An enquiry into the present state of visitation, in asylums for the reception of the insane

Front matter

f

Dr. I Jau

3?aztlu

CHAPTER I. Object of the Pamphlet

Several attempts have been made to calculate the number of insane persons in England, whose cases call for restraint and superintendence. By one gentleman they are estimated at 1 in 7000; by another, at 1 in 2000. The returns made from the West Riding of Yorkshire, prior to the erection of the Pauper Asylum at Wakefield, make the proportion of pauper lunatics to the whole population, 1 in 1000; and the enquiry made on this subject by the Scotch parochial clergy, by order of parliament, gave the proportion of lunatics and ideots in Scotland, at 1 in 400. If we consider the pauper patients to be double in number to patients superior in station, and calculating from the entire returns of the West Riding, the proportion would be 3 in 2000, or 18,000 to a

B population of twelve millions. When, then, it is the subject of insanity we investigate, we may say it is eighteen thousand prisoners, whose comfort and restoration is at stake : prisoners innocent of crimes, and suffering under the dispensations of Providence.

Those who have known the incalculable miseries heaped on these unhappy persons, by selfishness, ignorance, and inhumanity, have rarely failed to take a strong interest in their concerns ; but on a less praiseworthy principle their treatment is not unimportant. The neglect and hardships suffered by the insane, have aggravated and fixed the disorder; and when, under proper management, it would have speedily subsided, it has, from ill treatment, become permanent. From this cause, the quantity of insanity, at any given time, may have been doubled or trebled ; its attendant expenses being also doubled or trebled. If we have an hundred patients, whose disorder lasts one year each, on an average, and we take a period of ten years, there will be constantly, through that time, ten patients to provide for. But if the 100 patients are all permanently disordered, we should have 100 on hand during the entire ten years.

The proprietor, the keepers, and the domestic officers of a receptacle for the insane, must have a strong tendency to consider the interest of the patients and their own at direct variance. It is the interest of the patients to have spacious, airy accommodations; to have the least possible personal restraint, and the greatest possible personal attention as to cleanliness. Now these requisites imply both considerable expense and considerable trouble. The proprietor of an asylum would willingly avoid the expense, the keeper would willingly avoid the trouble. If a keeper can wrap one set of patients in blankets and chain them to a wall, and pin down another set to a floor covered with straw, without even the addition of a blanket, he has saved himself a great deal of the not very pleasant task of watching and cleaning ; and if forty patients can be chained down in cribs from Saturday to Monday, a keeper the less may suffice, and the actual keepers have a pleasant holiday. On these accounts, a perpetual and most vigilant superintendence of the concerns of an asylum becomes necessary. It is also necessary on another account. Patients are often not merely provoking by their stubborn and wilful conduct, but by positive violence towards their keepers or others; hence, restraint on the temper of the keeper himself becomes a matter of the greatest difficulty, and not to be obtained unless the keeper is under the control of motives of the strongest influence. The keeper must himself be kept. If he be not watched and punished, an asylum is likely to be little beyond an alternation of reciprocal violence between the prisoner and the gaoler. From these

B 2 causes, visitation has long been considered one of the first and most important matters to be attended to in the management of asylums. The Committee of the House of Commons, which sat last year, brought forward twenty-two propositions for the regulation of mad-houses ; and, with the exception of two or three inferior matters, the whole refer to licensing and inspection ; that is, the Committee considered visitation as the one thing needful. In this I entirely agree, having a full confidence that when visitation is fixed on due principles, every thing else which is requisite will, in time, follow. We are acquainted with visitation in various forms.

It is the object of the Second Chapter briefly to state the principal forms adopted in this country.

In the Third Chapter I propose to show, by different instances, the practical effects arising from each species of visitation. In doing this, I have been greatly aided by the Reports of the Committees of the House of Commons, which sat in 1815 and 1827; and by several pamphlets published about the year 1814, in reference to the investigation of the York Asylum : more especially by a history of that asylum written by Mr. J. Gray. These different documents comprise instances, very much detailed, of asylums under every species of superintendence ; and there is no system of superintendence under which a most highly objectionable state of things is not to be found. The superintendence of magistrates is least seen in its practical effects ; but there is every reason to believe, both from the nature of the houses where it is instituted, private houses kept for gain, and from the unfrequency of visitation, that it must be much less efficient than that of ordinary governors.

In the Fourth Chapter I have aimed at showing, that the state in which various places of reception were described to be in the preceding one, arose from no accident.il, temporary, or local cause ; but was permanently inherent in the very nature of the visitation itself.

