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

We shall return to this subject in a subsequent section, – “On the distribution of the chronic insane in cottage-homes.”

§ Transmission of unfit Cases to Asylums – improper Treatment prior to Admission

In preceding pages it has been remarked that the transfer of lunatics to asylums is regulated not by the nature of their case, and its amenability to treatment or amelioration, but by the circumstance of their being refractory and troublesome, annoying by their habits, or so infirm and sick as to require attentive nursing; or, in general, in such a state that their residence involves an increased and unworkhouse-like cost. The question of the recency of the attack is treated as of far less moment; for if the poor sufferer have what are called harmless delusions, or if he is only so melancholic that suicide is not constantly apprehended, then under these and such similar conditions, the economical theory of the establishment commonly preponderates over every consideration of the desirability of treatment in the presumedly expensive asylum, and the patient is retained. In course of time his malady becomes chronic, and in all probability incurable, and his condition so deteriorated in all respects by the absence of proper measures for his mental and moral treatment, that sooner or later his physical health gives way, or his habits grow inconveniently annoying and troublesome, and then it is that workhouse officials discover that the County Asylum is his suitable abode.

By this system of ‘clearance’ the workhouses are relieved of their most burdensome and costly inmates, who fall to the charge of asylums, in which their presence necessarily keeps down the rate of recoveries, multiplies the proportion of chronic lunatics, and increases the expenses and the rate of mortality.

The Medical Superintendents of our Asylums bear witness to the recklessness, and to the cruelty, at times, which often mark the doings of workhouse authorities when they wish to rid themselves of the cost and trouble of any of the lunatic poor in their keeping. The illustrations at hand, obtained from County Asylum Reports, are so numerous, that we must content ourselves with a selection of a few of the more striking.

Dr. Boyd, the distinguished physician of the Somerset County Asylum, makes the following statement in his Sixth Report (1853): – “Several aged persons, and many others in a feeble state, have been admitted during the year, so that the mortality, although less than in the preceding year, has still been considerable. For example, two cases have been recently admitted: one that of a man with dropsy, and broken down in constitution, who is reported to have been given to excess in drinking ardent spirits, and to have been subject to epileptic fits; he was disappointed at not being admitted into a general hospital, became violent, and was sent as a patient here; he has been free from fits since his admission, is rational, but apparently in the last stage of bodily disease. The other case is that of a woman about seventy, paralysed, and unable to sit up in the arm-chair without support. She was troublesome in the union workhouse, and was reported as dangerous, and so was sent to the asylum. There have been four males with paralysis recently sent in from being dirty in their habits… One female was improperly sent with delirium attending on fever: she died a fortnight after admission.” In his Ninth Report, this same Superintendent says, – “Some are sent to the asylum in a state of paralysis, some are aged and in a state of fatuity, and others when they become troublesome, or are in a diseased and feeble state of bodily health, and require more nurse-tending than they receive in the workhouses… Under the existing arrangements, lunatic asylums are gradually losing their proper character of hospitals for the recovery of the insane, and sinking down to be mere auxiliaries to workhouses.”

Out of eighty admissions at the Worcester County Asylum, fourteen were between sixty and eighty years of age, and for the most part “the subjects of organic disease of the brain, lungs, and heart, or suffered from long-continued mental disease, or from the superannuation of old age, and deficient nutrition of the brain and nervous centres. Four of them died during the year… During the early part of the year some correspondence was entered into with several Unions, from which patients had been sent in a dying or exhausted state; and the impropriety of such proceeding was pointed out by your Committee… It is not supposed that those unfortunate cases are wilfully detained with improper intentions at their homes or elsewhere, but from ignorance; and from want of the necessary appliances, and the assistance of those accustomed to the insane, proper measures cannot be adopted for their care and recovery,” and various injuries are inflicted.

