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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 tients in establishments, and they make the he may be liberated without risk to the pubfollowing remarks on this subject:-"That lic or himself, or to say of him that he is it should be less than the mortality among positively harmless. It does not appear, private patients is not surprising, consider however, 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 unrecovered. 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 prop especially 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 trust. wants 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 pri than counterbalances the advantages which vate dwellings, under the care of the Scotch better diet, better clothing, better bedding, Board, averaging from 1500 to 1600, no 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 enough 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, does benefit. This of course-the good of the patients-ought always to be the first consideration, and one which should give place to no other. But may we not sometimes be mistaken in thinking that a particular rule and method of doing good, to which we are wedded by long and pleasant association, continues, in all times and circumstances and for all objects, to be the unfailingly satisfactory method it was, as regarded those with

whom it had at first to deal?

"In determining on the propriety of the discharge of a patient, whether private or pauper, it appears to us," the Scotch Commissioners say, "that, as a rule, superintendents of asylums give comparatively little consideration to the question whether detention continues to be necessary or proper, provided they are satisfied that the patient is still of unsound mind. But the statuto ry form of the medical certificates requires not only that the patient must be of unsound mind, but also a proper person to be detained and taken care of," and they allude repeatedly to their reasons for holding that it is not "the intention of the Legislature that patients should be detained in asylums simply because they remain of unsound mind," and that, therefore, "their detention is justifiable only when their discharge would prove incompatible with the safety of the

not show that any injurious consequences have followed," and they add the important remark,-" Indeed, experience proves that danger is far more to be apprehended during the incubation of insanity, when mental discase is scarcely suspected, than at a later period, when its existence is fully recognis ed."

The following quotation from the Seventh Scotch Report will show with what breadth and fairness this question of the accumula tion in our asylums of chronic and harmless pauper patients has been considered :-"It might be proper and humane to provide hospitals for the treatment of all the poor suffering under mental or bodily ailments, in which they would receive the most judicious treatment, and enjoy far greater comforts than they could possibly command in their homes; but the State would shrink from any such general measure of relief, not only as uncalled for, but as detrimental to the independence and moral character of the people. In all charitable undertakings their feasibility and ultimate effects should be considered; and it may accordingly be well to inquire whether it is necessary or even proper that the insane should, with but comparatively few exceptions, be separated from the rest of the community, and be congregated together in asylums."

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Enough, we think, has now been said to show that there exists, in official quarters, a clear opinion that some of the pauper inmates of our asylums might properly be re moved and provided for elsewhere, the costly appliances of a fully appointed asylum being regarded as unnecessary in their cases. In whatever manner we dispose of the patients so removed, their withdrawal would of course be a relief to the asylums, and an immediate answer to the demand for increased accommodation. In their last Report, the Twenty-second, the English Commissioners say," It is the presence in costly establishments of so many insane persons, to whom a less elaborate provision would be more suitable, that constitutes the real grievance to the ratepayer." That there is a grievance is here admitted, and that it is one which is becoming more felt from year to year is beyond question. The annual cost of lunacy is already enormous, while its rate of increase is also great and constant, and gives no indication of a tendency to cease. In so beneficent a work as that of providing for the insane poor, the cost, we think, should not be too strictly regarded. If in anything, there should be liberality in this; but there should certainly be no unnecessary expenditure, which is waste. Real benefits should, if possible, be obtained for all the money laid out, and public charity should be ruled by the same considerations which rule private charity. This being so, This being so, if there are, as the English Commissioners here say, many insane persons maintained in costly establishments for whom a less elaborate and cheaper provision would not only be suitable, but "more suitable," there does appear to be a "real grievance" to the ratepayer. In their previous Report (the Twenty-first) the English Commissioners speak also of the positive benefit to certain patients of an "expensive associated accommodation, homely in character and simple in architecture;" and they say," All our experience points to the manifest advantage which not only the quiet working patients derive from this description of accommodation, but even some of the less orderly and tractable."

