Chapter VIII: Part 8

The determination of the cases proper for the secondary asylum lodged in the physician's hands would always enable him to retain those in the primary one, whose state, though chronic, would in his opinion be injuriously affected by a transfer, and any such others besides whose presence in the wards he might deem an advantage in the management. We mention the latter, because the opponents to separation insist on the benefits to an asylum accruing from the admixture of recent and chronic cases. And although we are not prepared to deny an opinion held by so many eminent men, yet we are on the other side not at all persuaded that the presence of old inmates is of any such real advantage, as supposed, to newly-introduced ones. We can assert, from experience, that recent cases can be very satisfactorily treated without the company of old ones; and we must, moreover, confess to certain misgivings that the actual presence of a long-standing case, often eloquent on the injustice of his detention, a Job's comforter to the new-comer, by his remarks on the severity of his disorder, with the assertion added, that there was nothing the matter with the speaker's self when he came into the house; full of gossip about all the mishaps of the place, and often exercising an annoying superiority and authority assumed on account of his position as one of the oldest inhabitants. To the statement of the value of their service in aiding the attendants and in watching their neighbours, we rejoin, there should be attendants enough to perform the duties of supervision; that many recent are equally serviceable as chronic cases, and stand in need of being encouraged by the attendants in taking part in those many minor details which characterize life in the wards of an asylum.

However this question of the utility of mixing chronic and recent patients together may be solved, we do not contemplate the existence of a primary asylum without the presence of more or fewer chronic cases, retained in it for the best medical and moral reasons. Likewise, on the other hand, the secondary asylum will not so exclusively be the abode of incurables. The lapse of time in a case of insanity most potently affects its chances of recovery, but it is not an invariable obstacle to it; for experience decidedly demonstrates that recovery may take place years after every hope of it has passed away, and that patients rally from their affliction, not after four or five years only, but even after ten and twenty; consequently, among the large number of chronic patients under treatment, there would doubtless be every year some restored to reason and to liberty; and the dreaded foreboding of perpetual confinement and hopeless incurability could not take possession of the minds even of those whose perceptions rendered them conscious of their condition and position.

To arrive at a correct judgment on this matter, let us look into it from another point of view, and compare the condition of a lunatic in the proposed chronic asylum with that of one in a large county asylum, conducted according to the prevailing system. Look to the fact, that in some of the existing large curative (?) asylums, not more than from 7 to 12 per cent. of their six or eight hundred, or one thousand inmates, are deemed curable, and say in what respect a patient introduced into an establishment of the sort, surrounded on every side by crowds of chronic lunatics, enjoys any superiority over one transmitted to a secondary asylum of the description we contemplate. Call such an institution what we may, announce it as a curative asylum, or as an hospital for curables, it matters not; to a fresh-comer it has all the drawbacks of a chronic asylum; for if he be alive to his condition, and can reflect on the position and circumstances in which he is placed, he may well find grounds for discouragement and despair on looking round the gigantic building, overflowing with the victims of chronic insanity, many of appearance, habits, and manners, repugnant to the higher and better feelings of any thinking, reflecting mortal; who count their residence there by years and even tens of years, with no prospect of release, and who, it may be in his imagination, are not, or have never been, so afflicted as himself. Can such a spectacle be otherwise than injurious to a recent case, sufficiently well to perceive it on admission, or coming to appreciate it during convalescence? and must not the recognition of his position by the patient be most painful and discouraging as one of a multitude, eliciting personally, except perhaps for the few first days, no more attention than the most crazy old inmate near him; submitted to the same daily routine, and having no superior with sufficient time on hand to hear at large his tale of woe, to soothe his irritated spirit, or to encourage him in his contest with his delusions and fears? If the case of the new-comer be chronic, the conditions he finds himself placed in are sufficiently distressing and annoying; but if it be recent and curable, they are damaging to his chance of recovery.

The comparison just drawn tells in favour of the system of separation. Recent cases would not, in the primary institution or hospital, find themselves an insignificant few surrounded by a host of chronic patients, and they would accordingly escape the evils of such a position; on the contrary, they would be placed under the most favourable conditions for recovery, be individually and efficiently attended to, and encouraged by the many convalescents around them to hope and strive after their own restoration to health and liberty.

The sketch presented of the evils of the companionship of long-disordered inmates with new-comers, especially when those are melancholic, is not an imaginary one, but drawn from experience. Often will a desponding patient observe, 'I shall become like such or such moping, demented lunatic'; and superintendents, if they would, might often record the ill-effects of example of older inmates upon those newly admitted.

Attempts by means of classification somewhat mitigate, where made, the evils of large asylums for recent cases, by keeping these to a certain measure apart from most of the other lunatics; but nothing can do away with the injurious impression on a mind sufficiently awake to receive it (on such a one, in short, as the question of the place of treatment can alone concern),--of being one member of many hundreds who have for years and years known no other residence than the huge house of detention they are in: and there is no compensation to be had for the loss of those special appliances, and that individual treatment, which only a properly-organized hospital can supply.

