Part 2
District physicians appointed in Italy and Germany, 169.--Recognition of principle of appointing district officers in England, in the instance of sanitary medical officers, 169.--District medical officers need to be independent, 170.--Extent of districts, 170.--Such officers to register and visit reported cases of lunacy, 170.--Their reports of cases valuable, 171.--Idiots also should be registered, 171.--District officer might sign order for admission to an asylum, 171.--Better qualified for the duty than magistrates, 171, 175.--Illustrations from evidence of Lord Shaftesbury and Mr. Gaskell, 172.--Suggestions respecting signature of orders, 172.--Objections to clergymen signing orders, 173.--Magistrate's order not required for private patients, 174.--Remarks on proposition of Commissioners to leave selection of cases in workhouses for asylum treatment to the Union medical officer, 175.--District officer best qualified for this duty, 175.--Additional protection afforded to lunatics by the appointment of district medical officers, 175.--District officer to inspect lunatics in workhouses, 176.--Regulations for his guidance, 176.--Lunatics in workhouses should be under certificate, 176.--Medical officer best judge of the wants of cases, 177.--No removal of lunatics from workhouses without supervision, 177.--Committee of visiting magistrates for workhouses, 178.--Principles of action of the Lunacy Commission, 178.--Commissioners' recommendation of visiting committees, 179.--Workhouses licensed to receive lunatics, 179.--Lunatics in workhouses reported by district officer, 180.--Visitation of pauper lunatics by parish authorities, 180.--No such visitation of county lunatics, 180.--Desirability that county lunatics should have a visitor, 181.--Determination of question of lunatics chargeable best left to district officer, 181.--Duties of district officer with outdoor pauper lunatics, 182.--Need of inspection of singly-placed lunatics, 182.--Cost of such inspection, 183.--District officer to visit single cases in lodgings, &c., 183.--To visit private asylums as the physician, joined in inspection with the magistrates, 183.--Position and remuneration of district officers, 184.--Such officers to be met with, 184.--District officers engaged in medico-legal inquiries, 185.--Such a class of officers much needed, 185.--Neglect of organization in State medical matters, 186.--A proper organization not necessarily costly, 186.
CHAP. X.--ON THE LUNACY COMMISSION.
Centralization dreaded as an evil, 187.--Importance of a central and independent body to the interests of the insane, 188, 192.--Want of power in the hands of Commissioners, 188.--Reasons for a central Board, 189.--More frequent visitation of asylums desired, 190.--Value of Commissioners' opinion on lunatic cases, 190.--Inquiries of Commissioners respecting the payment for patients, 190.--Divided authority of Commissioners and Magistrates in the case of private asylums, 191.--Anomaly of this state of things, 191.--Lunacy Commissioners too few, 192.--Magistrates not effectual as asylum visitors, 193.--Jurisdiction of the Commission should be the same throughout the country, 193.--Licensing powers of magistrates, 194.--Duties of office of Masters in Lunacy, 194.--Commissioners should visit all lunatics, whether Chancery or not, 195.--Proposed division of Lunacy Commission, 195, 198.--Advantages of the division proposed, 196.--Reasons for increasing Commission, 196.--Want of Commissioners' supervision of lunatics in gaols, 197.--Inadequacy of the present number of Commissioners, 197.--Appointment of Assistant Commissioners, 198.
CHAP. XI.--OF SOME PRINCIPLES IN THE CONSTRUCTION OF PUBLIC LUNATIC ASYLUMS.
Principles of construction in general use, 199.--Authorities on asylum construction, 200.--Examination of the 'ward system,' 200.--Sketch of the conditions of life in a 'ward,' 201.--Disadvantages of the arrangements, 201.--The arrangements of a ward vary widely from those of ordinary life, 202.--Day and night accommodation should be quite separate, 203.--Advantages of this plan, 204.--Salubrity, warming, and ventilation promoted, 205.--Economy resulting therefrom, 205.--Means of communication facilitated, 206.--Supervision facilitated, 207.--Classification improved, 207.--Domestic arrangements facilitated, 208.--Management facilitated, 209.--A smaller staff of attendants required, 210.--The cost of construction diminished, 210.--Objections to a third story removed, 211.
THE STATE OE LUNACY, AND THE LEGAL PROVISION FOR THE INSANE.
PRELIMINARY OBSERVATIONS.
The number of the Insane, and the legal provision requisite for their protection, care, and treatment, are subjects which will always recommend themselves to public attention and demand the interest alike of the political economist, the legislator, and the physician. To the first, the great questions of the prevalence of Insanity in the community, its increase or decrease, its hereditary character, and others of the same kind, possess importance in relation to the general prosperity and advance of the nation; to the second devolves the duty of devising measures to secure the protection both of the public and the lunatic, with due regard to the personal liberty, and the proper care and treatment, of the latter; to the last belongs the practical application of many of the provisions of the law, besides the exercise of professional skill in the management and treatment of the insane.
