Lincoln And Hanwell Progress Of Reform In The Treatment Of The Insane From 1844 To The Present Time

Before presenting official evidence of the gradual progress in the

condition of the insane in England, we must interpose in our history a

brief reference to the development of what every one knows as the

non-restraint system of treating the insane. It is, no doubt, true that

restraint begins the moment a patient enters an asylum, under whatever

name it may be disguised, but by this term is technically meant the

non-use of mechanical restraint of the limbs by the strait waistcoat,

leg-locks, etc. If, as indeed it may be granted, it had its real origin

in the humane system of treatment introduced into England long

previously, it was in the first instance at Lincoln, and subsequently at

Hanwell, adopted as a universal method, and as a rule having almost the

sanctity of a vow.



The following table shows, in the clearest manner, by what gradual steps

the experiment was tried and carried on at the former asylum. Dr.

Charlesworth was the visiting physician and Mr. R. Gardiner Hill the

house surgeon.



------+--------+-------------+---------------+-----------------

Year. Total Total Total number Total number of

number number of instances hours under

in the restrained. of restraint. restraint.

house.

------+--------+-------------+---------------+-----------------

1829 72 39 1727 20,424

1830 92 54 2364 27,113-3/4

1831 70 40 1004 10,830

1832 81 55 1401 15,671-1/2

1833 87 44 1109 12,003-1/2

1834 109 45 647 6,597

1835 108 28 323 2,874

1836 115 12 39 334

1837 130 2 3 28

------+--------+-------------+---------------+-----------------



Here we observe that in 1829 more than half the number of the inmates

were subjected to mechanical restraint, while in 1836, out of 115

patients, only twelve were so confined, and in 1837 there were only two

out of 130.[178] The total disuse of mechanical restraints followed.

They were, however, resorted to on one or two occasions subsequently.



In connection with the foregoing, it must be mentioned that the entries

of the visitors and the reports of the physicians alike agree in

describing the condition of the patients as much improved, the quiet of

the house increased, and the number of accidents and suicides as

materially reduced in number.



It would appear that the mitigation of restraint, as evidenced by these

minutes (which commence with 1819), "was ever the principle," to use Mr.

Hill's own words, "pressed upon the attention of the Boards of the

Lincoln Asylum by its able and humane physician, Dr. Charlesworth, at

whose suggestion many of the more cruel instruments of restraint were

long since destroyed, very many valuable improvements and facilities

gradually adopted, and machinery set in motion which has led to the

unhoped-for result of actual abolition, under a firm determination to

work out the system to its utmost applicable limits." Mr. Hill became

house surgeon in 1835; and it will be seen, by the table already given,

that the amount of restraint (which, in consequence of Dr.

Charlesworth's exertions, had already remarkably decreased) became less

and less under the united efforts of these gentlemen, until the close of

the year 1837, when restraint was entirely abolished; and while, on the

one hand, as Mr. Hill frankly acknowledges, "to his [Dr. Charlesworth's]

steady support, under many difficulties, I owe chiefly the success which

has attended my plans and labours," while Dr. Charlesworth's great

merit, both before and after Mr. Hill's appointment, must never be

overlooked, it is due to the latter gentleman to admit that he was the

first to assert the principle of the entire abolition of mechanical

restraint, as is stated in the "Fourteenth Annual Report of the Lincoln

Asylum," which report is signed by Dr. Charlesworth himself.



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-constituted 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.

Cassidy, 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

muffs 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 quantity of foot and hand cuffs

(iron), with chains and catches to fasten to a staple in the wall or

bedstead; 21-1/2 pairs of padded leather handcuffs; a larger quantity

of handcuffs, single and double, of iron; 22 sets of strong body

fastenings, very heavy chains covered with leather and iron handcuffs; a

large quantity 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

Middlesex 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 2451,9242,231 4,1552,054 2,346 4,400



2 ditto under

local acts -- -- -- 38 51 89 38 51 89



2 military and

naval hospitals164 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 metropolitan520 453 973 360 494 854 880 947 1,827

99 provincial 748 678 1,426 947 973 1,9201,695 1,651 3,346



Workhouses and

elsewhere[180] -- -- -- 4,1695,170 9,3394,169 5,170 9,339



Single patients

under

commission 172 110 282 -- -- -- 172 110 282

+------+-----+------+-----+-----+------+-----+------+------

Total 2,1611,911 4,0727,7019,12016,8019,68211,03120,893

-------------+------+-----+------+-----+-----+------+-----+------+------



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.



