128
Art. VIII.?LUNACY IN ENGLAND AND WALES. The Thirty fifth Report of the Commissioners in Lunacy deals with the statistics of madmen in England and Wales for the year ending December 31st, 1880. From it we learn that on January 1st last year the total number of persons of unsound mind under care and treatment in asylums, registered hospitals, licensed houses, and as private patients in unlicensed houses, Avas 50,175. Of admissions there were 15,240, viz.: 1,338 males and 1,276 female, as private patients; and 6,017 males, and 6,609 females, as paupers. Of the total admissions, 1,789 were transfers. After deducting these transfers, 1879 exhibits an increase of 160; but compared with 1878, the number is 119 less. The total number of patients were thus classified :? Private patient,
Paupers
.
{?^Ie8 {??e5
.
.
Total
J
;
'
'
3^}
.....
7,741 42,434 50.175
The readmissions in 1880 were 1,855, and compared with the ratios per cent, were, respectively, 12*11 and 12*18. The information as to discharges is interesting in connection
1879,
with the readmission : the total number was 9,317, of whom were males, and 5,041 females; 5,338 of them are entered as recoveries, and of the number 482 were private
4,276
patients.
Deaths reached 4,498
cases
only, however,
were
2,487 men, 2,011 women. In 1,656 post-mortem examinations conducted,
;
satisfactory to find that the Commissioners are alert prime importance of extending this very necessary means of enlarging our knowledge of cerebral pathology. As compared with previous years, moreover, there is a marked falling off in the number of autopsies performed, a fact difficult of explanation save on the ground of declining interest in the scientific study Whether or not this is justly to be attributed to of disease. those who are responsible for the omission, it is, nevertheless, much to be lamented that greater anxiety is not exhibited in this important respect; every medical superintendent should direct his earnest attention to the matter, and strive to supplement existing knowledge by every possible means in his power to r:nd it is
to the
LUNACY IN
129
ENGLAND AND WALES.
employ. From a study of appendix (B) of the Commissioners' Report, it is at once evident what large opportunities of pathological investigations are permitted to pass unutilised, and this too, even in the Metropolitan district, where the least possible excuse can be found for such neglect, since ample assistance is, Thus we find that, at Camberat all times, readily obtainable. well House, with an average resident population of 477, and in which 46 deaths occurred during 1880, there were no more than four autopsies performed. At Grove Hall, on the other hand, with 27 deaths, no less than 23 post mortems were conducted, the average resident lunatic population being 439. At Peckliam House there were 44 deaths, and four autopsies; at Bethnal House, 47 deaths, and only one post-mortem examination. Indeed, of the Metropolitan establishments, Grove Hall appears to be the only institution where any importance is attached to the method of investigation; a fact that cannot be too deeply deplored. Neither is much improvement exhibited when we have regard to extra-Metropolitan Asylums, the great majority of deaths being registered without any indication of their conAt Haydock Lodge, firmation by post mortem-examination. however, where 44 deaths occurred, 26 autopsies were performed; and at Fisherton House, 12, with 31 deaths. The following figures are indeed eminently suggestive in their bearing on this very important question :? Total Deaths, 1880 ,, Autopsies, 1880
Of the In ? ,,
4,498 1,656
there
autopsies performed,
were :
and
Borough Asylums County Registered Hospitals Metropolitan Licensed Houses
1,470
.....
Provincial ? Naval and Military Hospital and India ? Criminal Asylum Among Private Single Patients
...
?
?
Asylum
69 35 50 12
......
20
....
0
1,656
Further comparison of these numbers with the total deaths in each class of institution is still more suggestive. Thus the Metropolitan licensed houses contribute 212 deaths, and 35 autopsies; while Provincial licensed houses, with only 173 deaths, give At the Criminal Asylum, the cause of death 50 post mortems. would seem to have been investigated in every case, the number recorded under each head for this investigation being the same, In no instance was a post mortem made on a " private 20. single patient," of whom 29 died during the year. These figures deserve to be very attentively considered, and the inference they justify to be well kept in view. It is not, PART I.
VOL. VIII.
NEW
SERIES.
