CONTENTS.
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.
Objections to such separate establishments, 126.—Examination of the value of these objections, 127.—Cases to be transferred from one institution to the other, how determined, 128.—Mixture of recent with chronic cases undesirable, 128, 130.—Examination of the present relative position of acute and chronic cases, 129.—Separate treatment of recent cases desirable, 131.—Influence of distance on the utility of an asylum as a place of treatment, 131.—Borough asylums, 131.—Many chronic cases removable from asylums, 132.—Less expensive buildings needed for chronic cases, 132.—Views of the Lunacy Commissioners on these points, 132.—Evidence of Lord Shaftesbury, 134.—French system of dividing asylums into ‘quarters,’ 135.—Permissive power of Lunacy Act to build distinct asylums for chronic cases, 135.—On the powers of the Home Secretary to control asylum construction, 136.—Amendment of present Act proposed, 136.—On mixed asylums, for recent and chronic cases together, 137.—Conditions under which distinct institutions are desirable, 138.—Advantages of an hospital for recent cases, 138.—Number of inmates proper in such an hospital, 139.—Regulations required in it, 139.—Organization of asylums for chronic cases, 140.—Union of counties for the purpose of constructing joint asylums, 140.
§ Construction of distinct sections to asylums.
German system of ‘relative connexion’ of asylums for recent and chronic cases, 141.—Proposition of Lunacy Commissioners to place industrial classes of patients in distinct wards, 142.—Advantages of separate sections, 143.—Objections to a purely ‘industrial classification’ of patients, 144.
§ Distribution of the chronic insane in cottage homes.
Subdivision of asylums for chronic cases, 145.—Illustration of cottage provision for the insane at Gheel, 145.—The system at Gheel impracticable as a whole, 146.—The ‘cottage system’ deserving of trial under proper restrictions, 146.—Suggestions as to the arrangements required, 146.—‘Cottage system’ supplementary to asylums, 147.—Economy of ‘cottage system,’ 147.
§ Separate provision for epileptics and idiots.
Epileptics need separate provision, 148.—Idiots not fit inmates of lunatic asylums, 148.—Idiots require special asylum provision, 149.—Removal of idiots from workhouses, 150.
Chap. VIII.—REGISTRATION OF LUNATICS.
Necessity of registering the insane, 150.—Large number of insane at present unprotected, 151.—Legal advantages of registration, 151.—Desirability of correct statistics of insanity, 152.—Lord Shaftesbury’s evidence on this point, 152.—Registration as a means of discovering the existence and condition of lunatics, 152.—Registration would promote early treatment, 153.—Should be accompanied by visitation, 153.—Enactment necessary to regulate the sending of lunatics abroad, 153.—Practice pursued in Sardinia, 154.—Suggestions offered, 155.—All patients removed uncured from asylums ought to have the place of their removal reported, 155.—Objections raised to registration, 156.—Their validity examined, 156.—Principle of a compulsory registration and visitation of all lunatics recognized in Belgium, 158.—English enactments respecting ‘single’ patients, 159.—Their failure, 159.—Lunatics secluded under the name of ‘nervous’ patients, 160.—Lord Shaftesbury’s observations on defects in the Lunacy Laws respecting ‘single’ cases, 161.—Clauses to Act, proposed by his Lordship, to deal with ‘nervous’ patients, 161.—Clauses open to some objections, 162.—Lord Shaftesbury’s proposal to report every ‘nervous’ patient, 163.—Compulsory powers of Lunacy Act defective, 164.—Suggestions made, 164.—Proposition to report all lunatics to a district medical officer, who should visit, 165.—Additional certificate granted by this officer, 165.—Lunatics well protected, 165.—Modification of present form of certificates of insanity, 166.—Objections to two forms of certificates, 166.—Determination of the nature of certificate to be given, 167.—Clause in Scotch Asylums Act respecting ‘single’ cases, 167.—Need of mitigated certificates and of intermediate asylums for certain cases of mental disturbance, 168.
Chap. IX.—APPOINTMENT OF DISTRICT MEDICAL OFFICERS.
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 deta