Discussion on Private Lunatic Asylums
At a meeting of the South London District of the Metropolitan Counties Branch of the British Medical Association on January 21, Dr Alfred Carpenter in the chair, Dr Bucknill read the following Paper :? >
The questions connected with this subject, which your worthy Secretary has requested me to introduce to you, are so numerous and complicated, that I must attempt some delimi- tation of them by asking you to consider, in the first place, on what grounds medical men generally are interested in the exist- ence of private lunatic asylums, and in the laws under which they are established and to some extent regulated. If it be true, as is maintained in the most recently published work on lunacy law, that ” insanity is a purely relative term, at times employed to designate conditions of the mind, which are only diseases in the same sense that general debility is a disease, or in the same sense that bodily fatigue or want of change of air are diseases, and that every passion and emotion may, in prolonged excess, be said to constitute a degree of mental disorder”?if this be true, I cannot claim for the medical profession the right to arrogate any authoritative judgment upon the manner in which such ” conditions of the mind ” should be dealt with. But if insanity be a bodily disease, then medical men have a clear right to discuss, and finally to decide upon, the proper manner of its treatment; and the necessity, utility, and management of private lunatic asylums clearly come within the scope of such a discussion. I think that not only the con- viction of the profession, but the opinion of the public, will affirm the latter proposition, notwithstanding the operation of laws which have come down to us from times when insanity was thought to be something apart from disease?laws which have indeed been patched and enlarged as the crying needs of the time demanded, but which substantially deal with persons suffering from diseases affecting the mental powers in a different manner from that which is customary with regard to all other diseased persons. The operation of these laws has tended, and still more and and more tends, to sequester the insane from the care ar>d treatment of the medical profession at large to render more and more perplexing, dangerous, and difficult the medical treatment of any single case of lunacy ? to herd lunatics toge- 110 FRIVATE LUNATIC ASYLUMS. ther in special institutions where they can be more easily visited and accounted for by the authorities, and to create a class of men whom these authorities can make responsible to them- selves for the confinement and detention of the insane, accord- ing to certain regulations, but whom they do not and cannot make responsible for their proper medical treatment. It would, 1 think, be an excellent subject for one of our future discus- sions to ^ inquire to what extent the herding together of lunatics is beneficial or mischievous, even in those most credit- ably managed institutions for our destitute insane, which are more almshouses than hospitals?I mean the county asylums. But our present inquiry is restricted to institutions for the not destitute insane, institutions which certainly are not alms- houses, and which I am prepared to maintain are not hospitals. In what manner shall we regard these places for the confine- ment and detention of diseased persons, and to what decree are we called upon to extend our feelings of professional brotherhood and sympathy to the men who own them ? Surely none of us can fail to feel and respond to the ” strong claim on the kindly fellowship and protection of the whole profession ” of all medical “practitioners” honourably engaged in the treatment of the insane, and surely we should deny and resent any ” inconvenient and unfair aspersions which have been made upon their conduct.” But surely, also, there is a line of distinction to be drawn between the practitioner and the pro- prietor ; and although fairness is due to every one, I do not see, unless perchance I may be the proprietor of an asylum, why I should be bound to extend fellowship and protection to’ every one of that class. To take a parallel instance: say that I am a ship-doctor, one of a most useful class of practitioners towards whom we all feel the fullest professional fellowship.’ But I am also owner of the ship, or of shares in shipping; surely, I have no claim upon your fellowship as a shipowner.’ Doubtless the cause of the jumble of ideas on this subject which is entertained by the public, and from which the profes- sion is not free, is, that doctors are generally associated with asylums, and asylums with doctors ; but in reality the pecu- niary interest of medical men in private asylums is much smaller than you would suppose to be possible. There are ninety-eight private asylums in England and Wales; and of these forty-nine?being j ust one-half?are licensed to medical men alone, the remaining half being licensed to lay men or to women or to medical men in partnership for this purpose with lay men or with women. Moreover, of the asylums licensed to medical men, the proprietors of many of the most important ones are capitalists, or speculators, or trustees, or inheritors, or hilt-deep mortgagees, to whom they are not licensed, and whose names do not appear.
There are, therefore, two classes of persons connected with private asylums who stand towards us in very different rela- tions. First, there are the practitioners, whether paid by fee or by salary, to whom the whole profession owes kindly fellowship and protection; and, secondly, there are the proprietors of asylums, who may or may not be medical men, and whom we may fairly be allowed to criticise?whom, indeed, it is our strict duty to criticise?in the interests of our profession, of the public, and of those diseased persons whom they are permitted to hold in confinement.
Now, a great deal of misleading analogy has been drawn between the action of medical men, who in the ordinary practice of their profession receive payment in fees for their services, and that of the proprietors of lunatic asylums, who receive payment for the maintenance and detention of their inmates, which pay- ment, in so far as it exceeds the cost of such maintenance, is their profit. I can perhaps scarcely do better, to illustrate this constantly recurring analogy, than by quoting two passages from recent works on the subject of lunacy law reform. Dr William Wood, in his recent pamphlet on the Lunacy Law, expresses his opinion that ” if care be taken that no person shall be impro- perly placed in an asylum, there is no serious wrong inflicted on him if one who has been admitted under these precautions be kept some time after his apparent recovery,” on the ground, as he explains, of the possibility of relapse. Dr Wood proceeds to say: ” Unworthy motives are not attributed to the surgeon who prolongs his attendance on a patient who has broken his leg, and who thinks it his duty to watch and guard against impru- dent and premature use of the limb, though the bone has united. Why should not a physician in charge of an insane person, and why should not the friends of a patient, have the same measure of justice meted out to them as is without hesita- tion accorded to the surgeon ? ” (P. 57.)
Now, without commenting upon the justification of one of the peccadilloes of private lunatic asylums, the detention of patients after their apparent recovery, it must be observed that any surgeon who did act in the manner supposed would most certainly have unworthy motives attributed to him. Only, to make the analogy fit the case, this surgical patient must be put in such a condition that he can in no way help himself, and he must also be supposed to be incapable of saying to the surgeon that he had had enough of him; and also it should be assumed of him that his surgeon was paid by a third party, whose interest it might be that the bone should not speedily unite?
