Part 5

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.