+ All Categories
Home > Documents > REPORT OF The Lancet Commission ON LUNATIC ASYLUMS

REPORT OF The Lancet Commission ON LUNATIC ASYLUMS

Date post: 04-Jan-2017
Category:
Upload: hoangphuc
View: 214 times
Download: 2 times
Share this document with a friend
3
135 and algse, should grow year after year more sceptical of the power of these plants to produce diseases in men and animals, unless prior disease has opened the door for them. Whatever may be the conclusion on this wider point, we believe that they have shown good reasons for doubting the correctness of the view which attributes 11 Madura foot" to the action of a special fungus. REPORT OF The Lancet Commission ON LUNATIC ASYLUMS. WANDSWORTH ASYLUM. THE HOUSE AND ARRANGEMENTS. IN a Report addressed by the Committee of Visitors to Quarter Sessions in 1859, on the subject of a proposed en- largement of this asylum, we find the following remarks :- " The Committee are aware that medical opinions have been expressed in favour of asylums not containing more than 600 patients, or even a smaller number, as the most suitable for efficient supervision; but some of those were given when the number of large asylums was very small, and the system of superintending them not so well under- stood as at present. Indeed, the number of very large asylums is still small, as is also the number of medical men who can speak on this subject from their own personal experience. The Committee have found no inconvenience in the superintend- ence of the Surrey Asylum, which for a long time has contained more than 900 patients; and they are satisfced that, under judicious regulations, the patients in an asylum containing more than double the number may be maintained not only under proper care and treatment, but that they will have advantages in classification, and in constant medical supervision, to some extent, over patients in small asylums, and to a very great extent, it is believed, over those in wards connected with union-houses." As regards the superiority of asylums, cceteris paribus, to workhouses there can be no question ; but with respect to every other assertion in this statement we join issue. It is in- teresting to encounter an erroneous opinion expressed with so much confidence. The sentences we have printed in italics are, moreover, noteworthy as showing how closely the position assumed by a visiting committee sixteen years ago resem- bles that maintained by at least some committees at the present moment. We think there is reason to believe that the magistrates of the county south of the Thames have learnt wisdom. In any case, the tokens of lay "keepership" are not so manifest at Wandsworth as elsewhere. We con- fess it was not without misgiving that we found the medical superintendent styled 11 resident physician"; but, so far as it is possible to judge of practice by the rules laid down for its guidance, the authority of the medical superintendent seems to be well defined, and neither the Committee nor its officials appear to hamper his treatment. In a copy of the rules printed in 1873 is the following :- "He [i.e., the medical superintendent] shall be responsible for the management and the condition of the asylum, and shall superintend the whole of the medical and moral treat- ment of the patients and the general arrangements of the establishment, subject to the rules of the asylum and the direction of the Committee:’ The words in italics detract greatly from the value of authority entrusted to the medical superintendent; but in practical fact we do not, as we have said, detect the proofs of interference. Meanwhile, there are some discrepancies in the 11 Regulations " and "Orders" not entirely satisfactory. One of these relates to a matter of the first moment, and should receive attention. Under the head ,The Matron" we find :- " She shall cause every patient becoming dangerous or annoying to others to be quietly removed from the day- rooms or galleries; and shall immediately report the cir- cumstance to the medical officer on duty, who alone shall have the power of imposing restraint or seclusion." Among the "Orders" to ‘°Attendants" stands this :- " 2. When coercion is necessary, it is not to be attempted by an attendant single-handed. An excited patient will often resist with much violence a single person, but will submit quietly in the presence of two or more. Every in- stance of coercion or seclusion is to be immediately reported to the medical officer on duty." It is manifest that the widest possible difference, amount- ing to an open contradiction, must exist between a rule which prohibits anyone except the medical officer from placing a patient in seclusion and an order which requires the attendant, after he has secluded a patient, to report the fact to a medical officer. No attendant should, under any circumstances, be permitted to place an inmate in seclusion without the express order of a medical officer. The act of seclusion is in itself extreme coercion. The duration of the confinement is another matter, not affecting the fact. We understand the rule in Surrey to be that no attendant may seclude. If that be so, Rule 2, in the instructions to It at- tendants," ought to be expunged. It must produce a wrong impression, and ntay work mischief. No subordinate ought to be in a position even to threaten a patient with seclusion, much less to lock him up, and then report it. The building on Wandsworth- common is ill-adapted for an asylum attempting the work of a " hospital." There is evidently a widespread mistake as to these old and badly constructed buildings; and it is essentially an economic blunder. They would answer the purpose of homes for chronic and imbecile cases fairly well. The new erections, containing as they do the greatest air space-sadly deficient in the older houses,-the best fittings, and generally em- bodying the results of experience and the latest improve- ments, should certainly be employed as hospitals for acute cases, while the older houses are used for the incurable and chronic. As it is, the effect of drafting quiet cases to such places as Brook wood-or the workhouse asylums at Caterham and Leavesden-is to waste power and opportunity, at the same time, leaving the wards of an asylum like Wands worth crowded with excitable cases, which cannot be effectively treated within its walls. The construction, the manning with attendants, and the general arrangements of a hospital for acute cases of mental disease are essentially different from, and necessarily more costly than, those required in an asylum for harmless lunatics, imbeciles, or idiots. This is to some extent recognised in Surrey, but there has been, we fear, some misdirection in policy. Instead of the new houses being appropriated as hospitals for acute disease, they have been filled with quiet cases taken from the older asylums, and patients withdrawn from the licensed houses with a view to save expense. The procedure should have been exactly the reverse. New and severe cases which it may be possible to cure should obviously have been placed in the improved houses, and every effort devoted to their rapid treatment, if only to avoid the permanent cost of main- taining them as chronic cases. The old and badly con- structed asylums-of which Wandsworth is a striking exam- ple though greatly improved within the last three years- might then have been used exclusively for cases which do not require much more than humane guardianship and comfortable quarters. Had this policy been pursued, the erection of new buildings for single rooms, and other expensive alterations, which have been required at Wands- worth might have been avoided. No doubt, in a county where there exibts sufficient accommodation, of the best hospital class, for acute cases, it may be wise to build new blocks, es- pecially for chronic cases, and the outlay entailed will be comparatively small-though we doubt whether any asylum could possibly be erected and furnished more economically than the new buildings at Brookwood, which are marvels of cheapness and efficiency. But Surrey is not, so far as its older asylums are concerned, in the position of a county having hospital accommodation equal to its needs, and we venture to think true wisdom would suggest to the magis- trates of Surrey the expediency of making Brookwood the
Transcript
Page 1: REPORT OF The Lancet Commission ON LUNATIC ASYLUMS

