On the State of Lunacy and the Legal Provision for the Insane / With Observations on the Construction and Organization of Asylums

On the State of Lunacy and the Legal Provision for the Insane / With Observations on the Construction and Organization of Asylums

Author:
J. T. Arlidge
Author:
J. T. Arlidge
Format:
epub
language:
English

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Author: Arlidge, J. T. (John Thomas), 1822-1899
Psychiatric hospitals — Great Britain
Psychiatric epidemiology
Mental health services — Great Britain
Insanity (Law) — Great Britain
Mentally ill — Care — Great Britain
Psychology
Pathological — Epidemiology
On the State of Lunacy and the Legal Provision for the Insane
With Observations on the Construction and Organization of Asylums

On the State of Lunacy and
the Legal Provision for the Insane

 
 
ON THE
STATE OF LUNACY
AND THE
LEGAL PROVISION FOR THE INSANE,
WITH
OBSERVATIONS ON THE CONSTRUCTION AND
ORGANIZATION OF ASYLUMS.

 
BY
JOHN T. ARLIDGE, M.B., A.B. (Lond.),
LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS; ASSOCIATE OF KING’S
COLLEGE, LONDON; PHYSICIAN TO THE WEST OF LONDON HOSPITAL;
FORMERLY MEDICAL SUPERINTENDENT OF ST. LUKE’S
HOSPITAL, AND PHYSICIAN TO THE SURREY
DISPENSARY, ETC.

 
LONDON:
JOHN CHURCHILL, NEW BURLINGTON STREET.
1859.
 
 
PRINTED BY TAYLOR AND FRANCIS,
RED LION COURT, FLEET STREET.
 
 
TO
THE RIGHT HONOURABLE
THE EARL OF SHAFTESBURY,
CHAIRMAN OF THE COMMISSION OF LUNACY,
WHOSE LONG-CONTINUED AND UNTIRING EFFORTS IN BEHALF OF THE
INSANE
HAVE EARNED FOR HIM THE HIGHEST ESTEEM AND ADMIRATION
OF ALL WHO FEEL INTERESTED
IN THE WELFARE OF THAT CLASS OF THE AFFLICTED,

THIS TREATISE
IS, BY PERMISSION,
RESPECTFULLY DEDICATED BY HIS LORDSHIP’S MOST OBEDIENT
HUMBLE SERVANT,

THE AUTHOR.
 
 


PREFACE.

The writer of a book is usually expected to show cause for its production,—a custom which, however commendable as a sort of homage to his readers for challenging their attention to his lucubrations, must often put the ingenuity of an author to the test. Indeed the writer of this present treatise would feel some embarrassment in accounting for its production, did he not entertain the conviction that he has, in however imperfect a manner, supplied a work on several important subjects which have never before been so placed before the public, and which, moreover, occupy just now a most prominent position among the topics of the day.
In the last Parliament, up to the period of its dissolution, a Special Committee of the House of Commons was engaged in examining into the condition of lunatics and the laws of lunacy; and the present Government has re-appointed the Committee, in order to resume the inquiry preparatory to the introduction of new enactments into the Legislature. The subjects treated of in the following pages relate to the same matters which have engaged the attention of Parliament, and elicited the special inquiry mentioned, viz. the present state of Lunacy and of the legal provision for the Insane with reference to their future wants.
In order to a better appreciation of the existing provision for the insane, and of its defects, the author has introduced certain preliminary chapters on the number of the insane, on the increase of insanity, on the inadequacy of the existing public provision for the insane, and on the curability of insanity. In reviewing the character and extent of the provisions for the insane, the course adopted has been to regard them in reference to their effects on recovery, and to discover the conditions inimical to it, whether without or within asylums. Hence the evils of private treatment and of workhouse detention of lunatics, particularly of the latter, have largely claimed attention. The condition of pauper lunatics boarded with their friends or with strangers demanded special notice, as did the long-complained-of evils of sending unfit cases to the county asylums, often to the exclusion of recent and curable ones, which might by proper treatment be restored to health and society. Turning to the consideration of our public asylums, considered as curative institutions, the disposition to extend them to an unmanageable size, and to substitute routine for treatment, has called for animadversion, as an error pregnant with numerous evils to their afflicted inmates. Another error pointed out is that of appointing too small a medical staff to asylums; and in proving this, as well as in estimating the proper size of asylums, the experience and opinions of both English and foreign physicians are copiously referred to.
The future provision for the insane forms an important chapter, which, in order to consider the several schemes proposed, is divided into several sections, viz. concerning the propriety of building separate asylums for recent and for chronic cases—of constructing distinct sections—of distributing certain patients in cottage homes—of erecting separate institutions for epileptics and for idiots.
The registration of lunatics has appeared to the author’s mind of so great necessity and value that he has devoted several pages to unfold his views and to meet probable objections; and, in order to render the plan effectual, he has propounded as a complementary scheme the appointment of District Medical Officers, and entered into detail respecting the duties to be imposed upon them.
Viewing the Commission of Lunacy as the pivot upon which any system of supervising and protecting all classes of lunatics must turn, it became necessary to examine into the capability of the present Board for its duties; and the result of that examination is, that this Board is inadequate to the effectual performance of the duties at present allotted to it, and that it would be rendered still more so by the adoption of any scheme for a thoroughly complete inspection and guardianship of all lunatics. This conclusion suggests the proposition to enlarge the Commission, chiefly or wholly, by the appointment of Assistant Commissioners, charged particularly with the duties of Inspectors.
The concluding chapter, on asylum construction, may be considered supplementary. Its chief intent is to develope a principle generally ignored, although (unless the arguments in support of it fail) one of great importance if asylums are to serve, not as simple refuges for lunatics, but as instruments for treating them.
This résumé of the heads of subjects discussed in the ensuing pages will, on the one hand, show that the present is not to be reckoned as a medical treatise, but as one addressed to all who are interested either in the legislation for Lunatics or in their well-being and treatment; and, on the other, make good, it is trusted, the assertion that it occupies an untrodden field in the literature of insanity, and that its matter is good, even should its manner be thought not so.
Assuming the publication of the book to be justifiable, it only remains for the author to add that he has not undertaken its composition without bringing to the task thirteen years’ study and practical experience among the insane, treated in private houses, in licensed houses, and in public asylums, together with the fruits of observation gathered from the visitation of most of the principal asylums of France, Germany, and Italy.
In conclusion, he hopes that this small volume may in some measure contribute towards the amelioration of the condition of the insane, who have such especial claims on public sympathy and aid.
J. T. A.
Kensington, July 1859.
 
