We do not blame the medical men for not doing more, but we deprecate the system which places it out of their power to do so. No one can gainsay the possibility, nay, the actual occurrence, of avoidable deaths in the large asylums we condemn; and those who know the working of such institutions, know also that the duties are performed much after the sketch delineated, and could be got through in no greatly improved fashion.
But it must not be supposed, that it is only when disease exists or has to be discovered, that the delegation of the principal part of the supervision of patients to ordinary asylum attendants operates injuriously to their well-being; far from it, for many are the cases which require the presence of a more instructed and more sympathizing mind; of a person to appreciate their moral and mental condition; to overrule by his official position disorderly manifestations, to pacify the excitable, to encourage and cheer the melancholy; to espy and anticipate the wants of all; to hear the complaints of some, and to be the confidant of others; to mark the mental changes of individuals, and to adapt surrounding circumstances, their occupations and amusements accordingly. To give such superintendence, or, in other words, to apply such moral and mental treatment, the medical officer is the only fitting person; from him the patients will and do naturally look for it. Let any one follow a medical superintendent in his ordinary visits through the wards; and he will observe how ardently the visit is anticipated by many; how numerous are the little troubles and ailments they wish to disclose to the physician, and only to him; how often he can arrest excitement and calm irritation, only aggravated by the interposition of attendants; how often he can recognize mental and bodily symptoms demanding attention, and, in general, how largely he can supply those minutiæ of treatment, insignificant as they appear, and unthought of as they are by others, whose moral feelings, whose intellectual acumen, whose education and manners, and whose position are deficient to conceive them, and insufficient to put them in force.
There is no question, it must be granted, but that whatever medical supervision may be supplied, yet that the carrying out of most of the details of management must always devolve upon the attendants; it becomes, therefore, a matter of paramount importance to render that class of asylum functionaries as efficient as possible. They need be encouraged by good wages and good treatment; and, what is of great moment, these should be sufficiently good, to induce persons of a better class than that which usually furnishes attendants, to accept such posts. This idea will probably be scouted by the stickler to “a due regard for economy,” at first sight; but we think his economical penchant might be gratified by the plan of carrying out more fully in the wards the distinction of attendants upon the insane and of household servants. For is it not practicable to import the system adopted in the large London Hospitals, where the office of ‘sisters,’ to nurse the patients, is separated from that of under-nurse, to whom the cleanliness of the wards is committed? If so, the immediate attendants on the insane might receive higher wages without increasing the general expenditure of the asylum; for those concerned in the cleaning of the wards would only earn the wages of common household servants. We throw out this suggestion, in passing, for the nature of our treatise forbids our enlarging upon such matters of asylum organization; otherwise, much might be written respecting the duties and the remuneration of attendants, and the advantages of pensions for them after a certain term of faithful service.
To conclude this topic, we may remark that it would be easy, did the subject stand in need of proof, to multiply illustrations, showing that, to transfer the work of medical and moral supervision to attendants, in any similar extent and measure to that which must of necessity prevail in the excessively large asylums which County Magistrates rear in opposition to the decided opinion of those best able to judge, is to frustrate the object of those institutions as curative asylums, and to detract from their advantages as refuges for the incurable.
The evils of overgrown asylums have not, as might be expected, escaped the observation and reprobation of the Commissioners in Lunacy, who have referred to them in several of their Annual Reports, but more at large in that of 1857, wherein they detail their contest with the Middlesex magistrates respecting the further enlargement of the enormous asylums of Hanwell and Colney Hatch, and their strange defeat, the magistrates having contrived to influence the Home Secretary in opposition to the decided opinion of the Commissioners, though seconded by experience, by the general assent of all asylum physicians, and by their position as the referees appointed by the State in all matters touching the erection and management of asylums. With this acquiescence in the erroneous scheme of a County Magistracy in opposition to a Government Commission, we have at present no immediate concern, and may content ourselves with reporting it as an anomalous proceeding which ought never to have occurred: but to revert to the sentiments of the Commissioners, they are expressed in the following quotation from the Report mentioned.
“It has always been the opinion of this Board that asylums beyond a certain size are objectionable: they forfeit the advantage which nothing can replace, whether in general management or the treatment of disease, of individual and responsible supervision. To the cure or alleviation of insanity, few aids are so important as those which may be derived from vigilant observation of individual peculiarities; but where the patients assembled are so numerous that no medical officer can bring them within the range of his personal examination and judgment, such opportunities are altogether lost, and amid the workings of a great machine, the physician as well as the patient loses his individuality. When to this also is added, what experience has of late years shown, that the absence of a single and undivided responsibility is equally injurious to the general management, and that the rate of maintenance for patients in the larger buildings has a tendency to run higher than in buildings of a smaller size, it would seem as if the only tenable plea for erecting them ought to be abandoned. To the patients, undoubtedly, they bring no corresponding benefit. The more extended they are, the more abridged become their means of cure; and this, which should be the first object of an asylum, and by which alone any check can be given to the present gradual and steady increase in the number of pauper lunatics requiring accommodation, is unhappily no longer the leading characteristic of Colney Hatch or of Hanwell.”
As may be supposed, the disposition to build huge asylums is due to the same cause as that of the detention of insane persons in workhouses, viz. to the plea of economy; a plea, which we believe to be about as fallacious in the one case as in the other. The economy is supposed to arise from the saving in commissariat matters and in the governing staff; and it is no doubt proportionately cheaper to provision 1000 persons than 500, other things being the same. But, on the one hand, very competent persons assert that the cost of officers and servants for a population of 1000 insane is more than double that for one of half that amount, when proportionately compared. The multiplication of inferior officers beyond a certain point entails that of superior ones in a higher ratio to overlook them; there is not the same amount of productive labour considering the number employed. The capability of the superintendent to supervise his attendants and the patients stops at a certain point, and he need call to his aid a head attendant at superior wages, and so add an extra person to the staff; if the extent of his charge is farther increased by additional patients and their necessary attendants, then an officer of a higher grade is called for, and other overlookers of attendants and of the régime of the house. But figures showing the relative costs presently appealed to will do more to convince the reader of the fact under notice than any ‘aids to reflection’ we can supply.
There can be no question, that to build asylums for the insane above a certain size is a fallacy when viewed even in an economical aspect; but when regarded in relation to its ulterior consequences, the plan is not only erroneous, but reprehensible. Were it really the case that a pecuniary saving resulted from the aggregation of large masses of mentally disordered folk, according to the figures in the ledger of the institution, yet no positive gain could be boasted of until it was proved that every case was placed in the most favourable conditions for recovery. Can it be pretended that the very extensive asylums of this country, with their present corps of medical officers, furnish such conditions? Certainly not, if there be any truth in the account we have published of their evils and defects. And if those conditions are not supplied, the primary object of these institutions, i. e. the cure of the insane, is frustrated, and chronic lunacy increased. Where, then, is the economy, if patients, failing to receive the means of recovery, by reason of the constitution of the asylum on so large a scale, fall into chronic disease, and become permanent burdens on its funds? Where is the economy of a system, which, by standing in the way of efficient treatment, reduces the proportion per cent. of recoveries to twenty or thirty, when under different arrangements that proportion may equal 60 per cent. or upwards?