The Fifth Chapter proposes a system of visitation apparently complex, but, I trust, when well considered, of both easy and efficient operation. It is, in fact, a system of visitation upon visitation ; and when the visitor is not himself to be visited, we may surely foresee an early relaxation of his efforts.

The concluding Chapter contains observations on the sort of parliamentary visitation proposed by the committee of 1827.

CHAP. II. Of the different species of visitation

Though the visitation of receptacles for the insane in this country has been long established, its importance has been little considered, and its influence little felt. The hospitals of Bethlem and St. Luke's have been directed by governors, sometimes acting in a body, but more generally by committees. At Bethlem a committee is held weekly, for the purpose of communication with the officers of the house, as to the admission of patients, and other matters ; and once a month the committee professes personally to visit the whole establishment. The number of governors appears, from Mr. Bowen's pamphlet*, to be forty-two, but how they are appointed he does not say ; and to ascertain who they are appears a matter of such difficulty, that a guinea became a common douceur for a copy of the list, and in one case five guineas were refused.

* Historical Account of Bethlem, p. 9.

The York Lunatic Asylum, at the period of the important changes of 1814, was under the authority of all subscribers of £20. or upwards. An annual meeting of the governors was held at the summer-races ; there were four quarterly courts ; and, on any emergency, special courts might be called.

In all the above institutions, the government being in the hands either of persons elected into office, or of contributors to a considerable amount, bore a character of high respectability.

The statute of the 14th year of George the Third* created a new species of visitation. It compelled all houses for the reception of more than one patient, public hospitals excepted, to be licensed: in London and its vicinity, by commissioners appointed by the college of physicians : in other parts of England, by the magistrates in quarter sessions. Three commissioners were annually, or oftener, to visit in the former district ; a magistrate and a physician elsewhere, as often as it was deemed necessary.

The amended statute of 1808 f, which authorizes the erection of county asylums, for parish paupers, directs that such a number of magistrates as the case requires, shall annually be appointed visitors of the institution.

In all the above cases, visitation is confined to magistrates, commissioners appointed by the college of physicians, or to governors of public hospitals. But in some few hospitals, a species of visitation is directed, which has no connexion with their general government. In the Retreat, near York, the visitors may be appointed from the Society of Friends at large ; and, by the present rules of the York Asylum, the female visitors are chosen without reference to subscription, or subscribers' families. The naval part of the institution at Hoxton appears, independent of the ordinary visitation of commissioners, to be visited by the inspector of naval hospitals ; but this species of superintendence seems much to resemble that of parish officers, who, from time to time, go to view the situation of their paupers ; or that of a relation enquiring into a patient's health.

Chap. III

Elucidation, by facts, of the practical influence of each species of visitation. Visitation by governors.

Section I. Of The York Lunatic Asylum

This establishment, founded in 1772, was opened for patients in 1777. It had originally an annual meeting of governors, with unlimited power over its concerns; and half-yearly, and subsequently quarterly meetings, for ordinary purposes. Afterwards a committee of seven was appointed, as were also visitors. The committees and visitors gradually fell into disuse ; and from 1795 to the period of the new system of management in 1814, became obsolete.

Not many years after the asylum was well established, a* difference of opinion arose amongst the governors, respecting the advantages to be allowed to pauper patients. Whilst the dispute continued, the different courts were well attended; but at last the friends of Dr. Hunter having obtained a most decided preponderance in the institution, all opposition to their views were withdrawn, a state of general inactivity succeeded, and the meetings of the governors were little more than matters of form. They are thus described, and, as was allowed, fairly, in a pamphlet published during the progress of the reform of 1814: "At the quarterly meetings, four or five governors, with difficulty collected, summed up the items of a tradesman's bill, contracted with the butcher for the ensuing three months, ordered a wall to be pulled down or a door to be blocked up, wished each other a good morning, and retired. At the annual meetings little more occurred : whether the institution was in debt or in credit, how many patients had been admitted and how many discharged, were the usual limits of enquiry *." " I do not charge," continues the writer, "this conduct to hardness or apathy on the part of the governors. They did nothing, because they believed there was nothing to be donef."

At the annual August meeting, some persons of the highest rank, and many country gentlemen, usually attended ; with these were mingled several most respectable individuals from the vicinity ; and the state of the asylum was constantly praised, because it was honestly believed to deserve praising.

* Vindication of Mr. Higgins, p. 7. t lb. p. 8.

Towards the close of 1813, a case of alleged misconduct, brought forwards by Mr. Higgins, a magistrate of the West Riding of Yorkshire, attracted an unusual body of governors to the quarterly court. Twenty-seven were present, forming, apparently, a meeting entitled to the highest confidence and credit.

