Condition of Lunacy in England
182 Art. III.?
TnE Twenty-ninth Annual Report of the Commissioners in Lunacy has just been issued, containing valuable particulars and statistics, relating to the care and treatment at present existing in England of persons of unsound mind.
By perusal of its pages, we find that on the 1st January of the present year there were on the official books of the Commissioners 63,793 registered lunatics, showing an increase of 1,766 on that of the preceding year. Of this number 7,390 are registered as private lunatics, and 56,403 as pauper lunatics. Among the former class are included patients, not only residing in licensed houses, but also those maintained at the national cost at the Eoyal India Asylum, at the Yarmouth Naval Hospital, at Netley Abbey, Grove Hall, Bow, and at the Criminal Asylum, Broadmoor. Among the pauper lunatics are placed only those who are maintained wholly or in part by or charge- able to parishes, unions, counties, or boroughs.
The increase during the year of private patients is 98, and of paupers 1,668. The increase of the latter has taken place in the county and borough asylums by 1,157, in licensed houses by 168, in Broadmoor Criminal Asylum by 20, in workhouses by 358. But there is a decrease in the out-door paupers by 17, and also of 52 maintained in registered hospitals. The in- crease of private patients is 1 in county and borough hospitals, 81 in registered houses, 50 in licensed houses, 5 as “single patients ” under private care, but it has decreased in number by 7 in the Naval, Military and Indian asylums, and by 32 in the Criminal Asylum of Broadmoor. The total population between the years 1859 and 1875 has increased 21*63 per cent., but the private patients under care have increased as compared with 1859, 48*39 per cent., and the increase of the paupers in the same time under care is 77*47 per cent. At the present time there are 172 males and 269 females under care as single patients in private unlicensed houses.
Twelve interesting tables are given relating to the dis- tribution of the insane during the last fifteen years, both pauper and private; and it is a matter of congratulation to find by reference to Tables V., VI., and VII., that the recoveries have been 4 per cent, higher than they were last year, and 2 per cent, above the average of the last sixteen years, whilst the rate of mortality has remained stationary. We regret to find out of 32,529 inmates of County and Borough Asylums only 2,431, or a proportion of 7*47 per cent., are deemed curable, but this to a great extent appears to us to be due to the fact tliat these asylums are gradually becoming occupied by a large proportion of chronic and incurable patients, who might well be sustained in well-organised workhouse wards. The attention of the Commissioners has for some years been directed to the large number of epileptic patients who are found dead in bed, and to the frequent occurrence of suicide during the night, especially in public asylums. Attention was directed to this subject in the 26th and 28th Reports of the Commissioners in Lunacy, but notwithstanding the opinions therein expressed of the inefficiency of the night nursing in public asylums, proper precautions have not been hitherto taken.
The Commissioners think that special attendants should be .appointed for the exclusive care of these cases during the night, and that arrangements should be made either by alterations in existing wards, or by the construction of others affording ready facility for immediate supervision.
Epileptic cases are generally under the strictest supervision during the day, but during the night are apt to be neglected. The Commissioners write as follows : ” It is not only on account of the number of epileptics found dead in their beds, and of suicides which take place during the night?casualties which, under proper arrangements, might often have been pre- vented?that we continue to press our views, for we are strongly of opinion that the sick and dying also demand continuous nursing during the night. At the same time the epileptics should have assistance always at hand during their terrible seizures ; and all suicidal patients should receive that strict personal supervision which alone can secure their safety. In large asylums nothing less than the provision of special wards for these classes will meet the requirements of the case. Whether in small asylums suitable arrangements can be made for the suicidal cases in combination with the sick depends upon the construction of the buildings and the disposition of the superintendents, most of whom, we believe, are favourable to our views.”
