If for the purpose of comparison at different years we take one asylum, Ringmer in Sussex, there were in November 1829, nineteen patients, of whom five were under restraint by day, and seven by night. In 1830 (February) the number of patients was twenty, and of these eleven were under restraint by day and six by night; while in October of the same year, out of eighteen patients, there were nine under restraint. In 1831, there were twenty-two patients, ten of whom were under restraint. Writing in 1848, the Commissioners enumerate the various changes for the better which had then taken place, among which were—an active medical superintendence; the abolition of excessive use of mechanical restraint, there being sometimes only one or two, and occasionally no patient whatever, under mechanical restraint; the introduction of warm and cold baths; the cleanliness of the day-rooms and dormitories; the addition of a good library, and various amusements and means of occupation; and also an excellent dietary. Such is a sample of the happy change which was, in many instances, brought about by inspection.
The following classification of asylums in 1851 will show at a glance the progress made in providing accommodation from time to time, consequent upon legislation:—
1. Asylums existing prior to passing of Act 8 and 9 Vict., c. 126.
Accommodation for pauper lunatics at passing of the Act 5560 Additional accommodation provided therein since the passing of the Act 1753 —— Total accommodation 7313
2. Asylums in progress of erection at passing of Act 8 and 9 Vict., c. 126, and since opened.
Number for which designed 997 Subsequent additions 206 —— Total present accommodation 1203
3. Asylums erected or provided under the provisions of the Act 8 and 9 Vict., c. 126, and now opened.
Accommodation for pauper lunatics 1114
4. Asylums in progress of erection under Act 8 and 9 Vict., c. 126, and not yet opened.
Proposed accommodation for pauper lunatics 4299 Under provisions of previous Acts 6557 Under Act 8 and 9 Vict., c. 126 7372 ——— Total 13,929 Exclusive of 192 in Northampton Hospital.
Asylums existing prior to or at the passing of Act 8 and 9 Vict., c. 126—
Beds., Herts and Hants., Chester, Cornwall, Devon, Dorset, Gloucester, Kent, Lancaster (containing the largest number of patients, 700), Leicester and Rutland, Middlesex (Hanwell), Norfolk, Notts., Salop and Montgomery, Stafford, Suffolk, Surrey, West Riding, Yorkshire, Bristol (borough). Wales—Haverfordwest (town and county), Montgomery (see Salop).
Asylums in progress of erection at the passing of this Act, and since opened—
Oxford and Berks, Somerset, North and East Riding, Yorkshire. Wales—Anglesea, Carnarvon, Denbigh, Flint, Merioneth.
Total number for which designed 997 Additions since passing the Act 206 —— Total 1203
Counties in which no steps are taken to provide asylums—
Cumberland, Durham, Northampton, Sussex, Westmoreland.
Total accommodation 5560 Subsequent additions 1753 —— Total 7313
Asylums erected or provided under the above Act and now opened—
West Lancashire (Rainhill), East Lancashire (Prestwich, near Manchester), Birmingham (borough), Kingston-upon-Hull.
For these asylums the accommodation provided in the first instance was 1114.
There were still upwards of fifty boroughs for whose pauper lunatics no legal provision was made, and no asylum was then erected for the City of London.
Under the head of mechanical restraint, the Commissioners now report that it has still further diminished, and has in some houses been absolutely abolished. However, in fifty entries made in the books of thirty-six private asylums, abuses and defects are animadverted upon in fifteen instances in regard to restraint, in twenty instances in regard to bedding and clothing, nine in regard to diet, seven in regard to cleanliness, and four in regard to management and treatment. They observe that the number of lunatics in workhouses has diminished in a very marked degree.
In this Report the Commissioners take the opportunity of animadverting, also, upon the defective state of the law in regard to the property of lunatics; the good effect of the Act 8 and 9 Vict., c. 100, being lessened by this and other causes.
Turning to the year 1854, nearly ten years after the Act of 1845 had been in fruitful operation, we find the Commissioners attaching importance to the alterations recently made in the law of lunacy by the three important statutes, 16 and 17 Vict., c. 70 (the "Lunacy Regulation Act" of 1853) which refers to Chancery lunatics; 16 and 17 Vict., c. 90 (an amendment of the Act under which the Board was constituted); and 16 and 17 Vict., c. 97 (the "Lunatic Asylums Act," 1853).
These Acts, with 8 and 9 Vict., c. 100, and 15 and 16 Vict., c. 48, and the Acts relative to criminal lunatics, constituted at that period the code of law of lunacy.
The following counties still remained unprovided for:—Sussex, Cumberland, Westmoreland, Northumberland, Durham, Cambridge, Cardigan, Carmarthen, Glamorgan, Pembroke.
New private asylums were no longer licensed for paupers, in consequence of the accommodation provided for them in county asylums.
Complaints having been made of the treatment of patients at Hanwell, an inquiry had been instituted, which, in the opinion of the Commissioners, justified them. They appeared to have been due to the want of efficient supervision of male patients.
This Report of the Commissioners gives a series of interesting replies to a circular letter addressed to the superintendents and medical proprietors of nearly all the asylums in England and Wales, on non-restraint, upon which they observe, "as the general result which may be fairly deduced from a careful examination and review of the whole body of information thus collected, we feel ourselves fully warranted in stating that the disuse of instrumental restraint, as unnecessary and injurious to the patient, is practically the rule in nearly all the public institutions in the kingdom, and generally also in the best-conducted private asylums, even those where the restraint system, as an abstract principle admitting of no deviation or exception, has not in terms been adopted.
"For ourselves," they observe, "we have long been convinced, and have steadily acted on the conviction, that the possibility of dispensing with mechanical coercion in the management of the insane is, in a vast majority of cases, a mere question of expense, and that its continued, or systematic use in the asylums and licensed houses where it still prevails must in a great measure be ascribed to their want of suitable space and accommodations, their defective structural arrangements, or their not possessing an adequate staff of properly qualified attendants, and frequently to all these causes combined.
"Our matured views upon the subject will be best understood by stating the course we have followed in the discharge of our functions as visitors. In that capacity we have made it a principle to discourage, to the utmost, the employment of instrumental restraint in any form. Wherever we have found it in use, our uniform practice has been to inquire minutely into the circumstances and reasons alleged for its necessity, and to insist on recourse being had to those various other means which experience has proved in other houses to be effective substitutes for it....
"As respects the question of seclusion, its occasional use for short periods, chiefly during paroxysms of epilepsy or violent mania, is generally considered beneficial. At the same time, we would observe that the facilities which seclusion holds out to harsh or indolent attendants for getting rid of and neglecting troublesome patients under violent attacks of mania, instead of taking pains to soothe their irritated feelings, and work off their excitement by exercise and change of scene, render it liable to considerable abuse; and that, as a practice, it is open, though in a minor degree, to nearly the same objections which apply to the more stringent forms of mechanical restraint. We are therefore strongly of opinion that, when even seclusion is resorted to as a means of tranquillizing the patient, it should only be employed with the knowledge and direct sanction of the medical officer, and even then be of very limited duration.
"Further experience, we think, has shown that, except for the reception of epileptic patients during the continuance of their paroxysms, and in a few cases where there is a determined propensity to suicide, the utility of padded rooms is not so great as was at one time supposed; and that, for cases of ordinary maniacal excitement, seclusion in a common day-room or sleeping-room of moderate size, from which all articles that might furnish instruments of violence or destruction have been removed, and which is capable of being readily darkened, when required, by a locked shutter, will, in general, be found to answer every useful purpose."
As ten years had elapsed since the first attempt of any value to present the numbers of the insane in England (see page 211), it is of interest to compare with the table referred to, the following statement of the numbers on the 1st of January, 1854:—
GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE INSANE IN ENGLAND AND WALES, JANUARY 1, 1854.
+ + + Where Private Paupers. Total. confined. patients. + -+ -+ + + + + + + M. F. Total. M. F. Total. M. F. Total. + -+ -+ + + + + + + 33 county and borough asylums 147 146 293 5,791 6,878 12,669 5,938 7,024 12,962 2 military and naval hospitals 199 5 204 199 5 204 2 Bethlem and St. Luke's Hospitals 235 239 474 4 7 11 239 246 485 22 other public asylums 467 456 923 102 103 205 569 559 1,128 Licensed houses: 42 metropolitan 608 598 1,206 418 723 1,141 1,026 1,321 2,347 88 provincial 795 738 1,533 593 407 1,000 1,388 1,145 2,533 Workhouses and elsewhere 5,326 5,327 10,653 5,326 5,327 10,653 + -+ -+ + + + + + + Total 2,451 2,182 4,633 12,234 13,445 25,679 14,685 15,627 30,312 + -+ -+ + + + + + +
In their ninth Report the Commissioners speak of continued progress, and to show the beneficial effects of good and kind treatment, record the case of a lady visited by them in a private asylum, where they found her in a room by herself, in a sadly neglected condition, and very frequently placed under mechanical restraint. Her habits were dirty, and her opportunities of taking exercise few. In consequence of her unsatisfactory condition the Commissioners ordered her removal to another asylum (the York Retreat), and about twelve months afterwards saw her there, and made an entry to the effect that since her admission she had never been in restraint or seclusion; that her destructive and dirty habits had been corrected by constant attention, exercise out of doors, and association with other patients. The Commissioners found her quiet, orderly, clean, well-dressed, and so much improved in appearance that they had some difficulty at first in recognizing her.
