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 thepowerof 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 hasbeen 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—
The number of patients found lunatic by inquisition was 542; their incomes amounting to £280,000. In 1839 the corresponding numbers were 494 and £277,991.
The estimated annual amount expended at this time for maintenance of lunatics, or administered on their behalf, exceeded £750,000, thus distributed:
Adding the expense of maintaining many families cast upon the parish in consequence of the patient's insanity, and the expense of supporting many called imbecile, and the interest of large sums invested in public establishments, the Commissioners estimated the actual amount as little less than £1,000,000.
In the same Report the Commissioners observe "that they have found that, with some exceptions, the patients have apparently been humanely, and sometimes very judiciously treated. There is no reason to apprehend that the lunatic patient is now often subjected to cruelty or ill-treatment.... The massive bars, and rings, andchains 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]
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, therewere twenty-two patients, ten of whom were under restraint. Writing in 1848, the Commissioners enumerate the various changes for the better which had then taken place, among which were—an active medical superintendence; the abolition of excessive use of mechanical restraint, there being sometimes only one or two, and occasionally no patient whatever, under mechanical restraint; the introduction of warm and cold baths; the cleanliness of the day-rooms and dormitories; the addition of a good library, and various amusements and means of occupation; and also an excellent dietary. Such is a sample of the happy change which was, in many instances, brought about by inspection.
The following classification of asylums in 1851 will show at a glance the progress made in providing accommodation from time to time, consequent upon legislation:—
There were still upwards of fifty boroughs for whose pauper lunatics no legal provision was made, and no asylum was then erected for the City of London.
Under the head of mechanical restraint, the Commissioners now report that it has still further diminished, and has in some houses been absolutely abolished. However, in fifty entries made in the books of thirty-sixprivate 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 ofseclusion, 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 continuanceof their paroxysms, and in a few cases where there is a determined propensity to suicide, the utility of padded rooms is not so great as was at one time supposed; and that, for cases of ordinary maniacal excitement, seclusion in a common day-room or sleeping-room of moderate size, from which all articles that might furnish instruments of violence or destruction have been removed, and which is capable of being readily darkened, when required, by a locked shutter, will, in general, be found to answer every useful purpose."[186]
As ten years had elapsed since the first attempt of any value to present the numbers of the insane in England (seepage 211), it is of interest to compare with the table referred to, the following statement of the numbers on the 1st of January, 1854:—
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 wasestimated 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 whichits treatment entails, and the fatal interruption which it causes to everything like active industry, seldom fails to reduce its immediate victims, and generally also their families with them, to poverty, and ultimately to pauperism."
The Commissioners add—and we draw special attention to the statement—that "this is the main reason why, in our pauper lunatic asylums, many inmates are to be met with who have formerly held a respectable station in society, and who, in point of education and manners, are greatly superior to the inmates of a workhouse."[188]Hence we see how utterly fallacious is the conclusion constantly drawn from a study of the mere figures themselves that insanity is, to the extent indicated by them, more prevalent among the lower than the higher classes of society.
The very great importance of obtaining good attendants for asylums became a prominent subject now that the number of patients under treatment had so vastly increased, and it was clearly seen that the skill of the superintendent was of little avail unless effectually carried out by a well-qualified staff of attendants. It was necessary that they should be liberally remunerated, and that their position in the house should be made comfortable. The Commissioners recommended the appointment of head attendants of a superior class, whose duties should not be restricted to any one ward, but who should be responsible for the conduct of the other attendants. A well-educated lady had been found most useful inasylums as a companion to female patients of the upper classes. The Commissioners required notices to be transmitted to their offices of all dismissals for misconduct of nurses or attendants, and of the causes thereof; these notices being regularly filed for reference, in the event of inquiries being made as to the characters of applicants for employment.
