PROGRESS OF PSYCHOLOGICAL MEDICINE DURING THE LAST FORTY YEARS:
1841-1881.[292]
If, gentlemen, History be correctly defined as Philosophy teaching by
examples, I do not know that I could take any subject for my Address
more profitable or fitting than the Progress of Psychological Medicine
during the forty years which, expiring to-day, mark the life of the
Association over which, thanks to your suffrages, I have the honour to
preside this year--an honour greatly enhanced by the special
circumstances under which we assemble, arising out of the meeting in
this metropolis of the International Medical Congress. To it I would
accord a hearty welcome, speaking on behalf of this Association, which
numbers amongst its honorary members so many distinguished alienists,
American and European. Bounded by the limits of our four seas, we are in
danger of overlooking the merits of those who live and work beyond them.
I recall the observation of Arnold of Rugby, that if we were not a very
active people, our disunion from the Continent would make us nearly as
bad as the Chinese. "Foreigners say," he goes on to remark, "that our
insular situation cramps and narrows our minds. And this is not mere
nonsense either. What is wanted is a deep knowledge of, and sympathy
with, the European character and institutions, and then there would be a
hope that we might each impart to the other that in which we are
superior."
Do we not owe to France the classic works of Pinel and of
Esquirol--justly styled the Hippocrates of Psychological Medicine--works
whose value time can never destroy; and have not these masters in
Medical Psychology been followed by an array of brilliant names familiar
to us as household words, Georget, Bayle, Ferrus, Foville, Leuret,
Falret, Voisin, Trelat, Parchappe, Morel, Marce, who have passed
away,[293] and by those now living who, either inheriting their name or
worthy of their fame, will be inscribed on the long roll of celebrated
psychologists of which that country can boast.
If Haslam may seem to have stumbled upon General Paralysis, we may well
accord to French alienists the merit of having really discovered the
disorder which, in our department, is the most fascinating, as it has
formed the most prominent object of research, during the last forty
years.
To mention Austria and Germany, is to recall Langermann,
Feuchtersleben, Reil, Friedreich, Jacobi, Zeller, Griesinger, Roller,
and Flemming, who, full of years and honours, has now passed away.
Has not Belgium her Guislain, Holland her Schroeder van der Kolk, and
Italy her Chiaruggi?
And when I pass from Europe to the American continent, many well-known
names arise, at whose head stands the celebrated Dr. Rush. Woodward,
Bell, Brigham, and Howe (whose many-sided labour included the idiot)
will be long remembered, and now, alas! I have to include among the dead
an honoured name, over whom the grave has recently closed. Saintship is
not the exclusive property of the Church. Medicine has also her
calendar. Not a few physicians of the mind have deserved to be
canonized; and to our psychological Hagiology, I would now add the name
of Isaac Ray. With his fellow-workers in the same field, among whom are
men not less honoured, I would venture to express the sympathy of this
Association in the loss they have sustained. Nor can I pass from these
names, although departing from my intention of mentioning only the dead,
without paying a tribute of respect to that remarkable woman, Miss Dix,
who has a claim to the gratitude of mankind for having consecrated the
best years of her varied life to the fearless advocacy of the cause of
the insane, and to whose exertions not a few of the institutions for
their care and treatment in the States owe their origin.
Abroad, psychological journalism has been in advance of ours.
The French alienists established in 1843 their _Annales
Medico-Psychologiques_ (one of whose editors, M. Foville, is with us
to-day), five years before Dr. Winslow issued his Journal, the first
devoted to medical psychology in this country, and ten years before our
own _Journal_ appeared, in 1853.
The Germans and Americans began their Journals in the following
year--1844; the former, the _Allgemeine Zeitschrift fuer Psychiatrie_,
and the latter the _American Journal of Insanity_.
I believe that our Association has precedence of any other devoted to
Medical Psychology, and it is an interesting fact that its establishment
led to that of the corresponding Association in France--a society whose
secretary, M. Motet, I am glad to see among my auditors. The Association
of Medical Superintendents of American Institutions for the Insane was
instituted in 1844; that of Germany in 1864, the subject of Psychology
having previously formed a section of a Medical Association.
Returning to our own country, I may observe that when Dr. Hitch, of the
Gloucester Asylum, issued the circular which led to the formation of
this Association in 1841, almost half a century had elapsed since the
epoch (1792) which I may call the renaissance of the humane treatment of
the insane, when the Bicetre in France, and the York Retreat in England,
originated by their example an impulse still unspent, destined in the
course of years to triumph, as we witness to-day. This triumph was
secured, in large measure, by the efforts of two men who, forty years
ago, shortly after the well-known experiment at Lincoln, by the late
Mr. Robert Gardiner Hill, were actively engaged in ameliorating the
condition of the insane. Need I say that I refer to Lord Shaftesbury and
Dr. Conolly? The nobleman and the physician (alike forward to recognize
the services of the pioneers of 1792), each in his own sphere having a
common end in view, and animated by the same spirit, gave an impetus to
the movement, the value and far-reaching extent of which it is almost
impossible to exaggerate. Lord Shaftesbury,[294] celebrating his
eightieth birthday this year, still lives to witness the fruits of his
labours, of which the success of the well-known Acts with which his name
is associated, will form an enduring memorial. Dr. Conolly was in his
prime. He had been two years at Hanwell, and was contending against
great difficulties with the courageous determination which characterized
him. I do not hold the memory of Conolly in respect, merely or
principally because he was the apostle of non-restraint, but because,
although doubtless fallible (and indiscriminate eulogy would defeat its
object), he infused into the treatment of the insane a contagious
earnestness possessing a value far beyond any mere system or dogma. His
real merit, his true glory, is to have leavened the opinions and
stimulated the best energies of many of his contemporaries, to have
stirred their enthusiasm and inflamed their zeal, to have not only
transmitted but to have rendered brighter the torch which he seized from
the hands of his predecessors. He desired to be remembered after his
death by asylum superintendents as one who sincerely wished to place the
insane in better hands than those in which he too generally found them;
and I hold that, whatever may be our views on what we have chosen to
call non-restraint, we may cordially unite in fulfilling his desire.
As the non-restraint system--a term, it must be confessed, which cannot
boast of scientific precision, but is well understood--has been the
leading, and often engrossing, topic of discussion during the period now
under review, I must not omit a brief reference to it. No one will call
in question the statement as an historical fact that the Commissioners
in Lunacy and the medical superintendents of asylums in this country
are, with few exceptions, in favour of non-restraint. Dr. Lauder
Lindsay--for whose death, as well as that of Dr. Sherlock and of Dr.
White Williams, during the last year, the tribute of sorrowful regret
ought, in passing, to be paid--Dr. Lindsay, I say, had only a small
following in Great Britain. In Germany, on the other hand, although
Griesinger looked favourably upon the system, and Westphal has advocated
it, and Brosius has translated Conolly's standard work into German,
there has not been a general conversion, as may be seen by the
discussion which took place in 1879, at meetings of the Psychological
Society in Berlin and Heidelberg. In France, again, although Morel gave
it the sanction of his name, and Magnan has practised it recently, there
has been within the last twelve months a striking proof of
anti-non-restraint opinion among the French physicians, in an
interesting discussion at the Societe Medico-Psychologique. I wish here
only to chronicle the fact, and would urge the necessity of not
confounding honest differences of opinion with differences of humane
feeling. The non-restrainer is within his right when he practises the
system carried to its extremest lengths. He is within his right when he
preaches its advantages to others. But he is not within his right if he
denounces those physicians, equally humane as himself, who differ from
him in opinion and practice. I therefore unite with the observation of
Dr. Ray, by whom, as well as by the majority of his
fellow-psychologists, the non-restraint system as a doctrine was not
accepted, when he wrote thus in 1855, "Here, as well as everywhere else,
the privilege of free and independent inquiry cannot be invaded without
ultimate injury to the cause."[295]
The arguments in favour of mechanical restraint are clearly set forth by
Dr. John Gray, of the Utica Asylum, in his annual report of the present
year.
Leaving this subject let me recall to your recollection that when this
Association was formed, the care of the insane in England and Wales was
regulated by the Gordon-Ashley Act of 1828,[296] which, among other
reforms, had substituted for the authority of five Fellows of the
College of Physicians, who performed their duties in the most slovenly
manner, fifteen metropolitan Commissioners in Lunacy. I find, on
examining the Annual Report of these Commissioners issued in 1841, that
it does not extend over more than one page and a half! It is signed by
Ashley, Gordon, Turner, Southey, and Proctor. They report the number
confined in the thirty-three asylums within their jurisdiction as 2490.
Their verdict on inspecting them is expressed in half a dozen words,
namely, that the "result is upon the whole satisfactory."
"The business of this Commission," they say, "has very much increased,
partly by more frequent communications with the provinces (over which,
however, they have no direct legal control), and partly by the more
minute attention directed by the Commissioners to individual cases with
a view to the liberation of convalescent patients upon trial ... and the
consequence has been that many persons have been liberated who otherwise
would have remained in confinement."
That a state of things in which such an occurrence was possible should
be described as on the whole satisfactory, is somewhat remarkable, and
in reading this paragraph we cannot but contrast with it the very
different result of the investigation made by the Committee of the House
of Commons in 1877.
Again, nothing more strikingly marks the change which has taken place in
the inspection of asylums than the contrast between the last Report of
the Lunacy Commissioners, consisting of a bulky volume of more than four
hundred pages, and that of 1841, of a page and a half. In fact, the
Reports of the Commissioners form the best evidence to which I can refer
of the progress made from year to year in the provision for the insane,
and the gradual but uninterrupted amelioration of their condition.
An important advance was made in 1842 by the Act 5 and 6 Vict., c. 87,
which provided that provincial houses were to be visited by the
Metropolitan Commissioners, as well as those in their own district. They
were also to report whether restraint was practised in any asylum, and
whether the patients were properly amused and occupied. Not only was a
great step forward made by thus extending the inspecting power of these
Commissioners to the provinces, but their memorable Report on the state
of the asylums in England and Wales in 1844 led to the highly important
legislation of the following year (introduced by Lord Ashley)--the Act 8
and 9 Vict., c. 100, which along with the Acts of 1853 (16 and 17 Vict.,
cc. 96, 97)[297] and 1862 (25 and 26 Vict., c. 111) form, as you are
well aware, the Code of Lunacy Law under which, for the most part, the
care of the insane is determined and their protection secured.
I should like to have been able to state the number of recognized
lunatics in England and Wales forty years ago, but no return exists
which shows it. The nearest approach is to be found in the Report just
referred to of the Metropolitan Commissioners (1844), in which the
number of ascertained lunatics in England and Wales is stated to be
about 20,000, of whom only 11,272 were confined in asylums, whereas now
there are nearly 55,000. It is difficult to realize that there were then
only some 4000 patients in county asylums, these being 15 in number, and
that there were 21 counties in England and Wales in which there were no
asylums of any kind, public or private. At the present time, instead of
20,000 ascertained lunatics and idiots, we have 73,113--an increase
represented by the population of the City of York--instead of 15 county
asylums we have 51, with scarcely less than 40,000 patients, instead of
4000; while the provincial licensed houses have decreased from 99 to 59,
and the metropolitan increased by 2. The total number of asylums in
England and Wales in 1844 was 158,[298] now it is 175--excluding those
(3) erected under Hardy's Act. I need not say that these figures do not
necessarily point to an increase of lunacy, but may merely represent the
increased accommodation which ought to have been provided long before.
Into the general question of the spread of insanity I feel that it would
be impossible to enter satisfactorily now.
Recurring to the Metropolitan Commissioners' Report, I must observe that
while an immense advance took place between 1828, when they were
appointed, and 1844, the subsequent advance between the latter date and
now is such that we cannot but recognize the extremely beneficial
operation of the legislation which has marked this period. It must also
be gratifying to Scotch asylum superintendents, knowing as they do the
satisfactory condition of the insane in their country in 1881, to be
able to measure the progress made since Lord Ashley, in his speech in
1844, moved for an address to the Crown, praying her Majesty to take
into consideration the Commissioners' Report, for he there observes, "I
believe that not in any country in Europe, nor in any part of America,
is there any place in which pauper lunatics are in such a suffering and
degraded state as those in her Majesty's kingdom of Scotland." I need
not do more than chronicle the fact, in passing, that the reform in
Scotland dates, to a large extent, from the appointment of a Royal
Commission in 1855, and the action of the Board of Lunacy Commissioners
which was established in consequence. Legislation for Ireland and the
appointment of inspectors have likewise proved very beneficial in that
country. But restricting my remarks to England and Wales, I would
observe that the establishment by the Act of 1845 of the Lunacy Board as
at present constituted, and the rendering it compulsory upon counties to
provide asylums for pauper lunatics, are the chief causes of the
improvement to which I have referred, so far, at least, as it has been
brought about by legislation.
I will not dwell in detail on the lunacy legislation of these years. To
have said less would have been to overlook the salient and most
important facts of the period. To have said more would have been to
travel over the ground so ably occupied by Dr. Blandford in his
Presidential Address three years ago. He, by-the-by, complained of the
ever-increasing difficulty each President finds in selecting a subject
for his discourse, and then immediately proceeded to effectually lessen
the chances of his successors. What the last occupant of this Chair will
be able to discover new for his address I do not know. I can only think
of the funeral oration over this Association at its obsequies--when its
"dying eyes are closed," its "decent limbs composed," and its "humble
grave adorn'd,"
"By strangers honour'd, by survivors mourn'd."
On the Board of the Commissioners in Lunacy have sat two members of our
profession (one still living), to whose services I wish more especially
to refer. I allude to Dr. Prichard and Mr. Gaskell.
