284
Art. VI.?LUNACY IN ENGLAND. The twenty-second Report of the Commissioners in Lunacy lias just appeared. From a perusal of it we are made aware of the fact that there are 68,538 persons of unsound mind in England and Wales on January 1, 1878. The following summary shows the classification and distribution of the registered number of patients :? Total
Pauper Where maintained JI.
In
county and borough asylums
In
registered hospitals
208
In naval and military hospitals and Royal India Asylum In Criminal Lunatic
(Broadmoor)
Asylum
.
In workhouses: Ordinary workouses Metropolitan district asylun Private
255
463
M.
10,908 20,392 37,300 17,116 20,647 37,763
1,280 2,GS0
53
45
98
1,453
1,325
2,778
1,064
815 1,879 81!) 1,593
50 251
131 289
190 540
1,123 1,025
946
1,108
2,069 2,133
3G0
315
15
3G0
243
381
101
482
M
Provincial
T
1,400
In licensed houses:
Metropolitan.
F.
5,074 1,952
G,785 11,859 2,454 4,406
5,074 1,952
6,785 11,859 2,451 4,406 286
474
2,367
3,847
2,3G7
3 847
6,214
single patients
Out-door paupers
6,214
4,172 3,520 ',692 26,85'J 33,994 60,846
37,514
There are 265 lunatics who have been found so by inquisition residing in charge of committees who are not included in this number. There is an increase of 1,902 on those returned on January 1, 1877. The average number of resident patients contained in
borough asylums throughout the year was 36,668 ; during the year were 30*07 per cent, below the average of previous years ; but this is accounted for by the large proportion of chronic cases admitted by transfer from one asylum to the other and included in the total admissions.
county
and
the recoveries
If
we exclude these transfers, the recoveries would bear to the admissions the ratio of 37*29 per cent. The total number under detention on January 1 as private
lunacy in England.
285
and single patients was 46,059 in licensed houses and under single care. Out of this number 17,459 were male paupers, and 20,908 were female paupers. With regard to the supervision of epileptic cases the Commissioners say:? So far back as 1859, in our thirteenth Report, and again in 1872, in our twenty-sixth Report, we adverted to the very inadequate provision made in many of the large county asylums for the nursing and care of the patients during the night. At one time it was the practice in many asylums to employ the day attendants in rotation on night duty; this very objectionable arrangement is, however, now generally given up, and the system of employing special attendants for night duty alone is now the general rule in public asylums. Until recently, however, in many large asylums, the care of the patients during the night has been left to one attendant in each division, who was required to visit the different wards every two hours. Visits at such intervals are so obviously insufficient to afford proper protection to even the ordinary inmates, that we have taken every opportunity of pointing out to the Visitors the great importance of increasing the staff of night attendants generally, and we are glad to report that most asylums are now in a much more satisfactory state in this respect. The frequent deaths which at one time took place amongst the epileptics from suffocation in fits during the night, and also the occurrence of suicides?due, in many instances, to the want of careful watching?convinced us some years since of the futility of entrusting patients of the above classes to the irregular visits of the ordinary night attendants, and that the only way by which accidents could be guarded against, and fatal results in the majority of cases diminished, is by placing these patients under the care, during the night, of special attendants, with specific rules for their guidance, and in wards so arranged as to admit of the patients, whether in dormitories or single rooms, being under direct supervision. We have again the satisfaction of stating that the result in those asylums in which the arrangements have been fully Not only have carried out has been most encouraging, the accidental deaths in these classes of patients been very much reduced in number, but the importance of the system has been fully admitted, not only the medical officers of the asylums, but especially by the attendants, who are relieved of much anxiety during the night, and in many instances have expressed to us their sense of the value of the special provision for night watching. At present the arrangements for this purpose are more or less complete in 25 of the county and borough asylums. In "
"
280
LUNACY IN
ENGLAND.
they have been partially carried out, hut are imperfect in important particulars, chiefly in consequence of structural difficulties in the original buildings. In 6 asylums special wards are in progress, and in 12 no provision has as yet been made. Not only as respects the epileptic and 'suicidal patients do we hope that ere long we shall be able to report that proper arrangements, both structural and otherwise, have been made in all asylums in England and Wales, but also that the night nursing and care of the ordinary sick inmates is placed upon a more satisfactory footing than at present. In many asylums the sick and dying patients are still under the charge of the ordinary night attendants, and are consequently left for long periods without receiving that constant attention which their cases require. Special night attendants should, we think, be or sick wards of all asylums. in infirmaries the provided The Commissioners publish a table, being a return made to the Office from the various asylums, hospitals, and licensed houses The result is thus of the inmates who are regarded as suicidal. summarised :?County and borough asylums, 4,908, out of a total number of 35,863 ; hospitals, 632, out of a total number of 3,613; metropolitan licensed houses, 344, out of 2,735; pro16
"
"
vincial houses, 212, out of a number of 2,070. From this it appears that out of the total number of inmates in these institutions 13-76 per cent, were regarded as suicidally inclined. The actual number of deaths from suicide during the year was 18; this is somewhat less than 3 per 1,000 on the entire number of suicidal patients." In our present issue there are two papers on Suicide; and we think it would be interesting to our readers to publish in extenso the cases that have occurred in the county asylums during the past year, as given in the Keport:? " At the Cornwall Asylum a death by suicide occurred in the following circumstances:?A private patient, J. Or., was admitted on November 1876 in a state of melancholia. Prior to admission he had made an attempt on his own life by strangling, had refused food, and had also endeavoured to strangle an attendant. " Being narrowly watched and carefully fed, his bodily and mental condition had so far improved that he was placed in a single room, though still watched. Up to the lltli of January, 1877, he had made no suicidal attempt. On the afternoon of that day he contrived to secrete a knife from the table used by the attendants in the billiard-room. He retired to rest, and was visited hourly during the night and morning of the lltli and 12th of January by the night attendant. Soon after five in the morning this officer found the patient lying dead at the foot of liis bed witli his throat cut.
LUNACY IN
ENGLAND.
287
"
Tlie results of the evidence at the coroner's inquest, and of subsequent inquiries?first, as to the evident negligence through which J. Gr. had been able to obtain possession of the knife with which he killed himself; and, secondly, as to the apparent laxity of supervision, owing to which the fact of his having the knife in his bedroom had not been found out?were as follows:? " As to the first point, it appeared that the attendant, whose it duty was to count and put by the knives after the meals in the billiard-room, was at the time invalided, and his place supplied by any other attendant who could be spared, and that the attendant must have tailed properly to supervise the our
charge
substitute. " The medical superintendent, as regards the second point, stated that when J. G. was admitted, although in the certificates his suicidal tendencies were only mentioned by one of the medical men certifying, he was for a time under constant supervision, and not allowed access to his room at all, except in the presence of his attendant; latterly he had seemed better, and the constant supervision insisted on at first was relaxed, as he had shown no suicidal tendencies while in the asylum, and the evidence on this point in the certificate was certainly not
strong.
