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

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.