Lunacy In” England (England’s Irren-Wesen)
174 Art. II.?
The Address read at the opening of Section VIII. Mental Diseases of the International Medical Congress, by C. Lockhart Robertson, M.D., Cantab., F.H.C.P., Lord Chancellor’s Visitor in Lunacy, President of the Section.
Gentlemen,?In now opening the eighth section of this great International Medical Congress, and in offering to the alienists of Europe and America our cordial welcome to London, I must ask leave to explain to you that it is only by the accident of official position as senior physician to the Lord Chancellor, who, under the Royal prerogative and by statute, lias in England the guardianship of all lunatics and persons of unsound mind, that .1 occupy to-day this presidential chair. But for the desire of the Executive Committee thus to recognise the paramount authority of the Lord Chancellor in our department of medicine, I cannot doubt that the place I now fill would have been allotted to our most distinguished English writer on lunacy, Dr J. C. Bucknill, one of the vice-presidents of this Congress, whose writings and whose name are a household word in all the asylums where the English tongue is spoken. Called from my official position rather than on personal fitness to preside in this section, I may the more venture to ask at your hands a generous interpretation of my efforts, so to guide your deliberations here that they may advance the science and practice of this department of medicine in which we are all enrolled.
I think I shall best use this occasion by laying before you a brief statement of the present condition of the insane in England, and of the manner and method of their care and treatment. In the German tongue the word Irren-Wesen exactly expresses the subject of this address.
The number of the insane in England of whom we have official cognisance is about 71,000, being in the ratio of 27*9 per 10,000, or 1 in 350, of the population. Of these no less than 63,500 are paupers chargeable to the rates and maintained at the cost of the community. The remaining 7,600 are private patients, whose means vary from ?50 to ?50,000 a year, much the larger number being nearer ?50, for insanity necessarily tends, by arresting the power of production, to the impoverishment of its subjects. Thus, of the total of the insane in England, 90 per cent, are paupers maintained at the public cost, and 10 per cent, only are kept by their own resources.
There has, since the passing of the Lunacy Act of 1845, been a great yearly increase in the registered numbers of the insane, an increase chiefly if not solely among the pauper class, which admits of satisfactory explanation, as I have elsewhere* endeavoured to show, without accepting the popular fallacy of an increase of insanity ; a theory which, if carried to its logical conclusion, leads us to the result that as the registered lunatics in 1845 were as 1 to 800 of the population, while in 1880 they stand, as I have just stated, as 1 to 350, therefore lunacy in England has more than doubled during the last thirty years, which is a manifest fallacy. I only regret that my present limits preclude farther reference to this interesting problem.f My first table exhibits the number of the insane in England, with their place of residence and their proportion to the population in the decenniums 1860, 1870, and 1880. This table shows that the total registered number of the insane has risen from 38,000 in 1860, to 71,000 in 1880, and the ratio to the population from 19*1 per 10,000 to 27’9. It is evident from my figures that this increase is mainly in the pauper class. The private patients in 1860 numbered 5,065, in 1880 they were 7,620, and their ratio to the population 2-5 and 2*9 respectively, an increase of *4 only, as compared with the increase of 8*8 among the pauper lunatics, on each 10,000 of the population.
Table I. Showing the number of Lunatics in England and Wales in the several decenniums 1860, 1870, 1880, with their Place of Residence and their Proportion to the Population. Where detained (Place of Residence) In Public Asylums. In Private Asylums. In Workhouses . . In Private Dwellings Totals . , . Ratio per 10,000 of ) the population J 1860 Private Pauper Total 2,000 2,948 None 117 5,065 17,442 1,352 8,210 5,980 Private Pauper Total 19,442 4,300 8,219 6,097 32,993 j 38,058 2,780 3,144 None 356 6,280 28,229 1,760 11,358 7,086 48,433 31,009 4,904 11,358 7,442 54,713 18S0 ‘rivate Pauper Total 3,754 3,398 None 4G8 39,986 1,141 16,464 5,980 7,620 63,571 43,730 4,549 16,464 6,448 71,191
The alleged, Increase of Lunacy, Journal of Mental Science, April 1869. A
Farther Note on the alleged Increase of Lunacy, Journal of Mental Science, January 1871f In the Report of the Scotch Commissioners in Lunacy for 1880, this question
Table IT. gives tlie distribution per cent, of the 71,000 registered lunatics in England and Wales, and I have here contrasted the same with that of the 10,000 lunatics registered in Scotland.
Table II. Showing the Distribution per cent, of all Lunatics in England and Wales and in Scotland in 1880 (January st). In Public Asylums* . In Private Asylumsf In Workhouses^ . . In Private Dwellings? Total … Distribution per Cent. In England and Wales Private Fauper Total 5-0 50 None ?5 56*5 1-5 23-0 8561-5 65 23-0 90 100 In Scotland Private Pauper T otal 14 6 1 6 None 1-1 610 None 7-0 14 7 75*6 1*6 7-0 15-8 ? 100
Table II. is interesting as contrasting the total distribution of lunacy in England with that of Scotland. In England 61*5 per cent, of the lunacy of the country is maintained in the public asylums. In Scotland it reaches 75-6 per cent., while, on the other hand, the proportion of patients in private asylums is 6*5 per cent, in England as against 1*6 in Scotland. In England 9 per cent, only of all lunatics are placed for care in private dwellings; in Scotland the proportion rises to 15*8. In England we have 23 per cent, in workhouses; in Scotland there are only 7 per cent.
