On the State of Lunacy and the Legal Provision for the Insane
by J. T. Arlidge · English · Gutenberg #44320 · 642,945 chars · public domain (US)
The Project Gutenberg eBook of On the State of Lunacy and the Legal Provision for the Insane
This eBook is for the use of anyone anywhere in the United States and
most other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms
of the Project Gutenberg License included with this eBook or online
at www.gutenberg.org. If you are not located in the United States,
you will have to check the laws of the country where you are located
before using this eBook.
Title: On the State of Lunacy and the Legal Provision for the Insane
Author: J. T. Arlidge
Release date: December 1, 2013 [eBook #44320]
Most recently updated: October 23, 2024
Language: English
Other information and formats: www.gutenberg.org/ebooks/44320
Credits: Produced by The Online Distributed Proofreading Team at
http://www.pgdp.net (This file was produced from images
generously made available by The Internet Archive.)
*** START OF THE PROJECT GUTENBERG EBOOK 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.
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 detained, with the features of his malady,
and with all his wants, the physician devoted to the care of the Insane is
well qualified to offer suggestions and recommendations to the legislator.
Hence the present pages, in which the aim is to examine the present state
of lunacy; the advantages to be gained by early treatment; and the
adequacy of the existing legal provision for the Insane; and to offer some
suggestions for improving the condition, and for amending the laws
relating to the care and treatment, of this afflicted class of our
fellow-creatures.
The whole subject of the efficiency of the Lunacy Laws and of their
administration, occupies just now a prominent place in public attention,
owing to the rapid multiplication of County Asylums and the constantly
augmenting charges entailed by them; to the prevalent impression that
Insanity is rapidly increasing; to recent agitation in our Law Courts
respecting the legal responsibility of the Insane and the conditions under
which they should be subjected to confinement, and still more to the
proposed legislation on the matter during the present Session of
Parliament. It would be a great desideratum could the Lunacy Laws be
consolidated, and an arrest take place in the almost annual additions and
amendments made to them by Parliament; but, perhaps, this is next to
impracticable, owing to the attempts at any systematic, effectual, and
satisfactory legislation for the Insane, being really of very recent date,
and on that account subject to revisions enforced by experience of its
defects and errors. However, the present time appears singularly suited to
make the attempt at consolidation, so far as practicable, inasmuch as the
appointment of a special committee of the House of Commons on the Lunacy
Laws, furnishes the means for a complete investigation into existing
defects, and for receiving information and suggestions from those
practically acquainted with the requirements of the Insane, and with the
operations of existing enactments.
To fulfil the objects taken in hand, and, in the first place, to sketch
the present state of Lunacy in this country, it will be necessary to
investigate the number of the Insane, and the annual rate of their
increase; then to examine the extent of the present provision for them in
asylums and of probable future wants. This done, after a brief essay on
the curability of insanity, as a means of judging what may be done to
mitigate the evil, we shall review the present provision for lunatics,
point out its defects, and suggest various remedial measures, calculated
in our opinion to improve the condition of the Insane, diminish the evil
of the accumulation of chronic cases, and render asylums more serviceable
and efficient.
In carrying out our design, we shall be found in some measure occupying
ground already taken up by the Commissioners in Lunacy, and by some able
essayists in the Medical Journals. We do not regret this, although it may
deprive us somewhat of the merit of originality of conception and
elucidation, as it will strengthen our positions and enhance the value of
our remarks. Fortunately, too, we coincide generally with the opinions
from time to time put forth by the Lunacy Commissioners, to whom so great
merit is due for their labours in the interests of the insane, and for the
character and position our County Asylums enjoy in the estimation of our
own people and of foreign nations.
To attempt the character of a reformer when the affairs of Lunacy and
Lunatic Asylums are in such good hands may be deemed somewhat ambitious;
yet as sometimes an ordinary looker-on may catch sight of a matter which
has eluded the diligent observer, and, as the views and suggestions
advanced are the result of mature and independent thought, aided by
experience of considerable length, and very varied, the undertaking may,
we trust, be received with favour.
At all events, we flatter ourselves that the representation of the state
of Lunacy in England and Wales; the estimate of its increase and of the
provision made for it; the evils of workhouses as primary or permanent
receptacles for the Insane; the ill consequences of large asylums, and
some of the legal amendments proposed, are in themselves subjects
calculated to enlist the attention of all interested in the general
welfare of our lunatic population, and in the administration of the laws
and institutions designed whether for its protection or for its care and
treatment.
CHAP. I.--OF THE NUMBER OF THE INSANE.
This inquiry must be preliminary to any consideration of the provision
made or to be made for the Insane. In carrying it out, we have chiefly to
rely upon the annual Reports of the Commissioners in Lunacy along with, so
far as pauper lunatics are concerned, those of the Poor-Law Board.
However, these reports do not furnish us with complete statistics, and the
total number of our insane population can be only approximately
ascertained. The Lunacy Commission is principally occupied with those
confined in public asylums and hospitals, and in Licensed Houses, and
publishes only occasional imperfect returns of patients detained in
workhouses or singly in private dwellings. On the other hand, the Poor-Law
Board charges itself simply with the enumeration of pauper lunatics
supported out of poor-rates, whether in asylums or workhouses, or living
with friends or elsewhere. Hence the returns of neither of these public
Boards represent the whole case; and hence, too, the chief apparent
discrepancies which occur when those returns are compared.
To show this, we may copy the tables presented in Appendix H of the Report
of the Commissioners in Lunacy for 1857, p. 81.
"Increase of Lunatics of all classes during the last
five years, according to Commissioners' Reports 3932
1852 1857
Paupers 12,982 16,657
Private Patients 4,430 4,687
------ ------
17,412 21,344
"According to returns published by Poor Law Board
during same period 6535
1852 1857
County and Borough Asylums 9,412 13,488
Licensed Houses 2,584 1,908
Workhouses 5,055 6,800
With friends or elsewhere 4,107 5,497
------ ------
21,158 27,693."
This very considerable difference of 2603 patients between the two
estimates is mainly due--as reference to the summary (at p. 53) proves--to
the omission, on the part of the Lunacy Commissioners, of those resident
in workhouses and "with friends, or elsewhere," reckoned in the Table of
the Poor-Law Board. This explanation, however, is only partial, for, after
allowing for it, the two estimates are found to diverge very considerably.
Thus, on adding the numbers in the categories last named, viz. 5055 + 4107
= 9162, in 1852,--and 6800 + 5497 = 12,297, in 1857 to the total given by
the Commissioners in each of those years, viz. to 17,412 and 21,344,
respectively, we obtain a total of 26,574 in 1852, and one of 33,641 in
1857; a variation of 5416 in the former, and of 5948 in the latter year,
from the results given in the Table presented by the Poor-Law Board. Much
of this wide difference is explicable by the Board last mentioned not
having reckoned the private patients, who amounted in 1852 to 4430, and in
1857 to 4687. Still, after all attempts to balance the two accounts, there
is a difference unaccounted for, of 986 in 1852, and of 1261 in 1857.
No clue is given in the official documents to the cause of this
discrepancy, and we are left in doubt which estimate of our lunatic
population is the more correct. The excess occurs in the Commissioners'
Returns; for on adding together, in each year in question, the numbers
reported by the Poor-Law Board, as detained in County and Borough Asylums
and in Licensed Houses, we find that the totals respectively are less
than the whole number of paupers as calculated by the Lunacy
Commissioners, by the precise difference we have made out, viz. 986 in
1852 and 1261 in 1857. Of the two returns before us, we accept that of the
Lunacy Commission, viz. that there were, including those in workhouses,
and with friends or elsewhere, 26,574 reported Lunatics in 1852, and
33,641 in 1857; and account for this larger total by the fact that the
Poor-Law Board Returns apply only to Unions and omit the lunacy statistics
of many single parishes, under local acts, and some rural parishes under
'Gilbert's Act,'--containing in them together above a million and a half
people more than are found in unions. Moreover, the Poor-Law Board returns
do not include County and Borough Patients. Looking to these facts, the
excess of 986 in 1852, and of 1261 in 1857, over and above the totals
quoted from the Summary of the Poor-Law Board, is not surprising; indeed,
taking the average usually allowed of one lunatic in every 700, the number
in one million and a half would be above 2000; that is, more than half as
many again as 1261; a result, which would indicate the Commissioners'
total to be within the truth.
We have just used the term 'reported lunatics,' for, besides those under
certificates and those returned as chargeable to parishes, comprised in
the foregoing numbers, there are very many of whom no public board has
cognizance. Most such are private patients supported by their own means,
disposed singly in the residences of private persons, throughout the
length and breadth of the country, and, with few exceptions, without the
supervision, in reference to their accommodation and treatment, of any
public officer. The Lunacy Commissioners justly deplore this state of
things; lament their inability, under existing Acts, to remedy it, and
confess that not a tithe of such patients is reported to them, according
to the intention of the law (16 & 17 Vict. cap. 96. sect. xvi.). It would
appear that less than 200 such cases are known to them; and it would not
be an extravagant or unwarrantable estimate to calculate their whole
number at about half that of the inmates of Licensed Houses, viz. at 2000.
This number would comprise those found lunatic by Inquisition, not
enumerated in the Commissioners' summary, although under the inspection of
the "Medical Visitors of Lunatics." According to the returns moved for by
Mr. Tite "of the total number of Lunatics in respect of whom Commissions
in Lunacy are now in force," there were, on the 27th July, 1858, 602 such
lunatics, and 295 of them were, according to the Commissioners' tables,
detained in asylums or Licensed Houses, leaving 347 not reckoned upon. In
addition to this class of the insane there is an unascertained small
number of persons of unsound mind in the horde of vagrant paupers, alluded
to occasionally in the Lunacy Commissioners' Reports.
The number of Criminal Lunatics in asylums is noted in the returns, but
that of those in jails is not reckoned. Although this is comparatively
small, owing to the usual custom of transferring prisoners, when insane,
to asylums, yet, at any one period, a proportion sufficient to figure in a
calculation of the whole insane population of the country will always be
found. Nay more, besides such scattered instances in County Prisons, there
is a very appreciable number in the Government Jails and Reformatories, as
appears from the returns presented to Parliament (Reports of the Directors
of Convict Prisons, 1858.)
The prisons included in these reports are:--Pentonville, Millbank,
Portland, Portsmouth, Dartmoor, Parkhurst, Chatham, Brixton, Fulham
Refuge, and Lewes. In the course of 1857, 216 persons of unsound mind were
confined, some for a longer or shorter period, others for the whole of the
year, in one or other of those prisons. Making allowance for those of the
216 who by removal from one prison to another (a transfer apparently of
common occurrence, the rationale of which we should find it difficult to
explain), might be reckoned twice, it may be safely stated that at least
150 were in the prison-infirmaries in question the whole year. In fact,
the Infirmary of Dartmoor Prison has wards specially appropriated to
insane patients, and actually constitutes a criminal asylum of no
insignificant magnitude. For instance, the report tells us that on the 1st
of January, 1857, there remained in that prison 102 cases; that 41 were
received during the year; 37 discharged (where, or how, we are not told,
except of 3, who were sent to Bethlem Hospital); and 106 remained on the
1st of January 1858.
It is also worth noting that in this Dartmoor Prison Infirmary, 38
epileptics remained on January 1st, 1857; 22 were admitted, 13 discharged,
and 47 remained on January 1st, 1858. The total of epileptics coming under
notice in the infirmaries of the several prisons in question, in the
course of 1857, amounted to 135. The remarks on some of these cases of
epilepsy by the medical officers, are sufficient to show that the
convulsive malady has seriously affected the mental health, and that they
might rightly be placed in the category of the insane.
However, having no wish to enhance the proportion of the subjects for
Lunatic Asylums, we will deal only with those enumerated as mentally
disordered. These amounted, according to the preceding calculations, in
the Government Prisons, to 150, and it would seem no exaggerated estimate
to assert that an equal number may be found in the various other prisons
and reformatories throughout the country. To put the matter in another
form, 300 lunatics are to be found in English prisons at any date that a
census may be taken. Consequently this sum of 300 must be added in
calculating the total of insane persons in this kingdom.
To establish still further the proposition with which we set out, that our
public statistics of Insanity are incomplete, the history of every County
Asylum might be adduced: for, notwithstanding very considerable pains have
been taken, on the proposition to build a new asylum, to ascertain the
probable number of claimants, and a wide margin over and above that
estimate has been allowed in fixing on the extent of accommodation
provided, yet no sooner has the institution got into operation, than its
doors have been besieged by unheard-of applicants for admission, and
within one-half or one-third of the estimated time, its wards have been
filled and an extension rendered imperative. Such is a _résumé_ of the
general history of English County Asylums, attested in the strongest
manner by that of the Middlesex, the Lancashire, and the Montgomery
Asylums; and confirmatory of the fact of the augmentation of insanity in
the country at a rate exceeding, more or less, that collected from county
returns and public statistics. It is, moreover, to be observed, that the
official statistics represent the total of lunatics existing on one
particular day, usually the first of January, in each year, and take no
account of those many who are admitted and discharged within the year, and
who rightly should be reckoned in an estimate of the total number of the
insane belonging to that period.
The average daily number resident in asylums would be a more correct
representation of their insane population than the total taken on any one
day, although it would fail to show the lunacy of the year.
Lastly, to illustrate the point discussed, to indicate how imperfect our
present estimate of the prevalence of insanity most probably is, and to
show the difficulties and defects of any ordinary census, we may appeal to
the experience of the special commission charged by the legislature of
Massachusetts to examine the statistics of Lunacy and the condition of
Asylums in that State, as recorded in their report, published in 1855.
"In 1848" (they write, p. 18), "a committee of the Legislature, appointed
to 'consider the whole subject connected with insanity within the
commonwealth,' ascertained and reported the number of insane in this State
to be 1512, of whom 291 were able to furnish the means of their own
support, and 1156 were unable to do so, and the pecuniary condition of 65
was not ascertained.
"In making that survey in 1848, the Commissioners addressed their letters
of inquiry 'to the municipal authorities of every city and town in the
commonwealth.'
"These public officers had direct means of knowing the number and
condition of the pauper insane, and probably this part of the report was
complete; but they had no other facilities of knowing the condition of
those lunatics who were in private families, and supported by their own
property or by their friends, than other men not in office, and could only
speak of those who were within their circle of personal acquaintance.
Consequently the report included only a part of the independent insane who
were then actually in, or belonged to, the State."
"In 1850 (p. 11), the marshals, the agents of the national government who
were appointed to take the census, visited every family; and, among other
items of information, they asked for the insane and idiots in the
household.
"By this personal and official inquiry, made of some responsible member of
every family, the marshals obtained the account of only 1680 insane
persons and 791 idiots, which is but little more than two-thirds of the
number ascertained by this Commission.
"Making all due allowance for the increase of population, and consequently
of the insane and idiots, these figures undoubtedly show far less than the
real amount of lunacy and idiotcy at that time, and render it extremely
probable that many concealed the facts that the law required them to state
to the marshals."
Thus the marshals discovered the number of insane to be in 1850 nearly
double that returned in 1848, and from their apparently searching inquiry,
it might have been presumed that they had made a near approximation to the
truth in the figures they published. However, the most pains-taking and
varied investigations of the Special Commissioners in 1854, prove the
marshals to have much underrated the number, for the result arrived at
was, that in the autumn of the year just named, there were 3719 lunatics,
of whom 1087 were idiots, in the State of Massachusetts.
The partial explanation of the divergence in numbers, viz.:--"that it is
probable that many of the families refused or neglected to report to the
marshals the insane and idiots who were in their households,"--is of
itself an indication of one of the impediments to a correct enumeration of
the insane members of a community, even when such is attempted under
favourable circumstances. It is one likewise which, however operative in
the United States, where the public asylums are open to, and resorted to
by, all classes of the community, must be still more so in this country,
where family pride endeavours in every way to ignore and keep secret the
mental affliction of a member, as though it were a plague spot. Besides
this, in no English census yet taken, has the enumeration of the insane
constituted a special subject of inquiry.
This illustration from American experience, coupled with the
considerations previously advanced, suffice to demonstrate that the
published statistics of insanity in England and Wales are incomplete and
erroneous, and that the machinery hitherto employed for collecting them
has been imperfect. The corollary to this conclusion is, that the number
of lunatics mentioned in the public official papers is much below the real
one. However, the facts and figures in hand justify the attempt to fix a
number which may be taken to represent _approximatively_ the total insane
population of this kingdom.
In their last Report (1858), the English Commissioners in Lunacy state
that, on January 1st, 1858, there were confined in asylums, hospitals, and
Licensed Houses, 17,572 pauper, and 4738 private patients, exhibiting an
increase of 915 pauper and of 51 private cases upon the returns of the
year preceding.
