Part 4

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."