of a child away from its parents, for instance, lying at an hotel. But, in reality, the fees of medical men, even under the old sys- tem of charging for medicines, are not profits. They are charges for work and skill made upon, and paid by, voluntary agents, whereas the profit of a private asylum proprietor is that portion of the payment which is in excess of the cost, and which is great in proportion to the diminution of cost, and valuable in proportion to its continuance ; and, in the well-considered words of Mr. Wilkes and Mr. Lutwidge, reporting to Her Majesty on this very question, ” We fear it must be confessed by all that, where profit is the aim, it will too generally be pursued to the prejudice of those from whom it is derived.” (Report of Royal Commission on Lunatic Asylums in Ireland, 1858, p. 32.) Or, in the vehement words of Lord Shaftesbury: ” This vicious principle of profit runs through the whole.” ” I have no doubt that in the majority of instances, where they are acting on that abominable principle of profit, they screw them down to the lowest possible point.” (P. 100, Select Com. Report, 1859.) I said that I should make two quotations to illustrate the analogy which is often drawn between the action of medical men in the open profession, and of men, medical or not medical, dealing with diseased persons in asylums. The second quota- tion is from a speech of the late Mr. Wakley. I quote from that work?full of information and suggestion in lunacy matters ?The Care and Cure of the Insane, by Dr J. Mortimer Granville, according to whose quotation from Hansard, 3rd series, vol. 59, Mr. Wakley, in August 1841, said, in the House of Commons : ” I entreat the House to observe the operation of the law as regards lunatics. Suppose I have a relation who is possessed of a large fortune. I perceive certain eccentricities in the conduct of that individual. From the great affection I have for that relative, and the still greater affecticn I have for his property, I cause a commission of lunacy to be issued out, and, discovering him to be insane, place him in confinement. Then what motive of action is given, under the present system, to the person in whose charge the lunatic is placed ? Why, it calls into operation the principle of selfishness common to human nature. The proprietor of the asylum will argue that he gets ?400 a-year for the charge of the gentleman so long as he remains under that roof; and if he recovered, then he, the pro- prietor, would lose that annual amount. Suppose an honourable gentleman were to go a doctor and say, ‘My liver is diseased, and so long as it remains so I will give you ?100 a-year!’ what motive in such case would be given to the doctor ? ” The quotation proves how forcibly the situation was even then comprehended by this ” clear thinker and bold speaker ;” PRIVATE LUNATIC ASYLUMS. 113 although, to construct his analogy, he was obliged to suppose the existence of such an agreement as is never made in the open medical profession. I have heard that, in China, medical men are paid salaries so long as their patients remain in good health ; but a stated income received from a patient during the continu- ance of disease is, so far as I know, a thing unheard of out of asylums. I beg you to observe that all I have been saying has reference to the unchanging, and I fear unchangeable, principles which underlie human activities. I might have a good deal to say on the details of asylum management, if I thought it needful or desirable to do so; but I desire to put aside every word which may be construed to have a personal reference, and to ask your opinion, on the broad ground of principle, whether it is right that diseased and helpless persons should be detained and confined in asylums for the profit of private individuals; the amount of that profit depending upon what these individuals choose to expend upon the comfort and enjoyment of their inmates, and its continuance upon the duration of the disease, or what they choose to think its duration. May I not fairly ask you to consider what can possibly justify the existence of these institutions for private imprisonment, owned and kept by private people, lay and medical, male and female; there being nothing like a parallel instance in which the liberty of English- men is submitted to such control ? In former times, indeed, debtors were permitted to be kept in durance by sheriffs’ officers ; but a sheriff’s officer was not quite a private individual, and the thing was felt to be a scandal, and was abolished.
Control over the liberty of children is to a certain extent trans- ferred from their natural guardians to schoolmasters ; but this only lasts for a few months at a time, and the restraint imposed is a very different thing from the detention of a lunatic until he be discharged or die. But, the existence of these institutions being unquestionable, may I not further ask what good reasons can be given by medical men for sending patients to them ? We know pretty well what the motives of relatives are for so doing: separation from and safe guarding of the patient, secrecy, and perhaps the hope of cure. But have we, as medical men, any clear knowledge of the medical treatment carried on for purposes of cure in these places ? Have we, as medical men, any assurance that secrecy will be observed when it is right, and not attempted when it is wrong ? Above all, can we have any confidence that when, with or without medical treatment, our patients have recovered in these places, we shall be permitted to know the fact ? Or, if we should be so bold as to think that we have observed it for ourselves, are we sure that we shall not be contradicted and deceived ? Are we sure that our recovered patients will not be indefinitely detained, under tlie supposition that they only appear to have recovered, and may possibly have a relapse? Perhaps I may be wrong in the opinion that, under the best treatment and the most auspicious circumstances, patients do not often attain to perfect recovery in asylums, any more than they do so in fever hospitals; the last touch of treatment wanted being the cordial restorative of home or the tonic of liberty. But do not the proprietors of asylums often recognise the persistence of symptoms of insanity in patients who appear to us to have recovered, which no one else can observe ? If the matter were not too sad and serious, I could amuse you by descriptions of the manner in which I have myself been kept at bay in my diagnosis of recovery; for although, upon sufficient evidence, you may make up your mind with certitude as to the existence of mental disease, it requires great pains and patience and knowledge of your people to avoid being misled as to the possible existence of symptoms which you may not be capable of observing or of denying.
Suppose, for instance, that the proprietor tells you that your patient, who appears to have recovered, has had a slight stroke, with a little facial palsy and some slight mental obfuscation, which passed off the day before yesterday; or that he has had two or three slight epileptic seizures, and has been a little fierce and angry just after them; or that he hears voices at night and denies them in the morning?upon what principles of diagnosis are you to determine that the gentleman is drawing upon his inven- tion for his statements, and that he will not be inconsolable should the relapse occur which he assures you that he is anticipating? But, as I have referred, however slightly, to my own un- favourable experience, let me also say that I have met with and had the pleasure of knowing some men who are the proprietors of asylums who are as honourable and truthful and just as any men in existence; who forget their profits, and, as physicians, treat their patients with unfailing humanity and generosity and skill; whose doors are freely open for patients to leave with the earliest indication that change will be to the patients’ advantage; whose asylums are somewhat like lunatic clubs, in which the residence of patients is to a great extent voluntary; whose excellent practice, were it general, would go far to redeem a bad system; and whose active usefulness must survive any reasonable and beneficent change in the lunacy law. Of the present position of such men or of such a man in such a system one can only say, ” Que diable allait-il faire dans cette galere ? ” But what to do ?
In the first place, I may broadly state my opinion that no change of the law can be satisfactory which does not contemplate the eventual abolition of all private lunatic asylums. The deprivation of the personal liberty of any of the Queen’s subjects is an affair of the State, and must only be undertaken by the State. From that axiom there must be no flinching-. Such asylums as I have last described may survive, under some other name, as voluntary retreats for persons of defective or damaged mind. For lunatics who must be confined against their will asylums ought to be provided by the State, and managed by boards of governors. Moreover, the care and treatment of quiet and harmless cases of insanity by the open medical profession in domestic life, as single, or double, or treble cases, ought to be encouraged by the law and its administrators, and not dis- couraged, as it is at present. It may be very convenient to Commissioners that the insane should be gathered together in large herds or groups; but it is not to the advantage of any- one else except the custodians ; and the Commissioners must eventually conform to the requirements of the age, and prepare to inspect the treatment of the insane wherever it is most con- venient for the insane to be treated. And the idea of making everything smooth and easy for official visitation, which reached its climax in a proposal that for the convenience of the Commissioners every asylum should be close to a railway station, must be replaced by wider views of official duty.
