Chapter V (2)

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 Colney Hatch there were 1287 patients, while 713 more demanded admission. When, in 1831, Hanwell was built for 500, it was thought sufficient to provide for the whole of Middlesex! Two years after, however, it was full; in another two years it was reported to contain 100 patients more than it was built for, and after the lapse of another two years it had to be enlarged for 300 more; Colney Hatch having been constructed for 1200 patients belonging to the same county, and opened in 1851; and yet, within a period of less than five years, it became necessary to appeal to the ratepayers for further accommodation, and the latest return showed that, at the close of 1856, there were more than 1100 paupers belonging to the county unprovided for in either of its asylums. "Hardly had they been built, when the workhouses sent into each such a large number of chronic cases as at once necessarily excluded the more immediately curable, until the stage of cure was almost past; and the doors of the establishment became virtually closed not long after they were opened to the very inmates for whom only it was needful to have made such costly provision." Hence the Commissioners urged separate and cheaper asylums for old cases; but the committees of the asylums objected. The Secretary of State induced the two parties to meet, but, being unable to agree, the Commissioners reluctantly gave way.

In 1858 the amount of existing accommodation for pauper lunatics in the counties and boroughs was--for males, 7516; females, 8715; total, 16,231; and the additions then being made to old asylums amounted to--for males, 1172; females, 1309; total, 2481. The numbers for whom additional asylums were then being made were--males, 1169; females, 1157; total, 2326. The sum of these totals being 21,048. There were, on the 1st of January of this year, 17,572 pauper lunatics in asylums, of whom as many as 2467 were still confined in private asylums. There were now 33 county and 4 borough asylums, 15 registered hospitals, 37 metropolitan licensed houses, and 80 provincial licensed houses; also the Royal Naval Hospital. The total number of inmates in these establishments were (in the order enumerated) 15,163, 1751, 2623, 2647, 126, making a grand total of 22,310, including 295 patients found lunatic by inquisition.

The Commissioners point out that a military asylum is a desideratum, there being no provision for soldiers, while sailors were well cared for at Haslar Hospital.

The following particulars will show at a glance the provision made at this period for the insane in England and Wales:--

1. Boroughs having asylums: Birmingham, Bristol (in St. Peter's Hospital), Hull.

2. Boroughs erecting or about to erect asylums: Maidstone, Bristol, City of London.

3. Boroughs in union with counties: Cambridge, Colchester, Maldon, Gloucester, Leicester, Grantham, Lincoln, Stamford, Hereford, Nottingham, Abingdon, Oxford, Reading, Shrewsbury, Wenlock, Worcester.

4. Boroughs whose pauper lunatics are sent to asylums under contract or arrangements between justices, etc.: Plymouth, Chichester, Portsmouth, Southampton, Devizes, Salisbury, Chester, Derby, Barnstaple, Bideford, Dartmouth, Exeter, South Molten, Tiverton, Tewkesbury, Bridgewater, Bridgnorth, Ludlow, Penzance, Poole, Winchester, Newark, Oswestry, Bath, Lichfield, Scarborough.

5. Boroughs which have not made any statutory provision for the care of their pauper lunatics: Bedford, Newbury, Buckingham, Carmarthen, Andover, Canterbury, Dover, Hythe, Rochester, Sandwich, Tenterden, King's Lynn, Norwich, Thetford, Yarmouth, Northampton, Berwick-upon-Tweed, Newcastle-upon-Tyne, New Radnor, Bury St. Edmunds, Ipswich, Guildford, Hastings, York.

In 1862 the expense of pauper lunatics in asylums was thrown upon the common fund of the union, instead of on the particular parish. The effect was natural. Many patients were removed from workhouses to the county asylums, some of whom might well have remained there. There could be no objection to this, if the latter cost no more than the former; but seeing that where the one costs L200 per bed, the other would only cost L40, the effect is, from the point of view of the ratepayer, who usually objects to contribute to the formation of a free library, a very serious one.

Twenty years after the census of the insane made in 1844, and ten after the period to which the table given at p. 230 refers, we find the numbers as follow[192]:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE INSANE IN ENGLAND AND WALES, JANUARY 1, 1864.

