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ers, who know more about their pauper luca- | public, or with their own safety or welfare." tics in private dwellings than is known of the These are views which are commended by patients so disposed of in England, or Ire- common sense, and which there is no gainland, or France, tell us that the rate of mor- saying. It will sometimes be difficult
, no tality among them is lower than among pa- doubt, to determine of an insane person that tieuts in establishments, and they make the he may be libcrated without risk to the pubfollowing remarks on this subject :--" That lic or bimself, or to say of him that he is it should be less than the mortality among positively barmless. It does not appear, private patients is not surprising, consider- bowever, that this is a difficulty which in ing the amount of active disease in such es- practice would seriously or generally intertablishments; but that it should be so consid- fere with the discharge of the uprecovered
. erably less than what occurs in the lunatic There are very few who do not admit that a wards of poorhouses must appear remarkable, certain number of the insane may very propespecially when it is taken into account that erly be considered as harmless, and as being the patients in such wards are, for the most not more likely to prove an actual source of part, like those in private dwellings, idiots danger to the lieges than any other class of and dements, and that, as a rule, the physical the community. The insane are more trustwants of the former are more amply supplied. ed and have greater freedom than they ever We can offer no explanation of this fact, be- had, and all the documents before us show yond the conjecture that the manner of liv- that in their management there is a tendening in private dwellings, involving, as a rule, cy to attempt more in this direction. It greater freedom and greater variety, more appears, too, that among the insane in prithan counterbalances the advantages which vate dwellings, under the care of the Scotch better diet, better clothing, better bedding, Board, averaging from 1500 to 1600, Do better housing, and greater cleanliness might casualties have occurred during the ten be supposed to convey."
years of the Board's existence; while, as We have said cnough to show that these regards the discharges of the unrecovered official documents clearly indicate the possi- among private patients, which, as already bility of providing for some of the insane stated, are so much more frequent than poor otherwise than in asylums, not only among paupers, the Commissioners say, without injury to them, but with probable “ Our information, so far as it goes, benefit. This of course—the good of the not show that any injurious consequences patients-ought always to be the first con- have followed," and they add the important sideration, and one which should give place remark, —-" Indeed, experience proves that to no other. But may we not sometimes be danger is far more to be apprehended during mistaken in thinking that a particular rule the incubation of insanity, when mental and method of doing good, to which we are discase is scarcely suspected, than at a later wedded by long and pleasant association, period, when its existence is fully recogniscontinues, in all times and circumstances acd ed.” for all objects, to be the unfailingly satisfac. The following quotation from the Seventh tory method it was, as regarded those with Scotch Report will show with what breadth whom it had at first to deal ?
and fairness this question of the accumula"In determining on the propriety of the tion in our asylums of chronic and harmless discharge of a patient, whether private or pauper patients has been considered :-"It pauper, it appears to us," the Scotch Com- inight be proper and humane to provide missioners say, “that, as a rule, superinten hospitals for the treatment of all the poor dents of asylums give comparatively little suffering under mental or bodily ailments
, in consideration to the question whether de- which they would receive the most judicious tention continues to be necessary or proper, treatment, and enjoy far greater comforts provided they are satisfied that the patient than they could possibly command in their is still of unsound inind. But the statuto- homes; but the State would shrink frem ry form of the medical certificates requires any such general measure of relief, not only not only that the patient must be of unsound as uncalled for, but as detrimental to the inmind, but also a proper person to be detained dependence and moral character of the peoand taken care of;" and they allude repeat- ple. In all charitable undertakings their edly to their reasons for holding that it is feasibility and ultimate effects should be pot " the intention of the Legislature that considered, and it may accordingly be well patients should be detained in asylums sim. to inquire whether it is necessary or even ply because they remain of unsound mind,” proper that the insane should, with but and that, therefore, “ their detention is jus comparatively few exceptions, be separated tifiable only when their discharge would from the rest of the community, and be prove incompatible with the safety of the congregated together in asylums."
