Footnotes:

"For nought so vile that on the earth doth live,But to the earth some special good doth give;Nor aught so good, but strained from that fair use,Revolts from true birth, stumbling on abuse."

Employed without discrimination, regarded as a talisman in insomnia and excitement—petted, in short, when it ought to have been restrained—chloral became for a time the spoilt child of psychological medicine, and, like other spoilt children, it has disappointed the fond hopes of its parents.

When it is possible for a physician in asylum practice to write as Dr. Pritchard Davies has written this year in ourJournal, "On Chemical Restraint," to the effect that chloral, the bromides, and other sedatives are unnecessary, or even injurious; when, on the other hand, we have Dr. Hills replying that his experience at the Norfolk Asylum leads him to an entirely opposite conclusion; and Dr. Stokes, in America, writing thus in his report, after 7425 patients have been under treatment in his asylum, "without wishing to undervalue the great importance of an efficient system of moral treatment, great results can only be expected from a patient and persevering administration of powerful remedial agencies"—I say when such contrary opinions can be expressed by practical men, one feels how impossible it is to dogmatize upon the good effected by pharmaceuticalremedies in insanity, and how far we are yet from witnessing a consensus of opinion in regard to their value.

It must be frankly granted that Psychological Medicine can boast, as yet, of no specifics, nor is it likely, perhaps, that such a boast will ever be made. It may be difficult to suppress the hope, but we cannot entertain the expectation, that some future Sydenham will discover an anti-psychosis which will as safely and speedily cut short an attack of mania or melancholia as bark an attack of ague.

Rather must we rest satisfied with the general advance in treatment in a scientific direction. Most of us know asylums where, within forty years and much less, tartarized antimony was in daily use in large doses as a quietus, and where croton oil was administered in addition to black draughts to a surprising extent, all these remedies being now employed only on the rarest occasions. Take an actual example, one of many, in a particular asylum. A few years ago a patient, who had been much excited and very troublesome, was treated in season and out of season with strong purgatives and sedatives. It so happened that he then fell under a newrégime, which consisted in knocking off all these medicines and placing him under one attendant's entire supervision. The result was that he became as quiet and docile, though not cured, as any of the inmates of the asylum, and has remained so to the present time. But we may go further, and say that some cases of insanity are cured now which a few years ago wouldhave remained uncured. Indeed, in relation to the associated bodily state, it may be said that specific treatment has been adopted. Remedies, like iodide of potassium, in large doses, are employed in cases in which, from the increased attention directed in recent years to the somatic ætiology of insanity, a causal relation between the physical and mental condition has been recognized, and the mental symptoms have disappeared in the most marked manner; and so again in gouty melancholia, relief has been obtained by appropriate remedies and diet. These are illustrations of the directly scientific application of medicine to medical psychology, and it is in this direction we must hope for a really satisfactory advance.

On the other hand, there are the successes obtained by the employment of drugs without our being able to say why or how they have exerted a curative agency; and it is obvious that as the number of drugs has so much increased during the period over which my survey extends, the chances of hitting on the right remedy are proportionately increased. How often we see one, two, or three drugs exhibited in mania without any result, while a fourth acts like a charm. Only by studying in detail the special characteristics of each case, can we hope to find a clue which will serve as a guide to the treatment of a subsequent one.

In this country, Dr. Clouston has distinctly advanced our knowledge of the action and uses of narcotic remedies by experiments made to determine the effect on maniacal excitement of single doses of certainremedies, stimulants, and food; of, again, the effect on mania of prolonged courses of certain narcotic medicines, along with clinical observations on the effects of the same medicines in all kinds of insanity, and has determined the equivalent value of opium, bromide of potassium, and cannabis indica in the treatment of insanity.

Dr. Savage has experimented with one drug at a time on a number of patients, and has already given to the profession some valuable results in "Guy's Hospital Reports," and theJournal of Mental Science. "The West Riding Asylum Medical Reports" of Dr. Crichton Browne also contain some important experiments with drugs by himself and others; and in this connection I would notice the excellent clinical notes issued from time to time by Dr. Williams and other officers of the Haywards Heath Asylum, which are well worthy of more permanent record in the archives of the Association. I cannot, indeed, understand any one seriously maintaining that we are practically no better off in our medicinal resources now than we were forty years ago.

Whatever differences of opinion may exist in regard to the advantages gained by the introduction of new drugs, one thing is clear, that the employment and, let me add, the repose of patients, well-ordered arrangements, and the tact of the superintendent will oftentimes do more to reduce the amount of excitement and noise in an asylum than tons of chloral and bromide. For example, any one who has visited Hanwell knows that Dr. Rayner anticipates and prevents post-epileptic mania to a very large extent by the simple expedient of keepingpatients in bed after their fits, just as he finds forced alimentation of patients rarely necessary when rest is resorted to. It is striking to see how, even in an over-grown asylum and an old building, the results of good management and treatment can be highly satisfactory, and worthy of an institution of such historic fame.

But, after all, the question faces us, are there or are there not more insane persons cured in 1881 than in 1841?

One's first impulse, of course, is to take the statistics of recovery for a certain number of the more recent, and compare them with those of the earlier years, or to take the recoveries of the past forty and place them side by side with those of the previous forty years. The attempt, however, is fraught with so many fallacies that it is dangerous to make such a comparison. In a report of Bethlem Hospital, issued in 1841, Sir Alexander Morison stated—not as anything exceptional—that seventy per cent. of the patients had been discharged cured; while an examination of the recoveries at this hospital for the last ten years shows a much smaller proportion per cent. But I cannot accept these comparisons as proving anything one way or the other, as various causes, quite apart from the comparative success of treatment at different periods, may explain the difference. Take a single asylum, like Hanwell, and compare the recoveries of a later with an earlier period. I find a population so fluctuating in character, in regard to curability, that the comparison becomes utterly worthless,and although it is true that during the last quinquennium 28.1 per cent. have recovered, as against 26.3 per cent. during the first quinquennium of the past forty years, in spite of there having been more incurables received during the later period, the result is not so satisfactory when we divide into certain periods the whole time during which Hanwell has been open (omitting the first four years). It then appears that during two previous periods the recoveries were higher than 28.1 per cent., viz. from 1840 to 1849 and from 1865 to 1874. Thus:—

Or in quinquennial periods throughout:—

If to escape the fallacies connected with the comparison of different periods of the same asylum, we go to the Lunacy Blue Books, we do not get any reliable figures before 1870, on account of transfers having been previously included in the admissions, so that a faircomparison of recent and former recoveries worked on the admissions is impossible.