K
130
LUNACY IN
ENGLAND
AND
WALES.
too much to assert that the field of observation, neglected in this omission to confirm the causes of death among the insane, is one which, assiduously cultivated, could not fail to yield results of the greatest magnitude and importance; for it is a matter of constant reiteration, that our knowledge of primary lesions can be expected to increase in extent only by aid of psychological studies on all classes of patients. The Commissioners have done well in laying special stress on the paucity of post-mortem records, and, by urging with them the necessity for rigorous prosecution of this branch of objective research, we are maintaining a point we have unceasingly insisted on in the
perhaps,
past.
A curious and instructive case of homicide is reported to have occurred at the Prestwich (near Manchester) Asylum. One patient killed another with a crowbar while at work, in the presence of an attendant; and respecting him the superintendent says : " He was considered one of the best and steadiest farm-labourers. He had been an inmate of the asylum for about nine years ; was childish, but industrious ; and prior to the act itself, had never evinced any symptoms of violence. He was the last person in the world from whom a criminal outbreak would have been anticipated; it was instantaneous, perfectly unprovoked, and attended with absolutely no signs of anger in the face of the assailant, who, when he had struck two blows, and was prevented from dealing the third, showed no appearance of concern, and wished to resume his previous work." This case shows, as the Commissioners remark, that a chronic and usually tractable lunatic, who is not physically disabled^ may, at any time, become suddenly dangerous. The infrequency with which suicides are recorded speaks well for the careful supervision maintained over the unfortunate inmates of asylums. That this is necessarily of a strict character, is shown by the considerable proportion of the lunatics under treatment who are scheduled as suicidally inclined ; the actual number of successful attempts at self-destruction, howFive of these patients ever, during the year was twenty-one. committed the act while away on leave from the asylum ; and in one case it was committed before admission. They were distributed thus :? In ,, ?
County and Borough Asylums Metropolitan Licensed Houses Provincial Private
Among
?
Single
Patients
M.
F.
Total
7
12
...
1
5 3 1
...
1
1
2 2
10
10
20
1
4
In every case of suicide an inquest was of course held. Certain of the deaths possess elements of interest in connection with them.
LUNACY IN
ENGLAND AND
131
WALES.
Thus, at the Cumberland and Westmoreland Counties Asylum, a man precipitated himself through a dormitory window, from which the sash had been removed by another patient with a view to escaping. A recommendation consequent on this catastrophe, to so fix the window beads as to render their removal by patients impossible, has, to the Commissioners' regret, not been carried out. In another case, a male patient in the Somerset and Bath Asylum escaped from his attendant while proceeding to chapel, and, jumping into the reservoir, was drowned ; and a taste for needles which, after being swallowed, set up enteritis, terminating fatally, was the exciting cause of a third fatality. In almost every separate report on the condition and arrangements of public asylums visited by them, the Com missioners dwell on the insufficient night supervision of epileptics. A large number of inquests were held during the year on such patients as had died, from suffocation by pillows chiefly, during epileptiform attacks; and the conclusion is irresistible that, under an adequate system of watching, the frequency of such occurrences would be materially diminished. In some asylums a form of tell-tale" clock, with electric communications, is used to test the wakefulness of night nurses, who are required to prove themselves alert by periodically touching the instrument at regular intervals. Certain of the cases of death referred to were so unmistakably the consequence of help being withheld from the patients, that it is to be hoped a plan like that recommended will be universally adopted for the better protection of epileptics in the future. The question of restraint is one on which the Commissioners specially report in the case of institutions visited by them. Speaking generally, the employment of actual means of confinement is resorted to with extreme rarity in English asylums, the most common form of punishment of this description being temporary seclusion in a separate room. One instance is recorded of a boy at Earlswood, whose hands it had been found necessary to confine iu locked gloves for three months, on "
account of destructiveness ; but any such form of confinement
all but obsolete. Even with women it has been found to discard these former aids to the maintenance of discipline ; and we cannot but regard the change thus introduced as one of the most beneficial modern improvements. Doubtless a case will now and then be met with for which short of actual restraint in some form or other will
is
now
possible gradually
nothing suffice. now, and
The resources of the asylum in these extreme cases, but
even
by-and-by
we
certainly find our reports
shall
ment will be found in
physician, however,
rarely
that
no
at fault for
are
long;
record of confinek
a
132
LUNACY IN ENGLAND AND WALES.