Passing 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, Sussex; 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 Lordship'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 abolishing

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

classification 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.



And 12thly. That, when a patient is forced into and secluded in a small

room or cell, it is essentially coercion in another form, and under

another name; and that it is attended with quite as bad a moral effect,

as any that can arise from mechanical restraint.[183]



Passing on to 1847, we find the Commissioners in Lunacy, having acted

under the new powers conferred upon them by the two Acts passed since

the date of the Report of 1844 (8 and 9 Vict., cc. 100 and 126), able to

give a satisfactory sketch of the progress of reform in the condition of

asylums. "In several of the county asylums and hospitals," they observe,

"the adoption of a more gentle mode of management was originally

designed in the direction of these establishments, and was the result of

public opinion and of the example set by the managers of the Retreat

near York. A strong impression was made on the feelings and opinion of

the public in reference to the treatment of lunatics by the publication

of Mr. Tuke's account of the Retreat at York. The able writings of Dr.

Conolly have of late years contributed greatly to strengthen that

impression, and to bring about a much more humane treatment of lunatics

in many provincial asylums, than that which formerly prevailed."

Referring, then, to the Report of the Metropolitan Commissioners (1844)

it is observed that "proof is afforded therein that this amendment had

not extended itself to old establishments for the insane, and that much

severe and needless restraint continued to be practised in numerous

private, and in some public asylums. In many of the private asylums, and

more especially in those which received great numbers of pauper

patients, much mechanical coercion was practised, until it came to be in

great measure laid aside in consequence of the repeated advice and

interference of the Commissioners.... In private licensed asylums it

has been thought impracticable to avoid the occasional use of

mechanical coercion without incurring the risk of serious accidents.

Under these circumstances restraint of a mild kind is still practised,

but we look forward to its abolition, except, perhaps, in some

extraordinary cases, so far as pauper patients are concerned, when the

provisions of the Act for the establishment of county asylums shall have

been carried into effect. In the best-conducted county asylums it is now

seldom (and in a few establishments never) resorted to."[184]



At this period, the actual number of lunatics returned to the

Commissioners was only 18,814, but they estimated the number under some

kind of care, in England and Wales, at 26,516. There were--



-----------------------------------+----------+---------+----------

Location. Private. Pauper. Total.

-----------------------------------+----------+---------+----------

In county asylums, hospitals, and

licensed houses 3,574 9,652 13,226



Bethlem, and in naval and military

hospitals not subjected to

visitation of Commissioners 606 -- 606



Poor-law unions; placed under

local Acts -- 8,986 8,986



Gilbert's unions, and other places

not in union -- 176 176



Single patients found lunatic by

inquisition 307 307



Ditto in private houses with

persons receiving profit 130 -- 130



Excess of pauper patients in

workhouses, etc., estimated by

visiting Commissioners as at

least one-third over the number

number returned by parish

officers -- 3,053 3,053



Criminals in jails -- 32 32

+----------+---------+----------

Total 4,617 21,899 26,516

-----------------------------------+----------+---------+----------



The number of patients found lunatic by inquisition was 542; their

incomes amounting to L280,000. In 1839 the corresponding numbers were

494 and L277,991.