I have before me the statistics of the Siegburg Asylum, thanks to Dr. Ripping, from its opening to its close; and I find that the recoveries during the first twenty-five years amounted to forty-two per cent., and during the twenty-five years ending with the year 1877, they were forty-six per cent., thus showing an increase of four per cent. in the more recent period. As this asylum, now closed, has admitted curable cases only, these figures are among the few valuable statistics which I have been able to procure.

I have not succeeded in obtaining satisfactory comparative results by adopting, in the mixed asylums of England and Wales, the plan of working the recoveries, not on the total admissions, but on those only deemed curable; but to explain this fully would involve me in more detail than the occasion warrants.

I would add that in the United States, where reasons have been assigned why the statistics of asylums exhibit apparently fewer recoveries in the later than the earlier period of the last forty years, Dr. Pliny Earle has done good service by the remarkable contribution he has made to the question of the curability of insanity,[312]corroborating, at the same time, the somewhat unfavourable conclusion as to permanent recovery which Dr. Thurnam, in a work which will always be a Pharos to guide thosewho sail on waters where so many are shipwrecked, arrived at, after a laborious examination of the after history of cases discharged recovered from the York Retreat. It is likewise anything but reassuring to find that, out of the total number of lunatics under care in England and Wales, there are at this moment only 3592 who are deemed curable.[313]

Such, gentlemen, is my Retrospect of the Past. Meagre it has necessarily been, though occupying more of your time than I could have wished, but the number of subjects demanding reference must be my excuse.

We found, at the commencement of the period we have traversed, the accommodation provided for the insane scandalously insufficient, and the condition of many of the existing asylums calling loudly for a radical reform.

We witness to-day, throughout the kingdom, a large number of institutions in admirable working order, reflecting the greatest credit upon their superintendents and committees.

We found a wholly inadequate system of inspection.

We witness now a Board of Commissioners, which, without forfeiting the good will of the superintendents, carefully inspects the asylums throughout the provinces as well as the metropolis—as carefully and thoroughly, at any rate, as the same number of men originallyappointed to examine into the condition of some 20,000 patients can fulfil a like duty for above 70,000.

We found a resolute attempt being made to carry out and extend the humane system of treatment inaugurated nearly half a century before in France and England.

To-day we witness its success.

And had I had time to sketch the progress in the provision made for criminal lunatics, we should have found that just forty years ago was the commencement of what Dr. Nicolson has named the "Reactionary Period"—during which this Association petitioned the Government (in 1851) to establish a criminal lunatic asylum—followed in 1860 by the "Period of Centralization" or that of Broadmoor—an institution to-day so efficiently superintended by Dr. Orange.

And in what consists the superiority of the new over the old system of treatment—the nineteenth over the eighteenth century?

The old system was mainly one of brute force—the child alike of ignorance and fear.

The new does not indeed dispense with force, but it is a maxim of the reformed school, from which no one, whose opinion carries weight in psychological medicine, whether in America or in Europe, would dissent, that it should be reduced to the lowest possible point, consistent with safety and the good of the patient, and that humanity should dictate the means of repressing, or rather guarding against, violence, both as regards their amount and character.

The old system subjected patients, who underwent any medical treatment at all, to a miserable routine, often determined by the season of the year and the phases of the moon, rather than the condition of the patient.

The new does not pretend to possess a universal formula, or to have discovered the psychologist's stone, but strives to treat each patient according to individual indications.

The old system desired secrecy; the new is not afraid of publicity.

The old system, in short, believed in harshness and darkness; the creed of the new is, "I believe in sweetness and light."

Such are the results achieved for Psychological Medicine.

If this be the Retrospect of the Past, what is the Prospect of the Future? Will the progress of the last forty or the last ninety years be maintained? I trust it will, but one need not be a pessimist to be sensible that the humane treatment of the insane may have its ebb as well as its flow; that so far from its being true that there is a constant and certain tendency to humanity, there is also a strange tendency to relapse into inhuman ways. Vigilance is and always will be required, for if it be allowed to slumber, we but too well know that there is only one direction in which things will go when left to themselves—and that is downhill.

The functions—the mission—of this Association maybe regarded from a threefold point of view: first, in relation to insanity and the insane; secondly, in relation to its members; thirdly, in relation to the public.

I.—Under the first are comprised what in the original rules, drawn up by the founders of this Association forty years ago, were stated to be its objects, namely, "Improvement in the management of asylums and the treatment of the insane;" and further, "The acquirement of a more extensive and more correct knowledge of insanity."

Added to the improved management of asylums is the necessity now for making appropriate provision for idiots and imbeciles, and their education so far as practicable, grappling at the same time with the problem how best to provide for the mass of incurable pauper patients in the provinces, and the extension of middle-class asylums, and of cottages in connection with the central institution.

There are, of course, various ways in which the welfare of the patients in asylums can be promoted, by the attention directed by the Association to special points of importance. To instance only one, the occupation of patients, including systematic teaching which Dr. Lalor has so successfully developed in the Richmond Asylum, Dublin. Though very much has been done, there is, all, I think, will agree, room for more sustained effort in this direction. "There is one monster in the world—the idle man," are the words of one who has lately passed beyond the reach of praise or blame, which ought ever to be in the minds of those who direct our asylums. It may be that if more were done in futurein the spirit of this apophthegm of the Sage, if not the Saint, of Chelsea, there would be less chance of patients chewing the cud of bitter reflection and dwelling upon the delusions by which they are haunted and harassed.

In proportion as we feel the inadequacy of our means of cure, we must recognize the necessity of studying the ætiology of insanity, including thatdamnosa hæreditas, which is the cause of causes in so large a number of the cases coming under our treatment. But what induced the ancestral taint? It behoves us to pay more and more attention to those laws of inheritance in general to which Mr. Hutchinson has recently directed attention in his suggestive lectures at the College of Surgeons.

When M. Baillarger proposed that a similar association to this should be established in France, he gave, among other reasons, the advantage which would accrue from discussing this very question. "Every one," he said, "is assuredly decided upon the influence of heredity in the production of insanity (Mr. Buckle had not then written); but in this primary question, how many secondary ones there are which remain unsolved." Since he thus wrote, his own countrymen, Morel and Lucas, have, by their researches, advanced our knowledge, and rendered the task of their successors in the same field easier.