It was inevitable, as a result of the attention directed to the condition of the insane, and the greatly increased provision made for them in consequence, that there should be an alarming apparent increase of lunacy in the kingdom. In point of fact, the number of pauper lunatics had increased sixty-four per cent. in the eight years ending 1855.
At this period there were 13,579 patients in county and borough asylums, 1689 in registered hospitals, 2523 in metropolitan and 2588 in provincial licensed houses, and 114 in the Royal Naval Hospital.
The number of insane poor not in asylums was estimated at 10,500, of whom about half were inmates of workhouses, and the remainder with relations and strangers on an allowance from the parish.
There were various obvious explanations for the apparent increase of lunacy, viz. the greatly enlarged accommodation; the prolongation of life in consequence of kind care; the parochial authorities being required to take immediate proceedings for placing violent and recent cases under treatment; medical practitioners recognizing the nature of cases of insanity better; facilities of post-office, railway, and press bringing cases to light; medical officers being required to make quarterly returns under 17 and 18 Vict., c. 97, s. 66; and the efforts of the Commissioners to impress on guardians the importance of sending recent cases to asylums.
The increase of private patients during eight years had been at the rate of only fifteen per cent.; but the Commissioners point out that this conveys an imperfect view of the relative increase of pauper and private cases, inasmuch as a practice had sprung up by which persons who had never been themselves in receipt of relief, and who are not infrequently tradesmen or thriving artisans, had been permitted to place lunatic relatives in the county asylums as pauper patients, under an arrangement with the guardians for afterwards reimbursing to the parish the whole or part of the charge for their maintenance.
"Indeed, it may be said with truth that, except among what are termed the opulent classes, any protracted attack of insanity, from the heavy expenses which its treatment entails, and the fatal interruption which it causes to everything like active industry, seldom fails to reduce its immediate victims, and generally also their families with them, to poverty, and ultimately to pauperism."
The Commissioners add—and we draw special attention to the statement—that "this is the main reason why, in our pauper lunatic asylums, many inmates are to be met with who have formerly held a respectable station in society, and who, in point of education and manners, are greatly superior to the inmates of a workhouse." Hence we see how utterly fallacious is the conclusion constantly drawn from a study of the mere figures themselves that insanity is, to the extent indicated by them, more prevalent among the lower than the higher classes of society.
The very great importance of obtaining good attendants for asylums became a prominent subject now that the number of patients under treatment had so vastly increased, and it was clearly seen that the skill of the superintendent was of little avail unless effectually carried out by a well-qualified staff of attendants. It was necessary that they should be liberally remunerated, and that their position in the house should be made comfortable. The Commissioners recommended the appointment of head attendants of a superior class, whose duties should not be restricted to any one ward, but who should be responsible for the conduct of the other attendants. A well-educated lady had been found most useful in asylums as a companion to female patients of the upper classes. The Commissioners required notices to be transmitted to their offices of all dismissals for misconduct of nurses or attendants, and of the causes thereof; these notices being regularly filed for reference, in the event of inquiries being made as to the characters of applicants for employment.
Reviewing the condition of the insane generally at this time in workhouses, the Commissioners were able to report that, upon the whole, a sensible amelioration had taken place in their physical condition and in their treatment. They abstained, however, from any official sanction of the construction of lunatic wards in workhouses; for the patients were not provided with any suitable occupation, the means for exercise were generally wanting, and the attendants were too badly paid to allow of a reliance being placed on their services.
The large number living with strangers or relatives on parish allowance appeared to have seldom fallen within the personal observation of the Commissioners, who had chiefly to depend upon the annual returns from the clerks of the Board of Guardians, and on the quarterly returns from the medical officers of the various districts, whose returns were so defective and irregular that no definite conclusion could be drawn from their contents.
In their next Report the subject of workhouses still claimed the attention of the Commissioners, and they complained that, in direct contravention of the law, pauper patients were sent first to a workhouse, instead of an asylum. The sixty-seventh section of the Act of 1853 was disregarded altogether. Hence, if the patient was found manageable in the workhouse, he was detained there, or, if ultimately sent to the asylum, much valuable time had been lost, and his chance of cure greatly lessened. The Commissioners found their recommendations set at defiance, for the most part, whenever the report of the medical officer stated the patient to be "harmless." It was urged that the lunatic wards in workhouses should be placed in the position of licensed houses, and that the Commissioners and visitors should be invested with the same power in regard to them as they possessed over these establishments. But it became very clear that, however valuable the recommendations of the Commissioners might, and, indeed, have ultimately proved to be, they did not possess the authority of commands. At the infirmary asylum at Norwich unceasing suggestions for improvement were made for ten years, which were, "with very few exceptions, systematically disregarded." Then, but not till then, did the Commissioners appeal to the Secretary of State, to require the authorities of Norwich to provide for their lunatic poor, according to the statutes 8 and 9 Vict., c. 126, passed twelve years before. The Act of 1853, having introduced some modification for boroughs of small populations, left no further excuse for making proper provision. The Commissioners from time to time issued circulars to the various asylums, and intimated their intention to report to the Secretary of State (under s. 29 of the Act) the cases of all boroughs wherein proper provision had not been made for their pauper lunatics. "But even this last appeal did not fare more successfully; and all our reiterated inquiries and remonstrances have as yet made hardly a perceptible impression upon that almost general neglect of the law which it was hoped they might repair."
As regards the important class of single patients, the Commissioners had not found it practicable to visit them as they desired to do. Many, however, had been visited. Some were found indifferently accommodated, and otherwise in a very unsatisfactory state. The provisions of the law were extensively evaded.
As the views entertained and recommended by the Commissioners from time to time are of importance in regard to the construction of asylums, it may be observed that in their Report of 1857 they dwell on the evils of very large buildings, on account of the loss of individual and responsible supervision, the loss of the patient's individuality, and the tendency of the rate of maintenance for patients to run higher. It was also maintained that the divided responsibility consequent on such large institutions was injurious to management, and that the cures of patients were actually fewer. It was considered that the limits to the size of the Hanwell Asylum were reached, and indeed exceeded, viz. for 1020, but room for 600 patients more was required. So at Colney Hatch there were 1287 patients, while 713 more demanded admission. When, in 1831, Hanwell was built for 500, it was thought sufficient to provide for the whole of Middlesex! Two years after, however, it was full; in another two years it was reported to contain 100 patients more than it was built for, and after the lapse of another two years it had to be enlarged for 300 more; Colney Hatch having been constructed for 1200 patients belonging to the same county, and opened in 1851; and yet, within a period of less than five years, it became necessary to appeal to the ratepayers for further accommodation, and the latest return showed that, at the close of 1856, there were more than 1100 paupers belonging to the county unprovided for in either of its asylums. "Hardly had they been built, when the workhouses sent into each such a large number of chronic cases as at once necessarily excluded the more immediately curable, until the stage of cure was almost past; and the doors of the establishment became virtually closed not long after they were opened to the very inmates for whom only it was needful to have made such costly provision." Hence the Commissioners urged separate and cheaper asylums for old cases; but the committees of the asylums objected. The Secretary of State induced the two parties to meet, but, being unable to agree, the Commissioners reluctantly gave way.
In 1858 the amount of existing accommodation for pauper lunatics in the counties and boroughs was—for males, 7516; females, 8715; total, 16,231; and the additions then being made to old asylums amounted to—for males, 1172; females, 1309; total, 2481. The numbers for whom additional asylums were then being made were—males, 1169; females, 1157; total, 2326. The sum of these totals being 21,048. There were, on the 1st of January of this year, 17,572 pauper lunatics in asylums, of whom as many as 2467 were still confined in private asylums. There were now 33 county and 4 borough asylums, 15 registered hospitals, 37 metropolitan licensed houses, and 80 provincial licensed houses; also the Royal Naval Hospital. The total number of inmates in these establishments were (in the order enumerated) 15,163, 1751, 2623, 2647, 126, making a grand total of 22,310, including 295 patients found lunatic by inquisition.
The Commissioners point out that a military asylum is a desideratum, there being no provision for soldiers, while sailors were well cared for at Haslar Hospital.
The following particulars will show at a glance the provision made at this period for the insane in England and Wales:—
1. Boroughs having asylums: Birmingham, Bristol (in St. Peter's Hospital), Hull.
2. Boroughs erecting or about to erect asylums: Maidstone, Bristol, City of London.
3. Boroughs in union with counties: Cambridge, Colchester, Maldon, Gloucester, Leicester, Grantham, Lincoln, Stamford, Hereford, Nottingham, Abingdon, Oxford, Reading, Shrewsbury, Wenlock, Worcester.
