Footnotes:
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[140] Edinburgh Review, vol. xxviii. p. 433.
[141] The "Private Mad-house Bill" of 1814 was introduced, April 5th, "to repeal and render more effectual the provisions of the Act of the 14th of the King." Mr. Rose said there were actually cases in which it was found that the medical certificate was signed by the keeper of the house. His Bill provided for the periodical visitation of private mad-houses by magistrates. The Bill passed the Commons July 11, 1814. Its author stated that it had been introduced the year before and amply considered by a Committee of the House, who were unanimous for its adoption, but I find no reference whatever in Hansard in 1813 to any Bill or Committee (see Hansard, vol. xxvii.).
[142] The chief members of the Committee were Lord R. Seymour, Lord Binning, the Right Hon. G. Rose, the Hon. H. G. Bennet, Mr. Western, Mr. W. Smith, and the Hon. W. H. Lyttleton.
[143] Hansard, vol. xxx. p. 954.
[144] Edinburgh Review, vol. xxviii. p. 435.
[145] Op. cit., p. 441. "Even after the publication of the evidence, it was not until the enormity of retaining the offending parties had been expressly condemned in Parliament that Mr. Haslam, the apothecary, was dismissed" (p. 443).
[146] Minutes, Select Committee of the House of Commons, 1815, pp. 43 and 44. See also Mr. J. B. Sharpe's edition of this Report, each subject arranged under its distinct head, 8vo, pp. 411. London.
[147] Ibid., pp. 167, 168. In the Minutes of the Committee of 1816, it is stated that in the same asylum the inmates were subjected to brutal cruelties from the attendants; that they suffered very much from cold, and were infested with vermin (p. 2, et seq.).
It may be added, as showing the slowness of reform, that even when, in 1828, two medical superintendents were appointed at Bethnal Green, no less than seventy, out of four hundred patients, were in irons; there was no bath, no book or newspaper, and little or no employment.
[148] Minutes of Evidence, Select Committee on Mad-houses, 1815, p. 43.
[149] Hansard, vol. xxxi. p. 1146.
[150] Hansard, vol. xxxiv.
[151] Mr. Rose had recently died (1818). Though not immediately successful, his labours deserve our cordial recognition.
[152] Hansard, vol. xxxix. p. 974.
[153] 59 Geo. III. c. 127.
[154] "I do hereby certify that by the directions of L. M. and N. O., Justices of the Peace for the county of H., I have personally examined C. D., and that the said C. D. appears to me to be of insane mind." Unfortunately a medical certificate in those days was not always of great value. Too many were illiterate productions like the following, on which a patient was admitted to Dr. Finch's asylum, Salisbury: "Hey Broadway A Potcarey of Gillingham Certefy that Mr. James Burt Misfortin hapened by a Plow in the Hed which is the Ocaision of his Ellness and By the Rising and Falling of the Blood And I think a Blister and Bleeding and Meddesen Will be A Very Great thing but Mr James Burt wold not A Gree to be don at Home. March 21, 1809. Hay Broadway."
[155] "A General View of the Present State of Lunatics and Lunatic Asylums in Great Britain and Ireland."
[156] The cost of some of the asylums mentioned is worth noting:—Bedford, with 180 beds, £20,500; Cornwall, with 172, £18,780; Gloucester, with 120, £42,856; Lancaster, for 593, £100,695; Stafford, for 120, £36,500; Nottingham, for 170, £36,800; Norfolk, for 220, £50,000; Wakefield, for 420, £46,620. (Except Cornwall, land is included.)
[157] In reply it was asserted that the room was twenty-six feet long, and the number of cribs fifteen.
[158] In 1827 Sir A. Halliday wrote: "This Act, the inadequacy of which has long been ascertained and fully exposed, is still the only law by which mad-houses are licensed and regulated in England and Wales.... That it has remained so long upon the statute book must hereafter excite astonishment; and that even now, there should exist so much difficulty in having it altered and amended, is a fact scarcely to be credited. Yet such is the fact; and thousands of our fellow-men have been hurried to an untimely grave, in all the horrors of raving madness or helpless fatuity, without its being possible to get their condition altered or amended, merely because certain (we hope mistaken) prejudices were entertained by an exalted individual whose voice was long paramount in the senate; and we had almost added, through the influence of those who have realized immense fortunes as wholesale dealers and traffickers in this species of human misery."
[159] Hansard, vol. xviii. p. 583.
[160] Hansard, vol. xix. p. 195.
[161] See [Appendix D].
[162] Minutes of Evidence of Select Committee of the House of Commons, 1859, p. 65.
[163] The Act of 1828 was amended by 2 and 3 Will. IV., c. 107.
[164] 2 and 3 Will. IV., c. 107. The Metropolitan Commissioners were, under this Act, to be appointed by the Lord Chancellor instead of the Home Secretary. Not less than four or more than five were to be physicians, and two barristers.
[165] Hansard, vol. lxi. p. 806.
[166] 5 and 6 Vict., c. 87.
[167] Report of the Metropolitan Commissioners, 1844.
[168] For some of the details of this Report, see [chapter v].
[169] Hansard, vol. lxxvi. p. 1274.
[170] These were to be visited by a small private Committee named by the Lord Chancellor.
[171] 8 and 9 Vict., c. 100 and c. 126 (see [Appendix E].)
[172] For more particular provisions in these Acts and that of 1855 (18 and 19 Vict., c. 105), containing some further amendments, see [Appendix F].
[173] See [Appendix G].
[174] In the following year another statute (26 and 27 Vict., c. 110), entitled "An Act to amend the Lunacy Acts," was passed, but only consisted of three sections referring to one or two doubtful points in the previous Act, which do not require notice. How many Acts of Parliament are necessitated by the blundering obscurity of the person who, as draughtsman, escapes criticism?
[175] For an analysis of the evidence, and considerations thereupon, the writer may refer to an article in the Contemporary Review, October, 1877, entitled "Lunacy Legislation."
[176] "Parliamentary Debates," 3rd Series, vol. 261, p. 1278.
[177] Mr. Gordon died in 1864. In their Report of that year, the Commissioners "deplore the death of their colleague, Mr. Robert Gordon, whose name has been prominent, during the greater part of the last half century, in connection with efforts to ameliorate the condition of the insane," and add, "Down to the present time, Mr. Gordon has given to our labours, constant and valuable personal aid; and his unwearied and disinterested service, closed only by death, we must remember always with respect and gratitude." It may be mentioned here that Mr. Wynn, to whose exertions the Act of 1808 ([p. 128]) was due, lived to witness Lord Ashley's Act of 1846 passed, and was present in the House during the debate.
CHAPTER V.
LINCOLN AND HANWELL—PROGRESS OF REFORM IN THE TREATMENT OF THE INSANE FROM 1844 TO THE PRESENT TIME.
Before presenting official evidence of the gradual progress in the condition of the insane in England, we must interpose in our history a brief reference to the development of what every one knows as the non-restraint system of treating the insane. It is, no doubt, true that restraint begins the moment a patient enters an asylum, under whatever name it may be disguised, but by this term is technically meant the non-use of mechanical restraint of the limbs by the strait waistcoat, leg-locks, etc. If, as indeed it may be granted, it had its real origin in the humane system of treatment introduced into England long previously, it was in the first instance at Lincoln, and subsequently at Hanwell, adopted as a universal method, and as a rule having almost the sanctity of a vow.
The following table shows, in the clearest manner, by what gradual steps the experiment was tried and carried on at the former asylum. Dr. Charlesworth was the visiting physician and Mr. R. Gardiner Hill the house surgeon.
| Year. | Total number in the house. | Total number restrained. | Total number of instances of restraint. | Total number of hours under restraint. |
|---|---|---|---|---|
| 1829 | 72 | 39 | 1727 | 20,424 |
| 1830 | 92 | 54 | 2364 | 27,113¾ |
| 1831 | 70 | 40 | 1004 | 10,830 |
| 1832 | 81 | 55 | 1401 | 15,671½ |
| 1833 | 87 | 44 | 1109 | 12,003½ |
| 1834 | 109 | 45 | 647 | 6,597 |
| 1835 | 108 | 28 | 323 | 2,874 |
| 1836 | 115 | 12 | 39 | 334 |
| 1837 | 130 | 2 | 3 | 28 |
Here we observe that in 1829 more than half the number of the inmates were subjected to mechanical restraint, while in 1836, out of 115 patients, only twelve were so confined, and in 1837 there were only two out of 130.[178] The total disuse of mechanical restraints followed. They were, however, resorted to on one or two occasions subsequently.
In connection with the foregoing, it must be mentioned that the entries of the visitors and the reports of the physicians alike agree in describing the condition of the patients as much improved, the quiet of the house increased, and the number of accidents and suicides as materially reduced in number.
It would appear that the mitigation of restraint, as evidenced by these minutes (which commence with 1819), "was ever the principle," to use Mr. Hill's own words, "pressed upon the attention of the Boards of the Lincoln Asylum by its able and humane physician, Dr. Charlesworth, at whose suggestion many of the more cruel instruments of restraint were long since destroyed, very many valuable improvements and facilities gradually adopted, and machinery set in motion which has led to the unhoped-for result of actual abolition, under a firm determination to work out the system to its utmost applicable limits." Mr. Hill became house surgeon in 1835; and it will be seen, by the table already given, that the amount of restraint (which, in consequence of Dr. Charlesworth's exertions, had already remarkably decreased) became less and less under the united efforts of these gentlemen, until the close of the year 1837, when restraint was entirely abolished; and while, on the one hand, as Mr. Hill frankly acknowledges, "to his [Dr. Charlesworth's] steady support, under many difficulties, I owe chiefly the success which has attended my plans and labours," while Dr. Charlesworth's great merit, both before and after Mr. Hill's appointment, must never be overlooked, it is due to the latter gentleman to admit that he was the first to assert the principle of the entire abolition of mechanical restraint, as is stated in the "Fourteenth Annual Report of the Lincoln Asylum," which report is signed by Dr. Charlesworth himself.