Table III. gives the relative distribution per cent, of private and pauper lunatics respectively in England and Wales, and in Scotland.
of the apparent increase of insanity is ably discussed, and dealt with in a careful statistical inquiry. I can only here give their conclusion :?” We have frequently pointed out that the difference in these rates of increase is not necessarily due to an increasing amount of mental disease, but is probably due in a large measure to -what is only an increasing readiness to place persons as lunatics in establishments.” * Including County and District asylums and Scotch Parochial asylums, lunatic hospitals and Scotch chartered asylums, naval, military, and East India asylums, Idiot asylums, Broadmoor Criminal Asylum, and Perth Prison wards, f Including provincial and metropolitan licensed houses. j Including the metropolitan district asylums. ? Including 208 Chancery lunatics residing in the private houses of ” the committee of the person.”
Table III. Showing the Distribution per cent, on their several Numbers of the Private and Pauper Lunatics respectively in England and Wales and in Scotland in 1880. Where Maintained. In Public Asylums In Private Asylums . In Workhouses . In Private Dwellings . Total . Distribution per Cent. In England and Wales. Private. Pauper. 49-0 43 0 None 80 100 63 0 1-6 26-0 9-4 100 In Scotland. Private. Pauper. 84-0 9-5 None 6 5 100 73-7 None 85 17-8 100
Table III. brings strikingly before us the existing difference in tlie method of care and treatment of the insane in the two kingdoms. In England 43 per cent, of the private patients are in private asylums, while in Scotland the proportion is 9*5 only. The public asylums, on the other hand, have 84 per cent, of the Scotch private patients under treatment as against 49 in England. In England, owing to the traditional preference of the Court of Chancery for private dwellings for the care of its wards, we find the proportion of patients so placed stands as 8 to 6*5 in Scotland, while with pauper lunatics these figures are reversed, the proportion in England being 9*4 as contrasted with 17’8 in Scotland.
Public Asylums.
There are 43,700 patients in the public asylums of England, or 60*5 per cent, of the whole lunacy of the country. Of these 40,000 are pauper lunatics, and 3,700 are private patients. The former are maintained in the county and borough asylums, the latter are divided between these and the registered lunatic hospitals.
(a) County ctncl Borough Asylums.?The county and borough asylums of England,* sixty in number, contain 40,000 * A return was ordered by llie House of Commons to be printed August 14, 1878, of the cost of construction of each of the county asylums, the number of beds, the annual and weekly maintenance rate, the percentage of recoveries, deaths, &c. Unfortunately it has been, as regards England, carelessly prepared, and no abstract or summary of its contents or averages aro given. It is impossible to make out beds, varying from 2,000 to 250. They have been built and are administered under the provisions of the Lunacy Act of 1845. The average cost per bed has been under ?200; the weekly maintenance of each patient is 10s., to which must be added the interest on the cost of construction and the yearly repairs of the asylum, which are borne by the county rate, bringing the yearly cost for each pauper lunatic maintained in the county asylums to nearly ?40.
The government of the English county asylums is entrusted, by the Lunacy Act, 1845, to a committee of the justices of the peace, under the control of the Secretary of State for the Home Department. The administration is in the hands of the resident medical superintendent. A yearly inspection of the asylum is made by the Commissioners in Lunacy, and a yearly medical and financial report is presented by the committee and medical superintendent to the quarter sessions, and published. The proportion of cures (discharged recovered) in the county and borough asylums in the last decennium, 1870-80, was 40*28 per cent, on the admissions, and the mortality 10’59 on the mean population. In Scotland, during the same period, the recoveries were 41*6, and the deaths 8. The only private patients admissible under the statute are those bordering on pauperism, and whom the law requires, as to classification, diet, clothing, &c., to be treated as the paupers. Herein the English county asylums differ from those on the continent of Europe and in America, where alike, and I think most wisely, special and often excellent provision exists for the care and treatment of private patients. At the public asylums near Rouen, at Rome, at Munich, and at Utica, in the States, I have seen extremely good accommodation provided for private patients. In Mr. Dillwyn’s Lunacy Law Amendment Bill, 1881, which was read a second time on May 25, but has since been withdrawn for this session, there was a clause (section 4) enabling the visitors of county asylums to provide there suitable accommodation, by additional buildings or otherwise, for private patients. I regard this proposal as one of the most important reforms, since the Lunacy Act of 1845, in the treatment of the insane of the middle class, providing as it would for the small ratepayers, at a cost within their means, such care and treatment as they cannot obtain in the cheaper private asylums, where the clearly in “which asylums the yearly repairs are included in the total cost of construction, and in which they are omitted. The quarter sessions of Warwickshire have made no return at all! In contrast, in the same Parliamentary paper, stand the cle ir tables and summary relating to the public asylums of Scotland. From the English return we can only gather an approximate estimate of the cost of construction, amount of land, salaries, cures, &c., no averages being given. accommodation and comfort are absolutely below that of the county asylums, not to refer to the superior acquirements of the medical superintendents of the latter.
