Читать книгу On the State of Lunacy and the Legal Provision for the Insane - Arlidge John Thomas - Страница 6

In the preliminary chapters on the number and increase of the insane in this country, we limited ourselves to determine what that number and that increase were, and entered into no disquisition respecting the causes which have operated in filling our asylums with so many thousands of chronic and almost necessarily incurable patients. Nor shall we now attempt an investigation of them generally, for this has been well done by others, and particularly by the Lunacy Commissioners in their Ninth Report, 1855; but shall restrict ourselves to intimate that the increase of our lunatic population, mainly by accumulation, is due to neglect in past years; to the alteration of the laws requiring the erection of County Asylums for pauper lunatics generally; to the collection and discovery of cases aforetime unthought of and unknown; to the extension of the knowledge of the characters and requirements of the insane both among professional men and the public; and, lastly, to the advantages themselves of asylum accommodation which tend to prolong the lives of the inmates.

Such are among the principal causes of the astounding increase in the number of the insane of late years, relatively to the population of the country, some of which fortunately will in course of time be less productive. Those, however, which we now desire to investigate, are such as directly affect the curability of insanity, either by depriving its victims of early and efficient treatment, or by lessening the efficiency and usefulness of the public asylums.

The history of an insane patient is clearly divisible into three portions: 1st, that before admission into an asylum; 2nd, that of his residence in an asylum; and 3rd, of that after his discharge from it. The last division we have at present nothing to do with; and with reference to the causes influencing his curability, these group themselves under two heads parallel to the first two divisions of the patient’s history; viz. 1, those in operation external to, and 2, those prevailing in, asylums.

A. Causes external to Asylums

The chief cause belonging to this first class is that of delay in submitting recent cases to asylum care and treatment. This delay, as we have sufficiently proved, operates most seriously by diminishing the curability of insanity, and thereby favours the accumulation of chronic lunatics. It takes place in consequence either of the desire of friends to keep their invalid relatives at their homes; or of the economical notions of Poor-Law Officers, who, to avoid the greater cost of asylums, detain pauper lunatics in workhouses. Other causes of incurability and of the accumulation of incurables are found in injudicious management and treatment before admission, and in the transmission of unfit cases to asylums. To discuss the several points suggested in these considerations will require this chapter to be subdivided; and first we may treat of the Detention of Patients in their own homes.

§ Detention of Patients in their own homes

Although the immense importance of early treatment to recent cases of insanity is a truth so well established and so often advocated, yet the public generally fail to appreciate it, and from unfortunate notions of family discredit, from false pride and wounded vanity, delay submitting their afflicted relatives to efficient treatment. Unless the disorder manifest itself by such maniacal symptoms that no one can be blind to its real character, the wealthier classes especially will shut their eyes to the fact they are so unwilling to recognize, and call the mental aberration nervousness or eccentricity; and as they are unwilling to acknowledge the disorder, so are they equally indisposed to subject it to the most effectual treatment, by removing the patient from home, and the exciting influence of friends and surrounding circumstances in general, to a properly organized and managed asylum. Usually a patient with sufficient resources at command, is kept at home as long as possible, at great cost and trouble; and if he be too much for the control of his relatives and servants, attendants are hired from some Licensed House to manage him; the only notion prevailing in the minds of his friends being that means are needed to subdue his excitement and to overcome his violence. There are, in fact, no curative agencies at work around him, but on the contrary, more or fewer conditions calculated to exalt his furor, to agitate and disquiet his mind, and to aggravate his malady. The master of the house finds himself checked in his will; disobeyed by his servants; an object of curiosity, it may be, of wonder and alarm; and sadly curtailed in his liberty of action. The strange attendants forced upon him are to be yielded to only under passionate protests, and probably after a struggle. In all ways the mental disorder is kept up if not aggravated, and every day the chances of recovery are diminished. Perhaps matters may grow too bad for continued residence at home, or the malady have lasted so long, that the broken-up state of family and household can no longer be tolerated, and a transfer from home is necessitated. Yet even then removal to an asylum, – the only step which can hold out a fair prospect of recovery, is either rejected as quite out of the question, or submitted to usually after still longer delay, – a “trial” being made of a lodging with a medical man or other person, probably with an asylum attendant. By this plan certainly the patient is saved from the presence and excitement of his family, and placed under altered conditions, calculated to exercise in some respects a salutary influence on his mind; still many others are wanting, and no guarantee is attainable of the manner in which he is treated; for as a single patient, and as is usually the case, restrained without certificates, he is almost invariably unknown to the Commissioners, and virtually unprotected, even though a medical man be paid to attend him occasionally. At last, however, except for a few, the transfer to the asylum generally becomes inevitable, and too often too late to restore the disordered reason; and years of unavailing regret fail to atone for time and opportunity lost.

The same unwillingness to subject their insane friends to asylum care and treatment pervades, moreover, the less wealthy classes, and even the poorer grades of the middle class of society. Madness, to their conceptions likewise, brings with it a stigma on the family, and its occurrence must, it is felt, be kept a secret. Hence an asylum is viewed as an evil to be staved off as long as possible, and only resorted to when all other plans, or else the pecuniary means, are exhausted. If it be the father of the family who is attacked, the hope is, that in a few days or weeks he may resume his business or return to his office, as he might after ordinary bodily illness, without such loss of time as shall endanger his situation and prospects, and without the blemish of a report that he has been the inmate of a madhouse. If it be the wife, the hope is similar, that she will shortly be restored to her place and duties in her family. Should progress be less evident than desired, a change away from home will probably be suggested by the medical attendant, and at much expense and trouble carried out. But too frequently, alas! the hopes are blighted and the poor sufferer is at length removed with diminished chance of cure to an asylum.

