Thus:--

-------+-------------+------------------- | | Ratio per 10,000 Year. | Under care. | of number in | | detention to the | | population.

-------+-------------+------------------- 1869 | 53,117 | 23.93 1870 | 54,713 | 24.31 1871 | 56,755 | 24.91 1872 | 58,640 | 25.42 1873 | 60,296 | 25.82 1874 | 62,027 | 26.23 1875 | 63,793 | 26.64 1876 | 64,916 | 26.78 1877 | 66,636 | 27.14 1878 | 68,538 | 27.57 1879 | 69,885 | 27.77 1880 | 71,191 | 27.94 -------+-------------+-------------------

In other words, there were eight more patients under care for every 20,000 of the population in 1880 than in 1869. Had there been no increase in the number in detention, after allowing for increase of population, the number in 1880 would have been 53,177. It was, in fact, 71,191, _i.e._ 18,014 more.

We have now traced step by step the remarkable progress effected in the asylum care of our lunacy population. In concluding this chapter I would, however, observe that it would be a grave and mischievous mistake to suppose that, most valuable as is the provision for the insane by asylums, there are not many cases which may be treated outside these inst.i.tutions with the greatest advantage. Some patients are best cared for in their own homes, others in lodgings, and others in the houses of medical men. The extent to which non-asylum treatment can be carried out will be seen when we speak of Chancery patients. It will be observed that the number of single private patients is 448.

In regard to the location of pauper lunatics in private dwellings, it appears that while in England 6799, or 9.29 per cent., of their number live with their relatives or are boarded in private dwellings, nearly fifteen per cent. of insane paupers in Scotland are in private dwellings, inspected by the Lunacy Board.

Dr. Lockhart Robertson has expressed the opinion that "the utmost limits within which the county asylum can benefit, or is needed for the treatment of the insane poor, is fifty per cent. of their number, and that a further acc.u.mulation of lunatics there serve no practical purpose, and hence is an unjustifiable waste of public money."[209]

After pointing out the success of the metropolitan district asylums at Leavesden and Caterham, where upwards of four thousand chronic lunatics are maintained at the rate of seven shillings a week, he expresses his opinion that, if these arrangements were properly carried out, another fourteen per cent., or forty per cent. of the incurable and harmless pauper lunatics and idiots, might be placed in workhouses; his ideal standard for the distribution of pauper lunatics being--in county asylums, fifty per cent.; in workhouse wards, forty per cent.; leaving ten per cent. for care in private dwellings.

The number of beds in county and borough asylums amounts to 40,000, varying from 2000 to 250; the average cost per bed having been somewhat under 200, and the weekly maintenance and clothing of each patient 9s.

9d. If to this be added the interest on the cost of construction and asylum repair, the annual cost for each pauper lunatic in county asylums amounts to about 40.

The number of patients discharged cured, in county and borough asylums during the ten years 1871-1880, was 40.32 per cent. on the admissions, and the mortality 10.46 on the mean number resident.

The number of beds in registered lunatic hospitals (about 3000) ranges from 60 to 570, or, excluding idiot asylums, to 300, while the average weekly cost ranges from 14s. to 2 2s. The charges on the buildings are not included. For these Dr. Robertson adds five shillings a week, making the average weekly cost of maintenance 1 10s. or, including asylum construction and repairs, 1 15s.

The distribution of private patients, numbering 7741, was as follows on the 1st of January, 1881:--In registered hospitals, 2800, or 36.17 per cent.; in county asylums, 539, or 6.96 per cent.; in State asylums, 534, or 6.88 per cent.; in private asylums, 3420, or 44.17 per cent.; in private dwellings, 448, or 5.78 per cent.

The registered hospitals have, therefore, thirty-six per cent. of all the private patients, an important fact in looking to the future provision for this cla.s.s in lieu of private asylums. Their statistics of recovery and mortality are satisfactory. The recoveries per cent.

calculated on the admissions were 46.48 per cent. during the ten years 1871-1880; the annual mortality being 7.96 per cent.

As regards private asylums, there were forty-four per cent. of the private patients in England and Wales cared for in these establishments.

The recoveries per cent. in private asylums during the decennial period 1871-1880 were--in the metropolitan division 31.43, and in the provincial 35.11; the annual mortality being, in the metropolitan private asylums 10.93, and in the provincial asylums 8.63. It should be remembered, in contrasting these figures with those of registered hospitals, that a considerable number of pauper patients are still sent to private houses, and it may therefore be said that, so far as difference in social position affects recovery and death, the comparison is not altogether fair. At the same time, it is noteworthy that in the pauper asylums, the percentage of recovery is higher than in the metropolitan and provincial private asylums, and the percentage of mortality lower than in the licensed houses of the metropolis.

Numerous general considerations arise from a retrospect of the history which this and the preceding chapter contain, but they will more fitly form a part of a subsequent chapter of this volume, when a sketch of the results achieved by Psychological Medicine will be given, as presented in the author's Presidential Address at University College.

FOOTNOTES:

[178] "A Lecture on the Management of Lunatic Asylums," etc., by Robert Gardiner Hill. Published April, 1859 (delivered June 21, 1838). (See Appendix H.)

[179] Including the wards in the Manchester Hospital.

[180] Including thirty male and three female criminal lunatics in jails, according to the Parliamentary return for April, 1843.

[181] Exclusive of the lunatic ward of Guy's Hospital.

[182] Mr. Gaskell. See p. 209.

[183] Summary taken from the Report of the Metropolitan Commissioners, 1844.

[184] Second Report of the Commissioners in Lunacy, 1847, p. 224.

[185] Page 112. No return is made in regard to the inmates of other asylums.

[186] Eighth Report of the Commissioners in Lunacy, p. 43.

[187] Exclusive of 226 single patients under commission.

[188] Page 35.

[189] Act of 1853, ss. 64 and 66.

[190] Page 44.

[191] For a table showing the cost per head in asylums of various sizes, see Appendix I.

[192] Report of Commissioners in Lunacy, 1864.

[193] Exclusive of 159 single patients.

[194] Office of the Board, 37, Norfolk Street, Strand.

[195] Caterham cost a little more, viz., 89 a bed.

[196] Page 10.

[197] Page 35.

[198] Page 43.

[199] In the Commissioners' Report of 1871, p. 76, a case is reported in which the jury would not convict a woman who had the charge of a lunatic and admitted that "she strapped the patient once a month at the full of the moon," of ill-usage, although Mr. Justice Willes summed up strongly against her. In another case the Lunacy statute was disregarded, but Baron Martin summed up very leniently, much to the disapproval, not to say the disgust, of the Commissioners.

[200] Page 75.

[201] Page 81.

[202] Page 77.

[203] See page 196.

[204] Page 20.

[205] The order and description of these inst.i.tutions have been given in these decennial tables as far as possible in accordance with that of the table of 1844, in order to facilitate comparison.

[206] Exclusive of 208 lunatics so found by inquisition who reside in charge of their committees.

[207] For information in regard to Wales I am indebted Dr. W. Williams, the late medical superintendent of the Denbigh Asylum.

[208] Report, page 3.

[209] See Address at International Medical Congress, _Journal of Mental Science_, January, 1882.