Pauper lunatics in workhouses are stated (10th Annual Report of the Poor
Law Board, 1858) to have numbered 6947, and those receiving out-door
relief 12,756; making a total of 20,703. By the kindness of Mr. Purdy, the
head of the Statistical Department of the Poor-Law Office, we are enabled
to explain that it is the custom of the office to reckon pauper lunatics
in Asylums and Licensed Houses among those receiving out-door relief;
consequently the sum of 12,756 comprises both those patients provided for
as just specified, and others boarded with their friends or elsewhere. We,
however, learn further, from the same excellent authority, that, owing to
the imperfection of the periodical returns, only a comparatively small
portion of the pauper insane confined in Asylums and Licensed Houses is
included in that total. Indeed, the fact of its being very much smaller
than that of the lunatics in Asylums and Licensed Houses, clearly enough
shows that the latter are not reckoned in it except partially.
Considering that the Poor Law Board obtain no record of the pauper
insanity in one million and a half of the population of England and Wales,
nor of the number of insane belonging to counties and boroughs,--for this
reason, that their cost of maintenance is not directly defrayed out of the
poor-rates, there must necessarily be a much greater number in workhouses
at large than the 6947 mentioned, and no inconsiderable proportion of poor
lunatics dispersed abroad in the country not enumerated in the 5500
counted as existing in January 1st, 1857. On these grounds, we assume 8000
as an approximative figure to represent the total of insane poor not under
confinement in Asylums and Workhouses, believing fully that it will be
found, on the publication of the returns for this year (1859), within the
mark.
Private patients not in Asylums, or Licensed Houses, often confined
without certificates, and the majority unknown to the Lunacy
Commissioners, we have put down, at a moderate estimate, at 2000. The
present state of the law does not enable the Commissioners or others to
discover these, often, we fear, neglected patients: and, on the other
hand, the operation of the laws regulating asylums, and the feeling evoked
by certain public trials of individuals confined in Licensed Houses, have,
together, combined to render them more numerous, by inducing friends to
keep them at home, to send them abroad to Continental institutions, or to
place them under the care of private persons or attendants in lodgings.
This completes our enumeration; and the figures stand thus, on the 1st of
January, 1858:--
_Pauper._ _Private._ _Total._
In Asylums and Licensed Houses 17,572 4,738 22,310
In Workhouses 6,947 ... 6,947
With Friends, or elsewhere 8,000 2,000 10,000
In Prisons, Vagrants, &c. 300 ... 300
------- ------- -------
32,819 6,738 39,557
To extend the estimate to the commencement of the present year (1859), we
require to add the gross increase of lunatics during 1858 to the total
just arrived at: 39,557. What this increase may be cannot be decisively
stated; but to anticipate the estimate of it, which we shall presently
arrive at, viz. 1600 per annum, the result is, that _on the 1st of
January_ 1859 there were in England and Wales, in round numbers, 41,000
persons of unsound mind, or, to employ the legal phraseology, lunatics and
idiots.
It perhaps should be explained, and more particularly with reference to
those detained in workhouses or supported by their parishes at their own
houses, that besides idiots, or those congenitally deficient, a very large
proportion of them is composed of weak and imbecile folk, who would, in
olden times, have been considered and called "fools," and not lunatics,
and been let mix with their fellow-men, serve as their sport or their
dupes, and exhibit their hatred and revenge by malicious mischief and
fiendish cruelty. But, thanks to modern civilization and benevolence,
these poor creatures are rightly looked upon as proper objects for the
supervision, tending and kindness of those whom Providence has favoured
with a higher degree of intelligence. This act of philanthropy, effected
at a great cost, elevates at the same time, very materially, the ratio of
insane persons to the population, and thereby gives cause of alarm at the
prevalence of mental disorder, and makes our sanitary statistics contrast
unfavourably with those of foreign lands, where the same class of the sick
poor has not been so diligently sought out and brought together with a
view to their moral and material well-being.
CHAP. II.--ON THE INCREASE OF INSANITY.
The only data at hand to calculate the gross increase of the insane in
this country, year by year, or over a series of years, are those contained
in the Official Reports of the Commissioners in Lunacy and of the Poor-Law
Board. These, as we have just shown in the preceding chapter, are
incomplete as records of the state of lunacy, since they take no notice of
numerous patients not in recognized asylums. Moreover, the annual summary
of the returns made by the Commissioners of insane patients confined in
Asylums and Licensed Houses, represents a compound quantity, made up of
the increment by accumulation in past years, and of the fresh cases
admitted in any particular year, and remaining at its close. The same is
true of the figures supplied by the Poor-Law Board. Now, though these
summaries are useful to show the rate of accumulation of the insane in the
various receptacles for them, annually or over any fixed period, they do
not tell us how many persons are attacked by madness in any year, or other
space of time; or, in other words, they do not inform us whether there is
an actual increase, or a decrease in the annual number of persons becoming
insane.
This question of the simple increase or decrease of insanity cannot be
correctly answered. It is elucidated in some measure, so far as licensed
institutions for the insane are concerned, by the tables of admission for
different years furnished by the Reports of the Lunacy Commissioners; and
it may be assumed to be partially answered by the returns of the number of
lunatics in workhouses published by the Poor-Law Board, after an allowance
made for the diminution caused by deaths which have taken place in the
twelvemonth; but no means whatever exist of discovering the number of
persons annually attacked with mental disorder, who do not fall under the
cognizance of the public boards.
With the materials in hand, let us in the first place examine the results
which follow from a comparison of the Lunacy statistics of the
Commissioners, instituted at intervals of more or fewer years. By this
course we shall attain, not indeed an estimate of the progressive increase
of our insane population, but a valuable comparative return of the number
of those enjoying the advantages of asylum care and management in
different years. The summary presented in each annual report shows that
there were in
_Males._ _Females._ _Total._
1843--Private patients 1,989 1,801 = 3,790 }
Pauper patients 3,532 3,950 = 7,482 } = 11,272
1853--Private patients 2,331 2,099 = 4,430 }
Pauper patients 5,916 7,066 = 12,982 } = 17,412
1858--Private patients 2,508 2,230 = 4,738 }
Pauper patients 7,985 9,587 = 17,572 } = 22,310
From these tables it therefore appears that the accumulation of insane
persons in Asylums in the ten years between 1843 and 1853, equalled 6140;
and in the five years between 1853 and 1858, 4898; or progressed at the
rate of 614 per annum in the ten years, and of 979·6 (or in round numbers
980) per annum in the five years under review, or upwards of 50 per cent.
faster in the latter space of time.
In their Twelfth Report (1858) the Commissioners in Lunacy attempt to
calculate the probable demands for asylum accommodation on the 1st of
January 1860, from the increased number of lunatics in the space of one
year, from January 1st, 1857, to January 1st, 1858, amounting to 915. But
as we have pointed out in a paper in the "Journal of Mental Science" (vol.
v. 1859, p. 249), the conclusion drawn from such data must be fallacious.
For instance, a calculation on the result of one year's statistics is
evidently worth little. There are many causes at work in asylums which
materially affect the relative number of admissions and discharges, and
consequently produce an inequality in the rate of increase viewed year by
year. Moreover, where the same plan of calculation has been adopted in
determining what asylum accommodation was necessary, experience has soon
exhibited the fallacy, and both the admissions and the demands for
admission have far exceeded the total reckoned upon. To arrive at a nearer
approximation to the truth, the augmentation in the number of lunatics
ought to be noted for a space of several years; and to make the deduction
more satisfactory, the increase of the general population, the conditions
of the period affecting the material prosperity of the people, and its
political aspects; and, lastly, the mere circumstance of the opening of
new asylums,--a circumstance always followed by an unexpected influx of
patients, need be taken into account.
In the preceding considerations only the returns of lunatics in Asylums,
Hospitals, and Licensed Houses are discussed; but, as we have seen, there
is an almost equally large number detained in workhouses, or boarded with
their relatives, or other persons, at the expense of their parishes, whose
increase or decrease is a matter of kindred importance. On reviewing the
returns of their numbers at periods when they have been taken cognizance
of by the Lunacy Commission, we find that there were in workhouses and
elsewhere, together, in
1843 9,339
_In Workhouses._ _With Friends
and elsewhere._
1847 4,490 3,465 = 7,955
1857 6,800 5,497 = 12,297
exhibiting an increase of 4342 in the ten years between 1847 and 1857, and
a decrease in the four between 1843 and 1847 of 1384, owing, doubtless, to
the opening of new asylums during that space of time. The returns of the
two classes of Pauper Lunatics together being both so infrequently made,
and, as before shown (p. 8), open to criticism on account of their
incompleteness, we shall attempt to arrive at a more correct estimate of
increase than that just made. In the first place, with respect to Union
Workhouses, the Summary of Indoor Paupers, published by the Poor Law
Commission (10th Report, p. 196), affords the necessary data. According to
this tabular statement, we find, that, there were on the 1st of January in
each of the ensuing years the following numbers of pauper lunatics:--
1847 4,490
1849 4,842
1850 4,659
1851 5,029
1852 4,744
1853 4,954
1854 5,459
1855 5,960
1856 6,480
1857 6,488
1858 6,947
These columns show, that since 1847 the minimum number of insane, at a
corresponding date in each year, occurred in 1850. Once indeed since, but
at a different period of the year, viz. on July 1st, 1851, the number fell
to 4574, or 75 less than at the date before named. Two or three years
excepted, the increment has been progressive; at one time, indeed, much
more rapidly so than at another. The fluctuations observable are, in the
first place, due to the opening of new, or the repletion of existing,
asylum accommodation; and in a lesser degree, to the rise or fall of
pauperism in the community at large, or to an increased mortality at
times, as, for example, in 1849, when cholera prevailed--an event which in
part, at least, explains the smaller figure of insane inmates in 1850.
But whatever the fluctuations observable year by year may be, there is a
most distinct increase in the space of any five or ten years selected
from the list, suggestive of the unwelcome fact that, notwithstanding the
very large augmentation of asylum accommodation and the reduction of
numbers by death, the rate of accumulation has proceeded in a ratio
exceeding both those causes of decrease of workhouse inmates combined.
Thus, to take the decennial period between 1847 and 1857, we discover an
increase of just 2000, or an average annual one of 200; and, what is
remarkable, as large a total increase, within a few units, is met with in
the quinquennial period between 1853 and 1858, and consequently the yearly
average on the decennial period is doubled; viz. 400 instead of 200. This
doubling of the average in the last five years would be a more serious
fact, were it not that in 1853 the number of workhouse inmates had been
reduced upon 1851, and had only slightly advanced above that of 1849.
Rejecting the maximum rate of accumulation, we will calculate the average
of the last three years cited, from 1855 to 1858, a period during which
there has been no notable cause of fluctuation, and no such increase of
population as materially to affect the result, and for these reasons
better suited to the purpose. In this space of time the increment equalled
987, or an average of 329 per annum; which may fairly be considered to
represent the rate of accumulation of lunatics in Union Workhouses at the
present time.
The absence of returns of lunatics in the workhouses of parishes under
local Acts, is an obstacle to a precise computation of them; however, on
the assumption that the proportion of lunatics in those workhouses to the
population (1,500,000) of the parishes they belong to, is equal to that of
those in Union Workhouses to the estimated population (18,075,000) of the
Unions, and that the average increase is proportionate in the two cases,
this increase should equal 1/12th of 329, or somewhat more than 27, per
annum; making the total average rate of accumulation in workhouses at
large 356 annually.
Unfortunately, no separate record is regularly kept of those poor insane
persons who are boarded with friends or others, and their number has been
only twice published, viz. in 1847 and 1857, when, as seen in a preceding
page, it was, respectively, 3465 and 5497. These two sums exhibit an
increase of 2032 to have accrued in the ten years included between those
dates, or an average one of 203 per annum.
We have, above, calculated the average annual increase on those in Union
Workhouses and those with friends, at 434 annually; and consequently that
of the latter being 203, the yearly increase of the former stands,
according to the returns employed, at 231. However, we have proved that
the average increase, in Union Workhouses, has reached in the last three
years the amount of 329, and in workhouses at large 356, which, added to
203, produces 559, or in round numbers, 560, as the sum-total of
accumulation of pauper lunatics not in Asylums, Hospitals, or Licensed
Houses. Adding the annual rate of increase of the insane in Asylums, viz.
980, to that among paupers, unprovided with asylum accommodation, 560, we
obtain the total accumulation per annum of 1540 lunatics reported to the
public boards. To this sum there should rightly be added the accumulative
increase among insane persons not known to those boards, and which, in the
absence of any means to ascertain its amount, may be not extravagantly
conceived to raise the total to 1600.
We come now to the second part of our present task, viz. to discover the
comparative number of new cases in several past years, so as to obtain an
answer to the question,--Has there been an increase of the annual number
of persons attacked with lunacy during that period? for previous figures
leave no doubt there is an augmented ratio of insane persons in the
population of the country. At the outset of this inquiry an insuperable
difficulty to a correct registration of the number arises from the
circumstance that, during any term of years we may select, the
accommodation for the insane has never, even for one year, been fixed, but
has been progressively increased by the erection of new, and the
enlargement of old asylums. This occurrence, necessarily, very materially
affects the returns made by the Commissioners of the number of admissions
into asylums and Licensed Houses. Even if the comparison of the annual
admissions into any one County Asylum only, were of value to our purpose,
the same difficulty would ensue by reason of the enlargement of the
institution from time to time, and of the circumstance that, as it
progressively filled with chronic cases, the number of admissions will
have grown smaller. Likewise, the farther that the inquiry is extended
back, the more considerable will this difficulty in the desired
computation be. In short, it may be stated generally, that the proportion
of admissions will vary almost directly according to the accommodation
afforded by asylums, and the inducements offered to obtain it.
On the other hand, the consequences of the variations in asylum
accommodation upon the total of admissions are to a certain extent
compensated for by the fluctuations they produce upon the number of
lunatics not provided for in asylums; for this reason, that where a County
Asylum opens for the reception of patients, the majority of these are
withdrawn from Licensed Houses and workhouses, and thereby a reduction is
effected in the number of inmates of those establishments.
After the above considerations, it is clear that an estimate of the
number of insane persons in any year, as gathered from the statistics of
those brought under treatment in asylums or elsewhere, can be only an
approach to the truth. Still it is worth while to see what results follow
from an examination of the Returns of Admissions, as collected by the
Commissioners in Lunacy. It would be of no service to extend the inquiry
far backward in time, on account of the rapidity with which asylum
accommodation has been enlarged; we will therefore compare the admissions
over the space of four years, viz. 1854, 1855, 1856, and 1857, during
which the changes in asylums have been less considerable.
_Table of Admissions._
1854--County and Borough Asylums 4,620
Hospitals 868
Licensed Houses 2,161
-----
Total 7,649
-----
1855--County and Borough Asylums 4,342
Hospitals 828
Licensed Houses 2,196
-----
Total 7,366
-----
1856--County and Borough Asylums 4,538
Hospitals 777
Licensed Houses 2,091
-----
Total 7,406
-----
1857--County and Borough Asylums 4,781
Hospitals 790
Licensed Houses 2,324
-----
Total 7,895
-----
There is a remarkable degree of uniformity in the sum of admissions in
each of these four years; and if each several sum could be taken to
represent the accession of new cases of insanity in the course of the
year, there would appear no actual progressive increase of the disease in
the community during the four years considered. The average of the
admissions for that period is 7579; those therefore of 1854 and 1857 are
in excess, and those of 1855 and 1856 are within it. The widest
difference is observed in 1857, when a sudden rise takes place, which, by
the way, is not explicable by the greater provision of asylum
accommodation in that year than in the three preceding. Yet this increase
is not so striking when viewed in relation to the totals of other years;
for it exceeds the average only by 316, a sum little greater than that
expressing the decrease of 1855 upon the total of 1854.
It is difficult to decide what value should be assigned to these results,
deducible from a comparison of the yearly admissions, in determining the
question of the increase of insanity, viewed simply as that of the
comparative number attacked year by year,--it would, however, seem a not
unreasonable deduction from them, that the proportion of persons attacked
by mental disorder advances annually at a rate little above what the
progressive increase of population is sufficient to explain. If this be
so, the increase by accumulation of chronic and incurable cases becomes so
much the more remarkable, and an investigation of the circumstances
promoting, and of those tending to lessen, that accumulation, so much the
more important.
There are, as heretofore remarked, very many insane persons who are not
sent to asylums or private houses, at least to those in this country, and
whose relative number yearly it is impossible, in the absence of all
specific information, to compute. Although the agitation of the public
mind respecting private asylums, and the facility and economy of removing
insane persons abroad, may have latterly multiplied the number of such
unregistered patients, yet there is no reason to assume that their yearly
positive increase is other than very small.
