On the State of Lunacy and
the Legal Provision for the Insane

ON THE
STATE OF LUNACY
AND THE
LEGAL PROVISION FOR THE INSANE,
WITH
OBSERVATIONS ON THE CONSTRUCTION AND
ORGANIZATION OF ASYLUMS.

BY
JOHN T. ARLIDGE, M.B., A.B. (Lond.),
LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS; ASSOCIATE OF KING’S
COLLEGE, LONDON; PHYSICIAN TO THE WEST OF LONDON HOSPITAL;
FORMERLY MEDICAL SUPERINTENDENT OF ST. LUKE’S
HOSPITAL, AND PHYSICIAN TO THE SURREY
DISPENSARY, ETC.

LONDON:
JOHN CHURCHILL, NEW BURLINGTON STREET.
1859.

PRINTED BY TAYLOR AND FRANCIS,
RED LION COURT, FLEET STREET.

TO
THE RIGHT HONOURABLE
THE EARL OF SHAFTESBURY,
CHAIRMAN OF THE COMMISSION OF LUNACY,
WHOSE LONG-CONTINUED AND UNTIRING EFFORTS IN BEHALF OF THE
INSANE
HAVE EARNED FOR HIM THE HIGHEST ESTEEM AND ADMIRATION
OF ALL WHO FEEL INTERESTED
IN THE WELFARE OF THAT CLASS OF THE AFFLICTED,
THIS TREATISE
IS, BY PERMISSION,
RESPECTFULLY DEDICATED BY HIS LORDSHIP’S MOST OBEDIENT
HUMBLE SERVANT,
THE AUTHOR.

PREFACE.

The writer of a book is usually expected to show cause for its production,—a custom which, however commendable as a sort of homage to his readers for challenging their attention to his lucubrations, must often put the ingenuity of an author to the test. Indeed the writer of this present treatise would feel some embarrassment in accounting for its production, did he not entertain the conviction that he has, in however imperfect a manner, supplied a work on several important subjects which have never before been so placed before the public, and which, moreover, occupy just now a most prominent position among the topics of the day.

In the last Parliament, up to the period of its dissolution, a Special Committee of the House of Commons was engaged in examining into the condition of lunatics and the laws of lunacy; and the present Government has re-appointed the Committee, in order to resume the inquiry preparatory to the introduction of new enactments into the Legislature. The subjects treated of in the following pages relate to the same matters which have engaged the attention of Parliament, and elicited the special inquiry mentioned, viz. the present state of Lunacy and of the legal provision for the Insane with reference to their future wants.

In order to a better appreciation of the existing provision for the insane, and of its defects, the author has introduced certain preliminary chapters on the number of the insane, on the increase of insanity, on the inadequacy of the existing public provision for the insane, and on the curability of insanity. In reviewing the character and extent of the provisions for the insane, the course adopted has been to regard them in reference to their effects on recovery, and to discover the conditions inimical to it, whether without or within asylums. Hence the evils of private treatment and of workhouse detention of lunatics, particularly of the latter, have largely claimed attention. The condition of pauper lunatics boarded with their friends or with strangers demanded special notice, as did the long-complained-of evils of sending unfit cases to the county asylums, often to the exclusion of recent and curable ones, which might by proper treatment be restored to health and society. Turning to the consideration of our public asylums, considered as curative institutions, the disposition to extend them to an unmanageable size, and to substitute routine for treatment, has called for animadversion, as an error pregnant with numerous evils to their afflicted inmates. Another error pointed out is that of appointing too small a medical staff to asylums; and in proving this, as well as in estimating the proper size of asylums, the experience and opinions of both English and foreign physicians are copiously referred to.

The future provision for the insane forms an important chapter, which, in order to consider the several schemes proposed, is divided into several sections, viz. concerning the propriety of building separate asylums for recent and for chronic cases—of constructing distinct sections—of distributing certain patients in cottage homes—of erecting separate institutions for epileptics and for idiots.

The registration of lunatics has appeared to the author’s mind of so great necessity and value that he has devoted several pages to unfold his views and to meet probable objections; and, in order to render the plan effectual, he has propounded as a complementary scheme the appointment of District Medical Officers, and entered into detail respecting the duties to be imposed upon them.

Viewing the Commission of Lunacy as the pivot upon which any system of supervising and protecting all classes of lunatics must turn, it became necessary to examine into the capability of the present Board for its duties; and the result of that examination is, that this Board is inadequate to the effectual performance of the duties at present allotted to it, and that it would be rendered still more so by the adoption of any scheme for a thoroughly complete inspection and guardianship of all lunatics. This conclusion suggests the proposition to enlarge the Commission, chiefly or wholly, by the appointment of Assistant Commissioners, charged particularly with the duties of Inspectors.

The concluding chapter, on asylum construction, may be considered supplementary. Its chief intent is to develope a principle generally ignored, although (unless the arguments in support of it fail) one of great importance if asylums are to serve, not as simple refuges for lunatics, but as instruments for treating them.

This résumé of the heads of subjects discussed in the ensuing pages will, on the one hand, show that the present is not to be reckoned as a medical treatise, but as one addressed to all who are interested either in the legislation for Lunatics or in their well-being and treatment; and, on the other, make good, it is trusted, the assertion that it occupies an untrodden field in the literature of insanity, and that its matter is good, even should its manner be thought not so.

Assuming the publication of the book to be justifiable, it only remains for the author to add that he has not undertaken its composition without bringing to the task thirteen years’ study and practical experience among the insane, treated in private houses, in licensed houses, and in public asylums, together with the fruits of observation gathered from the visitation of most of the principal asylums of France, Germany, and Italy.

In conclusion, he hopes that this small volume may in some measure contribute towards the amelioration of the condition of the insane, who have such especial claims on public sympathy and aid.

J. T. A.

Kensington, July 1859.

CONTENTS.

THE STATE OE LUNACY,
AND THE LEGAL PROVISION FOR
THE INSANE.

PRELIMINARY OBSERVATIONS.

The number of the Insane, and the legal provision requisite for their protection, care, and treatment, are subjects which will always recommend themselves to public attention and demand the interest alike of the political economist, the legislator, and the physician. To the first, the great questions of the prevalence of Insanity in the community, its increase or decrease, its hereditary character, and others of the same kind, possess importance in relation to the general prosperity and advance of the nation; to the second devolves the duty of devising measures to secure the protection both of the public and the lunatic, with due regard to the personal liberty, and the proper care and treatment, of the latter; to the last belongs the practical application of many of the provisions of the law, besides the exercise of professional skill in the management and treatment of the insane.

Moreover it will not be denied that, owing to the intimate manner in which he is concerned with all that relates to the lunatic, with all the details of the laws regulating his custody and general treatment, as well as with the institutions in which he is detained, with the features of his malady, and with all his wants, the physician devoted to the care of the Insane is well qualified to offer suggestions and recommendations to the legislator. Hence the present pages, in which the aim is to examine the present state of lunacy; the advantages to be gained by early treatment; and the adequacy of the existing legal provision for the Insane; and to offer some suggestions for improving the condition, and for amending the laws relating to the care and treatment, of this afflicted class of our fellow-creatures.

The whole subject of the efficiency of the Lunacy Laws and of their administration, occupies just now a prominent place in public attention, owing to the rapid multiplication of County Asylums and the constantly augmenting charges entailed by them; to the prevalent impression that Insanity is rapidly increasing; to recent agitation in our Law Courts respecting the legal responsibility of the Insane and the conditions under which they should be subjected to confinement, and still more to the proposed legislation on the matter during the present Session of Parliament. It would be a great desideratum could the Lunacy Laws be consolidated, and an arrest take place in the almost annual additions and amendments made to them by Parliament; but, perhaps, this is next to impracticable, owing to the attempts at any systematic, effectual, and satisfactory legislation for the Insane, being really of very recent date, and on that account subject to revisions enforced by experience of its defects and errors. However, the present time appears singularly suited to make the attempt at consolidation, so far as practicable, inasmuch as the appointment of a special committee of the House of Commons on the Lunacy Laws, furnishes the means for a complete investigation into existing defects, and for receiving information and suggestions from those practically acquainted with the requirements of the Insane, and with the operations of existing enactments.

To fulfil the objects taken in hand, and, in the first place, to sketch the present state of Lunacy in this country, it will be necessary to investigate the number of the Insane, and the annual rate of their increase; then to examine the extent of the present provision for them in asylums and of probable future wants. This done, after a brief essay on the curability of insanity, as a means of judging what may be done to mitigate the evil, we shall review the present provision for lunatics, point out its defects, and suggest various remedial measures, calculated in our opinion to improve the condition of the Insane, diminish the evil of the accumulation of chronic cases, and render asylums more serviceable and efficient.

In carrying out our design, we shall be found in some measure occupying ground already taken up by the Commissioners in Lunacy, and by some able essayists in the Medical Journals. We do not regret this, although it may deprive us somewhat of the merit of originality of conception and elucidation, as it will strengthen our positions and enhance the value of our remarks. Fortunately, too, we coincide generally with the opinions from time to time put forth by the Lunacy Commissioners, to whom so great merit is due for their labours in the interests of the insane, and for the character and position our County Asylums enjoy in the estimation of our own people and of foreign nations.

To attempt the character of a reformer when the affairs of Lunacy and Lunatic Asylums are in such good hands may be deemed somewhat ambitious; yet as sometimes an ordinary looker-on may catch sight of a matter which has eluded the diligent observer, and, as the views and suggestions advanced are the result of mature and independent thought, aided by experience of considerable length, and very varied, the undertaking may, we trust, be received with favour.

At all events, we flatter ourselves that the representation of the state of Lunacy in England and Wales; the estimate of its increase and of the provision made for it; the evils of workhouses as primary or permanent receptacles for the Insane; the ill consequences of large asylums, and some of the legal amendments proposed, are in themselves subjects calculated to enlist the attention of all interested in the general welfare of our lunatic population, and in the administration of the laws and institutions designed whether for its protection or for its care and treatment.

Chap. I.—Of the Number of the Insane.

This inquiry must be preliminary to any consideration of the provision made or to be made for the Insane. In carrying it out, we have chiefly to rely upon the annual Reports of the Commissioners in Lunacy along with, so far as pauper lunatics are concerned, those of the Poor-Law Board. However, these reports do not furnish us with complete statistics, and the total number of our insane population can be only approximately ascertained. The Lunacy Commission is principally occupied with those confined in public asylums and hospitals, and in Licensed Houses, and publishes only occasional imperfect returns of patients detained in workhouses or singly in private dwellings. On the other hand, the Poor-Law Board charges itself simply with the enumeration of pauper lunatics supported out of poor-rates, whether in asylums or workhouses, or living with friends or elsewhere. Hence the returns of neither of these public Boards represent the whole case; and hence, too, the chief apparent discrepancies which occur when those returns are compared.

To show this, we may copy the tables presented in Appendix H of the Report of the Commissioners in Lunacy for 1857, p. 81.

This very considerable difference of 2603 patients between the two estimates is mainly due—as reference to the summary (at p. 53) proves—to the omission, on the part of the Lunacy Commissioners, of those resident in workhouses and “with friends, or elsewhere,” reckoned in the Table of the Poor-Law Board. This explanation, however, is only partial, for, after allowing for it, the two estimates are found to diverge very considerably. Thus, on adding the numbers in the categories last named, viz. 5055 + 4107 = 9162, in 1852,—and 6800 + 5497 = 12,297, in 1857 to the total given by the Commissioners in each of those years, viz. to 17,412 and 21,344, respectively, we obtain a total of 26,574 in 1852, and one of 33,641 in 1857; a variation of 5416 in the former, and of 5948 in the latter year, from the results given in the Table presented by the Poor-Law Board. Much of this wide difference is explicable by the Board last mentioned not having reckoned the private patients, who amounted in 1852 to 4430, and in 1857 to 4687. Still, after all attempts to balance the two accounts, there is a difference unaccounted for, of 986 in 1852, and of 1261 in 1857.

No clue is given in the official documents to the cause of this discrepancy, and we are left in doubt which estimate of our lunatic population is the more correct. The excess occurs in the Commissioners’ Returns; for on adding together, in each year in question, the numbers reported by the Poor-Law Board, as detained in County and Borough Asylums and in Licensed Houses, we find that the totals respectively are less than the whole number of paupers as calculated by the Lunacy Commissioners, by the precise difference we have made out, viz. 986 in 1852 and 1261 in 1857. Of the two returns before us, we accept that of the Lunacy Commission, viz. that there were, including those in workhouses, and with friends or elsewhere, 26,574 reported Lunatics in 1852, and 33,641 in 1857; and account for this larger total by the fact that the Poor-Law Board Returns apply only to Unions and omit the lunacy statistics of many single parishes, under local acts, and some rural parishes under ‘Gilbert’s Act,’—containing in them together above a million and a half people more than are found in unions. Moreover, the Poor-Law Board returns do not include County and Borough Patients. Looking to these facts, the excess of 986 in 1852, and of 1261 in 1857, over and above the totals quoted from the Summary of the Poor-Law Board, is not surprising; indeed, taking the average usually allowed of one lunatic in every 700, the number in one million and a half would be above 2000; that is, more than half as many again as 1261; a result, which would indicate the Commissioners’ total to be within the truth.

We have just used the term ‘reported lunatics,’ for, besides those under certificates and those returned as chargeable to parishes, comprised in the foregoing numbers, there are very many of whom no public board has cognizance. Most such are private patients supported by their own means, disposed singly in the residences of private persons, throughout the length and breadth of the country, and, with few exceptions, without the supervision, in reference to their accommodation and treatment, of any public officer. The Lunacy Commissioners justly deplore this state of things; lament their inability, under existing Acts, to remedy it, and confess that not a tithe of such patients is reported to them, according to the intention of the law (16 & 17 Vict. cap. 96. sect. xvi.). It would appear that less than 200 such cases are known to them; and it would not be an extravagant or unwarrantable estimate to calculate their whole number at about half that of the inmates of Licensed Houses, viz. at 2000. This number would comprise those found lunatic by Inquisition, not enumerated in the Commissioners’ summary, although under the inspection of the “Medical Visitors of Lunatics.” According to the returns moved for by Mr. Tite “of the total number of Lunatics in respect of whom Commissions in Lunacy are now in force,” there were, on the 27th July, 1858, 602 such lunatics, and 295 of them were, according to the Commissioners’ tables, detained in asylums or Licensed Houses, leaving 347 not reckoned upon. In addition to this class of the insane there is an unascertained small number of persons of unsound mind in the horde of vagrant paupers, alluded to occasionally in the Lunacy Commissioners’ Reports.

The number of Criminal Lunatics in asylums is noted in the returns, but that of those in jails is not reckoned. Although this is comparatively small, owing to the usual custom of transferring prisoners, when insane, to asylums, yet, at any one period, a proportion sufficient to figure in a calculation of the whole insane population of the country will always be found. Nay more, besides such scattered instances in County Prisons, there is a very appreciable number in the Government Jails and Reformatories, as appears from the returns presented to Parliament (Reports of the Directors of Convict Prisons, 1858.)

The prisons included in these reports are:—Pentonville, Millbank, Portland, Portsmouth, Dartmoor, Parkhurst, Chatham, Brixton, Fulham Refuge, and Lewes. In the course of 1857, 216 persons of unsound mind were confined, some for a longer or shorter period, others for the whole of the year, in one or other of those prisons. Making allowance for those of the 216 who by removal from one prison to another (a transfer apparently of common occurrence, the rationale of which we should find it difficult to explain), might be reckoned twice, it may be safely stated that at least 150 were in the prison-infirmaries in question the whole year. In fact, the Infirmary of Dartmoor Prison has wards specially appropriated to insane patients, and actually constitutes a criminal asylum of no insignificant magnitude. For instance, the report tells us that on the 1st of January, 1857, there remained in that prison 102 cases; that 41 were received during the year; 37 discharged (where, or how, we are not told, except of 3, who were sent to Bethlem Hospital); and 106 remained on the 1st of January 1858.

It is also worth noting that in this Dartmoor Prison Infirmary, 38 epileptics remained on January 1st, 1857; 22 were admitted, 13 discharged, and 47 remained on January 1st, 1858. The total of epileptics coming under notice in the infirmaries of the several prisons in question, in the course of 1857, amounted to 135. The remarks on some of these cases of epilepsy by the medical officers, are sufficient to show that the convulsive malady has seriously affected the mental health, and that they might rightly be placed in the category of the insane.

However, having no wish to enhance the proportion of the subjects for Lunatic Asylums, we will deal only with those enumerated as mentally disordered. These amounted, according to the preceding calculations, in the Government Prisons, to 150, and it would seem no exaggerated estimate to assert that an equal number may be found in the various other prisons and reformatories throughout the country. To put the matter in another form, 300 lunatics are to be found in English prisons at any date that a census may be taken. Consequently this sum of 300 must be added in calculating the total of insane persons in this kingdom.

To establish still further the proposition with which we set out, that our public statistics of Insanity are incomplete, the history of every County Asylum might be adduced: for, notwithstanding very considerable pains have been taken, on the proposition to build a new asylum, to ascertain the probable number of claimants, and a wide margin over and above that estimate has been allowed in fixing on the extent of accommodation provided, yet no sooner has the institution got into operation, than its doors have been besieged by unheard-of applicants for admission, and within one-half or one-third of the estimated time, its wards have been filled and an extension rendered imperative. Such is a résumé of the general history of English County Asylums, attested in the strongest manner by that of the Middlesex, the Lancashire, and the Montgomery Asylums; and confirmatory of the fact of the augmentation of insanity in the country at a rate exceeding, more or less, that collected from county returns and public statistics. It is, moreover, to be observed, that the official statistics represent the total of lunatics existing on one particular day, usually the first of January, in each year, and take no account of those many who are admitted and discharged within the year, and who rightly should be reckoned in an estimate of the total number of the insane belonging to that period.

The average daily number resident in asylums would be a more correct representation of their insane population than the total taken on any one day, although it would fail to show the lunacy of the year.

Lastly, to illustrate the point discussed, to indicate how imperfect our present estimate of the prevalence of insanity most probably is, and to show the difficulties and defects of any ordinary census, we may appeal to the experience of the special commission charged by the legislature of Massachusetts to examine the statistics of Lunacy and the condition of Asylums in that State, as recorded in their report, published in 1855.

“In 1848” (they write, p. 18), “a committee of the Legislature, appointed to ‘consider the whole subject connected with insanity within the commonwealth,’ ascertained and reported the number of insane in this State to be 1512, of whom 291 were able to furnish the means of their own support, and 1156 were unable to do so, and the pecuniary condition of 65 was not ascertained.

“In making that survey in 1848, the Commissioners addressed their letters of inquiry ‘to the municipal authorities of every city and town in the commonwealth.’

“These public officers had direct means of knowing the number and condition of the pauper insane, and probably this part of the report was complete; but they had no other facilities of knowing the condition of those lunatics who were in private families, and supported by their own property or by their friends, than other men not in office, and could only speak of those who were within their circle of personal acquaintance. Consequently the report included only a part of the independent insane who were then actually in, or belonged to, the State.”