Enough, we think, has now been said to I even more, attention to internal comforts, show that there exists, in official quarters, a might in reality have been the expression of clear opinion that some of the pauper in- a sounder philanthropy. The cost of three, mates of our asylums might properly be re for instance might have built four. But moved and provided for elsewhere, the costly apart from the consideration of cost, it is appliances of a fully appointed asylum be difficult to understand that their architecing regarded as unnecessary in their cases. tural beauties can have any good or useful In whatever manner we dispose of the pa- effect on insane persons, who belong chiefly tients so removed, their withdrawal would to the lower and little educated orders of of course be a relief to the asylums, and an society. Indeed, it might be maintained, and immediate answer to the demand for increas- with considerable show of reason, that for all ed accommodation. In their last Report, classes of the insane poor, buildings of a less the Twenty-second, the English Commis- pretentious and institutional, and of a more sioners say," It is the presence in costly home-like character would be an actual benestablishments of so many insane persons, to efit. The tendency of present opinion, in fact, whom a less elaborate provision would be appears to be in this direction. The treatmore suitable, that constitutes the real griev- ment of the insane approaches more and ance to the ratepayer." That there is more closely to family life, and the accom. a grievance is here admitted, and that it is modation provided for them may be expected one which is becoming more felt from year to depart less and less froin that of ordinary to year is beyond question. The annual dwellings. The quotation just given from a cost of lunacy is already enormous, while recent Report of the English Commissioners, its rate of increase is also great and con- shows that for a certain number of the insane, stant, and gives no indication of a tendency not consisting solely of harmless imbeciles, to cease. In so beneficent a work as that but including some of "the less orderly and of providing for the insane poor, the cost, tractable," simple and inexpensive structures we think, should not be too strictly regarded. are not only regarded as sufficient, but as If in anything, there should be liberality in better than structures which are more costly, this; but there should certainly be no un- more ornate, and more elaborate. necessary expenditure, which is waste. Real It would appear, then, from what has been benefits should, if possible, be obtained for said, that the English and Scotch Commisall the money laid out, and public charity sioners dwell much in their reports on the should be ruled by the same considerations enormous increase that has taken place in which rule private charity. This being so, the pauper population of our asylums, and if there are, as the English Commissioners on the rapid rate of growth still exhibited. here say, many insane persons maintained in The same feature characterizes the Irish and costly establishments for whom a less elabo- the French reports. On all hands it is felt that rate and cheaper provision would not only there is a problem to be solved, and that this be suitable, but "more suitable,” there does growth is a thing which it is desirable to arappear to be a "real grievance" to the rate- rest. It appears also to be as generally felt payer. In their previous Report (the Twen- that the accumulation of incurable and harmty-first) the English Commissioners speak less patients in establishments erected at also of the positive benefit to certain pa- great cost, with all the appliances and matients of an expensive associated accom- chinery for the treatment of curable and the modation, homely in character and simple in safe and proper keeping of dangerous or architecture; " and they say, “ All our troublesome patients, is unnecessary and unexperience points to the manifest advantage desirable. which not only the quiet working patients It must not be supposed, however, that derive from this description of accommoda- the present state of matters is a thing altotion, but even some of the less orderly and gether new, for however far back we go, we tractable."
find that whenever an asylum was erected in This high official approval of plain and in a district, its population began at once to expensive buildings for the accommodation grow in the way described, and to assume of the insane poor is very important. Many the same character as regards the great of the county asylums of England are hand. preponderance of incurable cases. Asylums some edifices, presenting a most imposing which at their opening are sufficient for the appearance. Their very grandeur impres- wants of the district—that is, which can reses us with the earnestness and largeness ceive every patient then in an asylum chargeof English philanthropy in this field, and able to the district, and have moreover, a we cannot look on them without a certain proper reserve of empty beds—not unfrepride. Yet buildings with less display of quently after two or three years are found outward ornament, but with as much, or full, or more than full; then comes a de
mand for additions, which are made and omission, that is, by being dropped out of
in . demand for further additions. This is and find the Commissioners in successive Rehas ever been, more or less exactly, the bis- ports pointing out the same evil, and inditory of all asylums which have been in op- cating the same remedy. But before exam. eration for any length of time. In their ining
the nature of this, and of other remeTwenty-first Report, for instance, the Eng- dies which have been proposed, we stop for a lish Commissioners point out that the pre- little to draw attention to an effect of the sent state of matters was found to exist in great accumulation of incurable patients in the older county asylums a quarter of a cen- asylums, which is alluded to in the 'quotatury ago :
tion just given from the Report of 1844.
