Chapter VI: Part 6

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.

"We received at least twelve persons, who, in my judgment, needed not, and therefore ought not to have been sent, viz. seven aged, being of 70, 74, 76, 78, 79, 80, and 82 years; three children, of 6, 8, and 10 years; and two adults. One of the children was not insane, but suffering from chorea (St. Vitus's dance) affecting the whole body. This disorder had, apparently, been mistaken for mania."

We will close these quotations by one from Dr. Bucknill's Report for 1854:--

"There can be little doubt that those asylums, the admission into which is restricted by legal formalities alone, are not unfrequently made use of as hospitals for the treatment of bodily disease and for the care of the bodily infirm. To such asylums patients are sent suffering from serious and troublesome bodily diseases, whose mental condition would never have been considered a sufficient cause for removal had it existed alone. The number of patients has not been small, who, from time to time, have been admitted into the Devon Asylum with serious disease of the several organs of the body, and with no greater amount of mental disturbance than is the frequent result of such disease.

"Patients have been admitted suffering from heart disease, aneurism, and cancer, with scarcely a greater amount of melancholy than might be expected to take place in many sane persons at the near and certain prospect of death. Some have been received in the last stages of consumption, with that amount only of cerebral excitement so common in this disorder; others have been received in the delirium or the stupor of typhus; while in several cases the mental condition was totally unknown after admission, and must have been unknown before, since the advanced condition of bodily disease prevented speech, and the expression of intelligence or emotion, either normal or morbid.

"These observations are made in no spirit of complaint. The capabilities of these institutions to treat all ailments of mind or body are indeed felt to be a source of satisfaction and pride. It ought, however, to be known, that this County Asylum is, to some extent, made use of as a public infirmary, and that the result of such employment must be expected in an obituary somewhat lengthened, if not also in a list of cures somewhat abbreviated."

Sufficient proofs are surely furnished in the above extracts, selected from many similar ones, to establish the general statements advanced at the beginning of the present subject, viz. that both recklessness and cruelty not unfrequently mark the proceedings of workhouse officials in their transmission of patients to the county asylums. They, moreover, supply facts to prove that the neglect in transferring proper cases for asylum treatment, and the inexcusable folly of sending to asylums the victims of second childishness, the imbecile paralytics, the peevish and perverse sufferers from chronic organic disease, such as poor consumptives, whose days are measured by the shortest span, tend to promote the accumulation of incurable inmates, to raise the mortality, and to increase the expenditure of these institutions. In fact, the annual returns of county asylum experience demonstrate that the transmission to asylums is regulated by no rule, and is attended by great abuses.

The practical lesson deducible from this is, that the matter must be placed in other hands, and guided according to some rational principles. The insane poor must no longer be left to pine in neglect and misery in their own homes, until their friends tire of the trouble of them, or some casual circumstance class them, in a relieving officer's opinion, as proper candidates for an asylum; nor must their presence in the workhouse be, for the future, regulated by the mere circumstance of the care, attention and expense they involve, in the estimation of workhouse governors. There need be some specially appointed officer, whose business it should be to know both the existence of every insane person in his district and his condition and treatment, and to report those who require the care of a curative asylum, those who only need the nursing and supervision of a chronic one, and those who can be duly and efficiently tended and cherished in the homes of their families. By the exertions of such an officer, we should no longer read of the removal of dying patients, only to die in the asylums; or of the victims of neglect and wretchedness detained in workhouses or their homes, until the advance of their mental malady, the complication of organic disease, or some casualty, has rendered them hopelessly incurable, and burdensome in cost,--a cause of a decreased rate of cures and of an augmentation of deaths in the asylum.

