Chapters in the History of the Insane in the British Isles
by Daniel Hack Tuke
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Returns ordered by Parliament in 1826 show that there were 1321 persons in private asylums, exclusive of those in London and within a radius of seven miles; 1147 in public asylums, exclusive of those in St. Luke's and Bethlem; and 53 in public jails; giving a total of 2521 for the several counties of England and Wales. Those in private asylums in and near London being estimated at 1761, and the asylums of St. Luke's and Bethlem at 500, the gross total for England and Wales was 4782. Sir Andrew Halliday did not hesitate to assert, after very careful inquiry, that the number actually in confinement, not only in the asylums, but with relations and keepers, exceeded 8000. He thought there were very few in Wales, or in "the Celtic tribes in other portions of the empire."[156]

Before leaving Halliday, I may add that he regarded Bethlem as, at this period, well conducted, but as having "too much of the leaven of the dark ages in its constitution, and too rigid a system of quackery, in regard to its being seen and visited by respectable strangers." He adds that in some respects "it is little better than when, in fact, it formed one of the lions of the metropolis, and the patients as wild beasts were shown at sixpence for each person admitted." Of St. Luke's he writes, "It is only fit to become a prison for confirmed idiots." He would have been surprised to witness how much can be effected by improvements of various kinds, although he might still wish that it were supplemented by some appendage in the country, if not removed there altogether.

A very important step was taken by Mr. R. Gordon in the House of Commons in 1827 (June 13th), by drawing attention to the pauper lunatics in Middlesex. He particularly referred to the dreadful state of misery of the pauper lunatics in London in the parishes of Marylebone and St. George's. When the overseers of the latter parish visited Dr. Warburton's asylum at Bethnal Green, they found, he said, in a room eighteen feet long, sixteen cribs,[157] with a patient in each crib, some of them chained and fastened down, and all of them in a state of great wretchedness. On one occasion, a visitor having gone there and reported that there was nothing objectionable, he repeated his visit next day, and discovered five rooms, in which the patients were in a most horrid state of misery; and this although the day before he was informed that he had seen everything. The unfortunate persons placed in these cribs were kept from Saturday night until Monday; their food being administered to them in the cribs. Mr. Gordon moved for a Select Committee to inquire into the condition of pauper lunatics in Middlesex, and for leave to bring in a Bill to amend 14 Geo. III. c. 49 (1774),[158] and to extend its provisions to pauper lunatics, to consolidate all Acts relative to lunatics and asylums, and to make further provisions thereto.

The Committee was appointed.

It specially directed its attention to the treatment of paupers in the parishes of Marylebone, St. George, Hanover Square, and St. Pancras, confined in the White House at Bethnal Green, belonging to Dr. Warburton. Its condition was frightful, and the Committee observes that if the White House is to be taken as a fair specimen of similar establishments, it cannot too strongly or too anxiously express its conviction that the greatest possible benefit will accrue to pauper patients by the erection of a county lunatic asylum.

The Committee reports that the defects and abuses in the management of houses for the reception of lunatics, to which the Select Committee of 1815 called the attention of the House of Commons, still exist in licensed houses where paupers are received in the neighbourhood of the metropolis, and that similar abuses elsewhere prevail. The evidence established that there was no due precaution with respect to the certificate of admission, the consideration of discharge, or the application of any curative process to the mental malady. The Committee therefore repeated the recommendations of the Committees of 1807 and 1815, and prepared a series of propositions as the basis of future legislation, repealing a number of Acts and recommending the consolidation, into one Act of Parliament, of the provisions for the insane, as well as further facilitating the erection of county asylums, and improving the treatment of pauper and criminal lunatics.

Dr. John Bright, secretary to the Commissioners, read from their records one entry, describing the condition of Holt's house, Lewisham, in Kent. In the year 1820, "in a close room in the yard, two men were shut by an external bolt, and the room was remarkably close and offensive. In an outhouse at the bottom of the yard, ventilated only by cracks in the wall, were enclosed three females. The door was padlocked; upon an open rail-bottomed crib herein, without straw, was chained a female by the wrists, arms, and legs, and fixed also by chains to the crib. Her wrists were blistered by the handcuffs; she was covered only by a rug. The only attendant upon all the lunatics appeared to be one female servant, who stated that she was helped by the patients."

Subsequent entries did not show any material improvement in the condition of the house.

Dr. Bright summarized the defects in the Lunacy Laws at that period, as regards the power vested in the Commissioners, as follows:—

"They are very defective in many points: in the first place, with respect to the granting licences, there is only one day in the year in which, according to the Act, the licences can be granted; then with respect to persons to whom the licence may be granted, any person applying for that licence is entitled to have one; again, any person committing any offence, save and except the refusing admission to Commissioners on their visitations, may be continued and is continued in the exercise of such powers as that licence communicates to him; the Commissioners have no power to disturb in the management of his house any keeper of a house, whatever offences he may have committed, or however unworthy he may appear to them to be. Supposing any person who had, in the eyes of the Commissioners, acted improperly, to apply in October, at the usual and the only period in the year for granting licences, they conceive (and they are advised) that they are obliged to grant a licence to that individual. There is another circumstance which I think is very important, which is the certificate which is granted; the Act is vague with respect to the medical person. It speaks of him as physician, surgeon, or apothecary; it does not say 'duly authorized to grant a licence,' and, in point of fact, a number of persons, calling themselves apothecaries, do sign certificates, and the Commissioners do not believe that they can prevent them so doing, or that the signature is invalid; and, again, it often happens, and very improperly, as the Commissioners think, that persons sign the certificate in two capacities. For instance, a medical man is, or calls himself, the friend of the person conveyed to the mad-house, and he signs again as a medical person; again, the keeper of a mad-house, who happens to be a medical person, signs a certificate, attesting the insanity of the party, and receiving that party into his house. The Commissioners always reprobate and endeavour to check such a practice, but not always successfully."

In the following year (February 19, 1828) Mr. Gordon, in pursuance of the instructions of the Committee, brought in a Bill to amend the law for the regulation of lunatic asylums. He said, among other things, that the medical certificate to be signed by an apothecary was interpreted to mean that it might be signed by any seller of drugs, and hence an apprentice, as soon as his indentures had expired, might consign a man to a mad-house. This reminds me of a mistake into which a distinguished German alienist has recently fallen, not unnaturally, from our double use of the word apothecary. He smiles at the absurdity of the British law allowing a mere druggist to sign a certificate of insanity! Mr. Gordon again refers to Dr. Warburton's house, and the patients in their cribs "wallowing in their filth throughout the whole of Sunday," while on Monday morning they were "in a state of nudity, covered with sores and ordure, and were carried into the yard to be suddenly plunged into cold water, even when ice was in the pails." The speaker added that it was impossible, with the strongest language, to describe the horrors of this place, and even maintained that the evidence before the Committee showed that, however bad, this house was good as compared with others of the same kind—if not much better than many of them.

He maintained that, unfortunately, the provision made by 14 Geo. III., c. 49, by which five Commissioners, appointed by the College of Physicians, licensed and were bound to visit these houses yearly, and, if they found anything improper, were directed to state to the College what they had discovered, had never been attended to in practice; at least, since 1800. The excuse for this negligence was that the complaint to the College censors (placed on a card in their room) did no good, and might therefore as well be abandoned. In fact, he found on inquiry that the Commissioners had done nothing—literally and strictly nothing. He then referred to a house where two patients were found lying in an outhouse, and three others chained down by the arms, wrists, and legs. Their wrists were blistered, and their persons covered only by rags. This was within five miles of London. He concluded by moving for leave to bring in a Bill "To Consolidate and Amend the several Acts respecting County Lunatic Asylums, and to Improve the Treatment of Pauper and Criminal Lunatics."

Lord Ashley seconded the motion, and leave was given to bring in the Bill,[159] which passed the House.

In the Upper House Lord Malmesbury moved the second reading of the above Bill. One object, he said, of the Lunatic Asylum Regulation Bill was to give to counties more power in establishing asylums. For private patients, two medical certificates and an order would now be required, and the like for single patients. In regard to the existing College Commissioners, he ridiculed the extraordinary circumstance that if, in the course of their visits of inspection, they found what was reprehensible in an asylum, they could not revoke the licence which they themselves had given. It was proposed to take the power from the College of Physicians and invest it in fifteen Metropolitan Commissioners appointed by the Home Secretary.[160]

This Act (9 Geo. IV., c. 40), based on the Report of the Committee, was passed July 15, 1828.[161]

The returns of pauper lunatics in England and Wales amounted to 9000, being 6700 in excess of the corresponding return of 1807; but nobody supposes that there had been that, or, in fact, any considerable increase in the number of the insane poor, but simply greater accuracy in obtaining statistics.