4. Boroughs whose pauper lunatics are sent to asylums under contract or arrangements between justices, etc.: Plymouth, Chichester, Portsmouth, Southampton, Devizes, Salisbury, Chester, Derby, Barnstaple, Bideford, Dartmouth, Exeter, South Molten, Tiverton, Tewkesbury, Bridgewater, Bridgnorth, Ludlow, Penzance, Poole, Winchester, Newark, Oswestry, Bath, Lichfield, Scarborough.
5. Boroughs which have not made any statutory provision for the care of their pauper lunatics: Bedford, Newbury, Buckingham, Carmarthen, Andover, Canterbury, Dover, Hythe, Rochester, Sandwich, Tenterden, King's Lynn, Norwich, Thetford, Yarmouth, Northampton, Berwick-upon-Tweed, Newcastle-upon-Tyne, New Radnor, Bury St. Edmunds, Ipswich, Guildford, Hastings, York.
In 1862 the expense of pauper lunatics in asylums was thrown upon the common fund of the union, instead of on the particular parish. The effect was natural. Many patients were removed from workhouses to the county asylums, some of whom might well have remained there. There could be no objection to this, if the latter cost no more than the former; but seeing that where the one costs L200 per bed, the other would only cost L40, the effect is, from the point of view of the ratepayer, who usually objects to contribute to the formation of a free library, a very serious one.
Twenty years after the census of the insane made in 1844, and ten after the period to which the table given at p. 230 refers, we find the numbers as follow:—
GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE INSANE IN ENGLAND AND WALES, JANUARY 1, 1864.
+ + + Where Private Paupers. Total. confined. patients. + -+ -+ + + + + + + M. F. Total. M. F. Total. M. F. Total. + -+ -+ + + + + + + 42 county and borough asylums 118 113 231 9,690 11,630 21,320 9,808 11,743 21,551 1 military and naval hospital 153 153 153 153 2 Bethlem and St. Luke's Hospitals 264 215 479 264 215 479 13 other public asylums 708 591 1,299 170 178 348 878 769 1,647 Licensed houses: 37 metropolitan 831 649 1,480 253 589 842 1,084 1,238 2,322 65 provincial 987 698 1,685 256 192 448 1,243 890 2,133 Workhouses and elsewhere 8,125 8,126 16,251 8,125 8,126 16,251 Broadmoor 95 95 95 95 + -+ -+ + + + + + + Total 3,061 2,226 5,327 18,494 20,810 39,304 22,555 23,076 44,631 + -+ -+ + + + + + +
We must not pass by the year 1867 without recording that at this period a statute important in its bearing on the provision made for the insane poor of London was enacted. This was the Metropolitan Poor Act, which established what are known as the Metropolitan District Asylums for Imbeciles at Leavesden (Hertfordshire), Caterham (Surrey), Hampstead, and Clapton. Legally these institutions are classed under workhouses.
Much difference of opinion exists as to the wisdom of having separate institutions for the incurable. That there is great danger of overlooking the fact that some incurable patients require quite as much attention as the curable is certain; they may indeed, if neglected, be reduced to a more pitiable condition than the latter; but this does not prove that, under the present safeguards provided by the legislature, there may not be a safe recourse to this mode of making provision for this class of the insane. At any rate, it is of interest to know what has been done in this direction during the last few years in England.
Asylums have been erected at Leavesden, near Watford, Herts; Caterham, Surrey; and Darenth, near Dartford, Kent, there being at Darenth both idiot schools and an institution for incurables.
These are the Metropolitan District Asylums.
As the primary object in adopting this kind of accommodation is economy, it is important to present a clear statement of the finances, omitting shillings and pence.
Take Leavesden as the example, where the accommodation is for 2000 patients (M. 900, F. 1100). The land, which was purchased in 1867 and 1880, has cost L9401, the area being eighty-four acres. The laying out the grounds, etc., cost L3000; the cost of building and drainage (up to Michaelmas, 1878) was L121,674; the engineering works, fixtures, and fittings cost L16,162; the furniture, bedding, and clothing, L16,235; the architect's and surveyor's charges, and clerk of works, L5108; solicitor's charges, printing, insurances, and all other charges, L1526; the total being L173,118, or L86 per bed. Taking out the items of furniture, bedding, and clothing, we have the sum of L77 per bed. How striking the difference when compared with the expense of an ordinary county asylum, the reader who has examined the figures given at page 166 will readily perceive.
Let us now pass on to the year 1870. We find the Commissioners able to state, as the result of very minute and careful inspection, that the Reports of their members during the previous year showed, on the whole, that good progress continued to be made in the mode of managing "these large and daily increasing institutions," and they add, "although in some instances it has been our duty to comment on shortcomings and cases of neglect, we have generally been able to bear testimony to the skill and zeal evinced by the medical superintendents in the execution of their very grave and difficult duties." On the other hand, they observe, "We regret that we shall have to describe several acts of violence committed by attendants in county asylums, which in three instances were followed by fatal results, but in only one of which, although careful inquiries were instituted, such evidence was obtained as would justify criminal proceedings."
The Report on the Liverpool Lunatic Hospital shows how far from satisfactory one, at least, of these institutions was at that time: "With few exceptions, the personal condition of the patients was found to be very indifferent, and indeed the reason alleged why the females in the lower wards were never on any occasion taken beyond the airing-court, was that they had no clothes fit to be seen in. The corresponding class of men was stated to be taken out as little as the women, and both were said to be rarely visited by any friends having an interest in them. The state of the furniture was discreditable in the extreme, and there was a general absence of tidiness throughout the hospital. The patients were, with few exceptions, quiet; not more than four or five of the better class of either sex were reported to have the opportunity of walking or driving out.... The seclusion in the fifteen months which had elapsed since the previous visit applied to five males on 62 occasions, and to 18 females on 132 occasions."
The Commissioners speak of "the invariable success attendant on such hospitals as have been built during the last few years, and specially at Cheadle."
In regard to licensed houses within their jurisdiction, they were reported to be "generally, as to the condition and management of such houses, of a very satisfactory character;" while of the provincial houses they say, "The Reports, for the most part, have not been unfavourable as to their condition and management."
In this Report the Commissioners comment on the operation of the Metropolitan Poor Act of 1867, which threw the maintenance of lunatics in asylums upon the common poor fund of the metropolis, and they observe that "it has induced the boards of guardians to relieve themselves of local charges, and this has greatly contributed to swell the removals from workhouses to asylums, notwithstanding that the patients have in large numbers been unable to be received nearer than in the county asylums of Northumberland, Yorkshire, Staffordshire, and Somersetshire, and although the rate of maintenance has ranged from 14s. to 17s. 6d. per week."
As the cost of lunatics is so important a question, it may here be stated that the total weekly cost per head in 1870 averaged in the county asylums 9s. 3d., including maintenance, medicine, clothing, and care. Under the maintenance account were comprised furniture and bedding, garden and farm, and miscellaneous expenses. The other items were provisions, clothing, salaries and wages, fuel, light and washing, surgery and dispensary, wine, tea. In this estimate was reckoned the deduction for moneys received for produce sold, exclusive of those consumed in the asylum.
The weekly cost in the following registered hospitals was as follows:—
L s. d. Coton Hill 1 7 1-1/2 Northampton 0 13 5-3/4 York Lunatic Hospital 0 18 0 York Retreat 1 1 2-3/4
It should be observed that Northampton was at this time essentially the pauper asylum for the county.
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We have already referred to the paramount importance of reliable attendants. "Nothing is easier," the Commissioners observe, "for a man in such a position, with unrestricted and uncontrolled power over the habits and happiness of another, than to act cruelly without being cruel." So long ago as 1851 a check was given to the conduct of attendants by a decision of the courts in that year. An attendant had been convicted of manslaughter on the evidence of a patient. This was appealed against, but the conviction was sustained. Lord Campbell laid it down that the only thing needful was for the patient to understand the nature of an oath and what he was saying. "But although this ruling has never since been disputed, the many subsequent attempts of the Commissioners to exact a rigid responsibility for acts of violence or cruelty in asylums have, through the indisposition of juries to accept the evidence principally available for proofs in such cases, more frequently failed than succeeded."
In each of the three previous years, proceedings had been taken against attendants, and with very limited success. In the beginning of 1870, however, a prosecution instituted by the magistrates of the Lancaster Asylum against two attendants for manslaughter on the evidence of a patient succeeded, and they were sentenced to seven years' penal servitude, a result which the Commissioners regarded as the most beneficial example within their experience. During the previous year, eighty-eight male attendants had been dismissed from service—fifty-three for drunkenness, insubordination, or neglect of duty, and thirty-five for assaults on patients; four only of these latter having had criminal prosecutions instituted against them, and of the former not one. Of the number dismissed, fifteen were in licensed houses, three in public hospitals, and the remaining seventy in county asylums. During the same period thirty-four female attendants were dismissed, of whom twenty-four were employed in county asylums. Eleven had been guilty of violence or rough usage to patients, there having been no prosecution in any instance. The Commissioners justly observe that, while "there has been no greater work of mercy and humanity than that which rescued the lunatic patients from stripes and filth, or continued restraint and isolation, yet it will remain to some degree still imperfect until he is also rescued from the possible chance of being subjected to the unwatched or unchecked humours and caprices of ignorant, careless, or cruel attendants."