The discussion of the large question of certification may well be postponed to another opportunity ; only I may observe that 1 think that no tinkering of the present certificate system will suffice to make it safe to the practitioner or satisfactory to the public. The medical man ought to be put firmly upon his right footing as the exponent of scientific opinion : and the action taken upon evidence of that opinion in so grave a matter as that of depriving a man of his liberty ought to be no less than that of the civil power, whatever may be determined for the best as to the judge, or the court, or to the form of inquiry. Moreover, great changes are needful in the administrators of the lunacy laws. The Commissioners in Lunacy are adminis- trators in the metropolitan district, and inspectors only in the remainder of England and Wales ; and it is very certain that the worst asylums to be found in the country are under their immediate jurisdiction. If their Board is to survive a thorough reform of the lunacy laws they ought at least to resign the control of the metropolitan asylums, and to instal the justices of the peace of the counties of Middlesex, Surrey, Kent, and Essex in the same authority which the justices of the peace possess in all other counties, the Commissioners themselves exercising everywhere an uniform power of inspection, report, and superintendence. But a more extensive change is still more i 2 116 PEIVATE LUNATIC ASYLUMS. needful and important, which would render needless this local and partial change. There are socially and logically but two classes of lunatics in the community?those who are destitute and those who are not; and there ought, accordingly, to be only two authorities to administer the lunacy laws, and two laws for them to administer, as they severally regard these two distinct classes of the insane. The present division of authority between the Lord Chancellor’s Officers in Lunacy, the Comm’ssioners in Lunacy, the Local Government Board and the Boards of Ghiardians, the Visiting Justices and Visitors of Asylums, the Boards of Clevedon and Caterham, &c., is intricate, confused, and mischievous. Instead of this, the Local Government Board, or the Minister of Health, when he is appointed, ought to be placed in authority over all subordinate authorities having control over the care and maintenance of all destitute lunatics; and the Lord Chancellor’s Officers in Lunacy, or, to speak with more technical accuracy, the Lord Chancellor, with all his subor- dinate Officers in Lunacy, under the Royal Prerogative, ought to have authority over all other lunatics and persons charged with their care and control. This change would leave no sphere of action for the present Board of Commissioners in Lunacy, the members of which might well be distributed between the two new and enlarged authorities, half of them going to the Local Govern- ment Board, and half of them to the Lord Chancellor. Upon this basis, the details of lunacy law reform could be built up with symmetry, science, and effect; but, without some broad basis of this kind, founded upon a logical principle, any reform of the lunacy laws which we may expect will be but some tinkering of the old pot where the light of day most inconveniently shines through its rust-eaten sides. Be assured, however, that the longer reform is delayed the more comprehensive it will be when it does come ; for the history of social politics is the opposite of that of the Sibylline leaves, and generally the longer you wait for it the larger it becomes. In the meanwhile be it our duty, both collectively and individually, to strive that this most piti- able and helpless class of diseased persons, from whom the profits of private lunatic asylums are derived, shall not suffer longer than we can help under the disadvantages of this worn-out old law. Sequestrated as they have been from our professional care, they are still, as diseased persons, the proper objects of our interest and regard ; and we owe it to them, not less than to ourselves ana to our profession, to strive that the law which governs their care and treatment shall be conceived and executed in the spirit of benevolence, of the scientific knowledge of disease, and of the true relations which the ethics of our pro- fession teach as being consistent with the true dignity and wel- fare of both medical practitioner and patient. PRIVATE LUNATIC ASYLUMS. 117 Mr. Nelson Hardy, Honorary District Secretary, read a letter from Dr Lush, M.P., in favour of the abolition of private asylums. The Chairman said that he protested strongly against any of the work referred to being thrown upon the Local Government Board. There ought to be a Minister of Health in this country, on whom should devolve the care of all institutions connected with the health of the people. He did not think that it was a matter that the Local Government Board could possibly deal with in a proper spirit. The medical profession should them- selves take the matter in hand, and should press strongly upon the Government the views that were put forward lately by Mr. Powell in his address on Public Health, so as to obtain from the Government a recognition of the rights of the medical profession and the appointment of a Minister of Health. One of the things that should be placed under his care was the management of the insane. He supported the observation made by Dr Bucknill with reference to the multitude of authorities that had the control of the poor lunatic. The expense that those authorities threw upon the State was much too large. He was taking part in the building of a third asylum for Surrey, to hold one thousand patients ; and the requirements of the Commissioners and of the Local Government Board had been such, in his opinion, as to lead to an enormously increased, and he thought unnecessary, expense in connection with that building. He had strong opinions with regard to the herding together of large numbers of lunatics: still the law required it; but the sooner some of the lunacy laws were altered (which ought to be done by medical aid) the better.
Dr Newington (Ticehurst) said that the question was not whether proprietors of private asylums had honesty of purpose, but whether they were obliged by law to have honesty of action ?whether there was not a sufficient guarantee for their honesty. Several charges had been made against them. One was made some years ago, and it originated in some terrible facts. It was said, first, that sane people were shut up ; and, secondly, that they were ill-treated by those who had charge of them. No doubt, previously to Mr. Warburton’s Bill (he believed in 1828), there was a vast amount of wrong done. But since then there had been various select committees, and those charges were practically abandoned by all who had any right to speak in the matter, including Dr Bucknill himself, the Visitors, and also the Commissioners. Even the philanthropists did not state that there was now anything like shutting up of sane people, or cruelty to those who were shut up. A third charge was, that the patients were detained after they were cured. If that had been true for many years, one absurd effect would be that the asylums would be blocked up. He would put before the meet- 118 PRIVATE LUNATIC ASYLUMS. ing a few figures extending over ten years, which he thought would put the case rather the other way. The average yearly residence in county asylums was in round numbers 32,000, and the admissions were 10,000?a proportion of 31. In the hospitals there were 785 admissions, and an average residence of 1,887 ; showing a proportion of 2-|. In private asylums there was an average residence of 4,445, the yearly admissions being 1,835 ; giving a proportion of 2f. Thus, in county asylums the proportion was 3A-, and in hospitals and private asylums together 2-|. In other words, supposing the various classes of asylums were absolutely empty, and there were no deaths or removals, it would take 3^ years to fill the county asylums ; 2^- years to fill the hospitals ; and 2f years to fill the private asylums. Another view was still more convincing. The average residence in the county asylums was 32,231; the discharges and deaths together amounted to 8,893. The average residence in hospitals was 1,887 ; discharges and deaths, 786. In pri- vate asylums the average residence was 4,445 ; discharges and deaths, 1,856. These proportions showed that, supposing no more admissions took place for a certain time, it would take three years and seven months to empty county asylums; two years and five months to empty hospitals; and two years and four months to empty private asylums. He found also that there were nearly 12,000 more in county asylums than there were ten years ago. In hospitals there were five fewer patients than there were ten years ago. In private asylums there were fewer now than there were ten years ago by 237. That showed that there was neither a stagnation nor a tendency to block up. It had been said that proprietors of private asylums did not wish to cure their patients, because it was better to keep them as patients. The average rate of yearly cure was calculated by dividing the admissions by the cures ; that was, supposing an asylum admitted one hundred patients in a year, and discharged forty-two, the rate of cure was put down at forty-two. The average rate of the cure of lunatic patients was between 38 and 40 per cent.; in private asylums it was about 32 per cent. Those figures, however, must not be taken alone. Dr Thurnam brought out some tables, and Dr Needham had followed, taking twenty-six or twenty-eight years of the more recent results. On the Select Committee of 1877, Mr. Wilkes, in his evidence, produced some figures which he had elaborated from reports of thirteen county asylums ; and it was shown that 54 per cent, of the patients taken into asylums within one year of the seizure should be cured, and that between 5 and 7 per cent, was all that could be expected to be cured after the first year. To compare with these figures he had not any extended returns from private asylums, as these did not publish printed reports; and he had therefore been obliged to take one hundred cases from his asylum at Ticehurst. Of these patients 31 were already cured, and 6 were patients that were curable ; if 4 were cured, there would be 35 cured out of 100. That would answer the objection that there was not a wish to cure the patients. If the figures were read in a prope1* way the private asylum proprietors did as much work towards recovery as their colleagues did in the public asylums or hospitals. As to the question of self-interest, the great fallacy in all this argument was that, because a man’s in- terest might lead him to do wrong, he was bound to do it. He did not see why private asylum proprietors should be neces- sarily wanting in honesty. A man’s interest might lie one way, but there was no necpssity for him to follow it. It was assuming that he had no moral integrity whatever. As to private patients, there were only about three thousand really private patients; a considerable number ought not to be placed in that category.
