History
When Dave Sheppard retired in 2020 he kindly gave me permission to publish the contents of his website (originally named after his firm, "Dave Sheppard Associates", then called "MHAandMCA"). It is a treasure trove. I've not had time to prepare everything for publication but have put the main headings online: let me know if you would like a copy of anything listed.
Jurors who returned a verdict of misadventure following the killing of one of the brothers at a hospital in Beverley, Yorkshire in 1285, stated that the accused had acted at 'the instigation of the devil' and that his illness had rendered him 'frantic and mad' and thus susceptible to the wiles of Satan.
De Prerogativa Regis 1324 "(The Royal Prerogative)", derived from feudal principles of land tenure, provided for the management of the estates of incapacitated tenants (mainly wardship of the lands of infants during the period of their minority). The estates of idiots and lunatics were treated differently. The Crown was entitled to the rents and profits of the estates of idiots for the duration of their life, subject to the expense of their maintenance and that of their dependent family. The Crown often entrusted the care of the idiot to someone who shared the profits of the Estate with the Crown, a practice alluded to as "begging a man for a fool." Lunatics were more favourably treated as the excess of income over the expense of their maintenance did not find its way into the royal coffers but was held in trust pending their recovery or, in the event of their death, for the benefit of their soul.
Bethlem, founded as the priory of the Order of St Mary of Bethlehem, in 1247, was first described as a 'hospice' or 'hospital' in 1329. It was seized by the Crown in 1375 and began to take 'lunatics' in 1377. A government inquiry in 1403 revealed a catalogue of abuses caused by absenteeism and corruption. Some of the revenues embezzled by the warden had been collected from the friends and relatives of patients who paid for long periods to have them kept (as they believed) in reputedly secure and comfortable accommodation with the constant solace of religion available in the hospital chapel. The neighbours of Agnes Coteneys had, for instance, collected alms for eighteen months so that she could make a full recovery in the hospital, where she evidently remained, at their expense, after regaining her reason. In 1403 - 4, there were 6 insane and 3 sane patients. This number grew slowly rising to 27 patients in 1634 and 44 in 1642. The hospital was rebuilt in 1676 on a new site to accommodate 130 - 150 patients, all of whom had to be poor and potentially curable to qualify for admission. The aim was for the maximum length of stay to be 12 months. Until the 17th century, Bethlem remained the only specialised place for the insane.
In 1541, the mayor and aldermen of Norwich issued orders for the expulsion of one Ralph Chamberlain, "being vexid wyth a dyvyll and beyng lunytick" from the city under pain of imprisonment.
An Act for the Relief of the Poor 1601 specified that each parish should take responsibility for the old and the sick, including idiots and lunatics, and provide work for the poor. It provided for unpaid churchwardens and others to be overseers of the poor. Outdoor relief was payable but often inadequate. The overseer was empowered to levy rates and arrears in each parish for the relief of its own paupers. Justices of the Peace could commit persons refusing work to the county Bridewell (house of correction) or the common gaol. Overseers could arrange for the impotent poor to be placed in workhouses. The mentally disordered were among those housed in these institutions where conditions were notoriously bad. However for the next 150 years, taxes were enforced only as a last resort as these rates were extremely unpopular and the most difficult to raise.
The Act of Settlement 1662 enabled aid to be restricted to those belonging to one's own parish. Workhouses, first established in the 1630's became common in most market towns by the middle of the 18th century and became the dumping grounds for the decrepit and dependent of all descriptions. By 1770 some workhouses were refusing to take lunatics. In 16th and 17th century England, society was more concerned about men rather than women who became insane. The stereotypical lunatic was Mad Tom, a tattered beggar, hardly better than a beast.
The earliest records in England of private madhouses on a regular basis are from 1670 onwards.
An Act for reducing the laws relating to Rogues, Vagabonds, Sturdy Beggars, and Vagrants into one Act of Parliament 1714, authorised two or more Justices of the Peace to secure the arrest of any person "furiously mad and dangerous", and "to be safely locked up in some secure place" i.e.. workhouse, lock-up, private madhouse, gaol, Bridewell (house of correction) for as long as the "lunacy or madness shall continue". Lunatics got the same treatment as other vagrants but were specifically excluded from whipping.