Referring back to this period, Lord Shaftesbury, in evidence given before a Committee of the House of Commons thirty years later, and dwelling upon the old regime, observed: "I mention these things because they never could be seen now (1859), and I think that those who come after us ought to know what things have existed within the memory of man. At the present time, when people go into an asylum, they see everything cleanly, orderly, decent, and quiet, and a great number of persons in this later generation cannot believe there was ever anything terrible in the management of insanity; and many say, 'After all, a lunatic asylum is not so terrible as I believed.' When we begun our visitations, one of the first rooms that we went into contained nearly a hundred and fifty patients, in every form of madness, a large proportion of them chained to the wall, some melancholy, some furious, but the noise and din and roar were such that we positively could not hear each other; every form of disease and every form of madness was there; I never beheld anything so horrible and so miserable. Turning from that room, we went into a court, appropriated to the women. In that court there were from fifteen to twenty women, whose sole dress was a piece of red cloth, tied round the waist with a rope; many of them with long beards, covered with filth; they were crawling on their knees, and that was the only place where they could be. I do not think that I ever witnessed brute beasts in such a condition, and this had subsisted for years, and no remedy could be applied to it. It was known to one or two physicians at the Royal College, who visited the place once a year; but they said, fairly enough, that, although they saw these things, they could not amend them." Lord Shaftesbury, after giving a short resume of the condition of the old York Asylum, as well as of that of Bethnal Green in 1827, went on to observe—a paragraph which will form the motto of my work—"I might multiply these instances almost indefinitely, but I thought it was desirable just to indicate the state of things that existed, in order to contrast the Past with the Present."[162]

In the interval between the Act of 1828[163] and the next Act of importance, several attempts were made at further legislation on the part of Mr. Gordon and Lord Somerset. A Bill passed both Houses in 1832.[164] In one instance a Bill which passed the Commons was characterized in the House of Lords as "one of the most abominable pieces of legislation that ever was seen." It was "monstrous." "Their lordships could never suffer such an abominable piece of legislation to be thrust down their throats." It is scarcely necessary to say that the lips from which this animated language proceeded were those of Henry Brougham, then the Lord Chancellor. The Bill was, of course, rejected.

In 1842 Lord Somerset brought forward a motion on the inspection of asylums, and pointed out that there was a very large class of persons to whose inspection the Act of 1828 did not apply, viz. those in confinement in their own houses, in separate lodgings, in public institutions, as county asylums, and the hospitals of Bethlem and St. Luke's. The object of his Bill was to extend the system of inspection in force in the metropolitan licensed asylums to the provinces. Barristers, he maintained, should be appointed, with a fixed salary, and not paid for their hour's work and allowed to practise. It is worthy of record that the returns at this period showed that there were about sixty or seventy houses licensed for the reception of insane persons in the country, and that there were actually twenty-five counties in England where there was not a single asylum licensed for the reception of lunatics, and not one in Wales.

This measure was characterized by Mr. Wakley as not only a very small one, but as an insult to medical men, as it only proposed barristers as the new Commissioners, adding that "in Scotland there was one system, in Ireland there was another, and in England there were several, and among them all there was not one which, on the whole, was entitled to the sanction and approbation of the public, or which was worthy of the adoption of the noble lord [Somerset]."

Lord Ashley approved of the Bill, and speaking of the work of the Commissioners, he said, "They have aimed at a medium line of policy, and an immense amount of human misery had been abated under the present law, and by the industry of those who carry it into execution."

It was in this speech that Lord Ashley made an observation which has not escaped the criticism of the medical profession, namely, "that a man of common sense could give as good an opinion as any medical man he ever knew," that is, "when it has been once established that the insanity of a patient did not arise from the state of his bodily health."[165]

It should be stated that Mr. Wakley moved an amendment on the first clause of the Bill, omitting "Barrister Commissioners," and inserting "Medical Commissioners." He spoke of the total failure of the Metropolitan Commission, and ultimately moved as an amendment that two of the Commissioners to be appointed should not have their profession stated, their appointment being left to the Lord Chancellor. This amendment was carried by a majority of three, but in the Bill provision was made for two more physicians and two more barristers.

On July 16th of the same year, on the motion that the order of the day for the further consideration of the Lunatic Asylums Bill be proceeded with, a member suggested its postponement until further discussion. Lord Somerset replied that the Bill was framed for the purpose of procuring further information on the subject, in order to legislate permanently upon it. On the House going into Committee Lord Ashley expressed a hope that the measure would tend to ameliorate the condition of the pauper lunatics throughout the kingdom. On this occasion Lord Ashley observed, in regard to the system of non-restraint, that he had formerly entertained some doubts as to the practicability of carrying it out; but that these doubts had been removed by a visit to the Hanwell Asylum. Having witnessed the system pursued there, he said he could not speak too highly either of the system itself, or the manner in which it was carried out by Dr. Conolly.

Having passed through Committee, the Bill was read a third time on the 28th of July, 1842, and in this instance was not rejected by the House of Lords.[166]

The Metropolitan Commissioners, invested with their enlarged powers, made a most thorough inquiry into the condition of the asylums in England and Wales, and presented a Report to Parliament in 1844, which must always possess great historic interest and value.[167] It constitutes the Doomsday Book of all that concerns institutions for the insane at that time.

The state of some asylums visited by the Commissioners was frightfully bad, notwithstanding the general progress which had been made since public attention had been directed to abuses and the several Acts of Parliament had been passed in order to remove them. These things, however, it must be remembered, were survivals of the past, not fair illustrations of the present; abuses which lingered on in spite of light and knowledge, and required stringent pains and penalties to force those who permitted them to abandon their practices.

On the 23rd of July, 1844, the indefatigable reformer of abuses connected with the treatment of lunatics, Lord Ashley, moved for an Address to the Crown, praying her Majesty to take into consideration the Report of the Metropolitan Commissioners in Lunacy[168] to the Lord Chancellor, presented to the House, the statute under which they acted expiring next session. He commented upon there being no official visitation of single houses. He believed that such a power "ought to be confided to some hand that would hunt out and expose the many horrible abuses that at present prevail." The only control was that if such patient resided more than twelve months in a house, the owner was compelled to communicate the name of that patient to the clerk of the Commission; but for the most part no notice was taken of this law, and it was frequently evaded by removing the patient, after a residence of eleven months, to some other lodging.

At this period (January 1, 1844) the number of lunatics and idiots chargeable to unions and parishes in England and Wales was 16,821. In county asylums there was provision for only 4155, leaving 12,666 poor insane, of whom there were in asylums under local Acts 89, in Bethlem and St. Luke's 121, in lunatic hospitals 343, while 2774 were in private asylums, leaving in workhouses and elsewhere 9339. Although a few of the existing county asylums were well adapted to their purpose, and a very large proportion of them were extremely well conducted, yet some were quite unfit for the reception of insane persons. Some were placed in ineligible sites, and others were deficient in the necessary means of providing outdoor employment for their paupers. Some also were ill contrived and defective in their internal construction and accommodation. Some afforded every advantage of science and treatment; others were wholly deficient in these points. All of them, however, had the advantage of constant supervision, and of not giving any profit to the superintendent. Lord Ashley especially referred to the admirable manner in which the asylums of Wakefield, Hanwell, Lincoln, Lancaster, and Gloucester were managed. "Why, then," his lordship asked, "are not these institutions multiplied? At this moment there are twenty-one counties in England and Wales without any asylum whatever, public or private. The expense is one cause. In some cases the cost of construction has been exceedingly great. The asylum most cheaply constructed is that of Wakefield, of which the average cost per head was L111, whilst the highest price was that of Gloucester, which had cost on the first accommodation L357 per head. In many cases the cost of construction had exceeded L200 per head. The cost of the Bedford Asylum, for 180 patients, was L20,500; that of Gloucester, for 261 patients, L51,366; that of Kent, for 300 patients, was L64,056; that of Hanwell, for 1000 patients, was L160,000, exclusive of L36,000 paid since 1835 for furniture and fittings. On the other hand, the best-constructed union-houses in the country had not cost more than L40 per head." Lord Ashley maintained that although, no doubt, a lunatic asylum was expensive, it ought not to be so to that enormous degree. The reason of this difference he did not know, except that many of them had been constructed with a great display of architecture, and some asylums were far too large. Adopting the opinion of the Report of the Commissioners, he maintained that no asylum for curable lunatics should contain more than 250 patients, and that perhaps 200 are as large a number as can be managed with the most benefit to themselves and the public in one asylum; and he quoted Dr. Conolly's stronger statement that 100 persons were the highest number that could be managed with convenience in one of these asylums. With regard to the number of private patients in asylums, there were 3790, of whom 973 were in private metropolitan, and 1426 in private provincial asylums. The paupers in the private houses were—metropolitan, 854; provincial, 1920. With respect to these, it was a very serious question how far any house should be licensed to take paupers for payment. The principle was very dangerous, and Lord Ashley pointed out that if the superintendent only got seven or eight shillings a week, he still must make a profit, and that there could be no doubt it was so. Quoting the Report of the Commissioners again, he said that many asylums had formerly been private houses; the mansion was sometimes engrossed by the proprietor and a few private patients, while the paupers were consigned to buildings formerly used as offices and outhouses. After adducing evidence of the deplorable condition of certain asylums, Lord Ashley asserted that the only remedy was the multiplication of county asylums, and if advice and example failed, they ought to appeal to the assistance of the law to compel the construction of an adequate number of asylums over the whole country. It was the duty of the State to provide receptacles for the incurable patients, apart from those devoted to remedial treatment. Parochial authorities, however, preferred keeping patients in the workhouse at an expense not exceeding two shillings a week, rather than send them to the county asylum, where the minimum charge was seven shillings a week.

It was true, Lord Ashley observed, that they could show but few instances of restoration to reason. How, indeed, was it possible? They could show, however, a mighty improvement in the condition of the sufferers, the alleviation of their state, their occupations and amusements (all, with some bright exceptions, of recent date), and that the services of religion had infused a momentary tranquillity; but they could show little else, and unless the Legislature should interfere and bring these unfortunates by force within the reach of sympathy and care, for every one restored to his senses we should see a hundred in whom the light of reason would be extinguished for ever. The speaker went on to say that there were two points of deep interest, to which the House would do well to advert for a moment—the question of restraint, and the admission and liberation of patients. "Upon restraint it was unnecessary to dwell very long, as it was a matter of internal arrangement, and beyond their immediate legislation; but he wished to direct the attention of the House to the chapter in the Report which handled that subject, that it might share the general satisfaction, and give praise to those good and able men, Mr. Tuke, Dr. Hitch, Dr. Corsellis, Dr. Conolly, Dr. de Vitre, Dr. Charlesworth and many more, who had brought all their high moral and intellectual qualities to bear on this topic, and had laboured to make rational and humane treatment to be the rule and principle of the government of lunacy."