 


CONTENTS.

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On the State of Lunacy and the Legal Provision for the Insane / With Observations on the Construction and Organization of Asylums
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PRELIMINARY OBSERVATIONS.
Importance of an inquiry relative to the number of the Insane, and the legal provision for them, 1.
 
Chap. I.—OF THE NUMBER OF THE INSANE.
Official returns imperfect, 3.—Divergence of returns of Lunacy Commissioners and of Poor-Law Board, 4.—Unreported ‘private’ lunatics, 5.—Criminal lunatics in prisons, 6.—Inadequate estimate of the number of the Insane, 7.—Illustration of the difficulty of discovering the true statistics of Lunacy, 7.—Number of pauper lunatics in workhouses, 9.—Paupers not enumerated in official returns, 9.—Estimate of the total number of the insane on 1st of January 1859, 10.—Causes of apparent increase, 10.
 
Chap. II.—ON THE INCREASE OF INSANITY.
Materials for calculation unsatisfactory, 11.—Rate of accumulation of the insane in asylums, 12.—Estimate of increase made by the Commissioners, 12.—Table of number of lunatic paupers in workhouses, 13.—Calculation of their rate of increase, 14.—Increase of pauper lunatics not in workhouses or asylums, 14.—Total increase and accumulation of lunatics, 15.—Positive increase of insanity by new cases, 15.—Table of admissions in four years, 16.—Total number of new cases added yearly, 17.—Expenditure on account of the pauper insane, 18.—Proportion of the insane to the population, 18.—Cause of accumulation of the insane, 19.—Suggestions for obtaining improved statistics of pauper lunatics, 19.
 
Chap. III.—STATE OF THE PRESENT PROVISION FOR THE INSANE IN ASYLUMS.—ITS INADEQUACY.
Commissioners’ calculation of asylum accommodation wanted, 20.—Their conclusion that the present provision is inadequate, 22.—On the accuracy of the Commissioners’ conclusions, 22.—Pauper lunatics accommodated in workhouses, and boarded out, 23.—Their unsatisfactory condition, 23.—Colony of insane at Gheel, in Belgium, 24.—Character of lunatics in workhouses, 25.—Unfit cases of insanity in workhouses, 25.—Commissioners’ estimate that one-half of lunatic inmates of workhouses are improperly detained, 26.—Estimate of asylum accommodation required, 26.
 
Chap. IV.—ON THE CURABILITY OF INSANITY.
Insanity a very curable disorder, 27.—Experience of American physicians, 27.—Exceptional circumstances in American asylums, 28.—Experience of St. Luke’s Hospital, London, 28.—Experience of the Derby County Asylum, 30.—Advantages of early treatment, 30.
 
