reports
HANWELL LUNATIC ASYLUM
The Fifty-ninth Report of the Visiting Justices of the Lunatic Asylum of
Hunwell. The Resident Physician's Report, and the Report of the Chaplain,
1841.
The Hanwell Lunatic Asylum has been the theatre of an experiment which will
not improbably produce an entire change in the treatment of insanity.
The Report before us gives the results of a total abandonment of all
personal restraints, except by occasional seclusion, in the treatment of
above 900 lunatics of every degree and character of disease.
Chastisement
and coercion, till within the last few years the habitual mode of treating
the insane, exist no longer in the largest lunatic asylum in the empire:-
one moreover where the class of patients being exclusively from the
poorer orders of society, bodily restraints might be deemed most of all
requisite, and mental or moral influences the least hopeful. Nevertheless,
sleeves, coercive chairs, leg-locks and straitwaistcoats have been
superseded for above two years, by the appliances of skill and kindness.
Hanwell is neither the only nor the first experiment of the disuse of
restraints, but it has there been made in the most unqualified manner and
on the largest scale: and as the new system has been the subject of much
controversy, the results of another year's experience are of great
interest.
preliminary report
The Visiting Justices, in a brief preliminary Report, very ably drawn up,
state that the question whether the non-coercive system had been too
rashly pursued, underwent prolonged discussion before the Court, at the
Michaelmas Quarter Sessions of last year, when it was resolved to defer
decision until the Court should have the benefit of the more lengthened
experience and matured judgment of the Visiting Justices.
Danger, both to
the insane and to their attendants, appears to have been the objection
mainly raised to the new system. The decision of the Visiting Justices is
now given in the following words :-
"But do the means which are now adopted at Hanwell offer an equal security
against the dangers to which every institution, and especially every large
institution for the insane is liable? Are they sufficient to guard, not
with absolute certainty, but with reasonable hope, against danger, equal at
least to the mode of management for which it has been substituted? The
Visiting Justices beg to answer distinctly in the affirmative: and to
state, as the result of their experience, that notwithstanding the many
obstacles with which the non-restraint system has had to struggle,
notwithstanding the difficulties which have unavoidably attended the
transition from one system to another, notwithstanding all these, and even
more than these obstacles by which the means have been materially weakened
that were relied on for complete success, that success has fully equalled
their hopes, and has presented advantages, which in their opinion more than
compensate the imperfections to which every human contrivance is liable."
In reply to the imputation that under the guise of humanity, there is more
actual cruelty in the Hanwell system, than in restraints which exasperate
the mind and torture the body, they state, that by the failure of their
system can such an imputation alone be justified.
"It has not failed, but has succeeded ; and the Visiting Justices have
perhaps one of the best proofs of its success in the testimonies of the
patients themselves, when they are restored to health, and are fully alive
to the comforts and advantages which they have enjoyed under it. The
committee are accustomed, on their appearing before them, to receive their
discharge, to examine them as to the degree of consciousness they possessed
during their malady, and it has been found that their consciousness, and
their recollection of what had passed, were much more distinct and perfect
than might be supposed. In answer to inquiries as to whether they were
satisfied with their treatment ; and whether they had anything to complain
of, they have uniformly, with but one exception, where a female complained
of having been once struck on the face by a nurse, expressed themselves
perfectly satisfied with the kindness and attention they had received, and
in some instances in such feeling terms as to convince the Visiting
Justices that kind treatment is not lost upon the insane, but is distinctly
and gratefully recollected when they are restored to reason."
details of management
The Report abounds with a variety of instructions as to the detail of
management; many of which appear essential to its success: such as the
perfect unanimity of the officers and attendants as respects the plan
itself:- a point but recently achieved at Hanwell.
The attendants moreover must be powerful in body and kind in disposition,
and of great forbearance of temper; they must, therefore.be a more highly
paid class than are ordinarily found in lunatic asylums, and they must also
be more numerous, viz. one to every eighteen patients.