There is a curious feature about the successive reports of the Commissioners in Lunacy, and one that is worthy of consideration. We refer to the recommendations invariably embodied in them in favour of improvements and extensions of the asylums visited. The question of providing a sufficient accommodation for even pauper lunatics is deserving of attention, so long as this class of the national poor is regarded as a special care of the State ; and yet it is impossible to feel that the necessary importance is attached to suggestions the carrying out of which must entail the outlay of ratepayers' contributions; indeed, it is rather an exception for a county asylum to be described in this report as including all the Commissioners could desire to observe. In place of this, we find regrets that a greater number of attendants are not engaged at certain asylums; that the medical staff is inadequate in others ; that recommendations as to drainage, or ventilation, or additional buildings, have been persistently neglected; and in some cases it is even asserted that buildings in use are quite unfitted for the purpose they are put to serve. During the year dealt with in the report, however, a good deal had been accomplished in the way of providing additional accommodation, as may be judged from the fact that extensions at the Cumberland and Westmoreland, and Lancaster County Asylums to the amount respectively of ?15,490 and ?78,329, were sanctioned by the Home Office. A large number of other asylums are also named as under process of enlargement, or about to be increased in size. It is worthy of notice that as many as four suicides of patients away on trial took place in 1880. In all these cases the patients were discharged from the asylum within six months of their admission, and it may well be asked whether this fact ought not to have an influence in determining in the future how far it may be advisable to permit any patient to leave the institution after so short a residence within it. Reference is made by the Commissioners to the birth of a child in Colney Hatch Asylum in June, 1880, the mother being a female patient who had lived in the asylum continuously since 1876. A strict inquiry was instituted by two members of the Board of Commissioners, who were convinced, after hearing all the evidence obtainable, that the offence had been committed by a plumber's labourer on an occasion when the On this subject the Commissioners ward nurse was asleep. remark, that " the impossibility of adequately punishing those persons employed in asylum?, who have carnal knowledge of female patients, was pointed out by us in our 33rd Report, when we recommended that the provisions against illusing and
LUNACY IN
ENGLAND AND WALES.
133
should be extended, so as to make this a criminal offence." In the 23rd Report (1869), the following passage occurs,
abusing patients at page 53
:?
"
Since the first formation of the older lunatic hospitals, such as Bethlehem, St. Luke's, the Bethel of Norwich, the Iletreat at York, and the York Hospital, a very material change has taken place in the provision made for the insane in this country, and the general erection of asylums in each county for paupers has, to a great extent, changed the character of the hospitals. While at one period the inmates were, with few exceptions, of the pauper class, and, in the absence of other provision for them, proper objects for gratuitous treatment, they are now chiefly of a higher social position, many of whom, though unable to meet the lowest charge at which patients are received into licensed houses, are still in a position to contribute something towards their maintenance. The great want at the present time we believe to be hospitals in which the insane of the middle class, who, though poor, are not reduced to pauperism, may be received at small sums, varying from 5s. to 10s., or 15s. a week, according to circumstances. So inadequate is the charitable aid afforded to this class by all the hospitals at present erected, that the pauper asylum is the only resort for them; and daily increasing numbers are sent there as ordinary paupers, the parishes being partly, or in some instances wholly, reimbursed for their maintenance. " To such an extent is this practised in county asylums, as to be frequently matter of formal complaint by the Visitors, imposing, as it is argued, a burden upon the ratepayers which they are not legally called upon to bear. To the patients
themselves, also, it is no less a hardship and injustice; and painful cases are constantly coming under our observation in which persons of education and social position, clergymen, barristers, medical men, and others, who, from reduced circumstances, are unable to meet the lowest charge at which admission
be obtained into licensed houses, are, as a last resource, driven to associate with paupers." In the present, 35th (1880) Report, the Commissioners
can
say:? " These remarks are now quite as true as they were eleven vears a go, and it is with great regret that we must report that on the whole, the Lunatic Hospitals are not fulfilling the expectations we at one time entertained, that their expansion and increased popularity among well-paying patients would materially add to the amount of charitable assistance available for the more necessitous class to which the above paragraph refers."