The last clause suggests another important argument for the treatment of recent cases in a distinct establishment or in separate sections. It is, that they require a peculiar provision made for them, involving greater expense, a more complete medical staff, a physician accustomed to their supervision and management, unfettered by that host of general duties which the presence of a multitude of chronic patients entails, and a staff of attendants disciplined to their care, and possessing many of the qualifications of nurses. Moreover, the building itself for this class of patients need be more expensively constructed and fitted than one for chronic inmates.

There is yet another reason against largely extending the size of a county asylum, and in favour of building, in the place of so doing, a distinct structure. This reason is to be found in the influence of distance as an obstacle to the transmission of the insane to an asylum for treatment, and to the visits of their friends to them during their confinement. The Lunacy Commissioners of the State of Massachusetts particularly remarked the operation of distance in debarring insane patients from treatment, and illustrated it by a table showing the numbers received from different places within the district it served, and in relation to their population, into the asylum. Likewise in this country, where the distance of the asylum is considerable, it is a reason for delay on the part of the parochial officers, who wish to avoid incurring the expense of removing the case, if they can in any way manage it in the workhouse.

But the evil of remoteness operates more frequently, and with much cruelty, against the visits of poor persons to see their afflicted relatives in asylums. Many can neither undertake the cost, nor spare the time required for the journey, notwithstanding the modern facilities of travelling. The same evil is likewise an impediment to the visits of parochial officers, who rightly possess a sort of legal guardianship over their lunatic poor in asylums.

Lord Shaftesbury, in his evidence before the Select Committee, 1859, very properly dwelt upon the advantages of visits from their friends to lunatics in asylums, and even proposed to make their visits compulsory by act of parliament. The Commissioners in Lunacy also, in their Twelfth Report (1858), gave examples of the distress not unfrequently attending on the separation of the patient in an asylum at a long distance from his friends. Such distress operates to the disadvantage of the patient, and increases the sorrow of his relatives.

Admitting there are advantages attending the multiplication of asylums instead of aggregating lunatics in very large ones, it would appear the correct policy for boroughs to build asylums for the refuge of their own insane; or, where small, to unite with other boroughs in the county for the same purpose, in place of contributing to the county-establishment, and inducing the magistrates to extend its size injuriously. In a case such as that of Middlesex, where the county asylums have attained such an unwieldy size as to be past acting as curative institutions, it would seem no improper extension of the law to make it imperative upon the large metropolitan boroughs to build apart for their own pauper lunatics. Of this we are persuaded, that it would soon be found to the profit of the boroughs to undertake to provide for their own pauper insane.

We regret that, in advocating the separation of chronic from recent cases, we place ourselves in antagonism to many distinguished men who have devoted themselves to the care of the insane, and among others to our former teacher and respected friend Dr. Conolly, from whose clinical visits and lectures at the Hanwell Asylum, many years ago, we derived our first lessons, in the management and treatment of the insane. But although regretting some divergence of opinion on this point, we are confident of his readiness to subscribe to that maxim of a liberal philosophy, expressed by the Latin poet, "_nullius addictus jurare in verba magistri_."

To return from this digression: there are two propositions to be established, viz.--1. That there are many cases of chronic mental disorder to be found in every county asylum, which encumber it, to the prejudice and exclusion of recent cases, and which could, without mental pain or damage, or any tangible disadvantage, be removed from the institution considered as a curative one. 2. That less elaborate structural adaptations, and a less expensive organization, would suffice for the proper care and treatment of a large number of chronic cases. Let it be understood, however, that neither in past nor future remarks is it our intention to argue against the existence of mixed asylums altogether,--for by careful classification in a moderately-sized establishment, a zealous physician, properly assisted, may contrive to do his duty, both towards the comparatively few acute, and the many chronic cases under his charge; but against the pretence of admitting recent patients for curative treatment in monster institutions filled with chronic cases, where individual daily recognition is all but impracticable, efficient medical supervision unattainable, and proper medical and moral treatment impossible.

Deferring for the present the inquiry, under what conditions of the insane population of a county should distinct asylums be constructed, let us see what are the views of the Lunacy Board bearing upon the two propositions put forth, and examine further into the means of providing for the future wants of the insane. So long since as 1844, the then Metropolitan Commissioners in Lunacy advised the institution of distinct asylums for the more chronic cases of insanity (Report, p. 92), and thus expressed themselves:--"It seems absolutely necessary that distinct places of refuge should be provided for lunatic patients who have become incurable. The great expenses of a lunatic hospital are unnecessary for incurable patients: the medical staff, the number of attendants, the minute classification, and the other requisites of a hospital for the cure of disease, are not required to the same extent. An establishment, therefore, upon a much less expensive scale would be sufficient."

