Chapters in the History of the Insane in the British Isles Part 17

The following counties still remained unprovided for:--Suss.e.x, c.u.mberland, Westmoreland, Northumberland, Durham, Cambridge, Cardigan, Carmarthen, Glamorgan, Pembroke.

New private asylums were no longer licensed for paupers, in consequence of the accommodation provided for them in county asylums.

Complaints having been made of the treatment of patients at Hanwell, an inquiry had been inst.i.tuted, which, in the opinion of the Commissioners, justified them. They appeared to have been due to the want of efficient supervision of male patients.

This Report of the Commissioners gives a series of interesting replies to a circular letter addressed to the superintendents and medical proprietors of nearly all the asylums in England and Wales, on non-restraint, upon which they observe, "as the general result which may be fairly deduced from a careful examination and review of the whole body of information thus collected, we feel ourselves fully warranted in stating that the disuse of instrumental restraint, as unnecessary and injurious to the patient, is practically the rule in nearly all the public inst.i.tutions in the kingdom, and generally also in the best-conducted private asylums, even those where the restraint system, as an abstract principle admitting of no deviation or exception, has not in terms been adopted.

"For ourselves," they observe, "we have long been convinced, and have steadily acted on the conviction, that the possibility of dispensing with mechanical coercion in the management of the insane is, in a vast majority of cases, a mere question of expense, and that its continued, or systematic use in the asylums and licensed houses where it still prevails must in a great measure be ascribed to their want of suitable s.p.a.ce and accommodations, their defective structural arrangements, or their not possessing an adequate staff of properly qualified attendants, and frequently to all these causes combined.

"Our matured views upon the subject will be best understood by stating the course we have followed in the discharge of our functions as visitors. In that capacity we have made it a principle to discourage, to the utmost, the employment of instrumental restraint in any form.

Wherever we have found it in use, our uniform practice has been to inquire minutely into the circ.u.mstances and reasons alleged for its necessity, and to insist on recourse being had to those various other means which experience has proved in other houses to be effective subst.i.tutes for it....

"As respects the question of _seclusion_, its occasional use for short periods, chiefly during paroxysms of epilepsy or violent mania, is generally considered beneficial. At the same time, we would observe that the facilities which seclusion holds out to harsh or indolent attendants for getting rid of and neglecting troublesome patients under violent attacks of mania, instead of taking pains to soothe their irritated feelings, and work off their excitement by exercise and change of scene, render it liable to considerable abuse; and that, as a practice, it is open, though in a minor degree, to nearly the same objections which apply to the more stringent forms of mechanical restraint. We are therefore strongly of opinion that, when even seclusion is resorted to as a means of tranquillizing the patient, it should only be employed with the knowledge and direct sanction of the medical officer, and even then be of very limited duration.

"Further experience, we think, has shown that, except for the reception of epileptic patients during the continuance of their paroxysms, and in a few cases where there is a determined propensity to suicide, the utility of padded rooms is not so great as was at one time supposed; and that, for cases of ordinary maniacal excitement, seclusion in a common day-room or sleeping-room of moderate size, from which all articles that might furnish instruments of violence or destruction have been removed, and which is capable of being readily darkened, when required, by a locked shutter, will, in general, be found to answer every useful purpose."[186]

As ten years had elapsed since the first attempt of any value to present the numbers of the insane in England (see page 211), it is of interest to compare with the table referred to, the following statement of the numbers on the 1st of January, 1854:--

GENERAL STATEMENT OF THE TOTAL NUMBER OF PERSONS ASCERTAINED TO BE INSANE IN ENGLAND AND WALES, JANUARY 1, 1854.[187]

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

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

----------------+---+-----+------+------+------+------+------+------+------ 33 county and | | | | | | | | | borough asylums |147| 146| 293| 5,791| 6,878|12,669| 5,938| 7,024|12,962 | | | | | | | | | 2 military and | | | | | | | | | naval hospitals|199| 5| 204| -- | -- | -- | 199| 5| 204 | | | | | | | | | 2 Bethlem and | | | | | | | | | St. Luke's | | | | | | | | | Hospitals |235| 239| 474| 4| 7| 11| 239| 246| 485 | | | | | | | | | 22 other public | | | | | | | | | asylums |467| 456| 923| 102| 103| 205| 569| 559| 1,128 | | | | | | | | | Licensed houses:| | | | | | | | | 42 metropolitan|608| 598| 1,206| 418| 723| 1,141| 1,026| 1,321| 2,347 88 provincial |795| 738| 1,533| 593| 407| 1,000| 1,388| 1,145| 2,533 | | | | | | | | | Workhouses and | | | | | | | | | elsewhere | --| -- | -- | 5,326| 5,327|10,653| 5,326| 5,327|10,653 +-----+-----+------+------+------+------+------+------+------ Total |2,451|2,182| 4,633|12,234|13,445|25,679|14,685|15,627|30,312 --------------+-----+-----+------+------+------+------+------+------+------