A charitable asylum was founded in Norwich (1713), a ward for incurable lunatics at Guys Hospital (1728), followed by charitable asylums at St Lukes, Woodside, London (1751), Newcastle upon Tyne (1764), Manchester (1766), York (1774), Leicester (1792), Liverpool (1797) and Hereford (1799). Bethlem made specific provision from the 1730's for incurables and in 1739 stated they would give priority for admission to dangerous rather than harmless incurables. St Lukes adopted the same stance in 1763.
An Act to amend and make more effectual the Laws relating to Rogues, Vagabonds, and other idle and disorderly Persons, and to Houses of Correction 1744 amended the previous legislation by including "those who by Lunacy or otherwise are furiously mad or so far disordered in their Senses that may be dangerous to be permitted to go Abroad" permitted two or more Justices of the Peace to direct a constable, church warden or overseer of the poor to apprehend "and be safely locked in some secure place ... (and if necessary) to be there chained ... for and during such time only as the lunacy or madness shall continue." Private madhouses, operated for profit, received not only detained people of means but occasionally pauper lunatics who were sent by the overseer because their presence in the workhouse disturbed the other inmates. They often received patients at the insistence of their relatives and, since the relative paid for the person's reception and care, there was little incentive for the proprietor to discharge the person from confinement.
In 1750, an appeal was launched to set up a second charity asylum in London which led to the setting up of St Lukes, Woodside the following year. During the 1760's, restraint was widely employed on the 260 patients by its ten or eleven staff. St Lukes forbade casual visitors from the start unlike Bethlem where the practice continued beyond 1770. The hospital moved in 1787 to a new site in Old Street.
An Act for regulating Madhouses 1774 followed two early cases of habeas corpus (Clark (1718) and Turlington (1761)) and a half-hearted Parliamentary investigation of London madhouses in 1763. The Act, introducing medical certification for insanity, provided for a £100 fine unless the proprietor of a private madhouse received the patient under "an Order, in Writing under the Hand and Seal of some Physician, Surgeon or Apothecary, that such person is proper to be received into such house or Place as a Lunatick." The statute proved little more than a token gesture as it was limited to private patients and did not include paupers who could still be confined by Magistrates under the Act of 1744. Paupers were the most likely to suffer from extremes of neglect and ill-treatment in unregulated madhouses, particularly since most proprietors were attempting to extract a profit from the pittance which the parish overseers allowed for their maintenance. The Act introduced a system in the Metropolitan area of licensing by five Commissioners elected annually by the Royal College of Physicians. A keeper who refused to admit the Commissioners forfeited their licence but their was no authority to withdraw a licence on the grounds of ill-treatment or neglect of patients. They were charged with annually inspecting metropolitan madhouses but it was later admitted that the visits took no more than 6 days a year to perform with as many as 6 - 8 madhouses being visited a day with only cursory inquiries as to the condition of the patients. The Commission was initially temporary but granted permanent status in 1786. In the rest of England and Wales comparative powers of visitation were given to Justices of the Peace who had to be accompanied by a medical practitioner.
Ticehurst, on the Sussex and Kent borders, opened in 1792, attracted the aristocracy and rapidly became the most expensive private asylum in England.
The Retreat, founded in York by William Tuke and the Society of Friends in 1792, followed the death in 1790 in mysterious circumstances of Hannah Mills, a Quaker patient in York Asylum. His grandson, Samuel, published an account in 1813 of the 'moral treatment' provided to inmates where "authority and order must be maintained, but these are better maintained by kindness, condescension, and indulgent attention, than by any severities whatsoever." During its first 15 years of operation, the Retreat claimed to have cured (i.e.. person was not readmitted to an asylum) 21 out of 31 cases of mania and 19 out of 30 cases of melancholia were the insanity was of recent origin. In longstanding cases, they discharged as recovered 10 out of 61 cases of mania and 6 out of 21 cases of melancholia. The Retreat began taking non-Quaker patients in 1820 and by the 1870's, 60% of the admissions had no Quaker connections.