I do not feel called upon from this chair (nor does time admit) to enforce and illustrate the now incontestable superiority of public asylums, even in a financial point, for the curative treatment of the insane poor as contrasted with the private licensed houses, to which, before the Act of 1845, they were farmed out by their respective parishes. ” Our present business is to affirm that poor lunatics ought to be maintained at the public charge. I entertain myself a very decided opinion that none of any class should be received for profit; but all I hope will agree that paupers, at any rate, should not be the objects of financial speculation.” These words, spoken by Lord Shaftesbury in the House of Commons when he introduced the Lunacy Act of 1845 (the Magna Charta of the insane poor), settled this question once for all. Whose voice will speak similar words of comfort and healing to the insane of the upper and middle classes, and declare with authority which shall no longer be questioned, ” that all insane captives whose freedom would not be dangerous should be liberated, and those who remain be surrounded with every safeguard of disinterestedness, humanity, and public responsibility ” ?
In here recording the success which has attended the Act of 1845?a success that led my friend Dr Paget, in his Harveian Oration, to call the sight of one of our English county asylums ” the most blessed manifestation of true civilisation that the world can present,”?I cannot refrain from adding a word of tribute to the memory of my revered friend John Conolly, whose work of freeing the insane from mechanical restraint, and of thereby founding our English school of psychological medicine, preceded the legislation promoted by the Earl of Shaftesbury, and ensured the success of these enactments.
In June, 1839, Dr Conolly was appointed resident physician at Hanwell.
In September he had abolished all mechanical restraints. The experiment was a trying one, for this great asylum contained 800 patients. But the experiment was successful; and continued experience proved incontestably that in a wellordered asylum the use even of the strait-waistcoat might be entirely discarded. Dr Conolly went further than this. He maintained that such restraints are in all cases positively injurious, that their use is utterly inconsistent with a good system of treatment; and that, on the contrary, the absence of all such restraints is naturally and necessarily associated with treatment such as that of lunatics ought to be, one which sxibstitutes menial for bodily control, and is governed in all its details by the purpose of preventing mental excitement, or of soothing it before it bursts out into violence. He urged this with feeling and persuasive eloquence, and gave in proof of it the results of his own experiment at Hanwell. For, from the time that all mechanical restraints were abolished, the occurrence of frantic behaviour among the lunatics became less and less frequent. Thus did the experiments of Charlesworth and Conolly confirm the principles of treatment Dr Conolly’s four annual reports of tlie County Lunatic Asylum at Hanwell for 1839,’40, ‘41, ‘42, still form the groundwork of our treatment of the insane poor in the English county asylums, while these asylums themselves?whose fame, I may be permitted to say, based as it is on the successful application of the English non-restraint system, has gone forth into the whole civilised world, and brought rescue to the most suffering and degraded of our race?stand throughout this fair land imperishable monuments of the statesman to whom they owe their origin, and of the physician who asserted the great principle on which the treatment within their walls is founded. “The system as now established,” Dr Conolly writes, ” will form no unimportant chapter in the history of medicine in relation to disorders of the mind. It has been carried into practical effect in an intellectual and practical age, unostentatiously, gradually, and carefully, and is, I trust, destined to endure as long as science continues to be pursued with a love of truth and a regard for the welfare of man.
We have made arrangements whereby you will have the opportunity of visiting and inspecting two of the best of the English county asylums, that for Sussex at Hay wards Heath, and for Surrey at Brookwood; the State Asylum for Criminal Lunatics at Broadmoor, as also the four great metropolitan asylums, with a joint population of 6,600 lunatics, at Hanwell, Colney Hatch, Banstead, and Wandsworth. There has since the Lunacy Act of 1845 been a steady increase in the number of pauper lunatics placed in the county asylums. In 1860 the proportion was 57 per cent., in 1870 it rose to 61 per cent., and in 1880 it was nearly 65 per cent, of their number. I think this continued increase is most injurious alike to the insane poor and to the due administration of the county asylums. The accumulation in such large numbers of harmless and incurable lunatics in these costly asylums is, moreover, a needless burden on the rates.
We may now, with an experience of thirty-five years, assert inaugurated by Daquin and Pinel; and prove that the best guide to the treatment of lunatics is to be found in the dictates of an enlightened and refined benevolence. And so the progress of science, by way of experiment, has led men to rules of practice nearer and nearer to the teachings of Christianity. To my eyes a pauper lunatic asylum, such as may now be seen in cur English counties, with its pleasant grounds, its airy and cleanly wards, its many comforts, and wise and kindly superintendence, provided for tho?e whose lot it is to bear the double burden of poverty and mental derangement?I say this sight is to me the most blessed manifestation of rrue civilisation that the world can present.”?The Harveian Oration, 1866, by George E. Paget, M.D. Cantab., Regius Professor of Medicine in the University of Cambridge.