The estimated annual amount expended at this time for maintenance of

lunatics, or administered on their behalf, exceeded L750,000, thus

distributed:



1. Cost of 9652 paupers in asylums, estimated at

8s. per week L200,762



2. Ditto of 8986 paupers in workhouses, etc., and

173 in parishes not in union (9159),

estimated at 3s. per week 71,440



3. Ditto of excess of 3053 paupers over the number

returned by the parish officer 23,813



4. Ditto of 3574 private patients in asylums, etc.,

at an average of 20s. per week 173,628



5. Income of 542 private patients found lunatic by

inquisition 280,000



6. Cost of 606 patients in Bethlem and the naval

and military hospitals, estimated at 10s.

per week 50,756



7. Ditto of 120 other single patients taken charge

of in separate houses at L100 a year 12,000



8. Thirty-two criminals in jails, estimated at 3s.

per week 249

--------

Total L777,648



Adding the expense of maintaining many families cast upon the parish in

consequence of the patient's insanity, and the expense of supporting

many called imbecile, and the interest of large sums invested in public

establishments, the Commissioners estimated the actual amount as little

less than L1,000,000.



In the same Report the Commissioners observe "that they have found that,

with some exceptions, the patients have apparently been humanely, and

sometimes very judiciously treated. There is no reason to apprehend that

the lunatic patient is now often subjected to cruelty or

ill-treatment.... The massive bars, and rings, and chains of iron

formerly resorted to are no longer seen. Any continued coercion is not

permitted. The name of every patient under restraint and in seclusion,

and the means by which such seclusion is effected, are recorded every

week in a journal. Thus the safeguards against lunatic patients being

subjected to harsh or unnecessary restraint from the cruelty, idleness,

or caprice of their attendants, have been multiplied, and the chances of

abuse reduced to a small amount."



The number of lunatics placed under mechanical restraint in licensed

houses in this year is given in the following table, it being premised

that wherever the number is not specified, "it may be assumed either

that there was no patient then under restraint, or that the number was

so small, and the restraint so trivial, as not to be deemed worthy of

special remark."[185]



------------------------------+-----------+-----------+------------

Number of Under

Asylum. patients. Criminals. restraint

last visit.

------------------------------+-----------+-----------+------------

METROPOLITAN LICENSED HOUSES.



Bethnal Green--Red House }

White House } 614 12 4

Bow--Grove Hall 291 -- 2

Brompton--Earls Court 32 -- 1

Camberwell--Camberwell House 246 1 5

Clapham--Retreat 15 -- 1

Clapton, Upper--Brook House 42 -- 1

Fulham--Beaufort House 5 -- 2

Hillingdon--Moorcroft House 50 -- 1

Hoxton--Hoxton House 416 -- 4

Kensington--Kensington House 44 -- 2

Peckham--Peckham House 409 4 4

Stoke Newington--

Northumberland House 35 -- 1

------------------------------+-----------+-----------+------------



------------------------------+-----------+-----------+------------

Number of Under

Asylum. patients. Criminals. restraint

last visit.

------------------------------+-----------+-----------+------------

PROVINCIAL LICENSED HOUSES.



