Читать книгу On the State of Lunacy and the Legal Provision for the Insane - Arlidge John Thomas - Страница 3

The only data at hand to calculate the gross increase of the insane in this country, year by year, or over a series of years, are those contained in the Official Reports of the Commissioners in Lunacy and of the Poor-Law Board. These, as we have just shown in the preceding chapter, are incomplete as records of the state of lunacy, since they take no notice of numerous patients not in recognized asylums. Moreover, the annual summary of the returns made by the Commissioners of insane patients confined in Asylums and Licensed Houses, represents a compound quantity, made up of the increment by accumulation in past years, and of the fresh cases admitted in any particular year, and remaining at its close. The same is true of the figures supplied by the Poor-Law Board. Now, though these summaries are useful to show the rate of accumulation of the insane in the various receptacles for them, annually or over any fixed period, they do not tell us how many persons are attacked by madness in any year, or other space of time; or, in other words, they do not inform us whether there is an actual increase, or a decrease in the annual number of persons becoming insane.

This question of the simple increase or decrease of insanity cannot be correctly answered. It is elucidated in some measure, so far as licensed institutions for the insane are concerned, by the tables of admission for different years furnished by the Reports of the Lunacy Commissioners; and it may be assumed to be partially answered by the returns of the number of lunatics in workhouses published by the Poor-Law Board, after an allowance made for the diminution caused by deaths which have taken place in the twelvemonth; but no means whatever exist of discovering the number of persons annually attacked with mental disorder, who do not fall under the cognizance of the public boards.

With the materials in hand, let us in the first place examine the results which follow from a comparison of the Lunacy statistics of the Commissioners, instituted at intervals of more or fewer years. By this course we shall attain, not indeed an estimate of the progressive increase of our insane population, but a valuable comparative return of the number of those enjoying the advantages of asylum care and management in different years. The summary presented in each annual report shows that there were in

From these tables it therefore appears that the accumulation of insane persons in Asylums in the ten years between 1843 and 1853, equalled 6140; and in the five years between 1853 and 1858, 4898; or progressed at the rate of 614 per annum in the ten years, and of 979·6 (or in round numbers 980) per annum in the five years under review, or upwards of 50 per cent. faster in the latter space of time.

In their Twelfth Report (1858) the Commissioners in Lunacy attempt to calculate the probable demands for asylum accommodation on the 1st of January 1860, from the increased number of lunatics in the space of one year, from January 1st, 1857, to January 1st, 1858, amounting to 915. But as we have pointed out in a paper in the “Journal of Mental Science” (vol. v. 1859, p. 249), the conclusion drawn from such data must be fallacious. For instance, a calculation on the result of one year’s statistics is evidently worth little. There are many causes at work in asylums which materially affect the relative number of admissions and discharges, and consequently produce an inequality in the rate of increase viewed year by year. Moreover, where the same plan of calculation has been adopted in determining what asylum accommodation was necessary, experience has soon exhibited the fallacy, and both the admissions and the demands for admission have far exceeded the total reckoned upon. To arrive at a nearer approximation to the truth, the augmentation in the number of lunatics ought to be noted for a space of several years; and to make the deduction more satisfactory, the increase of the general population, the conditions of the period affecting the material prosperity of the people, and its political aspects; and, lastly, the mere circumstance of the opening of new asylums, – a circumstance always followed by an unexpected influx of patients, need be taken into account.

In the preceding considerations only the returns of lunatics in Asylums, Hospitals, and Licensed Houses are discussed; but, as we have seen, there is an almost equally large number detained in workhouses, or boarded with their relatives, or other persons, at the expense of their parishes, whose increase or decrease is a matter of kindred importance. On reviewing the returns of their numbers at periods when they have been taken cognizance of by the Lunacy Commission, we find that there were in workhouses and elsewhere, together, in

exhibiting an increase of 4342 in the ten years between 1847 and 1857, and a decrease in the four between 1843 and 1847 of 1384, owing, doubtless, to the opening of new asylums during that space of time. The returns of the two classes of Pauper Lunatics together being both so infrequently made, and, as before shown (p. 8), open to criticism on account of their incompleteness, we shall attempt to arrive at a more correct estimate of increase than that just made. In the first place, with respect to Union Workhouses, the Summary of Indoor Paupers, published by the Poor Law Commission (10th Report, p. 196), affords the necessary data. According to this tabular statement, we find, that, there were on the 1st of January in each of the ensuing years the following numbers of pauper lunatics: —

These columns show, that since 1847 the minimum number of insane, at a corresponding date in each year, occurred in 1850. Once indeed since, but at a different period of the year, viz. on July 1st, 1851, the number fell to 4574, or 75 less than at the date before named. Two or three years excepted, the increment has been progressive; at one time, indeed, much more rapidly so than at another. The fluctuations observable are, in the first place, due to the opening of new, or the repletion of existing, asylum accommodation; and in a lesser degree, to the rise or fall of pauperism in the community at large, or to an increased mortality at times, as, for example, in 1849, when cholera prevailed – an event which in part, at least, explains the smaller figure of insane inmates in 1850.