" Since the death Mr. Adams learned, for the first time, that the patient had, before admission, actually made more Had these been made known to than one suicidal attempt. him before he would have taken a more serious view of the relax the strict case, and would consequently have hesitated to first. at taken precautions " At the Hants Asylum two deaths by suicide have occurred. " The first case was that of a young man, J. S., who had been an inmate of the asylum since February 187G. He was known to be labouring under strongly-marked suicidal tendencies. Written notice of this was given to the attendants in the ward where he first was placed. " At the time of his death he was in another ward, where The full complement of there were upwards of 40 patients. attendants to this ward was five, but at 11.10 in the morning of Sunday, the, 28th of January, one was absent on leave; two had accompanied. 12 of the patients to chapel; the fourth had been called away (it was stated in somewhat exceptional circumstances) for special duties elsewhere, so that one attendant alone remained in charge of 32 patients, including This man, soon after 11 oclock, unobserved by the single J. S. attendant, gained access to a sink-room, where, having first barricaded the door, he proceeded to hang himself by his
LUNACY IN ENGLAND.
288
The alarm was shortly after given by another patient, but before assistance could be procured and access through the window of the room could be obtained, by means of a ladder, J. S. was dead. "No evidence was forthcoming that the fact of the strongly suicidal propensities of this patient had been formally communicated to the attendants in this ward, although, indeed, we were assured by the medical superintendent that it was well known to all of them. In these circumstances it was impossible to fix the blame on the attendant left in charge. " In consequence of a recommendation from the Board a better system, that of filling up on admission, and causing to be passed with the patient from ward to ward, a parchment ticket indicating his suicidal or dangerous character, has been introduced into the asylum. We also advised a modification of the arrangements which had allowed so large a number of patients to be left temporarily in charge of a single attendant. " The second case of suicide at this asylum was of a male patient, admitted in January 1877, and then known to be suicidal. In May he had secreted a razor and cut his throat, but not so as to produce a fatal injury. From that time he was never left unwatclied, two persons, former attendants at the asylum, being specially engaged to watch him, one by other by day. In addition to this, an attendant from the staff was always told off night and day to assist in the supervision. " This arrangement was continued until the wound had entirely healed, and it was then thought sufficient to retain the services of the two special attendants, one of whom, Gr. C., had the night watch, while John Fleet was on duty by day. " On the 12th of July, Fleet took the patient into the male infirmary airing-ground. Here the patient asked leave to go to the closet, selecting a moment when the attendant, according to his own statement, was engaged in the unseasonable occupation of paring his toenails, and hence failed to notice which
braces.
night,"the
patient went. Fleet, in a minute or two, missing his patient, put on his stocking and boot and proceeded to the closet in search of him. The patient, however, had escaped through a door leading to a garden through which he and Fleet earlier in the day had passed, and'which he had contrived to stop from shutting perfectly. Arrived here, he easily got over a wall, and after traversing thirty yards of ground found himself on the railway. A train soon came in sight, and the patient was seen by the engineer deliberately to throw himself over the rails in front of it. The train passed over him, and he was killed.
way the "
289
LUNACY IN ENGLAND. "
The Committee of Visitors thought it their duty to mark seuse of Fleet's carelessness by proceeding summarily against him under section 123 of the Act 16 & 17 Vict, c. 97. He was convicted by the magistrates for wilful neglect of his patient; but, in consideration of the high character he had borne while in the asylum service, a penalty of ?2 only their
was
imposed.
"
At the Barming Heath Asylum a female patient admitted 25th April was found dead. She was stated on her admission papers to be suicidally disposed, but it was not till after her death that the medical superintendent was made aware that she had actually attempted self-destruction. Hence she was not, on admission, placed in a special dormitory for suicidal patients, of which there are now two in this asylum, but it was thought sufficient to give the night attendants instructions to see her frequently. She was placed in a single room to sleep, on account of restlessness, and on the night of the 9th of May was visited there (according to the nurses' statement) every An hour afterwards half-hour up to 5.15 in the morning. the day nurse coming on duty found her dead, suspended by her night-dress to a small hook used to fasten the window of the single room. She was quite dead. " It was a matter of great regret that the full history had not been disclosed to the medical superintendent; but independently of this we could not avoid expressing doubt as to the prudence of placing the patient in a single room without constant supervision, and where the fastening of the window afforded the means of suicide. " A female patient at thePrestwich Asylum contrived on the morning of Sunday, October the 21st, to slip uuperceived out of the ward in which she was placed, during the passage out of the ward of a number of her fellow-patients who were proceeding to divine service. This was a little before 10 a.m. She was almost immediately missed, but in some way, which a strict investigation has failed to discover, she had escaped from the asylum premises. " Her home was in Prestwicli, and she consequently was acquainted with the locality. Between 10 and 11 she was found in a pit of water, close to a footpath crossing a field near the asylum. Assistance was procured, and she was taken out of the water, but was dead. " This woman was admitted on the 19th of September, 1877; and being stated to be suicidal, proper notice was given to the attendants in charge of her. Up to the time of her death she had made no attempt on her own life. The officers of the asylum were not informed, until the fact came out at the on
PART II.
VOL. IV.
NEW SERIES.
X
LUNACY IN ENGLAND.
290
inquest, one
the
that she had
shortly
before
admission,
on
more
than
occasion, risen from bed at night and endeavoured to leave house, for the purpose of drowning herself. Neither the
jury, nor the medical superintendent considered the attendants to blame for her escape. " On the 6th of April, while in an airing court of this asylum, a male patient, named H.'E., was struck on the head with a chamber utensil by another patient, and received five severe cuts. This utensil had, with others, been placed in a yard separated from the airing court by a high paling, and it was lifted over the paling by H. E., who was able to do so by his hand inserting (said to have been a very small one) between the rails. It was snatched from him by the other patient, who with it then made the assault on H. E. The wounds were at once dressed, and H. E. was placed in bed; and although the cuts healed quickly the general condition of the patient rapidly deteriorated, and symptoms of inflammation of the lungs developed themselves. No other injuries than those on the head were for some time observed, but ultimately Mr. Clunn, the assistant medical officer, discovered indications of The patient bethe fracture of three ribs on the right side. A post-mortem 13tli of May. came worse, and died on the examination disclosed inflammation of the lungs and pleura, with considerable effusion into the cavity of the chest, resulting from the fracture of three ribs on the right side. It was found The patient was a that the ribs were exceedingly brittle. was held in the case, general paralytic. A coroner's inquest and the verdict of the jury was that ' the deceased died from pleuro-pneumonia induced by the fracture of three of his ribs, but when, how, or by what means those injuries were caused there is no evidence to show.' It appeared that there was an attendant with about 15 patients in the airing court at the time of the assault, which, however, was not witnessed by the attendant. It did not appear to us that blame attached to any of the staff of the asylum in connection with this case. " A female patient of the Somerset and Bath Asylum, aged G7, admitted in November 1872, committed suicide on the 2fith of August, 1877, by hanging herself to an iron fixture of the window of the single room, where, on account of her noisy and restless habits at night, she had been placed to sleep. Neither upon her admission nor subsequently was she Her health stated or considered to be suicidally disposed. had been failing, and she suffered from disease of the heart. The night nurse had seen her alive at 4 a.m., but on unlocking the door of the bedroom, at about a quarter to six, found her as above described and dead. No blame appeared to attach coroner,
LUNACY IN ENGLAND. to the
but orders were at of the single rooms by
attendants,
the windows
shutters.