135

and algse, should grow year after year more sceptical of thepower of these plants to produce diseases in men and

animals, unless prior disease has opened the door for them.Whatever may be the conclusion on this wider point, we

believe that they have shown good reasons for doubting thecorrectness of the view which attributes 11 Madura foot" tothe action of a special fungus.

REPORTOF

The Lancet CommissionON

LUNATIC ASYLUMS.

WANDSWORTH ASYLUM.

THE HOUSE AND ARRANGEMENTS.

IN a Report addressed by the Committee of Visitors toQuarter Sessions in 1859, on the subject of a proposed en-largement of this asylum, we find the following remarks :-" The Committee are aware that medical opinions have

been expressed in favour of asylums not containing morethan 600 patients, or even a smaller number, as the mostsuitable for efficient supervision; but some of those weregiven when the number of large asylums was very small,and the system of superintending them not so well under-stood as at present. Indeed, the number of very large asylumsis still small, as is also the number of medical men who canspeak on this subject from their own personal experience.The Committee have found no inconvenience in the superintend-ence of the Surrey Asylum, which for a long time has containedmore than 900 patients; and they are satisfced that, underjudicious regulations, the patients in an asylum containingmore than double the number may be maintained not only underproper care and treatment, but that they will have advantagesin classification, and in constant medical supervision, to someextent, over patients in small asylums, and to a very great extent,it is believed, over those in wards connected with union-houses."