An Act for the Safe Custody of Insane Persons Charged with Offences 1800 followed the attempted shooting of George III by James Hadfield, an ex-soldier, earlier in that year. The Court accepted he had a comprehensive delusional system which had been caused by brain damage following a serious head injury. This retroactive legislation provided for the special verdict of "not guilty by reason of insanity" for those who were insane at the time of the offence; however it contained no definition of insanity. A return of this special verdict meant that the accused person would be detained in "strict custody" in the County Gaol during His Majesty's Pleasure. In the first 5 years of its operation, 37 people were detained under this Act provoking complaints that "to confine such persons in a common Gaol is equally destructive of the recovery of the insane and of the security and comfort of the other prisoners.
By 1803, over a million people (1 in 9 of the population) were in receipt of either casual or permanent poor relief.
Brislington House in Bristol, the first purpose built asylum, was completed in 1806. Designed for an upper-class clientele, it provided for the segregation of patients according to the degree of their disorder and involved little or no restraint.
In 1807, there were 45 private madhouses in the country. Between 1804 and 1808, 1,128 men and 1,000 women were admitted to madhouses in the metropolis.
A Select Committee of the House of Commons was appointed in 1807 charged with investigating 'the state of the Criminal and Pauper Lunatics in England and Wales'. It subsequently recommended the erection of 16 District Asylums, each "to contain as large a number as possible, not exceeding 300." It indicated that of the 2,398 pauper lunatics reported, 1,1765 were in workhouses and a further 113 in houses of correction.
An Act for the Better Care and Maintenance of Pauper and Criminal Lunatics 1808 permitted insane offenders to be admitted to asylums at the expense of a responsible parish.
The Lunacy Asylum Enabling Act 1808 permitted counties to raise rates to build asylums for the insane but few responded.
In 1814, Godfrey Higgins, a Yorkshire magistrate expressed considerable concern about the mistreatment of a pauper whom he had ordered to be committed to the York Lunatic Asylum. He was a governor and discovered 13 women in a cell 12 feet by 7 feet 10 inches. He claimed 144 deaths had been covered up and, joining forces with the Tukes, forced an official investigation which provided evidence of murder and rape, extraordinarily widespread use of chains and other forms of restraint, massive embezzlement of funds and conditions of utter filth and neglect. At the same time, Edward Wakefield, a Quaker, announced an effort to set up a 'London Asylum' on the lines of the York Retreat. A Committee was formed and as part of its investigation into existing provision visited Bethlem on 2nd May 1814. The conditions of the building was deteriorating badly with some sections uninhabitable. This was reflected by the hospital census which showed a decline from 266 patients in 1800 to only 119 in 1814, with many of the pauper patients being transferred to Wharburton's private madhouses in Bethnal Green. The hospital employed only 4 keepers to supervise patients (16 keepers for 300 patients at St Lukes) and the inspecting party found that many were left naked or covered only with a blanket and many were chained to the walls of their cells for weeks or months at a time. 10 women were found chained by one arm or leg to the wall, naked except for an unfastenable blanket gown. In a lower gallery, James (often called William) Norris was discovered. He had been kept in Bethlem Hospital for somewhere between 9 and 14 years in a specially constructed iron restraint which encased his body from the neck down. This was attached by a short chain running from the floor to the ceiling. He could only lie on his back and move 12 inches away from the bar. Norris had attacked his keeper and fellow patients on a number of occasions but when visited by Wakefields's party of reformers was able to converse rationally.
Following the scandals at York and Bethlem, MP's successfully pressed for a Parliamentary investigation of conditions in madhouses and charity asylums and in April 1815 a Select Committee began its inquiry. The Select Committee on Madhouses in 1815 heard from the Royal College of Physicians as to the operation of the inspection of metropolitan madhouses. Their most recent visit had been to Sir John Miles's establishment in Hoxton where their inspection of the structure of the building and condition of its 486 inmates had been completed within two and a half hours! The Committee continued its inquiries the following year and it was alleged, but never proven, that conditions at two of the largest and best known private madhouses in London, Wharburton's Red and White Houses in Bethnal Green were as bad as at York and Bethlem asylums. As many as 100 patients were said to have died from typhus in the winter of 1810 - 11. Female patients were liable to be raped. Beating and whipping were common punishments and prolonged restraint was employed as a routine means of managing patients. In their final report on 1816, the Select Committee proposed two essential elements for reform. These were the provision of a system of asylums at public expense and a vigorous system of independent inspection.