This high official approval of plain and inexpensive buildings for the accommodation of the insane poor is very important. Many of the county asylums of England are handsome edifices, presenting a most imposing appearance. Their very grandeur impresses us with the earnestness and largeness of English philanthropy in this field, and we cannot look on them without a certain pride. Yet buildings with less display of outward ornament, but with as much, or

even more, attention to internal comforts, might in reality have been the expression of a sounder philanthropy. The cost of three, for instance might have built four. But apart from the consideration of cost, it is difficult to understand that their architec tural beauties can have any good or useful effect on insane persons, who belong chiefly to the lower and little educated orders of society. Indeed, it might be maintained, and with considerable show of reason, that for all classes of the insane poor, buildings of a less pretentious and institutional, and of a more home-like character would be an actual benefit. The tendency of present opinion, in fact, appears to be in this direction. The treatment of the insane approaches more and more closely to family life, and the accommodation provided for them may be expected to depart less and less from that of ordinary dwellings. The quotation just given from a recent Report of the English Commissioners, shows that for a certain number of the insane, not consisting solely of harmless imbeciles, but including some of "the less orderly and tractable," simple and inexpensive structures are not only regarded as sufficient, but as better than structures which are more costly, more ornate, and more elaborate.

It would appear, then, from what has been said, that the English and Scotch Commissioners dwell much in their reports on the enormous increase that has taken place in the pauper population of our asylums, and on the rapid rate of growth still exhibited. The same feature characterizes the Irish and the French reports. On all hands it is felt that there is a problem to be solved, and that this growth is a thing which it is desirable to arrest. It appears also to be as generally felt that the accumulation of incurable and harmless patients in establishments erected at great cost, with all the appliances and machinery for the treatment of curable and the safe and proper keeping of dangerous or troublesome patients, is unnecessary and undesirable.

It must not be supposed, however, that the present state of matters is a thing altogether new, for however far back we go, we find that whenever an asylum was erected in a district, its population began at once to grow in the way described, and to assume the same character as regards the great preponderance of incurable cases. Asylums which at their opening are sufficient for the wants of the district-that is, which can receive every patient then in an asylum chargeable to the district, and have moreover, a proper reserve of empty beds--not unfrequently after two or three years are found full, or more than full; then comes a de

mand for additions, which are made and omission, that is, by being dropped out of filled in their turn, to be followed by a fresh the Act then passed. And now again, we demand for further additions. This is and find the Commissioners in successive Rehas ever been, more or less exactly, the his- ports pointing out the same evil, and inditory of all asylums which have been in op- cating the same remedy. But before exameration for any length of time. In their ining the nature of this, and of other reme Twenty-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 tion is believed to have on the higher func tions of such institutions. We are told by the English Commissioners, in their Twenty-first Report, that to relieve asylums of the incurable and inoffensive patients who fill the wards, and for whom medicine can do little in the way of special treatment, would render them effective for the recep tion of curable cases, and such as require special care." The higher aims of an asylum are here well defined as the cure of the curable, and the safe and proper keeping of those who, though not curable, may be in such a state from mental disease as to re quire special care, and all the machinery of a well-appointed asylum. These aims appear to be seriously interfered with, when the wards are allowed to be cumbered with incurable and harmless patients; and it is declared to be a waste of the physician's skill and labour when they are expended chiefly on such objects. This must be true, in an emphatic sense, if the presence in an asylum of a crowd of incurables leads to the exclusion of the curable. In the Report of 1844, the Commissioners say "The dispos al of incurable patients, although a very serious and difficult question, is certainly of less moment than the exclusion of curable patients from asylums, which have been erected at great public cost, and are fitted up with every convenience for the purpose of cure " (p. 93); and with reference to one of the causes which operate "to fill lunatic asylums with incurable patients, and to pre vent the public from deriving any considera ble benefit from them as hospitals for the cure of lunacy," they say "This must con tinue to operate and neutralize all other efforts for the benefit of the insane, unless means are adopted to relieve the asylums from the pressure of incurable patients," (pp. 91, 92). If this were done, the duties of superintendents would no doubt become more medical and less administrative, and asylums would assume more the character of hospitals and less that of refuges for the infirm in mind; and from this change we might fairly expect a benefit in the long-run to mankind, through an extension of our

"So long since," they say, as 1844, the attention of the Commissioners who were appointed to report upon the condition of the various public and private asylums in England and Wales had been specially directed to the accumulation of chronic cases, which was, even at that period, taking place in many of the county asylums. They state at p. 92, 'In a certain portion of cases the patient neither recovers nor dies, but remains an incurable lunatic, requiring little medical skill in respect to his mental disease, and frequently living many years. A patient in this state requires a place of refuge; but his disease being beyond the reach of medical skill, it is quite evident that he should be removed from asylums instituted for the cure of insanity, in order to make room for others whose cases have not yet become hopeless. If some plan of this sort be not adopted, the asylums admitting paupers will necessarily continue full of incurable patients, and those whose cases will admit of cure will be unable to obtain admission until they themselves become incurable, and the skill and labor of the physician will then be wasted upon improper objects.

