: On the State of Lunacy and the Legal Provision for the Insane With Observations on the Construction and Organization of Asylums by Arlidge J T John Thomas - Psychiatric hospitals Great Britain; Psychiatric epidemiology; Mental health services Great Britai

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PRELIMINARY OBSERVATIONS.

Importance of an inquiry relative to the number of the Insane, and the legal provision for them, 1.

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.

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.

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.

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.

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 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' '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.

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.

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.

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.

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.

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