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

“Our last Report directed attention to the fact, that in providing, not merely for the harmless and demented, but for the more orderly and convalescing, the most suitable was also the least expensive mode; that they might satisfactorily be placed in buildings more simple in character, and far more economically constructed; and that therefore it was advisable, wherever the necessity for enlarging one of the existing asylums presented itself, that the question should be considered in reference to these two kinds of patients. And whether the mode adopted may be, for the convalescing, by simple and cheerful apartments detached from the main building, and with opportunity for association with the officials engaged in industrial pursuits; or, for harmless and chronic cases, by auxiliary rooms near the out-buildings, of plain or ordinary structure, without wide corridors or extensive airing-court walls, and simply warmed and ventilated; it is, we think, become manifest that some such changes of structure must be substituted for the system now pursued, if it be desired to retain the present buildings in their efficiency, and to justify the outlay upon them by their continued employment as really curative establishments. In this way only, as it seems to us, can justice be done to the rate-payer as well as to the pauper.”

Lastly, in their Supplementary Report on Lunatics in Workhouses (1859), they repeat their recommendations to erect distinct inexpensive buildings for chronic cases. The paragraph containing their suggestion has already been quoted (p. 82), and need not be repeated here.

The noble chairman of the Lunacy Board, according to his valuable evidence given before the Special Committee of Lunatics, just printed, appears to have been an early and constant advocate for constructing distinct receptacles for chronic and acute cases. In reply to query, No. 664, his lordship has more particularly enlarged upon the utility of the plan, and referred to the distinct proposition of the Board in 1845, that it should be carried out by the Committees of Asylums. The scheme of separately providing for many chronic lunatics has also received the valued support of Dr. Boyd (Seventh Report, Somerset Asylum, p. 10), who appears to contemplate the erection of the proposed building contiguous to the existing asylum, so as to make use of the patients’ labour “in preparing stone and lime, and in doing all the heavy part of the work,” and to unite the two establishments under a common administration and commissariat, as a plan attended with considerable economical advantages.

We do not deem it necessary to quote other authorities at large, in support of the system advocated; otherwise we might adduce many continental writers, especially among the Germans. It is fair to add, however, that in France generally “mixed asylums” are the rule, and that a few of these contain five or six hundred inmates, but none, we are happy to say, have acquired the prodigious dimensions of several of our English asylums. Moreover, the French system is to erect a number of detached buildings, or sections within the general area of the establishment, adapted to the different classes of the insane, according to the character of their disease, or to their condition as pensioners or paupers. We cannot here discuss the advantages or disadvantages of this plan, but it certainly obviates some of the evils of aggregation evidenced in English asylums, consisting of one continuous structure. It has just been said, that in no French asylum are so many lunatics congregated as in some English institutions; yet it is true, that the great Parisian hospices contain similar numbers; for instance, La Salpêtrière holds as many as 1300; but in this case the arrangement is such, that each of the five sections it is divided into, constitutes practically a distinct hospital for the insane, structurally separated, or quite detached; with subordinate quarters or sections, to provide for a proper classification of the inmates, and having its own grounds for exercise, &c., and its own medical staff. Thus, to the 1300 patients there are five physicians, having equal power and privileges, each one the head of his own section. We would not in any way adduce this extensive Parisian hospice as an example to follow, either in structure or organization; and have alluded to it in so many words only to show, that though equally large in its population, it is comparable in no other respect to the huge receptacles for the insane to be found in this country. Of the prevailing system in Germany we shall presently find occasion to speak.

Lastly, the 8th & 9th Vict. cap. 126, gave express powers to provide for the chronic insane in distinct establishments; in order, according to the marginal abstract to sect. xxvii., “to prevent exclusion from asylums of curable lunatics; separate provision to be made for chronic lunatics.” The chronic asylums were again referred to in sect. xlii. and in sect. lvi., which conferred the necessary powers on the visitors to remove the patients from one asylum to another. It is not worth while to repeat the clauses referred to, since the Act was repealed by the 16th & 17th Vict. cap. 97, and no re-enactment of them took place. Nevertheless, it is to be observed, that the last quoted Act contemplated the provision of asylum accommodation for the whole of the lunatics of each county, and with this object, by sect. xxx., empowered the justices, at any general or quarter sessions, to cause, or to direct the Committee of Visitors of the County Asylum to erect an additional asylum, or to enlarge the existing building, to supply the requisite accommodation; and further, put it into the power of a Secretary of State, “upon the Report of the Commissioners in Lunacy,” to call upon the magistrates of any county or borough to do the same.

