In the preliminary chapters on the number and increase of the insane in
this country, we limited ourselves to determine what that number and that
increase were, and entered into no disquisition respecting the causes
which have operated in filling our asylums with so many thousands of
chronic and almost necessarily incurable patients. Nor shall we now
attempt an investigation of them generally, for this has been well done by
others, and particularly by the Lunacy Commissioners in their Ninth
Report, 1855; but shall restrict ourselves to intimate that the increase
of our lunatic population, mainly by accumulation, is due to neglect in
past years; to the alteration of the laws requiring the erection of County
Asylums for pauper lunatics generally; to the collection and discovery of
cases aforetime unthought of and unknown; to the extension of the
knowledge of the characters and requirements of the insane both among
professional men and the public; and, lastly, to the advantages themselves
of asylum accommodation which tend to prolong the lives of the inmates.
Such are among the principal causes of the astounding increase in the
number of the insane of late years, relatively to the population of the
country, some of which fortunately will in course of time be less
productive. Those, however, which we now desire to investigate, are such
as directly affect the curability of insanity, either by depriving its
victims of early and efficient treatment, or by lessening the efficiency
and usefulness of the public asylums.
The history of an insane patient is clearly divisible into three portions:
1st, that before admission into an asylum; 2nd, that of his residence in
an asylum; and 3rd, of that after his discharge from it. The last division
we have at present nothing to do with; and with reference to the causes
influencing his curability, these group themselves under two heads
parallel to the first two divisions of the patient’s history; viz. 1,
those in operation external to, and 2, those prevailing in, asylums.
A. Causes external to Asylums.
The chief cause belonging to this first class is that of delay in
submitting recent cases to asylum care and treatment. This delay, as we
have sufficiently proved, operates most seriously by diminishing the
curability of insanity, and thereby favours the accumulation of chronic
lunatics. It takes place in consequence either of the desire of friends to
keep their invalid relatives at their homes; or of the economical notions
of Poor-Law Officers, who, to avoid the greater cost of asylums, detain
pauper lunatics in workhouses. Other causes of incurability and of the
accumulation of incurables are found in injudicious management and
treatment before admission, and in the transmission of unfit cases to
asylums. To discuss the several points suggested in these considerations
will require this chapter to be subdivided; and first we may treat of the
Detention of Patients in their own homes.
§ Detention of Patients in their own homes.
Although the immense importance of early treatment to recent cases of
insanity is a truth so well established and so often advocated, yet the
public generally fail to appreciate it, and from unfortunate notions of
family discredit, from false pride and wounded vanity, delay submitting
their afflicted relatives to efficient treatment. Unless the disorder
manifest itself by such maniacal symptoms that no one can be blind to its
real character, the wealthier classes especially will shut their eyes to
the fact they are so unwilling to recognize, and call the mental
aberration nervousness or eccentricity; and as they are unwilling to
acknowledge the disorder, so are they equally indisposed to subject it to
the most effectual treatment, by removing the patient from home, and the
exciting influence of friends and surrounding circumstances in general, to
a properly organized and managed asylum. Usually a patient with sufficient
resources at command, is kept at home as long as possible, at great cost
and trouble; and if he be too much for the control of his relatives and
servants, attendants are hired from some Licensed House to manage him; the
only notion prevailing in the minds of his friends being that means are
needed to subdue his excitement and to overcome his violence. There are,
in fact, no curative agencies at work around him, but on the contrary,
more or fewer conditions calculated to exalt his furor, to agitate and
disquiet his mind, and to aggravate his malady. The master of the house
finds himself checked in his will; disobeyed by his servants; an object of
curiosity, it may be, of wonder and alarm; and sadly curtailed in his
liberty of action. The strange attendants forced upon him are to be
yielded to only under passionate protests, and probably after a struggle.
In all ways the mental disorder is kept up if not aggravated, and every
day the chances of recovery are diminished. Perhaps matters may grow too
bad for continued residence at home, or the malady have lasted so long,
that the broken-up state of family and household can no longer be
tolerated, and a transfer from home is necessitated. Yet even then removal
to an asylum,—the only step which can hold out a fair prospect of
recovery, is either rejected as quite out of the question, or submitted to
usually after still longer delay,—a “trial” being made of a lodging with
a medical man or other person, probably with an asylum attendant. By this
plan certainly the patient is saved from the presence and excitement of
his family, and placed under altered conditions, calculated to exercise in
some respects a salutary influence on his mind; still many others are
wanting, and no guarantee is attainable of the manner in which he is
treated; for as a single patient, and as is usually the case, restrained
without certificates, he is almost invariably unknown to the
Commissioners, and virtually unprotected, even though a medical man be
paid to attend him occasionally. At last, however, except for a few, the
transfer to the asylum generally becomes inevitable, and too often too
late to restore the disordered reason; and years of unavailing regret fail
to atone for time and opportunity lost.
The same unwillingness to subject their insane friends to asylum care and
treatment pervades, moreover, the less wealthy classes, and even the
poorer grades of the middle class of society. Madness, to their
conceptions likewise, brings with it a stigma on the family, and its
occurrence must, it is felt, be kept a secret. Hence an asylum is viewed
as an evil to be staved off as long as possible, and only resorted to when
all other plans, or else the pecuniary means, are exhausted. If it be the
father of the family who is attacked, the hope is, that in a few days or
weeks he may resume his business or return to his office, as he might
after ordinary bodily illness, without such loss of time as shall endanger
his situation and prospects, and without the blemish of a report that he
has been the inmate of a madhouse. If it be the wife, the hope is similar,
that she will shortly be restored to her place and duties in her family.
Should progress be less evident than desired, a change away from home will
probably be suggested by the medical attendant, and at much expense and
trouble carried out. But too frequently, alas! the hopes are blighted and
the poor sufferer is at length removed with diminished chance of cure to
an asylum.
For the poorer members of the middle class, and for many moving in a
somewhat higher circle of society, whom the accession of mental disorder
impoverishes and cuts off from independence, there are, it is most deeply
to be regretted, few opportunities of obtaining proper asylum care and
treatment. In very many instances, the charges of even the cheapest
private asylum can be borne for only a limited period, and thus far, at
the cost of great personal sacrifices and self-denial. Sooner or later no
refuge remains except the County Asylum, where, it may be, from the
duration of his disorder, the patient may linger out the remainder of his
days. How happy for such a one is it—a person unacquainted with the
system of English County Asylums, might remark—that such an excellent
retreat is afforded! To this it may be replied, that the public asylum
ought not to be the dernier ressort of those too poor to secure the best
treatment and care in a well-found private establishment, and yet too
respectable to be classed and dealt with as paupers entirely and
necessarily dependent on the poor’s rate. Yet so it is under the operation
of the existing law and parochial usages, there is no intermediate
position, and to reap the benefits of the public asylum, the patient must
be classed with paupers and treated as one. His admission into it is
rendered as difficult, annoying, and degrading as it can be. His friends,
worn out and impoverished in their charitable endeavours to sustain him in
his independent position as a private patient, are obliged to plead their
poverty, and to sue as paupers the parish officials for the requisite
order to admit their afflicted relative to the benefits of the public
asylum as a Pauper Lunatic. In short, they have to pauperize him; to
announce to the world their own poverty, and to succumb to a proceeding
which robs them of their feelings of self-respect and independence, and by
which they lose caste in the eyes of their neighbours. As for the patient
himself, unless the nature and duration of his malady have sufficiently
dulled his perception and sensibilities, the consciousness of his position
as a registered pauper cannot fail to be prejudicial to his recovery;
opposed to the beneficial influences a well-regulated asylum is calculated
to exert, and to that mental calm and repose which the physician is
anxious to procure.
In the class of cases just sketched, we have presumed on the ability of
the friends to incur the cost of private treatment for a longer or shorter
period; but many are the persons among the middle classes, who if
overtaken by such a dire malady as insanity, are almost at once reduced to
the condition of paupers and compelled to be placed in the same category
with them. As with the class last spoken of, so with this one, the law
inflicts a like injury and social degradation, and at the same time
operates in impeding their access to proper treatment.
No one surely, who considers the question, and reflects on the necessary
consequences of the present legal requirement that, for a lunatic to enjoy
the advantages of a public asylum, towards which he may have for years
contributed, he must be formally declared chargeable to the rates as a
pauper,—can deny the conclusion that it is a provision which must entail
a social degradation upon the lunatic and his family, and act as a great
impediment to the transmission of numerous recent cases to the County
Asylum for early treatment.
It will be urged as an apology for it, that the test of pauperism rests on
a right basis; that it is contrived to save the rate-payer from the charge
of those occupying a sphere above the labouring classes, who fall, as a
matter of course, upon the parochial funds whenever work fails or illness
overtakes them. It is, in two words, a presumed economical scheme.
However, like many other such, it is productive of extravagance and loss,
and is practically inoperative as a barrier to the practice of imposition.
If it contributes to check the admission of cases at their outbreak into
asylums, as no one will doubt it does, it is productive of chronic
insanity and of permanent pauperism; and, therefore, besides the
individual injury inflicted, entails a charge upon the rates for the
remaining term of life of so many incurable lunatics.
If, on the contrary, our public asylums were not branded by the
appellation “Pauper;” if access to them were facilitated and the
pauperizing clause repealed, many unfortunate insane of the middle class
in question, would be transmitted to them for treatment; the public asylum
would not be regarded with the same misgivings and as an evil to be
avoided, but it would progressively acquire the character of an hospital,
and ought ultimately to be regarded as a place of cure, equivalent in
character to a general hospital, and as entailing no disgrace or discredit
on its occupant.
The Commissioners in Lunacy, in their Ninth Report (1855, p. 35), refer to
the admissions into County Asylums, of patients from the less rich classes
of society reduced to poverty by the occurrence of the mental malady, and
hint at their influence in swelling the number of the chronic insane,
owing to their transfer not taking place until after the failure of their
means and the persistence of their disorder for a more or less
considerable period. This very statement is an illustration in point; for
the circumstance deplored is the result of the indisposition on the part
of individuals to reduce their afflicted relatives to the level of paupers
by the preliminaries to, and by the act of, placing them in an asylum
blazoned to the world as the receptacle for paupers only; an act, whereby,
moreover, they advertise to all their own poverty, and their need to ask
parish aid for the support of their poor lunatic kindred.
On the continent of Europe and in the United States of America we obtain
ample evidence that the plan of pauperizing patients in order to render
them admissible to public asylums, is by no means necessary. Most
continental asylums are of a mixed character, receiving both paying and
non-paying inmates, and care is taken to investigate the means of every
applicant for admission, and those of his friends chargeable by law with
his maintenance. Those who are paid for are called “pensioners” or
boarders, and are divided into classes according to the sum paid, a
particular section of the asylum being assigned to each class. Besides
those pensioners who pay for their entire maintenance, there are others
whose means are inadequate to meet the entire cost, and who are assessed
to pay a larger or smaller share of it. Lowest in the scale of inmates are
those who are entirely chargeable to the departmental or provincial
revenue, being devoid of any direct or indirect means of support. Probably
the machinery of assessment in the continental states might not accord
with English notions and be too inquisitorial for adoption in toto; but
at all events, on throwing open public asylums for the reception of all
lunatics who may apply for it, without the brand of pauperism being
inflicted upon them, some scheme of fairly estimating the amount they
ought to contribute to their maintenance should be devised. For the richer
classes a plan of inquisition into their resources is provided, and there
seems no insuperable difficulty in contriving some machinery whereby those
less endowed with worldly goods might, at an almost nominal expense, have
their means duly examined and apportioned to their own support and that of
their families. Overseers and relieving officers are certainly not the
persons to be entrusted with any such scheme, nor would we advocate a
jury, for in such inquiries few should share; but would suggest it as
probably practicable that the amount of payment might be adjudged by two
or three of the Committee of Visitors of the Asylum with the Clerk of the
Guardians of the Union or Parish to which the lunatic belonged.
In the United States of America, every tax-payer and holder of property is
entitled as a tax-payer, when insane, to admission into the Asylum of the
State of which he is a citizen. He is considered as a contributor to the
erection and support of the institution, and as having therefore a claim
upon its aid if disease overtake him. The cost of his maintenance is borne
by the township or county to which he belongs, and the question of his
means to contribute towards it is determined by the county judge and a
jury. Most of the asylums of the Republic also receive boarders at fixed
terms, varying according to the accommodation desired; hence there are
very few private asylums in the States. In the State of New York there is
a special legal provision intended to encourage the early removal of
recent cases to the asylum; whereby persons not paupers, whose malady is
of less than one year’s duration, are admitted without payment, upon the
order of a county judge, granted to an application made to him, setting
forth the recent origin of the attack and the limited resources of the
patient. Such patients are retained two years, at the end of which time
they are discharged, their friends being held responsible for the
removal. Their cost in the asylum is defrayed by the county or parish to
which they belong.
We have said above, that the requirement of the declaration of pauperism
is ineffectual in guarding the interests of the rate-payer against the
cost of improper applicants. Indeed, the proceeding adopted to carry it
out is both absurd and useless, besides being, as just pointed out,
mischievous in its effects.
In the interpretation clause of “the Lunatic Asylums’ Act, 1853,” it is
ordered that a “Pauper shall mean every person maintained wholly or in
part by, or chargeable to, any Parish, Union, or County.” Hence when
insanity overtakes an unfortunate person who is not maintained by a parish
or union, it is required that he be made chargeable to one, or, as we have
briefly expressed the fact, that he be pauperized. To effect this object,
the rule is, that the patient shall reside at least a day and a night in a
workhouse. This proceeding, we repeat, carries absurdity on the face of
it. Either it may be a mere farce privately enacted between the parish
officers and the friends of the patient, to the complete frustration of
the law so far as the protection of the rate-payers is contemplated; or,
it may be made to inflict much pain and annoyance on the applicants by the
official obstructiveness, impertinent curiosity, obtuseness, and possible
ill-feeling of the parish functionaries in whose hands the law has
practically entrusted the principal administration of the details
regulating the access to our public asylums.
It is no secret among the superintendents of County Asylums, that by
private arrangements with the overseers or guardians of parishes, cases
gain admission contrary to the letter and spirit of the law, and to the
exclusion of those who have legally a prior and superior claim. We have,
indeed, the evidence of the Lunacy Commissioners, to substantiate this
assertion. In their Ninth Report (1855, p. 34) they observe,—“In some
districts a practice has sprung up, by which persons, who have never been
themselves in receipt of parochial relief, and who are not unfrequently
tradesmen, or thriving artisans, have been permitted to place lunatic
relations in the County Asylums, as pauper patients, under an arrangement
with the guardians for afterwards reimbursing to the parish the whole, or
part, of the charge for their maintenance. This course of proceeding is
stated to prevail to a considerable extent in the asylums of the
metropolitan counties, and its effect in occupying with patients, not
strictly or originally of the pauper class, the space and accommodations
which were designed for others who more properly belong to it, has more
than once been made the subject of complaint.”
Desiring, as we do, to see our County Asylums thrown open to the insane
generally, by the abolition of the pauper qualification, it is rather a
subject of congratulation that cases of the class referred to do obtain
admission into them, even when contrary to the letter of the law. But we
advance the quotation and assertion above to show, that the pauperizing
provision of the Act is ineffective in the attainment of its object; and
to remark, that the opportunities at connivance it offers to parochial
officials, must exercise a demoralizing influence and be subversive of
good government. If private arrangements can be made between the
applicants for an assumed favour, and parish officers, who will undertake
to say that there shall not be bribery and corruption?
Sufficient, we trust, has been said to demonstrate the evils of the
present system of pauperizing patients to qualify them for admission into
County Asylums, and the desirability of opening those institutions to all
lunatics of the middle classes whose means are limited, and whose social
position as independent citizens is jeopardized by the existence of their
malady. This class of persons, as before said, calls especially for
commiseration and aid; being so placed, on the one hand, that their
limited means must soon fail to afford them the succour of a private
asylum; and on the other, with the door of the public institution closed
against them, except at the penalty of pauperism and social degradation.
What we would desire is, that every recent case of insanity should at once
obtain admission into the public asylum of the county or borough, if
furnished with the necessary medical certificates and with an order from a
justice who has either seen the patient or received satisfactory evidence
as to his condition (see remarks on duties of district medical officers),
and obtained from the relatives an undertaking to submit to the assessment
made by a commission as above proposed, or constituted in any other manner
thought better; or the speedy admission of recent cases might otherwise be
secured by prescribing their attendance and that of their friends before
the weekly Committee of the Visitors of the Asylum, by whom the order for
reception might be signed on the requisite medical certificates being
produced, and the examination for the assessment of the patient’s
resources formally made, with the assistance possibly of some
representative of the parish interests,—such for instance as the Clerk to
the Board of Guardians.
In the County Courts the judges are daily in the habit of ordering
periodical payments to be made in discharge of debts upon evidence offered
to them of the earnings or trade returns of the debtor; and there seems no
a priori reason against the investigation of the resources of a person
whose friends apply for his admission into a County Asylum. It is for
them to show cause why the parish or county should assume the whole or the
partial cost of the patient’s maintenance, and this can be done before the
Committee of the Asylum or any private board of inquiry with little
annoyance or publicity. Rather than raise an obstacle to the admission of
the unfortunate sufferer, it would be better to receive him at once and to
settle pecuniary matters afterwards.