For a time there were, certainly, some drawbacks to the success of the Lincoln experiment, from the serious physical effects (such as broken ribs, etc.), which occasionally resulted from the struggles between attendants and patients; and it is probable that, had not the experiment been carried out on a much larger scale at Hanwell by Dr. Conolly, with far greater success, a reaction would have ensued, of infinite injury to the cause of the insane.
Dr. Conolly went to Hanwell in 1839; and in the first of an admirable series of reports written by him, we read, "The article of treatment in which the resident physician has thought it expedient to depart the most widely from the previous practice of the asylum, has been that which relates to the personal coercion, or forcible restraint, of the refractory patients.... By a list of restraints appended to this report, it will be seen that the daily number in restraint was in July so reduced, that there were sometimes only four, and never more than fourteen, at one time [out of eight hundred]; but, since the middle of August, there has not been one patient in restraint on the female side of the house; and since September 21st, not one on either side.... For patients who take off or destroy their clothes, strong dresses are provided, secured round the waist by a leathern belt, fastened by a small lock.... No form of waistcoat, no hand-straps, no leg-locks, nor any contrivance confining the trunk or limbs or any of the muscles, is now in use. The coercion-chairs (forty in number) have been altogether removed from the walls.... Several patients formerly consigned to them, silent and stupid, and sinking into fatuity, may now be seen cheerfully moving about the walls or airing-courts; and there can be no question that they have been happily set free from a thraldom, of which one constant and lamentable consequence was the acquisition of uncleanly habits."
In a later report (October, 1844) Dr. Conolly observes, "After five years' experience, I have no hesitation in recording my opinion that, with a well-constituted governing body, animated by philanthropy, directed by intelligence, and acting by means of proper officers (entrusted with a due degree of authority over attendants properly selected, and capable of exercising an efficient superintendence over the patients), there is no asylum in the world in which all mechanical restraints may not be abolished, not only with perfect safety, but with incalculable advantage."
Four years ago when I visited the Lancaster Asylum, I was shown a room containing the dire instruments of coercion formerly in use, and a most instructive exhibition it was. At my request the superintendent, Dr. Cassidy, has kindly provided me with the following list of these articles: 1 cap with straps; 4 stocks to prevent biting; 2 muzzles (leather) to cover face and fasten at the back of the head; 10 leather gloves, of various forms, perforated with holes, and cuffs of leather or iron; 14 double ditto, with irons for wrists; 1 kicking shoe; 11 leather muffs with straps; 4 stout arm leathers (long sleeves with closed ends) with cross-belt and chains; 8 heavy body straps, with shoulder-pieces, waist-belts, cross-belts, and pairs of handcuffs attached by short chains; 5 ditto of somewhat different make; 30 ditto, but with leather cuffs; 2 waist straps with leather cuffs attached; 9 pairs of leather cuffs padded; 11 pairs of leg-locks; a quantity of foot and hand cuffs (iron), with chains and catches to fasten to a staple in the wall or bedstead; 21½ pairs of padded leather handcuffs; a larger quantity of handcuffs, single and double, of iron; 22 sets of strong body fastenings, very heavy chains covered with leather and iron handcuffs; a large quantity of broad leather straps; a bag of padlocks; keys for handcuffs, etc.
Truly the iron must have entered into the soul of many a poor lunatic in those days. Mr. Gaskell began at once to remove handcuffs, etc., on his appointment as superintendent, February, 1840. The disuse of restraint is chronicled in the annual report, dated June, 1841. He resigned, January 16, 1849, to become a Commissioner in Lunacy.
The Metropolitan Commissioners in Lunacy, as we have seen in the previous chapter, issued a Report which forms an epoch in the history of the care and provision for the insane in England and Wales. It should be stated that, previous to the date of its preparation in 1844, the following asylums had been erected under the Acts 48 Geo. III., c. 96, and 9 Geo. IV., c. 40.
| County. | Town. | Date of opening. |
|---|---|---|
| Beds | Bedford | 1812 |
| Chester | Chester | 1829 |
| Cornwall | Bodmin | 1820 |
| Dorset | Forston, near Dorchester | 1832 |
| Gloucester | Gloucester | 1823 |
| Kent | Barming Heath, Maidstone | 1833 |
| Lancaster | Lancaster Moor | 1816 |
| Leicester | Leicester | 1837 |
| Middlesex | Hanwell | 1831 |
| Norfolk | Thorpe, near Norwich | 1814 |
| Nottingham | Nottingham | 1812 |
| Stafford | Stafford | 1818 |
| Suffolk | Melton, near Woodbridge | 1829 |
| Surrey | Springfield, Wandsworth | 1841 |
| York, West Riding | Wakefield | 1818 |
There were two asylums in operation at this date, which were declared by local Acts county asylums, subject to the provisions of 9 Geo. IV., c. 40, viz. St. Peter's Hospital, Bristol, incorporated in the year 1696; and one at Haverfordwest, county of Pembroke, 1824.
The military and naval hospitals were two in number, viz.—
| Hospital. | Nature. | Date of opening. |
|---|---|---|
| Fort Clarence, Chatham | Military | 1819 |
| Haslar Hospital, Gosport | Naval | 1818 |
Then there were the old hospitals of Bethlem and St. Luke's—the former more specially devoted to the insane in 1547, removed from Bishopsgate Street to Moorfields in 1676, and opened in St. George's Fields in 1815; the latter opened July 30, 1751.
The other public lunatic hospitals, nine[179] in number, were—
| Locality. | Name of Asylum. | Date of opening. |
|---|---|---|
| Exeter | St. Thomas' | 1801 |
| Lincoln | Lunatic Asylum | 1820 |
| Liverpool | „ „ | 1792 |
| Northampton | General Lunatic Asylum | 1838 |
| Norwich | Bethel Hospital | 1713 |
| Oxford (Headington) | Warneford Asylum | 1826 |
| York | Bootham Asylum | 1777 |
| „ | The Retreat | 1796 |
The total number of recognized lunatics on the 1st of January, 1844, were—
| Private | 4,072 |
| Pauper | 16,821 |
| Total | 20,893 |
They were thus distributed:—
| Where confined. | Private patients. | Paupers. | Total. | ||||||
|---|---|---|---|---|---|---|---|---|---|
| M. | F. | Total. | M. | F. | Total. | M. | F. | Total. | |
| 15 county asylums | 130 | 115 | 245 | 1,924 | 2,231 | 4,155 | 2,054 | 2,346 | 4,400 |
| 2 ditto under local acts | — | — | — | 38 | 51 | 89 | 38 | 51 | 89 |
| 2 military and naval hospitals | 164 | 4 | 168 | — | — | — | 164 | 4 | 168 |
| 2 Bethlem and St. Luke's Hospitals | 178 | 264 | 442 | 86 | 35 | 121 | 264 | 299 | 563 |
| 9 other public asylums | 249 | 287 | 536 | 177 | 166 | 343 | 426 | 453 | 879 |
| Licensed houses— | |||||||||
| 37 metropolitan | 520 | 453 | 973 | 360 | 494 | 854 | 880 | 947 | 1,827 |
| 99 provincial | 748 | 678 | 1,426 | 947 | 973 | 1,920 | 1,695 | 1,651 | 3,346 |
| Workhouses and elsewhere[180] | — | — | — | 4,169 | 5,170 | 9,339 | 4,169 | 5,170 | 9,339 |
| Single patients under commission | 172 | 110 | 282 | — | — | — | 172 | 110 | 282 |
| Total | 2,161 | 1,911 | 4,072 | 7,701 | 9,120 | 16,801 | 9,682 | 11,031 | 20,893 |
The number of asylums amounted to 166.[181]
At this period there were thirty-three metropolitan licensed houses receiving private patients only, and four which received paupers also.
The dates of opening of these thirty-three private asylums, so far as known, were: three in the last century, to wit, in 1744, 1758, and 1759; one in each of the following years, 1802, 1811, 1814, 1816, 1823, 1825, 1826, 1829, 1832, 1833, 1834, 1836, 1837, 1840, 1842, and 1843; and two in 1830, 1831, 1838, and 1839.
Passing from London to the provinces, we find fifty-five provincial licensed houses receiving private patients only, and forty-four receiving paupers, of which one was in Wales (Briton Ferry, near Swansea). The known dates of opening were: in 1718, Fonthill-Gifford in Wilts; in 1744, Lea Pale House, Stoke, near Guildford; in 1766, Belle Grove House, Newcastle-on-Tyne; in 1791, Droitwitch; and in 1792, Ticehurst, Sussex; one in each of the following years, 1800, 1802, 1803, 1806, 1808, 1812, 1814, 1816, 1818, 1821, 1824, and 1829; two in each of the years 1820, 1822, 1826, 1828, 1832, 1834, 1836, 1837, 1838, and 1842; three in each of the years 1825, 1831, 1839, and 1843; four in 1833; five in 1830, 1835, and 1840; and, finally, six in 1841. One of the asylums opened in 1843 was that in Wales, containing only three patients.
Of some asylums found by the Commissioners to be in a very disgraceful state, one is described as "deficient in every comfort and almost every convenience. The refractory patients were confined in strong chairs, their arms being also fastened to the chair. One of these—a woman—was entirely naked on both the days the Commissioners visited the asylum, and without doubt during the night. The stench was so offensive that it was almost impossible to remain there." In another, "in the small cheerless day-room of the males, with only one (unglazed) window, five men were restrained by leg-locks, called hobbles, and two were wearing, in addition, iron handcuffs and fetters from the wrist to the ankle; they were all tranquil. Chains were fastened to the floors in many places, and to many of the bedsteads." The Commissioners report of another house that "in one of the cells for the women, the dimensions of which were eight feet by four, and in which there was no table and only two wooden seats, we found three females confined. There was no glazing to the window.... The two dark cells, which joined the cell used for a day-room, are the sleeping-places for these three unfortunate beings. Two of them sleep in two cribs in one cell.... There is no window and no place for light or air, except a grate over the doors." The condition of the floor and straw, on which the patients lay, it is unnecessary to describe.
We should not be doing justice to the history of non-restraint if we did not state in full what the Commissioners found at this period to be the opinion of the superintendents of the asylums in England.