The pauper lunatics living in workhouses have as yet been omitted from the
present inquiry. Their yearly number is affected not only by the
introduction of fresh cases, but also by removals to asylums and by
deaths; or, in other words, it is a compound quantity of new inmates
received and of the accumulation of old. However, the returns above quoted
(p. 13) show that between 1855 and 1858 there was an increase of almost
exactly 1000, or, as before calculated, an average of 329 annually. The
Poor Law Board Report unfortunately gives no returns of the annual
admissions; hence we do not possess the means of discovering what
proportion of the growing increase observed is due year by year to the
accession of fresh inmates. The advancing growth in numbers of those
pauper insane receiving out-door relief is not clearly discoverable: from
the few data in possession, as before quoted (p. 14), about 200 are
annually added.
It appears pretty clearly, then, that there are at least 1600 reported
lunatics added to the insane population of the country yearly, and of
this increase only 60, or 1 in 26·66, are supported out of their own
resources in asylums; the remainder, with some few exceptions, falling
upon the rates for their entire maintenance.
It would therefore be difficult to exaggerate the importance of the
question of the provision for the insane poor in this country, both to the
political economist and to the legislator. There are certainly more than
1300 persons yearly so affected in mind as to be unfit or unable to take
care of themselves, and to obtain their own livelihood, and who, under
this distressing infliction of Providence, demand the care and charity of
their neighbours, and the succour of the State, properly to protect and
provide for them. To perform this duty at the least cost, compatible with
justice to these afflicted individuals, involves a tax upon the community
of which few persons have any adequate conception. Supposing, by way of
illustration, that the number mentioned required the accommodation of an
asylum, the cost of providing it, according to the system hitherto in
vogue, would nearly equal that incurred in the establishment and
maintenance of the Middlesex County Asylum at Colney Hatch, or a sum of
£300,000 for land, buildings, and fittings (equal, at 5 per cent. to a
yearly rental of £15,000), and an annual charge of £30,000 for
maintenance. The example of Colney Hatch, chosen for illustration, is a
very fair one, and the figures used in round numbers are actually within
the average expenditure in and for the establishment of County Asylums in
this country, as may be seen on reference to Appendix D. (Commissioners'
Report, 1854), and to the table of asylums in course of erection, printed
at p. 2 of their Twelfth Report (1858).
On applying these results to the total number of pauper lunatics in
Asylums, which, according to the return on the 1st of January 1858,
amounted to 15,000, the sum of £4,500,000 (not including interest) will
have been expended in providing them accommodation, and an annual charge
incurred of £450,000 for their care and maintenance. All this, too, is
independent of the cost on account of those maintained in Licensed Houses,
in workhouses, and in lodgings with friends or others, the amount of which
we do not possess sufficient information to determine.
The Commissioners in Lunacy, in their elaborate Report in 1844, took the
population of England and Wales at 16,480,082, and reckoned on the
existence of 20,893 lunatics on the 1st January of that year, of whom
16,542 were paupers. The latter, they calculated, stood in the proportion
of 1 to 1000 in the population, or, more correctly, 1 in 997; and the
total lunatics as 1 to 790. On the 1st of January 1857, they found the
pauper lunatics to be in the proportion of 1 in 701; whilst pauper and
private together equalled 1 in 600, to the estimated population,
19,408,364. Adopting the figures arrived at in the preceding discussion,
viz. that there are 41,000 insane persons in this country, and assuming
the population on the 1st of January, 1859, to have been 19,800,000, the
proportion of the insane would be as high as 1 in 483 persons.
This much-enlarged ratio of insanity to the population admits of several
explanations, without a resort to the belief that the disease is actually
and fearfully on the increase. As before said, we regard the accumulation
of chronic and incurable lunatics to be the chief element in raising the
total number, and this accumulation is favoured by all causes operating
against the cure of insanity; by the increased attention to the disease,
and by all those conditions improving the value of life of the insane,
supplied, at the present day, in accordance with the improved views
respecting their wants, and the necessity of placing them under conditions
favourable for their health, care and protection. On the operation of
these causes, favouring the multiplication of insane persons in the
community, we shall, however, not at present further enter, but proceed to
inquire how far the existing provision for the insane is adequate to their
requirements.
Before entering on this inquiry, a few words are wanting to convey a
suggestion or two respecting the collection of the statistics of pauper
lunatics. It is most desirable we should be able to discover, from the
official returns of the public boards, with precision, what number of
insane persons is wholly or partially chargeable to the Poor Rates, what
to Borough, and what to County Rates. The returns of the Poor-Law Office
ought not to be marred by the omission of the statistics of parishes,
which by local or special acts escape the direct jurisdiction of the
board. If the central board be denied a direct interference in their
parochial administration, it ought to be informed of the number of their
chargeable poor, including lunatics. It is equally unsatisfactory, that
the pauper registry kept by the Poor-Law Board is not rendered complete by
the record of all those chargeable to counties and boroughs, as this could
be so readily done by the clerks of county and borough magistrates.
An amendment, too, is desirable in the practice of the Poor-Law Office of
reckoning together in their tables pauper lunatics in asylums among the
recipients of out-door relief with those boarded with their friends or
elsewhere, whence it is impossible to gather the proportion of such class.
This technicality of considering workhouse inmates as the only recipients
of _in-door_ relief, to the exclusion of asylum patients who are in
reality receiving it in an equal degree, although in another building than
the workhouse, is an official peculiarity we can neither explain nor
approve; and it appears to us most desirable that lunatic paupers in
asylums should be arranged in a distinct column, and that the same should
be done with those living with their friends or others. By the adoption of
this plan the questions of the number of the pauper insane, of their
increase and decrease, whether in asylums or elsewhere, and of the
adequacy of accommodation for them, could be ascertained by a glance at
the tables. We would likewise desire to see those paupers belonging to
parishes not in union and under Local Acts, and those chargeable to
Counties and Boroughs, tabulated in a similar manner.
A practical suggestion, connected with the statistics of insanity, we owe
to Mr. Purdy, viz. that section 64 of the "Lunatic Asylums' Act, 1853" (16
& 17 Vict. cap. 97) should be amended by the insertion of a few words
requiring the clerks of unions to make the returns of the number of
chargeable lunatics on a specified day, as on the first of January in each
year. This practice was formerly enjoined, and probably its omission from
the Act now in force was accidental. The present enactment requires that
the clerks of unions "shall, on the first day of January in every year, or
as soon after as may be, make out and sign a true and faithful list of all
lunatics chargeable to the union or parish;" and the only alteration
required is the addition of two or three words at the end of this
paragraph, such as:--'on the first day of January of that year.' The want
of a fixed date of this kind, Mr. Purdy says, imposes great trouble in
getting the clerks to make their returns with reference to the same day in
the several unions and parishes.
CHAP. III.--STATE OF THE PRESENT PROVISION FOR THE INSANE IN ASYLUMS.--ITS
INADEQUACY.
In their Report for 1857, the Commissioners in Lunacy have presented us
with a memorandum of the present accommodation afforded in County Asylums,
and of that in course of being supplied, and have attempted further a
calculation of the probable requirements on the 1st of January 1860. The
former may be accepted as nearly correct, but the latter affords, as
before noticed, a rough, and not sufficiently accurate, estimate.
Their statement is, that on the 1st of January, 1858, 16,231 beds were
provided in public asylums; that, by the projected enlargement of existing
institutions, 2481 others would be obtained, and, by the completion of
eight asylums in course of erection, there would be added 2336 more--a
total of 4817, on or before January 1860. Of the increase in additional
buildings, 1000 beds, or thereabouts, would not be ready at so early a
date as that named; and in calculating existing provision, need be
deducted from the total of 2,336; consequently the accommodation in
County Asylums would, according to the Commissioners, in this year, 1859,
reach 20,000, and in 1860, 21,048.
The County Asylum accommodation on January 1st, 1858, expressed by the sum
of 16,231, exceeded the total of pauper lunatics returned as actually
partaking its advantages at that date, viz. 14,931, by the large number of
1300; showing a surplus to that amount, including beds, in infirmary
wards. What may be the precise number of the last, or, in other words, of
those generally inapplicable to ordinary cases, labouring under no
particular bodily infirmity, we cannot tell, but we feel sure that 1000 of
them would be available; in fact, the whole number by classification might
be rendered so. Be this so or not, the Commissioners have omitted any
reference to this present available accommodation, in calculating what may
be necessary in 1860.
On the other hand, they have rather over-estimated the future provision in
asylums, by adding together that in the Beds., Herts., and Hunts. Asylum
now in use, viz. 326, with that to be secured in the new one, viz. 504,
instead of counting on the difference only, 178, as representing the
actual increase obtained,--for the intention is to disuse the old
establishment as a county institution.
To proceed. The Commissioners calculate on an addition of 4817 beds to the
number provided in January 1858 (according to our correction, in round
numbers, 4500), and proceed to say, that "if to this estimate ... we apply
the ratio of increase in the numbers requiring accommodation observable
during the last year, some conclusion may be formed as to the period for
which these additional beds are likely to be found sufficient to meet the
constantly increasing wants of the country, and how far they will tend
towards the object we have sought most anxiously to promote ever since the
establishment of this Commission, namely, the ultimate closing of Licensed
Houses for pauper lunatics. On the 1st of January, 1857, the number of
pauper lunatics in County and Borough Asylums, Hospitals, and Licensed
Houses, amounted to 16,657. On the 1st of January, 1858, this number had
increased to 17,572, showing an increase during the year of 915 patients;
and of the total number 2467 were confined in the various metropolitan and
provincial Licensed Houses.
"Assuming, then, that during the next two years the progressive increase
in the number of pauper lunatics will be at least equal to that of the
year 1857, it follows, that on the 1st of January, 1860, accommodation for
1830 additional patients will be required; and if to this number be added
the 2467 patients who are now confined in Licensed Houses, there will
remain, to meet the wants of the ensuing year, only 520 vacant beds. It is
obvious, therefore, that if Licensed Houses are to be closed for the
reception of pauper lunatics, some scheme of a far more comprehensive
nature must be adopted in order to provide public accommodation for the
pauper lunatics of this country."
This conclusion must indeed be most unwelcome and discouraging to the
rate-payers, and to the magistracy, in whose hands the Government reposes
the duty of providing for the due care of pauper lunatics in County
Asylums. To the latter it must be most dispiriting, when we reflect on the
zeal and liberality which have generally marked their attempts to secure,
not merely the necessary accommodation, but that of the best sort, for the
insane poor of their several counties. It is, indeed, an astounding
statement for the tax-payer to hear, that, after the expenditure of one or
two millions sterling to secure the pauper lunatics of this country the
necessary protection, care, and treatment, and the annual burden for
maintenance, that a far more comprehensive scheme is demanded. No wonder
that the increase of insanity is viewed as so rapid and alarming; no
wonder that every presumed plan of saving expense by keeping patients out
of asylums should be readily resorted to.
The value of the conclusion, and of the facts whereon it rests, certainly
merit careful examination; and after the investigation made as to the
number of the insane, and their rate of increase and accumulation, such an
examination can be more readily accomplished.
To revert to the figures put forward by the Commissioners, of the number
of beds existing in asylums on the 1st of January, 1858, and of that to be
furnished by 1860. They reckoned on 16,231 beds at the former date, and on
the addition of 4817 by the year 1860, or a total of 21,048. We have,
however, shown, that in January 1858 there were 1300 vacant beds, and that
there was an over-estimate of the future increase by about 300, leaving,
without reckoning the number in progress, 1000 to meet coming claims. This
sum being therefore added, gives a total of 22,048 to supply the wants of
the pauper insane between the 1st of January, 1858, and the completion of
the new asylums in 1860. Using the average increase adopted by the
Commissioners, viz. 915 per annum, there would be at the commencement of
the year 1860, 1830 applicants for admission, to be added to the 2467
confined in Licensed Houses, whom the Lunacy Commissioners are so anxious
to transfer to county institutions, making in all 4297. But according to
our corrected valuation, there would be in the course of 1860, room for
5817 patients, that is, a surplus accommodation for 1520.
It must be admitted as incorrect on the part of the Commissioners, in the
Report just quoted, to calculate on the whole number of beds obtained by
new buildings, as available in January 1860, when, in all probability,
1000 of them will not be ready much before the close of the year; still,
after making allowance for the increased number of claimants accruing
between that date and the opening of the new asylums, there would,
according to the data used, remain vacancies for some thousand or more,
instead of the 520 reckoned upon by the Commissioners.
Our review, therefore, is thus far favourable, and suggestive of the
possibility of a breathing time before the necessity of a scheme of a "far
more comprehensive nature" need be adopted. But, alas! the inquiries
previously gone into concerning the number and increase of the insane
render any such hope fallacious, and prove that the Commissioners have
very much underestimated the number to be duly lodged and cared for in
asylums; unless indeed, after having secured the transfer of those now in
Licensed Houses to County Asylums, they should consider their exertions on
behalf of the unfortunate victims of mental disorder among the poor
brought to a close. Such an idea, however, is, we are persuaded, not
entertained by those gentlemen, who have, on the contrary, in their
Reports frequently advocated the provision of asylums for all the pauper
insane with few exceptions, and distinctly set forth the objections to
their detention in workhouses.
In fact, every well-wisher for the lunatic poor, is desirous to see
workhouses disused as receptacles for them, and it naturally appears more
important to transfer some of their inmates to proper asylums than to
dislodge those detained in Licensed Houses, where, most certainly, the
means of treatment and management available are superior to those existing
in workhouse wards.
But our efforts on behalf of the insane poor must not cease even when
those in workhouses are better cared for, since there then remains that
multitude of poor mentally disordered patients scattered among the
cottagers of the country, indifferently lodged, and not improbably,
indifferently treated, sustained on a mere pittance unwillingly doled out
by Poor-Law Guardians, and under no effectual supervision, either by the
parish medical officers or by the members of the Lunacy Board. Some
provision surely is necessary for this class of the insane; some effectual
watching over their welfare desirable; for the quarterly visits required
by law (16 & 17 Vict. cap. 97, sect. 66) to be made to them by the
overworked and underpaid Union Medical Officers cannot be deemed a
sufficient supervision of their wants and treatment. These visits, for
which the noble honorarium of 2_s._ 6_d._ is to be paid, whatever the
distance the medical officer may have to travel,--are intended by the
clause of the Act to qualify the visitor to certify "whether such lunatics
are or are not properly taken care of, and may or may not properly remain
out of an asylum;" but practically nothing further is attained by them
than a certificate that the pauper lunatic still exists as a burden upon
the parish funds; and even this much, as the Commissioners in Lunacy
testify, is not regularly and satisfactorily obtained. A proper inquiry
into the condition of the patient, the circumstances surrounding him, the
mode of management adopted, and into the means in use to employ or to
amuse him, cannot be expected from a parish medical officer at the
remuneration offered, engaged as he is in arduous duties; and, more
frequently than not, little acquainted with the features of mental
disease, or with the plans for its treatment, alleviation, or management.
Even in the village of Gheel in Belgium, which has for centuries served as
a receptacle for the insane, where there is a well-established system of
supervision by a physician and assistants, and where the villagers are
trained in their management, those visitors who have more closely looked
into its organization and working, have remarked numerous shortcomings and
irregularities. But compared with the plan of distributing poor demented
patients and idiots, as pursued in this country, in the homes of our
poorer classes and peasantry, unused to deal with them, too often
regarding them as the subjects of force rather than of persuasion and
kindness, and under merely nominal medical oversight four times a year,
Gheel is literally "a paradise of fools." Indeed a similar plan might with
great advantage be adopted, particularly in the immediate vicinity of our
large County Asylums.
But to return to the particular subject in question, viz. the proportion
of insane poor in workhouses and elsewhere who should rightly find
accommodation in asylums, a class of lunatics, as said before, not taken
into account by the Commissioners in their estimate of future
requirements.
We let pass the inquiry, what should be done for the 8000 poor imbecile
and idiotic paupers boarded in the homes of relatives or others, and
confine our observations to the 7947 inmates of workhouses. Now, although
we entertain a strong conviction of the evils of workhouses as receptacles
for the insane, with very few exceptions,--a conviction we shall presently
show good grounds for, yet, instead of employing our own estimate, we
shall endeavour to arrive at that formed by the Lunacy Commissioners, of
the proportion of lunatics living in them, for whom asylum accommodation
should be provided.
