285
Art. X.?PRIVATE ASYLUMS.
There
are existing in the Metropolitan district 39 Private Asylums licensed for the reception of lunatics, the Provincial number being 60. During the year most unjustifiable and unwarrantable attacks have been made against these institutions and their proprietors by not only the lay papers, but also by the British
Medical Journal. It must be a subject for congratulation to all those connected directly or indirectly with private asylums to read the remarks of the Commissioners in Lunacy in their last Report. Much correspondence has taken place on the question. The Medical Press and Circular, when speaking on the subject says:? " The unjustifiable and indiscriminate attacks which a large portion of the daily press has recently levelled against private lunatic asylums makes it incumbent on us to expose the senseless fallacies of those who have joined in the blatant cry against the proprietors of these establishments, amongst whom can be numbered some of the greatest philanthropists of the age; and the wholesale slanderers of a humane and honourable class should be reminded, that it is to these we are chiefly indebted for the great improvements which have taken place of late years in the treatment of the insane. " Without the slightest wish to detract from the great merits ?f our public pauper asylums, we think it fair that the special of small private asylums should be duly recognised, and it will relieve the minds of those who have relatives in them to learn that are not the ' hells' that some poor deluded they individuals would lead us to suppose. " It must be evident to in a public every candid observer that asylum where there is a proportion of three or four medical men to several hundred patients, it is impossible to give that particular attention to each one case which it would receive person had the a limited numbei of patients of superintendence only. particular symptoms of some subtle form of mental a serration must often be overlooked in so vast a crowd. In a Private asylum the duties of the superintendent are most anxious and arduous. His whole existence is mixed up with tbat of the Patients; he has to share their meals and their amusements. We is therefore necessarily subjected, not only to frequent petty
advantages
_
where^
286
PRIVATE
ASYLUMS.
annoyances, but it sometimes even happens that his life is placed in jeopardy. These molestations can be borne, but it must certainly be trying to his patience to have to endure the unprovoked slander of ignorant scribblers at a time when he believes himself usefully and benevolently employed in relieving the sufferings of his fellow creatures. " The most scrutinising inquiry by the Dillwyn Committee of the House of Commons has satisfactorily shown that no instance of mala fides could be proved against any proprietor of a private lunatic asylum. " One of our contemporaries has likened private asylums in part to hotels ; we were not before aware that a stranger could enter an institution of this sort and order a bed and bitter beer. " Private asylums at the present day differ very materially from what they were some years ago before the legislature took up the question; and in spite of what we read of in the papers, we state emphatically that it is impossible, under the existing state of our law, to confine or detain a person unjustly in a
private asylum. The unhappy sufferers are treated with the greatest kindit is the aim and effort of the ness and consideration, and not to detain his patient unjustly, and proprietor superintendent "
but to do all in his power to restore reason, and ' minister to a mind diseased.'" The Commissioners make the following remarks on Private
Asylums:?
"In our Twenty-fifth Report (for 1871) we took occasion to describe each licensed house then open in the metropolitan district; and in the Twenty-sixth Keport we gave particulars of those licensed by justices, prefaced by a general sketch of the character and condition of these proprietary establishments. We there stated that they were very different from what such houses had been within the memory of several members of our board, and that their gradual improvement had been very
great. "We can now report that, since 1872, a few only of the houses then referred to have been closed, and those few, with a single exception, in consequence of the death or retirement of the proprietors. Within certain limits, beyond which activity would defeat its object, our criticism of the details of management of licensed houses becomes year by year more and more searching; and although the amount of order, good management, comfort, and attention to the wants of the patients varies much, and is not everywhere thoroughly satisfactory, yet the general improvement continues, and consequently the standard aimed at becomes higher and higher.
PRIVATE
ASYLUMS.
