CHAPTER V._Chapters in the History of the Insane in the British Isles

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 | Total | Total number | Total number of

| number | number | of instances | hours under

| in the | restrained. | of restraint. | restraint.

| house. | | |

------+--------+-------------+---------------+-----------------

1829 | 72 | 39 | 1727 | 20,424

1830 | 92 | 54 | 2364 | 27,113-3/4

1831 | 70 | 40 | 1004 | 10,830

1832 | 81 | 55 | 1401 | 15,671-1/2

1833 | 87 | 44 | 1109 | 12,003-1/2

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; 21-1/2 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:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE

INSANE IN ENGLAND AND WALES, JANUARY 1, 1844.

----------------+----------------+------------------+-------------------

Where | Private | Paupers. | Total.

confined. | patients. | |

+---+-----+------+-----+-----+------+-----+------+------

|M. | F. |Total.| M. | F. |Total.| M. | F. |Total.

----------------+---+-----+------+-----+-----+------+-----+------+------

asylums |130| 115| 245|1,924|2,231| 4,155|2,054| 2,346| 4,400

| | | | | | | | |

local acts | --| -- | -- | 38| 51| 89| 38| 51| 89

| | | | | | | | |

naval hospitals|164| 4| 168| -- | -- | -- | 164| 4| 168

| | | | | | | | |

Hospitals |178| 264| 442| 86| 35| 121| 264| 299| 563

| | | | | | | | |

asylums |249| 287| 536| 177| 166| 343| 426| 453| 879

| | | | | | | | |

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

| | | | | | | | |

elsewhere[180] | --| -- | -- |4,169|5,170| 9,339|4,169| 5,170| 9,339

| | | | | | | | |

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 L280,000. In 1839 the corresponding numbers were

494 and L277,991.

The estimated annual amount expended at this time for maintenance of

lunatics, or administered on their behalf, exceeded L750,000, thus

distributed:

1. Cost of 9652 paupers in asylums, estimated at

8s. per week L200,762

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 L100 a year 12,000

8. Thirty-two criminals in jails, estimated at 3s.

per week 249

--------

Total L777,648

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 L1,000,000.

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]

------------------------------+-----------+-----------+------------

| Number of | | Under

Asylum. | patients. |Criminals. | 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

------------------------------+-----------+-----------+------------

| Number of | | Under

Asylum. | patients. |Criminals. | 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:--

1. Asylums existing prior to passing of Act 8 and 9 Vict., c. 126.

Accommodation for pauper lunatics at passing of the Act 5560

Additional accommodation provided therein since the

passing of the Act 1753

----

Total accommodation 7313

2. Asylums in progress of erection at passing of Act 8 and 9 Vict., c.

126, and since opened.

Number for which designed 997

Subsequent additions 206

----

Total present accommodation 1203

3. Asylums erected or provided under the provisions of the Act 8 and

9 Vict., c. 126, and now opened.

Accommodation for pauper lunatics 1114

4. Asylums in progress of erection under Act 8 and 9 Vict., c. 126,

and not yet opened.

Proposed accommodation for pauper lunatics 4299

Under provisions of previous Acts 6557

Under Act 8 and 9 Vict., c. 126 7372

------

Total 13,929

Exclusive of 192 in Northampton Hospital.

Asylums existing prior to or at the passing of Act 8 and 9 Vict., c.

126--

Beds., Herts and Hants., Chester, Cornwall, Devon, Dorset,

Gloucester, Kent, Lancaster (containing the largest number

of patients, 700), Leicester and Rutland, Middlesex

(Hanwell), Norfolk, Notts., Salop and Montgomery, Stafford,

Suffolk, Surrey, West Riding, Yorkshire, Bristol (borough).

Wales--Haverfordwest (town and county), Montgomery (see

Salop).

Asylums in progress of erection at the passing of this Act, and since

opened--

Oxford and Berks, Somerset, North and East Riding,

Yorkshire. Wales--Anglesea, Carnarvon, Denbigh, Flint,

Merioneth.