But there is yet another lesson to be learned from the foregoing extracts, confirmatory of our own experience, which we might well wish to ignore, viz. the want of knowledge, both of the characters of insanity and of the treatment it demands, among our professional brethren. Undoubtedly a vast stride has been made of late years in diffusing correct views of insanity and its treatment, yet much remains to be done; and it is humiliating to read of cases of delirium from fever, or from organic disease, affecting other organs than the brain; of patients afflicted with chorea; of others delirious from exhaustion or from alcoholic drinks, sent to asylums as cases of insanity. For it is to be remembered, that a medical certificate is a necessary preliminary to the entrance of every person into an asylum; and where the nature of the cases indicates no flagrant error of diagnosis, it at all events exhibits a carelessness or recklessness of the medical man, or his want of moral courage and of official independence, where, for example, he acts as the agent in sending to asylums the aged imbecile of fourscore years, or the poor restless, irritable victim of consumption or other fatal organic bodily disease. Moreover, it speaks ill of Union medical officers, who are entrusted with the supervision, medical care and treatment, and with the dietary of the lunatic poor, to read of the neglected and wretched state in which they are too often found, both in workhouses and in their own homes, and of the condition in which they sometimes are when received into asylums. The bonds and bands, the physical exhaustion from want of food, are matters rightly placed, in a greater or less measure, in their hands. The treatment by cupping, leeches, general bleeding, blistering and purging, and by other depressing means, lies wholly at their door; and such treatment, we regret to say, is still, by some medical practitioners, deemed proper, although experience has for years shown that madness is a disease of debility, and that to use debilitating means is the most direct way to render it incurable.

There is yet another indication of the deficiency of information among medical men in general, often noticed by asylum physicians, viz. their inability to recognize the peculiar form of paralysis attended with disordered mind, known as "general paralysis." Where, as at St. Luke's Hospital, at Bethlem, and at Hanwell, under the recent regulation for promoting the early treatment of recent cases, the existence of general paralysis disqualifies an applicant from admission, the rejection of patients, on the ground of its presence, often gives rise to disappointment and to irritation on the part of the medical men signing the certificates, who will stoutly deny the justice of the exclusion, because they see no such loss of motion or sensation as they do in hemiplegia or paraplegia, or those forms of palsy to which they are accustomed to restrict the appellation.

This defective knowledge of insanity and its treatment ought not to be found, were medical instruction complete. But whilst the medical curricula make no requirement of instruction in mental disease necessary to medical qualifications, they are expanded so as to comprehend almost every branch of human knowledge, under the heads of 'Preliminary Education' and of 'Collateral Sciences,' and yet ignore psychological medicine, as though human beings were without minds, or, at least, without minds subject to disorder. The consequence is, as facts above illustrate, medical men enter into practice with no conception of the varied phenomena of mental disorder; unable to diagnose it; unfit to treat it, and glad to keep out of the way of its sufferers. Some, as before intimated, associate it, in their views, with inflammatory or congestive disease, and treat it accordingly, by blood-letting and the other parts of the so-called antiphlogistic regimen, to the speedy destruction of the patient, by increased maniacal excitement and concurrent exhaustion, or to his extreme detriment in relation to his prospects of recovery. Let us hope that this state of things may ere long be entirely amended, and that medical practitioners may be required to understand disorders of the mind as perfectly as those of the lungs.

Before quitting the subject of this section, a brief comment on the state of the law regulating the transference of weak cases to asylums will not be misplaced. According to _sect._ lxvii. 16 & 17 Vict. cap. 97, providing for the examination of alleged lunatics prior to removal to an asylum, it is enacted, "that in case any pauper deemed to be lunatic, cannot, on account of his health or other cause, be conveniently taken before a Justice, such pauper may be examined at his own abode;" and that, if found lunatic, he shall be conveyed to an "Asylum, Hospital, or House...; provided also, that if the physician, surgeon, or apothecary by whom any such pauper shall be examined shall certify in writing that he is not in a fit state to be removed, his removal shall be suspended until the same or some other physician, surgeon, or apothecary shall certify in writing that he is fit to be removed; and every such physician, surgeon, and apothecary is required to give such last-mentioned certificate as soon as in his judgment it ought to be given." A similar provision is made in the case of "Lunatics wandering at large, not being properly taken care of, or being cruelly treated" or neglected by their relatives, by the section next following (_sect._ lxviii).