“In 1850 (p. 11), the marshals, the agents of the national government who were appointed to take the census, visited every family; and, among other items of information, they asked for the insane and idiots in the household.

“By this personal and official inquiry, made of some responsible member of every family, the marshals obtained the account of only 1680 insane persons and 791 idiots, which is but little more than two-thirds of the number ascertained by this Commission.

“Making all due allowance for the increase of population, and consequently of the insane and idiots, these figures undoubtedly show far less than the real amount of lunacy and idiotcy at that time, and render it extremely probable that many concealed the facts that the law required them to state to the marshals.”

Thus the marshals discovered the number of insane to be in 1850 nearly double that returned in 1848, and from their apparently searching inquiry, it might have been presumed that they had made a near approximation to the truth in the figures they published. However, the most pains-taking and varied investigations of the Special Commissioners in 1854, prove the marshals to have much underrated the number, for the result arrived at was, that in the autumn of the year just named, there were 3719 lunatics, of whom 1087 were idiots, in the State of Massachusetts.

The partial explanation of the divergence in numbers, viz.:—“that it is probable that many of the families refused or neglected to report to the marshals the insane and idiots who were in their households,”—is of itself an indication of one of the impediments to a correct enumeration of the insane members of a community, even when such is attempted under favourable circumstances. It is one likewise which, however operative in the United States, where the public asylums are open to, and resorted to by, all classes of the community, must be still more so in this country, where family pride endeavours in every way to ignore and keep secret the mental affliction of a member, as though it were a plague spot. Besides this, in no English census yet taken, has the enumeration of the insane constituted a special subject of inquiry.

This illustration from American experience, coupled with the considerations previously advanced, suffice to demonstrate that the published statistics of insanity in England and Wales are incomplete and erroneous, and that the machinery hitherto employed for collecting them has been imperfect. The corollary to this conclusion is, that the number of lunatics mentioned in the public official papers is much below the real one. However, the facts and figures in hand justify the attempt to fix a number which may be taken to represent approximatively the total insane population of this kingdom.

In their last Report (1858), the English Commissioners in Lunacy state that, on January 1st, 1858, there were confined in asylums, hospitals, and Licensed Houses, 17,572 pauper, and 4738 private patients, exhibiting an increase of 915 pauper and of 51 private cases upon the returns of the year preceding.

Pauper lunatics in workhouses are stated (10th Annual Report of the Poor Law Board, 1858) to have numbered 6947, and those receiving out-door relief 12,756; making a total of 20,703. By the kindness of Mr. Purdy, the head of the Statistical Department of the Poor-Law Office, we are enabled to explain that it is the custom of the office to reckon pauper lunatics in Asylums and Licensed Houses among those receiving out-door relief; consequently the sum of 12,756 comprises both those patients provided for as just specified, and others boarded with their friends or elsewhere. We, however, learn further, from the same excellent authority, that, owing to the imperfection of the periodical returns, only a comparatively small portion of the pauper insane confined in Asylums and Licensed Houses is included in that total. Indeed, the fact of its being very much smaller than that of the lunatics in Asylums and Licensed Houses, clearly enough shows that the latter are not reckoned in it except partially.

Considering that the Poor Law Board obtain no record of the pauper insanity in one million and a half of the population of England and Wales, nor of the number of insane belonging to counties and boroughs,—for this reason, that their cost of maintenance is not directly defrayed out of the poor-rates, there must necessarily be a much greater number in workhouses at large than the 6947 mentioned, and no inconsiderable proportion of poor lunatics dispersed abroad in the country not enumerated in the 5500 counted as existing in January 1st, 1857. On these grounds, we assume 8000 as an approximative figure to represent the total of insane poor not under confinement in Asylums and Workhouses, believing fully that it will be found, on the publication of the returns for this year (1859), within the mark.

Private patients not in Asylums, or Licensed Houses, often confined without certificates, and the majority unknown to the Lunacy Commissioners, we have put down, at a moderate estimate, at 2000. The present state of the law does not enable the Commissioners or others to discover these, often, we fear, neglected patients: and, on the other hand, the operation of the laws regulating asylums, and the feeling evoked by certain public trials of individuals confined in Licensed Houses, have, together, combined to render them more numerous, by inducing friends to keep them at home, to send them abroad to Continental institutions, or to place them under the care of private persons or attendants in lodgings.

This completes our enumeration; and the figures stand thus, on the 1st of January, 1858:—

To extend the estimate to the commencement of the present year (1859), we require to add the gross increase of lunatics during 1858 to the total just arrived at: 39,557. What this increase may be cannot be decisively stated; but to anticipate the estimate of it, which we shall presently arrive at, viz. 1600 per annum, the result is, that on the 1st of January 1859 there were in England and Wales, in round numbers, 41,000 persons of unsound mind, or, to employ the legal phraseology, lunatics and idiots.

It perhaps should be explained, and more particularly with reference to those detained in workhouses or supported by their parishes at their own houses, that besides idiots, or those congenitally deficient, a very large proportion of them is composed of weak and imbecile folk, who would, in olden times, have been considered and called “fools,” and not lunatics, and been let mix with their fellow-men, serve as their sport or their dupes, and exhibit their hatred and revenge by malicious mischief and fiendish cruelty. But, thanks to modern civilization and benevolence, these poor creatures are rightly looked upon as proper objects for the supervision, tending and kindness of those whom Providence has favoured with a higher degree of intelligence. This act of philanthropy, effected at a great cost, elevates at the same time, very materially, the ratio of insane persons to the population, and thereby gives cause of alarm at the prevalence of mental disorder, and makes our sanitary statistics contrast unfavourably with those of foreign lands, where the same class of the sick poor has not been so diligently sought out and brought together with a view to their moral and material well-being.

Chap. II.—On the Increase of Insanity.

The only data at hand to calculate the gross increase of the insane in this country, year by year, or over a series of years, are those contained in the Official Reports of the Commissioners in Lunacy and of the Poor-Law Board. These, as we have just shown in the preceding chapter, are incomplete as records of the state of lunacy, since they take no notice of numerous patients not in recognized asylums. Moreover, the annual summary of the returns made by the Commissioners of insane patients confined in Asylums and Licensed Houses, represents a compound quantity, made up of the increment by accumulation in past years, and of the fresh cases admitted in any particular year, and remaining at its close. The same is true of the figures supplied by the Poor-Law Board. Now, though these summaries are useful to show the rate of accumulation of the insane in the various receptacles for them, annually or over any fixed period, they do not tell us how many persons are attacked by madness in any year, or other space of time; or, in other words, they do not inform us whether there is an actual increase, or a decrease in the annual number of persons becoming insane.

This question of the simple increase or decrease of insanity cannot be correctly answered. It is elucidated in some measure, so far as licensed institutions for the insane are concerned, by the tables of admission for different years furnished by the Reports of the Lunacy Commissioners; and it may be assumed to be partially answered by the returns of the number of lunatics in workhouses published by the Poor-Law Board, after an allowance made for the diminution caused by deaths which have taken place in the twelvemonth; but no means whatever exist of discovering the number of persons annually attacked with mental disorder, who do not fall under the cognizance of the public boards.

With the materials in hand, let us in the first place examine the results which follow from a comparison of the Lunacy statistics of the Commissioners, instituted at intervals of more or fewer years. By this course we shall attain, not indeed an estimate of the progressive increase of our insane population, but a valuable comparative return of the number of those enjoying the advantages of asylum care and management in different years. The summary presented in each annual report shows that there were in

From these tables it therefore appears that the accumulation of insane persons in Asylums in the ten years between 1843 and 1853, equalled 6140; and in the five years between 1853 and 1858, 4898; or progressed at the rate of 614 per annum in the ten years, and of 979·6 (or in round numbers 980) per annum in the five years under review, or upwards of 50 per cent. faster in the latter space of time.

In their Twelfth Report (1858) the Commissioners in Lunacy attempt to calculate the probable demands for asylum accommodation on the 1st of January 1860, from the increased number of lunatics in the space of one year, from January 1st, 1857, to January 1st, 1858, amounting to 915. But as we have pointed out in a paper in the “Journal of Mental Science” (vol. v. 1859, p. 249), the conclusion drawn from such data must be fallacious. For instance, a calculation on the result of one year’s statistics is evidently worth little. There are many causes at work in asylums which materially affect the relative number of admissions and discharges, and consequently produce an inequality in the rate of increase viewed year by year. Moreover, where the same plan of calculation has been adopted in determining what asylum accommodation was necessary, experience has soon exhibited the fallacy, and both the admissions and the demands for admission have far exceeded the total reckoned upon. To arrive at a nearer approximation to the truth, the augmentation in the number of lunatics ought to be noted for a space of several years; and to make the deduction more satisfactory, the increase of the general population, the conditions of the period affecting the material prosperity of the people, and its political aspects; and, lastly, the mere circumstance of the opening of new asylums,—a circumstance always followed by an unexpected influx of patients, need be taken into account.

In the preceding considerations only the returns of lunatics in Asylums, Hospitals, and Licensed Houses are discussed; but, as we have seen, there is an almost equally large number detained in workhouses, or boarded with their relatives, or other persons, at the expense of their parishes, whose increase or decrease is a matter of kindred importance. On reviewing the returns of their numbers at periods when they have been taken cognizance of by the Lunacy Commission, we find that there were in workhouses and elsewhere, together, in

exhibiting an increase of 4342 in the ten years between 1847 and 1857, and a decrease in the four between 1843 and 1847 of 1384, owing, doubtless, to the opening of new asylums during that space of time. The returns of the two classes of Pauper Lunatics together being both so infrequently made, and, as before shown (p. 8), open to criticism on account of their incompleteness, we shall attempt to arrive at a more correct estimate of increase than that just made. In the first place, with respect to Union Workhouses, the Summary of Indoor Paupers, published by the Poor Law Commission (10th Report, p. 196), affords the necessary data. According to this tabular statement, we find, that, there were on the 1st of January in each of the ensuing years the following numbers of pauper lunatics:—

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.

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 2s. 6d. is to be paid, whatever the distance the medical officer may have to travel,—are intended by the clause of the Act to qualify the visitor to certify “whether such lunatics are or are not properly taken care of, and may or may not properly remain out of an asylum;” but practically nothing further is attained by them than a certificate that the pauper lunatic still exists as a burden upon the parish funds; and even this much, as the Commissioners in Lunacy testify, is not regularly and satisfactorily obtained. A proper inquiry into the condition of the patient, the circumstances surrounding him, the mode of management adopted, and into the means in use to employ or to amuse him, cannot be expected from a parish medical officer at the remuneration offered, engaged as he is in arduous duties; and, more frequently than not, little acquainted with the features of mental disease, or with the plans for its treatment, alleviation, or management.

Even in the village of Gheel in Belgium, which has for centuries served as a receptacle for the insane, where there is a well-established system of supervision by a physician and assistants, and where the villagers are trained in their management, those visitors who have more closely looked into its organization and working, have remarked numerous shortcomings and irregularities. But compared with the plan of distributing poor demented patients and idiots, as pursued in this country, in the homes of our poorer classes and peasantry, unused to deal with them, too often regarding them as the subjects of force rather than of persuasion and kindness, and under merely nominal medical oversight four times a year, Gheel is literally “a paradise of fools.” Indeed a similar plan might with great advantage be adopted, particularly in the immediate vicinity of our large County Asylums.

But to return to the particular subject in question, viz. the proportion of insane poor in workhouses and elsewhere who should rightly find accommodation in asylums, a class of lunatics, as said before, not taken into account by the Commissioners in their estimate of future requirements.

We let pass the inquiry, what should be done for the 8000 poor imbecile and idiotic paupers boarded in the homes of relatives or others, and confine our observations to the 7947 inmates of workhouses. Now, although we entertain a strong conviction of the evils of workhouses as receptacles for the insane, with very few exceptions,—a conviction we shall presently show good grounds for, yet, instead of employing our own estimate, we shall endeavour to arrive at that formed by the Lunacy Commissioners, of the proportion of lunatics living in them, for whom asylum accommodation should be provided.

The principal and special Report on Workhouses, in relation to their insane inmates, was published in 1847, and in it the Commissioners observe (p. 274), that they believe they “are warranted in stating, as the result of their experience, that of the entire number of lunatics in workhouses,—two-thirds at the least—are persons in whom, as the mental unsoundness or deficiency is a congenital defect, the malady is not susceptible of cure, in the proper sense of the expression, and whose removal to a curative Lunatic Asylum, except as a means of relieving the workhouse from dangerous or offensive inmates, can be attended with little or no benefit. A considerable portion of this numerous class, not less perhaps than a fourth of the whole, are subject to gusts of passion and violence, or are addicted to disgusting propensities, which render them unfit to remain in the workhouse.... But although persons of this description are seldom fit objects for a curative asylum, they are in general capable of being greatly improved, both intellectually and morally, by a judicious system of training and instruction; their dormant or imperfect faculties may be stimulated and developed; they may be gradually weaned from their disgusting propensities; habits of decency, subordination, and self-command may be inculcated, and their whole character as social beings may be essentially ameliorated.”

In their Ninth Report (1855), speaking of those classed in the Workhouse In-door Relief Lists, under the head of Lunatics or Idiots, they observe:—“These terms, which are themselves vague and comprehensive, are often applied with little discrimination, and in practice are made to include every intermediate degree of mental unsoundness, from imbecility on the one hand, to absolute lunacy or idiotcy on the other; and, in point of fact, a very large proportion of the paupers so classed in workhouses, especially in the rural districts, and perhaps four-fifths of the whole, are persons who may be correctly described as harmless imbeciles, whose mental deficiency is chronic or congenital, and who, if kept under a slight degree of supervision, are capable of useful and regular occupation. In the remainder, the infirmity of mind is for the most part combined with and consequent upon epilepsy or paralysis, or is merely the fatuity of superannuation and old age; and comparatively few come within the description of lunatics or idiots, as the terms are popularly understood.”

Lastly, in the Eleventh Report (1857), the class of pauper insane, whose detention in workhouses is allowable, is indicated in the following paragraph:—“They (workhouses) are no longer restricted to such pauper lunatics as requiring little more than the ordinary accommodation, and being capable of associating with the other inmates, no very grave objection rests against their receiving.... But these are now unhappily the exceptional cases.”

These extracts are certainly not precise enough to enable us to state, except very approximatively, what may be the estimate of the Lunacy Commissioners of the numbers who should be rightly placed in asylums. That first quoted appears to set aside one-third as proper inmates of a curative asylum, and amenable to treatment; and then to describe a fourth of the remaining two-thirds, that is, one-sixth, as proper objects of asylum care. On adding these quantities, viz. one-third to one-sixth, we get as the result, one-half as the proportion of workhouse insane considered to be fit subjects for asylums.

The second quotation by itself is of little use to our purpose, except in conjunction with the third one and with the context, as printed in the Report from which it is taken, relative to the general question of the evils of workhouses as receptacles for the insane. So examined in connection, the published statements and opinions of the Commission, lead to the conclusion that the great majority of the insane in workhouses should rightly enjoy the advantages of the supervision, general management, nursing, and dietary of asylums.

However, to escape the possible charge of attempting to magnify the deficiency of asylum accommodation, we will, for the time, assume that only one-half of the lunatic inmates of workhouses require asylum treatment; even then we had some 4000 to be provided with it at the beginning of 1858, and should have at the least 4500 by January 1860.

Having now reduced the estimate of the demands for asylum care to figures, it is practicable to calculate how far those demands can be met by the existing provision in asylums and what may be its deficiency.

On the one side, there will be, at the most moderate computation, made as far as possible from data furnished by the Reports of the Lunacy Commissioners, 4500 inmates of workhouses, who should, on or before January 1st, 1860, obtain asylum care and treatment. On the other, there will be, as above shown, about 1000 beds unoccupied at the date mentioned, after accommodation is afforded to the pauper residents in Licensed Houses, and to the number of insane resulting from accumulation and increase in the course of two years from January 1858. The consequence is, that in January 1860, there will remain some 3500 pauper lunatics unprovided for in proper asylums.

In the course of the preceding arguments, we have kept as closely as possible to data furnished by the Lunacy Commissioners’ Reports, and withal have made out, satisfactorily we trust, that the provision supplied by existing asylums and by those now in progress of erection, is inadequate to the requirements of the insane population of this country. The idea of its inadequacy would be very greatly enhanced by the employment of the statistical conclusions we have arrived at respecting the number of the insane and their rate of accumulation, and by the reception of the views we entertain against their detention, with comparatively few exceptions, in other receptacles than those specially constructed and organized for their care and treatment. The truth of our opinions we shall endeavour to establish in subsequent pages; and respecting the rate of accumulation of pauper cases, we feel confident that 1800 per annum is within the truth. To meet this increase, both the asylums in existence and those in course of erection are undoubtedly inadequate, and, as the necessary result, workhouse pauper inmates must continue to multiply.

If the opinion were accepted that public asylum accommodation should be provided for all the pauper poor, not many more than one-half are at present found to be in possession of it, that is, 17,000 of the 33,000 in the country. Hence it would be required, to more than double the present provision in asylums for pauper lunatics, to give room for all and to meet the rapid annual rate of accumulation.

Chap. IV.—on the curability of insanity.

An inquiry into the curability of insanity forms a natural pendent to that concerning the provision required for the insane, and is at the same time a fitting prelude to an investigation of the insufficiency and defects of the present organization of asylums: for it is important to satisfy ourselves as to what extent we may hope to serve the insane, by placing them under the most advantageous circumstances for treatment, before incurring the large expenditure for securing them.

Now it may be most confidently stated that insanity is a very curable disorder, if only it be brought early under treatment. American physicians go so far as to assert, that it is curable in the proportion of 90 per cent., and appeal to their asylum statistics to establish the assertion. The Lunacy Commission of the State of Massachusetts (op. cit. p. 69) thus write:—“In recent cases the recoveries amount to the proportion of 75 to 90 per cent. of all that are submitted to the restorative process. Yet it is an equally well-established fact, that these disorders of the brain tend to fix themselves permanently in the organization, and that they become more and more difficult to be removed with the lapse of time. Although three-fourths to nine-tenths may be healed if taken within a year after the first manifestation of the disorder, yet if this measure be delayed another year, and the diseases are from one to two years’ standing, the cures would probably be less than one-half of that proportion, even with the same restorative means; another and a third year added to the disease diminishes the prospect of cure, and in a still greater ratio than the second; and a fourth still more. The fifth reduces it so low, as to seem to be nothing.”

Dr. Kirkbride, Physician to the Pennsylvania Hospital for the Insane, in his book “On the Construction and Organization of Hospitals for the Insane,” says (p. 2):—“Of recent cases of insanity, properly treated, between 80 and 90 per cent. recover. Of those neglected or improperly managed, very few get well.”