As regards the superiority of asylums, cceteris paribus, toworkhouses there can be no question ; but with respect toevery other assertion in this statement we join issue. It is in-

teresting to encounter an erroneous opinion expressed withso much confidence. The sentences we have printed in italicsare, moreover, noteworthy as showing how closely the positionassumed by a visiting committee sixteen years ago resem-bles that maintained by at least some committees at thepresent moment. We think there is reason to believe thatthe magistrates of the county south of the Thames havelearnt wisdom. In any case, the tokens of lay "keepership"are not so manifest at Wandsworth as elsewhere. We con-fess it was not without misgiving that we found the medicalsuperintendent styled 11 resident physician"; but, so far asit is possible to judge of practice by the rules laid down forits guidance, the authority of the medical superintendentseems to be well defined, and neither the Committee norits officials appear to hamper his treatment. In a copy ofthe rules printed in 1873 is the following :-"He [i.e., the medical superintendent] shall be responsible

for the management and the condition of the asylum, andshall superintend the whole of the medical and moral treat-ment of the patients and the general arrangements of theestablishment, subject to the rules of the asylum and thedirection of the Committee:’

The words in italics detract greatly from the value ofauthority entrusted to the medical superintendent; but inpractical fact we do not, as we have said, detect the proofs ofinterference. Meanwhile, there are some discrepancies inthe 11 Regulations " and "Orders" not entirely satisfactory.One of these relates to a matter of the first moment, and

should receive attention. Under the head ,The Matron"we find :-" She shall cause every patient becoming dangerous or

annoying to others to be quietly removed from the day-rooms or galleries; and shall immediately report the cir-cumstance to the medical officer on duty, who alone shallhave the power of imposing restraint or seclusion."

Among the "Orders" to ‘°Attendants" stands this :-" 2. When coercion is necessary, it is not to be attempted

by an attendant single-handed. An excited patient willoften resist with much violence a single person, but willsubmit quietly in the presence of two or more. Every in-stance of coercion or seclusion is to be immediately reportedto the medical officer on duty."

It is manifest that the widest possible difference, amount-ing to an open contradiction, must exist between a rulewhich prohibits anyone except the medical officer fromplacing a patient in seclusion and an order which requiresthe attendant, after he has secluded a patient, to report thefact to a medical officer. No attendant should, under anycircumstances, be permitted to place an inmate in seclusionwithout the express order of a medical officer. The act ofseclusion is in itself extreme coercion. The duration of theconfinement is another matter, not affecting the fact. Weunderstand the rule in Surrey to be that no attendant mayseclude. If that be so, Rule 2, in the instructions to It at-tendants," ought to be expunged. It must produce a wrongimpression, and ntay work mischief. No subordinate oughtto be in a position even to threaten a patient with seclusion,much less to lock him up, and then report it.The building on Wandsworth- common is ill-adapted for

an asylum attempting the work of a " hospital." There isevidently a widespread mistake as to these old and badlyconstructed buildings; and it is essentially an economicblunder. They would answer the purpose of homes forchronic and imbecile cases fairly well. The new erections,containing as they do the greatest air space-sadly deficientin the older houses,-the best fittings, and generally em-bodying the results of experience and the latest improve-ments, should certainly be employed as hospitals for acutecases, while the older houses are used for the incurable andchronic. As it is, the effect of drafting quiet cases to suchplaces as Brook wood-or the workhouse asylums at Caterhamand Leavesden-is to waste power and opportunity, at thesame time, leaving the wards of an asylum like Wands worthcrowded with excitable cases, which cannot be effectivelytreated within its walls. The construction, the manningwith attendants, and the general arrangements of a hospitalfor acute cases of mental disease are essentially differentfrom, and necessarily more costly than, those required in anasylum for harmless lunatics, imbeciles, or idiots. This isto some extent recognised in Surrey, but there has been, wefear, some misdirection in policy. Instead of the new housesbeing appropriated as hospitals for acute disease, they havebeen filled with quiet cases taken from the older asylums,and patients withdrawn from the licensed houses with aview to save expense. The procedure should have beenexactly the reverse. New and severe cases which it may bepossible to cure should obviously have been placed in theimproved houses, and every effort devoted to their rapidtreatment, if only to avoid the permanent cost of main-taining them as chronic cases. The old and badly con-structed asylums-of which Wandsworth is a striking exam-ple though greatly improved within the last three years-might then have been used exclusively for cases whichdo not require much more than humane guardianshipand comfortable quarters. Had this policy been pursued,the erection of new buildings for single rooms, and otherexpensive alterations, which have been required at Wands-worth might have been avoided. No doubt, in a county wherethere exibts sufficient accommodation, of the best hospitalclass, for acute cases, it may be wise to build new blocks, es-pecially for chronic cases, and the outlay entailed will becomparatively small-though we doubt whether any asylumcould possibly be erected and furnished more economicallythan the new buildings at Brookwood, which are marvelsof cheapness and efficiency. But Surrey is not, so far asits older asylums are concerned, in the position of a countyhaving hospital accommodation equal to its needs, and weventure to think true wisdom would suggest to the magis-trates of Surrey the expediency of making Brookwood the