The principal and special Report on Workhouses, in relation to their
insane inmates, was published in 1847, and in it the Commissioners observe
(p. 274), that they believe they "are warranted in stating, as the result
of their experience, that of the entire number of lunatics in
workhouses,--two-thirds at the least--are persons in whom, as the mental
unsoundness or deficiency is a congenital defect, the malady is not
susceptible of cure, in the proper sense of the expression, and whose
removal to a curative Lunatic Asylum, except as a means of relieving the
workhouse from dangerous or offensive inmates, can be attended with little
or no benefit. A considerable portion of this numerous class, not less
perhaps than a fourth of the whole, are subject to gusts of passion and
violence, or are addicted to disgusting propensities, which render them
unfit to remain in the workhouse.... But although persons of this
description are seldom fit objects for a curative asylum, they are in
general capable of being greatly improved, both intellectually and
morally, by a judicious system of training and instruction; their dormant
or imperfect faculties may be stimulated and developed; they may be
gradually weaned from their disgusting propensities; habits of decency,
subordination, and self-command may be inculcated, and their whole
character as social beings may be essentially ameliorated."
In their Ninth Report (1855), speaking of those classed in the Workhouse
In-door Relief Lists, under the head of Lunatics or Idiots, they
observe:--"These terms, which are themselves vague and comprehensive, are
often applied with little discrimination, and in practice are made to
include every intermediate degree of mental unsoundness, from imbecility
on the one hand, to absolute lunacy or idiotcy on the other; and, in point
of fact, a very large proportion of the paupers so classed in workhouses,
especially in the rural districts, and perhaps four-fifths of the whole,
are persons who may be correctly described as harmless imbeciles, whose
mental deficiency is chronic or congenital, and who, if kept under a
slight degree of supervision, are capable of useful and regular
occupation. In the remainder, the infirmity of mind is for the most part
combined with and consequent upon epilepsy or paralysis, or is merely the
fatuity of superannuation and old age; and comparatively few come within
the description of lunatics or idiots, as the terms are popularly
understood."
Lastly, in the Eleventh Report (1857), the class of pauper insane, whose
detention in workhouses is allowable, is indicated in the following
paragraph:--"They (workhouses) are no longer restricted to such pauper
lunatics as requiring little more than the ordinary accommodation, and
being capable of associating with the other inmates, no very grave
objection rests against their receiving.... But these are now unhappily
the exceptional cases."
These extracts are certainly not precise enough to enable us to state,
except very approximatively, what may be the estimate of the Lunacy
Commissioners of the numbers who should be rightly placed in asylums. That
first quoted appears to set aside one-third as proper inmates of a
curative asylum, and amenable to treatment; and then to describe a fourth
of the remaining two-thirds, that is, one-sixth, as proper objects of
asylum care. On adding these quantities, viz. one-third to one-sixth, we
get as the result, one-half as the proportion of workhouse insane
considered to be fit subjects for asylums.
The second quotation by itself is of little use to our purpose, except in
conjunction with the third one and with the context, as printed in the
Report from which it is taken, relative to the general question of the
evils of workhouses as receptacles for the insane. So examined in
connection, the published statements and opinions of the Commission, lead
to the conclusion that the great majority of the insane in workhouses
should rightly enjoy the advantages of the supervision, general
management, nursing, and dietary of asylums.
However, to escape the possible charge of attempting to magnify the
deficiency of asylum accommodation, we will, for the time, assume that
only one-half of the lunatic inmates of workhouses require asylum
treatment; even then we had some 4000 to be provided with it at the
beginning of 1858, and should have at the least 4500 by January 1860.
Having now reduced the estimate of the demands for asylum care to figures,
it is practicable to calculate how far those demands can be met by the
existing provision in asylums and what may be its deficiency.
On the one side, there will be, at the most moderate computation, made as
far as possible from data furnished by the Reports of the Lunacy
Commissioners, 4500 inmates of workhouses, who should, on or before
January 1st, 1860, obtain asylum care and treatment. On the other, there
will be, as above shown, about 1000 beds unoccupied at the date mentioned,
after accommodation is afforded to the pauper residents in Licensed
Houses, and to the number of insane resulting from accumulation and
increase in the course of two years from January 1858. The consequence is,
that in January 1860, there will remain some 3500 pauper lunatics
unprovided for in proper asylums.
In the course of the preceding arguments, we have kept as closely as
possible to data furnished by the Lunacy Commissioners' Reports, and
withal have made out, satisfactorily we trust, that the provision supplied
by existing asylums and by those now in progress of erection, is
inadequate to the requirements of the insane population of this country.
The idea of its inadequacy would be very greatly enhanced by the
employment of the statistical conclusions we have arrived at respecting
the number of the insane and their rate of accumulation, and by the
reception of the views we entertain against their detention, with
comparatively few exceptions, in other receptacles than those specially
constructed and organized for their care and treatment. The truth of our
opinions we shall endeavour to establish in subsequent pages; and
respecting the rate of accumulation of pauper cases, we feel confident
that 1800 per annum is within the truth. To meet this increase, both the
asylums in existence and those in course of erection are undoubtedly
inadequate, and, as the necessary result, workhouse pauper inmates must
continue to multiply.
If the opinion were accepted that public asylum accommodation should be
provided for all the pauper poor, not many more than one-half are at
present found to be in possession of it, that is, 17,000 of the 33,000 in
the country. Hence it would be required, to more than double the present
provision in asylums for pauper lunatics, to give room for all and to meet
the rapid annual rate of accumulation.
CHAP. IV.--ON THE CURABILITY OF INSANITY.
An inquiry into the curability of insanity forms a natural pendent to that
concerning the provision required for the insane, and is at the same time
a fitting prelude to an investigation of the insufficiency and defects of
the present organization of asylums: for it is important to satisfy
ourselves as to what extent we may hope to serve the insane, by placing
them under the most advantageous circumstances for treatment, before
incurring the large expenditure for securing them.
Now it may be most confidently stated that insanity is a very curable
disorder, if only it be brought early under treatment. American physicians
go so far as to assert, that it is curable in the proportion of 90 per
cent., and appeal to their asylum statistics to establish the assertion.
The Lunacy Commission of the State of Massachusetts (_op. cit._ p. 69)
thus write:--"In recent cases the recoveries amount to the proportion of
75 to 90 per cent. of all that are submitted to the restorative process.
Yet it is an equally well-established fact, that these disorders of the
brain tend to fix themselves permanently in the organization, and that
they become more and more difficult to be removed with the lapse of time.
Although three-fourths to nine-tenths may be healed if taken within a year
after the first manifestation of the disorder, yet if this measure be
delayed another year, and the diseases are from one to two years'
standing, the cures would probably be less than one-half of that
proportion, even with the same restorative means; another and a third year
added to the disease diminishes the prospect of cure, and in a still
greater ratio than the second; and a fourth still more. The fifth reduces
it so low, as to seem to be nothing."
Dr. Kirkbride, Physician to the Pennsylvania Hospital for the Insane, in
his book "On the Construction and Organization of Hospitals for the
Insane," says (p. 2):--"Of recent cases of insanity, properly treated,
between 80 and 90 per cent. recover. Of those neglected or improperly
managed, very few get well."
This is certainly a very flattering estimate, and, inasmuch as it is
founded on experience, cannot fairly be questioned. However, before
comparing it with the results arrived at in this country, there are some
circumstances which call for remark. In the first place, American public
asylums are not branded with the appellation 'pauper,' they are called
'State Asylums,' and every facility is offered for the admission of cases,
and particularly of recent ones, whatever their previous civil condition.
Again, there is not in the United States the feeling of false pride, of
imaginary family dishonour or discredit, to the same extent which is
observed in this country, when it pleases Providence to visit a relative
with mental derangement,--to oppose the transmission to a place of
treatment. From these two causes it happens that in America the insane
ordinarily receive earlier attention than in this country. Lastly, the
United States' institutions, by being more accessible, admit a certain
proportion of cases of temporary delirium, the consequence of the abuse of
alcoholic drinks, of overwrought brain and general excitement,--causes
more active in that comparatively new, changing, and rapidly-developing
country than in ours. But such cases, which for the most part get well, do
not find their way into the asylums of this kingdom. Such are some of the
circumstances influencing favourably the ratio of cures in America, which
need be remembered when comparing it with that which is attained in our
own land.
The proportion of recoveries above stated, is calculated upon cases of
less than a year's duration. Let us see what can be effected in England
under conditions as similar as practicable, though not equally
advantageous. The most satisfactory results we can point to are those
obtained at St. Luke's Hospital, London, where the cures have averaged 62
per cent. upon the admissions during the last ten years. At this and
likewise at Bethlehem Hospital, the rules require that the disorder be not
of more than one year's duration at the time of application for admission,
and that it be not complicated with epilepsy or paralysis, maladies which
so seriously affect its curability. Such are the conditions favourable to
a high rate of recoveries enforced by rule. On the other hand, there are
at St. Luke's not a few circumstances in operation prejudicial to the
largest amount of success possible. Its locality is objectionable, its
general construction unfavourable, its grounds for exercise and amusement
very deficient, and the means of employment few. But apart from these
disadvantages, so prejudicial to its utility and efficiency, there are
other causes to explain its ratio of success being less than that
estimated by our American brethren to be practicable. Though the rule
excludes patients the benefit of the hospital if their disease be of more
than a year's duration, yet from the great difficulties attending in many
cases the inquiry respecting the first appearance of the insanity; its
sometimes insidious approach; the defect of observation, or the ignorance,
and sometimes the misrepresentations of friends, resorted to in order to
ensure success in their application to the charity, older cases gain
admission. Again, of those admitted in any year, there are always several
whose disorder is known to be of nine, ten, or eleven months' duration,
and at least a fourth in whom it is of six months' date and upwards.
Further, although the rules exclude epileptics and paralytics, yet at
times the history of fits is withheld by the patients' friends, or the
fits are conceived to be of a different character, or the paralysis is so
little developed as not to be very recognizable; and as in all ambiguous
cases,--whether it be the duration or the complication of the mental
disorder which is in doubt, the Committee of the Hospital give the benefit
of the doubt to the patient,--the consequence is, that several such
unfavourable cases are received annually. On referring to the statistical
tables of the institution, these "unfit" admissions are found to amount to
10 per cent.
We have thought these details desirable, on the one hand, to account for
the difference in the ratio of cures attained in St. Luke's compared with
that fixed by American writers; and on the other, to show that though the
rate of recoveries at that London Hospital is highly gratifying, it might
be rendered yet more so if certain impediments to success were removed,
and that similar benefits could be realized elsewhere if due provision
were made for the early and efficient treatment of the malady.
Were we at all singular in the assertion of the curability of insanity, we
should endeavour to establish it by an appeal to the statistics of
recoveries among recent cases in the different English asylums; but
instead of advancing a novel opinion, we are only bearing witness to a
well-recognized fact substantiated by general experience. This being so,
it would be fruitless to occupy time in quoting many illustrations from
Asylum Reports: one will answer our purpose.
At the Derby County Asylum, under the charge of Dr. Hitchman, a high rate
of cures has been reached. In the Third Report that able physician writes
(p. 5),--"It cannot be too often repeated, that the date of the patient's
illness at the time of admission is the chief circumstance which
determines whether four patients in a hundred, or seventy patients in a
hundred, shall be discharged cured. Of the 151 cases which have been
admitted into the asylum during the past year, eleven only have been
received within a week of the onset of their malady; of these eleven, ten
have been discharged cured,--the other has been but a short time under
treatment." In his Sixth Report (1857, p. 22), the same gentleman
observes,--"The cures during the past year have reached 60 per cent. upon
the admissions; but the most gratifying fact has been, that of twenty
patients, unafflicted with general paralysis, who were admitted within one
month of the primary attack of their maladies, sixteen have left the
asylum cured,--three are convalescent, and will probably be discharged at
the next meeting of the Committee, and the other one was in the last stage
of pulmonary consumption when she came to the asylum, and died in three
weeks after her admission."
After this review of what may be effected in restoring the subjects of
mental disorder to reason and society, to their homes and occupations, by
means of early treatment, it is discouraging to turn to the average result
of recoveries on admissions obtained in our County Asylums at large. This
average may be taken at 35 per cent., and therefore there will remain of
every 100 patients admitted, sixty-five, or, after deducting 10 per cent.
of deaths, fifty-five at the end of the year. This number, fifty-five,
might fairly be taken to represent the annual per centage of accumulation
of the insane in asylums, were the data employed sufficient and
satisfactory. But so far as we have yet examined the point, this
proportion is larger than a calculation made over a series of years, and
may be approximatively stated at 35 per cent. on the admissions.
How great would be the gain, alike to the poor lunatic and to those
chargeable with his maintenance, could this rapid rate of accumulation be
diminished, by raising that of recoveries, or, what is tantamount to it,
by securing to the insane prompt and efficient care and treatment! How
does it happen that this desideratum is not accomplished by the asylums in
existence? what are the impediments to success discoverable in their
organization and management, or in the history of their inmates prior to
admission? and what can be done to remedy discovered defects, and to
secure the insane the best chances of recovery? Such are some of the
questions to be next discussed.
CHAP. V.--ON THE CAUSES DIMINISHING THE CURABILITY OF INSANITY, AND
INVOLVING THE MULTIPLICATION OF CHRONIC LUNATICS.
In the preliminary chapters on the number and increase of the insane in
this country, we limited ourselves to determine what that number and that
increase were, and entered into no disquisition respecting the causes
which have operated in filling our asylums with so many thousands of
chronic and almost necessarily incurable patients. Nor shall we now
attempt an investigation of them generally, for this has been well done by
others, and particularly by the Lunacy Commissioners in their Ninth
Report, 1855; but shall restrict ourselves to intimate that the increase
of our lunatic population, mainly by accumulation, is due to neglect in
past years; to the alteration of the laws requiring the erection of County
Asylums for pauper lunatics generally; to the collection and discovery of
cases aforetime unthought of and unknown; to the extension of the
knowledge of the characters and requirements of the insane both among
professional men and the public; and, lastly, to the advantages themselves
of asylum accommodation which tend to prolong the lives of the inmates.
Such are among the principal causes of the astounding increase in the
number of the insane of late years, relatively to the population of the
country, some of which fortunately will in course of time be less
productive. Those, however, which we now desire to investigate, are such
as directly affect the curability of insanity, either by depriving its
victims of early and efficient treatment, or by lessening the efficiency
and usefulness of the public asylums.
The history of an insane patient is clearly divisible into three portions:
1st, that before admission into an asylum; 2nd, that of his residence in
an asylum; and 3rd, of that after his discharge from it. The last division
we have at present nothing to do with; and with reference to the causes
influencing his curability, these group themselves under two heads
parallel to the first two divisions of the patient's history; viz. 1,
those in operation external to, and 2, those prevailing in, asylums.
A. _Causes external to Asylums._
The chief cause belonging to this first class is that of delay in
submitting recent cases to asylum care and treatment. This delay, as we
have sufficiently proved, operates most seriously by diminishing the
curability of insanity, and thereby favours the accumulation of chronic
lunatics. It takes place in consequence either of the desire of friends to
keep their invalid relatives at their homes; or of the economical notions
of Poor-Law Officers, who, to avoid the greater cost of asylums, detain
pauper lunatics in workhouses. Other causes of incurability and of the
accumulation of incurables are found in injudicious management and
treatment before admission, and in the transmission of unfit cases to
asylums. To discuss the several points suggested in these considerations
will require this chapter to be subdivided; and first we may treat of the
Detention of Patients in their own homes.
§ _Detention of Patients in their own homes._
Although the immense importance of early treatment to recent cases of
insanity is a truth so well established and so often advocated, yet the
public generally fail to appreciate it, and from unfortunate notions of
family discredit, from false pride and wounded vanity, delay submitting
their afflicted relatives to efficient treatment. Unless the disorder
manifest itself by such maniacal symptoms that no one can be blind to its
real character, the wealthier classes especially will shut their eyes to
the fact they are so unwilling to recognize, and call the mental
aberration nervousness or eccentricity; and as they are unwilling to
acknowledge the disorder, so are they equally indisposed to subject it to
the most effectual treatment, by removing the patient from home, and the
exciting influence of friends and surrounding circumstances in general, to
a properly organized and managed asylum. Usually a patient with sufficient
resources at command, is kept at home as long as possible, at great cost
and trouble; and if he be too much for the control of his relatives and
servants, attendants are hired from some Licensed House to manage him; the
only notion prevailing in the minds of his friends being that means are
needed to subdue his excitement and to overcome his violence. There are,
in fact, no curative agencies at work around him, but on the contrary,
more or fewer conditions calculated to exalt his furor, to agitate and
disquiet his mind, and to aggravate his malady. The master of the house
finds himself checked in his will; disobeyed by his servants; an object of
curiosity, it may be, of wonder and alarm; and sadly curtailed in his
liberty of action. The strange attendants forced upon him are to be
yielded to only under passionate protests, and probably after a struggle.