The beautiful grounds for recreations and gardening, and the industrial
occupations for those who are sufficiently recovered to pursue them, form
important elements of the system. In fact, no resource is neglected of
which the effect is to calm the feelings, to remove excitement, to appease
passion, to divert the mind from the topics of its disease, and as the
ground-work of all moral remedies, to improve and establish bodily health
and strength.
The attention to cleanliness is extreme ; nor can a stronger evidence of
this be given than the fact that thirty thousand gallons of water, are
required for the daily use of the establishment. Scrupulous cleanliness in
every possible respect is among the most rigidly enforced rules; and a
variety of means compatible with the perfect freedom of the patient, both
at night and by day, are adopted, the simplicity and general success of
which leave little to be desired.
The Resident Physician's Report enters into further detail, and it
constitutes one of the best comparative accounts of the old and new systems
we have yet seen.
old mode of treatment
As respects the old mode of treatment, it is difficult to
rise from the perusal of the Report, without a strong conviction that
coercive appliances are inefficient as a means of preventing accidents ;
whilst their irritating effects on the violent, the alarm they occasion to
timid, and their tendency to debase those to whom they are applied,
creating incurable habits of uncleanliness, are evil from which the use of
restraints have been found inseparable.
One of the strongest objections to
instrumental restraints appears to be the liability of the attendants to
abuse the use of them.
On this point, Dr. Conolly says-
" As at that time no reports were ever made, or records kept, by the
attendants of the patients in restraint; whilst closets full of instruments
of restrain were at their command - it was impossible for the resident
physician ever to know, by night or by day, how many of the patients whom
it was his duty to protect, were in actual bondage. It was curiously
indicative of the perversion 'of feeling engendered by long familiarity
with restraint, that there was no par of the asylum in which they were more
freely employed than in the female infirmary."
" A young woman, (E.D.), in a state of chronic dementia, following attacks
of mania which had occurred six or seven years previously, was found on the
resident physician's first visit to the wards after this appointment,
fastened in her bed by a strap round her neck, by a strap round her waist,
and by straps to her feet. She also had on the sleeves, which enveloped her
hands in hard leather cases, and her hands were also fastened by short
straps connected with the strap round her waist. She was extremely feeble
and emaciated ; her skin was in a very irritable state. She could not get
out of bed, or raise herself up, or turn, or lift her hand to her mouth. In
this state she had been kept for some weeks. No cause was assigned, except
that she was troublesome - that she would undress herself - that she was
always in mischief. Day by day, with all the caution assumed to be
necessary, one after another of her galling restraints was removed. For a
short time she proved to be mischievous and troublesome in her powerless
way. She delighted in taking off the clothes from her irritable skin, and
she preferred standing up to lying down upon the irritating straw of her
bed. She one day broke a pane of glass (being still locked up in her room),
and squeezed part of her superfluous wardrobe through it. This habit was
discontinued when she was permitted to come into the gallery ; but, as she
was fond of taking any unappropriated bread, tea, or beer that she found in
the ward, the infirmary nurse, who had highly disapproved of all the
proceedings .u the patient's favour, contented herself with the milder
means of fastening a long strap to the waist-strap of the patient's dress,
and securing her by it to an iron bar, or a bench, or a heavy
restraint-chair. This thraldom being also forbidden, the patient gradually
became less troublesome, and being removed to another ward, slowly
recovered strength, and even became fat The poor girl had been a
music-mistress, and in a few weeks after her restraints were taken off, she
was led to the organ in the chapel by the matron, and induced to play. This
patient is yet in the asylum, imbecile, and incapable of employment, but
seldom mischievous or troublesome."