An exception might be taken to the wording of this paragraph, as assumptive of incurability being an absolute condition, and as countenancing the scheme of a refuge distinctly provided for incurables; both of them ideas repugnant to the humane mind, instructed by experience, that insanity, at almost any lapse of time, and under most forms, is not to be pronounced absolutely incurable, or beyond the hope of cure. The scope of the argument adduced can, however, not be objected to, for it will be generally admitted that less expensive institutions are needed for very chronic cases in general, and that it is an important object to clear the present curative asylums of such cases, so as to facilitate the admission and the early treatment of recent patients. The present Lunacy Board, in their Tenth Report, 1856, repeated these views, and pointed out the importance of erecting detached buildings in connexion with the offices used for the different occupations pursued in the establishment, instead of adding new stories, or new wings, to the main building.

In the Report for the following year (1857), the Commissioners returned to the subject, in connexion with the proposed enlargement of the Middlesex County Asylums; and, having remarked on the rapid accumulation and crowding of those refuges with chronic cases, so soon after that at Colney Hatch was opened, thus write (p. 13):--"Manifestly the remedy now was, not to exaggerate the mistake already committed, by additions on the same costly scale for purposes to which they would be as inappropriate; but, by a fresh classification and redistribution of the patients, not only to deal with existing evils, universally admitted, but to guard against a recurrence of evils exactly similar, by restoring to both asylums their proper functions of treatment and care. It had become not more matter of justice to the lunatics themselves, than of consideration for the rate-payers, to urge, that the additional accommodation required being for classes of patients, as to whom, for the most part, small hope of cure remained, might be supplied in an asylum much better suited to them, and of a far less costly character." At a subsequent page (p. 23), they recur to the theme. After pointing out that the plan of placing chronic, and presumed harmless patients taken out of asylums, in workhouses and "in their private homes," had signally failed, they observe:--"We are, therefore, brought back to the conclusion already stated ..., to which we find all reasoning upon the subject necessarily converge, and which we desire to impress as strongly as possible upon every one to whom the care of the insane is committed, that a new, and less costly kind of provision is now very generally required for large classes of pauper lunatics, to whom the existing expensive structures are unsuited.

"Our last Report directed attention to the fact, that in providing, not merely for the harmless and demented, but for the more orderly and convalescing, the most suitable was also the least expensive mode; that they might satisfactorily be placed in buildings more simple in character, and far more economically constructed; and that therefore it was advisable, wherever the necessity for enlarging one of the existing asylums presented itself, that the question should be considered in reference to these two kinds of patients. And whether the mode adopted may be, for the convalescing, by simple and cheerful apartments detached from the main building, and with opportunity for association with the officials engaged in industrial pursuits; or, for harmless and chronic cases, by auxiliary rooms near the out-buildings, of plain or ordinary structure, without wide corridors or extensive airing-court walls, and simply warmed and ventilated; it is, we think, become manifest that some such changes of structure must be substituted for the system now pursued, if it be desired to retain the present buildings in their efficiency, and to justify the outlay upon them by their continued employment as really curative establishments. In this way only, as it seems to us, can justice be done to the rate-payer as well as to the pauper."

Lastly, in their Supplementary Report on Lunatics in Workhouses (1859), they repeat their recommendations to erect distinct inexpensive buildings for chronic cases. The paragraph containing their suggestion has already been quoted (p. 82), and need not be repeated here.

The noble chairman of the Lunacy Board, according to his valuable evidence given before the Special Committee of Lunatics, just printed, appears to have been an early and constant advocate for constructing distinct receptacles for chronic and acute cases. In reply to query, No. 664, his lordship has more particularly enlarged upon the utility of the plan, and referred to the distinct proposition of the Board in 1845, that it should be carried out by the Committees of Asylums. The scheme of separately providing for many chronic lunatics has also received the valued support of Dr. Boyd (Seventh Report, Somerset Asylum, p. 10), who appears to contemplate the erection of the proposed building contiguous to the existing asylum, so as to make use of the patients' labour "in preparing stone and lime, and in doing all the heavy part of the work," and to unite the two establishments under a common administration and commissariat, as a plan attended with considerable economical advantages.

We do not deem it necessary to quote other authorities at large, in support of the system advocated; otherwise we might adduce many continental writers, especially among the Germans. It is fair to add, however, that in France generally "mixed asylums" are the rule, and that a few of these contain five or six hundred inmates, but none, we are happy to say, have acquired the prodigious dimensions of several of our English asylums. Moreover, the French system is to erect a number of detached buildings, or sections within the general area of the establishment, adapted to the different classes of the insane, according to the character of their disease, or to their condition as pensioners or paupers. We cannot here discuss the advantages or disadvantages of this plan, but it certainly obviates some of the evils of aggregation evidenced in English asylums, consisting of one continuous structure. It has just been said, that in no French asylum are so many lunatics congregated as in some English institutions; yet it is true, that the great Parisian hospices contain similar numbers; for instance, La Salpêtrière holds as many as 1300; but in this case the arrangement is such, that each of the five sections it is divided into, constitutes practically a distinct hospital for the insane, structurally separated, or quite detached; with subordinate quarters or sections, to provide for a proper classification of the inmates, and having its own grounds for exercise, &c., and its own medical staff. Thus, to the 1300 patients there are five physicians, having equal power and privileges, each one the head of his own section. We would not in any way adduce this extensive Parisian hospice as an example to follow, either in structure or organization; and have alluded to it in so many words only to show, that though equally large in its population, it is comparable in no other respect to the huge receptacles for the insane to be found in this country. Of the prevailing system in Germany we shall presently find occasion to speak.