We are glad to find that these recommendations have been carried out with excellent results in several asylums. The various suicides and casualties which have taken place during the year in the County Hospitals and Licensed Houses are given in extenso in the Report, and also the various alterations in the structural and other arrangements of these institutions. The condition of establishments, both public and private, for the reception of the insane, appears to ns to be highly satisfac- tory on the whole, with the exception of the accommodation provided for the reception of the insane in workhouses; and we beg here to express our disappointment and regret at the reluctance displayed by Boards of Guardians and medical officers connected with these institutions in carrying out the recom- mendations of the Visiting Commissioners ; and our remarks would here especially allude to the Union “Workhouse of Lang-port, the Brownlow Hill Workhouse, in the parish of Liver- pool, and the Nottingham Union Workhouse. We would also suggest that the relieving officers and others who are connected with the care of pauper lunatics should make themselves cog- nisant with what is required of them in the Act relating to the legal bearing of the several sections of the Lunacy Act. The Report before us contains actions which have been brought against officials for breaches of the Lunacy Acts, and we consider that at the present day it is a public disgrace that the cases here reported should have taken place. It is sufficient for our purpose to report briefly the facts relative to one of the cases here cited.
At the commencement of 1873, G-eorge Wilson, a retired servant in the Post Office, residing in the parish of Saint Mary, Islington, showed symptoms of mental aberration. Mr. Merri- field, the relieving officer of the parish, was informed that there was a lunatic in his parish not under proper control. Merrifield visited the house of the alleged lunatic three times, but he never saw Wilson, or attempted any steps for his proper supervision, notwithstanding he was informed that he was a dangerous lunatic. In fact, he neglected his duty in failing to comply with the 16 & 17 Vict. c. 97, s. 68, in giving notice of the fact to a Justice, in order that the prescribed steps for the proper detention in an asylum might be taken.
The lunatic, thus at large, attacked one of his sons with a hatchet and killed him, but was, when arraigned on trial for murder, unable to plead, and acquitted on the ground of insanity. The Relieving Officer was prosecuted by the Com- missioners for failing to comply with the Act; he was convicted and fined the full penalty of ?10.
The case to us amounts to positive manslaughter, and we trust Merrifield no longer retains the post of Relieving Officer, one for which he has proved himself to be unfitted. Another case in which the Commissioners justly decided to prosecute we give particulars of:
Mrs. Groulden, landlady of a public-house, maintained in her house amongst others Sarah Pownall, the daughter of her first husband. It appears that this person had for some time been considered eccentric, “but at the same time had been accustomed to perform the menial offices of household work. In April 1873, some of the neighbours failed to observe her going about as usual, and on enquiry it was found that she could not be induced to leave a small room in Mrs. Goulden’s house, which was appro- priated to her exclusive use. The Commissioners report that ” no active steps were taken to discover her real condition till the 24th of May last, when the room in which she lived was visited by the police. She was then found lying on a bed much too small for her, and made up of a carpet, an old sheet, and an old and dirty mattress. She lay with her knees nearly touching her chin, her legs were covered with excrement caked on to the skin; her hands and face were very dirty, her hair matted, whilst beneath the bed the floor was swimming with urine; the stench in the room’being unbearable.” Such then is the description given of a person, non compos mentis, whose friends have undertaken the care. By direction of the police the woman Pownall was washed and removed to another room, and on the following day, having been examined by a medical man, was forthwith conveyed to a County Asylum. Her mental state was that of great depression, but her bodily condition, on admission, was frightful. ” She was filthily dirty, very thin, and weak, her legs were contracted, so that they could not be straightened beyond an angle of thirty degrees to the thigh, there were sloughing sores over the thighs and knees and under the arms.” Such being the facts, the Commissioners most properly determined to proceed against Mrs. Groulden, under the 16 and 17 Vict, chapter 96, sec. 9, for the wilful neglect of Sarah Pownall. Summonses were issued, and the hearing fixed for the 6th of July.
