On the State of Lunacy and the Legal Provision for the Insane

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.

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.

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.