" Mr. Higgins's statement was read ; after which the accused servants of the house were called in and sworn. They denied, upon oath, the truth of the charges. No other evidence was called for ; nor was any minute committed to writing of what had been sworn by the servants *.

The following resolution was passed : " The governors having taken into their consideration the statement published in the York and other newspapers, respecting the treatment of William Vicars, lately a patient in this asylum, and having examined, upon oath, such witnesses as were competent to afford information on the same, are unanimously of opinion, that during the time that the said William Vicars remained in the asylum, he was treated with all possible care, attention, and humanity f."

This opinion, of gentlemen who, on any other occasion, would have been listened to with ready acquiescence, on the present produced nothing but

' History of the York Lunatic Asylum, by J. Gray, p. 31. + lb.

dissatisfaction. Thirteen new governors appeared at the adjourned quarterly court. New cases of alleged misconduct were produced ; a general enquiry was instituted ; and in the result, that system which had for years heen the object of repeated approbation, was wholly overturned ; and this too, not by any party newly intervening, but with the active and very useful co-operation of the old governors, as they were named, themselves. Every domestic officer and keeper, including those whose "all possible care, attention, and humanity" had, in Vicar's case, been eulogized, was removed ; the number of keepers was greatly increased ; alterations and additions, most important in their nature and extent, were made in the house and airing courts; committees and visitors were brought into a state of active superintendence ; in a word, measures entirely revolutionary * were established, in many cases by unanimous votes. Here then we have a system, for years superintended by a gentleman, not only of superior medical abilities, but highly valued in private life ; a system regularly approved by governors preeminently respectable, dissolved in a moment when reached by full and free enquiry. In this there was nothing local, nothing accidental, nothing attributable to individual character ; all was in the regular course of human institutions. And though many institu-

* Mr. J. Gray, p. 79.

tions, framed as this at York was prior to what may be called its dissolution, may exist long, and bear an imposing front, there is not one which is not internally hollow, and in its nature perishable.

Section II. — Bethlem Hospital

I have adverted, in the first instance, to the York Asylum, not from the peculiar importance of its case ; but in part because it preceded the others I shall speak of; and still more, because, after the delineation of Bethlem, the York case would have lost all power to attract attention. It would be most injurious to the former institution to call the cases similar; but both institutions exhibit the same system of government : that system had in both the same tendency; the nature of the evil was in both the same, the degree only different.

Bethlem Hospital was visited on the 2d of May, 1814. I take the account of what was seen there from the Parliamentary Report of the ensuing year *.

" At this visit, attended by the steward of the hospital, and also by a female keeper, we first proceeded to visit the women's galleries. One of the side-rooms contained about ten patients, each

* Report, 8vo. Baldwin, p. 45.

u

chained by one arm or leg to the wall ; the chain allowing them merely to stand up by the bench or form fixed to the wall, or to sit down again. The nakedness of each patient was covered by a blanket-gown only. The blanket-gown is a blanket formed something like a dressing-gown, with nothing to fasten it with in front. This constitutes the whole covering. The feet even were naked. One female in this side-room, thus chained, was an object remarkably striking. She mentioned her maiden and married names, and stated that she had been a teacher of languages. The keepers described her as a very accomplished lady, mistress of many languages, and corroborated her account of herself. The committee can hardly imagine a human being in a more degraded and brutalizing situation, than that in which I found this female, who held a coherent conversation with us, and was, of course, fully sensible of the mental and bodily condition of these wretched beings, who, equally without clothing, were closely chained to the same wall with herself. Unaware of the necessities of nature, some of them, though they contained life, appeared totally inanimate and unconscious of existence. The few minutes which we passed with this lady, did not permit us to form a judgment of the degree of restraint to which she ought to be subject ; but I unhesitatingly affirm, that her confinement with patients in whom she was compelled to witness the most disgusting ideotcy, and the most terrifying distraction of the human intellect, was injudicious and improper. She entreated to be allowed pencil and paper, for the purpose of amusing herself with drawing, which were given to her by one of the gentlemen with me. Many of these unfortunate women were locked up in their cells naked and chained on straw, with only one blanket for a covering. One, who was in that state by way of punishment, the keeper described as the most dissatisfied patient in the house. She talked coherently, complained of the want of tea and sugar ; and lamented that her friends, whom she stated to be respectable people, neither came to see her nor supplied her with little necessary comforts. The patients generally complained much of being deprived of tea and sugar. On leaving the gallery, we enquired of them whether the visit had been inconvenient or unpleasant. They all joined in saying, No; but, which was sufficiently apparent, that the visit of a friend was always pleasant.