287
A good deal of unfavourable comment has lately been made upon the licensed houses and their proprietors, both before the Select Committee of the House of Commons (whose report we shall have occasion presently to notice) and elsewhere. Some witnesses called by the Committee went so fax' as to urge the immediate abolition of all such houses, on the ground of the temptation to keep profitable patients longer than necessary.' " A system which places the insane in charge of persons who derive profit from their detention, is no doubt objectionable in theory ; and in practice (like many other things) may be open to abuse. But so far as regards the licensed houses in England and Wales, which alone come under our observation, we are convinced that, under the strict supervision and the safeguards which the Lunacy Acts provide, no such abuses are possible as have been in some quarters seriously alleged, such as the ' in' carceration of sane persons, or the prolonged detention for of insane persons who have entirely recovered motives corrupt their reason. " Nor are the proprietors of licensed houses open to the sweeping charges of dishonesty and self-seeking which have been brought against them as a body. It should not be forgotten that these persons to some extent are competing with each other and with the hospitals in a business which, to be remunerative, must be conducted on principles of ordinary prudence and common honesty. " Moreover, in the vast majority of cases (admitting that instances to the contrary might possibly be found), the speedy cure of an insane patient is, on pecuniary, if on no higher grounds, an object of the greatest importance to the persons with whom it rests to decide where to place him under treatment, and every cure that can be shown becomes in fact the hest advertisement of the establishment in which the cure is "
effected. Our own opinion is that the licensed houses supply at present a social want; and that their abolition, without the substitution of other and better establishments, would assuredly multiply cases of illegal charge and consequent neglect and illtreatment of lunatics, and would also lead to the clandestine removal of many such persons to foreign parts. " Were asylums for the reception of private patients erected at the public cost, we doubt whether such institutions would be more acceptable to the friends of wealthy patients than the hospitals now registered under the Lunacy Acts, which do not receive many lunatics of large fortune. What these substitutes should be is a matter of more difficulty. Certainly the ex"
288
PRIVATE ASYLUMS.
years does not show any disposition on the to increase the number of institutions such ' as the present hospitals, founded on the principle of applying the excess of payments of some patients for or towards the * support, provision, or benefit of other patients.' (8 & 9 Vict,
perience
of
past
part of the public
c.
100,
s.
114.)
These views, it will be seen, are much in accordance with the conclusions of the Select Committee appearing in page vi. of their report. The entire passage is as follows:? "' The Committee found the greatest diversity of opinion with regard to private licensed houses. Some witnesses urged the immediate abolition of all such houses, on the ground of the temptation to keep profitable patients longer than necessary. Others as confidently stated that such houses supplied an acknowledged want, that there was a greater percentage of cures among patients under private care than among those in public asylums, and that it was the interest of the proprietors of private asylums to maintain the character of their establishments; while in public asylums, though the temptation to detain unduly for the sake of profit could hardly be said to exist, yet that paid officials might lose personal interest in the good and careful Other witnesses, again, management of these institutions. took a view between these two extremes, and considered that no alteration of the law in this respect was necessary, but that the matter had better be left to the spontaneous action of the public; that the time might arrive when there would be sufficient accommodation in public institutions for all classes, such as exist in Scotland, in Cornwall, and at Cheadle in Cheshire.f When that time arrived it was possible that there would be no demand for licensed houses for the upper and middle classes, nor would lunatics be kept any longer in the wards of workhouses, which, it was represented, are often, especially in Ireland, most unfit for the purpose. In this opinion the Committee concur, and they would suggest that legislative facilities should be afforded, by enlargement of the powers of magistrates, or otherwise, for the extension of this system.' " Before leaving this head of our report, we will enter into a few particulars which may throw further light on the present position of the licensed houses. The number of patients in "
*
The only two Hospitals which
were not in existence in 1859, are Barnwood which took its rise from the separation of the charity" element from the Gloucester, and the Royal Albert Asylum for Idiots. Comm'ttee appear to refer to:?1. The "Chartered Asylums" of ]6 2. ^cot 1 and; The detached building at the Cornwall County Asylum in connection ty' w^ere Pr'vate patients are received at low rates; and, 3. The ? Manchester lunatic Hospital" at Cheadle, registered under 8 & 9 Vict. c 100
House,
""S Asylun\at
PRIVATE
ASYLUMS.