It will be a happy day for the insane, and for the contributors to their maintenance, when Visiting Justices arrive at the conviction, that they have not done all they can on behalf of the poor disordered people under their guardianship, when they have provided good lodging, board and clothing for them, and such a system of routine and discipline as to check the manifestation of their mental vagaries; and that it is not enough for a recent case, to introduce it into an asylum and the companionship of lunatics, with practically no positive provision for its medical treatment. It will be well, too, for the insane, when the truth becomes more generally assented to, that their malady is no mythical, spiritual alteration, but the consequence of a material lesion of the brain, the marvellous instrument, the subject and servant of the immortal soul, which can by its divine essence know no disorder.
This is perhaps, strictly speaking, a digression from the subject; yet erroneous ideas are the parents of erroneous practices, and those we have hinted at form no exception to the rule. But, to return, we have some excellent illustrative remarks on the fallacy of the belief in the economy of very large asylums, contained both in the Report of the American and of the English Lunacy Commissioners. The former thus write in their Report (op. cit. p. 136):—
“The policy which has built large establishments for the insane is a questionable one as applied to economy. After having built a house sufficiently large, and gathered a sufficient number of patients for their proper classification and for the employment of a competent corps of officers and attendants, and allowing each to receive just as much attention as his case requires, and providing no more, any increase of numbers will either crowd the house, or create the necessity of building more rooms; and their management must be either at the cost of that attention which is due to others, or must create the necessity of employing more persons to superintend and to watch them.
“If the house be crowded beyond the appropriate numbers, or if the needful attention and the healing influences due to each individual are diminished, the restorative process is retarded, and the recovery is rendered more doubtful; and if additional provision, both of accommodations and professional and subsidiary attendance, is made to meet the increase of patients beyond the best standard, it would cost at least as much per head as for the original number. Dr. Kirkbride thinks it would cost more, and that the actual recoveries of the curable, and the comfortable guardianship of the incurable, are not so easily attained in large hospitals as in such as come within the description herein proposed. ‘It might be supposed that institutions for a much larger number of patients than has been recommended could be supported at a less relative cost; but this is not found to be the case. There is always more difficulty in superintending details in a very large hospital; there are more sources of waste and loss; improvements are apt to be relatively more costly; and, without great care on the part of the officers, the patients will be less comfortable.’
“Besides the increased cost of maintaining and the diminished efficiency of a large establishment, there is the strong objection of distance and difficulty of access, which must limit the usefulness of a large hospital in the country, and prevent its diffusing its benefits equally over any considerable extent of territory to whose people it may open its doors.”
Having pointed out the evils of large asylums to their inmates, the English Commissioners, in their Eleventh Report (p. 11), remark, “that the rate of maintenance for patients in the larger buildings has a tendency to run higher than in buildings of a smaller size,” ... and that it therefore “would seem as if the only tenable plea for erecting them ought to be abandoned.” To substantiate this assertion, they appeal to the table of weekly charges of the several county asylums, set forth in the Appendix C.C. of the same Report, which certainly shows that the cost per head is at its maximum in those which receive the largest number of patients. This being so, surely no one can withhold assent to the just conclusion of the Commissioners, that the system of erecting asylums above certain dimensions ought to be abandoned, inasmuch as the only plea that can be urged in its behalf, that, namely, of its economy,—a bad plea, by the way, if the real interests of patients and ratepayers are concerned,—is founded in error.
One more topic needs a few words, viz. the very inadequate remuneration of the medical superintendents in some asylums,—a circumstance, confirmatory of the small value assigned by their Committees of Visitors to professional qualifications. The worst instances of underpayment are, in fact, met with in those very asylums where the number of inmates attains its maximum, and the medical provision for their care is at its minimum; where the administrative power of the medical men is the most limited and most interfered with, and their ability to discharge their duties conscientiously and efficiently, utterly crippled by the multitude of claimants upon their attention surrounding them; and where, in fine, they are merely accessory officials, useful in cases of sickness and accident. It must, indeed, be gratifying to the advocates of the rights of women to know, that in one asylum, at least, female labour is rated as equal to male professional labour; that the matron is as well paid as the medical officers, and more valued in the estimation of the Committee of Visitors. But, however this circumstance may be viewed by the partisans of the interests of the fair sex, we venture to believe that to most people it will appear a gross anomaly. For our own part, we consider also that it would be to the interests both of patients and rate-payers to elevate the position of the medical superintendents of asylums, and to pay them liberally.
As this section of our work is passing through the press, we have got the Report, just printed, “from the Select Committee on Lunatics,” and are most happy in being able to extract from its pages a very decided opinion expressed by the Earl of Shaftesbury respecting the scanty salaries of medical superintendents. His Lordship, in reply to the question (765), “Have you any other remedies to apply to county asylums?” said,—“I do not know whether it is a matter that could be introduced into the Bill, but I think the attention of the public should be very much drawn to the state of the medical superintendents in these asylums. It is perfectly clear, that to the greater proportion of the medical superintendents in these asylums, very much larger salaries should be given; and unless you do that, you cannot possibly secure the very best service.... The great object must be to raise the status and character of the superintendents to the highest possible point.” In the course of further examination on this subject, his Lordship repeats and adds to the opinion just recorded. For instance, he remarks,—“One of the great defects of the present system is, that the salaries of the medical officers are much too low for the service they perform. I think that the county ought to secure the very best talent and responsibility that can be found, and they ought to raise their salaries higher. I believe in some of the asylums the salaries are higher, but I hardly know one where the salary is adequate to the work done.... I cannot think that any superintendent ought to receive much less than from £500 to £600 a year, besides a house and allowances.”
In this matter, we hope the liberal views of the noble Chairman of the Lunacy Commission will sooner or later be reciprocated by the Visitors of Asylums; in the mean time, the thanks of the medical profession are heartily due to his Lordship for his able advocacy of its just claims.
§ Limit to be fixed to the size of Asylums.
One remedy against extending the evil consequences of large asylums, is to restrict the size of future buildings within certain limits. We do not hope to persuade the advocates of gigantic asylums, by any representation we can offer of their ill-effects to the patients and their false economy, to abandon their notions; but we do hope that there will be a parliamentary interdiction to their perpetuation, or that the Commissioners in Lunacy will have sufficient authority lodged in their hands to limit the size of future asylums.
Although all persons conversant with the treatment and requirements of the insane concur in condemning such huge asylums as Hanwell and Colney Hatch, yet there is some difference in opinion, of no very great extent indeed, among them with regard to the number of patients who should be assigned to the care of a single superintendent. Moreover, the number who may be treated in the same building and by one physician, will differ according to the nature of the cases—whether all acute, or all chronic, or mixed, acute and chronic together. In this country all the asylums are of a mixed character, but, excepting two or three hospitals for the insane, contain a large preponderance of chronic cases. They are, moreover, all spoken of by the Lunacy Commissioners as Curative Asylums.