----------------+------------------+--------------------+--------------------
Where | Private | Paupers. | Total.
confined. | patients. | |
+-----+-----+------+------+------+------+------+------+------
| M. | F. |Total.| M. | F. |Total.| M. | F. |Total.
----------------+-----+-----+------+------+------+------+------+------+------
42 county and | | | | | | | | |
borough asylums| 118| 113| 231| 9,690|11,630|21,320| 9,808|11,743|21,551
| | | | | | | | |
1 military and | | | | | | | | |
naval hospital | 153| -- | 153| -- | -- | -- | 153| -- | 153
| | | | | | | | |
2 Bethlem and | | | | | | | | |
St. Luke's | | | | | | | | |
Hospitals | 264| 215| 479| -- | -- | -- | 264| 215| 479
| | | | | | | | |
13 other public | | | | | | | | |
asylums | 708| 591| 1,299| 170| 178| 348| 878| 769| 1,647
| | | | | | | | |
Licensed houses:| | | | | | | | |
37 metropolitan| 831| 649| 1,480| 253| 589| 842| 1,084| 1,238| 2,322
65 provincial | 987| 698| 1,685| 256| 192| 448| 1,243| 890| 2,133
| | | | | | | | |
Workhouses and | | | | | | | | |
elsewhere | -- | -- | -- | 8,125| 8,126|16,251| 8,125| 8,126|16,251
| | | | | | | | |
Broadmoor | -- | -- | -- | -- | 95| 95| -- | 95| 95
+-----+-----+------+------+------+------+------+------+------
Total[193] |3,061|2,226| 5,327|18,494|20,810|39,304|22,555|23,076|44,631
----------------+-----+-----+------+------+------+------+------+------+------

We must not pass by the year 1867 without recording that at this period a statute important in its bearing on the provision made for the insane poor of London was enacted. This was the Metropolitan Poor Act, which established what are known as the Metropolitan District Asylums for Imbeciles at Leavesden (Hertfordshire), Caterham (Surrey), Hampstead, and Clapton. Legally these institutions are classed under workhouses.

Much difference of opinion exists as to the wisdom of having separate institutions for the incurable. That there is great danger of overlooking the fact that some incurable patients require quite as much attention as the curable is certain; they may indeed, if neglected, be reduced to a more pitiable condition than the latter; but this does not prove that, under the present safeguards provided by the legislature, there may not be a safe recourse to this mode of making provision for this class of the insane. At any rate, it is of interest to know what has been done in this direction during the last few years in England.

Asylums have been erected at Leavesden, near Watford, Herts; Caterham, Surrey; and Darenth, near Dartford, Kent, there being at Darenth both idiot schools and an institution for incurables.

These are the Metropolitan District Asylums.[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 L9401, the area being eighty-four acres. The laying out the grounds, etc., cost L3000; the cost of building and drainage (up to Michaelmas, 1878) was L121,674; the engineering works, fixtures, and fittings cost L16,162; the furniture, bedding, and clothing, L16,235; the architect's and surveyor's charges, and clerk of works, L5108; solicitor's charges, printing, insurances, and all other charges, L1526; the total being L173,118, or L86[195] per bed. Taking out the items of furniture, bedding, and clothing, we have the sum of L77 per bed. How striking the difference when compared with the expense of an ordinary county asylum, the reader who has examined the figures given at page 166 will readily perceive.

Let us now pass on to the year 1870. We find the Commissioners able to state, as the result of very minute and careful inspection, that the Reports of their members during the previous year showed, on the whole, that good progress continued to be made in the mode of managing "these large and daily increasing institutions," and they add, "although in some instances it has been our duty to comment on shortcomings and cases of neglect, we have generally been able to bear testimony to the skill and zeal evinced by the medical superintendents in the execution of their very grave and difficult duties."[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 said to be rarely visited by any friends having an interest in them. The state of the furniture was discreditable in the extreme, and there was a general absence of tidiness throughout the hospital. The patients were, with few exceptions, quiet; not more than four or five of the better class of either sex were reported to have the opportunity of walking or driving out.... The seclusion in the fifteen months which had elapsed since the previous visit applied to five males on 62 occasions, and to 18 females on 132 occasions."[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:--

L s. d.
Coton Hill 1 7 1-1/2
Northampton 0 13 5-3/4
York Lunatic Hospital 0 18 0
York Retreat 1 1 2-3/4

It should be observed that Northampton was at this time essentially the pauper asylum for the county.