We refer to the effect which that accumula. “So long since,” they say, as 1841, the at- tion is believed to have on the higher functention of the Commissioners who were appointed to report upon the condition of the tions of such institutions. We are told by various public and private asylums in England the English Commissioners, in their Twenand Wales had been specially directed to the ty-first Report, that to relieve asylums of accumulation of chronic cases, which was, even the incurable and inoffensive patients who at that period, taking place in many of the fill the wards, and for whom medicinc can county asylums. They state at p. 92, 'In a do little in the way of special treatment
, certain portion of cases the patient neither re
would render them “ effective for the recepcovers nor dies, but remains an incurable luna- tion of curable cases, and such as require tic, requiring little medical skill in respect to his mental disease, and frequently living many special care.". The higher aims of an asy. years. A patient in this state requires a place lum are here well defined as the cure of the of refuge ; but his disease being beyond the curable, and the safe and proper keeping of reach of medical skill, it is quite evident that those who, though not curable, may be in he should be removed from asylums instituted such a state from mental disease as to re. for the cure of insanity, in order to make room for others whose cases have not yet become
quire special care, and all the machinery of hopeless. If some plan of this sort be not
a well-appointed asylum. These aims apadopted, the asylums admitting papers will ne- pear to be seriously interfered with, when cessarily continue sull of incurable patients, the wards are allowed to be cumbered with and those whose cases will admit of cure will incurable and harmless patients; and it is be unable to obtain admission until they them- declared to be a waste of the physician's selves become incurable, and the skill and labor skill and labour when they are expended of the physician will then be wasted
chiefly on such objects. This must be true, proper objects. vi'. Urder these circumstances it seem absc
in an emphatic sense, if the presence in an lutely necessary that distinct places of refuge asylum of a crowd of incurables leads to the should be provided for lunatic patients who exolusion of the curable. In the Report of have become incurable. The great expenses of 1844, the Commissioners say—“The dispos. a lunatic hospital are unnecessary for incarable al of incurable patients, although a very patients; the medical stuff
, the number of at- serious and difficult question, is certainly of tendants, the minute classification, and the less moment than the exclusion of curable other requisitez of a hospital for the cure of disease, are not required to the same extent; patients from asylums, which have been an establishment, therefore, upon a much less erected at great public cost, and are fitted expensive scale would be sufficient.'