Let us now examine the opinions of some of the best authorities upon the subject, so that a tolerably accurate judgment may be formed of the limits within which the size of asylums should be restricted.
In 1844, the Metropolitan Commissioners in Lunacy laid it down as a rule that “no asylum for curable lunatics should contain more than 250 patients, and 200 is, perhaps, as large a number as can be managed with the most benefit to themselves and the public in one establishment.”—Report, 1844, p. 23. The present Commissioners have expressed similar views, which also were clearly stated before the Special Committee of the House of Commons this year, by the noble Chairman, the Earl of Shaftesbury.
If we look to American opinion, we find (Rep. Commiss. Massachus. 1855, p. 135) that “it is the unanimous opinion of the American Association of Medical Superintendents of Insane Asylums that not more than 250 patients should be gathered into one establishment, and that 200 is a better number. When this matter was discussed, there was no dissent as to the maximum; yet those who had the charge of the largest hospitals, and knew the disadvantages of large numbers, thought that a lower number should be adopted.
“Taking the average of the patients that now present themselves in Massachusetts, of whom 80 per cent. are supposed to be curable, and need active treatment, and 82 per cent. incurable, and require principally general management and soothing custodial guardianship, and having ‘due regard to the comfort and improvement of the patients,’ this limit of 250 should not be exceeded.
“The principal physician is the responsible manager of every case, and should therefore be personally acquainted with the character and condition of his patients, the peculiarities of the diseased mind, as manifested in each one, and the sources of trouble and depression, or exaltation and perversity. This knowledge is necessary, in order that he should be able to adapt his means of medical or of moral influence with the best hope of success.”
Dr. Kirkbride, in his special treatise on the Construction and Organization of Asylums, thus expresses his views (p. 10):—“Whatever differences of opinion may have formerly existed on this point (the size of the Institution), I believe there are none at present. All the best authorities agree that the number of insane confined in one hospital, should not exceed 250, and it is very important that at no time should a larger number be admitted than the building is calculated to accommodate comfortably, as a crowded institution cannot fail to exercise an unfavourable influence on the welfare of its patients. The precise number that may be properly taken care of in a single institution, will vary somewhat, according to the ratio of acute cases received, and of course to the amount of personal attention required from the chief medical officer. In State Institutions, when full, at least one half of all the cases will commonly be of a chronic character, and require little medical treatment. Even when thus proportioned, 250 will be found to be as many as the medical superintendent can visit properly every day, in addition to the performance of his other duties. When the proportion of acute or recent cases is likely to be much greater than that just referred to, the number of patients should be proportionately reduced, and 200 will then be found to be a preferable maximum. While no more patients should be received into any hospital than can be visited daily by the chief medical officer, it is desirable that the number should be sufficiently large to give an agreeable company to each class, and to permit a variety of occupations and amusements that would prove too costly for a small institution, unless filled with patients paying a very high rate of board, or possessed of some permanent endowment. It might be supposed that institutions for a much larger number of patients than has been recommended, could be supported at a less relative cost; but this is not found to be the case. There is always more difficulty in superintending details in a very large hospital—there are more sources of waste and loss; improvements are apt to be relatively more costly; and without great care on the part of the officers, the patients will be less comfortable.
“Whenever an existing State Institution built for 250 patients, contains that number, and does not meet the wants of the community, instead of crowding it, and thereby rendering all its inmates uncomfortable, or materially enlarging its capacity by putting up additional buildings, it will be found much better at once to erect an entirely new institution in another section of the State; for under any circumstances, the transfer of acute cases from a great distance, is an evil of serious magnitude, and constantly deplored by those who have the care of the insane.”
French authorities take the same views. M. Ferrus, who wrote so long back as 1834, and is now one of the Inspectors of Asylums in France, says, in his book, ‘Des Aliénés,’ that an asylum for the treatment of mental disorder ought not to contain above 150, or at most 250 patients; but that one having a mixed population of cases requiring treatment of incurables and idiots, may receive 400 or even 500 such inmates, provided the physician is afforded sufficient medical assistance. However, his brother inspector, M. Parchappe, whose able work, ‘Des principes à suivre dans la fondation et la construction des Asiles d’Aliénés’ (published so recently as 1853), forms the most valuable treatise on those subjects, does not approve so large a number of inmates to be collected in an asylum as M. Ferrus would sanction. He writes:—“After taking every consideration into account, I think the minimum of patients ought to be fixed at 200, and the maximum at 400. Below 200, the economical advantages decline rapidly without a compensatory benefit; above 400, although the economical advantages augment, it is at the detriment of the utility of the institution in its medical character.”
M. Guislain, the eminent Belgian physician, in his grand work on Insanity, remarks (vol. iii. p. 347), “It would be absurd to attempt to bring together in the same place a very large population; it would tend to foster an injurious degree of excitement; would render the management difficult or impossible; would destroy the unity of plan, and neutralize all scientific effort. The maximum ought not to exceed 300 or 350 insane persons. This limit cannot be exceeded without injury to the well-being of the inmates; but unfortunately this has been but too often disregarded, under the plea of certain views of organization or of economy.”
Jacobi placed the maximum of asylum population at 200 (Ueber die Anlegung und Errichtung von Irren-Heil-anstalten, p. 24); Roller expressed his opinion (Grundsätze für Errichtung neuer Irren-anstalten, p. 84) that one instituted for the treatment of cases (Heil-anstalt) should not at the most receive above 200; but that an asylum for chronic cases (Pflege-anstalt), connected with the other, may admit from 250 to 300, making a total population, under the same general direction, of 450 or 500; and Damerow (Ueber die Relative Verbindung der Irren-Heil-und Pflege-anstalten) unites in the same opinion.
It would be useless to multiply quotations; for, in short, there is complete unanimity among all those concerned in the direction of asylums, that such institutions, when of large size, are prejudicial to their inmates and withal not economical. There is likewise a very near coincidence of opinion perceptible with reference to the question of the number of patients which ought to be placed in the same building. Supposing the asylum to be specially devoted to the reception of recent cases, it is agreed that it ought to accommodate not more than 200, and that the smaller number of 150 inmates would be preferable. If a receptacle for both acute and chronic mental disease, some would limit the population to 250, whilst others would extend it to 400, provided the medical officers were increased in proportion.
The example of the German asylums under the direction of Damerow and Roller is peculiar; for the curable and chronic cases are not mixed, but placed separately in two sections or two institutions under a general medical direction within the same area. This is the system of ‘relative connexion’ of the “Heil-anstalt,”—institution for treatment, or the Hospital, and the “Pflege-anstalt,” the ‘nursing’ institution, or the asylum; to the former they would allot 200, and to the latter 300 as a maximum, making a total of 500 inmates under the same physician in chief and the same general administration, but each division separately served by its own staff and specially organized.