Intemperance also, as a cause as distinct from a symptom of insanity, requires to be more thoroughly examined into, and I am happy to say Dr. Hayes Newington, than whom no one could be better fitted for the task, has prepared a series of questions arrangedin a tabular form, which has been before the Statistical Committee, and will appear in theJournal.

Again, there remains for the future the continued research into the causal connection between certain mental symptoms or disorders and accompanying lesions of the brain and cord. Dr. Spitzka, of New York, in the prize essay which he is about to publish, enters carefully into this inquiry, and I am hopeful that his industry and talent will be rewarded by marked success. These and kindred investigations might, no doubt, be pursued in a more methodical manner than is always the case in English asylums. To this end, the appointment of a pathologist, as at Wakefield in our own country, and at the Utica Asylum in America, ought to become general.

Clinical teaching in our asylums admits of much greater development, though they may not be able to meet the demands made upon them, should examinations be required in medical psychology by the examining bodies. To-day the student has fortunately a very different position from that which fell to his lot forty years ago. He has at his command means of research then unknown, as the ophthalmoscope and sphygmograph, and all the modern improvements in the microscope and in preparing sections; and can he not experiment on knee jerks, and a host of reflex and electric phenomena never dreamt of by his predecessors? He has, moreover, the stimulus begotten of the sense that enough has been discovered to indicate how much precious treasure lies hidden beneath the ground he nowtreads, like the gold-digger whose ardour is quickened and labour repaid by the discovery of the minutest particle of the metal of which he is in search.

II. The second relation in which this Association stands—to its members—suggests that we must needs be alive to legislation affecting the rights of those who are engaged in this department of medicine. This association is not a trades union, but there are various points bearing on their position which have to be considered, as in connection with a Bill like Mr. Dillwyn's, or the matters discussed two years ago at the annual meeting, when brought forward by Dr. Murray Lindsay. It is true that for him who has taken mental science, in its widest sense, as his mistress; for him who has wooed her for her own sake, knowing full well that for him she may hold no dowry in hand or pocket, there is the supreme pleasure arising from study and observation themselves—that recompense which is better than gold, and more precious than rubies. All this is true; but none the less the superintendents of asylums have a right to expect not only that their services shall be adequately remunerated when in harness, but that they may count with certainty upon a fair provision in the evening of life.

III. With regard, thirdly, to the influence of this Association on public opinion, we should be strangely faithless to our mission, if we were not the expositors of the principles in accordance with which the insane ought to be regarded; if we did not endeavour to enlighten the community in the doctrines of true psychological science, and in that philanthropy which is asfar asunder as the poles from the fitful pseudo-philanthropy from which our country is unfortunately not free, the wild, ill-regulated, hysterical clamour with which we are epidemically visited, as injurious to the lunatic as it is to the interests of society at large.

This Association, further, ought to continue to bring before the lawyer what it regards as the just test of criminal responsibility; to entreat the educator not to defeat the object of his noble profession by exactions which transgress the limits by which Nature has bounded human capacity; and to warn parents, as Dr. Brigham did in his day with so much zeal, of the dangers to mental health arising from precocious forcing during the early growth of the brain, and with a tenfold greater necessity than when he wrote, in presence of the illimitable folly of examining boards, some of them medical, the members of which have not even the poor excuse of ignorance; and last, but not least, to counsel the teacher of religion against the peculiar dangers which attend his exalted mission, remembering that—

"Virtue itself turns vice, being misapplied."

Various, then, are the functions of our Association. But what, asks the late Sir James Stephen, the eloquent writer in theEdinburghis a party, political or religious, without a Review? and he replies, "A bell without a clapper." Such a bell would this Association have been without itsJournal, and it must gratefully attribute much of its success to the ability with which in the first instance Dr. Bucknill, and subsequently Drs. Robertson,Maudsley, Sibbald, and Clouston, have helped to make an otherwise clapperless bell articulate.

Through this organ of the Association, for which, speaking for my colleague and myself, I would venture to ask your loyal co-operation, much scientific work can be brought before the profession, many questions can be systematically discussed, and the invaluable experience of the superintendents of asylums on practical points be presented to its readers and permanently preserved.

The objects I have mentioned as calling for further attention, and many more, belong to the future of Psychological Medicine, and as I began my address with proposing to review the period bounded by the years 1841 and 1881, I will close it with expressing the hope that when a successor of mine in this office reviews the then vanished period between 1881 and 1921, he will be able to report an accelerated ratio of progress compared with that of the time I have attempted, so inadequately, to survey.

And may the Medico-Psychological Association, which I trust will always be identified with this progress, be about to enter, after its wanderings, "forty years long," a land flowing with milk and honey, won by conquests over ignorance, superstition, and cruelty—the triumphs of the application of humanity and medical science to the relief of mental weakness and suffering.