* * * * *

We have already referred to the paramount importance of reliable attendants. "Nothing is easier," the Commissioners observe, "for a man in such a position, with unrestricted and uncontrolled power over the habits and happiness of another, than to act cruelly without being cruel." So long ago as 1851 a check was given to the conduct of attendants by a decision of the courts in that year. An attendant had been convicted of manslaughter on the evidence of a patient. This was appealed against, but the conviction was sustained. Lord Campbell laid it down that the only thing needful was for the patient to understand the nature of an oath and what he was saying. "But although this ruling has never since been disputed, the many subsequent attempts of the Commissioners to exact a rigid responsibility for acts of violence or cruelty in asylums have, through the indisposition of juries[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 against them, and of the former not one. Of the number dismissed, fifteen were in licensed houses, three in public hospitals, and the remaining seventy in county asylums. During the same period thirty-four female attendants were dismissed, of whom twenty-four were employed in county asylums. Eleven had been guilty of violence or rough usage to patients, there having been no prosecution in any instance. The Commissioners justly observe that, while "there has been no greater work of mercy and humanity than that which rescued the lunatic patients from stripes and filth, or continued restraint and isolation, yet it will remain to some degree still imperfect until he is also rescued from the possible chance of being subjected to the unwatched or unchecked humours and caprices of ignorant, careless, or cruel attendants."[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 Lord Shaftesbury has publicly expressed his individual opinion that it is better for the views and wishes of the Commissioners to appear in the form of recommendations rather than commands.

* * * * *

Three years later, the condition of county and borough asylums was, with few exceptions, satisfactory, and declared by the Commissioners to be very creditable to the governing bodies and superintendents. Improvements had taken place in many of these institutions, and there was found to be a more general recognition of the humanizing and beneficial influence of cheerful and well-furnished wards, on even the most degraded patients. "Those at one time considered to be fit only to be congregated together in the most dreary rooms of the asylum, with tables and benches fastened to the floor, and with nothing to interest or amuse them, are now in many asylums placed in wards as well furnished as those occupied by the more orderly patients, with birds, aquariums, plants, and flowers in them, and pictures on the walls; communicating also with such wards are now very generally to be found well-planted and well-kept airing-courts. The less strict classification of the patients is also advantageously followed in many asylums, and in them what are termed "refractory wards" are properly abolished. Where arrangements for this purpose have been judiciously made and carried out with energy, the best results have followed, in the way of an improved condition and more orderly demeanour of those disposed to be turbulent, whilst the comfort of patients of a more tranquil character has not been prejudicially affected. The use of mechanical restraint in county and borough asylums, unless for surgical reasons, such as to prevent patients removing dressings or applications to wounds or injuries, or during the forcible administration of food, is, with few exceptions, abolished. In thirty-eight of the fifty-four asylums visited during the past year, there was no record whatever of its employment. In the cases of twenty-two patients, distributed over ten asylums, it had been resorted to for the above-mentioned reasons, and in six asylums it had been used to counteract violent suicidal or destructive propensities; the number of patients restrained for these latter reasons (exclusive of Colney Hatch and Wandsworth) having been one in the Macclesfield, nine in the Glamorgan, six in the Prestwich, and one in the Norwich Borough Asylum. In the Wandsworth Asylum it will be seen from the Report that, during a period of about sixteen months, thirty-three men and twelve women were recorded as having had their hands restrained by gloves for destructive propensities; and four males and one female had worn restraint dresses at night, two on account of their suicidal tendencies, and one for violence. At the visit to Colney Hatch, a very dangerous male epileptic was found restrained by wrist-straps and a belt, and from the register it appeared that he had been thus constantly restrained during the day for a period of nine months. Ten other male patients were also recorded as having been restrained; one having had his hands fastened, and the remainder having worn gloves, altogether on two hundred and fifty-three occasions.... At the same visit nine men were found wearing special strong canvas dresses, besides others who were clothed in an exceptional manner."

The objections which for a long time have been felt to frequent resort to seclusion find expression in this Report. The Commissioners, without questioning the utility of seclusion in certain cases, stated their conviction that "in a remedial point of view its value has been much exaggerated, and that in many instances it is employed unnecessarily and to an injurious extent, and for periods which are quite unjustifiable." Patients regard it as a punishment; and attendants are apt to make it take the place of constant supervision. Its frequent use indicates defective asylum organization or management. The Report states that it is no longer employed at the Durham, Stafford, Brentwood, and Brookwood Asylums; and only rarely at the Wakefield, Oxford, Northumberland, Carmarthen, Chester, Dorset, Glamorgan, Leicester, Lincoln, and Norfolk County Asylums, and those for the boroughs of Ipswich and Leicester, and for the City of London.