This is certainly a very flattering estimate, and, inasmuch as it is founded on experience, cannot fairly be questioned. However, before comparing it with the results arrived at in this country, there are some circumstances which call for remark. In the first place, American public asylums are not branded with the appellation ‘pauper,’ they are called ‘State Asylums,’ and every facility is offered for the admission of cases, and particularly of recent ones, whatever their previous civil condition. Again, there is not in the United States the feeling of false pride, of imaginary family dishonour or discredit, to the same extent which is observed in this country, when it pleases Providence to visit a relative with mental derangement,—to oppose the transmission to a place of treatment. From these two causes it happens that in America the insane ordinarily receive earlier attention than in this country. Lastly, the United States’ institutions, by being more accessible, admit a certain proportion of cases of temporary delirium, the consequence of the abuse of alcoholic drinks, of overwrought brain and general excitement,—causes more active in that comparatively new, changing, and rapidly-developing country than in ours. But such cases, which for the most part get well, do not find their way into the asylums of this kingdom. Such are some of the circumstances influencing favourably the ratio of cures in America, which need be remembered when comparing it with that which is attained in our own land.

The proportion of recoveries above stated, is calculated upon cases of less than a year’s duration. Let us see what can be effected in England under conditions as similar as practicable, though not equally advantageous. The most satisfactory results we can point to are those obtained at St. Luke’s Hospital, London, where the cures have averaged 62 per cent. upon the admissions during the last ten years. At this and likewise at Bethlehem Hospital, the rules require that the disorder be not of more than one year’s duration at the time of application for admission, and that it be not complicated with epilepsy or paralysis, maladies which so seriously affect its curability. Such are the conditions favourable to a high rate of recoveries enforced by rule. On the other hand, there are at St. Luke’s not a few circumstances in operation prejudicial to the largest amount of success possible. Its locality is objectionable, its general construction unfavourable, its grounds for exercise and amusement very deficient, and the means of employment few. But apart from these disadvantages, so prejudicial to its utility and efficiency, there are other causes to explain its ratio of success being less than that estimated by our American brethren to be practicable. Though the rule excludes patients the benefit of the hospital if their disease be of more than a year’s duration, yet from the great difficulties attending in many cases the inquiry respecting the first appearance of the insanity; its sometimes insidious approach; the defect of observation, or the ignorance, and sometimes the misrepresentations of friends, resorted to in order to ensure success in their application to the charity, older cases gain admission. Again, of those admitted in any year, there are always several whose disorder is known to be of nine, ten, or eleven months’ duration, and at least a fourth in whom it is of six months’ date and upwards. Further, although the rules exclude epileptics and paralytics, yet at times the history of fits is withheld by the patients’ friends, or the fits are conceived to be of a different character, or the paralysis is so little developed as not to be very recognizable; and as in all ambiguous cases,—whether it be the duration or the complication of the mental disorder which is in doubt, the Committee of the Hospital give the benefit of the doubt to the patient,—the consequence is, that several such unfavourable cases are received annually. On referring to the statistical tables of the institution, these “unfit” admissions are found to amount to 10 per cent.

We have thought these details desirable, on the one hand, to account for the difference in the ratio of cures attained in St. Luke’s compared with that fixed by American writers; and on the other, to show that though the rate of recoveries at that London Hospital is highly gratifying, it might be rendered yet more so if certain impediments to success were removed, and that similar benefits could be realized elsewhere if due provision were made for the early and efficient treatment of the malady.

Were we at all singular in the assertion of the curability of insanity, we should endeavour to establish it by an appeal to the statistics of recoveries among recent cases in the different English asylums; but instead of advancing a novel opinion, we are only bearing witness to a well-recognized fact substantiated by general experience. This being so, it would be fruitless to occupy time in quoting many illustrations from Asylum Reports: one will answer our purpose.

At the Derby County Asylum, under the charge of Dr. Hitchman, a high rate of cures has been reached. In the Third Report that able physician writes (p. 5),—“It cannot be too often repeated, that the date of the patient’s illness at the time of admission is the chief circumstance which determines whether four patients in a hundred, or seventy patients in a hundred, shall be discharged cured. Of the 151 cases which have been admitted into the asylum during the past year, eleven only have been received within a week of the onset of their malady; of these eleven, ten have been discharged cured,—the other has been but a short time under treatment.” In his Sixth Report (1857, p. 22), the same gentleman observes,—“The cures during the past year have reached 60 per cent. upon the admissions; but the most gratifying fact has been, that of twenty patients, unafflicted with general paralysis, who were admitted within one month of the primary attack of their maladies, sixteen have left the asylum cured,—three are convalescent, and will probably be discharged at the next meeting of the Committee, and the other one was in the last stage of pulmonary consumption when she came to the asylum, and died in three weeks after her admission.”

After this review of what may be effected in restoring the subjects of mental disorder to reason and society, to their homes and occupations, by means of early treatment, it is discouraging to turn to the average result of recoveries on admissions obtained in our County Asylums at large. This average may be taken at 35 per cent., and therefore there will remain of every 100 patients admitted, sixty-five, or, after deducting 10 per cent. of deaths, fifty-five at the end of the year. This number, fifty-five, might fairly be taken to represent the annual per centage of accumulation of the insane in asylums, were the data employed sufficient and satisfactory. But so far as we have yet examined the point, this proportion is larger than a calculation made over a series of years, and may be approximatively stated at 35 per cent. on the admissions.

How great would be the gain, alike to the poor lunatic and to those chargeable with his maintenance, could this rapid rate of accumulation be diminished, by raising that of recoveries, or, what is tantamount to it, by securing to the insane prompt and efficient care and treatment! How does it happen that this desideratum is not accomplished by the asylums in existence? what are the impediments to success discoverable in their organization and management, or in the history of their inmates prior to admission? and what can be done to remedy discovered defects, and to secure the insane the best chances of recovery? Such are some of the questions to be next discussed.

Chap. V.—on the causes diminishing the curability of insanity, and involving the multiplication of chronic lunatics.

In the preliminary chapters on the number and increase of the insane in this country, we limited ourselves to determine what that number and that increase were, and entered into no disquisition respecting the causes which have operated in filling our asylums with so many thousands of chronic and almost necessarily incurable patients. Nor shall we now attempt an investigation of them generally, for this has been well done by others, and particularly by the Lunacy Commissioners in their Ninth Report, 1855; but shall restrict ourselves to intimate that the increase of our lunatic population, mainly by accumulation, is due to neglect in past years; to the alteration of the laws requiring the erection of County Asylums for pauper lunatics generally; to the collection and discovery of cases aforetime unthought of and unknown; to the extension of the knowledge of the characters and requirements of the insane both among professional men and the public; and, lastly, to the advantages themselves of asylum accommodation which tend to prolong the lives of the inmates.

Such are among the principal causes of the astounding increase in the number of the insane of late years, relatively to the population of the country, some of which fortunately will in course of time be less productive. Those, however, which we now desire to investigate, are such as directly affect the curability of insanity, either by depriving its victims of early and efficient treatment, or by lessening the efficiency and usefulness of the public asylums.

The history of an insane patient is clearly divisible into three portions: 1st, that before admission into an asylum; 2nd, that of his residence in an asylum; and 3rd, of that after his discharge from it. The last division we have at present nothing to do with; and with reference to the causes influencing his curability, these group themselves under two heads parallel to the first two divisions of the patient’s history; viz. 1, those in operation external to, and 2, those prevailing in, asylums.

A. Causes external to Asylums.

The chief cause belonging to this first class is that of delay in submitting recent cases to asylum care and treatment. This delay, as we have sufficiently proved, operates most seriously by diminishing the curability of insanity, and thereby favours the accumulation of chronic lunatics. It takes place in consequence either of the desire of friends to keep their invalid relatives at their homes; or of the economical notions of Poor-Law Officers, who, to avoid the greater cost of asylums, detain pauper lunatics in workhouses. Other causes of incurability and of the accumulation of incurables are found in injudicious management and treatment before admission, and in the transmission of unfit cases to asylums. To discuss the several points suggested in these considerations will require this chapter to be subdivided; and first we may treat of the Detention of Patients in their own homes.

§ Detention of Patients in their own homes.

Although the immense importance of early treatment to recent cases of insanity is a truth so well established and so often advocated, yet the public generally fail to appreciate it, and from unfortunate notions of family discredit, from false pride and wounded vanity, delay submitting their afflicted relatives to efficient treatment. Unless the disorder manifest itself by such maniacal symptoms that no one can be blind to its real character, the wealthier classes especially will shut their eyes to the fact they are so unwilling to recognize, and call the mental aberration nervousness or eccentricity; and as they are unwilling to acknowledge the disorder, so are they equally indisposed to subject it to the most effectual treatment, by removing the patient from home, and the exciting influence of friends and surrounding circumstances in general, to a properly organized and managed asylum. Usually a patient with sufficient resources at command, is kept at home as long as possible, at great cost and trouble; and if he be too much for the control of his relatives and servants, attendants are hired from some Licensed House to manage him; the only notion prevailing in the minds of his friends being that means are needed to subdue his excitement and to overcome his violence. There are, in fact, no curative agencies at work around him, but on the contrary, more or fewer conditions calculated to exalt his furor, to agitate and disquiet his mind, and to aggravate his malady. The master of the house finds himself checked in his will; disobeyed by his servants; an object of curiosity, it may be, of wonder and alarm; and sadly curtailed in his liberty of action. The strange attendants forced upon him are to be yielded to only under passionate protests, and probably after a struggle. In all ways the mental disorder is kept up if not aggravated, and every day the chances of recovery are diminished. Perhaps matters may grow too bad for continued residence at home, or the malady have lasted so long, that the broken-up state of family and household can no longer be tolerated, and a transfer from home is necessitated. Yet even then removal to an asylum,—the only step which can hold out a fair prospect of recovery, is either rejected as quite out of the question, or submitted to usually after still longer delay,—a “trial” being made of a lodging with a medical man or other person, probably with an asylum attendant. By this plan certainly the patient is saved from the presence and excitement of his family, and placed under altered conditions, calculated to exercise in some respects a salutary influence on his mind; still many others are wanting, and no guarantee is attainable of the manner in which he is treated; for as a single patient, and as is usually the case, restrained without certificates, he is almost invariably unknown to the Commissioners, and virtually unprotected, even though a medical man be paid to attend him occasionally. At last, however, except for a few, the transfer to the asylum generally becomes inevitable, and too often too late to restore the disordered reason; and years of unavailing regret fail to atone for time and opportunity lost.

The same unwillingness to subject their insane friends to asylum care and treatment pervades, moreover, the less wealthy classes, and even the poorer grades of the middle class of society. Madness, to their conceptions likewise, brings with it a stigma on the family, and its occurrence must, it is felt, be kept a secret. Hence an asylum is viewed as an evil to be staved off as long as possible, and only resorted to when all other plans, or else the pecuniary means, are exhausted. If it be the father of the family who is attacked, the hope is, that in a few days or weeks he may resume his business or return to his office, as he might after ordinary bodily illness, without such loss of time as shall endanger his situation and prospects, and without the blemish of a report that he has been the inmate of a madhouse. If it be the wife, the hope is similar, that she will shortly be restored to her place and duties in her family. Should progress be less evident than desired, a change away from home will probably be suggested by the medical attendant, and at much expense and trouble carried out. But too frequently, alas! the hopes are blighted and the poor sufferer is at length removed with diminished chance of cure to an asylum.

For the poorer members of the middle class, and for many moving in a somewhat higher circle of society, whom the accession of mental disorder impoverishes and cuts off from independence, there are, it is most deeply to be regretted, few opportunities of obtaining proper asylum care and treatment. In very many instances, the charges of even the cheapest private asylum can be borne for only a limited period, and thus far, at the cost of great personal sacrifices and self-denial. Sooner or later no refuge remains except the County Asylum, where, it may be, from the duration of his disorder, the patient may linger out the remainder of his days. How happy for such a one is it—a person unacquainted with the system of English County Asylums, might remark—that such an excellent retreat is afforded! To this it may be replied, that the public asylum ought not to be the dernier ressort of those too poor to secure the best treatment and care in a well-found private establishment, and yet too respectable to be classed and dealt with as paupers entirely and necessarily dependent on the poor’s rate. Yet so it is under the operation of the existing law and parochial usages, there is no intermediate position, and to reap the benefits of the public asylum, the patient must be classed with paupers and treated as one. His admission into it is rendered as difficult, annoying, and degrading as it can be. His friends, worn out and impoverished in their charitable endeavours to sustain him in his independent position as a private patient, are obliged to plead their poverty, and to sue as paupers the parish officials for the requisite order to admit their afflicted relative to the benefits of the public asylum as a Pauper Lunatic. In short, they have to pauperize him; to announce to the world their own poverty, and to succumb to a proceeding which robs them of their feelings of self-respect and independence, and by which they lose caste in the eyes of their neighbours. As for the patient himself, unless the nature and duration of his malady have sufficiently dulled his perception and sensibilities, the consciousness of his position as a registered pauper cannot fail to be prejudicial to his recovery; opposed to the beneficial influences a well-regulated asylum is calculated to exert, and to that mental calm and repose which the physician is anxious to procure.

In the class of cases just sketched, we have presumed on the ability of the friends to incur the cost of private treatment for a longer or shorter period; but many are the persons among the middle classes, who if overtaken by such a dire malady as insanity, are almost at once reduced to the condition of paupers and compelled to be placed in the same category with them. As with the class last spoken of, so with this one, the law inflicts a like injury and social degradation, and at the same time operates in impeding their access to proper treatment.

No one surely, who considers the question, and reflects on the necessary consequences of the present legal requirement that, for a lunatic to enjoy the advantages of a public asylum, towards which he may have for years contributed, he must be formally declared chargeable to the rates as a pauper,—can deny the conclusion that it is a provision which must entail a social degradation upon the lunatic and his family, and act as a great impediment to the transmission of numerous recent cases to the County Asylum for early treatment.

It will be urged as an apology for it, that the test of pauperism rests on a right basis; that it is contrived to save the rate-payer from the charge of those occupying a sphere above the labouring classes, who fall, as a matter of course, upon the parochial funds whenever work fails or illness overtakes them. It is, in two words, a presumed economical scheme. However, like many other such, it is productive of extravagance and loss, and is practically inoperative as a barrier to the practice of imposition. If it contributes to check the admission of cases at their outbreak into asylums, as no one will doubt it does, it is productive of chronic insanity and of permanent pauperism; and, therefore, besides the individual injury inflicted, entails a charge upon the rates for the remaining term of life of so many incurable lunatics.

If, on the contrary, our public asylums were not branded by the appellation “Pauper;” if access to them were facilitated and the pauperizing clause repealed, many unfortunate insane of the middle class in question, would be transmitted to them for treatment; the public asylum would not be regarded with the same misgivings and as an evil to be avoided, but it would progressively acquire the character of an hospital, and ought ultimately to be regarded as a place of cure, equivalent in character to a general hospital, and as entailing no disgrace or discredit on its occupant.

The Commissioners in Lunacy, in their Ninth Report (1855, p. 35), refer to the admissions into County Asylums, of patients from the less rich classes of society reduced to poverty by the occurrence of the mental malady, and hint at their influence in swelling the number of the chronic insane, owing to their transfer not taking place until after the failure of their means and the persistence of their disorder for a more or less considerable period. This very statement is an illustration in point; for the circumstance deplored is the result of the indisposition on the part of individuals to reduce their afflicted relatives to the level of paupers by the preliminaries to, and by the act of, placing them in an asylum blazoned to the world as the receptacle for paupers only; an act, whereby, moreover, they advertise to all their own poverty, and their need to ask parish aid for the support of their poor lunatic kindred.

On the continent of Europe and in the United States of America we obtain ample evidence that the plan of pauperizing patients in order to render them admissible to public asylums, is by no means necessary. Most continental asylums are of a mixed character, receiving both paying and non-paying inmates, and care is taken to investigate the means of every applicant for admission, and those of his friends chargeable by law with his maintenance. Those who are paid for are called “pensioners” or boarders, and are divided into classes according to the sum paid, a particular section of the asylum being assigned to each class. Besides those pensioners who pay for their entire maintenance, there are others whose means are inadequate to meet the entire cost, and who are assessed to pay a larger or smaller share of it. Lowest in the scale of inmates are those who are entirely chargeable to the departmental or provincial revenue, being devoid of any direct or indirect means of support. Probably the machinery of assessment in the continental states might not accord with English notions and be too inquisitorial for adoption in toto; but at all events, on throwing open public asylums for the reception of all lunatics who may apply for it, without the brand of pauperism being inflicted upon them, some scheme of fairly estimating the amount they ought to contribute to their maintenance should be devised. For the richer classes a plan of inquisition into their resources is provided, and there seems no insuperable difficulty in contriving some machinery whereby those less endowed with worldly goods might, at an almost nominal expense, have their means duly examined and apportioned to their own support and that of their families. Overseers and relieving officers are certainly not the persons to be entrusted with any such scheme, nor would we advocate a jury, for in such inquiries few should share; but would suggest it as probably practicable that the amount of payment might be adjudged by two or three of the Committee of Visitors of the Asylum with the Clerk of the Guardians of the Union or Parish to which the lunatic belonged.

In the United States of America, every tax-payer and holder of property is entitled as a tax-payer, when insane, to admission into the Asylum of the State of which he is a citizen. He is considered as a contributor to the erection and support of the institution, and as having therefore a claim upon its aid if disease overtake him. The cost of his maintenance is borne by the township or county to which he belongs, and the question of his means to contribute towards it is determined by the county judge and a jury. Most of the asylums of the Republic also receive boarders at fixed terms, varying according to the accommodation desired; hence there are very few private asylums in the States. In the State of New York there is a special legal provision intended to encourage the early removal of recent cases to the asylum; whereby persons not paupers, whose malady is of less than one year’s duration, are admitted without payment, upon the order of a county judge, granted to an application made to him, setting forth the recent origin of the attack and the limited resources of the patient. Such patients are retained two years, at the end of which time they are discharged, their friends being held responsible for the removal. Their cost in the asylum is defrayed by the county or parish to which they belong.

We have said above, that the requirement of the declaration of pauperism is ineffectual in guarding the interests of the rate-payer against the cost of improper applicants. Indeed, the proceeding adopted to carry it out is both absurd and useless, besides being, as just pointed out, mischievous in its effects.

In the interpretation clause of “the Lunatic Asylums’ Act, 1853,” it is ordered that a “Pauper shall mean every person maintained wholly or in part by, or chargeable to, any Parish, Union, or County.” Hence when insanity overtakes an unfortunate person who is not maintained by a parish or union, it is required that he be made chargeable to one, or, as we have briefly expressed the fact, that he be pauperized. To effect this object, the rule is, that the patient shall reside at least a day and a night in a workhouse. This proceeding, we repeat, carries absurdity on the face of it. Either it may be a mere farce privately enacted between the parish officers and the friends of the patient, to the complete frustration of the law so far as the protection of the rate-payers is contemplated; or, it may be made to inflict much pain and annoyance on the applicants by the official obstructiveness, impertinent curiosity, obtuseness, and possible ill-feeling of the parish functionaries in whose hands the law has practically entrusted the principal administration of the details regulating the access to our public asylums.