Lastly, the 8th & 9th Vict. cap. 126, gave express powers to provide for the chronic insane in distinct establishments; in order, according to the marginal abstract to sect. xxvii., "to prevent exclusion from asylums of curable lunatics; separate provision to be made for chronic lunatics." The chronic asylums were again referred to in sect. xlii. and in sect. lvi., which conferred the necessary powers on the visitors to remove the patients from one asylum to another. It is not worth while to repeat the clauses referred to, since the Act was repealed by the 16th & 17th Vict. cap. 97, and no re-enactment of them took place. Nevertheless, it is to be observed, that the last quoted Act contemplated the provision of asylum accommodation for the whole of the lunatics of each county, and with this object, by sect. xxx., empowered the justices, at any general or quarter sessions, to cause, or to direct the Committee of Visitors of the County Asylum to erect an additional asylum, or to enlarge the existing building, to supply the requisite accommodation; and further, put it into the power of a Secretary of State, "upon the Report of the Commissioners in Lunacy," to call upon the magistrates of any county or borough to do the same.

This enactment may be enforced by the Lunacy Board so far as the Secretary of State can prevail with a body of magistrates to accede to it, "in such manner as the said Secretary of State may see fit, and direct." But this high official has no direct power to compel a Committee of Visitors under any sort of penalty. "It shall be lawful for such Secretary of State," says the clause, "to require" such additional asylum alteration or enlargement; but the history of the contest between that public officer and the Middlesex 'Committee of Visitors' appears to prove that his requisition may be neglected and set aside. "He found" (as Lord Shaftesbury tells us in his evidence, Rep. Select Comm., Query, No. 799), "that the passive resistance offered was beyond his power." We coincide with his lordship, that this ought never to have happened, and think, that the Secretary of State, acting under the representations and advice of the Lunacy Commissioners, ought to be armed with full powers to enforce the provision for pauper lunatics in asylums being rendered equal to the demand for it, according to some plan agreed to by them, in every county, in harmony with the true intent and purpose of the Act now in force.

In order to facilitate the carrying out of this design, and to limit the scope for the passive resistance and attempted delay of some county magistrates, the re-enactment of the sections of the 8th & 9th Vict. sect. 126, as quoted, appears desirable, viz. to sanction and promote the erection of distinct retreats for chronic cases. We are, indeed, glad to find, that in this recommendation we are also in accord with the noble lord at the head of the Lunacy Commission.

Looking at the matter in a general point of view, therefore, we appear to find, in the plan of separating the more chronic and most unpromising cases of lunacy from the recent and hopeful, so as to leave these in smaller numbers for the purpose of more direct and effectual treatment, one mode of improving and extending the future provision of the insane. However, to elucidate the scheme, we need go into further detail, so as to define more particularly the classes to be separately accommodated, and the extent to which the separation should be carried.

The grand distinction, above employed, in discussing the question of separation, has been that of recent and chronic cases, and it has been sought to ignore that of curable and incurable, as not only undesirable, but actually mischievous. By recent cases, we understand all those where the malady is of less than one year's duration, which form a class that demands the more active and constant attention and treatment of the physician, more purely medical care, more consideration and watching from the attendants, ampler measures for moral treatment, and for exercising salutary impressions on the mind; and withal, special arrangements and fittings in the asylum building itself. All these particular conditions for treatment and management are not to be obtained by recent cases of insanity, as we have insisted on throughout this chapter, in asylums which have grown beyond the size which a chief medical officer can personally supervise in all its details, and, so to speak, animate the whole machine. If this be admitted, and if the cure of the insane be treated as the primary and essential object of asylum detention, then surely the necessity of special provision for recent cases will be recognized.

In moderately sized asylums acute and chronic cases may be, as said before, received and treated together; for instance, in such as accommodate from 250 to 450 patients, provided that the physician-superintendent is properly assisted, for the proportion returned "as deemed curable" in the English county asylums,--a proportion which represents pretty nearly that of the recent cases, rarely exceeding 10 or 12 per cent.; consequently, the 40 or 50 demanding special supervision and medical care may be undertaken by the superintendent, if he be sufficiently assisted in the management of the chronic cases and in the carrying out of the general details of the establishment. On the other hand, a small, and perfectly distinct asylum for 40 or 50 patients could not be established or conducted so advantageously, and still less so economically; a circumstance, which will always avail to perpetuate the system of mixed asylums for acute and chronic cases together. Nevertheless, it must be borne in mind, that the 40 or 50 patients in the population of 300 or 400, do not constitute the whole number of recently attacked cases which may be admitted for treatment, but, so to say, the residue at a particular date; for instance, the first day of the year. Moreover, if the improvements in the law, and in its administration, suggested, are carried out, and the admission of patients immediately on the occurrence of their malady be facilitated, then, as a matter of course, the proportion of those "deemed curable" would be immensely increased; so much so, that it would be a very moderate estimate to reckon on 100 recent, to every 500 chronic cases; or, what is equivalent to this statement, the plan of placing patients under immediate treatment would cause the progressive decrease of chronic cases, and raise the standard of the asylum as a curative institution; a happy result, which, whilst it would necessitate a more complete medical staff, would at the same time well repay its cost.

