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ART. V.-1. Report of the Metropolitan Com- | in degree,-for there also a steady, though missioners in Lunacy to the Lord Chan- slower, rate of increase is taking place, givcellor. 1844. ing in the nine years from the beginning of 1858 to the beginning of 1867 a total increase of 1244.

2. Annual Reports of the Commissioners in Lunacy for England to the Lord Chan cellor.

3. Report of Her Majesty's Commissioners appointed to Inquire into the State of Lunatic Asylums in Scotland. 1857. 4. Annual Reports of the General Board of Commissioners in Lunacy for Scotland to the Secretary of State for the Home Department.

5. Report of the Commissioners of Inquiry into the State of the Lunatic Asylums, etc., in Ireland. 1858.

6. Annual Reports to the Lord Lieutenant on the District, Criminal, and Private Lunatic Asylums in Ireland. 1857.

7. Statistique des Asiles d'Aliénés de 1854 à 1860.

THE leading fact regarding Lunacy dis. closed in our Blue-books is its great in

crease.

At the beginning of 1867 there were 31,917 lunatics in the asylums of England and Wales. At the end of the same year their number had risen to 33,213. These are large numbers in themselves, but it is to their difference that we draw attention-a difference amounting to 1296. In other words, the number of persons placed in asylums was greater at the close of the year than at its commencement by nearly 1300, being an increase equal to the population of two large asylums.

When this fact arrests attention, the question which naturally suggests itself is-Was the year 1867 an exceptional one? The answer is, that it was not, and that the same rate of increase has been going on for many years. During 1866 it was 1046; during 1865 it was 1444; during 1864 it was 1140; and so on for the twenty years which went before. The average annual increase is about 1000, and it gives no indication of a tendency to pause, but holds on from year to year with remarkable steadiness.

If we examine the effect of this at the end of a long series of years, we have a result which cannot fail to startle. Going back, for instance, to 1849, at the beginning of that year we find 14,560 patients in the asylums of England and Wales, and 33,213 at the beginning of 1868, being an increase of about nineteen thousand in nineteen years, with nothing to indicate that there may not be a like increase in the nineteen to follow.

This is what we learn about the insane who are in asylums in England. What we learn about the same class in Scotland differs only N-5

VOL. L.

In Ireland, too, we have the same progressive increase, showing a difference of 1784 between the number of lunatics in asylums on the 1st of January 1857 and the number so provided for on the 1st of January 1868. As regards the numbers of the insane in asylums, therefore, the same increase is taking place in England, Scotland, and Ireland, though at different rates. And in this matter these countries do not stand alone, for what is true of them is true also, to a greater or less extent, of all the countries of Europe regarding which we have trustworthy information. In France, for instance, there was an average yearly increase of 750 for the twenty-six years before 1861, giving a total difference of 19,700 from the 1st of January 1835 to the 1st of January 1861that is, a difference between 10,539 and 30,239.

So much, then, for the fact of the increase and its general occurrence; what are we told as to its nature and causes? Does this great annual growth of the number of persons found under treatment in asylums imply that there is a great and constantly progressing increase of the liability to insanity among the people of civilized Europe? At first sight it certainly appears to do this, and we have a ready explanation in the damaging effects of the racing, bustle, and competition of modern life, which sends so many of the weaker among us to the wall. It will be comforting, however, if we find, on a closer examination of the figures, that they give no evidence of any marked increase in the production of insanity; aud we think that this is a comfort we may safely take.

But before looking at what the Blue-books and Yellow-books reveal to us on this point, it is necessary to state that the increase of the numbers of lunatics in asylums is far beyond what would be due to any increase of the population, great as that has been; and that strength appears thus to be given to the theory of a growing proclivity to insanity. Take the English numbers, and selecting the years 1857 and 1867, when the estimated population of England and Wales rose from 19,256,516 to 21,429,508, we find that for the first year lunatics in asylums were 1 in 902, and for the second year 1 in 671 of the general population. This statement shows a vast increase in the amount of insanity thought to require asylum treatment; but it does not follow that there must be a greater frequency in the occurren ce

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of the disease, in order to explain the greater of by the number of those for whom admisamount of it, so provided for, at a particular sion into asylums is sought. Thustime. That this is not the explanation of the increase, which is taking place, will be rendered more than probable if we examine the number of those who enter the asylums from year to year-a number which may be regarded as a fair expression of the rate of production. The result of such an examination will show that the annual number of admissions does not vary much. Such a number of years, however, must be dealt with. as will not involve any great change in the general population within the period; for it is clear that if the admissions of early years are compared with those of later or remote ones, there will probably be an increase due simply to a greater population. Take the five years from 1859 to 1863, and we find the admissions into the English asylums to be as follows:

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There is certainly no evidence within this period of a progressive advance in the number for whom admission is sought; but if the total admissions during the five years are contrasted with the total admissions during the preceding five, then there is, as there ought to be, a considerable increase, being in round numbers from 38,000 to 44,000. So also, going farther back for a period of five years, we find a rise from 36,000 to 38,000. More than one-half of this increase in the admissions may be regarded as a reasonable result of the increase of the population. The very sensible effect which the growth of the population may be expected to have on the number of admissions will be apparent when it is stated that the population rose from 17,150,018 to 21,429,508 during the twenty years before 1867, being an increase

of about one-fourth.

