“She had been employed many years in the laundry, and always imagined she was to be removed elsewhere—that on Monday morning a waggon would call at the gate for herself and her property. Accordingly, every Monday morning throughout the year, at 10 o’clock, she was accompanied to the gate, dressed with a coloured handkerchief pinned fancifully over her cap instead of a bonnet, and carrying a small parcel (her property) of the most heterogeneous contents—thimbles, ends of tape, polished bones, pebbles, pieces of smooth coal, &c. The waggon was never found to be in waiting, and Mary, without evincing any disappointment, walked cheerfully back to the laundry, telling the superintendent that ‘The waggon would be sure to come next Monday, but that she need not lose time, so she would work all this week.’”
In many asylums this method of treatment is thought calculated to feed the original delusion; but here, again, the judgment of the physician ought alone to determine the course to be taken in each individual case. In patients labouring under violent excitement, to oppose an hallucination, however absurd, would add fuel to the fire. Again, in a chronic case like that of the laundry-maid, the harmless fancy of the poor creature might not only be indulged in with impunity, but served to renew week by week her stock of cheerfulness.
The lunatic colony of Gheel, situated twelve miles south of Turnhont, in Belgium, amid a vast uncultivated plateau consisting of heath and sand, called the Campine, affords an extraordinary example of the pre-eminent advantages of the present mode of managing lunatics. Until the era of railroads this spot was so out of the ordinary track of the world, that but few persons even of those who were interested in the treatment of the insane were aware of its existence. Here we discover, like a fly in amber, a state of things which has lasted with little change for twelve hundred years. Here we see the last remnants of the priestly treatment of insanity, coupled with a system of non-restraint which certainly existed long before the term was ever heard of in England and France. Gheel owes its origin to a miracle. Saint Dympna, the daughter of an Irish king, suffered martyrdom in this place from the hand of her father in the sixth century. So great was her fame as the patron saint of lunatics, that her shrine, erected in the church dedicated to her, speedily became the resort of pilgrims, who journeyed hither in the hope of being cured of their madness or of preventing its advent. Her elegantly-sculptured tomb contains among other bassi-relievi one in which the devil is observed issuing from the head of a female lunatic, while prayers are being offered up by some priests and nuns, and close at hand another chained maniac seems anxiously awaiting his turn to be delivered from the demon. The idea carefully inculcated by the priests, that lunacy meant nothing more than a possession by the devil, has long been banished from other lands. Here, however, it has flourished for many centuries, and the ceremony of crawling beneath the tomb has existed so long, that the hands and knees of the devotees have worn away the pavement. The act is still occasionally performed amid a scene in which superstition and terror are combined in a manner calculated to cure any lunatic, if deep mental impressions were alone required to purge away his malady. But what is far more interesting and astonishing to those accustomed to the bolts and bars, the locks, wards, and high walls of crowded European asylums, is the almost entire liberty accorded to the lunatics resident in the town of Gheel and its neighbouring hamlets, to the number of 800, or one-tenth of the whole district. No palatial building, such as we encounter in nearly every county in England, is to be seen. The little army of pauper and other patients gathered from the whole superficies of Belgium, instead of being stowed away in one gigantic establishment, in which all ideas of life are merged in the iron routine of an enormous workhouse, are distributed over five hundred different dwellings, three hundred of which are cottages, or small farmhouses, in which the more violent and poorer classes are dispersed, and the remaining two hundred are situated in the town of Gheel, and are appropriated to quieter lunatics and those who are able to pay more liberally for their treatment. In these habitations the sufferers are placed under the care of the host and hostess; more than three persons never being domiciled under one roof, and generally not more than one. The lunatic shares in the usual life of the family; his occupations and employment are theirs, his little cares and enjoyments are the same as theirs. He goes forth to the fields to labour as in ordinary life; no stern walls perpetually imprison him, and make him desire to overleap them, as Rasselas desired to escape even from the Happy Valley. If it is not thought fit for him to labour with plough or spade, he remains at home, and takes care of the children, prunes the trees in the garden, and attends to the potage on the fire; or if a female, busies herself in the ordinary domestic duties of the house. The lunatics, as may be supposed, are not left to the discretionary mercies of the host and