The experienced Superintendent of the Beds., Herts., and Hunts. Asylum reports, in 1856, that of 111, as many as twelve died within three months of their being admitted; five did not survive a fortnight. “One male, an epileptic seventy-nine years of age, and having been bedridden for years from contracted limbs, and nearly exhausted from the journey, died on the twelfth day. A female, aged sixty-eight, with disease of the heart, died on the fourth day from exhaustion, having been some time without rest, and having refused her food previous to admission. A female in the last stage of pulmonary consumption, lived but seventeen days; and one very distressing case of a female … was brought to the asylum, who, worn out from constant excitement, and having a large wound on the leg, with ulcerations from ligatures on the wrists and ankles, sank on the fourteenth day. The two last-mentioned patients were reported to have refused food for nearly a week, but took every kind of nourishment offered to them from the moment they were in the Asylum.”

The Report of the Suffolk County Asylum records the admission of ten poor persons in 1852 “nearly seventy years of age, nine over seventy, three over eighty; sixteen in a state of bodily exhaustion; nine either idiots from birth, or imbeciles for a very long period; one child with well-known disease of the heart, and a woman, a cripple, scrofulous, blind and deaf.” “What,” asks Dr. Kirkman, the venerable Superintendent, “can be done more than good nursing to support a peevish mind in a patient eighty-four, admitted only a few days ago?” He adds, “To give other instances, one man was received some time back on a very qualified certificate, and upon whose case a qualified certificate only could be given; and another (somewhat experimentally) with the notice that his mania, if such it were, existed only in the want of a slight resistance to a wayward will; and another, a girl of sixteen, subsequently found not to be insane, but suffering from aggravated cataleptic hysteria, supposed to have been caused by fright, having spinal disease, and deformed throughout the body.”

Dr. Hitchman, whose Reports we have found so valuable in former sections of this work, has repeatedly called attention to the subject now under notice. In 1853 he writes: – “It is with feelings of deepest sorrow that your physician is compelled to state, that patients continue to be sent to the asylum in very advanced stages of bodily and mental disease… So long as no violent or overt act has been perpetrated; so long as the sufferer can be ‘managed’ in the privacy of his miserable home, or by the ‘cheap’ resources of a workhouse, he is often detained from the lunatic hospital. Disease, aggravated by neglect, continues its direful course, the ‘harmless’ lunatic becomes very dirty in his habits, or very violent in his conduct, windows are broken, clothes are torn, persons are injured, and the strap, the strait-waistcoat, and the chain are brought into service to control for a time the ravings and the mischief of the patient. Steps are now taken for his removal – bound, bruised, dirty, and paralysed, the poor creature is taken to an asylum. One glance is sufficient to reveal to the experienced eye that cure is hopeless; that while every resource of the Institution will be needed to sustain the exhausted energies of the patient – to preserve him from the sufferings consequent upon the loss of his self-control over the excretions of his body, yet for two or three years he may survive to swell the list of incurables – to diminish the per-centage of cures – to crowd the hospital, and, worse than all, to perpetuate this popular belief, and to encourage the pernicious practice, which are now leading to the moral death and social extinction of hundreds of our fellow-creatures.”

Speaking of the admissions in 1854, he says: – “Several were in advanced stages of bodily disease; thus, I. C. expired in eight hours after his arrival at this hospital. He was removed from the vehicle in which he was brought to his bed, where he remained tranquil until the moment of his decease. The state of great prostration in which he was brought, forbade the employment of the usual washing-bath; nor was he subjected to the fatigue of being shaved (of which he stood in much need) in consequence of his exhaustion. F. G., aged 76 years, admitted with the marks of restraint round her wrists, survived eighteen days – only by the administration of wine and warmth. S. C., brought bound by straps and a strait-waistcoat in the afternoon of the 18th, was so convulsed and epileptic, that she died on the morning of the 20th, having scarcely spoken during the time she was in the asylum. Others were in advanced stages of dropsy, phthisis, and general paralysis, and, although in a hopeless condition, lived on for several weeks under the fostering care of the Institution. One poor girl, admitted from Lincolnshire, in a perfectly helpless condition (the delirium of fever having been mistaken for the ravings of insanity), was conveyed from the vehicle to a water-bed, where she has remained in a state of great suffering for upwards of twelve weeks, and is never likely again to recover the use of her limbs.”