"During our visits," they say, "to the different asylums, we have endeavoured to ascertain the opinions of their medical superintendents in reference to the subject of restraint, and we will now state, in general terms, the result of our inquiries. Of the superintendents of asylums not employing mechanical restraint, those of the hospitals of Lincoln, Northampton, and Haslar, and of the county asylum at Hanwell, appear to consider that it is not necessary or advisable to resort to it in any case whatever, except for surgical purposes. On the other hand, the superintendent at Lancaster[182] hesitates in giving an opinion decidedly in favour of the non-restraint system. He thinks that, although much may be done without mechanical restraint of any kind, there are occasionally cases in which it may not only be necessary, but beneficial. The superintendent of the Suffolk Asylum considers that in certain cases, and more especially in a crowded and imperfectly constructed asylum, like the one under his charge, mechanical restraint, judiciously applied, might be preferable to any other species of coercion, as being both less irritating and more effectual. The superintendent of the Gloucester Asylum states that he has adopted the disuse of mechanical restraint, upon the conviction which his experience has given him during a trial of nearly three years. Of the superintendents of asylums who employ mechanical restraint, those of the Retreat at York, of the Warneford Asylum, and of the hospitals at Exeter, Manchester, Liverpool, and St. Luke's, consider that, although the cases are extremely rare in which mechanical restraint should be applied, it is, in some instances, necessary. Similar opinions are entertained by the superintendents of the county asylums of Bedford, Chester, Cornwall, Dorset, Kent, Norfolk, Nottingham, Leicester, Stafford, and the West Riding of York. At the Retreat at York mechanical or personal restraint has been always regarded as a 'necessary evil,' but it has not been thought right to dispense with the use of a mild and protecting personal restraint, believing that, independent of all consideration for the safety of the attendants, and of the patients themselves, it may in many cases be regarded as the least irritating, and therefore the kindest, method of control. Eight of the superintendents employing bodily restraint have stated their opinion to be that it is in some cases beneficial as well as necessary, and valuable as a precaution and a remedial agent; and three of them have stated that they consider it less irritating than holding with the hands; and one of them prefers it to seclusion.
"In all the houses receiving only private patients, restraint is considered to be occasionally necessary, and beneficial to the patients.... At the Cornwall Asylum, we found a man who voluntarily wrapped his arm round with bands of cloth from the fear of striking others. He untied the cloth himself at our request. We know the case of one lady, who goes home when she is convalescent, but voluntarily returns to the asylum when she perceives that her periodical attacks of insanity are about to return, in order that she may be placed under some restraint.
"Of the asylums entirely disusing restraint, in some of them, as we have stated, the patients have been found tranquil and comfortable, and in others they have been unusually excited and disturbed. Without, however, attaching undue importance to the condition of the asylum at the time of our visits, or to accidents that may happen under any system of managing the insane, it is nevertheless our duty to call your Lordship's attention to the fact that since the autumn of 1842 a patient and a superintendent have been killed; a matron has been so seriously injured that her life was considered to be in imminent danger (at Dr. Philp's house at Kensington); another superintendent has been so bitten as to cause serious apprehensions that his arm must have been amputated; and two keepers have been injured so as to endanger their lives. These fatal and serious injuries and accidents have been caused by dangerous patients, and some of them in asylums where either the system of non-coercion is voluntarily practised, or is adopted in deference to public opinion."
The following is a brief summary of the arguments of medical officers and superintendents advocating absolute non-restraint at that period:—
1. That their practice is the most humane, and most beneficial to the patient; soothing instead of coercing him during irritation; and encouraging him when tranquil to exert his faculties, in order to acquire complete self-control.
2. That a recovery thus obtained is likely to be more permanent than if obtained by other means; and that, in case of a tendency to relapse, the patient will, of his own accord, be more likely to endeavour to resist any return of his malady.
3. That mechanical restraint has a bad moral effect; that it degrades the patient in his own opinion; that it prevents any exertion on his part; and thus impedes his recovery.
4. That experience has demonstrated the advantage of entirely abolishing restraint, inasmuch as the condition of some asylums, where it had been previously practised in a moderate and very restricted degree, has been greatly improved, with respect to the tranquillity and the appearance of cheerfulness among the patients in general, after all mechanical coercion has been discontinued.
5. That mechanical restraint, if used at all, is liable to great abuse from keepers and nurses, who will often resort to it for the sake of avoiding trouble to themselves; and who, even when well disposed towards the patient, are not competent to judge of the extent to which it ought to be applied.
6. The patient may be controlled as effectually without mechanical restraint, as with it; and that the only requisites for enabling the superintendents of asylums to dispense with the use of mechanical restraint, are a greater number of attendants, and a better system of classification amongst the patients; and that the additional expense thereby incurred ought not to form a consideration where the comfort of the patients is concerned.
On the other hand, the medical and other superintendents of lunatic asylums who adopted a system of non-restraint as a general rule, but made exceptions in certain extreme cases, urged the following reasons for occasionally using some slight coercion:—
1. That it is necessary to possess, and to acquire as soon as possible, a certain degree of authority or influence over the patient, in order to enforce obedience to such salutary regulations as may be laid down for his benefit.
2. That, although this authority or influence is obtained in a majority of cases by kindness and persuasion, there are frequent instances where these means entirely fail. That it then becomes necessary to have recourse to other measures, and, at all events, to show the patient that, in default of his compliance, it is in the power of the superintendent to employ coercion.
3. That a judicious employment of authority mixed with kindness (and sometimes with indulgence) has been found to succeed better than any other method.
4. That the occasional use of slight mechanical restraint has, in many instances, been found to promote tranquillity by day and rest by night.
5. That it prevents, more surely than any supervision can effect, the patient from injuring himself or the other patients.
6. That, particularly in large establishments, the supervision must be trusted mainly to the attendants, who are not always to be depended on, and whose patience, in cases of protracted violence, is frequently worn out. That in such cases mild restraint insures more completely the safety of the attendants, and contributes much to the tranquillity and comfort of the surrounding patients.
7. That in many cases mild mechanical restraint tends less to irritate, and generally less to exhaust the patient, than the act of detaining him by manual strength, or forcing him into a place of seclusion, and leaving him at liberty to throw himself violently about for hours together.
8. That the expense of a number of attendants—not, indeed, more than sufficient to restrain a patient during a violent paroxysm, but nevertheless far beyond the ordinary exigencies of the establishment—is impracticable in asylums where only a small number of paupers are received.
9. That the occasional use of slight coercion, particularly in protracted cases, possesses this additional advantage: that it gives the patient the opportunity of taking exercise in the open air at times when, but for the use of it, he would necessarily be in a state of seclusion.
10. The system of non-restraint cannot be safely carried into execution without considerable additional expense; a matter which will necessarily enter into the consideration of those who are desirous of forming a correct opinion as to the precise benefits likely to arise from the adoption or rejection of such a system.
11. That the benefit to the patient himself, if indeed it exist at all, is not the only question; but that it ought to be considered, whether the doubtful advantage to himself ought to be purchased by the danger to which both he and his attendants and other patients are exposed, when restraint is altogether abolished.
And 12thly. That, when a patient is forced into and secluded in a small room or cell, it is essentially coercion in another form, and under another name; and that it is attended with quite as bad a moral effect, as any that can arise from mechanical restraint.[183]
Passing on to 1847, we find the Commissioners in Lunacy, having acted under the new powers conferred upon them by the two Acts passed since the date of the Report of 1844 (8 and 9 Vict., cc. 100 and 126), able to give a satisfactory sketch of the progress of reform in the condition of asylums. "In several of the county asylums and hospitals," they observe, "the adoption of a more gentle mode of management was originally designed in the direction of these establishments, and was the result of public opinion and of the example set by the managers of the Retreat near York. A strong impression was made on the feelings and opinion of the public in reference to the treatment of lunatics by the publication of Mr. Tuke's account of the Retreat at York. The able writings of Dr. Conolly have of late years contributed greatly to strengthen that impression, and to bring about a much more humane treatment of lunatics in many provincial asylums, than that which formerly prevailed." Referring, then, to the Report of the Metropolitan Commissioners (1844) it is observed that "proof is afforded therein that this amendment had not extended itself to old establishments for the insane, and that much severe and needless restraint continued to be practised in numerous private, and in some public asylums. In many of the private asylums, and more especially in those which received great numbers of pauper patients, much mechanical coercion was practised, until it came to be in great measure laid aside in consequence of the repeated advice and interference of the Commissioners.... In private licensed asylums it has been thought impracticable to avoid the occasional use of mechanical coercion without incurring the risk of serious accidents. Under these circumstances restraint of a mild kind is still practised, but we look forward to its abolition, except, perhaps, in some extraordinary cases, so far as pauper patients are concerned, when the provisions of the Act for the establishment of county asylums shall have been carried into effect. In the best-conducted county asylums it is now seldom (and in a few establishments never) resorted to."[184]
At this period, the actual number of lunatics returned to the Commissioners was only 18,814, but they estimated the number under some kind of care, in England and Wales, at 26,516. There were—
| Location. | Private. | Pauper. | Total. |
|---|---|---|---|
| In county asylums, hospitals, and licensed houses | 3,574 | 9,652 | 13,226 |
| Bethlem, and in naval and military hospitals not subjected to visitation of Commissioners | 606 | — | 606 |
| Poor-law unions; placed under local Acts | — | 8,986 | 8,986 |
| Gilbert's unions, and other places not in union | — | 176 | 176 |
| Single patients found lunatic by inquisition | 307 | — | 307 |
| Ditto in private houses with persons receiving profit | 130 | — | 130 |
| Excess of pauper patients in workhouses, etc., estimated by visiting Commissioners as at least one-third over the number number returned by parish officers | — | 3,053 | 3,053 |
| Criminals in jails | — | 32 | 32 |
| Total | 4,617 | 21,899 | 26,516 |
The number of patients found lunatic by inquisition was 542; their incomes amounting to £280,000. In 1839 the corresponding numbers were 494 and £277,991.