hostess. A strict system of supervision prevails, somewhat analogous to that of the lunacy commissioners and the visiting justices of England. The entire country is divided into four districts, each having a head guardian and a physician, to whom is entrusted the medical care of every inmate belonging to that section. There are, in addition, one consulting surgeon and one inspecting physician for the whole community. The general government of the colony is vested in the hands of eight persons, who dispense a code of laws especially devised for it. The burgomaster of Gheel presides over this managing committee, whose duties are to distribute the patients among the different dwellings, to watch over their treatment, and to admit or discharge them. A visiting commissioner is annually appointed, who inspects the dwellings of the different hosts, and sees that the patients are properly cared for. The oversight of the lunatics falls almost wholly upon the hostess, the man rarely interfering, unless called upon to control a disorderly patient. The people of Gheel, from having been engaged for ages in the treatment of the insane, are said to have acquired extraordinary tact in their management, which, Dr. Webster remarks, may be considered to exhibit a most judicious mixture of “mildness and force.” Although instruments of restraint, such as the strait-waistcoat, and the long leathern thong below the leg, to prevent patients from running away, are occasionally resorted to, the sectional physician must be instantly informed of their imposition, and their use cannot be continued without his sanction. So little are they required, that Dr. Webster found less restraint in this colony, unconfined by walls, than in the asylum at Mareville, in France, containing a similar number of lunatics. Yet there were fewer escapes than from the strictly-guarded restraint-abounding prison, only eleven persons having fled from Gheel in the course of last year, and nineteen from Mareville. Here also, it will be observed, there is no separation of the sexes. The lunatics live the life of the other inhabitants, and males and females associate in the same household. If we compare the effects of this simple treatment with that of the most expensive of our own asylums, we are compelled to admit that the balance is in favour of Gheel, where, notwithstanding the free admission of chronic cases, upwards of twenty-two per cent. of cures takes place annually, while at Hanwell and Colney Hatch the cures never exceed fifteen per cent. No fair comparison can be instituted between the expense per head at Gheel and in our English establishments, inasmuch as living is much cheaper in Belgium; but we may state, that the average cost of board and lodging for each pauper in the colony is 10l. per annum, or exactly the sum charged for lodging alone in our county asylums.[17]
A plan, towards which we have been slowly advancing during the last half-century, will speedily, we hope, be more closely followed. A trial is already, to some extent, being made of it in the neighbourhood of existing asylums, and might supplant, with immense advantage, the prevailing custom of building new wings, and over-populating old wards. The present system of enormous buildings, which destroys the individuality of the inmates, and suppresses all their old habits and modes of life, is evidently disapproved by the commissioners, as appears from the language they hold in their tenth annual report:—
“We have the best reason for believing that the patients derive a direct benefit, in many ways, from residing in cheerful, airy apartments detached from the main building, and associated with officials engaged in conducting industrial pursuits. A consciousness that he is useful, and thought worthy of confidence, is necessarily induced in the mind of every patient, by removal from the ordinary wards where certain restrictions are enforced, into a department where he enjoys a comparative degree of freedom; and this necessarily promotes self-respect and self-control, and proves highly salutary in forwarding the patient’s restoration. As a means of treatment, we consider this species of separate residence of the utmost importance, constituting in fact a probationary system for patients who are convalescing; giving them greater liberty of action, extended exercise, with facilities for occupation; and thus generating self-confidence, and becoming not only excellent tests of the sanity of the patient, but operating powerfully to promote a satisfactory cure. The want of such an intermediate place of residence is always much felt; and it often happens that a patient just recovered from an attack of insanity, and sent into the world direct from a large asylum, is found so unprepared to meet the trials he has to undergo, by any previous use of his mental faculties, that he soon relapses, and is under the necessity of being again returned within its walls. Commodious rooms contiguous to the farm-buildings are now in the course of construction at the Somerset County Asylum; and there is every reason to believe that the patients will derive benefit by residing in these apartments, which at once possess a domestic character, and afford every facility to carry on agricultural pursuits.”