§ Increase of the Medical Staff of Asylums.
In the next place, the medical staff of an asylum should be large enough to secure daily medical observation and attendance for each individual patient, along with a complete supervision of his moral condition, his amusements and employment. We have said that this provision is deficient in many English asylums, a statement amply confirmed by the opinions of others.
Dr. Kirkbride (op. cit. p. 44) lays it down as a rule, that “where there are 250 patients, especially if there is a large proportion of recent cases, besides the chief physician, two assistant physicians will be required, one of whom should perform the duties of apothecary. In some institutions, one assistant physician and an apothecary will be sufficient. If the full time of two assistant physicians, however, is taken up by their other duties among the patients, an apothecary may still be usefully employed in addition; and to him, other duties among the male patients may with propriety be assigned.”
French writers coincide in these views. M. Parchappe assigns to an asylum containing 200 to 250 patients, a physician with an assistant, besides a dispenser; to one having 300 to 360 inmates, a physician, two assistants and a dispenser, besides a director to superintend the general administration, who in some institutions is also a medical man.
In Germany, and generally in Italy, the medical staff is still larger in proportion to the number of patients. Jacobi apportions to an asylum for 150 or 200 lunatics, a chief physician, a second, and an assistant, besides the dispenser. Roller coincides with this, and the asylum at Illenau under his superintendence, consisting of two divisions, one for recent, the other for chronic cases, and containing in all 414 patients, has three physicians besides two assistants or ‘internes.’ So at Leubus, in Silesia, there are three physicians, although the inmates are only 150 in number; and the rule is, in other German asylums, containing 100 inmates, to have two physicians, besides one or two internes and a dispenser (pharmacien).
Allowing the opinions and practice of the eminent men quoted, and which in truth are shared in by every asylum superintendent, their due weight, it would seem no extravagant arrangement to allot to an asylum accommodating from 150 to 200 patients (recent and chronic cases together), a physician superintendent and an assistant; and a similar medical staff to an institution for 300 or 350 inmates, all in a state of confirmed chronic insanity, imbecility, and dementia. If the population in an asylum for chronic cases is further augmented to 450 or 600,—the latter number we hold to represent the maximum which can economically and with a just regard to efficient government and supervision and to the interests of the patients, be brought together in one establishment,—the medical superintendent will require the aid of two assistants and a dispenser.
Such aggregations as of 1000 to 2000 insane people are unwieldy and unmanageable with the best appointed medical staff, unless this be so numerous as utterly to invalidate the plea of economy, the only one, fallacious as it is, that can be produced by the advocates for their existence. And not only are they unmanageable, but also hygienically wrong; for it is a well-recognized fact, that the accumulation of large numbers of human beings in one place, tends to engender endemic disease, uniformly deteriorates the health, and favours the onset, progress, and fatality of all disorders. The history of large asylums bears testimony to the truth of this; for cholera has scourged more than one most severely, and dysentery and chronic or obstinate diarrhœa are pretty constant visitants in their wards.
The contrast between the opinions and practice of the distinguished men referred to and those of some Committees of Visitors respecting the value of medical attendance on the insane, the nature of the duties to be performed, and the amount of labour the superintendent of an asylum may accomplish, is most remarkable. What those of the former are, is stated already; what those held by the latter are, we have an illustration in the administration of the Colney Hatch and of the Hanwell Asylums. In the latter establishment we find two medical men appointed to superintend 1020 insane inmates, besides nearly 200 persons employed about it. True, we are informed by the Committee, that the superintendent of the female department, who has the larger number, some 600, under his charge, is assisted by the matron; and we are sure he must be thankful for any assistance rendered him; yet it is the first time that we have been called upon to recognize a matron as an assistant medical officer. However, we must accept it as a fact,—gratefully we cannot,—but with a protest against placing a subordinate officer on such an independent footing, against entrusting her with duties incompatible with her education and position, and with the relations which should subsist between her and the superintendent, and against making her his equal in the remuneration for her services.
Did occasion offer, we might ponder over this new development of the matronly office; inquire respecting the medical qualifications demanded, and the manner in which the Hanwell Committee have ascertained them; and meditate at length on the notions which govern the Visiting Justices in organizing and directing an asylum; but for the present, we will, for further example’s sake, note some of their opinions and doings in the management of the sister ‘refuge for lunatics’ at Colney Hatch. We shall, for this purpose, appeal to the Report for 1856, and to make the quotations used intelligible, will premise, that the steward, at that date, had turned architect, and produced a plan for the extensive enlargement of the asylum as proposed by the Magistrates; and that, very naturally, when writing about it, he was intent to prove that his plan was the best, the cheapest and the most convenient even to the medical superintendents who would be called upon to officiate in it when completed. This much being premised, we will quote the steward’s own words.
“I must also remind the Committee,” he observes, “that some three years since it was with them a matter of serious deliberation, whether it was advisable that the male and female departments should be placed under the care of one medical superintendent, and, in fact, whether one medical officer should have the supervision and direction of 1250 inmates, and an extended range of building; or whether the two departments should continue, as they are at present, separate and distinct.” What an excellent insight does this revelation of the cogitations of the Committee-room of the Middlesex Magistrates afford us of the sentiments these gentlemen entertain of the requirement and value of medical skill in an asylum; of the capacity, bodily and mental, of a superintendent for work! But, without waiting to fill up a sketch of the wondrous virtues and faculties which the superintendent of the 1250 insane patients need to possess in order to know all, supervise them, direct them, and attend to the multitudinous duties of his office as a physician and director, we will by a further extract gather clearer notions of the extent of the work thought to be not too much for him. The gist of the ensuing paragraph is, that the steward strives to prove that by adding a new story here and there, besides spurs from the previous building, he will increase greatly the accommodation without much augmenting the ambulatory labours of the medical officer. And alluding to one, the male division of the establishment, he proceeds to argue, that “if it is considered feasible for one person to superintend 1250 patients of both sexes in a building extending from one extreme to the other, nearly two-thirds of a mile, would it not be equally feasible to superintend 840 patients in a building one half the extent [here Mr. Steward forgets to count the number of furlongs added by his proposed new wards], provided they are conveniently and safely located, although these patients are all males?”
To this we may be allowed to subjoin some remarks we penned in a critique published in the ‘Asylum Journal’ (vol. ii. p. 271) for 1856, and in which many of the observations contained in the present work were briefly sketched. “Who, we ask, can dispute the feasibility of a medical or of any other man superintending 840, 1250, or two or three thousand patients, collected in an asylum or in a town, in the capacity of a director or governor, if subordinate agents in sufficient number are allowed him? But we think the question in relation to asylums is not, how we can govern our insane population most easily and at the least possible cost, but by what means can we succeed in curing the largest number of cases of insanity as they arise, and thus permanently keep down expenditure and save the rates. These results are certainly not to be attained by persevering in the old scheme of congregating lunatics by tens of hundreds, but by making suitable provision for the immediate treatment of the pauper insane in asylums properly organized for it, and under the direction of a sufficient medical staff.”