291
given to protect properly constructed
once
"The first case of suicide (on the male side) since the of the Sussex Asylum, at Hayward's Heath, in 1859, occurred there on the 9th April, when a male patient, T. C., who was admitted on January the 1st, 187G, was found hanging by the neck to a small tree or shrub in one of the airing
opening
courts.
" Although not marked as suicidal on his admission papers, J. C. had soon after shown some tendency in that direction, and in consequence had for some time been watched by night as well as by day. Towards the end of the year he had become more lost, and he scarcely possessed, it was thought, sufficient mind to plan or carry out any suicidal attempt. On the day of his death, however, being in the airing court with 148 other patients, and under the supervision of five attendants, he contrived to escape notice, and gaining the shelter of the shrubbery, hung himself there. He was missed soon after, but when found was dead. " The coroner's jury attached no blame to the attendants, but recommended that the shrubs should be thinned somewhat; a recommendation which has since been attended to. " A death by suicide occurred at the Worcester Asylum in March 1877. A male patient, who had been an inmate of the institution for nearly sixteen years, during no part ot which time he was thought to be suicidally disposed, was missed one afternoon, and was thought to have repeated an attempt Several attendants at escape which he had made in 1873. were at once ordered in pursuit of him, but very shortly after he was accidentally discovered hanging by the neck to an exposed gas-pipe in a beer-cellar seldom used, but to which he had obtained access from the place where he had been working, as his custom was, in charge of the engineer, lie was a trusted patient, and had been allowed considerable liberty. When found he was not quite dead, but the efforts of the medical officers to restore animation, though persisted in for nearly two hours, were ineffectual. " This was not a case in which any blame could, in our opinion, be fairly laid to the charge of anyone connected with the administration of the asylum. " A female patient of the Bethlehem Royal Hospital committed suicide in the following circumstances:? " She was admitted in March 1876 suffering from melancholia, and had shortly before made an attempt to cut her throat. She gradually improved; and having for the three x
2
LUNACY IN
292
ENGLAND.
previous to her death, in January 1877, appeared conwas placed in the convalescent ward. Here she assisted in the household work, and was considered by the nurses quite trustworthy. On the afternoon of Sunday, January 14, she was left in charge of an experienced attendant, with other patients who had not gone to chapel. This attendant noticed her at twenty minutes past three, but at four o'clock she was missing, and on a search being made she was found in a bath-room attached to the ward suspended to the window by a cord. The medical superintendent was immediately summoned, but he found life months
valescent, "
to be extinct. "
The door of the bath-room, it was positively stated by the attendant, had been locked, according to rule, at nine in the morning, and at three the attendant passed the door, and noticed that it was closed. Somewhat imprudently, as we thought, even with allowance for the greatly improved state of the patient, the nurse had sometimes lent her a key, and on the day of the death the key had been entrusted to her for a few minutes that she might fetch some beer. Probably she had availed herself of this opportunity of unlocking the bath-room door, in order to obtain access to the room later in the day. " The manner in which she had obtained the cord was not clearly ascertained. Considerable liberty had been allowed her, and it was thought possible that she might have got possesAfter a lengthened inquiry the sion of it outside the ward. coroner's jury came to no conclusion attributing blame to the officials of the hospital. " A female patient, Miss H., a lady of about 50 years of age, admitted into the Northampton Hospital in January 1877, with distinct suicidal delusions, which had driven her to attempt her own life, both by an overdose of a sedative and by strangling, died on the 26th of August of exhaustion from burns, caused by setting fire to her clothes on the 17th of that month. "
months of constant supervision in a special so much better and more cheerful, that it was considered proper to remove her to the first division of the first class. Strict injunctions were given to the attendants there that she was never to be left alone. When the other ladies were not in the drawing-room, where she usually sat, a nurse was to be in the room, and at all times a nurse was to be close at hand. There were four nurses to 16 patients, and the deceased was the only one requiring special cnre. On the evening of August the 17th the inmates of the ward were returning from
ward,
After
some
she had
appeared
LUNACY IN ENGLAND.
203
the dining-room to the drawing-room. One of the nurses seated in the gallery close to the door of the ante-room leading to the drawing-room saw Miss H. pass into the ante-room, and then, against orders, left her post to light some gas. In two or three minutes she heard screams, and on returning to the anteroom found Miss H. with her clothes on fire. She threw her down, enveloped her in a rug, and procured assistance. It appeared that Miss H., availing herself of the momentary negligence of the nurse, had turned into a small room opening into the She lit a twisted paper ante-room. Here gas was burning. which she had prepared, and so set light to her clothes, and, as she admitted, with the intention of suicide. The burns did not at first appear serious, but, as before stated, the patient died on August the 26th. " The nurse was severely reprimanded, and we did not press for any further punishment. " A suicide occurred at the York Lunatic Hospital in very peculiar circumstances. " A. A., a female private patient, aged G2, was admitted to the hospital in February 1875, suffering from mania, and with an intracapsular fracture of the left femur, owing to a then recent accident. " This injury had never been thoroughly repaired, and at the time of her death, in June last, A. A. was supposed to be unable to walk alone or even get out of bed by herself. " Previously to admission she was stated to have made two or more determined attempts at self-destruction by strangling. She was very noisy and restless, especially at night, and on this account had been placed in a single room, care being taken every evening to remove all articles of a dangerous character. " For about twelve months prior to her decease she had occupied the same room, and under the same conditions. In consequence of a complaint made to her friends of the darkness of her room she had been allowed for some time to have the shutter open, it being understood, as already stated, by all about her that she was unable to leave her bed. " Nevertheless, on the morning of June the 29tli, having be?en seen alive and spoken to by one of the night attendants at a before quarter six, she left her bed, and contriving to pass the body of her night-dress over the hinge of the open shutter, had strangled herself in a loop formed by the sleeve. A little before seven she was found dead by the day under-nurse, who came in to bring her clothes. " During her residence in the asylum she had never been known to the medical superintendent to have walked a yard without assistance, and was thought to be quite safe when in bed, especially when she was visited hourly at night.
294 "
LUNACY IN ENGLAND.
We concurred with the coroner's jury in
to anyone entrusted with her
attributing no blame
care.