For the poorer members of the middle class, and for many moving in a somewhat higher circle of society, whom the accession of mental disorder impoverishes and cuts off from independence, there are, it is most deeply to be regretted, few opportunities of obtaining proper asylum care and treatment. In very many instances, the charges of even the cheapest private asylum can be borne for only a limited period, and thus far, at the cost of great personal sacrifices and self-denial. Sooner or later no refuge remains except the County Asylum, where, it may be, from the duration of his disorder, the patient may linger out the remainder of his days. How happy for such a one is it – a person unacquainted with the system of English County Asylums, might remark – that such an excellent retreat is afforded! To this it may be replied, that the public asylum ought not to be the dernier ressort of those too poor to secure the best treatment and care in a well-found private establishment, and yet too respectable to be classed and dealt with as paupers entirely and necessarily dependent on the poor’s rate. Yet so it is under the operation of the existing law and parochial usages, there is no intermediate position, and to reap the benefits of the public asylum, the patient must be classed with paupers and treated as one. His admission into it is rendered as difficult, annoying, and degrading as it can be. His friends, worn out and impoverished in their charitable endeavours to sustain him in his independent position as a private patient, are obliged to plead their poverty, and to sue as paupers the parish officials for the requisite order to admit their afflicted relative to the benefits of the public asylum as a Pauper Lunatic. In short, they have to pauperize him; to announce to the world their own poverty, and to succumb to a proceeding which robs them of their feelings of self-respect and independence, and by which they lose caste in the eyes of their neighbours. As for the patient himself, unless the nature and duration of his malady have sufficiently dulled his perception and sensibilities, the consciousness of his position as a registered pauper cannot fail to be prejudicial to his recovery; opposed to the beneficial influences a well-regulated asylum is calculated to exert, and to that mental calm and repose which the physician is anxious to procure.

In the class of cases just sketched, we have presumed on the ability of the friends to incur the cost of private treatment for a longer or shorter period; but many are the persons among the middle classes, who if overtaken by such a dire malady as insanity, are almost at once reduced to the condition of paupers and compelled to be placed in the same category with them. As with the class last spoken of, so with this one, the law inflicts a like injury and social degradation, and at the same time operates in impeding their access to proper treatment.

No one surely, who considers the question, and reflects on the necessary consequences of the present legal requirement that, for a lunatic to enjoy the advantages of a public asylum, towards which he may have for years contributed, he must be formally declared chargeable to the rates as a pauper, – can deny the conclusion that it is a provision which must entail a social degradation upon the lunatic and his family, and act as a great impediment to the transmission of numerous recent cases to the County Asylum for early treatment.

It will be urged as an apology for it, that the test of pauperism rests on a right basis; that it is contrived to save the rate-payer from the charge of those occupying a sphere above the labouring classes, who fall, as a matter of course, upon the parochial funds whenever work fails or illness overtakes them. It is, in two words, a presumed economical scheme. However, like many other such, it is productive of extravagance and loss, and is practically inoperative as a barrier to the practice of imposition. If it contributes to check the admission of cases at their outbreak into asylums, as no one will doubt it does, it is productive of chronic insanity and of permanent pauperism; and, therefore, besides the individual injury inflicted, entails a charge upon the rates for the remaining term of life of so many incurable lunatics.

If, on the contrary, our public asylums were not branded by the appellation “Pauper;” if access to them were facilitated and the pauperizing clause repealed, many unfortunate insane of the middle class in question, would be transmitted to them for treatment; the public asylum would not be regarded with the same misgivings and as an evil to be avoided, but it would progressively acquire the character of an hospital, and ought ultimately to be regarded as a place of cure, equivalent in character to a general hospital, and as entailing no disgrace or discredit on its occupant.

The Commissioners in Lunacy, in their Ninth Report (1855, p. 35), refer to the admissions into County Asylums, of patients from the less rich classes of society reduced to poverty by the occurrence of the mental malady, and hint at their influence in swelling the number of the chronic insane, owing to their transfer not taking place until after the failure of their means and the persistence of their disorder for a more or less considerable period. This very statement is an illustration in point; for the circumstance deplored is the result of the indisposition on the part of individuals to reduce their afflicted relatives to the level of paupers by the preliminaries to, and by the act of, placing them in an asylum blazoned to the world as the receptacle for paupers only; an act, whereby, moreover, they advertise to all their own poverty, and their need to ask parish aid for the support of their poor lunatic kindred.

On the continent of Europe and in the United States of America we obtain ample evidence that the plan of pauperizing patients in order to render them admissible to public asylums, is by no means necessary. Most continental asylums are of a mixed character, receiving both paying and non-paying inmates, and care is taken to investigate the means of every applicant for admission, and those of his friends chargeable by law with his maintenance. Those who are paid for are called “pensioners” or boarders, and are divided into classes according to the sum paid, a particular section of the asylum being assigned to each class. Besides those pensioners who pay for their entire maintenance, there are others whose means are inadequate to meet the entire cost, and who are assessed to pay a larger or smaller share of it. Lowest in the scale of inmates are those who are entirely chargeable to the departmental or provincial revenue, being devoid of any direct or indirect means of support. Probably the machinery of assessment in the continental states might not accord with English notions and be too inquisitorial for adoption in toto; but at all events, on throwing open public asylums for the reception of all lunatics who may apply for it, without the brand of pauperism being inflicted upon them, some scheme of fairly estimating the amount they ought to contribute to their maintenance should be devised. For the richer classes a plan of inquisition into their resources is provided, and there seems no insuperable difficulty in contriving some machinery whereby those less endowed with worldly goods might, at an almost nominal expense, have their means duly examined and apportioned to their own support and that of their families. Overseers and relieving officers are certainly not the persons to be entrusted with any such scheme, nor would we advocate a jury, for in such inquiries few should share; but would suggest it as probably practicable that the amount of payment might be adjudged by two or three of the Committee of Visitors of the Asylum with the Clerk of the Guardians of the Union or Parish to which the lunatic belonged.