Page 2: REPORT OF The Lancet Commission ON LUNATIC ASYLUMS

136

hospital and appropriating Wands worth as an asylum vision over the manner in which the attendants dischargefor chronic and incurable cases. Of course no such their duty to the patients that would be exercised by gentle-arbitrary or wholesale separation of cases as would men over the grooms that feed their horses, or the keepersleave the wards of any asylum - hospital or chronic of their dogs and game. This is a duty the medical officersrefuge - without the ameliorating influence of some of asylums everywhere owe to themselves, not less than thequiet cases assoeiated with the more turbulent would patients confided to their guardianship. Everywhere attend-be prudent. But short of this extreme measure we are ants, we are convinced, maltreat, abuse, and terrify patientsconvinced that the acute cases should be treated apart, in when the backs of the medical officers are turned. Humanitycircumstances and under conditions especially favourable is only to be secured by turning suddenly upon the officials,to their recovery. We sometimes hear strong remarks as and no man need feel himself demeaned or aggrieved by beingto the depressing influence which would be exerted upon asked to bestow that care on the poor helpless creaturesmedical officers by having scarcely any cases under their entrusted to him which he owes to the dogs in his owntreatment which were hopeful. Against this argument kennel. By the way, what can be the meaning of the rulemust be set the wonderfully stimulating effect of feeling that stands at the top of page 13 in the printed book beforethat an institution is a hospital, properly so called, and us, to the effect that when the medical superintendent visitsable to enter the lists with any institution which selects its the department for females,, he shall be accompanied bycases on the ground of curability-as, for example, Bethlem, some female officer of the asylum ?" Surely this is a mistake.- in scientinc competition to produce the largest number of The purpose of the visit is to ascertain the condition of the"recoveries" and the smallest number of "re-admissions." wards and bedrooms. Nothing can make the inspectionWe venture to think that, looking at the matter from the necessary except some real or supposed neglect of duty onQuarter Sessions’ and ratepayers’ point of view, a county the part of the officials, yet the medical officer is to call upwould reap great advantages from the arrangement we one of those very officials to accompany him in his visit,suggest, would more readily overtake the rapid increase of which, according to the rule, is to be made unexpectedly atinsanity among the population, and, in the long run, save night! The instruction is simply absurd, and should bemoney in the matter of building and furnishing. But of at once expunged. The Committee must have relied onthese considerations we shall have more to urge in the its inherent sagacity, when such a nugatory direction wassequel, framed. It is strange the Commissioners in Lunacy, or theWandsworth is by no means a neglected house. Much officials advising the Right Hon. Robert Lowe, did not draw

