“In addition to the saving of cost and time obtained by adopting the plan we now recommend, we have the best reason for believing that the patients derived a direct benefit, in many ways, from residing in cheerful airy apartments detached from the main building, and associated with officials engaged in conducting industrial pursuits. A consciousness that he is useful, and thought worthy of confidence, is necessarily induced in the mind of every patient, by removal from the ordinary wards, where certain restrictions are enforced, into a department where he enjoys a comparative degree of freedom; and this necessarily promotes self-respect and self-control, and proves highly salutary in forwarding the patient’s restoration. As a means of treatment, we consider this species of separate residence of the utmost importance, constituting in fact a probationary system for patients who are convalescing; giving them greater liberty of action, extended exercise, with facilities for occupation; and thus generating self-confidence, and becoming not only excellent tests of the sanity of the patient, but operating powerfully to promote a satisfactory cure.
“The want of such an intermediate place of residence is always much felt; and it often happens, that a patient just recovered from an attack of insanity, and sent into the world direct from a large asylum, is found so unprepared to meet the trials he has to undergo, by any previous use of his mental faculties, that he soon relapses, and is under the necessity of being again returned within its walls.” (P. 27, Rep. 1856.)
The proposition of the Commissioners has been carried out to a certain extent in several large asylums; for instance, at the Leicester, the Wakefield, and the Devon. At the last it has been most fully developed in the construction of a detached building for 100 patients; respecting the excellence and cheapness of which, we have spoken in a previous page (p. 48).
The views of the Commissioners will meet with general approval. The prevalent system in France of breaking up an asylum into sections, more or less detached, we hold as preferable to the close aggregation of wards under one roof, with continuous corridors, seen in the majority of English Asylums. The correct principle to be pursued in an asylum is, to assimilate its character and arrangements as far as possible to those of the homes of the classes of persons detained in them. Can this be effected in a large building constructed as much unlike ordinary houses as it well can be; recalling in its general character that of an extensive factory, workhouse, or barrack, of somewhat more ornate architecture indeed, and with better “belongings” within and without, where the patients live by day in long corridors, and sleep by night in boxes opening out of the same, and where perhaps they are mustered and marched in great force into a great hall to eat their meals? Certainly all this is not home-like, however excellent to the lovers of routine or the admirers of military discipline. But the separation into sections greatly lessens this objectionable state of things; the population becomes thereby divided, so to speak, into families, overlooked and controllable as such. The advantage of transferring an improving patient from one ward to another is considerable; but it would be much more so, if the transfer were from one section to another; for the construction of separate sections admits of the architectural arrangements, the fittings, &c., being varied to a much greater extent than they can be in the case of wards, forming mere apartments of one large building, constructed, as it must be, on a nearly uniform plan.
From the same grounds likewise follow the economical advantages of distinct sections; for the more expensive building arrangements required for acute cases need not be repeated in the section for quiet, orderly, chronic, or for convalescent patients, where accommodation may be beneficially made to accord as nearly as possible with that of their cottage homes. If detached sections were adopted, the elaborate, complicated and costly systems of warming and ventilation would not be needed; there would be less to cherish the feeling of imprisonment; and, lastly, to recal the valuable observation of the Commissioners before quoted (p. 142), this species of separate residence would be a means of treatment “of the utmost importance, constituting in fact a probationary system,” and a most excellent addition to the means of ‘moral treatment’ now in operation. There is one subsidiary recommendation made by the Lunacy Commissioners, which we cannot so freely subscribe to, that, viz. of classifying the patients in sections according to their occupations. Those of the same trade or employment must, as a matter of course, be associated together, during the hours of labour; but at the expiration of those hours we would wish to see that association broken up. The congregation of the same mentally disordered persons always together is not desirable; the insane are selfish enough—absorbed in self, from the effects of their malady; and it should always be a point in treatment, to disturb this condition, to arouse the attention to others, and to other things; an effort which would be the more difficult in a small knot of people always accustomed to meet together, knowing each other’s ways and whims, and each thinking the other mad, though not himself. Again, if the workers are entirely separated from the drones in the hive, the latter are likely to remain drones still: they lose the benefit of example, which operates, as among children, so strongly with the insane.
To apply these observations to one class of workers, for example, to the laundresses: it seems to us scarcely merciful to keep these poor patients to the wash-tub all day; at the close of their labour to turn them into an adjoining room, and at night consign them to sleep over it. Instead of being thus scarcely allowed to escape the sphere and atmosphere of their toil, they should have their condition varied as far as possible, be brought into new scenes, mixed with others who have been otherwise engaged, and made to feel themselves patients in an asylum, and not washer-women. Is it, in short, not a radical error in the direction of an asylum, to place the inmates in such a position and under such circumstances, as to make them feel themselves workmen under compulsion, regularly employed, dealt with only as labourers and artisans, by being kept all day in their workshops, and in the evening and night brought together, because they are workers, and unlike the other residents of the asylum, who will in their opinion come to be regarded, as unlike themselves,—as the fitting occupants, and the only patients? Treated apart in the manner under notice, there would be nothing in the position or circumstances around the industrious inmate to suggest to him that he was a patient, except in name, as called so by the officials. We are, therefore, opposed to this industrial system of classification, and regard medical classification as the only proper one.
The division into quarters or sections is a plan more applicable to an asylum for chronic than to one for acute cases. In the latter, patients are to be treated specially and individually; and as sufferers from acute disease must be classified medically rather than with reference to any matters of management, occupation, and discipline, and are on the whole less conformable to general orders and plans: yet certain principal sections are wanted in them; as, for example, for the refractory and violent, for the quiet and orderly, and the convalescent. To some of the last named, a separate section, of a home-like character, regulated less as an asylum than as a family residence, and where the highest amount of liberty compatible with safety and order is the rule, would afford a most valuable means of treatment.
§ Distribution of the Chronic Insane in Cottage Homes.
The subdivision of an asylum for chronic cases could be carried very far. Not only might sections be appropriated specially to idiots, to epileptics, to imbeciles, and to the very aged and infirm in an infirmary, but also to several classes of the chronic insane not falling under either of those categories, distinguishable by the greater or less amount of trust to be reposed in them, by their dispositions and tendencies, and by their industrious and moral habits. However, there must be at some point a limit to the utility of subdividing an establishment necessitated by the requirements of its administration and of an effective and easy supervision; and as yet, in this country, the system of aggregation prevails most largely over that of segregation. English asylums have, some of them, detached wards and a few farm-buildings, affording lodging to patients engaged in industrial pursuits; but the plan of segregating their residents has not been pushed farther, except to a small extent by Dr. Bucknill, who has placed some selected pauper lunatics in the homes of cottagers living in the vicinity of the county asylum; for we cannot call the boarding out of the imbecile poor—scattered, as it were, broad-cast over the country, disposed of in cottages, according to the notions of the inferior parochial officers, and watched over only nominally,—a system of providing for them. If system at all, it is merely one for putting them out of the way, of escaping responsibility, and of hiding them from observation.
The colony of insane at Gheel, in Belgium, is the only one where the segregation of the insane has been systematically carried out. It presents most of the elements of success in its constitution and government. It has an organized medical staff; it is a naturally secluded locality; its sane inhabitants have been for ages accustomed to act as the guardians and nurses of the insane, and to receive them as boarders into their families. Yet, notwithstanding the eulogiums of many visitors to this village, others who have more minutely examined into it have detected many irregularities, and pointed out weighty objections against its management.