Reviewing the condition of the insane generally at this time in workhouses, the Commissioners were able to report that, upon the whole, a sensible amelioration had taken place in their physical condition and in their treatment. They abstained, however, from any official sanction of the construction of lunatic wards in workhouses; for the patients were not provided with any suitable occupation, the means for exercise were generally wanting, and the attendants were too badly paid to allow of a reliance being placed on their services.
The large number living with strangers or relatives on parish allowance appeared to have seldom fallen within the personal observation of the Commissioners, who had chiefly to depend upon the annual returns from the clerks of the Board of Guardians, and on the quarterly returns from the medical officers of the various districts,[189]whose returns were so defective and irregular that no definite conclusion could be drawn from their contents.
In their next Report the subject of workhouses still claimed the attention of the Commissioners, and they complained that, in direct contravention of the law,pauper patients were sent first to a workhouse, instead of an asylum. The sixty-seventh section of the Act of 1853 was disregarded altogether. Hence, if the patient was found manageable in the workhouse, he was detained there, or, if ultimately sent to the asylum, much valuable time had been lost, and his chance of cure greatly lessened. The Commissioners found their recommendations set at defiance, for the most part, whenever the report of the medical officer stated the patient to be "harmless." It was urged that the lunatic wards in workhouses should be placed in the position of licensed houses, and that the Commissioners and visitors should be invested with the same power in regard to them as they possessed over these establishments. But it became very clear that, however valuable the recommendations of the Commissioners might, and, indeed, have ultimately proved to be, they did not possess the authority of commands. At the infirmary asylum at Norwich unceasing suggestions for improvement were made forten 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) thecases of all boroughs wherein proper provision had not been made for their pauper lunatics. "But even this last appeal did not fare more successfully; and all our reiterated inquiries and remonstrances have as yet made hardly a perceptible impression upon that almost general neglect of the law which it was hoped they might repair."
As regards the important class of single patients, the Commissioners had not found it practicable to visit them as they desired to do. Many, however, had been visited. Some were found indifferently accommodated, and otherwise in a very unsatisfactory state. The provisions of the law were extensively evaded.[190]
As the views entertained and recommended by the Commissioners from time to time are of importance in regard to the construction of asylums, it may be observed that in their Report of 1857 they dwell on the evils of very large buildings, on account of the loss of individual and responsible supervision, the loss of the patient's individuality, and the tendency of the rate of maintenance for patients to run higher.[191]It was also maintained that the divided responsibility consequent on such large institutions was injurious to management, and that the cures of patients were actually fewer. It was considered that the limits to the size of the Hanwell Asylum were reached, and indeed exceeded, viz. for 1020, but room for 600 patients more was required. So at ColneyHatch 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 amountedto—for males, 1172; females, 1309; total, 2481. The numbers for whom additional asylums were then being made were—males, 1169; females, 1157; total, 2326. The sum of these totals being 21,048. There were, on the 1st of January of this year, 17,572 pauper lunatics in asylums, of whom as many as 2467 were still confined in private asylums. There were now 33 county and 4 borough asylums, 15 registered hospitals, 37 metropolitan licensed houses, and 80 provincial licensed houses; also the Royal Naval Hospital. The total number of inmates in these establishments were (in the order enumerated) 15,163, 1751, 2623, 2647, 126, making a grand total of 22,310, including 295 patients found lunatic by inquisition.
The Commissioners point out that a military asylum is a desideratum, there being no provision for soldiers, while sailors were well cared for at Haslar Hospital.
The following particulars will show at a glance the provision made at this period for the insane in England and Wales:—
1. Boroughs having asylums: Birmingham, Bristol (in St. Peter's Hospital), Hull.
2. Boroughs erecting or about to erect asylums: Maidstone, Bristol, City of London.
3. Boroughs in union with counties: Cambridge, Colchester, Maldon, Gloucester, Leicester, Grantham, Lincoln, Stamford, Hereford, Nottingham, Abingdon, Oxford, Reading, Shrewsbury, Wenlock, Worcester.