Passing now to asylums which exceed the limits assigned as falling within the compass of the abilities of any physician to superintend effectually for the greatest benefit to its inmates, we hold the opinion, that where these amount to 600 or 900, the most just and humane, and in the end the most economical policy, is, to divide the establishment. Yet even here, according to the present system regulating admissions, and the natural consequence of this, the small per-centage of acute cases under care at any one time, viz. from about 7 to 10 per cent. in the whole population, would perhaps be held to furnish too small a number to justify the cost of erection and maintenance of a wholly distinct hospital for their treatment. Still we are confident that, if in any county where the pauper lunatics in asylums attained the number mentioned, a distinct institution for the reception of recently afflicted persons were erected, and the admission of such patients were promoted, if that institution were free as a public one for the insane other than paupers, such as those from among the middle classes, unable to meet the costs of a proper private asylum--it would secure to itself the number of patients needed to warrant its establishment as a distinct institution, succeed even as an economical arrangement, and confer an immense boon both on pauper lunatics and their more unfortunate fellows in affliction, who are too rich for the "Pauper," and too poor for the "Private" Asylum.

Lastly, we come to the consideration of those overgrown establishments where from 1000 to 2000 lunatics are congregated under one roof. Such monstrosities ought never to have been constructed; they are nevertheless looked upon by their promoters with admiration, and spoken of with pride, though there is nothing in them to admire besides their magnitude and pseudo-military discipline, and no more in them to be proud of as county institutions than in enormous prisons; for as the latter indicate the neglected morality of the county, so do the vauntedly large asylums prove the neglected treatment of insanity. However, as the erection of these unmanageable structures is an accomplished fact, nothing is left than to deplore the fatal mistake; to take care that it is not repeated in other instances, and to insist on the construction of distinct hospitals for recent cases. The very existence of such an hospital would invite resort to it, and bring within its agency many cases which do not find their way into the existing institutions until, most probably, all hope of cure is well nigh gone. Moreover, just as mentioned above in reference to a proposed county hospital for lunatics, the law should intervene to secure the early transmission of all cases for treatment, and admission be granted to others besides paupers, under certain stipulations, by the payment of more or less of their cost.

In counties with a population of lunatics of the extent named, the difficulty of placing the chronic and recent cases of insanity in separate asylums vanishes; for the latter will always be forthcoming in sufficient number to justify a distinct institution for their treatment both on medical and economical grounds; and the former, we apprehend, will always be found numerous enough to occupy the accommodation provided. As refuges for old cases, the evils of the existing gigantic establishments would happily be mitigated, although not removed, by appropriating them solely to the use of long-standing cases of lunacy.

Where the construction of a distinct hospital for recent cases of lunacy is decided on as necessary, it should certainly accommodate not more than 300. All patients should be admitted whose disease is of less than one year's duration; but this limitation should not be so absolute as to prevent the physician to admit, after the lapse of a longer period, any cases which might appear to him amenable to successful treatment;--a point in prognosis, taught, and only taught, by experience in dealing with recent insanity. Although the great majority of the insane who recover, do so within the first year of their attack, yet statistics show that about 10 per cent. are restored in the course of the second year of treatment; it would therefore seem that two years would constitute a fair and sufficient period for the duration of residence in the primary asylum. Here again the knowledge and experience of the physicians must be allowed scope, both to discharge certain cases within the period named, and to retain others beyond it. We should not consider it expedient to reject all cases of epilepsy and general paralysis forthwith upon their application, although insanity so complicated is generally very hopeless; for an asylum with special appliances for treatment would at least be desirable to the victims of those sad maladies in their early stages.

It is unnecessary to define the classes of lunatics who would occupy the secondary asylums. As said before, we do not contemplate these institutions as mere places of refuge; we do not consider the attempt and the hope of cure relinquished in their wards, but that the means of treatment are diligently persevered with. We would have them to be neither hopeless retreats for patients, nor institutions calculated to encourage supineness or apathy on the part of their medical officers. Indeed a slender objection we have met with against the separation of the recent from chronic patients, involves a slur upon the medical profession in supposing a lack of interest and energy as incumbent upon the superintendent of an asylum for chronic lunatics;--a supposition, which reflects unfairly upon, and is untrue with respect to many superintendents of asylums actually in existence. Are not interest and zeal, we may ask, exercised for the benefit of those deemed incurable; are they not exercised on account of idiots even, for whom their absence might be esteemed not surprising? If cure is not attainable, the physician to the insane, unless unfit for his calling, seeks and finds his reward in ameliorating their condition; in elevating their mental and moral, and in improving their physical being.