For instance, at Grrove Hall there were 452 soldiers, paid for by the Government, and who therefore ought not to be regarded as private patients. With regard to single patients, it appeared that the cures were 9 per cent. “With regard to the originators of the charges, there were patients who always had grievances against the private asylum proprietors, and a few of these had lately abused them ; but against their statements could be put the kindness shown by other patients. As to the lay newspaper writers, their experience must be borrowed, and their informa- tion came through the narrow channel of a few people. The medical profession must depend for most of their knowledge on what they were told by other people. A writer in a medical paper had started weighted with an old editorial tradition; but he (Dr Newington) believed he had not had any practical know- ledge of insanity to back up his theoretical opinions. He would answer Dr Bucknill by quoting his opinions given before the Select Committee. He had expressed in his paper a wish to abolish private asylums. In answer to question 1,910 before the Select Committee, ” Would it not be desirable to get rid of private houses by degrees ? ” he observed, ” I should be very sorry to see them got rid of.”
Dr Bodington (Kingswinford) said that he desired to bear testimony to the endeavour which Dr Bucknill had made to treat the subject in a moderate and temperate manner. A great deal of heat had been imported into the controversy, not by the private proprietors of asylums, but by agitators against them. It was very desirable that members of the same profession, occupying different callings, should treat one another with temper, moderation, and forbearance. Dr Bucknill did not quite bear out his argument with regard to the analogy between private asylum proprietors and their profits and ordinary practi- tioners and their profits. In all callings there were some dis- honourable men, but it was hoped many more honourable ones. Dr Bucknill first stated that a number of charges might be made against proprietors, and then he took as exceptions a certain number of honourable men whom he had known. If private asylums were to be defended, they must be defended upon the ground of the medical proprietors being equally honourable with the rest of the profession. It seemed to him hard that, because the present private asylum proprietors hap- pened to be the incumbents of offices which had been handed down to them from time immemorial, they should be attacked as if they were a special race of pariahs not worthy to be asso- ciated with ordinary decent people. In the last report of the Commissioners there was some excellent testimony that medical proprietors of asylums were men of at least equal honour and equal sensitiveness to their honour with any other body of men. Dr Hicks said that he was one of the proprietors to whom Dr Bucknill had referred. He was not prepared to hear all he had heard ; but he was not surprised. He was anxious to hear what statements Dr Bucknill was going to make, and what facts he was going to bring forward to support those statements. Dr Bucknill had brought forward cases in support of the system of private patients. If Dr Bucknill had any facts to bring forward he ought to have done so; but he had not. Two years ago he (Dr Hicks) appeared, with Dr Bucknill, to prosecute a medical man for keeping a single case. It was a case under the care of a private medical man, and Dr Bucknill’s report proved that it was a most detestable one?such as could not possibly have occurred in any private asylum in this country, and such as, he would venture to say, had never been reported in this country. He believed Dr Bucknill had appeared on other occasions to prosecute cases of this kind; and yet he now stated that private asylums were most detestable places ; that the proprietors were the black sheep of the profession; and that their patients should be scattered far and wide, leaving them without government, protection, or anything else. The private cases were not perhaps visited once a year, while the private asylums were visited six times in a year, and every possible contingency had to be reported to the Commissioners. Dr. Bucknill had told him, on the occasion referred to, that he would like to have a private asylum in the suburbs of London, but that the Commissioners would not sanction it. [Dr Bucknill denied that he had said this.] Dr Hicks said that he was a proprietor, and he did his utmost to act honourably, and had never given cause of complaint. There were also other pro- piietors who bad had rio complaint brought against them; and yet Dr Bucknill charged them with keeping patients longer than ley ought to do, a:nd that they did it from personal motives; lat the proprietors had not attempted to discharge cases when they were cured.
Mr. W. Gr. Balfour did not think that the argument for an against private asylums was likely to do much good. Last session Mr. Dilhvyn introduced into Parliament a Bill contain- ing every one of the things which Dr Bucknill had proposed as reme les for existing evils. He did not see what was the use f eeP}n& UP ,^ls sor^ ?f warfare. He would rather bring e ore the meeting a resolution that it accepted Mr. Dillwyn’s i as a measure of reform in lunacy law, and that they should proceed to consider its clauses.
Ihe Chairman said that the meeting could hardly take up a resolution, because no notice had been given. What they f^616. s?uss*nS” was Bucknill’s paper. Any matters brought orwar m the paper Mr. Balfour would be justified in opposing. ?j j ^ lr sa*d that the meeting had before it a set of one-sided facts or half-truths. What Dr Bucknill said about asy ums^ was m a great measure true; but he had given only a - rut is. He did not say how many patients the proprietors ia or ?40 or ?G0 a year, which would not pay for their epp , ie did not tell of the good actions of the asylum pro- prie ors. These statements that were being made were only atoi a ing the public, and keeping the patients and the asylum proprietors in a state of dissatisfaction and discontent. He ^le ar^c^es which had appeared in the British ec real Journal on the subject. A new Bill would be intro- uced next session, founded upon Mr. Dillwyn’s. He suggested . f aPP?intment of a Committee to take Mr. Dillwyn’s Bill into consideration.
Mr. Nelson Hardy said that they could not go off from the iscussion of the paper read into another thing, which would require some time. There were two courses open : they might a journ the discussion for a fortnight; or, on the other hand, a er hearing Dr Bucknill’s reply, they might consider this iscussion closed, and start on the next occasion with the con- sideration of Mr. Dillwyn’s Bill.
3Pr* ^?od moved the adjournment of the discussion, i Ii. Lodington seconded the motion for the adjournment, e would ask Dr Bucknill to acknowledge that he had made a mistake in the recent trial to which he had referred in regard o ice-Chancellor Malins. He believed that the great majority oi medical asylum proprietors were in favour of abolition. In that he quite agreed with Dr Bucknill.