It is no secret among the superintendents of County Asylums, that by private arrangements with the overseers or guardians of parishes, cases gain admission contrary to the letter and spirit of the law, and to the exclusion of those who have legally a prior and superior claim. We have, indeed, the evidence of the Lunacy Commissioners, to substantiate this assertion. In their Ninth Report (1855, p. 34) they observe,—“In some districts a practice has sprung up, by which persons, who have never been themselves in receipt of parochial relief, and who are not unfrequently tradesmen, or thriving artisans, have been permitted to place lunatic relations in the County Asylums, as pauper patients, under an arrangement with the guardians for afterwards reimbursing to the parish the whole, or part, of the charge for their maintenance. This course of proceeding is stated to prevail to a considerable extent in the asylums of the metropolitan counties, and its effect in occupying with patients, not strictly or originally of the pauper class, the space and accommodations which were designed for others who more properly belong to it, has more than once been made the subject of complaint.”

Desiring, as we do, to see our County Asylums thrown open to the insane generally, by the abolition of the pauper qualification, it is rather a subject of congratulation that cases of the class referred to do obtain admission into them, even when contrary to the letter of the law. But we advance the quotation and assertion above to show, that the pauperizing provision of the Act is ineffective in the attainment of its object; and to remark, that the opportunities at connivance it offers to parochial officials, must exercise a demoralizing influence and be subversive of good government. If private arrangements can be made between the applicants for an assumed favour, and parish officers, who will undertake to say that there shall not be bribery and corruption?

Sufficient, we trust, has been said to demonstrate the evils of the present system of pauperizing patients to qualify them for admission into County Asylums, and the desirability of opening those institutions to all lunatics of the middle classes whose means are limited, and whose social position as independent citizens is jeopardized by the existence of their malady. This class of persons, as before said, calls especially for commiseration and aid; being so placed, on the one hand, that their limited means must soon fail to afford them the succour of a private asylum; and on the other, with the door of the public institution closed against them, except at the penalty of pauperism and social degradation.

What we would desire is, that every recent case of insanity should at once obtain admission into the public asylum of the county or borough, if furnished with the necessary medical certificates and with an order from a justice who has either seen the patient or received satisfactory evidence as to his condition (see remarks on duties of district medical officers), and obtained from the relatives an undertaking to submit to the assessment made by a commission as above proposed, or constituted in any other manner thought better; or the speedy admission of recent cases might otherwise be secured by prescribing their attendance and that of their friends before the weekly Committee of the Visitors of the Asylum, by whom the order for reception might be signed on the requisite medical certificates being produced, and the examination for the assessment of the patient’s resources formally made, with the assistance possibly of some representative of the parish interests,—such for instance as the Clerk to the Board of Guardians.

In the County Courts the judges are daily in the habit of ordering periodical payments to be made in discharge of debts upon evidence offered to them of the earnings or trade returns of the debtor; and there seems no a priori reason against the investigation of the resources of a person whose friends apply for his admission into a County Asylum. It is for them to show cause why the parish or county should assume the whole or the partial cost of the patient’s maintenance, and this can be done before the Committee of the Asylum or any private board of inquiry with little annoyance or publicity. Rather than raise an obstacle to the admission of the unfortunate sufferer, it would be better to receive him at once and to settle pecuniary matters afterwards.

We must here content ourselves with this general indication of the machinery available for apportioning the amount of payment to be made on account of their maintenance by persons not paupers, or for determining their claim upon the Asylum funds. Yet we cannot omit the opportunity to remark that the proceedings as ordered by the existing statute with a similar object are incomplete and unsatisfactory. These proceedings are set forth in sects. xciv. and civ. (16 & 17 Vict. cap. 97). The one section of the Act is a twin brother to the other, and it might be imagined by one not “learned in the law,” that one of the two sections might with little alteration suffice. Be this as it may, it is enacted that if it appear to two Justices (sect. xciv.) by whose order a patient has been sent to an asylum, or (sect. civ.) “to any Justice or Justices by this Act authorized to make any order for the payment of money for the maintenance of any Lunatic, that such Lunatic” has property or income available to reimburse the cost of his maintenance in the asylum, such Justices (sect. xciv.) shall apply to the nearest known relative or friend for payment, and if their notice be unattended to for one month, they may authorize a relieving officer or overseer to seize the goods, &c. of the patient, whether in the hands of a trustee or not, to the amount set forth in their order. Sect. civ. makes no provision for applying to relatives or friends in the first instance, but empowers the justice or justices to proceed in a similar way to that prescribed by sect. xciv., to repay the patient’s cost; with the additional proviso that, besides the relieving officer or overseer, “the Treasurer or some other officer of the County to which such Lunatic is chargeable, or in which any property of the Lunatic may be, or an officer of the Asylum in which such Lunatic may be,” may proceed to recover the amount charged against him.

Concerning these legal provisions, we may observe, that the state of the lunatic’s pecuniary condition is left to accidental discovery. The justices signing the order of admission (sect. xciv.) have no authority given them to institute inquiries, although they may learn by report that the patient for whom admission is solicited is not destitute of the means of maintenance. Nor are the justices who make the order for payment (sect. civ.) in any better position for ascertaining facts. There is, in short, no authorized and regular process for investigating the chargeability of those who are not actually in the receipt of parochial relief on or before application for their admission into the County Asylum, or who must necessarily be chargeable by their social position when illness befalls them. Again, according to the literal reading of the sections in question, no partial charge for maintenance can be proposed; no proportion of the cost can be assessed, where the patient’s resources are unequal to meet the whole. Lastly, the summary process of seizing the goods or property of any sort, entrusted to those who are most probably the informers of the justices, namely overseers and relieving officers; and, by sect. civ., carried out without any preliminary notice or application, and without any investigation of the truth of the reports which may reach the justices, is certainly a proceeding contrary to the ordinary notions of equity and justice.

§ Detention of Patients in Workhouses.

In the case of the insane poor, whose condition, circumstances, and social position have been such that whenever any misfortune, want of work, or sickness has overtaken them, the workhouse affords a ready refuge, the requirement of pauperization to qualify for admission to the County Asylum is in itself no hardship and no obstacle to their transmission to it. Probably the prevailing tactics of parish officers may at times contribute to delay the application for relief, but the great obstacle to bringing insane paupers under early and satisfactory treatment in the authorized receptacle for them—the County Asylum, is the prevalence of an economical theory respecting the much greater cheapness of workhouse compared with asylum detention. The practical result of this theory is, that generally where a pauper lunatic can by any means be managed in a workhouse, he is detained there. If troublesome, annoying, and expensive, he is referred to the County Asylum; this is the leading test for the removal; the consideration of the recent or chronic character of his malady is taken little or no account of.

In fresh cases the flattering hope is that the patients will soon recover, and that the presumed greater cost of asylum care can be saved; in old ones the feeling is that they are sufficiently cared for, if treated like the other pauper inmates, just that amount of precaution being attempted which may probably save a public scandal or calamity.

To the prevalence of these economical notions and practice may be attributed the large number of lunatics detained in workhouses (nearly 8000), and the equally large one living with their friends or others. Now it is very desirable to inquire whether these theories of the superior economy of workhouses compared with asylums as receptacles for the insane, are true and founded on facts. This question is in itself twofold, and leaves for investigation, first, that of the mere saving in money on account of maintenance and curative appliances; and secondly, that of the comparative fitness or unfitness, the advantages or disadvantages, the profit or loss, of the two kinds of institutions in relation to the welfare, the cure, and the relief of the poor patients placed in them. These questions press for solution in connexion with the subject of the accumulation of lunatics and the means to be adopted for its arrest, or, what is equivalent to this, for promoting the curability of the insane.

On making a comparative estimate of charges, it is essential to know whether the same elements of expenditure are included in the two cases; if the calculated cost per head for maintenance in workhouses and asylums respectively comprises the same items, and generally, if the conditions and circumstances so far as they affect their charges are rightly comparable. An examination we are confident, will prove that in no one of these respects are they so.

In the first place, the rate of maintenance in an asylum is calculated on the whole cost of board, clothing, bedding, linen, furniture, salaries, and incidental expenditure; that is, on the total disbursements of the establishment, exclusive only of the expenditure for building and repairs, which is charged to the county. On the contrary, the “in-maintenance” in workhouses comprises only the cost of food, clothing, and necessaries supplied to the inmates (see Poor-Law Board Tenth Report, p. 144). The other important items reckoned on in fixing the rate of cost per head in asylums are charged to the “establishment” account of the workhouse, and are omitted in the calculation of the rate of maintenance. Reference to the Tables given in the Poor-Law Board Returns (Tenth Report, p. 61, sub-column e and a portion of f) will prove that the expenditure on account of those other items must be nearly or quite equal to that comprehended under the head of “in-maintenance” cost.

We have no means at hand to calculate with sufficient precision what sum should be added to the “in-maintenance” cost of paupers per head in workhouses, but it is quite clear that the figures usually employed to represent it, cannot be rightly compared with those exhibiting the weekly charge of lunatics in asylums. At the very least half as much again must be added to a workhouse estimate before placing it in contrast with asylum cost.

Since the preceding remarks were written, Dr. Bucknill has favoured us with the Thirteenth Report of the Devon Asylum, in which he has discussed this same question and illustrated it by a special instance. To arrive at the actual cost of an adult sane pauper in a union-house, he gathered “the following particulars relative to the house of the St. Thomas Union in which this asylum is placed; a union, the population of which is 49,000, and which has the reputation of being one of the best managed in the kingdom. The cost of the maintenance of paupers in this union-house is 2s. 6d. per head, per week, namely, 2s. 2d. for food and 4d. for clothing. The establishment charges are 1s. 0½d. per head, per week, making a total of 3s. 6½d. for each inmate. The total number of pauper inmates during the twelfth week of the present quarter was 246; and of these 116 were infants and children, and 130 youths above sixteen and adults. A gentleman intimately acquainted with these accounts, some time since calculated for me that each adult pauper in the St. Thomas’s Union-house cost 5s. a week. Now the average cost of all patients in the Devon Asylum at the present time is 7s. 7d., but of this at least 2s. must be set down to the extra wages, diet, and other expenses needful in the treatment of the sick, and of violent and acute cases, leaving the cost of the great body of chronic patients at not more than 5s. 7d. a week. Now if a sane adult pauper in a union-house costs even 4s. 6d. a week, is it probable that an insane one would cost less than 5s. 7d.? For either extra cost must be incurred in his care, or he must disturb the discipline of the establishment, and every such disturbance is a source of expense.”

This quotation is really a reiteration of Dr. Bucknill’s conclusions as advanced in 1857, in an excellent paper in the ‘Asylum Journal’ (vol. iv. p. 460), and as a pendent to it the following extract from this paper is appropriate; viz. “that the cost of a chronic lunatic properly cared for, and supplied with a good dietary, in a County Asylum, is not greater than that of a chronic lunatic supplied with a coarse and scanty dietary, and detained in neglect and wretchedness as the inmate of a union workhouse.”

Another most important circumstance to be borne in mind when the cost of workhouses and asylums is contrasted, is that in the former establishments more than two-thirds of the inmates are children. Thus the recipients of in-door relief on the 1st of January, 1858, consisted, according to the Poor-Law Returns, of 74,141 adults, and 50,836 children under sixteen years of age. Now as the rate of maintenance is calculated on the whole population of a workhouse, adults and children together, it necessarily follows that it falls much within that of asylums, in which almost the whole population is adult. This very material difference in the character of the inmates of the two institutions may fairly be valued as equivalent to a diminution of one-fourth of the expense of maintenance in favour of workhouses; and without some such allowance, the comparison of the cost per head in asylums and union-houses respectively is neither fair nor correct.

Again, there is another difference between asylums and workhouses, which tells in favour of the latter in an economical point of view, whilst it proves that the expenditure of the two is not rightly comparable without making due allowance for it along with the foregoing considerations. This difference subsists in the character of the two institutions respectively; namely, that in the asylum the movements of the population are slight, whereas in the workhouse they are very considerable by the constant ingress and egress of paupers; driven to it by some passing misfortune or sickness, it may be for a week or two only or even less, and discharging themselves so soon as the temporary evil ceases to operate or the disorder is overcome: for the poor generally, except the old and decrepit who cannot help themselves, both dread a lodging in the workhouse, and escape from it as soon as possible; in fact, even when they have no roof of their own to shelter them, they will often use the union accommodation only partially, leaving it often by day and returning to it by night. All this implies a large fluctuation of inmates frequently only partially relieved, whether in the way of board or clothing; and consequently when the average cost per head of in-door paupers is struck, it appears in a greater or less degree lower than it would have done had the same constancy in numbers and in the duration and extent of the relief afforded prevailed as it does in asylums.

The effect of the fluctuations in population in union-houses ought, we understand, to be slight, if the “Orders in Council” laid down to guide parochial authorities in the calculation of the cost of their paupers, were adhered to; viz. that for all those belonging to any one parish in union, who may have received in-door relief during the year or for any less period of time, an equivalent should be found representing the number who have been inmates throughout the year; or the total extent of relief be expressed by estimating it to be equal to the support of one hypothetical individual for any number of years equivalent to the sum of the portions of time the entire number of the paupers of the particular parish received the benefits of the establishment. We do not feel sure that these plans of calculating the cost per head are faithfully and fully executed; the rough method of doing so, viz. by taking the whole cost of “in-maintenance” at the end of the year and dividing it by the number of its recipients, and assuming the quotient to represent the expenditure for each. Whether this be the case or not, these daily changes among its inmates, the frequent absence of many for a great part of the day and the like, are to be enumerated among the circumstances which tend to keep down expenditure of workhouses; and which are not found in asylums.

There is yet another feature about workhouses which distinguishes them from asylums, and is of considerable moment in the question of the comparative cost of maintenance in the two: this is, the circumstance of the population of workhouses being of a mixed character, of which the insane constitute merely a small section; while, on the contrary, that of asylums is entirely special, and each of its members to be considered a patient or invalid demanding particular care and special appliances. Therefore, a priori, no comparison as to their expenditure can justly be drawn between two institutions so dissimilar. Yet even this extent of dissimilarity between them is not all that exists; for the union-house is so constituted by law as to serve as a test of poverty; to offer no inducements to pauperism, and to curtail the cost of maintenance as far as possible. It has properly no organization for the detention, supervision, moral treatment and control, nor for the nursing or medical care of the insane; and when its establishment is attempted it is a step at variance with its primary intention, and involves an extra expenditure.

Consequently, before overseers or guardians can with any propriety contrast the workhouse charges of maintenance with those of asylums, it is their business to estimate what an adult pauper lunatic costs them per week, instead of, as usual, quoting the cost per head calculated on the whole of the inmates, old and young, sane and insane.

Once more, even after a fair estimate of the cost of an adult insane inmate of a workhouse is obtained, there is still another differential circumstance favourable to a less rate than can be anticipated in asylums; for this reason:—that in the former institutions the practice is to reject all violent cases, the major portion of recent ones, and, generally, all those who give particular annoyance and trouble; whilst the latter is, as it rightly should be, regarded as the fitting receptacle for all such patients;—that is, in other words, those classes of patients which entail the greatest expense are got rid of by the workhouses and undertaken by the asylums.

Dr. Bucknill has well expressed the same circumstances we have reviewed, in the following paragraph (Report, Devon Asylum, 1858, p. 13):—“In estimating the cost of lunatic paupers in asylums, the important consideration must not be omitted, that the charge made for the care and maintenance of lunatics in County Asylums is averaged upon those whose actual cost is much greater, and those whose actual cost is less than the mean; so that it would be unfair for the overseers of a parish to say of any single patient that he could be maintained for a smaller sum than that charged, when the probability is that there are or have been patients in the asylum from the same parish, whose actual cost to the asylum has been much greater than that charged to the parish. I have shown, that the actual cost of chronic patients in an asylum exceeds that of adult paupers in union-houses to a much smaller extent than has been stated: but if all patients of this description were removed from the asylum, the inevitable result must be that the average cost of those who remained would be augmented, so that the pecuniary result to the parishes in the county would be much the same. The actual cost of an individual patient, if all things are taken into calculation, is often three or four times greater than the average. Leaving out of consideration the welfare of the patients, it would be obviously unfair to the community, that a parish having four patients in the asylum, the actual cost of two of whom was 12s. a week, and of the other two only 4s. a week, should be allowed to remove the two who cost the smaller sum, and be still permitted to leave the other two at the average charge of 8s.”

The conclusion of the whole matter is, that cæteris paribus, i. e. supposing workhouses to be equally fitting receptacles for the insane as asylums, the differential cost of the two can only be estimated when it is ascertained that the items of maintenance are alike in the two, and after that an allowance is made for the different characters of their population and of their original purpose; that is, in the instance of workhouses, for the very large number of juvenile paupers; for the great fluctuations in the residents; for the mixed character of their inmates, of sane and insane together, and the small proportion of insane, and for the exclusion of the most expensive classes of such patients. Let these matters be fairly estimated, and we doubt much if, even primâ facie, it can be shown that the workhouse detention of pauper lunatics is more economical than that of properly constructed and organized asylums.

Should we even be so far successful as to make Poor-Law Guardians and Overseers perceive that the common rough-and-ready mode of settling the question of relative cost in asylums and workhouses, by contrasting the calculated rate per head for in-door relief with that for asylum care, is not satisfactory; we cannot cherish the flattering hope that they will be brought to perceive that, simply in an economical point of view, no saving at all is gained by the detention of the insane in workhouses. Those Poor-Law officials generally are so accustomed to haggle about fractional parts of a penny in voting relief, to look at an outlay of money only with reference to the moment, forgetful of future retribution for false economy, and to handle the figures representing in their estimate the economical superiority of the workhouse for the insane, when they desire to silence an opponent;—that the task of proving to them that their theory and practice are wrong, is equivalent to the infelicitous endeavour to convince men against their will.

Still, however unpromising our attempt may appear, it is not right to yield whilst any legitimate arguments are at hand; and our repertory of them, even of those suited to a contest concerning the pounds, shillings, and pence of the matter, is not quite exhausted; for we are prepared to prove, that asylum accommodation can be furnished to the lunatic poor at an outlay little or not at all exceeding that for workhouses.

Now this point to be argued, the cost of asylum construction, is not, like the foregoing considerations, chiefly the affair of Poor-Law Guardians and Overseers, but concerns more particularly the County Magistrates, inasmuch as it is defrayed out of the County instead of the Poor Rate. But although this is the case, there is no doubt that the very great expense of existing asylums has acted as an impediment to the construction of others, and has seemed to justify, to a certain extent, the improper detention of many insane persons in workhouses: for, on one side, asylums are found to have cost for their construction and fittings, £150, £200, and upwards per head, whilst on the other, workhouses are built at the small outlay, on an average, of eighty-six such establishments, of £22 per head. The “Return” made to the House of Commons, June 15, 1857, “of the cost of building Workhouses in England and Wales, erected since 1840,” shows indeed a very wide variation of cost in different places, from £13 per head for the Congleton Union House; £14 for the Erpingham; £16 for the Stockton and Tenterden, to £47 for the Kensington; £50 for the Dulverton; £59 for the City of London; £60 for St. Margaret Westminster; and £113 for the Paddington. This enormous difference of expenditure on workhouse lodging,—for, unlike asylum costs, it does not include fittings, extending from £13 to £113 per inmate,—is really inexplicable, after allowing for the varying ideas of parish authorities as to what a workhouse should be, and for the slight differences in the cost of building materials and labour in some parts of the country than in others. Either some workhouses must be most miserable and defective habitations even for paupers, or others must be very extravagant and needlessly expensive in their structure.