Footnotes:[Skip][292]Presidential Address, delivered at the Annual Meeting of the Medico-Psychological Association, held at University College, London, August 2, 1881.[293]I here do homage to the dead. Calmeil, Baillarger, and Brierre de Boismont still live, at an advanced age. (Since this address was given, the last named has died. See eloquent tribute to his memory by M. Motet, inJournal of Mental Science, April, 1882.)[294]As will be seen by the history of lunacy reform contained in this volume, Lord Shaftesbury's interest in the movement extends back as far as 1828.[295]American Journal of Insanity, April, 1855.[296]9 Geo. IV., c. 40.[297]Amended by 18 and 19 Vict., c. 105 (1855). Acts referring to Lunacy Commissions and Chancery Patients, 16 and 17 Vict., c. 70; 25 and 26 Vict., c. 86 (1862).[298]If parts of workhouses, etc., be included, 166. Seep. 211.[299]I should find it difficult to point to a more striking illustration of these remarks than the good work being done at the Lenzie Asylum by Dr. Rutherford.[300]"On the Construction, Organization, etc., of Hospitals for the Insane," by Thomas S. Kirkbride, M.D., LL.D. (Philadelphia, 1880), p. 300.[301]On the large degree to which patients, as shown by the experience of the Chancery Visitors, can be treated satisfactorily outside asylums, see pp.261and286; also Dr. Bucknill's trenchant little book, "Care of the Insane and their Legal Control," 1880.[302]"Ideal Characters of the Officers of a Hospital for the Insane," by I. Ray, M.D. Philadelphia, 1873.[303]See Dr. Baker's Annual Reports of the York Retreat, and Dr. Rees Philipps's last Report of the Wonford Asylum, Exeter, etc., etc.[304]"A Treatise on the Nervous Diseases of Women," by Thomas Laycock, M.D., 1840, chapter ix. p. 107.[305]British and Foreign Medical Review, January, 1845, p. 311.[306]"Remarks on Insanity, its Nature and Treatment," p. 14.[307]"I agree with Mr. Martineau in repudiating the materialistic hypothesis as utterly futile."—Herbert Spencer,Contemporary Review, June, 1872.[308]"Die Freiheit der Wissenschaft im Modernen Staat," by Rudolf Virchow. Berlin, 1877.[309]Preface to his work on Mental Alienation, p. 20.[310]"General Paralysis of the Insane," by Wm. Julius Mickle, M.D., M.R.C.P. London, 1880.[311]Among the groups of cases in which they were more decidedly present is that comprising many due to syphilis; that in which degenerative changes follow upon hæmorrhagic softening, and another in which they succeed to occlusion of vessels and its immediate results. In another, degeneration and atrophy follow, the brain state conditioning acute insanity; and in another they are secondary to brain injury, not to mention many other groups.[312]In the same department the services of another American alienist, Dr. Edward Jarvis, ought not to be forgotten. Among other works, his Report on the Idiotic and Insane in Massachusetts, 1854, was of great value.[313]It is a remarkable fact, showing the mass of incurable cases which have accumulated, that the number of curable cases now is only about 1000 more than it was in 1844 (2519).

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[292]Presidential Address, delivered at the Annual Meeting of the Medico-Psychological Association, held at University College, London, August 2, 1881.

[293]I here do homage to the dead. Calmeil, Baillarger, and Brierre de Boismont still live, at an advanced age. (Since this address was given, the last named has died. See eloquent tribute to his memory by M. Motet, inJournal of Mental Science, April, 1882.)

[294]As will be seen by the history of lunacy reform contained in this volume, Lord Shaftesbury's interest in the movement extends back as far as 1828.

[295]American Journal of Insanity, April, 1855.

[296]9 Geo. IV., c. 40.

[297]Amended by 18 and 19 Vict., c. 105 (1855). Acts referring to Lunacy Commissions and Chancery Patients, 16 and 17 Vict., c. 70; 25 and 26 Vict., c. 86 (1862).

[298]If parts of workhouses, etc., be included, 166. Seep. 211.

[299]I should find it difficult to point to a more striking illustration of these remarks than the good work being done at the Lenzie Asylum by Dr. Rutherford.

[300]"On the Construction, Organization, etc., of Hospitals for the Insane," by Thomas S. Kirkbride, M.D., LL.D. (Philadelphia, 1880), p. 300.

[301]On the large degree to which patients, as shown by the experience of the Chancery Visitors, can be treated satisfactorily outside asylums, see pp.261and286; also Dr. Bucknill's trenchant little book, "Care of the Insane and their Legal Control," 1880.

[302]"Ideal Characters of the Officers of a Hospital for the Insane," by I. Ray, M.D. Philadelphia, 1873.

[303]See Dr. Baker's Annual Reports of the York Retreat, and Dr. Rees Philipps's last Report of the Wonford Asylum, Exeter, etc., etc.

[304]"A Treatise on the Nervous Diseases of Women," by Thomas Laycock, M.D., 1840, chapter ix. p. 107.

[305]British and Foreign Medical Review, January, 1845, p. 311.

[306]"Remarks on Insanity, its Nature and Treatment," p. 14.

[307]"I agree with Mr. Martineau in repudiating the materialistic hypothesis as utterly futile."—Herbert Spencer,Contemporary Review, June, 1872.

[308]"Die Freiheit der Wissenschaft im Modernen Staat," by Rudolf Virchow. Berlin, 1877.

[309]Preface to his work on Mental Alienation, p. 20.

[310]"General Paralysis of the Insane," by Wm. Julius Mickle, M.D., M.R.C.P. London, 1880.

[311]Among the groups of cases in which they were more decidedly present is that comprising many due to syphilis; that in which degenerative changes follow upon hæmorrhagic softening, and another in which they succeed to occlusion of vessels and its immediate results. In another, degeneration and atrophy follow, the brain state conditioning acute insanity; and in another they are secondary to brain injury, not to mention many other groups.

[312]In the same department the services of another American alienist, Dr. Edward Jarvis, ought not to be forgotten. Among other works, his Report on the Idiotic and Insane in Massachusetts, 1854, was of great value.

[313]It is a remarkable fact, showing the mass of incurable cases which have accumulated, that the number of curable cases now is only about 1000 more than it was in 1844 (2519).

Incompleting the task which the author has attempted in the foregoing chapters in the History of the Insane in the British Isles, he is only too conscious that, in the endeavour to be concise as well as comprehensive, he has made many omissions. With every desire to be fair to all who have been engaged either in originating or in advancing the improved treatment of those who, suffering cruelly from a malady involving their very nature and being, have also been treated cruelly by their fellows, the writer fears that some names which ought to have been recorded and some institutions which ought to have been honourably mentioned, have been passed over in silence. Apart from unintentional oversight, it is not always easy to find in the Temple of Fame the precise niche in which to place the figure that would rightfully fill it, and the consequence is that the pedestal, as in some of our great public edifices, remains unoccupied. It may be said, however, in extenuation of any such omission, that it did not fall within the scope of this book to chronicle all the establishments which, in more humane methods of treatment, have been in advance ofothers, still less to complete the history up to the present day of those which have been mentioned. As it proceeded, the work has entered more into detail than was originally designed; thus, in the chapter on Scotland the sketch is filled in with particulars somewhat out of proportion to that attempted in the earlier chapters.