Dr Bucknill entirely concurred in what the Chairman had said with regard to the Minister of Health. He had only men- tioned the Local Grovernment Board as the authority in posses- sion; but, if the Grovernment were determined to appoint a Minister of Health, it would be quite right that that minister should have authority over the destitute insane throughout the country. ” Dr Newington’s speech had made a great impression upon him. His statistics were exceedingly interesting and valuable ; but there was a difference in the statistics of a large number of small institutions scattered over the country, many of which had neither clerks nor boards to regulate the move- ments of patients. He remembered a superintendent of a county asylum in the old days who got a reputation for a great proportion of recoveries ; but, after a while, it was found that he had a certain number of patients whom he discharged as cured every December and readmitted them every January. He was very much struck by what Lord Shaftesbury said in his evidence in 1877, that they sent out a great number of patients on trial whom they never heard any more of. What became of them ? They were certainly not understood to be cured. As regarded Dr Hicks’s statement, if he had thought fit to apply for a licence, the Commissioners in Lunacy would have been most willing to give him one.
The resolution for the adjournment was carried unani- mously.
At an adjourned meeting of the South London District of the Metropolitan Counties Branch, on Wednesday, February 4, the discussion on this subject was resumed by Mr. W. Gr. Balfour, who read the following paper :?
At the last meeting of this Society, Dr Bucknill fully explained to you what are regarded as the defects and short- comings of private asylums and their proprietors. These defects and shortcomings are denied by asylum proprietors, who believe that they have no existence except in the lively imagina- tions of a few chronic lunatics, whose insanity is of a type that unfits them to associate in the same buildings with their fellows more honestly afflicted. With such conflicting assertions put before them, it is not a matter for wonder that the public have a dim idea that all is not as it should be as regards the care and treatment of the insane ; that they readily pay attention to any description of a private asyum, however far- fetched, that is put before them in the lay an cf medical papers; and that they too easily believe what they hear.
When a veteran in lunacy like Dr Bucknill throws the weight of his vast experience into the question, and, by writing and speaking, joins in the crusade against private asylums, not PRIVATE LUNATIC ASYLUMS. 123 only the public, but even our own profession, have their faith in the value of these institutions shaken, and entertain grave uoubts as to the worth of their proprietors. Unfortunately for all interested in the treatment of the insane, there is not one of the charges brought against private asy urns and those who have to do with them which might not >e rue. Fortunately, however, for us all, these charges cannot e substantiated. Dr Bucknill and those with whom he associates himself in this matter fail to distinguish between W a ,rsht ^ an<^ w^at *s? hence the antagonism between them an e proprietors of private asylums. If we go to the root of e w lole matter, we will find that the unsatisfactoiy state of ie unacy law gives origin to the question in dispute. This unacy aw, were it not for the honesty of the medical profes- sion, could be so manipulated as to render insecure the liberty o any one of Her Majesty’s subjects. It is perfectly possible for an^ in rS?n falsely sent as insane to an asylum, to be unjus y treated while there, and to be detained, even when proper y confined, longer than necessary, if the lunacy law, and e unacy law alone, were the protecting agent; and it is this possi llity of wrong being done (that agitators lay hold of and convert into a reality) which furnishes the basis for all attacks upon pnvate asylums and their proprietors.
e can excuse the public for being led astray in this matter; Ju , gentlemen, can we extend the same forbearance to members o our own profession, who seem to ignore the great glory of ien calling, that its honour is above the law and prevents wiong-doing, for which the law makes, to say the least, most insecure provisions ?
On the question of profit derived from keeping private asylums Dr Bucknill expresses himself as adverse to members o the medical profession deriving gain from the treatment of e disease insanity in private asylums. I do not think he specified any particular gain obtained from the care and treat- ment of the insane in private asylums as an unfair gain; it seemed that any gain from such a source was wrong. From one point of view Dr Bucknill’s idea on this subject is highly laud- a e and deserving of our most serious consideration, whilst rom another it is simply absurd. Dr Bucknill will forgive me or pointing out that physicians, when they receive a guinea for a piescription, are not in the habit of calculating this guinea as the profit they derive for the paper and ink they use in writ- ing the prescription. Of course the paper and ink used by the physician cost money; but so do bricks, mortar, lands, servants, tood and clothing used in the treatment of the insane ; and even the medical profession cannot entirely overlook the cost of such tilings. Private asylums are to their proprietors neither more nor less than the paper and ink to the physician. In both cases it is the knowledge of the disease which is treated that is the source of income, and it is for this knowledge that payment is expected.
All the same statements and counter-statements on the subject under consideration will not allay the feeling against private asylums that exists in the minds of the public; and it behoves us, therefore, to see if by anything we can do we can give the public what it wants, and, at the same time, secure for our speciality that position which it ought to have. Would it not be advisable for asylum proprietors, instead of persistently refusing to recognise the defective state of the lunacy law, and being always ready to do battle for its defects by meeting charges unjustly brought against them, and for which the law alone is answerable, to turn to the public, and say: You think so badly of us and our asylums that you wish them done away with ; we are quite willing that it shall be so ; and, in order to help you, we advise you to go to Government and ask that the powers conferred on the justices of counties and boroughs to raise money for the purpose of providing accommodation for pauper lunatics in their respective districts should be extended, to enable the justices of counties and boroughs to raise money in like manner for the purpose of purchasing the private asylums and licensed houses, with all rights, &c., belonging to them in those districts ? Such a proposal as this, coming from asylum proprietors, would show that they, at any rate, were willing to bow to the opinion of the majority, which in all cases of public weal must be followed; and, on this point, Dr Buck- nill and I are agreed, but we arrive at the same opinion by very ditferent roads. If, gentlemen, you agree with Dr Bucknill and myself that it may be advisable to abolish private asylums as such, and hand them over to Grovernment, and that we ourselves should take the initiative in this change, the transfer could only be made on strictly commercial principles, for asylum-proprietors have their rights as well as other people; and, in parting with their asylums, they would expect, and are entitled, to receive adequate remuneration for what they give up.
I would suggest that the price paid by the justices to the proprietors of private asylums and licensed houses for the said establishments ought to be determined by the value of the land, buildings, plant, etc., belonging to, and used in the working of, the establishments, and by a sum of money paid to the pro- prietors in lieu of goodwill. As a business transaction, the total sum to be paid would require to be one which, if invested at fair interest, would return to asylum proprietors a yearly in- come equal to what tliey had when they parted with their asylums. Adopt this view of the question, and I can see no reason why the change of proprietary should not take place; at the same time, I can see for ourselves an opportunity of pro- moting the highest interests of our profession.