There is this much to be said in explanation of the contrast of cost in different workhouses, that in those belonging to large town populations, infirmary accommodation becomes an item of importance and involves increased expenditure, whilst in those situated in agricultural districts, this element of expense is almost wanting. Moreover it is in town workhouses generally that lunatic inmates are found, who, if not in the infirmary, are lodged in special wards, often so constructed as to meet their peculiar wants, and therefore more costly than the rest of the institution occupied by the ordinary pauper inmates. This is the same with saying that where workhouses are used as receptacles for the insane, it greatly enhances the cost of their construction.

It will be evident to every thinking person that the costs of asylum and of workhouse construction are not fairly comparable. The asylum is a special building; an instrument of treatment; peculiarly arranged for an invalid population, affording facilities for classification, recreation, and amusements; and fitted with costly expedients for warming and ventilation; whereas the workhouse is essentially a refuge for the destitute, necessarily made not too inviting in its accommodation and internal arrangements; suited to preserve the life of sound inmates who need little more than the shelter of a roof and the rude conveniences the majority of them have been accustomed to. Now these very characteristics of workhouses are among the best arguments against the detention of lunatics within these buildings; but of these hereafter.

There is doubtless a permissible pride in the ability to point to a well-built asylum, commanding attention by its dimensions and architectural merits, and we would be the last to decry the beauties and benefits of architecture, and know too, that an ugly exterior may cost as much or more than a meritorious one; yet we must confess to misgivings that there has been an unnecessary and wasteful expenditure in this direction. Nevertheless it is with asylums as with railways, the present race of directors are reaping instruction from the extravagances and errors its predecessors fell into.

The change of opinion among all classes respecting the character and wants of the insane and their mode of treatment, is of itself so great, that many of the structural adaptations and general dispositions formerly made at great cost, are felt to be no longer necessary, and the very correct and happy persuasion daily gains ground, that the less the insane are dealt with as prisoners, and treated with apprehension and mistrust, the more may their accommodation be assimilated to that of people in general, and secured at a diminished outlay.

All this suggests the possibility of constructing asylums at a much less cost than formerly, and of thereby lessening the force of one of the best pleas for using workhouses as receptacles for the insane. The possibility of so doing has been proved both theoretically and practically. In an essay ‘On the Construction of Public Asylums,’ published in the “Asylum Journal” for January 1858 (vol. iv. p. 188), we advocated the separation of the day- from the night-accommodation of patients, and the abolition of the system of corridors with day- and sleeping-rooms, or, as we briefly termed it, “the ward-system,” and showed that by so doing a third of the cost of construction might be saved, whilst the management of the institution would be facilitated, and the position of the patients improved. By a careful estimate, made by a professional architect, with the aid of the necessary drawings, for a building of considerable architectural pretension, it was calculated that most satisfactory, cheerful, and eligible accommodation could be secured, including farm-buildings, and fittings for warming, ventilation, drainage, gas, &c., at the rate of £90 per head for patients of all classes, or at one-half of the ordinary cost.

Experience has shown that chronic lunatics, at least, can be accommodated in an asylum at a lower rate, in fact, at little more than half the expense that we calculated upon.

Like other County Asylums, the Devon became filled with patients; still they came, and after attempts to cram more into the original edifice, by slight alterations, and by adding rooms here and there, it was at length found necessary to make a considerable enlargement. Instead of adding floors or wings to the old building, which would have called for a repetition of the same original expensive construction of walls, and of rooms and corridors, the Committee, with the advice of their excellent physician, wisely determined to construct a detached building on a new plan, which promised every necessary convenience and security with wonderful cheapness; and, for once in a way, an architect’s cheap estimate was not exceeded. Instead of £200 or £250 per head, as of old, accommodation was supplied at the rate of £38: 10s. per patient, including fittings for all the rooms and a kitchen:—a marvel, certainly, in asylum construction, and one which should have the effect of reviving the hopes and wishes of justices, once at least so laudably entertained, to provide in County Asylums for all pauper lunatics of the county.

It is only fair to remark, that, as Dr. Bucknill informs us (Asylum Journal, 1858, p. 323), this new section of the Devon Asylum is dependent on the old institution for the residences of officers, for chapel, dispensary, store-rooms, &c. “It is difficult,” writes Dr. Bucknill, “to estimate the proportion which these needful adjuncts to the wards of a complete asylum bear to the expense of the old building; they can scarcely, however, be estimated at so high a figure as one-eighth of the whole.” But, as a set-off against the increased cost per patient involved in supplying the necessary offices described by Dr. Bucknill, we may mention that there are twenty single sleeping-rooms provided in the building, and that a greater cost was thereby entailed, than many would think called for, where only chronic, and generally calm patients, were to be lodged.

These illustrations of what may be done in the way of obtaining good asylum accommodation for pauper lunatics at no greater rate, we are persuaded, than that incurred in attempting to provide properly for them in workhouses, furnish a most valid reason for discontinuing their detention in the latter, and the more so, if, as can be demonstrated, they are unfit receptacles for them.

The possibility of constructing cheap asylums being thus far proved, the question might be put, whether the internal cost of such institutions could not be lessened? We fear that there is not much room for reform in this matter, if the patients in asylums are rightly and justly treated, and the officers and attendants fairly remunerated. In producing power, an asylum exceeds a workhouse, and therein derives an advantage in diminishing expenditure and the cost of maintenance. On the other hand, the expenditure of a workhouse is much less in salaries, particularly in those given to its medical officer and servants, a form of economy which will never repay, and, we trust, will never be tried in asylums. Warming, ventilation, and lighting are less thought of, little attempted, and therefore less expensive items in workhouse than in asylum accounts. With respect to diet and clothing, workhouses ought to exhibit a considerable saving; but this saving is rather apparent than real, and certainly in the wrong direction; for lunatics of all sorts require a liberal dietary, warm clothing, and, from their habits frequently, more changes than the ordinary pauper inmates; yet these are provisions, which, except there is actual sickness or marked infirmity, the insane living in a workhouse do not enjoy; for they fare like the other inmates, are clothed the same, and are tended or watched over by other paupers; the saving, therefore, is at the cost of their material comfort and well-being. Excepting, therefore, the gain to be got by the labours of the patients, there is no set-off in favour of asylum charges; in short, in other respects none can be obtained without inflicting injury and injustice. On the other hand, workhouse expenditure need be raised if the requisite medical and general treatment, nursing, dietary, employment, and recreation are to be afforded; which is the same as saying, that workhouses, if receptacles for the insane at all, should be assimilated to asylums,—a principle, which, if admitted and acted upon, overturns at once the only argument for their use as such, viz. its economy.

The perception on the part of parochial authorities, that something more than the common lodging and attendance of the workhouse is called for by the insane inmates, has led to the construction of “Lunatic Wards” for their special accommodation, a scheme which may be characterized as an extravagant mistake, whether viewed in reference to economical principles or the welfare of the patients. If structurally adapted to their object, they must cost as much as a suitable asylum need; and if properly supervised and managed, if a sufficient dietary be allowed, and a proper staff of attendants hired, no conceivable economical advantage over an asylum can accrue. On the contrary, as Dr. Bucknill has remarked (Asylum Journal, vol. iv. p. 460), any such attempts at an efficient management of the insane in small and scattered asylums attached to Union Workhouses, will necessarily increase their rate of maintenance above that charged in a large central establishment, endowed with a more complete organization and with peculiar resources for their management.

Dr. Bucknill returns to the discussion of this point in his just published report (Rep. Devon Asylum, 1858, p. 11). He puts the question, “Would a number of small asylums, under the denomination of lunatic wards, be more economical than one central asylum?” and, thus proceeds to reply to it:—“The great probability is that they would not be; 1st, on account of the larger proportion of officials they would require; 2nd, on account of the derangement they would occasion to the severe economy which is required by the aim and purpose of union-houses as tests of destitution. Where lunatics do exist in union-houses in consequence of the want of accommodation in the County Asylum, the Commissioners in Lunacy insist upon the provision of what they consider things essential to the proper care of insane persons wherever they be placed. The following are the requirements which they insisted upon as essential in the Liverpool Workhouse:—a sufficient staff of responsible paid nurses and attendants; a fixed liberal dietary sanctioned by the Medical Superintendent of the asylum; good and warm clothing and bedding; the rooms rendered much more cheerful and better furnished; the flagged court-yards enlarged and planted as gardens; the patients frequently sent to walk in the country under proper care; regular daily medical visitation; and the use of the official books kept according to law in asylums. If the direct cost of such essentials be computed with the indirect cost of their influence upon the proper union-house arrangements, it will require no argument to prove that workhouse lunatic wards so conducted would effect no saving to the ratepayers. The measures needed to provide in the union-house kitchen a liberal dietary for the lunatic wards and a restricted one for the sane remainder, to control the staff of paid attendants, to arrange frequent walks into the country for part of the community, while the other part was kept strictly within the walls;—these would be inevitable sources of disturbance to the proper union-house discipline, which would entail an amount of eventual expenditure not easily calculated.”

If, on economical grounds, the system of Lunatic Wards has no evident merit, none certainly can be claimed for it on the score of its adaptation to their wants and welfare.

Indeed, the argument for workhouse accommodation, on the plea of economy, loses all its weight when the well-being of the insane is balanced against it. For, if there be any value in the universally accepted opinions of enlightened men, of all countries in Europe, of the requirements of the insane, of the desirability for them of a cheerful site, of ample space for out-door exercise, occupation and amusement, of in-door arrangements to while away the monotony of their confinement and cheer the mind, of good air, food and regimen, of careful watching and kind nursing, of active and constant medical supervision and control, or to sum up all in two words, of efficient medical and moral treatment,—then assuredly the wards of a workhouse do not furnish a fitting abode for them.

The unfitness of workhouses for the detention of the insane, and the evils attendant upon it, have been repeatedly pointed out by the Commissioners in Lunacy in their annual reports, and by several able writers. We were also glad to see from the report of his speech, on introducing the Lunatic Poor (Ireland) Bill into the House of Commons, that Lord Naas is strongly opposed to the detention of the insane in workhouses, and therein agrees with the Irish Special Lunacy Commissioners (1858, p. 18), who have placed their opinion on record in these words:—“It appears to us that there can be no more unsuitable place for the detention of insane persons than the ordinary lunatic wards of the Union Workhouses.” This is pretty nearly the same language as that used by the English Commissioners in 1844, viz. “We think that the detention in workhouses of not only dangerous lunatics, but of all lunatics and idiots whatever, is highly objectionable.”

To make good these general statements, we will, at the risk of some repetition, enter into a few particulars. On the one hand, the presence of lunatics in a workhouse is a source of annoyance, difficulty, and anxiety to the official staff and to the inmates, and withal of increased expense to the establishment. If some of them may be allowed to mix with the ordinary inmates, there are others who cannot, and whose individual liberty and comfort must be curtailed for the sake of the general order and management, and of the security and comfort of the rest.

Some very pertinent observations occur in the Report of the Massachusetts Lunacy Commission (op. cit. p. 166), on the mixing of the sane and insane together in the State Almshouses, which correspond to our Union Workhouses. They report that the superintendents “were unanimous in their convictions that the mingling of the insane with the sane in these houses operated badly, not only for both parties, but for the administration of the whole institution.” Further on, the Commissioners observe (p. 168), “By this mingling the sane and insane together, both parties are more disturbed and uncontrollable, and need more watchfulness and interference on the part of the superintendent and other officers.... It has a reciprocal evil effect in the management of both classes of inmates. The evil is not limited to breaches of order; for there is no security against violence from the attrition of the indiscreet and uneasy paupers with the excitable and irresponsible lunatics and idiots. Most of the demented insane, and many idiots, have eccentricities; they are easily excited and disturbed; and nothing is more common than for inmates to tease, provoke, and annoy them, in view of gratifying their sportive feelings and propensities, by which they often become excited and enraged to a degree to require confinement to ensure the safety of life.... The mingling of the state paupers, sane and insane, makes the whole more difficult and expensive to manage. It costs more labour, watchfulness, and anxiety to take care of them together than it would to take care of them separately.”

These sketches from America may be matched in our own country; and they truthfully represent the reciprocal disadvantages of mixing the sane and insane together in the same establishment.

Even supposing the presence of insane in workhouses involved, on the one hand, no disadvantages to the institutions, or to the sane inmates; yet on the other, the evils to the lunatic inhabitants would be condemnatory of it; for the insane necessarily suffer in proportion as the workhouse accommodation differs from that of asylums; or, inversely, as the economical arrangements and management of a workhouse approach those of an asylum. They suffer from many deficiencies and defects in locality and organization, in medical supervision and proper nursing and watching, in moral discipline, and in the means of classification, recreation, and employment.

Workhouses are commonly town institutions; their locality often objectionable; their structure indifferent and dull; their site and their courts for exercise confined and small, and their means of recreation and of occupation, especially out of doors, very limited. Petty officers of Unions so often figure before the world, and have been so admirably portrayed by Dickens and other delineators of character, on account of their peculiarities of manner and practice, that no sketch from us is needed to exhibit their unfitness as guardians and attendants upon the insane. As to workhouse nurses, little certainly can be expected from them, seeing that they are only pauper inmates pressed into the service; if aged, feeble and inefficient; if young, not unlikely depraved or weak-minded; always ignorant, and it may be often cruel; without remuneration or training, and chosen with little or no regard to their qualifications and fitness.

However satisfactory the structure of the ward and its supervision might be rendered, its connexion with a Union Workhouse will be disadvantageous to the good government and order of the establishment, as above noticed, and detrimental to the welfare of the insane confined in it. Thus it must be remembered that very many of the lunatic inmates have been reduced to seek parochial aid solely on account of the distressing affliction which has overtaken them; before its occurrence, they may have occupied an honourable and respectable position in society, and, consequently, where consciousness is not too much blunted, their position among paupers—too often the subjects of moral degradation—must chafe and pain the disordered mind and frustrate more or less all attempts at its restoration. To many patients, therefore, the detention in a workhouse is a punishment superadded to the many miseries their mental disorder inflicts upon them; and consequently, when viewed only in this light, ought not to be tolerated.

Of all cases of lunacy, the wards of a workhouse are least adapted to recent ones, for they are deficient of satisfactory means of treatment, whether medical or moral, and the only result of detention in them to be anticipated, must be to render the malady chronic and incurable. Yet although every asylum superintendent has reported against the folly and injury of the proceeding, and notwithstanding the distinct and strong condemnation of it by the Commissioners in Lunacy, the latter, in their Report for 1857, have to lament an increasing disposition, on the part of Union officers, to receive and keep recent cases in workhouses. Moral treatment we hold to be impossible in an establishment where there are no opportunities of classification, no proper supervision and attendance, and no means for the amusement and employment of the mind; but where, on the contrary, the place and organization are directly opposed to it, and the prospects of medical treatment are scarcely less unfavourable. An underpaid and overworked medical officer, in his hasty visits through the wards of the workhouse daily, or perhaps only three or four times a week, very frequently without any actual experience among the insane, cannot be expected to give any special attention to the Pauper Lunatics, who are mostly regarded as a nuisance in the establishment, to be meddled with as little as possible, and of whose condition only unskilled, possibly old and unfeeling pauper nurses, can give any account. Indeed, unless reported to be sick, it scarcely falls into the routine of the Union medical officer regularly to examine into the state and condition of the pauper lunatics. These remarks are confirmed by the statement of the Lunacy Commissioners, in their ‘Further Report,’ 1847 (p. 276), that pauper inmates, “in their character of lunatics merely, are rarely the objects of any special medical attention and care,” and that it “was never found (except perhaps in a few cases) that the medical officer had taken upon himself to apply remedies specially directed to the alleviation or cure of the mental disorder. Nor was this indeed to be expected, as the workhouse never can be a proper place for the systematic treatment of insanity.”

It would unnecessarily extend the subject to examine each point of management and organization affecting the well-being of the insane in detail, in order to show how unsuitable in all respects a workhouse must be for their detention; yet it may be worth while to direct attention to one or two other matters.

Except when some bodily ailment is apparent, the lunatic fare like the ordinary inmates; that is, they are as cheaply fed as possible, without regard to their condition as sufferers from disease, which, because mental, obtains no special consideration. It is in the power of the medical officer, on his visits, to order extra diet if he observes any reason in the general health to call for it; but the dependent position of this gentleman upon the parish authorities, and his knowledge that extra diet and its extra cost will bring down upon him the charge of extravagance and render his tenure of office precarious, are conditions antagonistic to his better sentiments concerning the advantages of superior nutriment to his insane patients.

Moreover, the cost of food is a principal item in that of the general maintenance of paupers, and one wherein the guardians of the poor believe they reap so great an economical advantage over asylums. But this very gain, so esteemed by poor-law guardians, is scouted as a mistake and proved an extravagance, i. e. if the life and well-being of the poor lunatics are considered, by the able superintendents of County Asylums. Dr. Bucknill has well argued this matter in a paper “On the Custody of the Insane Poor” (Asylum Journal, vol. iv. p. 460), and in the course of his remarks says,—“The insane cannot live on a low diet; and while they continue to exist, their lives are rendered wretched by it, owing to the irritability which accompanies mental disease. The assimilating functions in chronic insanity are sluggish and imperfect, and a dietary upon which sane people would retain good health, becomes in them the fruitful source of dysentery and other forms of fatal disease.”

In his just published Report, already quoted, the same excellent physician remarks (p. 9),—“A good diet is essential to the tranquil condition of many idiots and chronic lunatics, and is, without doubt, a principal reason why idiots are easily manageable in this asylum, who have been found to be unmanageable in union houses. The Royal Commission which has recently reported on the Lunatic Asylums in Ireland states this fact broadly, that ‘the ordinary workhouse dietary is unsuited and insufficient for any class of the insane.’ It is therefore my opinion, founded upon the above considerations, that neither the lunatics nor the idiots in the list presented are likely to retain their present state of tranquillity, and to be harmless to themselves and others, if they are placed in union houses, unless they are provided with those means which are found by experience to ensure the tranquillity of the chronic insane, and especially with a sufficient number of trustworthy attendants, and with a dietary adapted to their state of health. I have thought it desirable to ascertain the practice of charitable institutions especially devoted to the training of idiots, and I find that a fuller dietary is used in them than in this asylum.”

Until a recent date, it was the custom in workhouses, with few exceptions, to allow most of their insane inmates to mingle with the ordinary pauper inmates of the same age and sex, and in general to be very much on the same footing with them “in everything that regards diet, occupation, clothing, bedding, and other personal accommodation” (Report, 1847, p. 276).