4. Boroughs whose pauper lunatics are sent to asylums under contract or arrangements between justices, etc.:Plymouth, Chichester, Portsmouth, Southampton, Devizes, Salisbury, Chester, Derby, Barnstaple, Bideford, Dartmouth, Exeter, South Molten, Tiverton, Tewkesbury, Bridgewater, Bridgnorth, Ludlow, Penzance, Poole, Winchester, Newark, Oswestry, Bath, Lichfield, Scarborough.
5. Boroughs which have not made any statutory provision for the care of their pauper lunatics: Bedford, Newbury, Buckingham, Carmarthen, Andover, Canterbury, Dover, Hythe, Rochester, Sandwich, Tenterden, King's Lynn, Norwich, Thetford, Yarmouth, Northampton, Berwick-upon-Tweed, Newcastle-upon-Tyne, New Radnor, Bury St. Edmunds, Ipswich, Guildford, Hastings, York.
In 1862 the expense of pauper lunatics in asylums was thrown upon the common fund of the union, instead of on the particular parish. The effect was natural. Many patients were removed from workhouses to the county asylums, some of whom might well have remained there. There could be no objection to this, if the latter cost no more than the former; but seeing that where the one costs £200 per bed, the other would only cost £40, the effect is, from the point of view of the ratepayer, who usually objects to contribute to the formation of a free library, a very serious one.
Twenty years after the census of the insane made in 1844, and ten after the period to which the table given atp. 230refers, we find the numbers as follow[192]:—
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 safeguardsprovided by the legislature, there may not be a safe recourse to this mode of making provision for this class of the insane. At any rate, it is of interest to know what has been done in this direction during the last few years in England.
Asylums have been erected at Leavesden, near Watford, Herts; Caterham, Surrey; and Darenth, near Dartford, Kent, there being at Darenth both idiot schools and an institution for incurables.
These are the Metropolitan District Asylums.[194]
As the primary object in adopting this kind of accommodation is economy, it is important to present a clear statement of the finances, omitting shillings and pence.
Take Leavesden as the example, where the accommodation is for 2000 patients (M. 900, F. 1100). The land, which was purchased in 1867 and 1880, has cost £9401, the area being eighty-four acres. The laying out the grounds, etc., cost £3000; the cost of building and drainage (up to Michaelmas, 1878) was £121,674; the engineering works, fixtures, and fittings cost £16,162; the furniture, bedding, and clothing, £16,235; the architect's and surveyor's charges, and clerk of works, £5108; solicitor's charges, printing, insurances, and all other charges, £1526; the total being £173,118, or £86[195]per bed. Taking out the items of furniture, bedding, and clothing, we have the sum of £77 per bed. How striking the difference when compared with the expenseof an ordinary county asylum, the reader who has examined the figures given atpage 166will readily perceive.
Let us now pass on to the year 1870. We find the Commissioners able to state, as the result of very minute and careful inspection, that the Reports of their members during the previous year showed, on the whole, that good progress continued to be made in the mode of managing "these large and daily increasing institutions," and they add, "although in some instances it has been our duty to comment on shortcomings and cases of neglect, we have generally been able to bear testimony to the skill and zeal evinced by the medical superintendents in the execution of their very grave and difficult duties."[196]On the other hand, they observe, "We regret that we shall have to describe several acts of violence committed by attendants in county asylums, which in three instances were followed by fatal results, but in only one of which, although careful inquiries were instituted, such evidence was obtained as would justify criminal proceedings."
The Report on the Liverpool Lunatic Hospital shows how far from satisfactory one, at least, of these institutions was at that time: "With few exceptions, the personal condition of the patients was found to be very indifferent, and indeed the reason alleged why the females in the lower wards were never on any occasion taken beyond the airing-court, was that they had no clothes fit to be seen in. The corresponding class of men was stated to be taken out as little as the women, and both were saidto be rarely visited by any friends having an interest in them. The state of the furniture was discreditable in the extreme, and there was a general absence of tidiness throughout the hospital. The patients were, with few exceptions, quiet; not more than four or five of the better class of either sex were reported to have the opportunity of walking or driving out.... The seclusion in the fifteen months which had elapsed since the previous visit applied to five males on 62 occasions, and to 18 females on 132 occasions."[197]
The Commissioners speak of "the invariable success attendant on such hospitals as have been built during the last few years, and specially at Cheadle."