Apart from his official work, the former will always be remembered in
the republic of letters by his learned contributions to anthropology and
the literature of mental diseases, in which he is more especially
identified with the doctrine of Moral Insanity. Chronicler of the period
in which he enunciated or rather developed it, I cannot avoid a brief
reference to a theme which has caused so much heated discussion. As an
impartial historian I am bound to admit that his views are still by no
means unanimously adopted, and that I am only expressing my own
sentiments when I avow that what Latham says of Prichard's "Researches
into the Physical History of Mankind"--"Let those who doubt its value,
try to do without it"--applies to the teaching contained in the
remarkable treatise entitled "Different Forms of Insanity in relation to
Jurisprudence," published in 1842. We may well be dissatisfied with some
of the illustrations of the doctrine it supports. We may express in
different terms the generalization he has made as to the relation of
intellect and emotion; but I am greatly mistaken if we shall not from
time to time be confronted by facts which instantly raise the question
which presented itself with so much force to his acute mind, and which
does not appear to me to be successfully met by those who controvert the
conclusions at which Prichard arrived. The necessity of admitting in
some form or other the mental facts in dispute, is well illustrated by
the recent work by Krafft-Ebing on mental disorders. For what does this
practised mental expert do? He, although the supporter of mental
solidarity and the integrity of the Ego--adverse, therefore, to the
psychology in which the theory has been enshrined--feels that he must
admit into his classification some term which describes certain
emotional or volitional disorders, and can discover none better than
"moral insanity"--a practical, though reluctant, admission of the value
of Prichard's views after their discussion for forty years. I might also
refer as an indication of opinion to a most excellent article in the
last number of the _Journal_ by Dr. Savage, who, while recognizing the
abstract metaphysical difficulty of conceiving moral as distinct from
intellectual insanity, fully admits as a clinical fact the form of
mental disease for which Prichard contended, and had he been living he
would doubtless have claimed this article as a striking proof of the
vitality of his opinions.
One is certainly disposed to exclaim, if observation on the one hand
compels us to admit certain mental facts, and the metaphysician on the
other declares them to be unmetaphysical, so much the worse for
metaphysics!
Mr. Gaskell, in addition to his good work as a reformer at the Lancaster
Asylum, where may yet be seen preserved quite a museum of articles of
restraint formerly in use in that institution, and his efficient labours
as a Commissioner, was also, it may not be generally known, the real
cause of the practical steps taken in this country to educate the idiot.
It was in 1847 that he wrote some articles in _Chamber's Journal_,
giving an account of Seguin's Idiot School at the Bicetre, which he had
visited and been greatly interested in. These articles had the effect of
inducing Dr. Andrew Reed to interest himself in the establishment of a
school for idiots in England. The Highgate and Colchester Asylums for
idiots were instituted--the origin, as it proved, of the great
establishment at Earlswood. All, therefore, that has been done for this
pitiable class has been effected during the last forty years. The
indefatigable Seguin has passed away during the last twelve months. He
pursued to the last, with unabated zeal, a study possessing attractions
for only a limited number, and advocated the claims of idiots and
imbeciles with unceasing energy in the Old World and the New.
Fortunately his mantle has descended upon a worthy successor in the
person of his son, Dr. E. Seguin, of New York.
* * * * *
It has necessarily happened that the direction of public attention to
the larger and better provision for the insane in all civilized lands
has led to much consideration, and inevitably some difference of
opinion as regards the form and arrangement of asylums. But all will
admit that their construction has undergone a vast improvement in forty
years. The tendency at the present moment is to attach less importance
to bricks and mortar, and the security of the patient within a walled
enclosure, than to grant the largest possible amount of freedom, in
asylums, compatible with safety. The more this is carried out, the
easier, it is to be hoped, will it be to induce the friends of patients
to allow them to go in the earliest stage of the disorder to an asylum,
as readily as they would to a hydropathic establishment or an ordinary
hospital, to which end medical men may do much by ignoring the stupid
stigma still attaching to having been in an asylum. The treatment of the
insane ought to be such that we should be able to regard the asylums of
the land as one vast Temple of Health, in which the priests of
Esculapius, rivalling the Egyptians and Greeks of old, are constantly
ministering, and are sacrificing their time and talents on the altar of
Psyche.[299]
Most heartily do I agree with Dr. Kirkbride when he says that "Asylums
can never be dispensed with--no matter how persistently ignorance,
prejudice, or sophistry may declare to the contrary--without
retrograding to a greater or less extent to the conditions of a past
period with all the inhumanity and barbarity connected with it. To
understand what would be the situation of a people without hospitals
for their insane, it is only necessary to learn what their condition was
when there were none."[300]
In advocating the prompt and facile recourse to an asylum, I include, of
course, the cottage treatment of the insane so long ago resorted to by
Dr. Bucknill, and extended in so admirable a manner by my immediate
predecessor in this chair, whose practical observations last year on the
villas and cottages at Cheadle rendered his address one of the most
valuable that has been delivered. Moreover, I would not say a word in
disparagement of the placing of suitable cases in the houses of medical
men, or in lodgings, under frequent medical visitation.[301] I also
recognize the value of intermediate or border-land institutions, so long
as they are conducted with the sanction of the Commissioners and open to
their inspection.
The modern advocacy of the open-door system has been recently brought
under the notice of the Association by Dr. Needham, with the view of
obtaining a general expression of opinion on a practice, to the wisdom
of which he is disposed to demur.
But a less regard for mere bricks and mortar, the removal of high
boundary walls and contracted airing-courts, or the introduction of the
open-door system, do not lessen the importance of properly constructed
asylums. The works of Jacobi in Germany, Kirkbride in America, Parchappe
in France, and Conolly in England, must retain their value as classical
productions on this subject; while the contributions recently made by
Dr. Clouston present not only the general principles of asylum
construction, but the minute details of building, in the light of the
knowledge and experience of the present day.
I was fortunate in being able to render M. Parchappe some service when
he visited England to examine the construction of our asylums. Those who
formed his acquaintance on the occasion of this visit may remember his
mixed feelings on visiting them, how he demurred on the one hand to what
he regarded as too costly and ornamental, while, on the other hand, he
liked the English arrangement of the buildings better than the
Esquirol-Desportes system. I need not point out that those who have had
the planning of the county asylums in England have objected, as well as
Parchappe, to the distribution of isolated pavilions upon parallel
lines. Parchappe, while far from believing it to be indispensable to
make asylums monuments fitted to excite admiration for the richness of
their architecture, and indisposed to emulate our asylums, which, he
says, only belong to princely mansions, turns nevertheless from the
square courts and the isolated pavilions of Esquirol to apostrophize the
former in these glowing terms:--
"How much more suited to reanimate torpid intelligence and feeling, or
to distract and console melancholy among the unfortunate insane, these
edifices majestic in their general effect and comfortable in their
details, these grandiose parks, with luxuriant plantations and verdant
flowery lawns, whose harmonious association impresses upon English
asylums an exceptional character of calm and powerful beauty!"
Whether a stranger, having read this florid description of our asylums,
would not, on visiting them, be a little disappointed, I will not stop
to inquire. Probably during this or the following week, some of
Parchappe's compatriots may answer the question for themselves.
The fundamental question of the separation of the curable and incurable
classes has in different countries been earnestly discussed during the
last forty years. Kirkbride has entered his "special and earnest
protest" against this separation; his own countryman, Dr. Stearns, on
the other hand, has lately advocated it. In Germany, where, following
the lead of Langermann and Reil, complete separation of the curable in
one building was first realized under Jacobi at Siegburg, there has been
a complete reversion to the system of combining the two classes in one
institution. Parchappe, who opposed the separation of these classes, as
illusory if justice is done to the incurable in the construction of the
building provided for them, and mischievous if this is denied them, was
constrained to admit, however, in view of the enormous number of
lunatics in the Department of the Seine, that it was the least of two
evils to separate the epileptic and the idiotic from the curable.
In England the separation principle has been recognized in Hardy's Act
(30 Vict., c. 6) for the establishment in the metropolis of asylums for
the sick, insane, and other classes of the poor, 1867; and, again, in
the erection of such an asylum as Banstead for Middlesex--and I am
informed by Dr. Claye Shaw, who, from holding the office of
superintendent there, and formerly superintending the Metropolitan
District Asylum of Leavesden, is well calculated to judge, that the
experiment has proved successful, that the patients do not suffer, and
that the office of superintendent is not rendered unendurable. Regarded
from an economic point of view, it has been found practicable to provide
buildings at a cost of between L80 and L90 per bed, which, though not
aesthetic, are carefully planned for the care and oversight of the
inmates. This includes not only the land, but furnishing the asylum.
Five years ago this Association unanimously adopted a resolution,
expressing satisfaction that the Charity Organization Society had taken
up the subject of the better provision, in the provinces, for idiots,
imbeciles, and harmless lunatics, and the following year carried a
resolution, also unanimous, that the arrangement made for these classes
in the metropolitan district is applicable in its main principles to the
rest of England. But it does not follow that the separation of these
classes from the county asylums should be so complete, either as
respects locality or the governing board, as in the metropolitan
district; and, further, the Association expressed a strong opinion that
the boarding-out system, although impracticable in the urban districts,
should be attempted wherever possible in the country; the greatest care
being taken to select suitable cases, unless we wish to witness the
evils which Dr. Fraser has so graphically depicted in his report for
1877 of the Fife and Kinross Asylum. If pauper asylums can, without
injury to families, be relieved by harmless cases being sent home to the
extent Dr. Duckworth Williams has succeeded in doing in Sussex, and if,
as he proposes, they were periodically visited, their names being
retained on the asylum books, the enlargement of some asylums might be
rendered unnecessary.
But what, gentlemen, would be the best-contrived separation of cases,
what would the best-constructed asylum avail, unless the presiding
authority were equal to his responsible duties? Now, it is one of the
happy circumstances connected with the great movement which has taken
place in this and other countries, that men have arisen in large numbers
who have proved themselves equal to the task. We witness the creation of
an almost new character--the asylum superintendent.
One Sunday afternoon, some years ago, Dr. Ray fell asleep in his chair
while reading old Fuller's portraits of the Good Merchant, the Good
Judge, the Good Soldier, etc., in his work entitled "The Holy and
Profane State," and, so sleeping, dreamed he read a manuscript, the
first chapter of which was headed, "The Good Superintendent." Awakening
from his nap by the tongs falling on the hearth, the doctor determined
to reproduce from memory as much of his dream as possible for the
benefit of his brethren. One of these recovered fragments runs
thus:--"The Good Superintendent hath considered well his qualifications
for the office he hath assumed, and been governed not more by a regard
for his fortunes than by a hearty desire to benefit his fellow-men....
To fix his hold on the confidence and goodwill of his patients he
spareth no effort, though it may consume his time and tax his patience,
or encroach seemingly on the dignity of his office. A formal walk
through the wards, and the ordering of a few drugs, compriseth but a
small part of his means for restoring the troubled mind. To prepare for
this work, and to make other means effectual, he carefully studieth the
mental movements of his patients. He never grudges the moments spent in
quiet, familiar intercourse with them, for thereby he gaineth many
glimpses of their inner life that may help him in their treatment.... He
maketh himself the centre of their system around which they all revolve,
being held in their places by the attraction of respect and
confidence."[302]
And much more so admirable that it is difficult to stay one's hand. You
will, I think, agree with me that what Dr. Ray dreamed is better than
what many write when they are wide awake, and those familiar with Dr.
Ray's career, and his character, will be of the opinion of another
Transatlantic worthy (Dr. John Gray, of Utica) that in this act of
unconscious cerebration the dreamer unwittingly described himself--
"'The Good Superintendent!' Who is he?
The master asked again and again;
But answered himself, unconsciously,
And wrote his own life without a stain."
In what a strange land of shadows the superintendent lives! But for his
familiarity with it, its strangeness would oftener strike him. It
becomes a matter of course that those with whom he mixes in daily life
are of imperial or royal blood--nay, more, possess divine
attributes--and that some who are maintained for half a guinea a week
possess millions and quadrillions of gold. He lives, in truth, in a
world inhabited by the creatures of the imagination of those by whom he
is constantly surrounded--a domain in which _his_ views of life and
things in general are in a miserable minority--a phantom world of ideal
forms and unearthly voices and mysterious sounds, incessantly disputing
his authority, and commanding his patients in terms claiming
supernatural force to do those things which he orders them to leave
undone, and to leave undone those things which he orders them to do;
commanding them to be silent, to starve themselves, to kill, to mutilate
or hang themselves; in short, there is in this remarkable country,
peopled by so many thousand inhabitants, an _imperium in imperio_ which
renders the contest continuous between the rival authorities struggling
for supremacy, sometimes, it must be confessed, ending in the triumph of
the ideal forms, and the phantom voices, and the visionary sights, which
may be smiled at in our studies, and curiously analyzed in our
scientific alembics, but cannot be ignored in practice without the
occurrence of dire catastrophes, and the unpleasant realization of the
truth that idealism, phantasy, and vision may be transformed into
dangerous forms of force. It may be said, indeed, that the appropriate
motto of the medical superintendent is--"_Insanitas insanitatum, omnia
insanitas._"
With such an _entourage_ it is not surprising if the first residence in
an asylum as its responsible head--especially an asylum in the olden
days--should disconcert even a physician. A German psychologist once
declared, after passing his first night in an institution as
superintendent, that he could not remain there; he felt overwhelmed with
his position. Yet this physician remained not only over the next night,
but for thirty-five years, to live honoured and venerated as Maximilian
Jacobi, and departing to leave behind him "footprints on the sands of
time," from seeing which, others, in a similar hour of discouragement,
may again take heart.