A striking instance of the respective powers of the Committees of asylums and the Commissioners in Lunacy occurs in the Report of the latter for 1870. Death from broken ribs had taken place in a county asylum, and the Commissioners considered the cruelty of an attendant established. They reported inadequate supervision of the wards, as well as the attendants, in reply to which the committee of visitors asserted that they would not enter into any discussion on a subject upon which they considered themselves fully competent to determine how they should discharge their own duties. The Commissioners found that they had no alternative but to leave to the refractory committee the responsibility, which they had shown no unwillingness to assume, of the adoption or rejection of such recommendations. "The law which has required us to investigate and report as to matters affecting the management of county asylums, has invested us with no authority further to enforce our views." In the same way their authority was set at naught in an asylum where an idiot boy was found on the floor, strangled by a pocket-handkerchief, effected, there was every reason to believe, by one of the patients, and the Commissioners found that the deed could not have been perpetrated if attendants had been properly dispersed through the wards. The union authorities failed to get satisfaction from the committee, and the Secretary of State was memorialized by the guardians, who were backed up by the Commissioners, but in vain. Hence the Commissioners complained of "the limits thus placed to all real authority but that of the committee of visitors over establishments whose inmates are necessarily most at the mercy of attendants, and in which these cases of misconduct most frequently occur."
We have alluded to this circumstance, not to indicate that at the present time the committees of asylums set themselves in opposition to the recommendations of the Commissioners, but our historical sketch demands, in justice to the latter, who are often supposed to have unlimited power, that it should be known that desirable reforms may not be carried out in our asylums, and yet the fault may not lie at the door of the Lunacy Commissioners. And it should be stated that recently Lord Shaftesbury has publicly expressed his individual opinion that it is better for the views and wishes of the Commissioners to appear in the form of recommendations rather than commands.
* * * * *
Three years later, the condition of county and borough asylums was, with few exceptions, satisfactory, and declared by the Commissioners to be very creditable to the governing bodies and superintendents. Improvements had taken place in many of these institutions, and there was found to be a more general recognition of the humanizing and beneficial influence of cheerful and well-furnished wards, on even the most degraded patients. "Those at one time considered to be fit only to be congregated together in the most dreary rooms of the asylum, with tables and benches fastened to the floor, and with nothing to interest or amuse them, are now in many asylums placed in wards as well furnished as those occupied by the more orderly patients, with birds, aquariums, plants, and flowers in them, and pictures on the walls; communicating also with such wards are now very generally to be found well-planted and well-kept airing-courts. The less strict classification of the patients is also advantageously followed in many asylums, and in them what are termed "refractory wards" are properly abolished. Where arrangements for this purpose have been judiciously made and carried out with energy, the best results have followed, in the way of an improved condition and more orderly demeanour of those disposed to be turbulent, whilst the comfort of patients of a more tranquil character has not been prejudicially affected. The use of mechanical restraint in county and borough asylums, unless for surgical reasons, such as to prevent patients removing dressings or applications to wounds or injuries, or during the forcible administration of food, is, with few exceptions, abolished. In thirty-eight of the fifty-four asylums visited during the past year, there was no record whatever of its employment. In the cases of twenty-two patients, distributed over ten asylums, it had been resorted to for the above-mentioned reasons, and in six asylums it had been used to counteract violent suicidal or destructive propensities; the number of patients restrained for these latter reasons (exclusive of Colney Hatch and Wandsworth) having been one in the Macclesfield, nine in the Glamorgan, six in the Prestwich, and one in the Norwich Borough Asylum. In the Wandsworth Asylum it will be seen from the Report that, during a period of about sixteen months, thirty-three men and twelve women were recorded as having had their hands restrained by gloves for destructive propensities; and four males and one female had worn restraint dresses at night, two on account of their suicidal tendencies, and one for violence. At the visit to Colney Hatch, a very dangerous male epileptic was found restrained by wrist-straps and a belt, and from the register it appeared that he had been thus constantly restrained during the day for a period of nine months. Ten other male patients were also recorded as having been restrained; one having had his hands fastened, and the remainder having worn gloves, altogether on two hundred and fifty-three occasions.... At the same visit nine men were found wearing special strong canvas dresses, besides others who were clothed in an exceptional manner."
The objections which for a long time have been felt to frequent resort to seclusion find expression in this Report. The Commissioners, without questioning the utility of seclusion in certain cases, stated their conviction that "in a remedial point of view its value has been much exaggerated, and that in many instances it is employed unnecessarily and to an injurious extent, and for periods which are quite unjustifiable." Patients regard it as a punishment; and attendants are apt to make it take the place of constant supervision. Its frequent use indicates defective asylum organization or management. The Report states that it is no longer employed at the Durham, Stafford, Brentwood, and Brookwood Asylums; and only rarely at the Wakefield, Oxford, Northumberland, Carmarthen, Chester, Dorset, Glamorgan, Leicester, Lincoln, and Norfolk County Asylums, and those for the boroughs of Ipswich and Leicester, and for the City of London.
Legislation has exercised a great and, as some think, questionable influence upon the relative proportion of the insane in workhouses and asylums. The feeling that originally induced the Commissioners in Lunacy to urge the transference of lunatics from workhouses to county asylums was, no doubt, a laudable one, and in a large number of instances most advantageous. The condition of the insane in workhouses, however, became vastly improved, and it was impossible to deny that for many harmless chronic cases they were, to say the least, sufficiently comfortable in the workhouse. Then came the legislation of 1874, by which four shillings a week were allowed for every pauper lunatic in any asylum or licensed house, being reimbursed to the unions and parishes from which the patient was sent. Hence the strong inducement, in some counties at least, for it certainly does not hold good in all, to transfer lunatics detained in workhouses to the asylums, even when no occasion whatever arises out of the mental condition of the patient to justify such transference. The Commissioners themselves have recognized the difficulty and disadvantage of the operation of this legislation, and say in their twenty-ninth Report, 1875, that while this Act "may be beneficial in promoting the removal to asylums of a certain number of patients requiring such treatment, and who might possibly otherwise be deprived of it ... it remains to be seen whether the alteration in the incidents of the maintenance charged, will not also have the effect of causing unnecessarily the transfer to asylums of chronic cases, such as might be properly cared for in workhouses, thus rendering necessary, on the part of counties and boroughs, a still larger outlay than heretofore in providing additional asylum accommodation. The returns for the 1st of January last tend to show that such results are not unlikely to accompany the working of this new financial arrangement." The Irish inspectors in their report for 1875 calculate that the maximum number who could properly be transferred from asylums to workhouses is seven or eight per cent., and they make the observation, which no doubt is very just, that many patients who are quiet and demeanable under trained nurses in an asylum would become intractable elsewhere.
As we have now reached another decade, it will be well to afford the reader the opportunity of comparing the population of asylums, and workhouses, with that which we have given in 1844, 1854, and 1864.
GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE INSANE IN ENGLAND AND WALES, JANUARY 1, 1874.
+ + + Where Private Paupers. Total. confined. patients. + -+ -+ + + + + + + M. F. Total. M. F. Total. M. F. Total. + -+ -+ + + + + + + 31 county and borough asylums 194 221 415 14,238 16,718 30,956 14,432 16,939 31,371 3 military and naval hospitals, and Royal India Asylum 342 16 358 342 16 358 2 Bethlem and St. Luke's Hospitals 167 268 435 167 268 435 13 other public public asylums 1,107 891 1,998 174 165 339 1,281 1,056 2,337 Licensed houses: 39 metropolitan 1,006 787 1,793 257 614 871 1,263 1,401 2,664 67 provincial 772 754 1,526 200 323 523 972 1,077 2,049 1 Broadmoor 267 64 331 148 41 189 415 105 520 Private single patients 168 268 436 168 268 436 Workhouses: } Males, 6372; } females, 8646;} total, 15,018 } Elsewhere: } 9,084 12,773 21,857 9,084 12,773 21,857 Males, 2712; } females, 4127;} total; 6839 } + -+ -+ + + + + + + Total 4,023 3,269 7,292 24,101 30,634 54,735 28,124 33,903 62,027 + -+ -+ + + + + + +
Referring to the numbers of the insane in 1875, the Commissioners observe that they have increased beyond the growth of the population. This had been mainly among paupers, there having been 16.14 of this class in 1849, and 23.55 in 1875, per 10,000 of the population; while of private patients the advance had only been from 2.53 to 3.09 during the same period. The population increased from 1849 to 1875, 22.63 per cent. Private patients increased 48.39 per cent., and pauper patients 77.47 per cent.