Legislation has exercised a great and, as some think, questionable influence upon the relative proportion of the insane in workhouses and asylums. The feeling that originally induced the Commissioners in Lunacy to urge the transference of lunatics from workhouses to county asylums was, no doubt, a laudable one, and in a large number of instances most advantageous. The condition of the insane in workhouses, however, became vastly improved, and it was impossible to deny that for many harmless chronic cases they were, to say the least, sufficiently comfortable in the workhouse. Then came the legislation of 1874,[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 the maximum number who could properly be transferred from asylums to workhouses is seven or eight per cent., and they make the observation, which no doubt is very just, that many patients who are quiet and demeanable under trained nurses in an asylum would become intractable elsewhere.

As we have now reached another decade, it will be well to afford the reader the opportunity of comparing the population of asylums, and workhouses, with that which we have given in 1844, 1854, and 1864.

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE INSANE IN ENGLAND AND WALES, JANUARY 1, 1874.

----------------+------------------+--------------------+--------------------
Where | Private | Paupers. | Total.
confined.[205]| patients. | |
+-----+-----+------+------+------+------+------+------+------
| M. | F. |Total.| M. | F. |Total.| M. | F. |Total.
----------------+-----+-----+------+------+------+------+------+------+------
31 county and | | | | | | | | |
borough asylums| 194| 221| 415|14,238|16,718|30,956|14,432|16,939|31,371
| | | | | | | | |
3 military and | | | | | | | | |
naval | | | | | | | | |
hospitals, and | | | | | | | | |
Royal India | | | | | | | | |
Asylum | 342| 16| 358| -- | -- | -- | 342| 16| 358
| | | | | | | | |
2 Bethlem and | | | | | | | | |
St. Luke's | | | | | | | | |
Hospitals | 167| 268| 435| -- | -- | -- | 167| 268| 435
| | | | | | | | |
13 other public | | | | | | | | |
public asylums |1,107| 891| 1,998| 174| 165| 339| 1,281| 1,056| 2,337
| | | | | | | | |
Licensed houses:| | | | | | | | |
39 metropolitan|1,006| 787| 1,793| 257| 614| 871| 1,263| 1,401| 2,664
67 provincial | 772| 754| 1,526| 200| 323| 523| 972| 1,077| 2,049
| | | | | | | | |
1 Broadmoor | 267| 64| 331| 148| 41| 189| 415| 105| 520
| | | | | | | | |
Private single | | | | | | | | |
patients | 168| 268| 436| -- | -- | -- | 168| 268| 436
| | | | | | | | |
Workhouses: }| | | | | | | | |
Males, 6372; }| | | | | | | | |
females, 8646;}| | | | | | | | |
total, 15,018 }| | | | | | | | |
Elsewhere: }| -- | -- | -- | 9,084|12,773|21,857| 9,084|12,773|21,857
Males, 2712; }| | | | | | | | |
females, 4127;}| | | | | | | | |
total; 6839 }| | | | | | | | |
+-----+-----+------+------+------+------+------+------+------
Total[206] |4,023|3,269| 7,292|24,101|30,634|54,735|28,124|33,903|62,027
----------------+-----+-----+------+------+------+------+------+------+------

Referring to the numbers of the insane in 1875, the Commissioners observe that they have increased beyond the growth of the population. This had been mainly among paupers, there having been 16.14 of this class in 1849, and 23.55 in 1875, per 10,000 of the population; while of private patients the advance had only been from 2.53 to 3.09 during the same period. The population increased from 1849 to 1875, 22.63 per cent. Private patients increased 48.39 per cent., and pauper patients 77.47 per cent.

In regard to the treatment of the insane in Wales, it may be stated that until the Denbigh Asylum was opened in November, 1847, there was no institution for the reception of lunatics, except the small asylum at Haverfordwest, and a house licensed in 1843 for private and pauper patients in Glamorganshire.[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 L8000. By this time the Act was passed, and the subscribers made over their money to the counties, on condition that twenty-six separate beds should be kept for private patients--several of themselves to be members of the Committee. The private apartments form part of the same building, but the inmates do not associate with the paupers. The total accommodation was two hundred, and there was a great outcry at the building of such a large place. About fifteen years ago, two wings were added, each to hold one hundred beds, and last year an additional one of one hundred and thirty beds.