289
licensed houses (if we exclude the paupers, the inmates of idiot institutions, and the insane soldiers received in Grove Hall under a contract with the War Office) are 1,432 in the metropolitan district and 1,455 in the provinces; altogether 2,887 The houses in and about London are 37, but these persons. include four where idiots only are received. Those in the country are 60; they also include four receiving idiots only. Of the 33 metropolitan houses (excluding those which receive idiot children only) 13 have 30 patients and upwards. In the provinces, with 12 exceptions, the number of private patients does not, in any one house, exceed 30. Many licensees in town and country have fewer than 20 cases under their charge, and some are limited to the reception of two or three individuals brothers or sisters. The charges for care and treatment in licensed houses of course vary much, according to the extent of the accommodation and style of living. We find that the present average licensed houses which payment for "each patient in the 89 as receive lunatic distinguished from idiots, is
being "
private patients,
follows :? In 32 of the houses, receiving about 1,300 patients, the average payment is under ?100 per annum. " In 22, receiving about 750, the average payment is from ?100 to ?150 per annum. are "Thirty shillings and two guineas weekly, of ordinary a large proportion but patients this of in houses class, charges are received there at rates not exceeding one guinea, while To a week. comparatively few pay more than three guineas into any licensed house obtain admission for a
approximately
as
"
private patient thirty shillings a
week is, however, not the if patient be very infirm, impossible habits. or of noisy, destructive, dirty " In the remaining 35 houses the charges are higher. "In 18 of these, the average payments range from ?150 to
for
below easy, and it is almost a
payment
?200. "
In 13 from ?200 to ?280. In 4, from ?280 to ?330, and in one house they reach ?470, including cost of carriages, and other expensivein luxuries. the first-class "Against the highest sums demanded in most of that houses we should mention this set-off, viz.y them there are cases of very long standing whose cost of maintenance actually exceeds the small payments which can be obtained for their from the surviving members of "
support
their families. " Further particulars
as
to the extent of the licence of each
bouse, and as to the average number of patients resident, during 1878, are given, as heretofore, in the Appendix (B).
290 "
PRIVATE
In
ASYLUMS.
of these establishments are occasionally living, by relatives or connection of patients. We think that the association of such persons is often most beneficial. We also think that an additional guarantee is afforded for the proper care and treatment of all the insane inmates of a licensed house by the presence among them, and sharing their everyday life and general treatment, of one or more visitors of sound mind interested in checking maladministration, acting as so many watchful eyes over the attendants, and not restrained from complaint to us or to the proprietors by any fear of personal consequences. We therefore do all in our power to encourage the residence of such friends, and in ' one of the larger private asylums' in London several are our
some
special permission,
always staying.
"In the house just mentioned, and in many others, are also voluntary boarders residing by similar permission, being usually persons liable to recurrent insanity who feel the advantage of a regulated life, with constant access to medical advice. At our periodical visits we satisfy ourselves that they have not relapsed into certifiable unsoundness of mind, and that their stay is entirely their own wish. The presence of these individuals in licensed houses is another valuable check upon improper proceedings there, and affords some proof that the general management of the establishment (of which, while insane, the boarder has usually had experience) is not objectionable to him."
Art. X.?PRIVATE ASYLUMS.
There
are existing in the Metropolitan district 39 Private Asylums licensed for the reception of lunatics, the Provincial number being 60. During the year most unjustifiable and unwarrantable attacks have been made against these institutions and their proprietors by not only the lay papers, but also by the British
Medical Journal. It must be a subject for congratulation to all those connected directly or indirectly with private asylums to read the remarks of the Commissioners in Lunacy in their last Report. Much correspondence has taken place on the question. The Medical Press and Circular, when speaking on the subject says:? " The unjustifiable and indiscriminate attacks which a large portion of the daily press has recently levelled against private lunatic asylums makes it incumbent on us to expose the senseless fallacies of those who have joined in the blatant cry against the proprietors of these establishments, amongst whom can be numbered some of the greatest philanthropists of the age; and the wholesale slanderers of a humane and honourable class should be reminded, that it is to these we are chiefly indebted for the great improvements which have taken place of late years in the treatment of the insane. " Without the slightest wish to detract from the great merits ?f our public pauper asylums, we think it fair that the special of small private asylums should be duly recognised, and it will relieve the minds of those who have relatives in them to learn that are not the ' hells' that some poor deluded they individuals would lead us to suppose. " It must be evident to in a public every candid observer that asylum where there is a proportion of three or four medical men to several hundred patients, it is impossible to give that particular attention to each one case which it would receive person had the a limited numbei of patients of superintendence only. particular symptoms of some subtle form of mental a serration must often be overlooked in so vast a crowd. In a Private asylum the duties of the superintendent are most anxious and arduous. His whole existence is mixed up with tbat of the Patients; he has to share their meals and their amusements. We is therefore necessarily subjected, not only to frequent petty
advantages
_
where^
286
PRIVATE
ASYLUMS.
annoyances, but it sometimes even happens that his life is placed in jeopardy. These molestations can be borne, but it must certainly be trying to his patience to have to endure the unprovoked slander of ignorant scribblers at a time when he believes himself usefully and benevolently employed in relieving the sufferings of his fellow creatures. " The most scrutinising inquiry by the Dillwyn Committee of the House of Commons has satisfactorily shown that no instance of mala fides could be proved against any proprietor of a private lunatic asylum. " One of our contemporaries has likened private asylums in part to hotels ; we were not before aware that a stranger could enter an institution of this sort and order a bed and bitter beer. " Private asylums at the present day differ very materially from what they were some years ago before the legislature took up the question; and in spite of what we read of in the papers, we state emphatically that it is impossible, under the existing state of our law, to confine or detain a person unjustly in a
private asylum. The unhappy sufferers are treated with the greatest kindit is the aim and effort of the ness and consideration, and not to detain his patient unjustly, and proprietor superintendent "
but to do all in his power to restore reason, and ' minister to a mind diseased.'" The Commissioners make the following remarks on Private
Asylums:?