We must here content ourselves with this general indication of the
machinery available for apportioning the amount of payment to be made on
account of their maintenance by persons not paupers, or for determining
their claim upon the Asylum funds. Yet we cannot omit the opportunity to
remark that the proceedings as ordered by the existing statute with a
similar object are incomplete and unsatisfactory. These proceedings are
set forth in sects. xciv. and civ. (16 & 17 Vict. cap. 97). The one
section of the Act is a twin brother to the other, and it might be
imagined by one not “learned in the law,” that one of the two sections
might with little alteration suffice. Be this as it may, it is enacted
that if it appear to two Justices (sect. xciv.) by whose order a patient
has been sent to an asylum, or (sect. civ.) “to any Justice or Justices
by this Act authorized to make any order for the payment of money for the
maintenance of any Lunatic, that such Lunatic” has property or income
available to reimburse the cost of his maintenance in the asylum, such
Justices (sect. xciv.) shall apply to the nearest known relative or
friend for payment, and if their notice be unattended to for one month,
they may authorize a relieving officer or overseer to seize the goods, &c.
of the patient, whether in the hands of a trustee or not, to the amount
set forth in their order. Sect. civ. makes no provision for applying to
relatives or friends in the first instance, but empowers the justice or
justices to proceed in a similar way to that prescribed by sect. xciv.,
to repay the patient’s cost; with the additional proviso that, besides the
relieving officer or overseer, “the Treasurer or some other officer of the
County to which such Lunatic is chargeable, or in which any property of
the Lunatic may be, or an officer of the Asylum in which such Lunatic may
be,” may proceed to recover the amount charged against him.
Concerning these legal provisions, we may observe, that the state of the
lunatic’s pecuniary condition is left to accidental discovery. The
justices signing the order of admission (sect. xciv.) have no authority
given them to institute inquiries, although they may learn by report that
the patient for whom admission is solicited is not destitute of the means
of maintenance. Nor are the justices who make the order for payment
(sect. civ.) in any better position for ascertaining facts. There is,
in short, no authorized and regular process for investigating the
chargeability of those who are not actually in the receipt of parochial
relief on or before application for their admission into the County
Asylum, or who must necessarily be chargeable by their social position
when illness befalls them. Again, according to the literal reading of the
sections in question, no partial charge for maintenance can be proposed;
no proportion of the cost can be assessed, where the patient’s resources
are unequal to meet the whole. Lastly, the summary process of seizing the
goods or property of any sort, entrusted to those who are most probably
the informers of the justices, namely overseers and relieving officers;
and, by sect. civ., carried out without any preliminary notice or
application, and without any investigation of the truth of the reports
which may reach the justices, is certainly a proceeding contrary to the
ordinary notions of equity and justice.
§ Detention of Patients in Workhouses.
In the case of the insane poor, whose condition, circumstances, and social
position have been such that whenever any misfortune, want of work, or
sickness has overtaken them, the workhouse affords a ready refuge, the
requirement of pauperization to qualify for admission to the County Asylum
is in itself no hardship and no obstacle to their transmission to it.
Probably the prevailing tactics of parish officers may at times contribute
to delay the application for relief, but the great obstacle to bringing
insane paupers under early and satisfactory treatment in the authorized
receptacle for them—the County Asylum, is the prevalence of an economical
theory respecting the much greater cheapness of workhouse compared with
asylum detention. The practical result of this theory is, that generally
where a pauper lunatic can by any means be managed in a workhouse, he is
detained there. If troublesome, annoying, and expensive, he is referred to
the County Asylum; this is the leading test for the removal; the
consideration of the recent or chronic character of his malady is taken
little or no account of.
In fresh cases the flattering hope is that the patients will soon recover,
and that the presumed greater cost of asylum care can be saved; in old
ones the feeling is that they are sufficiently cared for, if treated like
the other pauper inmates, just that amount of precaution being attempted
which may probably save a public scandal or calamity.
To the prevalence of these economical notions and practice may be
attributed the large number of lunatics detained in workhouses (nearly
8000), and the equally large one living with their friends or others. Now
it is very desirable to inquire whether these theories of the superior
economy of workhouses compared with asylums as receptacles for the insane,
are true and founded on facts. This question is in itself twofold, and
leaves for investigation, first, that of the mere saving in money on
account of maintenance and curative appliances; and secondly, that of the
comparative fitness or unfitness, the advantages or disadvantages, the
profit or loss, of the two kinds of institutions in relation to the
welfare, the cure, and the relief of the poor patients placed in them.
These questions press for solution in connexion with the subject of the
accumulation of lunatics and the means to be adopted for its arrest, or,
what is equivalent to this, for promoting the curability of the insane.
On making a comparative estimate of charges, it is essential to know
whether the same elements of expenditure are included in the two cases; if
the calculated cost per head for maintenance in workhouses and asylums
respectively comprises the same items, and generally, if the conditions
and circumstances so far as they affect their charges are rightly
comparable. An examination we are confident, will prove that in no one of
these respects are they so.
In the first place, the rate of maintenance in an asylum is calculated on
the whole cost of board, clothing, bedding, linen, furniture, salaries,
and incidental expenditure; that is, on the total disbursements of the
establishment, exclusive only of the expenditure for building and repairs,
which is charged to the county. On the contrary, the “in-maintenance” in
workhouses comprises only the cost of food, clothing, and necessaries
supplied to the inmates (see Poor-Law Board Tenth Report, p. 144). The
other important items reckoned on in fixing the rate of cost per head in
asylums are charged to the “establishment” account of the workhouse, and
are omitted in the calculation of the rate of maintenance. Reference to
the Tables given in the Poor-Law Board Returns (Tenth Report, p. 61,
sub-column e and a portion of f) will prove that the expenditure on
account of those other items must be nearly or quite equal to that
comprehended under the head of “in-maintenance” cost.
We have no means at hand to calculate with sufficient precision what sum
should be added to the “in-maintenance” cost of paupers per head in
workhouses, but it is quite clear that the figures usually employed to
represent it, cannot be rightly compared with those exhibiting the weekly
charge of lunatics in asylums. At the very least half as much again must
be added to a workhouse estimate before placing it in contrast with asylum
cost.
Since the preceding remarks were written, Dr. Bucknill has favoured us
with the Thirteenth Report of the Devon Asylum, in which he has discussed
this same question and illustrated it by a special instance. To arrive at
the actual cost of an adult sane pauper in a union-house, he gathered “the
following particulars relative to the house of the St. Thomas Union in
which this asylum is placed; a union, the population of which is 49,000,
and which has the reputation of being one of the best managed in the
kingdom. The cost of the maintenance of paupers in this union-house is
2s. 6d. per head, per week, namely, 2s. 2d. for food and 4d. for
clothing. The establishment charges are 1s. 0½d. per head, per
week, making a total of 3s. 6½d. for each inmate. The total number
of pauper inmates during the twelfth week of the present quarter was 246;
and of these 116 were infants and children, and 130 youths above sixteen
and adults. A gentleman intimately acquainted with these accounts, some
time since calculated for me that each adult pauper in the St. Thomas’s
Union-house cost 5s. a week. Now the average cost of all patients in the
Devon Asylum at the present time is 7s. 7d., but of this at least
2s. must be set down to the extra wages, diet, and other expenses
needful in the treatment of the sick, and of violent and acute cases,
leaving the cost of the great body of chronic patients at not more than
5s. 7d. a week. Now if a sane adult pauper in a union-house costs even
4s. 6d. a week, is it probable that an insane one would cost less than
5s. 7d.? For either extra cost must be incurred in his care, or he
must disturb the discipline of the establishment, and every such
disturbance is a source of expense.”
This quotation is really a reiteration of Dr. Bucknill’s conclusions as
advanced in 1857, in an excellent paper in the ‘Asylum Journal’ (vol. iv.
p. 460), and as a pendent to it the following extract from this paper is
appropriate; viz. “that the cost of a chronic lunatic properly cared for,
and supplied with a good dietary, in a County Asylum, is not greater than
that of a chronic lunatic supplied with a coarse and scanty dietary, and
detained in neglect and wretchedness as the inmate of a union workhouse.”
Another most important circumstance to be borne in mind when the cost of
workhouses and asylums is contrasted, is that in the former establishments
more than two-thirds of the inmates are children. Thus the recipients of
in-door relief on the 1st of January, 1858, consisted, according to the
Poor-Law Returns, of 74,141 adults, and 50,836 children under sixteen
years of age. Now as the rate of maintenance is calculated on the whole
population of a workhouse, adults and children together, it necessarily
follows that it falls much within that of asylums, in which almost the
whole population is adult. This very material difference in the character
of the inmates of the two institutions may fairly be valued as equivalent
to a diminution of one-fourth of the expense of maintenance in favour of
workhouses; and without some such allowance, the comparison of the cost
per head in asylums and union-houses respectively is neither fair nor
correct.
Again, there is another difference between asylums and workhouses, which
tells in favour of the latter in an economical point of view, whilst it
proves that the expenditure of the two is not rightly comparable without
making due allowance for it along with the foregoing considerations. This
difference subsists in the character of the two institutions respectively;
namely, that in the asylum the movements of the population are slight,
whereas in the workhouse they are very considerable by the constant
ingress and egress of paupers; driven to it by some passing misfortune or
sickness, it may be for a week or two only or even less, and discharging
themselves so soon as the temporary evil ceases to operate or the disorder
is overcome: for the poor generally, except the old and decrepit who
cannot help themselves, both dread a lodging in the workhouse, and escape
from it as soon as possible; in fact, even when they have no roof of their
own to shelter them, they will often use the union accommodation only
partially, leaving it often by day and returning to it by night. All this
implies a large fluctuation of inmates frequently only partially relieved,
whether in the way of board or clothing; and consequently when the average
cost per head of in-door paupers is struck, it appears in a greater or
less degree lower than it would have done had the same constancy in
numbers and in the duration and extent of the relief afforded prevailed as
it does in asylums.
The effect of the fluctuations in population in union-houses ought, we
understand, to be slight, if the “Orders in Council” laid down to guide
parochial authorities in the calculation of the cost of their paupers,
were adhered to; viz. that for all those belonging to any one parish in
union, who may have received in-door relief during the year or for any
less period of time, an equivalent should be found representing the number
who have been inmates throughout the year; or the total extent of relief
be expressed by estimating it to be equal to the support of one
hypothetical individual for any number of years equivalent to the sum of
the portions of time the entire number of the paupers of the particular
parish received the benefits of the establishment. We do not feel sure
that these plans of calculating the cost per head are faithfully and fully
executed; the rough method of doing so, viz. by taking the whole cost of
“in-maintenance” at the end of the year and dividing it by the number of
its recipients, and assuming the quotient to represent the expenditure
for each. Whether this be the case or not, these daily changes among its
inmates, the frequent absence of many for a great part of the day and the
like, are to be enumerated among the circumstances which tend to keep down
expenditure of workhouses; and which are not found in asylums.
There is yet another feature about workhouses which distinguishes them
from asylums, and is of considerable moment in the question of the
comparative cost of maintenance in the two: this is, the circumstance of
the population of workhouses being of a mixed character, of which the
insane constitute merely a small section; while, on the contrary, that of
asylums is entirely special, and each of its members to be considered a
patient or invalid demanding particular care and special appliances.
Therefore, a priori, no comparison as to their expenditure can justly be
drawn between two institutions so dissimilar. Yet even this extent of
dissimilarity between them is not all that exists; for the union-house is
so constituted by law as to serve as a test of poverty; to offer no
inducements to pauperism, and to curtail the cost of maintenance as far as
possible. It has properly no organization for the detention, supervision,
moral treatment and control, nor for the nursing or medical care of the
insane; and when its establishment is attempted it is a step at variance
with its primary intention, and involves an extra expenditure.
Consequently, before overseers or guardians can with any propriety
contrast the workhouse charges of maintenance with those of asylums, it is
their business to estimate what an adult pauper lunatic costs them per
week, instead of, as usual, quoting the cost per head calculated on the
whole of the inmates, old and young, sane and insane.
Once more, even after a fair estimate of the cost of an adult insane
inmate of a workhouse is obtained, there is still another differential
circumstance favourable to a less rate than can be anticipated in asylums;
for this reason:—that in the former institutions the practice is to
reject all violent cases, the major portion of recent ones, and,
generally, all those who give particular annoyance and trouble; whilst the
latter is, as it rightly should be, regarded as the fitting receptacle for
all such patients;—that is, in other words, those classes of patients
which entail the greatest expense are got rid of by the workhouses and
undertaken by the asylums.
Dr. Bucknill has well expressed the same circumstances we have reviewed,
in the following paragraph (Report, Devon Asylum, 1858, p. 13):—“In
estimating the cost of lunatic paupers in asylums, the important
consideration must not be omitted, that the charge made for the care and
maintenance of lunatics in County Asylums is averaged upon those whose
actual cost is much greater, and those whose actual cost is less than the
mean; so that it would be unfair for the overseers of a parish to say of
any single patient that he could be maintained for a smaller sum than that
charged, when the probability is that there are or have been patients in
the asylum from the same parish, whose actual cost to the asylum has been
much greater than that charged to the parish. I have shown, that the
actual cost of chronic patients in an asylum exceeds that of adult paupers
in union-houses to a much smaller extent than has been stated: but if all
patients of this description were removed from the asylum, the inevitable
result must be that the average cost of those who remained would be
augmented, so that the pecuniary result to the parishes in the county
would be much the same. The actual cost of an individual patient, if all
things are taken into calculation, is often three or four times greater
than the average. Leaving out of consideration the welfare of the
patients, it would be obviously unfair to the community, that a parish
having four patients in the asylum, the actual cost of two of whom was
12s. a week, and of the other two only 4s. a week, should be allowed
to remove the two who cost the smaller sum, and be still permitted to
leave the other two at the average charge of 8s.”
The conclusion of the whole matter is, that cæteris paribus, i. e.
supposing workhouses to be equally fitting receptacles for the insane as
asylums, the differential cost of the two can only be estimated when it is
ascertained that the items of maintenance are alike in the two, and after
that an allowance is made for the different characters of their population
and of their original purpose; that is, in the instance of workhouses, for
the very large number of juvenile paupers; for the great fluctuations in
the residents; for the mixed character of their inmates, of sane and
insane together, and the small proportion of insane, and for the exclusion
of the most expensive classes of such patients. Let these matters be
fairly estimated, and we doubt much if, even primâ facie, it can be
shown that the workhouse detention of pauper lunatics is more economical
than that of properly constructed and organized asylums.
Should we even be so far successful as to make Poor-Law Guardians and
Overseers perceive that the common rough-and-ready mode of settling the
question of relative cost in asylums and workhouses, by contrasting the
calculated rate per head for in-door relief with that for asylum care, is
not satisfactory; we cannot cherish the flattering hope that they will be
brought to perceive that, simply in an economical point of view, no saving
at all is gained by the detention of the insane in workhouses. Those
Poor-Law officials generally are so accustomed to haggle about fractional
parts of a penny in voting relief, to look at an outlay of money only
with reference to the moment, forgetful of future retribution for false
economy, and to handle the figures representing in their estimate the
economical superiority of the workhouse for the insane, when they desire
to silence an opponent;—that the task of proving to them that their
theory and practice are wrong, is equivalent to the infelicitous endeavour
to convince men against their will.
Still, however unpromising our attempt may appear, it is not right to
yield whilst any legitimate arguments are at hand; and our repertory of
them, even of those suited to a contest concerning the pounds, shillings,
and pence of the matter, is not quite exhausted; for we are prepared to
prove, that asylum accommodation can be furnished to the lunatic poor at
an outlay little or not at all exceeding that for workhouses.
Now this point to be argued, the cost of asylum construction, is not, like
the foregoing considerations, chiefly the affair of Poor-Law Guardians and
Overseers, but concerns more particularly the County Magistrates, inasmuch
as it is defrayed out of the County instead of the Poor Rate. But although
this is the case, there is no doubt that the very great expense of
existing asylums has acted as an impediment to the construction of others,
and has seemed to justify, to a certain extent, the improper detention of
many insane persons in workhouses: for, on one side, asylums are found to
have cost for their construction and fittings, £150, £200, and upwards per
head, whilst on the other, workhouses are built at the small outlay, on an
average, of eighty-six such establishments, of £22 per head. The “Return”
made to the House of Commons, June 15, 1857, “of the cost of building
Workhouses in England and Wales, erected since 1840,” shows indeed a very
wide variation of cost in different places, from £13 per head for the
Congleton Union House; £14 for the Erpingham; £16 for the Stockton and
Tenterden, to £47 for the Kensington; £50 for the Dulverton; £59 for the
City of London; £60 for St. Margaret Westminster; and £113 for the
Paddington. This enormous difference of expenditure on workhouse
lodging,—for, unlike asylum costs, it does not include fittings,
extending from £13 to £113 per inmate,—is really inexplicable, after
allowing for the varying ideas of parish authorities as to what a
workhouse should be, and for the slight differences in the cost of
building materials and labour in some parts of the country than in others.
Either some workhouses must be most miserable and defective habitations
even for paupers, or others must be very extravagant and needlessly
expensive in their structure.
There is this much to be said in explanation of the contrast of cost in
different workhouses, that in those belonging to large town populations,
infirmary accommodation becomes an item of importance and involves
increased expenditure, whilst in those situated in agricultural districts,
this element of expense is almost wanting. Moreover it is in town
workhouses generally that lunatic inmates are found, who, if not in the
infirmary, are lodged in special wards, often so constructed as to meet
their peculiar wants, and therefore more costly than the rest of the
institution occupied by the ordinary pauper inmates. This is the same with
saying that where workhouses are used as receptacles for the insane, it
greatly enhances the cost of their construction.
It will be evident to every thinking person that the costs of asylum and
of workhouse construction are not fairly comparable. The asylum is a
special building; an instrument of treatment; peculiarly arranged for an
invalid population, affording facilities for classification, recreation,
and amusements; and fitted with costly expedients for warming and
ventilation; whereas the workhouse is essentially a refuge for the
destitute, necessarily made not too inviting in its accommodation and
internal arrangements; suited to preserve the life of sound inmates who
need little more than the shelter of a roof and the rude conveniences the
majority of them have been accustomed to. Now these very characteristics
of workhouses are among the best arguments against the detention of
lunatics within these buildings; but of these hereafter.
