Chapter II: Part 2

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.