Lord Ashley pointed out that the law required no medical certificate whatever for a pauper patient, except when admitted into a private asylum. It appears that in Wales at that time there were 1177 pauper lunatics, 36 of whom were in English county asylums, and 41 in English licensed houses, 90 in union workhouses, and 1010 living with their friends, many of them being in a wretched condition. Lord Ashley quoted a letter from one of the Commissioners, written in Wales, in which it was stated, "We have met with one case which we think most atrocious. A. B. was sent to the Hereford Asylum from near Brecon on November 28, 1843. She died on January 30th. She was in such a shocking state that the proprietor wished not to admit her; she had been kept chained in the house of a married daughter. From being long chained in a crouching posture, her knees were forced up to her chin, and she sat wholly upon her heels and her hips, and considerable excoriation had taken place where her knees pressed upon her stomach. She could move about, and was generally maniacal. When she died it required very considerable dissection to get her pressed into her coffin! This might be taken as a sample of Welsh lunatics."

The improvement in the condition of Dr. Warburton's asylum at Bethnal Green, which was the original cause of the Commission of Inquiry being appointed in 1827, now presented, it appears, a most agreeable picture of what might be done by vigilant inspection. "Whereas in 1828 there were commonly 150 to 200 of the patients restrained by leg-locks, chains, and other fetters—certainly during the night—in 1844 there were, out of 582 patients, only 5 whose violence rendered this species of restriction necessary, and even the confinement or coercion resorted to was of the most moderate description, and in the opinion of the visiting officers most necessary."

Lord Ashley concluded his speech with the following eloquent words:—"Sir, these subjects may be dull, and want the light and shade of more exciting topics; but the expense which is incurred, the numbers that suffer, and the nature of their sufferings, will perhaps justify the present demand upon your time and patience. The House possesses the means of applying a real and speedy remedy; these unhappy persons are outcasts from all the social and domestic affections of private life—nay, more, from all its cares and duties, and have no refuge but in the laws. You can prevent by the agency you shall appoint, as you have in many instances prevented, the recurrence of frightful cruelties; you can soothe the days of the incurable, and restore many sufferers to health and usefulness.... I trust, therefore, that I shall stand excused, though I have consumed so much of your valuable time, when you call to mind that the Motion is made on behalf of the most helpless, if not the most afflicted, portion of the human race."[169]

Sir James Graham does not appear to have been affected by this appeal, for, declining immediate action, he stated that the condition of pauper lunatics would come under the consideration of the House next session. He recommended the House to approach the subject of the inspection of private houses with great caution.

In the summer of 1845 (June 6th) Lord Ashley returned to the subject, and brought forward in the House of Commons two Bills for England and Wales only, although he said, "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." After pointing out that the then existing law was embodied in nine statutes, divisible into four classes—County Asylums, Licensed Asylums and Public Asylums, Persons found lunatic by inquisition, and Criminal Lunatics, he observed that his Bill only touched the two first classes, and amended the single Act contained under the first class, as also the three Acts contained under the second class, namely, 2 and 3 Will. IV., c. 107; 3 and 4 Will. IV., c. 64; and 5 and 6 Vict., c. 87; which various statutes were proposed by him to be consolidated into one—"A Bill for the Regulation of the Care and Treatment of Lunatics in England and Wales." After referring to the state of the law as it existed under 14 Geo. III., the only law regulating private asylums prior to Mr. Gordon's measure of 1828, Lord Ashley proposed to establish a permanent Commission of Lunacy, giving power of far more detailed and frequent visitation than previously, and placing "hospitals" under proper regulation by requiring them to have the same orders and certificates as in licensed asylums, and the same visitation as in county asylums. The person signing the order of a pauper patient would be required to examine him beforehand, and the medical officer certifying his insanity was to see him within seven days of his confinement. On admission the mental and bodily condition of the patient, and in the event of his death, the cause thereof, were to be stated. Injuries and acts of violence were to be recorded and a case-book kept. A return was to be made of all single patients received for profit.[170] Workhouses containing lunatics were to be subjected to regular visitation. These were some of the provisions of the first Bill.

The second was an extension of the Act of 9 Geo. IV., c. 40, and was of the highest importance, for the provision of county and borough asylums, instead of being permissive, was made compulsory. Where insufficient accommodation had been provided, it was required to increase it. It was proposed to erect some separate buildings at less cost for incurable, or rather chronic, cases. The above Bill was to be extended to boroughs having separate quarter sessions, and to every place not contributing to county rates. All lunatics not chargeable, whether wandering or otherwise, were to be apprehended, and those whose friends were unable to pay for them admitted as paupers. A quarterly inspection by a medical man of lunatics not in asylums was required, and a list was to be sent to the Commissioners in Lunacy.

Lord Ashley, after paying the tribute of respect and admiration due to Pinel, referred in conclusion to the introduction of a humane system of treatment into this country at York, adding that it must be grateful to the feelings of the author of the "Description of the Retreat" "to perceive that his example has obtained not only the approval, but the imitation of the best and wisest men of this country, and, I may add, of America."

Lord Ashley's Bill introduced for the first time a permanent Lunacy Commission. It comprised six paid Commissioners at salaries of L1500 each, which, he observed, would be economical in the end. In Mr. Gordon's Act the Commissioners were appointed for one year, to be renewed annually, and consisted of ten unpaid members and five physicians, who were paid at the rate of one guinea an hour for their attendance, with power to carry into effect the new Act within the metropolitan district. This act and the Commission were renewed in 1832, when two barristers were added on the same terms. In 1834, having been always a member of the Commission, Lord Ashley became the chairman. The Act had been renewed periodically every three years until the year 1842, when Lord Somerset brought in a Bill, the object of which was greatly to extend the operation of the Metropolitan Commission. The number of physicians was then augmented to seven, and the barristers to four; and it was also provided that the Commissioners should receive five guineas a day during the performance of their duties in the provinces. Immediately after that Act (5 and 6 Vict., c. 87) the Commissioners had entered upon their enlarged duties. The consequence was that in each year the establishments visited by them were:

Visited once a year.

Seventeen county asylums, or asylums brought within the scope of 9 Geo. IV. (1828), (twelve county asylums, five county and subscription asylums).

Eleven of mixed character (mostly by subscription and partly by income from charitable foundations).

Two military and naval hospitals.

Visited twice a year.

Ninety-nine houses licensed by justices in session (fifty-nine receiving only private patients, forty private and pauper).

Visited four times a year.

In metropolitan district: Thirty-seven houses licensed by Metropolitan Commissioners (thirty-three for private patients only; four for private and pauper).

Total public and private asylums, January 1, 1844, 166.

The result of these investigations was, Lord Ashley observed, the Report presented to the House last session, when he moved for an Address to the Queen, but withdrew it upon the Government promising to bring in a Bill. Ultimately, however, the Government had requested him to undertake it.

The two Bills, having passed the Houses of Parliament, received the Royal assent on the 4th and 8th of August, 1845.[171] They have been well called the Magna Charta of the liberties of the insane.

After these Acts had been in operation for eight years, it was found that various amendments were needed, and in February, 1853, Lord St. Leonards introduced, along with another Bill lessening the expense arising out of lunacy inquisitions, one consolidating the laws respecting asylums, and one amending Lord Shaftesbury's Act (c. 100). They constitute the 16 and 17 Vict., c. 96 and c. 97.

The former, entitled "An Act to amend an Act passed in the ninth year of Her Majesty 'for the Regulation of the Care and Treatment of Lunatics,'" has reference mainly to private asylums and hospitals. The same order and certificates which were required for admission into an asylum were now necessary for single patients. It was enacted that medical men should specify the facts upon which their opinion of a patient's insanity was based, distinguishing those observed by themselves from those communicated by others. Bethlem Hospital was by the thirty-fifth section of this Act made subject to the provisions of the Lunacy Acts.