I cannot pass from this subject without enforcing, as a practical
comment, the necessity of asylum physicians having a very liberal supply
of holidays, so as to insure a complete change of thought from not only
the objective but the subjective world in which they live, and this
before the time comes when they are unable to throw off their work from
their minds, as happened to a hard-working friend of mine, who, even
during his holiday among the Alps, must needs dream one night that he
was making a post-mortem upon himself, and on another night rose from
his bed in a state of somnambulism to perform certain aberrant and
disorderly acts, not unlike what his patients would have performed in
the day.
I have heard it suggested that superintendents should have six weeks'
extra holiday every third year, five of them to be spent in visiting
asylums. Whether this is the best way of acquiring an interchange of
experience or not, I will not decide, but no doubt the feeling, how
desirable it is men should compare notes with their fellow-workers,
prompted the founders of our Association (which was expected to be more
peripatetic than has proved to be the case) to determine that its
members should at its annual meetings carefully examine some institution
for the insane.
It is not too much to say that only second in importance to a good
superintendent is a good attendant, and of him also Dr. Ray dreamed in
his Sunday afternoon vision, and his description is equally excellent.
I am sure that it will be admitted that the last forty years have seen a
vast improvement in the character of attendants, and among them are to
be found many conscientious, trustworthy men and women, forbearing to
their charge and loyal to their superintendent. It is not the less true
that for asylums for the middle and higher classes the addition of
companionship of a more educated character is desirable, and it is
satisfactory to observe that there is an increasing recognition of its
importance, as evidenced by the Reports of our asylums.[303]
* * * * *
One word now in regard to the advance in our classification of mental
disorders, though I hardly dare to even touch thus lightly upon so
delicate a subject, for I have observed that it is one of those
questions in our department of medicine--dry and unexciting as it may
at first sight seem to be--which possess a peculiar polemical charm.
Few circumstances are more noteworthy than the attacks which have been
made upon the citadel of the Pinel-Esquirol classification, the
symptomatological expression of the disease--attacks not new forty years
ago, but renewed with great force and spirit by Luther Bell in America,
and subsequently by Schroeder van der Kolk in Holland, Morel in France,
and Skae in Britain. When Dr. Bell asserted that this system of symptoms
"would not bear the test of accuracy as regards the cause of the disease
or the pathological condition of the sufferer;" that the forms in use
"were merely the changing external symptoms, often having scarcely a
diurnal continuance before passing from one to another," and
constituting a division useless as regards moral or medical
treatment--he expressed in a nutshell all the objections since urged
against the orthodox classification by the other alienists I have
mentioned. These, however, substituted a mixed aetiological or
pathogenetic classification, which Bell did not, and this classification
is, in its essential characters, on its trial to-day. The wave of
thought which bore these attempts to the surface, was a wholesome
indication of the desire to look beneath the mere symptom right down to
the physical state which occasioned it, and upon which the somatic
school of German alienists had long before laid so much stress. The
movement has been useful, if for no other reason than that it has
concentrated attention afresh and more definitely upon the conditions
which may stand in causal relation with the mental disorder, nor has it
been without its influence in affecting the terms generally employed in
the nomenclature of insanity. At the same time it is very striking to
observe how the great types of mental disorder adopted and in part
introduced by the great French alienists have essentially held their
ground, and if their citadel has had in some points to parley with a
foeman worthy of their steel, and even treat with him as an honourable
rival, they remain still in possession, and their classification of
symptoms seems likely to remain there for long to come. As such, these
types are partly founded upon clinical and, to some extent, pathological
observation, and may well be allowed with a few additional forms to
stand side by side with a somato-aetiological nomenclature, as it grows
up slowly and cautiously, reared on scientific observation and research;
and had Skae been living he would have rejoiced to hear Mr. Hutchinson
assert the other day that in all diseases, "our future classification
must be one of causes and not external symptoms, if we would desire to
construct anything like a natural system, and trace the real relation of
diseases to their origin."
* * * * *
In a sketch, however brief, of the progress of Psychological Medicine
since the foundation of this Association in 1841, it would be a serious
omission not to notice the important contributions of the late Professor
Laycock shortly before as well as after that year. In 1840 he first
promulgated the opinion that "the brain, although the organ of
consciousness, is subject to the laws of reflex action, and in this
respect does not differ from other ganglia of the nervous system."[304]
And in a paper read before the British Association, September, 1844, he
observed, "Insanity and dreaming present the best field for
investigating the laws of that extension of action from one portion of
the brain to the other, by which ideas follow each other in sequence,
giving as an illustration the case of a patient at the York Retreat,
whose will being suspended, he expressed ideas as they spontaneously
arose in associated sequence, the combination being singularly varied,
but traceable to a common root or centre of impulse." "Researches of
this kind," Laycock continues, "whether instituted on the insane, the
somnambulist, the dreamer, or the delirious, must be considered like
researches in analytical chemistry. The re-agent is the impression made
on the brain; the molecular changes following the applications of the
re-agent are made known to us as ideas."[305]
Time will not allow me to cite other passages in these remarkable
papers, or later ones; but these are sufficient to show the germ at that
early period of the doctrine of cerebral reflex action, and the
unconscious cerebration of Carpenter, the seeds having been already sown
by Unzer and Prochaska, and arising out of it, that of automatic states
occasioned or permitted by the abeyance of a higher restraining
power--the Will, according to Laycock, in the case he employs as an
illustration of his doctrine. His teaching in regard to mental and
nervous disorders due to vaso-motor disturbance also deserves
recognition.
Dr. Henry Monro, again, in a treatise published in 1851, put forward a
theory of the pathology of insanity, the essence of which was that the
cerebral masses having lost their static equilibrium exhibit in their
functions two different degrees of deficient nervous action
(coincidently), viz. irritable excess of action and partial paralysis.
He maintained that these two states do not fall alike upon all the seats
of mental operations, but that there is "a partial suspension of action"
of "higher faculties, such as reason and will," while there is an
irritable excess of action of the seats of the more elementary
faculties, such as conception, etc., and hence delusions and the
excessive rapidity of successive ideas. Dr. Monro compares this
condition to a case of paralysis, combined with convulsions; and
discusses the question whether the temporary and partial paralysis
occurring as he supposes in insanity, "results directly and entirely
from excessive depression of the nervous centres of those higher
faculties, or partly in an _indirect_ manner from nervous energy being
abstracted to other parts which are in more violent exercise at the
time."[306]
This, it will be seen, is a still clearer statement of the doctrine that
insanity is caused by the depression or paralysis of the higher nervous
centres and excessive action of others.
As is well known, Dr. Hughlings Jackson, whose views regarding active
states of nerve structures as liberations of energy or discharges, are
familiar to us all, has adopted and extended Laycock's doctrine, which
he designates as "one of inestimable value," and has urged the
importance of Monro's doctrine of negative and positive states in cases
of insanity, using the term "insanity" in an exceedingly wide sense. He
has pointed out that Anstie and Thompson Dickson have also stated the
doctrine that so-called "exaltation of faculties" in many morbid states
is owing to "insubordination from loss of control," and that the same
was said in effect by Symonds, of Bristol. Adopting the hypothesis of
evolution as enunciated by Herbert Spencer, Dr. Hughlings Jackson thinks
that cases of insanity, and indeed all other nervous diseases, may be
considered as examples of Dissolution, this being, I need not say, the
term Spencer uses for the process which is the reverse of Evolution.
Insanity, then, according to this view, is dissolution beginning at the
highest cerebral centres, which centres, according to Jackson, represent
or re-represent the whole organism. There are distinguishable, he
believes, cases of uniform dissolution, the process affecting the
highest centres nearly uniformly, and cases of partial dissolution in
which only some parts of these centres are affected. The dissolution,
again, whether uniform or partial, varies in "depth;" the deeper it is,
the more general are the manifestations remaining possible. The degree
of "depth" of dissolution is, however, but one factor in this
comparative study of insanity. Another is the rapidity with which it is
effected. To this, Dr. Jackson attaches extreme importance, believing
that degrees of it account for degrees of activity of those nervous
arrangements next lower than those _hors de combat_ in the dissolution.
Another factor is the kind of person to whom dissolution "comes." And
the last factor is the influence of circumstances on the patient
undergoing mental dissolution. All factors should, of course, be
considered in each case, or, as Dr. Jackson characteristically puts it,
"insanity is a function of four variables." I refer to these opinions to
show the direction in which some modern speculation on the nature of
insanity tends, that thus tracing the course of thought in recent years
we may see how, step by step, certain views have been reached, some of
them generally adopted, others regarded as still requiring proof before
they can be accepted.
The negative and positive view of the nature of insanity receives
support, I think, from the phenomena of Hypnotism which, about forty
years ago, attracted, under the name of Mesmerism, so much attention in
England in consequence of the proceedings of Dr. Elliotson in the
hospital and college where we meet to-day. This was in 1838, and Braid's
attention was arrested by what he witnessed in 1841. It is no reason
because we have re-christened mesmerism that we should ignore the merit
of those who, as to matters of fact, were in the right, however mistaken
their interpretation may have been.
Elliotson recorded some striking examples of induced hallucinations and
delusions, and in an article in the _Journal_ in 1866, I endeavoured to
show how suggestive similar instances which I then reported are in
relation to certain forms of insanity, and also in relation to sudden
recovery from mental disease; the conclusion being forced upon us that
there may be cases in which no change takes place in the brain which the
ablest microscopist is likely to detect, but a dynamic change--one more
or less temporary in the relative functional power of different cerebral
centres, involving loss or excess of inhibition.
Nor can I, in connection with the reference to cerebral localization,
allow to pass unrecorded the researches of Fritsch, Hitzig, and Ferrier,
on account of the intimate, although only partial relation in which they
stand to mental pathology--a relation promising to become more
intelligible and therefore more important as the true meaning of the
psycho-motor centres becomes better understood; for that we are only on
the threshold of this inquiry must be evident, when men like Goltz,
Munk, and other investigators call in question the conclusions which
have been arrived at.
But be the final verdict what it may, when I look back to the time when
"Solly on the Brain" was our standard work, and then turn to Ferrier's
treatise on its functions, to the remarkable works of Luys, and to Dr.
Bastian's valuable contribution to the International Series, I cannot
but feel how unquestionable has been the advance made in the physiology
of the brain, strangely bent as Nature is on keeping her secrets
whenever the wonderful nexus which binds together, yet confounds not,
mind and brain, is the subject of investigation.
* * * * *
The past forty years have witnessed a great change in the recognition of
mental disease as an integral part of disorders of the nervous system,
and medical psychology is less and less regarded as a fragment detached
from the general domain of medicine. Contributions from all lands have
conspired to produce this effect, the somatic school of psychologists in
Germany having exerted, probably, the most influence. And we are proud
to number in France among our roll of associates a physician who, not
only by his pathological researches into diseases of the brain and cord,
but by his clinical study of affections closely allied to mental
derangement, has by the brilliant light he has thrown upon the whole
range of diseases of the nervous system, advanced the recognition of
which I have just spoken. I need not say that I refer to our
distinguished honorary member, Professor Charcot.
No one will deny that the relations of mind and brain, physiologically
and pathologically considered, have in our own country been ably handled
by Dr. Maudsley. Those who most widely differ from some of his
conclusions will acknowledge this ability, and that his works are
expressed in language which, with this author, is certainly not employed
to conceal his thoughts. To trace the influence of these writings, and
those of Herbert Spencer, Bain, and others of the same school, on the
current belief of psychologists would, however, carry me far beyond the
legitimate limits of an address, but I may be allowed to observe that
here, as elsewhere, we must not confound clearly ascertained facts in
biology and mental evolution with the theories which are elaborated from
them. The former will remain; the latter may prove perishable hay and
stubble, and when we overlook or ignore this distinction, it must be
admitted that we expose ourselves to the just rebuke of the celebrated
Professor of Berlin when he protests against "the attempts that are made
to proclaim the problems of research as actual facts, the opinion of
scientists as established science, and thereby to put in a false light
before the eyes of the less informed masses, not merely the methods of
science, but also its whole position in regard to the intellectual life
of men and nations." He is surely right when he insists that if we
explain attraction and repulsion as exhibitions of mind, we simply throw
Psyche out of the window and Psyche ceases to be Psyche;[307] and when,
allowing that it is easy to say that a cell consists of minute
particles, and these we call plastidules, that plastidules are composed
of carbon and hydrogen, oxygen, nitrogen, and are endued with a special
soul, which soul is the product of some of the forces which the chemical
atom possesses, he affirms that this is one of those positions which is
still unapproachable, adding, "I feel like a sailor who puts forth into
an abyss, the extent of which he cannot see;" and, again, "I must enter
my decided protest against the attempt to make a premature extension of
our doctrine in this manner--never ceasing to repeat a hundred-fold a
hundred times, 'Do not take this for established truth.'"[308]
We all believe in cerebral development according to what we call natural
laws or causes, and in the parallel phenomena of mind; as also in the
arrested and morbid action of brain-power by infractions of laws or by
causes no less natural. In this sense we are all evolutionists. The
differences of opinion arise when the ultimate relations of matter and
mind are discussed, and when a designing force at the back of these laws
is debated. But these questions in their relation to mental evolution,
as to evolution in general, do not enter the domain of practical
science, and are not affected by the degree of remoteness, according to
our human reckoning, of this force or "Ultimate Power."
