IS INSANITY ON THE INCREASE?

A NOTORIOUS case recently decided before Baron Huddlestone, and on which I asked last week a question of the Home Secretary, has directed fresh attention to the treatment of the insane; the issue raised by the question-is insanity on the increase ?-is of even greater importance.

Engaged as I have been, for many years and under special circumstances, in studying the statistics of insanity, I have reluctantly come to the conclusion that facts and figures establish clearly the progressive growth of the malady. Within the last half-century the whole system relating to the lodgment, care, and management of the mentally afflicted has been completely revolutionised. How great the change has been may be shown by a brief sketch of the conditions under which the insane lived, or rather pined away and died, some fifty or sixty years ago. The first enactment relating to pauper lunatics is the 17 Geo. II., c. 5, under which any two parties could cause them to be apprehended and locked up in some secure place "and there chained." Referring to the "enormities" existing in public as well as private asylums previous to 1827, the Lunacy Commissioners, in their Report for the year 1846, point out in strong language that they can scarcely be exaggerated, comprising "almost every species of cruelty, insult, and neglect to which helpless and friendless people can be exposed when abandoned to the charge of ignorant, idle, and ferocious keepers, acting without conscience or control." Speaking of one of the great metropolitan asylums, which is now a model of reform, the same Report says: "At that time (1815) female as well as male patients were chained to the walls, covered only with a blanket formed into something like a gown. One man (whose case is well known) was kept confined in chains for fourteen years without the smallest interval of liberty. Stout iron rings were riveted round his arms, body, and neck, the latter being made to slide upwards and downwards on a massive iron bar inserted in the wall." In 1816 it was stated in evidence that the patients were subjected to brutal cruelties from the attendants; that they suffered very much from cold, one patient having lost her toes from mortification proceeding from cold; and that they were in other respects in the most deplorable plight. The Commissioners add that there were seventy out of about four hundred "almost invariably in irons." What the nature of the kind treatment was is expressed in the succeeding sentence: "Food, straw, and fire are allowed, but no blankets or dress, as they destroy them for want of keepers and other restraints which would be provided in a regular lunatic asylum.'" Just one recorded piece of evidence as to how they fared outside.

One of the witnesses1 examined before the committee of 1817 draws the following appalling picture: "There is nothing so shocking as madness in the cabin of the peasant. When the man is out labouring in the fields for his bread, and the care of the woman of the house is scarcely sufficient for the attendance on the children, when a strong young man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin, not high. enough to stand up in, with a crib over it to prevent his getting up. The hole is about five feet deep, and they give the wretched being his food there, and there he dies." Under such conditions longevity was out of the question, recovery impossible. Lunatics were killed off and ceased to be a cause of anxiety and danger to the body politic. Since the date of that Report (1846) the change has been marvellous indeed. Stately structures have been erected of noble architectural design and vast proportions (one of them can accommodate over 2,500 persons), and furnished with every modern appliance for convenience, comfort, and even luxury. Amusements, theatricals, concerts, out-of-door and in-door occupation and exercise, games of all sorts, Turkish baths, everything in short that sympathy for human suffering could suggest, has been generously provided at an enormous and constantly increasing expenditure of public money. In the meantime the possible cure of this terrible and mysterious malady has received no less attention than the kindly treatment of the insane.

I do not propose to go back to the barbaric age, although the figures from the earliest records indicate a continuous annual increment in the number of registered lunatics. It will be sufficient for our purpose to begin with the statistics of twenty years ago, when the present system may be said to have reached maturity, and to let the Reports of the Lunacy Commissioners, English, Irish, and Scotch, tell their own tale. For the sake of brevity and clearness, a comparison will be made of the Reports of 1882, 1872, and 1862, with this exception, that as the English Commissioners do not in their Report of 1862 particularly discuss the increase of insanity for the reason that they had fully discussed it in their last preceding (15th) Report, the opinions expressed in the latter will be quoted on this point.

The English Lunacy Commissioners, in their fifteenth Report (p. 75), say: "During the ten years from the 1st of January, 1849, to the 1st of January, 1859, the number of patients in the various asylums of England and Wales have advanced from 14,560 to 22,853; this increase has been principally in public asylums. In county and borough asylums the advance has been from 6,494 to 15,845, making an increase of 9,351; in lunatic hospitals from

(1) The Right Hon. Denis Brown.

(2) These figures do not include the insane in workhouses.

1,195 to 1,992, making an increase of 857. . . . . The great increase which has taken place in the number of patients in asylums is limited almost entirely to pauper and criminal patients." It is remarkable to note the morbid official anxiety manifested from time to time to explain away what people will persist in calling "the apparent increase of insanity." With that object the Lunacy Commissioners enter into very elaborate arguments, attributing "the apparent increase" now to one cause, now to another.

But what of the asylums as curative hospitals for the treatment of lunacy? Have they had any and what effect in retarding the growth of numbers? These are questions of vital importance, and the Commissioners' observations on this point are as follows: Though it might be fairly supposed that the increased proportion of cures in recent cases sent to asylums, caused by the improved modes of treatment now adopted, would have had the effect of diminishing the aggregate numbers resident, this latter cause of decrease, in the comparatively few recent cases admitted, has apparently been more than counterbalanced by the prolongation of the lives of the many chronic cases brought under care." Then is it to be expected that when all these old chronic cases, whose lives have been admittedly prolonged by the effects of sanitary regulations, improved diet, and other benefits, shall have passed away, the time may then arrive when further accumulations will cease, and the curative operation of the improved system come into full play, and assert itself by an annual reduction in the numbers of the insane?