Again, in crediting various asylums, as Lincoln, Hanwell, and Lancaster, with introducing non-restraint, the author has not found space for more than a reference to the meritorious course pursued at an early period at the Suffolk Asylum, the Gloucester Asylum, and at Northampton from its opening (1838), and at the Haslar Hospital.[314]

The writer would have been glad, had the proposed limits of the book admitted of it, to describe much more fully the rise and growth of those charitable institutions, the endowed or registered hospitals for the insane, which have in England formed so important, and, on the whole, so successful, an experiment in providing care and treatment for the insane of the poor but non-pauper class, supplemented as they have been by the payments of the rich. At the present moment, the principle and the method by which these institutions are governed attract much earnest attention, and appear to not a few to afford the best alternative provision for the middle and upper classes, as against asylums carried on by private enterprise. It may be so. Abuses which in former days were possible, could not occur under the legislative restrictions of our time; but it must not beoverlooked that their annals have disclosed, in some instances, abuses as great and inhumanities as shocking as any that have disgraced the history of private houses. How abominably even such institutions have been managed, has already been depicted in a notorious example; how admirably, might have been shown, had space allowed, as regards the same institution in the hands of men who, like Dr. Needham, have maintained the reforms previously introduced within its once dishonoured walls, and carried forward that humane system of treatment which, Phœnix-like, arose from its ashes. The author would have liked to do justice to other hospitals—as that at Northampton, which under Dr. Bayley's remarkable power of organization has proved so great a success; that at Cheadle, which under Mr. Mould's exhaustless energy has shown how the various needs of different phases of mental disorder may be met by various modifications in the provision made for their care outside the walls of the asylum, thus combining cottage treatment with the control of the central establishment; and, lastly, that at Coton Hill, Stafford, which now and for many years has been superintended by Dr. Hewitson—an institution due to a wave of public feeling in favour of an institution for those in reduced circumstances, which bore this practical fruit after some temporary discouragement.

Of the work done by county asylum superintendents it is impossible to speak too highly; in fact, it would be difficult to know when to stop, were one to be mentioned. Superintendents of the vast asylums of Middlesex,Lancashire, and Yorkshire deserve the recognition of services performed day by day with faithful diligence, not always sufficiently appreciated, and not always without peril, as instanced in the case of the late superintendent of Brookwood, Dr. Brushfield.[315]

As of those whose hourly labour is performed in these and other institutions, so of those who were labourers, however humble, in the early days of asylum reform at the close of the last and the beginning of the present century, it must never be forgotten that work unobserved by the public eye, but conscientiously performed for the unfortunate class which, to a large extent, is unable to appreciate or thank the kindly hand which shields them from cruelty or saves them from neglect, will find its reward in the conscience; and also in the increased happiness of those whom it benefits, though it may not set the worker on any pinnacle of fame. It is to such that the author of "Romola" refers when speaking of the "valiant workers whose names are not registered where every day we turn the leaf to read them, but whose labours make a part, though an unrecognized part, of our inheritance, like the ploughing and the sowing of past generations."

Footnotes:[Skip][314]See Report of the Metropolitan Commissioners. 1844.[315]Since the above was in type, another example has occurred in the case of Dr. Orange, who has been assaulted by a criminal lunatic, and narrowly escaped serious injury.

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[314]See Report of the Metropolitan Commissioners. 1844.

[315]Since the above was in type, another example has occurred in the case of Dr. Orange, who has been assaulted by a criminal lunatic, and narrowly escaped serious injury.

Inaddition to the maps of Ralf Agas (cir. 1560?) and Braun and Hogenberg (1572), there is an earlier view of London and Westminster by Anthony van der Wyngrede, 1543, in the Bodleian Library, Oxford, but it is worthless for the purpose of tracing the outline of Bethlem. No additional light is thrown on the buildings by the view of London and Westminster in Norden's "Speculum Brittanniæ," engraved by Pieter van dem Keere, 1593. It appears to be agreed that, whatever the date or designer of the so-called "Agas" may be, it is "the earliest reliable survey of London." Virtue's reprint is dated 1737. Mr. Overall's "Facsimile from the original in the possession of the Corporation of the City of London" was published in 1874. It is, however, only by a careful study of the original with a magnifying glass and a good light, that the outline of the Bethlem buildings can be made out.

Smith, in his "Topography of London" (1816), p. 36, says that the only plan of London showing the first Bethlem which he had been able to meet with is that by Hollar. This map showed Moorfields divided into quarters, with trees surrounding each division, the site of the second Bethlem being then an uninterrupted space, and a cluster of five windmills standing on the site of the north side of Finsbury, a part of which in Mr. Smith's memory was called Mill Hill. Hollar's rare map (1666 or 1667) is so much later than Agas, that we have not followed its distribution of the buildings. In Faithorne's map, published a few years earlier (1658), from a survey in 1640, "Bedlame" is represented as a quadrangle, with a gate in thewall on the south side. There is a very clear outline of the first Bethlem in Lee and Glynne's map of London (in Mr. Gardner's collection), published at the Atlas and Hercules, Fleet Street, without date. This map is also in the British Museum. Mr. Coote, of the Map Department, fixes the date at about 1705. Rocque's map of London (1746) shows Bethlem distinctly. This map, and Ogilby's, formed the basis of Mr. Newton's "London in the Olden Time," 1855.

With regard to the story of the skeleton in irons and Sir T. Rowe's burying-ground, mentioned atp. 49, it is not disputed that he was concerned in the burying-ground of Bethlem; but the skeleton appears to have been found some distance from this spot. What is stated in Strype's "Stow" (Bk. ii. p. 96, edit. 1720), is that in 1569 "Sir Thomas Rowe caused to be enclosed with a wall about one acre, being part of the said hospital of Bethlem, to wit, on the west, on the bank of Deep Ditch, parting the hospital from Moorfields. This he did for burial in case of such parishes of London as wanted ground convenient within their parishes. This was called New Churchyard near Bethlem."

There are some very fine prints of thesecondBethlem Hospital in the Print Room of the British Museum. Of these (to which Mr. Crace's collection is a recent valuable addition), and the prints in Mr. Gardner's private collection and the Guildhall Library, the following list has been prepared. I have again to thank Mr. Gardner and Mr. Coote for their assistance. I have also to thank Mr. Crace for allowing me to see his prints before they were removed to the British Museum.

1. Inscribed "Hospitium Mente Captorum Londinense. Frontispicium Hospitii (vulgo Bedlam dicti) mente captis destinati, sub auspiciis colendissimi viri Gulielmi Turner Equitis aurati Senatoris non ita pridem Prætoris LondiniPræsidis dignissimi nec non Beniamini Ducane Armigeri Thesaurarii fidelissimi; cæterorumque ejusdem Hospitii GubernatorumA.D.MDCLXXV mense Aprili fundati, anno sequento mensi Juli consummati." R. White sculp. Printed by John Garrett, 1690. 47 in. by 22½ in. Crace Collection, 26/3; Guildhall Library.