The experience of the Kent Asylum is similar. The age of eleven persons admitted in 1853 averaged 64, and twelve were from 72 to 75. “In many of these the malady was simply decay of mind, or was due to apoplectic seizures, and attended by palsy.”

In the Report for 1857-1858, Dr. Huxley goes more at large into the question of unfitness for asylum admission, and the vigour and clearness of his remarks induces us to quote them at length. He observes: – “It seems difficult to understand on what principle patients are sometimes sent. One man, for an intemperate threat uttered under considerable provocation, is hastened off to the asylum. He can then only be deemed insane in a constructive sense, and in reliance on the undoubted good faith of the whole proceedings for his removal. He is seen to be sane; he remains so, and merely awaits the next discharging-day. In the interval he has had time to reflect on the danger of uncontrolled speech; but perhaps he and his family ought not to have incurred the reproach (as it is held) of insanity in the blood. Perhaps, also, he ought not to have swelled the list of persons insane, adding his mite to the evidence which supports the general belief in an actual increase of disorders of the mind.

“Again, the facility with which a drunken prostitute finds admission and re-admission is astonishing. The delirium, rather than insanity proper, produced by excessive drinking, has, indeed, some alarming modes of expression; but it is a different thing from true mental derangement, and is transient, the patient being generally nearly all right again on arrival. I confess to a feeling which grudges to such patients the benefits of an asylum and association with the inmates who are truly unfortunate. Their detention is wholly unsatisfactory; it leads to nothing. Long or short, it proves no warning against a return to former bad courses; whilst the presence of people (I do not call them patients) of this sort seriously injures the interior comfort of the wards. Ought such cases to swell the returns of lunacy? Then, in estimating the supposed growth of insanity among the people, let the fact be remembered, that here is one contributing element, which was not represented until of late years. Once again, the extent to which strongly-marked senility is now made the reason for admission to the asylum is, I think, unprecedented. To grow childish, wilful, and intractable; to lose memory, and forget the good habits of a life; to take no note of times and seasons; to wake by night and be restless, and to become generally incapable, are the rule rather than the exception at the close of an extended life. I do not think these natural ills ought to be the cause so frequently as they are found to be, for sending the subjects of them to an asylum. Workhouses may not contain the little special accommodation needful for such cases; but it would not be a good argument to hold, that because they do not, the asylum must be the proper receptacle.

“Poverty is, truly, the great evil; it has no friends able to help. Persons in middle society do not put away their aged relatives because of their infirmities, and I think it was not always the custom for worn-out paupers to be sent to the asylum. May not this practice be justly regarded as an abuse of the asylum? It is one more of the ways in which, at this day, the apparent increase of insanity is sustained. It is not a real increase, since the aged have ever been subject to this sort of unsoundness.

“Decayed persons, once placed in an asylum, are ever after held to have been rightfully deemed insane. If any of their descendants, therefore, become mentally afflicted, the hereditary taint is straightway accounted to them. This is, indeed, to show cause why all the world should be mad! I hold it to be wrong to send persons to an asylum merely on account of second childhood, and a wrong operating to general disparagement. In the first place, the practice is only an indirect consequence of poverty; next, it helps improperly to force asylums to a size inconsistent with their best management; and thirdly, it is one amongst other apparent, but not real grounds, for that increase of mental disorder, which is apprehended with such general alarm.

“We received at least twelve persons, who, in my judgment, needed not, and therefore ought not to have been sent, viz. seven aged, being of 70, 74, 76, 78, 79, 80, and 82 years; three children, of 6, 8, and 10 years; and two adults. One of the children was not insane, but suffering from chorea (St. Vitus’s dance) affecting the whole body. This disorder had, apparently, been mistaken for mania.”