It will not be denied that at least the foundations of the pathology of
insanity have been more securely laid in cerebral physiology during the
last forty years, in spite of the fact that the relation of the minute
structure of the brain to its functions, and the nature of the force in
operation, still elude our grasp. The so-called disorders of the mind
having been brought within the range of the pathologist, what can he
tell us now of the post-mortem lesions of the insane? Can he give a
satisfactory reply to the question asked by Pinel in his day, "Is it
possible to establish any relation between the physical appearances
manifested after death, and the lesions of intellectual function
observed during life?"[309]
It is a little more than forty years since Lelut published his work
entitled "The Value of Cerebral Alterations in Acute Delirium and
Insanity," and Parchappe his "Recherches," to be followed by other works
containing valuable contributions to the pathological anatomy of mental
disease. To attempt to enumerate the contributions to this department
abroad and at home would be simply impossible on the present occasion. I
cannot, however, omit to notice how early Dr. Bucknill was in the field,
as his laborious examination of a number of brains of the insane to
determine the amount of cerebral atrophy and the specific gravity, bear
witness, as also his demonstration of the changes which take place, not
only in the brain and its membranes, but in the cord, in general
paralysis; these observations, along with those of Dr. Boyd, having been
fully confirmed by subsequent observers.
I recall here, with interest, a visit I paid eight and twenty years ago
to Schroeder van der Kolk at Utrecht, whom I found full of enthusiasm
(although racked at the time with neuralgia) in the midst of his
microscopical sections. And this enthusiasm I cannot but suspect
insensibly coloured what he saw in the brains and cords of the insane,
or he would hardly have said, as he did say, that he had never failed
during a quarter of a century to find a satisfactory explanation after
death of the morbid mental phenomena observed during life.
It must not, however, be forgotten that Parchappe, just forty years ago,
was able to speak as strongly in regard to the brains of general
paralytics; and that of others he said that it would be nearer the truth
to assert that you can, than that you cannot, distinguish between a sane
and an insane brain.
Since that period microscopes of higher power have been sedulously
employed by European and American histologists, and in our country the
example set by Lockhart Clarke has been followed by many able and
successful investigators. I had intended to enumerate in some detail the
gains of pathological anatomy in cerebro-mental diseases, and to
endeavour to apportion to those who have cultivated this field of
research their respective merits; but I find it better to consider what
is the practical result of these researches. I may, however, so far
depart from this course as to mention the memoirs of Dr. J. B. Tuke in
the _Edinburgh Medical Journal_ of 1868 and 1869, and elsewhere, on
account of their importance in the history of the morbid histology of
insanity.
Returning to the practical question of the knowledge now possessed by
the cerebral pathologist, I will put into the witness box Professor
Westphal and Dr. Herbert Major, as having enjoyed and utilized large
opportunities for making microscopic and macroscopic examinations of the
insane, and not being hasty--some think the former too slow--to admit
the presence of distinctive lesions.
Now, Professor Westphal informs me that he is unable to trace, in the
majority of post-mortems of the insane who have not suffered from
general paralysis, any morbid appearance of the brain or its membranes,
either with the naked eye or the microscope. He maintains that it would
be impossible to designate amongst a hundred miscellaneous brains those
which have belonged to insane persons, if the cases of general paralysis
had been eliminated.
Dr. Major speaks guardedly; but inclines to think that, even putting
aside general paralytics, the sane may be _generally_ distinguished from
the insane brain. His experience at Wakefield shows that in only
seventeen per cent. of the autopsies (excluding general paralysis) the
brain showed no decided morbid change. "It must be always remembered,"
Dr. Major writes, "that the difficulty is not to distinguish between the
insane brain on the one hand and a perfectly healthy and vigorous sane
brain on the other--the difference between these two extremes is, in my
own experience, most striking and startling. The difficulty is to
distinguish between the insane brain and that of an individual sane, but
in whom the brain is (as in time it may be) anaemic, wasted, or even
with tracts of softening. Still," he adds, "I think, generally speaking,
the sane organ may be distinguished from the insane, the decision
turning largely on the _degree_ of the degenerative or other morbid
change."
Again, taking only cases of general paralysis, Professor Westphal holds
that in by far the greater number of brains of insane persons dying in
an advanced stage, morbid appearances similar to those which he has
described in Griesinger's "Archiv. I.," etc., can be traced; the morbid
appearances of the cord occurring more constantly than those of the
brain.
Dr. Major found that of the post-mortems of paralytics, all displayed
appreciable morbid lesions, although in five per cent. of cases they
were not typical of general paralysis.
Then coming definitely to the question whether these pathologists have,
to any considerable extent, been able to connect the morbid appearances
found in cases of insanity with the symptoms, including motor troubles,
Dr. Major says that at present he cannot; and Professor Westphal says
that he regards "the connection of morbid symptoms with the changes
found after death as exceedingly uncertain and doubtful."
I should observe that Dr. Major grounds his statements upon his own
recent experience and observation at Wakefield, and that he is not
disputing the greater preference shown by certain lesions in general
paralysis for particular localities; but only that he does not yet see
his way to connect them with the abnormal symptoms present during life.
The researches carried on by Dr. Mickle, contributed to our _Journal_
(January, 1876), and those of Dr. Crichton Browne, published with
illustrations in the "West Riding Reports," must be regarded along with
M. Voisin's large work and Hitzig's article in Ziemssen's "Cyclopaedia,"
as placing before us whatever evidence can be adduced on the relations
between the pathology of general paralysis and cerebral physiology.
Hitzig, who from his investigations into the cerebral motor centres,
and his position in an asylum for the insane, ought to be qualified to
judge, surmises that those localities of the brain by the electrical
irritation of which in animals he produced epileptiform attacks bearing
the closest resemblance to the attacks of paralytics, are affected in
general paralysis. He thinks, moreover, that as destruction of these
cortical spots causes disturbance of motion, resembling the symptoms
pathognomonic of grey degeneration of the posterior columns observed in
general paralysis, there is an added reason for assuming this
connection.
Dr. Mickle in his recent excellent work on general paralysis has
exercised much cautious discrimination in admitting the relation between
the symptoms and the alleged psycho-motor centres, and while his
researches in a rich field of observation at the Grove Hall Asylum lead
him to find some cerebral lesion in every case, especially in the
fronto-parietal region, he cautions against the "too ready indictment of
motor centres in the cerebral cortex as answerable for the most frequent
and characteristic motor impairment, that of the lips, tongue, face, and
articulatory organs generally;" fully believing, however, that in the
production of these symptoms the cortical lesion is at the very least an
important factor. "Whether the principal mental symptoms can be entirely
referred," he says, "to the organic changes in certain frontal (and
parietal) convolutions--the motor to those of the so-called cortical
motor zone--the sensory to those of certain portions of the
temporo-sphenoidal and parietal--must remain a matter of question,"
while in regard to the convulsive attacks, Dr. Mickle has in some cases
been "unable to trace a harmony between these and the results of
physiological experiment; in other cases they have seemed to harmonize
fairly."[310] Dr. Mickle informs me that in the insane other than
general paralytics, he has in the majority found some lesion in the
brain and membranes.[311]
These results of research in cerebro-mental pathological anatomy and
physiology may not seem, when placed side by side with the sanguine
opinions of Schroeder van der Kolk and Parchappe, to present so
triumphant a proof of progress and solid gain as might be desired or
expected, and much, we must admit, has to be done before Pinel's
question can be answered with the fulness we should wish. Nevertheless
the advance is very considerable, and the best proof of the accumulating
knowledge of the morbid histology of the brain and cord in the insane
will, I think, be given this week by the collection of microscopical
preparations of Gudden, Holler, etc., brought together by the untiring
energy of Dr. Savage, including his own at Bethlem Hospital. I have but
to point out how impossible such an exhibition would have been forty
years ago to give significance to the contrast between 1841 and 1881;
thanks to those who, although they may still often see as "through a
glass darkly," have so wonderfully advanced the application of
microscopic examination to the tissue of the brain, and prepared such
beautiful sections of diseased brain and cord.
Another proof of progress might have been given, had time allowed of a
reference to what has been done in the study of the brains of idiots,
both morphologically and histologically, by Mierzejewski, Luys, and
others, these results being sufficient to prove, had we no other
evidence, the fundamental truth of cerebro-mental pathology--the
dependence of healthy mind on healthy brain.
We are surely justified in expecting that by a prolonged examination of
every part of the brain structure, and the notation of the mental
symptoms, we shall arrive in future at more definite results; that the
locality of special disorders will be discovered, and that the
correlation of morbid mental and diseased cerebral states will become
more and more complete, that the scientific classification of mental
maladies may be one day based upon pathological as well as clinical
knowledge, and psychology be founded, in part at least, upon our
acquaintance with the functions of the brain. Let us hope, also, even
though it be a hope in the sense rather of desire than of expectation,
that by these discoveries the successful treatment of mental disorders
may be proportionately advanced.
* * * * *
I would now turn to the very important question whether the treatment
of the insane has advanced since 1841?
Of course, so far as this includes moral treatment and management, it
has advanced in all civilized countries in a manner calculated, all will
admit, to cause the liveliest feelings of satisfaction. Putting aside
_moral_ treatment, we cannot boast, it must be confessed, of the same
unanimity of judgment. If, however, it must be admitted that as respects
details, _Tot capita, tot sensus_, it will be allowed that,
notwithstanding the so many heads, and the as many opinions, the general
principles of treatment based upon a just view of the general pathology
of insanity, are accepted by all. There were too many who, forty years
ago, bled freely for mania, and I remember Conolly, at even a later
period, complaining of the number of patients brought to him hopelessly
demented in consequence of the heroic treatment to which, when maniacal,
they had been subjected by men who, no doubt, still believed with
Paracelsus when he said, "What avails in mania except opening a vein?
Then the patient will recover. This is the arcanum. Not camphor, not
sage and marjoram, not clysters, not this, not that, but phlebotomy."
Well, this treatment by the Paracelsuses of 1841 has been supplanted by
the more rational therapeutics which we witness in 1881.
Dr. Stokes, the highly respected superintendent of the Mount Hope
Retreat, Baltimore, thus writes in his last annual report: "Forty years
ago, when this institution was opened, large blood-lettings--in the
standing, recumbent, or sitting posture, to the amount of thirty or
forty ounces--were recommended in acute mania, followed up by local
depletion, by leeches, to the number of twenty or thirty, to the
temples. The moral treatment, hygienic measures, exercise, and suitable
occupation were almost wholly ignored. Drastic purgatives, ... the
shower bath, large and frequent doses of tartarized antimony, and
mercury to the extent of producing ptyalism, were the most popular
remedial agents in the treatment of insanity. This, in general terms,
was the system advocated and practised when, forty years ago, this
institution entered upon its godlike mission."
If the success of the treatment of insanity bore any considerable
proportion to the number of the remedies which have been brought
forward, it would be my easy and agreeable duty to record the triumphs
of medicine in the distressing malady which they are employed to combat.
But this, unhappily, is not the case. Hypodermic injections of morphia,
the administration of the bromides, chloral hydrate, hyoscyamine,
physostigma, cannabis indica, amyl nitrite, conium, digitalis, ergot,
pilocarpine, the application of electricity, the use of the Turkish bath
and the wet pack, and other remedies too numerous to mention, have had
their strenuous advocates during late years. Each remedy, however, let
us hope, leaves a certain residuum of usefulness behind it, though
failing to fulfil all the hopes raised on its first trial.
Dr. Ramskill lately avowed his opinion in my hearing that the advent of
the bromide has done infinite mischief. Others, attacking chloral, would
maintain that while the bromide has slain its thousands, chloral hydrate
has slain its tens of thousands. In spite of this, however, Dr.
Ramskill, doubtless, continues to employ the bromide; and who would wish
to be deprived of chloral, or any other drug, because of its abuse?
"For nought so vile that on the earth doth live,
But to the earth some special good doth give;
Nor aught so good, but strained from that fair use,
Revolts from true birth, stumbling on abuse."
Employed without discrimination, regarded as a talisman in insomnia and
excitement--petted, in short, when it ought to have been
restrained--chloral became for a time the spoilt child of psychological
medicine, and, like other spoilt children, it has disappointed the fond
hopes of its parents.
When it is possible for a physician in asylum practice to write as Dr.
Pritchard Davies has written this year in our _Journal_, "On Chemical
Restraint," to the effect that chloral, the bromides, and other
sedatives are unnecessary, or even injurious; when, on the other hand,
we have Dr. Hills replying that his experience at the Norfolk Asylum
leads him to an entirely opposite conclusion; and Dr. Stokes, in
America, writing thus in his report, after 7425 patients have been under
treatment in his asylum, "without wishing to undervalue the great
importance of an efficient system of moral treatment, great results can
only be expected from a patient and persevering administration of
powerful remedial agencies"--I say when such contrary opinions can be
expressed by practical men, one feels how impossible it is to dogmatize
upon the good effected by pharmaceutical remedies in insanity, and how
far we are yet from witnessing a consensus of opinion in regard to their
value.
It must be frankly granted that Psychological Medicine can boast, as
yet, of no specifics, nor is it likely, perhaps, that such a boast will
ever be made. It may be difficult to suppress the hope, but we cannot
entertain the expectation, that some future Sydenham will discover an
anti-psychosis which will as safely and speedily cut short an attack of
mania or melancholia as bark an attack of ague.