2. A New Prospect of yeNorth Side of yeCity of London, with new Bedlam, and Moorefields (showing New St. Paul's). 1710. 58 in. by 22½ in.

This print is a later edition of one by J. Nutting, 1689, in which old St. Paul's is shown. Crace Collection, 26/1.

3. On a scroll, "Hospitium mente captorum Londinense." New Bedlam in Moorefields. Soly fec. Sold by H. Overton, cir. 1730. 22¾ in. by 16½ in. Gardner Collection; British Museum.

4. Painting of Bethlem Hospital (fresco) in one of the rooms of the Foundling Hospital, by Haytley. 1746.

5. The Hospital of Bethlem (L'Hospital de Fou). A view showing also Moorgate. J. Maurer del.; T. Bowles sculp. 1747. 16 in. by 10½ in. Gardner Collection; Crace Collection, 26/6; Guildhall Library.

6. Hospital of Bedlam. Smaller copy of Bowles's print. Gardner Collection.

7. Interior of Bedlam, by Hogarth. 1735. Gardner Collection.

8. Bethlehem, a Poem, with a view of Bethlehem. By J. Clark. 1749.

9. Bethlehem in Moorfields. 1752. By B. Cole.

10. The Hospital called Bedlam. 1754. Gardner Collection.

11. View of Hospital of Bethlehem. 6 in. by 10 in. Robert Sayer, cir. 1760.

12. Visit to Bedlam. R. Newton. 1794.

13. Mezzotint of Bethlehem, by Malton. 1798. 11 in. by 9 in.

14. Bethlem Hospital as it appeared in 1811 (proof). Arnold del.; Watkins sculp. Guildhall Library.

15. London Wall and Bethlehem Hospital. Etching by J. T. Smith. 1812.

16. South-west View of Bethlem Hospital and London Wall, 1814. Smith del. et sculp. Guildhall Library.

17. Two clever water-colour drawings of Bethlem. Gardner Collection.

18. Water-colour drawing of gate with the recumbent figures by Cibber. Richardson. Gardner Collection.

19. The two figures on the pediment of the gate by Cibber. Stothard del.; Sharp sculp. 1783. Guildhall Library.

20. The same. Burell sculp. 1805. 6½ in. by 4½ in. Crace Collection.

21. The same engraved by Warren in Hughson's "London," vol. iii. p. 81. Gardner Collection.

22. A portrait of William Norris as confined in Bethlem Hospital. Arnold fec. 1814.

23. New Bedlam in Moorfields, 6½ in. by 9½ in., and another 5½ in. by 6½ in. No date or name of artist. Gardner Collection.

24. Das Narren Hospital Bethlehem. Dutch print. No date. Gardner Collection.

25. Plan of Moorfields and Bethlem Hospital. Gardner Collection.

26. New Bedlam in Moorfields. 10½ in. by 7 in. Very early view. No date. Gardner Collection.

27. The New Prospect of Bedlam, Moorfields. By John King. 10 in. by 4 in. No date (costume cir. Will. III.).

28. The Hospital of Bethlehem. 9 in. by 14 in. No date. Gardner Collection.

29. Curious and quaint drawing of Moorfields and Bethlehem. 13 in. by 21 in. Gardner Collection.

30. Bethlehem Hospital, by Toms. 7½ in. by 15. Gardner Collection.

31. Three views. Hospital de Bethlem; New Bedlam; Bethlehem. Gardner Collection.

32. Bethlehem in St. George's Fields. Ground Plan of New Bethlem Hospital. Basire sculp. 1819. This, with five other views by Shepherd, etc., are in the Guildhall Library.

1. "Enthusiasm displayed." The Rev. John Whitfield preaching under a tree in Upper Moorfields, with view of "St. Luke's Hospital for Lunaticks" in the background. J. Griffiths pinx.; R. Tranker sculp. 1750. 19¾ in. by 15 in. Gardner Collection; Crace Collection, 33/19.

2. Elevation of St. Luke's Hospital in a pamphlet entitled "Reasons for the Establishing, etc., of St. Luke's." 1765. Guildhall Library.

3. Another elevation. J. Dance arch. et sculp. 1784. 15 in. by 4½ in. Gardner Collection; Crace Collection, 33/15.

4. Front view of the New St. Luke's Hospital, lately erected in the City Road. Deeble del. et sculp. 1785. Gardner Collection; Guildhall Library.

5. St. Luke's Hospital, Old Street Road. A coloured print from a drawing by F. A. Shepherd. 1814. 8 in. by 5¼ in. Original drawing in the Gardner Collection; Crace Collection, 33/16.

6. Lunatic Hospital of St. Luke's. Aquatint. Gardner Collection.

7. Front View of the New St. Luke's Hospital. No date. Gardner Collection.

8. Ditto. Ditto. 15 in. by 5 in. Gardner Collection.

9. Sepia drawing of St. Luke's. Gardner Collection.

10. Two original drawings by John Carter. Gardner Collection.

11. Lunatick Hospital of St. Luke, published by Ackermann. 1815. Gardner Collection; Guildhall Library.

12. St. Luke's Hospital, Old Street Road. Shepherd del.; Sands sculp. 1815. Gardner Collection; Guildhall Library.

13. St. Luke's Hospital. Higham del. et sculp. 1817. Guildhall Library.

14. Lunatic Hospital, St. Luke's. S.W. view. T. H. Shepherd del.; J. Gough sculp. 1837. 5¾ in. by 3½ in. Gardner Collection; Crace Collection, 33/18.

15. Interior of St. Luke's. Rowlandson and Pugin del. et sculp.; Stahler aquat. 1809. Gardner Collection; Guildhall Library.

