Chapters in the History of the Insane in the British Isles Part 15

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

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

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

Four years ago when I visited the Lancaster Asylum, I was shown a room containing the dire instruments of coercion formerly in use, and a most instructive exhibition it was. At my request the superintendent, Dr.

Ca.s.sidy, has kindly provided me with the following list of these articles: 1 cap with straps; 4 stocks to prevent biting; 2 muzzles (leather) to cover face and fasten at the back of the head; 10 leather gloves, of various forms, perforated with holes, and cuffs of leather or iron; 14 double ditto, with irons for wrists; 1 kicking shoe; 11 leather m.u.f.fs with straps; 4 stout arm leathers (long sleeves with closed ends) with cross-belt and chains; 8 heavy body straps, with shoulder-pieces, waist-belts, cross-belts, and pairs of handcuffs attached by short chains; 5 ditto of somewhat different make; 30 ditto, but with leather cuffs; 2 waist straps with leather cuffs attached; 9 pairs of leather cuffs padded; 11 pairs of leg-locks; a quant.i.ty of foot and hand cuffs (iron), with chains and catches to fasten to a staple in the wall or bedstead; 21 pairs of padded leather handcuffs; a larger quant.i.ty of handcuffs, single and double, of iron; 22 sets of strong body fastenings, very heavy chains covered with leather and iron handcuffs; a large quant.i.ty of broad leather straps; a bag of padlocks; keys for handcuffs, etc.

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

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

------------------+--------------------------+----------------- County. | Town. | Date of opening.

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

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

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

-------------------------+-----------+-------------------- Hospital. | Nature. | Date of opening.

-------------------------+-----------+-------------------- Fort Clarence, Chatham | Military | 1819 Haslar Hospital, Gosport | Naval | 1818 -------------------------+-----------+--------------------

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

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

--------------------+------------------------+------------------ Locality. | Name of Asylum. | Date of opening.

--------------------+------------------------+------------------ Exeter | St. Thomas' | 1801 Lincoln | Lunatic Asylum | 1820 Liverpool | | 1792 Northampton | General Lunatic Asylum | 1838 Norwich | Bethel Hospital | 1713 Oxford (Headington) | Warneford Asylum | 1826 York | Bootham Asylum | 1777 | The Retreat | 1796 --------------------+------------------------+------------------

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

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

They were thus distributed:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE INSANE IN ENGLAND AND WALES, JANUARY 1, 1844.

----------------+----------------+------------------+------------------- Where | Private | Paupers. | Total.

confined. | patients. | | +---+-----+------+-----+-----+------+-----+------+------ |M. | F. |Total.| M. | F. |Total.| M. | F. |Total.

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

The number of asylums amounted to 166.[181]

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

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

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

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

Two of them sleep in two cribs in one cell.... There is no window and no place for light or air, except a grate over the doors." The condition of the floor and straw, on which the patients lay, it is unnecessary to describe.

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

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

but it has not been thought right to dispense with the use of a mild and protecting personal restraint, believing that, independent of all consideration for the safety of the attendants, and of the patients themselves, it may in many cases be regarded as the least irritating, and therefore the kindest, method of control. Eight of the superintendents employing bodily restraint have stated their opinion to be that it is in some cases beneficial as well as necessary, and valuable as a precaution and a remedial agent; and three of them have stated that they consider it less irritating than holding with the hands; and one of them prefers it to seclusion.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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