The estimated annual amount expended at this time for maintenance of lunatics, or administered on their behalf, exceeded £750,000, thus distributed:
| 1. Cost of 9652 paupers in asylums, estimated at 8s. per week | £200,762 |
| 2. Ditto of 8986 paupers in workhouses, etc., and 173 in parishes not in union (9159), estimated at 3s. per week | 71,440 |
| 3. Ditto of excess of 3053 paupers over the number returned by the parish officer | 23,813 |
| 4. Ditto of 3574 private patients in asylums, etc., at an average of 20s. per week | 173,628 |
| 5. Income of 542 private patients found lunatic by inquisition | 280,000 |
| 6. Cost of 606 patients in Bethlem and the naval and military hospitals, estimated at 10s. per week | 50,756 |
| 7. Ditto of 120 other single patients taken charge of in separate houses at £100 a year | 12,000 |
| 8. Thirty-two criminals in jails, estimated at 3s. per week | 249 |
| Total | £777,648 |
Adding the expense of maintaining many families cast upon the parish in consequence of the patient's insanity, and the expense of supporting many called imbecile, and the interest of large sums invested in public establishments, the Commissioners estimated the actual amount as little less than £1,000,000.
In the same Report the Commissioners observe "that they have found that, with some exceptions, the patients have apparently been humanely, and sometimes very judiciously treated. There is no reason to apprehend that the lunatic patient is now often subjected to cruelty or ill-treatment.... The massive bars, and rings, and chains of iron formerly resorted to are no longer seen. Any continued coercion is not permitted. The name of every patient under restraint and in seclusion, and the means by which such seclusion is effected, are recorded every week in a journal. Thus the safeguards against lunatic patients being subjected to harsh or unnecessary restraint from the cruelty, idleness, or caprice of their attendants, have been multiplied, and the chances of abuse reduced to a small amount."
The number of lunatics placed under mechanical restraint in licensed houses in this year is given in the following table, it being premised that wherever the number is not specified, "it may be assumed either that there was no patient then under restraint, or that the number was so small, and the restraint so trivial, as not to be deemed worthy of special remark."[185]
| Asylum. | Number of patients. | Criminals. | Under restraint last visit. |
|---|---|---|---|
| Metropolitan Licensed Houses. | |||
| Bethnal Green—Red House White House | 614 | 12 | 4 |
| Bow—Grove Hall | 291 | — | 2 |
| Brompton—Earls Court | 32 | — | 1 |
| Camberwell—Camberwell House | 246 | 1 | 5 |
| Clapham—Retreat | 15 | — | 1 |
| Clapton, Upper—Brook House | 42 | — | 1 |
| Fulham—Beaufort House | 5 | — | 2 |
| Hillingdon—Moorcroft House | 50 | — | 1 |
| Hoxton—Hoxton House | 416 | — | 4 |
| Kensington—Kensington House | 44 | — | 2 |
| Peckham—Peckham House | 409 | 4 | 4 |
| Stoke Newington—Northumberland House | 35 | — | 1 |
| Asylum. | Number of patients. | Criminals. | Under restraint last visit. |
|---|---|---|---|
| Provincial Licensed Houses. | |||
| Derby—Green Hill House | 25 | — | 1 |
| Durham—Gateshead Fell | 92 | 8 | 1 |
| Essex—High Beach | 34 | — | 2 |
| Gloucester—Fishponds | 45 | — | 1 |
| „ Northwoods | 29 | — | 1 |
| „ Fairford | 175 | 1 | 1 |
| Hants—Grove Place | 78 | 1 | 1 |
| Herefordshire—Whitchurch | 32 | 2 | 1 |
| Kent—West Malling Place | 40 | — | 3 |
| Lancaster—Blakely House | 24 | — | 1 |
| Northumberland—Bell Grove House | 13 | — | 1 |
| Oxford—Witney | 11 | — | 2 |
| „ Hook-Norton | 57 | 1 | 2 |
| Somerset—Bailbrook House | 92 | 3 | 10 |
| Stafford—Oulton Retreat | 25 | — | 2 |
| „ Sandfield | 44 | — | 1 |
| Sussex—Ringmer | 3 | — | 1 |
| Warwick—Duddeston Hall | 87 | 3 | 6 |
| „ Kingstown House | 91 | — | 2 |
| Wilts—Bellevue House | 181 | 5 | 5 |
| „ Fiddington House | 193 | 3 | 3 |
| Worcester—Droitwich | 91 | 2 | 2 |
| York, East Riding—Hull and East Riding Refuge | 115 | 8 | 1 |
| „ „ Hessle | 12 | — | 1 |
| „ West Riding—Castleton Lodge | 15 | — | 1 |
| „ „ Grove House | 41 | — | 5 |
| „ „ Heworth | 29 | — | 1 |
If for the purpose of comparison at different years we take one asylum, Ringmer in Sussex, there were in November 1829, nineteen patients, of whom five were under restraint by day, and seven by night. In 1830 (February) the number of patients was twenty, and of these eleven were under restraint by day and six by night; while in October of the same year, out of eighteen patients, there were nine under restraint. In 1831, there were twenty-two patients, ten of whom were under restraint. Writing in 1848, the Commissioners enumerate the various changes for the better which had then taken place, among which were—an active medical superintendence; the abolition of excessive use of mechanical restraint, there being sometimes only one or two, and occasionally no patient whatever, under mechanical restraint; the introduction of warm and cold baths; the cleanliness of the day-rooms and dormitories; the addition of a good library, and various amusements and means of occupation; and also an excellent dietary. Such is a sample of the happy change which was, in many instances, brought about by inspection.
The following classification of asylums in 1851 will show at a glance the progress made in providing accommodation from time to time, consequent upon legislation:—
There were still upwards of fifty boroughs for whose pauper lunatics no legal provision was made, and no asylum was then erected for the City of London.
Under the head of mechanical restraint, the Commissioners now report that it has still further diminished, and has in some houses been absolutely abolished. However, in fifty entries made in the books of thirty-six private asylums, abuses and defects are animadverted upon in fifteen instances in regard to restraint, in twenty instances in regard to bedding and clothing, nine in regard to diet, seven in regard to cleanliness, and four in regard to management and treatment. They observe that the number of lunatics in workhouses has diminished in a very marked degree.
In this Report the Commissioners take the opportunity of animadverting, also, upon the defective state of the law in regard to the property of lunatics; the good effect of the Act 8 and 9 Vict., c. 100, being lessened by this and other causes.
Turning to the year 1854, nearly ten years after the Act of 1845 had been in fruitful operation, we find the Commissioners attaching importance to the alterations recently made in the law of lunacy by the three important statutes, 16 and 17 Vict., c. 70 (the "Lunacy Regulation Act" of 1853) which refers to Chancery lunatics; 16 and 17 Vict., c. 90 (an amendment of the Act under which the Board was constituted); and 16 and 17 Vict., c. 97 (the "Lunatic Asylums Act," 1853).
These Acts, with 8 and 9 Vict., c. 100, and 15 and 16 Vict., c. 48, and the Acts relative to criminal lunatics, constituted at that period the code of law of lunacy.
The following counties still remained unprovided for:—Sussex, Cumberland, Westmoreland, Northumberland, Durham, Cambridge, Cardigan, Carmarthen, Glamorgan, Pembroke.
New private asylums were no longer licensed for paupers, in consequence of the accommodation provided for them in county asylums.
Complaints having been made of the treatment of patients at Hanwell, an inquiry had been instituted, which, in the opinion of the Commissioners, justified them. They appeared to have been due to the want of efficient supervision of male patients.
This Report of the Commissioners gives a series of interesting replies to a circular letter addressed to the superintendents and medical proprietors of nearly all the asylums in England and Wales, on non-restraint, upon which they observe, "as the general result which may be fairly deduced from a careful examination and review of the whole body of information thus collected, we feel ourselves fully warranted in stating that the disuse of instrumental restraint, as unnecessary and injurious to the patient, is practically the rule in nearly all the public institutions in the kingdom, and generally also in the best-conducted private asylums, even those where the restraint system, as an abstract principle admitting of no deviation or exception, has not in terms been adopted.
"For ourselves," they observe, "we have long been convinced, and have steadily acted on the conviction, that the possibility of dispensing with mechanical coercion in the management of the insane is, in a vast majority of cases, a mere question of expense, and that its continued, or systematic use in the asylums and licensed houses where it still prevails must in a great measure be ascribed to their want of suitable space and accommodations, their defective structural arrangements, or their not possessing an adequate staff of properly qualified attendants, and frequently to all these causes combined.
"Our matured views upon the subject will be best understood by stating the course we have followed in the discharge of our functions as visitors. In that capacity we have made it a principle to discourage, to the utmost, the employment of instrumental restraint in any form. Wherever we have found it in use, our uniform practice has been to inquire minutely into the circumstances and reasons alleged for its necessity, and to insist on recourse being had to those various other means which experience has proved in other houses to be effective substitutes for it....
"As respects the question of seclusion, its occasional use for short periods, chiefly during paroxysms of epilepsy or violent mania, is generally considered beneficial. At the same time, we would observe that the facilities which seclusion holds out to harsh or indolent attendants for getting rid of and neglecting troublesome patients under violent attacks of mania, instead of taking pains to soothe their irritated feelings, and work off their excitement by exercise and change of scene, render it liable to considerable abuse; and that, as a practice, it is open, though in a minor degree, to nearly the same objections which apply to the more stringent forms of mechanical restraint. We are therefore strongly of opinion that, when even seclusion is resorted to as a means of tranquillizing the patient, it should only be employed with the knowledge and direct sanction of the medical officer, and even then be of very limited duration.