But whatever the fluctuations observable year by year may be, there is a most distinct increase in the space of any five or ten years selected from the list, suggestive of the unwelcome fact that, notwithstanding the very large augmentation of asylum accommodation and the reduction of numbers by death, the rate of accumulation has proceeded in a ratio exceeding both those causes of decrease of workhouse inmates combined. Thus, to take the decennial period between 1847 and 1857, we discover an increase of just 2000, or an average annual one of 200; and, what is remarkable, as large a total increase, within a few units, is met with in the quinquennial period between 1853 and 1858, and consequently the yearly average on the decennial period is doubled; viz. 400 instead of 200. This doubling of the average in the last five years would be a more serious fact, were it not that in 1853 the number of workhouse inmates had been reduced upon 1851, and had only slightly advanced above that of 1849.

Rejecting the maximum rate of accumulation, we will calculate the average of the last three years cited, from 1855 to 1858, a period during which there has been no notable cause of fluctuation, and no such increase of population as materially to affect the result, and for these reasons better suited to the purpose. In this space of time the increment equalled 987, or an average of 329 per annum; which may fairly be considered to represent the rate of accumulation of lunatics in Union Workhouses at the present time.

The absence of returns of lunatics in the workhouses of parishes under local Acts, is an obstacle to a precise computation of them; however, on the assumption that the proportion of lunatics in those workhouses to the population (1,500,000) of the parishes they belong to, is equal to that of those in Union Workhouses to the estimated population (18,075,000) of the Unions, and that the average increase is proportionate in the two cases, this increase should equal 1⁄12th of 329, or somewhat more than 27, per annum; making the total average rate of accumulation in workhouses at large 356 annually.

Unfortunately, no separate record is regularly kept of those poor insane persons who are boarded with friends or others, and their number has been only twice published, viz. in 1847 and 1857, when, as seen in a preceding page, it was, respectively, 3465 and 5497. These two sums exhibit an increase of 2032 to have accrued in the ten years included between those dates, or an average one of 203 per annum.

We have, above, calculated the average annual increase on those in Union Workhouses and those with friends, at 434 annually; and consequently that of the latter being 203, the yearly increase of the former stands, according to the returns employed, at 231. However, we have proved that the average increase, in Union Workhouses, has reached in the last three years the amount of 329, and in workhouses at large 356, which, added to 203, produces 559, or in round numbers, 560, as the sum-total of accumulation of pauper lunatics not in Asylums, Hospitals, or Licensed Houses. Adding the annual rate of increase of the insane in Asylums, viz. 980, to that among paupers, unprovided with asylum accommodation, 560, we obtain the total accumulation per annum of 1540 lunatics reported to the public boards. To this sum there should rightly be added the accumulative increase among insane persons not known to those boards, and which, in the absence of any means to ascertain its amount, may be not extravagantly conceived to raise the total to 1600.

We come now to the second part of our present task, viz. to discover the comparative number of new cases in several past years, so as to obtain an answer to the question, – Has there been an increase of the annual number of persons attacked with lunacy during that period? for previous figures leave no doubt there is an augmented ratio of insane persons in the population of the country. At the outset of this inquiry an insuperable difficulty to a correct registration of the number arises from the circumstance that, during any term of years we may select, the accommodation for the insane has never, even for one year, been fixed, but has been progressively increased by the erection of new, and the enlargement of old asylums. This occurrence, necessarily, very materially affects the returns made by the Commissioners of the number of admissions into asylums and Licensed Houses. Even if the comparison of the annual admissions into any one County Asylum only, were of value to our purpose, the same difficulty would ensue by reason of the enlargement of the institution from time to time, and of the circumstance that, as it progressively filled with chronic cases, the number of admissions will have grown smaller. Likewise, the farther that the inquiry is extended back, the more considerable will this difficulty in the desired computation be. In short, it may be stated generally, that the proportion of admissions will vary almost directly according to the accommodation afforded by asylums, and the inducements offered to obtain it.