"Urder these circumstances it seem absc

lutely necessary that distinct places of refuge should be provided for lunatic patients who have become incurable. The great expenses of a lunatic hospital are unnecessary for incurable patients; the medical staff, the number of attendants, the minute classification, and the other requisites of a hospital for the cure of disease, are not required to the same extent; an establishment, therefore, upon a much less expensive scale would be sufficient.'

The whole matter under review is well and clearly stated in this quotation from a Report, which was written twenty-five years

ago.

The influence of that admirable Report on the well-being and happiness of the insane poor, not in England only, but in all the divisions of the empire, and in all the countries of Europe, and among all the civilized nations of the earth, must have far exceeded anything which even that distinguished philanthropist, whose name first follows it, could have ventured to expect when he affixed his signature. But in this particular matter the recommendations and suggestions of the Report have had no practical effect. They became and continued to be law till 1853, when they ceased to be law by

erected at a cost which is moderate, when compared with that of the main buildings. But the detached blocks in these instances must be regarded merely as enlargements of existing asylums, and not in any correct sense as separate institutions. They do not, therefore, obviate some of the evils which result from the accumulation

knowledge of the nature of insanity, and of the means of treatment. Referring to the time when many of the chronic insane who are incurable and harmless will be withdrawn from our asylums, Dr. Maudsley, in his work on the Physiology and Pathology of the Mind, speaks thus of the effects of such a withdrawal:-"Then will asylums, instead of being vast receptacles for the con-of chronic harmless patients. They are ccalment and safe keeping of lunacy, acquire more and more the character of hospitals for the insane; while those who superintend them being able to give more time and attention to the scientific study of insanity, and to the means of its treatment, will no longer be open to the reproach of forgetting their character as physicians, and degenerating into mere house-stewards, farm ers, or secretaries." This may be regarded as a strong way of putting the case, but it will be generally felt that it strikes at an evil which is real at an evil, however, which cannot be quickly or easily corrected. All this, however, may be true of asylums they may not be perfect; there may even be grave errors about them; and yet they may deserve to the full, as we think they do, the culogy passed on them by Dr. Paget in the Harveian Oration for 1866: "To my eyes," he said, "a pauper lunatic asylum, such as may now be seen in our English counties, with its pleasant grounds, its airy and cleanly wards, its many, conforts, and wise and kindly superintendence, provided for those whose lot it is to bear the double burthen of poverty and mental derangement, I say this sight is to me the most blessed manifestation of true civilisation that the world can present."

We come now to examine the remedies proposed for the evils, which are believed to arise from this great accumulation of incurable patients in asylums, and first as to the proposed outlets. These are-(1.) transference to buildings intermediate in character between the workhouse or poorhouse* and the county asylums; (2.) transference to the workhouse or poorhouse itself; and (3.) transference to private dwellings.

The first is evidently the scheme which meets with most approval from the English Commissioners, and it is that which was most strongly recommended by the Commissioners of Inquiry in 1844. Already, indeed, in a certain sense, and to some extent, it has been acted on, as, for instance, at Kent, Devon, Chester, Prestwich, etc., where detached blocks have been

*What is called a workhouse in England and Ire

land is called a poorhouse in Scotland.

simply additions to asylums, at a moderate instead of a considerable cost; and we can scarcely look on them as presenting a new mode of providing for a certain class of the insane. Detached blocks, erected at a moderate cost, might and perhaps should be a feature in the original design of every asylum; and in many instances certainly additions and extensions should be made in this way. On these views the English Commissioners appear to act, for with reference to this subject they say :-" In the enlargement of existing county asylums, as well as in the erection of new ones, it has been our practice to advocate, as far as possible, the construction, for the more quiet and trustworthy patients, especially those employed on the farm, or in the laundry and workshops, of inexpensive associated accommodation, homely in character and simple in architecture." Nothing can be clearer, we think, than the propriety of what is here recommended, whether in the interest of the insane or of the ratepayer. But we learn that a limit may be reached, and indeed has been reached, in making extensions on this plan-a plan which cannot properly be regarded as furnishing an outlet for the harmless incurables who crowd the wards and interfere with the usefulness of an asylum, since they are not thus really withdrawn from the establishment, but remain in it, though in a different part. Asylums might, as easily in this as in any other way, grow into monster establishments like those at Hanwell and Colney Hatch; and so nearly universal now is the condemnation of such asylums, that it appears scarcely necessary to point out that this should be avoided if possible. "Each succeeding year," the English Commissioners say, "confirms us in the opinion we have so often expressed as to the many evils resulting from the congregation of very large numbers of the insane under one roof and one management."