134
LUNACY IN
ENGLAND AND WALES.
An important section of the Report is that devoted to a criticism of Mr. Dillwyn's Bill " to amend the laws relating to lunatics." The Commissioners express their emphatic opinion that the provisions of the Bill are calculated to do more injury than good, and particularly in respect to the certification to be required, and to the clause dealing "with the reception of lunatics into asylums. Of the latter clause they write:? " This clause appeared to us to be calculated materially to increase the difficulty of placing a lunatic, not being a pauper, under care and treatment for his disorder, and so to add indefinitely to the aggregate number of chronic lunatics. " Now for forty years and more this Board, and their predecessors, the 4 Metropolitan Commissioners in Lunacy,' have persistently, and we hope, not unsuccessfully, directed their endeavours towards securing the early treatment of mental disease, upon which, according to all experience, recovery so materially depends. It can, therefore, be no matter of surprise to your lordship that we should view with extreme jealousy any proposed alteration of the law which might seem calculated to check such early treatment. " At the same time, we must not affect ignorance of the fact that this and other provisions of the Bill are the outcome of an
feeling, somewhat widely spread, though chiefly among persons who have little special knowledge on the subject, but depend on constantly reiterated assertions that further safeguards are needed for the protection of the liberty of persons alleged to be insane. The existence of such a feeling is, doubtless, to be regretted, but it would be, we venture to think, entirely contrary to sound principle to alter the law in an important particular without evidence of recent abuse." We venture to think that every competent critic of the measure referred to will entirely agree with the view of it held by the Commissioners in Lunacy. Nor are they less earnest in condemnation of the requirements that the certificate on which a lunatic shall be committed must be signed by a medical man holding some sort of public qualification, and strengthened with an order signed by some public functionary. On this the Commissioners observe with justice :? " The proposal, we apprehend, must practically come to this; that in every case of private lunacy, one of the two certificates now required must be given by a medical officer of the Poor Law Union. " With every respect to these gentlemen, it cannot be said either that they are, merely as Poor Law officers, better judges of insanity than their fellow-practitioners, or that the fact of appointment to a poorly paid office by a board of guaruneasy
LUNACY IN ENGLAND AND WALES.
135
dians affords any guarantee for responsibility or respectability exceeding that of other medical men with similar educational qualifications. Here, then, we fail to see any further security for the liberty of the subject, while, on the other hand, it certainly appears a most ill-advised arrangement to refer the question of the insanity of the patient, and the necessity of placing him under care and treatment, to the opinion of a medical man whose official position, such as it is, would not necessarily imply any particular acquaintance with mental disease ; and who, by the very nature of the caee, would often be the youngest practitioner, and the least experienced in the whole neighbour"
hood. "
There are, no doubt, many local practitioners of the highest repute who happen to hold a poor-law appointment. They would continue, as at present, to be called in to most cases of insanity arising in their district, but, supposing them to be persons of skill, experience, and high moral character, they would owe none of these qualifications to the accident that they were also medical officers of the Poor Law Union. In large towns, the patient would usually lose the advantage, which he now often enjoys, of being seen and examined by some one of the chief consulting physicians of the place; for the family attendant who has seen most of the case would, in general, give one certificate, and then the papers would be completed by the 'official' certificate, for the independence or for the scientific value of which the public appointment' would not afford the slightest guarantee." "
'
The final conclusions of the Commissioners are as follows:? " The certain result of this measure would be, we strongly feel, to increase in many cases the reluctance, already very great, to place a relation under early treatment, a matter of the
utmost importance. " The probable result also would be, that to avoid publicity, patients of the upper classes would be clandestinely confined in England, or would be removed illegally to the Continent for treatment, and deprived of all the protection of visitation." There is very much of a, deeply interesting nature in this exhaustive report to which we have not yet referred. Space, however, compels us to close this notice here, and in doing so to tender our hearty thanks to the Commissioners in for the able and valuable report dealing with lunacy in England and Wales in 1880.