It strikes us forcibly that the commissioners have tended to create the evil they deprecate in not protesting against the erection of gigantic asylums; but it is cheering to find that the idea of supplemental buildings possessing a “domestic character” has taken possession of their minds, and that they are now enforcing it on the minds of others with their well-known zeal and ability. The Devon Asylum, among others, has adopted the plan; and its accomplished physician, Dr. Bucknill, the editor of the Asylum Journal, bears important testimony to the great advantages to be derived from it.
“I have recommended the erection of an inexpensive building, detached from, but within the grounds of the present asylum, in preference to an extension of the asylum itself. My reasons for this recommendation are, that such a building will afford a useful and important change for patients for whom a change from the wards is desirable. The system of placing patients in detached buildings, resembling in their construction and arrangements an ordinary English house, has been found to afford beneficial results in the so-called cottages which this institution at present possesses. These cottages are much preferred to the wards by the patients themselves, and permission to reside in them is much coveted. I am also convinced that such auxiliary buildings can be erected at much less expense than would be incurred by the enlargement and alteration of the asylum itself. I propose that in the new building the patients shall cook and wash for themselves.”
“These cottages are much preferred to the wards by the patients themselves, and permission to reside in them is much coveted.” In these few lines we read the condemnation of huge structures like Colney Hatch, built externally on the model of a palace, and internally on that of a workhouse, in which the poor lunatic but rarely finds any object of human interest, where his free-will is reduced to the level of that of a convict, and the very air of heaven necessary to his health is doled out at intervals, when, with infinite lockings and unlockings, the attendants order a batch of persons into the stagnant and tiresome airing courts. Infinitely better for the lunatics would be the freedom and homeliness of the smallest cottage to the formal monotony of cheerless wards; better far that they should, as Dr. Bucknill suggests, cook and wash for themselves, than that the offices should be performed wholesale in the steam-laundry and the steam-kitchen. A patient would undoubtedly feel a far greater interest in peeling his own potatoes for the pot, and in cooking his own bit of bacon, than in receiving them ready cooked. It is the duty of the physician to interest the patient in his daily work, and no more effectual method of accomplishing this could be suggested than in putting him to work for himself.
Wherever large asylums are already erected, no better plan could perhaps be suggested than the building of satellite cottages, which would form a kind of supplementary Gheel to the central establishment; but we should like to see the experiment tried, in some new district, of reproducing in its integrity the Belgian system. The colony of Gheel was once a desert like the country which surrounds it; it is now, through the happy application of pauper lunatic labour, one of the most productive districts of the Low Countries. Have we no unoccupied Dartmoors on which we could erect cottages, and train the cottagers to receive the insane as members of the family? The performance of domestic offices, the society of the goodwife and goodman, and the influence of the children, would do far more to restore the disordered brain of the lunatic—pauper or otherwise—than all the organization of the asylum, with its daily routine, proceeding with the inexorable monotonous motion of a machine, and treating its inmates rather as senseless atoms than as sentient beings, capable, though mad, of taking an interest in things around them, and especially awake to the pleasure of being dealt with as individuals rather than as undistinguishable parts of a crowd. The children are of particular moment. Lunatics are singularly gentle to them, and are interested in all their actions. At Gheel it is customary to send the bairns into the fields to conduct the patients home from their labour in the evening; and we learn from Dr. Webster that a violent madman, who would not stir upon the command of his host, will suffer himself to be led, without a murmur, by an urchin scarcely higher than his knee. The presence of the young in the ward of an asylum seems to light it up like a sunbeam. The love of children does indeed lie at the very foundation of the human heart, and we cannot estimate too highly their beneficial influence upon the brain which is recovering from the horrors of insanity.
