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.
Chap. VII.—on the future provision for the insane.
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?