Inreference to the writers on insanity at the close of the eighteenth century, Dr. Pargeter, in the work referred to atp. 142, after dwelling slightly on the pathology, causation, and nature of insanity, becomes disheartened and exclaims, "Here our researches must stop, and we must declare that wonderful are the works of the Lord and His ways past finding out" (p. 15). Of asylums he says, "The conduct of public hospitals or institutions for the reception of lunatics needs no remark; the excellence in the management of them is its own encomium" (p. 123). Of private madhouses under the management of regular physicians, he ventured to say that "people might securely trust that in them the afflicted would be judiciously and tenderly treated, and also managed by servants selected and instructed with such judgment as will make them as zealous of their own character and reputation, as of the honour of their employers. In such hands we may place implicit confidence; and a perfect assurance that in such anabode dwells nothing offensive or obnoxious to humanity—here no greedy heir, no interested relations will be permitted to compute a time for the patient's fate to afford them an opportunity to pillage and to plunder. But such dwellings are the seats of honour, courtesy, kindness, gentleness, mercy, and whatsoever things are honest and of good report." Such was the comfortable satisfaction with which a worthy man in 1792 regarded the condition of the insane in English asylums in that year. He admits, however, that in private asylums kept by illiterate persons, compassion as well as integrity is oftentimes to be suspected, and quotes a passage from a paper written in 1791, which asserts that "if the gaolers of the mind do not find a patient mad, their oppressive tyranny soon makes him so."

The work written by Dr. Mason Cox (Fishponds, near Bristol) was the best medical treatise of the day on insanity. Unlike Cullen, he objects to "stripes" in the treatment of the insane. On the cold bath he says, "Even so late as Boerhaave we have the most vague directions for its employment; such as keeping the patient immersed till he is almost drowned, or while the attendants could repeat the Miserere.... The mode recommended and so successfully practised by Dr. Currie of Liverpool is certainly the best, that of suddenly immersing the maniac in the very acme of his paroxysm; and this may be easily accomplished if the patient, previously secured by a strait waistcoat, be fixed in a common Windsor chair by strong broad straps of leather or web girth" (p. 135, 3rd edit., 1813). The author observes that it is certainly worth trying whether keeping a patient for days in succession in a state of intoxication would be beneficial, where every other means has failed (p. 75).

Bethlem Hospital. Used for lunatics about 1400.

St. Luke's Hospital. Founded 1751.

Liverpool Royal Lunatic Hospital, associated with the Royal Infirmary. 1792.

Manchester Royal Lunatic Hospital, in connection with the Royal Infirmary. 1706. (Removed to Cheadle, 1849.)

Bethel Hospital, Norwich. 1713.

The Lunatic Ward of Guy's Hospital. 1728. (New building, 1797.)

The York Lunatic Hospital, Bootham. 1777.

St. Peter's Hospital, Bristol. Incorporated 1696.

Brooke House, Clapton (Dr. Monro's). 1759.

Hoxton Asylum. 1744.

Fonthill-Gifford, Hindon, Wilts. 1718.

Droitwich Asylum. 1791.

Belle Grove House, Newcastle-on-Tyne. 1766.

Lea Pale House, Stoke, near Guildford. 1744.

Ticehurst, Sussex. 1792.

The number of lunatics in London and in the country, returned under the Act of 1774 (14 Geo. III., c. 49), from that year to the projection of the York Retreat (1792), was 6405; and from 1792 to the Select Committee of 1815, 12,938.

In 1775 the number registered during the year was 406; and in 1791, after various rises and falls, it was also 406.

In 1792 the number rose to 491, and in 1815 to 850; the lowest being 414 in 1807, and the highest 700 in 1812.

The above list of asylums shows how scanty was the provision made for the care of the insane at the time of thefoundation of the York Retreat. I may here add that, in addition to the notice taken of this experiment by the writers on the Continent mentioned in the text, the attention of the Germans was forcibly directed to it by Dr. Max. Jacobi, of Siegburg. He visited York, and, much struck by what he witnessed there, translated into German the greater part of the "Description of the Retreat." The late superintendent of the Retreat, Dr. Kitching, who filled that office for many years with much efficiency, spent a considerable time at the Siegburg Asylum, comparing notes with Dr. Jacobi.

Thefifteen persons appointed Commissioners in Lunacy for the metropolitan district, five of whom were physicians, were paid £1 an hour, and were appointed for one year. They were to meet quarterly for the purpose of granting licences, those in the provinces being granted by justices at quarter sessions, where three or more justices were to be elected to visit the provincial licensed houses, together with at least one medical Visitor.

Three of the Commissioners were to visit licensed houses in the metropolitan district four times a year.

Two justices to visit licensed houses in the provinces, accompanied by the medical Visitor, four times a year.

An annual report was to be prepared and presented to the Secretary of State for the Home Department.

Private patients were not to be admitted to asylums without the certificates of two medical men and an order; the certificates being in force fourteen days before admission.

Pauper patients were not to be admitted without one medical certificate and the order of two justices, or an overseer and clergyman.

The proprietor of an asylum had to transmit a copy of documents to the Commissioners or justices, as the case might be.

Single patients to be received on like order and certificates. No regular visitation of this class instituted.

It should be stated that among the previous Acts, now repealed, there was a small Act passed May 2, 1815, notwithstanding the failure of Mr. Rose to induce Parliament to undertake legislation based on the evidence given before the Committee of that year. This was the Act 55 Geo. III., c. 46, entitled, "An Act to amend an Act 48 Geo. III., c. 96 (1808), being an Act for the better Care and Maintenance of Lunatics being Paupers or Criminals in England."

The committee of visiting justices of lunatic asylums were to be elected annually.

Subscribers to lunatic asylums erected by voluntary contributions, who should unite with any county, might elect a committee of governors to act with committee of visiting justices.

Justices to fix sums to be expended in purchase of lands, houses, etc., or in erecting buildings.

Overseers of the poor to return lists of all lunatics and idiots within their parishes, verified on oath and accompanied with a medical certificate.

When any asylum could accommodate more lunatics, magistrate might order an addition under certain regulations.

Thefollowing are the clauses of the Act which provide for the expense of carrying out its provisions.