In all ways the mental disorder is kept up if not aggravated, and every
day the chances of recovery are diminished. Perhaps matters may grow too
bad for continued residence at home, or the malady have lasted so long,
that the broken-up state of family and household can no longer be
tolerated, and a transfer from home is necessitated. Yet even then removal
to an asylum,--the only step which can hold out a fair prospect of
recovery, is either rejected as quite out of the question, or submitted to
usually after still longer delay,--a "trial" being made of a lodging with
a medical man or other person, probably with an asylum attendant. By this
plan certainly the patient is saved from the presence and excitement of
his family, and placed under altered conditions, calculated to exercise in
some respects a salutary influence on his mind; still many others are
wanting, and no guarantee is attainable of the manner in which he is
treated; for as a single patient, and as is usually the case, restrained
without certificates, he is almost invariably unknown to the
Commissioners, and virtually unprotected, even though a medical man be
paid to attend him occasionally. At last, however, except for a few, the
transfer to the asylum generally becomes inevitable, and too often too
late to restore the disordered reason; and years of unavailing regret fail
to atone for time and opportunity lost.
The same unwillingness to subject their insane friends to asylum care and
treatment pervades, moreover, the less wealthy classes, and even the
poorer grades of the middle class of society. Madness, to their
conceptions likewise, brings with it a stigma on the family, and its
occurrence must, it is felt, be kept a secret. Hence an asylum is viewed
as an evil to be staved off as long as possible, and only resorted to when
all other plans, or else the pecuniary means, are exhausted. If it be the
father of the family who is attacked, the hope is, that in a few days or
weeks he may resume his business or return to his office, as he might
after ordinary bodily illness, without such loss of time as shall endanger
his situation and prospects, and without the blemish of a report that he
has been the inmate of a madhouse. If it be the wife, the hope is similar,
that she will shortly be restored to her place and duties in her family.
Should progress be less evident than desired, a change away from home will
probably be suggested by the medical attendant, and at much expense and
trouble carried out. But too frequently, alas! the hopes are blighted and
the poor sufferer is at length removed with diminished chance of cure to
an asylum.
For the poorer members of the middle class, and for many moving in a
somewhat higher circle of society, whom the accession of mental disorder
impoverishes and cuts off from independence, there are, it is most deeply
to be regretted, few opportunities of obtaining proper asylum care and
treatment. In very many instances, the charges of even the cheapest
private asylum can be borne for only a limited period, and thus far, at
the cost of great personal sacrifices and self-denial. Sooner or later no
refuge remains except the County Asylum, where, it may be, from the
duration of his disorder, the patient may linger out the remainder of his
days. How happy for such a one is it--a person unacquainted with the
system of English County Asylums, might remark--that such an excellent
retreat is afforded! To this it may be replied, that the public asylum
ought not to be the _dernier ressort_ of those too poor to secure the best
treatment and care in a well-found private establishment, and yet too
respectable to be classed and dealt with as paupers entirely and
necessarily dependent on the poor's rate. Yet so it is under the operation
of the existing law and parochial usages, there is no intermediate
position, and to reap the benefits of the public asylum, the patient must
be classed with paupers and treated as one. His admission into it is
rendered as difficult, annoying, and degrading as it can be. His friends,
worn out and impoverished in their charitable endeavours to sustain him in
his independent position as a private patient, are obliged to plead their
poverty, and to sue as paupers the parish officials for the requisite
order to admit their afflicted relative to the benefits of the public
asylum as a Pauper Lunatic. In short, they have to pauperize him; to
announce to the world their own poverty, and to succumb to a proceeding
which robs them of their feelings of self-respect and independence, and by
which they lose caste in the eyes of their neighbours. As for the patient
himself, unless the nature and duration of his malady have sufficiently
dulled his perception and sensibilities, the consciousness of his position
as a registered pauper cannot fail to be prejudicial to his recovery;
opposed to the beneficial influences a well-regulated asylum is calculated
to exert, and to that mental calm and repose which the physician is
anxious to procure.
In the class of cases just sketched, we have presumed on the ability of
the friends to incur the cost of private treatment for a longer or shorter
period; but many are the persons among the middle classes, who if
overtaken by such a dire malady as insanity, are almost at once reduced to
the condition of paupers and compelled to be placed in the same category
with them. As with the class last spoken of, so with this one, the law
inflicts a like injury and social degradation, and at the same time
operates in impeding their access to proper treatment.
No one surely, who considers the question, and reflects on the necessary
consequences of the present legal requirement that, for a lunatic to enjoy
the advantages of a public asylum, towards which he may have for years
contributed, he must be formally declared chargeable to the rates as a
pauper,--can deny the conclusion that it is a provision which must entail
a social degradation upon the lunatic and his family, and act as a great
impediment to the transmission of numerous recent cases to the County
Asylum for early treatment.
It will be urged as an apology for it, that the test of pauperism rests on
a right basis; that it is contrived to save the rate-payer from the charge
of those occupying a sphere above the labouring classes, who fall, as a
matter of course, upon the parochial funds whenever work fails or illness
overtakes them. It is, in two words, a presumed economical scheme.
However, like many other such, it is productive of extravagance and loss,
and is practically inoperative as a barrier to the practice of imposition.
If it contributes to check the admission of cases at their outbreak into
asylums, as no one will doubt it does, it is productive of chronic
insanity and of permanent pauperism; and, therefore, besides the
individual injury inflicted, entails a charge upon the rates for the
remaining term of life of so many incurable lunatics.
If, on the contrary, our public asylums were not branded by the
appellation "Pauper;" if access to them were facilitated and the
pauperizing clause repealed, many unfortunate insane of the middle class
in question, would be transmitted to them for treatment; the public asylum
would not be regarded with the same misgivings and as an evil to be
avoided, but it would progressively acquire the character of an hospital,
and ought ultimately to be regarded as a place of cure, equivalent in
character to a general hospital, and as entailing no disgrace or discredit
on its occupant.
The Commissioners in Lunacy, in their Ninth Report (1855, p. 35), refer to
the admissions into County Asylums, of patients from the less rich classes
of society reduced to poverty by the occurrence of the mental malady, and
hint at their influence in swelling the number of the chronic insane,
owing to their transfer not taking place until after the failure of their
means and the persistence of their disorder for a more or less
considerable period. This very statement is an illustration in point; for
the circumstance deplored is the result of the indisposition on the part
of individuals to reduce their afflicted relatives to the level of paupers
by the preliminaries to, and by the act of, placing them in an asylum
blazoned to the world as the receptacle for paupers only; an act, whereby,
moreover, they advertise to all their own poverty, and their need to ask
parish aid for the support of their poor lunatic kindred.
On the continent of Europe and in the United States of America we obtain
ample evidence that the plan of pauperizing patients in order to render
them admissible to public asylums, is by no means necessary. Most
continental asylums are of a mixed character, receiving both paying and
non-paying inmates, and care is taken to investigate the means of every
applicant for admission, and those of his friends chargeable by law with
his maintenance. Those who are paid for are called "pensioners" or
boarders, and are divided into classes according to the sum paid, a
particular section of the asylum being assigned to each class. Besides
those pensioners who pay for their entire maintenance, there are others
whose means are inadequate to meet the entire cost, and who are assessed
to pay a larger or smaller share of it. Lowest in the scale of inmates are
those who are entirely chargeable to the departmental or provincial
revenue, being devoid of any direct or indirect means of support. Probably
the machinery of assessment in the continental states might not accord
with English notions and be too inquisitorial for adoption _in toto_; but
at all events, on throwing open public asylums for the reception of all
lunatics who may apply for it, without the brand of pauperism being
inflicted upon them, some scheme of fairly estimating the amount they
ought to contribute to their maintenance should be devised. For the richer
classes a plan of inquisition into their resources is provided, and there
seems no insuperable difficulty in contriving some machinery whereby those
less endowed with worldly goods might, at an almost nominal expense, have
their means duly examined and apportioned to their own support and that of
their families. Overseers and relieving officers are certainly not the
persons to be entrusted with any such scheme, nor would we advocate a
jury, for in such inquiries few should share; but would suggest it as
probably practicable that the amount of payment might be adjudged by two
or three of the Committee of Visitors of the Asylum with the Clerk of the
Guardians of the Union or Parish to which the lunatic belonged.
In the United States of America, every tax-payer and holder of property is
entitled as a tax-payer, when insane, to admission into the Asylum of the
State of which he is a citizen. He is considered as a contributor to the
erection and support of the institution, and as having therefore a claim
upon its aid if disease overtake him. The cost of his maintenance is borne
by the township or county to which he belongs, and the question of his
means to contribute towards it is determined by the county judge and a
jury. Most of the asylums of the Republic also receive boarders at fixed
terms, varying according to the accommodation desired; hence there are
very few private asylums in the States. In the State of New York there is
a special legal provision intended to encourage the early removal of
recent cases to the asylum; whereby persons not paupers, whose malady is
of less than one year's duration, are admitted without payment, upon the
order of a county judge, granted to an application made to him, setting
forth the recent origin of the attack and the limited resources of the
patient. Such patients are retained two years, at the end of which time
they are discharged, their friends being held responsible for the
removal. Their cost in the asylum is defrayed by the county or parish to
which they belong.
We have said above, that the requirement of the declaration of pauperism
is ineffectual in guarding the interests of the rate-payer against the
cost of improper applicants. Indeed, the proceeding adopted to carry it
out is both absurd and useless, besides being, as just pointed out,
mischievous in its effects.
In the interpretation clause of "the Lunatic Asylums' Act, 1853," it is
ordered that a "Pauper shall mean every person maintained wholly or in
part by, or chargeable to, any Parish, Union, or County." Hence when
insanity overtakes an unfortunate person who is not maintained by a parish
or union, it is required that he be made chargeable to one, or, as we have
briefly expressed the fact, that he be pauperized. To effect this object,
the rule is, that the patient shall reside at least a day and a night in a
workhouse. This proceeding, we repeat, carries absurdity on the face of
it. Either it may be a mere farce privately enacted between the parish
officers and the friends of the patient, to the complete frustration of
the law so far as the protection of the rate-payers is contemplated; or,
it may be made to inflict much pain and annoyance on the applicants by the
official obstructiveness, impertinent curiosity, obtuseness, and possible
ill-feeling of the parish functionaries in whose hands the law has
practically entrusted the principal administration of the details
regulating the access to our public asylums.
It is no secret among the superintendents of County Asylums, that by
private arrangements with the overseers or guardians of parishes, cases
gain admission contrary to the letter and spirit of the law, and to the
exclusion of those who have legally a prior and superior claim. We have,
indeed, the evidence of the Lunacy Commissioners, to substantiate this
assertion. In their Ninth Report (1855, p. 34) they observe,--"In some
districts a practice has sprung up, by which persons, who have never been
themselves in receipt of parochial relief, and who are not unfrequently
tradesmen, or thriving artisans, have been permitted to place lunatic
relations in the County Asylums, as pauper patients, under an arrangement
with the guardians for afterwards reimbursing to the parish the whole, or
part, of the charge for their maintenance. This course of proceeding is
stated to prevail to a considerable extent in the asylums of the
metropolitan counties, and its effect in occupying with patients, not
strictly or originally of the pauper class, the space and accommodations
which were designed for others who more properly belong to it, has more
than once been made the subject of complaint."
Desiring, as we do, to see our County Asylums thrown open to the insane
generally, by the abolition of the pauper qualification, it is rather a
subject of congratulation that cases of the class referred to do obtain
admission into them, even when contrary to the letter of the law. But we
advance the quotation and assertion above to show, that the pauperizing
provision of the Act is ineffective in the attainment of its object; and
to remark, that the opportunities at connivance it offers to parochial
officials, must exercise a demoralizing influence and be subversive of
good government. If private arrangements can be made between the
applicants for an assumed favour, and parish officers, who will undertake
to say that there shall not be bribery and corruption?
Sufficient, we trust, has been said to demonstrate the evils of the
present system of pauperizing patients to qualify them for admission into
County Asylums, and the desirability of opening those institutions to all
lunatics of the middle classes whose means are limited, and whose social
position as independent citizens is jeopardized by the existence of their
malady. This class of persons, as before said, calls especially for
commiseration and aid; being so placed, on the one hand, that their
limited means must soon fail to afford them the succour of a private
asylum; and on the other, with the door of the public institution closed
against them, except at the penalty of pauperism and social degradation.
What we would desire is, that every recent case of insanity should at once
obtain admission into the public asylum of the county or borough, if
furnished with the necessary medical certificates and with an order from a
justice who has either seen the patient or received satisfactory evidence
as to his condition (see remarks on duties of district medical officers),
and obtained from the relatives an undertaking to submit to the assessment
made by a commission as above proposed, or constituted in any other manner
thought better; or the speedy admission of recent cases might otherwise be
secured by prescribing their attendance and that of their friends before
the weekly Committee of the Visitors of the Asylum, by whom the order for
reception might be signed on the requisite medical certificates being
produced, and the examination for the assessment of the patient's
resources formally made, with the assistance possibly of some
representative of the parish interests,--such for instance as the Clerk to
the Board of Guardians.
In the County Courts the judges are daily in the habit of ordering
periodical payments to be made in discharge of debts upon evidence offered
to them of the earnings or trade returns of the debtor; and there seems no
_a priori_ reason against the investigation of the resources of a person
whose friends apply for his admission into a County Asylum. It is for
them to show cause why the parish or county should assume the whole or the
partial cost of the patient's maintenance, and this can be done before the
Committee of the Asylum or any private board of inquiry with little
annoyance or publicity. Rather than raise an obstacle to the admission of
the unfortunate sufferer, it would be better to receive him at once and to
settle pecuniary matters afterwards.
We must here content ourselves with this general indication of the
machinery available for apportioning the amount of payment to be made on
account of their maintenance by persons not paupers, or for determining
their claim upon the Asylum funds. Yet we cannot omit the opportunity to
remark that the proceedings as ordered by the existing statute with a
similar object are incomplete and unsatisfactory. These proceedings are
set forth in _sects._ xciv. and civ. (16 & 17 Vict. cap. 97). The one
section of the Act is a twin brother to the other, and it might be
imagined by one not "learned in the law," that one of the two sections
might with little alteration suffice. Be this as it may, it is enacted
that if it appear to two Justices (_sect._ xciv.) by whose order a patient
has been sent to an asylum, or (_sect._ civ.) "to any Justice or Justices
by this Act authorized to make any order for the payment of money for the
maintenance of any Lunatic, that such Lunatic" has property or income
available to reimburse the cost of his maintenance in the asylum, such
Justices (_sect._ xciv.) shall apply to the nearest known relative or
friend for payment, and if their notice be unattended to for one month,
they may authorize a relieving officer or overseer to seize the goods, &c.
of the patient, whether in the hands of a trustee or not, to the amount
set forth in their order. _Sect._ civ. makes no provision for applying to
relatives or friends in the first instance, but empowers the justice or
justices to proceed in a similar way to that prescribed by _sect._ xciv.,
to repay the patient's cost; with the additional proviso that, besides the
relieving officer or overseer, "the Treasurer or some other officer of the
County to which such Lunatic is chargeable, or in which any property of
the Lunatic may be, or an officer of the Asylum in which such Lunatic may
be," may proceed to recover the amount charged against him.
Concerning these legal provisions, we may observe, that the state of the
lunatic's pecuniary condition is left to accidental discovery. The
justices signing the order of admission (_sect._ xciv.) have no authority
given them to institute inquiries, although they may learn by report that
the patient for whom admission is solicited is not destitute of the means
of maintenance. Nor are the justices who make the order for payment
(_sect._ civ.) in any better position for ascertaining facts. There is,
in short, no authorized and regular process for investigating the
chargeability of those who are not actually in the receipt of parochial
relief on or before application for their admission into the County
Asylum, or who must necessarily be chargeable by their social position
when illness befalls them. Again, according to the literal reading of the
sections in question, no partial charge for maintenance can be proposed;
no proportion of the cost can be assessed, where the patient's resources
are unequal to meet the whole. Lastly, the summary process of seizing the
goods or property of any sort, entrusted to those who are most probably
the informers of the justices, namely overseers and relieving officers;
and, by _sect._ civ., carried out without any preliminary notice or
application, and without any investigation of the truth of the reports
which may reach the justices, is certainly a proceeding contrary to the
ordinary notions of equity and justice.
§ _Detention of Patients in Workhouses._
In the case of the insane poor, whose condition, circumstances, and social
position have been such that whenever any misfortune, want of work, or
sickness has overtaken them, the workhouse affords a ready refuge, the
requirement of pauperization to qualify for admission to the County Asylum
is in itself no hardship and no obstacle to their transmission to it.