Rather must we rest satisfied with the general advance in treatment in a
scientific direction. Most of us know asylums where, within forty years
and much less, tartarized antimony was in daily use in large doses as a
quietus, and where croton oil was administered in addition to black
draughts to a surprising extent, all these remedies being now employed
only on the rarest occasions. Take an actual example, one of many, in a
particular asylum. A few years ago a patient, who had been much excited
and very troublesome, was treated in season and out of season with
strong purgatives and sedatives. It so happened that he then fell under
a new _regime_, which consisted in knocking off all these medicines and
placing him under one attendant's entire supervision. The result was
that he became as quiet and docile, though not cured, as any of the
inmates of the asylum, and has remained so to the present time. But we
may go further, and say that some cases of insanity are cured now which
a few years ago would have remained uncured. Indeed, in relation to the
associated bodily state, it may be said that specific treatment has been
adopted. Remedies, like iodide of potassium, in large doses, are
employed in cases in which, from the increased attention directed in
recent years to the somatic aetiology of insanity, a causal relation
between the physical and mental condition has been recognized, and the
mental symptoms have disappeared in the most marked manner; and so again
in gouty melancholia, relief has been obtained by appropriate remedies
and diet. These are illustrations of the directly scientific application
of medicine to medical psychology, and it is in this direction we must
hope for a really satisfactory advance.
On the other hand, there are the successes obtained by the employment of
drugs without our being able to say why or how they have exerted a
curative agency; and it is obvious that as the number of drugs has so
much increased during the period over which my survey extends, the
chances of hitting on the right remedy are proportionately increased.
How often we see one, two, or three drugs exhibited in mania without any
result, while a fourth acts like a charm. Only by studying in detail the
special characteristics of each case, can we hope to find a clue which
will serve as a guide to the treatment of a subsequent one.
In this country, Dr. Clouston has distinctly advanced our knowledge of
the action and uses of narcotic remedies by experiments made to
determine the effect on maniacal excitement of single doses of certain
remedies, stimulants, and food; of, again, the effect on mania of
prolonged courses of certain narcotic medicines, along with clinical
observations on the effects of the same medicines in all kinds of
insanity, and has determined the equivalent value of opium, bromide of
potassium, and cannabis indica in the treatment of insanity.
Dr. Savage has experimented with one drug at a time on a number of
patients, and has already given to the profession some valuable results
in "Guy's Hospital Reports," and the _Journal of Mental Science_. "The
West Riding Asylum Medical Reports" of Dr. Crichton Browne also contain
some important experiments with drugs by himself and others; and in this
connection I would notice the excellent clinical notes issued from time
to time by Dr. Williams and other officers of the Haywards Heath Asylum,
which are well worthy of more permanent record in the archives of the
Association. I cannot, indeed, understand any one seriously maintaining
that we are practically no better off in our medicinal resources now
than we were forty years ago.
Whatever differences of opinion may exist in regard to the advantages
gained by the introduction of new drugs, one thing is clear, that the
employment and, let me add, the repose of patients, well-ordered
arrangements, and the tact of the superintendent will oftentimes do more
to reduce the amount of excitement and noise in an asylum than tons of
chloral and bromide. For example, any one who has visited Hanwell knows
that Dr. Rayner anticipates and prevents post-epileptic mania to a very
large extent by the simple expedient of keeping patients in bed after
their fits, just as he finds forced alimentation of patients rarely
necessary when rest is resorted to. It is striking to see how, even in
an over-grown asylum and an old building, the results of good management
and treatment can be highly satisfactory, and worthy of an institution
of such historic fame.
* * * * *
But, after all, the question faces us, are there or are there not more
insane persons cured in 1881 than in 1841?
One's first impulse, of course, is to take the statistics of recovery
for a certain number of the more recent, and compare them with those of
the earlier years, or to take the recoveries of the past forty and place
them side by side with those of the previous forty years. The attempt,
however, is fraught with so many fallacies that it is dangerous to make
such a comparison. In a report of Bethlem Hospital, issued in 1841, Sir
Alexander Morison stated--not as anything exceptional--that seventy per
cent. of the patients had been discharged cured; while an examination of
the recoveries at this hospital for the last ten years shows a much
smaller proportion per cent. But I cannot accept these comparisons as
proving anything one way or the other, as various causes, quite apart
from the comparative success of treatment at different periods, may
explain the difference. Take a single asylum, like Hanwell, and compare
the recoveries of a later with an earlier period. I find a population so
fluctuating in character, in regard to curability, that the comparison
becomes utterly worthless, and although it is true that during the last
quinquennium 28.1 per cent. have recovered, as against 26.3 per cent.
during the first quinquennium of the past forty years, in spite of there
having been more incurables received during the later period, the result
is not so satisfactory when we divide into certain periods the whole
time during which Hanwell has been open (omitting the first four years).
It then appears that during two previous periods the recoveries were
higher than 28.1 per cent., viz. from 1840 to 1849 and from 1865 to
1874. Thus:--
1835-39 (inclusive) 25.3
1840-49 28.5
1850-54 25.2
1855-64 27.9
1865-74 30.4
1875-79 26.3
Or in quinquennial periods throughout:--
1835-39 (inclusive) 24.8
1840-44 26.3
1845-49 32.1
1850-54 25.2
1855-59 30.7
1860-64 27.0
1865-69 30.4
1870-74 30.5
1875-79 26.3
If to escape the fallacies connected with the comparison of different
periods of the same asylum, we go to the Lunacy Blue Books, we do not
get any reliable figures before 1870, on account of transfers having
been previously included in the admissions, so that a fair comparison
of recent and former recoveries worked on the admissions is impossible.
I have before me the statistics of the Siegburg Asylum, thanks to Dr.
Ripping, from its opening to its close; and I find that the recoveries
during the first twenty-five years amounted to forty-two per cent., and
during the twenty-five years ending with the year 1877, they were
forty-six per cent., thus showing an increase of four per cent. in the
more recent period. As this asylum, now closed, has admitted curable
cases only, these figures are among the few valuable statistics which I
have been able to procure.
I have not succeeded in obtaining satisfactory comparative results by
adopting, in the mixed asylums of England and Wales, the plan of working
the recoveries, not on the total admissions, but on those only deemed
curable; but to explain this fully would involve me in more detail than
the occasion warrants.
I would add that in the United States, where reasons have been assigned
why the statistics of asylums exhibit apparently fewer recoveries in the
later than the earlier period of the last forty years, Dr. Pliny Earle
has done good service by the remarkable contribution he has made to the
question of the curability of insanity,[312] corroborating, at the same
time, the somewhat unfavourable conclusion as to permanent recovery
which Dr. Thurnam, in a work which will always be a Pharos to guide
those who sail on waters where so many are shipwrecked, arrived at,
after a laborious examination of the after history of cases discharged
recovered from the York Retreat. It is likewise anything but reassuring
to find that, out of the total number of lunatics under care in England
and Wales, there are at this moment only 3592 who are deemed
curable.[313]
* * * * *
Such, gentlemen, is my Retrospect of the Past. Meagre it has necessarily
been, though occupying more of your time than I could have wished, but
the number of subjects demanding reference must be my excuse.
We found, at the commencement of the period we have traversed, the
accommodation provided for the insane scandalously insufficient, and the
condition of many of the existing asylums calling loudly for a radical
reform.
We witness to-day, throughout the kingdom, a large number of
institutions in admirable working order, reflecting the greatest credit
upon their superintendents and committees.
We found a wholly inadequate system of inspection.
We witness now a Board of Commissioners, which, without forfeiting the
good will of the superintendents, carefully inspects the asylums
throughout the provinces as well as the metropolis--as carefully and
thoroughly, at any rate, as the same number of men originally appointed
to examine into the condition of some 20,000 patients can fulfil a like
duty for above 70,000.
We found a resolute attempt being made to carry out and extend the
humane system of treatment inaugurated nearly half a century before in
France and England.
To-day we witness its success.
And had I had time to sketch the progress in the provision made for
criminal lunatics, we should have found that just forty years ago was
the commencement of what Dr. Nicolson has named the "Reactionary
Period"--during which this Association petitioned the Government (in
1851) to establish a criminal lunatic asylum--followed in 1860 by the
"Period of Centralization" or that of Broadmoor--an institution to-day
so efficiently superintended by Dr. Orange.
And in what consists the superiority of the new over the old system of
treatment--the nineteenth over the eighteenth century?
The old system was mainly one of brute force--the child alike of
ignorance and fear.
The new does not indeed dispense with force, but it is a maxim of the
reformed school, from which no one, whose opinion carries weight in
psychological medicine, whether in America or in Europe, would dissent,
that it should be reduced to the lowest possible point, consistent with
safety and the good of the patient, and that humanity should dictate the
means of repressing, or rather guarding against, violence, both as
regards their amount and character.
The old system subjected patients, who underwent any medical treatment
at all, to a miserable routine, often determined by the season of the
year and the phases of the moon, rather than the condition of the
patient.
The new does not pretend to possess a universal formula, or to have
discovered the psychologist's stone, but strives to treat each patient
according to individual indications.
The old system desired secrecy; the new is not afraid of publicity.
The old system, in short, believed in harshness and darkness; the creed
of the new is, "I believe in sweetness and light."
Such are the results achieved for Psychological Medicine.
* * * * *
If this be the Retrospect of the Past, what is the Prospect of the
Future? Will the progress of the last forty or the last ninety years be
maintained? I trust it will, but one need not be a pessimist to be
sensible that the humane treatment of the insane may have its ebb as
well as its flow; that so far from its being true that there is a
constant and certain tendency to humanity, there is also a strange
tendency to relapse into inhuman ways. Vigilance is and always will be
required, for if it be allowed to slumber, we but too well know that
there is only one direction in which things will go when left to
themselves--and that is downhill.
The functions--the mission--of this Association may be regarded from a
threefold point of view: first, in relation to insanity and the insane;
secondly, in relation to its members; thirdly, in relation to the
public.
I.--Under the first are comprised what in the original rules, drawn up
by the founders of this Association forty years ago, were stated to be
its objects, namely, "Improvement in the management of asylums and the
treatment of the insane;" and further, "The acquirement of a more
extensive and more correct knowledge of insanity."
Added to the improved management of asylums is the necessity now for
making appropriate provision for idiots and imbeciles, and their
education so far as practicable, grappling at the same time with the
problem how best to provide for the mass of incurable pauper patients in
the provinces, and the extension of middle-class asylums, and of
cottages in connection with the central institution.
There are, of course, various ways in which the welfare of the patients
in asylums can be promoted, by the attention directed by the Association
to special points of importance. To instance only one, the occupation of
patients, including systematic teaching which Dr. Lalor has so
successfully developed in the Richmond Asylum, Dublin. Though very much
has been done, there is, all, I think, will agree, room for more
sustained effort in this direction. "There is one monster in the
world--the idle man," are the words of one who has lately passed beyond
the reach of praise or blame, which ought ever to be in the minds of
those who direct our asylums. It may be that if more were done in
future in the spirit of this apophthegm of the Sage, if not the Saint,
of Chelsea, there would be less chance of patients chewing the cud of
bitter reflection and dwelling upon the delusions by which they are
haunted and harassed.
In proportion as we feel the inadequacy of our means of cure, we must
recognize the necessity of studying the aetiology of insanity, including
that _damnosa haereditas_, which is the cause of causes in so large a
number of the cases coming under our treatment. But what induced the
ancestral taint? It behoves us to pay more and more attention to those
laws of inheritance in general to which Mr. Hutchinson has recently
directed attention in his suggestive lectures at the College of
Surgeons.
When M. Baillarger proposed that a similar association to this should be
established in France, he gave, among other reasons, the advantage which
would accrue from discussing this very question. "Every one," he said,
"is assuredly decided upon the influence of heredity in the production
of insanity (Mr. Buckle had not then written); but in this primary
question, how many secondary ones there are which remain unsolved."
Since he thus wrote, his own countrymen, Morel and Lucas, have, by their
researches, advanced our knowledge, and rendered the task of their
successors in the same field easier.
Intemperance also, as a cause as distinct from a symptom of insanity,
requires to be more thoroughly examined into, and I am happy to say Dr.
Hayes Newington, than whom no one could be better fitted for the task,
has prepared a series of questions arranged in a tabular form, which
has been before the Statistical Committee, and will appear in the
_Journal_.
Again, there remains for the future the continued research into the
causal connection between certain mental symptoms or disorders and
accompanying lesions of the brain and cord. Dr. Spitzka, of New York, in
the prize essay which he is about to publish, enters carefully into this
inquiry, and I am hopeful that his industry and talent will be rewarded
by marked success. These and kindred investigations might, no doubt, be
pursued in a more methodical manner than is always the case in English
asylums. To this end, the appointment of a pathologist, as at Wakefield
in our own country, and at the Utica Asylum in America, ought to become
general.
Clinical teaching in our asylums admits of much greater development,
though they may not be able to meet the demands made upon them, should
examinations be required in medical psychology by the examining bodies.
To-day the student has fortunately a very different position from that
which fell to his lot forty years ago. He has at his command means of
research then unknown, as the ophthalmoscope and sphygmograph, and all
the modern improvements in the microscope and in preparing sections; and
can he not experiment on knee jerks, and a host of reflex and electric
phenomena never dreamt of by his predecessors? He has, moreover, the
stimulus begotten of the sense that enough has been discovered to
indicate how much precious treasure lies hidden beneath the ground he
now treads, like the gold-digger whose ardour is quickened and labour
repaid by the discovery of the minutest particle of the metal of which
he is in search.
II. The second relation in which this Association stands--to its
members--suggests that we must needs be alive to legislation affecting
the rights of those who are engaged in this department of medicine. This
association is not a trades union, but there are various points bearing
on their position which have to be considered, as in connection with a
Bill like Mr. Dillwyn's, or the matters discussed two years ago at the
annual meeting, when brought forward by Dr. Murray Lindsay. It is true
that for him who has taken mental science, in its widest sense, as his
mistress; for him who has wooed her for her own sake, knowing full well
that for him she may hold no dowry in hand or pocket, there is the
supreme pleasure arising from study and observation themselves--that
recompense which is better than gold, and more precious than rubies. All
this is true; but none the less the superintendents of asylums have a
right to expect not only that their services shall be adequately
remunerated when in harness, but that they may count with certainty upon
a fair provision in the evening of life.