In their ninth Report the Commissioners speak of continued progress, and to show the beneficial effects of good and kind treatment, record the case of a lady visited by them in a private asylum, where they found her in a room by herself, in a sadly neglected condition, and very frequently placed under mechanical restraint. Her habits were dirty, and her opportunities of taking exercise few. In consequence of her unsatisfactory condition the Commissioners ordered her removal to another asylum (the York Retreat), and about twelve months afterwards saw her there, and made an entry to the effect that since her admission she had never been in restraint or seclusion; that her destructive and dirty habits had been corrected by constant attention, exercise out of doors, and a.s.sociation with other patients. The Commissioners found her quiet, orderly, clean, well-dressed, and so much improved in appearance that they had some difficulty at first in recognizing her.

It was inevitable, as a result of the attention directed to the condition of the insane, and the greatly increased provision made for them in consequence, that there should be an alarming apparent increase of lunacy in the kingdom. In point of fact, the number of pauper lunatics had increased sixty-four per cent. in the eight years ending 1855.

At this period there were 13,579 patients in county and borough asylums, 1689 in registered hospitals, 2523 in metropolitan and 2588 in provincial licensed houses, and 114 in the Royal Naval Hospital.

The number of insane poor not in asylums was estimated at 10,500, of whom about half were inmates of workhouses, and the remainder with relations and strangers on an allowance from the parish.

There were various obvious explanations for the apparent increase of lunacy, viz. the greatly enlarged accommodation; the prolongation of life in consequence of kind care; the parochial authorities being required to take immediate proceedings for placing violent and recent cases under treatment; medical pract.i.tioners recognizing the nature of cases of insanity better; facilities of post-office, railway, and press bringing cases to light; medical officers being required to make quarterly returns under 17 and 18 Vict., c. 97, s. 66; and the efforts of the Commissioners to impress on guardians the importance of sending recent cases to asylums.

The increase of private patients during eight years had been at the rate of only fifteen per cent.; but the Commissioners point out that this conveys an imperfect view of the relative increase of pauper and private cases, inasmuch as a practice had sprung up by which persons who had never been themselves in receipt of relief, and who are not infrequently tradesmen or thriving artisans, had been permitted to place lunatic relatives in the county asylums as pauper patients, under an arrangement with the guardians for afterwards reimbursing to the parish the whole or part of the charge for their maintenance.

"Indeed, it may be said with truth that, except among what are termed the opulent cla.s.ses, any protracted attack of insanity, from the heavy expenses which its treatment entails, and the fatal interruption which it causes to everything like active industry, seldom fails to reduce its immediate victims, and generally also their families with them, to poverty, and ultimately to pauperism."

The Commissioners add--and we draw special attention to the statement--that "this is the main reason why, in our pauper lunatic asylums, many inmates are to be met with who have formerly held a respectable station in society, and who, in point of education and manners, are greatly superior to the inmates of a workhouse."[188] Hence we see how utterly fallacious is the conclusion constantly drawn from a study of the mere figures themselves that insanity is, to the extent indicated by them, more prevalent among the lower than the higher cla.s.ses of society.

The very great importance of obtaining good attendants for asylums became a prominent subject now that the number of patients under treatment had so vastly increased, and it was clearly seen that the skill of the superintendent was of little avail unless effectually carried out by a well-qualified staff of attendants. It was necessary that they should be liberally remunerated, and that their position in the house should be made comfortable. The Commissioners recommended the appointment of head attendants of a superior cla.s.s, whose duties should not be restricted to any one ward, but who should be responsible for the conduct of the other attendants. A well-educated lady had been found most useful in asylums as a companion to female patients of the upper cla.s.ses. The Commissioners required notices to be transmitted to their offices of all dismissals for misconduct of nurses or attendants, and of the causes thereof; these notices being regularly filed for reference, in the event of inquiries being made as to the characters of applicants for employment.