up with every convenience for the purpose
of cure" (p. 93); and with reference to one The whole matter under review is well of the causes which operate " to fill lunatio and clearly stated in this quotation from a asylums with incurable patients, and to preReport, which was written twenty-five years vent the public from deriving any considera: ago. The influence of that admirable Re- ble benefit from them as hospitals for the port on the well-being and bappiness of the cure of lunacy,” they say—“This must coninsane poor, not in England only, but in all tinue to operate and neutralize all other the divisions of the empire, and in all the efforts for the benefit of the insane, unless countries of Europe, and among all the civil- means are adopted to relieve the asylums ized nations of the earth, must have far ex- from the pressure of incurable patients," ceeded anything which even that distin- (pp. 91, 92). If this were done, the duties guished philanthropist, whose name first fol. of superintendents would no doubt become lows it, could have ventured to expect when more medical and less adıninistrative, and he affixed his signature. But in this partic- asylums would assume more the character of alar matter the recommendations and sug: hospitals and less that of refuges for the ingestions of the Report have liad no practical firm in mind; and from this change we effect. They became and continued to be might fairly expect a benefit in the long-run law till 1853, when they ceased to be law by to inankind, through an extension of our
knowledge of the nature of insanity, and of erected at a cost which is moderate, when the means of treatment. Referring to the compared with that of the main buildings. time when many of the chronic insane who But the detached blocks in these instances are incurable and harmless will be with must be regarded merely as enlargements drawn from our asylums, Dr. Maudsley, in of existing asylums, and not in any corhis work on the Physiology and Pathology rect sense as separate institutions. They of the Mind, speaks thus of the effects of do not, therefore, obviate some of the such a withdrawal :-" Then will asylums, evils which result from the accumulation instead of being vast receptacles for the con- of chronic harmless patients. They are ccalment and safe keeping of lunacy, acquire simply additions to asylums, at a moderate more and more the character of hospitals for instead of a considerable cost; and we can the insane; while those who superintend scarcely look on them as presenting a new them being able to give more time and at- mode of providing for a certain class of tention to the scientific study of insanity, the insane. Detached blocks, erected at a and to the means of its treatment, will no moderate cost, might and perhaps should longer be open to the reproach of forget. be a feature in the original design of every ting their character as physicians, and de- asylum ; and in inany instances certainly generating into mere house-stewards, farm. additions and extensions should be made ers, or secretaries." This may be regarded in this way. On these views the English as a strong way of putting the case, but it Commissioners appear to act, for with refwill be generally felt that it strikes at an érence to this subject they say :-"In the evil which is real—at an evil, however, / enlargement of existing county asylums, as which cannot be quickly or easily corrected. well as in the erection of new ones, it has All this, however, may be true of asylums- been our practice to advocate, as far as they may not be perfect; there may even possible, the construction, for the more be grave errors about them; and yet they quiet and trustworthy patients, especially may deserve to the full, as we think they those employed on the farm, or in the do, the culogy passed on them by Dr. laundry and workshops, of inexpensive as. Paget in the Harveian Oration for 1866: sociated accommodation, homely in char"To my eyes," he said, "a pauper lunatic acter and simple in architecture.” Nothing asylun, such as may now be seen in our can be clearer, we think, than the propriety English counties, with its pleasant grounds, of what is here recommended, whether in its airy and cleanly wards, its many, con- the interest of the insane or of the rateforts, and wise and kindly superio tendence, payer. But we learn that a limit may be provided for those whose lot it is to bear the reached, and indeed has been reached, in double burthen of poverty and mental de making extensions on this plan-a plan rangement,-I say this sight is to me the which cannot properly be regarded as furmost blessed manifestation of true civilisation nishing an outlet for the harmless incurables that the world can present.”
who crowd the wards and interfere with the We come now to examine the remedies usefulness of an asylum, since they are not proposed for the evils, which are believed thus really withdrawn from the establishto arise from this great accumulation of ment, but remain in it, though in a differincurable patients in asylums, and first as ent part. Asylums might, as easily in this to the proposed outlets. These are(1.) as in any other way, grow into monster transference to buildings intermediate in establishments like those at Hanwell and character between the workhouse or poor- | Colney Flatch ; and so nearly universal house * and the county asylums; (2.) trans- now is the condemnation of such asylums, ference to the workhouse or poorhonse it that it appears scarcely necessary to point self; and (3.) transference to private dwell out that this should be avoided if possible. ings.
"Each succeeding year," the English ComThe first is evidently the scheme which missioners say, “ confirms us in the opinion meets with most approval from the Eng- we have so often expressed as to the many lish Commissioners, and it is that which evils resulting from the congregation of was most strongly recommended by the very large numbers of the insane under Commissioners of Inquiry in 1844. Al- one roof and one management.” ready, indeed, in a certain sense, and to We think, however, that in this form of some extent, it has been acted on, as, for accommodation, “intermediate between the instance, at Kent, Devon, Chester, Prest- workhouse and the asylum," the Commiswich, etc., where detached blocks have been sioners have more in view than simply in
expensive extensions of existing asylums; * What is called a workhouse in England and Ire- but effect has not yet been given, so far as land is called a poorhouse in Scotland.