The latter statute, entitled "An Act to Consolidate and Amend the Laws for the Provision and Regulation of Lunatic Asylums for Counties and Boroughs, and for the Maintenance and Care of Pauper Lunatics in England and Wales," repealed the 8 and 9 Vict., c. 126; 9 and 10 Vict., c. 84; and 10 and 11 Vict., c. 43. Many sections refer to the particular mode of determining the manner in which an asylum shall be provided for the paupers of a county and borough, whether for the county alone, or with some other county or borough, or with the subscribers to any hospital, or with the visiting committee of a county asylum for the joint use of an existing asylum. The parish medical officer was directed to visit all the paupers in it every quarter, whether in the workhouse or not, and report to the guardians or overseer those who, in his judgment, might be properly confined in an asylum. Thus the tendency of the Act was, in this and other ways, calculated to add to the numbers under care, and, therefore, to make the apparent increase of insanity greater. Three classes of lunatics were contemplated by this Act, viz. pauper lunatics; wandering lunatics, whether paupers or not; lunatics not paupers and not wandering, who are cruelly treated or neglected. The Commissioners might order the removal of a lunatic from an asylum, unless the medical officer certified such patient to be dangerous; and the latter might be overruled by the consent of two visiting justices to his discharge. A large number of the sections of this Act provide in detail for the settlement, etc., of pauper lunatics. Penalties were enacted in the event of any superintendent or other officer of an asylum ill-treating or neglecting a patient.[172]

* * * * *

One of those waves of suspicion and excitement which occasionally pass over the public mind in regard to the custody of the insane, occurred in 1858. Sensational articles appeared in the papers, and novels were written to hold up those connected with the care and treatment of the insane to public obloquy. The author himself did not escape animadversion, and was represented in a newspaper as a brutal mad-doctor using a whip upon an unfortunate patient "in an institution of which better things might have been expected." That the charge was the offspring of a bewildered editor, who confused person and place in an incredible manner, and was obliged to acknowledge that he had been the victim of his own imagination, only shows how the paroxysms of sudden passion and indignation to which John Bull is liable, may lead to the most ridiculous mistakes. However, there must be some fire where there is smoke, and one or two unfortunate events gave colour to the assertion, persistently made, that asylums were the abodes of injustice and cruelty. A Select Committee of the House of Commons was appointed in February, 1859, to inquire into the operation of the Acts of Parliament and Regulations for the Care and Treatment of Lunatics and their Property, including Sir George Grey, Mr. Walpole, Mr. Whitbread, Mr. Drummond, Mr. Kekewich, and others; and evidence was given by the Earl of Shaftesbury, Mr. Barlow, Mr. Gaskell, Dr. Southey, Dr. Conolly, Dr. Hood, Dr. Bright, Dr. Bucknill, Mr. Lutwidge, etc.

The Committee commence their Report with presenting the following comparison of the number of lunatics in 1844, 1858, and 1859:—

- - Location. 1844. 1858. 1859. - - Private patients in asylums, hospitals, and licensed houses 3,790 4,612 4,762 Pauper lunatics and idiots in asylums, hospitals, and licensed houses 7,482 17,572 18,022 Pauper lunatics and idiots in workhouses (655) and with friends, etc. 9,339 13,163 13,208 20,611 35,347 35,992 -

the last figure showing an increase of 15,000 over the number in 1844, and being one in six hundred in the population. The Committee point out that from 1808 to 1845 the justices had the power to provide, in every county, proper houses for pauper lunatics, but were not obliged to do so. There were in 1859 forty county asylums. Of seventy-one boroughs bound to provide asylums, about forty had done so.

As to public asylums, the evidence brought forward convinced the Committee that little alteration was required in the law, they being "well looked after and carefully attended to." It was suggested that they might be in some instances too large, and the staff of attendants too small and not sufficiently paid. Also that it might be desirable to erect, in connection with them, detached buildings of a simple and inexpensive character for the reception of imbecile and chronic patients.

It was considered that the chief evil for which a remedy was required lay in the detention of a large number of pauper lunatics in workhouses, amounting to 68,000 January 1st, 1857, and 7632 on January 1st, 1859. "It cannot be denied that, with regard to those who are really lunatics, there is a great absence of proper supervision, attendance, and medical treatment. In some workhouses there are not even separate wards; mechanical restraint is frequently applied, because the imperfect state of the accommodation will not admit of a better mode of treatment; in many cases, the medical officers of a union cannot have the special knowledge requisite for the management of the insane; and it may generally be concluded that the special appliances of a union workhouse are not by any means equivalent, as to this class of inmates, to those of a lunatic asylum." The Committee did not recommend the removal of all cases, but that no person should be detained in a workhouse respecting whose sanity a doubt existed, without a medical certificate, renewable quarterly; that there should be distinct wards for such patients, with distinct attendance; that the guardians should visit such patients once a quarter, and make a special entry of their condition; that the Commissioners should visit them at least once a year; and that the same power of removing any patient to an asylum should be given to the Commissioners as that possessed by the justices.

Lord Shaftesbury on this occasion recommended that magistrates should be empowered to provide asylums by money raised on the security of the rates, for all the non-pauper classes. "When I look into the whole matter," he said, "I see that the principle of profit vitiates the whole thing; it is at the bottom of all these movements that we are obliged to counteract by complicated legislation, and if we could but remove that principle of making a profit, we should confer an inestimable blessing upon the middle classes, getting rid of half the legislation, and securing an admirable, sound, and efficient system of treatment of lunacy." The Committee, however, while encouraging such asylums founded on private contributions, could not recommend that a burden should be imposed on the ratepayers, or that their establishment should be compulsory.

The Committee suggested as safeguards against the improper detention of lunatics in private asylums (after dismissing the proposal to require the sanction of a magistrate) various important precautions.

1. Worthy of consideration whether the certificate should be verified before a magistrate, so as to enable him to determine whether the Act has been complied with. 2. The certificate authorizing detention to be limited to three months. 3. The order to state the time when the patient was last seen, and not to be effective unless the applicant had seen the patient within three months. 4. Copy of order and certificate to be sent to the Commissioners within twenty-four hours, instead of within seven days. 5. The patient to be visited as soon as possible by the Commissioners or by some person acting directly under their authority. 6. The person who signs the order for admission to a private asylum to visit the patient at least every six months—a clause in Mr. Gordon's Act, but omitted in that of 1845. 7. Patients to have a prima facie right to receive visits from and correspond with friends. 8. To make it penal for any medical man to receive a patient in a single house without apprising the Commissioners of it.

Other suggestions of the Committee had reference to Chancery lunatics, criminal lunatics, and the composition and powers of the Lunacy Board.

When this Committee met, the Acts in force were essentially similar to what they now are (the only important subsequent statute being that of 1862), viz. for public asylums, the 16 and 17 Vict., c. 97, and 18 and 19 Vict., 105, and for private asylums, 8 and 9 Vict., c. 100, 16 and 17 Vict., c. 96, and 18 and 19 Vict., c. 105. According to these Acts, the great principle which governs asylums where private patients are kept may be said to be that no person can receive into his house more than one patient, if he derives any profit therefrom, unless he has a licence granted to him for that purpose, and submits to the regulations which that licence implies.

Legislation followed in 1862, in the statute 25 and 26 Vict., c. 111, entitled "An Act to amend the Law relating to Lunatics."[173]

It made pauper lunatics chargeable upon the common fund of the union, instead of the particular parish. In addition to many matters of detail in reference to the establishment of asylums, and an important section in regard to the use of workhouses for chronic lunatics, additional safeguards were given to prevent the improper admission of patients into institutions for the insane, much care being shown in reference to the abuse of private asylums. Persons signing orders for admission must have seen the patient within one month. Certain persons were prohibited from signing any certificate or order for the reception of any private patient into a licensed or other house, viz. those receiving a percentage on, or otherwise interested in, the payments to be made by any patient received into such houses; as well as any medical attendant as defined by the Lunacy Act of 1845. If defective medical certificates were not amended within fourteen days, the Commissioners were empowered to order the patient's discharge. On admission of patient, the documents, with the exception of the "statement," were to be transmitted to the Lunacy Board within one clear day, instead of after two and before the expiration of seven, as formerly. Increased visitation of asylums by Commissioners was provided, one of whom might visit any asylum, hospital, or jail, in addition to the visits required by two of them. Regulations were made in regard to patients being absent on trial, the transmission of their letters, and the further protection of single patients. These and some other sections were the outcome of the suggestions of 1859-60.[174]

In 1874 a Poor Law Act granted four shillings per head out of the Consolidated Fund to paupers in asylums, to the effects of which we shall have to refer in the next chapter.

It is necessary now to chronicle the appointment of the Select Committee of 1877, known as Mr. Dillwyn's Committee, the result, to a large extent, of a feeling of uneasiness in the public mind, or rather, a portion of it, relative to the too easy admission of patients into asylums, and their too difficult exit, when once there. The grossest charges were made against the proprietors of licensed asylums, and the Commissioners themselves were charged with culpable laxity. As might be expected, some changes in the law were suggested likely to prove beneficial, and the Report of the Committee contained sundry recommendations of importance. The charges, however, from which the inquiry originated, fell to the ground; and had the appointment of the Committee had no other result, the advantage would have been great, in presenting a most gratifying contrast to the revelations which took place fifty years before, in 1827.[175]

The conclusions at which the Committee arrived were that, "although the present system was not free from risks which might be lessened, though not wholly removed, by amendments in the existing law and practice, yet, assuming that the strongest cases against the present system were brought before them, allegations of mala fides or of serious abuses were not substantiated.... The Committee cannot avoid observing here, that the jealousy with which the treatment of lunatics is watched at the present day, and the comparatively trifling nature of the abuses alleged, present a remarkable contrast to the horrible cruelty with which asylums were too frequently conducted less than half a century ago, to the apathy with which the exposure of such atrocities by successive Committees of this House was received, both by Parliament and the country, and to the difficulty with which remedial enactments were carried through the legislature.... Nevertheless, the anomalous state of the law, which undoubtedly permits forcible arrest and deportation by private individuals and the fearful consequences of fraud or error, have induced the Committee carefully to inquire whether any additional safeguards may be devised."