Probably the prevailing tactics of parish officers may at times contribute
to delay the application for relief, but the great obstacle to bringing
insane paupers under early and satisfactory treatment in the authorized
receptacle for them--the County Asylum, is the prevalence of an economical
theory respecting the much greater cheapness of workhouse compared with
asylum detention. The practical result of this theory is, that generally
where a pauper lunatic can by any means be managed in a workhouse, he is
detained there. If troublesome, annoying, and expensive, he is referred to
the County Asylum; this is the leading test for the removal; the
consideration of the recent or chronic character of his malady is taken
little or no account of.
In fresh cases the flattering hope is that the patients will soon recover,
and that the presumed greater cost of asylum care can be saved; in old
ones the feeling is that they are sufficiently cared for, if treated like
the other pauper inmates, just that amount of precaution being attempted
which may probably save a public scandal or calamity.
To the prevalence of these economical notions and practice may be
attributed the large number of lunatics detained in workhouses (nearly
8000), and the equally large one living with their friends or others. Now
it is very desirable to inquire whether these theories of the superior
economy of workhouses compared with asylums as receptacles for the insane,
are true and founded on facts. This question is in itself twofold, and
leaves for investigation, first, that of the mere saving in money on
account of maintenance and curative appliances; and secondly, that of the
comparative fitness or unfitness, the advantages or disadvantages, the
profit or loss, of the two kinds of institutions in relation to the
welfare, the cure, and the relief of the poor patients placed in them.
These questions press for solution in connexion with the subject of the
accumulation of lunatics and the means to be adopted for its arrest, or,
what is equivalent to this, for promoting the curability of the insane.
On making a comparative estimate of charges, it is essential to know
whether the same elements of expenditure are included in the two cases; if
the calculated cost per head for maintenance in workhouses and asylums
respectively comprises the same items, and generally, if the conditions
and circumstances so far as they affect their charges are rightly
comparable. An examination we are confident, will prove that in no one of
these respects are they so.
In the first place, the rate of maintenance in an asylum is calculated on
the whole cost of board, clothing, bedding, linen, furniture, salaries,
and incidental expenditure; that is, on the total disbursements of the
establishment, exclusive only of the expenditure for building and repairs,
which is charged to the county. On the contrary, the "in-maintenance" in
workhouses comprises only the cost of food, clothing, and necessaries
supplied to the inmates (see Poor-Law Board Tenth Report, p. 144). The
other important items reckoned on in fixing the rate of cost per head in
asylums are charged to the "establishment" account of the workhouse, and
are omitted in the calculation of the rate of maintenance. Reference to
the Tables given in the Poor-Law Board Returns (Tenth Report, p. 61,
sub-column _e_ and a portion of _f_) will prove that the expenditure on
account of those other items must be nearly or quite equal to that
comprehended under the head of "in-maintenance" cost.
We have no means at hand to calculate with sufficient precision what sum
should be added to the "in-maintenance" cost of paupers per head in
workhouses, but it is quite clear that the figures usually employed to
represent it, cannot be rightly compared with those exhibiting the weekly
charge of lunatics in asylums. At the very least half as much again must
be added to a workhouse estimate before placing it in contrast with asylum
cost.
Since the preceding remarks were written, Dr. Bucknill has favoured us
with the Thirteenth Report of the Devon Asylum, in which he has discussed
this same question and illustrated it by a special instance. To arrive at
the actual cost of an adult sane pauper in a union-house, he gathered "the
following particulars relative to the house of the St. Thomas Union in
which this asylum is placed; a union, the population of which is 49,000,
and which has the reputation of being one of the best managed in the
kingdom. The cost of the maintenance of paupers in this union-house is
2_s._ 6_d._ per head, per week, namely, 2_s._ 2_d._ for food and 4_d._ for
clothing. The establishment charges are 1_s._ 0-1/2_d._ per head, per
week, making a total of 3_s._ 6-1/2_d._ for each inmate. The total number
of pauper inmates during the twelfth week of the present quarter was 246;
and of these 116 were infants and children, and 130 youths above sixteen
and adults. A gentleman intimately acquainted with these accounts, some
time since calculated for me that each adult pauper in the St. Thomas's
Union-house cost 5_s._ a week. Now the average cost of all patients in the
Devon Asylum at the present time is 7_s._ 7_d._, but of this at least
2_s._ must be set down to the extra wages, diet, and other expenses
needful in the treatment of the sick, and of violent and acute cases,
leaving the cost of the great body of chronic patients at not more than
5_s._ 7_d._ a week. Now if a sane adult pauper in a union-house costs even
4_s._ 6_d._ a week, is it probable that an insane one would cost less than
5_s._ 7_d._? For either extra cost must be incurred in his care, or he
must disturb the discipline of the establishment, and every such
disturbance is a source of expense."
This quotation is really a reiteration of Dr. Bucknill's conclusions as
advanced in 1857, in an excellent paper in the 'Asylum Journal' (vol. iv.
p. 460), and as a pendent to it the following extract from this paper is
appropriate; viz. "that the cost of a chronic lunatic properly cared for,
and supplied with a good dietary, in a County Asylum, is not greater than
that of a chronic lunatic supplied with a coarse and scanty dietary, and
detained in neglect and wretchedness as the inmate of a union workhouse."
Another most important circumstance to be borne in mind when the cost of
workhouses and asylums is contrasted, is that in the former establishments
more than two-thirds of the inmates are children. Thus the recipients of
in-door relief on the 1st of January, 1858, consisted, according to the
Poor-Law Returns, of 74,141 adults, and 50,836 children under sixteen
years of age. Now as the rate of maintenance is calculated on the whole
population of a workhouse, adults and children together, it necessarily
follows that it falls much within that of asylums, in which almost the
whole population is adult. This very material difference in the character
of the inmates of the two institutions may fairly be valued as equivalent
to a diminution of one-fourth of the expense of maintenance in favour of
workhouses; and without some such allowance, the comparison of the cost
per head in asylums and union-houses respectively is neither fair nor
correct.
Again, there is another difference between asylums and workhouses, which
tells in favour of the latter in an economical point of view, whilst it
proves that the expenditure of the two is not rightly comparable without
making due allowance for it along with the foregoing considerations. This
difference subsists in the character of the two institutions respectively;
namely, that in the asylum the movements of the population are slight,
whereas in the workhouse they are very considerable by the constant
ingress and egress of paupers; driven to it by some passing misfortune or
sickness, it may be for a week or two only or even less, and discharging
themselves so soon as the temporary evil ceases to operate or the disorder
is overcome: for the poor generally, except the old and decrepit who
cannot help themselves, both dread a lodging in the workhouse, and escape
from it as soon as possible; in fact, even when they have no roof of their
own to shelter them, they will often use the union accommodation only
partially, leaving it often by day and returning to it by night. All this
implies a large fluctuation of inmates frequently only partially relieved,
whether in the way of board or clothing; and consequently when the average
cost per head of in-door paupers is struck, it appears in a greater or
less degree lower than it would have done had the same constancy in
numbers and in the duration and extent of the relief afforded prevailed as
it does in asylums.
The effect of the fluctuations in population in union-houses ought, we
understand, to be slight, if the "Orders in Council" laid down to guide
parochial authorities in the calculation of the cost of their paupers,
were adhered to; viz. that for all those belonging to any one parish in
union, who may have received in-door relief during the year or for any
less period of time, an equivalent should be found representing the number
who have been inmates throughout the year; or the total extent of relief
be expressed by estimating it to be equal to the support of one
hypothetical individual for any number of years equivalent to the sum of
the portions of time the entire number of the paupers of the particular
parish received the benefits of the establishment. We do not feel sure
that these plans of calculating the cost per head are faithfully and fully
executed; the rough method of doing so, viz. by taking the whole cost of
"in-maintenance" at the end of the year and dividing it by the number of
its recipients, and assuming the quotient to represent the expenditure
for each. Whether this be the case or not, these daily changes among its
inmates, the frequent absence of many for a great part of the day and the
like, are to be enumerated among the circumstances which tend to keep down
expenditure of workhouses; and which are not found in asylums.
There is yet another feature about workhouses which distinguishes them
from asylums, and is of considerable moment in the question of the
comparative cost of maintenance in the two: this is, the circumstance of
the population of workhouses being of a mixed character, of which the
insane constitute merely a small section; while, on the contrary, that of
asylums is entirely special, and each of its members to be considered a
patient or invalid demanding particular care and special appliances.
Therefore, _a priori_, no comparison as to their expenditure can justly be
drawn between two institutions so dissimilar. Yet even this extent of
dissimilarity between them is not all that exists; for the union-house is
so constituted by law as to serve as a test of poverty; to offer no
inducements to pauperism, and to curtail the cost of maintenance as far as
possible. It has properly no organization for the detention, supervision,
moral treatment and control, nor for the nursing or medical care of the
insane; and when its establishment is attempted it is a step at variance
with its primary intention, and involves an extra expenditure.
Consequently, before overseers or guardians can with any propriety
contrast the workhouse charges of maintenance with those of asylums, it is
their business to estimate what an adult pauper lunatic costs them per
week, instead of, as usual, quoting the cost per head calculated on the
whole of the inmates, old and young, sane and insane.
Once more, even after a fair estimate of the cost of an adult insane
inmate of a workhouse is obtained, there is still another differential
circumstance favourable to a less rate than can be anticipated in asylums;
for this reason:--that in the former institutions the practice is to
reject all violent cases, the major portion of recent ones, and,
generally, all those who give particular annoyance and trouble; whilst the
latter is, as it rightly should be, regarded as the fitting receptacle for
all such patients;--that is, in other words, those classes of patients
which entail the greatest expense are got rid of by the workhouses and
undertaken by the asylums.
Dr. Bucknill has well expressed the same circumstances we have reviewed,
in the following paragraph (Report, Devon Asylum, 1858, p. 13):--"In
estimating the cost of lunatic paupers in asylums, the important
consideration must not be omitted, that the charge made for the care and
maintenance of lunatics in County Asylums is averaged upon those whose
actual cost is much greater, and those whose actual cost is less than the
mean; so that it would be unfair for the overseers of a parish to say of
any single patient that he could be maintained for a smaller sum than that
charged, when the probability is that there are or have been patients in
the asylum from the same parish, whose actual cost to the asylum has been
much greater than that charged to the parish. I have shown, that the
actual cost of chronic patients in an asylum exceeds that of adult paupers
in union-houses to a much smaller extent than has been stated: but if all
patients of this description were removed from the asylum, the inevitable
result must be that the average cost of those who remained would be
augmented, so that the pecuniary result to the parishes in the county
would be much the same. The actual cost of an individual patient, if all
things are taken into calculation, is often three or four times greater
than the average. Leaving out of consideration the welfare of the
patients, it would be obviously unfair to the community, that a parish
having four patients in the asylum, the actual cost of two of whom was
12_s._ a week, and of the other two only 4_s._ a week, should be allowed
to remove the two who cost the smaller sum, and be still permitted to
leave the other two at the average charge of 8_s._"
The conclusion of the whole matter is, that _cæteris paribus_, _i. e._
supposing workhouses to be equally fitting receptacles for the insane as
asylums, the differential cost of the two can only be estimated when it is
ascertained that the items of maintenance are alike in the two, and after
that an allowance is made for the different characters of their population
and of their original purpose; that is, in the instance of workhouses, for
the very large number of juvenile paupers; for the great fluctuations in
the residents; for the mixed character of their inmates, of sane and
insane together, and the small proportion of insane, and for the exclusion
of the most expensive classes of such patients. Let these matters be
fairly estimated, and we doubt much if, even _primâ facie_, it can be
shown that the workhouse detention of pauper lunatics is more economical
than that of properly constructed and organized asylums.
Should we even be so far successful as to make Poor-Law Guardians and
Overseers perceive that the common rough-and-ready mode of settling the
question of relative cost in asylums and workhouses, by contrasting the
calculated rate per head for in-door relief with that for asylum care, is
not satisfactory; we cannot cherish the flattering hope that they will be
brought to perceive that, simply in an economical point of view, no saving
at all is gained by the detention of the insane in workhouses. Those
Poor-Law officials generally are so accustomed to haggle about fractional
parts of a penny in voting relief, to look at an outlay of money only
with reference to the moment, forgetful of future retribution for false
economy, and to handle the figures representing in their estimate the
economical superiority of the workhouse for the insane, when they desire
to silence an opponent;--that the task of proving to them that their
theory and practice are wrong, is equivalent to the infelicitous endeavour
to convince men against their will.
Still, however unpromising our attempt may appear, it is not right to
yield whilst any legitimate arguments are at hand; and our repertory of
them, even of those suited to a contest concerning the pounds, shillings,
and pence of the matter, is not quite exhausted; for we are prepared to
prove, that asylum accommodation can be furnished to the lunatic poor at
an outlay little or not at all exceeding that for workhouses.
Now this point to be argued, the cost of asylum construction, is not, like
the foregoing considerations, chiefly the affair of Poor-Law Guardians and
Overseers, but concerns more particularly the County Magistrates, inasmuch
as it is defrayed out of the County instead of the Poor Rate. But although
this is the case, there is no doubt that the very great expense of
existing asylums has acted as an impediment to the construction of others,
and has seemed to justify, to a certain extent, the improper detention of
many insane persons in workhouses: for, on one side, asylums are found to
have cost for their construction and fittings, £150, £200, and upwards per
head, whilst on the other, workhouses are built at the small outlay, on an
average, of eighty-six such establishments, of £22 per head. The "Return"
made to the House of Commons, June 15, 1857, "of the cost of building
Workhouses in England and Wales, erected since 1840," shows indeed a very
wide variation of cost in different places, from £13 per head for the
Congleton Union House; £14 for the Erpingham; £16 for the Stockton and
Tenterden, to £47 for the Kensington; £50 for the Dulverton; £59 for the
City of London; £60 for St. Margaret Westminster; and £113 for the
Paddington. This enormous difference of expenditure on workhouse
lodging,--for, unlike asylum costs, it does not include fittings,
extending from £13 to £113 per inmate,--is really inexplicable, after
allowing for the varying ideas of parish authorities as to what a
workhouse should be, and for the slight differences in the cost of
building materials and labour in some parts of the country than in others.
Either some workhouses must be most miserable and defective habitations
even for paupers, or others must be very extravagant and needlessly
expensive in their structure.
There is this much to be said in explanation of the contrast of cost in
different workhouses, that in those belonging to large town populations,
infirmary accommodation becomes an item of importance and involves
increased expenditure, whilst in those situated in agricultural districts,
this element of expense is almost wanting. Moreover it is in town
workhouses generally that lunatic inmates are found, who, if not in the
infirmary, are lodged in special wards, often so constructed as to meet
their peculiar wants, and therefore more costly than the rest of the
institution occupied by the ordinary pauper inmates. This is the same with
saying that where workhouses are used as receptacles for the insane, it
greatly enhances the cost of their construction.
It will be evident to every thinking person that the costs of asylum and
of workhouse construction are not fairly comparable. The asylum is a
special building; an instrument of treatment; peculiarly arranged for an
invalid population, affording facilities for classification, recreation,
and amusements; and fitted with costly expedients for warming and
ventilation; whereas the workhouse is essentially a refuge for the
destitute, necessarily made not too inviting in its accommodation and
internal arrangements; suited to preserve the life of sound inmates who
need little more than the shelter of a roof and the rude conveniences the
majority of them have been accustomed to. Now these very characteristics
of workhouses are among the best arguments against the detention of
lunatics within these buildings; but of these hereafter.
There is doubtless a permissible pride in the ability to point to a
well-built asylum, commanding attention by its dimensions and
architectural merits, and we would be the last to decry the beauties and
benefits of architecture, and know too, that an ugly exterior may cost as
much or more than a meritorious one; yet we must confess to misgivings
that there has been an unnecessary and wasteful expenditure in this
direction. Nevertheless it is with asylums as with railways, the present
race of directors are reaping instruction from the extravagances and
errors its predecessors fell into.
The change of opinion among all classes respecting the character and wants
of the insane and their mode of treatment, is of itself so great, that
many of the structural adaptations and general dispositions formerly made
at great cost, are felt to be no longer necessary, and the very correct
and happy persuasion daily gains ground, that the less the insane are
dealt with as prisoners, and treated with apprehension and mistrust, the
more may their accommodation be assimilated to that of people in general,
and secured at a diminished outlay.
