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place a patient in an asylum, includes an expression of opinion that he is a proper person to be detained under care and treatment; and, accordingly, some medical men, while admitting a patient to be of unsound mind, have refused to certify that he was a proper person to be detained under care and treatment, when the question of sending him to an asylum was also involved. The practical result of such refusal is to deprive the Board of all power to compel improvement in the condition of a patient; and, in this way, a pauper lunatic, for whose care we are legally responsible, if not certified to be a proper person to be detained under care and treatment,' is practically removed from our jurisdiction, without being placed under that of the Board of Supervision, whose authority, in matters of treatment, is now limited to ordinary paupers.
"Occasionally, also, medical men have refused to grant certificates in the cases of patients suffering under certain forms of insanity, on the ground that they do not come within the scope of the Act.
"From the vague and unsatisfactory nature of the definition of lunacy, we have in several instances had no alternative but, with regret, to yield our own views to those expressed by the local medical men, and to leave the patient in circumstances which we considered unsuitable."
The efforts of legislation appear to be directed rather to prevent the undue detention of patients in asylums, than to insure the fitness of all who are admitted, but it appears to us that the latter object is of far greater importance than the former. There is a certain amount of suspicion attaching to those who have been patients in an asylum, and therefore it is of the greatest importance that care should be taken not to place any person under such a disability unnecessarily; but this question having been settled, it is of far greater consequence that his perfect recovery should be established than that his discharge should be incautiously hastened; a few weeks' longer treatment may make a certain cure of a doubtful recovery; whereas premature interference, and the knowledge on the part of the patient that it may be exercised at any moment if he is only sufficiently pertinacious, will have a tendency to keep up the excitement of uncertainty in his mind, and may, if it result in his discharge before his medical adviser thinks it prudent, bring about a relapse.
A minute table is given exhibiting the distribution of inmates within the cognizance of the Scotch Commissioners. We gather from this that in a population of 2,888,742 inhabitants, there are 9474 pauper and 1450 private lunatics.
Having ascertained as nearly as they could the number of insane persons in Scotland, the next duty of the Commissioners was to see that proper provision was made for them in suitable asylums or otherwise; they say:
"We do not conceal from ourselves the practical difficulties which lie in the way of determining with accuracy the number of insane at large who should be placed in asylums. The conclusions at which we arrived were not altogether based on the nature or curability of the malady, but were influenced also by the circumstances in which the patient was placed, and the degree of care bestowed upon him. We asked ourselves whether, in the interests of the patient himself or in those of society, it seemed most desirable to place him in an asylum or to leave him at home, and our decision was taken upon a general consideration of all the facts of each case. For in addition to the mental and bodily condition of the patient, as well as the general circumstances by which
he was surrounded, we felt bound also to take into account the constitution of our asylums; and we were conscious that our difficulties would often have been materially lessened had these establishments been based upon the idea of providing a diversity of accommodation for patients affected with different degrees of mental incapacity. There are many persons, for example, whose mental condition requires that they should be placed under the care and control of others, yet whom we would hesitate to deprive of liberty to the extent almost necessarily involved in sending them to lunatic asylums as at present constituted.'