In regard to the treatment of the insane in Wales, it may be stated that until the Denbigh Asylum was opened in November, 1847, there was no institution for the reception of lunatics, except the small asylum at Haverfordwest, and a house licensed in 1843 for private and pauper patients in Glamorganshire. Most of the paupers were kept in their homes or workhouses; others sent to asylums. Before the Act was passed making it compulsory on the counties to provide accommodation, several philanthropic gentlemen, impressed with the desirability of having an institution for private patients in North Wales, and where all the officers should possess a knowledge of Welsh, which language alone the vast majority of the inhabitants knew at that time, collected about L8000. By this time the Act was passed, and the subscribers made over their money to the counties, on condition that twenty-six separate beds should be kept for private patients—several of themselves to be members of the Committee. The private apartments form part of the same building, but the inmates do not associate with the paupers. The total accommodation was two hundred, and there was a great outcry at the building of such a large place. About fifteen years ago, two wings were added, each to hold one hundred beds, and last year an additional one of one hundred and thirty beds.
It appears that many of the first patients received at the Denbigh Asylum had been most cruelly treated at their own home, or where placed with strangers; some being kept tied and in seclusion for years, and shamefully neglected. The following is an extract from the first Medical Report:—"In the case of one man, who was goaded by unkind and harsh treatment into a state of ferocious mania (and who was brought into the asylum manacled so cruelly that he will bear the marks of the handcuffs while he lives), it is most gratifying to be enabled to state that he gradually became confiding and tractable, and he is now as harmless as any patient in the house. In another instance, a poor young creature, who before her admission was tied down to her bed for months, quickly discovered the difference between the treatment she had previously been subject to and the kindness and freedom she experienced at the asylum, and very soon gained confidence in those about her, and rapidly recovered. Soon after her discharge from the asylum, she wrote to the matron, to request to be taken back as a servant, and she is now an excellent assistant in the wards, and a general favourite with the patients. We have the satisfaction of stating that we have never been obliged to resort to any mechanical restraint, beyond temporary seclusion in a padded room, etc." Complaints occur in the earlier reports of the disinclination either of friends or of the poor law authorities to send in patients before they become unmanageable, and many of those admitted arrived secured by handcuffs or tied down in carts.
Take another extract from the Report for 1851. "We were requested to turn into a respectable farmhouse, and upon going upstairs we were horrified to find the farmer's wife with her hands secured, and a large cart-rope tied round her body to keep her in bed. The room was filthy. We found she had been in this state for nine months, and no proper remedial measures taken. Surely some protection should be thrown over such a sufferer!"
Again, in the Report for 1853: "One most atrocious case of an opposite kind of treatment has fallen within our notice during the year. It is most deplorable to contemplate, after the repeated generous efforts made by the press, both Welsh and English, to diffuse useful knowledge upon the subject of insanity, that in a Christian country, and in a populous district, and with the knowledge of most of the neighbouring inhabitants, a fellow-creature should have been permitted to be chained by both his legs in a miserable shed for seven long years. The case is so painfully interesting, that we will add to this Report the document which was sent to the Lord Chancellor, who, at the instigation of the Commissioners in Lunacy, issued an order for visiting the poor sufferer. The Commissioners, with laudable alacrity, ordered a prosecution to be instituted, and the principal offender was tried at the Carnarvonshire assizes, convicted, and sentenced to be imprisoned.... What renders the conduct of the friends of Evan Roberts more inexcusable is the fact of his having been perfectly sane when visited, and having remained so ever since.
Denbigh, June 16, 1853.
"In obedience to the order of the Lord Chancellor, etc., I have to report that I found Evan Roberts in a small shed, six feet wide and nine feet four inches long, which had been built for the purpose. The room had a small skylight in the roof, and a window about a foot and a half square in the gable, just above the bed, which admits of being partially opened, but which was closed at the time of my visit, and, as he (Evan Roberts) stated, was seldom opened. The room felt very close and damp. There was no fireplace, or any other means of ventilation except the door and window. The approach to the room was through a sort of scullery, and very dark and obscure. Evan Roberts was lying on a chaff bed on a wooden bedstead, to which both his legs were chained, by fetters fastened and riveted, just above his ankles.... The appearance of the poor man was pale and pasty, like a plant long deprived of air and solar influence. His bodily health is tolerably good, and his condition rather inclined to be fat and stout; he said his appetite was good, and that he was not stinted in his food, such as it was. During a lengthened interview, and a very close examination, I failed to discover the existence of any hallucination or delusion of any kind; on the contrary, he was very sensible and intelligent....
"I collected from his mother and sister that Evan Roberts was forty-eight years of age; that he had been liable to periodical mania for twenty-seven years, and which the mother attributed to some injury to his head, received in a rural affray; that at first the maniacal paroxysms were unfrequent, but that they had become more violent and frequent as he advanced in life. About seven years ago, his violence became so great, that he threatened to murder his father and brother; and it was at that time that he was first chained to the bed. This restraint has never been relaxed, although both mother and sister admitted that he was perfectly sane and harmless for many weeks and months continuously. For the first five years he was confined upstairs, and it was only about two years ago that he was carried into the shed he now occupies.... Finding that the poor fellow was awed by the presence of his mother and sister, I requested them to retire, as I wished to examine the alleged lunatic free from their presence and interference. The mother for some time refused to comply with my request; but upon being told that I would report her refusal, she very doggedly complied. The poor man then became less reserved; he complained bitterly of the state in which the room had long been suffered to remain....
"The poor man complained that the chaff in his bed was never changed, or even shaken, except once, since his confinement in the shed; and from the dampness of the room, and the warmth of his body, it had become rotten, and like a wet sod....
"R. LLOYD WILLIAMS.
"R. W. S. Lutwidge, Esq."
"The Commissioners in Lunacy applied to the Lord Chancellor for an order to visit the farmer's wife mentioned in one of our former reports as having been tied to her bed by a cart rope and her hands secured by a muff. She was accordingly visited, and a report upon her case sent to the Commissioners, who directed an inquiry to be made with a view to her removal to an asylum. The family obtained information of this investigation, and considerable amendment in the treatment of the lunatic took place before the justices and the medical officer appointed to visit her arrived, and no order for her removal was made. We have reason to know that the poor creature is still under restraint, and her hands secured; she is strapped to a chair, which is fastened to the leg of a strong table."
We pass now to 1879, in order that we may consider the changes which had taken place during the quinquennium succeeding the year in which we have given a return of the number of insane in England and Wales, and their distribution. The following figures are derived from the thirty-third Report of the Lunacy Commissioners, and exhibit the total number of registered lunatics, idiots, and persons of unsound mind on the 1st of January, 1879:—In county and borough asylums, 38,871; naval and military hospitals and Royal India Asylum, 342; Bethlem and St. Luke's Hospitals, 430; other public asylums, 2407; metropolitan licensed houses, 2664; provincial, 2049; Broadmoor, 483; workhouses (ordinary), 11,697; metropolitan district asylums, 4308; outdoor paupers, 6230; private single patients, 472; total, 69,885; exclusive of 202 Chancery lunatics in the charge of committees.
On the next page will be found the general distribution and numbers of the insane, January 1, 1881. A more detailed statement will be given, in the Appendix (K I.), of the county asylums and lunatic hospitals now existing for the care and cure of the insane, with the numbers confined therein.
On the 1st of January, 1881, the proportion per cent. maintained in asylums, hospitals, and licensed houses was 64.91; in workhouses, 25.72; and as outdoor paupers, 9.37.
As some of the tables of the Commissioners extend back twenty-three years, exhibiting the number, sex, classification, and distribution of all registered lunatics, January 1, 1859-1881, as also the ratio of the total insane to the total population, we may derive much valuable information for the purpose of our historical review.
Thus there were in England and Wales:—
- - Location. Patients. Patients. 1859. 1881. - - In county and borough asylums 15,844 41,355 In registered hospitals 1,855 2,948 In metropolitan private asylums 2,551 2,511 In provincial " " 2,465 2,115 In naval and military hospitals and Royal India Asylum 164 307 In Broadmoor Asylum for Not opened 491 criminal lunatics till 1863 In workhouses Ordinary workhouses 7,963 12,093 Metropolitan district asylums Not opened 4,718 till 1870 Residing with relatives or 5,920 6,575 others (pauper and private) - M. 16,756} M. 32,973} Total F. 20,006} 36,762 F. 40,140} 73,113 - -
Of the 36,762 in 1859, 4980 were in private and 31,782 pauper patients. Of the 73,113, in 1881, 7741 were private and 65,372 pauper patients. In 1859 the ratio of the total registered lunatics to the population (per 10,000) was 18.67, the ratio of private lunatics to population being 2.53, and of pauper lunatics to population 16.14. In 1881 the ratio of the total lunatics of the population was 28.34, the ratio of private lunatics to 25.34. These figures bring out very distinctly the fact that the great increase of lunatics during the period between 1859 and 1881 is among the poor. It must, however, be repeated that insanity itself brings with it pauperism to many who have once been independent and educated, but who fall, through the misfortune entailed by the malady, into the category of paupers.