We will close these quotations by one from Dr. Bucknill’s Report for 1854: —

“There can be little doubt that those asylums, the admission into which is restricted by legal formalities alone, are not unfrequently made use of as hospitals for the treatment of bodily disease and for the care of the bodily infirm. To such asylums patients are sent suffering from serious and troublesome bodily diseases, whose mental condition would never have been considered a sufficient cause for removal had it existed alone. The number of patients has not been small, who, from time to time, have been admitted into the Devon Asylum with serious disease of the several organs of the body, and with no greater amount of mental disturbance than is the frequent result of such disease.

“Patients have been admitted suffering from heart disease, aneurism, and cancer, with scarcely a greater amount of melancholy than might be expected to take place in many sane persons at the near and certain prospect of death. Some have been received in the last stages of consumption, with that amount only of cerebral excitement so common in this disorder; others have been received in the delirium or the stupor of typhus; while in several cases the mental condition was totally unknown after admission, and must have been unknown before, since the advanced condition of bodily disease prevented speech, and the expression of intelligence or emotion, either normal or morbid.

“These observations are made in no spirit of complaint. The capabilities of these institutions to treat all ailments of mind or body are indeed felt to be a source of satisfaction and pride. It ought, however, to be known, that this County Asylum is, to some extent, made use of as a public infirmary, and that the result of such employment must be expected in an obituary somewhat lengthened, if not also in a list of cures somewhat abbreviated.”

Sufficient proofs are surely furnished in the above extracts, selected from many similar ones, to establish the general statements advanced at the beginning of the present subject, viz. that both recklessness and cruelty not unfrequently mark the proceedings of workhouse officials in their transmission of patients to the county asylums. They, moreover, supply facts to prove that the neglect in transferring proper cases for asylum treatment, and the inexcusable folly of sending to asylums the victims of second childishness, the imbecile paralytics, the peevish and perverse sufferers from chronic organic disease, such as poor consumptives, whose days are measured by the shortest span, tend to promote the accumulation of incurable inmates, to raise the mortality, and to increase the expenditure of these institutions. In fact, the annual returns of county asylum experience demonstrate that the transmission to asylums is regulated by no rule, and is attended by great abuses.

The practical lesson deducible from this is, that the matter must be placed in other hands, and guided according to some rational principles. The insane poor must no longer be left to pine in neglect and misery in their own homes, until their friends tire of the trouble of them, or some casual circumstance class them, in a relieving officer’s opinion, as proper candidates for an asylum; nor must their presence in the workhouse be, for the future, regulated by the mere circumstance of the care, attention and expense they involve, in the estimation of workhouse governors. There need be some specially appointed officer, whose business it should be to know both the existence of every insane person in his district and his condition and treatment, and to report those who require the care of a curative asylum, those who only need the nursing and supervision of a chronic one, and those who can be duly and efficiently tended and cherished in the homes of their families. By the exertions of such an officer, we should no longer read of the removal of dying patients, only to die in the asylums; or of the victims of neglect and wretchedness detained in workhouses or their homes, until the advance of their mental malady, the complication of organic disease, or some casualty, has rendered them hopelessly incurable, and burdensome in cost, – a cause of a decreased rate of cures and of an augmentation of deaths in the asylum.

But there is yet another lesson to be learned from the foregoing extracts, confirmatory of our own experience, which we might well wish to ignore, viz. the want of knowledge, both of the characters of insanity and of the treatment it demands, among our professional brethren. Undoubtedly a vast stride has been made of late years in diffusing correct views of insanity and its treatment, yet much remains to be done; and it is humiliating to read of cases of delirium from fever, or from organic disease, affecting other organs than the brain; of patients afflicted with chorea; of others delirious from exhaustion or from alcoholic drinks, sent to asylums as cases of insanity. For it is to be remembered, that a medical certificate is a necessary preliminary to the entrance of every person into an asylum; and where the nature of the cases indicates no flagrant error of diagnosis, it at all events exhibits a carelessness or recklessness of the medical man, or his want of moral courage and of official independence, where, for example, he acts as the agent in sending to asylums the aged imbecile of fourscore years, or the poor restless, irritable victim of consumption or other fatal organic bodily disease. Moreover, it speaks ill of Union medical officers, who are entrusted with the supervision, medical care and treatment, and with the dietary of the lunatic poor, to read of the neglected and wretched state in which they are too often found, both in workhouses and in their own homes, and of the condition in which they sometimes are when received into asylums. The bonds and bands, the physical exhaustion from want of food, are matters rightly placed, in a greater or less measure, in their hands. The treatment by cupping, leeches, general bleeding, blistering and purging, and by other depressing means, lies wholly at their door; and such treatment, we regret to say, is still, by some medical practitioners, deemed proper, although experience has for years shown that madness is a disease of debility, and that to use debilitating means is the most direct way to render it incurable.