On the other hand, the consequences of the variations in asylum accommodation upon the total of admissions are to a certain extent compensated for by the fluctuations they produce upon the number of lunatics not provided for in asylums; for this reason, that where a County Asylum opens for the reception of patients, the majority of these are withdrawn from Licensed Houses and workhouses, and thereby a reduction is effected in the number of inmates of those establishments.

After the above considerations, it is clear that an estimate of the number of insane persons in any year, as gathered from the statistics of those brought under treatment in asylums or elsewhere, can be only an approach to the truth. Still it is worth while to see what results follow from an examination of the Returns of Admissions, as collected by the Commissioners in Lunacy. It would be of no service to extend the inquiry far backward in time, on account of the rapidity with which asylum accommodation has been enlarged; we will therefore compare the admissions over the space of four years, viz. 1854, 1855, 1856, and 1857, during which the changes in asylums have been less considerable.

Table of Admissions.

There is a remarkable degree of uniformity in the sum of admissions in each of these four years; and if each several sum could be taken to represent the accession of new cases of insanity in the course of the year, there would appear no actual progressive increase of the disease in the community during the four years considered. The average of the admissions for that period is 7579; those therefore of 1854 and 1857 are in excess, and those of 1855 and 1856 are within it. The widest difference is observed in 1857, when a sudden rise takes place, which, by the way, is not explicable by the greater provision of asylum accommodation in that year than in the three preceding. Yet this increase is not so striking when viewed in relation to the totals of other years; for it exceeds the average only by 316, a sum little greater than that expressing the decrease of 1855 upon the total of 1854.

It is difficult to decide what value should be assigned to these results, deducible from a comparison of the yearly admissions, in determining the question of the increase of insanity, viewed simply as that of the comparative number attacked year by year, – it would, however, seem a not unreasonable deduction from them, that the proportion of persons attacked by mental disorder advances annually at a rate little above what the progressive increase of population is sufficient to explain. If this be so, the increase by accumulation of chronic and incurable cases becomes so much the more remarkable, and an investigation of the circumstances promoting, and of those tending to lessen, that accumulation, so much the more important.

There are, as heretofore remarked, very many insane persons who are not sent to asylums or private houses, at least to those in this country, and whose relative number yearly it is impossible, in the absence of all specific information, to compute. Although the agitation of the public mind respecting private asylums, and the facility and economy of removing insane persons abroad, may have latterly multiplied the number of such unregistered patients, yet there is no reason to assume that their yearly positive increase is other than very small.

The pauper lunatics living in workhouses have as yet been omitted from the present inquiry. Their yearly number is affected not only by the introduction of fresh cases, but also by removals to asylums and by deaths; or, in other words, it is a compound quantity of new inmates received and of the accumulation of old. However, the returns above quoted (p. 13) show that between 1855 and 1858 there was an increase of almost exactly 1000, or, as before calculated, an average of 329 annually. The Poor Law Board Report unfortunately gives no returns of the annual admissions; hence we do not possess the means of discovering what proportion of the growing increase observed is due year by year to the accession of fresh inmates. The advancing growth in numbers of those pauper insane receiving out-door relief is not clearly discoverable: from the few data in possession, as before quoted (p. 14), about 200 are annually added.

It appears pretty clearly, then, that there are at least 1600 reported lunatics added to the insane population of the country yearly, and of this increase only 60, or 1 in 26·66, are supported out of their own resources in asylums; the remainder, with some few exceptions, falling upon the rates for their entire maintenance.

It would therefore be difficult to exaggerate the importance of the question of the provision for the insane poor in this country, both to the political economist and to the legislator. There are certainly more than 1300 persons yearly so affected in mind as to be unfit or unable to take care of themselves, and to obtain their own livelihood, and who, under this distressing infliction of Providence, demand the care and charity of their neighbours, and the succour of the State, properly to protect and provide for them. To perform this duty at the least cost, compatible with justice to these afflicted individuals, involves a tax upon the community of which few persons have any adequate conception. Supposing, by way of illustration, that the number mentioned required the accommodation of an asylum, the cost of providing it, according to the system hitherto in vogue, would nearly equal that incurred in the establishment and maintenance of the Middlesex County Asylum at Colney Hatch, or a sum of £300,000 for land, buildings, and fittings (equal, at 5 per cent. to a yearly rental of £15,000), and an annual charge of £30,000 for maintenance. The example of Colney Hatch, chosen for illustration, is a very fair one, and the figures used in round numbers are actually within the average expenditure in and for the establishment of County Asylums in this country, as may be seen on reference to Appendix D. (Commissioners’ Report, 1854), and to the table of asylums in course of erection, printed at p. 2 of their Twelfth Report (1858).