Among the changes proposed (most of which are of the nature of safeguards), or in some instances hinted at rather than proposed, were:—an emergency certificate as in Scotland, signed by one medical man, but if the patient remains in the asylum more than three days, two fresh certificates to be obtained; in addition to report now required after the admission of the patient, a careful statement to be prepared from the case book and sent to the Lunacy Board at the end of the first month; the order on which every patient is admitted to continue in force for not more than three years, when a special report should be sent to the Board by the superintendent, and repeated annually; the original order to be given by a near relative as in Ireland, or some responsible person who could be called to account; the patient being visited every six months by the person signing the order, the "surest mode of guarding against unduly prolonged detention consisting in frequent and careful visitation of all places in which any lunatic is confined, with full power placed in the hands of the Commissioners to order his discharge, and in the more general adoption of the system of probationary release." Reports to be sent to the Commissioners of patients kept under restraint in private families or religious houses in the British Isles, not for profit, provided that the reports are confidential, and the patients confirmed lunatics, and not merely suffering under temporary derangement. On showing good cause for such a course, any person, as in Scotland, with the sanction of the Commissioners, to send two medical men to test the condition of any patient under control. Personal examination of patients, such as that made by the Chancery Visitors, to be extended to them irrespective of the possession of property. "Either the Chancery lunatics, who number less than a thousand, have too much cure bestowed upon them, or the others, who exceed sixty-five thousand, have far too little.... It seems physically impossible that, with the present strength of the Lunacy Commissioners, minute supervision of those who require it can be efficiently exercised." Amalgamation of the two departments might obviate waste of power in visiting, stricter supervision being also exercised over single patients, who are only visited once a year, there being nothing in the Acts to necessitate even this visitation. Transference of administration of property of persons unable to manage it, without deprivation of liberty, suggested. Particular workhouses to be devoted to harmless lunatics, who now crowd the asylums, by a common action of the workhouse authorities within certain areas. Voluntary boarders to be allowed to go to asylums, whether they have already been in confinement or not, notice being sent to the Lunacy Board of their admission. The existence of private asylums to be left to the spontaneous action of the public, sufficient accommodation in public asylums as in Scotland, Cornwall, and at Cheadle, being encouraged and facilitated by enlargement of the powers of magistrates, and other means calculated to extend this system. Greater freedom of patients in asylums, and of their visitation by friends, and in correspondence, are regarded as valuable securities against the infringement of personal liberty. Whatever changes are made, a consolidation of the Lunacy Acts would be most desirable. Such were the main proposals.

These suggestions of the Committee have not yet borne fruit, but will, no doubt, be of service in future lunacy legislation.

Mr. Dillwyn, in introducing his last Bill (May 25, 1881),[176] proposed that no one should be confined as a lunatic except upon an order of the justice of the peace; that no one should be incarcerated except at the instance of a near relative, or of some solicitor of repute. There was also provision that due notice should be given before a justice made the order, and that the order must be authorized by two medical men, one of whom should be the medical officer of the district. For violent lunatics he proposed the Scotch law, which permitted an emergency certificate, enabling persons who had paroxysms of lunacy to be detained for twenty-four hours, but not longer, except on the order of some competent authority. In the matter of discharges, he proposed that patients should be discharged on the order of a Judge in Chambers, a stipendiary magistrate, or a County Court judge, who should order two medical men to visit the lunatic, and report on the case; and such judge, after communicating with the Lunacy Commissioners, might order the lunatic to be liberated within ten days. As to private asylums, Mr. Dillwyn knew that the proposals he made bearing upon them would be met by the argument of vested interests on the part of the proprietors, but he did not think such interests ought to be exceptionally respected. He did not wish to introduce compulsion, but proposed that justices should be enabled to raise money by way of terminable annuities for the reception in public asylums of those who could pay. Mr. Dillwyn on this occasion was in a generous mood, for he observed that "he had nothing to say against private asylums, which, on the whole, were very well conducted." What he objected to was the interest which the proprietors had in keeping their patients as long as possible. Mr. Dillwyn objected to the present system of inspection, and made certain proposals with a view to increase its efficiency—including a paid chairman of the Lunacy Board. Mr. Dillwyn's Bill never reached the stage of the third reading, nor was it discussed in committee; and the Government, which expressed a hope that they might be able to take the matter in hand, has not yet found time to bring in a Bill.

* * * * *

It will be seen from the foregoing sketch that the example of a better system of treatment slowly but surely exercised a beneficial effect, combined as it was by the exposure of the neglect and cruelty which for the most part marked the treatment in asylums, workhouses, and also the home care of the insane; that the demand for legislative inquiry and interference followed; and that the system of inspection has, step by step, been rendered stricter and more effective. First there was introduced the visitation by the College of Physicians, through five of its Fellows—a miserable failure. Then there was, in 1828, the appointment of Metropolitan Commissioners, whose authority was in 1842 extended to the whole of England and Wales; and, last of all, was the establishment of the Board of Lunacy Commissioners on the basis upon which it is now constituted. So woefully slow, if eventually successful, is the march of events in the progress of reform.

There have been several members of the legislature who have honourably distinguished themselves by advocating in Parliament the claims of a class whose unhappy characteristic it is that they are unable to advocate their own cause, among whom may be mentioned Mr. T. Townshend, Mr. Wynn, Mr. Rose, Mr. Gordon, Lord Somerset; but to no single legislator is so great a debt of gratitude due as to Lord Shaftesbury, whose untiring efforts, and conciliatory yet firm bearing, in bringing forward his measures for the relief of the insane, combined with a thorough mastery of the question and an intimate acquaintance with the condition of houses for their care and treatment, have effected the greatest good, and served to carry into extensive operation, principles already enunciated, it is true, and even partially practised, but requiring the strong arm of the law to enforce their recognition throughout the Kingdom. The extent of obligation the insane and their friends owe to Lord Shaftesbury, who for more than fifty years has devoted himself to their interest, can only be fully estimated by those who have carefully traced his unwearied assiduity in conducting measures through Parliament, providing for the erection of lunatic asylums and the proper visitation of their inmates, and who are acquainted with the manner in which he has filled the office of Chairman of the existing Lunacy Board since it was formed. At that period Mr. Sheil could say in the House, without fear of contradiction, that "it may be truly stated that the noble lord had added nobility even to the name of Ashley, and that he had made humanity one of 'Shaftesbury's Characteristics.'"[177]


[140] Edinburgh Review, vol. xxviii. p. 433.

[141] The "Private Mad-house Bill" of 1814 was introduced, April 5th, "to repeal and render more effectual the provisions of the Act of the 14th of the King." Mr. Rose said there were actually cases in which it was found that the medical certificate was signed by the keeper of the house. His Bill provided for the periodical visitation of private mad-houses by magistrates. The Bill passed the Commons July 11, 1814. Its author stated that it had been introduced the year before and amply considered by a Committee of the House, who were unanimous for its adoption, but I find no reference whatever in Hansard in 1813 to any Bill or Committee (see Hansard, vol. xxvii.).

[142] The chief members of the Committee were Lord R. Seymour, Lord Binning, the Right Hon. G. Rose, the Hon. H. G. Bennet, Mr. Western, Mr. W. Smith, and the Hon. W. H. Lyttleton.

[143] Hansard, vol. xxx. p. 954.

[144] Edinburgh Review, vol. xxviii. p. 435.

[145] Op. cit., p. 441. "Even after the publication of the evidence, it was not until the enormity of retaining the offending parties had been expressly condemned in Parliament that Mr. Haslam, the apothecary, was dismissed" (p. 443).

[146] Minutes, Select Committee of the House of Commons, 1815, pp. 43 and 44. See also Mr. J. B. Sharpe's edition of this Report, each subject arranged under its distinct head, 8vo, pp. 411. London.

[147] Ibid., pp. 167, 168. In the Minutes of the Committee of 1816, it is stated that in the same asylum the inmates were subjected to brutal cruelties from the attendants; that they suffered very much from cold, and were infested with vermin (p. 2, et seq.).

It may be added, as showing the slowness of reform, that even when, in 1828, two medical superintendents were appointed at Bethnal Green, no less than seventy, out of four hundred patients, were in irons; there was no bath, no book or newspaper, and little or no employment.

[148] Minutes of Evidence, Select Committee on Mad-houses, 1815, p. 43.

[149] Hansard, vol. xxxi. p. 1146.

[150] Hansard, vol. xxxiv.

[151] Mr. Rose had recently died (1818). Though not immediately successful, his labours deserve our cordial recognition.

[152] Hansard, vol. xxxix. p. 974.

[153] 59 Geo. III. c. 127.

[154] "I do hereby certify that by the directions of L. M. and N. O., Justices of the Peace for the county of H., I have personally examined C. D., and that the said C. D. appears to me to be of insane mind." Unfortunately a medical certificate in those days was not always of great value. Too many were illiterate productions like the following, on which a patient was admitted to Dr. Finch's asylum, Salisbury: "He{y} Broadway A Potcarey of Gillingham Certefy that Mr. James Burt Misfortin hapened by a Plow in the Hed which is the Ocaision of his Ellness and By the Rising and Falling of the Blood And I think a Blister and Bleeding and Meddesen Will be A Very Great thing but Mr James Burt wold not A Gree to be don at Home. March 21, 1809. H{ay} Broadway."

[155] "A General View of the Present State of Lunatics and Lunatic Asylums in Great Britain and Ireland."

[156] The cost of some of the asylums mentioned is worth noting:—Bedford, with 180 beds, L20,500; Cornwall, with 172, L18,780; Gloucester, with 120, L42,856; Lancaster, for 593, L100,695; Stafford, for 120, L36,500; Nottingham, for 170, L36,800; Norfolk, for 220, L50,000; Wakefield, for 420, L46,620. (Except Cornwall, land is included.)

[157] In reply it was asserted that the room was twenty-six feet long, and the number of cribs fifteen.