There is doubtless a permissible pride in the ability to point to a
well-built asylum, commanding attention by its dimensions and
architectural merits, and we would be the last to decry the beauties and
benefits of architecture, and know too, that an ugly exterior may cost as
much or more than a meritorious one; yet we must confess to misgivings
that there has been an unnecessary and wasteful expenditure in this
direction. Nevertheless it is with asylums as with railways, the present
race of directors are reaping instruction from the extravagances and
errors its predecessors fell into.
The change of opinion among all classes respecting the character and wants
of the insane and their mode of treatment, is of itself so great, that
many of the structural adaptations and general dispositions formerly made
at great cost, are felt to be no longer necessary, and the very correct
and happy persuasion daily gains ground, that the less the insane are
dealt with as prisoners, and treated with apprehension and mistrust, the
more may their accommodation be assimilated to that of people in general,
and secured at a diminished outlay.
All this suggests the possibility of constructing asylums at a much less
cost than formerly, and of thereby lessening the force of one of the best
pleas for using workhouses as receptacles for the insane. The possibility
of so doing has been proved both theoretically and practically. In an
essay ‘On the Construction of Public Asylums,’ published in the “Asylum
Journal” for January 1858 (vol. iv. p. 188), we advocated the separation
of the day- from the night-accommodation of patients, and the abolition of
the system of corridors with day- and sleeping-rooms, or, as we briefly
termed it, “the ward-system,” and showed that by so doing a third of the
cost of construction might be saved, whilst the management of the
institution would be facilitated, and the position of the patients
improved. By a careful estimate, made by a professional architect, with
the aid of the necessary drawings, for a building of considerable
architectural pretension, it was calculated that most satisfactory,
cheerful, and eligible accommodation could be secured, including
farm-buildings, and fittings for warming, ventilation, drainage, gas, &c.,
at the rate of £90 per head for patients of all classes, or at one-half of
the ordinary cost.
Experience has shown that chronic lunatics, at least, can be accommodated
in an asylum at a lower rate, in fact, at little more than half the
expense that we calculated upon.
Like other County Asylums, the Devon became filled with patients; still
they came, and after attempts to cram more into the original edifice, by
slight alterations, and by adding rooms here and there, it was at length
found necessary to make a considerable enlargement. Instead of adding
floors or wings to the old building, which would have called for a
repetition of the same original expensive construction of walls, and of
rooms and corridors, the Committee, with the advice of their excellent
physician, wisely determined to construct a detached building on a new
plan, which promised every necessary convenience and security with
wonderful cheapness; and, for once in a way, an architect’s cheap estimate
was not exceeded. Instead of £200 or £250 per head, as of old,
accommodation was supplied at the rate of £38: 10s. per patient,
including fittings for all the rooms and a kitchen:—a marvel, certainly,
in asylum construction, and one which should have the effect of reviving
the hopes and wishes of justices, once at least so laudably entertained,
to provide in County Asylums for all pauper lunatics of the county.
It is only fair to remark, that, as Dr. Bucknill informs us (Asylum
Journal, 1858, p. 323), this new section of the Devon Asylum is dependent
on the old institution for the residences of officers, for chapel,
dispensary, store-rooms, &c. “It is difficult,” writes Dr. Bucknill, “to
estimate the proportion which these needful adjuncts to the wards of a
complete asylum bear to the expense of the old building; they can
scarcely, however, be estimated at so high a figure as one-eighth of the
whole.” But, as a set-off against the increased cost per patient involved
in supplying the necessary offices described by Dr. Bucknill, we may
mention that there are twenty single sleeping-rooms provided in the
building, and that a greater cost was thereby entailed, than many would
think called for, where only chronic, and generally calm patients, were to
be lodged.
These illustrations of what may be done in the way of obtaining good
asylum accommodation for pauper lunatics at no greater rate, we are
persuaded, than that incurred in attempting to provide properly for them
in workhouses, furnish a most valid reason for discontinuing their
detention in the latter, and the more so, if, as can be demonstrated, they
are unfit receptacles for them.
The possibility of constructing cheap asylums being thus far proved, the
question might be put, whether the internal cost of such institutions
could not be lessened? We fear that there is not much room for reform in
this matter, if the patients in asylums are rightly and justly treated,
and the officers and attendants fairly remunerated. In producing power, an
asylum exceeds a workhouse, and therein derives an advantage in
diminishing expenditure and the cost of maintenance. On the other hand,
the expenditure of a workhouse is much less in salaries, particularly in
those given to its medical officer and servants, a form of economy which
will never repay, and, we trust, will never be tried in asylums. Warming,
ventilation, and lighting are less thought of, little attempted, and
therefore less expensive items in workhouse than in asylum accounts. With
respect to diet and clothing, workhouses ought to exhibit a considerable
saving; but this saving is rather apparent than real, and certainly in the
wrong direction; for lunatics of all sorts require a liberal dietary, warm
clothing, and, from their habits frequently, more changes than the
ordinary pauper inmates; yet these are provisions, which, except there is
actual sickness or marked infirmity, the insane living in a workhouse do
not enjoy; for they fare like the other inmates, are clothed the same, and
are tended or watched over by other paupers; the saving, therefore, is at
the cost of their material comfort and well-being. Excepting, therefore,
the gain to be got by the labours of the patients, there is no set-off in
favour of asylum charges; in short, in other respects none can be obtained
without inflicting injury and injustice. On the other hand, workhouse
expenditure need be raised if the requisite medical and general treatment,
nursing, dietary, employment, and recreation are to be afforded; which is
the same as saying, that workhouses, if receptacles for the insane at all,
should be assimilated to asylums,—a principle, which, if admitted and
acted upon, overturns at once the only argument for their use as such,
viz. its economy.
The perception on the part of parochial authorities, that something more
than the common lodging and attendance of the workhouse is called for by
the insane inmates, has led to the construction of “Lunatic Wards” for
their special accommodation, a scheme which may be characterized as an
extravagant mistake, whether viewed in reference to economical principles
or the welfare of the patients. If structurally adapted to their object,
they must cost as much as a suitable asylum need; and if properly
supervised and managed, if a sufficient dietary be allowed, and a proper
staff of attendants hired, no conceivable economical advantage over an
asylum can accrue. On the contrary, as Dr. Bucknill has remarked (Asylum
Journal, vol. iv. p. 460), any such attempts at an efficient management of
the insane in small and scattered asylums attached to Union Workhouses,
will necessarily increase their rate of maintenance above that charged in
a large central establishment, endowed with a more complete organization
and with peculiar resources for their management.
Dr. Bucknill returns to the discussion of this point in his just published
report (Rep. Devon Asylum, 1858, p. 11). He puts the question, “Would a
number of small asylums, under the denomination of lunatic wards, be more
economical than one central asylum?” and, thus proceeds to reply to
it:—“The great probability is that they would not be; 1st, on account of
the larger proportion of officials they would require; 2nd, on account of
the derangement they would occasion to the severe economy which is
required by the aim and purpose of union-houses as tests of destitution.
Where lunatics do exist in union-houses in consequence of the want of
accommodation in the County Asylum, the Commissioners in Lunacy insist
upon the provision of what they consider things essential to the proper
care of insane persons wherever they be placed. The following are the
requirements which they insisted upon as essential in the Liverpool
Workhouse:—a sufficient staff of responsible paid nurses and attendants;
a fixed liberal dietary sanctioned by the Medical Superintendent of the
asylum; good and warm clothing and bedding; the rooms rendered much more
cheerful and better furnished; the flagged court-yards enlarged and
planted as gardens; the patients frequently sent to walk in the country
under proper care; regular daily medical visitation; and the use of the
official books kept according to law in asylums. If the direct cost of
such essentials be computed with the indirect cost of their influence upon
the proper union-house arrangements, it will require no argument to prove
that workhouse lunatic wards so conducted would effect no saving to the
ratepayers. The measures needed to provide in the union-house kitchen a
liberal dietary for the lunatic wards and a restricted one for the sane
remainder, to control the staff of paid attendants, to arrange frequent
walks into the country for part of the community, while the other part was
kept strictly within the walls;—these would be inevitable sources of
disturbance to the proper union-house discipline, which would entail an
amount of eventual expenditure not easily calculated.”
If, on economical grounds, the system of Lunatic Wards has no evident
merit, none certainly can be claimed for it on the score of its adaptation
to their wants and welfare.
Indeed, the argument for workhouse accommodation, on the plea of economy,
loses all its weight when the well-being of the insane is balanced against
it. For, if there be any value in the universally accepted opinions of
enlightened men, of all countries in Europe, of the requirements of the
insane, of the desirability for them of a cheerful site, of ample space
for out-door exercise, occupation and amusement, of in-door arrangements
to while away the monotony of their confinement and cheer the mind, of
good air, food and regimen, of careful watching and kind nursing, of
active and constant medical supervision and control, or to sum up all in
two words, of efficient medical and moral treatment,—then assuredly the
wards of a workhouse do not furnish a fitting abode for them.
The unfitness of workhouses for the detention of the insane, and the evils
attendant upon it, have been repeatedly pointed out by the Commissioners
in Lunacy in their annual reports, and by several able writers. We were
also glad to see from the report of his speech, on introducing the Lunatic
Poor (Ireland) Bill into the House of Commons, that Lord Naas is strongly
opposed to the detention of the insane in workhouses, and therein agrees
with the Irish Special Lunacy Commissioners (1858, p. 18), who have placed
their opinion on record in these words:—“It appears to us that there can
be no more unsuitable place for the detention of insane persons than the
ordinary lunatic wards of the Union Workhouses.” This is pretty nearly the
same language as that used by the English Commissioners in 1844, viz. “We
think that the detention in workhouses of not only dangerous lunatics, but
of all lunatics and idiots whatever, is highly objectionable.”
To make good these general statements, we will, at the risk of some
repetition, enter into a few particulars. On the one hand, the presence of
lunatics in a workhouse is a source of annoyance, difficulty, and anxiety
to the official staff and to the inmates, and withal of increased expense
to the establishment. If some of them may be allowed to mix with the
ordinary inmates, there are others who cannot, and whose individual
liberty and comfort must be curtailed for the sake of the general order
and management, and of the security and comfort of the rest.
Some very pertinent observations occur in the Report of the Massachusetts
Lunacy Commission (op. cit. p. 166), on the mixing of the sane and
insane together in the State Almshouses, which correspond to our Union
Workhouses. They report that the superintendents “were unanimous in their
convictions that the mingling of the insane with the sane in these houses
operated badly, not only for both parties, but for the administration of
the whole institution.” Further on, the Commissioners observe (p. 168),
“By this mingling the sane and insane together, both parties are more
disturbed and uncontrollable, and need more watchfulness and interference
on the part of the superintendent and other officers.... It has a
reciprocal evil effect in the management of both classes of inmates. The
evil is not limited to breaches of order; for there is no security against
violence from the attrition of the indiscreet and uneasy paupers with the
excitable and irresponsible lunatics and idiots. Most of the demented
insane, and many idiots, have eccentricities; they are easily excited and
disturbed; and nothing is more common than for inmates to tease, provoke,
and annoy them, in view of gratifying their sportive feelings and
propensities, by which they often become excited and enraged to a degree
to require confinement to ensure the safety of life.... The mingling of
the state paupers, sane and insane, makes the whole more difficult and
expensive to manage. It costs more labour, watchfulness, and anxiety to
take care of them together than it would to take care of them separately.”
These sketches from America may be matched in our own country; and they
truthfully represent the reciprocal disadvantages of mixing the sane and
insane together in the same establishment.
Even supposing the presence of insane in workhouses involved, on the one
hand, no disadvantages to the institutions, or to the sane inmates; yet on
the other, the evils to the lunatic inhabitants would be condemnatory of
it; for the insane necessarily suffer in proportion as the workhouse
accommodation differs from that of asylums; or, inversely, as the
economical arrangements and management of a workhouse approach those of an
asylum. They suffer from many deficiencies and defects in locality and
organization, in medical supervision and proper nursing and watching, in
moral discipline, and in the means of classification, recreation, and
employment.
Workhouses are commonly town institutions; their locality often
objectionable; their structure indifferent and dull; their site and their
courts for exercise confined and small, and their means of recreation and
of occupation, especially out of doors, very limited. Petty officers of
Unions so often figure before the world, and have been so admirably
portrayed by Dickens and other delineators of character, on account of
their peculiarities of manner and practice, that no sketch from us is
needed to exhibit their unfitness as guardians and attendants upon the
insane. As to workhouse nurses, little certainly can be expected from
them, seeing that they are only pauper inmates pressed into the service;
if aged, feeble and inefficient; if young, not unlikely depraved or
weak-minded; always ignorant, and it may be often cruel; without
remuneration or training, and chosen with little or no regard to their
qualifications and fitness.
However satisfactory the structure of the ward and its supervision might
be rendered, its connexion with a Union Workhouse will be disadvantageous
to the good government and order of the establishment, as above noticed,
and detrimental to the welfare of the insane confined in it. Thus it must
be remembered that very many of the lunatic inmates have been reduced to
seek parochial aid solely on account of the distressing affliction which
has overtaken them; before its occurrence, they may have occupied an
honourable and respectable position in society, and, consequently, where
consciousness is not too much blunted, their position among paupers—too
often the subjects of moral degradation—must chafe and pain the
disordered mind and frustrate more or less all attempts at its
restoration. To many patients, therefore, the detention in a workhouse is
a punishment superadded to the many miseries their mental disorder
inflicts upon them; and consequently, when viewed only in this light,
ought not to be tolerated.
Of all cases of lunacy, the wards of a workhouse are least adapted to
recent ones, for they are deficient of satisfactory means of treatment,
whether medical or moral, and the only result of detention in them to be
anticipated, must be to render the malady chronic and incurable. Yet
although every asylum superintendent has reported against the folly and
injury of the proceeding, and notwithstanding the distinct and strong
condemnation of it by the Commissioners in Lunacy, the latter, in their
Report for 1857, have to lament an increasing disposition, on the part of
Union officers, to receive and keep recent cases in workhouses. Moral
treatment we hold to be impossible in an establishment where there are no
opportunities of classification, no proper supervision and attendance, and
no means for the amusement and employment of the mind; but where, on the
contrary, the place and organization are directly opposed to it, and the
prospects of medical treatment are scarcely less unfavourable. An
underpaid and overworked medical officer, in his hasty visits through the
wards of the workhouse daily, or perhaps only three or four times a week,
very frequently without any actual experience among the insane, cannot be
expected to give any special attention to the Pauper Lunatics, who are
mostly regarded as a nuisance in the establishment, to be meddled with as
little as possible, and of whose condition only unskilled, possibly old
and unfeeling pauper nurses, can give any account. Indeed, unless reported
to be sick, it scarcely falls into the routine of the Union medical
officer regularly to examine into the state and condition of the pauper
lunatics. These remarks are confirmed by the statement of the Lunacy
Commissioners, in their ‘Further Report,’ 1847 (p. 276), that pauper
inmates, “in their character of lunatics merely, are rarely the objects of
any special medical attention and care,” and that it “was never found
(except perhaps in a few cases) that the medical officer had taken upon
himself to apply remedies specially directed to the alleviation or cure of
the mental disorder. Nor was this indeed to be expected, as the workhouse
never can be a proper place for the systematic treatment of insanity.”
It would unnecessarily extend the subject to examine each point of
management and organization affecting the well-being of the insane in
detail, in order to show how unsuitable in all respects a workhouse must
be for their detention; yet it may be worth while to direct attention to
one or two other matters.
Except when some bodily ailment is apparent, the lunatic fare like the
ordinary inmates; that is, they are as cheaply fed as possible, without
regard to their condition as sufferers from disease, which, because
mental, obtains no special consideration. It is in the power of the
medical officer, on his visits, to order extra diet if he observes any
reason in the general health to call for it; but the dependent position of
this gentleman upon the parish authorities, and his knowledge that extra
diet and its extra cost will bring down upon him the charge of
extravagance and render his tenure of office precarious, are conditions
antagonistic to his better sentiments concerning the advantages of
superior nutriment to his insane patients.
Moreover, the cost of food is a principal item in that of the general
maintenance of paupers, and one wherein the guardians of the poor believe
they reap so great an economical advantage over asylums. But this very
gain, so esteemed by poor-law guardians, is scouted as a mistake and
proved an extravagance, i. e. if the life and well-being of the poor
lunatics are considered, by the able superintendents of County Asylums.
Dr. Bucknill has well argued this matter in a paper “On the Custody of the
Insane Poor” (Asylum Journal, vol. iv. p. 460), and in the course of his
remarks says,—“The insane cannot live on a low diet; and while they
continue to exist, their lives are rendered wretched by it, owing to the
irritability which accompanies mental disease. The assimilating functions
in chronic insanity are sluggish and imperfect, and a dietary upon which
sane people would retain good health, becomes in them the fruitful source
of dysentery and other forms of fatal disease.”
In his just published Report, already quoted, the same excellent physician
remarks (p. 9),—“A good diet is essential to the tranquil condition of
many idiots and chronic lunatics, and is, without doubt, a principal
reason why idiots are easily manageable in this asylum, who have been
found to be unmanageable in union houses. The Royal Commission which has
recently reported on the Lunatic Asylums in Ireland states this fact
broadly, that ‘the ordinary workhouse dietary is unsuited and insufficient
for any class of the insane.’ It is therefore my opinion, founded upon the
above considerations, that neither the lunatics nor the idiots in the list
presented are likely to retain their present state of tranquillity, and to
be harmless to themselves and others, if they are placed in union houses,
unless they are provided with those means which are found by experience to
ensure the tranquillity of the chronic insane, and especially with a
sufficient number of trustworthy attendants, and with a dietary adapted to
their state of health. I have thought it desirable to ascertain the
practice of charitable institutions especially devoted to the training of
idiots, and I find that a fuller dietary is used in them than in this
asylum.”
Until a recent date, it was the custom in workhouses, with few exceptions,
to allow most of their insane inmates to mingle with the ordinary pauper
inmates of the same age and sex, and in general to be very much on the
same footing with them “in everything that regards diet, occupation,
clothing, bedding, and other personal accommodation” (Report, 1847, p.