Moreover it will not be denied that, owing to the intimate manner in which he is concerned with all that relates to the lunatic, with all the details of the laws regulating his custody and general treatment, as well as with the institutions in which he is detained, with the features of his malady, and with all his wants, the physician devoted to the care of the Insane is well qualified to offer suggestions and recommendations to the legislator. Hence the present pages, in which the aim is to examine the present state of lunacy; the advantages to be gained by early treatment; and the adequacy of the existing legal provision for the Insane; and to offer some suggestions for improving the condition, and for amending the laws relating to the care and treatment, of this afflicted class of our fellow-creatures.
The whole subject of the efficiency of the Lunacy Laws and of their administration, occupies just now a prominent place in public attention, owing to the rapid multiplication of County Asylums and the constantly augmenting charges entailed by them; to the prevalent impression that Insanity is rapidly increasing; to recent agitation in our Law Courts respecting the legal responsibility of the Insane and the conditions under which they should be subjected to confinement, and still more to the proposed legislation on the matter during the present Session of Parliament. It would be a great desideratum could the Lunacy Laws be consolidated, and an arrest take place in the almost annual additions and amendments made to them by Parliament; but, perhaps, this is next to impracticable, owing to the attempts at any systematic, effectual, and satisfactory legislation for the Insane, being really of very recent date, and on that account subject to revisions enforced by experience of its defects and errors. However, the present time appears singularly suited to make the attempt at consolidation, so far as practicable, inasmuch as the appointment of a special committee of the House of Commons on the Lunacy Laws, furnishes the means for a complete investigation into existing defects, and for receiving information and suggestions from those practically acquainted with the requirements of the Insane, and with the operations of existing enactments.
To fulfil the objects taken in hand, and, in the first place, to sketch the present state of Lunacy in this country, it will be necessary to investigate the number of the Insane, and the annual rate of their increase; then to examine the extent of the present provision for them in asylums and of probable future wants. This done, after a brief essay on the curability of insanity, as a means of judging what may be done to mitigate the evil, we shall review the present provision for lunatics, point out its defects, and suggest various remedial measures, calculated in our opinion to improve the condition of the Insane, diminish the evil of the accumulation of chronic cases, and render asylums more serviceable and efficient.
In carrying out our design, we shall be found in some measure occupying ground already taken up by the Commissioners in Lunacy, and by some able essayists in the Medical Journals. We do not regret this, although it may deprive us somewhat of the merit of originality of conception and elucidation, as it will strengthen our positions and enhance the value of our remarks. Fortunately, too, we coincide generally with the opinions from time to time put forth by the Lunacy Commissioners, to whom so great merit is due for their labours in the interests of the insane, and for the character and position our County Asylums enjoy in the estimation of our own people and of foreign nations.
To attempt the character of a reformer when the affairs of Lunacy and Lunatic Asylums are in such good hands may be deemed somewhat ambitious; yet as sometimes an ordinary looker-on may catch sight of a matter which has eluded the diligent observer, and, as the views and suggestions advanced are the result of mature and independent thought, aided by experience of considerable length, and very varied, the undertaking may, we trust, be received with favour.
At all events, we flatter ourselves that the representation of the state of Lunacy in England and Wales; the estimate of its increase and of the provision made for it; the evils of workhouses as primary or permanent receptacles for the Insane; the ill consequences of large asylums, and some of the legal amendments proposed, are in themselves subjects calculated to enlist the attention of all interested in the general welfare of our lunatic population, and in the administration of the laws and institutions designed whether for its protection or for its care and treatment.
CHAP. I.--OF THE NUMBER OF THE INSANE.
This inquiry must be preliminary to any consideration of the provision made or to be made for the Insane. In carrying it out, we have chiefly to rely upon the annual Reports of the Commissioners in Lunacy along with, so far as pauper lunatics are concerned, those of the Poor-Law Board. However, these reports do not furnish us with complete statistics, and the total number of our insane population can be only approximately ascertained. The Lunacy Commission is principally occupied with those confined in public asylums and hospitals, and in Licensed Houses, and publishes only occasional imperfect returns of patients detained in workhouses or singly in private dwellings. On the other hand, the Poor-Law Board charges itself simply with the enumeration of pauper lunatics supported out of poor-rates, whether in asylums or workhouses, or living with friends or elsewhere. Hence the returns of neither of these public Boards represent the whole case; and hence, too, the chief apparent discrepancies which occur when those returns are compared.
To show this, we may copy the tables presented in Appendix H of the Report of the Commissioners in Lunacy for 1857, p. 81.