[158] In 1827 Sir A. Halliday wrote: "This Act, the inadequacy of which has long been ascertained and fully exposed, is still the only law by which mad-houses are licensed and regulated in England and Wales.... That it has remained so long upon the statute book must hereafter excite astonishment; and that even now, there should exist so much difficulty in having it altered and amended, is a fact scarcely to be credited. Yet such is the fact; and thousands of our fellow-men have been hurried to an untimely grave, in all the horrors of raving madness or helpless fatuity, without its being possible to get their condition altered or amended, merely because certain (we hope mistaken) prejudices were entertained by an exalted individual whose voice was long paramount in the senate; and we had almost added, through the influence of those who have realized immense fortunes as wholesale dealers and traffickers in this species of human misery."

[159] Hansard, vol. xviii. p. 583.

[160] Hansard, vol. xix. p. 195.

[161] See Appendix D.

[162] Minutes of Evidence of Select Committee of the House of Commons, 1859, p. 65.

[163] The Act of 1828 was amended by 2 and 3 Will. IV., c. 107.

[164] 2 and 3 Will. IV., c. 107. The Metropolitan Commissioners were, under this Act, to be appointed by the Lord Chancellor instead of the Home Secretary. Not less than four or more than five were to be physicians, and two barristers.

[165] Hansard, vol. lxi. p. 806.

[166] 5 and 6 Vict., c. 87.

[167] Report of the Metropolitan Commissioners, 1844.

[168] For some of the details of this Report, see chapter v.

[169] Hansard, vol. lxxvi. p. 1274.

[170] These were to be visited by a small private Committee named by the Lord Chancellor.

[171] 8 and 9 Vict., c. 100 and c. 126 (see Appendix E.)

[172] For more particular provisions in these Acts and that of 1855 (18 and 19 Vict., c. 105), containing some further amendments, see Appendix F.

[173] See Appendix G.

[174] In the following year another statute (26 and 27 Vict., c. 110), entitled "An Act to amend the Lunacy Acts," was passed, but only consisted of three sections referring to one or two doubtful points in the previous Act, which do not require notice. How many Acts of Parliament are necessitated by the blundering obscurity of the person who, as draughtsman, escapes criticism?

[175] For an analysis of the evidence, and considerations thereupon, the writer may refer to an article in the Contemporary Review, October, 1877, entitled "Lunacy Legislation."

[176] "Parliamentary Debates," 3rd Series, vol. 261, p. 1278.

[177] Mr. Gordon died in 1864. In their Report of that year, the Commissioners "deplore the death of their colleague, Mr. Robert Gordon, whose name has been prominent, during the greater part of the last half century, in connection with efforts to ameliorate the condition of the insane," and add, "Down to the present time, Mr. Gordon has given to our labours, constant and valuable personal aid; and his unwearied and disinterested service, closed only by death, we must remember always with respect and gratitude." It may be mentioned here that Mr. Wynn, to whose exertions the Act of 1808 (p. 128) was due, lived to witness Lord Ashley's Act of 1846 passed, and was present in the House during the debate.



Before presenting official evidence of the gradual progress in the condition of the insane in England, we must interpose in our history a brief reference to the development of what every one knows as the non-restraint system of treating the insane. It is, no doubt, true that restraint begins the moment a patient enters an asylum, under whatever name it may be disguised, but by this term is technically meant the non-use of mechanical restraint of the limbs by the strait waistcoat, leg-locks, etc. If, as indeed it may be granted, it had its real origin in the humane system of treatment introduced into England long previously, it was in the first instance at Lincoln, and subsequently at Hanwell, adopted as a universal method, and as a rule having almost the sanctity of a vow.

The following table shows, in the clearest manner, by what gradual steps the experiment was tried and carried on at the former asylum. Dr. Charlesworth was the visiting physician and Mr. R. Gardiner Hill the house surgeon.

- - - Year. Total Total Total number Total number of number number of instances hours under in the restrained. of restraint. restraint. house. - - - 1829 72 39 1727 20,424 1830 92 54 2364 27,113-3/4 1831 70 40 1004 10,830 1832 81 55 1401 15,671-1/2 1833 87 44 1109 12,003-1/2 1834 109 45 647 6,597 1835 108 28 323 2,874 1836 115 12 39 334 1837 130 2 3 28 - - -

Here we observe that in 1829 more than half the number of the inmates were subjected to mechanical restraint, while in 1836, out of 115 patients, only twelve were so confined, and in 1837 there were only two out of 130.[178] The total disuse of mechanical restraints followed. They were, however, resorted to on one or two occasions subsequently.

In connection with the foregoing, it must be mentioned that the entries of the visitors and the reports of the physicians alike agree in describing the condition of the patients as much improved, the quiet of the house increased, and the number of accidents and suicides as materially reduced in number.

It would appear that the mitigation of restraint, as evidenced by these minutes (which commence with 1819), "was ever the principle," to use Mr. Hill's own words, "pressed upon the attention of the Boards of the Lincoln Asylum by its able and humane physician, Dr. Charlesworth, at whose suggestion many of the more cruel instruments of restraint were long since destroyed, very many valuable improvements and facilities gradually adopted, and machinery set in motion which has led to the unhoped-for result of actual abolition, under a firm determination to work out the system to its utmost applicable limits." Mr. Hill became house surgeon in 1835; and it will be seen, by the table already given, that the amount of restraint (which, in consequence of Dr. Charlesworth's exertions, had already remarkably decreased) became less and less under the united efforts of these gentlemen, until the close of the year 1837, when restraint was entirely abolished; and while, on the one hand, as Mr. Hill frankly acknowledges, "to his [Dr. Charlesworth's] steady support, under many difficulties, I owe chiefly the success which has attended my plans and labours," while Dr. Charlesworth's great merit, both before and after Mr. Hill's appointment, must never be overlooked, it is due to the latter gentleman to admit that he was the first to assert the principle of the entire abolition of mechanical restraint, as is stated in the "Fourteenth Annual Report of the Lincoln Asylum," which report is signed by Dr. Charlesworth himself.

For a time there were, certainly, some drawbacks to the success of the Lincoln experiment, from the serious physical effects (such as broken ribs, etc.), which occasionally resulted from the struggles between attendants and patients; and it is probable that, had not the experiment been carried out on a much larger scale at Hanwell by Dr. Conolly, with far greater success, a reaction would have ensued, of infinite injury to the cause of the insane.

Dr. Conolly went to Hanwell in 1839; and in the first of an admirable series of reports written by him, we read, "The article of treatment in which the resident physician has thought it expedient to depart the most widely from the previous practice of the asylum, has been that which relates to the personal coercion, or forcible restraint, of the refractory patients.... By a list of restraints appended to this report, it will be seen that the daily number in restraint was in July so reduced, that there were sometimes only four, and never more than fourteen, at one time [out of eight hundred]; but, since the middle of August, there has not been one patient in restraint on the female side of the house; and since September 21st, not one on either side.... For patients who take off or destroy their clothes, strong dresses are provided, secured round the waist by a leathern belt, fastened by a small lock.... No form of waistcoat, no hand-straps, no leg-locks, nor any contrivance confining the trunk or limbs or any of the muscles, is now in use. The coercion-chairs (forty in number) have been altogether removed from the walls.... Several patients formerly consigned to them, silent and stupid, and sinking into fatuity, may now be seen cheerfully moving about the walls or airing-courts; and there can be no question that they have been happily set free from a thraldom, of which one constant and lamentable consequence was the acquisition of uncleanly habits."

In a later report (October, 1844) Dr. Conolly observes, "After five years' experience, I have no hesitation in recording my opinion that, with a well-constituted governing body, animated by philanthropy, directed by intelligence, and acting by means of proper officers (entrusted with a due degree of authority over attendants properly selected, and capable of exercising an efficient superintendence over the patients), there is no asylum in the world in which all mechanical restraints may not be abolished, not only with perfect safety, but with incalculable advantage."

Four years ago when I visited the Lancaster Asylum, I was shown a room containing the dire instruments of coercion formerly in use, and a most instructive exhibition it was. At my request the superintendent, Dr. Cassidy, has kindly provided me with the following list of these articles: 1 cap with straps; 4 stocks to prevent biting; 2 muzzles (leather) to cover face and fasten at the back of the head; 10 leather gloves, of various forms, perforated with holes, and cuffs of leather or iron; 14 double ditto, with irons for wrists; 1 kicking shoe; 11 leather muffs with straps; 4 stout arm leathers (long sleeves with closed ends) with cross-belt and chains; 8 heavy body straps, with shoulder-pieces, waist-belts, cross-belts, and pairs of handcuffs attached by short chains; 5 ditto of somewhat different make; 30 ditto, but with leather cuffs; 2 waist straps with leather cuffs attached; 9 pairs of leather cuffs padded; 11 pairs of leg-locks; a quantity of foot and hand cuffs (iron), with chains and catches to fasten to a staple in the wall or bedstead; 21-1/2 pairs of padded leather handcuffs; a larger quantity of handcuffs, single and double, of iron; 22 sets of strong body fastenings, very heavy chains covered with leather and iron handcuffs; a large quantity of broad leather straps; a bag of padlocks; keys for handcuffs, etc.

Truly the iron must have entered into the soul of many a poor lunatic in those days. Mr. Gaskell began at once to remove handcuffs, etc., on his appointment as superintendent, February, 1840. The disuse of restraint is chronicled in the annual report, dated June, 1841. He resigned, January 16, 1849, to become a Commissioner in Lunacy.

The Metropolitan Commissioners in Lunacy, as we have seen in the previous chapter, issued a Report which forms an epoch in the history of the care and provision for the insane in England and Wales. It should be stated that, previous to the date of its preparation in 1844, the following asylums had been erected under the Acts 48 Geo. III., c. 96, and 9 Geo. IV., c. 40.