There is yet another indication of the deficiency of information among medical men in general, often noticed by asylum physicians, viz. their inability to recognize the peculiar form of paralysis attended with disordered mind, known as “general paralysis.” Where, as at St. Luke’s Hospital, at Bethlem, and at Hanwell, under the recent regulation for promoting the early treatment of recent cases, the existence of general paralysis disqualifies an applicant from admission, the rejection of patients, on the ground of its presence, often gives rise to disappointment and to irritation on the part of the medical men signing the certificates, who will stoutly deny the justice of the exclusion, because they see no such loss of motion or sensation as they do in hemiplegia or paraplegia, or those forms of palsy to which they are accustomed to restrict the appellation.

This defective knowledge of insanity and its treatment ought not to be found, were medical instruction complete. But whilst the medical curricula make no requirement of instruction in mental disease necessary to medical qualifications, they are expanded so as to comprehend almost every branch of human knowledge, under the heads of ‘Preliminary Education’ and of ‘Collateral Sciences,’ and yet ignore psychological medicine, as though human beings were without minds, or, at least, without minds subject to disorder. The consequence is, as facts above illustrate, medical men enter into practice with no conception of the varied phenomena of mental disorder; unable to diagnose it; unfit to treat it, and glad to keep out of the way of its sufferers. Some, as before intimated, associate it, in their views, with inflammatory or congestive disease, and treat it accordingly, by blood-letting and the other parts of the so-called antiphlogistic regimen, to the speedy destruction of the patient, by increased maniacal excitement and concurrent exhaustion, or to his extreme detriment in relation to his prospects of recovery. Let us hope that this state of things may ere long be entirely amended, and that medical practitioners may be required to understand disorders of the mind as perfectly as those of the lungs.

Before quitting the subject of this section, a brief comment on the state of the law regulating the transference of weak cases to asylums will not be misplaced. According to sect. lxvii. 16 & 17 Vict. cap. 97, providing for the examination of alleged lunatics prior to removal to an asylum, it is enacted, “that in case any pauper deemed to be lunatic, cannot, on account of his health or other cause, be conveniently taken before a Justice, such pauper may be examined at his own abode;” and that, if found lunatic, he shall be conveyed to an “Asylum, Hospital, or House…; provided also, that if the physician, surgeon, or apothecary by whom any such pauper shall be examined shall certify in writing that he is not in a fit state to be removed, his removal shall be suspended until the same or some other physician, surgeon, or apothecary shall certify in writing that he is fit to be removed; and every such physician, surgeon, and apothecary is required to give such last-mentioned certificate as soon as in his judgment it ought to be given.” A similar provision is made in the case of “Lunatics wandering at large, not being properly taken care of, or being cruelly treated” or neglected by their relatives, by the section next following (sect. lxviii).

Further, by sect. lxxvii., empowering the Visitors of Asylums to remove patients, it is provided “that no person shall be removed under any such order without a medical certificate signed by the medical officer of the asylum, or the medical practitioner, or one of the medical practitioners, keeping, residing in, or visiting the hospital, or licensed house, from which such person is ordered to be removed, certifying that he is in a fit condition of bodily health to be removed in pursuance of such order.”