“The Treatment of the Insane without Mechanical Restraint,” by John
Conolly, M.D Edin,D.C.L. London: Smith, Elder, & Co. 18o6. LUNACY IN ENGLAND. 181 that the utmost limits within which the county asylum can benefit or is needed for the treatment of the insane poor is 50 per cent, of their number,* and that a further accumulation of lunatics there serves no practical purpose, and hence is an unjustifiable waste of public money. The workhouses contain 16,500 pauper lunatics, or 26 per cent, of their number. A recent statute facilitates the adaptation of wards in the county workhousesf for the reception of lunatics ; and if these arrangements were properly carried out, I think another 14 per cent., or 40 per cent, of the incurable and harmless pauper lunatics and idiots, might be provided for in the workhouses. That this is no fancy estimate I may quote the parish of Brighton, long distinguished for its wise and liberal administration of the Poor-law, which has already 36 per cent, of its insane poor in the workhouse wards, and 55 per cent, only in the county asylum. The transfer of twenty chronic cases?no impossible feat?from Ilaywards Heath to the Brighton workhouse wards would at once bring the Brighton statistics up to my ideal standard for the distribution of pauper lunatics?viz., in county asylums, 50 per cent.; in workhouse wards, 40 per cent.; leaving 10 per cent, for care in private dwellings. (b) Lunatic Hospitals {Middle-class Public Asylums).? Besides the county asylums for the insane poor we have in England fifteen lunatic hospitals, including the idiot asylums at Earlswood and Lancaster, where the principle of hospital treatment followed in the county asylums is applied to the insane of the upper and middle class with the most satisfactory results.
The following table gives a list of these asylums, with the * There is a unanimous concurrence of opinion on the part of the Lunacy officials nnd the Visiting Justices, that the grant from the Consolidated Fund of 4s. a week made by Lord Beaconsfield’s Government in 1874, for every pauper lunatic detained in the county asylums, has led to a needless increase in the admission there of aged lunatics and idiot children, who were and can with equal facility be kept in the workhouses. This grant has risen year by year, and in the estimates of 1881-82 is placed at ?425,000. Instead of relieving the lauded interest, as this ill-considered attempt to shift part of their burden on the fund-holders was intended, it has actually increased the county rate by the forced enlargements and extension of the county asylums. The editor of The Times, in 1874: and 1878, allowed me at some length to direct attention to this yearly increasing misdirection of the public funds. It is to be hoped that when the heavy local taxation of England is readjusted, this outlet of wasteful expenditure may not be overlooked.
f The success ot the metropolitan district asylums at Leavesden, Caterham, and Darenth, -which contain 4,470 chronic lunatics maintained at the rate of 7s. a week, shows how, even in so difficult a place as London, the treatment of chronic and harmless pauper lunatics in workhouse wards is to be accomplished, with a large saving to the ratepayers and a relief to the crowded wards of the county asylums, which are thus made available for the curative treatment of acute and recent cases.
date of their foundation, their present accommodation (number of beds), and their average weekly cost of maintenance. Table IV. The Registered Lunatic Hospitals (Middle-class Asylums) in England, with the Date of th’ir Foundation, the Number of Beds, and the Average Weekly Cost of Maintenance in 1880. Name and Site of Asylum. (Registered Hospital.) Date of Foundation Number of Beds Average Weekly Cost * Bethlem Royal Hospital St. Luke’s Hospital … York Lunatic Hospital Friends’ Retreat, York Wonford House, Exeter Lincoln Lunatic Hospital … Bethel Hospital, Norwich … Warneford Asylum, Oxford … St. Andrew’s Hospital, Northampton Cheedle Asylum, Manchester The Coppice, Nottingham … Coton Hill, Stafford … Barnwood House, Gloucester Earlswood Idiot Asylum Albert Idiot Asylum, Lancaster 1400 1751 1777 1792 1801 1820 1825 1826 1836 1819 1859 1854 1860 1847 1864 300 200 160 150 100 to 70 70 300 180 70 150 110 570 350 ? s. d. 1 11 7 0 19 3 1 1 1 1 12 6 1 11 0 1 S 2 0 15 2 1 2 7 1 10 1 2 2 0 1 10 4 1 12 10 1 14 3 0 18 2 0 14 0
These asylums have nearly 3,000 beds, and the average weekly cost of maintenance is ?. 10s., or, including the fabric account, .?1. 15s.
There are 7,828 private lunatics registered in England, who are thus distributed :? In registered hospitals 2702 or 36 per cent.”l In public In county asylums 484 or 6 ? > asylums In state asylums 558 or 7 ,, J 49 p. c. In private asylums 3408 or 43 ., In private dwellings 676 or 8 ?
The existing lunatic hospitals, or middle-class public asylums, thus already receive 36 per cent, of all the private patients. The advocates of this method of treatment of the insane, as opposed to the private asylum system, may now fairly say that by thus providing for the care and treatment of 36 per cent, of the private lunatics they have demonstrated the practicability of this method as applicable to the other 43 per cent, now in private asylums.