In the United States of America, every tax-payer and holder of property is entitled as a tax-payer, when insane, to admission into the Asylum of the State of which he is a citizen. He is considered as a contributor to the erection and support of the institution, and as having therefore a claim upon its aid if disease overtake him. The cost of his maintenance is borne by the township or county to which he belongs, and the question of his means to contribute towards it is determined by the county judge and a jury. Most of the asylums of the Republic also receive boarders at fixed terms, varying according to the accommodation desired; hence there are very few private asylums in the States. In the State of New York there is a special legal provision intended to encourage the early removal of recent cases to the asylum; whereby persons not paupers, whose malady is of less than one year’s duration, are admitted without payment, upon the order of a county judge, granted to an application made to him, setting forth the recent origin of the attack and the limited resources of the patient. Such patients are retained two years, at the end of which time they are discharged, their friends being held responsible for the removal. Their cost in the asylum is defrayed by the county or parish to which they belong.

We have said above, that the requirement of the declaration of pauperism is ineffectual in guarding the interests of the rate-payer against the cost of improper applicants. Indeed, the proceeding adopted to carry it out is both absurd and useless, besides being, as just pointed out, mischievous in its effects.

In the interpretation clause of “the Lunatic Asylums’ Act, 1853,” it is ordered that a “Pauper shall mean every person maintained wholly or in part by, or chargeable to, any Parish, Union, or County.” Hence when insanity overtakes an unfortunate person who is not maintained by a parish or union, it is required that he be made chargeable to one, or, as we have briefly expressed the fact, that he be pauperized. To effect this object, the rule is, that the patient shall reside at least a day and a night in a workhouse. This proceeding, we repeat, carries absurdity on the face of it. Either it may be a mere farce privately enacted between the parish officers and the friends of the patient, to the complete frustration of the law so far as the protection of the rate-payers is contemplated; or, it may be made to inflict much pain and annoyance on the applicants by the official obstructiveness, impertinent curiosity, obtuseness, and possible ill-feeling of the parish functionaries in whose hands the law has practically entrusted the principal administration of the details regulating the access to our public asylums.

It is no secret among the superintendents of County Asylums, that by private arrangements with the overseers or guardians of parishes, cases gain admission contrary to the letter and spirit of the law, and to the exclusion of those who have legally a prior and superior claim. We have, indeed, the evidence of the Lunacy Commissioners, to substantiate this assertion. In their Ninth Report (1855, p. 34) they observe, – “In some districts a practice has sprung up, by which persons, who have never been themselves in receipt of parochial relief, and who are not unfrequently tradesmen, or thriving artisans, have been permitted to place lunatic relations in the County Asylums, as pauper patients, under an arrangement with the guardians for afterwards reimbursing to the parish the whole, or part, of the charge for their maintenance. This course of proceeding is stated to prevail to a considerable extent in the asylums of the metropolitan counties, and its effect in occupying with patients, not strictly or originally of the pauper class, the space and accommodations which were designed for others who more properly belong to it, has more than once been made the subject of complaint.”

Desiring, as we do, to see our County Asylums thrown open to the insane generally, by the abolition of the pauper qualification, it is rather a subject of congratulation that cases of the class referred to do obtain admission into them, even when contrary to the letter of the law. But we advance the quotation and assertion above to show, that the pauperizing provision of the Act is ineffective in the attainment of its object; and to remark, that the opportunities at connivance it offers to parochial officials, must exercise a demoralizing influence and be subversive of good government. If private arrangements can be made between the applicants for an assumed favour, and parish officers, who will undertake to say that there shall not be bribery and corruption?

Sufficient, we trust, has been said to demonstrate the evils of the present system of pauperizing patients to qualify them for admission into County Asylums, and the desirability of opening those institutions to all lunatics of the middle classes whose means are limited, and whose social position as independent citizens is jeopardized by the existence of their malady. This class of persons, as before said, calls especially for commiseration and aid; being so placed, on the one hand, that their limited means must soon fail to afford them the succour of a private asylum; and on the other, with the door of the public institution closed against them, except at the penalty of pauperism and social degradation.

What we would desire is, that every recent case of insanity should at once obtain admission into the public asylum of the county or borough, if furnished with the necessary medical certificates and with an order from a justice who has either seen the patient or received satisfactory evidence as to his condition (see remarks on duties of district medical officers), and obtained from the relatives an undertaking to submit to the assessment made by a commission as above proposed, or constituted in any other manner thought better; or the speedy admission of recent cases might otherwise be secured by prescribing their attendance and that of their friends before the weekly Committee of the Visitors of the Asylum, by whom the order for reception might be signed on the requisite medical certificates being produced, and the examination for the assessment of the patient’s resources formally made, with the assistance possibly of some representative of the parish interests, – such for instance as the Clerk to the Board of Guardians.

In the County Courts the judges are daily in the habit of ordering periodical payments to be made in discharge of debts upon evidence offered to them of the earnings or trade returns of the debtor; and there seems no a priori reason against the investigation of the resources of a person whose friends apply for his admission into a County Asylum. It is for them to show cause why the parish or county should assume the whole or the partial cost of the patient’s maintenance, and this can be done before the Committee of the Asylum or any private board of inquiry with little annoyance or publicity. Rather than raise an obstacle to the admission of the unfortunate sufferer, it would be better to receive him at once and to settle pecuniary matters afterwards.