276).
This mingling of the sane and insane, having been found subversive of good
order and management, gave rise first to the plan of placing most of the
latter class in particular wards, many of them in the infirmary, and,
subsequently, owing to the advance of public opinion respecting the wants
of the insane, to the construction, in many unions, of special lunatic
wards, emulating more or less the character and purposes of asylums. The
false economy of this plan has been already exposed; and although the
Lunacy Commissioners have always set their faces against lunatic wards,
yet their construction has of late been so rapid as to call forth a more
energetic denunciation of it:—“Impressed strongly (the Commissioners
write, Report, 1857, p. 17) with a sense of their many evils, it became
our duty, during the past year, to address the Poor-Law Board against the
expediency of affording any encouragement or sanction to the further
construction, in connexion with Union Workhouses, of lunatic wards.”
The evils of lunatic wards, alluded to in the last-quoted paragraph, are
thus enlarged upon in another page of the same Report (p. 15):—“It is
obvious that the state of the workhouses, as receptacles for the insane,
is becoming daily a subject of greater importance. They are no longer
restricted to such pauper lunatics as,—requiring little more than the
ordinary accommodation, and being capable of associating with the other
inmates,—no very grave objection rests against their receiving. Indeed it
will often happen that residence in a workhouse, under such conditions, is
beneficial to patients of this last-mentioned class; by the inducements
offered, from the example of those around them, to engage in ordinary
domestic duties and occupations, and so to acquire gradually the habit of
restraining and correcting themselves. But these are now unhappily the
exceptional cases. Many of the larger workhouses, having lunatic wards
containing from 40 to 120 inmates, are becoming practically lunatic
asylums in everything but the attendance and appliances which ensure the
proper treatment, and above all, in the supervision which forms the
principal safeguard of patients detained in asylums regularly constituted.
“The result is, that detention in workhouses not only deteriorates the
more harmless and imbecile cases to which originally they are not
unsuited, but has the tendency to render chronic and permanent such as
might have yielded to early care. The one class, no longer associating
with the other inmates, but congregated in separate wards, rapidly
degenerate into a condition requiring all the attendance and treatment to
be obtained only in a well-regulated asylum; and the others, presenting
originally every chance of recovery, but finding none of its appliances or
means, rapidly sink into that almost hopeless state which leaves them
generally for life a burthen on their parishes. Nor can a remedy be
suggested so long as this workhouse system continues. The attendants for
the most part are pauper inmates, totally unfitted for the charge imposed
upon them. The wards are gloomy, and unprovided with any means for
occupation, exercise, or amusement; and the diet, essential above all else
to the unhappy objects of mental disease, rarely in any cases exceeds that
allowed for the healthy and able-bodied inmates.”
The subject had previously received their attention, and is thus referred
to in their Ninth Report (p. 38):—“They are very rarely provided with any
suitable occupation or amusement for the inmates. The means of healthful
exercise and labour out of doors are generally entirely wanting, and the
attendants (who are commonly themselves paupers) are either gratuitous, or
so badly organized and so poorly requited, that no reliance can be placed
on the efficiency of their services. In short, the wards become in fact
places for the reception and detention of lunatics, without possessing any
of the safeguards and appliances which a well-constructed and well-managed
lunatic asylum affords. Your Lordship, therefore, will not be surprised to
learn that while we have used our best endeavours to remedy their obvious
defects and to ameliorate as far as possible the condition of their
inmates, we have from the first uniformly abstained from giving any
official sanction or encouragement to their construction.”
They further make this general observation:—“So far as the lunatic and
idiotic inmates are concerned, the condition of the workhouses which have
separate wards expressly appropriated to the use of that class, is
generally inferior to that of the smaller workhouses, and in some
instances extremely unsatisfactory.”
Dr. Bucknill, whose excellent remarks on lunatic wards in their economical
aspect we have already quoted, has very ably canvassed the question of
their fitness as receptacles for the insane, and, in a paper in the
‘Asylum Journal’ (vol. iii. p. 497), thus treats on it:—“It is deserving
of consideration, whether the introduction of liberally-conducted lunatic
wards into a Union Workhouse would not interfere with the working of the
latter in its legitimate scope and object. A workhouse is the test of
destitution. To preserve its social utility, its economy must always be
conducted on a parsimonious scale. No luxuries must be permitted within
its sombre walls; even the comforts and conveniences of life must be
maintained in it below the average of those attainable by the industry of
the labouring poor. How can a liberally-conducted lunatic ward be
engrafted upon such a system? It would leaven the whole lump with the
taint of liberality, and the so-called pauper bastile would, in the eyes
of the unthrifty and indolent poor, be deprived of the reputation which
drives them from its portals.”
There is a general concurrence among all persons competent to form any
opinion on the matter, that workhouses are most unfit places for the
reception of recent cases of insanity. On the other hand, there is a
prevalent belief that there is a certain class of the insane, considered
“harmless,” for whom such abodes are not unsuitable. The Lunacy
Commissioners, in the extract from the Eleventh Report above quoted,
partake in this opinion: let us therefore endeavour to ascertain, as
precisely as we can, the class of patients intended, and the proportion
they bear to the usual lunatic inmates of Union Workhouses.
In their ‘Further Report’ for 1847, the Commissioners enter into a
particular examination of the characters of the lunatics found in
workhouses, and class them under three heads (p. 257):—1st, those who,
from birth, or from an early period of life, have exhibited a marked
deficiency of intellect as compared with the ordinary measure of
understanding among persons of the same age and station; 2ndly, those who
are demented or fatuous; that is to say, those whose faculties, not
originally defective, have been subsequently lost, or become greatly
impaired through the effects of age, accident, or disease; and 3rdly,
those who are deranged or disordered in mind, in other words, labouring
under positive mental derangement, or, as it is popularly termed,
“insanity.” Those in whom epilepsy or paralysis is complicated with
unsoundness of mind, although their case requires a separate
consideration, do not in strictness constitute a fourth class, but may
properly be referred, according to the character of their malady and its
effects upon their mental condition, to one or other of these three
classes.
Further on in the Report, after remarking on the difficulties besetting
their inquiry, they write (p. 274):—
“We believe, however, we are warranted in stating, as the result of our
experience thus far, that of the entire number of lunatics in workhouses,
whom we have computed at 6020 or thereabouts, two-thirds at the least, or
upwards of 4000, would be properly placed in the first of the three
classes in the foregoing arrangement; or, in other words, are persons in
whom, as the mental unsoundness or deficiency is a congenital defect, the
malady is not susceptible of cure, in the proper sense of the expression;
and whose removal to a curative lunatic asylum, except as a means of
relieving the workhouse from dangerous or offensive inmates, can be
attended with little or no benefit.
“A considerable portion of this numerous class, not less, perhaps, than a
fourth of the whole, are subject to gusts of passion and violence, or are
addicted to disgusting propensities, which render them unfit to remain in
the workhouse; and it is the common practice, when accommodation can be
procured, to effect the removal of such persons to a lunatic asylum, where
their vicious propensities are kept under control, and where, if they
cannot be corrected, they at least cease to be offensive or dangerous. But
although persons of this description are seldom fit objects for a curative
asylum, they are in general capable of being greatly improved, both
intellectually and morally, by a judicious system of training and
instruction; their dormant or imperfect faculties may be stimulated and
developed; they may be gradually weaned from their disgusting
propensities; habits of decency, subordination, and self-command may be
inculcated, and their whole character as social beings may be essentially
ameliorated.”
The conclusion to be deduced from these extracts is, that one-fourth or
two-thirds, that is, one-sixth of the whole number of occupants in
workhouses of unsound mind, found in 1846, were unfit for those
receptacles, and demanded the provision of institutions in which a moral
discipline could be carried out, and their whole condition, as social
beings, ameliorated and elevated. A further examination of the data
supplied in the same Report will establish the conviction that, besides
the proportion just arrived at, requiring removal to fitting asylums,
there is another one equally large demanding the same provision.
In this number are certainly to be placed all those of the third class
“labouring under positive mental derangement,” and who, although reported
as “comparatively few” in 1846, have subsequently been largely multiplied,
according to the evidence of the ‘Eleventh Report’ (ante, p. 56). Those,
again, “in whom epilepsy or paralysis is complicated with unsoundness of
mind,” are not suitable inmates for workhouse wards. No form of madness is
more terrible than the furor attendant on epileptic fits; none more
dangerous; and, even should the convulsive affection have so seriously
damaged the nervous centres that no violence need be dreaded, yet the
peril of the fits to the patient himself, and their painful features,
render him an unfit inmate of any other than an establishment provided
with proper appliances and proper attendants. As to the paralytic insane,
none call for more commiseration, or more careful tending and
nursing—conditions not commonly to be found in workhouses.
The Commissioners in Lunacy have not omitted the consideration of
workhouses as receptacles for epileptics and paralytics, and have arrived
at the following conclusions:—After treating, in the first place, of
epileptics whose fits are slight and infrequent, and the mental
disturbance mild and of short duration, they observe that, as such persons
“always require a certain amount of supervision, and as they are quite
incompetent, when the fits are upon them, to take care of themselves, and
generally become violent and dangerous, it would seem that the workhouse
can seldom be a suitable place for their reception, and that their
treatment and care would be more properly provided for in a chronic
hospital especially appropriated to the purpose.”
Concerning paralytics, they state that they are far less numerous than
epileptics, and being for the most part helpless and bedridden, are
treated as sick patients in the infirmary of the workhouse. Their opinion
is, however, that a chronic hospital would be a more appropriate
receptacle for them,—a conclusion in which all must coincide, who know
how much can be done to prolong and render more tolerable their frail and
painful existence, by good diet and by assiduous and gentle nursing,—by
such means, in short, as are not to be looked for in establishments where
rigid economy must be enforced, and pauper life weighed against its cost.
To turn now to the second class of workhouse Lunatic Inmates, the demented
from age, accident, or disease: these, we do not hesitate to say, are not
suitably accommodated in workhouses, for, like the paralytic, they require
careful supervision, good diet and kind nursing; they are full-grown
children, unable to help or protect themselves, to control their habits
and tendencies; often feeble and tottering, irritable and foolish, and,
without the protection and kindness of others, the helpless subjects of
many ills. For such, the whole organization of the workhouse is unsuited;
even the infirmary is not a fitting refuge; for, on the one hand, they are
an annoyance to the other inmates, and, on the other, pauper nurses—whose
office is often thrust upon them without regard to their fitness for
it,—are not fitting guardians for them. In fine, where age, accident or
disease has so deteriorated the mental faculties, we have a complication
of physical and mental injury to disqualify the patient from partaking
with his fellow-paupers in the common accommodation, diet, and nursing.
In the reverse order which we have pursued, the first class of congenital,
imbecile, and idiotic inmates comes to be considered last. This happens by
the method of exclusion adopted in the argument; for the second and third
classes have been set aside as proper inmates of some other institution
than a workhouse, and it now remains to inquire, who among the
representatives of the first class are not improperly detained in
workhouses. This class includes, as already seen, some two-thirds of the
whole number of inmates mentally disordered; and among whom, we presume,
are to be found those individuals who may, in the Commissioners’ opinion,
mix advantageously with the general residents of the establishment. The
number of the last cannot, we believe, be otherwise than very small; for
the very supposition that there is imbecility of mind, is a reason of
greater or less force, according to circumstances, for not exposing them
to the contact of an indiscriminate group of individuals, more especially
of that sort to be generally found in workhouses. The evils of mingling
the sane and insane in such establishments have already been insisted
upon; and besides these, such imbecile patients as are under review, lack
in workhouses those means of employment and diversion which modern
philanthropy has suggested to ameliorate and elevate their physical and
moral condition.
Lastly, if the remaining members of this class be considered, in whom the
imbecility amounts to idiocy, the propriety of removing them from the
workhouse will be questioned by few. Indeed, will any one now-a-days
advocate the “laissez faire” system in the case of idiots? Experience
has demonstrated that they are improveable, mentally, morally, and
physically; and if so, it is the duty of a christian community to provide
the means and opportunities for effecting such improvement. It cannot be
contended that the workhouse furnishes them; on the contrary, it is
thoroughly defective and objectionable by its character and arrangements,
and, as the Commissioners report, (op. cit. p. 259) a very unfit abode
for idiots.
On looking over the foregoing review of the several classes of lunatic
inmates of workhouses distinguished by the Commissioners in Lunacy, the
opinion to be collected clearly is, that only a very few partially
imbecile individuals among them are admissible into workhouses, if their
bodily health, their mental condition, their due supervision and their
needful comforts and conveniences are to be duly attended to and provided
for. In accordance with the views we entertain, as presently developed, of
the advantages of instituting asylums for confirmed chronic, quiet, and
imbecile patients, we should permit, if any at all, only such imbecile
individuals as residents in workhouses, who could pass muster among the
rest, without annoyance, prejudice or discomfort to themselves or others,
and be employed in the routine occupations of the establishment.
So much is heard among poor-law guardians and magistrates about a class of
“harmless patients” suitably disposed of in workhouses and rightly
removeable from asylums, that a few remarks are called for concerning
them. To the eye of a casual visitor of an asylum, there does certainly
appear a large number of patients, so quiet, so orderly, so useful and
industrious, that, although there is something evidently wrong about their
heads, yet the question crosses the mind, whether asylum detention is
called for in their case. The doubt is not entertained by the experienced
observer, for he knows well that the quiet, order, and industry observable
are the results of a well-organized system of management and control; and
that if this fails, the goodly results quickly vanish to be replaced by
the bitter fruits generated by disordered minds. The “harmless” patient of
the asylum ward becomes out of it a mischievous, disorderly, and probably
dangerous lunatic. In fact, the tranquillity of many asylum inmates is
subject to rude shocks and disturbances, even under the care and
discipline of the Institution; and the inoffensive-looking patient of
to-day may, by his changed condition, be a source of anxiety, and a
subject for all the special appliances it possesses, to-morrow.
Any Asylum Superintendent would be embarrassed to select a score of
patients from several hundred under his care whom he could deliberately
pronounce to be literally “harmless” if transferred to the workhouse. He
might be well able to certify that for months or years they have gone on
quietly and well under the surrounding influences and arrangements of the
asylum, but he could not guarantee that this tranquillity should be
undisturbed by the change to the wards of the workhouse; that untrained
attendants and undesirable associates should not rekindle the latent
tendency to injure and destroy; that defective organization and the
absence of regular and regulated means of employment and recreation should
not revive habits of idleness and disorder; or that a less ample dietary,
less watchfulness and less attention to the physical health, should not
aggravate the mental condition and engender those disgusting habits, which
a good diet and assiduous watching are known to be the best expedients to
remedy.
Dr. Bucknill has some very cogent remarks on this subject in his last
Report of the Devon Asylum (p. 6). “The term ‘harmless patients,’ or in
the words of the statute, those ‘not dangerous to themselves or others’
(he writes), I believe to be inapplicable to any insane person who is not
helpless from bodily infirmity or total loss of mind: it can only with
propriety be used as a relative term, meaning that the patient is not so
dangerous as others are, or that he is not known to be refractory or
suicidal. It should not be forgotten, that the great majority of homicides
and suicides, committed by insane persons, have been committed by those
who had previously been considered harmless; and this is readily explained
by the fact, that those known to be dangerous or suicidal are usually
guarded in such a manner as to prevent the indulgence of their
propensities; whilst the so-called harmless lunatic or idiot has often
been left without the care which all lunatics require, until some mental
change has taken place, or some unusual source of irritation has been
experienced, causing a sudden and lamentable event. In an asylum such
patients may truly be described as not dangerous to themselves or others,
because they are constantly seen by medical men experienced in observing
the first symptoms of mental change or excitement, and in allaying them by
appropriate remedies; they are also placed under the constant watchfulness
and care of skilful attendants, and they are removed from many causes of
irritation and annoyance to which they would be exposed if at large, in
villages or union houses.
“It not unfrequently happens that idiots who have lived for many years in
union houses, and have always been considered harmless and docile, under
the influence of some sudden excitement, commit a serious overt act, and
are then sent to an asylum. One of the most placid and harmless patients
in this asylum, who is habitually entrusted with working tools, is a
criminal lunatic, of weak intellect, who committed a homicide on a boy,
who teased him while he was breaking stones on the road. If this is the
case with those suffering only from mental deficiency, it is evidently
more likely to occur in those suffering from any form of mental disease,
which is often liable to change its character, and to pass from the form
of depression to one of excitement. For these reasons I am convinced that
all lunatics, and many strong idiots, can only be considered as ‘not
dangerous to themselves or others,’ when they are placed under that amount
of superintendence and care which it has been found most desirable and
economical to provide for them in centralized establishments for the
purpose.
“For the above reasons, I am unable to express the opinion that any insane
patients who are not helpless from bodily infirmity or total loss of mind
are unconditionally harmless to themselves and others. I have, however,
made out a list of sixty patients who are incurable, and who are likely,
under proper care, to be harmless to themselves and others.
“Of the patients in this list who are lunatic, only nine have sufficient
bodily strength to be engaged in industrial pursuits. The remaining
twenty-three are so far incapacitated by the infirmities of old age, or by
bodily disease, or by loss of mental power, that they are unable to be
employed, and require careful nursing and frequent medical attendance. The
patients who have sufficient bodily strength to be employed, are also with
the least degree of certainty to be pronounced harmless to themselves and
others. As the result of long training, they willingly and quietly
discharge certain routine employments under proper watch; but it is
probable, that if removed from their present position, any attempts made
to employ them by persons unaccustomed to the peculiarities of the insane,
will be the occasion of mental excitement and danger.
“The twenty-eight idiots have, with few exceptions, been sent to the
asylum from union houses, where it has been found undesirable to detain
them, on account either of their violent conduct, or of their dirty
habits, or some other peculiarity connected with their state of mental
deficiency; habits of noise or indecency for instance.”