On applying these results to the total number of pauper lunatics in Asylums, which, according to the return on the 1st of January 1858, amounted to 15,000, the sum of £4,500,000 (not including interest) will have been expended in providing them accommodation, and an annual charge incurred of £450,000 for their care and maintenance. All this, too, is independent of the cost on account of those maintained in Licensed Houses, in workhouses, and in lodgings with friends or others, the amount of which we do not possess sufficient information to determine.

The Commissioners in Lunacy, in their elaborate Report in 1844, took the population of England and Wales at 16,480,082, and reckoned on the existence of 20,893 lunatics on the 1st January of that year, of whom 16,542 were paupers. The latter, they calculated, stood in the proportion of 1 to 1000 in the population, or, more correctly, 1 in 997; and the total lunatics as 1 to 790. On the 1st of January 1857, they found the pauper lunatics to be in the proportion of 1 in 701; whilst pauper and private together equalled 1 in 600, to the estimated population, 19,408,364. Adopting the figures arrived at in the preceding discussion, viz. that there are 41,000 insane persons in this country, and assuming the population on the 1st of January, 1859, to have been 19,800,000, the proportion of the insane would be as high as 1 in 483 persons.

This much-enlarged ratio of insanity to the population admits of several explanations, without a resort to the belief that the disease is actually and fearfully on the increase. As before said, we regard the accumulation of chronic and incurable lunatics to be the chief element in raising the total number, and this accumulation is favoured by all causes operating against the cure of insanity; by the increased attention to the disease, and by all those conditions improving the value of life of the insane, supplied, at the present day, in accordance with the improved views respecting their wants, and the necessity of placing them under conditions favourable for their health, care and protection. On the operation of these causes, favouring the multiplication of insane persons in the community, we shall, however, not at present further enter, but proceed to inquire how far the existing provision for the insane is adequate to their requirements.

Before entering on this inquiry, a few words are wanting to convey a suggestion or two respecting the collection of the statistics of pauper lunatics. It is most desirable we should be able to discover, from the official returns of the public boards, with precision, what number of insane persons is wholly or partially chargeable to the Poor Rates, what to Borough, and what to County Rates. The returns of the Poor-Law Office ought not to be marred by the omission of the statistics of parishes, which by local or special acts escape the direct jurisdiction of the board. If the central board be denied a direct interference in their parochial administration, it ought to be informed of the number of their chargeable poor, including lunatics. It is equally unsatisfactory, that the pauper registry kept by the Poor-Law Board is not rendered complete by the record of all those chargeable to counties and boroughs, as this could be so readily done by the clerks of county and borough magistrates.

An amendment, too, is desirable in the practice of the Poor-Law Office of reckoning together in their tables pauper lunatics in asylums among the recipients of out-door relief with those boarded with their friends or elsewhere, whence it is impossible to gather the proportion of such class. This technicality of considering workhouse inmates as the only recipients of in-door relief, to the exclusion of asylum patients who are in reality receiving it in an equal degree, although in another building than the workhouse, is an official peculiarity we can neither explain nor approve; and it appears to us most desirable that lunatic paupers in asylums should be arranged in a distinct column, and that the same should be done with those living with their friends or others. By the adoption of this plan the questions of the number of the pauper insane, of their increase and decrease, whether in asylums or elsewhere, and of the adequacy of accommodation for them, could be ascertained by a glance at the tables. We would likewise desire to see those paupers belonging to parishes not in union and under Local Acts, and those chargeable to Counties and Boroughs, tabulated in a similar manner.

A practical suggestion, connected with the statistics of insanity, we owe to Mr. Purdy, viz. that section 64 of the “Lunatic Asylums’ Act, 1853” (16 & 17 Vict. cap. 97) should be amended by the insertion of a few words requiring the clerks of unions to make the returns of the number of chargeable lunatics on a specified day, as on the first of January in each year. This practice was formerly enjoined, and probably its omission from the Act now in force was accidental. The present enactment requires that the clerks of unions “shall, on the first day of January in every year, or as soon after as may be, make out and sign a true and faithful list of all lunatics chargeable to the union or parish;” and the only alteration required is the addition of two or three words at the end of this paragraph, such as: – ‘on the first day of January of that year.’ The want of a fixed date of this kind, Mr. Purdy says, imposes great trouble in getting the clerks to make their returns with reference to the same day in the several unions and parishes.