We cannot but commend the care and judgment manifested here in deciding a difficult question, and we are disposed to think that the Commissioners have hit the right nail on the head in pointing out the want of a diversity of accommodation for patients afflicted with different degrees of mental incapacity. The Report says, beyond all question transference to an asylum is very often calculated to prove most beneficial to an insane patient; but the extent to which asylums have contributed to diminish insanity is not so easily determined, because doubtless a certain number of these recoveries would have taken place out of asylums, under judicious treatment. The following observations appear to us worthy of the most attentive consideration:
"It cannot be too often repeated, that in the treatment of insanity loss of time is unfavourable to recovery, and that every impediment that is thrown in the way of immediate treatment acts most prejudicially upon the patient by tending to render permanent the aberration from normal action, which, under favourable circumstances, would speedily have subsided. We are therefore of opinion, that asylums are capable of rendering to humanity far greater services than they have yet achieved. There cannot, however, be the smallest doubt that these establishments have, even in times past, proved of great public utility, by undertaking the treatment and management of patients requiring special medical care, and of those whom, from violence or other peculiarity, it is found dangerous or impossible to retain in private houses. Moreover, it has been clearly proved that the discipline of an asylum exercises a most beneficial and curative influence upon many patients who, if left at home, would probably have become confirmed lunatics, and is calculated to ameliorate in a very remarkable manner the condition even of the most intractable incurable cases. It is very certain, then, that asylums prove of the greatest service both to the patients and the public; and therefore the question to be considered is, not whether their extension is required, but whether, as at present constituted, they fulfil all the expectations which led to their erection, and which the expense of their maintenance might warrant us in entertaining. Beyond all other aims, an asylum should have for its object the cure of the insane and the diminution of insanity. Now, in relation to this malady, two important facts have been clearly established, first, that one chief cause of the affection is hereditary predisposition; and secondly, that the success of curative treatment depends in a very great degree upon its being undertaken at an early stage of the disease. In the course of our investigations, we have obtained abundant proof that fatuous female paupers frequently become the mothers of illegitimate children, who in their turn, grow up imbeciles, or become lunatics; and although there is naturally more difficulty in tracing the source of idiotcy or insanity to a paternal origin, there can be little doubt that male fatuous paupers contribute to this evil. In illustration of these remarks, we shall here give the result of our investigations in one county into this painful aspect of insanity. The number of single patients visited or reported on amounted to 349. Of these, 33 were reported to the visiting Commissioners as illegitimate
22 being registered paupers, and the remaining 11 indigent private cases. the 349, 113 were females above 17 years of age. Of these, 22 were in circumstances affording adequate protection to their chastity. Of the remaining 91, 15 were known to have given birth to illegitimate children, and 5 to have borne more than one child. Of the 15 mothers, 3 are known to have been illegitimate, and 12 are at present paupers; of their children, 6 are known to be idiots. There are, besides, in the county, 3 other idiots who are known to be the offspring of insane or imbecile mothers, who are dead or have disappeared. These facts are most deplorable; nevertheless, it would be esteemed a harsh measure to send all such cases to asylums, and yet society has a right to demand that all persons who are supported on charitable funds should be placed in such circumstances, and under such control, as will guard against the propagation of this social evil. This result, we are of opinion, might be obtained by attaching to asylums adjunct houses, in which such patients, and others of analogous character, could be placed, without to the same extent depriving them of liberty as the patients in the asylum proper. And we are further of opinion, that many of the objections at present entertained, both by the friends of such patients and the public generally, in regard to placing them in asylums, would be obviated by the proposed modification of these establishments. Moreover, experience shows that there is frequently great unwillingness on the part of relatives to send to asylums patients who are suffering from the milder and incipient forms of insanity. Yet these are precisely the cases in which removal from the home circle is most likely to exercise a beneficial influence."
One, perhaps, of the most important considerations attending the absolute liberty of the insane, is the certainty that a considerable number will propagate the malady by multiplying the species; and the facts mentioned in the foregoing quotation, shocking as they are to contemplate, only represent one phase of this fearful evil. It is pretty certain that the offspring of patients whose minds at the time of conception are unsound, will be liable, as they grow up, to become insane themselves; and we are disposed to attribute a great deal of the increase of insanity to this circumstance, that no precautions are taken to guard against this danger, and indeed no regard is paid to this consideration in deciding whether a patient, recovered up to a certain point, should be liberated unconditionally. Undoubtedly, as the Commissioners say, "society has a right to demand that all persons who are supported on charitable funds should be placed in such circumstances, and under such control, as will guard against the propagation of this social evil." We would claim for society an extended right as affecting all persons, without regard to means, who at the same time that they are distinctly insane, are also in a position to propagate this social evil. The diminution of insanity is quite as important in the middle and upper classes as in the lower grades; and we think that some restrictions should equally be placed on them, considering that it is a question involving the degeneration of our race. At any rate, it would be well that the matter should receive more consideration than it has hitherto done, especially when deciding upon the unconditional liberation of a patient whose perfect recovery is doubtful.