has been done, and more is promised, to make it efficient. attention to the nonsensical regulation before the code wasWe do not propose to touch largely on details, but shall passed and officially signed. We are glad to learn that ancontent ourselves with pointing out some of the more efficient system of night-watching by inspectors walking on anoticeable evils and defects which seem to call for remedy. " beat" through the epileptic dormitories on each side hasIn the first place, we would draw the attention of the just been inaugurated. A very effective precaution has alsoVisiting Committee to the need of a little more liberality, been taken against the danger from suffocation to whichIn very small matters especially, it is paltry to be mean. For patients of this class are exposed, by the provision of loosely-example, in the new block of single rooms, was it worth stuffed hair pillows, through which they can breathe forwhile to give fair-sized windows to the frontage of the some time even if the face be buried in the cushion. Thebuilding, and save a few hundreds by dimly lighting staff of ordinary attendants is in the proportion of about onethe rooms at the back with windows barely half the size P to eleven patients. The asylum will now accommodate 1078Then, again, might not the painting and decorating be ex- inmates. The weekly charge is 9s. 7d. per head. Speakingpedited, so as to make the interior throughout more cheery generally, we consider the patients at this asylum well caredand homelike? We confess to some disappointment with for, and considerately controlled. Their appearance denotesthe appearance of the wards after the promise which has efficient nursing, a sufficient dietary, and fair, though withalbeen long extant of rendering this asylum more present- somewhat dingy, clothing. The refractory patients do notable. The walls are to a very large extent still bare of pic- appear either irritated by surroundings, cowed into sub-tures. There is a lack of warm colouring. The single jection by terrorism, or enfeebled by the use of drugs.rooms generally look wofully comfortless, and scarcely any There are a good many aged and bedridden patients, andof the wards are well furnished. None can be described as many wet and dirty cases, but we saw nothing to indicatepleasure-inspiring. There are very few musical instruments neglect or unhealthiness. The chapel is much too small,or appliances for amusement in the wards. The orna- old-fashioned, and gloomy. It might with advantage bements are meagre and the surroundings generally not attrac- applied to some other purpose, and a detached building intive. Probably it would require a somewhat generous, the grounds would replace it advantegeously. There is aperhaps even lavish, outlay to make the asylum really cottage hospital, but, from some inscrutable cause, we trustcomfortable; but, cost what it may, the object should be not parsimony, it is unprovided with a disinfecting chamberattained, and without delay. Flowers, plants, aviaries, or a laundry, and is, therefore, only partially available forpianos, bagatelle-boards, ornaments, coloured prints, and perfect isolation in the event of epidemic disease. Thereextensive wall decorations are sadly needed ; and, while fully is a fairly large recreation hall, used by day as a needleworkrecognising what has been accomplished, we must urge the room for the female patients. It is fitted with a suitablewant of greater expedition and a more liberal hand. Then, theatrical stage. The entertainments, including balls andagain, the atmosphere of the asylum is by no means satis- performances, are frequent, and we believe the authoritiesfactory. It abounds with faint but offensive odours ; cer- contemplate an extension of the system of associated amuse-tainly not the result of any lack of care or cleanliness. We ments. The proportion of patients employed is fairly goodmake full allowance for the circumstance that our visit was and improving. The precautions against fire are ample, butmade in weather which necessitated the closing of doors and we think the arrangements might be modified. For example,windows. Nevertheless, the sculleries, sinks, and drains the jet-pipes should be kept attached to the hose, and therequire careful examination throughout. Can it be possible latter connected with the hydrants, as at Hanwell. We can-there is stint in the use of water for bathing, washing, or not pass from this branch of the subject without warmlyflushing purposes? No asylum of the class can be worked acknowledging how much has been done to improve thewith less than fifty or sixty gallons per head per day of the asylum and to mitigate the evils incident to its defectiveresident population. The site lies high, and the water runs original construction. The struggle with circumstancesaway rapidly, requiring frequent and almost profuse has been earnestand intelligent, thereformsaccomplished areflushing to cleanse the drains. The dormitories are better great and of the highest value. But the cry is still for morethan the day rooms, but some of them strike a little cold, and more sweeping, amendments. It seems ungracious toalthough the building generally is well heated. The airing dwell on faults where an unwearied endeavour to removecourts are fairly good, and still undergoing improve- evils, redress grievances, and supply deficiencies is apparent,ment. The attendance seems well organised, and by a but the welfare and wise treatment of the insane is every-judicious system of visiting the wards unexpectedly by where a matter of vital moment and urgent public concern,day and night, and inqniring into the proceedings of the and it is with the view of strengthening the hands of thoseofficials, the medical officers apparently succeed in preserv- who feel the need of progress, and entreating the considera-ing good order. We think this system of watching the tion of others who fail to perceive the pressing call for im-attendants admirable, and we are glad to learn that the provement, that we strenuously plead for greater enter-medical offiuers willingly exercise the same jealous super- prise and liberality.

Page 3: REPORT OF The Lancet Commission ON LUNATIC ASYLUMS

137

TREATMENT.