Chap. V.—ON THE CAUSES DIMINISHING THE CURABILITY OF INSANITY, AND INVOLVING THE MULTIPLICATION OF CHRONIC
A. Causes external to Asylums.
§ Detention of Patients in their own homes.
Absence of all curative influences at home, 32.—Causes of delay in submitting patients to treatment, 33.—Impediments to transmission to county asylums, 34.—Evils of pauper test in public asylums, 34.—Characters of Continental asylums, 35.—Practice followed in America, 36.—Scheme of assessment of means of those applying for admission to public asylums, 36.—Failure of the pauper test to protect the rate-payers, 37.—Its demoralizing and degrading effects, 38.—Suggestion as to conditions and mode of admission into county asylums, 38.—Act in force to recover the costs of maintenance objectionable and inefficient, 39.
 
§ Detention of Patients in Workhouses.
Detention practised on economical considerations, 40.—Examination of the value of such considerations, 41.—Estimated cost in asylums and in workhouses includes different items in the two, 41.—Illustration from the Devon Asylum Report, 42.—Children constitute above two-thirds of workhouse inmates, 42.—Material effect of this on the cost of maintenance, 42.—Inmates of asylums almost all adult, 42.—Fluctuations among inmates of workhouses greater than in asylums, 43.—Mode of estimating the rate per head of cost in workhouses, 43.—Population of workhouses, sane and insane mixed, 44;—that of asylums of insane especially, 44.—Those insane who involve increased cost rejected from workhouses, 44.—Remarks on this point by Dr. Bucknill, 44.—Economy of workhouses for the insane doubtful, 45.—Cost of asylums contrasted with that of workhouses, 46.—System of asylum structure hitherto adopted unnecessarily expensive, 47.—Workhouses and asylums not fairly comparable as to cost, 47.—Plan to diminish cost of asylums one-half, 48.—Chronic lunatics can be provided with asylum accommodation at a rate not exceeding that for workhouses, 48.—Internal cost of asylums and workhouses compared, 49.—Mistaken policy of constructing lunatic wards, 50.—Unfitness of workhouses for insane patients, 51, 75.—Evils attending presence of lunatics in workhouses, 52.—American experience in the matter, 52.—Workhouses unfit by structure and organization, 52, 75.—Workhouse detention especially prejudicial to recent cases, 53, 81.—Deficiency of medical care and of nursing in workhouses, 54, 78.—The dietary of workhouses insufficient for lunatics, 54, 77.—Injurious effects of workhouse wards upon lunatics, 56, 77.—Lunacy Commissioners’ remarks thereon, 56.—Dr. Bucknill’s remarks on the same subject, 57.—Characters of the lunatic inmates of workhouses, 58.—The majority of them imbecile and idiotic, 58.—Proportion especially claiming asylum care, 59.—Epileptics and paralytics unfit inmates of workhouses, 59.—Old demented cases badly provided for in workhouses, 59.—Imbecile patients are, as a rule, unfit inmates, 60.—Idiots improperly detained in workhouses, 61.—None but a few imbeciles permissible in workhouses, 61.—On the class of supposed ‘harmless’ lunatics, 61.—Remarks by Dr. Bucknill on this class, 62.—Experience of the Surrey magistrates on transferring ‘harmless’ patients to workhouses, 63.—Degradation of the patients’ condition in workhouses, 64.—Legality of workhouse detention examined, 65.—Remarks on this subject by the Lunacy Commissioners, 66.—Clauses of the Lunacy Asylums Act bearing on the subject, 66.—Defects of the law in protecting the pauper insane, 68.—Remarks of the Lunacy Commissioners on the anomalies of the law, 68.—Objections to the powers conferred upon parochial officers, 68.—The law obscure, and open to evasion, 69.—Duties of the parish medical officers ill-defined, 69.—Proposal of a district medical officer, 70.—Contravention of the law by Boards of Guardians, 71, 81.—The further construction of lunatic wards should be stopped, 72.—Necessity for the supervision of the Lunacy Commissioners over workhouses, 72.—Several amendments of the Lunacy Laws suggested, 73.—Proposed regulations for supervision of workhouses containing lunatics, 73, 82.—Lunatics in workhouses should be under certificates, 73.—Proposal to increase powers of Lunacy Commissioners over workhouses, 74.—On the Supplement to the ‘Twelfth Report’ (1859) ‘of the Commissioners in Lunacy,’ on workhouses, 74.—Abstract of its contents:—unfitness of workhouses for lunatics, 75.—Workhouses in large towns most objectionable, 76.—Lunatic wards more objectionable than the intermixture of the insane with the other inmates, 76.—Miserable state of the insane in lunatic wards, 76, 79.—No efficient visitation of workhouse lunatics, 77.—Insufficiency of the dietary for insane inmates, 77.—Medical treatment and nursing most defective, 78.—Fearful abuse of mechanical restraint in workhouses, 78.—Wretched neglect and want in the internal arrangements for lunatics in workhouses, 79.—Abuse of seclusion in workhouses, 80.—Varieties of mechanical restraint employed, 80.—Absence of all means for exercise and occupation, 80.—Lunatics in workhouses committed to gaol, 80.—Neglect and contravention of the law by parish officers, 81.—Amendments in the law suggested by the Lunacy Commissioners, 81.—Proposal to erect asylums for chronic cases, 82, 126.—Visiting Justices of Asylums to supervise workhouse lunatic inmates, 73, 82.
 