If private asylums become Government property, it would he necessary to allocate them into districts; and that the justices of counties and boroughs should appoint for each dis- trict a duly qualified medical man to act as medical director of the public asylums in those counties and boroughs, to generally superintend the management of all the asylums. The medical director so appointed shoidd be responsible to the justices in general and quarter sessions, who would determine his salary, and provide him with such assistance as might be deemed ad- visable to enable him to discharge .the duties imposed on him. It would also be necessary that the officers, medical and otherwise, holding office in private asylums or licensed houses at the time of transfer of these establishments from the pro- prietors to the justices, should be continued in their offices. The salaries should be arranged between the said officers and the committee of visitors, subject to appeal by the officers to the Commissioners in Lunacy in the event of any salary offered by the committee of visitors being considered by them unfair. The decision of the Commissioners in Lunacy to be final. All officers so appointed should be entitled to the provision as to superannuation, grants, etc., at present in use in public asylums. These two proposals, I submit, would, if carried out at once, raise the speciality to the front rank of medical services. A new and valuable appointment would be created, open to all connected with lunacy. The present medical proprietors of asylums would retain their original capital, and would receive Government appointments at fixed salaries whilst they were able to work, and a pension when incapacitated for further service. They would have independent positions, and be freed from much that, in discharging their duty, is at present distasteful to them. Last, but not least, they would be cleared of that unjust sus- picion which now attaches to them, that they, and they alone amongst medical men, do professional work for gain, and gain only.
In order to place all private asylums in the country on the same footing, it would be necessary that Dr Bucknill’s proposal regarding private asylums in the metropolitan districts should be carried out; and for this purpose it should be enacted that private asylums and licensed houses situated in the metropolitan district, and being under what is termed ” the immediate juris- diction ” of the Commissioners in Lunacy, should be in future under the jurisdiction of the justices in their respective dis- tricts. In addition to the reason given above for such a step, tliere is another, and one of much greater importance to us as medical men. The law, as it at present stands, provides for the Commissioners in Lunacy granting licences within a certain area to persons to receive lunatics for care and treatment into their houses. The Commissioners in Lunacy interpret this clause of the law as conferring on them the power to refuse to license houses, notwithstanding compliance with all the re- quirements necessary before a licence can be granted. By this course of action they virtually establish a monopoly in the treatment of disease in the metropolitan district, and conserve to a number of our profession, and to them alone, the power to receive patients in that district. On this ground, we, as medical men, are bound to come into antagonism with the Commissioners, as it is our duty to maintain that we, and we only, are the proper persons to decide how and where our patients shall be treated.
Dr Bucknill suggested that the Lunacy Commissioners and the Lord Chancellor’s Visitors should be amalgamated. Such a step as this would, in all probability, be highly advantageous ; and, in contemplating such a change, it might be well were we to try to have the Commissioners more largely represented by members of our own profession.
Thus far I have dealt with Dr Bucknill’s remarks mainly as they relate to the profession ; they must also be considered as affecting the public. As before stated, any person may, under the present law, grant an order for the reception of any other person as a lunatic into a private asylum. A wife may give an order for the confinement of her husband, a husband for his wife, a servant for his master, or a master for his servant; even a complete stranger may sign away the liberty of a person regarding whom he absolutely does not know any- thing. It is quite possible, as stated by Dr Bucknill, for a wife to be sent to an asylum without the knowledge of her husband ; but I am at a loss to conceive by what power of reasoning he should imply, far less hold it up as a cause of complaint to you, that medical proprietors of asylums are responsible for such a state of things. Would lie accuse the surgeons of any hospital in the country of wrong doing, because they receive into their hospitals and treat people who require treatment unknown to their relatives ? Asylum proprietors have legal authority for such a step ; and if, acting strictly on this authority, they receive persons into their asylums, are they to be blamed because some of the relatives are ignorant as to where their friends may be ?
There is a protecting agent which prevents persons from being unjustly deprived of their liberty by being sent as lunatics to asylums; for, before such a step can be taken, two medical certificates of insanity must be obtained. It is these medical cer- tificates, which cannot, I am proud to say, be dishonestly bought, that are the safeguard of the public. That not one of the agitators can point to a single case of false certificates having been granted, and substantiate it, is only another instance of the integrity of an honourable ‘profession. This, gentlemen, is the opinion we asylum-proprietors entertain has to how you do your duty; and I feel sure you will believe me when I say that, were it possible for the same person to be brought to us certified as a lunatic, we should refuse to receive such a case. Neverthe- less, there still remains, as an inheritance from bygone days, the vulgar delusion that insanity is different from any other disease, and requires for its treatment isolation in some establishment which shall combine the properties of hospital and menagerie.
Many things are concerned in keeping this feeling alive in the country; and I am sorry to see that the Commissioners in Lunacy, by objecting to persons, feeling for the first time that they are going insane, being received as voluntary patients into asylums, are helping to perpetuate such an unhealthy idea. The evidence given before the Select Committee of the House of Commons showed that, in regard to the law as it provides for the admission of persons said to be of unsound mind into asylums, twenty-eight witnesses were asked to state whether or not they considered that it was sufficiently stringent to prevent injustice from being done. Of the twenty-eight, twenty-five Were of opinion that by alterations affecting either the order of admission or the medical certificates, increased protection would be afforded. In order that the public may have their desire fulfilled, that when any of their number go insane they shall receive not only treatment, but a legal right to be secluded from the world whilst undergoing this treatment, granted by some constituted legal authority, it would be well to provide that it shall not be lawful for any person to be received as a lunatic into any asylum except upon an order granted by a justice of the peace of the district in which the lunatic resides. Such order should be granted by the justice upon a petition subscribed by the party applying for the same, who must be a blood-relation or a householder, and of age, accompanied by a statement of particulars regarding said lunatic, and by certi- ficates under the hands of two registered medical persons, neither of whom should he related to the lunatic, or in any way interested in the asylum to which it is proposed to send the lunatic; and no superintendent of any asylum should receive or detain any person as a lunatic therein, unless there should he produced to, and left with, such superin- tendent such order by a justice, dated within fourteen days prior to the reception of the lunatic. Provided that the superin- tendent of any asylum might receive and detain therein, for any period not exceeding forty-eight hours, any person as a lunatic, whose case was duly certified by one medical person to he a case of emergency, thereby affording time to obtain the additional certificate and the order of the justice.
One of Dr Bucknill’s strongest accusations against private asylums is, that persons are detained in those places longer than necessary. This assertion has two sides to it, like everything else. It is just possible that what might appear to Dr Bucknill, with only limited knowledge of a particular case, unnecessary detention would, to those most conversant with all the circum- stances of the case, be not only necessary but essential for the safety of the individual whom it most concerns?viz., the patient. Even if an error in this way sometimes takes place, it is, as a rule, an error on the right side.
At present it is extremely difficult for asylum proprietors to advise continued detention when the friends of patients wish them to be liberated, although their experience tells them that the detention is needful; and I should think that they more frequently err in discharging rather than keeping persons in their asylums. Seventeen witnesses were asked by the Select Committee whether detention in private asylums was unduly prolonged, and of those ten admitted that it was possible and probable, and four that it might take piace.
The transfer of private asylums to the Grovernment would relieve their proprietors from all suspicion of wrongdoing in this way; and to make the public security more complete, it would be well to provide that in no case shall the powers conferred by the justice’s order remain in force longer than the first day of January first occurring after the expiry of two years from the date on which it was granted, or than the first day of January in each succeeding year, unless the superintendent or medical attendant of the asylum in which the lunatic is detained, on each of the said first days of January, or within fourteen clear days immediately preceding, grant and transmit to the Commissioners in Lunacy a certificate to the effect that the detention is ne- cessary and proper, either for his or her own welfare, or the safety of the public.