Further, by _sect._ lxxvii., empowering the Visitors of Asylums to remove patients, it is provided "that no person shall be removed under any such order without a medical certificate signed by the medical officer of the asylum, or the medical practitioner, or one of the medical practitioners, keeping, residing in, or visiting the hospital, or licensed house, from which such person is ordered to be removed, certifying that he is in a fit condition of bodily health to be removed in pursuance of such order."

From the clauses above quoted, it is evidently the intent of the law to shield the unfortunate sufferers from mental disease, where prostrated by exhaustion or by organic lesions, against hasty and injudicious removal detrimental to their condition, or dangerous to life; yet, as already seen, these provisions are inoperative in preventing the evil. Those, indeed, regulating the transfer or removal of patients to or from an asylum are to a certain extent obligatory, and are probably attended to; but it is not so with those designed to protect lunatics from injurious removals under the direction of parochial authorities, as enacted by _sect._ lxvii. For by this section it is left to the discretion of the medical practitioner called in, to examine the patient, and to certify, in writing, to his unfitness for removal; but much too commonly, according to the testimony of every asylum superintendent, the humane intentions of the law are neglected. This 67th section need, therefore, to be assimilated to the 77th, so far as to make it imperative on the part of the medical man who examines the patient, to certify "that he is in a fit state of bodily health to be removed."

This is but a slight amendment, but it might save many a poor creature in a totally broken-down, exhausted, or moribund state, from being carried to an asylum far away, only to pine away and die. It is hard to write against the members of one's own profession, but the details put forth by asylum physicians of the manner in which patients are conveyed to the public institutions, and of the state in which they are received, demand, on the score of humanity, a condemnation of the indifference and negligence which sometimes mark the performance of duties rightly chargeable to parochial medical officers. Partial excuses for these officers may be found in abundance, on account of their usual wretched remuneration, and the too dependent position they occupy in reference to the parish boards appointing them; but no sufficient explanation appears for their withholding a certificate allowed by law, which might prevent the removal of a patient delirious with fever, of one perishing from heart disease or consumption, or of one dying from the exhaustion of cerebral excitement and defective nutrition.

CHAP. VI.--CAUSES DIMINISHING THE CURABILITY OF INSANITY, AND INVOLVING THE MULTIPLICATION OF CHRONIC LUNATICS.

Other causes than those already examined are in existence, sending to diminish the curability and to multiply the permanent sufferers of insanity, to be found unfortunately in the character and constitution of the very establishments constructed to afford requisite care and treatment for our pauper lunatics. According to the division of our subject (p. 31), these causes belong to the second head; or are--

B. _Causes in operation within Asylums._

§ _Magisterial interference. Excessive size of Asylums. Insufficient medical supervision._

There are in too many asylums grave errors of construction, government, and management, which detract from their utility, and damage the interests of both superintendents and patients. In several there is too much magisterial meddling, subversive of that unity of action and management which should prevail in an asylum, as it must do in a ship, and prejudicial to the position and authority of the superintendents, by diminishing their responsibility, their self-respect and independence, and their importance in the estimation of those under their direction. The visiting justices of an asylum mistake their office when they descend from matters of general administration and supervision to those of superintendence and internal management. When they exchange their legal position as occasional visitors of the wards for that of weekly or more frequent inspectors; when they directly occupy themselves with the details of the establishment, with the circumstances affecting the patients, with their occupations and amusements, irrespective of the medical officer; when they suffer themselves to be appealed to, and to act as referees in matters of internal discipline; when they assume to themselves the hiring and discharging of attendants; and when, without taking counsel with the medical superintendent, they determine on alterations and additions to their asylum,--they are most certainly pursuing a policy calculated to disturb and destroy the government and the successful operation of the establishment. A meddling policy is in all ways mischievous and bad; it irritates honourable minds, and deters them in their praiseworthy and noble endeavours to merit approval and reward; whilst it at the same time acts as an incentive to apathy, indolence, and neglect: for freedom and independence of action, a feeling of trust reposed, and of merit appreciated, are necessary to the cheerful, energetic and efficient performance of duties. So soon as the zeal of any man of ordinary moral sensibility is doubted, so soon as his competency for his office is so far questioned by the activity and interference of others in his particular field of labour, so soon is a check given to his best endeavours in the discharge of his duties, his interest in them abates, and a blow is inflicted upon his feelings and self-respect. In short, it cannot be disputed, that if an asylum have a duly qualified and trustworthy superintendent, the less a committee of visitors interferes with its internal organization and the direction of its details, the more advantageous is it for the well-being of the institution.