It appears that many of the first patients received at the Denbigh Asylum had been most cruelly treated at their own home, or where placed with strangers; some being kept tied and in seclusion for years, and shamefully neglected. The following is an extract from the first Medical Report:--"In the case of one man, who was goaded by unkind and harsh treatment into a state of ferocious mania (and who was brought into the asylum manacled so cruelly that he will bear the marks of the handcuffs while he lives), it is most gratifying to be enabled to state that he gradually became confiding and tractable, and he is now as harmless as any patient in the house. In another instance, a poor young creature, who before her admission was tied down to her bed for months, quickly discovered the difference between the treatment she had previously been subject to and the kindness and freedom she experienced at the asylum, and very soon gained confidence in those about her, and rapidly recovered. Soon after her discharge from the asylum, she wrote to the matron, to request to be taken back as a servant, and she is now an excellent assistant in the wards, and a general favourite with the patients. We have the satisfaction of stating that we have never been obliged to resort to any mechanical restraint, beyond temporary seclusion in a padded room, etc." Complaints occur in the earlier reports of the disinclination either of friends or of the poor law authorities to send in patients before they become unmanageable, and many of those admitted arrived secured by handcuffs or tied down in carts.

Take another extract from the Report for 1851. "We were requested to turn into a respectable farmhouse, and upon going upstairs we were horrified to find the farmer's wife with her hands secured, and a large cart-rope tied round her body to keep her in bed. The room was filthy. We found she had been in this state for nine months, and no proper remedial measures taken. Surely some protection should be thrown over such a sufferer!"

Again, in the Report for 1853: "One most atrocious case of an opposite kind of treatment has fallen within our notice during the year. It is most deplorable to contemplate, after the repeated generous efforts made by the press, both Welsh and English, to diffuse useful knowledge upon the subject of insanity, that in a Christian country, and in a populous district, and with the knowledge of most of the neighbouring inhabitants, a fellow-creature should have been permitted to be chained by both his legs in a miserable shed for seven long years. The case is so painfully interesting, that we will add to this Report the document which was sent to the Lord Chancellor, who, at the instigation of the Commissioners in Lunacy, issued an order for visiting the poor sufferer. The Commissioners, with laudable alacrity, ordered a prosecution to be instituted, and the principal offender was tried at the Carnarvonshire assizes, convicted, and sentenced to be imprisoned.... What renders the conduct of the friends of Evan Roberts more inexcusable is the fact of his having been perfectly sane when visited, and having remained so ever since.

_Denbigh, June 16, 1853._

"SIR,

"In obedience to the order of the Lord Chancellor, etc., I
have to report that I found Evan Roberts in a small shed, six
feet wide and nine feet four inches long, which had been
built for the purpose. The room had a small skylight in the
roof, and a window about a foot and a half square in the
gable, just above the bed, which admits of being partially
opened, but which was closed at the time of my visit, and, as
he (Evan Roberts) stated, was seldom opened. The room felt
very close and damp. There was no fireplace, or any other
means of ventilation except the door and window. The approach
to the room was through a sort of scullery, and very dark and
obscure. Evan Roberts was lying on a chaff bed on a wooden
bedstead, to which both his legs were chained, by fetters
fastened and riveted, just above his ankles.... The
appearance of the poor man was pale and pasty, like a plant
long deprived of air and solar influence. His bodily health
is tolerably good, and his condition rather inclined to be
fat and stout; he said his appetite was good, and that he was
not stinted in his food, such as it was. During a lengthened
interview, and a very close examination, I failed to discover
the existence of any hallucination or delusion of any kind;
on the contrary, he was very sensible and intelligent....

"I collected from his mother and sister that Evan Roberts was
forty-eight years of age; that he had been liable to
periodical mania for twenty-seven years, and which the mother
attributed to some injury to his head, received in a rural
affray; that at first the maniacal paroxysms were unfrequent,
but that they had become more violent and frequent as he
advanced in life. About seven years ago, his violence became
so great, that he threatened to murder his father and
brother; and it was at that time that he was first chained to
the bed. This restraint has never been relaxed, although both
mother and sister admitted that he was perfectly sane and
harmless for many weeks and months continuously. For the
first five years he was confined upstairs, and it was only
about two years ago that he was carried into the shed he now
occupies.... Finding that the poor fellow was awed by the
presence of his mother and sister, I requested them to
retire, as I wished to examine the alleged lunatic free from
their presence and interference. The mother for some time
refused to comply with my request; but upon being told that I
would report her refusal, she very doggedly complied. The
poor man then became less reserved; he complained bitterly of
the state in which the room had long been suffered to
remain....