beg Lunacy
we
Art. VIII.?LUNACY IN ENGLAND AND WALES. The Thirty fifth Report of the Commissioners in Lunacy deals with the statistics of madmen in England and Wales for the year ending December 31st, 1880. From it we learn that on January 1st last year the total number of persons of unsound mind under care and treatment in asylums, registered hospitals, licensed houses, and as private patients in unlicensed houses, Avas 50,175. Of admissions there were 15,240, viz.: 1,338 males and 1,276 female, as private patients; and 6,017 males, and 6,609 females, as paupers. Of the total admissions, 1,789 were transfers. After deducting these transfers, 1879 exhibits an increase of 160; but compared with 1878, the number is 119 less. The total number of patients were thus classified :? Private patient,
Paupers
.
{?^Ie8 {??e5
.
.
Total
J
;
'
'
3^}
.....
7,741 42,434 50.175
The readmissions in 1880 were 1,855, and compared with the ratios per cent, were, respectively, 12*11 and 12*18. The information as to discharges is interesting in connection
1879,
with the readmission : the total number was 9,317, of whom were males, and 5,041 females; 5,338 of them are entered as recoveries, and of the number 482 were private
4,276
patients.
Deaths reached 4,498
cases
only, however,
were
2,487 men, 2,011 women. In 1,656 post-mortem examinations conducted,
;
satisfactory to find that the Commissioners are alert prime importance of extending this very necessary means of enlarging our knowledge of cerebral pathology. As compared with previous years, moreover, there is a marked falling off in the number of autopsies performed, a fact difficult of explanation save on the ground of declining interest in the scientific study Whether or not this is justly to be attributed to of disease. those who are responsible for the omission, it is, nevertheless, much to be lamented that greater anxiety is not exhibited in this important respect; every medical superintendent should direct his earnest attention to the matter, and strive to supplement existing knowledge by every possible means in his power to r:nd it is
to the
LUNACY IN
129
ENGLAND AND WALES.
employ. From a study of appendix (B) of the Commissioners' Report, it is at once evident what large opportunities of pathological investigations are permitted to pass unutilised, and this too, even in the Metropolitan district, where the least possible excuse can be found for such neglect, since ample assistance is, Thus we find that, at Camberat all times, readily obtainable. well House, with an average resident population of 477, and in which 46 deaths occurred during 1880, there were no more than four autopsies performed. At Grove Hall, on the other hand, with 27 deaths, no less than 23 post mortems were conducted, the average resident lunatic population being 439. At Peckliam House there were 44 deaths, and four autopsies; at Bethnal House, 47 deaths, and only one post-mortem examination. Indeed, of the Metropolitan establishments, Grove Hall appears to be the only institution where any importance is attached to the method of investigation; a fact that cannot be too deeply deplored. Neither is much improvement exhibited when we have regard to extra-Metropolitan Asylums, the great majority of deaths being registered without any indication of their conAt Haydock Lodge, firmation by post mortem-examination. however, where 44 deaths occurred, 26 autopsies were performed; and at Fisherton House, 12, with 31 deaths. The following figures are indeed eminently suggestive in their bearing on this very important question :? Total Deaths, 1880 ,, Autopsies, 1880
Of the In ? ,,
4,498 1,656
there
autopsies performed,
were :
and
Borough Asylums County Registered Hospitals Metropolitan Licensed Houses
1,470
.....
Provincial ? Naval and Military Hospital and India ? Criminal Asylum Among Private Single Patients
...
?
?
Asylum
69 35 50 12
......
20
....
0
1,656
Further comparison of these numbers with the total deaths in each class of institution is still more suggestive. Thus the Metropolitan licensed houses contribute 212 deaths, and 35 autopsies; while Provincial licensed houses, with only 173 deaths, give At the Criminal Asylum, the cause of death 50 post mortems. would seem to have been investigated in every case, the number recorded under each head for this investigation being the same, In no instance was a post mortem made on a " private 20. single patient," of whom 29 died during the year. These figures deserve to be very attentively considered, and the inference they justify to be well kept in view. It is not, PART I.
VOL. VIII.
NEW
SERIES.