" On December the 15th, 1876, a patient named H. 0. comThe circummitted suicide at the Wonford House, Exeter. stances were not fully before our Board until their first meeting in January 1877, and in consequence of this the occurrence was not noticed in our 31st Report. " The patient was described as suicidal on his admission in November 1876, and it appeared from the certificates that he had threatened to destro}7 himself, justifying his intention by insane reasoning, but he bad not made any actual attempt. " The parchment ticket used in the Hospital was filled up with a statement that he was ' suicidal,' but ' not actively so,' and by some mismanagement this ticket was not shown to the attendant who was in charge of the patient on the night of his death. " Early in the morning in question H. 0. was allowed to He was not very leave the dormitory for a natural purpose. and the a few minutes after watched attendant, by strictly leaving the dormitory he made his way to the end of the corridor The attendant and jumped through the window at the end. followed him down the corridor and called him back, thinking he was mistaking the way, and on finding he did not turn back ran after him, but was too late to prevent his leap, the injuries from which proved fatal. " It was a matter of great regret that, considering the facts disclosed in the certificates, the ticket had not more strongly indicated the patient's tendency to suicide, and that it had not been duly shown to the attendant in charge. "In May 1875 a young man, A. H. F., was admitted as a private patient to this hospital, labouring under melancholia, and with delusions that he had committed some great crime and was being pursued in consequence. " Though not noted on his admission papers to be suicidal, he showed at first a decided tendency in this direction. " On June the 26th, through a want of proper supervision, he made his escape, but was brought back to the hospital early the next morning. " On the 31st of July he again escaped from the airing ground, with the assistance of another patient, the attendant in charge having left him, as he stated, for about a minute. He was not retaken for thirteen days, when he was found by the police wandering at a considerable distance from the hospital. It did not appear that during his absence he had made any attempt on his life. " On his return the medical superintendent thought it ad-
LUNACY
IN
ENGLAND.
295
visable
to change his associations, and placed him in ' the second gallery.' Here he gave no trouble, occupied himself with drawing and in other ways, and, in consequence of his apparent improvement, was transferred at the end of a week to 'the first ffallerv,' where he continued to occupv himself
rationally. "
About this time his mother, in business in Exeter, began discharge on trial. Dr. Lyle thought this preHe allowed him to and not recommend it. would mature, pay several visits for the day to his mother's house, being taken thither and brought back to the hospital under proper to press for his
care.
On the 8th of September, the mother continuing to press trial, leave of absence was given by the Committee of hospital, she having first written a letter to the medical superintendent accepting the responsibility of his charge. Mrs. F. was distinctly cautioned as to her son's suicidal tendency, and of the consequent necessity for constant watch"
for the
a
fulness.
" The next to his mother's
there.
day
he
was
found dead in
a
house, having hung himself by
cellar belonging cord to a beam
a
" After full consideration we were unable to acquit the medical superintendent of want of caution and judgment in yielding to the pressure of the patient's friends and consenting to the leave of absence. We also intimated our opinion that the repeated success of the attempts at escape was not creditable to the management of the institution." Increased accommodation is required for asylums in
Glamorgan, Lancashire, Norfolk, and Salop. There are 16 registered hospitals under
the jurisdiction of the 1st of January, 1878, 2,778 patients, being an increase of 40 on the numbers The admissions were 898, and the of the previous year. discharges 062, of whom 188 had recovered; and the deaths were registered as 196. On the 1st of January, 1878, there were 38 metropolitan licensed houses; the total number of patients being 2,148 males, and 2,054 females. Of this number 310 were males, and 420 females of the pauper class. The inmates in workhouses considered to be of unsound mind amounted to 16,038 on the 1st of January, 1878. The Commissioners visited 208 of these institutions during the year 1877. The condition of the inmates is reported as favourThe Report contains an account of an able on the whole. illegal reception of a patient into Elm House, Cliiswick, on an the Commissioners, which contained,
on
LUNACY IN ENGLAND.
296
order signed by a person who had not seen the patient within the time required by the Act. There is also an account of the illegal detention of an insane lady in Manor House, Northfleet, Kent, and at a rectoryhouse in Dorsetshire. The appended letter appears in Appendix Q, and is of interest, showing the various inquiries made by the Commissioners when visiting asylums. The Report contains most valuable statistical records of the various asylums in England and Wales, with a detailed account of the visitation of .the county asylums, hospitals, and other public institutions, including the Criminal Lunatic Ptospital, at Broadmoor, the excellent management and arrangement of which we had an opportunity of visiting during the past year, and which reflects great credit upon Dr. Orange and his assistants. The Report before us is a faithful record of all that relates to lunacy, and of itself bears evidence of the zeal and earnestness with which the Commissioners perform their arduous but most responsible duties :? "
Office
of
Commissioners in Lunacy, 19 Whitehall Place, S.W.: October 1877.
"
Sin,?The Commissioners in Lunacy having received the statutory notice of your appointment at the last Quarter Ses-
clerk to the Visitors of licensed houses in the county for the ensuing year, direct me to transmit to you the enclosed copies of a summary of the principal heads of inquiry which the Lunacy Acts prescribe on visitation of these establishments. " A similar summary has long been in use by the Commissioners themselves, and they think that the Visitors, especially such gentlemen as may have been now appointed for the first time, may find the enclosed card of service in directing (though not in limiting) those inquiries which experience has found very valuable in the work of improving the condition and sions
as
of
treatment of insane patients. " I am to ask you to take an early opportunity of placing one of the cards in the hands of each of your Visitors. A further supply can, if required, be had on application to me. "
"
I am,
" "
To
."
Sir,
Your obedient servant, Charles Srencee Perceval, "
Secretary.
297
LUNACY IN ENGLAND.
"Visitation "
(Acts 8
& 9 Vict.
c.
100,
of
s.
Licensed Houses.
62; and
25 & 26 Vict.
c.
"
111, s. 29.) (medical
Visits to be made by two at least of Visitors Visitor to be one), four times at least in every year. " Two additional visits every year by any one or tlie Visitors. "
Chief
Statutory c.
"
Heads of
100,
ss.
Inquiry
at Visits.
62, 64, 65, 50, 66.)
1. Divine Service: When
performed;
(8
more
of
& 9. Vict,
to what number of
patients. " " " " "
2. Occupations and amusements. 3. Restraint and seclusion : Amount of, and reasons for. 4. Classification of patients. 5. Pauper patients : Condition on admission ; dietary.
6. List of patients. 7. Orders and certificates of patients admitted since last visit to be inspected ; license to be examined and signed at first visit after grant or renewal. " 8. Letters of private patients endorsed under Section 40, Acts 25 & 26 Vict. c. 111. " 9. Books to be inspected and signed, viz.:? Book of admissions. Register of discharges and deaths. Medical visitation book. Case book. " 10. Entries to be made? "In Visitors' book, as to condition of house and patients: Number under restraint; irregularities in orders and certificates: whether previous suggestions by Commissioners or Visitors have been attended to or not; results of statutory and other inquiries. " [The proportion of patients to attendants, their capacity and conduct, though not a statutory subject of inquiry, is very important.] " In Patients' book : Observations as to state of mind or body of any patient." "
Art. VI.?LUNACY IN ENGLAND. The twenty-second Report of the Commissioners in Lunacy lias just appeared. From a perusal of it we are made aware of the fact that there are 68,538 persons of unsound mind in England and Wales on January 1, 1878. The following summary shows the classification and distribution of the registered number of patients :? Total
Pauper Where maintained JI.