Probably the following extract from the Report of the Committee of the
Surrey Asylum (1856) may have more weight with some minds than any of the
arguments and illustrations previously adduced, to prove that the
detention of presumed “harmless patients” in workhouses will not answer.
The declaration against the plan on the part of the Surrey magistrates is
the more important, because they put it into practice with the persuasion
that it would work well. But to let them speak for themselves, they
write,—“The committee adverted at considerable length in their last
Annual Report to the circumstance of the asylum being frequently unequal
to the requirements of the County, and of their intention to attempt to
remedy the defect by discharging all those patients, who, being harmless
and inoffensive, it was considered might be properly taken care of in
their respective union houses.
“The plan has been tried, and has not been successful. Patients who, under
the liberal and gentle treatment they experience in the asylum, are quiet
and tractable, are not necessarily so under the stricter regulations of a
workhouse; indeed, so far as the experiment has been tried, the reverse
has been found to be the case; most of the patients so discharged having
been shortly afterwards returned to the asylum, or placed in some other
institution for the insane, in consequence of their having become, with
the inmates of the workhouse, ‘a mutual annoyance to each other.’ Any
arrangement, short of an entire separation from the other inmates of the
workhouse, will be found to be inefficient.” This is the same as saying
that if lunatics are to reside in workhouses, a special asylum must be
instituted in the establishment for their care, and the comfort and safety
of the other inmates.
If the well-being of the insane were the only question to be settled, no
difficulty would attend the solution, for experience has most clearly
evidenced the vast advantages of asylums over workhouses as receptacles
for insane patients, whatever the form or degree of their malady. Dr.
Bucknill has some very forcible remarks in his paper on “The Custody of
the Insane Poor” (Asylum Journal, vol. iv. p. 460), with illustrative
cases; and in his Report last quoted, reverts to this subject of the
relative advantages of asylums and workhouses; but we forbear to quote, if
only from fear of being thought to enlarge unduly upon a question which
has been decided long ago by the observation and experience of all those
concerned in the management of the pauper insane; viz. that whatever the
type and degree of mental disorder and of fatuity, its sufferers become
improved in properly managed asylums, as intellectual, moral, and social
beings upon removal from workhouses; and by a reverse transfer, are
deteriorated in mind, and rendered more troublesome and more costly. To
the workhouse the lunatic ward is an excrescence, and its inmates an
annoyance: in its organization, there is an absence or deficiency of
almost all those means conducive to remedy or remove the mental infirmity,
and the very want of which contributes as much as positive neglect and
maltreatment to render the patient’s condition worse, by lowering his
mental and moral character. But such deterioration or degradation is not
an isolated evil, or the mere negation of a better state; for it acts as a
positive energy in developing moral evil, and brings in its train
perverseness, destructiveness, loss of natural decency in habits,
conversation and conduct, and many other ills which render their subjects
painfully humiliating as human beings, and a source of trouble, annoyance,
and expense to all those concerned with them.
In a previous page we have sought to determine what was the proportion of
lunatic inmates found by the Lunacy Commissioners in workhouses considered
to be not improperly detained in them, and have estimated it at one-half
of the whole number. The foregoing examination, however, of the adaptation
of workhouses for the several classes of lunatics distinguishable, leads
to the conviction that a very much less proportion than one-half ought to
be found in those establishments. For our own part, we would wish to see
the proportion reduced by the exclusion of most of its component members,
reckoned as “harmless” patients; a reduction which would well nigh make
the proportion vanish altogether. What is to be done with the lunatics
removed from workhouses, is a question to be presently investigated.
But before proceeding further, some consideration of the legal bearings of
workhouse detention of lunatics is wanting, for it has been advanced by
some writers that such detention is illegal.
Now, in the first place, it must be admitted that a workhouse is not by
law, nor in its intent and purpose, a place of imprisonment or detention.
Its inmates are free to discharge themselves, and to leave it at will when
they no longer stand in need of its shelter and maintenance. Whilst in it,
they are subject to the general rules of workhouse-government, and to a
superior authority, empowered, if not by statute, yet by orders of the
Poor-Law Board, or by Bye-Laws of the Guardians, to exercise discipline by
the enforcement of penalties involving a certain measure of punishment.
Temporary seclusion in a room may be countenanced, although not positively
permitted by law; but prolonged confinement, the deprivation of liberty,
and a persistent denial of free egress from the house, are proceedings
opposed to the true principles of English law.
Yet it may be that a plea for their detention might be sustained in the
case of sick or invalid patients (with whom the insane would be numbered)
under certificate of the parochial medical officer, provided no friend
came forward to guarantee their proper care, or that they could not show
satisfactorily the means of obtaining it; for, of such cases, the
workhouse authorities may be considered the rightful and responsible
guardians, required in the absence of friends to undertake their charge
and maintenance. Upon such grounds, probably, cause might be shown for the
detention of the greater part of workhouse lunatic inmates, although there
is no Act of Parliament explicitly to sanction it. Should such a plea be
admitted, the notion, entertained by Dr. Bucknill, that an action would
lie for false imprisonment against the Master and Guardians of the
workhouse, would be found erroneous.
The Lunacy Commissioners presented some remarks on this question,
indicating a similar view to that just advanced in their ‘Further Report,’
1847. For instance (p. 287, op. cit.), they observed:—
“How far a system of this kind, which virtually places in the hands of the
masters, many of whom are ignorant, and some of whom maybe capricious and
tyrannical, an almost absolute control over the personal liberty of so
many of their fellow men, is either warranted by law, or can be wholesome
in itself, are questions which seem open to considerable doubt. Probably
if the legality of the detention came to be contested before a judicial
tribunal in any individual case, the same considerations of necessity or
expediency which originally led to the practice, might be held to justify
the particular act, provided it were shown that the party complaining of
illegal detention could not be safely trusted at large, and that his
detention, therefore, though compulsory, instead of being a grievance, was
really for his benefit as well as that of the community.”
Again, in the second place, the law, without direct legislation to that
effect, yet admits,—by the provisions it makes for pauper lunatics not in
asylums or licensed houses, and by the distinction it establishes between
persons proper to be sent to an asylum, and lunatics generally
so-called,—that insane patients may be detained elsewhere than in
asylums. For instance, by sect. lxvi. 16 & 17 Vict. cap. 97, 1853,
provision is made for a quarterly visit by the Union or Parish Medical
Officer to any Pauper Lunatic not being in a Workhouse, Asylum,
Registered Hospital, or Licensed House, in order that he may ascertain how
the lunatic is treated, and whether he “may or may not properly remain out
of an asylum.” So likewise by sect. lxiv. of the same Act, the clerk or
overseers are required to “make out and sign a true and faithful list of
all lunatics chargeable to the Union or Parish in the form in schedule
(D).” This form is tabular, and presents five columns, under the heading
of “where maintained,” of which three are intended for the registry of the
numbers not confined in Asylums, Hospitals, and Licensed Houses, but who
are (1) in workhouses, (2) in lodgings, or boarding out, or (3) residing
with relatives.
Further, the law distinguishes, by implication, a class of lunatics as
specially standing in need of Asylum care, and as distinct from others. By
the Poor-Law Amendment Act (4 & 5 Will. IV. cap. 76. sect. 45), it is
ordered that nothing in that Act “shall authorize the detention in any
workhouse of any dangerous lunatic, insane person, or idiot for any longer
period than fourteen days; and every person wilfully detaining in any
workhouse any such lunatic, insane person, or idiot for more than fourteen
days, shall be deemed guilty of a misdemeanour.” This section is still in
force, is constantly acted upon by the Poor-Law Board, and is legally so
read as if the word ‘dangerous’ were repeated before the three divisions
of mentally-disordered persons referred to, viz. lunatics, insane persons,
and idiots. So, likewise, by sect. lxvii. (16 & 17 Vict. cap. 97)—the
“Lunatic Asylums’ Act, 1853,” now in operation,—the transmission of an
insane individual to an asylum is contingent on the declaration that he is
“a lunatic and a proper person to be sent to an asylum.”
Moreover, by sect. lxxix. of the same Act, it is competent to any three
Visitors of an asylum, or to any two in conjunction with the Medical
Officer of the asylum, to discharge on trial for a specified time “any
person detained in such asylum, whether such person be recovered or not;”
and by the following section (lxxx.) it is ordered, that, upon receipt of
the notice of such discharge, “the Overseers or Relieving Officers
respectively shall cause such lunatic to be forthwith removed to their
parish, or to the workhouse of the Union.” By the 79th section it is
further provided, that “in case any person so allowed to be absent on
trial for any period do not return at the expiration of such period, and a
medical certificate as to his state of mind, certifying that his detention
in an Asylum is no longer necessary, be not sent to the Visitors, he may,
at any time, within fourteen days after the expiration of such period, be
retaken, as herein provided in the case of an escape.”
On the other hand, simple removal from an asylum is by the 77th section,
curiously enough interdicted except to another asylum, a Registered
Hospital, or a Licensed House. This intent, too, of the section is not
changed by the amendment, sect. viii. 18 & 19 Vict. cap. 105. Lastly, no
other place than an Asylum, Registered Hospital, or Licensed House, is
constituted lawful by sect. lxxii. for the reception of any person found
lunatic and under “order by a Justice or Justices, or by a Clergyman and
Overseer or Relieving Officer, to be dealt with as such.” But this section
has to be read in connexion with preceding ones, for instance, with
sect. lvii., by which it is laid down that the Justices or other legal
authority must satisfy themselves not only that the individual is a
lunatic, but also that he is “a proper person to be sent to an asylum.”
These quotations indicate the state of the law respecting the detention of
lunatics elsewhere than in asylums. This state cannot be held to be
satisfactory: it evidently allows the detention of lunatics in workhouses,
while at the same time it affords them little protection against false
imprisonment, and makes no arrangement for their due supervision and care,
except by means of the visits of the Lunacy Commissioners, which are only
made from time to time, not oftener than once a year, and rarely so often.
The alleged lunatics are for the most part placed and kept in confinement
without any legal document to sanction the proceeding; without a
certificate of their mental alienation, and without an order from a
magistrate. Within the workhouse, they are, unless infirm or sick, treated
like ordinary paupers, save in the deprivation of their liberty of exit;
they may be mechanically restrained, or placed in close seclusion by the
order of the master, who is likely enough to appreciate the sterner means
of discipline and repression, but not the moral treatment as pursued in
asylums; and, lastly, they live deprived of all those medical and general
measures of amelioration and recovery as here before sketched.
An extract from the ‘Further Report’ of the Commissioners in Lunacy will
form a fitting appendix to the observations just made. It occurs at p. 287
(op. cit.), and stands thus:—
“It certainly appears to be a great anomaly, that while the law, in its
anxiety to guard the liberty of the subject, insists that no persons who
are insane—not even dangerous pauper lunatics—shall be placed or kept in
confinement in a lunatic asylum without orders and medical certificates in
a certain form, it should at the same time be permitted to the master of a
workhouse forcibly to detain in the house, and thus to deprive of personal
liberty, any inmate whom, upon his own sole judgment and responsibility,
he may pronounce to be a person of unsound mind, and therefore unfit to be
at large.”
It is unsatisfactory that the law recognizes the distinction between
dangerous and other lunatics, designated as “harmless;” for we have
pointed out that no such rigid separation can be made; that it is with
very few exceptions impracticable to say with certainty what patients are
harmless and what not, inasmuch as their state is chiefly determined by
surrounding conditions, by the presence or absence of moral control and
treatment. It is likewise to be regretted that so much is left to the
discretion of relieving officers and overseers, in the determination of
the lunatics “proper to be sent to an asylum;” for those parish
functionaries nearly always display a proclivity, where relief is to be
afforded, to any plan which at first sight promises to be the most cheap;
and hence it is, as remarked in previous pages, they think to serve the
rate-payers best by keeping, if practicable, the insane in workhouses. The
expediency of asylum treatment for those who claim it, is surely not a
question to be determined by such officers. Yet the wording of the Act
(sect. lxvii.), that, if they have notice from the parish medical
officer of any pauper who “is, or is deemed to be a lunatic, and a proper
person to be sent to an asylum,” or if they in any other manner gain
knowledge of a pauper “who is, or is deemed to be a lunatic, and a proper
person to be sent to an asylum, they shall within three days” give notice
thereof to a magistrate,—seems to put the solution of the question pretty
much in their hands. Although when they receive a notice of a pauper
lunatic from the union medical officer, they would appear by sect. lxx.
to be bound to apprise a Justice of the matter, yet, in the absence of
such a notice, an equal power in determining on the case is lodged in
their hands as in those of the medical officer, by the phrase “is, or is
deemed to be a lunatic, and a proper person to be sent to an asylum;” for
this clause respecting the fitness of the case, reads with the parts of
the sentence as though it stood thus in full—‘is a lunatic and a proper
person to be sent to an asylum, or is deemed a lunatic and a proper person
to be sent to an asylum;’ and there is nothing in sect. lxx. to enforce,
under these circumstances, a notice being sent to a Justice. It is,
indeed, evidently left to the discretion of the overseer or relieving
officer to report a case of lunacy falling within his own knowledge to a
Justice, for he is empowered to assume the function of deciding whether it
is or is not a proper one for an asylum. Moreover, we cannot refrain from
thinking that a parochial medical officer is not always sufficiently
independent, as a paid employé, to certify to the propriety of asylum
care so often as he might do, where the guardians or other directors of
parish affairs are imbued with rigid notions of economy, and hold the
asylum cost for paupers in righteous abhorrence. In fine, were this
enactment for reporting pauper lunatics to County and Borough Justices, in
order to obtain a legal sanction for their detention, sufficiently clear
and rigidly enforced, there would not be so many lunatics in workhouses,
and none of those very unfit ones animadverted upon by the Commissioners
in Lunacy (see p. 25, and 11th Rep. C. L. 1857).
The first clause of sect. lxvii. is ambiguous; for though it is
evidently intended primarily to make the Union medical officer the vehicle
of communicating the knowledge of the existence of pauper lunatics in his
parish, yet it is neither made his business to inquire after such
persons, nor when he knows of their existence, to visit and ascertain
their condition. It is left open for him to act upon a report that such a
pauper “is deemed to be a lunatic, and a proper person to be sent to an
asylum,” without seeing the individual; but generally he will officially
hear first of such patients through the channel of the relieving officer,
by receiving an order to visit them. Indeed, the relieving officer is
legally the first person to be informed of a pauper requiring medical or
other relief; and, as we have seen, it is competent for him to decide on
the question of asylum transmission or not for any case coming directly to
his knowledge. Hence, in the exercise of his wisdom, he may order the
lunatic forthwith into the Union-house, and call upon the medical officer
there to visit him. The consignment of the lunatic to the workhouse being
now an accomplished fact, it becomes a hazardous enterprise, and a
gratuitous task on the part of the medical officer (for no remuneration is
offered for his report), to give the relieving officer or overseer a
written notice that the poor patient should rightly be sent to the asylum,
when he knows that those parish authorities have made up their minds that
it is not a proper case to be sent there. In fact, the law makes no demand
of a notice from the medical officer of the Union necessary where the
knowledge of a lunatic pauper first reaches the relieving officer or
overseer, or where the patient is already in the workhouse; and no report
will be sought from him under such circumstances, unless the parochial
authorities decide that they will not take charge of the case in the
workhouse.
The object of the 67th and five following sections is evidently to promote
the discovery of pauper lunatics, and to ensure the early transmission of
all those amenable to treatment to County Asylums; but these advantages
are not attained, the legal machinery being defective. To fulfil the
intention, it should be made imperative on the part of the relatives or
friends to make known the occurrence of a case of lunacy at its first
appearance to a duly-appointed medical man, who should visit and register
it, and, with the concurrence of a magistrate, order detention in a
properly-constituted asylum. Such a medical officer would have a district
assigned to him; of his duties at large we shall have occasion hereafter
to speak; to allude further to them in this place will cause us to diverge
too widely from the subject under consideration.
The 67th section of the “Lunatic Asylums’ Act,” which has above been
submitted to criticism, we find referred to in the Lunacy Commissioners’
Eleventh Report, wherein it is spoken of as disregarded by parochial
authorities; its ambiguity and the loophole to a contravention of its
meaning being, however, unnoticed. The reference occurs in the following
passage (op. cit. p. 16), which censures a practice we have already
animadverted upon:—
“And here we take occasion to remark, that if the law were more strictly
carried out in one particular, the same temptation to a mistaken and
ill-judged economy would not so frequently present itself to Boards of
Guardians; nor could it so often occur to them as an advantage, that they
should themselves manage their insane poor by the resources at their own
disposal. A custom prevails, very generally, of sending all pauper
lunatics to the workhouses in the first instance, instead of at once
procuring an order for their transmission to an asylum; and nothing has
more contributed to the many recent and acute cases improperly so
detained. The practice, it is hardly necessary to say, is in direct
contravention of the law applicable to insane paupers. Assuming that they
come ordinarily at first under the care of the District Parish Surgeon, he
is bound to give notice (under the 67th section of the Lunatic Asylums’
Act) to the Relieving Officer, by whom communication is to be made to the
Magistrate, upon whose order they are to be conveyed to an Asylum; but in
effect these provisions are disregarded altogether. And thus it follows,
that the patient, if found to be manageable in the workhouse, is
permanently detained there; or even should he ultimately find his way to
an asylum, it is not until so much valuable time has been lost that his
chances of cure are infinitely lessened. For, although it is our
invariable habit, on the occasion of visiting workhouses, to recommend the
removal to asylums of all whom we consider as curable, or exposed to
treatment unsuited to their state, we find nothing so difficult as the
enforcement of such recommendations; and for the most part the Report of
the Medical Officer of the Union, to the effect that the patient is
‘harmless,’ is suffered to outweigh any opinion we can offer.”