Total number for which designed 997

Additions since passing the Act 206

----

Total 1203

Counties in which no steps are taken to provide asylums--

Cumberland, Durham, Northampton, Sussex, Westmoreland.

Total accommodation 5560

Subsequent additions 1753

----

Total 7313

Asylums erected or provided under the above Act and now opened--

West Lancashire (Rainhill), East Lancashire (Prestwich, near

Manchester), Birmingham (borough), Kingston-upon-Hull.

For these asylums the accommodation provided in the first instance was

1114.

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:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE

INSANE IN ENGLAND AND WALES, JANUARY 1, 1854.[187]

----------------+----------------+--------------------+--------------------

Where | Private | Paupers. | Total.

confined. | patients. | |

+---+-----+------+------+------+------+------+------+------

|M. | F. |Total.| M. | F. |Total.| M. | F. |Total.

----------------+---+-----+------+------+------+------+------+------+------

borough asylums |147| 146| 293| 5,791| 6,878|12,669| 5,938| 7,024|12,962

| | | | | | | | |

naval hospitals|199| 5| 204| -- | -- | -- | 199| 5| 204

| | | | | | | | |

Hospitals |235| 239| 474| 4| 7| 11| 239| 246| 485

| | | | | | | | |

asylums |467| 456| 923| 102| 103| 205| 569| 559| 1,128

| | | | | | | | |

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

| | | | | | | | |

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 L200 per bed, the other would only cost

L40, 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]:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE

INSANE IN ENGLAND AND WALES, JANUARY 1, 1864.

----------------+------------------+--------------------+--------------------

Where | Private | Paupers. | Total.

confined. | patients. | |

+-----+-----+------+------+------+------+------+------+------

| M. | F. |Total.| M. | F. |Total.| M. | F. |Total.

----------------+-----+-----+------+------+------+------+------+------+------

borough asylums| 118| 113| 231| 9,690|11,630|21,320| 9,808|11,743|21,551

| | | | | | | | |

naval hospital | 153| -- | 153| -- | -- | -- | 153| -- | 153

| | | | | | | | |

Hospitals | 264| 215| 479| -- | -- | -- | 264| 215| 479

| | | | | | | | |

asylums | 708| 591| 1,299| 170| 178| 348| 878| 769| 1,647

| | | | | | | | |

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

| | | | | | | | |

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 L9401, the area being eighty-four acres. The laying out

the grounds, etc., cost L3000; the cost of building and drainage (up to

Michaelmas, 1878) was L121,674; the engineering works, fixtures, and

fittings cost L16,162; the furniture, bedding, and clothing, L16,235;

the architect's and surveyor's charges, and clerk of works, L5108;

solicitor's charges, printing, insurances, and all other charges, L1526;

the total being L173,118, or L86[195] per bed. Taking out the items of

furniture, bedding, and clothing, we have the sum of L77 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:--

L s. d.

Coton Hill 1 7 1-1/2

Northampton 0 13 5-3/4

York Lunatic Hospital 0 18 0

York Retreat 1 1 2-3/4

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.

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE

INSANE IN ENGLAND AND WALES, JANUARY 1, 1874.

----------------+------------------+--------------------+--------------------

Where | Private | Paupers. | Total.

confined.[205]| patients. | |

+-----+-----+------+------+------+------+------+------+------

| M. | F. |Total.| M. | F. |Total.| M. | F. |Total.

----------------+-----+-----+------+------+------+------+------+------+------

borough asylums| 194| 221| 415|14,238|16,718|30,956|14,432|16,939|31,371

| | | | | | | | |

Asylum | 342| 16| 358| -- | -- | -- | 342| 16| 358

| | | | | | | | |

Hospitals | 167| 268| 435| -- | -- | -- | 167| 268| 435

| | | | | | | | |

public asylums |1,107| 891| 1,998| 174| 165| 339| 1,281| 1,056| 2,337

| | | | | | | | |

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

| | | | | | | | |

patients | 168| 268| 436| -- | -- | -- | 168| 268| 436

| | | | | | | | |

Workhouses: }| | | | | | | | |

Males, 6372; }| | | | | | | | |

females, 8646;}| | | | | | | | |

total, 15,018 }| | | | | | | | |

Elsewhere: }| -- | -- | -- | 9,084|12,773|21,857| 9,084|12,773|21,857

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

L8000. 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. | Patients.

