bered that the conferring of this power is desirable, not simply to make the workhouses available for the reception of chronic cases from asylums, but also for the sake of the ten thousand patients who are already in them.

So much, then, for the condition of the insane in the workhouses of England. We turn now to the class similarly disposed of in the poorhouses of Scotland, excluding, of course, those found in what are called parochial asylums (six in number),-institutions which have no exact analogue in England, and which receive all classes of pauper patients, curable and incurable. They were found in existence at the passing of the Lunacy Law in 1857, and were continued from a regard to vested interests. They are now licensed by the Commissioners in the same manner as private asylums.

reported on in the same terms as at first, As we go on, we hear of greater readiness on the part of parochial boards to carry out the suggestions of the Board of Lunacy; of liberality in management; of an increase in the number of attendants; of provisions for exercise, occupation, and amusement; of the introduction of comfortable furniture and objects of decoration; of wards in excellent order, cheerful and well ventilated, with patients clean in person, well clothed, and well fed; of patients judiciously selec ted and well cared for; and of many other things which indicate a progress in the right direction, and which convey, on the whole, a favourable impression of the spirit in which these small institutions have of late been conducted. One important and pleasing evidence of the improvement which ap pears to have taken place, is to be found in the diminished rate of mortality. During the first five years, from 1858 to 1862 in

annually on the numbers resident, while during the last five years from 1863 to 1867 inclusive, it had fallen to 7.3 per cent. a result probably due to improved hygienic conditions, that is, to such things as better food, better clothing, better housing, more exercise in the open air, more occupation and amusement, and less of a wearisome monotony in the existence of the patients.

The patients we have presently to deal with are those found in the lunatic wards of poorhouses which hold from the Com-clusive, the mortality was 10.9 per cent. missioners a limited license-so called, because in granting it, it is a condition that none but incurables and harmless patients shall be received. For each case admitted the sanction of the Board is accordingly required. The dietary is also prescribed by the Commissioners, and a reference to it, in their Fifth Report, will show that it is as liberal as that adopted in the public and district asylums. The value of this sufficient supply of good food cannot be overestimated, for, as the English Commissioners tell us, "nothing has been so clearly established in the treatment of insanity as the importance of a good supply of nutritious food, whether to promote recovery in the curable, or to prevent deterioration in others."

In various respects, as might be anticipated, the need of applying for a license is found to be productive of good results; and when the conditions are not observed, and all efforts to make the state of the wards and of their inmates satisfactory have failed, then the license is withdrawn, as appears to have happened in the case of two poorhouses, viz., those at Dunfermline and

It only remains now to notice the condition of the insane in the poorhouses of Ire land, which we shall do briefly. In their last Report the Inspectors in Lunacy say:"We found the insane inmates of poorhouses inspected by us during the year, on the whole, well attended to, and their crea ture comforts duly provided for." Poor house accommodation, however, does not seem to be much in favour with the Inspec tors as an outlet for the harmless incurables who fill the asylums of Ireland, as they do the asylums of England and Scotland. They appear rather to be disposed to recommend that form of accommodation inter mediate betwen asylums and workhouses, which we have already described. Indeed, in the Clonmel Auxiliary Asylum there is already an institution exclusively devoted to When we read the earlier Reports of the the reception of chronic and incurable cases Scotch Commissioners, we hear of little but of insanity, and they appear to contemplate "the generally unsatisfactory condition of the erection of other institutions of a like pauper lunatics in poorhouses," but as we character, so that, as they say, "by establish reach the later Reports we become sensible ing inexpensive refuges for the incurably of a change, and this not a change of opin- insane, the district asylums may be left free ion on the part of the Commissioners, but scope to fulfil their true object of hospitals a change in the state of the poorhouses for the treatment and cure of lunacy-a themselves. They appear, in short, to have position which most of them are far from undergone improvement; and, having ceas-occupying at present, owing to the fact that ed to be what they were, can no longer be they contain 70 per cent. of chronic and in