66 1866 "1867

The increase during the last two of these years in the number of those admitted into the asylums of Scotland is decided, and is probably referable to the operation of causes of a temporary nature, such, for instance, as may arise from the opening of the district asylums. At present we are only concerned to point out that these figures, as a whole, give no evidence of a progressive increase of admissions from year to year, corresponding to the progressive increase of the number resident. It will be enough to give one illustration of what is meant by this, though it would be easy to give many from the fig ures relating either to England, Scotland, or

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number of patients, who are in the asylums The very considerable yearly increase of the of England, is not shown by these figures to be related to an increased production of lunacy, if that may be estimated by the number of those who are admitted into asylums. On the contrary, the yearly increase of the numbers resident did not rise and fall with the admissions, but maintained a progress which, if not wholly independent, was clear

The steadiness, however, of the numbers admitted into asylums from year to year, during this period, between 1859 and 1863, may possibly have been accidental. But we find that the same thing occurs during other shortly so to a great extent. periods of consecutive years. Thus, for instance, the four years which follow the quinquennium already referred to, show that

In 1864 there were 9,367 admissions.

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as to indicate any marked growth in the people's liability to insanity.

That it is desirable to go over this ground, and to show what is taking place in reference to the numbers of the insane in asylums, will be apparent as we advance. It supplies information which is generally needed, for the much that is written about lunacy is not much read. Closely as the subject concerns us all, it is not one which proves attractive in whatever shape it presents itself, but especially when it comes before us in the serious shape of Blue-books.

tention, for the constantly recurring demand for increased asylum accommodation is leading many to ask if there is no way of avoiding it without injury to the insane.

The official documents before us abound, as we stated, in allusions to the subject, and display on all hands a desire to discover a remedy for what is generally felt to be an evil. Before referring, however, to these opinions, we must examine one or two points in the character and movement of asylum populations, for the purpose of making such a reference more easily understood.

First, then, it must be borne in mind that lunatics in asylums are divided into two classes-private and pauper; and we have to

confined to the last, or pauper class. Thus, the total increase of lunatics in the asylums of England and Wales, between the 1st of January 1861 and the 1st of January 1865, was 4095; and this increase was composed of 4040 pauper, and 55 private patients--being an increase in five years of about 20 per cent. on the starting number for pauper, and of about 1 per cent. on that for private patients. The same thing is observed in Scotland, and is commented on by the Commissioners,

Reverting, then, to the question of the increase of lunatics in asylums, it is scarcely necessary to point out that the annual discharges must be less than the annual admis-point out that the increase is almost entirely sions, by an amount which shall exactly represent the yearly increase of the number resident. In other words, the increase takes place by a process of this kind :-There are say 30,000 lunatics in the asylums of any country at the beginning of any year, and during that year 10,000 patients are admited, but only 9000 discharged; it is clear that at the end of the year we shall have 31,000 patients in the asylums, or 1000 more than at its commencement. If next year there be again 10,000 admissions, and only 9000 discharges, we shall have 32,000 patients resident, or an increase of 2000 in two years, and so on. This is more or less exactly what appears to be taking place in the various countries of Europe. More or less exactly, we say, but not exactly, since the demand for admission is also increasing some what beyond the increase due to a growing population. Still, such growing proportion of admissions to the population is not to be compared with the growing proportion of residents to the population. The last advances more rapidly than the first, and may even go on, at a considerable rate, when no increase is taking place in the admissions; as happened, for instance, in the asylums of England during the period of five years referred to in the last tabular statement, which shows a decline in the annual admissions, yet gives at the end of the period, notwithstanding this decline, an increase of 5533 in the number of patients resident in asylums. If the yearly admissions and the yearly discharges were equal, the increase of residents would of course cease, and the population of asylums would remain stationary. Such a result can only be brought about in two ways by increasing the discharges or diminishing the admissions. Is there any thing, then, to show that either or both of these can be done? There is much in the documents under review bearing on the question, which is one that presses on public at

Secondly, discharges are made up of threeclasses, namely, recovered, not recovered, and dead. To augment the first and diminish the last of these classes seems everywhere to be earnestly aimed at; but with regard to the number of the middle class -the discharged unrecovered-there is a difference of opinion as to whether it should or should not be made larger, If it could be made larger, there would of course be pro tanto a check to the growth of the population of our asylums. And here we are led naturally to inquire whether the slow advance in the number of private patients in asylums, as compared with that of the number of paupers, can be due to a more frequent discharge of the unrecovered among the first than among the last. Whether it be or be not due to this, it appears that there is actually a constant and considerable difference between the proportion of the unrecovered to the total discharges in the two classes of patients, and we find the point thus discussed in the last Report of the Scotch Commissioners.

