In a large asylum there must be general routine: it can be conducted only by routine; and the attendants are the immediate agents in carrying it out. Their duties necessarily partake largely of a household character; they are engaged in cleaning and polishing, in bed-making and dressing, in fetching and carrying, and in serving meals. But along with these they are entrusted with certain parts of the ‘moral treatment’ of the patients,—in enforcing the regulations as to exercise, employment, amusement, the distribution of meals, and the general cleanliness and order both of the wards and their inmates; and in the exercise of these functions acquire much knowledge respecting the character and habits of those under their care. Yet withal, they are not fit and efficient persons to have medical duties delegated to them. They are not qualified to observe and record the symptoms of disease, to note its changes, nor, except under close surveillance, to apply remedies externally or internally.
Such is the onset or the serious march of bodily sickness not unfrequently, that even the experienced medical observer is prone to overlook it. This is true where disease attacks those sound in mind, and able to express their sufferings, and to lend the aid of their intelligence towards the discovery of the nature and seat of their malady; but the danger of oversight is increased tenfold when the insane are the subjects of bodily lesion. Where the mind is enfeebled and sensibility blunted, and where melancholy broods heavily over its victim, disease is to be discovered only by a watchful and experienced practitioner of medicine; for the unfortunate patient will make no complaint, and the fatal malady may evince itself to the ordinary uninstructed observer by no sufficient symptom to awaken attention; and even where the mind is not imbecile, nor weighed down by its fears and profound apathy, yet the features of its disorder will interfere, in most instances, with the appreciation and interpretation of the symptoms which may reach the knowledge of those about the sufferer, and thereby mask the disease from the non-professional looker-on, and render its diagnosis even difficult to the medical examiner.
With respect to the female attendants of asylums, it may also be observed, that they are frequently young women without experience in disease, and rarely qualified as nurses conversant with certain medical matters; and, from our own observation, they are found to be often backward and shy in reporting particulars respecting the female patients, and badly qualified in administering to their wants when sick. Moreover, equally with the male attendants, there is, by their education and training, no security for a well-governed temper, for long suffering, patience and sympathy. Indeed, the wages given in most asylums are not sufficient to induce a higher class of young women to accept the onerous and often painful and disagreeable duties of attendants on the insane, than that which furnishes housemaids and kitchenmaids to respectable families. If, therefore, their origin be only looked to, it would be contrary to experience to expect from the nurses of asylums, as a body, the possession of high moral principle and sensibility, of correct notions of duty, and of a hearty interest in their duties. We make these remarks, with no intention to censure the whole race of asylum nurses, among whom are many meritorious women; but merely to enforce the opinion that something may be done to improve their character and condition, and that, as a class, they are not rightly chargeable with duties of the kind and to the extent we are engaged in pointing out. On the contrary, their history, position, and education conspire to make them servants in tone and character, unfit often to exercise the discipline and authority entrusted to them; whilst the general duties connected with the cleanliness and order of their wards and rooms, and the observation of the universal routine of the asylum, contribute to the same effect, and the more so in large establishments, where the almost constant supervision of the superintendent is wanting, where individual interest in patients is all but dead, and where their number renders the inmates mere automatons, acted on in this or that fashion according to the rules governing the great machine.
From the necessity of the case, the medical superintendent of a colossal asylum is compelled mainly to trust to the observation of his attendants to discover disease, and to report mishaps. He has his mile or upwards of wards and offices to perambulate daily, and, to keep up some connexion with their four or five hundred inmates, must adopt some general plan. For instance, he refers to the attendant of each ward he enters, demands from him if he has anything to report, wends his way through the apartment, looks right and left, remarks if the floor and rooms are duly swept and garnished; now and then inspects the bed and bedding, bids good morning to more or fewer of the patients who may be present, and unless Brown or Jones has something to report of any one of them, bids good day to all, to recommence the same operation in the next ward. Now Brown or Jones might have had something to report had they medical eyes, and information to detect the first symptoms of disease in one of their patients; but as they have not, the disorder has a fair opportunity to steal a march upon the doctor, and possibly to take such firm possession of its victim before this or that attendant is persuaded something is going wrong, that the doctor only commences his professional operations against it in time to render his certificate of death satisfactory, and the result explicable without a coroner’s inquest.