Stranraer.

curable cases." Such establishments would legislative protection and care; but unless undoubtedly relieve asylums of their incur- it be worse to have had and lost than never ables, and much can be said in recommen- to have had at all, a patient so withdrawn dation of them. If extensively adopted, the from an asylum is not more to be pitied development of poorhouse accommodation, than a like patient who has never obtained under good regulations, would of course be admission. So long, therefore, as the State unnecessary. has so trifling a control over the condition of the insane poor in private dwellings, and remains at so great a distance from them in its concern about their welfare, there must necessarily be hesitation in recommending the discharge from asylums of unrecovered patients who are to be provided for in private dwellings. In various Reports the English Commissioners point out the necessity of extending a larger amount of supervision over pauper patients who are detained out of asylums, and of affording them a greater protection than they have at present. Little, we are informed, is known of the condition of the 6564 pauper lunatics so provided for in England, and that little is not favourable. In many instances the Commissioners believe that they are "in a deplorable and neglected state;" and we fear that it is too true that this is the case.

We have now examined two of the proposed outlets for the chronic harmless patients in asylums, viz., refuge asylums, and workhouses or poorhouses. There remains, however, a third,-that, namely, which would consist of the discharge of some of the unrecovered into private dwellings. And here again, as in the case of poorhouses, we should be dealing with a mode of providing for the insane which is already in extensive operation. In England, for instance, on the 1st of January 1867, there were 6638 pauper lunatics so disposed of; in Scotland, at the same date, 1548; and in Ireland, on the 31st of December 1867, 6564;-making a total for Great Britain and Ireland of 14,750. In England and Scotland the numbers refer only to those lunatics who are in receipt of parochial aid, but the number for Ireland includes more than these, though the vast majority may safely be regarded as belonging to the insane poor. Fifteen thousand lunatics at large appears a very great number, yet it is almost certainly much below the fact. In Scotland, indeed, it appears to be known that the number would be at least twice that given, if we included private patients, or those not in receipt of relief, a large proportion of whom, however, are said to be on the confines of pauperism. It would be safe, therefore, to estimate the number of the insane in private dwellings in Great Britain and Ireland as certainly exceeding 20,000.*

In their Twenty-first Report the Commissioners tell us that the application of this system of placing the harmless and incurable insane poor in private houses, “as a means of relieving the asylums in England of their harmless chronic patients, and thus providing for the reception of recent and ourable cases, has been strongly advocated in some quarters;" and they add that they "have strong reasons for doubting whether the system could advantageously be extended so as to afford any material relief to the county asylums, or that it works so satisfactorily in this country as to render its more general adoption at all desirable." We think these doubts are well founded, for the Many, we think, will be surprised to learn system, so far as we know, cannot be said to that this large class of the insane is almost work well in England (which is the country without legislative protection, except in here referred to); and to foster it as an Scotland, though what has been revealed outlet for chronic patients from asylums from time to time as to their condition, and would be dangerous, so long at least as the what might be expected in their circum- Commissioners have no closer connexion stances, indicate that they require State Care with and control over it than the remote and as much as do the insane poor provided for almost nominal one which presently exists. in great establishments, which are presided That that control and connexion should be over by physicians of a superior class, and made closer is desirable for reasons altogoverned by gentlemen of high social stand-gether apart from the question of providing ing in the districts whose wants the asylums are intended to meet. The English Commissioners very properly feel that it would be a hardship to remove a pauper patient from a public asylum, when the doing so would deprive him in a great measure of

for the chronic patients in asylums,-reasons which might tend to reduce rather than increase their number, reasons, in short, of humanity, having reference solely to the host of pauper patients already in private dwellings, whose state is too often most unsatisfactory, and who have as clear a claim on the State's care as many of their fellow-sufferers, who have drifted into asy

lums more by a sort of chance than by any | Scotch Commissioners leaves little doubt essential difference of mental or bodily con- as to the possibility of making such a prodition. vision in private dwellings for the comfort and safety of a selected class of insane persons, as shall be reasonably satisfactory, and advantageous both to patients and ratepay. ers. The Commissioners admit the value of" the greater amount of liberty accorded to the patients, their more domestic treat ment, and their more thoroughly recognised individuality;" and they say, "there are many persons whose mental condition requires that they should be placed under the care and control of others, yet whom we would hesitate to deprive of liberty to the extent almost necessarily involved in sending them to asylumns.”