This enactment may be enforced by the Lunacy Board so far as the Secretary of State can prevail with a body of magistrates to accede to it, “in such manner as the said Secretary of State may see fit, and direct.” But this high official has no direct power to compel a Committee of Visitors under any sort of penalty. “It shall be lawful for such Secretary of State,” says the clause, “to require” such additional asylum alteration or enlargement; but the history of the contest between that public officer and the Middlesex ‘Committee of Visitors’ appears to prove that his requisition may be neglected and set aside. “He found” (as Lord Shaftesbury tells us in his evidence, Rep. Select Comm., Query, No. 799), “that the passive resistance offered was beyond his power.” We coincide with his lordship, that this ought never to have happened, and think, that the Secretary of State, acting under the representations and advice of the Lunacy Commissioners, ought to be armed with full powers to enforce the provision for pauper lunatics in asylums being rendered equal to the demand for it, according to some plan agreed to by them, in every county, in harmony with the true intent and purpose of the Act now in force.

In order to facilitate the carrying out of this design, and to limit the scope for the passive resistance and attempted delay of some county magistrates, the re-enactment of the sections of the 8th & 9th Vict. sect. 126, as quoted, appears desirable, viz. to sanction and promote the erection of distinct retreats for chronic cases. We are, indeed, glad to find, that in this recommendation we are also in accord with the noble lord at the head of the Lunacy Commission.

Looking at the matter in a general point of view, therefore, we appear to find, in the plan of separating the more chronic and most unpromising cases of lunacy from the recent and hopeful, so as to leave these in smaller numbers for the purpose of more direct and effectual treatment, one mode of improving and extending the future provision of the insane. However, to elucidate the scheme, we need go into further detail, so as to define more particularly the classes to be separately accommodated, and the extent to which the separation should be carried.

The grand distinction, above employed, in discussing the question of separation, has been that of recent and chronic cases, and it has been sought to ignore that of curable and incurable, as not only undesirable, but actually mischievous. By recent cases, we understand all those where the malady is of less than one year’s duration, which form a class that demands the more active and constant attention and treatment of the physician, more purely medical care, more consideration and watching from the attendants, ampler measures for moral treatment, and for exercising salutary impressions on the mind; and withal, special arrangements and fittings in the asylum building itself. All these particular conditions for treatment and management are not to be obtained by recent cases of insanity, as we have insisted on throughout this chapter, in asylums which have grown beyond the size which a chief medical officer can personally supervise in all its details, and, so to speak, animate the whole machine. If this be admitted, and if the cure of the insane be treated as the primary and essential object of asylum detention, then surely the necessity of special provision for recent cases will be recognized.

In moderately sized asylums acute and chronic cases may be, as said before, received and treated together; for instance, in such as accommodate from 250 to 450 patients, provided that the physician-superintendent is properly assisted, for the proportion returned “as deemed curable” in the English county asylums,—a proportion which represents pretty nearly that of the recent cases, rarely exceeding 10 or 12 per cent.; consequently, the 40 or 50 demanding special supervision and medical care may be undertaken by the superintendent, if he be sufficiently assisted in the management of the chronic cases and in the carrying out of the general details of the establishment. On the other hand, a small, and perfectly distinct asylum for 40 or 50 patients could not be established or conducted so advantageously, and still less so economically; a circumstance, which will always avail to perpetuate the system of mixed asylums for acute and chronic cases together. Nevertheless, it must be borne in mind, that the 40 or 50 patients in the population of 300 or 400, do not constitute the whole number of recently attacked cases which may be admitted for treatment, but, so to say, the residue at a particular date; for instance, the first day of the year. Moreover, if the improvements in the law, and in its administration, suggested, are carried out, and the admission of patients immediately on the occurrence of their malady be facilitated, then, as a matter of course, the proportion of those “deemed curable” would be immensely increased; so much so, that it would be a very moderate estimate to reckon on 100 recent, to every 500 chronic cases; or, what is equivalent to this statement, the plan of placing patients under immediate treatment would cause the progressive decrease of chronic cases, and raise the standard of the asylum as a curative institution; a happy result, which, whilst it would necessitate a more complete medical staff, would at the same time well repay its cost.