We must here content ourselves with this general indication of the machinery available for apportioning the amount of payment to be made on account of their maintenance by persons not paupers, or for determining their claim upon the Asylum funds. Yet we cannot omit the opportunity to remark that the proceedings as ordered by the existing statute with a similar object are incomplete and unsatisfactory. These proceedings are set forth in sects. xciv. and civ. (16 & 17 Vict. cap. 97). The one section of the Act is a twin brother to the other, and it might be imagined by one not “learned in the law,” that one of the two sections might with little alteration suffice. Be this as it may, it is enacted that if it appear to two Justices (sect. xciv.) by whose order a patient has been sent to an asylum, or (sect. civ.) “to any Justice or Justices by this Act authorized to make any order for the payment of money for the maintenance of any Lunatic, that such Lunatic” has property or income available to reimburse the cost of his maintenance in the asylum, such Justices (sect. xciv.) shall apply to the nearest known relative or friend for payment, and if their notice be unattended to for one month, they may authorize a relieving officer or overseer to seize the goods, &c. of the patient, whether in the hands of a trustee or not, to the amount set forth in their order. Sect. civ. makes no provision for applying to relatives or friends in the first instance, but empowers the justice or justices to proceed in a similar way to that prescribed by sect. xciv., to repay the patient’s cost; with the additional proviso that, besides the relieving officer or overseer, “the Treasurer or some other officer of the County to which such Lunatic is chargeable, or in which any property of the Lunatic may be, or an officer of the Asylum in which such Lunatic may be,” may proceed to recover the amount charged against him.

Concerning these legal provisions, we may observe, that the state of the lunatic’s pecuniary condition is left to accidental discovery. The justices signing the order of admission (sect. xciv.) have no authority given them to institute inquiries, although they may learn by report that the patient for whom admission is solicited is not destitute of the means of maintenance. Nor are the justices who make the order for payment (sect. civ.) in any better position for ascertaining facts. There is, in short, no authorized and regular process for investigating the chargeability of those who are not actually in the receipt of parochial relief on or before application for their admission into the County Asylum, or who must necessarily be chargeable by their social position when illness befalls them. Again, according to the literal reading of the sections in question, no partial charge for maintenance can be proposed; no proportion of the cost can be assessed, where the patient’s resources are unequal to meet the whole. Lastly, the summary process of seizing the goods or property of any sort, entrusted to those who are most probably the informers of the justices, namely overseers and relieving officers; and, by sect. civ., carried out without any preliminary notice or application, and without any investigation of the truth of the reports which may reach the justices, is certainly a proceeding contrary to the ordinary notions of equity and justice.

§ Detention of Patients in Workhouses

In the case of the insane poor, whose condition, circumstances, and social position have been such that whenever any misfortune, want of work, or sickness has overtaken them, the workhouse affords a ready refuge, the requirement of pauperization to qualify for admission to the County Asylum is in itself no hardship and no obstacle to their transmission to it. Probably the prevailing tactics of parish officers may at times contribute to delay the application for relief, but the great obstacle to bringing insane paupers under early and satisfactory treatment in the authorized receptacle for them – the County Asylum, is the prevalence of an economical theory respecting the much greater cheapness of workhouse compared with asylum detention. The practical result of this theory is, that generally where a pauper lunatic can by any means be managed in a workhouse, he is detained there. If troublesome, annoying, and expensive, he is referred to the County Asylum; this is the leading test for the removal; the consideration of the recent or chronic character of his malady is taken little or no account of.

In fresh cases the flattering hope is that the patients will soon recover, and that the presumed greater cost of asylum care can be saved; in old ones the feeling is that they are sufficiently cared for, if treated like the other pauper inmates, just that amount of precaution being attempted which may probably save a public scandal or calamity.

To the prevalence of these economical notions and practice may be attributed the large number of lunatics detained in workhouses (nearly 8000), and the equally large one living with their friends or others. Now it is very desirable to inquire whether these theories of the superior economy of workhouses compared with asylums as receptacles for the insane, are true and founded on facts. This question is in itself twofold, and leaves for investigation, first, that of the mere saving in money on account of maintenance and curative appliances; and secondly, that of the comparative fitness or unfitness, the advantages or disadvantages, the profit or loss, of the two kinds of institutions in relation to the welfare, the cure, and the relief of the poor patients placed in them. These questions press for solution in connexion with the subject of the accumulation of lunatics and the means to be adopted for its arrest, or, what is equivalent to this, for promoting the curability of the insane.

On making a comparative estimate of charges, it is essential to know whether the same elements of expenditure are included in the two cases; if the calculated cost per head for maintenance in workhouses and asylums respectively comprises the same items, and generally, if the conditions and circumstances so far as they affect their charges are rightly comparable. An examination we are confident, will prove that in no one of these respects are they so.

In the first place, the rate of maintenance in an asylum is calculated on the whole cost of board, clothing, bedding, linen, furniture, salaries, and incidental expenditure; that is, on the total disbursements of the establishment, exclusive only of the expenditure for building and repairs, which is charged to the county. On the contrary, the “in-maintenance” in workhouses comprises only the cost of food, clothing, and necessaries supplied to the inmates (see Poor-Law Board Tenth Report, p. 144). The other important items reckoned on in fixing the rate of cost per head in asylums are charged to the “establishment” account of the workhouse, and are omitted in the calculation of the rate of maintenance. Reference to the Tables given in the Poor-Law Board Returns (Tenth Report, p. 61, sub-column e and a portion of f) will prove that the expenditure on account of those other items must be nearly or quite equal to that comprehended under the head of “in-maintenance” cost.

We have no means at hand to calculate with sufficient precision what sum should be added to the “in-maintenance” cost of paupers per head in workhouses, but it is quite clear that the figures usually employed to represent it, cannot be rightly compared with those exhibiting the weekly charge of lunatics in asylums. At the very least half as much again must be added to a workhouse estimate before placing it in contrast with asylum cost.