"Increase of Lunatics of all classes during the last five years, according to Commissioners' Reports 3932
1852 1857 Paupers 12,982 16,657 Private Patients 4,430 4,687 ------ ------ 17,412 21,344
"According to returns published by Poor Law Board during same period 6535
1852 1857 County and Borough Asylums 9,412 13,488 Licensed Houses 2,584 1,908 Workhouses 5,055 6,800 With friends or elsewhere 4,107 5,497 ------ ------ 21,158 27,693."
This very considerable difference of 2603 patients between the two estimates is mainly due--as reference to the summary (at p. 53) proves--to the omission, on the part of the Lunacy Commissioners, of those resident in workhouses and "with friends, or elsewhere," reckoned in the Table of the Poor-Law Board. This explanation, however, is only partial, for, after allowing for it, the two estimates are found to diverge very considerably. Thus, on adding the numbers in the categories last named, viz. 5055 + 4107 = 9162, in 1852,--and 6800 + 5497 = 12,297, in 1857 to the total given by the Commissioners in each of those years, viz. to 17,412 and 21,344, respectively, we obtain a total of 26,574 in 1852, and one of 33,641 in 1857; a variation of 5416 in the former, and of 5948 in the latter year, from the results given in the Table presented by the Poor-Law Board. Much of this wide difference is explicable by the Board last mentioned not having reckoned the private patients, who amounted in 1852 to 4430, and in 1857 to 4687. Still, after all attempts to balance the two accounts, there is a difference unaccounted for, of 986 in 1852, and of 1261 in 1857.
No clue is given in the official documents to the cause of this discrepancy, and we are left in doubt which estimate of our lunatic population is the more correct. The excess occurs in the Commissioners' Returns; for on adding together, in each year in question, the numbers reported by the Poor-Law Board, as detained in County and Borough Asylums and in Licensed Houses, we find that the totals respectively are less than the whole number of paupers as calculated by the Lunacy Commissioners, by the precise difference we have made out, viz. 986 in 1852 and 1261 in 1857. Of the two returns before us, we accept that of the Lunacy Commission, viz. that there were, including those in workhouses, and with friends or elsewhere, 26,574 reported Lunatics in 1852, and 33,641 in 1857; and account for this larger total by the fact that the Poor-Law Board Returns apply only to Unions and omit the lunacy statistics of many single parishes, under local acts, and some rural parishes under 'Gilbert's Act,'--containing in them together above a million and a half people more than are found in unions. Moreover, the Poor-Law Board returns do not include County and Borough Patients. Looking to these facts, the excess of 986 in 1852, and of 1261 in 1857, over and above the totals quoted from the Summary of the Poor-Law Board, is not surprising; indeed, taking the average usually allowed of one lunatic in every 700, the number in one million and a half would be above 2000; that is, more than half as many again as 1261; a result, which would indicate the Commissioners' total to be within the truth.
We have just used the term 'reported lunatics,' for, besides those under certificates and those returned as chargeable to parishes, comprised in the foregoing numbers, there are very many of whom no public board has cognizance. Most such are private patients supported by their own means, disposed singly in the residences of private persons, throughout the length and breadth of the country, and, with few exceptions, without the supervision, in reference to their accommodation and treatment, of any public officer. The Lunacy Commissioners justly deplore this state of things; lament their inability, under existing Acts, to remedy it, and confess that not a tithe of such patients is reported to them, according to the intention of the law (16 & 17 Vict. cap. 96. sect. xvi.). It would appear that less than 200 such cases are known to them; and it would not be an extravagant or unwarrantable estimate to calculate their whole number at about half that of the inmates of Licensed Houses, viz. at 2000. This number would comprise those found lunatic by Inquisition, not enumerated in the Commissioners' summary, although under the inspection of the "Medical Visitors of Lunatics." According to the returns moved for by Mr. Tite "of the total number of Lunatics in respect of whom Commissions in Lunacy are now in force," there were, on the 27th July, 1858, 602 such lunatics, and 295 of them were, according to the Commissioners' tables, detained in asylums or Licensed Houses, leaving 347 not reckoned upon. In addition to this class of the insane there is an unascertained small number of persons of unsound mind in the horde of vagrant paupers, alluded to occasionally in the Lunacy Commissioners' Reports.
The number of Criminal Lunatics in asylums is noted in the returns, but that of those in jails is not reckoned. Although this is comparatively small, owing to the usual custom of transferring prisoners, when insane, to asylums, yet, at any one period, a proportion sufficient to figure in a calculation of the whole insane population of the country will always be found. Nay more, besides such scattered instances in County Prisons, there is a very appreciable number in the Government Jails and Reformatories, as appears from the returns presented to Parliament (Reports of the Directors of Convict Prisons, 1858.)