One of the most important points in reference to insane paupers, as we have already intimated, is the bringing them as speedily as possible under treatment. The reluctance of the lunatic himself to be removed is usually extreme, and it is marvellous what ingenuity he will often employ to thwart the design. Southey relates that a madman who was being conveyed from Rye to Bedlam slept in the Borough. He suspected whither he was going, and, having contrived by rising early to elude his attendant, he went to Bedlam, and told the keepers that he was about to bring them a patient. “But,” said he, “in order to lead him willingly, he has been persuaded that I am mad, and accordingly I shall come as the madman. He will be very outrageous when you seize him, but you must clap on a strait-waistcoat.” The device completely succeeded. The lunatic returned home, the sane man was shut up, and until he was exchanged at the end of four days, remained in his strait-waistcoat, having doubtless exhibited a violence which amply justified its use. The aversion of the sufferer himself to be taken away coincides with an equal aversion on the part of his relatives and friends to send him from home, nor do they take the step till the madness grows intolerable. Precious time is thus lost at the outset, and when the removal occurs it is mostly to the workhouse. Here the patient is usually kept during the remainder of the curable stage of his malady. The parochial authorities are generally guided by an immediate consideration for the pockets of the rate-payers, rather than by any care for the welfare of the lunatic; and, as they can maintain him in the “house” at three shillings a-week—when they would have to pay nine if they transferred him to the county asylum—in the workhouse he remains until he becomes so dirty or troublesome in his habits that the guardians are willing to pay the difference to get rid of him. The first few months of the disease, within the narrow limits of which full 60 per cent. of the recoveries take place, are thus allowed to run to waste. Months fly by, and the victim subsides into the class of incurables. This produces a second evil. As the drafts of incurables are perpetually flowing into the asylums, they become “blocked up” in the course of a few years, and are converted into houses for the detention of hopeless cases. To this condition three-fourths of the asylums are already reduced, and the efforts of philanthropic medicine are brought to a dead lock by the short-sightedness of the parish authorities, who do not consider that for the sake of saving a few shillings in the board of Betty Smith in the first weeks of her craziness, they are converting her into a chronic burthen, seeing that she will probably live on to a good old age in the asylum, and cause them an ultimate expenditure of hundreds of pounds. To the swifter removal after the outbreak of the disorder we must look for a permanent remedy; but in the mean time something must be done to disembarrass the public asylums of the dead-weight of hopeless cases, if we seriously intend to take advantage of the curative appliances we already possess. The commissioners seem inclined to favour the erection of separate asylums for those who are beyond the reach of medical art. To us it seems that the more economical plan would be to apportion certain wards in the various workhouses for the reception of chronic cases, and to draft off the idiots alone to special establishments. By this means our water-logged asylums would speedily right themselves, and again become what they should never have ceased to be—hospitals for the cure of the insane. At present we encourage an elaborate system for the manufacture of life-long lunatics. It is well known that the cures of early cases of insanity throughout England amount to 45 per cent., and at Bethlehem and St. Luke’s, where no others are received, the cures have amounted to 62 per cent. and 72 per cent. respectively; whereas at Colney Hatch, Hanwell, and the Surrey County Asylum, the three great receptacles for the weepings of the metropolitan workhouses, the average cures do not exceed 15 per cent. If we take the lowest averages of cures, there is still a difference of 30 per cent. of human creatures who sink down into the cheerless night of chronic dementia and idiotcy, or who dream away the remainder of their lives in hopeless childishness. Another ground of complaint is, that a degree of clerk’s work is imposed upon the medical superintendents of large asylums which is quite inconsistent with a proper discharge of their chief duty—the recovery of their patients. Irrespective of the routine-labour of making daily and quarterly and yearly reports, which is very considerable, they have far more to do in their strictly professional capacity than they can possibly accomplish. The three great asylums near the metropolis contain upwards of 3,000 patients, or the population of a good-sized country town; and their moral and physical training is confided to exactly six medical men, or as many as will be found in an hospital of a hundred beds! It is needless to observe how little attention can be paid to each individual, and that the more promising patients must be inevitably swamped in the sea of hopeless lunatics. As long as our asylums remain mere houses of detention, the want of medical superintendence is not so apparent; but immediately these establishments are restored to their proper functions, we predict that the evil will become too glaring to last.