- County. Town. Date of opening. - Beds Bedford 1812 Chester Chester 1829 Cornwall Bodmin 1820 Dorset Forston, near Dorchester 1832 Gloucester Gloucester 1823 Kent Barming Heath, Maidstone 1833 Lancaster Lancaster Moor 1816 Leicester Leicester 1837 Middlesex Hanwell 1831 Norfolk Thorpe, near Norwich 1814 Nottingham Nottingham 1812 Stafford Stafford 1818 Suffolk Melton, near Woodbridge 1829 Surrey Springfield, Wandsworth 1841 York, West Riding Wakefield 1818

There were two asylums in operation at this date, which were declared by local Acts county asylums, subject to the provisions of 9 Geo. IV., c. 40, viz. St. Peter's Hospital, Bristol, incorporated in the year 1696; and one at Haverfordwest, county of Pembroke, 1824.

The military and naval hospitals were two in number, viz.—

- - Hospital. Nature. Date of opening. - - Fort Clarence, Chatham Military 1819 Haslar Hospital, Gosport Naval 1818 - -

Then there were the old hospitals of Bethlem and St. Luke's—the former more specially devoted to the insane in 1547, removed from Bishopsgate Street to Moorfields in 1676, and opened in St. George's Fields in 1815; the latter opened July 30, 1751.

The other public lunatic hospitals, nine[179] in number, were—

Locality. Name of Asylum. Date of opening. Exeter St. Thomas' 1801 Lincoln Lunatic Asylum 1820 Liverpool " " 1792 Northampton General Lunatic Asylum 1838 Norwich Bethel Hospital 1713 Oxford (Headington) Warneford Asylum 1826 York Bootham Asylum 1777 " The Retreat 1796

The total number of recognized lunatics on the 1st of January, 1844, were—

Private 4,072 Pauper 16,821 ——— Total 20,893

They were thus distributed:—


+ + + - Where Private Paupers. Total. confined. patients. + -+ -+ + -+ -+ + -+ + M. F. Total. M. F. Total. M. F. Total. + -+ -+ + -+ -+ + -+ + 15 county asylums 130 115 245 1,924 2,231 4,155 2,054 2,346 4,400 2 ditto under local acts 38 51 89 38 51 89 2 military and naval hospitals 164 4 168 164 4 168 2 Bethlem and St. Luke's Hospitals 178 264 442 86 35 121 264 299 563 9 other public asylums 249 287 536 177 166 343 426 453 879 Licensed houses: 37 metropolitan 520 453 973 360 494 854 880 947 1,827 99 provincial 748 678 1,426 947 973 1,920 1,695 1,651 3,346 Workhouses and elsewhere[180] 4,169 5,170 9,339 4,169 5,170 9,339 Single patients under commission 172 110 282 172 110 282 + + -+ + -+ -+ + -+ + Total 2,161 1,911 4,072 7,701 9,120 16,801 9,682 11,031 20,893 -+ + -+ + -+ -+ + -+ +

The number of asylums amounted to 166.[181]

At this period there were thirty-three metropolitan licensed houses receiving private patients only, and four which received paupers also.

The dates of opening of these thirty-three private asylums, so far as known, were: three in the last century, to wit, in 1744, 1758, and 1759; one in each of the following years, 1802, 1811, 1814, 1816, 1823, 1825, 1826, 1829, 1832, 1833, 1834, 1836, 1837, 1840, 1842, and 1843; and two in 1830, 1831, 1838, and 1839.

Passing from London to the provinces, we find fifty-five provincial licensed houses receiving private patients only, and forty-four receiving paupers, of which one was in Wales (Briton Ferry, near Swansea). The known dates of opening were: in 1718, Fonthill-Gifford in Wilts; in 1744, Lea Pale House, Stoke, near Guildford; in 1766, Belle Grove House, Newcastle-on-Tyne; in 1791, Droitwitch; and in 1792, Ticehurst, Sussex; one in each of the following years, 1800, 1802, 1803, 1806, 1808, 1812, 1814, 1816, 1818, 1821, 1824, and 1829; two in each of the years 1820, 1822, 1826, 1828, 1832, 1834, 1836, 1837, 1838, and 1842; three in each of the years 1825, 1831, 1839, and 1843; four in 1833; five in 1830, 1835, and 1840; and, finally, six in 1841. One of the asylums opened in 1843 was that in Wales, containing only three patients.

Of some asylums found by the Commissioners to be in a very disgraceful state, one is described as "deficient in every comfort and almost every convenience. The refractory patients were confined in strong chairs, their arms being also fastened to the chair. One of these—a woman—was entirely naked on both the days the Commissioners visited the asylum, and without doubt during the night. The stench was so offensive that it was almost impossible to remain there." In another, "in the small cheerless day-room of the males, with only one (unglazed) window, five men were restrained by leg-locks, called hobbles, and two were wearing, in addition, iron handcuffs and fetters from the wrist to the ankle; they were all tranquil. Chains were fastened to the floors in many places, and to many of the bedsteads." The Commissioners report of another house that "in one of the cells for the women, the dimensions of which were eight feet by four, and in which there was no table and only two wooden seats, we found three females confined. There was no glazing to the window.... The two dark cells, which joined the cell used for a day-room, are the sleeping-places for these three unfortunate beings. Two of them sleep in two cribs in one cell.... There is no window and no place for light or air, except a grate over the doors." The condition of the floor and straw, on which the patients lay, it is unnecessary to describe.

We should not be doing justice to the history of non-restraint if we did not state in full what the Commissioners found at this period to be the opinion of the superintendents of the asylums in England.

"During our visits," they say, "to the different asylums, we have endeavoured to ascertain the opinions of their medical superintendents in reference to the subject of restraint, and we will now state, in general terms, the result of our inquiries. Of the superintendents of asylums not employing mechanical restraint, those of the hospitals of Lincoln, Northampton, and Haslar, and of the county asylum at Hanwell, appear to consider that it is not necessary or advisable to resort to it in any case whatever, except for surgical purposes. On the other hand, the superintendent at Lancaster[182] hesitates in giving an opinion decidedly in favour of the non-restraint system. He thinks that, although much may be done without mechanical restraint of any kind, there are occasionally cases in which it may not only be necessary, but beneficial. The superintendent of the Suffolk Asylum considers that in certain cases, and more especially in a crowded and imperfectly constructed asylum, like the one under his charge, mechanical restraint, judiciously applied, might be preferable to any other species of coercion, as being both less irritating and more effectual. The superintendent of the Gloucester Asylum states that he has adopted the disuse of mechanical restraint, upon the conviction which his experience has given him during a trial of nearly three years. Of the superintendents of asylums who employ mechanical restraint, those of the Retreat at York, of the Warneford Asylum, and of the hospitals at Exeter, Manchester, Liverpool, and St. Luke's, consider that, although the cases are extremely rare in which mechanical restraint should be applied, it is, in some instances, necessary. Similar opinions are entertained by the superintendents of the county asylums of Bedford, Chester, Cornwall, Dorset, Kent, Norfolk, Nottingham, Leicester, Stafford, and the West Riding of York. At the Retreat at York mechanical or personal restraint has been always regarded as a 'necessary evil,' but it has not been thought right to dispense with the use of a mild and protecting personal restraint, believing that, independent of all consideration for the safety of the attendants, and of the patients themselves, it may in many cases be regarded as the least irritating, and therefore the kindest, method of control. Eight of the superintendents employing bodily restraint have stated their opinion to be that it is in some cases beneficial as well as necessary, and valuable as a precaution and a remedial agent; and three of them have stated that they consider it less irritating than holding with the hands; and one of them prefers it to seclusion.

"In all the houses receiving only private patients, restraint is considered to be occasionally necessary, and beneficial to the patients.... At the Cornwall Asylum, we found a man who voluntarily wrapped his arm round with bands of cloth from the fear of striking others. He untied the cloth himself at our request. We know the case of one lady, who goes home when she is convalescent, but voluntarily returns to the asylum when she perceives that her periodical attacks of insanity are about to return, in order that she may be placed under some restraint.

"Of the asylums entirely disusing restraint, in some of them, as we have stated, the patients have been found tranquil and comfortable, and in others they have been unusually excited and disturbed. Without, however, attaching undue importance to the condition of the asylum at the time of our visits, or to accidents that may happen under any system of managing the insane, it is nevertheless our duty to call your Lordship's attention to the fact that since the autumn of 1842 a patient and a superintendent have been killed; a matron has been so seriously injured that her life was considered to be in imminent danger (at Dr. Philp's house at Kensington); another superintendent has been so bitten as to cause serious apprehensions that his arm must have been amputated; and two keepers have been injured so as to endanger their lives. These fatal and serious injuries and accidents have been caused by dangerous patients, and some of them in asylums where either the system of non-coercion is voluntarily practised, or is adopted in deference to public opinion."

The following is a brief summary of the arguments of medical officers and superintendents advocating absolute non-restraint at that period:—

1. That their practice is the most humane, and most beneficial to the patient; soothing instead of coercing him during irritation; and encouraging him when tranquil to exert his faculties, in order to acquire complete self-control.

2. That a recovery thus obtained is likely to be more permanent than if obtained by other means; and that, in case of a tendency to relapse, the patient will, of his own accord, be more likely to endeavour to resist any return of his malady.

3. That mechanical restraint has a bad moral effect; that it degrades the patient in his own opinion; that it prevents any exertion on his part; and thus impedes his recovery.