The prisons included in these reports are:--Pentonville, Millbank, Portland, Portsmouth, Dartmoor, Parkhurst, Chatham, Brixton, Fulham Refuge, and Lewes. In the course of 1857, 216 persons of unsound mind were confined, some for a longer or shorter period, others for the whole of the year, in one or other of those prisons. Making allowance for those of the 216 who by removal from one prison to another (a transfer apparently of common occurrence, the rationale of which we should find it difficult to explain), might be reckoned twice, it may be safely stated that at least 150 were in the prison-infirmaries in question the whole year. In fact, the Infirmary of Dartmoor Prison has wards specially appropriated to insane patients, and actually constitutes a criminal asylum of no insignificant magnitude. For instance, the report tells us that on the 1st of January, 1857, there remained in that prison 102 cases; that 41 were received during the year; 37 discharged (where, or how, we are not told, except of 3, who were sent to Bethlem Hospital); and 106 remained on the 1st of January 1858.
It is also worth noting that in this Dartmoor Prison Infirmary, 38 epileptics remained on January 1st, 1857; 22 were admitted, 13 discharged, and 47 remained on January 1st, 1858. The total of epileptics coming under notice in the infirmaries of the several prisons in question, in the course of 1857, amounted to 135. The remarks on some of these cases of epilepsy by the medical officers, are sufficient to show that the convulsive malady has seriously affected the mental health, and that they might rightly be placed in the category of the insane.
However, having no wish to enhance the proportion of the subjects for Lunatic Asylums, we will deal only with those enumerated as mentally disordered. These amounted, according to the preceding calculations, in the Government Prisons, to 150, and it would seem no exaggerated estimate to assert that an equal number may be found in the various other prisons and reformatories throughout the country. To put the matter in another form, 300 lunatics are to be found in English prisons at any date that a census may be taken. Consequently this sum of 300 must be added in calculating the total of insane persons in this kingdom.
To establish still further the proposition with which we set out, that our public statistics of Insanity are incomplete, the history of every County Asylum might be adduced: for, notwithstanding very considerable pains have been taken, on the proposition to build a new asylum, to ascertain the probable number of claimants, and a wide margin over and above that estimate has been allowed in fixing on the extent of accommodation provided, yet no sooner has the institution got into operation, than its doors have been besieged by unheard-of applicants for admission, and within one-half or one-third of the estimated time, its wards have been filled and an extension rendered imperative. Such is a _résumé_ of the general history of English County Asylums, attested in the strongest manner by that of the Middlesex, the Lancashire, and the Montgomery Asylums; and confirmatory of the fact of the augmentation of insanity in the country at a rate exceeding, more or less, that collected from county returns and public statistics. It is, moreover, to be observed, that the official statistics represent the total of lunatics existing on one particular day, usually the first of January, in each year, and take no account of those many who are admitted and discharged within the year, and who rightly should be reckoned in an estimate of the total number of the insane belonging to that period.
The average daily number resident in asylums would be a more correct representation of their insane population than the total taken on any one day, although it would fail to show the lunacy of the year.
Lastly, to illustrate the point discussed, to indicate how imperfect our present estimate of the prevalence of insanity most probably is, and to show the difficulties and defects of any ordinary census, we may appeal to the experience of the special commission charged by the legislature of Massachusetts to examine the statistics of Lunacy and the condition of Asylums in that State, as recorded in their report, published in 1855.
"In 1848" (they write, p. 18), "a committee of the Legislature, appointed to 'consider the whole subject connected with insanity within the commonwealth,' ascertained and reported the number of insane in this State to be 1512, of whom 291 were able to furnish the means of their own support, and 1156 were unable to do so, and the pecuniary condition of 65 was not ascertained.
"In making that survey in 1848, the Commissioners addressed their letters of inquiry 'to the municipal authorities of every city and town in the commonwealth.'
"These public officers had direct means of knowing the number and condition of the pauper insane, and probably this part of the report was complete; but they had no other facilities of knowing the condition of those lunatics who were in private families, and supported by their own property or by their friends, than other men not in office, and could only speak of those who were within their circle of personal acquaintance. Consequently the report included only a part of the independent insane who were then actually in, or belonged to, the State."
"In 1850 (p. 11), the marshals, the agents of the national government who were appointed to take the census, visited every family; and, among other items of information, they asked for the insane and idiots in the household.
"By this personal and official inquiry, made of some responsible member of every family, the marshals obtained the account of only 1680 insane persons and 791 idiots, which is but little more than two-thirds of the number ascertained by this Commission.
"Making all due allowance for the increase of population, and consequently of the insane and idiots, these figures undoubtedly show far less than the real amount of lunacy and idiotcy at that time, and render it extremely probable that many concealed the facts that the law required them to state to the marshals."