In regard to licensed houses within their jurisdiction, they were reported to be "generally, as to the condition and management of such houses, of a very satisfactory character;" while of the provincial houses they say, "The Reports, for the most part, have not been unfavourable as to their condition and management."[198]
In this Report the Commissioners comment on the operation of the Metropolitan Poor Act of 1867, which threw the maintenance of lunatics in asylums upon the common poor fund of the metropolis, and they observe that "it has induced the boards of guardians to relieve themselves of local charges, and this has greatly contributed to swell the removals from workhouses to asylums, notwithstanding that the patients have in large numbers been unable to be received nearer than in the county asylums of Northumberland, Yorkshire, Staffordshire,and Somersetshire, and although the rate of maintenance has ranged from 14s.to 17s.6d.per week."
As the cost of lunatics is so important a question, it may here be stated that the total weekly cost per head in 1870 averaged in the county asylums 9s.3d., including maintenance, medicine, clothing, and care. Under the maintenance account were comprised furniture and bedding, garden and farm, and miscellaneous expenses. The other items were provisions, clothing, salaries and wages, fuel, light and washing, surgery and dispensary, wine, tea. In this estimate was reckoned the deduction for moneys received for produce sold, exclusive of those consumed in the asylum.
The weekly cost in the following registered hospitals was as follows:—
It should be observed that Northampton was at this time essentially the pauper asylum for the county.
We have already referred to the paramount importance of reliable attendants. "Nothing is easier," the Commissioners observe, "for a man in such a position, with unrestricted and uncontrolled power over the habits and happiness of another, than to act cruelly without being cruel." So long ago as 1851 a check was given to the conduct of attendants by a decision of the courts in that year. An attendant had been convicted ofmanslaughter on the evidence of a patient. This was appealed against, but the conviction was sustained. Lord Campbell laid it down that the only thing needful was for the patient to understand the nature of an oath and what he was saying. "But although this ruling has never since been disputed, the many subsequent attempts of the Commissioners to exact a rigid responsibility for acts of violence or cruelty in asylums have, through the indisposition of juries[199]to accept the evidence principally available for proofs in such cases, more frequently failed than succeeded."[200]
In each of the three previous years, proceedings had been taken against attendants, and with very limited success. In the beginning of 1870, however, a prosecution instituted by the magistrates of the Lancaster Asylum against two attendants for manslaughter on the evidence of a patient succeeded, and they were sentenced to seven years' penal servitude, a result which the Commissioners regarded as the most beneficial example within their experience. During the previous year, eighty-eight male attendants had been dismissed from service—fifty-three for drunkenness, insubordination, or neglect of duty, and thirty-five for assaults on patients; four only of these latter having had criminal prosecutions instituted againstthem, and of the former not one. Of the number dismissed, fifteen were in licensed houses, three in public hospitals, and the remaining seventy in county asylums. During the same period thirty-four female attendants were dismissed, of whom twenty-four were employed in county asylums. Eleven had been guilty of violence or rough usage to patients, there having been no prosecution in any instance. The Commissioners justly observe that, while "there has been no greater work of mercy and humanity than that which rescued the lunatic patients from stripes and filth, or continued restraint and isolation, yet it will remain to some degree still imperfect until he is also rescued from the possible chance of being subjected to the unwatched or unchecked humours and caprices of ignorant, careless, or cruel attendants."[201]