The patient, however, died on the 25th of June in the Asylum, from exhaustion, and at the inquest, held upon the 6tli of July, the Coroner’s jury returned a verdict that the death had been accelerated by the culpable neglect of Mrs. Groulden, who was accordingly committed for manslaughter. The enquiry before the magistrates was held on the ] 3th of July, and Mrs. Groulden was acquitted of manslaughter, and convicted only of misdemeanour under the above-mentioned provisions of the Lunacy Act. On the 11th of August, Mrs. Goulden was found guilty at the Assizes at Chester of manslaughter, but in con- sequence of her age and infirmity was recommended to mercy, and sentenced to six months’ imprisonment with hard labour. This of itself should convince those who at the present day are wont to ignore the responsibility incurred by those who undertake the charge of persons of unsound mind, that the charge is a grave one, and if abused, will be met with. its just reward. And it is perfectly monstrous, notwithstanding the popular cry, to suppose that persons of unsound mind in private houses, whether pauper or private, can receive the care, surveillance, and treatment provided for them in Asylums and Licensed Houses.
An important addition to the particulars required by 8 & 9 Vict. c. 100, to he inserted in the case-hook kept at licensed houses, has been recently made by the Commissioners. Upon the admission of a patient the presence or absence of bruises must be mentioned by the medical superintendent in the case- book. This we consider most advisable. We have recently had a case under our especial notice in which, notwithstanding symptoms of dangerous and acute mania had for some time been evinced, the friends and relatives refused to take any active steps for placing the patient under legal restraint until they were compelled to do so in consequence of very alarming symptoms. The patient was in such a violent state that it was impossible for her to travel by rail, and she had to be placed in a carriage and driven to the asylum. Upon her admission, on an examination it was found she was covered with bruises on her arms and legs, the result of being forcibly held down in her violent struggles ; entries of these bruises were made in accordance with the instructions of the Commissioners in Lunacy to which we have referred. In some cases the relatives might unjustly attribute bruises to the attendants at the asylum, but this cannot be done now, as will be seen by the excellency of this proviso.
The following are the Revised Orders respecting the Case Book:
Case Book Order. Eevised, 1874. ‘ 8 and 9 Vict. c. 100, s. 60. The Commissioners in Lunacy, by virtue of the power vested in them by the Act of Parliament passed in the Session holden in the 8th and 9th years of the reign of Her present Majesty, intituled ” An Act for the Regulation of the Care and Treatment of Lunatics,” do hereby order and Direct?
That the Medical ” Case Book,” by the said Act directed to be kept in every Licensed House and Hospital, shall be kept in the form hereinafter mentioned, viz.:
First. A statement to be entered of the name, age, sex, and previous occupation of the patient, and whether married, single, or widowed.
Secondly. An accurate description to be given of the external appearance of the patient upon admission : of the habit of body, and temperament; appearance of eyes, expression of countenance, and any peculiarity in form of head; physical state of the vascular and respiratory organs, and of the abdominal viscera, and their respective functions; state of the pulse, tongue, skin, &c.; and the presence or absence, on admission, of bruises or other injuries to be noted.
Thirdly. A description to be given of the phenomena of mental disorder: the manner and period of the attack, with a minute account of the symptoms, and the changes produced in the patient’s temper or disposition; specifying whether the malady displays itself by any, and what, illusions or irrational conduct, or morbid or dangerous habits or propensities; whether it has occasioned any failure of memory or understanding, or is con- nected with epilepsy, or ordinary paralysis, or symptoms of general paralysis, such as tremulous movements of the tongue, defect of articulation, or weakness or unsteadiness of gait.
Fourthly. Every particular to be entered which can be obtained respecting the previous history of the patient: what are believed to have been the predisposing and exciting causes of the attack; what the previous habits, active or sedentary, temperate or other- wise ; whether the patient has experienced any former attacks, and if so, at what periods; whether any relatives have been subject to insanity; and whether the present attack has been preceded by any premonitory symptoms, such as restlessness, unusual elevation or depression of spirits, or any remarkable deviation from ordinary habits and conduct; and whether the patient has undergone any, and what previous treatment, or has been subjected to personal restraint.