Reviewing the condition of the insane generally at this time in workhouses, the Commissioners were able to report that, upon the whole, a sensible amelioration had taken place in their physical condition and in their treatment. They abstained, however, from any official sanction of the construction of lunatic wards in workhouses; for the patients were not provided with any suitable occupation, the means for exercise were generally wanting, and the attendants were too badly paid to allow of a reliance being placed on their services.

The large number living with strangers or relatives on parish allowance appeared to have seldom fallen within the personal observation of the Commissioners, who had chiefly to depend upon the annual returns from the clerks of the Board of Guardians, and on the quarterly returns from the medical officers of the various districts,[189] whose returns were so defective and irregular that no definite conclusion could be drawn from their contents.

In their next Report the subject of workhouses still claimed the attention of the Commissioners, and they complained that, in direct contravention of the law, pauper patients were sent first to a workhouse, instead of an asylum. The sixty-seventh section of the Act of 1853 was disregarded altogether. Hence, if the patient was found manageable in the workhouse, he was detained there, or, if ultimately sent to the asylum, much valuable time had been lost, and his chance of cure greatly lessened. The Commissioners found their recommendations set at defiance, for the most part, whenever the report of the medical officer stated the patient to be "harmless." It was urged that the lunatic wards in workhouses should be placed in the position of licensed houses, and that the Commissioners and visitors should be invested with the same power in regard to them as they possessed over these establishments. But it became very clear that, however valuable the recommendations of the Commissioners might, and, indeed, have ultimately proved to be, they did not possess the authority of commands. At the infirmary asylum at Norwich unceasing suggestions for improvement were made for _ten years_, which were, "with very few exceptions, systematically disregarded." Then, but not till then, did the Commissioners appeal to the Secretary of State, to require the authorities of Norwich to provide for their lunatic poor, according to the statutes 8 and 9 Vict., c. 126, pa.s.sed twelve years before. The Act of 1853, having introduced some modification for boroughs of small populations, left no further excuse for making proper provision. The Commissioners from time to time issued circulars to the various asylums, and intimated their intention to report to the Secretary of State (under s. 29 of the Act) the cases of all boroughs wherein proper provision had not been made for their pauper lunatics. "But even this last appeal did not fare more successfully; and all our reiterated inquiries and remonstrances have as yet made hardly a perceptible impression upon that almost general neglect of the law which it was hoped they might repair."

As regards the important cla.s.s of single patients, the Commissioners had not found it practicable to visit them as they desired to do. Many, however, had been visited. Some were found indifferently accommodated, and otherwise in a very unsatisfactory state. The provisions of the law were extensively evaded.[190]

As the views entertained and recommended by the Commissioners from time to time are of importance in regard to the construction of asylums, it may be observed that in their Report of 1857 they dwell on the evils of very large buildings, on account of the loss of individual and responsible supervision, the loss of the patient's individuality, and the tendency of the rate of maintenance for patients to run higher.[191]

It was also maintained that the divided responsibility consequent on such large inst.i.tutions 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 Middles.e.x! 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 200 per bed, the other would only cost 40, the effect is, from the point of view of the ratepayer, who usually objects to contribute to the formation of a free library, a very serious one.

Twenty years after the census of the insane made in 1844, and ten after the period to which the table given 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 pa.s.s 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 (Hertfords.h.i.+re), Caterham (Surrey), Hampstead, and Clapton. Legally these inst.i.tutions are cla.s.sed under workhouses.

Much difference of opinion exists as to the wisdom of having separate inst.i.tutions 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 cla.s.s 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 inst.i.tution 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 s.h.i.+llings and pence.

Take Leavesden as the example, where the accommodation is for 2000 patients (M. 900, F. 1100). The land, which was purchased in 1867 and 1880, has cost 9401, the area being eighty-four acres. The laying out the grounds, etc., cost 3000; the cost of building and drainage (up to Michaelmas, 1878) was 121,674; the engineering works, fixtures, and fittings cost 16,162; the furniture, bedding, and clothing, 16,235; the architect's and surveyor's charges, and clerk of works, 5108; solicitor's charges, printing, insurances, and all other charges, 1526; the total being 173,118, or 86[195] per bed. Taking out the items of furniture, bedding, and clothing, we have the sum of 77 per bed. How striking the difference when compared with the expense of an ordinary county asylum, the reader who has examined the figures given at page 166 will readily perceive.

Let us now pa.s.s 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 inst.i.tutions," 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 inst.i.tuted, 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 inst.i.tutions 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 cla.s.s 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 cla.s.s of either s.e.x 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."