Since the preceding remarks were written, Dr. Bucknill has favoured us with the Thirteenth Report of the Devon Asylum, in which he has discussed this same question and illustrated it by a special instance. To arrive at the actual cost of an adult sane pauper in a union-house, he gathered “the following particulars relative to the house of the St. Thomas Union in which this asylum is placed; a union, the population of which is 49,000, and which has the reputation of being one of the best managed in the kingdom. The cost of the maintenance of paupers in this union-house is 2s. 6d. per head, per week, namely, 2s. 2d. for food and 4d. for clothing. The establishment charges are 1s. 0½d. per head, per week, making a total of 3s. 6½d. for each inmate. The total number of pauper inmates during the twelfth week of the present quarter was 246; and of these 116 were infants and children, and 130 youths above sixteen and adults. A gentleman intimately acquainted with these accounts, some time since calculated for me that each adult pauper in the St. Thomas’s Union-house cost 5s. a week. Now the average cost of all patients in the Devon Asylum at the present time is 7s. 7d., but of this at least 2s. must be set down to the extra wages, diet, and other expenses needful in the treatment of the sick, and of violent and acute cases, leaving the cost of the great body of chronic patients at not more than 5s. 7d. a week. Now if a sane adult pauper in a union-house costs even 4s. 6d. a week, is it probable that an insane one would cost less than 5s. 7d.? For either extra cost must be incurred in his care, or he must disturb the discipline of the establishment, and every such disturbance is a source of expense.”

This quotation is really a reiteration of Dr. Bucknill’s conclusions as advanced in 1857, in an excellent paper in the ‘Asylum Journal’ (vol. iv. p. 460), and as a pendent to it the following extract from this paper is appropriate; viz. “that the cost of a chronic lunatic properly cared for, and supplied with a good dietary, in a County Asylum, is not greater than that of a chronic lunatic supplied with a coarse and scanty dietary, and detained in neglect and wretchedness as the inmate of a union workhouse.”

Another most important circumstance to be borne in mind when the cost of workhouses and asylums is contrasted, is that in the former establishments more than two-thirds of the inmates are children. Thus the recipients of in-door relief on the 1st of January, 1858, consisted, according to the Poor-Law Returns, of 74,141 adults, and 50,836 children under sixteen years of age. Now as the rate of maintenance is calculated on the whole population of a workhouse, adults and children together, it necessarily follows that it falls much within that of asylums, in which almost the whole population is adult. This very material difference in the character of the inmates of the two institutions may fairly be valued as equivalent to a diminution of one-fourth of the expense of maintenance in favour of workhouses; and without some such allowance, the comparison of the cost per head in asylums and union-houses respectively is neither fair nor correct.

Again, there is another difference between asylums and workhouses, which tells in favour of the latter in an economical point of view, whilst it proves that the expenditure of the two is not rightly comparable without making due allowance for it along with the foregoing considerations. This difference subsists in the character of the two institutions respectively; namely, that in the asylum the movements of the population are slight, whereas in the workhouse they are very considerable by the constant ingress and egress of paupers; driven to it by some passing misfortune or sickness, it may be for a week or two only or even less, and discharging themselves so soon as the temporary evil ceases to operate or the disorder is overcome: for the poor generally, except the old and decrepit who cannot help themselves, both dread a lodging in the workhouse, and escape from it as soon as possible; in fact, even when they have no roof of their own to shelter them, they will often use the union accommodation only partially, leaving it often by day and returning to it by night. All this implies a large fluctuation of inmates frequently only partially relieved, whether in the way of board or clothing; and consequently when the average cost per head of in-door paupers is struck, it appears in a greater or less degree lower than it would have done had the same constancy in numbers and in the duration and extent of the relief afforded prevailed as it does in asylums.

The effect of the fluctuations in population in union-houses ought, we understand, to be slight, if the “Orders in Council” laid down to guide parochial authorities in the calculation of the cost of their paupers, were adhered to; viz. that for all those belonging to any one parish in union, who may have received in-door relief during the year or for any less period of time, an equivalent should be found representing the number who have been inmates throughout the year; or the total extent of relief be expressed by estimating it to be equal to the support of one hypothetical individual for any number of years equivalent to the sum of the portions of time the entire number of the paupers of the particular parish received the benefits of the establishment. We do not feel sure that these plans of calculating the cost per head are faithfully and fully executed; the rough method of doing so, viz. by taking the whole cost of “in-maintenance” at the end of the year and dividing it by the number of its recipients, and assuming the quotient to represent the expenditure for each. Whether this be the case or not, these daily changes among its inmates, the frequent absence of many for a great part of the day and the like, are to be enumerated among the circumstances which tend to keep down expenditure of workhouses; and which are not found in asylums.

There is yet another feature about workhouses which distinguishes them from asylums, and is of considerable moment in the question of the comparative cost of maintenance in the two: this is, the circumstance of the population of workhouses being of a mixed character, of which the insane constitute merely a small section; while, on the contrary, that of asylums is entirely special, and each of its members to be considered a patient or invalid demanding particular care and special appliances. Therefore, a priori, no comparison as to their expenditure can justly be drawn between two institutions so dissimilar. Yet even this extent of dissimilarity between them is not all that exists; for the union-house is so constituted by law as to serve as a test of poverty; to offer no inducements to pauperism, and to curtail the cost of maintenance as far as possible. It has properly no organization for the detention, supervision, moral treatment and control, nor for the nursing or medical care of the insane; and when its establishment is attempted it is a step at variance with its primary intention, and involves an extra expenditure.

Consequently, before overseers or guardians can with any propriety contrast the workhouse charges of maintenance with those of asylums, it is their business to estimate what an adult pauper lunatic costs them per week, instead of, as usual, quoting the cost per head calculated on the whole of the inmates, old and young, sane and insane.

Once more, even after a fair estimate of the cost of an adult insane inmate of a workhouse is obtained, there is still another differential circumstance favourable to a less rate than can be anticipated in asylums; for this reason: – that in the former institutions the practice is to reject all violent cases, the major portion of recent ones, and, generally, all those who give particular annoyance and trouble; whilst the latter is, as it rightly should be, regarded as the fitting receptacle for all such patients; – that is, in other words, those classes of patients which entail the greatest expense are got rid of by the workhouses and undertaken by the asylums.