They can also appeal to the official statistics to show their * The fabric charges are not included in these figures. Another 5s. a week must be added to complete this estimated weekly cost of maintenance.
superiority as regards results over the private asylums. In the last decennium, 1870-80, the average recoveries per cent, on the admissions in the registered hospitals was 46’84 ; in the metropolitan private asylums it was 30-5 ; and in the provincial private asylums 34*7. The mean annual mortality during the same period was in the registered hospitals 8*12 ; in the metropolitan private asylums it rose to 11*01; and in the provincial private asylums it was 8*81. They may, moreover, point to Scotland and say that while in England 49 per cent, of the private patients only are provided for in public asylums, 84 per cent, are so cared for in Scotland. What has been accomplished in Scotland may surely be done in England. And certainly, as their strong and final argument, they may challenge a comparison of these asylums, conducted at half the cost, with the best of the private asylums in England. We have made arrangements for your visiting Bethlem* and St. Luke’s in London, and also the middle-class asylum, St. Andrew’s Hospital, Northampton. I should very much like you to see St. Andrew’s Hospital, which now contains 300 private patients of the upper and middle classes, from whose payments it derives a revenue of ?40,000 a year, of which ?10,000 was saved last year for further extensions. It would be difficult to over-praise the power of organisation which has enabled Mr. Bayley, the medical superintendent, to achieve this great result in the last ten years only. I can from frequent visitation speak of the order and comfort which reign throughout this asylum. Mr. Dillwyn’s Select Committee, in their Beport (March 28, 1878), suggested ” that legislative facilities should be afforded by enlargement of the powers of the magistrates or otherwise for the extension of the public asylum system for private patients,” and in his Lunacy Law Amendment Bill, 1881, read a second time in May, Section 1 enables the justices to provide asylums for the separate use of private lunatics in like manner as the county pauper asylums were built. There can be no doubt, after the experience I have just related of St. Andrew’s Hospital, Northampton, that, especially in the populous Home Counties, where no public provision for private lunatics exists, several such asylums, with 300 beds, might be built on the credit of the rates, and would in 30 years repay the capital and interest sunk out of the profits, and without, therefore, costing the ratepayers one penny. This clause alone would have made of Mr. Dillwyn’s Bill a great gift to the insane of the upper and middle class.| I cannot * In the Journal of Mental Science for July, 1876, there is a very interesting sketch of the History of Bethlem Hospital since 1400, by Dr Hack Tuke. f I brought this whole subject before the Brighton Medical Society in 1862, in a paper on The want of a Middle-class Asylum in Sussex, subsequently inserted in the Journal of Mental Science for January 1863.
but regret that so valuable a measure had to be withdrawn from want of time. It is already a well-worn complaint that home legislation is in England sadly impeded by the weary Irish agitation and debates.
Another method of providing public accommodation for private patients was laid by me before Mr. Dillwyn’s Select Committee, in a Memorandum on the Establishment of three State Asylums for Chancery Lunatics, signed by Dr Bucknill, Dr Crichton Browne, and myself. The insane wards of the Court of Chancery pay upwards of ?100,000 a year for care and treatment in private asylums. Certainly no loss could be incurred by the Treasury in advancing sums to build these asylums, where the yearly profits would, as at St. Andrew’s Hospital, ensure the regular repayment of capital and interest. As the Court of Chancery controls in every detail the expenditure of the income of its insane wards, it is not an unreasonable demand to require that Court to provide fit public asylum accommodation, and such as the visitors deem necessary, for the Chancery patients now placed in private asylums, in the selection of which their official visitors have no voice, and over the conduct and management of which they exercise no control. II. Private Asylums.
There are 3,400, or 43 per cent., of the private patients in England confined in private asylums, of whom 1,850 or 54 per cent, are in the thirty-five metropolitan licensed houses which are under the sole control and direction of the Commissioners in Lunacy, who diligently visit them six times a year. The remaining 1,550, or 46 per cent., are in the sixty-one provincial licensed houses which are under the jurisdiction of the justices in quarter sessions, but are inspected twice a year by the Lunacy Commissioners. I cannot?even did I so desire?avoid, in an address like the present, stating to you my opinion of this method of treatment of the insane. The tenor of my remarks, when referring to the extension of the lunatic hospitals (middle-class asylums), has already shown the direction towards which my opinions and feelings tend. John Stuart Mill, the strenuous advocate of freedom of contract, nevertheless, in his Political Economy, in treating of this subject, observes that ” insane persons should everywhere be regarded as proper objects of the care of the State,” and, in quoting this authority, I must add, from long personal observation, my opinion that it would be for the interests of the insane of the upper and middle class to be treated as are the paupers in public asylums, where no questions of self-interest can arise, and where the physician’s remuneration is a fixed salary, and not the difference between the payments made by his patients for board and lodging and the sums he may expend on their maintenance. ” Is there not,” writes Dr. Maudsley, ” sufficient reason to believe that proper medical supervision and proper medical treatment might be equally well if not better secured by dissociating the medical element entirely from all questions of profit and loss, and allowing it the unfettered exercise of its healing function ? Eminent and accomplished physicians would then engage in this branch of practice who now avoid it because it involves so many disagreeable necessities.”