The extreme liability to abuse, which the restraint system labours under,
arises from the saving of trouble which it offers to the attendant:
" A prolonged maniacal attack is not unfrequently characterized by a
continual activity and a most ingenious disposition to mischief. When
restraints were employed, these restless and troublesome patients were very
frequent subjects of it. It prevented the necessity for the almost
continual watching required, and which was too irksome to be borne by an
attendant who could at once be relieved from his care by putting the
patient's hands in a leather muff, or locking his ankles together. The
inconvenience then created fell chiefly on the patient; and many such
patients were by degrees allowed to be either in constant or in very
frequent restraint; always greatly to their detriment, and sometimes to
their entire ruin. The patients now alluded to are seldom violent; they are
easily amused, and when amused are as playful as children : but they are
irritable, and become uncertain in their temper under the annoyance of
mechanical restraints."
Cases in which extreme severity has been used in other asylums are of
constant and, we regret to find, of recent occurrence.
" In the course of the year, several patients have been admitted in
restraints, and many more marked with restraints imposed before admission.
The management of all these cases has proved perfectly practicable without
restraints."
Dr. Conolly states no stronger fact than the following, to prove how great
a tendency habitual employment of restraint has to harden the feelings of
the attendants, and blunt their humanity, of which, under other
circumstances, they are by no means destitute :
"The resident physician cannot forget having more than once discovered
that dying patients were not released from restraints. Even in the
restlessness of death their feet were strapped or chained to the bedstead,
and an order to liberate them seemed to occasion surprise."
The resource which is adopted at Hanwell in cases of extreme violence is
that of seclusion.
" But to secure the advantages of seclusion, it must be remembered, that
the term is applied to the temporary confinement of a lunatic in his own
bedroom ; sometimes with the light partially excluded, sometimes almost
entirely ; that it must not be hastily resorted to ; not carried into
effect with anger, but steadily accomplished, when persuasion fails, by a
sufficient number of attendants ; that it must not be accompanied with
irritating expressions ; nor applied as a punishment; nor unreasonably
prolonged. The state of the patient in seclusion should be ascertained from
time to time through the inspection-plate ; and any appearance of
contrition should be met with kindness."
It seldom fails, it appears,
" to tranquillize the patient in a short time,
and is generally productive of immediate composure."
It is also obviously a
far less exciting course to the others than that of the spectacle of an
infuriated patient running about the ward degraded and irritated by the
muff or sleeves. The imposition of such restraints, moreover, was often
accomplished only after a severe struggle,always severest when restraint
was most required, and a revengeful feeling was usually left in the
patient's mind, which does not ensue from seclusion.
In the controversy on the relative merits of the two systems, the Report,
we think, judiciously, avoids entering, further than by the statement, that
wherever the non-coercive system has been tried,as at Lincoln, Melton,
Northampton, and Lancaster, "it is reported to be successful." While in the
cases of complicated difficulty, where restraint has been alleged to be
indispensable, it does not appear that any trial of the other system has
been ever made,the impossibility of so treating them resting wholly on
assumption.
Dr. Conolly rightly says, that he attributes the hostile feeling, where it
exists against the soothing method, to a want of opportunity of seeing the
questioned system in actual operation, and to a forgetfulness that whether
the system be right or wrong, its professed object is to avoid unnecessary
cruelty. We can only believe that to a humane mind, the effect, where
successful, of an abandonment of severity towards so pitiably helpless a
being as a lunatic, must make a man an enthusiast in its favour, nor do we
anywise wonder at the Doctor's somewhat impassioned testimony to its
merits.
The statistical tables, to which we shall presently refer, are of great
value, and they are compiled with apparent care and skill.
Chaplain's Report
To the Physician's Report succeeds one from the Chaplain. That it is nearly
barren of information is to be excused by the shortness of the chaplain's
experience, he having been appointed to the office
within the last few months. If, however, he has had no time to
cull fruits, he has had sufficient
at least to become abundantly impressed with the difficulties of his task,
to which he refers no less than six times in as many pages. The facts
stated are, that
"the far greater number of the patients appear to him to have
fallen victims to the disease whilst uninstructed in the truths of
revelation, or at least uninfluenced by them"
The Church Service shortened
to an hour's duration is used on Sunday morning, and sermon is preached in
the afternoon.