The treatment at Wandsworth is intelligent and humane.The use of drugs is wisely restricted, and reliance uponmoral measures in preserving order and promoting re-

covery is the first recourse. Restraint is neither whollyabandoned nor extensively employed. Gloves are occasion-ally in use, and seclusion has been considered necessary andadministered, though not recklessly, as the following tablewill show :-

We must repeat that "seclusion" forms a very fair testof the efficiency of the general service and moral treatmentin any asylum, more particularly when, as at Wandsworth,the medical superintendent is reluctant to resort to thisexpedient. The failure to control a turbulent patient bymoral influences, where it is desired that these influencesshould suffice, commonly indicates either a clumsy discipline,an unwise classification of cases, or something amiss in themanner in which attendants discharge their onerous and

arise from the d(-4’ects of the building and crowding in someof the wards. The county would benefit financially and therecent cases would gain considerably in the probabilities of"cure," if, instead of increasing the number of inmates,the multitude could be reduced to such proportions as wouldpermit the medical superintendent to carry out a moreserviceable system of classification, and direct personaltreatment. There are dtrk corners in some of the wardswhich it is impossible to light, but which should not onany account be used as day-space, and there are cases

now thrown into the closest contact which should be

kept widely asunder. It is vain to urge these pointsunless the magistrates are prepared to adopt a boldpolicy and apply the building and arrangements totheir only legitimate use, and convert the asyluminto a place of shelter for comparatively mild or chroniccases. As elsewhere, we passed the patients carefullyunder review in the wards-which is a better methodof examination than crowding them into the halls for thepurpose of formal inquiries,-and, with the exception of afew pronounced convalescent and about to be discharged,we do not, so far as a cursory scrutiny may be trusted, be-lieve there are any patients now in the house improperly orunduly detained. It is not in the county asylums that suchcases are to be found. There may be some in the licensedhouses; but on this point we offer no opinion at present.Cases of the class may, and perhaps occasionally do, chal-lenge notice among the patients received as "transfers"from these houses; but we are glad to know that every in-dividual is most carefully examined by the medical super-intendent on reception, and, if not proved to be insane, isin due course discharged. We shall have more to observeon the very difficult and perilous question of discharge indoubtful cases when we come to deal with the points of

Surrey County Lunatic Asylum at Wandsworth.

§ This percentage is upon the number of cases "deemed curable" among those remaining on Dec 31st of the previous year (llthcolumn), and of cases " deemed curable" among those admitted during the current year (5th column).

most difficult routine duties. A judicious and useful prac-tice of weighing patients on admission and at discharge hasbeen introduced, and speaks well for the management. Thegradual extension of liberty to patients is a principle of thetreatment, and walks beyond the asylum grounds are

organised under proper restrictions. The chief obstacles toa thoroughly scientific treatment at Wands worth obviously

* "Owing to the numerous changes, and the exchange of quiet and harm-less for noisy and violent patients, the tranquillity of the wards has beendisturbed to an unusual extent."-Report for 1871.t " During the last and present year, owing to the removal of 279 quiet,

harmless, imbecile patients to Caterham, and to the admission of 719 newcases, many of them of the worst type, the necessity for seclusion has in-creased amongst the crowded and dangerous inmates. In two wards of themale division, occupied by the most violent class, the superficial day spaceis only 29 ft. and 35 ft. respectively for each patient; consequently, collisionsare frequent and unavoidable."-Report for 1872.t " Under all the circumstances-and it must be remembered that when-

ever the key is turned upon a patient it counts as seclusion-this returnis favourable and creditable to the attendants. Immunity from seclusion ’’can only be obtained by the help of a numerous and well-trained staff of iattendants."-Report for 1873.

practical interest developed in the course of this inquiry,seriatim, at the close.

RESULTS.

The total of "curable" cases at Wandsworth bears a

proportion of 43’05 per cent. to the total of "admissions."The percentage of "recoveries" on curable cases is 5497." General paralysis" accounts for 173 of the 655 deaths re-turned during the ten years, or 26 41 per cent. The mean

proportion of deaths on admissions is 38.59. The recoveriesnumber 33-1 per cent. on the admissions.

Our acknowledgments are due to Dr. J. Strange Biggs,the medical superintendent, and to Mr. Frederick H. Ward,the senior assistant medical officer.

[Corrections in the Report on Colney-hatch Asylum.-In the section onTreatment," p. 67, first column, 14th line from the bottom, for " mis-chievous results of crowding similar cases was," read zre-re. The total ofIn-stances of 8ecZlUion in the table, p. 68, first colnmn, should be 7755,t instead of 7635.


Recommended