In those counties in which the number of the insane and the prevalence of insanity are not sufficiently extended as to justify the institution of a distinct curative asylum, the plan of the union of counties, as followed for the provision of the ordinary asylums, suggests itself to the mind. Practically, however, we believe, it is a plan which would not answer, since it would render arrangements between counties in possession of asylums difficult, and their accounts complicated. The only way in which it could be made feasible would be by the levying of a general rate throughout the country for the maintenance of lunatics, and by dividing the country into districts, as is the practice in Scotland and Ireland, apportioned in size to the population, to each of which an asylum for chronic, and one for recent cases of insanity, might be assigned. Such a scheme of a general rate, however, we do not expect to see realized, although many arguments are adducible in support of it. Sir Charles Wood, when Chancellor of the Exchequer, made the proposition to contribute on behalf of the maintenance of asylums a portion of the proceeds of the general taxation of the country; but the scheme met with little favour, and was dropped. The principal objections advanced against it were, that it was wrong in principle, a novel and uncalled for attempt to interfere with local government, and no more to be justified than would be a contribution from the revenue of the country towards providing for the relief of any other form of disease. Respecting the last objection, it is worth noting, that District Dispensaries throughout Ireland are partially supported by Parliamentary grants; surely, therefore, if the principle of subsidizing hospitals or dispensaries is admitted in one part of the United Kingdom, there can be nothing unreasonable in a proposition to extend it to another.

Where to provide for the lunatic population of a county considerably exceeds the legitimate dimensions of a single asylum, and yet the proportion of recent cases is too small to warrant the construction of a distinct institution for them, we have proposed the establishment of two asylums, each of a mixed character. Under such circumstances, and likewise where a single asylum threatens to outgrow a manageable size, there are certain very advantageous arrangements to be made, adapted to secure much more efficient treatment, particularly of recent cases, than is usually provided under the present system of aggregating all under one roof to be subjected to one course of routine and discipline. These arrangements are effected by the

§ _Construction of distinct Sections to Asylums._

The French system of asylum construction, as before noticed, is to divide the building into several, more or less, sometimes quite distinct sections, having a general administration and offices in common. The number of sections and the character of their residents is a matter of medical classification, and in each one there is a mixture of acute and chronic cases, just as in our asylum wards; the combination being regulated by the similarity in the phases of their malady, as, for instance, if refractory; if epileptic; if clean and orderly; or demented, paralytic and dirty. In Germany, on the contrary, although this same medical classification is carried out, there is a primary separation of the insane of the province or state into acute and chronic. But in the mode of providing for the treatment of the two classes apart, two plans are pursued, one termed that of "absolute separation," and the other of "relative connexion" (relativ verbindung); the former consists in placing recent and chronic cases in buildings completely detached; each one having its own staff, organization and management; the latter, whilst keeping the chronic and recent cases apart, possesses a common medical and general administration in a building composed of two principal sections, either forming parts of the same structure (as at Illenau, in Baden), or detached, but within the same area (as at Halle, in Saxon Prussia). Damerow is the most able advocate of the system of relative connexion, on which he has largely written, and it is one which appears to be gaining ground in Germany.

Now, except in the case of the overgrown Middlesex Asylums, where the Lunacy Commissioners distinctly recommended a third asylum to be erected, the plans propounded by that Board for affording additional accommodation in institutions already large enough, are in principle much that of the "relative connexion" system as proposed by the Germans. The reports above quoted, in connexion with the question of separating recent from chronic cases, show generally what the plans of the Commissioners are. They would erect "detached day-rooms and associated dormitories near the wash-houses on the women's side, and the workshops and farm-buildings on the men's side." (10th Report, 1856, p. 27.) To prove the advantages of the plan, they go on to say, "In making our visitations to the larger County Asylums, we have repeatedly observed that a considerable portion of time is occupied by the servants, who have charge of the wash-house and workshop department, in merely collecting the patients in the wards, and in conducting them to and from their respective places of employment. In one asylum, we ascertained by minute inquiries that not less than one hour and a half was thus every day wasted by the servants, and was passed unprofitably and unpleasantly by the patients themselves.

"In addition to the saving of cost and time obtained by adopting the plan we now recommend, we have the best reason for believing that the patients derived a direct benefit, in many ways, from residing in cheerful airy apartments detached from the main building, and associated with officials engaged in conducting industrial pursuits. A consciousness that he is useful, and thought worthy of confidence, is necessarily induced in the mind of every patient, by removal from the ordinary wards, where certain restrictions are enforced, into a department where he enjoys a comparative degree of freedom; and this necessarily promotes self-respect and self-control, and proves highly salutary in forwarding the patient's restoration. As a means of treatment, we consider this species of separate residence of the utmost importance, constituting in fact a probationary system for patients who are convalescing; giving them greater liberty of action, extended exercise, with facilities for occupation; and thus generating self-confidence, and becoming not only excellent tests of the sanity of the patient, but operating powerfully to promote a satisfactory cure.