In this quotation, therefore, we have an official proof that the defective
and ambiguous legislation above commented upon is practically not without
its mischievous fruits to the well-being of the insane poor. To amend it,
some such scheme as we have sketched is called for to secure the reporting
of lunatics, their examination and registration, and the legal sanction to
their detention for the purposes of their own safety and that of others,
and of their treatment; and were it not that at the present moment asylum
accommodation cannot be afforded to all the pauper lunatics of the
kingdom, their confinement in workhouses ought to be at once rendered
illegal. Convinced as we are, that asylums for the insane could be
erected, fitted, organized, and maintained at a cost which would leave no
pecuniary advantage economically on the side of workhouses; and that, even
were the primary expenditure of the latter considerably less, they would
in the long run be more expensive on account of their unfitness for
lunatic patients, whatever the type of their malady, the injuries they
entail on the well-being of all, and the chronic insanity they produce and
foster,—it is with much reluctance we are forced to endorse the statement
made by the Commissioners in Lunacy, in their 11th Report (p. 17), that
workhouse “Lunatic Wards will have to be continued for some time longer,”
until, we may add, a more comprehensive, and withal a modified scheme be
brought into operation, to cherish, to succour, and to cure those
suffering under the double evil of poverty and insanity. Though a remedy
to meet the whole case must unfortunately be delayed, yet the Lunacy
Commissioners nevertheless need continue energetically to discourage the
plan of building special lunatic wards to workhouses, as one, according to
their own showing, indeed, fraught with very many evils to their inmates.
Such erections ought, in fact, to be rendered illegal; the money spent on
them would secure proper accommodation in connexion with a duly organized
and managed asylum, as demonstrated in previous pages (p. 48), for all
those classes of pauper lunatics, which, under any sort of plea or
pretence, can be detained in workhouses. Lastly, we must look to the
Commissioners to maintain an active supervision over workhouse
inmates,—to hold, at least, an annual “jail delivery” of every
union-house, to order the immediate transfer of evidently improper
inmates, and to remove others, so to speak, for trial.
The “leading principles,” as laid down by the Commissioners in 1847
(Report, p. 269), and to which, in subsequent Reports, they state their
continued adhesion, are as good as the present state of lunacy and lunatic
asylums permit to be enforced; but they can be enforced only by the
Commissioners themselves, or others possessing equal authority; for
workhouse officials will interpret them through the medium of their own
coloured vision; and if magistrates were entrusted with the task, we have
no confidence that it would be efficiently performed by them as
inexperienced, non-medical men, with whom economical considerations will
hold the first place. The principles referred to are expressed in the
following paragraph:—
“We have invariably maintained that the permanent detention in a workhouse
of any person of unsound mind, whether apparently dangerous or not, whose
case is of recent origin, or otherwise presents any hope of cure through
the timely application of judicious treatment, or who is noisy, violent,
and unmanageable, or filthy and disgusting in his habits, and must
therefore be a nuisance to the other inmates, is an act of cruelty and
injustice, as well as of great impolicy; and we have on all occasions
endeavoured, so far as our authority extends, to procure the speedy
removal of persons of that description to a lunatic asylum.”
The following practical suggestions, calculated to improve the condition
of the insane poor, are deducible from the foregoing remarks on workhouses
considered as receptacles for lunatics.
1. The County Asylums should afford aid to all insane persons unable to
procure proper care and treatment in private asylums; and 2, such patients
should be directly transmitted to them; the circumstance of their entire
or partial liability to the poor-rates being, if necessary, subsequently
investigated. 3. As a corollary to the last suggestion, the primary
removal of patients to a workhouse should, save in very exceptional cases,
such as of distance from the asylum and unmanageable violence at home, be
rendered illegal; or, what is nearly tantamount to it, for the future no
alleged lunatic should be suffered to become an inmate of a workhouse,
except with the written authority of the District Medical Officer or
Inspector proposed to be appointed. 4. Without the sanction of this
officer, likewise, no lunatic should be permitted to be discharged or
removed from a workhouse. This is necessary for the patient’s protection,
for securing him against confinement in any house or lodging under
disadvantages to his moral and physical well-being, to check improper
discharges, and to protect the asylum against the transfer to it of unfit
cases, a circumstance which will presently be shown to be of frequent
occurrence. 5. No person should be detained as a lunatic or idiot, or as a
person of unsound mind in a workhouse, except under a similar order as
that required in the case of asylum detention, and a medical certificate
to the fact of his insanity. 6. If workhouses need be used, whether as
temporary or as permanent receptacles for the insane, they should be
directly sanctioned by law, placed under proper regulations, and under
effective supervision, not only of the Lunacy Commissioners, but also of a
Committee of Visitors, and of the District Medical Officer, whose duty it
would be to watch over the welfare of the insane inmates, their treatment,
diet, occupation, and amusement. The Visitors should be other than
guardians or overseers of the poor of the union or parish in which the
workhouse is situated, although every union should be represented on the
Committee; and they might be selected from the magistrates, and from the
respectable classes among the rate-payers. If the county were large, it
might be advantageously divided into districts, a Committee of Visitors of
Workhouses being appointed in each district. 7. Every workhouse containing
lunatics should be licensed as a place of detention for them by the
Committee of Visitors, who should have authority to revoke the license.
This power of revoking the license should be also vested in the
Commissioners in Lunacy. 8. Every such workhouse, and the number of its
insane inmates, should be reported to the Lunacy Commissioners. According
to our scheme, the District Medical Officer would do this, as well as
report generally to the Lunacy Board, the condition and circumstances both
of the workhouse and of its insane inmates. 9. For the future, the
erection or the appropriation of distinct lunatic wards to workhouses
should be interdicted by law.
By the preceding suggestions reforms are, indeed, proposed to render
confinement in workhouses legal; to make it more satisfactory; to provide
for effectual supervision, and in general to assimilate the wards of
union-houses more closely to those of asylums. Yet all this is done only
on the ground of the necessity for some legislation on these matters, and
more particularly under the pressing circumstances of the time. The
present state of lunacy compels acquiescence in the Lunacy Commissioners’
statement, that workhouse-wards must for some time longer be used for the
detention of insane paupers; and this fact alone supplies an apology for
making suggestions to improve them. Moreover, apart from it, the workhouse
will at times necessarily be the temporary refuge for some few cases, and
may be occupied as a permanent dwelling by those rare instances of
imbecility of mind which can be allowed to intermingle with the other
inmates, and be usefully occupied; and for these reasons it need be
rendered both a legal and not unsuitable abode. At the same time, it is
most desirable that the Lunacy Commissioners should be able not only to
discourage, but also to veto the construction of lunatic-wards for the
future, on the grounds already so largely pointed out; and for this
reason, moreover, that where such wards exist, they are thought good
enough for their poor inmates, and are looked upon as asylums over which
the county institution has little preference. The existence, therefore, of
any specially erected or adapted ward, may always be urged against the
proposition for further expenditure in providing for pauper lunatics
elsewhere in suitable asylums;—a plea, which should consequently be set
aside by overturning the foundation whereon it rests.
Since the preceding observations on the detention of pauper lunatics in
workhouses were in print, a most important supplementary Report on the
subject has been put forth by the Commissioners in Lunacy (Supplement to
the Twelfth Report; ordered to be printed 15th of April, 1859). We have
read this Report with pleasure, so far as it confirms the views we have
taken, but with surprise and pain at the details it unfolds of practices
the most revolting to our better feelings, and, in general, of a state of
things discreditable to a civilized and christian country. By being
confirmatory of the opinions and statements advanced by us, it may be said
to give an official sanction to them; and as it is one of the most
important documents ever issued by the Board, we shall attempt an
analysis of its contents.
In the first place, the Commissioners resort to some recent corrected
returns of the Poor-Law Board, and discover that the number of pauper
lunatics in workhouses was, on the 1st of January, 1858, 7555, i. e.
upwards of 500 above that returned in the Tenth Report of the same Board,
and referred to in the foregoing pages; and on the 1st of July in that
same year it amounted to 7666. They then proceed to describe the
“character and forms of insanity most prevalent in workhouses,” and show
that their insane inmates all require protection and control; that “some,
reduced to poverty by their disease, are of superior habits to those of
ordinary paupers, and require better accommodation than a workhouse
affords. Many are weak in body, and require better diet. Many require
better nursing, better clothing, and better bedding; almost all (and
particularly those who are excitable) require more healthful exercise,
and, with rare exceptions, all require more tender care and more vigilant
superintendence than is given to them in any workhouse whatsoever.”
On turning to the “Design and Construction of Union Buildings,” they
rightly point out that the stringent conditions to ensure economy, and to
check imposition and abuse, the “reduced diet, task labour, confinement
within the narrow limits of the workhouse premises,” the plan of
separating the inmates into classes, the scanty means of out-door
exercise, &c., are inimical to the well-being of the insane residents. In
the “Modes of Workhouse Direction and Administration” there is great
unfitness. The rules under which the officers act “are mainly devised to
check disorderly conduct in ordinary paupers; and it is needless to say
with how much impropriety they are extended to the insane. Any increase of
excitement, or outbreak of violence, occurring in the cases of such
patients, instead of being regarded as a manifestation of diseased action
requiring medical or soothing treatment, has subjected the individual to
punishment, and in several instances led to his imprisonment in a jail. In
addition to these hardships, the lunatic patient is for the most part
precluded from leaving the workhouse at his own will. In effect he becomes
a prisoner there for life, incapable of asserting his rights, often of
signifying his wants, yet amenable to as much punishment as if he were
perfectly sane, and a willing offender against the laws or regulations of
the place. Nor, as will hereafter be seen, is his lot much bettered in the
particular cases where it is found convenient to the authorities to relax
those restrictions, and give him the power at will to discharge himself.”
Rural workhouses of small size are generally preferable abodes for the
insane than those of larger dimensions, since their “arrangements have a
more homely and domestic character, and there are more means of occupation
and of free exercise in the open air;” and where their imbecile inmates
can be associated with the ordinary paupers, and regularly employed, their
condition is not unfavourable; “but these form only the exceptions.”
Workhouses in the metropolis and in large towns generally, are for the
most part “of great size, old, badly constructed, and placed in the midst
of dense populations. The weak-minded and insane inmates are here
generally crowded into rooms of insufficient size, sometimes in an attic
or basement, which are nevertheless made to serve both for day and
sleeping accommodation. They have no opportunity of taking exercise; and,
from the want of space and means of separation, are sometimes associated
with the worst characters, are subjected unnecessarily to seclusion and
mechanical restraint, and are deprived of many of the requisites essential
to their well-being.”
“Of the 655 workhouses in England and Wales, somewhat more than a tenth
part are provided with separate lunatic and idiot wards.”
The “Objections to Intermixture of Inmates” are briefly stated. “There is
no mode of complying with suggestions for” the peculiar benefit of insane
inmates, “without disturbing the general economy of the house,—a fact
which shows how important it is that no lunatic or idiot should be
retained for whom any special arrangements are necessary.” Separate
lunatic wards are declared to be more objectionable than the intermixture
of the pauper inmates. Only occasionally are such wards found at all
tolerable; and even then, the constant medical supervision, proper
attendants and nursing, sufficient diet, exercise, occupation, and other
needful provisions, are deficient. The majority are thus sketched:—“In
some of the wards attached to the old workhouses the rooms are crowded,
the ventilation imperfect, the yards small and surrounded by high walls;
and in the majority of instances the bed-rooms are used also as day-rooms.
In these rooms the patients are indiscriminately mixed together; and there
is no opportunity for classification. There is no separation where the
association is injurious; and no association where such would be
beneficial. In fact, patients of all varieties of character,—the weak,
the infirm, the quiet, the agitated, the violent and vociferous, the dirty
and epileptic,—are all mingled together, and the excitement or noise of
one or more injures and disturbs the others. The restless are often
confined to bed to prevent annoyance to the other patients, and the infirm
are thus disposed of for the want of suitable seats. Their condition when
visited in the daytime is obviously bad, and at night must be infinitely
worse. Even in workhouses where the wards are so constructed as to provide
day-rooms, these are often gloomy, much too small in size, and destitute
of ordinary comforts; while the furniture is so poor and insufficient,
that in some instances, there being no tables whatever, the patients are
compelled to take their meals upon their knees. Other cases to be
hereafter mentioned will indeed show that it is reserved for lunatic wards
of this description, and now happily for them only, to continue to exhibit
some portion of that disregard of humanity and decency, which at one time
was a prevailing characteristic in the treatment of insanity.”
Not only, again, are there no sufficiently responsible authorities in the
house, and no qualified responsible attendants, but also no records of
restraint, of seclusion, of accident, or injury, or of medical or other
treatment. “Above all, there is no efficient and authoritative official
visitation. The Visiting Justices never inspect the lunatic wards in
workhouses, and our own visits are almost useless, except as enabling us
to detect the evil that exists at the time of our visit, and which, after
all, we have no power to remove.” The “Results of Neglect in Deteriorating
the Condition of Patients” of all classes are ably portrayed. In the
absence of attentive and experienced persons to watch and to supply their
wants, many of the insane suffer unheeded and without complaint, to the
prejudice of their mental and bodily state; or become inattentive to
natural wants, and prone to violence and mischief. “In a very recent case
of semi-starvation at the Bath Union, when the frauds and thefts of some
of the attendants had, for a considerable time, systematically deprived
the patients of a full half of their ordinary allowance of food, the only
complaint made was by the wan and wasted looks of the inmates.”
In the two next sections the Commissioners insist that the duty of
distinguishing the cases in workhouses to be classified as “Lunatics,
Insane Persons and Idiots,” should be performed by the medical man
independently of the master; and that, without examination and sanction
from that officer, no person of weak mind should be discharged, or allowed
to discharge himself. Very ample cause for this latter proposition is
shown in the illustrations appended, particularly in the case of imbecile
females, who not unfrequently become, when at large, the prey to the
vicious, further burden the parish by their illegitimate offspring, and
often by an idiotic race.
“The diet necessary for the insane” is required to be more liberal than
for other inmates; yet the Commissioners have “in very numerous instances”
animadverted upon its inadequacy, both in quantity and quality, but
without result, except “in very few instances:” for, notwithstanding that
“the medical officer of a Union has full power” (by the Consolidated Order
207, art. No. 4) “to give directions, and make suggestions as to the diet,
classification and treatment of the sick paupers, and paupers of unsound
mind,” yet, we are sorry to learn, that “the power thus given, although
backed by our constant recommendations, is rarely exercised by the medical
officer.”
This circumstance is so far confirmatory of a view we have above taken,
that the medical officer of a parish or union is neither sufficiently
independent, as the paid employé of the guardians, to carry out measures
that may be necessary for the alleviation of the condition of lunatics in
workhouses, where such means involve increased cost (we regret to
entertain the notion); nor always sufficiently acquainted with the wants
of the insane.
Considering the disadvantages of workhouses as receptacles for them, the
general statement follows naturally, that as a class of workhouse inmates,
the lunatics “are manifestly lower in health and condition than the same
class in asylums. Hence,” add the Commissioners, “the patients’ bodily
health and mental state decline upon removal from asylums to
workhouses—an effect chiefly due to the inferior diet.” There are great
“variations in workhouse dietaries,”—from one spare meat dinner in the
week to a meat dinner daily. This latter provision is furnished “in a very
small number of houses.” These dietaries are indeed much inferior to those
considered necessary for criminals in jails; a fact that affords a sad
comment on English consistency, which is thus found dealing with more
favour and consideration towards those who have transgressed the laws of
their country, than to those whose only crime is poverty, or poverty
complicated with disease or infirmity.
Medical treatment would, in truth, seem to be not legally provided at all
for lunatics in workhouses: no clause makes a visit of the union medical
officer to the lunatic-ward of a workhouse imperative. As examples of the
slight esteem in which medical supervision is held, the Leicester and the
Winchcombe houses are quoted. In the former, the visits of the medical
officer were only made quarterly; in the latter, by stipulation three
times a week, but in practice very irregularly. Attendance and nursing
are, as might be expected, on a par with medical treatment. Even imbeciles
have been found exercising the functions of nurses, and, generally
speaking, the selection of attendants is made from old and feeble people,
having no experience, no aptness for the duties, no particular qualities
of intellect or temper to recommend them, and receiving such a mere
pretence, if any at all, in the way of remuneration for their trouble,
that no painstaking efforts can be looked for from them. “Yet to such
individuals, strait waistcoats, straps, shackles, and other means of
restraining the person are not unfrequently entrusted; and they are,
moreover, possessed of the power of thwarting and punishing at all times,
for any acts of annoyance or irregular conduct, which, although arising
from disease, are nevertheless often sufficient to provoke punishment from
an impatient and irresponsible nurse.”
The interior accommodation, fittings, and furniture are, if not abominably
bad, excessively defective: and on reaching this part of the Report, where
the details of internal fittings and management come under review, the
impression derivable from its perusal is akin to that gathered from the
revelations of madhouses made by the Parliamentary Committees of 1814 and
1815. The sketch of the evils suffered by lunatics in workhouses, which we
have ourselves attempted in past pages, tells a flattering tale compared
with the realities unfolded to us by the Commissioners, and adds a tenfold
force to the arguments against the detention of lunatics in such places.
To continue the practice would be to perpetuate a blot upon the internal
polity, the philanthropy and the Christianity of the country. Let those
who would know the whole case refer to the Report in question; it is
sufficient for our purpose to attempt a mere outline of its revelations.
Patients are frequently kept in bed because there are no suitable seats
for them; a tub at times answers the double purpose of a urinal and a
wash-basin; a privy is partitioned off in a small dormitory; baths are
almost unknown; a trough or sink common to all supplies the want of basins
for washing, and an outhouse or the open air furnishes the appropriate
place for personal ablutions. Clothing, again, is often ragged and
insufficient; in an unwarmed dormitory, a single blanket, or only a
coverlet, is all the covering afforded by night; loose straw in a trough
bedstead usually constitutes the bed for wet and dirty patients to nestle
in; and whether the bed be straw or not, the practice of using it night
after night, when “filthy with dirt, and often rotting from frequent
wetting, has been many times animadverted upon.” In some workhouses two
male patients are constantly placed in the same bed; nor is the character
of the bedfellows much heeded; for a sane and insane, two idiots, one
clean and one dirty, and even two dirty inmates, have been found
associated together in the same bed, occasionally in a state of complete
nudity.