An important table, introduced for the first time into the last Report of the Commissioners, shows the annual ratio of fresh admissions to the population; hence the transfers and the admissions into idiot asylums are excluded. The value of this table consists in this—that, although the gross admissions into asylums have increased, due in part to the capitation grant of four shillings introduced in 1874, the ratio of the yearly increase of the fresh admissions to the population has been slight, showing, as the Commissioners observe, that the total number of the insane under care during the twelve years embraced by the table is "mainly due to accumulation, and not to a greater annual production of insanity." This table does not include workhouses.
- - - Ratio per 10,000 Year. Admissions. of admissions to the population. - - - 1869 10,472 4.71 1870 10,219 4.54 1871 10,528 4.62 1872 10,604 4.59 1873 11,212 4.80 1874 11,912 5.03 1875 12,442 5.19 1876 12,857 5.30 1877 12,969 5.28 1878 13,343 5.36 1879 13,101 5.20 1880 13,240 5.19 - - -
It would thus appear that in 1880 scarcely one patient more per 20,000 persons in England and Wales was freshly admitted into asylums, etc. Had there been no increase at all, after allowing for increase of population, the number admitted in 1880 would have been 12,011. It was, in fact, 13,240, i.e. 1229 more.
Taking the actual number of the insane in detention during the same years shows a very different result, for accumulation is here included, and swells the returns.
- - - Ratio per 10,000 Year. Under care. of number in detention to the population. - - - 1869 53,117 23.93 1870 54,713 24.31 1871 56,755 24.91 1872 58,640 25.42 1873 60,296 25.82 1874 62,027 26.23 1875 63,793 26.64 1876 64,916 26.78 1877 66,636 27.14 1878 68,538 27.57 1879 69,885 27.77 1880 71,191 27.94 - - -
In other words, there were eight more patients under care for every 20,000 of the population in 1880 than in 1869. Had there been no increase in the number in detention, after allowing for increase of population, the number in 1880 would have been 53,177. It was, in fact, 71,191, i.e. 18,014 more.
* * * * *
We have now traced step by step the remarkable progress effected in the asylum care of our lunacy population. In concluding this chapter I would, however, observe that it would be a grave and mischievous mistake to suppose that, most valuable as is the provision for the insane by asylums, there are not many cases which may be treated outside these institutions with the greatest advantage. Some patients are best cared for in their own homes, others in lodgings, and others in the houses of medical men. The extent to which non-asylum treatment can be carried out will be seen when we speak of Chancery patients. It will be observed that the number of single private patients is 448.
In regard to the location of pauper lunatics in private dwellings, it appears that while in England 6799, or 9.29 per cent., of their number live with their relatives or are boarded in private dwellings, nearly fifteen per cent. of insane paupers in Scotland are in private dwellings, inspected by the Lunacy Board.
Dr. Lockhart Robertson has expressed the opinion that "the utmost limits within which the county asylum can benefit, or is needed for the treatment of the insane poor, is fifty per cent. of their number, and that a further accumulation of lunatics there serve no practical purpose, and hence is an unjustifiable waste of public money." After pointing out the success of the metropolitan district asylums at Leavesden and Caterham, where upwards of four thousand chronic lunatics are maintained at the rate of seven shillings a week, he expresses his opinion that, if these arrangements were properly carried out, another fourteen per cent., or forty per cent. of the incurable and harmless pauper lunatics and idiots, might be placed in workhouses; his ideal standard for the distribution of pauper lunatics being—in county asylums, fifty per cent.; in workhouse wards, forty per cent.; leaving ten per cent. for care in private dwellings.
The number of beds in county and borough asylums amounts to 40,000, varying from 2000 to 250; the average cost per bed having been somewhat under L200, and the weekly maintenance and clothing of each patient 9s. 9-1/4d. If to this be added the interest on the cost of construction and asylum repair, the annual cost for each pauper lunatic in county asylums amounts to about L40.
The number of patients discharged cured, in county and borough asylums during the ten years 1871-1880, was 40.32 per cent. on the admissions, and the mortality 10.46 on the mean number resident.
The number of beds in registered lunatic hospitals (about 3000) ranges from 60 to 570, or, excluding idiot asylums, to 300, while the average weekly cost ranges from 14s. to L2 2s. The charges on the buildings are not included. For these Dr. Robertson adds five shillings a week, making the average weekly cost of maintenance L1 10s. or, including asylum construction and repairs, L1 15s.
The distribution of private patients, numbering 7741, was as follows on the 1st of January, 1881:—In registered hospitals, 2800, or 36.17 per cent.; in county asylums, 539, or 6.96 per cent.; in State asylums, 534, or 6.88 per cent.; in private asylums, 3420, or 44.17 per cent.; in private dwellings, 448, or 5.78 per cent.
The registered hospitals have, therefore, thirty-six per cent. of all the private patients, an important fact in looking to the future provision for this class in lieu of private asylums. Their statistics of recovery and mortality are satisfactory. The recoveries per cent. calculated on the admissions were 46.48 per cent. during the ten years 1871-1880; the annual mortality being 7.96 per cent.
As regards private asylums, there were forty-four per cent. of the private patients in England and Wales cared for in these establishments. The recoveries per cent. in private asylums during the decennial period 1871-1880 were—in the metropolitan division 31.43, and in the provincial 35.11; the annual mortality being, in the metropolitan private asylums 10.93, and in the provincial asylums 8.63. It should be remembered, in contrasting these figures with those of registered hospitals, that a considerable number of pauper patients are still sent to private houses, and it may therefore be said that, so far as difference in social position affects recovery and death, the comparison is not altogether fair. At the same time, it is noteworthy that in the pauper asylums, the percentage of recovery is higher than in the metropolitan and provincial private asylums, and the percentage of mortality lower than in the licensed houses of the metropolis.
Numerous general considerations arise from a retrospect of the history which this and the preceding chapter contain, but they will more fitly form a part of a subsequent chapter of this volume, when a sketch of the results achieved by Psychological Medicine will be given, as presented in the author's Presidential Address at University College.
 "A Lecture on the Management of Lunatic Asylums," etc., by Robert Gardiner Hill. Published April, 1859 (delivered June 21, 1838). (See Appendix H.)
 Including the wards in the Manchester Hospital.
 Including thirty male and three female criminal lunatics in jails, according to the Parliamentary return for April, 1843.
 Exclusive of the lunatic ward of Guy's Hospital.
 Mr. Gaskell. See p. 209.
 Summary taken from the Report of the Metropolitan Commissioners, 1844.
 Second Report of the Commissioners in Lunacy, 1847, p. 224.
 Page 112. No return is made in regard to the inmates of other asylums.
 Eighth Report of the Commissioners in Lunacy, p. 43.
 Exclusive of 226 single patients under commission.
 Page 35.
 Act of 1853, ss. 64 and 66.
 Page 44.
 For a table showing the cost per head in asylums of various sizes, see Appendix I.
 Report of Commissioners in Lunacy, 1864.
 Exclusive of 159 single patients.
 Office of the Board, 37, Norfolk Street, Strand.
 Caterham cost a little more, viz., L89 a bed.
 Page 10.
 Page 35.
 Page 43.
 In the Commissioners' Report of 1871, p. 76, a case is reported in which the jury would not convict a woman who had the charge of a lunatic and admitted that "she strapped the patient once a month at the full of the moon," of ill-usage, although Mr. Justice Willes summed up strongly against her. In another case the Lunacy statute was disregarded, but Baron Martin summed up very leniently, much to the disapproval, not to say the disgust, of the Commissioners.
 Page 75.
 Page 81.
 Page 77.
 See page 196.
 Page 20.
 The order and description of these institutions have been given in these decennial tables as far as possible in accordance with that of the table of 1844, in order to facilitate comparison.
 Exclusive of 208 lunatics so found by inquisition who reside in charge of their committees.
 For information in regard to Wales I am indebted Dr. W. Williams, the late medical superintendent of the Denbigh Asylum.
 Report, page 3.
 See Address at International Medical Congress, Journal of Mental Science, January, 1882.
OUR CRIMINAL LUNATICS—BROADMOOR.
No one at the present day is likely to underrate the importance and interest of the subject of this chapter.
An Act was passed in regard to criminal lunatics in the year 1800 (39 and 40 Geo. III., c. 94). It was partially repealed in 1838 (1 and 2 Vict., c. 14); that is to say, so far as the former authorized magistrates to commit to jails or houses of correction, persons apprehended under circumstances denoting derangement of mind and the purpose of committing a crime. The Act of 1838 made other provisions for the safe custody of such persons. Persons in custody under the repealed provision of the previous Act, or hereafter apprehended as insane or dangerous idiots, might be sent to a lunatic asylum, hospital, or licensed house; two justices of the place where such person is apprehended having called to their assistance a medical man, and having satisfied themselves that he is insane or a dangerous idiot; nothing, however, herein contained preventing the relations from taking lunatics under their own care.
This Act did not alter the laws relating to the discharge of persons ceasing to be insane, or dangerous idiots, from any county asylum, hospital, or licensed house.
In 1840 an Act was passed (3 and 4 Vict., c. 54) "for making further Provision for the Confinement and Maintenance of Insane Prisoners."