we can discover, to any such view. Some
thing of the kind, however, will be done who is an object of great pity and generally when the district asylums are erected, for infirm in body as well as in unind, and who which provision is made in the hastily is detained against his will and for the term framed and ill-considered Metropolitan Poor of his life, should have much better treatAct of 1867. These institutions, it is true, ment and care than is given to the ordinary are intended only for the reception of such poor in establishments, a main feature of patients as are presently in the workhouses whose organization and management is that of the metropolis; but there is every rea- they shall tend to the repression of pauperson to believe that they will not stop there. ism. They will of course receive such of the If we turn, however, as we shall first do
, lunatic poor as are now in the workhouses; to the Reports of the English Commission but it will be found in practice that they ers, we shall find that the condition of all will also receive many patients who ought | lunatics in all workhouses is by no means to be sent to fully appointed asylums, and described as unsatisfactory. On the conmany who have already been there, and trary, of the condition of the insane in many who, but for the erection of these many of them these Reports speak well institutions, would not have been sent as We have already given a quotation from lunatics either to asylums or to work their Eighteenth Report, in which it is houses.
stated that in " very many of the smaller We come now to consider the second of workhouses,” where the insane inmates mis the proposed outlets for the incurables con- freely with sane, and are employed with gregated in asylums, namely, a transference them, “the result is so satisfactory in all of some of them to workhouses or poor respects that their condition is, in our opinhouses. These are institutions which have ion, even preferable to that of the same not to be created. They exist already; and class in some well-ordered asylunis." And already, indeed, contain no inconsiderable this suggests the remark, that in work. number of such patients as it has been pro- houses and poorhouses there are two ways posed to transfer to them from asylums. of disposing of the insane-(1.) in associaThus, our latest information shows that on tion with the ordinary inmates, and (2.) in the 1st of January 1867 there were 10,307 separate wards. The first method, as we in the workhouses of England ; on the 31st should expect, is generally found in small December 1867, 2705 iv the poorhouses of workhouses, and the Commissioners, revert Ireland ; and on the 1st of January 1867, ing to the subject in their Twenty-first Ro 998 in the poorhouses of Scotland, making port, write as follows:“Where the ina total of 14,010 appearing in official re- mates of unsound mind are not so numer turns as thus provided for. Large as this ous as to require wards for their accommonumber is, there is every reason to believe dation, apart from the ordinary inmates
, that it is considerably below the real num- nor of such habits or teudencies as to renber of the insane who are presently inmates der necessary a treatment not commonly of our workhouses and poorhouses. extended to all, the report is generally
To adopt, therefore, this second mode of favourable.” It appears, then, that there relieving the pressure for accommodation, are some lunatics in the workhouses of and of obviating the extension of asylums, England who would not be benefitted by would merely be to give development to a removal to asylums.
These, however, are thing which exists, and has long existed. not in wards set apart for them, but are in Before expressing approval or disapproval association with the ordinary inmates. of the scheme, we first turn to see what is What, now, are we told of the condition said of the condition of those of the insane of those who are found in separate wards ? poor who are already provided for in this These wards are on different scales-somo
large, and others comparatively small; and We may observe, before entering on de- it is of the former-the larger that the tails, that there has been, and still is, a Reports of the Commissioner's speak most general and strong dislike to this mode of favourably. “On the other haud,” they providing for the insane poor, and that to say in their Twenty-first Report, “ there has foster it would be regarded by not a few as been frequent favourable report from houses retrogression, and a departure from the under quite different conditions, where, as benevolent views which, for the last thirty in many of the larger towns throughout the years, have regulated the care and treat- kingdom, the inmates of unsound mind, colment of these unfortunates. The very lected in the workhouses, have become so names, poorhouse and workhouse, appear to numerous as to require' special arrangedisclose an unfitness of things; and we ments for their accommodation ;
" and they start with a feeling that an incurable lunatic, speak elsewhere of the creditable condi