Further, the want of exercise and employment, the absence of supervision
and control, and the entrusting of means of coercion to irresponsible and
unfit attendants, lead to the most shocking abuse of restraint, and to
cruel seclusion.
“The requirement occasionally made by the Visiting Commissioner, that the
Master shall make a written record of such proceedings, is utterly
neglected. The dark, strong cells, constructed for the solitary
confinement of refractory paupers, are used for the punishment of the
insane, merely to prevent trouble; quiet helpless creatures, from whom no
violence could be apprehended, are kept in bed during the daytime, or
coerced; and even the dead-house has been made to serve the purpose of a
seclusion-room.”
“The Examples of Restraint practised,” as adduced in the Report, recall to
mind all those barbarities which civilized men of the present day are in
the habit of congratulating themselves as matters of the past, and the
subject of history. The catalogue of appliances for restraint reappears
once more on the scene; and we read of straps, leather muffs, leg-locks,
hobbles, chains and staples, strait-jackets, and other necessary
paraphernalia, as of yore, worn for days, or weeks, or months. Excellent
matter, indeed, in all this, to garnish a discourse on the advancement of
civilization, on the prevalence of improved notions respecting the
treatment of the insane, or on some similar topic addressed to the vanity
of the present generation!
But the chapter does not end here. “It would be difficult to select places
so entirely unfit for the purpose of exercise, or so prejudicial to the
mental or bodily state of the person confined,” as the yards or spaces set
apart for it; and yet “of all the miseries undergone by this afflicted
class, under the manifold disadvantages before described, and of all the
various sources of irritation and discomfort to which we have shown that
they are exposed, there is probably none which has a worse effect than the
exclusion from all possibility of healthy movement. Nothing more
powerfully operates to promote tranquillity than the habit of extensive
exercise; and in its absence, the patients often become excited, and
commit acts of violence more or less grave, exposing them at once to
restraint or seclusion, and not unfrequently to punishment. In not a few
instances the outbreak has been looked upon as an offence or breach of
discipline, and as the act of a responsible person; and the patient has
been taken before a magistrate and committed to prison.
“A very grave injustice, it is hardly necessary to add, is thus committed,
in punishing by imprisonment individuals who are recognized and officially
returned as being of unsound mind. These persons in no respect differ from
the class of the insane usually met with in asylums, and are equally
entitled to the same protection, and the same exemption from punishment.
Instead of such protection, however, the patient is exposed to double
injury:—first, he is subjected to various sources of irritation while
confined in the workhouse, directly occasioning excitement; and, secondly,
the mental disturbance resulting therefrom is regarded as a crime, and is
punished by imprisonment.”
The Commissioners in Lunacy next direct attention to the principal cause
of the evils described, which they discover in the neglect and evasion of
the duties imposed by the law on the officers of parishes and unions, in
the interests of the pauper insane. Thus, as remarked in previous
pages,—“Instead of causing the patient to be dealt with as directed by
the 67th and 68th sections of the Lunatic Asylums’ Act, 1853, and
immediate steps to be taken for his direct removal to the asylum,
workhouses have been to a great extent made use of primarily as places for
the reception, and (in many instances) for the detention of recent cases
of insanity.
“The workhouse is thus illegally made to supply the place of a lunatic
establishment, and the asylum, with its attendant comforts and means of
cure, which the law has provided for the insane poor, is altogether
disregarded; or it comes into operation only when the patient, by long
neglect, has become almost hopelessly incurable. We should remark that
this occurs most frequently in the larger workhouses, and in those having
insane wards.”
... “How totally unfit even workhouses having insane wards are for the
proper treatment of recent curable cases, we have endeavoured to exhibit
in some detail. Nevertheless, the practice of making use of them for all
classes of insane patients is rapidly increasing, and our efforts to check
it have proved hitherto quite ineffectual.”
After further adverting to the influence of the neglect of the laws in
increasing pauper lunacy, they very briefly discuss the comparative cost
of lunatics in workhouses and in asylums, but their examination adds
nothing to what we have much more fully put forward on this subject.
Their “conclusion” contains some valuable suggestions, more or less
identical with those we have ourselves independently advanced, and which
may be briefly summed up as follows:—
“To remedy many of the evils adverted to would, in our opinion, be
impracticable, so long as insane patients are detained in workhouses,
whether mixed with other inmates or placed in distinct wards.
“The construction and management of workhouses present insurmountable
obstacles to the proper treatment of the disease of insanity; and
therefore the removal of the majority of the patients, and the adoption of
stringent measures to prevent the admission of others, have become
absolutely necessary.”
The notions of parish authorities of the very great comparative economy of
workhouses over asylums rest, say the Commissioners, on a false basis; and
to place the question fairly before them, “it is essential that the mode
of keeping the accounts should be assimilated in each, and that in the
asylum only food and clothing should be charged to the parishes, and all
other expenses to the county. In such case, we believe it would be found
that the charges in each would be brought so nearly to a level, that there
would exist little or no inducement on the plea of economy to tempt the
guardians to keep their insane patients in workhouses, instead of sending
them at once to a county asylum.”
To provide proper accommodation for the insane poor in workhouses,
inasmuch as many asylums are on “so large a scale as not to admit of the
necessary extension, whilst some are of a size much beyond that which is
compatible with their efficient working,” the Commissioners propose “the
erection of inexpensive buildings, adapted for the residence of idiotic,
chronic, and harmless patients, in direct connexion with, or at a
convenient distance from, the existing institutions. These auxiliary
asylums, which should be under the management of the present visiting
justices, would be intermediate between union workhouses and the principal
curative asylums. The cost of building need not, in general, much exceed
one-half of that incurred in the erection of ordinary asylums; and the
establishment of officers and attendants would be upon a smaller and more
economical scale than those required in the principal asylums.”
“Whether or not such additional institutions as we recommend be provided,
we think it essential that visiting justices of asylums should be invested
with full power, by themselves or their medical officers, to visit
workhouses, and to order the removal of insane inmates therefrom to
asylums at their discretion. They should also be empowered, upon the
report of the Commissioners, to order the removal into the asylum of
pauper patients boarded with strangers.”
“And in the event of our obtaining your Lordship’s approval of such
suggestions for legislative enactment, we would further recommend that it
should include the following provisions:—
“No lunatic, or alleged lunatic, to be received into or detained in a
workhouse, unless he shall have been duly taken before a justice or
officiating clergyman, and adjudged by him as not proper to be sent to an
asylum.
“In any case, however, wherein an order for a lunatic’s reception into an
asylum shall be made by a justice or officiating clergyman, it shall be
competent to him, if, for special reasons to be set forth in his order, he
shall deem it expedient, to direct that such lunatic be taken, pro
tempore, to the workhouse, and there detained for such limited period,
not exceeding two clear days, as may be necessary, pending arrangements
for his removal to the asylum.
“A list of all inmates of unsound mind to be kept by the medical officer
of a workhouse, and left accessible to the Visiting Commissioners.
“The medical officer to specify, in such list, the forms of mental
disorder, and to indicate the patients whom he may deem curable, or
otherwise likely to benefit by, or in other respects proper for, removal
to an asylum.
“The Visiting Commissioner, and the Poor-Law Inspector, to be empowered to
order and direct the relieving officer to take any insane inmate before a
justice, under the provisions of the 67th Section of the Lunatic Asylums’
Act, 1853.
“In all cases of inmates of unsound mind temporarily detained in
workhouses, the medical officer to be invested with full powers as
respects classification, diet, employment, and medical and moral
treatment, and otherwise.”
Of some of these suggestions we shall take a future opportunity to speak,
and at present pass from the consideration of the state and wants of
lunatics in workhouses to notice, briefly, the condition of those living
with their friends or elsewhere.
§ Pauper Lunatics living with their relatives or with strangers.
In the previous chapter “On the state of the present provision for the
Insane,” some remarks have been made on the class of lunatic poor living
with their relatives or strangers, calculated to arrest attention to their
numbers and their neglected position. The Commissioners in Lunacy have as
a rule, and in the absence of particular information, calculated that they
are about equal in number to those resident in workhouses. Considering the
imperfect nature of the statistical records of them, and the fact that
they escape official observation and inquiry to a much greater extent than
even the lunatic inmates of workhouses, we have assumed them to be more
numerous, and that there are 8000 so distributed in the homes of our
industrial classes.
Of these 8000, more or less, poor persons, dependent, on account of
distinct imbecility or idiocy, upon others for protection and support, no
one outside their abodes, it may be generally said, thoroughly knows their
condition, although a partial knowledge may be possessed by the parochial
authorities of the union or parish to which they are chargeable. To these
authorities, however, they possess no interest; they are regarded as
burdens upon the public purse, to be arranged for on the cheapest terms.
The only person at all responsible for their condition is the parish
medical officer, who is required by sect. 66 (16 & 17 Vic. cap. 97) to
visit them quarterly, and to certify “whether such lunatics are or are not
properly taken care of, and may or may not remain out of an asylum.”
In the first place, the matter of deciding what pauper reported as insane,
imbecile, or idiotic is actually so, is not by law given to any parochial
officer; hence it frequently happens that differences of opinion and
divisions arise between the medical officer on the one hand, and the
poor-law guardians on the other, as to the chargeability of this and that
pauper to the parish as insane; and the decision acquires intensified
importance from the fact that one half-crown per quarter is at stake on
each pauper chattle in dispute; for if the medical man gain the day, just
that sum has to be squeezed out of the rate-payers to compensate him for
his quarterly call upon the admitted lunatic. We leave the reader to
imagine the battlings of the vestrymen on the knotty point; sane or not
insane, that is the question, the solution of which must cause the
consumption of much time and breath yearly to many an honourable board of
guardians, to animated discussions, bold definitions and fine-drawn
distinctions, lost to the profanum vulgus enjoying no seat in the
conclave.
Here, then, appears a duty which, in our opinion, should be performed by a
duly appointed officer, such as a district medical inspector or examiner;
for we would deprive the guardians of the poor of all voice in deciding on
the sanity or insanity of any individual. The law might with equal or with
greater propriety leave the decision of the success or non-success of the
operation of vaccination to a vestry, as that of the question under
remark. Further, since many might argue, that to leave the determination
of the question to an officer like the parish medical man, directly
interested in settling it in one way, and who might saddle the parish with
an annual charge for every poor person in it who did not come up to his
standard of mental strength, would be unfair to the rate-payers; an
independent opinion, given by an officer in no way interested in the
decision of the point at issue, would seem to afford the very best means
of settling the point, and a sufficient guarantee against any supposable
irregularities. We would suggest, therefore, that the district inspector
should visit every poor person wholly or partially chargeable, or proposed
to be made chargeable to any parish, as being of unsound mind, and make a
return to the parochial authorities and to the Poor-Law Board, and that
the certificate of this officer should be held to be a sufficient proof of
the insanity of the individual.
But the duties of this officer, in relation to the lunatic poor under
consideration, would not stop here. In his visit we would require him to
investigate more narrowly than a Union medical officer can be expected to
do at the remuneration offered, and amid his many other arduous
engagements,—into the condition and the circumstances by which the poor
patient is surrounded, to report thereon to the Lunacy Board and to the
proper Union officials, and in general to state, in the words of the Act,
whether he is or is not properly taken care of, and is or is not a fit
subject for asylum care. The officer we propose, would approach the
inquiry independently of the parish authorities, and indifferent to their
censure, having no position and no pay to lose by his decision; whilst as
an experienced physician, understanding the varying features of mental
disorder, and the conditions necessary to its amelioration or cure, his
opinions would claim greater respect.
Inasmuch as it is impossible, owing to their small number, for the Lunacy
Commissioners, without totally neglecting their other duties, to make
themselves acquainted with the condition of these pauper lunatics,
scattered here and there over the country, in cottages and lodgings, we
really possess, as before said, under the existing system, no information
worth having, what that condition really is. Judging from the state in
which workhouse lunatic inmates are found, the impression is unavoidable,
that the pauper lunatics under notice must be in a worse one, since there
is not only no sort of supervision over them equivalent to that provided
in workhouses, but also the sums allowed towards their maintenance are
most scanty, and, where they are lodged with strangers, no care and no
sustenance beyond what is felt to be actually paid for, can be presumed to
be given. Now and then a glimpse of the actual state of things is casually
afforded by the Report of a County Asylum; and such are the glimpses we
have got through this medium, that, except to arouse public attention by
their recital, in order to bring about a reform, it were well, for the
sake of the reputation of the country, that the revelations were
unrecorded. Asylum superintendents could, indeed, more frequently raise
the veil upon scenes of wretchedness and cruelty undergone by our lunatic
poor in the habitations where parish officials place or keep them; but
they generally forbear to do so in their Reports, although enough is shown
by the description of the state in which patients are admitted into the
asylums, and of the length of time that has been suffered to elapse since
the commencement of their sad malady.
Dr. Hitchman, in the Reports of the Derby County Asylum, has more than
once referred to the state of patients on admission from their homes or
lodgings. Thus, in 1853, he narrates the case of a poor woman who had been
demented for five years, and “kept at home until she fell into the fire
and became extensively and severely burnt;” and not till after this
accident was she taken to the asylum. A little way further on, in the same
Report, he observes,—“Those only who have lived in public asylums know
the misery, the wretchedness, and the wrong which are constantly inflicted
upon lunatics in obscure places, even by their relatives and ‘friends,’
and which cease only with the life of the patient, unless he be conveyed
to a well-conducted institution. It is, moreover, a remarkable phenomenon,
that many individuals who perpetrate these enormities upon their kith and
kin, who have habitually fastened them with cords, who have deprived them
of a proper supply of clothing or of food, who have, in short, rendered
them permanent cripples in body, as well as hopeless idiots in mind, have
done so without malice, as a general rule, without passion, by slow
degrees, and with no conception whatever of the present suffering or
ultimate mischief effected by their proceedings. They affect no secrecy
among their neighbours while these things are going on. Familiarity to the
spectacle blinds their perceptions and blunts their feelings.... Others
there are, who, from penurious and selfish motives, inflict much wrong
upon the lunatic. Of such a kind appears the following:—‘T. G., removed
from the custody of his relatives by the order of the magistrates. Has
been insane thirty-eight years, under the management of his relatives, who
have generally had him confined in an out-building.’ ‘He is stated to have
been unclothed for many years. When brought into the asylum he was naked,
except that around his pelvis were the remains of an article of dress; his
hands were tightly bound to each other by ligatures passing around the
wrists. When in the cart he was covered with a blanket, but this fell from
him during his struggles on being removed. He roared hideously as he was
being conveyed to the wards. He is a person of lofty stature and great
size. His head and neck are very large; one side of his forehead is
greatly disfigured by scars, and he has lost an eye. His ears have been
deprived of their normal shape, and their lobes much thickened by the
deposition of fibrine or other matter. His lips are large and pouting. His
beard has been long unshaven, but has been recently cut with a pair of
scissors. The bones and muscles of his arms are of great size; his lower
extremities are red, swollen, and ‘pit,’ under pressure; one of his toes
is deprived of its nail, and the whole foot appears to have suffered from
the effects of cold. He walks with a stooping gait, and appears unable to
retain the erect posture without support. He resists powerfully all
attempts to clothe him, and appears to be entirely ignorant of the use of
a bedstead. He whines after the manner of a dog that has lost its home. He
dreads all who approach him; on being taken from his room in the evening,
he hurried back to it with all the haste he could, and on all occasions he
shrinks from observation. He is lost to every sense of decency; nakedness
is congenial to him, but he will sometimes coil himself in a blanket for
the sake of its warmth. He is guided by the lowest instincts only, and his
whole appearance and manner, his fears, his whines, his peculiar skulking
from observation, his bent gait, his straight hair, large lips, and
gigantic fore-arm painfully remind one of the more sluggish of the
Anthropoid Apes, and tell but too plainly to what sad depths the human
being can sink under the combined influence of neglect and disease.’”
The same excellent physician reverts to these cases in his Fourth Report
(1855), and laments the sad condition of health, and the horrible state of
neglect of many patients on their admission. He says, “One or two patients
had been confined by manacles in their own cottages until rescued by
charitable interference, and were brought to the asylum with their wrists
and ankles excoriated by the ligatures deemed necessary for their proper
control.” One such case had been confined twenty-five years in his
cottage-home.
These illustrations will suffice for our purpose. They indicate the
existence of abuses and wrongs here in England, too similar, alas! to
those the Special Lunacy Commission of Scotland brought to light by their
well-known inquiry in 1855 (Report, Edinburgh, 1857), and such as the
general description in their Report, and the particulars in Appendix K,
too amply demonstrate. It is referred to as “the wretched state” of single
patients living with their friends or others, and well merits the
designation. They found these poor afflicted beings generally in a state
of moral and physical degradation, ill-fed, ill-treated, ill-clothed,
miserably lodged, shockingly dirty, abused, restrained by all sorts of
mechanical contrivances of the coarser kind, or left to wander unheeded
and uncared for; whilst among the imbecile or fatuous women, many were the
instances where they had become the mothers of an illegitimate and often
idiotic offspring. Judging from the specimens before us, we repeat, we
have great misgivings lest a similar searching inquiry into the condition
of pauper lunatics in England distributed in the homes of our cottagers
and labouring classes, should reveal a state of things no less disgraceful
to a civilized country.