Derby--Green Hill House 25 -- 1

Durham--Gateshead Fell 92 8 1

Essex--High Beach 34 -- 2

Gloucester--Fishponds 45 -- 1

" Northwoods 29 -- 1

" Fairford 175 1 1

Hants--Grove Place 78 1 1

Herefordshire--Whitchurch 32 2 1

Kent--West Malling Place 40 -- 3

Lancaster--Blakely House 24 -- 1

Northumberland--Bell Grove

House 13 -- 1

Oxford--Witney 11 -- 2

" Hook-Norton 57 1 2

Somerset--Bailbrook House 92 3 10

Stafford--Oulton Retreat 25 -- 2

" Sandfield 44 -- 1

Sussex--Ringmer 3 -- 1

Warwick--Duddeston Hall 87 3 6

" Kingstown House 91 -- 2

Wilts--Bellevue House 181 5 5

" Fiddington House 193 3 3

Worcester--Droitwich 91 2 2

York, East Riding--Hull and

East Riding Refuge 115 8 1

" " Hessle 12 -- 1

" West Riding--Castleton

Lodge 15 -- 1

" " Grove House 41 -- 5

" " Heworth 29 -- 1

------------------------------+-----------+-----------+------------



If for the purpose of comparison at different years we take one asylum,

Ringmer in Sussex, there were in November 1829, nineteen patients, of

whom five were under restraint by day, and seven by night. In 1830

(February) the number of patients was twenty, and of these eleven were

under restraint by day and six by night; while in October of the same

year, out of eighteen patients, there were nine under restraint. In

1831, there were twenty-two patients, ten of whom were under

restraint. Writing in 1848, the Commissioners enumerate the various

changes for the better which had then taken place, among which were--an

active medical superintendence; the abolition of excessive use of

mechanical restraint, there being sometimes only one or two, and

occasionally no patient whatever, under mechanical restraint; the

introduction of warm and cold baths; the cleanliness of the day-rooms



and dormitories; the addition of a good library, and various amusements

and means of occupation; and also an excellent dietary. Such is a sample

of the happy change which was, in many instances, brought about by

inspection.



The following classification of asylums in 1851 will show at a glance

the progress made in providing accommodation from time to time,

consequent upon legislation:--



1. Asylums existing prior to passing of Act 8 and 9 Vict., c. 126.



Accommodation for pauper lunatics at passing of the Act 5560

Additional accommodation provided therein since the

passing of the Act 1753

----

Total accommodation 7313



2. Asylums in progress of erection at passing of Act 8 and 9 Vict., c.

126, and since opened.



Number for which designed 997

Subsequent additions 206

----

Total present accommodation 1203



3. Asylums erected or provided under the provisions of the Act 8 and

9 Vict., c. 126, and now opened.



Accommodation for pauper lunatics 1114



4. Asylums in progress of erection under Act 8 and 9 Vict., c. 126,

and not yet opened.



Proposed accommodation for pauper lunatics 4299

Under provisions of previous Acts 6557

Under Act 8 and 9 Vict., c. 126 7372

------

Total 13,929

Exclusive of 192 in Northampton Hospital.



Asylums existing prior to or at the passing of Act 8 and 9 Vict., c.

126--



Beds., Herts and Hants., Chester, Cornwall, Devon, Dorset,

Gloucester, Kent, Lancaster (containing the largest number

of patients, 700), Leicester and Rutland, Middlesex

(Hanwell), Norfolk, Notts., Salop and Montgomery, Stafford,

Suffolk, Surrey, West Riding, Yorkshire, Bristol (borough).

Wales--Haverfordwest (town and county), Montgomery (see

Salop).



Asylums in progress of erection at the passing of this Act, and since

opened--



Oxford and Berks, Somerset, North and East Riding,

Yorkshire. Wales--Anglesea, Carnarvon, Denbigh, Flint,

Merioneth.



Total number for which designed 997

Additions since passing the Act 206

----

Total 1203



Counties in which no steps are taken to provide asylums--



Cumberland, Durham, Northampton, Sussex, Westmoreland.



Total accommodation 5560

Subsequent additions 1753

----

Total 7313



Asylums erected or provided under the above Act and now opened--



West Lancashire (Rainhill), East Lancashire (Prestwich, near

Manchester), Birmingham (borough), Kingston-upon-Hull.



For these asylums the accommodation provided in the first instance was

1114.



There were still upwards of fifty boroughs for whose pauper lunatics no

legal provision was made, and no asylum was then erected for the City of

London.



Under the head of mechanical restraint, the Commissioners now report

that it has still further diminished, and has in some houses been

absolutely abolished. However, in fifty entries made in the books of

thirty-six private asylums, abuses and defects are animadverted upon in

fifteen instances in regard to restraint, in twenty instances in regard

to bedding and clothing, nine in regard to diet, seven in regard to

cleanliness, and four in regard to management and treatment. They

observe that the number of lunatics in workhouses has diminished in a

very marked degree.



In this Report the Commissioners take the opportunity of animadverting,

also, upon the defective state of the law in regard to the property of

lunatics; the good effect of the Act 8 and 9 Vict., c. 100, being

lessened by this and other causes.