Again, many asylums have grown to such a magnitude, that their general management is unwieldy, and their due medical and moral care and supervision an impossibility. They have grown into lunatic colonies of eight or nine hundred, or even of a thousand or more inhabitants, comfortably lodged and clothed, fed by a not illiberal commissariat, watched and waited on by well-paid attendants, disciplined and drilled to a well-ordered routine, gratified by entertainments, and employed where practicable, and, on the whole, considered as paupers, very well off; but in the character of patients, labouring under a malady very amenable to treatment, if not too long neglected, far from receiving due consideration and care.

Although the aggregation of large numbers of diseased persons, and of lunatics among others, is to be deprecated on various grounds, hygienic and others, yet the objections might be felt as of less weight, contrasted with the presumed economical and administrative advantages accruing from the proceeding, were the medical staff proportionately augmented, and the mental malady of the inmates of a chronic and generally incurable character. But, in the instance of the monster asylums referred to, neither is the medical staff at all proportionate to the number of patients, nor are their inmates exclusively chronic lunatics. The medical officer is charged with the care and supervision of some three, four, or five hundred insane people, among whom are cases of recent attack, and of bodily disease of every degree of severity, and to whom a considerable accession of fresh cases is annually made; and to his duties as physician are added more or fewer details of administration, and all those of the internal management of the institution, which bear upon the moral treatment of its inmates, and are necessary even to an attempt at its harmonious and successful working.

Now, little reflection is needed to beget the conviction, that a medical man thus surcharged with duties cannot efficiently perform them; and the greater will his insufficiency be, the larger the number of admissions, and of recent or other cases demanding medical treatment. He may contrive, indeed, to keep his asylum in good order, to secure cleanliness and general quiet, to provide an ample general dietary, and such like, but he will be unable to do all that he ought to do for the cure and relief of the patients entrusted to him as a physician. To treat insane people aright, they must be treated as individuals, and not _en masse_; they must be individually known, studied, and attended to both morally and medically. If recent insanity is to be treated, each case must be closely watched in all its psychical and physical manifestations, and its treatment be varied according to its changing conditions. Can a medical man, surrounded by several hundred insane patients, single-handed, fulfil his medical duties to them effectively, even had he no other duties to perform, and were relieved from the general direction of the asylum? Can he exercise a vigilant and efficient superintendence over the inmates? Can he watch and personally inform himself of their mental, moral and bodily condition, prescribe their appropriate treatment, diagnose disease and detect its many variations; secure the due administration of medicines and of external appliances; order the necessary food and regimen; feed those who would starve themselves; attend to casualties and to sanitary arrangements; judiciously arrange the classification, the employments and recreations; keep the history of cases, make and record autopsies, and watch the carrying out of his wishes by the attendants? Can, we repeat, an asylum superintendent properly perform these, and those many other minor duties of his office, conceivable to all those who experimentally understand the matter, though not readily conveyed by description? Can any person perform these duties, if they were separable, without injury to the working of the institution, from the many details of general management which the position of superintendent has attached to it? Can he be justly held accountable, if the huge and complex machine goes wrong in any part? Can he feel sure that his patients are well looked after, attended to according to his wishes, and kindly treated? Can he do justice, lastly, as a physician, to any one afflicted patient, whose restoration to health and to society depends on the efficient exercise of his medical skill, and do this without neglecting other patients and other duties? To these questions, surely, every thinking, reasoning man will reply in the negative.

The consequence is, that asylum superintendents, who thus find themselves overburdened with multifarious and onerous duties, and feel the hopelessness of a personal and efficient discharge of all of them, are driven to a system of routine and general discipline, as the only one whereby the huge machine in their charge can work, and look upon recoveries as casual successes or undesigned coincidences (_see further_, p. 119).