And as complaints were made to the Select Committee regarding the difficulty there is for persons interested in lunatics obtaining access to them, and it has been pointed out that the necessary permission could only be granted by the person who signed the order for admission or by the Commissioners in Lunacy, it would be well to provide that it shall be lawful for any person, having procured and produced the certificate of two medical persons approved by the Commissioners in Lunacy, hearing that any lunatic may without risk or injury to the public or to the lunatic himself be set at large, and also an order from the Commissioners in Lunacy for the liberation of the lunatic, to require the superintendent of the asylum in which such lunatic is confined to liberate such lunatic. These suggestions are found to work perfectly well in other countries; they legally provide a valuable safeguard against unjust deten- tion in asylums, and there seems no reason why they should not be used in England. Dr Bucknill advocates the individual rather than the associated treatment of the insane. I have seen both plans tried, and where they can be worked together they are produc- tive of great good; but once admit that chronic and harmless lunatics should be removed from asylums and placed under private care, and (independent of the difficulties which would arise alike to patient and the profession) you implant into the country a source of evil for the present and the future which nothing will get rid of. The removal of chronic lunatics from asylums would result in the loss of one of the principal curative agents which asylum doctors possess ; to increased taxation, as what is paid for chronic cases helps to balance the cost of keep- ing acute; to asylums becoming places where it would be impossible for sane persons to live for any length of time, without reverting to the old system of treatment with chains and whip, and to numerous other ills, which only those connected with asylums can realise.
The suggestions placed before you as a means of remedying some of the ills alluded to by Dr Bucknill are only meant to furnish a basis upon which a measure, partly of reform and partly of alteration, might be constructed. I have tried to put matters relating to private asylums and their proprietors, com- plained of by those who are opposed to them, in their true light. I have pointed out that the insinuations which are being con- stantly laid before the public against private asylums and their proprietors are founded on a defective state of the lunacy law, and not on faults attaching to the asylums, or to those to whom they belong. I sincerely trust that, if accusations are brought against asylum proprietors in the future, they will be individual and specific, in order that they may be answered ; and where defects exist having their origin in the lunacy law that the lunacy law may hear the blame.
Dr William Wood had moved the adjournment of the dis- cussion because he thought that Dr Bucknill had not been sufficiently understood. His paper had been read, not as a voluntary communication, but in response to a request from the Secretary of the district. The paper must, then, be looked on as the production of a literary athlete, rather than of an eminent physician attacking his professional brethren. With regard to the proposed abolition of private asylums, he would ask, Who are those who wish that private asylums should be abolished ? It would scarcely be said that the patients themselves would wish it as a rule. No doubt there would be exceptions; but these would abolish asylums altogether. It certainly would not be the friends of patients, because they were under no kind of com- pulsion to make use of the asylums ; and, as regarded the public generally, it could not be pretended that any case had been made out to rouse them to action. It must, then, be the gene- rally philanthropic desire of the literary profession to protect the oppressed, which in fact personated public opinion and asked for the abolition of private asylums, not because they had dis- regarded the claims of the public, but lest they might be tempted to take unfair advantage of the powers entrusted to them. He contended that private asylums, far from being deserving of obloquy, were entitled to the gratitude of the public, for they had rendered an important service in providing the means of treating the insane of the upper and middle classes. Dr Bucknill had expressed the opinion that ” the deprivation of the liberty of any of the Queen’s subjects was an affair of the State alonethis observation, however, applied with precisely the same force to public asylums, whose authority to receive patients was identical with that of private asylums. He admitted that the deprivation of the liberty of any of the Queen’s subjects was an affair of the State alone. The State had availed itself of the services of private individuals, and by legislative enactment had directly authorised them to take care of insane persons, for whose safety and treatment there was no other provision. It had also the aid of private individuals in such part of the duty of maintaining the safety and integrity of the empire as the Government thought could be better carried out by such means. All governments had availed themselves of private assistance, even in the most important of their functions; and so in the case of insanity they had availed themselves of the assistance of private asylums, and in fact directly so until recently, in the charge of what were called criminal lunatics in Dr Lush’s asylum at Salisbury, and up to the present time in the charge PRIVATE LUNATIC ASYLUMS. 131 of insane soldiers in Dr Stocker’s asylum at Bow. The pro- prietors of private asylums were not so foolish as to expect that they would be maintained for their own personal benefit, if the Government had reason to believe that the work would be better done under some different system; but they would ask that, if any such good reason could be shown why in the best interests of the public they should be abolished, their past ser- vices should be fairly considered. Dr Hack Tuke said the most salient feature in Dr Bucknill’s paper was, that the time had come for abolishing private asylums. He supposed that, in the abstract, the State had the right to interfere to abolish them, and therefore it became a question of expediency; and this would depend on whether there was a very great abuse or any strong public feeling against them ; and on the feeling of private proprietors themselves. He thought the time had come for some radical change, such as transfer to the State; but it should not be on the ground of proved abuse. It must be on that which really lay at the bottom of public feeling on the subject?the undesirableness of helpless persons being confined against their will by those who derived profit for keeping them. However little this could be proved to end in abuse, it had become expedient to contemplate a change; and this was greatly facilitated by the readiness of the proprietors themselves to yield to public opinion, provided proper compensation were made. He thought Mr. Dillwyn’s Bill, if modified, might possibly prove satisfactory both to them and to the public.
Dr Rayner said Dr Bucknill had spoken of lunatics being ” herded together,” but this happened more in public than in private asylums, and was due to want of a sufficient number of medical officers. Dr Bodington advocated the abolition of private asylums on the ground that it would be beneficial both to the public and the proprietors, who, of course, must be fairly treated. Dr L. Forbes Winslow said: I have come here this evening in consequence of seeing the prominence which has been given to the last discussion in the daily press. I think it only proper that in such an important matter both sides of the question should be freely discussed at your meeting. I am, therefore, glad of an opportunity of doing so.
There are few subjects that can engage the serious attention and consideration of the friend of humanity of more importance and at the same time of more painful interest than the condition of the insane.
The feelings of everyone who is in the enjoyment of that greatest of earthly blessings, the mens scina in corpore scino, are enlisted on behalf of the poor soul who, bereft of nature’s light and guide, is degraded below his species, and reduced to the level of the beast which perishes.