Turning to the year 1854, nearly ten years after the Act of 1845 had

been in fruitful operation, we find the Commissioners attaching

importance to the alterations recently made in the law of lunacy by the

three important statutes, 16 and 17 Vict., c. 70 (the "Lunacy Regulation

Act" of 1853) which refers to Chancery lunatics; 16 and 17 Vict., c. 90

(an amendment of the Act under which the Board was constituted); and 16

and 17 Vict., c. 97 (the "Lunatic Asylums Act," 1853).



These Acts, with 8 and 9 Vict., c. 100, and 15 and 16 Vict., c. 48, and

the Acts relative to criminal lunatics, constituted at that period the

code of law of lunacy.



The following counties still remained unprovided for:--Sussex,

Cumberland, Westmoreland, Northumberland, Durham, Cambridge, Cardigan,

Carmarthen, Glamorgan, Pembroke.



New private asylums were no longer licensed for paupers, in consequence

of the accommodation provided for them in county asylums.



Complaints having been made of the treatment of patients at Hanwell, an

inquiry had been instituted, which, in the opinion of the Commissioners,

justified them. They appeared to have been due to the want of efficient

supervision of male patients.



This Report of the Commissioners gives a series of interesting replies

to a circular letter addressed to the superintendents and medical

proprietors of nearly all the asylums in England and Wales, on

non-restraint, upon which they observe, "as the general result which may

be fairly deduced from a careful examination and review of the whole

body of information thus collected, we feel ourselves fully warranted in

stating that the disuse of instrumental restraint, as unnecessary and

injurious to the patient, is practically the rule in nearly all the

public institutions in the kingdom, and generally also in the

best-conducted private asylums, even those where the restraint system,

as an abstract principle admitting of no deviation or exception, has not

in terms been adopted.



"For ourselves," they observe, "we have long been convinced, and have

steadily acted on the conviction, that the possibility of dispensing

with mechanical coercion in the management of the insane is, in a vast

majority of cases, a mere question of expense, and that its continued,

or systematic use in the asylums and licensed houses where it still

prevails must in a great measure be ascribed to their want of suitable

space and accommodations, their defective structural arrangements, or

their not possessing an adequate staff of properly qualified attendants,

and frequently to all these causes combined.



"Our matured views upon the subject will be best understood by stating

the course we have followed in the discharge of our functions as

visitors. In that capacity we have made it a principle to discourage, to

the utmost, the employment of instrumental restraint in any form.

Wherever we have found it in use, our uniform practice has been to

inquire minutely into the circumstances and reasons alleged for its

necessity, and to insist on recourse being had to those various other

means which experience has proved in other houses to be effective

substitutes for it....



"As respects the question 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 6,87812,669 5,938 7,02412,962



2 military and

naval hospitals199 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 metropolitan608 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 5,32710,653 5,326 5,32710,653

+-----+-----+------+------+------+------+------+------+------

Total 2,4512,182 4,63312,23413,44525,67914,68515,62730,312

--------------+-----+-----+------+------+------+------+------+------+------



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 association with other patients. The Commissioners found her

quiet, orderly, clean, well-dressed, and so much improved in appearance

that they had some difficulty at first in recognizing her.



It was inevitable, as a result of the attention directed to the

condition of the insane, and the greatly increased provision made for

them in consequence, that there should be an alarming apparent increase

of lunacy in the kingdom. In point of fact, the number of pauper

lunatics had increased sixty-four per cent. in the eight years ending

1855.



At this period there were 13,579 patients in county and borough asylums,

1689 in registered hospitals, 2523 in metropolitan and 2588 in

provincial licensed houses, and 114 in the Royal Naval Hospital.



The number of insane poor not in asylums 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 practitioners recognizing the nature of

cases of insanity better; facilities of post-office, railway, and press

bringing cases to light; medical officers being required to make

quarterly returns under 17 and 18 Vict., c. 97, s. 66; and the efforts

of the Commissioners to impress on guardians the importance of sending

recent cases to asylums.