All this relates to England. The state of the case in Scotland differs considerably. There the control of the Board of Lunacy over pauper patients in private dwellings appears to be direct and immediate. In the first place, no patient can be so disposed of without the sanction of the Board, and, in the second place, all arrangements so made are personally inspected and inquired into by officers of the Board. These two facts alone seem to us to establish a wide and fundamental difference between the systems of the two countries; and this difference must make much possible and right in the one which would scarcely be prudent in the other, and may naturally be expected to lead to somewhat different views regarding this mode of providing for some of the insane. The experience of the English Commissioners must rest, in this matter, on their dealings with patients who are perhaps injudiciously selected, about whom they have little information, and over whom as little control, while such cases as are brought in detail under their notice are not likely to be the cases of patients who are living in comfort. The Scotch experience, on the other hand, rests on a minute knowledge of the condition of all cases, good and bad, and on constant and personal dealings with the patients,-in efforts to secure a proper selection, and to make their condition satisfactory. This wider scope of the Scotch Lunacy Law is seen also in its relation to poorhouses. It is designed to embrace within its care the whole body of the insane poor, wherever placed, and it is in this respect more comprehensive, perhaps, than any of the Lunacy laws of Europe. In France, for example, the 53,160 lunatics in private dwellings are left without any special care on the part of the State.

The reports as to the condition of those selected patients, whose residence in private dwellings has received the sanction of the Scotch Board, is, on the whole, satisfactory, and it does not appear, from anything we can learn, that it would be a benefit to these patients to place them in asylums. Their condition, too, has undergone improvement. "We have acquired," the Commissioners say in their Seventh Report, "an extensive and accurate knowledge of the condition of pauper single patients in all parts of the country, and we have the satisfaction of stating that, by the repeated suggestions made at successive visits, a considerable improvement has been effected." Altogether, a perusal of the Report of the

It is of importance to learn, as we do from the Eighth Report, that "accidents to patients detained in private dwellings with the sanction of the Board are of extremely rare occurrence," and perhaps of more im portance still to know that," so far as mortality is a test of treatment, the condition of single patients must be considered as more favourable than that of any class in establishments." These facts show that a great amount of liberty can be given to no small number of the insane without risk of injury to themselves or to the lieges, and that this freedom appears, in a sense, to be food to them, since, when in the enjoyment of it, with worse food and less care, they live longer. The system of providing for some of the insane poor in private dwellings may never receive, or may be long before it receives, any such development as will make it extensively useful as a relief to the pressure for asylum accommodation. There are many practical difficulties in the way, even if it were in every respect desirable that it should take this growth. whether it does so or not, we think that the experience of the system in Scotland has been useful in showing (1.) the necessity of a careful and well-regulated supervision over pauper patients in private dwellings, and (2.) the great amount of freedom which can be safely and beneficially accorded to many of the insane; (3.) that it has thus exercised an indirect influence on asylum construction and management, and tended to widen our ideas of non-restraint. "I cannot but think," says Dr. Maudsley in the work already referred to, "that future progress in the improvement of the treat ment of the insane lies in the direction of lessening the sequestration and increasing the liberty of them." Here and there, in the serial literature relating to mental dis ease, both of this country, and of France, and Germany, and America, as well as in