"The path of the religious teacher of the insane, (the
chaplain thinks,) must lie in the mean, between excitement and irritation."
We should be disposed to think that it ought to avoid both, and that unless
the teacher be able to convey, and the patient to receive consolation and
soothing influences from religion, there must either be incapacity in the
one or unfitness in the other.
"That a degree of excitement is unavoidable in every case,"
is an assertion which, if correct in the true meaning of
the terms used, would prove the insane of all grades and descriptions to be
incapable of receiving the calming and quiet influences of religion ; a
conclusion too painful to be accepted, and unquestionably too broad for
credence, on the authority if so brief an experience as that of the
chaplain of the Hanwell Lunatic Asylum.
The doctrine that
"excitement may, if judiciously directed, be beneficial
in its effects,"
is one which, applied to lunatics, requires much
explanation ; for it certainly appears irreconcilable with the system of
soothing and calming, which is the rule of the establishment in every other
respect. The rule not to excite, is certainly one of which the violation
can alone be vindicated by lengthened experience, or the soundest and
strongest reasons. In the absence of either, he chaplain says
"This course [of judicious excitement] always intricate when the mind is
sane, becomes doubly difficult when its faculties are in derangement, It is
your chaplain's anxious endeavour to discover and scrupulously to follow
it."
We frankly confess that it is with the greatest satisfaction we learn that
a course, doubly more difficult than one which is always intricate, will
not be allowed until the chaplain has discovered it. In the interim, we
would venture to suggest the strictest adherence on his part to such
instruction as he finds soothes and quiets the mind of his flock, and which
shall be wholly divested of the undiscovered benefits of excitement. He
surely needs not to be reminded that the pure precepts and principles of
the Gospel afford abundance of consolation and peace applicable to minds
diseased as well as sane. He has undertaken an office of unlimited
responsibility, and hitherto unfathomed interest and scope. It strikes us
forcibly that his course must be one of investigation, rather than of
experiment. It is not as though his trust were one of which the character
and most fitting mode of discharging it were known and established. The
system of treating lunatics otherwise than as brutes, is of present origin;
the substitution of moral and mental remedy for the instruments of mere
physical coercion, are of today. The mental physician has even newer
ground to tread than the bodily one. The one has changed his mode of
treatment; the office of the
other is now called into being. The records of cure by chains and fetters,
afford no clue to the administration of spiritual appliances. In a work so
novel and a path as yet so little trodden, it seems that a thorough
comprehension of the disease is primarily essential to the choice of the
mode of cure. To probe the phenomena of lunacy, to trace the seat of the
disease in the mind, to distinguish its peculiarities, classify its
different descriptions and characters, to define their attributes, measure
their comparative strength, and ascertain their degree of connexion with
bodily infirmity, appear to us to be desiderata preliminary to the
discovery or application of the spiritual and mental treatment of insanity.
These then will be the legitimate duties of the chaplain. He is aided, not
merely by the discretion and observation of the resident physician ; but by
a variety of
moral and physical statistics, in great measure demarcating
the distinctions, as far as they be historically traced, among the
patients. These may serve as aids to his own judgment in the pursuit of the
more elaborate portion of his investigation. But in the daily and hourly
offices of his ministry among the sorely afflicted minds of his flock, we
apprehend that our Saviour has superseded the necessity of any discovery in
the fields of excitement, by the simple invitation,
" Come unto me all ye
that labour and are heavy laden, and I will give ye rest."
The statistics of the Hanwell Asylum are very interesting. The number of
patients in September last was 918, of whom 387 were males, and 531
females. This large preponderance of females over males, has not existed
during the whole period of the establishment of the asylum, viz. since May
1831 ; for the total number of male patients admitted has been 1109, and of
female patients, 1133, up to this time. From 1831 to 1833 inclusive, the
number of females admitted considerably preponderated over the males ; but
from 1834 to 1837, fewer females than males were admitted.
For the last
four years the admissions have been as follows :