Probably all not directly interested in this system, and many who, to their own regret, are so, will concur that, if the work had to be begun anew, the idea of licensed private asylums for the treatment of the insane^ of the upper and middle class would be, by every authority in the State, as definitely condemned as was in 1845 the practice of farming out the insane poor to lay speculators in lunacy. It is, however, a different matter dealing with an established system, and I am not of those who call for the suppression of all private asylums. The friends of many patients in England distinctly prefer them to public asylums, and some patients, who have had experience of both, contrast the personal consideration and study of their little wants which they receive in private asylums with the discipline and drill of the public institutions. I sae no reason why private asylums should not continue to exist side by side with the public middle-class asylums. Time and competition will show which system shall ultimately gain the approval of the public. I am glad to find this opinion supported by Dr. Arthur Mitchell, Commissioner in Lunacy for Scotland, in his evidence before the Parliamentary Committee of 1877. ” I think,” he said, ” there should be no legislation tending to the suppression of private asylums. I would let the principles of free trade settle the matter. If the public have confidence in private asylums, and encourage them, I would let private asylums exist. I would give them no privileges, and would simply take care that the inspection and control over them are sufficient.”
The verdict of public opinion in Scotland has been definitely against the private asylum system. While in England 43 per cent, of the private patients are confined in private asylums, the proportion in Scotland falls to 9*5. If private asylums are to continue, there should be entire freedom of trade in the business. The Lunacy Commissioners have for many years placed endless impediments in the way of licensing new and small asylums in the metropolitan district. I entirely differ from this policy, and I think that small asylums for four or six patients, licensed to medical men, would tend to lessen the existing evils of the larger private asylums. The monopoly which the Commissioners have established in the metropolitan district has certainly not raised the asylums there to a higher standard than those of the provinces, where free trade in lunacy prevails. I am tempted to say that it has had the contrary effect.
III. The Insane in Private Dwellings. Further reform in the treatment of the insane is not merely a question of whether and how they shall be detained in public or private asylums, but rather whether and when they should be placed in asylums at all, and when and how they shall be liberated from their imprisonment and restored to the freedom of private life. This is the reform in lunacy treatment which is beginning at last to take hold on the public mind in England, and has received a new impulse by the recent publication of an essay by Dr Bucknill On the Care of the Insane and their Legal Control.*
It is more than twenty years ago since the question of the needless sequestration of the insane was first raised in England by my friend Baron Jaromir Mundy, of Moravia. He spoke then to dull and heedless ears. I remember well I thought him an amiable enthusiast, and I said there was no fit or proper treatment for the insane to be found out of the walls of an asylum. I have since learnt a wiser experience. Well did he say, on leaving us, arbores serit diligens agricola quarum fruetus nunquam aspiciet. I am very glad to have this opportunity of doing honour to the zeal and far-seeing wisdom of the first preacher of this new crusade; would he were here with us to-day to accept my formal adherence to his cause. There is, I believe, for a large number of the incurable insane, a better lot in store than to drag on their weary days in asylum confinement:?
The staring eye glazed o’er with sapless days, The slow mechanic pacings to and fro, The set gray life and apathetic end.
In my evidence before Mr. Dillwyn’s Select Committee in 1877 I was examined at some length on this question, and I stated that, but for my experience as Lord Chancellor’s Visitor, * Macmillan & Co., second edition. London, 1880. and if I had not personally watched their cases, I could never have believed that patients who were such confirmed lunatics could be treated in private families in the way that Chancery lunatics are. I also said that one-third of the Chancery patients were already so treated out of asylums, and I added that I was of opinion that one-third of the present inmates of the private asylums might be placed in family treatment with safety. In support of this opinion I put in this table :? Table V.
Showing the Proportion per cent, in Asylums and in Private Dwellings of the Chancery Lunatics and of the Private Patients (Lunatics not Paupers) under the Commissioners in Lunacy in England and Wales and in Scotlan d. Chancery Lunatics English Private Lunatics Scotch Private Lunatics Proportion per Cext. In Lunatic Asylums 654 94-1 93-8 Under Home Treatment in Private Dwellings 34-G 5-9 6-1
This table deserves your attention. If 34*6 per cent, of the Chancery lunatics are successfully treated in private dwellings, while only 65-4 per cent, are in asylums, it is evident that of the private patients under the Lunacy Commissioners, of whom 94 per cent, are in asylums, some 30 per cent, are there needlessly, and hence wrongly confined. I see instances of such cases every visit I pay to the private asylums.