K
130
LUNACY IN
ENGLAND
AND
WALES.
too much to assert that the field of observation, neglected in this omission to confirm the causes of death among the insane, is one which, assiduously cultivated, could not fail to yield results of the greatest magnitude and importance; for it is a matter of constant reiteration, that our knowledge of primary lesions can be expected to increase in extent only by aid of psychological studies on all classes of patients. The Commissioners have done well in laying special stress on the paucity of post-mortem records, and, by urging with them the necessity for rigorous prosecution of this branch of objective research, we are maintaining a point we have unceasingly insisted on in the
perhaps,
past.
A curious and instructive case of homicide is reported to have occurred at the Prestwich (near Manchester) Asylum. One patient killed another with a crowbar while at work, in the presence of an attendant; and respecting him the superintendent says : " He was considered one of the best and steadiest farm-labourers. He had been an inmate of the asylum for about nine years ; was childish, but industrious ; and prior to the act itself, had never evinced any symptoms of violence. He was the last person in the world from whom a criminal outbreak would have been anticipated; it was instantaneous, perfectly unprovoked, and attended with absolutely no signs of anger in the face of the assailant, who, when he had struck two blows, and was prevented from dealing the third, showed no appearance of concern, and wished to resume his previous work." This case shows, as the Commissioners remark, that a chronic and usually tractable lunatic, who is not physically disabled^ may, at any time, become suddenly dangerous. The infrequency with which suicides are recorded speaks well for the careful supervision maintained over the unfortunate inmates of asylums. That this is necessarily of a strict character, is shown by the considerable proportion of the lunatics under treatment who are scheduled as suicidally inclined ; the actual number of successful attempts at self-destruction, howFive of these patients ever, during the year was twenty-one. committed the act while away on leave from the asylum ; and in one case it was committed before admission. They were distributed thus :? In ,, ?
County and Borough Asylums Metropolitan Licensed Houses Provincial Private
Among
?
Single
Patients
M.
F.
Total
7
12
...
1
5 3 1
...
1
1
2 2
10
10
20
1
4
In every case of suicide an inquest was of course held. Certain of the deaths possess elements of interest in connection with them.
LUNACY IN
ENGLAND AND
131
WALES.
Thus, at the Cumberland and Westmoreland Counties Asylum, a man precipitated himself through a dormitory window, from which the sash had been removed by another patient with a view to escaping. A recommendation consequent on this catastrophe, to so fix the window beads as to render their removal by patients impossible, has, to the Commissioners' regret, not been carried out. In another case, a male patient in the Somerset and Bath Asylum escaped from his attendant while proceeding to chapel, and, jumping into the reservoir, was drowned ; and a taste for needles which, after being swallowed, set up enteritis, terminating fatally, was the exciting cause of a third fatality. In almost every separate report on the condition and arrangements of public asylums visited by them, the Com missioners dwell on the insufficient night supervision of epileptics. A large number of inquests were held during the year on such patients as had died, from suffocation by pillows chiefly, during epileptiform attacks; and the conclusion is irresistible that, under an adequate system of watching, the frequency of such occurrences would be materially diminished. In some asylums a form of tell-tale" clock, with electric communications, is used to test the wakefulness of night nurses, who are required to prove themselves alert by periodically touching the instrument at regular intervals. Certain of the cases of death referred to were so unmistakably the consequence of help being withheld from the patients, that it is to be hoped a plan like that recommended will be universally adopted for the better protection of epileptics in the future. The question of restraint is one on which the Commissioners specially report in the case of institutions visited by them. Speaking generally, the employment of actual means of confinement is resorted to with extreme rarity in English asylums, the most common form of punishment of this description being temporary seclusion in a separate room. One instance is recorded of a boy at Earlswood, whose hands it had been found necessary to confine iu locked gloves for three months, on "
account of destructiveness ; but any such form of confinement
all but obsolete. Even with women it has been found to discard these former aids to the maintenance of discipline ; and we cannot but regard the change thus introduced as one of the most beneficial modern improvements. Doubtless a case will now and then be met with for which short of actual restraint in some form or other will
is
now
possible gradually
nothing suffice. now, and
The resources of the asylum in these extreme cases, but
even
by-and-by
we
certainly find our reports
shall
ment will be found in
physician, however,
rarely
that
no
at fault for
are
long;
record of confinek
a
132
LUNACY IN ENGLAND AND WALES.