This mingling of the sane and insane, having been found subversive of good order and management, gave rise first to the plan of placing most of the latter class in particular wards, many of them in the infirmary, and, subsequently, owing to the advance of public opinion respecting the wants of the insane, to the construction, in many unions, of special lunatic wards, emulating more or less the character and purposes of asylums. The false economy of this plan has been already exposed; and although the Lunacy Commissioners have always set their faces against lunatic wards, yet their construction has of late been so rapid as to call forth a more energetic denunciation of it:—“Impressed strongly (the Commissioners write, Report, 1857, p. 17) with a sense of their many evils, it became our duty, during the past year, to address the Poor-Law Board against the expediency of affording any encouragement or sanction to the further construction, in connexion with Union Workhouses, of lunatic wards.”

The evils of lunatic wards, alluded to in the last-quoted paragraph, are thus enlarged upon in another page of the same Report (p. 15):—“It is obvious that the state of the workhouses, as receptacles for the insane, is becoming daily a subject of greater importance. They are no longer restricted to such pauper lunatics as,—requiring little more than the ordinary accommodation, and being capable of associating with the other inmates,—no very grave objection rests against their receiving. Indeed it will often happen that residence in a workhouse, under such conditions, is beneficial to patients of this last-mentioned class; by the inducements offered, from the example of those around them, to engage in ordinary domestic duties and occupations, and so to acquire gradually the habit of restraining and correcting themselves. But these are now unhappily the exceptional cases. Many of the larger workhouses, having lunatic wards containing from 40 to 120 inmates, are becoming practically lunatic asylums in everything but the attendance and appliances which ensure the proper treatment, and above all, in the supervision which forms the principal safeguard of patients detained in asylums regularly constituted.

“The result is, that detention in workhouses not only deteriorates the more harmless and imbecile cases to which originally they are not unsuited, but has the tendency to render chronic and permanent such as might have yielded to early care. The one class, no longer associating with the other inmates, but congregated in separate wards, rapidly degenerate into a condition requiring all the attendance and treatment to be obtained only in a well-regulated asylum; and the others, presenting originally every chance of recovery, but finding none of its appliances or means, rapidly sink into that almost hopeless state which leaves them generally for life a burthen on their parishes. Nor can a remedy be suggested so long as this workhouse system continues. The attendants for the most part are pauper inmates, totally unfitted for the charge imposed upon them. The wards are gloomy, and unprovided with any means for occupation, exercise, or amusement; and the diet, essential above all else to the unhappy objects of mental disease, rarely in any cases exceeds that allowed for the healthy and able-bodied inmates.”

The subject had previously received their attention, and is thus referred to in their Ninth Report (p. 38):—“They are very rarely provided with any suitable occupation or amusement for the inmates. The means of healthful exercise and labour out of doors are generally entirely wanting, and the attendants (who are commonly themselves paupers) are either gratuitous, or so badly organized and so poorly requited, that no reliance can be placed on the efficiency of their services. In short, the wards become in fact places for the reception and detention of lunatics, without possessing any of the safeguards and appliances which a well-constructed and well-managed lunatic asylum affords. Your Lordship, therefore, will not be surprised to learn that while we have used our best endeavours to remedy their obvious defects and to ameliorate as far as possible the condition of their inmates, we have from the first uniformly abstained from giving any official sanction or encouragement to their construction.”

They further make this general observation:—“So far as the lunatic and idiotic inmates are concerned, the condition of the workhouses which have separate wards expressly appropriated to the use of that class, is generally inferior to that of the smaller workhouses, and in some instances extremely unsatisfactory.”

Dr. Bucknill, whose excellent remarks on lunatic wards in their economical aspect we have already quoted, has very ably canvassed the question of their fitness as receptacles for the insane, and, in a paper in the ‘Asylum Journal’ (vol. iii. p. 497), thus treats on it:—“It is deserving of consideration, whether the introduction of liberally-conducted lunatic wards into a Union Workhouse would not interfere with the working of the latter in its legitimate scope and object. A workhouse is the test of destitution. To preserve its social utility, its economy must always be conducted on a parsimonious scale. No luxuries must be permitted within its sombre walls; even the comforts and conveniences of life must be maintained in it below the average of those attainable by the industry of the labouring poor. How can a liberally-conducted lunatic ward be engrafted upon such a system? It would leaven the whole lump with the taint of liberality, and the so-called pauper bastile would, in the eyes of the unthrifty and indolent poor, be deprived of the reputation which drives them from its portals.”

There is a general concurrence among all persons competent to form any opinion on the matter, that workhouses are most unfit places for the reception of recent cases of insanity. On the other hand, there is a prevalent belief that there is a certain class of the insane, considered “harmless,” for whom such abodes are not unsuitable. The Lunacy Commissioners, in the extract from the Eleventh Report above quoted, partake in this opinion: let us therefore endeavour to ascertain, as precisely as we can, the class of patients intended, and the proportion they bear to the usual lunatic inmates of Union Workhouses.

In their ‘Further Report’ for 1847, the Commissioners enter into a particular examination of the characters of the lunatics found in workhouses, and class them under three heads (p. 257):—1st, those who, from birth, or from an early period of life, have exhibited a marked deficiency of intellect as compared with the ordinary measure of understanding among persons of the same age and station; 2ndly, those who are demented or fatuous; that is to say, those whose faculties, not originally defective, have been subsequently lost, or become greatly impaired through the effects of age, accident, or disease; and 3rdly, those who are deranged or disordered in mind, in other words, labouring under positive mental derangement, or, as it is popularly termed, “insanity.” Those in whom epilepsy or paralysis is complicated with unsoundness of mind, although their case requires a separate consideration, do not in strictness constitute a fourth class, but may properly be referred, according to the character of their malady and its effects upon their mental condition, to one or other of these three classes.

Further on in the Report, after remarking on the difficulties besetting their inquiry, they write (p. 274):—

“We believe, however, we are warranted in stating, as the result of our experience thus far, that of the entire number of lunatics in workhouses, whom we have computed at 6020 or thereabouts, two-thirds at the least, or upwards of 4000, would be properly placed in the first of the three classes in the foregoing arrangement; or, in other words, are persons in whom, as the mental unsoundness or deficiency is a congenital defect, the malady is not susceptible of cure, in the proper sense of the expression; and whose removal to a curative lunatic asylum, except as a means of relieving the workhouse from dangerous or offensive inmates, can be attended with little or no benefit.

“A considerable portion of this numerous class, not less, perhaps, than a fourth of the whole, are subject to gusts of passion and violence, or are addicted to disgusting propensities, which render them unfit to remain in the workhouse; and it is the common practice, when accommodation can be procured, to effect the removal of such persons to a lunatic asylum, where their vicious propensities are kept under control, and where, if they cannot be corrected, they at least cease to be offensive or dangerous. But although persons of this description are seldom fit objects for a curative asylum, they are in general capable of being greatly improved, both intellectually and morally, by a judicious system of training and instruction; their dormant or imperfect faculties may be stimulated and developed; they may be gradually weaned from their disgusting propensities; habits of decency, subordination, and self-command may be inculcated, and their whole character as social beings may be essentially ameliorated.”

The conclusion to be deduced from these extracts is, that one-fourth or two-thirds, that is, one-sixth of the whole number of occupants in workhouses of unsound mind, found in 1846, were unfit for those receptacles, and demanded the provision of institutions in which a moral discipline could be carried out, and their whole condition, as social beings, ameliorated and elevated. A further examination of the data supplied in the same Report will establish the conviction that, besides the proportion just arrived at, requiring removal to fitting asylums, there is another one equally large demanding the same provision.

In this number are certainly to be placed all those of the third class “labouring under positive mental derangement,” and who, although reported as “comparatively few” in 1846, have subsequently been largely multiplied, according to the evidence of the ‘Eleventh Report’ (ante, p. 56). Those, again, “in whom epilepsy or paralysis is complicated with unsoundness of mind,” are not suitable inmates for workhouse wards. No form of madness is more terrible than the furor attendant on epileptic fits; none more dangerous; and, even should the convulsive affection have so seriously damaged the nervous centres that no violence need be dreaded, yet the peril of the fits to the patient himself, and their painful features, render him an unfit inmate of any other than an establishment provided with proper appliances and proper attendants. As to the paralytic insane, none call for more commiseration, or more careful tending and nursing—conditions not commonly to be found in workhouses.

The Commissioners in Lunacy have not omitted the consideration of workhouses as receptacles for epileptics and paralytics, and have arrived at the following conclusions:—After treating, in the first place, of epileptics whose fits are slight and infrequent, and the mental disturbance mild and of short duration, they observe that, as such persons “always require a certain amount of supervision, and as they are quite incompetent, when the fits are upon them, to take care of themselves, and generally become violent and dangerous, it would seem that the workhouse can seldom be a suitable place for their reception, and that their treatment and care would be more properly provided for in a chronic hospital especially appropriated to the purpose.”

Concerning paralytics, they state that they are far less numerous than epileptics, and being for the most part helpless and bedridden, are treated as sick patients in the infirmary of the workhouse. Their opinion is, however, that a chronic hospital would be a more appropriate receptacle for them,—a conclusion in which all must coincide, who know how much can be done to prolong and render more tolerable their frail and painful existence, by good diet and by assiduous and gentle nursing,—by such means, in short, as are not to be looked for in establishments where rigid economy must be enforced, and pauper life weighed against its cost.

To turn now to the second class of workhouse Lunatic Inmates, the demented from age, accident, or disease: these, we do not hesitate to say, are not suitably accommodated in workhouses, for, like the paralytic, they require careful supervision, good diet and kind nursing; they are full-grown children, unable to help or protect themselves, to control their habits and tendencies; often feeble and tottering, irritable and foolish, and, without the protection and kindness of others, the helpless subjects of many ills. For such, the whole organization of the workhouse is unsuited; even the infirmary is not a fitting refuge; for, on the one hand, they are an annoyance to the other inmates, and, on the other, pauper nurses—whose office is often thrust upon them without regard to their fitness for it,—are not fitting guardians for them. In fine, where age, accident or disease has so deteriorated the mental faculties, we have a complication of physical and mental injury to disqualify the patient from partaking with his fellow-paupers in the common accommodation, diet, and nursing.

In the reverse order which we have pursued, the first class of congenital, imbecile, and idiotic inmates comes to be considered last. This happens by the method of exclusion adopted in the argument; for the second and third classes have been set aside as proper inmates of some other institution than a workhouse, and it now remains to inquire, who among the representatives of the first class are not improperly detained in workhouses. This class includes, as already seen, some two-thirds of the whole number of inmates mentally disordered; and among whom, we presume, are to be found those individuals who may, in the Commissioners’ opinion, mix advantageously with the general residents of the establishment. The number of the last cannot, we believe, be otherwise than very small; for the very supposition that there is imbecility of mind, is a reason of greater or less force, according to circumstances, for not exposing them to the contact of an indiscriminate group of individuals, more especially of that sort to be generally found in workhouses. The evils of mingling the sane and insane in such establishments have already been insisted upon; and besides these, such imbecile patients as are under review, lack in workhouses those means of employment and diversion which modern philanthropy has suggested to ameliorate and elevate their physical and moral condition.

Lastly, if the remaining members of this class be considered, in whom the imbecility amounts to idiocy, the propriety of removing them from the workhouse will be questioned by few. Indeed, will any one now-a-days advocate the “laissez faire” system in the case of idiots? Experience has demonstrated that they are improveable, mentally, morally, and physically; and if so, it is the duty of a christian community to provide the means and opportunities for effecting such improvement. It cannot be contended that the workhouse furnishes them; on the contrary, it is thoroughly defective and objectionable by its character and arrangements, and, as the Commissioners report, (op. cit. p. 259) a very unfit abode for idiots.

On looking over the foregoing review of the several classes of lunatic inmates of workhouses distinguished by the Commissioners in Lunacy, the opinion to be collected clearly is, that only a very few partially imbecile individuals among them are admissible into workhouses, if their bodily health, their mental condition, their due supervision and their needful comforts and conveniences are to be duly attended to and provided for. In accordance with the views we entertain, as presently developed, of the advantages of instituting asylums for confirmed chronic, quiet, and imbecile patients, we should permit, if any at all, only such imbecile individuals as residents in workhouses, who could pass muster among the rest, without annoyance, prejudice or discomfort to themselves or others, and be employed in the routine occupations of the establishment.

So much is heard among poor-law guardians and magistrates about a class of “harmless patients” suitably disposed of in workhouses and rightly removeable from asylums, that a few remarks are called for concerning them. To the eye of a casual visitor of an asylum, there does certainly appear a large number of patients, so quiet, so orderly, so useful and industrious, that, although there is something evidently wrong about their heads, yet the question crosses the mind, whether asylum detention is called for in their case. The doubt is not entertained by the experienced observer, for he knows well that the quiet, order, and industry observable are the results of a well-organized system of management and control; and that if this fails, the goodly results quickly vanish to be replaced by the bitter fruits generated by disordered minds. The “harmless” patient of the asylum ward becomes out of it a mischievous, disorderly, and probably dangerous lunatic. In fact, the tranquillity of many asylum inmates is subject to rude shocks and disturbances, even under the care and discipline of the Institution; and the inoffensive-looking patient of to-day may, by his changed condition, be a source of anxiety, and a subject for all the special appliances it possesses, to-morrow.

Any Asylum Superintendent would be embarrassed to select a score of patients from several hundred under his care whom he could deliberately pronounce to be literally “harmless” if transferred to the workhouse. He might be well able to certify that for months or years they have gone on quietly and well under the surrounding influences and arrangements of the asylum, but he could not guarantee that this tranquillity should be undisturbed by the change to the wards of the workhouse; that untrained attendants and undesirable associates should not rekindle the latent tendency to injure and destroy; that defective organization and the absence of regular and regulated means of employment and recreation should not revive habits of idleness and disorder; or that a less ample dietary, less watchfulness and less attention to the physical health, should not aggravate the mental condition and engender those disgusting habits, which a good diet and assiduous watching are known to be the best expedients to remedy.

Dr. Bucknill has some very cogent remarks on this subject in his last Report of the Devon Asylum (p. 6). “The term ‘harmless patients,’ or in the words of the statute, those ‘not dangerous to themselves or others’ (he writes), I believe to be inapplicable to any insane person who is not helpless from bodily infirmity or total loss of mind: it can only with propriety be used as a relative term, meaning that the patient is not so dangerous as others are, or that he is not known to be refractory or suicidal. It should not be forgotten, that the great majority of homicides and suicides, committed by insane persons, have been committed by those who had previously been considered harmless; and this is readily explained by the fact, that those known to be dangerous or suicidal are usually guarded in such a manner as to prevent the indulgence of their propensities; whilst the so-called harmless lunatic or idiot has often been left without the care which all lunatics require, until some mental change has taken place, or some unusual source of irritation has been experienced, causing a sudden and lamentable event. In an asylum such patients may truly be described as not dangerous to themselves or others, because they are constantly seen by medical men experienced in observing the first symptoms of mental change or excitement, and in allaying them by appropriate remedies; they are also placed under the constant watchfulness and care of skilful attendants, and they are removed from many causes of irritation and annoyance to which they would be exposed if at large, in villages or union houses.

“It not unfrequently happens that idiots who have lived for many years in union houses, and have always been considered harmless and docile, under the influence of some sudden excitement, commit a serious overt act, and are then sent to an asylum. One of the most placid and harmless patients in this asylum, who is habitually entrusted with working tools, is a criminal lunatic, of weak intellect, who committed a homicide on a boy, who teased him while he was breaking stones on the road. If this is the case with those suffering only from mental deficiency, it is evidently more likely to occur in those suffering from any form of mental disease, which is often liable to change its character, and to pass from the form of depression to one of excitement. For these reasons I am convinced that all lunatics, and many strong idiots, can only be considered as ‘not dangerous to themselves or others,’ when they are placed under that amount of superintendence and care which it has been found most desirable and economical to provide for them in centralized establishments for the purpose.

“For the above reasons, I am unable to express the opinion that any insane patients who are not helpless from bodily infirmity or total loss of mind are unconditionally harmless to themselves and others. I have, however, made out a list of sixty patients who are incurable, and who are likely, under proper care, to be harmless to themselves and others.

“Of the patients in this list who are lunatic, only nine have sufficient bodily strength to be engaged in industrial pursuits. The remaining twenty-three are so far incapacitated by the infirmities of old age, or by bodily disease, or by loss of mental power, that they are unable to be employed, and require careful nursing and frequent medical attendance. The patients who have sufficient bodily strength to be employed, are also with the least degree of certainty to be pronounced harmless to themselves and others. As the result of long training, they willingly and quietly discharge certain routine employments under proper watch; but it is probable, that if removed from their present position, any attempts made to employ them by persons unaccustomed to the peculiarities of the insane, will be the occasion of mental excitement and danger.

“The twenty-eight idiots have, with few exceptions, been sent to the asylum from union houses, where it has been found undesirable to detain them, on account either of their violent conduct, or of their dirty habits, or some other peculiarity connected with their state of mental deficiency; habits of noise or indecency for instance.”

Probably the following extract from the Report of the Committee of the Surrey Asylum (1856) may have more weight with some minds than any of the arguments and illustrations previously adduced, to prove that the detention of presumed “harmless patients” in workhouses will not answer. The declaration against the plan on the part of the Surrey magistrates is the more important, because they put it into practice with the persuasion that it would work well. But to let them speak for themselves, they write,—“The committee adverted at considerable length in their last Annual Report to the circumstance of the asylum being frequently unequal to the requirements of the County, and of their intention to attempt to remedy the defect by discharging all those patients, who, being harmless and inoffensive, it was considered might be properly taken care of in their respective union houses.

“The plan has been tried, and has not been successful. Patients who, under the liberal and gentle treatment they experience in the asylum, are quiet and tractable, are not necessarily so under the stricter regulations of a workhouse; indeed, so far as the experiment has been tried, the reverse has been found to be the case; most of the patients so discharged having been shortly afterwards returned to the asylum, or placed in some other institution for the insane, in consequence of their having become, with the inmates of the workhouse, ‘a mutual annoyance to each other.’ Any arrangement, short of an entire separation from the other inmates of the workhouse, will be found to be inefficient.” This is the same as saying that if lunatics are to reside in workhouses, a special asylum must be instituted in the establishment for their care, and the comfort and safety of the other inmates.

If the well-being of the insane were the only question to be settled, no difficulty would attend the solution, for experience has most clearly evidenced the vast advantages of asylums over workhouses as receptacles for insane patients, whatever the form or degree of their malady. Dr. Bucknill has some very forcible remarks in his paper on “The Custody of the Insane Poor” (Asylum Journal, vol. iv. p. 460), with illustrative cases; and in his Report last quoted, reverts to this subject of the relative advantages of asylums and workhouses; but we forbear to quote, if only from fear of being thought to enlarge unduly upon a question which has been decided long ago by the observation and experience of all those concerned in the management of the pauper insane; viz. that whatever the type and degree of mental disorder and of fatuity, its sufferers become improved in properly managed asylums, as intellectual, moral, and social beings upon removal from workhouses; and by a reverse transfer, are deteriorated in mind, and rendered more troublesome and more costly. To the workhouse the lunatic ward is an excrescence, and its inmates an annoyance: in its organization, there is an absence or deficiency of almost all those means conducive to remedy or remove the mental infirmity, and the very want of which contributes as much as positive neglect and maltreatment to render the patient’s condition worse, by lowering his mental and moral character. But such deterioration or degradation is not an isolated evil, or the mere negation of a better state; for it acts as a positive energy in developing moral evil, and brings in its train perverseness, destructiveness, loss of natural decency in habits, conversation and conduct, and many other ills which render their subjects painfully humiliating as human beings, and a source of trouble, annoyance, and expense to all those concerned with them.