Another convert to his cause, made by Baron Mundy, is one of the distinguished vice-presidents of this section, Dr Henry Maudsley, who, in 1867, in the first edition of his work on the Physiology and Pathology of the Mind, strenuously condemns the indiscriminate sequestration of the insane in asylums, observing:?” the principle which guides the present practice is, that an insane person, by the simple warrant of his insanity, should be shut up in an asylum, the exceptions being made of particular cases. This I hold to be an erroneous principle. The true principle to guide our practice should be this: that no one, sane or insane, should ever be entirely deprived of his liberty, unless for his own protection, or for the protection of society.” Dr Maudsley (to strengthen his argument) pointed to the condition of the numerous Chancery patients in England who are living in private houses. ” I have,” lie writes, ” the best authority for saying that their condition is eminently satisfactory, and such as it is impossible it could be in the best asylum,” and he concluded an elaborate defence of this method of cure with this remark:?” I cannot but think that future progress in the improvement of the treatment of the insane lies in the direction of lessening the sequestration, and increasing the liberty of them. Many chronic insane, incurable and harmless, will be allowed to spend the remaining days of their sorrowful pilgrimage in private families, having the comforts of family life, and the priceless blessing of the utmost freedom that is compatible with their proper care.”
In his recent essay on The Care of the Insane, Dr Bucknill has a chapter entitled ” Household Harmony “? After many moody thoughts, At last by notes of household harmony They quite forgot their loss of liberty.
I give you therefrom his final and weighty conclusions in his own words :?” It is not merely the happv change which takes place in confirmed lunatics when they are judiciously removed from the dreary detention of the asylum into domestic life ; it is the efficiency of the domestic treatment of lunacy during the whole course of the disease which constitutes its greatest value, and of this the author’s fullest and latest experience has convinced him that the curative influences of asylums have been vastly overrated, and that those of isolated treatment in domestic care have been greatly undervalued.”
What I have hitherto said under this section applies to the home treatment of private patients. The treatment of pauper lunatics in private dwellings is another part of this question, and in which important financial results are involved. The system takes its origin from Grheel, and has been adopted in Scotland with great success. No less than 14*7 per cent, of the insane poor in Scotland are placed in private dwellings, under the official inspection of the Lunacy Board. I)r. Arthur Mitchell’s evidence before Mr. Dillwyn’s Select Committee and the several annual reports of the Scotch Commissioners give details of this method of treatment, which my limits only allow me now to refer you to. Financially the cost of this treatment does not reach Is. a day; in the county asylums (including the cost of the fabric) it is not less than 2s., a difference of 100 per cent, in expenditure.
With regard to England, 6,000 pauper lunatics, or 8-5 per cent, of their number, are registered as living with their relatives, or boarded in private dwellings, under the authority of tlie boards of guardians, whose medical officers visit the patients every quarter, and make returns to the Visitors of the county asylums, to the Lunacy Commissioners, and to the Local Government Board. None of these authorities, however, take much notice of the returns, and little or nothing is known of the condition, care, or treatment of these 6,000 pauper lunatics. Any further amendment of the Lunacy Law should certainly, in some way, bring them within the cognisance and inspection of the Lunacy Commissioners, as is done in Scotland.
A successful effort further to extend this system in England is related by Dr S. W. D. Williams, the Medical Superintendent of the Sussex County Asylum, Hay wards Heath, in his evidence before Mr. Dillwyn’s Select Committee, and also in a paper, Our Overcrowded Lunatic Asylums, published by him in the Journal of Mental Science for January 1872. My limits compel me to be satisfied with this brief reference to the important questions included in this third section of my address, ” The Insane in Private Dwellings.”
Tiie English Lunacy Law.
Lastly, I would say a few words on the Lunacy Law of England, which, setting aside the special statutes, dating from King Edward II., regulating the proceedings in Chancery, are the result of the legislation of 1845, and consist chiefly of Acts amending other Acts. They form a large volume, which has been carefully edited by Mr. Fry.* A Bill for the general consolidation and amendment of these several statutes is an urgent need. The Government of Lord Beaconsfield announced, in Her Majesty’s speech from the throne on the opening of Parliament in February 1880, that such a measure was in preparation; and although the political necessities of the Irish question have this year unfortunately absorbed all the energies and time of the Government, we have assurance, in the extreme solicitude which the Lord Chancellor on all occasions so markedly shows for the welfare of the insane, that the Government will be prepared to give the question of Lunacy Law Reform their early and careful attention. I am disposed to think that, previous to such legislation, a Eoyal Commission should be issued to investigate and report on the working in detail of the Lunacy Law, and to make suggestions for its consolidation and amendment.
“The Lunacy Acts: containing the statutes relating to Private Lunatics,
Pauper Lunatics, Criminal Lunatics, Commissioners of Lunacy, Public and Private Ajylums, and the Commissioners in Lunacy; with an Introductory Commentary, &C.” By Panby P. Pry, of Lincoln’s Inn, Barrister-at-law. Second Edition.
It is exactly twenty-one years since a Parliamentary Committee reported to the House ” On the Operation of the Acts of Parliament and Regulations for the Care and Treatment of Lunatics and their PropertyMany changes have passed over this department of medicine since the date of that report, and the temporary amendments of the Lunacy Law of 1845, which resulted therefrom, have almost served their purpose. The chief of these enactments ” the Lunacy Acts Amendment Act 1862,” passed the following year, and embodied the various suggestions of the Lunacy Commissioners, based on their experience of the working of the Act of 1845, and from an official point of view was a valuable contribution to the Lunacy Law, but it failed to give effect to many of the recommendations of the Select Committee of 1860. In the same year passed “the Lunacy Eegulation Act 1862,” which led to considerable amendment of the proceedings in Chancery. The important requisite, however, of a cheap and speedy method of placing the property of lunatics under the guardianship of the Lord Chancellor has yet to be attained. One of the most experienced officials in Chancery, Master Barlow, in his evidence before Mr. Dillwyn’s Committee, in 1877, said :?”I am a great advocate for a great reform in Lunacy (Chancery) proceedings; I would facilitate the business of the procedure in the office, and shorten it in such a way as to reduce the costs.”