"The want of such an intermediate place of residence is always much felt; and it often happens, that a patient just recovered from an attack of insanity, and sent into the world direct from a large asylum, is found so unprepared to meet the trials he has to undergo, by any previous use of his mental faculties, that he soon relapses, and is under the necessity of being again returned within its walls." (P. 27, Rep. 1856.)

The proposition of the Commissioners has been carried out to a certain extent in several large asylums; for instance, at the Leicester, the Wakefield, and the Devon. At the last it has been most fully developed in the construction of a detached building for 100 patients; respecting the excellence and cheapness of which, we have spoken in a previous page (p. 48).

The views of the Commissioners will meet with general approval. The prevalent system in France of breaking up an asylum into sections, more or less detached, we hold as preferable to the close aggregation of wards under one roof, with continuous corridors, seen in the majority of English Asylums. The correct principle to be pursued in an asylum is, to assimilate its character and arrangements as far as possible to those of the homes of the classes of persons detained in them. Can this be effected in a large building constructed as much unlike ordinary houses as it well can be; recalling in its general character that of an extensive factory, workhouse, or barrack, of somewhat more ornate architecture indeed, and with better "belongings" within and without, where the patients live by day in long corridors, and sleep by night in boxes opening out of the same, and where perhaps they are mustered and marched in great force into a great hall to eat their meals? Certainly all this is not home-like, however excellent to the lovers of routine or the admirers of military discipline. But the separation into sections greatly lessens this objectionable state of things; the population becomes thereby divided, so to speak, into families, overlooked and controllable as such. The advantage of transferring an improving patient from one ward to another is considerable; but it would be much more so, if the transfer were from one section to another; for the construction of separate sections admits of the architectural arrangements, the fittings, &c., being varied to a much greater extent than they can be in the case of wards, forming mere apartments of one large building, constructed, as it must be, on a nearly uniform plan.

From the same grounds likewise follow the economical advantages of distinct sections; for the more expensive building arrangements required for acute cases need not be repeated in the section for quiet, orderly, chronic, or for convalescent patients, where accommodation may be beneficially made to accord as nearly as possible with that of their cottage homes. If detached sections were adopted, the elaborate, complicated and costly systems of warming and ventilation would not be needed; there would be less to cherish the feeling of imprisonment; and, lastly, to recal the valuable observation of the Commissioners before quoted (p. 142), this species of separate residence would be a means of treatment "of the utmost importance, constituting in fact a probationary system," and a most excellent addition to the means of 'moral treatment' now in operation. There is one subsidiary recommendation made by the Lunacy Commissioners, which we cannot so freely subscribe to, that, viz. of classifying the patients in sections according to their occupations. Those of the same trade or employment must, as a matter of course, be associated together, during the hours of labour; but at the expiration of those hours we would wish to see that association broken up. The congregation of the same mentally disordered persons always together is not desirable; the insane are selfish enough--absorbed in self, from the effects of their malady; and it should always be a point in treatment, to disturb this condition, to arouse the attention to others, and to other things; an effort which would be the more difficult in a small knot of people always accustomed to meet together, knowing each other's ways and whims, and each thinking the other mad, though not himself. Again, if the workers are entirely separated from the drones in the hive, the latter are likely to remain drones still: they lose the benefit of example, which operates, as among children, so strongly with the insane.

To apply these observations to one class of workers, for example, to the laundresses: it seems to us scarcely merciful to keep these poor patients to the wash-tub all day; at the close of their labour to turn them into an adjoining room, and at night consign them to sleep over it. Instead of being thus scarcely allowed to escape the sphere and atmosphere of their toil, they should have their condition varied as far as possible, be brought into new scenes, mixed with others who have been otherwise engaged, and made to feel themselves patients in an asylum, and not washer-women. Is it, in short, not a radical error in the direction of an asylum, to place the inmates in such a position and under such circumstances, as to make them feel themselves workmen under compulsion, regularly employed, dealt with only as labourers and artisans, by being kept all day in their workshops, and in the evening and night brought together, because they are workers, and unlike the other residents of the asylum, who will in their opinion come to be regarded, as unlike themselves,--as the fitting occupants, and the only patients? Treated apart in the manner under notice, there would be nothing in the position or circumstances around the industrious inmate to suggest to him that he was a patient, except in name, as called so by the officials. We are, therefore, opposed to this _industrial system_ of classification, and regard medical classification as the only proper one.

The division into quarters or sections is a plan more applicable to an asylum for chronic than to one for acute cases. In the latter, patients are to be treated specially and individually; and as sufferers from acute disease must be classified medically rather than with reference to any matters of management, occupation, and discipline, and are on the whole less conformable to general orders and plans: yet certain principal sections are wanted in them; as, for example, for the refractory and violent, for the quiet and orderly, and the convalescent. To some of the last named, a separate section, of a home-like character, regulated less as an asylum than as a family residence, and where the highest amount of liberty compatible with safety and order is the rule, would afford a most valuable means of treatment.