How totally different, too, are the views of Jacobi to those of the Middlesex Magistrates concerning the office of superintendent, and the extent of work of which he is capable! In his treatise on Asylum Construction (Tuke’s Translation, p. 23), he presents the following sensible remarks:—“It is not that I should consider a more numerous family (than 200) incompatible with the right management of the farming and household economy, nor with the domestic care of the patients; both these might perhaps be organized in an establishment containing a number equal to the largest just named (four or six hundred), in such a manner as to leave nothing to be desired; but it is in regard to the higher government of the establishment, and the treatment of the patients as such, in its widest signification, which must rest upon the shoulders of a single individual,—the director of the establishment,—that I am convinced the number of patients should not exceed two hundred. For when it is considered that the duties of the governor embrace the control of all the economical and domestic arrangements, as well as of the whole body of officers and servants; that he must devote a great share of his time to the writing, correspondence, and consultations connected with his office; that as first physician, he is entrusted with the personal charge and medical treatment of every individual committed to his care; that he must daily and hourly determine, not only the general outlines, but the particular details of the best means for promoting the interests of the collective community, as well as of every separate person composing it; and that, besides all this, he is responsible to science for the results of his medical observations in the establishment over which he presides; nor less so for the promotion of his own advancement as a man and a philosopher;—it will be readily granted, that the given maximum of two hundred patients for a single establishment ought never to be exceeded. Indeed, a man of even extraordinary abilities would find himself unequal to the task of discharging these duties, in an establishment containing two hundred patients, were he not supported by such assistance as will hereafter be described; and were there not a great number amongst even this multitude of patients requiring not constant, or at least, a less degree of medical attention.”
Many writers on asylum organization, particularly those of the Continent, insist very strongly on so far limiting the size of asylums for the insane, that they may be superintended by one chief medical officer, aided indeed by assistants, but without colleagues of coordinate powers. The venerable Jacobi took this view, and desired that the director of an asylum should be the prime authority in all its details of management, and insisted that the institution should not by its size overmatch his powers to superintend it and its inmates as individuals. Thus, after reviewing the nature of the duties devolving on the chief physician, he observes (p. 192, Tuke’s translation), “It follows as a necessary consequence that one man must be placed at the head of the establishment,” ... and that “his mind must pervade the whole establishment.” Likewise M. Parchappe joins in the same opinion; and after speaking (Des Principes, p. 43) of the impossibility of proper medical supervision in a very large asylum, observes, “that to divide the medical direction among two or more physicians is extremely detrimental to the superiority which the medical superintendent ought to hold in the general administration of asylums, and to that unity of purpose and opinions required in the interests of the patients.”
Without citing other foreign writers to substantiate the view under consideration, we may call attention to the fact, that the Lunacy Commissioners, who have always so stoutly advocated the position of the medical officer as the superintendent of an asylum, likewise appear to accept the same principle; for in their Eleventh Report (p. 11), they remark, that besides the direct injury inflicted upon patients when congregated in excessive numbers in the same institution, “experience has of late years shown, that the absence of a single and undivided responsibility is equally injurious to the general management.”
Lastly, the Committee of Visitors of the Surrey County Asylum appear,—judging from their recent appointment of a chief physician to their institution, paramount to the medical officers of the divisions, and invested with full powers as director,—to have arrived at the just conviction that there must be unity and uniformity in the management of an institution. However, we regret to say that this conviction is unaccompanied by that other which Jacobi and Parchappe would associate with it, viz. that the size of the asylum should be no larger than will admit of the chief physician acquainting himself with every case individually, and treating it accordingly. Whilst, indeed, by their proceeding, they constitute the chief physician a governor of a large establishment, and the director of the household and of its economy, they at the same time deprive him of his professional character by removing the opportunities of exhibiting it beyond his reach, both by the relations they place him in to the other medical officers, and by the enormous aggregation of patients they surround him with.
Few objections, we presume, are to be found to the principle of having a chief medical officer paramount to all others engaged in the work of an asylum; and although, considered as a medical superintendent, his professional qualities are not in much requisition in so large an institution as the Surrey County Asylum, yet we regard such an appointment as most desirable, and as preferable to the system of dividing the management between two medical officers, as pursued in the Middlesex County Asylums. Indeed, the value of the principle of concentrating power in the hands of a chief officer, under the name of governor, or of some equivalent term, is recognized by its adoption in large institutions of every sort in the country. Such enormous asylums as those referred to, partake rather of the nature of industrial than of medical establishments. Their primary object is to utilize the population as far as practicable, and this end can be attained in a large majority of the inmates; consequently an able director is of more consequence than a skilful physician; for the latter is needed by a very small minority, by such a section, in fact, as is represented by the inmates of a workhouse infirmary only compared with its entire population. Therefore, since the enormous asylums in existence are not to be got rid of, it is desirable to give them an organization as perfect as practicable; and it is under this aspect that we approve the plan of the Surrey Magistrates in appointing a director paramount to every other officer. The approval of this proceeding, however, does not minish aught from our objections to such enormous institutions, considered as curative asylums for the insane. As a refuge for chronic lunatics, an asylum so organized and superintended as is the Surrey, may subserve a useful purpose; but we hold it to be an unsuitable place for recent cases demanding treatment as individuals suffering from a curable disease, and requiring the exercise of the skill and experience of a medical man specially directed to it.
While the system of congregating so many hundreds of lunatics in one establishment, and the magisterial principle of providing for the care and maintenance and of non-intervention in the individual treatment of the insane prevail, no objection can be taken to the practice of Committees of Visitors in according the first merit when candidates come forward for the office of medical superintendent of an asylum, to qualifications for the routine government of large masses, for the allotment of labour, for the regulation of the domestic economy of a house, for the profitable management of the farm; in short, for qualities desirable in a governor of a reformatory-school or prison. Indeed, they are right in so doing, when they wish to have a well-disciplined and profitably worked asylum; and when their institution attains the dignity of a lunatic colony, it is the best course they can adopt, for medical qualifications in such an establishment sink into insignificance amidst the varied details of general administration, which fall to the lot of the superintendent. But the case would be materially changed were the primary object of an asylum the successful treatment of its inmates, and were its dimensions within the limit to afford its superintendent the opportunity to know all, and to treat all its patients as individuals to be benefited by his professional skill. In selecting the physician of such an asylum, the administrative and agricultural qualifications he might possess, though far from being unnecessary or unimportant, should occupy a secondary place in the estimation of Committees of Visitors; and the primary requirement should be the possession of properly certified medical skill, of experience in the nature and treatment of insanity, in the wants and management of the insane, and of asylums for them; of evident interest and zeal in his work, and of those intellectual and moral endowments adapted to minister to the mind diseased, to rule by kindness and forbearance, and at the same time with the firmness of authority.