All this suggests the possibility of constructing asylums at a much less
cost than formerly, and of thereby lessening the force of one of the best
pleas for using workhouses as receptacles for the insane. The possibility
of so doing has been proved both theoretically and practically. In an
essay 'On the Construction of Public Asylums,' published in the "Asylum
Journal" for January 1858 (vol. iv. p. 188), we advocated the separation
of the day- from the night-accommodation of patients, and the abolition of
the system of corridors with day- and sleeping-rooms, or, as we briefly
termed it, "the ward-system," and showed that by so doing a third of the
cost of construction might be saved, whilst the management of the
institution would be facilitated, and the position of the patients
improved. By a careful estimate, made by a professional architect, with
the aid of the necessary drawings, for a building of considerable
architectural pretension, it was calculated that most satisfactory,
cheerful, and eligible accommodation could be secured, including
farm-buildings, and fittings for warming, ventilation, drainage, gas, &c.,
at the rate of £90 per head for patients of all classes, or at one-half of
the ordinary cost.
Experience has shown that chronic lunatics, at least, can be accommodated
in an asylum at a lower rate, in fact, at little more than half the
expense that we calculated upon.
Like other County Asylums, the Devon became filled with patients; still
they came, and after attempts to cram more into the original edifice, by
slight alterations, and by adding rooms here and there, it was at length
found necessary to make a considerable enlargement. Instead of adding
floors or wings to the old building, which would have called for a
repetition of the same original expensive construction of walls, and of
rooms and corridors, the Committee, with the advice of their excellent
physician, wisely determined to construct a detached building on a new
plan, which promised every necessary convenience and security with
wonderful cheapness; and, for once in a way, an architect's cheap estimate
was not exceeded. Instead of £200 or £250 per head, as of old,
accommodation was supplied at the rate of £38: 10_s._ per patient,
including fittings for all the rooms and a kitchen:--a marvel, certainly,
in asylum construction, and one which should have the effect of reviving
the hopes and wishes of justices, once at least so laudably entertained,
to provide in County Asylums for _all_ pauper lunatics of the county.
It is only fair to remark, that, as Dr. Bucknill informs us (Asylum
Journal, 1858, p. 323), this new section of the Devon Asylum is dependent
on the old institution for the residences of officers, for chapel,
dispensary, store-rooms, &c. "It is difficult," writes Dr. Bucknill, "to
estimate the proportion which these needful adjuncts to the wards of a
complete asylum bear to the expense of the old building; they can
scarcely, however, be estimated at so high a figure as one-eighth of the
whole." But, as a set-off against the increased cost per patient involved
in supplying the necessary offices described by Dr. Bucknill, we may
mention that there are twenty single sleeping-rooms provided in the
building, and that a greater cost was thereby entailed, than many would
think called for, where only chronic, and generally calm patients, were to
be lodged.
These illustrations of what may be done in the way of obtaining good
asylum accommodation for pauper lunatics at no greater rate, we are
persuaded, than that incurred in attempting to provide properly for them
in workhouses, furnish a most valid reason for discontinuing their
detention in the latter, and the more so, if, as can be demonstrated, they
are unfit receptacles for them.
The possibility of constructing cheap asylums being thus far proved, the
question might be put, whether the internal cost of such institutions
could not be lessened? We fear that there is not much room for reform in
this matter, if the patients in asylums are rightly and justly treated,
and the officers and attendants fairly remunerated. In producing power, an
asylum exceeds a workhouse, and therein derives an advantage in
diminishing expenditure and the cost of maintenance. On the other hand,
the expenditure of a workhouse is much less in salaries, particularly in
those given to its medical officer and servants, a form of economy which
will never repay, and, we trust, will never be tried in asylums. Warming,
ventilation, and lighting are less thought of, little attempted, and
therefore less expensive items in workhouse than in asylum accounts. With
respect to diet and clothing, workhouses ought to exhibit a considerable
saving; but this saving is rather apparent than real, and certainly in the
wrong direction; for lunatics of all sorts require a liberal dietary, warm
clothing, and, from their habits frequently, more changes than the
ordinary pauper inmates; yet these are provisions, which, except there is
actual sickness or marked infirmity, the insane living in a workhouse do
not enjoy; for they fare like the other inmates, are clothed the same, and
are tended or watched over by other paupers; the saving, therefore, is at
the cost of their material comfort and well-being. Excepting, therefore,
the gain to be got by the labours of the patients, there is no set-off in
favour of asylum charges; in short, in other respects none can be obtained
without inflicting injury and injustice. On the other hand, workhouse
expenditure need be raised if the requisite medical and general treatment,
nursing, dietary, employment, and recreation are to be afforded; which is
the same as saying, that workhouses, if receptacles for the insane at all,
should be assimilated to asylums,--a principle, which, if admitted and
acted upon, overturns at once the only argument for their use as such,
viz. its economy.
The perception on the part of parochial authorities, that something more
than the common lodging and attendance of the workhouse is called for by
the insane inmates, has led to the construction of "Lunatic Wards" for
their special accommodation, a scheme which may be characterized as an
extravagant mistake, whether viewed in reference to economical principles
or the welfare of the patients. If structurally adapted to their object,
they must cost as much as a suitable asylum need; and if properly
supervised and managed, if a sufficient dietary be allowed, and a proper
staff of attendants hired, no conceivable economical advantage over an
asylum can accrue. On the contrary, as Dr. Bucknill has remarked (Asylum
Journal, vol. iv. p. 460), any such attempts at an efficient management of
the insane in small and scattered asylums attached to Union Workhouses,
will necessarily increase their rate of maintenance above that charged in
a large central establishment, endowed with a more complete organization
and with peculiar resources for their management.
Dr. Bucknill returns to the discussion of this point in his just published
report (Rep. Devon Asylum, 1858, p. 11). He puts the question, "Would a
number of small asylums, under the denomination of lunatic wards, be more
economical than one central asylum?" and, thus proceeds to reply to
it:--"The great probability is that they would not be; 1st, on account of
the larger proportion of officials they would require; 2nd, on account of
the derangement they would occasion to the severe economy which is
required by the aim and purpose of union-houses as tests of destitution.
Where lunatics do exist in union-houses in consequence of the want of
accommodation in the County Asylum, the Commissioners in Lunacy insist
upon the provision of what they consider things essential to the proper
care of insane persons wherever they be placed. The following are the
requirements which they insisted upon as _essential_ in the Liverpool
Workhouse:--a sufficient staff of responsible paid nurses and attendants;
a fixed liberal dietary sanctioned by the Medical Superintendent of the
asylum; good and warm clothing and bedding; the rooms rendered much more
cheerful and better furnished; the flagged court-yards enlarged and
planted as gardens; the patients frequently sent to walk in the country
under proper care; regular daily medical visitation; and the use of the
official books kept according to law in asylums. If the direct cost of
such essentials be computed with the indirect cost of their influence upon
the proper union-house arrangements, it will require no argument to prove
that workhouse lunatic wards so conducted would effect no saving to the
ratepayers. The measures needed to provide in the union-house kitchen a
liberal dietary for the lunatic wards and a restricted one for the sane
remainder, to control the staff of paid attendants, to arrange frequent
walks into the country for part of the community, while the other part was
kept strictly within the walls;--these would be inevitable sources of
disturbance to the proper union-house discipline, which would entail an
amount of eventual expenditure not easily calculated."
If, on economical grounds, the system of Lunatic Wards has no evident
merit, none certainly can be claimed for it on the score of its adaptation
to their wants and welfare.
Indeed, the argument for workhouse accommodation, on the plea of economy,
loses all its weight when the well-being of the insane is balanced against
it. For, if there be any value in the universally accepted opinions of
enlightened men, of all countries in Europe, of the requirements of the
insane, of the desirability for them of a cheerful site, of ample space
for out-door exercise, occupation and amusement, of in-door arrangements
to while away the monotony of their confinement and cheer the mind, of
good air, food and regimen, of careful watching and kind nursing, of
active and constant medical supervision and control, or to sum up all in
two words, of efficient medical and moral treatment,--then assuredly the
wards of a workhouse do not furnish a fitting abode for them.
The unfitness of workhouses for the detention of the insane, and the evils
attendant upon it, have been repeatedly pointed out by the Commissioners
in Lunacy in their annual reports, and by several able writers. We were
also glad to see from the report of his speech, on introducing the Lunatic
Poor (Ireland) Bill into the House of Commons, that Lord Naas is strongly
opposed to the detention of the insane in workhouses, and therein agrees
with the Irish Special Lunacy Commissioners (1858, p. 18), who have placed
their opinion on record in these words:--"It appears to us that there can
be no more unsuitable place for the detention of insane persons than the
ordinary lunatic wards of the Union Workhouses." This is pretty nearly the
same language as that used by the English Commissioners in 1844, viz. "We
think that the detention in workhouses of not only dangerous lunatics, but
of all lunatics and idiots whatever, is highly objectionable."
To make good these general statements, we will, at the risk of some
repetition, enter into a few particulars. On the one hand, the presence of
lunatics in a workhouse is a source of annoyance, difficulty, and anxiety
to the official staff and to the inmates, and withal of increased expense
to the establishment. If some of them may be allowed to mix with the
ordinary inmates, there are others who cannot, and whose individual
liberty and comfort must be curtailed for the sake of the general order
and management, and of the security and comfort of the rest.
Some very pertinent observations occur in the Report of the Massachusetts
Lunacy Commission (_op. cit._ p. 166), on the mixing of the sane and
insane together in the State Almshouses, which correspond to our Union
Workhouses. They report that the superintendents "were unanimous in their
convictions that the mingling of the insane with the sane in these houses
operated badly, not only for both parties, but for the administration of
the whole institution." Further on, the Commissioners observe (p. 168),
"By this mingling the sane and insane together, both parties are more
disturbed and uncontrollable, and need more watchfulness and interference
on the part of the superintendent and other officers.... It has a
reciprocal evil effect in the management of both classes of inmates. The
evil is not limited to breaches of order; for there is no security against
violence from the attrition of the indiscreet and uneasy paupers with the
excitable and irresponsible lunatics and idiots. Most of the demented
insane, and many idiots, have eccentricities; they are easily excited and
disturbed; and nothing is more common than for inmates to tease, provoke,
and annoy them, in view of gratifying their sportive feelings and
propensities, by which they often become excited and enraged to a degree
to require confinement to ensure the safety of life.... The mingling of
the state paupers, sane and insane, makes the whole more difficult and
expensive to manage. It costs more labour, watchfulness, and anxiety to
take care of them together than it would to take care of them separately."
These sketches from America may be matched in our own country; and they
truthfully represent the reciprocal disadvantages of mixing the sane and
insane together in the same establishment.
Even supposing the presence of insane in workhouses involved, on the one
hand, no disadvantages to the institutions, or to the sane inmates; yet on
the other, the evils to the lunatic inhabitants would be condemnatory of
it; for the insane necessarily suffer in proportion as the workhouse
accommodation differs from that of asylums; or, inversely, as the
economical arrangements and management of a workhouse approach those of an
asylum. They suffer from many deficiencies and defects in locality and
organization, in medical supervision and proper nursing and watching, in
moral discipline, and in the means of classification, recreation, and
employment.
Workhouses are commonly town institutions; their locality often
objectionable; their structure indifferent and dull; their site and their
courts for exercise confined and small, and their means of recreation and
of occupation, especially out of doors, very limited. Petty officers of
Unions so often figure before the world, and have been so admirably
portrayed by Dickens and other delineators of character, on account of
their peculiarities of manner and practice, that no sketch from us is
needed to exhibit their unfitness as guardians and attendants upon the
insane. As to workhouse nurses, little certainly can be expected from
them, seeing that they are only pauper inmates pressed into the service;
if aged, feeble and inefficient; if young, not unlikely depraved or
weak-minded; always ignorant, and it may be often cruel; without
remuneration or training, and chosen with little or no regard to their
qualifications and fitness.
However satisfactory the structure of the ward and its supervision might
be rendered, its connexion with a Union Workhouse will be disadvantageous
to the good government and order of the establishment, as above noticed,
and detrimental to the welfare of the insane confined in it. Thus it must
be remembered that very many of the lunatic inmates have been reduced to
seek parochial aid solely on account of the distressing affliction which
has overtaken them; before its occurrence, they may have occupied an
honourable and respectable position in society, and, consequently, where
consciousness is not too much blunted, their position among paupers--too
often the subjects of moral degradation--must chafe and pain the
disordered mind and frustrate more or less all attempts at its
restoration. To many patients, therefore, the detention in a workhouse is
a punishment superadded to the many miseries their mental disorder
inflicts upon them; and consequently, when viewed only in this light,
ought not to be tolerated.
Of all cases of lunacy, the wards of a workhouse are least adapted to
recent ones, for they are deficient of satisfactory means of treatment,
whether medical or moral, and the only result of detention in them to be
anticipated, must be to render the malady chronic and incurable. Yet
although every asylum superintendent has reported against the folly and
injury of the proceeding, and notwithstanding the distinct and strong
condemnation of it by the Commissioners in Lunacy, the latter, in their
Report for 1857, have to lament an increasing disposition, on the part of
Union officers, to receive and keep recent cases in workhouses. Moral
treatment we hold to be impossible in an establishment where there are no
opportunities of classification, no proper supervision and attendance, and
no means for the amusement and employment of the mind; but where, on the
contrary, the place and organization are directly opposed to it, and the
prospects of medical treatment are scarcely less unfavourable. An
underpaid and overworked medical officer, in his hasty visits through the
wards of the workhouse daily, or perhaps only three or four times a week,
very frequently without any actual experience among the insane, cannot be
expected to give any special attention to the Pauper Lunatics, who are
mostly regarded as a nuisance in the establishment, to be meddled with as
little as possible, and of whose condition only unskilled, possibly old
and unfeeling pauper nurses, can give any account. Indeed, unless reported
to be sick, it scarcely falls into the routine of the Union medical
officer regularly to examine into the state and condition of the pauper
lunatics. These remarks are confirmed by the statement of the Lunacy
Commissioners, in their 'Further Report,' 1847 (p. 276), that pauper
inmates, "in their character of lunatics merely, are rarely the objects of
any special medical attention and care," and that it "was never found
(except perhaps in a few cases) that the medical officer had taken upon
himself to apply remedies specially directed to the alleviation or cure of
the mental disorder. Nor was this indeed to be expected, as the workhouse
never can be a proper place for the systematic treatment of insanity."
It would unnecessarily extend the subject to examine each point of
management and organization affecting the well-being of the insane in
detail, in order to show how unsuitable in all respects a workhouse must
be for their detention; yet it may be worth while to direct attention to
one or two other matters.
Except when some bodily ailment is apparent, the lunatic fare like the
ordinary inmates; that is, they are as cheaply fed as possible, without
regard to their condition as sufferers from disease, which, because
mental, obtains no special consideration. It is in the power of the
medical officer, on his visits, to order extra diet if he observes any
reason in the general health to call for it; but the dependent position of
this gentleman upon the parish authorities, and his knowledge that extra
diet and its extra cost will bring down upon him the charge of
extravagance and render his tenure of office precarious, are conditions
antagonistic to his better sentiments concerning the advantages of
superior nutriment to his insane patients.
Moreover, the cost of food is a principal item in that of the general
maintenance of paupers, and one wherein the guardians of the poor believe
they reap so great an economical advantage over asylums. But this very
gain, so esteemed by poor-law guardians, is scouted as a mistake and
proved an extravagance, _i. e._ if the life and well-being of the poor
lunatics are considered, by the able superintendents of County Asylums.
Dr. Bucknill has well argued this matter in a paper "On the Custody of the
Insane Poor" (Asylum Journal, vol. iv. p. 460), and in the course of his
remarks says,--"The insane cannot live on a low diet; and while they
continue to exist, their lives are rendered wretched by it, owing to the
irritability which accompanies mental disease. The assimilating functions
in chronic insanity are sluggish and imperfect, and a dietary upon which
sane people would retain good health, becomes in them the fruitful source
of dysentery and other forms of fatal disease."
In his just published Report, already quoted, the same excellent physician
remarks (p. 9),--"A good diet is essential to the tranquil condition of
many idiots and chronic lunatics, and is, without doubt, a principal
reason why idiots are easily manageable in this asylum, who have been
found to be unmanageable in union houses. The Royal Commission which has
recently reported on the Lunatic Asylums in Ireland states this fact
broadly, that 'the ordinary workhouse dietary is unsuited and insufficient
for any class of the insane.' It is therefore my opinion, founded upon the
above considerations, that neither the lunatics nor the idiots in the list
presented are likely to retain their present state of tranquillity, and to
be harmless to themselves and others, if they are placed in union houses,
unless they are provided with those means which are found by experience to
ensure the tranquillity of the chronic insane, and especially with a
sufficient number of trustworthy attendants, and with a dietary adapted to
their state of health. I have thought it desirable to ascertain the
practice of charitable institutions especially devoted to the training of
idiots, and I find that a fuller dietary is used in them than in this
asylum."