It was enacted that if any person while in prison under sentence of death, transportation, or imprisonment, or under a charge of any offence, or for not finding bail, or in consequence of any summary conviction, or under any other civil process, shall appear to be insane, it shall be lawful for two justices to inquire, with the aid of two medical men, as to the insanity of such person; and if it be duly certified by such justices and medical men that he is insane, it shall be lawful for one of the principal Secretaries of State to direct his removal to such county asylum or other proper receptacle as the Secretary of State may judge proper, to remain under confinement until it shall be duly certified by two medical men to the Secretary of State that such person has become of sound mind; whereupon he is authorized, if such person remain subject to be continued in custody, to issue his warrant to the person in whose charge he may be, directing that he shall be removed to the prison from whence he has been taken, or if the period of imprisonment has expired, then he shall be discharged. It was also enacted that when a person charged with misdemeanors is acquitted on the plea of insanity, he shall be kept in strict custody during Her Majesty's pleasure, the jury being required to find specially whether such person was insane at the time of the commission of such offence, and to declare whether such person was acquitted by them on account of such insanity.
The Earl of Shaftesbury introduced the subject of the provision for criminal lunatics in the House of Lords in 1852, and moved for an Address to Her Majesty on the expediency of establishing a State Asylum for the care and custody of those who are denominated criminal lunatics. He said that the subject had been never propounded before to them in a specific form, and the custody of these criminals had been a great bar to the improvement of public and private asylums. The Commissioners had already reported on these evils in 1849, 1850, and 1851. The Government alone had refused assistance. Having pointed out the four classes into which they are divided, he stated that the statutes by which they were confined were three in number, namely, 39 and 40 Geo. III., c. 94; 1 and 2 Vict., c. 14; 3 and 4 Vict., c. 54.
He directed attention to a fifth class, those affected with some derangement of mind, who, unless restrained, were in danger of committing offences. Under the last-named Act, they were treated as criminals. Formerly any magistrate could commit them to jail, or other place for safe custody under 39 and 40 Geo. III.; but by the Act of 3 and 4 Vict. their condition had been somewhat alleviated, inasmuch as it required that two justices of the peace should commit the parties, under medical advice, and that they should not be sent to jail, but to an asylum or licensed house. None of these parties except those who had been committed by the justices could be again discharged unless by authority of the Secretary of State.
It appears that there were then 439 criminal lunatics in England and Wales (360 males, 79 females); 138 for offences against life, 188 for offences against property and person, short of attempts to murder, 40 for misdemeanor, 43 for want of sureties who had become afterwards insane, and 30 summarily convicted for minor offences. Of this number there were 103 in Bethlem Hospital, 59 in Fisherton House, Salisbury, and the remainder in various asylums. After adducing reasons for the non-association of criminal lunatics with ordinary patients, Lord Shaftesbury insisted that the most efficient remedy was a State asylum; and that this was confirmed by the success of Dundrum, Ireland.
In the course of his speech he eulogized the system of treatment—"the great and blessed glory of modern science"—adopted by Pinel in France, and by the York Retreat in England, adding, "Oh, si sic omnia! It has become the special pursuit of professors of this department of medicine in the three kingdoms. By the blessing of God it has achieved miracles. I have, perhaps, a right to say so, having officiated now as a Commissioner in Lunacy for more than twenty years, and witnessed the transition from the very depth of misery and neglect to the present height of comfort and ease. The filthy and formidable prison is converted into the cleanly and cheerful abode; the damp and gloomy court-yard is exchanged for healthy exercise and labour in the field and garden. Visit the largest asylum, and you will no longer hear those frightful yells that at first terrified and always depressed the boldest hearts. Mechanical restraint is almost unknown; houses where many were chained during the day, and hundreds, I will assert, during the night, have hardly a strait waistcoat or a manacle in the whole establishment; and instead of the keeper with his whip and his bunch of leg-locks, you may see the clergyman or the schoolmaster engaged in their soothing and effective occupations."
The Earl of Derby promised the subject should not be lost sight of, and the motion was withdrawn. He said that our criminal lunatics were maintained at Bethlem at an annual cost of L34 per head, those at Fisherton House at L30, and throughout the country at L26 per head. A new asylum would cost L50,000, perhaps nearer L100,000, and he thought that the same discipline and separate treatment might be carried out just as well in a general as in a State asylum.
We pass on to the important Act of 1860 (23 and 24 Vict., c. 75), "to make Better Provision for the Custody and Care of Criminal Lunatics." After citing the Acts 39 and 40 Geo. III., c. 94; 3 and 4 Vict., c. 54; 5 and 6 Vict., c. 29; 6 and 7 Vict., c. 26—by the last two Acts of which the Secretary of the State was empowered to order any convict in Pentonville or Millbank prison becoming or found insane during confinement to be removed to such lunatic asylum as he might think proper—and stating in the preamble the expediency of making provision for the custody and care of criminal lunatics in an asylum appropriated to that purpose, this statute enacted that it shall be lawful to provide an asylum for criminal lunatics, and for the Secretary of State to direct to be conveyed to such asylum any person for whose safe custody, during her pleasure Her Majesty is authorized to give order, or whom the Secretary of State might direct to be removed to a lunatic asylum under any of the before-mentioned Acts, or any person sentenced to be kept in penal servitude who may be shown to the satisfaction of the Secretary of State to be insane or unfit from imbecility of mind for penal discipline; the Secretary of State being empowered to direct to be removed to such asylum any person who, under any previous order of Her Majesty or warrant of the Secretary of State, may have been placed in any asylum.
It was enacted that nothing in this statute should affect the authority of the Crown as to making other provision for the custody of a criminal lunatic, as before the Act was passed.
Other sections refer to the government and supervision of the asylum, the discharge of patients after their term of imprisonment has expired, and for the visitation of the asylum by the Commissioners in Lunacy.
From this Act sprang the asylum we proceed to describe.
Every one who reads the newspaper is familiar with the common expression occurring in the trials of prisoners who escape punishment on the ground of insanity, "To be detained during Her Majesty's pleasure;" but very few would be able to answer the question, What becomes of these persons? Those who desire to know their destination may incline to accompany us to Broadmoor in Berkshire, about four miles from the Bracknell station on the South Western Railway, and thirty miles from London. This is the State Criminal Asylum for England and Wales, and was erected nineteen years ago (1863), in conformity with the Act passed in 1860, which, as we have seen, provided that criminal lunatics should be separately cared for by the State.
The site of the institution is well chosen, covers three hundred acres, and commands an extensive and uninterrupted view. The building is of red brick, with a chapel in the centre, and consists of three stories, with distinct additional blocks at the extreme end. It is built on the corridor plan, with day-rooms, and single and associated dormitories. The windows alone indicate, from outside, the character of the building, being protected by strong vertical iron bars. In some parts of the building, for the females, these bars do not extend to the whole height of the window, and escape would in such cases not be difficult. In other parts of this division, and throughout the male division, the windows are securely protected. In this and other ways the house is more secure than it was formerly. I find in regard to escapes that, from the opening of the asylum in 1863 up to the end of 1877, there have been not more than twenty-three. During the last three years there have been none. The majority were recaptured on the next or following day; one not till three months; and four were never discovered. Four escaped from the airing-court; three while out with a walking party; and four from breaking the window-guard; while one escaped from his bedroom by making an aperture in the wall. An attendant connived at one patient's escape, was prosecuted, and convicted. I may add that prior to the opening of Broadmoor, the proportion of escapes of criminal lunatics detained in England elsewhere was much greater. The opening of Broadmoor has also affected the mortality of this class, having reduced it materially. Some probably regard this as an actual disadvantage; but whatever political economists may say, medical science only sanctions, as yet at least, the adoption of that course of hygiene and treatment which most conduces to the prolongation of human life.
There were, when I visited Broadmoor, 500 inmates—400 men and 100 women, or thereabouts. When we consider that of these unfortunate people, more than 300 have either murdered some one, or attempted to murder or maim some one, it may well cause reflection, alike sad and philosophical, on what a disordered brain may lead its possessor to do, what acts to commit. Ninety had killed their own children as well as, in some instances, the wife or husband; upwards of twenty, their wives; eight, their mothers; four, their fathers; and one, both parents. And another reflection may be made, to the credit of the institution, that no case of actual murder has occurred since it was opened, and that, taking the year before we write, good order was maintained, no premeditated act of violence was committed, and there was no suicide.