The only apology permissible for detaining lunatics in workhouses, is that there is no asylum accommodation for them to be had; and the only one attempted on behalf of the construction of colossal asylums is, that the demands for admission and the existing numbers are so many, and the majority of cases chronic and incurable, that the most economical means of providing for them must be adopted, which means are (so it is supposed) found in aggregating masses under one direction and one commissariat. Now, whilst we have, on the one hand, contended that workhouses should be as soon as possible disused as receptacles for the insane, we have, on the other hand, endeavoured to prove that very large asylums are neither economical nor desirable, especially if the cure of lunatics, and not their custody only, is contemplated by their erection. Indeed the attempt to keep pace in providing accommodation for the insane poor with their multiplication by accumulation and positive increase or fresh additions, has failed, according to the mode in which the attempt has hitherto been made. New asylums have been built and old ones enlarged throughout the country, and between 1843 and the end of 1857, the accommodation in them had been increased threefold; whilst, at the same time, pauper lunatics had so multiplied, that their number in licensed houses remained almost the same, and the inmates of workhouses and chargeable imbeciles and idiots residing with their friends or with strangers, had very largely increased. The history of pauper lunacy in Middlesex furnishes one of the most striking commentaries upon the system pursued to provide for its accumulation, and on its failure. “When (we quote the 11th Report of the Commissioners in Lunacy, 1857, p. 12), in 1831, Hanwell was built for 500 patients, it was supposed to be large enough to meet all the wants of the county. But, two years later, it was full; after another two years, it was reported to contain 100 patients more than it had been built for; after another two years, it had to be enlarged for 300 more; and at this time (Colney Hatch having been meanwhile constructed for the reception of 1200 lunatic paupers belonging to the same county) Hanwell contains upwards of 1000 patients. Colney Hatch was opened in 1851; within a period of less than five years, it became necessary to appeal to the rate-payers for further accommodation; and the latest returns show that, at the close of 1856, there were more than 1100 pauper lunatics belonging to the county unprovided for in either of its asylums.” At this conjuncture the Commissioners proposed a third asylum, so that they might, “by a fresh classification and redistribution of the patients, not only deal with existing evils universally admitted, but guard against a recurrence of evils exactly similar, by restoring to both asylums their proper functions of treatment and care.” However, instead of adopting this wise policy, the Committee of Visitors insisted on following out their old scheme of adding to the existing asylums, in the vain hope of meeting the requirements of the county; and have proceeded to increase the accommodation of Hanwell to upwards of 1600, and that of Colney Hatch Asylum to nearly 2100 beds. Yet let them be assured they have taken a very false step, and that though they heap story on story and add wing to wing, they will be unable to keep pace with the demands of the pauper lunatics of the county; nor will they succeed in the attempt, until they make the curative treatment of the insane the first principle in their official attempts to put into execution those lunacy laws confided to their administration by the legislature.
Perceiving that this scheme of adding to asylums until they grow into small towns defeats the object of such institutions as places of treatment and cure, and that it will continue to fail, as it has hitherto failed, to supply the demands for accommodation, the Commissioners remarked in their last (12th) Report, that “a scheme of a far more comprehensive nature” is called for to meet increasing events. They have not hinted in that Report at any scheme, but we may gather from other similar documents, especially from that of 1857, that one important plan they have in view is to remove a large number of chronic, imbecile and idiotic patients from the existing, expensively built and organized asylums, and to place them in others erected, adapted and organized for their reception at a much less cost. By this means they count both on rendering the asylums generally, now in existence, available as curative institutions for the reception of new cases as they arise, and on arresting the tendency and the need to erect such enormous edifices as do discredit to the good sense of the magistrates of the counties possessing them.
We agree with the Commissioners in the general features of the plan advanced, and indeed, in our notice of the Reports of the Middlesex County Asylums, in 1856 (Asylum Journal, vol. ii. p. 354 et seq.), advocated the establishment in that county of a third asylum especially for the treatment of the recent cases as they occurred. Now the adoption of any such plan implies the recognition of a principle which has been very much discussed, viz. that of separating one portion of a number of insane people from another, as less curable or incurable. However, the Commissioners in Lunacy avoid discussion, and treat the matter in its practical bearings; still a brief critical examination of it will not be here misplaced.
§ Separate Asylums for the more recent and for chronic cases.
The proposition of placing recent and chronic cases of lunacy in distinct establishments is often so put as to beg the question. It is asked if any one can undertake to say categorically that any case of insanity is incurable, and thereupon to transfer it to an asylum for incurables? To the question thus put every humane person will reply in the negative; he will start at the idea of consigning an afflicted creature, conscious of his fate, to an abode, which, like Dante’s Inferno, bears over its portal the sentence, “Abandon hope all ye who enter here.” But a solution thus extorted is in no way a reply to the question of the expediency or inexpediency of making a distinction in place and arrangement for the treatment of recent and of chronic cases of lunacy severally; for this is a matter of classification, and one particularly and necessarily called for, where the insane are aggregated in large numbers, and the conditions of treatment required for the great mass of chronic cases are insufficient for the well-being of the acute. The real practical questions are,—1, Cannot the subjects of recent insanity be separated advantageously, and with a view to their more effectual and successful treatment, from a majority of the sufferers from chronic insanity, imbecility and fatuity, and particularly so where the total number of the asylum inmates exceeds the powers of the medical officer to study and treat them as individuals? and, 2, Does not the separation of the very chronic, and according to all probability, the incurable, afford the opportunity to provide suitably for the care of that vast multitude of poor lunatics, at present denied asylum accommodation; and to effect this at such an expenditure, as renders it practicable to do so, and thereby to meet the present and future requirements of the insane?
Several eminent psychologists have taken up the question of separating recent and probably curable cases from others found in asylums, in an abstract point of view, as if it were equivalent to forming an absolute decision on the grand question of the curability or incurability of the patients dealt with; and, as a matter of course, their adverse view of the subject has found numerous abettors. The subject is, however, well deserving of examination de novo, in the present juncture, when some decided scheme must be agreed to for the future provision of the insane, and for repairing the consequences of past errors.
In the first place, let us ask, are the harrowing descriptions of the deep depression and despair felt by patients on their removal after one or two or more years’ residence in a curative asylum to another occupied by chronic cases, true and sketched from nature? we think not. Writers have rather portrayed the sensations they would themselves, in the possession of full consciousness and of high sensibility, experience by a transfer to an institution as hopelessly mad, and have overlooked both the state of mental abasement and blunted sensibility which chronic insanity induces in so many of its victims, and still more the fact that no such absolute and universal separation of acute and chronic, as they picture to their minds, is intended.