Dr. Bucknill has well expressed the same circumstances we have reviewed, in the following paragraph (Report, Devon Asylum, 1858, p. 13): – “In estimating the cost of lunatic paupers in asylums, the important consideration must not be omitted, that the charge made for the care and maintenance of lunatics in County Asylums is averaged upon those whose actual cost is much greater, and those whose actual cost is less than the mean; so that it would be unfair for the overseers of a parish to say of any single patient that he could be maintained for a smaller sum than that charged, when the probability is that there are or have been patients in the asylum from the same parish, whose actual cost to the asylum has been much greater than that charged to the parish. I have shown, that the actual cost of chronic patients in an asylum exceeds that of adult paupers in union-houses to a much smaller extent than has been stated: but if all patients of this description were removed from the asylum, the inevitable result must be that the average cost of those who remained would be augmented, so that the pecuniary result to the parishes in the county would be much the same. The actual cost of an individual patient, if all things are taken into calculation, is often three or four times greater than the average. Leaving out of consideration the welfare of the patients, it would be obviously unfair to the community, that a parish having four patients in the asylum, the actual cost of two of whom was 12s. a week, and of the other two only 4s. a week, should be allowed to remove the two who cost the smaller sum, and be still permitted to leave the other two at the average charge of 8s.”

The conclusion of the whole matter is, that cæteris paribus, i. e. supposing workhouses to be equally fitting receptacles for the insane as asylums, the differential cost of the two can only be estimated when it is ascertained that the items of maintenance are alike in the two, and after that an allowance is made for the different characters of their population and of their original purpose; that is, in the instance of workhouses, for the very large number of juvenile paupers; for the great fluctuations in the residents; for the mixed character of their inmates, of sane and insane together, and the small proportion of insane, and for the exclusion of the most expensive classes of such patients. Let these matters be fairly estimated, and we doubt much if, even primâ facie, it can be shown that the workhouse detention of pauper lunatics is more economical than that of properly constructed and organized asylums.

Should we even be so far successful as to make Poor-Law Guardians and Overseers perceive that the common rough-and-ready mode of settling the question of relative cost in asylums and workhouses, by contrasting the calculated rate per head for in-door relief with that for asylum care, is not satisfactory; we cannot cherish the flattering hope that they will be brought to perceive that, simply in an economical point of view, no saving at all is gained by the detention of the insane in workhouses. Those Poor-Law officials generally are so accustomed to haggle about fractional parts of a penny in voting relief, to look at an outlay of money only with reference to the moment, forgetful of future retribution for false economy, and to handle the figures representing in their estimate the economical superiority of the workhouse for the insane, when they desire to silence an opponent; – that the task of proving to them that their theory and practice are wrong, is equivalent to the infelicitous endeavour to convince men against their will.

Still, however unpromising our attempt may appear, it is not right to yield whilst any legitimate arguments are at hand; and our repertory of them, even of those suited to a contest concerning the pounds, shillings, and pence of the matter, is not quite exhausted; for we are prepared to prove, that asylum accommodation can be furnished to the lunatic poor at an outlay little or not at all exceeding that for workhouses.

Now this point to be argued, the cost of asylum construction, is not, like the foregoing considerations, chiefly the affair of Poor-Law Guardians and Overseers, but concerns more particularly the County Magistrates, inasmuch as it is defrayed out of the County instead of the Poor Rate. But although this is the case, there is no doubt that the very great expense of existing asylums has acted as an impediment to the construction of others, and has seemed to justify, to a certain extent, the improper detention of many insane persons in workhouses: for, on one side, asylums are found to have cost for their construction and fittings, £150, £200, and upwards per head, whilst on the other, workhouses are built at the small outlay, on an average, of eighty-six such establishments, of £22 per head. The “Return” made to the House of Commons, June 15, 1857, “of the cost of building Workhouses in England and Wales, erected since 1840,” shows indeed a very wide variation of cost in different places, from £13 per head for the Congleton Union House; £14 for the Erpingham; £16 for the Stockton and Tenterden, to £47 for the Kensington; £50 for the Dulverton; £59 for the City of London; £60 for St. Margaret Westminster; and £113 for the Paddington. This enormous difference of expenditure on workhouse lodging, – for, unlike asylum costs, it does not include fittings, extending from £13 to £113 per inmate, – is really inexplicable, after allowing for the varying ideas of parish authorities as to what a workhouse should be, and for the slight differences in the cost of building materials and labour in some parts of the country than in others. Either some workhouses must be most miserable and defective habitations even for paupers, or others must be very extravagant and needlessly expensive in their structure.

There is this much to be said in explanation of the contrast of cost in different workhouses, that in those belonging to large town populations, infirmary accommodation becomes an item of importance and involves increased expenditure, whilst in those situated in agricultural districts, this element of expense is almost wanting. Moreover it is in town workhouses generally that lunatic inmates are found, who, if not in the infirmary, are lodged in special wards, often so constructed as to meet their peculiar wants, and therefore more costly than the rest of the institution occupied by the ordinary pauper inmates. This is the same with saying that where workhouses are used as receptacles for the insane, it greatly enhances the cost of their construction.

It will be evident to every thinking person that the costs of asylum and of workhouse construction are not fairly comparable. The asylum is a special building; an instrument of treatment; peculiarly arranged for an invalid population, affording facilities for classification, recreation, and amusements; and fitted with costly expedients for warming and ventilation; whereas the workhouse is essentially a refuge for the destitute, necessarily made not too inviting in its accommodation and internal arrangements; suited to preserve the life of sound inmates who need little more than the shelter of a roof and the rude conveniences the majority of them have been accustomed to. Now these very characteristics of workhouses are among the best arguments against the detention of lunatics within these buildings; but of these hereafter.