There is a curious feature about the successive reports of the Commissioners in Lunacy, and one that is worthy of consideration. We refer to the recommendations invariably embodied in them in favour of improvements and extensions of the asylums visited. The question of providing a sufficient accommodation for even pauper lunatics is deserving of attention, so long as this class of the national poor is regarded as a special care of the State ; and yet it is impossible to feel that the necessary importance is attached to suggestions the carrying out of which must entail the outlay of ratepayers' contributions; indeed, it is rather an exception for a county asylum to be described in this report as including all the Commissioners could desire to observe. In place of this, we find regrets that a greater number of attendants are not engaged at certain asylums; that the medical staff is inadequate in others ; that recommendations as to drainage, or ventilation, or additional buildings, have been persistently neglected; and in some cases it is even asserted that buildings in use are quite unfitted for the purpose they are put to serve. During the year dealt with in the report, however, a good deal had been accomplished in the way of providing additional accommodation, as may be judged from the fact that extensions at the Cumberland and Westmoreland, and Lancaster County Asylums to the amount respectively of ?15,490 and ?78,329, were sanctioned by the Home Office. A large number of other asylums are also named as under process of enlargement, or about to be increased in size. It is worthy of notice that as many as four suicides of patients away on trial took place in 1880. In all these cases the patients were discharged from the asylum within six months of their admission, and it may well be asked whether this fact ought not to have an influence in determining in the future how far it may be advisable to permit any patient to leave the institution after so short a residence within it. Reference is made by the Commissioners to the birth of a child in Colney Hatch Asylum in June, 1880, the mother being a female patient who had lived in the asylum continuously since 1876. A strict inquiry was instituted by two members of the Board of Commissioners, who were convinced, after hearing all the evidence obtainable, that the offence had been committed by a plumber's labourer on an occasion when the On this subject the Commissioners ward nurse was asleep. remark, that " the impossibility of adequately punishing those persons employed in asylum?, who have carnal knowledge of female patients, was pointed out by us in our 33rd Report, when we recommended that the provisions against illusing and
LUNACY IN
ENGLAND AND WALES.
133
should be extended, so as to make this a criminal offence." In the 23rd Report (1869), the following passage occurs,
abusing patients at page 53
:?
"
Since the first formation of the older lunatic hospitals, such as Bethlehem, St. Luke's, the Bethel of Norwich, the Iletreat at York, and the York Hospital, a very material change has taken place in the provision made for the insane in this country, and the general erection of asylums in each county for paupers has, to a great extent, changed the character of the hospitals. While at one period the inmates were, with few exceptions, of the pauper class, and, in the absence of other provision for them, proper objects for gratuitous treatment, they are now chiefly of a higher social position, many of whom, though unable to meet the lowest charge at which patients are received into licensed houses, are still in a position to contribute something towards their maintenance. The great want at the present time we believe to be hospitals in which the insane of the middle class, who, though poor, are not reduced to pauperism, may be received at small sums, varying from 5s. to 10s., or 15s. a week, according to circumstances. So inadequate is the charitable aid afforded to this class by all the hospitals at present erected, that the pauper asylum is the only resort for them; and daily increasing numbers are sent there as ordinary paupers, the parishes being partly, or in some instances wholly, reimbursed for their maintenance. " To such an extent is this practised in county asylums, as to be frequently matter of formal complaint by the Visitors, imposing, as it is argued, a burden upon the ratepayers which they are not legally called upon to bear. To the patients
themselves, also, it is no less a hardship and injustice; and painful cases are constantly coming under our observation in which persons of education and social position, clergymen, barristers, medical men, and others, who, from reduced circumstances, are unable to meet the lowest charge at which admission
be obtained into licensed houses, are, as a last resource, driven to associate with paupers." In the present, 35th (1880) Report, the Commissioners
can
say:? " These remarks are now quite as true as they were eleven vears a go, and it is with great regret that we must report that on the whole, the Lunatic Hospitals are not fulfilling the expectations we at one time entertained, that their expansion and increased popularity among well-paying patients would materially add to the amount of charitable assistance available for the more necessitous class to which the above paragraph refers."