In a previous page we have sought to determine what was the proportion of lunatic inmates found by the Lunacy Commissioners in workhouses considered to be not improperly detained in them, and have estimated it at one-half of the whole number. The foregoing examination, however, of the adaptation of workhouses for the several classes of lunatics distinguishable, leads to the conviction that a very much less proportion than one-half ought to be found in those establishments. For our own part, we would wish to see the proportion reduced by the exclusion of most of its component members, reckoned as “harmless” patients; a reduction which would well nigh make the proportion vanish altogether. What is to be done with the lunatics removed from workhouses, is a question to be presently investigated.

But before proceeding further, some consideration of the legal bearings of workhouse detention of lunatics is wanting, for it has been advanced by some writers that such detention is illegal.

Now, in the first place, it must be admitted that a workhouse is not by law, nor in its intent and purpose, a place of imprisonment or detention. Its inmates are free to discharge themselves, and to leave it at will when they no longer stand in need of its shelter and maintenance. Whilst in it, they are subject to the general rules of workhouse-government, and to a superior authority, empowered, if not by statute, yet by orders of the Poor-Law Board, or by Bye-Laws of the Guardians, to exercise discipline by the enforcement of penalties involving a certain measure of punishment. Temporary seclusion in a room may be countenanced, although not positively permitted by law; but prolonged confinement, the deprivation of liberty, and a persistent denial of free egress from the house, are proceedings opposed to the true principles of English law.

Yet it may be that a plea for their detention might be sustained in the case of sick or invalid patients (with whom the insane would be numbered) under certificate of the parochial medical officer, provided no friend came forward to guarantee their proper care, or that they could not show satisfactorily the means of obtaining it; for, of such cases, the workhouse authorities may be considered the rightful and responsible guardians, required in the absence of friends to undertake their charge and maintenance. Upon such grounds, probably, cause might be shown for the detention of the greater part of workhouse lunatic inmates, although there is no Act of Parliament explicitly to sanction it. Should such a plea be admitted, the notion, entertained by Dr. Bucknill, that an action would lie for false imprisonment against the Master and Guardians of the workhouse, would be found erroneous.

The Lunacy Commissioners presented some remarks on this question, indicating a similar view to that just advanced in their ‘Further Report,’ 1847. For instance (p. 287, op. cit.), they observed:—

“How far a system of this kind, which virtually places in the hands of the masters, many of whom are ignorant, and some of whom maybe capricious and tyrannical, an almost absolute control over the personal liberty of so many of their fellow men, is either warranted by law, or can be wholesome in itself, are questions which seem open to considerable doubt. Probably if the legality of the detention came to be contested before a judicial tribunal in any individual case, the same considerations of necessity or expediency which originally led to the practice, might be held to justify the particular act, provided it were shown that the party complaining of illegal detention could not be safely trusted at large, and that his detention, therefore, though compulsory, instead of being a grievance, was really for his benefit as well as that of the community.”

Again, in the second place, the law, without direct legislation to that effect, yet admits,—by the provisions it makes for pauper lunatics not in asylums or licensed houses, and by the distinction it establishes between persons proper to be sent to an asylum, and lunatics generally so-called,—that insane patients may be detained elsewhere than in asylums. For instance, by sect. lxvi. 16 & 17 Vict. cap. 97, 1853, provision is made for a quarterly visit by the Union or Parish Medical Officer to any Pauper Lunatic not being in a Workhouse, Asylum, Registered Hospital, or Licensed House, in order that he may ascertain how the lunatic is treated, and whether he “may or may not properly remain out of an asylum.” So likewise by sect. lxiv. of the same Act, the clerk or overseers are required to “make out and sign a true and faithful list of all lunatics chargeable to the Union or Parish in the form in schedule (D).” This form is tabular, and presents five columns, under the heading of “where maintained,” of which three are intended for the registry of the numbers not confined in Asylums, Hospitals, and Licensed Houses, but who are (1) in workhouses, (2) in lodgings, or boarding out, or (3) residing with relatives.

Further, the law distinguishes, by implication, a class of lunatics as specially standing in need of Asylum care, and as distinct from others. By the Poor-Law Amendment Act (4 & 5 Will. IV. cap. 76. sect. 45), it is ordered that nothing in that Act “shall authorize the detention in any workhouse of any dangerous lunatic, insane person, or idiot for any longer period than fourteen days; and every person wilfully detaining in any workhouse any such lunatic, insane person, or idiot for more than fourteen days, shall be deemed guilty of a misdemeanour.” This section is still in force, is constantly acted upon by the Poor-Law Board, and is legally so read as if the word ‘dangerous’ were repeated before the three divisions of mentally-disordered persons referred to, viz. lunatics, insane persons, and idiots. So, likewise, by sect. lxvii. (16 & 17 Vict. cap. 97)—the “Lunatic Asylums’ Act, 1853,” now in operation,—the transmission of an insane individual to an asylum is contingent on the declaration that he is “a lunatic and a proper person to be sent to an asylum.”

Moreover, by sect. lxxix. of the same Act, it is competent to any three Visitors of an asylum, or to any two in conjunction with the Medical Officer of the asylum, to discharge on trial for a specified time “any person detained in such asylum, whether such person be recovered or not;” and by the following section (lxxx.) it is ordered, that, upon receipt of the notice of such discharge, “the Overseers or Relieving Officers respectively shall cause such lunatic to be forthwith removed to their parish, or to the workhouse of the Union.” By the 79th section it is further provided, that “in case any person so allowed to be absent on trial for any period do not return at the expiration of such period, and a medical certificate as to his state of mind, certifying that his detention in an Asylum is no longer necessary, be not sent to the Visitors, he may, at any time, within fourteen days after the expiration of such period, be retaken, as herein provided in the case of an escape.”

On the other hand, simple removal from an asylum is by the 77th section, curiously enough interdicted except to another asylum, a Registered Hospital, or a Licensed House. This intent, too, of the section is not changed by the amendment, sect. viii. 18 & 19 Vict. cap. 105. Lastly, no other place than an Asylum, Registered Hospital, or Licensed House, is constituted lawful by sect. lxxii. for the reception of any person found lunatic and under “order by a Justice or Justices, or by a Clergyman and Overseer or Relieving Officer, to be dealt with as such.” But this section has to be read in connexion with preceding ones, for instance, with sect. lvii., by which it is laid down that the Justices or other legal authority must satisfy themselves not only that the individual is a lunatic, but also that he is “a proper person to be sent to an asylum.”

These quotations indicate the state of the law respecting the detention of lunatics elsewhere than in asylums. This state cannot be held to be satisfactory: it evidently allows the detention of lunatics in workhouses, while at the same time it affords them little protection against false imprisonment, and makes no arrangement for their due supervision and care, except by means of the visits of the Lunacy Commissioners, which are only made from time to time, not oftener than once a year, and rarely so often. The alleged lunatics are for the most part placed and kept in confinement without any legal document to sanction the proceeding; without a certificate of their mental alienation, and without an order from a magistrate. Within the workhouse, they are, unless infirm or sick, treated like ordinary paupers, save in the deprivation of their liberty of exit; they may be mechanically restrained, or placed in close seclusion by the order of the master, who is likely enough to appreciate the sterner means of discipline and repression, but not the moral treatment as pursued in asylums; and, lastly, they live deprived of all those medical and general measures of amelioration and recovery as here before sketched.

An extract from the ‘Further Report’ of the Commissioners in Lunacy will form a fitting appendix to the observations just made. It occurs at p. 287 (op. cit.), and stands thus:—

“It certainly appears to be a great anomaly, that while the law, in its anxiety to guard the liberty of the subject, insists that no persons who are insane—not even dangerous pauper lunatics—shall be placed or kept in confinement in a lunatic asylum without orders and medical certificates in a certain form, it should at the same time be permitted to the master of a workhouse forcibly to detain in the house, and thus to deprive of personal liberty, any inmate whom, upon his own sole judgment and responsibility, he may pronounce to be a person of unsound mind, and therefore unfit to be at large.”

It is unsatisfactory that the law recognizes the distinction between dangerous and other lunatics, designated as “harmless;” for we have pointed out that no such rigid separation can be made; that it is with very few exceptions impracticable to say with certainty what patients are harmless and what not, inasmuch as their state is chiefly determined by surrounding conditions, by the presence or absence of moral control and treatment. It is likewise to be regretted that so much is left to the discretion of relieving officers and overseers, in the determination of the lunatics “proper to be sent to an asylum;” for those parish functionaries nearly always display a proclivity, where relief is to be afforded, to any plan which at first sight promises to be the most cheap; and hence it is, as remarked in previous pages, they think to serve the rate-payers best by keeping, if practicable, the insane in workhouses. The expediency of asylum treatment for those who claim it, is surely not a question to be determined by such officers. Yet the wording of the Act (sect. lxvii.), that, if they have notice from the parish medical officer of any pauper who “is, or is deemed to be a lunatic, and a proper person to be sent to an asylum,” or if they in any other manner gain knowledge of a pauper “who is, or is deemed to be a lunatic, and a proper person to be sent to an asylum, they shall within three days” give notice thereof to a magistrate,—seems to put the solution of the question pretty much in their hands. Although when they receive a notice of a pauper lunatic from the union medical officer, they would appear by sect. lxx. to be bound to apprise a Justice of the matter, yet, in the absence of such a notice, an equal power in determining on the case is lodged in their hands as in those of the medical officer, by the phrase “is, or is deemed to be a lunatic, and a proper person to be sent to an asylum;” for this clause respecting the fitness of the case, reads with the parts of the sentence as though it stood thus in full—‘is a lunatic and a proper person to be sent to an asylum, or is deemed a lunatic and a proper person to be sent to an asylum;’ and there is nothing in sect. lxx. to enforce, under these circumstances, a notice being sent to a Justice. It is, indeed, evidently left to the discretion of the overseer or relieving officer to report a case of lunacy falling within his own knowledge to a Justice, for he is empowered to assume the function of deciding whether it is or is not a proper one for an asylum. Moreover, we cannot refrain from thinking that a parochial medical officer is not always sufficiently independent, as a paid employé, to certify to the propriety of asylum care so often as he might do, where the guardians or other directors of parish affairs are imbued with rigid notions of economy, and hold the asylum cost for paupers in righteous abhorrence. In fine, were this enactment for reporting pauper lunatics to County and Borough Justices, in order to obtain a legal sanction for their detention, sufficiently clear and rigidly enforced, there would not be so many lunatics in workhouses, and none of those very unfit ones animadverted upon by the Commissioners in Lunacy (see p. 25, and 11th Rep. C. L. 1857).

The first clause of sect. lxvii. is ambiguous; for though it is evidently intended primarily to make the Union medical officer the vehicle of communicating the knowledge of the existence of pauper lunatics in his parish, yet it is neither made his business to inquire after such persons, nor when he knows of their existence, to visit and ascertain their condition. It is left open for him to act upon a report that such a pauper “is deemed to be a lunatic, and a proper person to be sent to an asylum,” without seeing the individual; but generally he will officially hear first of such patients through the channel of the relieving officer, by receiving an order to visit them. Indeed, the relieving officer is legally the first person to be informed of a pauper requiring medical or other relief; and, as we have seen, it is competent for him to decide on the question of asylum transmission or not for any case coming directly to his knowledge. Hence, in the exercise of his wisdom, he may order the lunatic forthwith into the Union-house, and call upon the medical officer there to visit him. The consignment of the lunatic to the workhouse being now an accomplished fact, it becomes a hazardous enterprise, and a gratuitous task on the part of the medical officer (for no remuneration is offered for his report), to give the relieving officer or overseer a written notice that the poor patient should rightly be sent to the asylum, when he knows that those parish authorities have made up their minds that it is not a proper case to be sent there. In fact, the law makes no demand of a notice from the medical officer of the Union necessary where the knowledge of a lunatic pauper first reaches the relieving officer or overseer, or where the patient is already in the workhouse; and no report will be sought from him under such circumstances, unless the parochial authorities decide that they will not take charge of the case in the workhouse.

The object of the 67th and five following sections is evidently to promote the discovery of pauper lunatics, and to ensure the early transmission of all those amenable to treatment to County Asylums; but these advantages are not attained, the legal machinery being defective. To fulfil the intention, it should be made imperative on the part of the relatives or friends to make known the occurrence of a case of lunacy at its first appearance to a duly-appointed medical man, who should visit and register it, and, with the concurrence of a magistrate, order detention in a properly-constituted asylum. Such a medical officer would have a district assigned to him; of his duties at large we shall have occasion hereafter to speak; to allude further to them in this place will cause us to diverge too widely from the subject under consideration.

The 67th section of the “Lunatic Asylums’ Act,” which has above been submitted to criticism, we find referred to in the Lunacy Commissioners’ Eleventh Report, wherein it is spoken of as disregarded by parochial authorities; its ambiguity and the loophole to a contravention of its meaning being, however, unnoticed. The reference occurs in the following passage (op. cit. p. 16), which censures a practice we have already animadverted upon:—

“And here we take occasion to remark, that if the law were more strictly carried out in one particular, the same temptation to a mistaken and ill-judged economy would not so frequently present itself to Boards of Guardians; nor could it so often occur to them as an advantage, that they should themselves manage their insane poor by the resources at their own disposal. A custom prevails, very generally, of sending all pauper lunatics to the workhouses in the first instance, instead of at once procuring an order for their transmission to an asylum; and nothing has more contributed to the many recent and acute cases improperly so detained. The practice, it is hardly necessary to say, is in direct contravention of the law applicable to insane paupers. Assuming that they come ordinarily at first under the care of the District Parish Surgeon, he is bound to give notice (under the 67th section of the Lunatic Asylums’ Act) to the Relieving Officer, by whom communication is to be made to the Magistrate, upon whose order they are to be conveyed to an Asylum; but in effect these provisions are disregarded altogether. And thus it follows, that the patient, if found to be manageable in the workhouse, is permanently detained there; or even should he ultimately find his way to an asylum, it is not until so much valuable time has been lost that his chances of cure are infinitely lessened. For, although it is our invariable habit, on the occasion of visiting workhouses, to recommend the removal to asylums of all whom we consider as curable, or exposed to treatment unsuited to their state, we find nothing so difficult as the enforcement of such recommendations; and for the most part the Report of the Medical Officer of the Union, to the effect that the patient is ‘harmless,’ is suffered to outweigh any opinion we can offer.”

In this quotation, therefore, we have an official proof that the defective and ambiguous legislation above commented upon is practically not without its mischievous fruits to the well-being of the insane poor. To amend it, some such scheme as we have sketched is called for to secure the reporting of lunatics, their examination and registration, and the legal sanction to their detention for the purposes of their own safety and that of others, and of their treatment; and were it not that at the present moment asylum accommodation cannot be afforded to all the pauper lunatics of the kingdom, their confinement in workhouses ought to be at once rendered illegal. Convinced as we are, that asylums for the insane could be erected, fitted, organized, and maintained at a cost which would leave no pecuniary advantage economically on the side of workhouses; and that, even were the primary expenditure of the latter considerably less, they would in the long run be more expensive on account of their unfitness for lunatic patients, whatever the type of their malady, the injuries they entail on the well-being of all, and the chronic insanity they produce and foster,—it is with much reluctance we are forced to endorse the statement made by the Commissioners in Lunacy, in their 11th Report (p. 17), that workhouse “Lunatic Wards will have to be continued for some time longer,” until, we may add, a more comprehensive, and withal a modified scheme be brought into operation, to cherish, to succour, and to cure those suffering under the double evil of poverty and insanity. Though a remedy to meet the whole case must unfortunately be delayed, yet the Lunacy Commissioners nevertheless need continue energetically to discourage the plan of building special lunatic wards to workhouses, as one, according to their own showing, indeed, fraught with very many evils to their inmates. Such erections ought, in fact, to be rendered illegal; the money spent on them would secure proper accommodation in connexion with a duly organized and managed asylum, as demonstrated in previous pages (p. 48), for all those classes of pauper lunatics, which, under any sort of plea or pretence, can be detained in workhouses. Lastly, we must look to the Commissioners to maintain an active supervision over workhouse inmates,—to hold, at least, an annual “jail delivery” of every union-house, to order the immediate transfer of evidently improper inmates, and to remove others, so to speak, for trial.

The “leading principles,” as laid down by the Commissioners in 1847 (Report, p. 269), and to which, in subsequent Reports, they state their continued adhesion, are as good as the present state of lunacy and lunatic asylums permit to be enforced; but they can be enforced only by the Commissioners themselves, or others possessing equal authority; for workhouse officials will interpret them through the medium of their own coloured vision; and if magistrates were entrusted with the task, we have no confidence that it would be efficiently performed by them as inexperienced, non-medical men, with whom economical considerations will hold the first place. The principles referred to are expressed in the following paragraph:—

“We have invariably maintained that the permanent detention in a workhouse of any person of unsound mind, whether apparently dangerous or not, whose case is of recent origin, or otherwise presents any hope of cure through the timely application of judicious treatment, or who is noisy, violent, and unmanageable, or filthy and disgusting in his habits, and must therefore be a nuisance to the other inmates, is an act of cruelty and injustice, as well as of great impolicy; and we have on all occasions endeavoured, so far as our authority extends, to procure the speedy removal of persons of that description to a lunatic asylum.”

The following practical suggestions, calculated to improve the condition of the insane poor, are deducible from the foregoing remarks on workhouses considered as receptacles for lunatics.

1. The County Asylums should afford aid to all insane persons unable to procure proper care and treatment in private asylums; and 2, such patients should be directly transmitted to them; the circumstance of their entire or partial liability to the poor-rates being, if necessary, subsequently investigated. 3. As a corollary to the last suggestion, the primary removal of patients to a workhouse should, save in very exceptional cases, such as of distance from the asylum and unmanageable violence at home, be rendered illegal; or, what is nearly tantamount to it, for the future no alleged lunatic should be suffered to become an inmate of a workhouse, except with the written authority of the District Medical Officer or Inspector proposed to be appointed. 4. Without the sanction of this officer, likewise, no lunatic should be permitted to be discharged or removed from a workhouse. This is necessary for the patient’s protection, for securing him against confinement in any house or lodging under disadvantages to his moral and physical well-being, to check improper discharges, and to protect the asylum against the transfer to it of unfit cases, a circumstance which will presently be shown to be of frequent occurrence. 5. No person should be detained as a lunatic or idiot, or as a person of unsound mind in a workhouse, except under a similar order as that required in the case of asylum detention, and a medical certificate to the fact of his insanity. 6. If workhouses need be used, whether as temporary or as permanent receptacles for the insane, they should be directly sanctioned by law, placed under proper regulations, and under effective supervision, not only of the Lunacy Commissioners, but also of a Committee of Visitors, and of the District Medical Officer, whose duty it would be to watch over the welfare of the insane inmates, their treatment, diet, occupation, and amusement. The Visitors should be other than guardians or overseers of the poor of the union or parish in which the workhouse is situated, although every union should be represented on the Committee; and they might be selected from the magistrates, and from the respectable classes among the rate-payers. If the county were large, it might be advantageously divided into districts, a Committee of Visitors of Workhouses being appointed in each district. 7. Every workhouse containing lunatics should be licensed as a place of detention for them by the Committee of Visitors, who should have authority to revoke the license. This power of revoking the license should be also vested in the Commissioners in Lunacy. 8. Every such workhouse, and the number of its insane inmates, should be reported to the Lunacy Commissioners. According to our scheme, the District Medical Officer would do this, as well as report generally to the Lunacy Board, the condition and circumstances both of the workhouse and of its insane inmates. 9. For the future, the erection or the appropriation of distinct lunatic wards to workhouses should be interdicted by law.