In
county and borough asylums
In
registered hospitals
208
In naval and military hospitals and Royal India Asylum In Criminal Lunatic
(Broadmoor)
Asylum
.
In workhouses: Ordinary workouses Metropolitan district asylun Private
255
463
M.
10,908 20,392 37,300 17,116 20,647 37,763
1,280 2,GS0
53
45
98
1,453
1,325
2,778
1,064
815 1,879 81!) 1,593
50 251
131 289
190 540
1,123 1,025
946
1,108
2,069 2,133
3G0
315
15
3G0
243
381
101
482
M
Provincial
T
1,400
In licensed houses:
Metropolitan.
F.
5,074 1,952
G,785 11,859 2,454 4,406
5,074 1,952
6,785 11,859 2,451 4,406 286
474
2,367
3,847
2,3G7
3 847
6,214
single patients
Out-door paupers
6,214
4,172 3,520 ',692 26,85'J 33,994 60,846
37,514
There are 265 lunatics who have been found so by inquisition residing in charge of committees who are not included in this number. There is an increase of 1,902 on those returned on January 1, 1877. The average number of resident patients contained in
borough asylums throughout the year was 36,668 ; during the year were 30*07 per cent, below the average of previous years ; but this is accounted for by the large proportion of chronic cases admitted by transfer from one asylum to the other and included in the total admissions.
county
and
the recoveries
If
we exclude these transfers, the recoveries would bear to the admissions the ratio of 37*29 per cent. The total number under detention on January 1 as private
lunacy in England.
285
and single patients was 46,059 in licensed houses and under single care. Out of this number 17,459 were male paupers, and 20,908 were female paupers. With regard to the supervision of epileptic cases the Commissioners say:? So far back as 1859, in our thirteenth Report, and again in 1872, in our twenty-sixth Report, we adverted to the very inadequate provision made in many of the large county asylums for the nursing and care of the patients during the night. At one time it was the practice in many asylums to employ the day attendants in rotation on night duty; this very objectionable arrangement is, however, now generally given up, and the system of employing special attendants for night duty alone is now the general rule in public asylums. Until recently, however, in many large asylums, the care of the patients during the night has been left to one attendant in each division, who was required to visit the different wards every two hours. Visits at such intervals are so obviously insufficient to afford proper protection to even the ordinary inmates, that we have taken every opportunity of pointing out to the Visitors the great importance of increasing the staff of night attendants generally, and we are glad to report that most asylums are now in a much more satisfactory state in this respect. The frequent deaths which at one time took place amongst the epileptics from suffocation in fits during the night, and also the occurrence of suicides?due, in many instances, to the want of careful watching?convinced us some years since of the futility of entrusting patients of the above classes to the irregular visits of the ordinary night attendants, and that the only way by which accidents could be guarded against, and fatal results in the majority of cases diminished, is by placing these patients under the care, during the night, of special attendants, with specific rules for their guidance, and in wards so arranged as to admit of the patients, whether in dormitories or single rooms, being under direct supervision. We have again the satisfaction of stating that the result in those asylums in which the arrangements have been fully Not only have carried out has been most encouraging, the accidental deaths in these classes of patients been very much reduced in number, but the importance of the system has been fully admitted, not only the medical officers of the asylums, but especially by the attendants, who are relieved of much anxiety during the night, and in many instances have expressed to us their sense of the value of the special provision for night watching. At present the arrangements for this purpose are more or less complete in 25 of the county and borough asylums. In "
"
280
LUNACY IN
ENGLAND.
they have been partially carried out, hut are imperfect in important particulars, chiefly in consequence of structural difficulties in the original buildings. In 6 asylums special wards are in progress, and in 12 no provision has as yet been made. Not only as respects the epileptic and 'suicidal patients do we hope that ere long we shall be able to report that proper arrangements, both structural and otherwise, have been made in all asylums in England and Wales, but also that the night nursing and care of the ordinary sick inmates is placed upon a more satisfactory footing than at present. In many asylums the sick and dying patients are still under the charge of the ordinary night attendants, and are consequently left for long periods without receiving that constant attention which their cases require. Special night attendants should, we think, be or sick wards of all asylums. in infirmaries the provided The Commissioners publish a table, being a return made to the Office from the various asylums, hospitals, and licensed houses The result is thus of the inmates who are regarded as suicidal. summarised :?County and borough asylums, 4,908, out of a total number of 35,863 ; hospitals, 632, out of a total number of 3,613; metropolitan licensed houses, 344, out of 2,735; pro16
"
"
vincial houses, 212, out of a number of 2,070. From this it appears that out of the total number of inmates in these institutions 13-76 per cent, were regarded as suicidally inclined. The actual number of deaths from suicide during the year was 18; this is somewhat less than 3 per 1,000 on the entire number of suicidal patients." In our present issue there are two papers on Suicide; and we think it would be interesting to our readers to publish in extenso the cases that have occurred in the county asylums during the past year, as given in the Keport:? " At the Cornwall Asylum a death by suicide occurred in the following circumstances:?A private patient, J. Or., was admitted on November 1876 in a state of melancholia. Prior to admission he had made an attempt on his own life by strangling, had refused food, and had also endeavoured to strangle an attendant. " Being narrowly watched and carefully fed, his bodily and mental condition had so far improved that he was placed in a single room, though still watched. Up to the lltli of January, 1877, he had made no suicidal attempt. On the afternoon of that day he contrived to secrete a knife from the table used by the attendants in the billiard-room. He retired to rest, and was visited hourly during the night and morning of the lltli and 12th of January by the night attendant. Soon after five in the morning this officer found the patient lying dead at the foot of liis bed witli his throat cut.
LUNACY IN
ENGLAND.
287
"
Tlie results of the evidence at the coroner's inquest, and of subsequent inquiries?first, as to the evident negligence through which J. Gr. had been able to obtain possession of the knife with which he killed himself; and, secondly, as to the apparent laxity of supervision, owing to which the fact of his having the knife in his bedroom had not been found out?were as follows:? " As to the first point, it appeared that the attendant, whose it duty was to count and put by the knives after the meals in the billiard-room, was at the time invalided, and his place supplied by any other attendant who could be spared, and that the attendant must have tailed properly to supervise the our
charge
substitute. " The medical superintendent, as regards the second point, stated that when J. G. was admitted, although in the certificates his suicidal tendencies were only mentioned by one of the medical men certifying, he was for a time under constant supervision, and not allowed access to his room at all, except in the presence of his attendant; latterly he had seemed better, and the constant supervision insisted on at first was relaxed, as he had shown no suicidal tendencies while in the asylum, and the evidence on this point in the certificate was certainly not
strong.