"Further experience, we think, has shown that, except for the reception of epileptic patients during the continuance of their paroxysms, and in a few cases where there is a determined propensity to suicide, the utility of padded rooms is not so great as was at one time supposed; and that, for cases of ordinary maniacal excitement, seclusion in a common day-room or sleeping-room of moderate size, from which all articles that might furnish instruments of violence or destruction have been removed, and which is capable of being readily darkened, when required, by a locked shutter, will, in general, be found to answer every useful purpose."[186]
As ten years had elapsed since the first attempt of any value to present the numbers of the insane in England (see [page 211]), it is of interest to compare with the table referred to, the following statement of the numbers on the 1st of January, 1854:—
| Where confined. | Private patients. | Paupers. | Total. | ||||||
|---|---|---|---|---|---|---|---|---|---|
| M. | F. | Total. | M. | F. | Total. | M. | F. | Total. | |
| 33 county and borough asylums | 147 | 146 | 293 | 5,791 | 6,878 | 12,669 | 5,938 | 7,024 | 12,962 |
| 2 military and naval hospitals | 199 | 5 | 204 | — | — | — | 199 | 5 | 204 |
| 2 Bethlem and St. Luke's Hospitals | 235 | 239 | 474 | 4 | 7 | 11 | 239 | 246 | 485 |
| 22 other public asylums | 467 | 456 | 923 | 102 | 103 | 205 | 569 | 559 | 1,128 |
| Licensed houses— | |||||||||
| 42 metropolitan | 608 | 598 | 1,206 | 418 | 723 | 1,141 | 1,026 | 1,321 | 2,347 |
| 88 provincial | 795 | 738 | 1,533 | 593 | 407 | 1,000 | 1,388 | 1,145 | 2,533 |
| Workhouses and elsewhere | — | — | — | 5,326 | 5,327 | 10,653 | 5,326 | 5,327 | 10,653 |
| Total | 2,451 | 2,182 | 4,633 | 12,234 | 13,445 | 25,679 | 14,685 | 15,627 | 30,312 |
In their ninth Report the Commissioners speak of continued progress, and to show the beneficial effects of good and kind treatment, record the case of a lady visited by them in a private asylum, where they found her in a room by herself, in a sadly neglected condition, and very frequently placed under mechanical restraint. Her habits were dirty, and her opportunities of taking exercise few. In consequence of her unsatisfactory condition the Commissioners ordered her removal to another asylum (the York Retreat), and about twelve months afterwards saw her there, and made an entry to the effect that since her admission she had never been in restraint or seclusion; that her destructive and dirty habits had been corrected by constant attention, exercise out of doors, and association with other patients. The Commissioners found her quiet, orderly, clean, well-dressed, and so much improved in appearance that they had some difficulty at first in recognizing her.
It was inevitable, as a result of the attention directed to the condition of the insane, and the greatly increased provision made for them in consequence, that there should be an alarming apparent increase of lunacy in the kingdom. In point of fact, the number of pauper lunatics had increased sixty-four per cent. in the eight years ending 1855.
At this period there were 13,579 patients in county and borough asylums, 1689 in registered hospitals, 2523 in metropolitan and 2588 in provincial licensed houses, and 114 in the Royal Naval Hospital.
The number of insane poor not in asylums was estimated at 10,500, of whom about half were inmates of workhouses, and the remainder with relations and strangers on an allowance from the parish.
There were various obvious explanations for the apparent increase of lunacy, viz. the greatly enlarged accommodation; the prolongation of life in consequence of kind care; the parochial authorities being required to take immediate proceedings for placing violent and recent cases under treatment; medical practitioners recognizing the nature of cases of insanity better; facilities of post-office, railway, and press bringing cases to light; medical officers being required to make quarterly returns under 17 and 18 Vict., c. 97, s. 66; and the efforts of the Commissioners to impress on guardians the importance of sending recent cases to asylums.
The increase of private patients during eight years had been at the rate of only fifteen per cent.; but the Commissioners point out that this conveys an imperfect view of the relative increase of pauper and private cases, inasmuch as a practice had sprung up by which persons who had never been themselves in receipt of relief, and who are not infrequently tradesmen or thriving artisans, had been permitted to place lunatic relatives 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.
"Indeed, it may be said with truth that, except among what are termed the opulent classes, any protracted attack of insanity, from the heavy expenses which its treatment entails, and the fatal interruption which it causes to everything like active industry, seldom fails to reduce its immediate victims, and generally also their families with them, to poverty, and ultimately to pauperism."
The Commissioners add—and we draw special attention to the statement—that "this is the main reason why, in our pauper lunatic asylums, many inmates are to be met with who have formerly held a respectable station in society, and who, in point of education and manners, are greatly superior to the inmates of a workhouse."[188] Hence we see how utterly fallacious is the conclusion constantly drawn from a study of the mere figures themselves that insanity is, to the extent indicated by them, more prevalent among the lower than the higher classes of society.
The very great importance of obtaining good attendants for asylums became a prominent subject now that the number of patients under treatment had so vastly increased, and it was clearly seen that the skill of the superintendent was of little avail unless effectually carried out by a well-qualified staff of attendants. It was necessary that they should be liberally remunerated, and that their position in the house should be made comfortable. The Commissioners recommended the appointment of head attendants of a superior class, whose duties should not be restricted to any one ward, but who should be responsible for the conduct of the other attendants. A well-educated lady had been found most useful in asylums as a companion to female patients of the upper classes. The Commissioners required notices to be transmitted to their offices of all dismissals for misconduct of nurses or attendants, and of the causes thereof; these notices being regularly filed for reference, in the event of inquiries being made as to the characters of applicants for employment.
Reviewing the condition of the insane generally at this time in workhouses, the Commissioners were able to report that, upon the whole, a sensible amelioration had taken place in their physical condition and in their treatment. They abstained, however, from any official sanction of the construction of lunatic wards in workhouses; for the patients were not provided with any suitable occupation, the means for exercise were generally wanting, and the attendants were too badly paid to allow of a reliance being placed on their services.
The large number living with strangers or relatives on parish allowance appeared to have seldom fallen within the personal observation of the Commissioners, who had chiefly to depend upon the annual returns from the clerks of the Board of Guardians, and on the quarterly returns from the medical officers of the various districts,[189] whose returns were so defective and irregular that no definite conclusion could be drawn from their contents.
In their next Report the subject of workhouses still claimed the attention of the Commissioners, and they complained that, in direct contravention of the law, pauper patients were sent first to a workhouse, instead of an asylum. The sixty-seventh section of the Act of 1853 was disregarded altogether. Hence, if the patient was found manageable in the workhouse, he was detained there, or, if ultimately sent to the asylum, much valuable time had been lost, and his chance of cure greatly lessened. The Commissioners found their recommendations set at defiance, for the most part, whenever the report of the medical officer stated the patient to be "harmless." It was urged that the lunatic wards in workhouses should be placed in the position of licensed houses, and that the Commissioners and visitors should be invested with the same power in regard to them as they possessed over these establishments. But it became very clear that, however valuable the recommendations of the Commissioners might, and, indeed, have ultimately proved to be, they did not possess the authority of commands. At the infirmary asylum at Norwich unceasing suggestions for improvement were made for ten years, which were, "with very few exceptions, systematically disregarded." Then, but not till then, did the Commissioners appeal to the Secretary of State, to require the authorities of Norwich to provide for their lunatic poor, according to the statutes 8 and 9 Vict., c. 126, passed twelve years before. The Act of 1853, having introduced some modification for boroughs of small populations, left no further excuse for making proper provision. The Commissioners from time to time issued circulars to the various asylums, and intimated their intention to report to the Secretary of State (under s. 29 of the Act) the cases of all boroughs wherein proper provision had not been made for their pauper lunatics. "But even this last appeal did not fare more successfully; and all our reiterated inquiries and remonstrances have as yet made hardly a perceptible impression upon that almost general neglect of the law which it was hoped they might repair."
As regards the important class of single patients, the Commissioners had not found it practicable to visit them as they desired to do. Many, however, had been visited. Some were found indifferently accommodated, and otherwise in a very unsatisfactory state. The provisions of the law were extensively evaded.[190]
As the views entertained and recommended by the Commissioners from time to time are of importance in regard to the construction of asylums, it may be observed that in their Report of 1857 they dwell on the evils of very large buildings, on account of the loss of individual and responsible supervision, the loss of the patient's individuality, and the tendency of the rate of maintenance for patients to run higher.[191] It was also maintained that the divided responsibility consequent on such large institutions was injurious to management, and that the cures of patients were actually fewer. It was considered that the limits to the size of the Hanwell Asylum were reached, and indeed exceeded, viz. for 1020, but room for 600 patients more was required. So at Colney Hatch there were 1287 patients, while 713 more demanded admission. When, in 1831, Hanwell was built for 500, it was thought sufficient to provide for the whole of Middlesex! Two years after, however, it was full; in another two years it was reported to contain 100 patients more than it was built for, and after the lapse of another two years it had to be enlarged for 300 more; Colney Hatch having been constructed for 1200 patients belonging to the same county, and opened in 1851; and yet, within a period of less than five years, it became necessary to appeal to the ratepayers for further accommodation, and the latest return showed that, at the close of 1856, there were more than 1100 paupers belonging to the county unprovided for in either of its asylums. "Hardly had they been built, when the workhouses sent into each such a large number of chronic cases as at once necessarily excluded the more immediately curable, until the stage of cure was almost past; and the doors of the establishment became virtually closed not long after they were opened to the very inmates for whom only it was needful to have made such costly provision." Hence the Commissioners urged separate and cheaper asylums for old cases; but the committees of the asylums objected. The Secretary of State induced the two parties to meet, but, being unable to agree, the Commissioners reluctantly gave way.
In 1858 the amount of existing accommodation for pauper lunatics in the counties and boroughs was—for males, 7516; females, 8715; total, 16,231; and the additions then being made to old asylums amounted to—for males, 1172; females, 1309; total, 2481. The numbers for whom additional asylums were then being made were—males, 1169; females, 1157; total, 2326. The sum of these totals being 21,048. There were, on the 1st of January of this year, 17,572 pauper lunatics in asylums, of whom as many as 2467 were still confined in private asylums. There were now 33 county and 4 borough asylums, 15 registered hospitals, 37 metropolitan licensed houses, and 80 provincial licensed houses; also the Royal Naval Hospital. The total number of inmates in these establishments were (in the order enumerated) 15,163, 1751, 2623, 2647, 126, making a grand total of 22,310, including 295 patients found lunatic by inquisition.
The Commissioners point out that a military asylum is a desideratum, there being no provision for soldiers, while sailors were well cared for at Haslar Hospital.