The manner in which the expenses of maintaining pauper lunatics should be defrayed has engaged the attention of those connected with asylums in England; and the Commissioners have found that it has
an important bearing on the welfare of the insane poor in Scotland. They say:
"There is no doubt that the tendency to regard a pauper lunatic as not a proper person to be detained in an asylum is strongly fostered by the smaller expenditure necessary for the maintenance of the patient at home. Under the present law, each parish supports directly the burden of its poor; and, accordingly, the increased expenditure which an asylum generally involves, by exercising a direct effect upon the parochial rates, affords a strong inducement to delay, or altogether to dispense with, the removal of patients. We are decidedly of opinion that it would greatly conduce to the benefit of the insane poor if the rate for their maintenance in asylums were levied on the whole district, or even on the whole country, instead of on the individual parishes to which the patients belong; and we think that it would not be difficult to guard against the reception or detention of cases which might, with more propriety, be detained in private houses, by leaving it to the district medical inspector to determine, with the right of appeal by parishes to the Board, whether or not the case was one which should be refused admission. There can, we think, be no doubt that the present system, by throwing impediments in the way of early treatment, tends to convert into confirmed insanity many cases of excitement or depression, which, under prompt attention, would have proved of mere temporary duration. If the maintenance of patients, when detained at home, fell directly upon the parishes, but became a district burden when they were placed in asylums, it is very certain that many of the objections now brought forward against the removal of pauper lunatics would cease to be urged. Should, however, the proposal here made appear too sweeping in its nature, an intermediate course might be taken, by which a fixed and moderate sum should be charged to the parishes, and the balance be defrayed by a rate levied on the district."
The Commissioners believe that considerable success would attend the cottage system of accommodation as an adjunct to the district asylums. It is very gratifying to know that in their experience kind and humane treatment is extensively found in cottages, even under the present system of imperfect supervision, and they have reason to think from what they have observed, that under the immediate superintendence of asylum officers, it could be so fostered in growth as to open up a prospect of escape from the many questions that are every year rendering the care and management of the insane poor a problem of more difficult solution. They go on to observe:
In every country of Europe, the question of the accommodation of the insane is daily becoming more and more embarrassing, and we see how in England, notwithstanding the wealth of the country and the humane spirit of the people and of the legislature, the increase in the number of lunatics keeps ahead of all the exertions made for their accommodation. This is a grave fact which deserves our most serious consideration before we commit ourselves to the building of asylums, in the expectation that no further call will be made upon us. No doubt it is theoretically easy to maintain the doctrine that asylum accommodation should be provided for all the insane poor, and that_no expense should be spared in supplying the wants of this afflicted class. But the sane poor have also their claims, and the question may be asked, How far is it right that an idiot or a lunatic in a state of dementia or general paralysis, who is beyond all hope of being restored to sanity, and who, moreover, is little able to appreciate kindness or to derive pleasure from the care and attention bestowed upon him, should receive treatment greatly superior to that bestowed
upon an aged or infirm ordinary pauper, who though in a sense also incurable, is more capable of appreciating kindness and showing gratitude in return? In England, the poor-house is open to the able-bodied labourer, but in Scotland it is reserved for the aged and helpless poor, and accordingly with us there is not perhaps the same reason for drawing a distinction between the treatment of ordinary paupers and that of incurable pauper lunatics. But there will always be this essential difference between the two classes calling for special consideration in their treatment, that the latter are labouring under a degree of mental incapacity which renders them altogether dependent upon the care of others, and incapable of appealing against harshness or neglect. Still, as we must place a limit on our charitable expenditure, we should beware of making such a distinction in their treatment as might raise a doubt as to its propriety, and must therefore take care not to be too lavish with the one hand, lest we be forced to be too penurious with the other. On this account we lean towards any scheme that will embrace good and economical accommodation for the whole insane poor, rather than to one which, from the expense of carrying it out, will sooner or later be of only partial application."
It is very satisfactory to find the Commissioners able to report that the condition of the insane in Scotland has been already considerably ameliorated since the Report of the Royal Commissioners. Mechanical restraint has been almost entirely abolished, both in public and private asylums, having been resorted to in one or two instances only, in which there appeared to the Commissioners to be good grounds for its application, whilst in no case that came under their observation or notice was seclusion improperly applied or injuriously extended.
The Report is accompanied by various appendices and statistical tables, including correspondence and evidence upon which the Commissioners found some of their opinions and conclusions, and shows the result of the treatment pursued in the various asylums of Scotland. For these and other matters we refer our readers to the document itself, which will well repay the attentive perusal of all who are interested in the welfare of the insane, and merits and receives our highest commendation.