" Since the death Mr. Adams learned, for the first time, that the patient had, before admission, actually made more Had these been made known to than one suicidal attempt. him before he would have taken a more serious view of the relax the strict case, and would consequently have hesitated to first. at taken precautions " At the Hants Asylum two deaths by suicide have occurred. " The first case was that of a young man, J. S., who had been an inmate of the asylum since February 187G. He was known to be labouring under strongly-marked suicidal tendencies. Written notice of this was given to the attendants in the ward where he first was placed. " At the time of his death he was in another ward, where The full complement of there were upwards of 40 patients. attendants to this ward was five, but at 11.10 in the morning of Sunday, the, 28th of January, one was absent on leave; two had accompanied. 12 of the patients to chapel; the fourth had been called away (it was stated in somewhat exceptional circumstances) for special duties elsewhere, so that one attendant alone remained in charge of 32 patients, including This man, soon after 11 oclock, unobserved by the single J. S. attendant, gained access to a sink-room, where, having first barricaded the door, he proceeded to hang himself by his
LUNACY IN ENGLAND.
288
The alarm was shortly after given by another patient, but before assistance could be procured and access through the window of the room could be obtained, by means of a ladder, J. S. was dead. "No evidence was forthcoming that the fact of the strongly suicidal propensities of this patient had been formally communicated to the attendants in this ward, although, indeed, we were assured by the medical superintendent that it was well known to all of them. In these circumstances it was impossible to fix the blame on the attendant left in charge. " In consequence of a recommendation from the Board a better system, that of filling up on admission, and causing to be passed with the patient from ward to ward, a parchment ticket indicating his suicidal or dangerous character, has been introduced into the asylum. We also advised a modification of the arrangements which had allowed so large a number of patients to be left temporarily in charge of a single attendant. " The second case of suicide at this asylum was of a male patient, admitted in January 1877, and then known to be suicidal. In May he had secreted a razor and cut his throat, but not so as to produce a fatal injury. From that time he was never left unwatclied, two persons, former attendants at the asylum, being specially engaged to watch him, one by other by day. In addition to this, an attendant from the staff was always told off night and day to assist in the supervision. " This arrangement was continued until the wound had entirely healed, and it was then thought sufficient to retain the services of the two special attendants, one of whom, Gr. C., had the night watch, while John Fleet was on duty by day. " On the 12th of July, Fleet took the patient into the male infirmary airing-ground. Here the patient asked leave to go to the closet, selecting a moment when the attendant, according to his own statement, was engaged in the unseasonable occupation of paring his toenails, and hence failed to notice which
braces.
night,"the
patient went. Fleet, in a minute or two, missing his patient, put on his stocking and boot and proceeded to the closet in search of him. The patient, however, had escaped through a door leading to a garden through which he and Fleet earlier in the day had passed, and'which he had contrived to stop from shutting perfectly. Arrived here, he easily got over a wall, and after traversing thirty yards of ground found himself on the railway. A train soon came in sight, and the patient was seen by the engineer deliberately to throw himself over the rails in front of it. The train passed over him, and he was killed.
way the "
289
LUNACY IN ENGLAND. "
The Committee of Visitors thought it their duty to mark seuse of Fleet's carelessness by proceeding summarily against him under section 123 of the Act 16 & 17 Vict, c. 97. He was convicted by the magistrates for wilful neglect of his patient; but, in consideration of the high character he had borne while in the asylum service, a penalty of ?2 only their
was
imposed.
"
At the Barming Heath Asylum a female patient admitted 25th April was found dead. She was stated on her admission papers to be suicidally disposed, but it was not till after her death that the medical superintendent was made aware that she had actually attempted self-destruction. Hence she was not, on admission, placed in a special dormitory for suicidal patients, of which there are now two in this asylum, but it was thought sufficient to give the night attendants instructions to see her frequently. She was placed in a single room to sleep, on account of restlessness, and on the night of the 9th of May was visited there (according to the nurses' statement) every An hour afterwards half-hour up to 5.15 in the morning. the day nurse coming on duty found her dead, suspended by her night-dress to a small hook used to fasten the window of the single room. She was quite dead. " It was a matter of great regret that the full history had not been disclosed to the medical superintendent; but independently of this we could not avoid expressing doubt as to the prudence of placing the patient in a single room without constant supervision, and where the fastening of the window afforded the means of suicide. " A female patient at thePrestwich Asylum contrived on the morning of Sunday, October the 21st, to slip uuperceived out of the ward in which she was placed, during the passage out of the ward of a number of her fellow-patients who were proceeding to divine service. This was a little before 10 a.m. She was almost immediately missed, but in some way, which a strict investigation has failed to discover, she had escaped from the asylum premises. " Her home was in Prestwicli, and she consequently was acquainted with the locality. Between 10 and 11 she was found in a pit of water, close to a footpath crossing a field near the asylum. Assistance was procured, and she was taken out of the water, but was dead. " This woman was admitted on the 19th of September, 1877; and being stated to be suicidal, proper notice was given to the attendants in charge of her. Up to the time of her death she had made no attempt on her own life. The officers of the asylum were not informed, until the fact came out at the on
PART II.
VOL. IV.
NEW SERIES.
X
LUNACY IN ENGLAND.
290
inquest, one
the
that she had
shortly
before
admission,
on
more
than
occasion, risen from bed at night and endeavoured to leave house, for the purpose of drowning herself. Neither the
jury, nor the medical superintendent considered the attendants to blame for her escape. " On the 6th of April, while in an airing court of this asylum, a male patient, named H.'E., was struck on the head with a chamber utensil by another patient, and received five severe cuts. This utensil had, with others, been placed in a yard separated from the airing court by a high paling, and it was lifted over the paling by H. E., who was able to do so by his hand inserting (said to have been a very small one) between the rails. It was snatched from him by the other patient, who with it then made the assault on H. E. The wounds were at once dressed, and H. E. was placed in bed; and although the cuts healed quickly the general condition of the patient rapidly deteriorated, and symptoms of inflammation of the lungs developed themselves. No other injuries than those on the head were for some time observed, but ultimately Mr. Clunn, the assistant medical officer, discovered indications of The patient bethe fracture of three ribs on the right side. A post-mortem 13tli of May. came worse, and died on the examination disclosed inflammation of the lungs and pleura, with considerable effusion into the cavity of the chest, resulting from the fracture of three ribs on the right side. It was found The patient was a that the ribs were exceedingly brittle. was held in the case, general paralytic. A coroner's inquest and the verdict of the jury was that ' the deceased died from pleuro-pneumonia induced by the fracture of three of his ribs, but when, how, or by what means those injuries were caused there is no evidence to show.' It appeared that there was an attendant with about 15 patients in the airing court at the time of the assault, which, however, was not witnessed by the attendant. It did not appear to us that blame attached to any of the staff of the asylum in connection with this case. " A female patient of the Somerset and Bath Asylum, aged G7, admitted in November 1872, committed suicide on the 2fith of August, 1877, by hanging herself to an iron fixture of the window of the single room, where, on account of her noisy and restless habits at night, she had been placed to sleep. Neither upon her admission nor subsequently was she Her health stated or considered to be suicidally disposed. had been failing, and she suffered from disease of the heart. The night nurse had seen her alive at 4 a.m., but on unlocking the door of the bedroom, at about a quarter to six, found her as above described and dead. No blame appeared to attach coroner,
LUNACY IN ENGLAND. to the
but orders were at of the single rooms by
attendants,
the windows
shutters.