"The poor man complained that the chaff in his bed was never
changed, or even shaken, except once, since his confinement
in the shed; and from the dampness of the room, and the
warmth of his body, it had become rotten, and like a wet
sod....

"R. LLOYD WILLIAMS.

"R. W. S. Lutwidge, Esq."

"The Commissioners in Lunacy applied to the Lord Chancellor for an order to visit the farmer's wife mentioned in one of our former reports as having been tied to her bed by a cart rope and her hands secured by a muff. She was accordingly visited, and a report upon her case sent to the Commissioners, who directed an inquiry to be made with a view to her removal to an asylum. The family obtained information of this investigation, and considerable amendment in the treatment of the lunatic took place before the justices and the medical officer appointed to visit her arrived, and no order for her removal was made. We have reason to know that the poor creature is still under restraint, and her hands secured; she is strapped to a chair, which is fastened to the leg of a strong table."

We pass now to 1879, in order that we may consider the changes which had taken place during the quinquennium succeeding the year in which we have given a return of the number of insane in England and Wales, and their distribution. The following figures are derived from the thirty-third Report of the Lunacy Commissioners, and exhibit the total number of registered lunatics, idiots, and persons of unsound mind on the 1st of January, 1879:--In county and borough asylums, 38,871; naval and military hospitals and Royal India Asylum, 342; Bethlem and St. Luke's Hospitals, 430; other public asylums, 2407; metropolitan licensed houses, 2664; provincial, 2049; Broadmoor, 483; workhouses (ordinary), 11,697; metropolitan district asylums, 4308; outdoor paupers, 6230; private single patients, 472; total, 69,885; exclusive of 202 Chancery lunatics in the charge of committees.

On the next page will be found the general distribution and numbers of the insane, January 1, 1881. A more detailed statement will be given, in the Appendix (K I.), of the county asylums and lunatic hospitals now existing for the care and cure of the insane, with the numbers confined therein.

On the 1st of January, 1881, the proportion per cent. maintained in asylums, hospitals, and licensed houses was 64.91; in workhouses, 25.72; and as outdoor paupers, 9.37.

As some of the tables of the Commissioners extend back twenty-three years, exhibiting the number, sex, classification, and distribution of all registered lunatics, January 1, 1859-1881, as also the ratio of the total insane to the total population, we may derive much valuable information for the purpose of our historical review.

Thus there were in England and Wales:--

-------------------------------+------------------+-----------------
Location. | Patients. | Patients.
| 1859. | 1881.
-------------------------------+------------------+-----------------
In county and borough asylums | 15,844 | 41,355
In registered hospitals | 1,855 | 2,948
In metropolitan private asylums| 2,551 | 2,511
In provincial " " | 2,465 | 2,115
In naval and military hospitals| |
and Royal India Asylum | 164 | 307
In Broadmoor Asylum for | Not opened | 491
criminal lunatics | till 1863 |
In workhouses-- | |
Ordinary workhouses | 7,963 | 12,093
Metropolitan district asylums| Not opened | 4,718
| till 1870 |
Residing with relatives or | 5,920 | 6,575
others (pauper and private) | |
+------------------+-----------------
|M. 16,756} |M. 32,973}
Total |F. 20,006} 36,762 |F. 40,140} 73,113
-------------------------------+------------------+-----------------

Of the 36,762 in 1859, 4980 were in private and 31,782 pauper patients. Of the 73,113, in 1881, 7741 were private and 65,372 pauper patients. In 1859 the ratio of the total registered lunatics to the population (per 10,000) was 18.67, the ratio of private lunatics to population being 2.53, and of pauper lunatics to population 16.14. In 1881 the ratio of the total lunatics of the population was 28.34, the ratio of private lunatics to 25.34. These figures bring out very distinctly the fact that the great increase of lunatics during the period between 1859 and 1881 is among the poor. It must, however, be repeated that insanity itself brings with it pauperism to many who have once been independent and educated, but who fall, through the misfortune entailed by the malady, into the category of paupers.