The following particulars will show at a glance the provision made at this period for the insane in England and Wales:—
1. Boroughs having asylums: Birmingham, Bristol (in St. Peter's Hospital), Hull.
2. Boroughs erecting or about to erect asylums: Maidstone, Bristol, City of London.
3. Boroughs in union with counties: Cambridge, Colchester, Maldon, Gloucester, Leicester, Grantham, Lincoln, Stamford, Hereford, Nottingham, Abingdon, Oxford, Reading, Shrewsbury, Wenlock, Worcester.
4. Boroughs whose pauper lunatics are sent to asylums under contract or arrangements between justices, etc.: Plymouth, Chichester, Portsmouth, Southampton, Devizes, Salisbury, Chester, Derby, Barnstaple, Bideford, Dartmouth, Exeter, South Molten, Tiverton, Tewkesbury, Bridgewater, Bridgnorth, Ludlow, Penzance, Poole, Winchester, Newark, Oswestry, Bath, Lichfield, Scarborough.
5. Boroughs which have not made any statutory provision for the care of their pauper lunatics: Bedford, Newbury, Buckingham, Carmarthen, Andover, Canterbury, Dover, Hythe, Rochester, Sandwich, Tenterden, King's Lynn, Norwich, Thetford, Yarmouth, Northampton, Berwick-upon-Tweed, Newcastle-upon-Tyne, New Radnor, Bury St. Edmunds, Ipswich, Guildford, Hastings, York.
In 1862 the expense of pauper lunatics in asylums was thrown upon the common fund of the union, instead of on the particular parish. The effect was natural. Many patients were removed from workhouses to the county asylums, some of whom might well have remained there. There could be no objection to this, if the latter cost no more than the former; but seeing that where the one costs £200 per bed, the other would only cost £40, the effect is, from the point of view of the ratepayer, who usually objects to contribute to the formation of a free library, a very serious one.
Twenty years after the census of the insane made in 1844, and ten after the period to which the table given at [p. 230] refers, we find the numbers as follow[192]:—
| Where confined. | Private patients. | Paupers. | Total. | ||||||
|---|---|---|---|---|---|---|---|---|---|
| M. | F. | Total. | M. | F. | Total. | M. | F. | Total. | |
| 42 county and borough asylums | 118 | 113 | 231 | 9,690 | 11,630 | 21,320 | 9,808 | 11,743 | 21,551 |
| 1 military and naval hospital | 153 | — | 153 | — | — | — | 153 | — | 153 |
| 2 Bethlem and St. Luke's Hospitals | 264 | 215 | 479 | — | — | — | 264 | 215 | 479 |
| 13 other public asylums | 708 | 591 | 1,299 | 170 | 178 | 348 | 878 | 769 | 1,647 |
| Licensed houses— | |||||||||
| 37 metropolitan | 831 | 649 | 1,480 | 253 | 589 | 842 | 1,084 | 1,238 | 2,322 |
| 65 provincial | 987 | 698 | 1,685 | 256 | 192 | 448 | 1,243 | 890 | 2,133 |
| Workhouses and elsewhere | — | — | — | 8,125 | 8,126 | 16,251 | 8,125 | 8,126 | 16,251 |
| Broadmoor | — | — | — | — | 95 | 95 | — | 95 | 95 |
| Total[193] | 3,061 | 2,226 | 5,327 | 18,494 | 20,810 | 39,304 | 22,555 | 23,076 | 44,631 |
We must not pass by the year 1867 without recording that at this period a statute important in its bearing on the provision made for the insane poor of London was enacted. This was the Metropolitan Poor Act, which established what are known as the Metropolitan District Asylums for Imbeciles at Leavesden (Hertfordshire), Caterham (Surrey), Hampstead, and Clapton. Legally these institutions are classed under workhouses.
Much difference of opinion exists as to the wisdom of having separate institutions for the incurable. That there is great danger of overlooking the fact that some incurable patients require quite as much attention as the curable is certain; they may indeed, if neglected, be reduced to a more pitiable condition than the latter; but this does not prove that, under the present safeguards provided by the legislature, there may not be a safe recourse to this mode of making provision for this class of the insane. At any rate, it is of interest to know what has been done in this direction during the last few years in England.
Asylums have been erected at Leavesden, near Watford, Herts; Caterham, Surrey; and Darenth, near Dartford, Kent, there being at Darenth both idiot schools and an institution for incurables.
These are the Metropolitan District Asylums.[194]
As the primary object in adopting this kind of accommodation is economy, it is important to present a clear statement of the finances, omitting shillings and pence.
Take Leavesden as the example, where the accommodation is for 2000 patients (M. 900, F. 1100). The land, which was purchased in 1867 and 1880, has cost £9401, the area being eighty-four acres. The laying out the grounds, etc., cost £3000; the cost of building and drainage (up to Michaelmas, 1878) was £121,674; the engineering works, fixtures, and fittings cost £16,162; the furniture, bedding, and clothing, £16,235; the architect's and surveyor's charges, and clerk of works, £5108; solicitor's charges, printing, insurances, and all other charges, £1526; the total being £173,118, or £86[195] per bed. Taking out the items of furniture, bedding, and clothing, we have the sum of £77 per bed. How striking the difference when compared with the expense of an ordinary county asylum, the reader who has examined the figures given at [page 166] will readily perceive.
Let us now pass on to the year 1870. We find the Commissioners able to state, as the result of very minute and careful inspection, that the Reports of their members during the previous year showed, on the whole, that good progress continued to be made in the mode of managing "these large and daily increasing institutions," and they add, "although in some instances it has been our duty to comment on shortcomings and cases of neglect, we have generally been able to bear testimony to the skill and zeal evinced by the medical superintendents in the execution of their very grave and difficult duties."[196] On the other hand, they observe, "We regret that we shall have to describe several acts of violence committed by attendants in county asylums, which in three instances were followed by fatal results, but in only one of which, although careful inquiries were instituted, such evidence was obtained as would justify criminal proceedings."
The Report on the Liverpool Lunatic Hospital shows how far from satisfactory one, at least, of these institutions was at that time: "With few exceptions, the personal condition of the patients was found to be very indifferent, and indeed the reason alleged why the females in the lower wards were never on any occasion taken beyond the airing-court, was that they had no clothes fit to be seen in. The corresponding class of men was stated to be taken out as little as the women, and both were said to be rarely visited by any friends having an interest in them. The state of the furniture was discreditable in the extreme, and there was a general absence of tidiness throughout the hospital. The patients were, with few exceptions, quiet; not more than four or five of the better class of either sex were reported to have the opportunity of walking or driving out.... The seclusion in the fifteen months which had elapsed since the previous visit applied to five males on 62 occasions, and to 18 females on 132 occasions."[197]
The Commissioners speak of "the invariable success attendant on such hospitals as have been built during the last few years, and specially at Cheadle."
In regard to licensed houses within their jurisdiction, they were reported to be "generally, as to the condition and management of such houses, of a very satisfactory character;" while of the provincial houses they say, "The Reports, for the most part, have not been unfavourable as to their condition and management."[198]
In this Report the Commissioners comment on the operation of the Metropolitan Poor Act of 1867, which threw the maintenance of lunatics in asylums upon the common poor fund of the metropolis, and they observe that "it has induced the boards of guardians to relieve themselves of local charges, and this has greatly contributed to swell the removals from workhouses to asylums, notwithstanding that the patients have in large numbers been unable to be received nearer than in the county asylums of Northumberland, Yorkshire, Staffordshire, and Somersetshire, and although the rate of maintenance has ranged from 14s. to 17s. 6d. per week."
As the cost of lunatics is so important a question, it may here be stated that the total weekly cost per head in 1870 averaged in the county asylums 9s. 3d., including maintenance, medicine, clothing, and care. Under the maintenance account were comprised furniture and bedding, garden and farm, and miscellaneous expenses. The other items were provisions, clothing, salaries and wages, fuel, light and washing, surgery and dispensary, wine, tea. In this estimate was reckoned the deduction for moneys received for produce sold, exclusive of those consumed in the asylum.
The weekly cost in the following registered hospitals was as follows:—
| £ | s. | d. | |
|---|---|---|---|
| Coton Hill | 1 | 7 | 1½ |
| Northampton | 0 | 13 | 5¾ |
| York Lunatic Hospital | 0 | 18 | 0 |
| York Retreat | 1 | 1 | 2¾ |
It should be observed that Northampton was at this time essentially the pauper asylum for the county.