4. That experience has demonstrated the advantage of entirely abolishing restraint, inasmuch as the condition of some asylums, where it had been previously practised in a moderate and very restricted degree, has been greatly improved, with respect to the tranquillity and the appearance of cheerfulness among the patients in general, after all mechanical coercion has been discontinued.

5. That mechanical restraint, if used at all, is liable to great abuse from keepers and nurses, who will often resort to it for the sake of avoiding trouble to themselves; and who, even when well disposed towards the patient, are not competent to judge of the extent to which it ought to be applied.

6. The patient may be controlled as effectually without mechanical restraint, as with it; and that the only requisites for enabling the superintendents of asylums to dispense with the use of mechanical restraint, are a greater number of attendants, and a better system of classification amongst the patients; and that the additional expense thereby incurred ought not to form a consideration where the comfort of the patients is concerned.

On the other hand, the medical and other superintendents of lunatic asylums who adopted a system of non-restraint as a general rule, but made exceptions in certain extreme cases, urged the following reasons for occasionally using some slight coercion:—

1. That it is necessary to possess, and to acquire as soon as possible, a certain degree of authority or influence over the patient, in order to enforce obedience to such salutary regulations as may be laid down for his benefit.

2. That, although this authority or influence is obtained in a majority of cases by kindness and persuasion, there are frequent instances where these means entirely fail. That it then becomes necessary to have recourse to other measures, and, at all events, to show the patient that, in default of his compliance, it is in the power of the superintendent to employ coercion.

3. That a judicious employment of authority mixed with kindness (and sometimes with indulgence) has been found to succeed better than any other method.

4. That the occasional use of slight mechanical restraint has, in many instances, been found to promote tranquillity by day and rest by night.

5. That it prevents, more surely than any supervision can effect, the patient from injuring himself or the other patients.

6. That, particularly in large establishments, the supervision must be trusted mainly to the attendants, who are not always to be depended on, and whose patience, in cases of protracted violence, is frequently worn out. That in such cases mild restraint insures more completely the safety of the attendants, and contributes much to the tranquillity and comfort of the surrounding patients.

7. That in many cases mild mechanical restraint tends less to irritate, and generally less to exhaust the patient, than the act of detaining him by manual strength, or forcing him into a place of seclusion, and leaving him at liberty to throw himself violently about for hours together.

8. That the expense of a number of attendants—not, indeed, more than sufficient to restrain a patient during a violent paroxysm, but nevertheless far beyond the ordinary exigencies of the establishment—is impracticable in asylums where only a small number of paupers are received.

9. That the occasional use of slight coercion, particularly in protracted cases, possesses this additional advantage: that it gives the patient the opportunity of taking exercise in the open air at times when, but for the use of it, he would necessarily be in a state of seclusion.

10. The system of non-restraint cannot be safely carried into execution without considerable additional expense; a matter which will necessarily enter into the consideration of those who are desirous of forming a correct opinion as to the precise benefits likely to arise from the adoption or rejection of such a system.

11. That the benefit to the patient himself, if indeed it exist at all, is not the only question; but that it ought to be considered, whether the doubtful advantage to himself ought to be purchased by the danger to which both he and his attendants and other patients are exposed, when restraint is altogether abolished.

And 12thly. That, when a patient is forced into and secluded in a small room or cell, it is essentially coercion in another form, and under another name; and that it is attended with quite as bad a moral effect, as any that can arise from mechanical restraint.[183]

Passing on to 1847, we find the Commissioners in Lunacy, having acted under the new powers conferred upon them by the two Acts passed since the date of the Report of 1844 (8 and 9 Vict., cc. 100 and 126), able to give a satisfactory sketch of the progress of reform in the condition of asylums. "In several of the county asylums and hospitals," they observe, "the adoption of a more gentle mode of management was originally designed in the direction of these establishments, and was the result of public opinion and of the example set by the managers of the Retreat near York. A strong impression was made on the feelings and opinion of the public in reference to the treatment of lunatics by the publication of Mr. Tuke's account of the Retreat at York. The able writings of Dr. Conolly have of late years contributed greatly to strengthen that impression, and to bring about a much more humane treatment of lunatics in many provincial asylums, than that which formerly prevailed." Referring, then, to the Report of the Metropolitan Commissioners (1844) it is observed that "proof is afforded therein that this amendment had not extended itself to old establishments for the insane, and that much severe and needless restraint continued to be practised in numerous private, and in some public asylums. In many of the private asylums, and more especially in those which received great numbers of pauper patients, much mechanical coercion was practised, until it came to be in great measure laid aside in consequence of the repeated advice and interference of the Commissioners.... In private licensed asylums it has been thought impracticable to avoid the occasional use of mechanical coercion without incurring the risk of serious accidents. Under these circumstances restraint of a mild kind is still practised, but we look forward to its abolition, except, perhaps, in some extraordinary cases, so far as pauper patients are concerned, when the provisions of the Act for the establishment of county asylums shall have been carried into effect. In the best-conducted county asylums it is now seldom (and in a few establishments never) resorted to."[184]

At this period, the actual number of lunatics returned to the Commissioners was only 18,814, but they estimated the number under some kind of care, in England and Wales, at 26,516. There were—

- - Location. Private. Pauper. Total. - - In county asylums, hospitals, and licensed houses 3,574 9,652 13,226 Bethlem, and in naval and military hospitals not subjected to visitation of Commissioners 606 606 Poor-law unions; placed under local Acts 8,986 8,986 Gilbert's unions, and other places not in union 176 176 Single patients found lunatic by inquisition 307 307 Ditto in private houses with persons receiving profit 130 130 Excess of pauper patients in workhouses, etc., estimated by visiting Commissioners as at least one-third over the number number returned by parish officers 3,053 3,053 Criminals in jails 32 32 - Total 4,617 21,899 26,516 - -

The number of patients found lunatic by inquisition was 542; their incomes amounting to L280,000. In 1839 the corresponding numbers were 494 and L277,991.

The estimated annual amount expended at this time for maintenance of lunatics, or administered on their behalf, exceeded L750,000, thus distributed:

1. Cost of 9652 paupers in asylums, estimated at 8s. per week L200,762

2. Ditto of 8986 paupers in workhouses, etc., and 173 in parishes not in union (9159), estimated at 3s. per week 71,440

3. Ditto of excess of 3053 paupers over the number returned by the parish officer 23,813

4. Ditto of 3574 private patients in asylums, etc., at an average of 20s. per week 173,628

5. Income of 542 private patients found lunatic by inquisition 280,000

6. Cost of 606 patients in Bethlem and the naval and military hospitals, estimated at 10s. per week 50,756

7. Ditto of 120 other single patients taken charge of in separate houses at L100 a year 12,000

8. Thirty-two criminals in jails, estimated at 3s. per week 249 ———— Total L777,648

Adding the expense of maintaining many families cast upon the parish in consequence of the patient's insanity, and the expense of supporting many called imbecile, and the interest of large sums invested in public establishments, the Commissioners estimated the actual amount as little less than L1,000,000.

In the same Report the Commissioners observe "that they have found that, with some exceptions, the patients have apparently been humanely, and sometimes very judiciously treated. There is no reason to apprehend that the lunatic patient is now often subjected to cruelty or ill-treatment.... The massive bars, and rings, and chains of iron formerly resorted to are no longer seen. Any continued coercion is not permitted. The name of every patient under restraint and in seclusion, and the means by which such seclusion is effected, are recorded every week in a journal. Thus the safeguards against lunatic patients being subjected to harsh or unnecessary restraint from the cruelty, idleness, or caprice of their attendants, have been multiplied, and the chances of abuse reduced to a small amount."

The number of lunatics placed under mechanical restraint in licensed houses in this year is given in the following table, it being premised that wherever the number is not specified, "it may be assumed either that there was no patient then under restraint, or that the number was so small, and the restraint so trivial, as not to be deemed worthy of special remark."[185]

+ -+ -+ Number of Under Asylum. patients. Criminals. restraint last visit. + -+ -+ METROPOLITAN LICENSED HOUSES. Bethnal Green Red House } White House } 614 12 4 Bow Grove Hall 291 2 Brompton Earls Court 32 1 Camberwell Camberwell House 246 1 5 Clapham Retreat 15 1 Clapton, Upper Brook House 42 1 Fulham Beaufort House 5 2 Hillingdon Moorcroft House 50 1 Hoxton Hoxton House 416 4 Kensington Kensington House 44 2 Peckham Peckham House 409 4 4 Stoke Newington Northumberland House 35 1 + -+ -+

+ -+ -+ Number of Under Asylum. patients. Criminals. restraint last visit. + -+ -+ PROVINCIAL LICENSED HOUSES. Derby Green Hill House 25 1 Durham Gateshead Fell 92 8 1 Essex High Beach 34 2 Gloucester Fishponds 45 1 " Northwoods 29 1 " Fairford 175 1 1 Hants Grove Place 78 1 1 Herefordshire Whitchurch 32 2 1 Kent West Malling Place 40 3 Lancaster Blakely House 24 1 Northumberland Bell Grove House 13 1 Oxford Witney 11 2 " Hook-Norton 57 1 2 Somerset Bailbrook House 92 3 10 Stafford Oulton Retreat 25 2 " Sandfield 44 1 Sussex Ringmer 3 1 Warwick Duddeston Hall 87 3 6 " Kingstown House 91 2 Wilts Bellevue House 181 5 5 " Fiddington House 193 3 3 Worcester Droitwich 91 2 2 York, East Riding Hull and East Riding Refuge 115 8 1 " " Hessle 12 1 " West Riding Castleton Lodge 15 1 " " Grove House 41 5 " " Heworth 29 1 + -+ -+

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