An important table, introduced for the first time into the last Report of the Commissioners, shows the annual ratio of fresh admissions to the population; hence the transfers and the admissions into idiot asylums are excluded. The value of this table consists in this--that, although the gross admissions into asylums have increased, due in part to the capitation grant of four shillings introduced in 1874, the ratio of the yearly increase of the fresh admissions to the population has been slight, showing, as the Commissioners observe, that the total number of the insane under care during the twelve years embraced by the table is "mainly due to accumulation, and not to a greater annual production of insanity."[208] This table does not include workhouses.

Thus:--

-------+-------------+-------------------
| | Ratio per 10,000
Year. | Admissions. | of admissions to
| | the population.
-------+-------------+-------------------
1869 | 10,472 | 4.71
1870 | 10,219 | 4.54
1871 | 10,528 | 4.62
1872 | 10,604 | 4.59
1873 | 11,212 | 4.80
1874 | 11,912 | 5.03
1875 | 12,442 | 5.19
1876 | 12,857 | 5.30
1877 | 12,969 | 5.28
1878 | 13,343 | 5.36
1879 | 13,101 | 5.20
1880 | 13,240 | 5.19
-------+-------------+-------------------

It would thus appear that in 1880 scarcely one patient more per 20,000 persons in England and Wales was freshly admitted into asylums, etc. Had there been no increase at all, after allowing for increase of population, the number admitted in 1880 would have been 12,011. It was, in fact, 13,240, _i.e._ 1229 more.

Taking the actual number of the insane in detention during the same years shows a very different result, for accumulation is here included, and swells the returns.

Thus:--

-------+-------------+-------------------
| | Ratio per 10,000
Year. | Under care. | of number in
| | detention to the
| | population.
-------+-------------+-------------------
1869 | 53,117 | 23.93
1870 | 54,713 | 24.31
1871 | 56,755 | 24.91
1872 | 58,640 | 25.42
1873 | 60,296 | 25.82
1874 | 62,027 | 26.23
1875 | 63,793 | 26.64
1876 | 64,916 | 26.78
1877 | 66,636 | 27.14
1878 | 68,538 | 27.57
1879 | 69,885 | 27.77
1880 | 71,191 | 27.94
-------+-------------+-------------------

In other words, there were eight more patients under care for every 20,000 of the population in 1880 than in 1869. Had there been no increase in the number in detention, after allowing for increase of population, the number in 1880 would have been 53,177. It was, in fact, 71,191, _i.e._ 18,014 more.

* * * * *

We have now traced step by step the remarkable progress effected in the asylum care of our lunacy population. In concluding this chapter I would, however, observe that it would be a grave and mischievous mistake to suppose that, most valuable as is the provision for the insane by asylums, there are not many cases which may be treated outside these institutions with the greatest advantage. Some patients are best cared for in their own homes, others in lodgings, and others in the houses of medical men. The extent to which non-asylum treatment can be carried out will be seen when we speak of Chancery patients. It will be observed that the number of single private patients is 448.

In regard to the location of pauper lunatics in private dwellings, it appears that while in England 6799, or 9.29 per cent., of their number live with their relatives or are boarded in private dwellings, nearly fifteen per cent. of insane paupers in Scotland are in private dwellings, inspected by the Lunacy Board.

Dr. Lockhart Robertson has expressed the opinion that "the utmost limits within which the county asylum can benefit, or is needed for the treatment of the insane poor, is fifty per cent. of their number, and that a further accumulation of lunatics there serve no practical purpose, and hence is an unjustifiable waste of public money."[209] After pointing out the success of the metropolitan district asylums at Leavesden and Caterham, where upwards of four thousand chronic lunatics are maintained at the rate of seven shillings a week, he expresses his opinion that, if these arrangements were properly carried out, another fourteen per cent., or forty per cent. of the incurable and harmless pauper lunatics and idiots, might be placed in workhouses; his ideal standard for the distribution of pauper lunatics being--in county asylums, fifty per cent.; in workhouse wards, forty per cent.; leaving ten per cent. for care in private dwellings.

The number of beds in county and borough asylums amounts to 40,000, varying from 2000 to 250; the average cost per bed having been somewhat under L200, and the weekly maintenance and clothing of each patient 9s. 9-1/4d. If to this be added the interest on the cost of construction and asylum repair, the annual cost for each pauper lunatic in county asylums amounts to about L40.