We have thus, at a comparatively recent date (1860) a clear, definite, and distinct pronouncement from the highest official authority in England on the subject, that the then increase in the numbers of the insane was only apparent. The sequel will tell whether or not the Commissioners correctly appraised the situation; but the strangest thing of all is that this verdict is in direct conflict with the statement made to a Select Committee of the House of Commons the year before by the Chairman of the Commissioners himself, and which I will presently quote. No doubt the assigned causes of the apparent increase are true to a limited extent. They might even be considered reassuring if we had a hope that the maximum was reached or was within a measurable distance.

The

new system had been then for many years in operation, and should have brought to light most, if not all, latent cases of insanity, and drawn them within the scope of official cognizance; but if it was still doing this work, the unreality of the apparent increase would be satisfactorily established, as the mere discovery of numbers, the previous existence of which was not officially known, could not be regarded in any sense as an augmentation. This may be, and I do not suggest that it is not, a rational way of accounting for some

portion of the growth. But as increase upon increase comes to be recorded, the pregnant fact remains that in the year 1862, long after the new and improved methods for treating and "curing insanity were in full action, and after the Commissioners had accounted for every previous increase of numbers in the same manner, having, it may be said, played out the development theory, there was, according to the highest official testimony, a stock, if I may use the expression, of 41,129 registered lunatics in England.

I will now advert to Ireland at the same period. The Irish Commissioners, in the opening statement of their eleventh Report presented to Parliament in 1862, say: "The insane classes of all denominations placed directly under our control and inspection amounted, on the 31st December last, to 8,055." The whole tenour of their remarks betokens a growing demand upon the resources of existing institutions and the necessity for extending more and more the means of relieving the pressure by further provision. The constant repetition of such phrases as "insufficient accommodation" and "overcrowded state," used, too, in regard to asylums which had been a few years before enlarged or otherwise relieved, indicates, not alone the rapid development of previously existing cases, but an actual increase of numbers. The registered lunatics in Ireland all told amounted in 1844 to 4,714; they had thus increased, or been developed, in eighteen years by 3,341.

Next as to Scotland. To bring the statistics in line with those of England and Ireland, it is necessary to state that when the Scotch. Lunacy Board was formed in 1857, the total number of insane under official cognizance, as stated in their first Report to Parliament (1858), was 5,748. In the four years intervening between that date and our point of departure it had risen to 6,341. We have thus to begin with, on the 1st of January, 1862, a stock of 55,525 insane persons registered and under official cognizance-namely, in England, 41,129, in Ireland 8,055, in Scotland 6,341.

We now come to the examination of the first decennial period, namely the ten years ending the 1st of January, 1872, when it might have been thought that the development theory was exhausted. The twenty-sixth Report of the Commissioners in Lunacy opens thus: "The returns made to our office show that the total number of lunatics, idiots, and persons of unsound mind in England and Wales registered on the 1st of January last were 58,640, being an increase of 1,885 upon the cases recorded on the 1st of January, 1871. These numbers do not include 170 lunatics so found by inquisition." As already shown, the number on the 1st of January, 1862, was 41,129, so that in ten years the stock of registered lunacy in England alone increased by 17,681. This was indeed development at railway speed. The Irish Lunacy Commissioners, in their twenty-first Report to Parliament (1872), refer to the lunatic asylum system in that

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country as "a system which has, since the establishment of this department (1846) as a distinct branch of the public service, fully trebled the existing provision for the insane poor. . . . It has also devolved upon us in summarizing periodically the statistics of insanity to record a regular annual increase in the number of insane persons brought within our knowledge, as shown by the returns obtained by us from various sources; and the statistics of the year now under review (1871) exhibit, we regret to state, a far greater apparent increase than those of any previous year." The Commissioners, looking back for a period of five-and-twenty years, and having given an abstract of the returns of all classes of the insane in 1846, proceed to say: "It would thus appear that while the asylum accommodation has been increased somewhat more than threefold within the period referred to, the known proportion of the insane to the sane population has likewise increased to an extent that is rather startling, the ratio being in 1846 as 1 to 661, and in 1871 a fraction below 1 to 300." On this it is only right to observe that the population of Ireland in 1846 was 8,287,848, and that it had fallen in 1871 to 5,395,007; and this fact must have considerably affected the ratio of insanity in the latter year, especially as emigra tion, one great cause of the decline, did not of course touch the lunatic class. On the other hand, the astounding fact appears that notwithstanding a diminishing population, the actual numbers of registered lunatics increased in ten years from 8,055 to 10,767.

Then again as to Scotland, the Commissioners say in the opening statement of their fourteenth Report: "Since the 1st of January, 1858, the number of lunatics officially known to the Board has increased from 5,794 to 7,606." Having shown the changes which took place in the manner of distribution, the Report proceeds: "These figures show that of the increase of 2,504 which has taken place in the number of patients in public and parochial asylums, 407 arise from the decrease in private asylums and 285 from the decrease in private dwellings, leaving an increase of 1,812 ascribable to the growth of lunacy, or at any rate to the increased number of lunatics in asylums." This is a very artless admission, and the words italicised should be borne in mind when we come to discuss the opinion of the Scotch Lunacy Board, on the returns in the next decennial period. I confess that on reading this admission, at once so frank and so judiciously guarded, I put it down to the cautious candour of the Scottish character. There is an actual increase in a given period; the facts and figures are then self-evident.

Yielding for a moment to common sense, they venture to ascribe the result to the "growth of lunacy "-a not irrational deduction; but observing that their longer established colleagues in England and Ireland scout the idea of such a cause, and are prepared to stand or fall by the development theory, they decline to run counter to