After the evidence given by Dr Arthur Mitchell before Mr. Dillwyn’s Select Committee of 1877, it is evident that in the consolidation and amendment of the English Lunacy Laws, the Scottish Lunacy Law and practice must be carefully considered. It is in Scotland alone that the whole lunacy of the kingdom is under the control and cognisance of the Lunacy Board.*
Again, the relation of the Lunacy Commissioners to the county asylums under the County Financial Boards (whose advent is nigh at hand) is a difficult question, the final solution of which will influence for good or evil the future of these asylums. Herein also falls the question I have before referred to, of the annual Parliamentary grant for pauper lunatics maintained in asylums, and reaching now to half a million a year. Is the central government to check, through the distribution of this grant, the county boards ; or are they to retain the same authority over the county asylums as is now exercised by the justices in quarter sessions? The whole * I may be pardoned, if I venture here to refer to the annual reports of the Commissioners in Lunacy for Scotland, as containing an amount of well-digested statistical information regarding the lunacy of the kingdom, which we search for in vain elsewhere.
future efficiency of tlie English county asylums depends upon the right adjustment of the relative control given to the local authorities through the new county boards, and to the central government through the Commissioners in Lunacy. There is also for consideration, as in contrast with the Lunacy Laws of Scotland, the divided jurisdiction of the Local Government Board and the Commissioners in Lunacy over pauper lunatics in workhouses, of whom 17,000, or 26 per cent, of their number, are there and in the metropolitan district asylums under the control of the Local Government Board with the merest shadow of inspection by the Lunacy Commissioners. Again, to what extent is the credit of the ratepayers to be used in the establishment of public asylums for private patients ? I have already said how much I desire to see the public asylum system, as now existing in the registered lunatic hospitals, extended, more particularly in the Home Counties, by this method. Then the wide question of official asylum inspection. Is the present amount of it enough, and the method of it sufficient for the needs and protection of the insane, or does the Lunacy Commission require both extension and remodelling?
These are but a few examples of the difficulties besetting the question before us of the consolidation and amendment of the English Lunacy Law, and which lead me to the opinion that the whole subject, now ripe for solution, requires skilful and scientific sifting by a Royal Commission, previous to any consolidating and amending Act being laid before Parliament. I am glad to have this occasion to express my personal confidence in the ability, industry, and integrity with which the existing Lunacy Law is administered by the Commissioners. If I were disposed to criticise their policy, I might say that they trust too much to their one remedial agent, the extension of the county asylums, for meeting all the requirements and exigencies of the insane poor, while as regards the private asylums, with 54 per cent, of the private asylum population under their sole control in the metropolitan district, that they have from the first, since 1845, been content to enforce the remedying of immediate shortcomings, rather than endeavoured to place before the proprietors any standard of excellence to which they shall attain.
In concluding my remarks on the last section of my subject?the Lunacy Law of England?I would say that no mere amending Act like that of 1862, embodying simply the further suggestions of the Lunacy Commissioners, will satisfy the requirements of the medical profession or of the public. In the evidence taken before Mr. Dillwyn’s Select Committee in 1877 will be found many suggestions for the further amendment of the Lunacy Law of an important character, one or two of which Mr. Dillwyn embodied in his Lunacy Law Amendment Bill of this year, which, as I have already said, has been withdrawn. It is impossible for any private member of Parliament, actuated though he be by an earnest desire to remedy grave evils, to deal with so wide and complicated a question as the consolidation and amendment of the English Lunacy Law. No one is more fully aware of this impossibility than is Mr. Dillwyn, and no member of the House is prepared more heartily to support the Government in passing a wide and comprehensive measure of Lunacy Law Eeform.
I fear, gentlemen, that I have exceeded the limits of an opening address. Yet the wide subject which I selected? Lunacy in England (England’s Irren- Wesen)?did not admit of shorter treatment or of further compression. It is, after all, but a bare outline that I have to-day been able to sketch, of the present condition of the insane in England and the manner and method of their care and treatment. I may claim to have endeavoured to give you a truthful picture of our present state, and I certainly have not desired to hide our many shortcomings from you. Indeed, my object in selecting this subject for my address, is the hope, that the position I fill to-day in this great International Medical Congress, may gain for my ideas on lunacy reform, which I have thus brought before this section, a practical recognition such as I could not, under other circumstances, expect my humble opinions to command. If such a result should follow, I truly believe that the use I have made of this great opportunity, may be the means of extending to the insane of all classes in England that further measure of protection and liberty, which the experience of the past working in the County Asylums of the Lunacy Act of 1845, on the lines of the non-restraint system, has now shown to be alike practicable and safe.
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