"In our Twenty-fifth Report (for 1871) we took occasion to describe each licensed house then open in the metropolitan district; and in the Twenty-sixth Keport we gave particulars of those licensed by justices, prefaced by a general sketch of the character and condition of these proprietary establishments. We there stated that they were very different from what such houses had been within the memory of several members of our board, and that their gradual improvement had been very
great. "We can now report that, since 1872, a few only of the houses then referred to have been closed, and those few, with a single exception, in consequence of the death or retirement of the proprietors. Within certain limits, beyond which activity would defeat its object, our criticism of the details of management of licensed houses becomes year by year more and more searching; and although the amount of order, good management, comfort, and attention to the wants of the patients varies much, and is not everywhere thoroughly satisfactory, yet the general improvement continues, and consequently the standard aimed at becomes higher and higher.
PRIVATE
ASYLUMS.
287
A good deal of unfavourable comment has lately been made upon the licensed houses and their proprietors, both before the Select Committee of the House of Commons (whose report we shall have occasion presently to notice) and elsewhere. Some witnesses called by the Committee went so fax' as to urge the immediate abolition of all such houses, on the ground of the temptation to keep profitable patients longer than necessary.' " A system which places the insane in charge of persons who derive profit from their detention, is no doubt objectionable in theory ; and in practice (like many other things) may be open to abuse. But so far as regards the licensed houses in England and Wales, which alone come under our observation, we are convinced that, under the strict supervision and the safeguards which the Lunacy Acts provide, no such abuses are possible as have been in some quarters seriously alleged, such as the ' in' carceration of sane persons, or the prolonged detention for of insane persons who have entirely recovered motives corrupt their reason. " Nor are the proprietors of licensed houses open to the sweeping charges of dishonesty and self-seeking which have been brought against them as a body. It should not be forgotten that these persons to some extent are competing with each other and with the hospitals in a business which, to be remunerative, must be conducted on principles of ordinary prudence and common honesty. " Moreover, in the vast majority of cases (admitting that instances to the contrary might possibly be found), the speedy cure of an insane patient is, on pecuniary, if on no higher grounds, an object of the greatest importance to the persons with whom it rests to decide where to place him under treatment, and every cure that can be shown becomes in fact the hest advertisement of the establishment in which the cure is "
effected. Our own opinion is that the licensed houses supply at present a social want; and that their abolition, without the substitution of other and better establishments, would assuredly multiply cases of illegal charge and consequent neglect and illtreatment of lunatics, and would also lead to the clandestine removal of many such persons to foreign parts. " Were asylums for the reception of private patients erected at the public cost, we doubt whether such institutions would be more acceptable to the friends of wealthy patients than the hospitals now registered under the Lunacy Acts, which do not receive many lunatics of large fortune. What these substitutes should be is a matter of more difficulty. Certainly the ex"
288
PRIVATE ASYLUMS.
years does not show any disposition on the to increase the number of institutions such ' as the present hospitals, founded on the principle of applying the excess of payments of some patients for or towards the * support, provision, or benefit of other patients.' (8 & 9 Vict,
perience
of
past
part of the public
c.
100,
s.
114.)