The number of patients discharged cured, in county and borough asylums during the ten years 1871-1880, was 40.32 per cent. on the admissions, and the mortality 10.46 on the mean number resident.

The number of beds in registered lunatic hospitals (about 3000) ranges from 60 to 570, or, excluding idiot asylums, to 300, while the average weekly cost ranges from 14s. to L2 2s. The charges on the buildings are not included. For these Dr. Robertson adds five shillings a week, making the average weekly cost of maintenance L1 10s. or, including asylum construction and repairs, L1 15s.

The distribution of private patients, numbering 7741, was as follows on the 1st of January, 1881:--In registered hospitals, 2800, or 36.17 per cent.; in county asylums, 539, or 6.96 per cent.; in State asylums, 534, or 6.88 per cent.; in private asylums, 3420, or 44.17 per cent.; in private dwellings, 448, or 5.78 per cent.

The registered hospitals have, therefore, thirty-six per cent. of all the private patients, an important fact in looking to the future provision for this class in lieu of private asylums. Their statistics of recovery and mortality are satisfactory. The recoveries per cent. calculated on the admissions were 46.48 per cent. during the ten years 1871-1880; the annual mortality being 7.96 per cent.

As regards private asylums, there were forty-four per cent. of the private patients in England and Wales cared for in these establishments. The recoveries per cent. in private asylums during the decennial period 1871-1880 were--in the metropolitan division 31.43, and in the provincial 35.11; the annual mortality being, in the metropolitan private asylums 10.93, and in the provincial asylums 8.63. It should be remembered, in contrasting these figures with those of registered hospitals, that a considerable number of pauper patients are still sent to private houses, and it may therefore be said that, so far as difference in social position affects recovery and death, the comparison is not altogether fair. At the same time, it is noteworthy that in the pauper asylums, the percentage of recovery is higher than in the metropolitan and provincial private asylums, and the percentage of mortality lower than in the licensed houses of the metropolis.

Numerous general considerations arise from a retrospect of the history which this and the preceding chapter contain, but they will more fitly form a part of a subsequent chapter of this volume, when a sketch of the results achieved by Psychological Medicine will be given, as presented in the author's Presidential Address at University College.

FOOTNOTES:

[178] "A Lecture on the Management of Lunatic Asylums," etc., by Robert Gardiner Hill. Published April, 1859 (delivered June 21, 1838). (See Appendix H.)

[179] Including the wards in the Manchester Hospital.

[180] Including thirty male and three female criminal lunatics in jails, according to the Parliamentary return for April, 1843.

[181] Exclusive of the lunatic ward of Guy's Hospital.

[182] Mr. Gaskell. See p. 209.

[183] Summary taken from the Report of the Metropolitan Commissioners, 1844.

[184] Second Report of the Commissioners in Lunacy, 1847, p. 224.

[185] Page 112. No return is made in regard to the inmates of other asylums.

[186] Eighth Report of the Commissioners in Lunacy, p. 43.

[187] Exclusive of 226 single patients under commission.

[188] Page 35.

[189] Act of 1853, ss. 64 and 66.

[190] Page 44.

[191] For a table showing the cost per head in asylums of various sizes, see Appendix I.

[192] Report of Commissioners in Lunacy, 1864.

[193] Exclusive of 159 single patients.

[194] Office of the Board, 37, Norfolk Street, Strand.

[195] Caterham cost a little more, viz., L89 a bed.

[196] Page 10.

[197] Page 35.

[198] Page 43.

[199] In the Commissioners' Report of 1871, p. 76, a case is reported in which the jury would not convict a woman who had the charge of a lunatic and admitted that "she strapped the patient once a month at the full of the moon," of ill-usage, although Mr. Justice Willes summed up strongly against her. In another case the Lunacy statute was disregarded, but Baron Martin summed up very leniently, much to the disapproval, not to say the disgust, of the Commissioners.

[200] Page 75.

[201] Page 81.

[202] Page 77.

[203] See page 196.

[204] Page 20.

[205] The order and description of these institutions have been given in these decennial tables as far as possible in accordance with that of the table of 1844, in order to facilitate comparison.

[206] Exclusive of 208 lunatics so found by inquisition who reside in charge of their committees.

[207] For information in regard to Wales I am indebted Dr. W. Williams, the late medical superintendent of the Denbigh Asylum.

[208] Report, page 3.

[209] See Address at International Medical Congress, _Journal of Mental Science_, January, 1882.