"The number of private patients annually brought under our cognisance is, as we have stated, more than a third of the corresponding number of pauper patients. The recoveries are nearly in the same ratio; but it appears that

and State Criminal Asylums are included in the *After 1865, the inmates of the Naval, Military, English returns, and are all entered as private patients.

the proportion of private removed unrecovered from our registers is so much higher than that of pauper patients as to afford an explanation sufficient to account for the difference in the degree of accumulation of the two classes.

"This difference is a matter of so much practical importance that we may be excused for further illustrating it by reference to the Twenty-first Report of the English Commissioners in Lunacy. Of 24,590 patients in the county and borough asylumns of England at 1st January 1867 only 216 were private. On the other hand, of 6694 patients in hospitals and licensed houses 5070 were private. In contrast, the number of patients discharged unrecovered from the county and borough asylumns in 1866 was only 894, against 1106 similar discharges from the hospitals and licensed houses. The influence of this result on the accumulation of pauper patients in asylums is very remarkable. At 1st January 1866 the private patients in English asylums were 5276, and the pauper patients 24,995. At 1st January 1867 the private patients were 5286, and the pauper patients 25,998. There was thus in 1866 an increase of only 10 private patients against an increase of 1003 pauper patients. The proportion of private to pauper patients, estimated on the numbers resident, was es 1 to 5, whereas their rate

of increase was 1 to 100."

This difference in the proportion of private and pauper patients discharged unrecovered may depend on certain private patients being improperly discharged, or on certain pauper patients being unnecessarily, and in that sense improperly, detained, or it may depend on other and more obscure causes. But so far as regards the increase of lunatics in asylums, it is clear that we are chiefly interested in learning whether there is any ground for the conclusion that it depends on certain pauper patients being unnecessarily detained in asylums. With this object, the first thing we have to do is to examine the constituents of the pauper population of our asylums, and the Twenty-first Report of the English Commissioners in Lunacy supplies the best information we have on the description and state of pauper patients in asylums. From it we find that" of the 24,748 pauper patients in public asylums in England and Wales on the first of January, 1867, as many as 22,257 are returned as probably incurable, only 2491, or 10 per cent., being considered as offering any hope of recovery." The two Middlesex asylums, with a pauper population of 3759, had only 139 curable patients, or 3.7 per cent. That this, or something closely like it, is the state of the case in England, Scotland, Ireland, France, etc., is not generally known. As regards England, it is no exaggerated statement, for in the same Report the Commissioners say, "In distinguishing the probably curable from the incurable cases we suggested that those

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which were regarded as doubtful should be included in the former class, so that the return may be regarded as in no degree exaggerating the chronic or incurable pauper population of our public asylums." We are accustomed to think of asylums as hospitals for the treatment and cure of mental disease, but it is not easy to understand how the huge asylums of Hanwell and Colney Hatch, with their 3.7 per cent, or the Surrey Asylum, with its 2.4 per cent., of patients giving "any hope of recovery," can be regarded in that light.

Of these two classes, the curable and the incurable, the latter was further divided into the quiet and harmless, and the excitable, ciolent, or dangerous. This gives us, in the 22,257 probably incurable cases, 14,620 returned as "excited, violent, or dangerous;" and 7637, or nearly a third of the total number,

as

quiet and harmless."

So that out of the whole number (24,748) of pauper patients in the public asylums of England and Wales on the 1st January 1867, there were 7637, or about 31 per cent., who were both incura ble, and quiet and harmless. Great as this number is, there is little doubt, from what the Commissioners say, that it is below the num ber of those who might properly have been returned as quiet and harmless. Eleven of the asylums, for instance, show only 8 per cent. of the quiet and harmless in their 4467 incurable inmates. If we deduct these fig. ures, the remaining asylums show no less than 41 per cent. of the harmless in their 17, 790 incurable inmates. One of these eleven asylums returns 42 probably curable cases. The probably incurable thus form nearly the whole population, and of these about 95 per cent. are tabulated as excited, violent, or dan gerous. We turned to the reports made by the Commissioners at their annual visits to this asylum, and were gratified to find that they spoke of nothing but quiet and order, and not of what might reasonably have been expected from a crowd of lunatics, with a character so much worse than that given of the insane generally in the public asylums of England. We conclude, therefore, that this, and such exceptional returns, must have been due to some misapprehension of what was meant in asking them; and we think we may safely assume that at least 7637 of the pau per insane in the public asylums of England in 1867 are properly described as both incu rable and quiet and harmless; and among chiefly we must look for patients unnecessa rily detained, if there are any.