Indeed, we believe that, even among patients who retain the consciousness and the powers of reflection to appreciate the transfer, no such lively despair as authors depict is felt. In the course of our experience at St. Luke’s Hospital, we have seen many patients discharged ‘uncured’ after the year’s treatment in that institution, and transferred to an asylum, without noting the painful and prejudicial effects on their mental condition supposed. Disappointment too is felt by patients rather at discovering that on their discharge from one asylum they are to be transferred to another, instead of being set at liberty and returned to their homes; for few of the insane recognize their malady, and they will think much less about the character of the asylum they are in, than their confinement and restricted liberty. Again, it is not at all necessary to contrast the two institutions, by calling the one an asylum for curables, and the other an asylum for incurables; indeed, such a class as incurables should never be heard of, for we are not called upon to define it. The two asylums might be spoken of as respectively intended for acute and for chronic cases; or the one as an hospital, the other as an asylum for the insane; or better still, perhaps, the one as the primary (for primary treatment), and the other as the secondary institution.
The removal, and the date at which it should take place, should be left to the discrimination of the medical officer. No period need be fixed at which treatment in the primary institution should be given up; the nature, the prospects, and the requirements of a case must determine when treatment therein should be replaced by treatment in the secondary asylum. Moreover, no barrier should be opposed to a reversed transfer; a trial in another institution is often beneficial, and it would be an advantage to have the opportunity of making it. In the removal from the hospital to the asylum there would be no declaration that the patient was incurable, but only that his case was such as not longer to require the special appliances of the former, although it still needed the supervision of an asylum, and a perseverance in a course of treatment and nursing fully and particularly supplied by the resources of the latter.
The determination of the cases proper for the secondary asylum lodged in the physician’s hands would always enable him to retain those in the primary one, whose state, though chronic, would in his opinion be injuriously affected by a transfer, and any such others besides whose presence in the wards he might deem an advantage in the management. We mention the latter, because the opponents to separation insist on the benefits to an asylum accruing from the admixture of recent and chronic cases. And although we are not prepared to deny an opinion held by so many eminent men, yet we are on the other side not at all persuaded that the presence of old inmates is of any such real advantage, as supposed, to newly-introduced ones. We can assert, from experience, that recent cases can be very satisfactorily treated without the company of old ones; and we must, moreover, confess to certain misgivings that the actual presence of a long-standing case, often eloquent on the injustice of his detention, a Job’s comforter to the new-comer, by his remarks on the severity of his disorder, with the assertion added, that there was nothing the matter with the speaker’s self when he came into the house; full of gossip about all the mishaps of the place, and often exercising an annoying superiority and authority assumed on account of his position as one of the oldest inhabitants. To the statement of the value of their service in aiding the attendants and in watching their neighbours, we rejoin, there should be attendants enough to perform the duties of supervision; that many recent are equally serviceable as chronic cases, and stand in need of being encouraged by the attendants in taking part in those many minor details which characterize life in the wards of an asylum.
However this question of the utility of mixing chronic and recent patients together may be solved, we do not contemplate the existence of a primary asylum without the presence of more or fewer chronic cases, retained in it for the best medical and moral reasons. Likewise, on the other hand, the secondary asylum will not so exclusively be the abode of incurables. The lapse of time in a case of insanity most potently affects its chances of recovery, but it is not an invariable obstacle to it; for experience decidedly demonstrates that recovery may take place years after every hope of it has passed away, and that patients rally from their affliction, not after four or five years only, but even after ten and twenty; consequently, among the large number of chronic patients under treatment, there would doubtless be every year some restored to reason and to liberty; and the dreaded foreboding of perpetual confinement and hopeless incurability could not take possession of the minds even of those whose perceptions rendered them conscious of their condition and position.
To arrive at a correct judgment on this matter, let us look into it from another point of view, and compare the condition of a lunatic in the proposed chronic asylum with that of one in a large county asylum, conducted according to the prevailing system. Look to the fact, that in some of the existing large curative (?) asylums, not more than from 7 to 12 per cent. of their six or eight hundred, or one thousand inmates, are deemed curable, and say in what respect a patient introduced into an establishment of the sort, surrounded on every side by crowds of chronic lunatics, enjoys any superiority over one transmitted to a secondary asylum of the description we contemplate. Call such an institution what we may, announce it as a curative asylum, or as an hospital for curables, it matters not; to a fresh-comer it has all the drawbacks of a chronic asylum; for if he be alive to his condition, and can reflect on the position and circumstances in which he is placed, he may well find grounds for discouragement and despair on looking round the gigantic building, overflowing with the victims of chronic insanity, many of appearance, habits, and manners, repugnant to the higher and better feelings of any thinking, reflecting mortal; who count their residence there by years and even tens of years, with no prospect of release, and who, it may be in his imagination, are not, or have never been, so afflicted as himself. Can such a spectacle be otherwise than injurious to a recent case, sufficiently well to perceive it on admission, or coming to appreciate it during convalescence? and must not the recognition of his position by the patient be most painful and discouraging as one of a multitude, eliciting personally, except perhaps for the few first days, no more attention than the most crazy old inmate near him; submitted to the same daily routine, and having no superior with sufficient time on hand to hear at large his tale of woe, to soothe his irritated spirit, or to encourage him in his contest with his delusions and fears? If the case of the new-comer be chronic, the conditions he finds himself placed in are sufficiently distressing and annoying; but if it be recent and curable, they are damaging to his chance of recovery.
The comparison just drawn tells in favour of the system of separation. Recent cases would not, in the primary institution or hospital, find themselves an insignificant few surrounded by a host of chronic patients, and they would accordingly escape the evils of such a position; on the contrary, they would be placed under the most favourable conditions for recovery, be individually and efficiently attended to, and encouraged by the many convalescents around them to hope and strive after their own restoration to health and liberty.
The sketch presented of the evils of the companionship of long-disordered inmates with new-comers, especially when those are melancholic, is not an imaginary one, but drawn from experience. Often will a desponding patient observe, ‘I shall become like such or such moping, demented lunatic’; and superintendents, if they would, might often record the ill-effects of example of older inmates upon those newly admitted.
Attempts by means of classification somewhat mitigate, where made, the evils of large asylums for recent cases, by keeping these to a certain measure apart from most of the other lunatics; but nothing can do away with the injurious impression on a mind sufficiently awake to receive it (on such a one, in short, as the question of the place of treatment can alone concern),—of being one member of many hundreds who have for years and years known no other residence than the huge house of detention they are in: and there is no compensation to be had for the loss of those special appliances, and that individual treatment, which only a properly-organized hospital can supply.
The last clause suggests another important argument for the treatment of recent cases in a distinct establishment or in separate sections. It is, that they require a peculiar provision made for them, involving greater expense, a more complete medical staff, a physician accustomed to their supervision and management, unfettered by that host of general duties which the presence of a multitude of chronic patients entails, and a staff of attendants disciplined to their care, and possessing many of the qualifications of nurses. Moreover, the building itself for this class of patients need be more expensively constructed and fitted than one for chronic inmates.
There is yet another reason against largely extending the size of a county asylum, and in favour of building, in the place of so doing, a distinct structure. This reason is to be found in the influence of distance as an obstacle to the transmission of the insane to an asylum for treatment, and to the visits of their friends to them during their confinement. The Lunacy Commissioners of the State of Massachusetts particularly remarked the operation of distance in debarring insane patients from treatment, and illustrated it by a table showing the numbers received from different places within the district it served, and in relation to their population, into the asylum. Likewise in this country, where the distance of the asylum is considerable, it is a reason for delay on the part of the parochial officers, who wish to avoid incurring the expense of removing the case, if they can in any way manage it in the workhouse.