We have already referred to the paramount importance of reliable attendants. "Nothing is easier," the Commissioners observe, "for a man in such a position, with unrestricted and uncontrolled power over the habits and happiness of another, than to act cruelly without being cruel." So long ago as 1851 a check was given to the conduct of attendants by a decision of the courts in that year. An attendant had been convicted of manslaughter on the evidence of a patient. This was appealed against, but the conviction was sustained. Lord Campbell laid it down that the only thing needful was for the patient to understand the nature of an oath and what he was saying. "But although this ruling has never since been disputed, the many subsequent attempts of the Commissioners to exact a rigid responsibility for acts of violence or cruelty in asylums have, through the indisposition of juries[199] to accept the evidence principally available for proofs in such cases, more frequently failed than succeeded."[200]
In each of the three previous years, proceedings had been taken against attendants, and with very limited success. In the beginning of 1870, however, a prosecution instituted by the magistrates of the Lancaster Asylum against two attendants for manslaughter on the evidence of a patient succeeded, and they were sentenced to seven years' penal servitude, a result which the Commissioners regarded as the most beneficial example within their experience. During the previous year, eighty-eight male attendants had been dismissed from service—fifty-three for drunkenness, insubordination, or neglect of duty, and thirty-five for assaults on patients; four only of these latter having had criminal prosecutions instituted against them, and of the former not one. Of the number dismissed, fifteen were in licensed houses, three in public hospitals, and the remaining seventy in county asylums. During the same period thirty-four female attendants were dismissed, of whom twenty-four were employed in county asylums. Eleven had been guilty of violence or rough usage to patients, there having been no prosecution in any instance. The Commissioners justly observe that, while "there has been no greater work of mercy and humanity than that which rescued the lunatic patients from stripes and filth, or continued restraint and isolation, yet it will remain to some degree still imperfect until he is also rescued from the possible chance of being subjected to the unwatched or unchecked humours and caprices of ignorant, careless, or cruel attendants."[201]
A striking instance of the respective powers of the Committees of asylums and the Commissioners in Lunacy occurs in the Report of the latter for 1870. Death from broken ribs had taken place in a county asylum, and the Commissioners considered the cruelty of an attendant established. They reported inadequate supervision of the wards, as well as the attendants, in reply to which the committee of visitors asserted that they would not enter into any discussion on a subject upon which they considered themselves fully competent to determine how they should discharge their own duties. The Commissioners found that they had no alternative but to leave to the refractory committee the responsibility, which they had shown no unwillingness to assume, of the adoption or rejection of such recommendations. "The law which has required us to investigate and report as to matters affecting the management of county asylums, has invested us with no authority further to enforce our views." In the same way their authority was set at naught in an asylum where an idiot boy was found on the floor, strangled by a pocket-handkerchief, effected, there was every reason to believe, by one of the patients, and the Commissioners found that the deed could not have been perpetrated if attendants had been properly dispersed through the wards. The union authorities failed to get satisfaction from the committee, and the Secretary of State was memorialized by the guardians, who were backed up by the Commissioners, but in vain. Hence the Commissioners complained of "the limits thus placed to all real authority but that of the committee of visitors over establishments whose inmates are necessarily most at the mercy of attendants, and in which these cases of misconduct most frequently occur."[202]
We have alluded to this circumstance, not to indicate that at the present time the committees of asylums set themselves in opposition to the recommendations of the Commissioners, but our historical sketch demands, in justice to the latter, who are often supposed to have unlimited power, that it should be known that desirable reforms may not be carried out in our asylums, and yet the fault may not lie at the door of the Lunacy Commissioners. And it should be stated that recently Lord Shaftesbury has publicly expressed his individual opinion that it is better for the views and wishes of the Commissioners to appear in the form of recommendations rather than commands.
Three years later, the condition of county and borough asylums was, with few exceptions, satisfactory, and declared by the Commissioners to be very creditable to the governing bodies and superintendents. Improvements had taken place in many of these institutions, and there was found to be a more general recognition of the humanizing and beneficial influence of cheerful and well-furnished wards, on even the most degraded patients. "Those at one time considered to be fit only to be congregated together in the most dreary rooms of the asylum, with tables and benches fastened to the floor, and with nothing to interest or amuse them, are now in many asylums placed in wards as well furnished as those occupied by the more orderly patients, with birds, aquariums, plants, and flowers in them, and pictures on the walls; communicating also with such wards are now very generally to be found well-planted and well-kept airing-courts. The less strict classification of the patients is also advantageously followed in many asylums, and in them what are termed "refractory wards" are properly abolished. Where arrangements for this purpose have been judiciously made and carried out with energy, the best results have followed, in the way of an improved condition and more orderly demeanour of those disposed to be turbulent, whilst the comfort of patients of a more tranquil character has not been prejudicially affected. The use of mechanical restraint in county and borough asylums, unless for surgical reasons, such as to prevent patients removing dressings or applications to wounds or injuries, or during the forcible administration of food, is, with few exceptions, abolished. In thirty-eight of the fifty-four asylums visited during the past year, there was no record whatever of its employment. In the cases of twenty-two patients, distributed over ten asylums, it had been resorted to for the above-mentioned reasons, and in six asylums it had been used to counteract violent suicidal or destructive propensities; the number of patients restrained for these latter reasons (exclusive of Colney Hatch and Wandsworth) having been one in the Macclesfield, nine in the Glamorgan, six in the Prestwich, and one in the Norwich Borough Asylum. In the Wandsworth Asylum it will be seen from the Report that, during a period of about sixteen months, thirty-three men and twelve women were recorded as having had their hands restrained by gloves for destructive propensities; and four males and one female had worn restraint dresses at night, two on account of their suicidal tendencies, and one for violence. At the visit to Colney Hatch, a very dangerous male epileptic was found restrained by wrist-straps and a belt, and from the register it appeared that he had been thus constantly restrained during the day for a period of nine months. Ten other male patients were also recorded as having been restrained; one having had his hands fastened, and the remainder having worn gloves, altogether on two hundred and fifty-three occasions.... At the same visit nine men were found wearing special strong canvas dresses, besides others who were clothed in an exceptional manner."
The objections which for a long time have been felt to frequent resort to seclusion find expression in this Report. The Commissioners, without questioning the utility of seclusion in certain cases, stated their conviction that "in a remedial point of view its value has been much exaggerated, and that in many instances it is employed unnecessarily and to an injurious extent, and for periods which are quite unjustifiable." Patients regard it as a punishment; and attendants are apt to make it take the place of constant supervision. Its frequent use indicates defective asylum organization or management. The Report states that it is no longer employed at the Durham, Stafford, Brentwood, and Brookwood Asylums; and only rarely at the Wakefield, Oxford, Northumberland, Carmarthen, Chester, Dorset, Glamorgan, Leicester, Lincoln, and Norfolk County Asylums, and those for the boroughs of Ipswich and Leicester, and for the City of London.
Legislation has exercised a great and, as some think, questionable influence upon the relative proportion of the insane in workhouses and asylums. The feeling that originally induced the Commissioners in Lunacy to urge the transference of lunatics from workhouses to county asylums was, no doubt, a laudable one, and in a large number of instances most advantageous. The condition of the insane in workhouses, however, became vastly improved, and it was impossible to deny that for many harmless chronic cases they were, to say the least, sufficiently comfortable in the workhouse. Then came the legislation of 1874,[203] by which four shillings a week were allowed for every pauper lunatic in any asylum or licensed house, being reimbursed to the unions and parishes from which the patient was sent. Hence the strong inducement, in some counties at least, for it certainly does not hold good in all, to transfer lunatics detained in workhouses to the asylums, even when no occasion whatever arises out of the mental condition of the patient to justify such transference. The Commissioners themselves have recognized the difficulty and disadvantage of the operation of this legislation, and say in their twenty-ninth Report, 1875, that while this Act "may be beneficial in promoting the removal to asylums of a certain number of patients requiring such treatment, and who might possibly otherwise be deprived of it ... it remains to be seen whether the alteration in the incidents of the maintenance charged, will not also have the effect of causing unnecessarily the transfer to asylums of chronic cases, such as might be properly cared for in workhouses, thus rendering necessary, on the part of counties and boroughs, a still larger outlay than heretofore in providing additional asylum accommodation. The returns for the 1st of January last tend to show that such results are not unlikely to accompany the working of this new financial arrangement."[204] The Irish inspectors in their report for 1875 calculate that the maximum number who could properly be transferred from asylums to workhouses is seven or eight per cent., and they make the observation, which no doubt is very just, that many patients who are quiet and demeanable under trained nurses in an asylum would become intractable elsewhere.
As we have now reached another decade, it will be well to afford the reader the opportunity of comparing the population of asylums, and workhouses, with that which we have given in 1844, 1854, and 1864.
| Where confined.[205] | Private patients. | Paupers. | Total. | ||||||
|---|---|---|---|---|---|---|---|---|---|
| M. | F. | Total. | M. | F. | Total. | M. | F. | Total. | |
| 31 county and borough asylums | 194 | 221 | 415 | 14,238 | 16,718 | 30,956 | 14,432 | 16,939 | 31,371 |
| 3 military and naval hospitals, and Royal India Asylum | 342 | 16 | 358 | — | — | — | 342 | 16 | 358 |
| 2 Bethlem and St. Luke's Hospitals | 167 | 268 | 435 | — | — | — | 167 | 268 | 435 |
| 13 other public asylums | 1,107 | 891 | 1,998 | 174 | 165 | 339 | 1,281 | 1,056 | 2,337 |
| Licensed houses— | |||||||||
| 39 metropolitan | 1,006 | 787 | 1,793 | 257 | 614 | 871 | 1,263 | 1,401 | 2,664 |
| 67 provincial | 772 | 754 | 1,526 | 200 | 323 | 523 | 972 | 1,077 | 2,049 |
| 1 Broadmoor | 267 | 64 | 331 | 148 | 41 | 189 | 415 | 105 | 520 |
| Private single patients | 168 | 268 | 436 | — | — | — | 168 | 268 | 436 |
| Workhouses: Males, 6372; females, 8646; total, 15,018 | — | — | — | 9,084 | 12,773 | 21,857 | 9,084 | 12,773 | 21,857 |
| Elsewhere: Males, 2712; females, 4127; total; 6839 | |||||||||
| Total[206] | 4,023 | 3,269 | 7,292 | 24,101 | 30,634 | 54,735 | 28,124 | 33,903 | 62,027 |
Referring to the numbers of the insane in 1875, the Commissioners observe that they have increased beyond the growth of the population. This had been mainly among paupers, there having been 16.14 of this class in 1849, and 23.55 in 1875, per 10,000 of the population; while of private patients the advance had only been from 2.53 to 3.09 during the same period. The population increased from 1849 to 1875, 22.63 per cent. Private patients increased 48.39 per cent., and pauper patients 77.47 per cent.
In regard to the treatment of the insane in Wales, it may be stated that until the Denbigh Asylum was opened in November, 1847, there was no institution for the reception of lunatics, except the small asylum at Haverfordwest, and a house licensed in 1843 for private and pauper patients in Glamorganshire.[207] Most of the paupers were kept in their homes or workhouses; others sent to asylums. Before the Act was passed making it compulsory on the counties to provide accommodation, several philanthropic gentlemen, impressed with the desirability of having an institution for private patients in North Wales, and where all the officers should possess a knowledge of Welsh, which language alone the vast majority of the inhabitants knew at that time, collected about £8000. By this time the Act was passed, and the subscribers made over their money to the counties, on condition that twenty-six separate beds should be kept for private patients—several of themselves to be members of the Committee. The private apartments form part of the same building, but the inmates do not associate with the paupers. The total accommodation was two hundred, and there was a great outcry at the building of such a large place. About fifteen years ago, two wings were added, each to hold one hundred beds, and last year an additional one of one hundred and thirty beds.