There is doubtless a permissible pride in the ability to point to a well-built asylum, commanding attention by its dimensions and architectural merits, and we would be the last to decry the beauties and benefits of architecture, and know too, that an ugly exterior may cost as much or more than a meritorious one; yet we must confess to misgivings that there has been an unnecessary and wasteful expenditure in this direction. Nevertheless it is with asylums as with railways, the present race of directors are reaping instruction from the extravagances and errors its predecessors fell into.

The change of opinion among all classes respecting the character and wants of the insane and their mode of treatment, is of itself so great, that many of the structural adaptations and general dispositions formerly made at great cost, are felt to be no longer necessary, and the very correct and happy persuasion daily gains ground, that the less the insane are dealt with as prisoners, and treated with apprehension and mistrust, the more may their accommodation be assimilated to that of people in general, and secured at a diminished outlay.

All this suggests the possibility of constructing asylums at a much less cost than formerly, and of thereby lessening the force of one of the best pleas for using workhouses as receptacles for the insane. The possibility of so doing has been proved both theoretically and practically. In an essay ‘On the Construction of Public Asylums,’ published in the “Asylum Journal” for January 1858 (vol. iv. p. 188), we advocated the separation of the day- from the night-accommodation of patients, and the abolition of the system of corridors with day- and sleeping-rooms, or, as we briefly termed it, “the ward-system,” and showed that by so doing a third of the cost of construction might be saved, whilst the management of the institution would be facilitated, and the position of the patients improved. By a careful estimate, made by a professional architect, with the aid of the necessary drawings, for a building of considerable architectural pretension, it was calculated that most satisfactory, cheerful, and eligible accommodation could be secured, including farm-buildings, and fittings for warming, ventilation, drainage, gas, &c., at the rate of £90 per head for patients of all classes, or at one-half of the ordinary cost.

Experience has shown that chronic lunatics, at least, can be accommodated in an asylum at a lower rate, in fact, at little more than half the expense that we calculated upon.

Like other County Asylums, the Devon became filled with patients; still they came, and after attempts to cram more into the original edifice, by slight alterations, and by adding rooms here and there, it was at length found necessary to make a considerable enlargement. Instead of adding floors or wings to the old building, which would have called for a repetition of the same original expensive construction of walls, and of rooms and corridors, the Committee, with the advice of their excellent physician, wisely determined to construct a detached building on a new plan, which promised every necessary convenience and security with wonderful cheapness; and, for once in a way, an architect’s cheap estimate was not exceeded. Instead of £200 or £250 per head, as of old, accommodation was supplied at the rate of £38: 10s. per patient, including fittings for all the rooms and a kitchen: – a marvel, certainly, in asylum construction, and one which should have the effect of reviving the hopes and wishes of justices, once at least so laudably entertained, to provide in County Asylums for all pauper lunatics of the county.

It is only fair to remark, that, as Dr. Bucknill informs us (Asylum Journal, 1858, p. 323), this new section of the Devon Asylum is dependent on the old institution for the residences of officers, for chapel, dispensary, store-rooms, &c. “It is difficult,” writes Dr. Bucknill, “to estimate the proportion which these needful adjuncts to the wards of a complete asylum bear to the expense of the old building; they can scarcely, however, be estimated at so high a figure as one-eighth of the whole.” But, as a set-off against the increased cost per patient involved in supplying the necessary offices described by Dr. Bucknill, we may mention that there are twenty single sleeping-rooms provided in the building, and that a greater cost was thereby entailed, than many would think called for, where only chronic, and generally calm patients, were to be lodged.

These illustrations of what may be done in the way of obtaining good asylum accommodation for pauper lunatics at no greater rate, we are persuaded, than that incurred in attempting to provide properly for them in workhouses, furnish a most valid reason for discontinuing their detention in the latter, and the more so, if, as can be demonstrated, they are unfit receptacles for them.

The possibility of constructing cheap asylums being thus far proved, the question might be put, whether the internal cost of such institutions could not be lessened? We fear that there is not much room for reform in this matter, if the patients in asylums are rightly and justly treated, and the officers and attendants fairly remunerated. In producing power, an asylum exceeds a workhouse, and therein derives an advantage in diminishing expenditure and the cost of maintenance. On the other hand, the expenditure of a workhouse is much less in salaries, particularly in those given to its medical officer and servants, a form of economy which will never repay, and, we trust, will never be tried in asylums. Warming, ventilation, and lighting are less thought of, little attempted, and therefore less expensive items in workhouse than in asylum accounts. With respect to diet and clothing, workhouses ought to exhibit a considerable saving; but this saving is rather apparent than real, and certainly in the wrong direction; for lunatics of all sorts require a liberal dietary, warm clothing, and, from their habits frequently, more changes than the ordinary pauper inmates; yet these are provisions, which, except there is actual sickness or marked infirmity, the insane living in a workhouse do not enjoy; for they fare like the other inmates, are clothed the same, and are tended or watched over by other paupers; the saving, therefore, is at the cost of their material comfort and well-being. Excepting, therefore, the gain to be got by the labours of the patients, there is no set-off in favour of asylum charges; in short, in other respects none can be obtained without inflicting injury and injustice. On the other hand, workhouse expenditure need be raised if the requisite medical and general treatment, nursing, dietary, employment, and recreation are to be afforded; which is the same as saying, that workhouses, if receptacles for the insane at all, should be assimilated to asylums, – a principle, which, if admitted and acted upon, overturns at once the only argument for their use as such, viz. its economy.

The perception on the part of parochial authorities, that something more than the common lodging and attendance of the workhouse is called for by the insane inmates, has led to the construction of “Lunatic Wards” for their special accommodation, a scheme which may be characterized as an extravagant mistake, whether viewed in reference to economical principles or the welfare of the patients. If structurally adapted to their object, they must cost as much as a suitable asylum need; and if properly supervised and managed, if a sufficient dietary be allowed, and a proper staff of attendants hired, no conceivable economical advantage over an asylum can accrue. On the contrary, as Dr. Bucknill has remarked (Asylum Journal, vol. iv. p. 460), any such attempts at an efficient management of the insane in small and scattered asylums attached to Union Workhouses, will necessarily increase their rate of maintenance above that charged in a large central establishment, endowed with a more complete organization and with peculiar resources for their management.