§ _Distribution of the Chronic Insane in Cottage Homes._

The subdivision of an asylum for chronic cases could be carried very far. Not only might sections be appropriated specially to idiots, to epileptics, to imbeciles, and to the very aged and infirm in an infirmary, but also to several classes of the chronic insane not falling under either of those categories, distinguishable by the greater or less amount of trust to be reposed in them, by their dispositions and tendencies, and by their industrious and moral habits. However, there must be at some point a limit to the utility of subdividing an establishment necessitated by the requirements of its administration and of an effective and easy supervision; and as yet, in this country, the system of aggregation prevails most largely over that of segregation. English asylums have, some of them, detached wards and a few farm-buildings, affording lodging to patients engaged in industrial pursuits; but the plan of segregating their residents has not been pushed farther, except to a small extent by Dr. Bucknill, who has placed some selected pauper lunatics in the homes of cottagers living in the vicinity of the county asylum; for we cannot call the boarding out of the imbecile poor--scattered, as it were, broad-cast over the country, disposed of in cottages, according to the notions of the inferior parochial officers, and watched over only nominally,--a system of providing for them. If system at all, it is merely one for putting them out of the way, of escaping responsibility, and of hiding them from observation.

The colony of insane at Gheel, in Belgium, is the only one where the segregation of the insane has been systematically carried out. It presents most of the elements of success in its constitution and government. It has an organized medical staff; it is a naturally secluded locality; its sane inhabitants have been for ages accustomed to act as the guardians and nurses of the insane, and to receive them as boarders into their families. Yet, notwithstanding the eulogiums of many visitors to this village, others who have more minutely examined into it have detected many irregularities, and pointed out weighty objections against its management.

The questions may be fairly put,--Are the irregularities inevitable? Are the objections inseparable from the system? To discuss these points in detail would carry us far beyond the limits we must observe; but we may express our belief in the value of the system, considered as such, although we do not see how or where it can be applied to a similar extent as found at Gheel. The irregularities which have been remarked are remediable, and the objections generally removeable. It is a defect at Gheel, that there is no central establishment of the character of an asylum and infirmary, and it is a mistake to undertake the charge of recent and violent cases, and of epileptics for the most part, and likewise of paralytics, in cottages under cottagers' supervision only. Other classes of patients might be pointed out as unfit residents in peasants' families. The system, in short, is pushed to an extreme in this place; but this error does not invalidate it as a system. Objectionable cases for the cottage home could be collected in a central establishment, and there would be plenty left to partake of the "air libre et la vie de famille," which a recent physician of the colony of Gheel, M. Parigot, commended in his _brochure_ addressed to the consideration of the friends of the insane.

Many who have become acquainted with the system pursued at Gheel have been enraptured by its many apparent advantages, the liberty it affords, and the great cheapness of its management, and have wished to import it as a whole into this country. Such a scheme we regard as both impracticable and undesirable; yet we at the same time believe something may be attempted in the same direction most beneficially (see p. 89). The attempt should first be made in connexion with some of our county asylums of a moderate size. A similar secluded district as that of the commune of Gheel is, thanks to Providence, not to be found perhaps in England; but this is of no such primary importance: a moderate distance from considerable towns, or from large villages, is all that is strictly requisite, and several asylums are so situated. The difficulty of place being encountered, a more serious one appears, viz. that of finding suitable cottagers to undertake the charge of patients. At first, a suitable class could not be reckoned on; but, according to the laws of supply and demand, it would only require time to form such a class. Sufficient inducements only are wanting, and probably those supplied would be found so. It is an advantage to a cottager to have a constant lodger, to receive a certain weekly payment; and it would constitute a greater one to have as an inmate one who could assist in certain labours of the house and garden. We might hope to see old attendants of the asylum settled around, after retirement from their employment, with a pension; and to the care of such two or three, or even more, selected patients might be entrusted. If the land belonging to the asylum were of sufficient extent, the patients boarding around might still be employed upon it; or, if they were artisans, they might daily resort to its workshops, its bakehouse or brewhouse, just as the ordinary peasant labourer goes to and fro to his place of employment. The asylum would thus still reap the benefit of the patients' labour, and this arrangement, we believe, would work better than one providing for their employment with strangers at a distance from the institution.

By limiting the area inhabited by patients in lodgings to that immediately surrounding the asylum, a satisfactory supervision could be exercised by the authorities; and on the occurrence of illness, or a change in the mental condition, a transfer to the asylum could be speedily accomplished. Again, by keeping the insane within a moderate range of the asylum, and by retaining them as labourers on its grounds, the advantages of a central general administration would be found in the provision and distribution of food and clothing.

In previous pages we have advocated, under certain conditions, the erection of distinct asylums for chronic cases of insanity; to this plan the system just developed, of boarding out a certain number in cottages, must be held as supplementary. A chronic, or a moderate, manageable-sized, mixed asylum must form the nucleus of the 'cottage system' of providing for the insane. The cases must be selected from the asylum-residents, and the selection be left with the medical superintendent. The persons receiving patients must be held responsible to the superintendent, and to the members of the Lunacy Board, for their proper care and management, and they must enter into some sort of covenant with the Visitors of the asylum. To carry out the scheme under notice, many matters of detail are required, but these it would be out of place here to enter upon.