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Chap. V. – on the causes diminishing the curability of insanity, and involving the multiplication of chronic lunatics

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.