Until a recent date, it was the custom in workhouses, with few exceptions,
to allow most of their insane inmates to mingle with the ordinary pauper
inmates of the same age and sex, and in general to be very much on the
same footing with them "in everything that regards diet, occupation,
clothing, bedding, and other personal accommodation" (Report, 1847, p.
276).
This mingling of the sane and insane, having been found subversive of good
order and management, gave rise first to the plan of placing most of the
latter class in particular wards, many of them in the infirmary, and,
subsequently, owing to the advance of public opinion respecting the wants
of the insane, to the construction, in many unions, of special lunatic
wards, emulating more or less the character and purposes of asylums. The
false economy of this plan has been already exposed; and although the
Lunacy Commissioners have always set their faces against lunatic wards,
yet their construction has of late been so rapid as to call forth a more
energetic denunciation of it:--"Impressed strongly (the Commissioners
write, Report, 1857, p. 17) with a sense of their many evils, it became
our duty, during the past year, to address the Poor-Law Board against the
expediency of affording any encouragement or sanction to the further
construction, in connexion with Union Workhouses, of lunatic wards."
The evils of lunatic wards, alluded to in the last-quoted paragraph, are
thus enlarged upon in another page of the same Report (p. 15):--"It is
obvious that the state of the workhouses, as receptacles for the insane,
is becoming daily a subject of greater importance. They are no longer
restricted to such pauper lunatics as,--requiring little more than the
ordinary accommodation, and being capable of associating with the other
inmates,--no very grave objection rests against their receiving. Indeed it
will often happen that residence in a workhouse, under such conditions, is
beneficial to patients of this last-mentioned class; by the inducements
offered, from the example of those around them, to engage in ordinary
domestic duties and occupations, and so to acquire gradually the habit of
restraining and correcting themselves. But these are now unhappily the
exceptional cases. Many of the larger workhouses, having lunatic wards
containing from 40 to 120 inmates, are becoming practically lunatic
asylums in everything but the attendance and appliances which ensure the
proper treatment, and above all, in the supervision which forms the
principal safeguard of patients detained in asylums regularly constituted.
"The result is, that detention in workhouses not only deteriorates the
more harmless and imbecile cases to which originally they are not
unsuited, but has the tendency to render chronic and permanent such as
might have yielded to early care. The one class, no longer associating
with the other inmates, but congregated in separate wards, rapidly
degenerate into a condition requiring all the attendance and treatment to
be obtained only in a well-regulated asylum; and the others, presenting
originally every chance of recovery, but finding none of its appliances or
means, rapidly sink into that almost hopeless state which leaves them
generally for life a burthen on their parishes. Nor can a remedy be
suggested so long as this workhouse system continues. The attendants for
the most part are pauper inmates, totally unfitted for the charge imposed
upon them. The wards are gloomy, and unprovided with any means for
occupation, exercise, or amusement; and the diet, essential above all else
to the unhappy objects of mental disease, rarely in any cases exceeds that
allowed for the healthy and able-bodied inmates."
The subject had previously received their attention, and is thus referred
to in their Ninth Report (p. 38):--"They are very rarely provided with any
suitable occupation or amusement for the inmates. The means of healthful
exercise and labour out of doors are generally entirely wanting, and the
attendants (who are commonly themselves paupers) are either gratuitous, or
so badly organized and so poorly requited, that no reliance can be placed
on the efficiency of their services. In short, the wards become in fact
places for the reception and detention of lunatics, without possessing any
of the safeguards and appliances which a well-constructed and well-managed
lunatic asylum affords. Your Lordship, therefore, will not be surprised to
learn that while we have used our best endeavours to remedy their obvious
defects and to ameliorate as far as possible the condition of their
inmates, we have from the first uniformly abstained from giving any
official sanction or encouragement to their construction."
They further make this general observation:--"So far as the lunatic and
idiotic inmates are concerned, the condition of the workhouses which have
separate wards expressly appropriated to the use of that class, is
generally inferior to that of the smaller workhouses, and in some
instances extremely unsatisfactory."
Dr. Bucknill, whose excellent remarks on lunatic wards in their economical
aspect we have already quoted, has very ably canvassed the question of
their fitness as receptacles for the insane, and, in a paper in the
'Asylum Journal' (vol. iii. p. 497), thus treats on it:--"It is deserving
of consideration, whether the introduction of liberally-conducted lunatic
wards into a Union Workhouse would not interfere with the working of the
latter in its legitimate scope and object. A workhouse is the test of
destitution. To preserve its social utility, its economy must always be
conducted on a parsimonious scale. No luxuries must be permitted within
its sombre walls; even the comforts and conveniences of life must be
maintained in it below the average of those attainable by the industry of
the labouring poor. How can a liberally-conducted lunatic ward be
engrafted upon such a system? It would leaven the whole lump with the
taint of liberality, and the so-called pauper bastile would, in the eyes
of the unthrifty and indolent poor, be deprived of the reputation which
drives them from its portals."
There is a general concurrence among all persons competent to form any
opinion on the matter, that workhouses are most unfit places for the
reception of recent cases of insanity. On the other hand, there is a
prevalent belief that there is a certain class of the insane, considered
"harmless," for whom such abodes are not unsuitable. The Lunacy
Commissioners, in the extract from the Eleventh Report above quoted,
partake in this opinion: let us therefore endeavour to ascertain, as
precisely as we can, the class of patients intended, and the proportion
they bear to the usual lunatic inmates of Union Workhouses.
In their 'Further Report' for 1847, the Commissioners enter into a
particular examination of the characters of the lunatics found in
workhouses, and class them under three heads (p. 257):--1st, those who,
from birth, or from an early period of life, have exhibited a marked
deficiency of intellect as compared with the ordinary measure of
understanding among persons of the same age and station; 2ndly, those who
are demented or fatuous; that is to say, those whose faculties, not
originally defective, have been subsequently lost, or become greatly
impaired through the effects of age, accident, or disease; and 3rdly,
those who are deranged or disordered in mind, in other words, labouring
under positive mental derangement, or, as it is popularly termed,
"insanity." Those in whom epilepsy or paralysis is complicated with
unsoundness of mind, although their case requires a separate
consideration, do not in strictness constitute a fourth class, but may
properly be referred, according to the character of their malady and its
effects upon their mental condition, to one or other of these three
classes.
Further on in the Report, after remarking on the difficulties besetting
their inquiry, they write (p. 274):--
"We believe, however, we are warranted in stating, as the result of our
experience thus far, that of the entire number of lunatics in workhouses,
whom we have computed at 6020 or thereabouts, two-thirds at the least, or
upwards of 4000, would be properly placed in the first of the three
classes in the foregoing arrangement; or, in other words, are persons in
whom, as the mental unsoundness or deficiency is a congenital defect, the
malady is not susceptible of cure, in the proper sense of the expression;
and whose removal to a curative lunatic asylum, except as a means of
relieving the workhouse from dangerous or offensive inmates, can be
attended with little or no benefit.
"A considerable portion of this numerous class, not less, perhaps, than a
fourth of the whole, are subject to gusts of passion and violence, or are
addicted to disgusting propensities, which render them unfit to remain in
the workhouse; and it is the common practice, when accommodation can be
procured, to effect the removal of such persons to a lunatic asylum, where
their vicious propensities are kept under control, and where, if they
cannot be corrected, they at least cease to be offensive or dangerous. But
although persons of this description are seldom fit objects for a curative
asylum, they are in general capable of being greatly improved, both
intellectually and morally, by a judicious system of training and
instruction; their dormant or imperfect faculties may be stimulated and
developed; they may be gradually weaned from their disgusting
propensities; habits of decency, subordination, and self-command may be
inculcated, and their whole character as social beings may be essentially
ameliorated."
The conclusion to be deduced from these extracts is, that one-fourth or
two-thirds, that is, one-sixth of the whole number of occupants in
workhouses of unsound mind, found in 1846, were unfit for those
receptacles, and demanded the provision of institutions in which a moral
discipline could be carried out, and their whole condition, as social
beings, ameliorated and elevated. A further examination of the data
supplied in the same Report will establish the conviction that, besides
the proportion just arrived at, requiring removal to fitting asylums,
there is another one equally large demanding the same provision.
In this number are certainly to be placed all those of the third class
"labouring under positive mental derangement," and who, although reported
as "comparatively few" in 1846, have subsequently been largely multiplied,
according to the evidence of the 'Eleventh Report' (_ante_, p. 56). Those,
again, "in whom epilepsy or paralysis is complicated with unsoundness of
mind," are not suitable inmates for workhouse wards. No form of madness is
more terrible than the furor attendant on epileptic fits; none more
dangerous; and, even should the convulsive affection have so seriously
damaged the nervous centres that no violence need be dreaded, yet the
peril of the fits to the patient himself, and their painful features,
render him an unfit inmate of any other than an establishment provided
with proper appliances and proper attendants. As to the paralytic insane,
none call for more commiseration, or more careful tending and
nursing--conditions not commonly to be found in workhouses.
The Commissioners in Lunacy have not omitted the consideration of
workhouses as receptacles for epileptics and paralytics, and have arrived
at the following conclusions:--After treating, in the first place, of
epileptics whose fits are slight and infrequent, and the mental
disturbance mild and of short duration, they observe that, as such persons
"always require a certain amount of supervision, and as they are quite
incompetent, when the fits are upon them, to take care of themselves, and
generally become violent and dangerous, it would seem that the workhouse
can seldom be a suitable place for their reception, and that their
treatment and care would be more properly provided for in a chronic
hospital especially appropriated to the purpose."
Concerning paralytics, they state that they are far less numerous than
epileptics, and being for the most part helpless and bedridden, are
treated as sick patients in the infirmary of the workhouse. Their opinion
is, however, that a chronic hospital would be a more appropriate
receptacle for them,--a conclusion in which all must coincide, who know
how much can be done to prolong and render more tolerable their frail and
painful existence, by good diet and by assiduous and gentle nursing,--by
such means, in short, as are not to be looked for in establishments where
rigid economy must be enforced, and pauper life weighed against its cost.
To turn now to the second class of workhouse Lunatic Inmates, the demented
from age, accident, or disease: these, we do not hesitate to say, are not
suitably accommodated in workhouses, for, like the paralytic, they require
careful supervision, good diet and kind nursing; they are full-grown
children, unable to help or protect themselves, to control their habits
and tendencies; often feeble and tottering, irritable and foolish, and,
without the protection and kindness of others, the helpless subjects of
many ills. For such, the whole organization of the workhouse is unsuited;
even the infirmary is not a fitting refuge; for, on the one hand, they are
an annoyance to the other inmates, and, on the other, pauper nurses--whose
office is often thrust upon them without regard to their fitness for
it,--are not fitting guardians for them. In fine, where age, accident or
disease has so deteriorated the mental faculties, we have a complication
of physical and mental injury to disqualify the patient from partaking
with his fellow-paupers in the common accommodation, diet, and nursing.
In the reverse order which we have pursued, the first class of congenital,
imbecile, and idiotic inmates comes to be considered last. This happens by
the method of exclusion adopted in the argument; for the second and third
classes have been set aside as proper inmates of some other institution
than a workhouse, and it now remains to inquire, who among the
representatives of the first class are not improperly detained in
workhouses. This class includes, as already seen, some two-thirds of the
whole number of inmates mentally disordered; and among whom, we presume,
are to be found those individuals who may, in the Commissioners' opinion,
mix advantageously with the general residents of the establishment. The
number of the last cannot, we believe, be otherwise than very small; for
the very supposition that there is imbecility of mind, is a reason of
greater or less force, according to circumstances, for not exposing them
to the contact of an indiscriminate group of individuals, more especially
of that sort to be generally found in workhouses. The evils of mingling
the sane and insane in such establishments have already been insisted
upon; and besides these, such imbecile patients as are under review, lack
in workhouses those means of employment and diversion which modern
philanthropy has suggested to ameliorate and elevate their physical and
moral condition.
Lastly, if the remaining members of this class be considered, in whom the
imbecility amounts to idiocy, the propriety of removing them from the
workhouse will be questioned by few. Indeed, will any one now-a-days
advocate the "_laissez faire_" system in the case of idiots? Experience
has demonstrated that they are improveable, mentally, morally, and
physically; and if so, it is the duty of a christian community to provide
the means and opportunities for effecting such improvement. It cannot be
contended that the workhouse furnishes them; on the contrary, it is
thoroughly defective and objectionable by its character and arrangements,
and, as the Commissioners report, (_op. cit._ p. 259) a very unfit abode
for idiots.
On looking over the foregoing review of the several classes of lunatic
inmates of workhouses distinguished by the Commissioners in Lunacy, the
opinion to be collected clearly is, that only a very few partially
imbecile individuals among them are admissible into workhouses, if their
bodily health, their mental condition, their due supervision and their
needful comforts and conveniences are to be duly attended to and provided
for. In accordance with the views we entertain, as presently developed, of
the advantages of instituting asylums for confirmed chronic, quiet, and
imbecile patients, we should permit, if any at all, only such imbecile
individuals as residents in workhouses, who could pass muster among the
rest, without annoyance, prejudice or discomfort to themselves or others,
and be employed in the routine occupations of the establishment.
So much is heard among poor-law guardians and magistrates about a class of
"harmless patients" suitably disposed of in workhouses and rightly
removeable from asylums, that a few remarks are called for concerning
them. To the eye of a casual visitor of an asylum, there does certainly
appear a large number of patients, so quiet, so orderly, so useful and
industrious, that, although there is something evidently wrong about their
heads, yet the question crosses the mind, whether asylum detention is
called for in their case. The doubt is not entertained by the experienced
observer, for he knows well that the quiet, order, and industry observable
are the results of a well-organized system of management and control; and
that if this fails, the goodly results quickly vanish to be replaced by
the bitter fruits generated by disordered minds. The "harmless" patient of
the asylum ward becomes out of it a mischievous, disorderly, and probably
dangerous lunatic. In fact, the tranquillity of many asylum inmates is
subject to rude shocks and disturbances, even under the care and
discipline of the Institution; and the inoffensive-looking patient of
to-day may, by his changed condition, be a source of anxiety, and a
subject for all the special appliances it possesses, to-morrow.
Any Asylum Superintendent would be embarrassed to select a score of
patients from several hundred under his care whom he could deliberately
pronounce to be literally "harmless" if transferred to the workhouse. He
might be well able to certify that for months or years they have gone on
quietly and well under the surrounding influences and arrangements of the
asylum, but he could not guarantee that this tranquillity should be
undisturbed by the change to the wards of the workhouse; that untrained
attendants and undesirable associates should not rekindle the latent
tendency to injure and destroy; that defective organization and the
absence of regular and regulated means of employment and recreation should
not revive habits of idleness and disorder; or that a less ample dietary,
less watchfulness and less attention to the physical health, should not
aggravate the mental condition and engender those disgusting habits, which
a good diet and assiduous watching are known to be the best expedients to
remedy.
Dr. Bucknill has some very cogent remarks on this subject in his last
Report of the Devon Asylum (p. 6). "The term 'harmless patients,' or in
the words of the statute, those 'not dangerous to themselves or others'
(he writes), I believe to be inapplicable to any insane person who is not
helpless from bodily infirmity or total loss of mind: it can only with
propriety be used as a relative term, meaning that the patient is not so
dangerous as others are, or that he is not known to be refractory or
suicidal. It should not be forgotten, that the great majority of homicides
and suicides, committed by insane persons, have been committed by those
who had previously been considered harmless; and this is readily explained
by the fact, that those known to be dangerous or suicidal are usually
guarded in such a manner as to prevent the indulgence of their
propensities; whilst the so-called harmless lunatic or idiot has often
been left without the care which all lunatics require, until some mental
change has taken place, or some unusual source of irritation has been
experienced, causing a sudden and lamentable event. In an asylum such
patients may truly be described as not dangerous to themselves or others,
because they are constantly seen by medical men experienced in observing
the first symptoms of mental change or excitement, and in allaying them by
appropriate remedies; they are also placed under the constant watchfulness
and care of skilful attendants, and they are removed from many causes of
irritation and annoyance to which they would be exposed if at large, in
villages or union houses.
"It not unfrequently happens that idiots who have lived for many years in
union houses, and have always been considered harmless and docile, under
the influence of some sudden excitement, commit a serious overt act, and
are then sent to an asylum. One of the most placid and harmless patients
in this asylum, who is habitually entrusted with working tools, is a
criminal lunatic, of weak intellect, who committed a homicide on a boy,
who teased him while he was breaking stones on the road. If this is th
Showing first 200,000 characters. Full text: gutenberg.org/ebooks/44320