291
given to protect properly constructed
once
"The first case of suicide (on the male side) since the of the Sussex Asylum, at Hayward's Heath, in 1859, occurred there on the 9th April, when a male patient, T. C., who was admitted on January the 1st, 187G, was found hanging by the neck to a small tree or shrub in one of the airing
opening
courts.
" Although not marked as suicidal on his admission papers, J. C. had soon after shown some tendency in that direction, and in consequence had for some time been watched by night as well as by day. Towards the end of the year he had become more lost, and he scarcely possessed, it was thought, sufficient mind to plan or carry out any suicidal attempt. On the day of his death, however, being in the airing court with 148 other patients, and under the supervision of five attendants, he contrived to escape notice, and gaining the shelter of the shrubbery, hung himself there. He was missed soon after, but when found was dead. " The coroner's jury attached no blame to the attendants, but recommended that the shrubs should be thinned somewhat; a recommendation which has since been attended to. " A death by suicide occurred at the Worcester Asylum in March 1877. A male patient, who had been an inmate of the institution for nearly sixteen years, during no part ot which time he was thought to be suicidally disposed, was missed one afternoon, and was thought to have repeated an attempt Several attendants at escape which he had made in 1873. were at once ordered in pursuit of him, but very shortly after he was accidentally discovered hanging by the neck to an exposed gas-pipe in a beer-cellar seldom used, but to which he had obtained access from the place where he had been working, as his custom was, in charge of the engineer, lie was a trusted patient, and had been allowed considerable liberty. When found he was not quite dead, but the efforts of the medical officers to restore animation, though persisted in for nearly two hours, were ineffectual. " This was not a case in which any blame could, in our opinion, be fairly laid to the charge of anyone connected with the administration of the asylum. " A female patient of the Bethlehem Royal Hospital committed suicide in the following circumstances:? " She was admitted in March 1876 suffering from melancholia, and had shortly before made an attempt to cut her throat. She gradually improved; and having for the three x
2
LUNACY IN
292
ENGLAND.
previous to her death, in January 1877, appeared conwas placed in the convalescent ward. Here she assisted in the household work, and was considered by the nurses quite trustworthy. On the afternoon of Sunday, January 14, she was left in charge of an experienced attendant, with other patients who had not gone to chapel. This attendant noticed her at twenty minutes past three, but at four o'clock she was missing, and on a search being made she was found in a bath-room attached to the ward suspended to the window by a cord. The medical superintendent was immediately summoned, but he found life months
valescent, "
to be extinct. "
The door of the bath-room, it was positively stated by the attendant, had been locked, according to rule, at nine in the morning, and at three the attendant passed the door, and noticed that it was closed. Somewhat imprudently, as we thought, even with allowance for the greatly improved state of the patient, the nurse had sometimes lent her a key, and on the day of the death the key had been entrusted to her for a few minutes that she might fetch some beer. Probably she had availed herself of this opportunity of unlocking the bath-room door, in order to obtain access to the room later in the day. " The manner in which she had obtained the cord was not clearly ascertained. Considerable liberty had been allowed her, and it was thought possible that she might have got possesAfter a lengthened inquiry the sion of it outside the ward. coroner's jury came to no conclusion attributing blame to the officials of the hospital. " A female patient, Miss H., a lady of about 50 years of age, admitted into the Northampton Hospital in January 1877, with distinct suicidal delusions, which had driven her to attempt her own life, both by an overdose of a sedative and by strangling, died on the 26th of August of exhaustion from burns, caused by setting fire to her clothes on the 17th of that month. "
months of constant supervision in a special so much better and more cheerful, that it was considered proper to remove her to the first division of the first class. Strict injunctions were given to the attendants there that she was never to be left alone. When the other ladies were not in the drawing-room, where she usually sat, a nurse was to be in the room, and at all times a nurse was to be close at hand. There were four nurses to 16 patients, and the deceased was the only one requiring special cnre. On the evening of August the 17th the inmates of the ward were returning from
ward,
After
some
she had
appeared
LUNACY IN ENGLAND.
203
the dining-room to the drawing-room. One of the nurses seated in the gallery close to the door of the ante-room leading to the drawing-room saw Miss H. pass into the ante-room, and then, against orders, left her post to light some gas. In two or three minutes she heard screams, and on returning to the anteroom found Miss H. with her clothes on fire. She threw her down, enveloped her in a rug, and procured assistance. It appeared that Miss H., availing herself of the momentary negligence of the nurse, had turned into a small room opening into the She lit a twisted paper ante-room. Here gas was burning. which she had prepared, and so set light to her clothes, and, as she admitted, with the intention of suicide. The burns did not at first appear serious, but, as before stated, the patient died on August the 26th. " The nurse was severely reprimanded, and we did not press for any further punishment. " A suicide occurred at the York Lunatic Hospital in very peculiar circumstances. " A. A., a female private patient, aged G2, was admitted to the hospital in February 1875, suffering from mania, and with an intracapsular fracture of the left femur, owing to a then recent accident. " This injury had never been thoroughly repaired, and at the time of her death, in June last, A. A. was supposed to be unable to walk alone or even get out of bed by herself. " Previously to admission she was stated to have made two or more determined attempts at self-destruction by strangling. She was very noisy and restless, especially at night, and on this account had been placed in a single room, care being taken every evening to remove all articles of a dangerous character. " For about twelve months prior to her decease she had occupied the same room, and under the same conditions. In consequence of a complaint made to her friends of the darkness of her room she had been allowed for some time to have the shutter open, it being understood, as already stated, by all about her that she was unable to leave her bed. " Nevertheless, on the morning of June the 29tli, having be?en seen alive and spoken to by one of the night attendants at a before quarter six, she left her bed, and contriving to pass the body of her night-dress over the hinge of the open shutter, had strangled herself in a loop formed by the sleeve. A little before seven she was found dead by the day under-nurse, who came in to bring her clothes. " During her residence in the asylum she had never been known to the medical superintendent to have walked a yard without assistance, and was thought to be quite safe when in bed, especially when she was visited hourly at night.
294 "
LUNACY IN ENGLAND.
We concurred with the coroner's jury in
to anyone entrusted with her
attributing no blame
care.