134
LUNACY IN
ENGLAND AND WALES.
An important section of the Report is that devoted to a criticism of Mr. Dillwyn's Bill " to amend the laws relating to lunatics." The Commissioners express their emphatic opinion that the provisions of the Bill are calculated to do more injury than good, and particularly in respect to the certification to be required, and to the clause dealing "with the reception of lunatics into asylums. Of the latter clause they write:? " This clause appeared to us to be calculated materially to increase the difficulty of placing a lunatic, not being a pauper, under care and treatment for his disorder, and so to add indefinitely to the aggregate number of chronic lunatics. " Now for forty years and more this Board, and their predecessors, the 4 Metropolitan Commissioners in Lunacy,' have persistently, and we hope, not unsuccessfully, directed their endeavours towards securing the early treatment of mental disease, upon which, according to all experience, recovery so materially depends. It can, therefore, be no matter of surprise to your lordship that we should view with extreme jealousy any proposed alteration of the law which might seem calculated to check such early treatment. " At the same time, we must not affect ignorance of the fact that this and other provisions of the Bill are the outcome of an
feeling, somewhat widely spread, though chiefly among persons who have little special knowledge on the subject, but depend on constantly reiterated assertions that further safeguards are needed for the protection of the liberty of persons alleged to be insane. The existence of such a feeling is, doubtless, to be regretted, but it would be, we venture to think, entirely contrary to sound principle to alter the law in an important particular without evidence of recent abuse." We venture to think that every competent critic of the measure referred to will entirely agree with the view of it held by the Commissioners in Lunacy. Nor are they less earnest in condemnation of the requirements that the certificate on which a lunatic shall be committed must be signed by a medical man holding some sort of public qualification, and strengthened with an order signed by some public functionary. On this the Commissioners observe with justice :? " The proposal, we apprehend, must practically come to this; that in every case of private lunacy, one of the two certificates now required must be given by a medical officer of the Poor Law Union. " With every respect to these gentlemen, it cannot be said either that they are, merely as Poor Law officers, better judges of insanity than their fellow-practitioners, or that the fact of appointment to a poorly paid office by a board of guaruneasy
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dians affords any guarantee for responsibility or respectability exceeding that of other medical men with similar educational qualifications. Here, then, we fail to see any further security for the liberty of the subject, while, on the other hand, it certainly appears a most ill-advised arrangement to refer the question of the insanity of the patient, and the necessity of placing him under care and treatment, to the opinion of a medical man whose official position, such as it is, would not necessarily imply any particular acquaintance with mental disease ; and who, by the very nature of the caee, would often be the youngest practitioner, and the least experienced in the whole neighbour"
hood. "
There are, no doubt, many local practitioners of the highest repute who happen to hold a poor-law appointment. They would continue, as at present, to be called in to most cases of insanity arising in their district, but, supposing them to be persons of skill, experience, and high moral character, they would owe none of these qualifications to the accident that they were also medical officers of the Poor Law Union. In large towns, the patient would usually lose the advantage, which he now often enjoys, of being seen and examined by some one of the chief consulting physicians of the place; for the family attendant who has seen most of the case would, in general, give one certificate, and then the papers would be completed by the 'official' certificate, for the independence or for the scientific value of which the public appointment' would not afford the slightest guarantee." "
'
The final conclusions of the Commissioners are as follows:? " The certain result of this measure would be, we strongly feel, to increase in many cases the reluctance, already very great, to place a relation under early treatment, a matter of the
utmost importance. " The probable result also would be, that to avoid publicity, patients of the upper classes would be clandestinely confined in England, or would be removed illegally to the Continent for treatment, and deprived of all the protection of visitation." There is very much of a, deeply interesting nature in this exhaustive report to which we have not yet referred. Space, however, compels us to close this notice here, and in doing so to tender our hearty thanks to the Commissioners in for the able and valuable report dealing with lunacy in England and Wales in 1880.
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