The inadequacy of the medical staff of most asylums is a consequence, in part, of the conduct of superintendents themselves, and in part of the notions of economy, and of the little value in which medical aid is held by Visiting Justices in general. The contrast of a well-ordered asylum at the present day, with the prison houses, the ill-usage and neglect of the unhappy insane at a period so little removed from it, has produced so striking an effect on mankind at large, that public attention is attracted and riveted to those measures whereby the change has been brought about; in other words, to the moral means of treatment,--to the liberty granted, the comforts of life secured, the amusements contrived, and the useful employment promoted,--all which can, to a greater or less extent, be carried out equally by an unprofessional as by a professional man. It is therefore not so surprising that the importance of a medical attendant is little appreciated, and that the value of medical treatment is little heeded.

There has, in fact, been a revulsion of popular feeling in favour of the moral treatment and employment of the insane; and, as a popular sentiment never wants advocates, so it has been with the one in question; and by the laudation by physicians of the so-called moral means of treatment, and the oblivion into which medical aid has been allowed to fall, magistrates, like other mortals, have had their convictions strengthened, that medical superintendents, considered in their professional capacity, are rather ornamental than essential members of an asylum staff; very well in their way in cases of casual sickness or injury, useful to legalize the exit of the inmates from the world, and not bad scape-goats in misadventures and unpleasant investigations into the management, and in general not worse administrators, under the safeguard of their own magisterial oversight, than would be members of most other occupations and professions.

As before remarked, the magnitude of an asylum, and the paucity of its medical officers, are matters of much more serious import where recent cases of insanity are under treatment. In a colossal refuge for the insane, a patient may be said to lose his individuality, and to become a member of a machine so put together as to move with precise regularity and invariable routine;--a triumph of skill adapted to show how such unpromising materials as crazy men and women may be drilled into order and guided by rule, but not an apparatus calculated to restore their pristine condition and their independent self-governing existence. In all cases admitting of recovery, or of material amelioration, a gigantic asylum is a gigantic evil, and, figuratively speaking, a manufactory of chronic insanity. The medical attendant, as said before, is so distracted by multitudinous duties, that the sufferer from the acute attack can claim little more attention than his chronic neighbour, except at the sacrifice of other duties. No frequent watching several times a day, and no special interest in the individual case, can be looked for. There is such a thing as a facility in observing and dealing with the phenomena of acute mental disorder, acquired by experience; but it would be well nigh unjust to expect it in a medical officer, in whose field of observation a case of recent attack is the exception, and chronic insanity the rule, among the hundreds around.

The practical result of this state of things is, that the recently attacked patient almost inevitably obtains less attention than he needs from the physician, who, from lack of sufficient personal observation, must trust to the reports of others, to the diligence, skill and fidelity of his attendants, and who, in fine, is compelled to repose work in others' hands which should rightly fall into his own.

This being the case, the character of the attendants for experience, knowledge, tact and honesty acquires importance directly proportionate to the size of asylums, and the degree of inability of the medical superintendents to perform his duties personally. Now, though we need testify to the excellent qualities of some asylum attendants, yet, notwithstanding any admissions of this sort, it is a serious question how far such agents should be employed to supply the defects and omissions of proper medical supervision and treatment. The class of society from which they are usually derived; their common antecedents, as persons unsuccessful or dissatisfied with their previous calling, or otherwise tempted by the higher wages obtainable in asylums, are circumstances not calculated to prepossess the feelings in favour of their employment in that sort of attendance on the insane alluded to. They have no preliminary instruction or training, but have to learn their duties in the exercise of them. Many are their failures, many their faults, and often are they very inefficient, as the records of every asylum testify; yet, on the whole, considering their antecedents, and the nature of the duties imposed upon them, their success is remarkable. However, whatever their character as a body, as individuals they require the direct and ever-active oversight and control of the superintendent. The institution of head-attendants is a great relief to the labour of the latter, but rightly affords him no opportunity to relax his own inspection and watchfulness.