A striking instance of the respective powers of the Committees of asylums and the Commissioners in Lunacy occurs in the Report of the latter for 1870. Death from broken ribs had taken place in a county asylum, and the Commissioners considered the cruelty of an attendant established. They reported inadequate supervision of the wards, as well as the attendants, in reply to which the committee of visitors asserted that they would not enter into any discussion on a subject upon which they considered themselves fully competent to determine how they should discharge their own duties. The Commissioners found that they had no alternative but to leave to the refractory committee the responsibility,which they had shown no unwillingness to assume, of the adoption or rejection of such recommendations. "The law which has required us to investigate and report as to matters affecting the management of county asylums, has invested us with no authority further to enforce our views." In the same way their authority was set at naught in an asylum where an idiot boy was found on the floor, strangled by a pocket-handkerchief, effected, there was every reason to believe, by one of the patients, and the Commissioners found that the deed could not have been perpetrated if attendants had been properly dispersed through the wards. The union authorities failed to get satisfaction from the committee, and the Secretary of State was memorialized by the guardians, who were backed up by the Commissioners, but in vain. Hence the Commissioners complained of "the limits thus placed to all real authority but that of the committee of visitors over establishments whose inmates are necessarily most at the mercy of attendants, and in which these cases of misconduct most frequently occur."[202]
We have alluded to this circumstance, not to indicate that at the present time the committees of asylums set themselves in opposition to the recommendations of the Commissioners, but our historical sketch demands, in justice to the latter, who are often supposed to have unlimited power, that it should be known that desirable reforms may not be carried out in our asylums, and yet the fault may not lie at the door of the Lunacy Commissioners. And it should be stated that recently LordShaftesbury 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 ofpatients 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 worngloves, 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, becamevastly improved, and it was impossible to deny that for many harmless chronic cases they were, to say the least, sufficiently comfortable in the workhouse. Then came the legislation of 1874,[203]by which four shillings a week were allowed for every pauper lunatic in any asylum or licensed house, being reimbursed to the unions and parishes from which the patient was sent. Hence the strong inducement, in some counties at least, for it certainly does not hold good in all, to transfer lunatics detained in workhouses to the asylums, even when no occasion whatever arises out of the mental condition of the patient to justify such transference. The Commissioners themselves have recognized the difficulty and disadvantage of the operation of this legislation, and say in their twenty-ninth Report, 1875, that while this Act "may be beneficial in promoting the removal to asylums of a certain number of patients requiring such treatment, and who might possibly otherwise be deprived of it ... it remains to be seen whether the alteration in the incidents of the maintenance charged, will not also have the effect of causing unnecessarily the transfer to asylums of chronic cases, such as might be properly cared for in workhouses, thus rendering necessary, on the part of counties and boroughs, a still larger outlay than heretofore in providing additional asylum accommodation. The returns for the 1st of January last tend to show that such results are not unlikely to accompany the working of this new financial arrangement."[204]The Irish inspectors in their report for 1875 calculate that themaximum 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.
Referring to the numbers of the insane in 1875, the Commissioners observe that they have increased beyond the growth of the population. This had been mainly among paupers, there having been 16.14 of this class in 1849, and 23.55 in 1875, per 10,000 of the population; while of private patients the advance had only been from 2.53 to 3.09 during the same period. The population increased from 1849 to 1875, 22.63 per cent. Private patients increased 48.39 per cent., and pauper patients 77.47 per cent.
In regard to the treatment of the insane in Wales, it may be stated that until the Denbigh Asylum was opened in November, 1847, there was no institution for the reception of lunatics, except the small asylum at Haverfordwest, and a house licensed in 1843 for private and pauper patients in Glamorganshire.[207]Most of the paupers were kept in their homes or workhouses; others sent to asylums. Before the Act was passed making it compulsory on the counties to provide accommodation, several philanthropic gentlemen, impressed with the desirability of having an institution for private patients in North Wales, and where all the officers should possess a knowledge of Welsh, which language alone the vast majority of the inhabitants knew at that time, collected about £8000. By this time the Act was passed, and the subscribers made over their money to the counties, on condition that twenty-six separate beds should be kept for private patients—several of themselves to bemembers 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.