" In the men's wing, in the side-room, six patients were chained close to the wall ; five handcuffed, and one locked to the wall by the right arm, as well as by the right leg : he was very noisy. All were naked, except as to the blanket-gown, or a small rug on the shoulders, and without shoes. One complained much of the coldness of his feet. One of us felt them : they were very cold. The patients in this room, except the noisy one, and the poor lad with cold feet, who was lucid when we saw him, were dreadful ideots. Their nakedness, and their mode of confinement, gave this room the complete appearance of a dogkennel. From the patients not being classed, some appear objects of resentment to the others. We saw a quiet, civil man, a soldier, a native of Poland, brutally attacked by another soldier, who, we were informed by the keepers, always singled out the Pole as an object of resentment. They saw there was no means of separating these men, except by locking one up in solitary confinement. Whilst looking at some of the bed-lying patients, a man arose, naked, from his bed, and had deliberately and quietly walked a few paces from his cell-door along the gallery. He was instantly seized by the keepers, thrown into his bed, and leg-locked, without enquiry or observation. Chains were universally substituted for the strait-waistcoat. In the men's wing were about 75 or 76 patients, with two keepers and an assistant ; and about the same number of patients on the women's side. The patients were in no way distinguished from each other as to disease, than as those who were not walking about or chained in the side-rooms were lying, stark naked, upon straw, on their bedsteads, each in a separate cell, with a single blanket or rug, in which the patient usually lay huddled up, as if impatient of cold, and generally chained to the bed-place in the shape of a trough. About one-fifth* were in this state, or chained in the side-rooms. It appeared that the wet patients, and all who were inclined to lie abed, were allowed to do so, from being less troublesome in that state than when up and dressed. In one of the cells on the lower gallery, we saw William Norris. He stated himself to be fifty-five years of age, and that he had been confined about fourteen years ; that, in consequence of attempting to defend himself from what he conceived to be the improper treatment of his keeper, he was fastened by a long chain, which, passing through a partition, enabled the keeper, by going into the next cell, to draw him close to the wall at pleasure ; that, to prevent this, Norris muffled the chain with straw, so as to hinder its passing through the wall; that he afterwards was confined in the manner we saw him ; namely, a stout iron ring was rivetted round his neck, from which a short chain passed to a ring made to slide upwards or downwards on an upright massive iron bar, more than six feet high, inserted into the wall. Round his body a strong iron bar, about two inches wide,

* In the York Asylum, (see Annual Report, 1824,) the number of patients under restraint, including every species, however slight, is about five in the hundred. In some of the houses mentioned in the parliamentary evidence of 1815 and 1S27, the proportion is said to be still less.

C was rivetted ; on each side the bar was a circular projection, which being fastened to and enclosing each of his arms, pinioned them close to his sides. This waist-bar was secured by two similar bars, which, passing over his shoulders, were rivetted to the waist-bar both before and behind. The iron ring round his neck was connected to the bars on his shoulders by a double link. From each of these bars another short chain passed to the ring on the upright iron bar. We were informed he was enabled to raise himself, so as to stand against the wall, on the pillow of his bed in the troughbed in which he lay. But it is impossible for him to advance from the wall in which the iron bar is soldered, on account of the shortness of his chains, which were only twelve inches long. It was, I conceive, equally out of his power to repose in any other position than on his back, the projections which on each side of the waist-bar enclosed his arms, rendering it impossible for him to lie on his side, even if the length of the chains from his neck and shoulders would permit it. His right leg was chained to the trough, in which he had remained, thus encaged and chained, more than twelve years. To prove the unnecessary restraint inflicted on this unfortunate man, he informed us he had, for some years, been able to withdraw his arms from the manacles which encompassed them. He then withdrew one of them ; and observing an expression of surprise, he said, that when his arms were withdrawn, lie was compelled to rest tliem on the edges of the circular projections, which was more painful than keeping them within. His position, we were informed, was mostly lying down ; and that, as it was inconvenient to raise himself and stand upright, he very seldom did so : that he read a great deal of books of all kinds, history, lives, or any thing that the keepers could get him ; the newspaper every day ; and conversed perfectly coherent on the passing topics and events of the war, in which he felt particular interest. On each day that we saw him, he discoursed coolly, and gave rational and deliberate answers to the different questions put to him. The whole of this statement, relative to William Norris, was confirmed by the keepers.