And yet no mechanical restraint was resorted to, no fetters, no strait waistcoats, no leg-locks or straps. Some patients are, of course, secluded in a single room in which a bed made on the floor is the only furniture allowed, and in which the window is protected by a shutter if the patient breaks glass. The room is, when the shutter is closed, only partially dark, as there are two small windows near the ceiling, out of the patient's reach. By the side of the door is an inspection plate, or narrow slit in the wall, with a movable glazed frame, opening outwards, through which the occupant of the room can be observed when necessary. These rooms are well ventilated, and are warmed by means of hot water. I should not proceed further without stating that, in addition to the class of cases to which I referred in the beginning of this paper—those, viz., detained during Her Majesty's pleasure, including those certified to be insane while awaiting their trial, or found insane on arraignment, or acquitted on the ground of insanity, or reprieved on this ground immediately after their sentence—besides these there are convicts who become insane while undergoing their penal servitude. As a rule, however, male convicts of this class are no longer sent to Broadmoor; the superintendent having discovered that it was necessary to keep insane convicts distinct from the other class, to secure their safe detention more completely and certainly; that is to say, to separate lunatic criminals from criminal lunatics, or, as they are usually called, "Queen's pleasure men"—a distinction sometimes really as important as that which exists between a horse-chestnut and a chestnut horse. It will be readily understood that the convicts—really criminals, and often desperate criminals, they are—may differ widely from those who in an access of insanity have committed a crime, and that men who leave prison discipline at Pentonville, or elsewhere, to enjoy the comparative comfort of asylum life at Broadmoor, are very likely either to sham madness in order to stay there, or escape in order to avoid having to complete, on recovery, their term of servitude. Anything better than that. In insisting on this distinct classification and accommodation, Dr. Orange did not, in the first instance, intend, I suppose, to prevent the convict class being provided for at Broadmoor; but having set the ball in motion, it went on and on; and instead of an additional building being erected for the convict men, a regulation was made in 1874 preventing their being sent in future to Broadmoor. For the women of this class there was and is ample room, an additional wing having been erected fifteen years ago.
Again, there is a reason, on the side of the prison authorities, why convicts when insane should not be sent to Broadmoor. They are naturally unwilling that the history of their previous treatment should be known and scrutinized at another place. Hence they greatly prefer retaining them in the prisons, or sending them to one in which provision has been specially made for insane convict men.
It will probably occur to some to ask whether many or any of those who are "Queen's pleasure men" (or women) are found to have been improperly acquitted when subjected to the careful and prolonged medical scrutiny which a residence at Broadmoor allows of; whether, in short, mercy, based on medical knowledge, has mistakenly interfered with the proper action of justice and law? In this matter the doctors and the lawyers are frequently on opposite sides, and the former often find it hard work to rescue an insane prisoner from the clutches of the law. On the other hand, it may be admitted that, as regards some physicians at least, a juster view is sometimes as necessary as it is on the part of the lawyers. When absurd reasons are given in the witness-box for a prisoner's insanity—reasons which would equally establish the madness of many persons in society whom no one regards as insane—it is not surprising that the judges are cautious in admitting the plea of insanity on medical evidence. In seeking a reply to the above question, it is satisfactory to find that if the evidence of medical experts tends to induce juries to acquit on the ground of insanity those who are responsible agents and ought to be punished, there have only been a few scattered cases admitted which were "doubtful"—whether at Bethlem, when criminal lunatics were sent there, before Broadmoor existed, or at the latter, since it was opened. It is also a satisfaction to know that cases of this kind have not been more frequent of late than formerly; and this, although there has been in the present generation a marked increase in the number acquitted on the ground of insanity. Thus from 1836 to 1848, the ratio of the insane to the prisoners tried was only one in thirty-two; between 1848 and 1862 it was one in seventeen; and between 1862 and 1874 as many as one in fourteen. It is surely much better that a man should occasionally escape the punishment he deserves, than that any should be punished who labour under mental disease. To show the difficulty of arriving at a conclusion as to the mental responsibility of persons charged with crime, I may mention the case of a schoolmaster who, not many years ago, used his cane on a boy in a very savage manner, pursued him under the table, and destroyed the sight of one eye. This man was sentenced to five years' penal servitude. He was, of course, under the notice of the surgeon of the prison to which he was sent, and was regarded by him as sane. The schoolmasters and pupil-teachers, however, took the case up, and agitated for further examination into the state of the man's mind. Dr. Orange was employed to examine him, and, thoroughly familiar with criminal lunatics, succeeded in discovering unmistakable proofs of insanity. In fact, he was so poorly the morning of the day he committed this assault, so uncomfortable in his head, and so irritable in mind, that he sent word to the school to say that he was too ill to attend to his duties. It was a school examination, however, and the authorities insisted upon his going. They therefore were mainly to blame for the circumstance which followed. This man was saved from punishment by Dr. Orange's representations, and subsequent observation confirmed the opinion he formed at the time, that he was not only irritable and suspicious, but was labouring under a delusion. He was a dangerous lunatic, in short, when he committed the offence.
In going through the wards I conversed with the superintendent on the main points of interest in connection with the management of the institution, and on some of the characteristics presented by those who are admitted.
I remarked on the low mortality which I knew obtained there. "Ah," said the doctor, laughing, "that goes against us, rather than for us. We are blamed for keeping the patients too well!" Since the opening of the asylum, the yearly average of death has been at the rate of 2.97 per cent. of the number resident. As to diet it is no doubt difficult to understand why this class should fare better, as they seem to do, than ordinary patients in the county asylums. In one particular, indeed, a change in the direction of economy has been made, and a very reasonable change it is. It is connected with an important question which arises, How far can the system of rewards for work be beneficially carried out?
It appears that until some ten years ago, the main reward for useful work was a luncheon of bread-and-cheese and beer in the forenoon, with another, though smaller, allowance of beer in the afternoon. Both these allowances of beer (which were additional to the dinner supply) were discontinued in 1875, and in lieu of them a small portion of the money value of the work done was credited to the workers, with permission to spend it on any trifling luxury they might desire. It was found that the executed value of the work in the shoemakers' shop in 1876 was more than that done in 1873 (the year before this experiment was tried), by 160 per cent., whilst in the tailors' shop the increase was 120 per cent.; corresponding results being obtained in other departments. Hence, in spite of the gratuities to the patients so employed, the yearly cost has been considerably reduced. During one year the saving in beer alone amounted to L165, whilst the saving in paid labour was very much greater.
Financial considerations must be a very important practical point in the existence of Broadmoor. The State pays for it; an annual grant from the House of Commons must be asked for, and the Government must be prepared to show that the amount is not unreasonable. Now the weekly cost of the inmates is eighteen shillings each. That of the inmates of our county asylums averages about half a guinea. It may therefore not unreasonably be asked, Why is this? What have the criminal lunatics done to deserve so much more money being lavished upon them? The chief reason is, that a greater proportion of attendants must be provided for this class, and that is costly. At Broadmoor the proportion of attendants to patients is one in five; in asylums generally, much less liberal, say one in eleven; besides which, they are paid better (as they ought to be), at Broadmoor. Ten years ago the cost per head was as high as twenty-three shillings a week.
A considerable number of the inmates are, as has been intimated, usefully employed. Thus, during the year, 167 men and women were occupied in one way or other, in addition to reading and writing, music, etc. Eighty-six were employed in making and repairing clothing for patients, and bed and house linen for patients and attendants; 144 in cleaning the wards; 40 in the garden and on the farm; 29 in the laundry; 26 in making or repairing uniform clothing, boots and shoes, etc.; 17 in making and repairing furniture, mattresses, mats, carpets, etc. I went into one room where there was a printing-press, and a printer handed me the printed programme of a concert shortly to be held in the asylum. The total value of the labour of patients alone amounted, in 1881, to L2835.
In the carrying out of a system of labour so beneficial to the patient, and so useful to the institution, relaxation and amusement are not forgotten. The patients play at chess, draughts, billiards, bagatelle, etc.; and out-of-door games comprise bowls, cricket, and croquet. There is a library well supplied with papers and journals; and one patient was pointed out who himself contributes to a magazine. There is a band which includes seventeen patients, as well as some attendants, and enlivens the inmates twice in the course of the week.
This sounds very pleasant, but honesty requires us to give the other side of the picture, as portrayed in the words of Mr. Burt, the chaplain; and perhaps nothing serves better to show how much credit is due to the superintendent for the admirable management of an institution containing such elements as these. He said (some years ago) that although he had laboured in asylums and prisons for a long period, it had never fallen to his lot before to witness depravity and unhappiness in such aggravated forms. "In other asylums, when the mind resumes anything like healthy action, there is hope of discharge; in prisons, the period of detention, however long, has some definite duration; but here the fear of relapse, and the terrible acts to which relapse may lead, render the condition of release rarely attainable; for many the period of detention is indefinite, and hope is almost excluded. In prison, whatever may be the depravity, it is kept under some restraint by reason and by fear of consequences; but here there are patients with passions depraved to the utmost, upon whom neither reason, nor shame, nor fear impose any restraint."
One Sunday, about fifteen years ago, during the Communion, and when the chaplain was in the middle of the Collect for the Queen, an event took place, the account of which I take from his own description. A patient with a sudden yell rushed at Dr. Meyer (then the superintendent), who was kneeling, surrounded by his family, close to the altar, and a deadly blow was struck at his head with a large stone slung in a handkerchief. The stone inflicted a serious injury, and the blow would have been fatal, if it had not been somewhat turned aside by the promptness with which the arm of the patient was seized by an attendant. A scene of so dreadful a character has very rarely been witnessed in a Christian church. Is it surprising that Mr. Burt cannot look back upon this occurrence without horror, and that he has never felt able to say the particular collect which was interrupted in so awful a manner?