these

It appears to us necessary that all should be said which has been said, in order to secure the reader's being made sufficiently mas ter of the situation. We have endeavoured

to maintain a sequence in the statement, so as to make it easily followed by those who are not familiar with the questions involved. With the same object, we now repeat the conclusions already given, and add to them such other conclusions as seem to be warranted by the further stage of the inquiry, at which we have arrived.

We have found that there is a great progressive increase of the iusane in our asylums, with no prospect of an arrest; that admissions into asylums are rising with the growth of the population, and somewhat beyond it, but not in such a way as to account for the great advance in the numbers resident, or to give grounds for the belief that men are in any marked degree more liable to insanity than they were; that the growth of the population of our asylums is mainly composed of paupers, and that men conversant with the subject have accounted for this by the more frequent discharge of the unrecovered among private than among pauper patients; that 90 per cent. of the pauper inmates of our asylums are probably incurable, and that only 10 per cent. offer any hope of recovery; that of the 90 per cent. of incurables, one third may be regarded as quiet and harmless; and that if we have more patients in our asylums than need be there, we may expect to find them among this last class.

We have seen, in short, that the great bulk of the pauper inmates of our asylums consists of chronic and incurable cases, many of whom are quiet and harmless, and that the continuing growth of the population of our asylums results from an accumulation and storing up of this class of the insane. If, then, the growth is to be checked, and the pressure for asylum accommodation relieved, one of the ways, by which we may hope to accomplish this, must be by a larger withdrawal of the incurable, or, in other words, by an increase in the discharges of the unrecovered. There are difficulties, however, in the way, and in practice these are neither few nor trifling. "It is very natural," the Scotch Commissioners say in their Seventh Report, "that superintendents of asylums should acquire the conviction that the insane can nowhere be under more favorable circumstances than in such establishments, and that they should even doubt the propriety of discharging any one who has not recovered." The Commissioners themselves, however, do not appear to be much troubled with this doubt, for further on in the same Report they say: "We are not of opinion that insane patients must necessarily be better cared for in asylums than anywhere else, and we are accordingly opposed to the view that, as a matter of course, lodgment in an asylum should always

be resorted to. The fact that there are many patients who cannot be satisfactorily cared for except in such establishments should not be allowed to lead to the belief that this manner of disposal is in all instances the best for the patients." "Viewed even in the most favorable light," they say in their Tenth Report, "detention in an asylum partakes a good deal of the character of imprisonment. There is a necessity to conform to the rules of the institution, to sacrifice individual inclinations, and to obey the orders of the officials and attendants." In spite of this view of asylum life, which is undoubtedly correct, when we read the Reports of the Commissioners and Inspectors of Lunacy, and see how much is done to promote the well-being of the poorest patient in an asylum, and how freely skill and time and money are expended to secure his comfort, we do not wonder that superintendents should hesitate before recommending the removal of a patient, even though incurable and inoffensive, from so much care. Yet they may be wrong, and the Scotch Commissioners right. If such a patient, for instance, were to pass from one of the magnificent county asylums of England to the ordinary wards of a workhouse, there are few who would not regret that so great a down-come had been regarded as necessary. But it appears that the regret may be about a loss which turns out to be no loss, but a gain; for the English Commissioners tell us in their Eighteenth Report, that "there is a class of patients among the idiotic and weak-minded, whose quiet habits and tractable dispositions not only permit of their living in all respects with the ordinary paupers of workhouses, but even render them very often the most trustworthy and useful of all the inmates in employments about the house. In very many of the smaller country workhouses, where the practice is encouraged of so mixing them with the sane, and, as far as possible, of employing them, the result is so satisfactory in all respects that their condition is, in our opinion, even preferable to that of the same class in some well-ordered asylums." To such patients, therefore, if this be correct, removal from the workhouse to an asylum would be a loss of happiness, and if that be so, why should the loss be sustained?

Suppose, again, that the patient went from the asylum to the care of his friends-poor working people-where he would live in a rough and perhaps dirty way, and where the outside of the aid he would receive from the parish would be 6d. or 9d. a day. Who of us would not pity him? Yet it appears that the change would probably give him a chance of living longer, for the Scotch Commission

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