In a large asylum there must be general routine: it can be conducted only by routine; and the attendants are the immediate agents in carrying it out. Their duties necessarily partake largely of a household character; they are engaged in cleaning and polishing, in bed-making and dressing, in fetching and carrying, and in serving meals. But along with these they are entrusted with certain parts of the 'moral treatment' of the patients,--in enforcing the regulations as to exercise, employment, amusement, the distribution of meals, and the general cleanliness and order both of the wards and their inmates; and in the exercise of these functions acquire much knowledge respecting the character and habits of those under their care. Yet withal, they are not fit and efficient persons to have medical duties delegated to them. They are not qualified to observe and record the symptoms of disease, to note its changes, nor, except under close surveillance, to apply remedies externally or internally.

Such is the onset or the serious march of bodily sickness not unfrequently, that even the experienced medical observer is prone to overlook it. This is true where disease attacks those sound in mind, and able to express their sufferings, and to lend the aid of their intelligence towards the discovery of the nature and seat of their malady; but the danger of oversight is increased tenfold when the insane are the subjects of bodily lesion. Where the mind is enfeebled and sensibility blunted, and where melancholy broods heavily over its victim, disease is to be discovered only by a watchful and experienced practitioner of medicine; for the unfortunate patient will make no complaint, and the fatal malady may evince itself to the ordinary uninstructed observer by no sufficient symptom to awaken attention; and even where the mind is not imbecile, nor weighed down by its fears and profound apathy, yet the features of its disorder will interfere, in most instances, with the appreciation and interpretation of the symptoms which may reach the knowledge of those about the sufferer, and thereby mask the disease from the non-professional looker-on, and render its diagnosis even difficult to the medical examiner.

With respect to the female attendants of asylums, it may also be observed, that they are frequently young women without experience in disease, and rarely qualified as nurses conversant with certain medical matters; and, from our own observation, they are found to be often backward and shy in reporting particulars respecting the female patients, and badly qualified in administering to their wants when sick. Moreover, equally with the male attendants, there is, by their education and training, no security for a well-governed temper, for long suffering, patience and sympathy. Indeed, the wages given in most asylums are not sufficient to induce a higher class of young women to accept the onerous and often painful and disagreeable duties of attendants on the insane, than that which furnishes housemaids and kitchenmaids to respectable families. If, therefore, their origin be only looked to, it would be contrary to experience to expect from the nurses of asylums, as a body, the possession of high moral principle and sensibility, of correct notions of duty, and of a hearty interest in their duties. We make these remarks, with no intention to censure the whole race of asylum nurses, among whom are many meritorious women; but merely to enforce the opinion that something may be done to improve their character and condition, and that, as a class, they are not rightly chargeable with duties of the kind and to the extent we are engaged in pointing out. On the contrary, their history, position, and education conspire to make them servants in tone and character, unfit often to exercise the discipline and authority entrusted to them; whilst the general duties connected with the cleanliness and order of their wards and rooms, and the observation of the universal routine of the asylum, contribute to the same effect, and the more so in large establishments, where the almost constant supervision of the superintendent is wanting, where individual interest in patients is all but dead, and where their number renders the inmates mere automatons, acted on in this or that fashion according to the rules governing the great machine.

From the necessity of the case, the medical superintendent of a colossal asylum is compelled mainly to trust to the observation of his attendants to discover disease, and to report mishaps. He has his mile or upwards of wards and offices to perambulate daily, and, to keep up some connexion with their four or five hundred inmates, must adopt some general plan. For instance, he refers to the attendant of each ward he enters, demands from him if he has anything to report, wends his way through the apartment, looks right and left, remarks if the floor and rooms are duly swept and garnished; now and then inspects the bed and bedding, bids good morning to more or fewer of the patients who may be present, and unless Brown or Jones has something to report of any one of them, bids good day to all, to recommence the same operation in the next ward. Now Brown or Jones might have had something to report had they medical eyes, and information to detect the first symptoms of disease in one of their patients; but as they have not, the disorder has a fair opportunity to steal a march upon the doctor, and possibly to take such firm possession of its victim before this or that attendant is persuaded something is going wrong, that the doctor only commences his professional operations against it in time to render his certificate of death satisfactory, and the result explicable without a coroner's inquest.