" On Wednesday, the 7th of June, when we again visited Bethlem, we discovered that all the male patients who were then naked and chained to their beds in the cells, were in that situation by way of punishment for misbehaviour, and not from disease. In consequence of the discovery made by the gentleman who went with me, and myself, of the situation of William Norris, and of a drawing which we procured to be made of him in his irons, he was visited by the following gentlemen : George Holme Sumner, Esq. M. P. the Honourable Henry Grey Bennet, M. P' R. J. Lambton, Esq. M. P. Thomas Thompson, Esq. M. P. and other

c 2 members of the house of commons ; and I have now to state, that at this last visit I observed that the whole of the irons had been removed from Norris's body ; and that the length of chain from his neck, which was only twelve inches, had been doubled.

" I was at Bethlem on Saturday week, the 23d of April*, and found that the old steward, Mr. Alvoine, no longer held the office ; and that a new steward, Mr. Wallet, was filling his situation. Mr. Wallet sent for an official governor, Mr. Deputy Greenaway, of Bishopsgate-street, to attend me ; and although the number of patients was nearly the same as during the last year, I found but one single one chained to his bed, and not a single patient in any one of the side-rooms, chained to the wall. Mrs. Fenwick, the teacher of languages to whom I have referred, was walking about the gallery, who, Mr. Wallet told me, was an entirely different creature, since she had been treated like a human being.

" Mr. Deputy Greenaway stated, that a great reformation had taken place in the hospital lately, very much in consequence of a speech that Lord Robert Seymour had made in parliament ; and that so far from the inspection which took place last year having done any harm, he was satisfied that the hospital had been essentially served. I asked

* 1825. The former visits were in 1824.

Mr. Alvoine, who were the governors. He said it was more than his place was worth to tell."

This statement was met by no counter evidence ; was confirmed by several members, Mr. Bennet, Mr. Smith, Mr. Western ; and is repeated, as to the mode of confining Norris, in the Report of the Bethlem Committee *.

Such a situation of things was not to be concealed, or to be received with indifference by the public. Opinion soon ran so high against the hospital, that a select committee of its governors met on the 24th of June, 1814, " for the purpose of enquiring into the management of the hospital, and the general health of the patients f." This committee consisted of the president, treasurer, three noblemen, three members of parliament, and eleven other gentlemen ; and was, beyond doubt, of the first respectability. The committee " examined the physician, apothecary, steward, and keepers of the hospital ; and also received the information of such of the governors as have been, for many years past, in the habit of attending the weekly committees, and also of going over the hospital and viewing the state of the patients^:" But the committee does not appear to have examined any person who was, or had been, a patient in the house ; or any of the gentlemen who had visited it ; or any person conversant in

* Evidence, p. 133 to 139. t Appendix, No. 3. J lb.

the management of insane patients, and unconnected with the establishment.

The Report, which was signed unanimously by the above gentlemen, comprises the following passages : " With respect to the general charge of cruelty and bad management, this committee is of opinion, on the fullest consideration, that no foundation whatever exists for such a charge ; that, in the opinion of this committee, every attention has, on the contrary, been paid in the hospital to the cleanliness, the health, and the comfort of the patients confined therein ; and that every degree of indulgence, consistent with the security of the patients and the safety of those employed, has been observed." After a description of Norris's restraint, which appears quite accurate, the Report proceeds : " This committee is of opinion that the peculiar nature of the case before them did justify its application, in this particular instance ; and that so far from having been attended with the effects which have been attributed to it, it appears to have been, upon the whole, rather a merciful and humane, than a rigorous and severe imposition."

Do we not, from the example of York Asylum and of Bethlem, see the evils necessarily incident to the ordinary routine of a close system of government ? At York, the forms of visitation are regularly gone through, and that by persons eminently respectable. At Bethlem, the same proceeding takes place. At York, a charge is laid against the institution : so it is in Bethlem. Governors meet in each place to enquire. The enquiry is instinctively carried on in each place on the same principles. Each committee enquires where no truth was to be found; and enquires with that esprit de corps, that disposition to selfsatisfaction and applause, by which men acting together are animated. An indignant vindication takes place in both cases. In both, the vindication is scouted by the public. Genuine enquiry in both cases follows. In the one institution, universal mismanagement is found to have prevailed : in the other, scenes shocking to humanity are exhibited. That really efficient visitor, the voice of the public, is no sooner heard, than one of the institutions is thoroughly regenerated: the other has lost all its horrors.

One very ingenious mode of defence is adopted in the Bethlem committee's report. The imputation of undue rigour is attributed to the admission of incurable patients. " No fewer than one half of the patients, both male and female, at present in the hospital, are incurable patients; and, consequently, have been received as dangerous patients, and so in the main continue *." By what happy chance or skill were the incurable patients of June 23d, 1814, all, save one, cured on the 23d April, 1815; when the one remaining