment offered to them from the moment they were in the Asylum.”
The Report of the Suffolk County Asylum records the admission of ten poor persons in 1852 “nearly seventy years of age, nine over seventy, three over eighty; sixteen in a state of bodily exhaustion; nine either idiots from birth, or imbeciles for a very long period; one child with well-known disease of the heart, and a woman, a cripple, scrofulous, blind and deaf.” “What,” asks Dr. Kirkman, the venerable Superintendent, “can be done more than good nursing to support a peevish mind in a patient eighty-four, admitted only a few days ago?” He adds, “To give other instances, one man was received some time back on a very qualified certificate, and upon whose case a qualified certificate only could be given; and another (somewhat experimentally) with the notice that his mania, if such it were, existed only in the want of a slight resistance to a wayward will; and another, a girl of sixteen, subsequently found not to be insane, but suffering from aggravated cataleptic hysteria, supposed to have been caused by fright, having spinal disease, and deformed throughout the body.”
Dr. Hitchman, whose Reports we have found so valuable in former sections of this work, has repeatedly called attention to the subject now under notice. In 1853 he writes: – “It is with feelings of deepest sorrow that your physician is compelled to state, that patients continue to be sent to the asylum in very advanced stages of bodily and mental disease… So long as no violent or overt act has been perpetrated; so long as the sufferer can be ‘managed’ in the privacy of his miserable home, or by the ‘cheap’ resources of a workhouse, he is often detained from the lunatic hospital. Disease, aggravated by neglect, continues its direful course, the ‘harmless’ lunatic becomes very dirty in his habits, or very violent in his conduct, windows are broken, clothes are torn, persons are injured, and the strap, the strait-waistcoat, and the chain are brought into service to control for a time the ravings and the mischief of the patient. Steps are now taken for his removal – bound, bruised, dirty, and paralysed, the poor creature is taken to an asylum. One glance is sufficient to reveal to the experienced eye that cure is hopeless; that while every resource of the Institution will be needed to sustain the exhausted energies of the patient – to preserve him from the sufferings consequent upon the loss of his self-control over the excretions of his body, yet for two or three years he may survive to swell the list of incurables – to diminish the per-centage of cures – to crowd the hospital, and, worse than all, to perpetuate this popular belief, and to encourage the pernicious practice, which are now leading to the moral death and social extinction of hundreds of our fellow-creatures.”
Speaking of the admissions in 1854, he says: – “Several were in advanced stages of bodily disease; thus, I. C. expired in eight hours after his arrival at this hospital. He was removed from the vehicle in which he was brought to his bed, where he remained tranquil until the moment of his decease. The state of great prostration in which he was brought, forbade the employment of the usual washing-bath; nor was he subjected to the fatigue of being shaved (of which he stood in much need) in consequence of his exhaustion. F. G., aged 76 years, admitted with the marks of restraint round her wrists, survived eighteen days – only by the administration of wine and warmth. S. C., brought bound by straps and a strait-waistcoat in the afternoon of the 18th, was so convulsed and epileptic, that she died on the morning of the 20th, having scarcely spoken during the time she was in the asylum. Others were in advanced stages of dropsy, phthisis, and general paralysis, and, although in a hopeless condition, lived on for several weeks under the fostering care of the Institution. One poor girl, admitted from Lincolnshire, in a perfectly helpless condition (the delirium of fever having been mistaken for the ravings of insanity), was conveyed from the vehicle to a water-bed, where she has remained in a state of great suffering for upwards of twelve weeks, and is never likely again to recover the use of her limbs.”
The experience of the Kent Asylum is similar. The age of eleven persons admitted in 1853 averaged 64, and twelve were from 72 to 75. “In many of these the malady was simply decay of mind, or was due to apoplectic seizures, and attended by palsy.”
In the Report for 1857-1858, Dr. Huxley goes more at large into the question of unfitness for asylum admission, and the vigour and clearness of his remarks induces us to quote them at length. He observes: – “It seems difficult to understand on what principle patients are sometimes sent. One man, for an intemperate threat uttered under considerable provocation, is hastened off to the asylum. He can then only be deemed insane in a constructive sense, and in reliance on the undoubted good faith of the whole proceedings for his removal. He is seen to be sane; he remains so, and merely awaits the next discharging-day. In the interval he has had time to reflect on the danger of uncontrolled speech; but perhaps he and his family ought not to have incurred the reproach (as it is held) of insanity in the blood. Perhaps, also, he ought not to have swelled the list of persons insane, adding his mite to the evidence which supports the general belief in an actual increase of disorders of the mind.
“Again, the facility with which a drunken prostitute finds admission and re-admission is astonishing. The delirium, rather than insanity proper, produced by excessive drinking, has, indeed, some alarming modes of expression; but it is a different thing from true mental derangement, and is transient, the patient being generally nearly all right again on arrival. I confess to a feeling which grudges to such patients the benefits of an asylum and association with the inmates who are truly unfortunate. Their detention is wholly unsatisfactory; it leads to nothing. Long or short, it proves no warning against a return to former bad courses; whilst the presence of people (I do not call them patients) of this sort seriously injures the interior comfort of the wards. Ought such cases to swell the returns of lunacy? Then, in estimating the supposed growth of insanity among the people, let the fact be remembered, that here is one contributing element, which was not represented until of late years. Once again, the extent to which strongly-marked senility is now made the reason for admission to the asylum is, I think, unprecedented. To grow childish, wilful, and intractable; to lose memory, and forget the good habits of a life; to take no note of times and seasons; to wake by night and be restless, and to become generally incapable, are the rule rather than the exception at the close of an extended life. I do not think these natural ills ought to be the cause so frequently as they are found to be, for sending the subjects of them to an asylum. Workhouses may not contain the little special accommodation needful for such cases; but it would not be a good argument to hold, that because they do not, the asylum must be the proper receptacle.
“Poverty is, truly, the great evil; it has no friends able to help. Persons in middle society do not put away their aged relatives because of their infirmities, and I think it was not always the custom for worn-out paupers to be sent to the asylum. May not this practice be justly regarded as an abuse of the asylum? It is one more of the ways in which, at this day, the apparent increase of insanity is sustained. It is not a real increase, since the aged have ever been subject to this sort of unsoundness.
“Decayed persons, once placed in an asylum, are ever after held to have been rightfully deemed insane. If any of their descendants, therefore, become mentally afflicted, the hereditary taint is straightway accounted to them. This is, indeed, to show cause why all the world should be mad! I hold it to be wrong to send persons to an asylum merely on account of second childhood, and a wrong operating to general disparagement. In the first place, the practice is only an indirect consequence of poverty; next, it helps improperly to force asylums to a size inconsistent with their best management; and thirdly, it is one amongst other apparent, but not real grounds, for that increase of mental disorder, which is apprehended with such general alarm.