To recall a conviction before expressed, additional legislative provision
is demanded for this class of pauper insane. The quarterly visit of the
hard-worked and underpaid Union Medical Officer or of his Assistant,
affords no sufficient guarantee, even when regularly made, that they are
duly taken care of, and not improperly deprived of the advantages of
asylum treatment. But if we accept official statements, these visits are
irregularly made and much neglected, and the reports of them far from
properly attended to. In the Report of the Hants Asylum for 1856, the
Committee took occasion to remark on the extended neglect and the
inefficiency of these legal visits and reports; and though the
Commissioners in Lunacy admit that of late matters have improved, yet they
say that they are far from satisfactory. From these and other
considerations adverted to, we have suggested that the inspection of the
lunatic poor in question should be specially undertaken by the District
Medical Officer, and that a report on them should after each visit be made
to the Lunacy Commission, and, with advantage, also to the Poor-Law Board.
This officer should be informed of every pauper or other lunatic living
with friends or others, and should investigate, as said above, all the
circumstances surrounding him, and decide whether or not a transference to
an asylum would be for the better. It would consequently be for him to
select and recommend the removal to an asylum of all such patients as
afforded a prospect of recovery; and since good food and proper nursing
improve not only the body, but also the mind and the moral feelings, and
promote the lasting relief of the mental disorder,—it should also devolve
upon him to signify the extent and mode of out-door relief to be afforded.
Defective and faulty nutrition concurs powerfully to produce insanity,
and, when it is induced, to make it permanent; the best policy must
therefore be to nourish pauper lunatics sufficiently;—a policy, which we
see, however, under existing circumstances, no prospect of being acted
upon by the guardians of the poor.
The allowance made to out-door lunatic paupers differs much; for it may be
intended to supply almost all the moderate wants of the recipient, or only
a small part of them. It is always, however, very limited, and less than
the calculated cost of in-door paupers per head, and can never suffice to
procure the poor patient adequate nourishment and suitable attendance and
clothing. Its amount, moreover, is regulated by no definite principles,
but is left very much to the caprice of the relieving officers, and to the
liberal or the opposite sentiments in the ascendant among the parochial
guardians. It is contributed as a grant in aid to the relatives of the
patient, and to those not related as a compensation for the outlay and
trouble incurred on his account. The former are naturally liable to the
maintenance of their lunatic kinsman, and no sufficient objection obtains
to his being detained among them, provided his condition is not prejudiced
by his exclusion from an asylum, and is duly watched over by competent
medical officers, and that those relatives are able to afford him proper
control, food and clothing, with or without parochial assistance. But the
case is different in respect of those not related to the patient, who as
strangers can have little interest in him; but who, on the contrary, have
to make his detention serve their own purposes so far as possible, and
cannot be expected to do or supply more than they are paid for. Now, as
the weekly allowance from the parish is to be by rule kept as low as it
can be, the lowest offers possess the highest recommendation for
acceptance, and the comforts and well-being of the poor imbecile or
idiotic people are almost necessarily sacrificed at the shrine of economy.
The whole system, therefore, of boarding pauper lunatics in the homes of
the poor unconnected with them by blood, as now pursued without
restrictions or method, appears fraught with injury to those helpless
beings. What sort of attention, food, and lodging can be expected for some
3 or 4 shillings a week? What sort of supervision and control can be
looked for from a poor, illiterate labourer or artisan? Even a patient’s
own relatives may and do grudge the cost and the trouble he puts them to,
or they may be very imperfectly able to furnish in their cottage-home the
means needed to ensure his protection and the conveniences and comforts of
others, and be ill-adapted by character and education to act as his
directors and guardians. But these difficulties and defects are augmented
manifold when the patient becomes a dweller among strangers.
Only under very peculiar circumstances indeed would we tolerate the
boarding of pauper lunatics with strangers; when, for instance, their
comforts and safety are hedged round by legal provisions sufficiently
ample, and by systematized arrangements to secure them. These ends are to
be attained by taking the selection of the abode and the pecuniary details
from the hands of parochial officers, and by entrusting them to some
competent medical man, who should be responsible that the patients are
properly cared for and treated. It should be for him to select the
residence, and in so doing to seek out those who by character and
condition are best fitted for the charge. If the law were so amended that
asylum relief should be afforded to all on the appearance of their malady,
the majority of those to be provided for in lodgings would come from the
class of chronic, imbecile patients, accounted harmless, whose discharge
from the asylum under proper surveillance might be recommended. Hence it
would render the scheme more perfect and satisfactory, to retain these
chronic lunatics in homes within a moderate distance of the County Asylum
they were previously placed in, so that they might be under the
supervision of the medical staff of that institution, and that the
propriety of their prolonged absence from it, or of their return to it,
might be therefore determinable by those best qualified to judge from past
experience of their case.
Yet, in all probability, this restriction as to the district for
receiving patients as boarders, would not always be practicable; and
frequently, where the insane poor had near relatives capable and willing
to receive them under their care, though at a distance from the asylum, it
would not be desirable to sacrifice the advantages of the guardianship of
friends to those obtainable by vicinity to the asylum; and, from these or
other causes, many poor insane people would be found distributed here and
there throughout a county under the charge of cottagers and others. In
their cases we would make the District Medical Inspector the special
protector and guardian of their interests and well-being provided by law,
and require him to visit them at least twice a quarter, report on their
condition, and on the fitness or unfitness of the persons boarding them.
In all cases, he should as a preliminary proceeding inquire into the
accommodation and general circumstances of the persons proposing to
receive an individual of unsound mind into their family, and should reject
the application of those who are unable to afford suitable conveniences
and adequate management.
Could a properly-organized system of supervision and control be
established, the disposal of poor insane persons in the homes of the
industrious classes would not be open to the objections it is at present,
when no adequate legal provision to ensure their inspection and welfare is
in existence. Indeed, it would be an improvement and blessing to many of
the chronic lunatics in our great asylums, could they so far be set at
liberty, and have their original independence restored to them by a
distribution in the cottage-homes of our country, where, under sufficient
control, they could exercise useful employments, and relieve the rates of
part of their cost. We have used the term ‘cottage-homes’ advisedly,
because it is evident, that, except in very small towns, a town-residence
would be most unsuitable.
The example of the great colony of insane persons at Gheel, in Belgium,
has suggested this plan of boarding lunatics in the homes of the working
classes, chiefly of agriculturists, to the minds of many English
philanthropists desirous to ameliorate the condition of our pauper insane,
and to lessen the large costs of asylum provision. The only attempt,
however, as far as we are aware, partaking at all of the conditions
calculated to render such a scheme satisfactory and successful, hitherto
made, is that on a small scale at the Devon Asylum under the direction of
Dr. Bucknill, and we are happy to find from this gentleman’s Report that
the arrangement has hitherto worked well.
We shall return to this subject in a subsequent section,—“On the
distribution of the chronic insane in cottage-homes.”
§ Transmission of unfit Cases to Asylums—improper Treatment prior to Admission.
In preceding pages it has been remarked that the transfer of lunatics to
asylums is regulated not by the nature of their case, and its amenability
to treatment or amelioration, but by the circumstance of their being
refractory and troublesome, annoying by their habits, or so infirm and
sick as to require attentive nursing; or, in general, in such a state that
their residence involves an increased and unworkhouse-like cost. The
question of the recency of the attack is treated as of far less moment;
for if the poor sufferer have what are called harmless delusions, or if he
is only so melancholic that suicide is not constantly apprehended, then
under these and such similar conditions, the economical theory of the
establishment commonly preponderates over every consideration of the
desirability of treatment in the presumedly expensive asylum, and the
patient is retained. In course of time his malady becomes chronic, and in
all probability incurable, and his condition so deteriorated in all
respects by the absence of proper measures for his mental and moral
treatment, that sooner or later his physical health gives way, or his
habits grow inconveniently annoying and troublesome, and then it is that
workhouse officials discover that the County Asylum is his suitable abode.
By this system of ‘clearance’ the workhouses are relieved of their most
burdensome and costly inmates, who fall to the charge of asylums, in which
their presence necessarily keeps down the rate of recoveries, multiplies
the proportion of chronic lunatics, and increases the expenses and the
rate of mortality.
The Medical Superintendents of our Asylums bear witness to the
recklessness, and to the cruelty, at times, which often mark the doings of
workhouse authorities when they wish to rid themselves of the cost and
trouble of any of the lunatic poor in their keeping. The illustrations at
hand, obtained from County Asylum Reports, are so numerous, that we must
content ourselves with a selection of a few of the more striking.
Dr. Boyd, the distinguished physician of the Somerset County Asylum, makes
the following statement in his Sixth Report (1853):—“Several aged
persons, and many others in a feeble state, have been admitted during the
year, so that the mortality, although less than in the preceding year, has
still been considerable. For example, two cases have been recently
admitted: one that of a man with dropsy, and broken down in constitution,
who is reported to have been given to excess in drinking ardent spirits,
and to have been subject to epileptic fits; he was disappointed at not
being admitted into a general hospital, became violent, and was sent as a
patient here; he has been free from fits since his admission, is rational,
but apparently in the last stage of bodily disease. The other case is that
of a woman about seventy, paralysed, and unable to sit up in the arm-chair
without support. She was troublesome in the union workhouse, and was
reported as dangerous, and so was sent to the asylum. There have been
four males with paralysis recently sent in from being dirty in their
habits.... One female was improperly sent with delirium attending on
fever: she died a fortnight after admission.” In his Ninth Report, this
same Superintendent says,—“Some are sent to the asylum in a state of
paralysis, some are aged and in a state of fatuity, and others when they
become troublesome, or are in a diseased and feeble state of bodily
health, and require more nurse-tending than they receive in the
workhouses.... Under the existing arrangements, lunatic asylums are
gradually losing their proper character of hospitals for the recovery of
the insane, and sinking down to be mere auxiliaries to workhouses.”
Out of eighty admissions at the Worcester County Asylum, fourteen were
between sixty and eighty years of age, and for the most part “the subjects
of organic disease of the brain, lungs, and heart, or suffered from
long-continued mental disease, or from the superannuation of old age, and
deficient nutrition of the brain and nervous centres. Four of them died
during the year.... During the early part of the year some correspondence
was entered into with several Unions, from which patients had been sent in
a dying or exhausted state; and the impropriety of such proceeding was
pointed out by your Committee.... It is not supposed that those
unfortunate cases are wilfully detained with improper intentions at their
homes or elsewhere, but from ignorance; and from want of the necessary
appliances, and the assistance of those accustomed to the insane, proper
measures cannot be adopted for their care and recovery,” and various
injuries are inflicted.
The experienced Superintendent of the Beds., Herts., and Hunts. Asylum
reports, in 1856, that of 111, as many as twelve died within three months
of their being admitted; five did not survive a fortnight. “One male, an
epileptic seventy-nine years of age, and having been bedridden for years
from contracted limbs, and nearly exhausted from the journey, died on the
twelfth day. A female, aged sixty-eight, with disease of the heart, died
on the fourth day from exhaustion, having been some time without rest, and
having refused her food previous to admission. A female in the last stage
of pulmonary consumption, lived but seventeen days; and one very
distressing case of a female ... was brought to the asylum, who, worn out
from constant excitement, and having a large wound on the leg, with
ulcerations from ligatures on the wrists and ankles, sank on the
fourteenth day. The two last-mentioned patients were reported to have
refused food for nearly a week, but took every kind of nourishment offered
to them from the moment they were in the Asylum.”
The Report of the Suffolk County Asylum records the admission of ten poor
persons in 1852 “nearly seventy years of age, nine over seventy, three
over eighty; sixteen in a state of bodily exhaustion; nine either idiots
from birth, or imbeciles for a very long period; one child with well-known
disease of the heart, and a woman, a cripple, scrofulous, blind and deaf.”
“What,” asks Dr. Kirkman, the venerable Superintendent, “can be done more
than good nursing to support a peevish mind in a patient eighty-four,
admitted only a few days ago?” He adds, “To give other instances, one man
was received some time back on a very qualified certificate, and upon
whose case a qualified certificate only could be given; and another
(somewhat experimentally) with the notice that his mania, if such it were,
existed only in the want of a slight resistance to a wayward will; and
another, a girl of sixteen, subsequently found not to be insane, but
suffering from aggravated cataleptic hysteria, supposed to have been
caused by fright, having spinal disease, and deformed throughout the
body.”
Dr. Hitchman, whose Reports we have found so valuable in former sections
of this work, has repeatedly called attention to the subject now under
notice. In 1853 he writes:—“It is with feelings of deepest sorrow that
your physician is compelled to state, that patients continue to be sent to
the asylum in very advanced stages of bodily and mental disease.... So
long as no violent or overt act has been perpetrated; so long as the
sufferer can be ‘managed’ in the privacy of his miserable home, or by the
‘cheap’ resources of a workhouse, he is often detained from the lunatic
hospital. Disease, aggravated by neglect, continues its direful course,
the ‘harmless’ lunatic becomes very dirty in his habits, or very violent
in his conduct, windows are broken, clothes are torn, persons are injured,
and the strap, the strait-waistcoat, and the chain are brought into
service to control for a time the ravings and the mischief of the patient.
Steps are now taken for his removal—bound, bruised, dirty, and paralysed,
the poor creature is taken to an asylum. One glance is sufficient to
reveal to the experienced eye that cure is hopeless; that while every
resource of the Institution will be needed to sustain the exhausted
energies of the patient—to preserve him from the sufferings consequent
upon the loss of his self-control over the excretions of his body, yet for
two or three years he may survive to swell the list of incurables—to
diminish the per-centage of cures—to crowd the hospital, and, worse than
all, to perpetuate this popular belief, and to encourage the pernicious
practice, which are now leading to the moral death and social extinction
of hundreds of our fellow-creatures.”
Speaking of the admissions in 1854, he says:—“Several were in advanced
stages of bodily disease; thus, I. C. expired in eight hours after his
arrival at this hospital. He was removed from the vehicle in which he was
brought to his bed, where he remained tranquil until the moment of his
decease. The state of great prostration in which he was brought, forbade
the employment of the usual washing-bath; nor was he subjected to the
fatigue of being shaved (of which he stood in much need) in consequence of
his exhaustion. F. G., aged 76 years, admitted with the marks of restraint
round her wrists, survived eighteen days—only by the administration of
wine and warmth. S. C., brought bound by straps and a strait-waistcoat in
the afternoon of the 18th, was so convulsed and epileptic, that she died
on the morning of the 20th, having scarcely spoken during the time she was
in the asylum. Others were in advanced stages of dropsy, phthisis, and
general paralysis, and, although in a hopeless condition, lived on for
several weeks under the fostering care of the Institution. One poor girl,
admitted from Lincolnshire, in a perfectly helpless condition (the
delirium of fever having been mistaken for the ravings of insanity), was
conveyed from the vehicle to a water-bed, where she has remained in a
state of great suffering for upwards of twelve weeks, and is never likely
again to recover the use of her limbs.”
The experience of the Kent Asylum is similar. The age of eleven persons
admitted in 1853 averaged 64, and twelve were from 72 to 75. “In many of
these the malady was simply decay of mind, or was due to apoplectic
seizures, and attended by palsy.”
In the Report for 1857-1858, Dr. Huxley goes more at large into the
question of unfitness for asylum admission, and the vigour and clearness
of his remarks induces us to quote them at length. He observes:—“It seems
difficult to understand on what principle patients are sometimes sent. One
man, for an intemperate threat uttered under considerable provocation, is
hastened off to the asylum. He can then only be deemed insane in a
constructive sense, and in reliance on the undoubted good faith of the
whole proceedings for his removal. He is seen to be sane; he remains so,
and merely awaits the next discharging-day. In the interval he has had
time to reflect on the danger of uncontrolled speech; but perhaps he and
his family ought not to have incurred the reproach (as it is held) of
insanity in the blood. Perhaps, also, he ought not to have swelled the
list of persons insane, adding his mite to the evidence which supports the
general belief in an actual increase of disorders of the mind.
“Again, the facility with which a drunken prostitute finds admission and
re-admission is astonishing. The delirium, rather than insanity proper,
produced by excessive drinking, has, indeed, some alarming modes of
expression; but it is a different thing from true mental derangement, and
is transient, the patient being generally nearly all right again on
arrival. I confess to a feeling which grudges to such patients the
benefits of an asylum and association with the inmates who are truly
unfortunate. Their detention is wholly unsatisfactory; it leads to
nothing. Long or short, it proves no warning against a return to former
bad courses; whilst the presence of people (I do not call them patients)
of this sort seriously injures the interior comfort of the wards. Ought
such cases to swell the returns of lunacy? Then, in estimating the
supposed growth of insanity among the people, let the fact be remembered,
that here is one contributing element, which was not represented until of
late years. Once again, the extent to which strongly-marked senility is
now made the reason for admission to the asylum is, I think,
unprecedented. To grow childish, wilful, and intractable; to lose memory,
and forget the good habits of a life; to take no note of times and
seasons; to wake by night and be restless, and to become generally
incapable, are the rule rather than the exception at the close of an
extended life. I do not think these natural ills ought to be the cause so
frequently as they are found to be, for sending the subjects of them to an
asylum. Workhouses may not contain the little special accommodation
needful for such cases; but it would not be a good argument to hold, that
because they do not, the asylum must be the proper receptacle.
“Poverty is, truly, the great evil; it has no friends able to help.
Persons in middle society do not put away their aged relatives because of
their infirmities, and I think it was not always the custom for worn-out
paupers to be sent to the asylum. May not this practice be justly regarded
as an abuse of the asylum? It is one more of the ways in which, at this
day, the apparent increase of insanity is sustained. It is not a real
increase, since the aged have ever been subject to this sort of
unsoundness.
“Decayed persons, once placed in an asylum, are ever after held to have
been rightfully deemed insane. If any of their descendants, therefore,
become mentally afflicted, the hereditary taint is straightway accounted
to them. This is, indeed, to show cause why all the world should be mad! I
hold it to be wrong to send persons to an asylum merely on account of
second childhood, and a wrong operating to general disparagement. In the
first place, the practice is only an indirect consequence of poverty;
next, it helps improperly to force asylums to a size inconsistent with
their best management; and thirdly, it is one amongst other apparent, but
not real grounds, for that increase of mental disorder, which is
apprehended with such general alarm.
“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.