These views, it will be seen, are much in accordance with the conclusions of the Select Committee appearing in page vi. of their report. The entire passage is as follows:? "' The Committee found the greatest diversity of opinion with regard to private licensed houses. Some witnesses urged the immediate abolition of all such houses, on the ground of the temptation to keep profitable patients longer than necessary. Others as confidently stated that such houses supplied an acknowledged want, that there was a greater percentage of cures among patients under private care than among those in public asylums, and that it was the interest of the proprietors of private asylums to maintain the character of their establishments; while in public asylums, though the temptation to detain unduly for the sake of profit could hardly be said to exist, yet that paid officials might lose personal interest in the good and careful Other witnesses, again, management of these institutions. took a view between these two extremes, and considered that no alteration of the law in this respect was necessary, but that the matter had better be left to the spontaneous action of the public; that the time might arrive when there would be sufficient accommodation in public institutions for all classes, such as exist in Scotland, in Cornwall, and at Cheadle in Cheshire.f When that time arrived it was possible that there would be no demand for licensed houses for the upper and middle classes, nor would lunatics be kept any longer in the wards of workhouses, which, it was represented, are often, especially in Ireland, most unfit for the purpose. In this opinion the Committee concur, and they would suggest that legislative facilities should be afforded, by enlargement of the powers of magistrates, or otherwise, for the extension of this system.' " Before leaving this head of our report, we will enter into a few particulars which may throw further light on the present position of the licensed houses. The number of patients in "
*
The only two Hospitals which
were not in existence in 1859, are Barnwood which took its rise from the separation of the charity" element from the Gloucester, and the Royal Albert Asylum for Idiots. Comm'ttee appear to refer to:?1. The "Chartered Asylums" of ]6 2. ^cot 1 and; The detached building at the Cornwall County Asylum in connection ty' w^ere Pr'vate patients are received at low rates; and, 3. The ? Manchester lunatic Hospital" at Cheadle, registered under 8 & 9 Vict. c 100
House,
""S Asylun\at
PRIVATE
ASYLUMS.
289
licensed houses (if we exclude the paupers, the inmates of idiot institutions, and the insane soldiers received in Grove Hall under a contract with the War Office) are 1,432 in the metropolitan district and 1,455 in the provinces; altogether 2,887 The houses in and about London are 37, but these persons. include four where idiots only are received. Those in the country are 60; they also include four receiving idiots only. Of the 33 metropolitan houses (excluding those which receive idiot children only) 13 have 30 patients and upwards. In the provinces, with 12 exceptions, the number of private patients does not, in any one house, exceed 30. Many licensees in town and country have fewer than 20 cases under their charge, and some are limited to the reception of two or three individuals brothers or sisters. The charges for care and treatment in licensed houses of course vary much, according to the extent of the accommodation and style of living. We find that the present average licensed houses which payment for "each patient in the 89 as receive lunatic distinguished from idiots, is
being "
private patients,
follows :? In 32 of the houses, receiving about 1,300 patients, the average payment is under ?100 per annum. " In 22, receiving about 750, the average payment is from ?100 to ?150 per annum. are "Thirty shillings and two guineas weekly, of ordinary a large proportion but patients this of in houses class, charges are received there at rates not exceeding one guinea, while To a week. comparatively few pay more than three guineas into any licensed house obtain admission for a
approximately
as
"
private patient thirty shillings a
week is, however, not the if patient be very infirm, impossible habits. or of noisy, destructive, dirty " In the remaining 35 houses the charges are higher. "In 18 of these, the average payments range from ?150 to
for
below easy, and it is almost a
payment
?200. "
In 13 from ?200 to ?280. In 4, from ?280 to ?330, and in one house they reach ?470, including cost of carriages, and other expensivein luxuries. the first-class "Against the highest sums demanded in most of that houses we should mention this set-off, viz.y them there are cases of very long standing whose cost of maintenance actually exceeds the small payments which can be obtained for their from the surviving members of "
support
their families. " Further particulars
as
to the extent of the licence of each
bouse, and as to the average number of patients resident, during 1878, are given, as heretofore, in the Appendix (B).
290 "
PRIVATE
In
ASYLUMS.
of these establishments are occasionally living, by relatives or connection of patients. We think that the association of such persons is often most beneficial. We also think that an additional guarantee is afforded for the proper care and treatment of all the insane inmates of a licensed house by the presence among them, and sharing their everyday life and general treatment, of one or more visitors of sound mind interested in checking maladministration, acting as so many watchful eyes over the attendants, and not restrained from complaint to us or to the proprietors by any fear of personal consequences. We therefore do all in our power to encourage the residence of such friends, and in ' one of the larger private asylums' in London several are our
some
special permission,
always staying.
"In the house just mentioned, and in many others, are also voluntary boarders residing by similar permission, being usually persons liable to recurrent insanity who feel the advantage of a regulated life, with constant access to medical advice. At our periodical visits we satisfy ourselves that they have not relapsed into certifiable unsoundness of mind, and that their stay is entirely their own wish. The presence of these individuals in licensed houses is another valuable check upon improper proceedings there, and affords some proof that the general management of the establishment (of which, while insane, the boarder has usually had experience) is not objectionable to him."