We do not blame the medical men for not doing more, but we deprecate the system which places it out of their power to do so. No one can gainsay the possibility, nay, the actual occurrence, of avoidable deaths in the large asylums we condemn; and those who know the working of such institutions, know also that the duties are performed much after the sketch delineated, and could be got through in no greatly improved fashion.

But it must not be supposed, that it is only when disease exists or has to be discovered, that the delegation of the principal part of the supervision of patients to ordinary asylum attendants operates injuriously to their well-being; far from it, for many are the cases which require the presence of a more instructed and more sympathizing mind; of a person to appreciate their moral and mental condition; to overrule by his official position disorderly manifestations, to pacify the excitable, to encourage and cheer the melancholy; to espy and anticipate the wants of all; to hear the complaints of some, and to be the confidant of others; to mark the mental changes of individuals, and to adapt surrounding circumstances, their occupations and amusements accordingly. To give such superintendence, or, in other words, to apply such moral and mental treatment, the medical officer is the only fitting person; from him the patients will and do naturally look for it. Let any one follow a medical superintendent in his ordinary visits through the wards; and he will observe how ardently the visit is anticipated by many; how numerous are the little troubles and ailments they wish to disclose to the physician, and only to him; how often he can arrest excitement and calm irritation, only aggravated by the interposition of attendants; how often he can recognize mental and bodily symptoms demanding attention, and, in general, how largely he can supply those minutiæ of treatment, insignificant as they appear, and unthought of as they are by others, whose moral feelings, whose intellectual acumen, whose education and manners, and whose position are deficient to conceive them, and insufficient to put them in force.

There is no question, it must be granted, but that whatever medical supervision may be supplied, yet that the carrying out of most of the details of management must always devolve upon the attendants; it becomes, therefore, a matter of paramount importance to render that class of asylum functionaries as efficient as possible. They need be encouraged by good wages and good treatment; and, what is of great moment, these should be sufficiently good, to induce persons of a better class than that which usually furnishes attendants, to accept such posts. This idea will probably be scouted by the stickler to "a due regard for economy," at first sight; but we think his economical penchant might be gratified by the plan of carrying out more fully in the wards the distinction of attendants upon the insane and of household servants. For is it not practicable to import the system adopted in the large London Hospitals, where the office of 'sisters,' to nurse the patients, is separated from that of under-nurse, to whom the cleanliness of the wards is committed? If so, the immediate attendants on the insane might receive higher wages without increasing the general expenditure of the asylum; for those concerned in the cleaning of the wards would only earn the wages of common household servants. We throw out this suggestion, in passing, for the nature of our treatise forbids our enlarging upon such matters of asylum organization; otherwise, much might be written respecting the duties and the remuneration of attendants, and the advantages of pensions for them after a certain term of faithful service.

To conclude this topic, we may remark that it would be easy, did the subject stand in need of proof, to multiply illustrations, showing that, to transfer the work of medical and moral supervision to attendants, in any similar extent and measure to that which must of necessity prevail in the excessively large asylums which County Magistrates rear in opposition to the decided opinion of those best able to judge, is to frustrate the object of those institutions as curative asylums, and to detract from their advantages as refuges for the incurable.

The evils of overgrown asylums have not, as might be expected, escaped the observation and reprobation of the Commissioners in Lunacy, who have referred to them in several of their Annual Reports, but more at large in that of 1857, wherein they detail their contest with the Middlesex magistrates respecting the further enlargement of the enormous asylums of Hanwell and Colney Hatch, and their strange defeat, the magistrates having contrived to influence the Home Secretary in opposition to the decided opinion of the Commissioners, though seconded by experience, by the general assent of all asylum physicians, and by their position as the referees appointed by the State in all matters touching the erection and management of asylums. With this acquiescence in the erroneous scheme of a County Magistracy in opposition to a Government Commission, we have at present no immediate concern, and may content ourselves with reporting it as an anomalous proceeding which ought never to have occurred: but to revert to the sentiments of the Commissioners, they are expressed in the following quotation from the Report mentioned.