Fifthly. During the first month after admission, entries to be made at least once in every week, and oftener where the nature of the case requires it. Afterwards, in recent or curable cases, entries to be made at least once in every month ; and in chronic cases, subject to little variation, once in every three months. In all cases an accurate record to be kept of the medicines administered, and other remedies employed, with the results, and also of all injuries and accidents.
That the several particulars, hereinbefore required to be recorded, be set forth in a manner so clear and distinct as to admit of being easily referred to, and extracted, whenever the Commissioners shall so require:
And that the present order be in substitution for those of the 9th January 1846, and of the 20th March 1863, and that a copy hereof be inserted at the commencement of the Case Book. Dated this 16th day of March 1874. Office of Commissioners in Lunacy: 19 Whitehall Place. It is generally the custom now for the Commissioners in Lunacy to send to each patient discharged as ” Recovered ” the following statement:
Office of Commissioners in Lunacy: 19 Whitehall Place, S.W. 187 . I am to inform you that Notice has been received at this Office, that on the day of you were discharged from care and treatment as a person of unsound mind. The Commissioners desire that you should understand that you are now a perfectly free agent, and that no interference with your liberty of action will be justifiable under colour of the Lunacy Laws, except ?under fresh order and certificates.
As a proof that you have received this note, I am to ask you to tear off the acknowledgment on the fourth page, to sign it, and post it to this office. I am Your obedient servant, Secretary.
We cannot altogether endorse this resolution of the Board. There are many patients who, when placed in an asylum?fortu- nately for their well-being?are under the impression that they come there voluntarily, their friends wishing them to think so in order to avoid exciting them unnecessarily. It appears to us, that when patients have been discharged recovered, it is unwise in most instances to make them aware of all the particulars of their detention, for by so doing it may be the means of causing much mental distress, and perhaps inducing a relapse. We will take, for sake of illustration, the following case:?A gentleman, whose bodily health is in a bad state, suffers from well-marked symptoms of melancholia, with delusions. He is desirous of placing himself under active supervision in an asylum; certificates and order for admission are duly filled up and signed, and he is received into the asylum as a patient in a fit state to associate with the family of the physician, at the same time imagining he has come voluntarily. Having resided for three months at the asylum, and receiving active treatment both for body and mind, he leaves the asylum ” recovered.” Within a few days of his dis- charge he finds that he was legally certificated as a lunatic; much domestic grief and unhappiness are the result, and a relapse in all probability ensues.
The Commissioners briefly and feelingly allude to the death of Mr. Bryan Waller Proctor, one of the honorary members of the Commission.
The Eeport carefully describes the condition of the various County Asylums and Hospitals for the poor, and it is highly * Recovered, or as the case may be.
gratifying to find that the reports are generally of a favourable description, and everything appears to be done for the comfort and care of the patients.
The criminal asylum at Broadmoor contains about 429 men and 116 women. The Commissioners say, “We learnt with satisfaction that no person certified to be insane whilst undergoing sentence of penal servitude has been sent to this asylum from Millbank since November. If no more patients of the convict class are sent here, those now in the asylum con- victed in England, and sentenced to penal servitude for various terms, will within ten years have served their time, and can then be transferred to other asylums; but 19 convicted abroad, 12 convicted in Scotland, and 21 sentenced in this country to penal servitude for life, will ten years hence still be here, if alive and insane.”
Another asylum is contemplated for the lunatic convicts now accumulating in prison, and for other convicts who may become insane. The asylum appears to be in a satisfactory condition.
The Report is most instructive, especially to those connected with the treatment and care of the insane, and our thanks are due to the Commissioners for their endeavours to further the kind and skilful management of the insane. Insanity is not what it was some years ago; we have now a recognised Board to inspect asylums, and everything is done to cure the patients by skilful treatment combined with kindness.
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