|’ Man’s boasted prerogative denied, the hapless lunatic wan- ders, frail, helpless, uncared for, on the shores of this great universe, depending for very existence upon the sympathy of those more fortunate. But, alas ! too often those under whose supervision he has been, placed, instead of being assisted and aided in their sacred mission to win him back to light and reason by kindness and protection, are harassed and interfered with in their work by unjust accusations and groundless asser- tions on the part of some persons who are strongly prejudiced. I approach the consideration of the subject in no unfriendly spirit with the gentleman who opened the debate on the last occasion. Dr Bucknill is one for whose opinion I have always entertained the greatest respect and esteem, and from his world-wide reputation and skill it is with a certain amount of apprehension and diffidence that I find myself, as I do on this occasion, diametrically opposed to his views. I trust, however, that any remarks I may make this evening may be accepted ex pleno animo, and in no other way. The question of the abolition of private asylums is one which from time to time has cropped up, generally as a rule after some sensational case of lunacy which has occupied the attention of our law courts, and has been made a bete noire for attacking these institutions and their proprietors. It is an extraordinary fact, however, that in all the recent great lunacy trials private asylums have come out of the attack without a single impeachment against them, whilst their proprietors remain unspotted and unscathed. Not- withstanding this the cry is still for their abolition. For many years committees of the Houses of Parliament have sat at various intervals to discuss private asylums and their management. I hold in my hand a pamphlet entitled The First Annual Report of Madhouses, made in the year 1816, and ordered by the House of Commons to be printed April 26, 1816. This is very rare, and I shall be happy to pass it round, for the perusal of the meeting. It is not my intention to consider in detail the various Acts of Parliament which have been passed since this period; suffice it to say, that mainly to the exertions of Lord Shaftesbury we have our present Act 8 and 9, and which many attempts have been made to upset. I think, however, I must draw your attention to the late Committee of the House which sat two years back. After various allegations and accusations had been brought against proprietors of private asylums, and the evidence had been heard pro and con., the following appears in the report of the Lunacy Committee as a result of their investigations, that no mala fides had been proved against the medical proprietors of private asylums. After this the matter should have ended, at least for the present. It has, however, been again brought forward with renewed vigour and renewed opposition. In the year 1859 Lord Shaftesbury gave evidence before the then sitting Lunacy Committee which was condemnatory of private asylums : ” At present, from a variety of causes, the licensed houses are in a far better condition in every sense of the word; more is expended on them by the proprietors, and I must do them the justice to say that the change is very great; and so far as the evidence I gave in 1859 is correct I should not give it now. I can speak in high terms of many licensed houses and their proprietors ; but I will add that, if you relax your vigilance ever so little, whether it be of licensed houses, or of hospitals, or of county asylums, the whole thing will speedily go back to its former level.” These are the words and the opinion of one for whom we have the greatest respect, as he speaks authoritatively on the question.
I am not here this evening to defend our Act of Parliament, but to endeavour to show that we perform our duties in a right spirit. Is it just that the proprietors of private asylums should be held up to opprobrium? Individually speaking, which may also be taken as the opinion of those physicians and surgeons who are the licensed proprietors of private asylums, T say that when it can be proved that we have detained patients in our asylums longer than is absolutely necessary for their welfare and cure, or have received them when we ought not to have done so, so soon, I say, erase our names from your medical associations, strike us out from being members of our medical corporations, deprive us of those diplomas which we have so honourably obtained, and of those degrees which we have earned?banish us, I say, from society, and leave us to grovel about the earth as a disgrace to humanity; therefore, anyone who so insults medical proprietors of private asylums insults the whole of the profession. For have we not studied at the same medical schools? Do we not hold the same degrees ? Have we not had the same medical teaching, the same moral and social training, as you ? Have we not all the same feelings and desire to act honourably? The poor un- happy lunatics are not now chained like felons to some foul pestilential dungeon, there left to the gaze of those anxious to gratify a morbid curiosity. Gratitude and immortal glory must be given to those who exposed and laid bare these frightful atrocities, and so assisted the physician ” in minis- tering to a mind diseased,” and those names will stand prominently and most honourably forward in the history of civilisation. Philanthropy was never more needed or employed to better purpose.
I have no wish or desire to attempt to suggest legislative measures for private asylums ; suffice it to say that I shall hail with pleasure any clause in the new Act which shall be of itself sufficient to protect proprietors from a possibility of accusation. I have simply come here stung to indignation with the unjust stigma, and to maintain and protect what is dearer to an Englishman than his life, his honour?this I have come to-night to vindicate.
Who steals my purse steals trash. But he that filches from me my good name Robs me of that which not enriches him And makes me poor indeed.
Dr Bucknill, in reply, read extracts from the evidence of Mr. Balfour before the Select Committee of 1877, before he became the proprietor of a private asylum. Mr. Balfour said : ” Private asylums are the property of individuals who derive large incomes from keeping them ; it is the interest of the pro- prietor to have as many good paying patients as possible in his house ; it is not his interest to get rid of patients who pay well; and, as the law is, it is as nearly as possible impossible for any person to get out of a private asylum without the sanction of the person who signed the application, should the person who signed the application be unwilling to apply for the discharge. There are thus two things against the persons getting out; the one is the desire of the medical officer so to keep them in the house, the other is the unwillingness of the relative or the person who applied for the admission to take him out.” Mr. Balfour’s account of that element of asylum-life upon which the good or ill treatment of the patients most depended was even more instructive. After telling the Committee that “the language of attendants is often coarse and rough, and the patients get pushed about in a rough way,” Mr. Balfour replied to a question as to whether the proprietors of asylums are generally willing to give such pay as will secure them good attendants, ” They take men as cheaply as they can get them; the cheaper they can get attendants into the asylum the better for them, because it is so much more gain.” Much had been said of the advantage which the superior secresy of private asylums offered to the upper classes. There was no more privacy in private asylums than in hospitals for the insane, if so much. On the other hand, there was such a thing as im- proper secresy. And if private asylums had no advantages over hospitals in respect of secresy, they were under every dis- advantage in respect of the temptations to detain patients unduly, to neglect corrective treatment, and to exact the uttermost farthing which the patients or their friends could pay. He was extremely sorry for those professional men who, having sensitive feelings as to professional honour, were engaged in keeping private asylums ; and he heartily wished them suc- cess in any attempts they might make to escape from their embarrassing position. He had made no attack upon pro- fessional honour or professional duties, but simply upon the business of keeping lunatics for profit; and that it was a business was proved by the disreputable discount business which existed until it was stopped by law, and by the still existing system of letting out attendants on job, and taking half their wages, and also by the system of requiring long notice before a patient could be removed from an asylum. He knew of a patient at the present time in a private asylum, the proprietor of which had demanded six months’ notice before the patient could be removed, although such removal had been recommended by the authorities. It was quite a mistake to say that Lord Shaftesbury had changed his opinion about private asylums. What he had said was, that the present generation of asylum- keepers was better than the last. It was also an inaccuracy to state that the verdict of the Select Committee of 1877 had been in favour of the private asylums. The Committee, in their report, recommended that legislative facilities should be afforded by enlargement of the powers of magistrates or otherwise foi the extension of the system of public institutions for all classes of the insane, by which means they considered that the demand for licensed houses for the upper and middle classes would cease. The meaning of the Committee was clearly that, in their opinion, it was not desirable to abolish private lunatic asylums im- mediately ; but that public asylums for the upper and middle classes should be established, by the operation of which, through the spontaneous selection of the public, private lunatic asylums would be starved out of existence. Dr Bucknill, in conclusion, thanked the members for the patience with which they had listened to opinions which he would willingly have made more agreeable to them had it been possible to do so. Some one had said, in the meeting that there was really no public opinion on the matter ; but, in May last, Mr. Cross, the Home Secretary, said to a deputation on the Drunkards’ Bill that ” there was a great feeling at the present moment throughout the country against private lunatic asylums altogether.”
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