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to build a large establishment for all, or to build many small separate establishments, there could be no doubt that he would give the preference to the former. And this is undeniably true, just as the further statement that it is cheaper per head to board a large collected number than to provide for them separately. If, indeed, we had only to do with family treatment, as understood when so-called cottages are built in England, or if Mundy's plan were adopted according to which every house set apart for family treatment is provided with its seclusion room, its padded-room, its bath-room, etc., so as really to represent a small asylum-if such experiments in family treatment as these are what are thought of, it is unnecessary to say that they have no bearing on what has been discussed here. We have here to do rather with the utilisation of existing dwellings, to avail ourselves of habitations which have more accommodation than is required for their present occupants; and thus, as it were, to render productive certain capital which would otherwise lie dormant. Even if it were necessary in order to make them thoroughly satisfactory to add a story or build a room, our architect would, without doubt, regard this as cheaper than to purchase an extensive site, and then build an asylum on it. Cyon, indeed, remarks justly that many asylums have been erected in too splendid a style, and are maintained too luxuriously. But it may be doubted whether the least expensive asylums could compete with the simple form of family treatment. And it will not do to compare in this respect the asylums of different countries, which differ in social and economical conditions; if we wish fairly to investigate the cost of the two forms of treatment, we must make our comparisons between them as they are found in the same country.
The result of our inquiry seems on the whole to be, that we must recognise in the organisation of the family system, as it exists in Scotland, an advance in lunacy administration; and we must conclude that a similar organisation is desirable for other countries. What has been attained--the bringing of lunatics not in asylums under professional supervision-is an object which has scarcely been approached elsewhere, but which cannot long be anywhere delayed. As regards the supervision of asylums, public opinion is already prepared to demand the utmost. No regulation seems to be severe enough to allay that public terror, illegal incarceration in asylums. The evils to which this feeling leads when
it is embodied in legislation, are shown in the French lunacy law, whose disadvantages have lately received their due condemnation from Pelman.* The admission of patients has been surrounded by such difficulties that they generally arrive at the asylum much too late; but, on the other hand, it is not less difficult at present to get incurable patients out after they have been once received. It seems to occur to no one to require any supervision over the public when they have to do with the insane. It is here, however, that real dangers exist which are wholly ignored by the law. Cases are kept in concealment, and not sent to asylums till they have become incurable; and instead of care they often receive the roughest treatment. The public hears nothing of these except when by accident collateral circumstances drag such a case as that of Barbara Ubryk into the light of day. The results of such negleet are matters of daily observation in asylums.
These remarks are applicable in different degrees to different parts of our fatherland. Attempts are being made in many places by enlightening the public and the authorities to have patients brought early to the asylums. And it is endeavoured in many asylums to exert a certain amount of supervision over discharged patients as long as possible. But the object cannot be completely attained until a special law is passed, and a suitable authority constituted with power to see it carried out. What is required is a lunacy law, but a law founded on principles diametrically opposed to those of the French law. Whether the Scottish pattern should be exactly copied—whether the inspecting authority, which would, of course, have also to undertake the supervision of asylums, should be similarly constituted-does not require immediate discussion here. The fundamental principles may, however, be adopted with confidence from Scotland.
Strasburg, June, 1874.
* Ueber Irrengesetzgebung und das französische Irrengesetz.
Zeitschrift f. Psych. 31 Bd., Heft. 1.
An Illustration of Local Differences in the Distribution of
Insanity. By P. Maury DEAS, M.B., M.S., Lond.,
(Read at a Quarterly Meeting of the Medico-Psychological Association, held at
Glasgow, April, 1873.)
That the amount and types of insanity vary in different countries, and even in different portions of the same country, has long been a recognised fact; but my object in this short paper is, by means of an illustration drawn from one district, to show within what narrow limits, as regards locality, great differences may be observed in the distribution of insanity.
Our district, comprising the eastern and north-eastern portions of Cheshire, embraces five Unions, with a total population at last census of 267,000. The population of the respective Unions, which, for convenience, I shall designate A, B, C, D, E, is as follows:
A is mainly agricultural, with small townships.
In B, the staple industry is cotton, but it contains a number of small townships, scattered over a hilly, rugged country.
C is partly manufacturing (silk); partly rural and country townships.
D is devoted to silk, and consists mainly of a large town, situated in a deep valley, on the banks of a small and much polluted river.
E consists of a large township, devoted to cotton; the chief town being again in a valley, with a highly polluted river running through it.
I mention these points to show that there are marked differences, physically and socially, between the various Unions.
The first thing that drew my attention to this subject was the large excess of male admissions during last year (1873), the men exceeding the women by no less than 50 per cent.
As a rule, the number of female admissions slightly exceeds that of the males, though even a cursory glace at the statistics
of different Asylums will show that the variations in the relative numbers of the sexes are considerable,
Since the opening of this Asylum the men have each year exceeded the women. In 1871 and 1872 the excess of men was only four, but in 1873 it rose to 21.
I find that for several years previous to 1868 the male and female admissions to the old Chester Asylum were almost exactly equal; but since that date the males have exceeded the females, and apparently in an increasing ratio. At the close of 1871 the numbers remaining comprised, for the first time, more men than women; and at the end of 1872 the difference amounted to 21.
Out of 249 patients transferred from the old to the new Asylum in 1871, 108 were men and 141 women. This excess of women was, no doubt, mainly due to the fact that, even where the sexes are in equal numbers on admission, there is a greater tendency in the women to accumulate from the smaller mortality which prevails among them. Owing to the death rate among the male patients here having been very high (13.6), and that among the women exceptionally low (5:3), there were at the end of 1873 still 22 more women than men, in spite of the great increase in the male admissions.
Confining ourselves now to the five Unions I have indicated, I find that the average numbers of patients in the Asylum belonging to these Unions on December 31st, of the four years 1866-69 inclusive, were 114 men and 143 women.
The corresponding number for the four years 1870-73 inclusive, were 125 men and 151 women.
In other words, while the men increased 10 per cent., the women only increased 5, and this in spite of the natural tendency in the women to accumulate over the men, and the exceptional death-rates of the last two years.
The admissions show this fact still more clearly. Of the patients transferred from Chester in 1871, 43 per cent. were men, and 57 women; while in the new cases admitted since, the proportions have been exactly reversed, viz., 57 per cent. of men to 43 of women-during the last year the ratio of men rising to 60 per cent.
In order to look into the matter a little more closely, I took the Unions separately. I was led to do this by observing that, although the women transferred from the Chester Asylum exceeded the men by 33, yet that in one Union there were more men than women.
The following table shows the percentage of men on the admissions from the five Unions. 1st-Transferred from Chester. 2nd-On the total new cases since the opening. 3rd-On the admissions of 1873,
It will be seen from this that Union D has the highest proportion both among the transfers and the new cases, and was the only one in which the men exceeded the women at the opening of the Asylum ; and in this respect also it stood alone at the close of 1873.
The proportion of men on the total new cases shows that while in C, D, and E they were considerably in excess, in A the sexes were almost equal, and in B the men were only 30 per cent. It will also be noticed that had an exceptionally low proportion of men among the transfers ; and it may be added that the increase in the proportion among the new cases was mainly in 1873, when it rose to 71 per cent.
In connection with this I have prepared the following table, which shows the total number under treatment from each Union, the percentage of these affected with Organic Brain Disease, including General Paralysis, Epilepsy, Softening, &c.; also the percentage who have been discharged, and who have died.
Organic Disease. covered and Deaths.
80 114 122