| 1859. | 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 | Not opened | 491

criminal lunatics | till 1863 |

In workhouses-- | |

Ordinary workhouses | 7,963 | 12,093

Metropolitan district asylums| Not opened | 4,718

| till 1870 |

Residing with relatives or | 5,920 | 6,575

others (pauper and private) | |

+------------------+-----------------

|M. 16,756} |M. 32,973}

Total |F. 20,006} 36,762 |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:--

-------+-------------+-------------------

| | Ratio per 10,000

Year. | Admissions. | 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:--

-------+-------------+-------------------

| | Ratio per 10,000

Year. | Under care. | of number in

| | detention to the

| | population.

-------+-------------+-------------------

1869 | 53,117 | 23.93

1870 | 54,713 | 24.31

1871 | 56,755 | 24.91

1872 | 58,640 | 25.42

1873 | 60,296 | 25.82

1874 | 62,027 | 26.23

1875 | 63,793 | 26.64

1876 | 64,916 | 26.78

1877 | 66,636 | 27.14

1878 | 68,538 | 27.57

1879 | 69,885 | 27.77

1880 | 71,191 | 27.94

-------+-------------+-------------------

In other words, there were eight more patients under care for every

20,000 of the population in 1880 than in 1869. Had there been no

increase in the number in detention, after allowing for increase of

population, the number in 1880 would have been 53,177. It was, in fact,

71,191, _i.e._ 18,014 more.

* * * * *

We have now traced step by step the remarkable progress effected in the

asylum care of our lunacy population. In concluding this chapter I

would, however, observe that it would be a grave and mischievous mistake

to suppose that, most valuable as is the provision for the insane by

asylums, there are not many cases which may be treated outside these

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 L200, and the weekly maintenance and clothing of each patient 9s.

9-1/4d. 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 L40.

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 L2 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 L1 10s. or, including asylum

construction and repairs, L1 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.

FOOTNOTES:

[178] "A Lecture on the Management of Lunatic Asylums," etc., by Robert

Gardiner Hill. Published April, 1859 (delivered June 21, 1838). (See

Appendix H.)

[179] Including the wards in the Manchester Hospital.

[180] Including thirty male and three female criminal lunatics in jails,

according to the Parliamentary return for April, 1843.

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

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

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

1844.

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

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

asylums.

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

[187] Exclusive of 226 single patients under commission.

[188] Page 35.

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

[190] Page 44.

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

see Appendix I.

[192] Report of Commissioners in Lunacy, 1864.

[193] Exclusive of 159 single patients.

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

[195] Caterham cost a little more, viz., L89 a bed.

[196] Page 10.

[197] Page 35.

[198] Page 43.

[199] In the Commissioners' Report of 1871, p. 76, a case is reported in

which the jury would not convict a woman who had the charge of a lunatic

and admitted that "she strapped the patient once a month at the full of

the moon," of ill-usage, although Mr. Justice Willes summed up strongly

against her. In another case the Lunacy statute was disregarded, but

Baron Martin summed up very leniently, much to the disapproval, not to

say the disgust, of the Commissioners.

[200] Page 75.

[201] Page 81.

[202] Page 77.

[203] See page 196.

[204] Page 20.

[205] The order and description of these institutions have been given in

these decennial tables as far as possible in accordance with that of the

table of 1844, in order to facilitate comparison.

[206] Exclusive of 208 lunatics so found by inquisition who reside in

charge of their committees.

[207] For information in regard to Wales I am indebted Dr. W. Williams,

the late medical superintendent of the Denbigh Asylum.

[208] Report, page 3.

[209] See Address at International Medical Congress, _Journal of Mental

Science_, January, 1882.