§ Pauper Lunatics living with relatives or strangers.
Number of such lunatics, 83.—Neglect of their condition, 83.—Question of insanity should be left to the district medical officer, 84, 175.—This officer should visit and report on their condition, 85, 87.—Indications of the unsatisfactory state of this class of pauper lunatics, 85.—Evidence from Dr. Hitchman’s Reports, 85.—Wretched state of ‘single’ pauper patients in Scotland, 87.—Neglect of Poor-law medical officers towards such patients, 87.—Objections to boarding pauper lunatics with strangers, 88.—District medical officer to select their residence, 89, 146.—Advantage of keeping them in lodgings near asylums, 89, 146.—Distribution of lunatics in cottage homes, 90, 145.—Notice of the colony of insane at Gheel, 90, 145.
 
§ Unfit cases sent to asylums.Improper treatment prior to admission.
Recklessness and cruelty in transmitting patients, 91.—Non-lunatic cases sent to asylums, 91.—Cases of very aged persons sent, 92.—Previous horrible neglect of patients, and their moribund state on admission, 93.—Extracts from Reports of asylum superintendents illustrative of the facts, 91-96.—Transfer of lunatics to asylums must be committed to some competent and independent officer, 97.—Want of instruction for medical men in insanity, 97;—Errors committed owing to the want of it, 98.—Neglect of psychological medicine in medical education, 98.—Law regulating transfer of weak cases to asylums, 99.—An amendment of the law requisite, 99.
 
Chap. VI.—CAUSES OPERATING WITHIN ASYLUMS TO DIMINISH THE CURABILITY OF INSANITY, AND INVOLVING A MULTIPLICATION OF CHRONIC LUNATICS.
§ Magisterial interference and § Excessive size of asylums.
Defective medical staff in large asylums, 102.—Efficient treatment impossible, 102, 121.—Degeneration of management into routine, 103.—Exclusive estimation of so-called ‘moral treatment,’ 103.—A very large asylum especially prejudicial to recent cases, 104.—Delegation of medical duties to attendants, 105.—Evils of absence of medical supervision over individual patients, 105.—Evils of large asylums upon character of attendants, 106.—Routine character of medical visits, 107, 143.—Necessity of medical supervision being complete, 107, 115, 121.—Distinction of asylum attendants into two classes—attendants proper, or nurses, and cleaners, 108.—Objections advanced by the Lunacy Commissioners to large lunatic asylums, 109.—The erection of large asylums supposed to be economical, 110.—The supposition fallacious, 110.—Commissioners’ remarks on these topics, 111.—Rate of maintenance higher in the largest asylums, 112.—Inadequate remuneration of medical superintendents, 113.—Lord Shaftesbury’s advocacy of improved salaries, 113.
 
§ Limit to be fixed to the size of asylums.
Proper number to be accommodated in an asylum, 114, 137, et seq.—Estimate of American physicians, 115.—Estimate of French and German physicians, 116.—Peculiar organization of German asylums, 117, 141.
 
§ Increase of the medical staff of asylums.
Opinions of foreign physicians on the subject, 118.—Estimate of the medical staff requisite, 118.—Erroneous views prevalent in some asylums, 119.—Illustration furnished by the Middlesex asylums, 119.—Jacobi’s views of asylum organization, 121.—Advantages of unity in the organization of asylums, 122.—Appointment of a chief physician, paramount in authority, 122.—Circumstances affecting the selection of asylum superintendents, 123.
 
Chap. VII.—ON THE FUTURE PROVISION FOR THE INSANE.
Rapid extension in the demand for accommodation, 125.—Illustrated by reference to the Middlesex asylums, 125.
 
§ Separate asylums for the more recent and for chronic cases.