Dr. Bucknill returns to the discussion of this point in his just published report (Rep. Devon Asylum, 1858, p. 11). He puts the question, “Would a number of small asylums, under the denomination of lunatic wards, be more economical than one central asylum?” and, thus proceeds to reply to it: – “The great probability is that they would not be; 1st, on account of the larger proportion of officials they would require; 2nd, on account of the derangement they would occasion to the severe economy which is required by the aim and purpose of union-houses as tests of destitution. Where lunatics do exist in union-houses in consequence of the want of accommodation in the County Asylum, the Commissioners in Lunacy insist upon the provision of what they consider things essential to the proper care of insane persons wherever they be placed. The following are the requirements which they insisted upon as essential in the Liverpool Workhouse: – a sufficient staff of responsible paid nurses and attendants; a fixed liberal dietary sanctioned by the Medical Superintendent of the asylum; good and warm clothing and bedding; the rooms rendered much more cheerful and better furnished; the flagged court-yards enlarged and planted as gardens; the patients frequently sent to walk in the country under proper care; regular daily medical visitation; and the use of the official books kept according to law in asylums. If the direct cost of such essentials be computed with the indirect cost of their influence upon the proper union-house arrangements, it will require no argument to prove that workhouse lunatic wards so conducted would effect no saving to the ratepayers. The measures needed to provide in the union-house kitchen a liberal dietary for the lunatic wards and a restricted one for the sane remainder, to control the staff of paid attendants, to arrange frequent walks into the country for part of the community, while the other part was kept strictly within the walls; – these would be inevitable sources of disturbance to the proper union-house discipline, which would entail an amount of eventual expenditure not easily calculated.”

If, on economical grounds, the system of Lunatic Wards has no evident merit, none certainly can be claimed for it on the score of its adaptation to their wants and welfare.

Indeed, the argument for workhouse accommodation, on the plea of economy, loses all its weight when the well-being of the insane is balanced against it. For, if there be any value in the universally accepted opinions of enlightened men, of all countries in Europe, of the requirements of the insane, of the desirability for them of a cheerful site, of ample space for out-door exercise, occupation and amusement, of in-door arrangements to while away the monotony of their confinement and cheer the mind, of good air, food and regimen, of careful watching and kind nursing, of active and constant medical supervision and control, or to sum up all in two words, of efficient medical and moral treatment, – then assuredly the wards of a workhouse do not furnish a fitting abode for them.

The unfitness of workhouses for the detention of the insane, and the evils attendant upon it, have been repeatedly pointed out by the Commissioners in Lunacy in their annual reports, and by several able writers. We were also glad to see from the report of his speech, on introducing the Lunatic Poor (Ireland) Bill into the House of Commons, that Lord Naas is strongly opposed to the detention of the insane in workhouses, and therein agrees with the Irish Special Lunacy Commissioners (1858, p. 18), who have placed their opinion on record in these words: – “It appears to us that there can be no more unsuitable place for the detention of insane persons than the ordinary lunatic wards of the Union Workhouses.” This is pretty nearly the same language as that used by the English Commissioners in 1844, viz. “We think that the detention in workhouses of not only dangerous lunatics, but of all lunatics and idiots whatever, is highly objectionable.”

To make good these general statements, we will, at the risk of some repetition, enter into a few particulars. On the one hand, the presence of lunatics in a workhouse is a source of annoyance, difficulty, and anxiety to the official staff and to the inmates, and withal of increased expense to the establishment. If some of them may be allowed to mix with the ordinary inmates, there are others who cannot, and whose individual liberty and comfort must be curtailed for the sake of the general order and management, and of the security and comfort of the rest.

Some very pertinent observations occur in the Report of the Massachusetts Lunacy Commission (op. cit. p. 166), on the mixing of the sane and insane together in the State Almshouses, which correspond to our Union Workhouses. They report that the superintendents “were unanimous in their convictions that the mingling of the insane with the sane in these houses operated badly, not only for both parties, but for the administration of the whole institution.” Further on, the Commissioners observe (p. 168), “By this mingling the sane and insane together, both parties are more disturbed and uncontrollable, and need more watchfulness and interference on the part of the superintendent and other officers… It has a reciprocal evil effect in the management of both classes of inmates. The evil is not limited to breaches of order; for there is no security against violence from the attrition of the indiscreet and uneasy paupers with the excitable and irresponsible lunatics and idiots. Most of the demented insane, and many idiots, have eccentricities; they are easily excited and disturbed; and nothing is more common than for inmates to tease, provoke, and annoy them, in view of gratifying their sportive feelings and propensities, by which they often become excited and enraged to a degree to require confinement to ensure the safety of life… The mingling of the state paupers, sane and insane, makes the whole more difficult and expensive to manage. It costs more labour, watchfulness, and anxiety to take care of them together than it would to take care of them separately.”

These sketches from America may be matched in our own country; and they truthfully represent the reciprocal disadvantages of mixing the sane and insane together in the same establishment.

Even supposing the presence of insane in workhouses involved, on the one hand, no disadvantages to the institutions, or to the sane inmates; yet on the other, the evils to the lunatic inhabitants would be condemnatory of it; for the insane necessarily suffer in proportion as the workhouse accommodation differs from that of asylums; or, inversely, as the economical arrangements and management of a workhouse approach those of an asylum. They suffer from many deficiencies and defects in locality and organization, in medical supervision and proper nursing and watching, in moral discipline, and in the means of classification, recreation, and employment.