But

systematic works on the subject, opinions | our public asylums-that is, (1.) refuge asymore or less like the foregoing have appear- lums, as they may be called; (2.) worked from time to time, and with increasing houses or poorhouses; and (3.) privaté frequency, during the last eight or ten years. dwellings-it appears to us that, under propOne quotation we shall give, and we select er regulations, they can all, to some extent, it from the work on Mental Pathology be made serviceable, and that a diversity and Therapeutics, by Professor Griesinger, of accommodation for patients in different whose untimely death is being, even now, conditions of mental incapacity is desirable, so widely and deeply deplored. We give it from considerations alike of science, of hu partly because of the weighty name of its manity, and of economy. It would make inauthor, but in part also because it refers to sanity differ from every other diseased state, a peculiar institution in Belgium, which has to suppose that all those who labour under greatly modified the opinions even of those it must be disposed of and provided for in who dislike or condemn it:one and the same manner. What is necessary for one may be neither necessary nor good for another. Nay more, what is proper for a patient at an early period of his malady may be inappropriate at a later. No one would think of making the same provision for the shortsighted and the utterly blind, or for the club-footed and the legless. Between insanity and such conditions there is not, of course, anything like an exact parallelism, but there is a sufficient approach to it to justify the illustration we have used. The providing for the diseased in mind is a much more complicated and difficult matter than the providing for other classes of sufferers; and when we have succeeded in devising a scheme of provision which satisfies us, we are naturally, and we think properly, unwilling to quit it, or readily to admit that there has arisen a change in the circumstances which calls for a modification of the system, so as to maintain the efficiency of the higher purposes it is intended to serve.

"A colony of the insane," Griesinger says, "has been formed in the remarkable Belgian village of Gheel, in which, for several hundred years past, lunatics have lived together with the inhabitants, and even resided in their families. In former times people frequently resorted thither to supplicate the aid of Dymphne, the patron saint of the insane, although people are seldom in the habit now of consulting her oracle..... Out of a population of about 9,000, it has from 900 to 1,000 inhabitants who are insane. The lunatics enjoy an amount of pleasure and freedom which never could be permitted them in an asylum. All who are capable of it share in the mechanical or agricultural employments of the sane. The treatment, in the main, is very mild, and restraint is never made use of without previously consulting a physician. Suicide is rare, and the general physical health so good that in 1888 two of the patients reached upwards of 100 years of age. Owing to the peculiar situation of Gheel, escape by the patients is difficult. With all its advantages, it has undoubted drawbacks. .. But the experiment at Gheel has proved that the greater number of the insane do not require the confinement of an asylum; that many of them can safely be trusted with more liberty than those institutions allow; and that association in family life is very beneficial to many insane patients."

As regards the insane at large in Ireland, we have not much late information, except as regards their numbers; but we may safely assume that their condition in 1858, as disclosed in the Report of the Commissioners of Inquiry (page 38), has not undergone any material change. At that time the number of such patients was 3,352; and of these more than one-half (1767) were returned as "well treated; 29 ten-elevenths (3029) were considered "harmless; " and more than two-thirds (2371) were "resident with relatives." There were also, however, 1585 "neglected," 80 "living alone," and 565 "vagrant; so that there was much room for improvement, and great need of humane enactments regarding them. These figures refer only to the insane poor.

From this examination of the three proposed outlets for the chronic insane who fill

If, then, it be desirable to relieve our public asylums of their harmless incurable patients, and if intermediate or refuge asylums, workhouses or poorhouses, and private dwellings are to aid in this and to receive such patients, it must be, we think, by bringing them under better regulations and better supervision.

But the question of an increase in the discharges of unrecovered pauper patients has other aspects besides that which relates to the provision of suitable receptacles.

It has been said, for instance, that it is highly desirable to bring the propriety of detaining patients periodically, and in a formal manner, under review. Many patients who enter asylums neither recover nor die, but remain there-still insane, it is true→→→ but their bodily mental condition may have undergone great changes; and it is said that there ought to be some procedure which would force, as it were, a careful consideration of the question whether their insanity is still such as to warrant or need continued detention. To accomplish this, a change was lately introduced into the Scotch Luna