III. With regard, thirdly, to the influence of this Association on
public opinion, we should be strangely faithless to our mission, if we
were not the expositors of the principles in accordance with which the
insane ought to be regarded; if we did not endeavour to enlighten the
community in the doctrines of true psychological science, and in that
philanthropy which is as far asunder as the poles from the fitful
pseudo-philanthropy from which our country is unfortunately not free,
the wild, ill-regulated, hysterical clamour with which we are
epidemically visited, as injurious to the lunatic as it is to the
interests of society at large.
This Association, further, ought to continue to bring before the lawyer
what it regards as the just test of criminal responsibility; to entreat
the educator not to defeat the object of his noble profession by
exactions which transgress the limits by which Nature has bounded human
capacity; and to warn parents, as Dr. Brigham did in his day with so
much zeal, of the dangers to mental health arising from precocious
forcing during the early growth of the brain, and with a tenfold greater
necessity than when he wrote, in presence of the illimitable folly of
examining boards, some of them medical, the members of which have not
even the poor excuse of ignorance; and last, but not least, to counsel
the teacher of religion against the peculiar dangers which attend his
exalted mission, remembering that--
"Virtue itself turns vice, being misapplied."
Various, then, are the functions of our Association. But what, asks the
late Sir James Stephen, the eloquent writer in the _Edinburgh_ is a
party, political or religious, without a Review? and he replies, "A bell
without a clapper." Such a bell would this Association have been without
its _Journal_, and it must gratefully attribute much of its success to
the ability with which in the first instance Dr. Bucknill, and
subsequently Drs. Robertson, Maudsley, Sibbald, and Clouston, have
helped to make an otherwise clapperless bell articulate.
Through this organ of the Association, for which, speaking for my
colleague and myself, I would venture to ask your loyal co-operation,
much scientific work can be brought before the profession, many
questions can be systematically discussed, and the invaluable experience
of the superintendents of asylums on practical points be presented to
its readers and permanently preserved.
The objects I have mentioned as calling for further attention, and many
more, belong to the future of Psychological Medicine, and as I began my
address with proposing to review the period bounded by the years 1841
and 1881, I will close it with expressing the hope that when a successor
of mine in this office reviews the then vanished period between 1881 and
1921, he will be able to report an accelerated ratio of progress
compared with that of the time I have attempted, so inadequately, to
survey.
And may the Medico-Psychological Association, which I trust will always
be identified with this progress, be about to enter, after its
wanderings, "forty years long," a land flowing with milk and honey, won
by conquests over ignorance, superstition, and cruelty--the triumphs of
the application of humanity and medical science to the relief of mental
weakness and suffering.
FOOTNOTES:
[292] Presidential Address, delivered at the Annual Meeting of the
Medico-Psychological Association, held at University College, London,
August 2, 1881.
[293] I here do homage to the dead. Calmeil, Baillarger, and Brierre de
Boismont still live, at an advanced age. (Since this address was given,
the last named has died. See eloquent tribute to his memory by M. Motet,
in _Journal of Mental Science_, April, 1882.)
[294] As will be seen by the history of lunacy reform contained in this
volume, Lord Shaftesbury's interest in the movement extends back as far
as 1828.
[295] _American Journal of Insanity_, April, 1855.
[296] 9 Geo. IV., c. 40.
[297] Amended by 18 and 19 Vict., c. 105 (1855). Acts referring to
Lunacy Commissions and Chancery Patients, 16 and 17 Vict., c. 70; 25 and
26 Vict., c. 86 (1862).
[298] If parts of workhouses, etc., be included, 166. See p. 211.
[299] I should find it difficult to point to a more striking
illustration of these remarks than the good work being done at the
Lenzie Asylum by Dr. Rutherford.
[300] "On the Construction, Organization, etc., of Hospitals for the
Insane," by Thomas S. Kirkbride, M.D., LL.D. (Philadelphia, 1880), p.
300.
[301] On the large degree to which patients, as shown by the experience
of the Chancery Visitors, can be treated satisfactorily outside asylums,
see pp. 261 and 286; also Dr. Bucknill's trenchant little book, "Care of
the Insane and their Legal Control," 1880.
[302] "Ideal Characters of the Officers of a Hospital for the Insane,"
by I. Ray, M.D. Philadelphia, 1873.
[303] See Dr. Baker's Annual Reports of the York Retreat, and Dr. Rees
Philipps's last Report of the Wonford Asylum, Exeter, etc., etc.
[304] "A Treatise on the Nervous Diseases of Women," by Thomas Laycock,
M.D., 1840, chapter ix. p. 107.
[305] _British and Foreign Medical Review_, January, 1845, p. 311.
[306] "Remarks on Insanity, its Nature and Treatment," p. 14.
[307] "I agree with Mr. Martineau in repudiating the materialistic
hypothesis as utterly futile."--Herbert Spencer, _Contemporary Review_,
June, 1872.
[308] "Die Freiheit der Wissenschaft im Modernen Staat," by Rudolf
Virchow. Berlin, 1877.
[309] Preface to his work on Mental Alienation, p. 20.
[310] "General Paralysis of the Insane," by Wm. Julius Mickle, M.D.,
M.R.C.P. London, 1880.
[311] Among the groups of cases in which they were more decidedly
present is that comprising many due to syphilis; that in which
degenerative changes follow upon haemorrhagic softening, and another in
which they succeed to occlusion of vessels and its immediate results. In
another, degeneration and atrophy follow, the brain state conditioning
acute insanity; and in another they are secondary to brain injury, not
to mention many other groups.
[312] In the same department the services of another American alienist,
Dr. Edward Jarvis, ought not to be forgotten. Among other works, his
Report on the Idiotic and Insane in Massachusetts, 1854, was of great
value.
[313] It is a remarkable fact, showing the mass of incurable cases
which have accumulated, that the number of curable cases now is only
about 1000 more than it was in 1844 (2519).
CONCLUSION.
In completing the task which the author has attempted in the foregoing
chapters in the History of the Insane in the British Isles, he is only
too conscious that, in the endeavour to be concise as well as
comprehensive, he has made many omissions. With every desire to be fair
to all who have been engaged either in originating or in advancing the
improved treatment of those who, suffering cruelly from a malady
involving their very nature and being, have also been treated cruelly by
their fellows, the writer fears that some names which ought to have been
recorded and some institutions which ought to have been honourably
mentioned, have been passed over in silence. Apart from unintentional
oversight, it is not always easy to find in the Temple of Fame the
precise niche in which to place the figure that would rightfully fill
it, and the consequence is that the pedestal, as in some of our great
public edifices, remains unoccupied. It may be said, however, in
extenuation of any such omission, that it did not fall within the scope
of this book to chronicle all the establishments which, in more humane
methods of treatment, have been in advance of others, still less to
complete the history up to the present day of those which have been
mentioned. As it proceeded, the work has entered more into detail than
was originally designed; thus, in the chapter on Scotland the sketch is
filled in with particulars somewhat out of proportion to that attempted
in the earlier chapters.
Again, in crediting various asylums, as Lincoln, Hanwell, and Lancaster,
with introducing non-restraint, the author has not found space for more
than a reference to the meritorious course pursued at an early period at
the Suffolk Asylum, the Gloucester Asylum, and at Northampton from its
opening (1838), and at the Haslar Hospital.[314]
The writer would have been glad, had the proposed limits of the book
admitted of it, to describe much more fully the rise and growth of those
charitable institutions, the endowed or registered hospitals for the
insane, which have in England formed so important, and, on the whole, so
successful, an experiment in providing care and treatment for the insane
of the poor but non-pauper class, supplemented as they have been by the
payments of the rich. At the present moment, the principle and the
method by which these institutions are governed attract much earnest
attention, and appear to not a few to afford the best alternative
provision for the middle and upper classes, as against asylums carried
on by private enterprise. It may be so. Abuses which in former days were
possible, could not occur under the legislative restrictions of our
time; but it must not be overlooked that their annals have disclosed,
in some instances, abuses as great and inhumanities as shocking as any
that have disgraced the history of private houses. How abominably even
such institutions have been managed, has already been depicted in a
notorious example; how admirably, might have been shown, had space
allowed, as regards the same institution in the hands of men who, like
Dr. Needham, have maintained the reforms previously introduced within
its once dishonoured walls, and carried forward that humane system of
treatment which, Phoenix-like, arose from its ashes. The author would
have liked to do justice to other hospitals--as that at Northampton,
which under Dr. Bayley's remarkable power of organization has proved so
great a success; that at Cheadle, which under Mr. Mould's exhaustless
energy has shown how the various needs of different phases of mental
disorder may be met by various modifications in the provision made for
their care outside the walls of the asylum, thus combining cottage
treatment with the control of the central establishment; and, lastly,
that at Coton Hill, Stafford, which now and for many years has been
superintended by Dr. Hewitson--an institution due to a wave of public
feeling in favour of an institution for those in reduced circumstances,
which bore this practical fruit after some temporary discouragement.
Of the work done by county asylum superintendents it is impossible to
speak too highly; in fact, it would be difficult to know when to stop,
were one to be mentioned. Superintendents of the vast asylums of
Middlesex, Lancashire, and Yorkshire deserve the recognition of
services performed day by day with faithful diligence, not always
sufficiently appreciated, and not always without peril, as instanced in
the case of the late superintendent of Brookwood, Dr. Brushfield.[315]
As of those whose hourly labour is performed in these and other
institutions, so of those who were labourers, however humble, in the
early days of asylum reform at the close of the last and the beginning
of the present century, it must never be forgotten that work unobserved
by the public eye, but conscientiously performed for the unfortunate
class which, to a large extent, is unable to appreciate or thank the
kindly hand which shields them from cruelty or saves them from neglect,
will find its reward in the conscience; and also in the increased
happiness of those whom it benefits, though it may not set the worker on
any pinnacle of fame. It is to such that the author of "Romola" refers
when speaking of the "valiant workers whose names are not registered
where every day we turn the leaf to read them, but whose labours make a
part, though an unrecognized part, of our inheritance, like the
ploughing and the sowing of past generations."
FOOTNOTES:
[314] See Report of the Metropolitan Commissioners. 1844.
[315] Since the above was in type, another example has occurred in the
case of Dr. Orange, who has been assaulted by a criminal lunatic, and
narrowly escaped serious injury.
APPENDIX A.
(Page 61.)
In addition to the maps of Ralf Agas (cir. 1560?) and Braun and
Hogenberg (1572), there is an earlier view of London and Westminster by
Anthony van der Wyngrede, 1543, in the Bodleian Library, Oxford, but it
is worthless for the purpose of tracing the outline of Bethlem. No
additional light is thrown on the buildings by the view of London and
Westminster in Norden's "Speculum Brittanniae," engraved by Pieter van
dem Keere, 1593. It appears to be agreed that, whatever the date or
designer of the so-called "Agas" may be, it is "the earliest reliable
survey of London." Virtue's reprint is dated 1737. Mr. Overall's
"Facsimile from the original in the possession of the Corporation of the
City of London" was published in 1874. It is, however, only by a careful
study of the original with a magnifying glass and a good light, that the
outline of the Bethlem buildings can be made out.
Smith, in his "Topography of London" (1816), p. 36, says that the only
plan of London showing the first Bethlem which he had been able to meet
with is that by Hollar. This map showed Moorfields divided into
quarters, with trees surrounding each division, the site of the second
Bethlem being then an uninterrupted space, and a cluster of five
windmills standing on the site of the north side of Finsbury, a part of
which in Mr. Smith's memory was called Mill Hill. Hollar's rare map
(1666 or 1667) is so much later than Agas, that we have not followed its
distribution of the buildings. In Faithorne's map, published a few years
earlier (1658), from a survey in 1640, "Bedlame" is represented as a
quadrangle, with a gate in the wall on the south side. There is a very
clear outline of the first Bethlem in Lee and Glynne's map of London (in
Mr. Gardner's collection), published at the Atlas and Hercules, Fleet
Street, without date. This map is also in the British Museum. Mr. Coote,
of the Map Department, fixes the date at about 1705. Rocque's map of
London (1746) shows Bethlem distinctly. This map, and Ogilby's, formed
the basis of Mr. Newton's "London in the Olden Time," 1855.
With regard to the story of the skeleton in irons and Sir T. Rowe's
burying-ground, mentioned at p. 49, it is not disputed that he was
concerned in the burying-ground of Bethlem; but the skeleton appears to
have been found some distance from this spot. What is stated in Strype's
"Stow" (Bk. ii. p. 96, edit. 1720), is that in 1569 "Sir Thomas Rowe
caused to be enclosed with a wall about one acre, being part of the said
hospital of Bethlem, to wit, on the west, on the bank of Deep Ditch,
parting the hospital from Moorfields. This he did for burial in case of
such parishes of London as wanted ground convenient within their
parishes. This was called New Churchyard near Bethlem."
There are some very fine prints of the _second_ Bethlem Hospital in the
Print Room of the British Museum. Of these (to which Mr. Crace's
collection is a recent valuable addition), and the prints in Mr.
Gardner's private collection and the Guildhall Library, the following
list has been prepared. I have again to thank Mr. Gardner and Mr. Coote
for their assistance. I have also to thank Mr. Crace for allowing me to
see his prints before they were removed to the British Museum.
VIEWS OF BETHLEM HOSPITAL.