It appears that many of the first patients received at the Denbigh Asylum had been most cruelly treated at their own home, or where placed with strangers; some being kept tied and in seclusion for years, and shamefully neglected. The following is an extract from the first Medical Report:—"In the case of one man, who was goaded by unkind and harsh treatment into a state of ferocious mania (and who was brought into the asylum manacled so cruelly that he will bear the marks of the handcuffs while he lives), it is most gratifying to be enabled to state that he gradually became confiding and tractable, and he is now as harmless as any patient in the house. In another instance, a poor young creature, who before her admission was tied down to her bed for months, quickly discovered the difference between the treatment she had previously been subject to and the kindness and freedom she experienced at the asylum, and very soon gained confidence in those about her, and rapidly recovered. Soon after her discharge from the asylum, she wrote to the matron, to request to be taken back as a servant, and she is now an excellent assistant in the wards, and a general favourite with the patients. We have the satisfaction of stating that we have never been obliged to resort to any mechanical restraint, beyond temporary seclusion in a padded room, etc." Complaints occur in the earlier reports of the disinclination either of friends or of the poor law authorities to send in patients before they become unmanageable, and many of those admitted arrived secured by handcuffs or tied down in carts.
Take another extract from the Report for 1851. "We were requested to turn into a respectable farmhouse, and upon going upstairs we were horrified to find the farmer's wife with her hands secured, and a large cart-rope tied round her body to keep her in bed. The room was filthy. We found she had been in this state for nine months, and no proper remedial measures taken. Surely some protection should be thrown over such a sufferer!"
Again, in the Report for 1853: "One most atrocious case of an opposite kind of treatment has fallen within our notice during the year. It is most deplorable to contemplate, after the repeated generous efforts made by the press, both Welsh and English, to diffuse useful knowledge upon the subject of insanity, that in a Christian country, and in a populous district, and with the knowledge of most of the neighbouring inhabitants, a fellow-creature should have been permitted to be chained by both his legs in a miserable shed for seven long years. The case is so painfully interesting, that we will add to this Report the document which was sent to the Lord Chancellor, who, at the instigation of the Commissioners in Lunacy, issued an order for visiting the poor sufferer. The Commissioners, with laudable alacrity, ordered a prosecution to be instituted, and the principal offender was tried at the Carnarvonshire assizes, convicted, and sentenced to be imprisoned.... What renders the conduct of the friends of Evan Roberts more inexcusable is the fact of his having been perfectly sane when visited, and having remained so ever since.
Denbigh, June 16, 1853.
"Sir,
"In obedience to the order of the Lord Chancellor, etc., I have to report that I found Evan Roberts in a small shed, six feet wide and nine feet four inches long, which had been built for the purpose. The room had a small skylight in the roof, and a window about a foot and a half square in the gable, just above the bed, which admits of being partially opened, but which was closed at the time of my visit, and, as he (Evan Roberts) stated, was seldom opened. The room felt very close and damp. There was no fireplace, or any other means of ventilation except the door and window. The approach to the room was through a sort of scullery, and very dark and obscure. Evan Roberts was lying on a chaff bed on a wooden bedstead, to which both his legs were chained, by fetters fastened and riveted, just above his ankles.... The appearance of the poor man was pale and pasty, like a plant long deprived of air and solar influence. His bodily health is tolerably good, and his condition rather inclined to be fat and stout; he said his appetite was good, and that he was not stinted in his food, such as it was. During a lengthened interview, and a very close examination, I failed to discover the existence of any hallucination or delusion of any kind; on the contrary, he was very sensible and intelligent....
"I collected from his mother and sister that Evan Roberts was forty-eight years of age; that he had been liable to periodical mania for twenty-seven years, and which the mother attributed to some injury to his head, received in a rural affray; that at first the maniacal paroxysms were unfrequent, but that they had become more violent and frequent as he advanced in life. About seven years ago, his violence became so great, that he threatened to murder his father and brother; and it was at that time that he was first chained to the bed. This restraint has never been relaxed, although both mother and sister admitted that he was perfectly sane and harmless for many weeks and months continuously. For the first five years he was confined upstairs, and it was only about two years ago that he was carried into the shed he now occupies.... Finding that the poor fellow was awed by the presence of his mother and sister, I requested them to retire, as I wished to examine the alleged lunatic free from their presence and interference. The mother for some time refused to comply with my request; but upon being told that I would report her refusal, she very doggedly complied. The poor man then became less reserved; he complained bitterly of the state in which the room had long been suffered to remain....
"The poor man complained that the chaff in his bed was never changed, or even shaken, except once, since his confinement in the shed; and from the dampness of the room, and the warmth of his body, it had become rotten, and like a wet sod....
"R. Lloyd Williams.
"R. W. S. Lutwidge, Esq."
"The Commissioners in Lunacy applied to the Lord Chancellor for an order to visit the farmer's wife mentioned in one of our former reports as having been tied to her bed by a cart rope and her hands secured by a muff. She was accordingly visited, and a report upon her case sent to the Commissioners, who directed an inquiry to be made with a view to her removal to an asylum. The family obtained information of this investigation, and considerable amendment in the treatment of the lunatic took place before the justices and the medical officer appointed to visit her arrived, and no order for her removal was made. We have reason to know that the poor creature is still under restraint, and her hands secured; she is strapped to a chair, which is fastened to the leg of a strong table."
We pass now to 1879, in order that we may consider the changes which had taken place during the quinquennium succeeding the year in which we have given a return of the number of insane in England and Wales, and their distribution. The following figures are derived from the thirty-third Report of the Lunacy Commissioners, and exhibit the total number of registered lunatics, idiots, and persons of unsound mind on the 1st of January, 1879:—In county and borough asylums, 38,871; naval and military hospitals and Royal India Asylum, 342; Bethlem and St. Luke's Hospitals, 430; other public asylums, 2407; metropolitan licensed houses, 2664; provincial, 2049; Broadmoor, 483; workhouses (ordinary), 11,697; metropolitan district asylums, 4308; outdoor paupers, 6230; private single patients, 472; total, 69,885; exclusive of 202 Chancery lunatics in the charge of committees.
On the next page will be found the general distribution and numbers of the insane, January 1, 1881. A more detailed statement will be given, in the Appendix ([K I.]), of the county asylums and lunatic hospitals now existing for the care and cure of the insane, with the numbers confined therein.
On the 1st of January, 1881, the proportion per cent. maintained in asylums, hospitals, and licensed houses was 64.91; in workhouses, 25.72; and as outdoor paupers, 9.37.
As some of the tables of the Commissioners extend back twenty-three years, exhibiting the number, sex, classification, and distribution of all registered lunatics, January 1, 1859-1881, as also the ratio of the total insane to the total population, we may derive much valuable information for the purpose of our historical review.
Thus there were in England and Wales:—
| Location. | Patients. 1859. | Patients. 1881. | ||
|---|---|---|---|---|
| In county and borough asylums | 15,844 | 41,355 | ||
| In registered hospitals | 1,855 | 2,948 | ||
| In metropolitan private asylums | 2,551 | 2,511 | ||
| In provincial „ „ | 2,465 | 2,115 | ||
| In naval and military hospitals and Royal India Asylum | 164 | 307 | ||
| In Broadmoor Asylum for criminal lunatics | Not opened till 1863 | 491 | ||
| In workhouses— | ||||
| Ordinary workhouses | 7,963 | 12,093 | ||
| Metropolitan district asylums | Not opened till 1870 | 4,718 | ||
| Residing with relatives or others (pauper and private) | 5,920 | 6,575 | ||
| Total | M. 16,756 F. 20,006 | 36,762 | M. 32,973 F. 40,140 | 73,113 |
Of the 36,762 in 1859, 4980 were in private and 31,782 pauper patients. Of the 73,113, in 1881, 7741 were private and 65,372 pauper patients. In 1859 the ratio of the total registered lunatics to the population (per 10,000) was 18.67, the ratio of private lunatics to population being 2.53, and of pauper lunatics to population 16.14. In 1881 the ratio of the total lunatics of the population was 28.34, the ratio of private lunatics to 25.34. These figures bring out very distinctly the fact that the great increase of lunatics during the period between 1859 and 1881 is among the poor. It must, however, be repeated that insanity itself brings with it pauperism to many who have once been independent and educated, but who fall, through the misfortune entailed by the malady, into the category of paupers.
An important table, introduced for the first time into the last Report of the Commissioners, shows the annual ratio of fresh admissions to the population; hence the transfers and the admissions into idiot asylums are excluded. The value of this table consists in this—that, although the gross admissions into asylums have increased, due in part to the capitation grant of four shillings introduced in 1874, the ratio of the yearly increase of the fresh admissions to the population has been slight, showing, as the Commissioners observe, that the total number of the insane under care during the twelve years embraced by the table is "mainly due to accumulation, and not to a greater annual production of insanity."[208] This table does not include workhouses.
Thus:—
| Year. | Admissions. | Ratio per 10,000 of admissions to the population. |
|---|---|---|
| 1869 | 10,472 | 4.71 |
| 1870 | 10,219 | 4.54 |
| 1871 | 10,528 | 4.62 |
| 1872 | 10,604 | 4.59 |
| 1873 | 11,212 | 4.80 |
| 1874 | 11,912 | 5.03 |
| 1875 | 12,442 | 5.19 |
| 1876 | 12,857 | 5.30 |
| 1877 | 12,969 | 5.28 |
| 1878 | 13,343 | 5.36 |
| 1879 | 13,101 | 5.20 |
| 1880 | 13,240 | 5.19 |
It would thus appear that in 1880 scarcely one patient more per 20,000 persons in England and Wales was freshly admitted into asylums, etc. Had there been no increase at all, after allowing for increase of population, the number admitted in 1880 would have been 12,011. It was, in fact, 13,240, i.e. 1229 more.
Taking the actual number of the insane in detention during the same years shows a very different result, for accumulation is here included, and swells the returns.
Thus:—
| Year. | Under care. | Ratio per 10,000 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 institutions 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 accumulation 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. 9¼d. 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 class 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.