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

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.