1. Inscribed "Hospitium Mente Captorum Londinense. Frontispicium
Hospitii (vulgo Bedlam dicti) mente captis destinati, sub auspiciis
colendissimi viri Gulielmi Turner Equitis aurati Senatoris non ita
pridem Praetoris Londini Praesidis dignissimi nec non Beniamini Ducane
Armigeri Thesaurarii fidelissimi; caeterorumque ejusdem Hospitii
Gubernatorum A.D. MDCLXXV mense Aprili fundati, anno sequento mensi Juli
consummati." R. White sculp. Printed by John Garrett, 1690. 47 in. by
22-1/2 in. Crace Collection, 26/3; Guildhall Library.
2. A New Prospect of y{e} North Side of y{e} City of London, with new
Bedlam, and Moorefields (showing New St. Paul's). 1710. 58 in. by 22-1/2
in.
This print is a later edition of one by J. Nutting, 1689, in which old
St. Paul's is shown. Crace Collection, 26/1.
3. On a scroll, "Hospitium mente captorum Londinense." New Bedlam in
Moorefields. Soly fec. Sold by H. Overton, cir. 1730. 22-3/4 in. by
16-1/2 in. Gardner Collection; British Museum.
4. Painting of Bethlem Hospital (fresco) in one of the rooms of the
Foundling Hospital, by Haytley. 1746.
5. The Hospital of Bethlem (L'Hospital de Fou). A view showing also
Moorgate. J. Maurer del.; T. Bowles sculp. 1747. 16 in. by 10-1/2 in.
Gardner Collection; Crace Collection, 26/6; Guildhall Library.
6. Hospital of Bedlam. Smaller copy of Bowles's print. Gardner
Collection.
7. Interior of Bedlam, by Hogarth. 1735. Gardner Collection.
8. Bethlehem, a Poem, with a view of Bethlehem. By J. Clark. 1749.
9. Bethlehem in Moorfields. 1752. By B. Cole.
10. The Hospital called Bedlam. 1754. Gardner Collection.
11. View of Hospital of Bethlehem. 6 in. by 10 in. Robert Sayer, cir.
1760.
12. Visit to Bedlam. R. Newton. 1794.
13. Mezzotint of Bethlehem, by Malton. 1798. 11 in. by 9 in.
14. Bethlem Hospital as it appeared in 1811 (proof). Arnold del.;
Watkins sculp. Guildhall Library.
15. London Wall and Bethlehem Hospital. Etching by J. T. Smith. 1812.
16. South-west View of Bethlem Hospital and London Wall, 1814. Smith
del. et sculp. Guildhall Library.
17. Two clever water-colour drawings of Bethlem. Gardner Collection.
18. Water-colour drawing of gate with the recumbent figures by Cibber.
Richardson. Gardner Collection.
19. The two figures on the pediment of the gate by Cibber. Stothard
del.; Sharp sculp. 1783. Guildhall Library.
20. The same. Burell sculp. 1805. 6-1/2 in. by 4-1/2 in. Crace
Collection.
21. The same engraved by Warren in Hughson's "London," vol. iii. p. 81.
Gardner Collection.
22. A portrait of William Norris as confined in Bethlem Hospital. Arnold
fec. 1814.
23. New Bedlam in Moorfields, 6-1/2 in. by 9-1/2 in., and another 5-1/2
in. by 6-1/2 in. No date or name of artist. Gardner Collection.
24. Das Narren Hospital Bethlehem. Dutch print. No date. Gardner
Collection.
25. Plan of Moorfields and Bethlem Hospital. Gardner Collection.
26. New Bedlam in Moorfields. 10-1/2 in. by 7 in. Very early view. No
date. Gardner Collection.
27. The New Prospect of Bedlam, Moorfields. By John King. 10 in. by 4
in. No date (costume cir. Will. III.).
28. The Hospital of Bethlehem. 9 in. by 14 in. No date. Gardner
Collection.
29. Curious and quaint drawing of Moorfields and Bethlehem. 13 in. by 21
in. Gardner Collection.
30. Bethlehem Hospital, by Toms. 7-1/2 in. by 15. Gardner Collection.
31. Three views. Hospital de Bethlem; New Bedlam; Bethlehem. Gardner
Collection.
32. Bethlehem in St. George's Fields. Ground Plan of New Bethlem
Hospital. Basire sculp. 1819. This, with five other views by Shepherd,
etc., are in the Guildhall Library.
VIEWS OF ST. LUKE'S.
1. "Enthusiasm displayed." The Rev. John Whitfield preaching under a
tree in Upper Moorfields, with view of "St. Luke's Hospital for
Lunaticks" in the background. J. Griffiths pinx.; R. Tranker sculp.
1750. 19-3/4 in. by 15 in. Gardner Collection; Crace Collection, 33/19.
2. Elevation of St. Luke's Hospital in a pamphlet entitled "Reasons for
the Establishing, etc., of St. Luke's." 1765. Guildhall Library.
3. Another elevation. J. Dance arch. et sculp. 1784. 15 in. by 4-1/2 in.
Gardner Collection; Crace Collection, 33/15.
4. Front view of the New St. Luke's Hospital, lately erected in the City
Road. Deeble del. et sculp. 1785. Gardner Collection; Guildhall Library.
5. St. Luke's Hospital, Old Street Road. A coloured print from a drawing
by F. A. Shepherd. 1814. 8 in. by 5-1/4 in. Original drawing in the
Gardner Collection; Crace Collection, 33/16.
6. Lunatic Hospital of St. Luke's. Aquatint. Gardner Collection.
7. Front View of the New St. Luke's Hospital. No date. Gardner
Collection.
8. Ditto. Ditto. 15 in. by 5 in. Gardner Collection.
9. Sepia drawing of St. Luke's. Gardner Collection.
10. Two original drawings by John Carter. Gardner Collection.
11. Lunatick Hospital of St. Luke, published by Ackermann. 1815.
Gardner Collection; Guildhall Library.
12. St. Luke's Hospital, Old Street Road. Shepherd del.; Sands sculp.
1815. Gardner Collection; Guildhall Library.
13. St. Luke's Hospital. Higham del. et sculp. 1817. Guildhall Library.
14. Lunatic Hospital, St. Luke's. S.W. view. T. H. Shepherd del.; J.
Gough sculp. 1837. 5-3/4 in. by 3-1/2 in. Gardner Collection; Crace
Collection, 33/18.
15. Interior of St. Luke's. Rowlandson and Pugin del. et sculp.; Stahler
aquat. 1809. Gardner Collection; Guildhall Library.
APPENDIX B.
(Page 142.)
In reference to the writers on insanity at the close of the eighteenth
century, Dr. Pargeter, in the work referred to at p. 142, after dwelling
slightly on the pathology, causation, and nature of insanity, becomes
disheartened and exclaims, "Here our researches must stop, and we must
declare that wonderful are the works of the Lord and His ways past
finding out" (p. 15). Of asylums he says, "The conduct of public
hospitals or institutions for the reception of lunatics needs no remark;
the excellence in the management of them is its own encomium" (p. 123).
Of private madhouses under the management of regular physicians, he
ventured to say that "people might securely trust that in them the
afflicted would be judiciously and tenderly treated, and also managed by
servants selected and instructed with such judgment as will make them as
zealous of their own character and reputation, as of the honour of their
employers. In such hands we may place implicit confidence; and a perfect
assurance that in such an abode dwells nothing offensive or obnoxious
to humanity--here no greedy heir, no interested relations will be
permitted to compute a time for the patient's fate to afford them an
opportunity to pillage and to plunder. But such dwellings are the seats
of honour, courtesy, kindness, gentleness, mercy, and whatsoever things
are honest and of good report." Such was the comfortable satisfaction
with which a worthy man in 1792 regarded the condition of the insane in
English asylums in that year. He admits, however, that in private
asylums kept by illiterate persons, compassion as well as integrity is
oftentimes to be suspected, and quotes a passage from a paper written in
1791, which asserts that "if the gaolers of the mind do not find a
patient mad, their oppressive tyranny soon makes him so."
The work written by Dr. Mason Cox (Fishponds, near Bristol) was the best
medical treatise of the day on insanity. Unlike Cullen, he objects to
"stripes" in the treatment of the insane. On the cold bath he says,
"Even so late as Boerhaave we have the most vague directions for its
employment; such as keeping the patient immersed till he is almost
drowned, or while the attendants could repeat the Miserere.... The mode
recommended and so successfully practised by Dr. Currie of Liverpool is
certainly the best, that of suddenly immersing the maniac in the very
acme of his paroxysm; and this may be easily accomplished if the
patient, previously secured by a strait waistcoat, be fixed in a common
Windsor chair by strong broad straps of leather or web girth" (p. 135,
3rd edit., 1813). The author observes that it is certainly worth trying
whether keeping a patient for days in succession in a state of
intoxication would be beneficial, where every other means has failed (p.
75).
APPENDIX C.
(Page 146.)
ASYLUMS IN OPERATION IN 1792.
Bethlem Hospital. Used for lunatics about 1400.
St. Luke's Hospital. Founded 1751.
Liverpool Royal Lunatic Hospital, associated with the Royal Infirmary.
1792.
Manchester Royal Lunatic Hospital, in connection with the Royal
Infirmary. 1706. (Removed to Cheadle, 1849.)
Bethel Hospital, Norwich. 1713.
The Lunatic Ward of Guy's Hospital. 1728. (New building, 1797.)
The York Lunatic Hospital, Bootham. 1777.
St. Peter's Hospital, Bristol. Incorporated 1696.
Brooke House, Clapton (Dr. Monro's). 1759.
Hoxton Asylum. 1744.
Fonthill-Gifford, Hindon, Wilts. 1718.
Droitwich Asylum. 1791.
Belle Grove House, Newcastle-on-Tyne. 1766.
Lea Pale House, Stoke, near Guildford. 1744.
Ticehurst, Sussex. 1792.
The number of lunatics in London and in the country, returned under the
Act of 1774 (14 Geo. III., c. 49), from that year to the projection of
the York Retreat (1792), was 6405; and from 1792 to the Select Committee
of 1815, 12,938.
In 1775 the number registered during the year was 406; and in 1791,
after various rises and falls, it was also 406.
In 1792 the number rose to 491, and in 1815 to 850; the lowest being 414
in 1807, and the highest 700 in 1812.
The above list of asylums shows how scanty was the provision made for
the care of the insane at the time of the foundation of the York
Retreat. I may here add that, in addition to the notice taken of this
experiment by the writers on the Continent mentioned in the text, the
attention of the Germans was forcibly directed to it by Dr. Max. Jacobi,
of Siegburg. He visited York, and, much struck by what he witnessed
there, translated into German the greater part of the "Description of
the Retreat." The late superintendent of the Retreat, Dr. Kitching, who
filled that office for many years with much efficiency, spent a
considerable time at the Siegburg Asylum, comparing notes with Dr.
Jacobi.
APPENDIX D.
(Page 173.)
9 GEO. IV., C. 40 (1828).
The fifteen persons appointed Commissioners in Lunacy for the
metropolitan district, five of whom were physicians, were paid L1 an
hour, and were appointed for one year. They were to meet quarterly for
the purpose of granting licences, those in the provinces being granted
by justices at quarter sessions, where three or more justices were to be
elected to visit the provincial licensed houses, together with at least
one medical Visitor.
Three of the Commissioners were to visit licensed houses in the
metropolitan district four times a year.
Two justices to visit licensed houses in the provinces, accompanied by
the medical Visitor, four times a year.
An annual report was to be prepared and presented to the Secretary of
State for the Home Department.
Private patients were not to be admitted to asylums without the
certificates of two medical men and an order; the certificates being in
force fourteen days before admission.
Pauper patients were not to be admitted without one medical certificate
and the order of two justices, or an overseer and clergyman.
The proprietor of an asylum had to transmit a copy of documents to the
Commissioners or justices, as the case might be.
Single patients to be received on like order and certificates. No
regular visitation of this class instituted.
It should be stated that among the previous Acts, now repealed, there
was a small Act passed May 2, 1815, notwithstanding the failure of Mr.
Rose to induce Parliament to undertake legislation based on the evidence
given before the Committee of that year. This was the Act 55 Geo. III.,
c. 46, entitled, "An Act to amend an Act 48 Geo. III., c. 96 (1808),
being an Act for the better Care and Maintenance of Lunatics being
Paupers or Criminals in England."
The committee of visiting justices of lunatic asylums were to be elected
annually.
Subscribers to lunatic asylums erected by voluntary contributions, who
should unite with any county, might elect a committee of governors to
act with committee of visiting justices.
Justices to fix sums to be expended in purchase of lands, houses, etc.,
or in erecting buildings.
Overseers of the poor to return lists of all lunatics and idiots within
their parishes, verified on oath and accompanied with a medical
certificate.
When any asylum could accommodate more lunatics, magistrate might order
an addition under certain regulations.
APPENDIX E.
(Page 188.)
8 AND 9 VICT., C. 100 (1845).
The following are the clauses of the Act which provide for the expense
of carrying out its provisions.
By this statute it was enacted, after repealing 2 and 3 Will. IV., c.
