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

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.