" On December the 15th, 1876, a patient named H. 0. comThe circummitted suicide at the Wonford House, Exeter. stances were not fully before our Board until their first meeting in January 1877, and in consequence of this the occurrence was not noticed in our 31st Report. " The patient was described as suicidal on his admission in November 1876, and it appeared from the certificates that he had threatened to destro}7 himself, justifying his intention by insane reasoning, but he bad not made any actual attempt. " The parchment ticket used in the Hospital was filled up with a statement that he was ' suicidal,' but ' not actively so,' and by some mismanagement this ticket was not shown to the attendant who was in charge of the patient on the night of his death. " Early in the morning in question H. 0. was allowed to He was not very leave the dormitory for a natural purpose. and the a few minutes after watched attendant, by strictly leaving the dormitory he made his way to the end of the corridor The attendant and jumped through the window at the end. followed him down the corridor and called him back, thinking he was mistaking the way, and on finding he did not turn back ran after him, but was too late to prevent his leap, the injuries from which proved fatal. " It was a matter of great regret that, considering the facts disclosed in the certificates, the ticket had not more strongly indicated the patient's tendency to suicide, and that it had not been duly shown to the attendant in charge. "In May 1875 a young man, A. H. F., was admitted as a private patient to this hospital, labouring under melancholia, and with delusions that he had committed some great crime and was being pursued in consequence. " Though not noted on his admission papers to be suicidal, he showed at first a decided tendency in this direction. " On June the 26th, through a want of proper supervision, he made his escape, but was brought back to the hospital early the next morning. " On the 31st of July he again escaped from the airing ground, with the assistance of another patient, the attendant in charge having left him, as he stated, for about a minute. He was not retaken for thirteen days, when he was found by the police wandering at a considerable distance from the hospital. It did not appear that during his absence he had made any attempt on his life. " On his return the medical superintendent thought it ad-
LUNACY
IN
ENGLAND.
295
visable
to change his associations, and placed him in ' the second gallery.' Here he gave no trouble, occupied himself with drawing and in other ways, and, in consequence of his apparent improvement, was transferred at the end of a week to 'the first ffallerv,' where he continued to occupv himself
rationally. "
About this time his mother, in business in Exeter, began discharge on trial. Dr. Lyle thought this preHe allowed him to and not recommend it. would mature, pay several visits for the day to his mother's house, being taken thither and brought back to the hospital under proper to press for his
care.
On the 8th of September, the mother continuing to press trial, leave of absence was given by the Committee of hospital, she having first written a letter to the medical superintendent accepting the responsibility of his charge. Mrs. F. was distinctly cautioned as to her son's suicidal tendency, and of the consequent necessity for constant watch"
for the
a
fulness.
" The next to his mother's
there.
day
he
was
found dead in
a
house, having hung himself by
cellar belonging cord to a beam
a
" After full consideration we were unable to acquit the medical superintendent of want of caution and judgment in yielding to the pressure of the patient's friends and consenting to the leave of absence. We also intimated our opinion that the repeated success of the attempts at escape was not creditable to the management of the institution." Increased accommodation is required for asylums in
Glamorgan, Lancashire, Norfolk, and Salop. There are 16 registered hospitals under
the jurisdiction of the 1st of January, 1878, 2,778 patients, being an increase of 40 on the numbers The admissions were 898, and the of the previous year. discharges 062, of whom 188 had recovered; and the deaths were registered as 196. On the 1st of January, 1878, there were 38 metropolitan licensed houses; the total number of patients being 2,148 males, and 2,054 females. Of this number 310 were males, and 420 females of the pauper class. The inmates in workhouses considered to be of unsound mind amounted to 16,038 on the 1st of January, 1878. The Commissioners visited 208 of these institutions during the year 1877. The condition of the inmates is reported as favourThe Report contains an account of an able on the whole. illegal reception of a patient into Elm House, Cliiswick, on an the Commissioners, which contained,
on
LUNACY IN ENGLAND.
296
order signed by a person who had not seen the patient within the time required by the Act. There is also an account of the illegal detention of an insane lady in Manor House, Northfleet, Kent, and at a rectoryhouse in Dorsetshire. The appended letter appears in Appendix Q, and is of interest, showing the various inquiries made by the Commissioners when visiting asylums. The Report contains most valuable statistical records of the various asylums in England and Wales, with a detailed account of the visitation of .the county asylums, hospitals, and other public institutions, including the Criminal Lunatic Ptospital, at Broadmoor, the excellent management and arrangement of which we had an opportunity of visiting during the past year, and which reflects great credit upon Dr. Orange and his assistants. The Report before us is a faithful record of all that relates to lunacy, and of itself bears evidence of the zeal and earnestness with which the Commissioners perform their arduous but most responsible duties :? "
Office
of
Commissioners in Lunacy, 19 Whitehall Place, S.W.: October 1877.
"
Sin,?The Commissioners in Lunacy having received the statutory notice of your appointment at the last Quarter Ses-
clerk to the Visitors of licensed houses in the county for the ensuing year, direct me to transmit to you the enclosed copies of a summary of the principal heads of inquiry which the Lunacy Acts prescribe on visitation of these establishments. " A similar summary has long been in use by the Commissioners themselves, and they think that the Visitors, especially such gentlemen as may have been now appointed for the first time, may find the enclosed card of service in directing (though not in limiting) those inquiries which experience has found very valuable in the work of improving the condition and sions
as
of
treatment of insane patients. " I am to ask you to take an early opportunity of placing one of the cards in the hands of each of your Visitors. A further supply can, if required, be had on application to me. "
"
I am,
" "
To
."
Sir,
Your obedient servant, Charles Srencee Perceval, "
Secretary.
297
LUNACY IN ENGLAND.
"Visitation "
(Acts 8
& 9 Vict.
c.
100,
of
s.
Licensed Houses.
62; and
25 & 26 Vict.
c.
"
111, s. 29.) (medical
Visits to be made by two at least of Visitors Visitor to be one), four times at least in every year. " Two additional visits every year by any one or tlie Visitors. "
Chief
Statutory c.
"
Heads of
100,
ss.
Inquiry
at Visits.
62, 64, 65, 50, 66.)
1. Divine Service: When
performed;
(8
more
of
& 9. Vict,
to what number of
patients. " " " " "
2. Occupations and amusements. 3. Restraint and seclusion : Amount of, and reasons for. 4. Classification of patients. 5. Pauper patients : Condition on admission ; dietary.
6. List of patients. 7. Orders and certificates of patients admitted since last visit to be inspected ; license to be examined and signed at first visit after grant or renewal. " 8. Letters of private patients endorsed under Section 40, Acts 25 & 26 Vict. c. 111. " 9. Books to be inspected and signed, viz.:? Book of admissions. Register of discharges and deaths. Medical visitation book. Case book. " 10. Entries to be made? "In Visitors' book, as to condition of house and patients: Number under restraint; irregularities in orders and certificates: whether previous suggestions by Commissioners or Visitors have been attended to or not; results of statutory and other inquiries. " [The proportion of patients to attendants, their capacity and conduct, though not a statutory subject of inquiry, is very important.] " In Patients' book : Observations as to state of mind or body of any patient." "
