On the State of Lunacy and the Legal Provision for the Insane / With Observations on the Construction and Organization of Asylums

by J. T. Arlidge

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.”