By this statute it was enacted, after repealing 2 and 3 Will. IV., c. 107; 3 and 4 Will. IV., c. 64; 5 and 6 Will. IV., c. 22; 1 and 2 Vict., c. 73; 3 Vict., c. 4; 5 and 6 Vict., c. 87, that the Commissioners in Lunacy under 5 and 6 Vict., c. 84, should be henceforth called "the Masters in Lunacy," and that new Commissioners in Lunacy should be appointed. The Commissioners were to grant licences for the reception of lunatics within a certain jurisdiction of the metropolis; justices of the peace in general or quarter sessions licensing houses for the reception of lunatics and appointing Visitors in all other parts of England and Wales, including a medical man. For every licence granted a sum to be paid of ten shillings for every private patient and two shillings and sixpence for every pauper, or so much more as shall make up the sum of fifteen pounds, these moneys being applied towards the payment of the expenses of the Commissioners or any charge incurred by their authority. The secretary of the Commissioners to make out an annual account of moneys received and paid by him in the execution of the Act, to be laid before the Lords Commissioners of the Treasury, the balance (if any) to be paid into the Exchequer to the account of the Consolidated Fund, such accounts being laid before Parliament every year, the Treasury being empowered to pay out of the Consolidated Fund any balance of payments over receipts which may be necessary. With regard to the application of moneys received by the clerk of the peace for provincial licences, they were to be applied towards the payment of the clerk to the Visitors for the county,and the remuneration of the medical Visitors, and other expenses incurred in the execution of the Act, the accounts being laid before the justices at the general or quarter sessions, who shall direct the balance (if any) to be paid into the hands of the treasurer of the county or borough in aid of the rate; any balance of payment over receipts being paid out of the county or borough funds.

There was paid into the Exchequer in the year ending March 31, 1880, £1376 for licences in the metropolitan district, besides £18 stamps. Lunacy Board expenses, £15,064.

I have not any accurate returns of the amounts received from the provincial houses, but on a rough estimate these licences produce to the counties in the aggregate £1452, and £30 to the Imperial Exchequer, per annum.

In the following year, August 26, 1846, an Act was passed "to amend the Law concerning Lunatic Asylums and the Care of Pauper Lunatics in England," and was to be construed with 8 and 9 Vict., c. 126. There were only twelve sections. It was passed to clear up doubts which had been entertained as to the meaning of certain clauses in the above Act. It was repealed by 16 and 17 Vict., c. 97.

Afterthe legislation of 1853, the Acts referred to atp. 190andp. 188constituted, with 8 and 9 Vict., c. 100, and 15 and 16 Vict., c. 48, and the Acts relative to criminal lunatics, the then code of Lunacy Law.

Lord St. Leonards' first Act,p. 188(16 and 17 Vict., c. 70), enacts that when the Commissioners shall report to the Lord Chancellor that they are of opinion that the property of anylunatic, not so found by inquisition, is not duly protected, or the income thereof not duly applied for his benefit, such report shall be deemed tantamount to any order or petition for inquiry supported by evidence, and the case shall proceed as nearly as may be in all respects as therein directed upon the presentation of a petition for inquiry.

The next Act (16 and 17 Vict., c. 96) prescribes amended forms of orders and certificates, notices of admission, and of the medical visitation book.

The requirements on the part of the medical man signing the certificate are laid down.

Empowers proprietors or superintendents of licensed houses (with consent of Commissioners) to entertain as a boarder any patient desiring to remain after his discharge, or any relation or friend of a patient.

Authorizes amendment of any order or certificate within fourteen days after admission of patient.

Permits the Commissioners to allow medical visitation of single patients less frequently than once a fortnight.

Empowers one or more Visitors to visit single patients at request of Commissioners, and report to them their condition.

Directs that the medical man who visits a single patient shall make an annual report to the Commissioners of the mental and bodily health of such patient.

Empowers the Lord Chancellor to discharge single patients.

Directs that notice of the recovery of every patient shall be sent to his friends, or in case of a pauper to his parish officers, and in case of death of a patient in any hospital or licensed house, a statement of the cause, etc., to the coroner.

Authorizes transfer of a private patient (with consent of two Commissioners) from one asylum, hospital, or licensed house to another, without any fresh order or certificate, and similarly as to single patients.

Empowers the Lord Chancellor, on the representation of the Commissioners, to require a statement of the property andapplication of the income of any person detained as a lunatic under an order and certificates.

Extends to the Commissioners the powers vested in the private committee, as to single patients, by the Act 8 and 9 Vict., c. 100, s. 111.

Repeals s. 27 of 8 and 9 Vict., c. 100, as to the visitation of workhouses; and enacts that one or more Commissioners shall visit such workhouses as the Board shall direct.

Authorizes the Commissioners in urgent cases to employ any competent person to visit any lunatic and to report to them.

Directs committee of every hospital to submit regulations to the Secretary of State for approval, and to send a copy to Commissioners.

Empowers Commissioners, with sanction of the Secretary of State, to make regulations for the government of licensed houses.

Enacts that Bethlem Hospital shall be subject to the provisions of Act 8 and 9 Vict., c. 100.

The third Act (16 and 17 Vict., c. 97) repeals the several Acts then in force respecting county and borough lunatic asylums, and re-enacts most of the provisions therein contained, with certain additions and improvements.

It authorizes justices of boroughs, instead of providing asylums for their own use, or in arranging with counties, etc., to contract with the Visitors of any asylum for the reception of their pauper lunatics, in consideration of certain payments.

The powers of the Visitors were enlarged in many ways.

When a county or borough asylum can accommodate more than its own pauper lunatics, the Visitors are empowered to permit the admission of the pauper lunatics of any other county or borough, or lunatics who are not paupers, but proper objects to be admitted into a public asylum, such non-pauper patients to have the same accommodation, in all respects, as the pauper lunatics.

The Visitors are directed to appoint a medical officer to be superintendent of the asylum.

They are empowered to grant superannuation annuities to the officers and servants.

They are directed to make an annual report to the general or quarter sessions of the state of the asylum.

Every pauper lunatic, not in an asylum, hospital, or licensed house, is to be visited every quarter by the medical officer of the parish or union, who is to make return thereof; and the medical officer is to be paid two shillings and sixpence for every visit.

The forms of orders, statements, and medical certificates are amended, and the medical officers of unions are permitted to sign certificates.

The medical man certifying is required to state his qualification, when and where the patient was examined, and to specify facts indicating insanity; distinguishing facts observed by himself from those communicated to him by others.

Visitors are empowered to order the removal of pauper patients to and from asylums, and also to discharge or permit the absence on trial of any patient. The Commissioners are empowered to direct the removal of any lunatic from any asylum, hospital, or licensed house to any other.

The person signing the order for admission of a private patient into an asylum may discharge such patient, subject, in the case of dangerous lunatics, to the consent of the visiting justices. Any person having authority to discharge a private patient is empowered (with consent of two Commissioners) to transfer him to another asylum or to the care of any person.

Orders and certificates, if defective, may be amended within fourteen days.

Patients escaping may be retaken within fourteen days.

This statute did not re-enact the clause contained in the Act it repealed respecting workhouses.

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