We think, however, that in this form of accommodation, " intermediate between the workhouse and the asylum," the Commissioners have more in view than simply inexpensive extensions of existing asylums; but effect has not yet been given, so far as we can discover, to any such view. Some

thing of the kind, however, will be done when the district asylums are erected, for which provision is made in the hastily framed and ill-considered Metropolitan Poor Act of 1867. These institutions, it is true, are intended only for the reception of such patients as are presently in the workhouses of the metropolis; but there is every reason to believe that they will not stop there. They will of course receive such of the lunatic poor as are now in the workhouses; but it will be found in practice that they will also receive many patients who ought to be sent 'to fully appointed asylums, and many who have already been there, and many who, but for the erection of these institutions, would not have been sent as lunatics either to asylums or to work houses.

We come now to consider the second of the proposed outlets for the incurables congregated in asylums, namely, a transference of some of them to workhouses or poorhouses. These are institutions which have not to be created. They exist already; and already, indeed, contain no inconsiderable number of such patients as it has been proposed to transfer to them from asylums. Thus, our latest information shows that on the 1st of January 1867 there were 10,307 in the workhouses of England; on the 31st December 1867, 2705 in the poorhouses of Ireland; and on the 1st of January 1867, 998 in the poorhouses of Scotland, making a total of 14,010 appearing in official returns as thus provided for. Large as this number is, there is every reason to believe that it is considerably below the real number of the insane who are presently inmates of our workhouses and poorhouses.

To adopt, therefore, this second mode of relieving the pressure for accommodation, and of obviating the extension of asylums, would merely be to give development to a thing which exists, and has long existed. Before expressing approval or disapproval of the scheme, we first turn to see what is said of the condition of those of the insane poor who are already provided for in this

manner.

We may observe, before entering on details, that there has been, and still is, a general and strong dislike to this mode of providing for the insane poor, and that to foster it would be regarded by not a few as retrogression, and a departure from the benevolent views which, for the last thirty years, have regulated the care and treatment of these unfortunates. The very names, poorhouse and workhouse, appear to disclose an unfitness of things; and we start with a feeling that an incurable lunatic,

who is an object of great pity and generally infirm in body as well as in mind, and who is detained against his will and for the term of his life, should have much better treatment and care than is given to the ordinary poor in establishments, a main feature of whose organization and management is that they shall tend to the repression of pauperism.

If we turn, however, as we shall first do, to the Reports of the English Commissioners, we shall find that the condition of all lunatics in all workhouses is by no means described as unsatisfactory. On the contrary, of the condition of the insane in many of them these Reports speak well We have already given a quotation from their Eighteenth Report, in which it is stated that in " I very many of the smaller workhouses," where the insane inmates mix freely with sane, and are employed with them, "the result is so satisfactory in all respects that their condition is, in our opin ion, even preferable to that of the same class in some well-ordered asylums." And this suggests the remark, that in work houses and poorhouses there are two ways of disposing of the insane-(1.) in associa tion with the ordinary inmates, and (2.) in separate wards. The first method, as we should expect, is generally found in small workhouses, and the Commissioners, revert ing to the subject in their Twenty-first Re port, write as follows:-"Where the inmates of unsound mind are not so numer ous as to require wards for their accommo dation, apart from the ordinary inmates, nor of such habits or tendencies as to ren der necessary a treatment not commonly extended to all, the report is generally favourable." It appears, then, that there are some lunatics in the workhouses of England who would not be benefitted by removal to asylums. These, however, are not in wards set apart for them, but are in association with the ordinary inmates.

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What, now, are we told of the condition of those who are found in separate wards? These wards are on different scales-somo large, and others comparatively small; and it is of the former-the larger-that the Reports of the Commissioners speak most favourably. On the other haud," they say in their Twenty-first Report, "there has been frequent favourable report from houses under quite different conditions, where, as in many of the larger towns throughout the kingdom, the inmates of unsound mind, collected in the workhouses, have become so numerous as to require special arrange ments for their accommodation;" and they speak elsewhere of the " creditable condi

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