The increase of private patients during eight years had been at the rate

of only fifteen per cent.; but the Commissioners point out that this

conveys an imperfect view of the relative increase of pauper and private

cases, inasmuch as a practice had sprung up by which persons who had

never been themselves in receipt of relief, and who are not infrequently

tradesmen or thriving artisans, had been permitted to place lunatic

relatives in the county asylums as pauper patients, under an arrangement

with the guardians for afterwards reimbursing to the parish the whole or

part of the charge for their maintenance.



"Indeed, it may be said with truth that, except among what are termed

the opulent classes, any protracted attack of insanity, from the heavy

expenses 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

classes of society.



The very great importance of obtaining good attendants for asylums

became a prominent subject now that the number of patients under

treatment had so vastly increased, and it was clearly seen that the

skill of the superintendent was of little avail unless effectually

carried out by a well-qualified staff of attendants. It was necessary

that they should be liberally remunerated, and that their position in

the house should be made comfortable. The Commissioners recommended the

appointment of head attendants of a superior class, whose duties should

not be restricted to any one ward, but who should be responsible for the

conduct of the other attendants. A well-educated lady had been found

most useful in asylums as a companion to female patients of the upper

classes. The Commissioners required notices to be transmitted to their

offices of all dismissals for misconduct of nurses or attendants, and of

the causes thereof; these notices being regularly filed for reference,

in the event of inquiries being made as to the characters of applicants

for employment.



Reviewing the condition of the insane generally at this time in

workhouses, the Commissioners were able to report that, upon the whole,

a sensible amelioration had taken place in their physical condition and

in their treatment. They abstained, however, from any official sanction

of the construction of lunatic wards in workhouses; for the patients

were not provided with any suitable occupation, the means for exercise

were generally wanting, and the attendants were too badly paid to allow

of a reliance being placed on their services.



The large number living with strangers or relatives on parish allowance

appeared to have seldom fallen within the personal observation of the

Commissioners, who had chiefly to depend upon the annual returns from

the clerks of the Board of Guardians, and on the quarterly returns from

the medical officers of the various districts,[189] whose returns were

so defective and irregular that no definite conclusion could be drawn

from their contents.



In their next Report the subject of workhouses still claimed the

attention of the Commissioners, and they complained that, in direct

contravention of the law, pauper patients were sent first to a

workhouse, instead of an asylum. The sixty-seventh section of the Act of

1853 was disregarded altogether. Hence, if the patient was found

manageable in the workhouse, he was detained there, or, if ultimately

sent to the asylum, much valuable time had been lost, and his chance of

cure greatly lessened. The Commissioners found their recommendations set

at defiance, for the most part, whenever the report of the medical

officer stated the patient to be "harmless." It was urged that the

lunatic wards in workhouses should be placed in the position of licensed

houses, and that the Commissioners and visitors should be invested with

the same power in regard to them as they possessed over these

establishments. But it became very clear that, however valuable the

recommendations of the Commissioners might, and, indeed, have ultimately

proved to be, they did not possess the authority of commands. At the

infirmary asylum at Norwich unceasing suggestions for improvement were

made 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, passed twelve years before. The Act

of 1853, having introduced some modification for boroughs of small

populations, left no further excuse for making proper provision. The

Commissioners from time to time issued circulars to the various asylums,

and intimated their intention to report to the Secretary of State (under

s. 29 of the Act) 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 class of single patients, the Commissioners had

not found it practicable to visit them as they desired to do. Many,

however, had been visited. Some were found indifferently accommodated,

and otherwise in a very unsatisfactory state. The provisions of the law

were extensively evaded.[190]



As the views entertained and recommended by the Commissioners from time

to time are of importance in regard to the construction of asylums, it

may be observed that in their Report of 1857 they dwell on the evils of

very large buildings, on account of the loss of individual and

responsible supervision, the loss of the patient's individuality, and

the tendency of the rate of maintenance for patients to run higher.[191]

It was also maintained that the divided responsibility consequent on

such large institutions was injurious to management, and that the cures

of patients were actually fewer. It was considered that the limits to

the size of the Hanwell Asylum were reached, and indeed exceeded, viz.

for 1020, but room for 600 patients more was required. So at 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 9,69011,63021,320 9,8