107; 3 and 4 Will. IV., c. 64; 5 and 6 Will. IV., c. 22; 1 and 2 Vict.,
c. 73; 3 Vict., c. 4; 5 and 6 Vict., c. 87, that the Commissioners in
Lunacy under 5 and 6 Vict., c. 84, should be henceforth called "the
Masters in Lunacy," and that new Commissioners in Lunacy should be
appointed. The Commissioners were to grant licences for the reception of
lunatics within a certain jurisdiction of the metropolis; justices of
the peace in general or quarter sessions licensing houses for the
reception of lunatics and appointing Visitors in all other parts of
England and Wales, including a medical man. For every licence granted a
sum to be paid of ten shillings for every private patient and two
shillings and sixpence for every pauper, or so much more as shall make
up the sum of fifteen pounds, these moneys being applied towards the
payment of the expenses of the Commissioners or any charge incurred by
their authority. The secretary of the Commissioners to make out an
annual account of moneys received and paid by him in the execution of
the Act, to be laid before the Lords Commissioners of the Treasury, the
balance (if any) to be paid into the Exchequer to the account of the
Consolidated Fund, such accounts being laid before Parliament every
year, the Treasury being empowered to pay out of the Consolidated Fund
any balance of payments over receipts which may be necessary. With
regard to the application of moneys received by the clerk of the peace
for provincial licences, they were to be applied towards the payment of
the clerk to the Visitors for the county, and the remuneration of the
medical Visitors, and other expenses incurred in the execution of the
Act, the accounts being laid before the justices at the general or
quarter sessions, who shall direct the balance (if any) to be paid into
the hands of the treasurer of the county or borough in aid of the rate;
any balance of payment over receipts being paid out of the county or
borough funds.
There was paid into the Exchequer in the year ending March 31, 1880,
L1376 for licences in the metropolitan district, besides L18 stamps.
Lunacy Board expenses, L15,064.
I have not any accurate returns of the amounts received from the
provincial houses, but on a rough estimate these licences produce to the
counties in the aggregate L1452, and L30 to the Imperial Exchequer, per
annum.
In the following year, August 26, 1846, an Act was passed "to amend the
Law concerning Lunatic Asylums and the Care of Pauper Lunatics in
England," and was to be construed with 8 and 9 Vict., c. 126. There were
only twelve sections. It was passed to clear up doubts which had been
entertained as to the meaning of certain clauses in the above Act. It
was repealed by 16 and 17 Vict., c. 97.
APPENDIX F.
(Page 190.)
After the legislation of 1853, the Acts referred to at p. 190 and p. 188
constituted, with 8 and 9 Vict., c. 100, and 15 and 16 Vict., c. 48, and
the Acts relative to criminal lunatics, the then code of Lunacy Law.
Lord St. Leonards' first Act, p. 188 (16 and 17 Vict., c. 70), enacts
that when the Commissioners shall report to the Lord Chancellor that
they are of opinion that the property of any lunatic, not so found by
inquisition, is not duly protected, or the income thereof not duly
applied for his benefit, such report shall be deemed tantamount to any
order or petition for inquiry supported by evidence, and the case shall
proceed as nearly as may be in all respects as therein directed upon the
presentation of a petition for inquiry.
The next Act (16 and 17 Vict., c. 96) prescribes amended forms of orders
and certificates, notices of admission, and of the medical visitation
book.
The requirements on the part of the medical man signing the certificate
are laid down.
Empowers proprietors or superintendents of licensed houses (with consent
of Commissioners) to entertain as a boarder any patient desiring to
remain after his discharge, or any relation or friend of a patient.
Authorizes amendment of any order or certificate within fourteen days
after admission of patient.
Permits the Commissioners to allow medical visitation of single patients
less frequently than once a fortnight.
Empowers one or more Visitors to visit single patients at request of
Commissioners, and report to them their condition.
Directs that the medical man who visits a single patient shall make an
annual report to the Commissioners of the mental and bodily health of
such patient.
Empowers the Lord Chancellor to discharge single patients.
Directs that notice of the recovery of every patient shall be sent to
his friends, or in case of a pauper to his parish officers, and in case
of death of a patient in any hospital or licensed house, a statement of
the cause, etc., to the coroner.
Authorizes transfer of a private patient (with consent of two
Commissioners) from one asylum, hospital, or licensed house to another,
without any fresh order or certificate, and similarly as to single
patients.
Empowers the Lord Chancellor, on the representation of the
Commissioners, to require a statement of the property and application
of the income of any person detained as a lunatic under an order and
certificates.
Extends to the Commissioners the powers vested in the private committee,
as to single patients, by the Act 8 and 9 Vict., c. 100, s. 111.
Repeals s. 27 of 8 and 9 Vict., c. 100, as to the visitation of
workhouses; and enacts that one or more Commissioners shall visit such
workhouses as the Board shall direct.
Authorizes the Commissioners in urgent cases to employ any competent
person to visit any lunatic and to report to them.
Directs committee of every hospital to submit regulations to the
Secretary of State for approval, and to send a copy to Commissioners.
Empowers Commissioners, with sanction of the Secretary of State, to make
regulations for the government of licensed houses.
Enacts that Bethlem Hospital shall be subject to the provisions of Act 8
and 9 Vict., c. 100.
The third Act (16 and 17 Vict., c. 97) repeals the several Acts then in
force respecting county and borough lunatic asylums, and re-enacts most
of the provisions therein contained, with certain additions and
improvements.
It authorizes justices of boroughs, instead of providing asylums for
their own use, or in arranging with counties, etc., to contract with the
Visitors of any asylum for the reception of their pauper lunatics, in
consideration of certain payments.
The powers of the Visitors were enlarged in many ways.
When a county or borough asylum can accommodate more than its own pauper
lunatics, the Visitors are empowered to permit the admission of the
pauper lunatics of any other county or borough, or lunatics who are not
paupers, but proper objects to be admitted into a public asylum, such
non-pauper patients to have the same accommodation, in all respects, as
the pauper lunatics.
The Visitors are directed to appoint a medical officer to be
superintendent of the asylum.
They are empowered to grant superannuation annuities to the officers
and servants.
They are directed to make an annual report to the general or quarter
sessions of the state of the asylum.
Every pauper lunatic, not in an asylum, hospital, or licensed house, is
to be visited every quarter by the medical officer of the parish or
union, who is to make return thereof; and the medical officer is to be
paid two shillings and sixpence for every visit.
The forms of orders, statements, and medical certificates are amended,
and the medical officers of unions are permitted to sign certificates.
The medical man certifying is required to state his qualification, when
and where the patient was examined, and to specify facts indicating
insanity; distinguishing facts observed by himself from those
communicated to him by others.
Visitors are empowered to order the removal of pauper patients to and
from asylums, and also to discharge or permit the absence on trial of
any patient. The Commissioners are empowered to direct the removal of
any lunatic from any asylum, hospital, or licensed house to any other.
The person signing the order for admission of a private patient into an
asylum may discharge such patient, subject, in the case of dangerous
lunatics, to the consent of the visiting justices. Any person having
authority to discharge a private patient is empowered (with consent of
two Commissioners) to transfer him to another asylum or to the care of
any person.
Orders and certificates, if defective, may be amended within fourteen
days.
Patients escaping may be retaken within fourteen days.
This statute did not re-enact the clause contained in the Act it
repealed respecting workhouses.
18 AND 19 VICT., C. 105 (1855).
In 1855 was passed the Act 18 and 19 Vict., c. 105, "to amend the
Lunatic Asylum Acts and the Acts passed in the Ninth and Seventeenth
Years of Her Majesty, for the Regulation of the Care and Treatment of
Lunatics."
By this statute it was enacted that any single county or borough might
unite with the subscribers to a registered hospital, and that the
proportion of expenses between any county and borough might be fixed
with reference to accommodation likely to be required.
Other sections provide in detail for the maintenance of county and
borough asylums, and other matters which it is unnecessary to enumerate.
APPENDIX G.
(Page 195.)
A short summary is added of the provisions in force at the time of the
Select Committee of 1859-60, for the protection of private patients.
They remain essentially the same.
In the metropolis, the power of licensing is exclusively in the hands of
the Metropolitan Commissioners. In the provincial districts it rests
with the justices at quarter sessions. These licenses are annually
renewed, and they may be revoked by the Lord Chancellor. The patients
are admitted upon an order signed by some relative or friend, with a
statement of all the particulars of the case. This statement must be
supported by the certificates of two medical practitioners, who, having
examined the patient separately within seven days previous to the
reception, state that he is a person of unsound mind, and a proper
person to be detained under care and treatment. It must also specify the
grounds upon which their opinion has been formed, viz. the facts
observed by themselves or communicated by others. After two and before
the expiration of seven clear days, the proprietor or superintendent of
the licensed house must transmit to the Commissioners, and also to the
visiting justices, if the licensed house is within their jurisdiction, a
copy of the order and certificates. The licensed house must be visited
by two of the Commissioners, four times at least every year, if it lies
within their immediate jurisdiction; and if beyond, it must be visited
four times at least by Visitors appointed by the justices, one of whom
shall be a medical man, and twice at least by two of the Commissioners.
In the course of such visits, inquiries are directed to be made as to
the occupation, amusement, classification, condition, and dietary of the
different patients, and also whether a system of non-coercion has been
adopted or not; and where it shall appear, either to the Commissioners
or to the visiting justices, that a patient is detained without
sufficient cause, they have the power, under certain conditions, of
ordering his discharge. When a patient recovers, the proprietor or
superintendent is required to send notice of such recovery to the person
who signed the order for his reception; and if such patient is not
discharged or removed within fourteen days, the proprietor is required
immediately to transmit a similar notice to the Commissioners or
visiting justices, as the case may be. When a patient dies, the medical
practitioner who attended such patient during his illness is to cause a
statement to be entered in the case-book, setting forth the time and
cause of death, and the duration of the disease of which the patient
died, and a copy of such statement, within two days, must be transmitted
to the coroner. In addition to these specific provisions, the
Commissioners have power from time to time to make regulations for the
government of any of these licensed houses, and they must report
annually to the Lord Chancellor the number of visits they have made, the
number of patients they have seen, the state and condition of the house,
the care of the patients therein, and such other particulars as they may
think deserving of notice (p. vi.).
25 AND 26 VICT., C. 111, "THE LUNACY ACTS AMENDMENT ACT, 1862."
In consequence of the importance of the Act of 1862, the Commissioners
issued the following circular noting its chief provisions:--
_Private Patients._
Sec. 23.--The order must be dated within one month prior to reception;
the person signing the order must himself have seen the patient within
one month prior to its date; and a statement of the time and place when
the patient was so seen must be appended to the order.
Sec. 25.--When possible, every order must contain the name and address
of one or more relations of the lunatic, to whom notice of the death of
a lunatic must be sent.
Sec. 24.--Besides the persons hitherto prohibited from signing
certificates and orders, the following also are now disqualified:--Any
person receiving any percentage on or otherwise interested in the
payments for patients, and the medical attendant as defined in the
Lunacy Act, c. 100. Also 15 and 16 Vict., c. 96, s. 12; c. 97, s. 76.
Sec. 26.--Where a patient received as a pauper is made a private
patient, no fresh order or certificate is required, and _vice versa_.
Sec 28.--With the exception of the statement by the medical officer as
to a patient's mental and bodily condition, all the documents heretofore
required to be sent to the Commissioners after two or before seven clear
days from the reception of the patient, must in future be sent within
one clear day from such reception. The medical officer's statement is,
as heretofore, not to be sent until after two and before seven clear
days.
_Letters of Patients._
Sec 40.--Without special directions to the contrary, letters addressed
to the Commissioners, committees of Visitors, committees of a hospital,
and the Visitors of licensed houses, must be forwarded unopened. Other
letters must also be forwarded, unless, by an endorsement thereon, the
superintendent or other person having charge of patients should prohibit
their transmission. Letters so endorsed to be laid before Commissioners,
committees, or Visitors at next visit.
Sec. 38.--Absence on trial may be permitted to patients, in the same way
as leave of absence for the benefit of health is permitted under s. 86,
c. 100.
Sec. 43.--In the absence of any person qualified to discharge, a
discharge or removal may be ordered by the Commissioners.
_Pauper Patients._
Sec. 25.--The order must contain the name and address of one or more
relations of the lunatic, and notice of the death of the lunatic must be
sent to such relation.
Sec. 38.--A pauper permitted to be absent on trial from a licensed house
or hospital may have such an allowance made to him by order of the
Commissioners, Visitors, or committees as would be charged for him were
he in the house or hospital.
_Licensed Houses and Hospitals._
Secs. 14 and 15.--No fresh licence can be granted by justices without
inspection and report by the Commissioners. Notices of alterations in
houses licensed by justices must be given to Commissioners. Their report
must be considered by the justices before licence is granted or
alterations are consented to.
Sec. 16.--The physician, surgeon, or apothecary not being a licensee,
where any such is by law required to reside in or visit a licensed
house, must in the metropolitan district be approved of by the
Commissioners, and in the provincial district by the visiting justices.
A penalty is imposed on any person infringing the terms of his licence
as to numbers, sex, or class.
Sec. 18.--With consent of two of the Commissioners, or, in the case of
the provincial licensed houses, of two of the Visitors, a person who
may have been a patient within five years immediately preceding, may be
received as a boarder into a licensed house (extension of c. 96, s. 6).
Sec. 29.--Licensed houses may be visited at any time by one or more of
the Commissioners or Visitors, but in the metropolitan district they
must be so visited twice in the year, in addition to the present visits
by two Commissioners, and in the provincial districts similarly by
Visitors. Commissioners and Visitors visiting singly have substantially
the same powers of inspection and inquiry as when visiting together. To
these the sixty-second section of the Act does not apply.
Sec. 39.--A penalty is now imposed on any officer or servant conniving
at an escape.
Sec. 43.--In the absence of any person qualified under ss. 72, 73, c.
100, the Commissioners may order discharge or removal of a patient.
Sec. 38.--Absence on trial may be permitted to patients, in the same way
as leave of absence for the benefit of health is permitted under s. 86,
c. 100.
_Medical Certificates._
Sec 27.--Where medical certificates have been returned with a written
direction of the Commissioners for amendment, and such amendment shall
not have been made within fourteen days, the Commissioners may order the
patient's discharge.
Sec. 22.--Lunatics so found by inquisition may be received without
certificate on an order of the committee, accompanied by an official
copy of the order appointing such Committee.[316]
_Workhouses._