We do not blame the medical men for not doing more, but we deprecate the system which places it out of their power to do so. No one can gainsay the possibility, nay, the actual occurrence, of avoidable deaths in the large asylums we condemn; and those who know the working of such institutions, know also that the duties are performed much after the sketch delineated, and could be got through in no greatly improved fashion.
But it must not be supposed, that it is only when disease exists or has to be discovered, that the delegation of the principal part of the supervision of patients to ordinary asylum attendants operates injuriously to their well-being; far from it, for many are the cases which require the presence of a more instructed and more sympathizing mind; of a person to appreciate their moral and mental condition; to overrule by his official position disorderly manifestations, to pacify the excitable, to encourage and cheer the melancholy; to espy and anticipate the wants of all; to hear the complaints of some, and to be the confidant of others; to mark the mental changes of individuals, and to adapt surrounding circumstances, their occupations and amusements accordingly. To give such superintendence, or, in other words, to apply such moral and mental treatment, the medical officer is the only fitting person; from him the patients will and do naturally look for it. Let any one follow a medical superintendent in his ordinary visits through the wards; and he will observe how ardently the visit is anticipated by many; how numerous are the little troubles and ailments they wish to disclose to the physician, and only to him; how often he can arrest excitement and calm irritation, only aggravated by the interposition of attendants; how often he can recognize mental and bodily symptoms demanding attention, and, in general, how largely he can supply those minutiæ of treatment, insignificant as they appear, and unthought of as they are by others, whose moral feelings, whose intellectual acumen, whose education and manners, and whose position are deficient to conceive them, and insufficient to put them in force.
There is no question, it must be granted, but that whatever medical supervision may be supplied, yet that the carrying out of most of the details of management must always devolve upon the attendants; it becomes, therefore, a matter of paramount importance to render that class of asylum functionaries as efficient as possible. They need be encouraged by good wages and good treatment; and, what is of great moment, these should be sufficiently good, to induce persons of a better class than that which usually furnishes attendants, to accept such posts. This idea will probably be scouted by the stickler to “a due regard for economy,” at first sight; but we think his economical penchant might be gratified by the plan of carrying out more fully in the wards the distinction of attendants upon the insane and of household servants. For is it not practicable to import the system adopted in the large London Hospitals, where the office of ‘sisters,’ to nurse the patients, is separated from that of under-nurse, to whom the cleanliness of the wards is committed? If so, the immediate attendants on the insane might receive higher wages without increasing the general expenditure of the asylum; for those concerned in the cleaning of the wards would only earn the wages of common household servants. We throw out this suggestion, in passing, for the nature of our treatise forbids our enlarging upon such matters of asylum organization; otherwise, much might be written respecting the duties and the remuneration of attendants, and the advantages of pensions for them after a certain term of faithful service.
To conclude this topic, we may remark that it would be easy, did the subject stand in need of proof, to multiply illustrations, showing that, to transfer the work of medical and moral supervision to attendants, in any similar extent and measure to that which must of necessity prevail in the excessively large asylums which County Magistrates rear in opposition to the decided opinion of those best able to judge, is to frustrate the object of those institutions as curative asylums, and to detract from their advantages as refuges for the incurable.
The evils of overgrown asylums have not, as might be expected, escaped the observation and reprobation of the Commissioners in Lunacy, who have referred to them in several of their Annual Reports, but more at large in that of 1857, wherein they detail their contest with the Middlesex magistrates respecting the further enlargement of the enormous asylums of Hanwell and Colney Hatch, and their strange defeat, the magistrates having contrived to influence the Home Secretary in opposition to the decided opinion of the Commissioners, though seconded by experience, by the general assent of all asylum physicians, and by their position as the referees appointed by the State in all matters touching the erection and management of asylums. With this acquiescence in the erroneous scheme of a County Magistracy in opposition to a Government Commission, we have at present no immediate concern, and may content ourselves with reporting it as an anomalous proceeding which ought never to have occurred: but to revert to the sentiments of the Commissioners, they are expressed in the following quotation from the Report mentioned.
“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.”