By the preceding suggestions reforms are, indeed, proposed to render confinement in workhouses legal; to make it more satisfactory; to provide for effectual supervision, and in general to assimilate the wards of union-houses more closely to those of asylums. Yet all this is done only on the ground of the necessity for some legislation on these matters, and more particularly under the pressing circumstances of the time. The present state of lunacy compels acquiescence in the Lunacy Commissioners’ statement, that workhouse-wards must for some time longer be used for the detention of insane paupers; and this fact alone supplies an apology for making suggestions to improve them. Moreover, apart from it, the workhouse will at times necessarily be the temporary refuge for some few cases, and may be occupied as a permanent dwelling by those rare instances of imbecility of mind which can be allowed to intermingle with the other inmates, and be usefully occupied; and for these reasons it need be rendered both a legal and not unsuitable abode. At the same time, it is most desirable that the Lunacy Commissioners should be able not only to discourage, but also to veto the construction of lunatic-wards for the future, on the grounds already so largely pointed out; and for this reason, moreover, that where such wards exist, they are thought good enough for their poor inmates, and are looked upon as asylums over which the county institution has little preference. The existence, therefore, of any specially erected or adapted ward, may always be urged against the proposition for further expenditure in providing for pauper lunatics elsewhere in suitable asylums;—a plea, which should consequently be set aside by overturning the foundation whereon it rests.

Since the preceding observations on the detention of pauper lunatics in workhouses were in print, a most important supplementary Report on the subject has been put forth by the Commissioners in Lunacy (Supplement to the Twelfth Report; ordered to be printed 15th of April, 1859). We have read this Report with pleasure, so far as it confirms the views we have taken, but with surprise and pain at the details it unfolds of practices the most revolting to our better feelings, and, in general, of a state of things discreditable to a civilized and christian country. By being confirmatory of the opinions and statements advanced by us, it may be said to give an official sanction to them; and as it is one of the most important documents ever issued by the Board, we shall attempt an analysis of its contents.

In the first place, the Commissioners resort to some recent corrected returns of the Poor-Law Board, and discover that the number of pauper lunatics in workhouses was, on the 1st of January, 1858, 7555, i. e. upwards of 500 above that returned in the Tenth Report of the same Board, and referred to in the foregoing pages; and on the 1st of July in that same year it amounted to 7666. They then proceed to describe the “character and forms of insanity most prevalent in workhouses,” and show that their insane inmates all require protection and control; that “some, reduced to poverty by their disease, are of superior habits to those of ordinary paupers, and require better accommodation than a workhouse affords. Many are weak in body, and require better diet. Many require better nursing, better clothing, and better bedding; almost all (and particularly those who are excitable) require more healthful exercise, and, with rare exceptions, all require more tender care and more vigilant superintendence than is given to them in any workhouse whatsoever.”

On turning to the “Design and Construction of Union Buildings,” they rightly point out that the stringent conditions to ensure economy, and to check imposition and abuse, the “reduced diet, task labour, confinement within the narrow limits of the workhouse premises,” the plan of separating the inmates into classes, the scanty means of out-door exercise, &c., are inimical to the well-being of the insane residents. In the “Modes of Workhouse Direction and Administration” there is great unfitness. The rules under which the officers act “are mainly devised to check disorderly conduct in ordinary paupers; and it is needless to say with how much impropriety they are extended to the insane. Any increase of excitement, or outbreak of violence, occurring in the cases of such patients, instead of being regarded as a manifestation of diseased action requiring medical or soothing treatment, has subjected the individual to punishment, and in several instances led to his imprisonment in a jail. In addition to these hardships, the lunatic patient is for the most part precluded from leaving the workhouse at his own will. In effect he becomes a prisoner there for life, incapable of asserting his rights, often of signifying his wants, yet amenable to as much punishment as if he were perfectly sane, and a willing offender against the laws or regulations of the place. Nor, as will hereafter be seen, is his lot much bettered in the particular cases where it is found convenient to the authorities to relax those restrictions, and give him the power at will to discharge himself.”

Rural workhouses of small size are generally preferable abodes for the insane than those of larger dimensions, since their “arrangements have a more homely and domestic character, and there are more means of occupation and of free exercise in the open air;” and where their imbecile inmates can be associated with the ordinary paupers, and regularly employed, their condition is not unfavourable; “but these form only the exceptions.” Workhouses in the metropolis and in large towns generally, are for the most part “of great size, old, badly constructed, and placed in the midst of dense populations. The weak-minded and insane inmates are here generally crowded into rooms of insufficient size, sometimes in an attic or basement, which are nevertheless made to serve both for day and sleeping accommodation. They have no opportunity of taking exercise; and, from the want of space and means of separation, are sometimes associated with the worst characters, are subjected unnecessarily to seclusion and mechanical restraint, and are deprived of many of the requisites essential to their well-being.”

“Of the 655 workhouses in England and Wales, somewhat more than a tenth part are provided with separate lunatic and idiot wards.”

The “Objections to Intermixture of Inmates” are briefly stated. “There is no mode of complying with suggestions for” the peculiar benefit of insane inmates, “without disturbing the general economy of the house,—a fact which shows how important it is that no lunatic or idiot should be retained for whom any special arrangements are necessary.” Separate lunatic wards are declared to be more objectionable than the intermixture of the pauper inmates. Only occasionally are such wards found at all tolerable; and even then, the constant medical supervision, proper attendants and nursing, sufficient diet, exercise, occupation, and other needful provisions, are deficient. The majority are thus sketched:—“In some of the wards attached to the old workhouses the rooms are crowded, the ventilation imperfect, the yards small and surrounded by high walls; and in the majority of instances the bed-rooms are used also as day-rooms. In these rooms the patients are indiscriminately mixed together; and there is no opportunity for classification. There is no separation where the association is injurious; and no association where such would be beneficial. In fact, patients of all varieties of character,—the weak, the infirm, the quiet, the agitated, the violent and vociferous, the dirty and epileptic,—are all mingled together, and the excitement or noise of one or more injures and disturbs the others. The restless are often confined to bed to prevent annoyance to the other patients, and the infirm are thus disposed of for the want of suitable seats. Their condition when visited in the daytime is obviously bad, and at night must be infinitely worse. Even in workhouses where the wards are so constructed as to provide day-rooms, these are often gloomy, much too small in size, and destitute of ordinary comforts; while the furniture is so poor and insufficient, that in some instances, there being no tables whatever, the patients are compelled to take their meals upon their knees. Other cases to be hereafter mentioned will indeed show that it is reserved for lunatic wards of this description, and now happily for them only, to continue to exhibit some portion of that disregard of humanity and decency, which at one time was a prevailing characteristic in the treatment of insanity.”

Not only, again, are there no sufficiently responsible authorities in the house, and no qualified responsible attendants, but also no records of restraint, of seclusion, of accident, or injury, or of medical or other treatment. “Above all, there is no efficient and authoritative official visitation. The Visiting Justices never inspect the lunatic wards in workhouses, and our own visits are almost useless, except as enabling us to detect the evil that exists at the time of our visit, and which, after all, we have no power to remove.” The “Results of Neglect in Deteriorating the Condition of Patients” of all classes are ably portrayed. In the absence of attentive and experienced persons to watch and to supply their wants, many of the insane suffer unheeded and without complaint, to the prejudice of their mental and bodily state; or become inattentive to natural wants, and prone to violence and mischief. “In a very recent case of semi-starvation at the Bath Union, when the frauds and thefts of some of the attendants had, for a considerable time, systematically deprived the patients of a full half of their ordinary allowance of food, the only complaint made was by the wan and wasted looks of the inmates.”

In the two next sections the Commissioners insist that the duty of distinguishing the cases in workhouses to be classified as “Lunatics, Insane Persons and Idiots,” should be performed by the medical man independently of the master; and that, without examination and sanction from that officer, no person of weak mind should be discharged, or allowed to discharge himself. Very ample cause for this latter proposition is shown in the illustrations appended, particularly in the case of imbecile females, who not unfrequently become, when at large, the prey to the vicious, further burden the parish by their illegitimate offspring, and often by an idiotic race.

“The diet necessary for the insane” is required to be more liberal than for other inmates; yet the Commissioners have “in very numerous instances” animadverted upon its inadequacy, both in quantity and quality, but without result, except “in very few instances:” for, notwithstanding that “the medical officer of a Union has full power” (by the Consolidated Order 207, art. No. 4) “to give directions, and make suggestions as to the diet, classification and treatment of the sick paupers, and paupers of unsound mind,” yet, we are sorry to learn, that “the power thus given, although backed by our constant recommendations, is rarely exercised by the medical officer.”

This circumstance is so far confirmatory of a view we have above taken, that the medical officer of a parish or union is neither sufficiently independent, as the paid employé of the guardians, to carry out measures that may be necessary for the alleviation of the condition of lunatics in workhouses, where such means involve increased cost (we regret to entertain the notion); nor always sufficiently acquainted with the wants of the insane.

Considering the disadvantages of workhouses as receptacles for them, the general statement follows naturally, that as a class of workhouse inmates, the lunatics “are manifestly lower in health and condition than the same class in asylums. Hence,” add the Commissioners, “the patients’ bodily health and mental state decline upon removal from asylums to workhouses—an effect chiefly due to the inferior diet.” There are great “variations in workhouse dietaries,”—from one spare meat dinner in the week to a meat dinner daily. This latter provision is furnished “in a very small number of houses.” These dietaries are indeed much inferior to those considered necessary for criminals in jails; a fact that affords a sad comment on English consistency, which is thus found dealing with more favour and consideration towards those who have transgressed the laws of their country, than to those whose only crime is poverty, or poverty complicated with disease or infirmity.

Medical treatment would, in truth, seem to be not legally provided at all for lunatics in workhouses: no clause makes a visit of the union medical officer to the lunatic-ward of a workhouse imperative. As examples of the slight esteem in which medical supervision is held, the Leicester and the Winchcombe houses are quoted. In the former, the visits of the medical officer were only made quarterly; in the latter, by stipulation three times a week, but in practice very irregularly. Attendance and nursing are, as might be expected, on a par with medical treatment. Even imbeciles have been found exercising the functions of nurses, and, generally speaking, the selection of attendants is made from old and feeble people, having no experience, no aptness for the duties, no particular qualities of intellect or temper to recommend them, and receiving such a mere pretence, if any at all, in the way of remuneration for their trouble, that no painstaking efforts can be looked for from them. “Yet to such individuals, strait waistcoats, straps, shackles, and other means of restraining the person are not unfrequently entrusted; and they are, moreover, possessed of the power of thwarting and punishing at all times, for any acts of annoyance or irregular conduct, which, although arising from disease, are nevertheless often sufficient to provoke punishment from an impatient and irresponsible nurse.”

The interior accommodation, fittings, and furniture are, if not abominably bad, excessively defective: and on reaching this part of the Report, where the details of internal fittings and management come under review, the impression derivable from its perusal is akin to that gathered from the revelations of madhouses made by the Parliamentary Committees of 1814 and 1815. The sketch of the evils suffered by lunatics in workhouses, which we have ourselves attempted in past pages, tells a flattering tale compared with the realities unfolded to us by the Commissioners, and adds a tenfold force to the arguments against the detention of lunatics in such places. To continue the practice would be to perpetuate a blot upon the internal polity, the philanthropy and the Christianity of the country. Let those who would know the whole case refer to the Report in question; it is sufficient for our purpose to attempt a mere outline of its revelations. Patients are frequently kept in bed because there are no suitable seats for them; a tub at times answers the double purpose of a urinal and a wash-basin; a privy is partitioned off in a small dormitory; baths are almost unknown; a trough or sink common to all supplies the want of basins for washing, and an outhouse or the open air furnishes the appropriate place for personal ablutions. Clothing, again, is often ragged and insufficient; in an unwarmed dormitory, a single blanket, or only a coverlet, is all the covering afforded by night; loose straw in a trough bedstead usually constitutes the bed for wet and dirty patients to nestle in; and whether the bed be straw or not, the practice of using it night after night, when “filthy with dirt, and often rotting from frequent wetting, has been many times animadverted upon.” In some workhouses two male patients are constantly placed in the same bed; nor is the character of the bedfellows much heeded; for a sane and insane, two idiots, one clean and one dirty, and even two dirty inmates, have been found associated together in the same bed, occasionally in a state of complete nudity.

Further, the want of exercise and employment, the absence of supervision and control, and the entrusting of means of coercion to irresponsible and unfit attendants, lead to the most shocking abuse of restraint, and to cruel seclusion.

“The requirement occasionally made by the Visiting Commissioner, that the Master shall make a written record of such proceedings, is utterly neglected. The dark, strong cells, constructed for the solitary confinement of refractory paupers, are used for the punishment of the insane, merely to prevent trouble; quiet helpless creatures, from whom no violence could be apprehended, are kept in bed during the daytime, or coerced; and even the dead-house has been made to serve the purpose of a seclusion-room.”

“The Examples of Restraint practised,” as adduced in the Report, recall to mind all those barbarities which civilized men of the present day are in the habit of congratulating themselves as matters of the past, and the subject of history. The catalogue of appliances for restraint reappears once more on the scene; and we read of straps, leather muffs, leg-locks, hobbles, chains and staples, strait-jackets, and other necessary paraphernalia, as of yore, worn for days, or weeks, or months. Excellent matter, indeed, in all this, to garnish a discourse on the advancement of civilization, on the prevalence of improved notions respecting the treatment of the insane, or on some similar topic addressed to the vanity of the present generation!

But the chapter does not end here. “It would be difficult to select places so entirely unfit for the purpose of exercise, or so prejudicial to the mental or bodily state of the person confined,” as the yards or spaces set apart for it; and yet “of all the miseries undergone by this afflicted class, under the manifold disadvantages before described, and of all the various sources of irritation and discomfort to which we have shown that they are exposed, there is probably none which has a worse effect than the exclusion from all possibility of healthy movement. Nothing more powerfully operates to promote tranquillity than the habit of extensive exercise; and in its absence, the patients often become excited, and commit acts of violence more or less grave, exposing them at once to restraint or seclusion, and not unfrequently to punishment. In not a few instances the outbreak has been looked upon as an offence or breach of discipline, and as the act of a responsible person; and the patient has been taken before a magistrate and committed to prison.

“A very grave injustice, it is hardly necessary to add, is thus committed, in punishing by imprisonment individuals who are recognized and officially returned as being of unsound mind. These persons in no respect differ from the class of the insane usually met with in asylums, and are equally entitled to the same protection, and the same exemption from punishment. Instead of such protection, however, the patient is exposed to double injury:—first, he is subjected to various sources of irritation while confined in the workhouse, directly occasioning excitement; and, secondly, the mental disturbance resulting therefrom is regarded as a crime, and is punished by imprisonment.”

The Commissioners in Lunacy next direct attention to the principal cause of the evils described, which they discover in the neglect and evasion of the duties imposed by the law on the officers of parishes and unions, in the interests of the pauper insane. Thus, as remarked in previous pages,—“Instead of causing the patient to be dealt with as directed by the 67th and 68th sections of the Lunatic Asylums’ Act, 1853, and immediate steps to be taken for his direct removal to the asylum, workhouses have been to a great extent made use of primarily as places for the reception, and (in many instances) for the detention of recent cases of insanity.

“The workhouse is thus illegally made to supply the place of a lunatic establishment, and the asylum, with its attendant comforts and means of cure, which the law has provided for the insane poor, is altogether disregarded; or it comes into operation only when the patient, by long neglect, has become almost hopelessly incurable. We should remark that this occurs most frequently in the larger workhouses, and in those having insane wards.”

... “How totally unfit even workhouses having insane wards are for the proper treatment of recent curable cases, we have endeavoured to exhibit in some detail. Nevertheless, the practice of making use of them for all classes of insane patients is rapidly increasing, and our efforts to check it have proved hitherto quite ineffectual.”

After further adverting to the influence of the neglect of the laws in increasing pauper lunacy, they very briefly discuss the comparative cost of lunatics in workhouses and in asylums, but their examination adds nothing to what we have much more fully put forward on this subject.

Their “conclusion” contains some valuable suggestions, more or less identical with those we have ourselves independently advanced, and which may be briefly summed up as follows:—

“To remedy many of the evils adverted to would, in our opinion, be impracticable, so long as insane patients are detained in workhouses, whether mixed with other inmates or placed in distinct wards.

“The construction and management of workhouses present insurmountable obstacles to the proper treatment of the disease of insanity; and therefore the removal of the majority of the patients, and the adoption of stringent measures to prevent the admission of others, have become absolutely necessary.”

The notions of parish authorities of the very great comparative economy of workhouses over asylums rest, say the Commissioners, on a false basis; and to place the question fairly before them, “it is essential that the mode of keeping the accounts should be assimilated in each, and that in the asylum only food and clothing should be charged to the parishes, and all other expenses to the county. In such case, we believe it would be found that the charges in each would be brought so nearly to a level, that there would exist little or no inducement on the plea of economy to tempt the guardians to keep their insane patients in workhouses, instead of sending them at once to a county asylum.”

To provide proper accommodation for the insane poor in workhouses, inasmuch as many asylums are on “so large a scale as not to admit of the necessary extension, whilst some are of a size much beyond that which is compatible with their efficient working,” the Commissioners propose “the erection of inexpensive buildings, adapted for the residence of idiotic, chronic, and harmless patients, in direct connexion with, or at a convenient distance from, the existing institutions. These auxiliary asylums, which should be under the management of the present visiting justices, would be intermediate between union workhouses and the principal curative asylums. The cost of building need not, in general, much exceed one-half of that incurred in the erection of ordinary asylums; and the establishment of officers and attendants would be upon a smaller and more economical scale than those required in the principal asylums.”

“Whether or not such additional institutions as we recommend be provided, we think it essential that visiting justices of asylums should be invested with full power, by themselves or their medical officers, to visit workhouses, and to order the removal of insane inmates therefrom to asylums at their discretion. They should also be empowered, upon the report of the Commissioners, to order the removal into the asylum of pauper patients boarded with strangers.”

“And in the event of our obtaining your Lordship’s approval of such suggestions for legislative enactment, we would further recommend that it should include the following provisions:—