But the evil of remoteness operates more frequently, and with much cruelty, against the visits of poor persons to see their afflicted relatives in asylums. Many can neither undertake the cost, nor spare the time required for the journey, notwithstanding the modern facilities of travelling. The same evil is likewise an impediment to the visits of parochial officers, who rightly possess a sort of legal guardianship over their lunatic poor in asylums.
Lord Shaftesbury, in his evidence before the Select Committee, 1859, very properly dwelt upon the advantages of visits from their friends to lunatics in asylums, and even proposed to make their visits compulsory by act of parliament. The Commissioners in Lunacy also, in their Twelfth Report (1858), gave examples of the distress not unfrequently attending on the separation of the patient in an asylum at a long distance from his friends. Such distress operates to the disadvantage of the patient, and increases the sorrow of his relatives.
Admitting there are advantages attending the multiplication of asylums instead of aggregating lunatics in very large ones, it would appear the correct policy for boroughs to build asylums for the refuge of their own insane; or, where small, to unite with other boroughs in the county for the same purpose, in place of contributing to the county-establishment, and inducing the magistrates to extend its size injuriously. In a case such as that of Middlesex, where the county asylums have attained such an unwieldy size as to be past acting as curative institutions, it would seem no improper extension of the law to make it imperative upon the large metropolitan boroughs to build apart for their own pauper lunatics. Of this we are persuaded, that it would soon be found to the profit of the boroughs to undertake to provide for their own pauper insane.
We regret that, in advocating the separation of chronic from recent cases, we place ourselves in antagonism to many distinguished men who have devoted themselves to the care of the insane, and among others to our former teacher and respected friend Dr. Conolly, from whose clinical visits and lectures at the Hanwell Asylum, many years ago, we derived our first lessons, in the management and treatment of the insane. But although regretting some divergence of opinion on this point, we are confident of his readiness to subscribe to that maxim of a liberal philosophy, expressed by the Latin poet, “nullius addictus jurare in verba magistri.”
To return from this digression: there are two propositions to be established, viz.—1. That there are many cases of chronic mental disorder to be found in every county asylum, which encumber it, to the prejudice and exclusion of recent cases, and which could, without mental pain or damage, or any tangible disadvantage, be removed from the institution considered as a curative one. 2. That less elaborate structural adaptations, and a less expensive organization, would suffice for the proper care and treatment of a large number of chronic cases. Let it be understood, however, that neither in past nor future remarks is it our intention to argue against the existence of mixed asylums altogether,—for by careful classification in a moderately-sized establishment, a zealous physician, properly assisted, may contrive to do his duty, both towards the comparatively few acute, and the many chronic cases under his charge; but against the pretence of admitting recent patients for curative treatment in monster institutions filled with chronic cases, where individual daily recognition is all but impracticable, efficient medical supervision unattainable, and proper medical and moral treatment impossible.
Deferring for the present the inquiry, under what conditions of the insane population of a county should distinct asylums be constructed, let us see what are the views of the Lunacy Board bearing upon the two propositions put forth, and examine further into the means of providing for the future wants of the insane. So long since as 1844, the then Metropolitan Commissioners in Lunacy advised the institution of distinct asylums for the more chronic cases of insanity (Report, p. 92), and thus expressed themselves:—“It seems absolutely necessary that distinct places of refuge should be provided for lunatic patients who have become incurable. The great expenses of a lunatic hospital are unnecessary for incurable patients: the medical staff, the number of attendants, the minute classification, and the other requisites of a hospital for the cure of disease, are not required to the same extent. An establishment, therefore, upon a much less expensive scale would be sufficient.”
An exception might be taken to the wording of this paragraph, as assumptive of incurability being an absolute condition, and as countenancing the scheme of a refuge distinctly provided for incurables; both of them ideas repugnant to the humane mind, instructed by experience, that insanity, at almost any lapse of time, and under most forms, is not to be pronounced absolutely incurable, or beyond the hope of cure. The scope of the argument adduced can, however, not be objected to, for it will be generally admitted that less expensive institutions are needed for very chronic cases in general, and that it is an important object to clear the present curative asylums of such cases, so as to facilitate the admission and the early treatment of recent patients. The present Lunacy Board, in their Tenth Report, 1856, repeated these views, and pointed out the importance of erecting detached buildings in connexion with the offices used for the different occupations pursued in the establishment, instead of adding new stories, or new wings, to the main building.
In the Report for the following year (1857), the Commissioners returned to the subject, in connexion with the proposed enlargement of the Middlesex County Asylums; and, having remarked on the rapid accumulation and crowding of those refuges with chronic cases, so soon after that at Colney Hatch was opened, thus write (p. 13):—“Manifestly the remedy now was, not to exaggerate the mistake already committed, by additions on the same costly scale for purposes to which they would be as inappropriate; but, by a fresh classification and redistribution of the patients, not only to deal with existing evils, universally admitted, but to guard against a recurrence of evils exactly similar, by restoring to both asylums their proper functions of treatment and care. It had become not more matter of justice to the lunatics themselves, than of consideration for the rate-payers, to urge, that the additional accommodation required being for classes of patients, as to whom, for the most part, small hope of cure remained, might be supplied in an asylum much better suited to them, and of a far less costly character.” At a subsequent page (p. 23), they recur to the theme. After pointing out that the plan of placing chronic, and presumed harmless patients taken out of asylums, in workhouses and “in their private homes,” had signally failed, they observe:—“We are, therefore, brought back to the conclusion already stated ..., to which we find all reasoning upon the subject necessarily converge, and which we desire to impress as strongly as possible upon every one to whom the care of the insane is committed, that a new, and less costly kind of provision is now very generally required for large classes of pauper lunatics, to whom the existing expensive structures are unsuited.
“Our last Report directed attention to the fact, that in providing, not merely for the harmless and demented, but for the more orderly and convalescing, the most suitable was also the least expensive mode; that they might satisfactorily be placed in buildings more simple in character, and far more economically constructed; and that therefore it was advisable, wherever the necessity for enlarging one of the existing asylums presented itself, that the question should be considered in reference to these two kinds of patients. And whether the mode adopted may be, for the convalescing, by simple and cheerful apartments detached from the main building, and with opportunity for association with the officials engaged in industrial pursuits; or, for harmless and chronic cases, by auxiliary rooms near the out-buildings, of plain or ordinary structure, without wide corridors or extensive airing-court walls, and simply warmed and ventilated; it is, we think, become manifest that some such changes of structure must be substituted for the system now pursued, if it be desired to retain the present buildings in their efficiency, and to justify the outlay upon them by their continued employment as really curative establishments. In this way only, as it seems to us, can justice be done to the rate-payer as well as to the pauper.”