The Care and Maintenance of Lunatics Act 1815 required overseers of the poor to return lists of lunatics and idiots within parishes accompanied by certificates from medical practitioners.
Between 1816 and 1819, former members of the Select Committee unsuccessfully presented bills on 3 occasions proposing a permanent commission of 8, to be appointed by the Home Office, with power, not only to inspect private madhouses, but also to lay down and enforce standards for the management of these institutions and the treatment of patients. Between 1815 and 1824, 4,461 men and 3,443 women were admitted to private madhouses.
A Select Committee on Pauper Lunatics in the County of Middlesex and on Lunatic Asylums, set up in 1827, followed concerns about conditions in one of Wharburtons houses. It heard further evidence of abuse, maltreatment and neglect of the inmates of the White House where patients necessarily performed most of the work in the asylum e.g.. there were only 2 paid attendants for 164 male pauper lunatics. To allow the few attendants some free time at weekends, patients were placed in cribs at 3pm each Saturday, secured with chains, and left there until Monday morning.
The Madhouse Act 1828 repealed the 1774 Act and increased the size of the Metropolitan Commissioners to 15 (minimum of 5 medical practitioners). Appointed by the Home Secretary on a part-time basis, only the five physician Commissioners received token payment, the rest giving their services free. They were given the power to release any person who was in their estimation improperly confined. They could now recommend that a private madhouse proprietor's license be revoked if conditions were unsatisfactory. The Act also introduced the first legal requirements with respect to medical attendance: each asylum had to make arrangements for a doctor to visit the patients at least once a week and sign a weekly register. Where an asylum contained more than 100 patients, it had to employ a medical superintendent. This provision only applied to private madhouses and not county asylums or to the charity or 'subscription' asylums. Two JPs (or the Overseer of the Poor and one Clergyman) had the power to sign an order for the reception of pauper lunatics but the order had to be based upon, and accompanied by a medical certificate.
The County Asylums Act 1828 added very little to previous legislation but did create a precedent for some central government interest in the internal affairs of county asylums by requiring magistrates to send annual returns of admissions, discharges and deaths to the Home Office and that the Secretary of State could send a visitor to any county asylum although the visitor had no power to intervene in asylum administration. In 1832, the Lord Chancellor introduced legislation to replace two of the lay commissioners with two barristers acting as legal commissioners.
The Poor Law Amendment Act 1834 restricted access to outdoor relief and therefore to qualify for assistance, the poor had to enter a workhouse. Local parishes combined forces with others and, as Unions, established one large workhouse for each area governed by a Board of Guardians. The Act restricted the detention of any dangerous lunatic, insane person or idiot in any workhouse for no more than 14 days. This led to the dangerous lunatic being admitted to the county asylum with the workhouses retaining the non-dangerous pauper lunatic. Furthermore the Poor Law Commissioners considered that the workhouse was unsuitable for lunatic paupers as the detention of any curable lunatic in a workhouse was highly objectionable on the grounds of humanity and economy.
Northampton General Lunatic Asylum, a charitable hospital (now St Andrews - the largest independent psychiatric hospital in the United Kingdom) opened in 1838 and, in a unique arrangement, took all the county pauper patients on a contractual basis. In 1841 John Clare was admitted as a pauper patient. Funds were later made available for him to be included on a list of private patients. He remained there for 22 years writing some of his finest poetry.
John Conolly, touring institutions in 1839, found straitjackets, hand and leg cuffs, and "various coarse devices of leather and iron" employed extensively in almost all asylums.
The Insane Prisoners Act 1840 gave the Home Secretary the power to transfer from prison to an asylum any person awaiting trial or serving sentence of imprisonment on the basis of a certificate of insanity signed by 2 Justices of the Peace and 2 doctors.
The Association of Medical Officers of Asylums and Hospitals for the Insane was formed in 1841 but did not begin publishing their own journal (the Asylum Journal) until 1853.
By 1842 only 17 asylums had been built with none in the West Midlands or the North. In 1844 there were just under 21,000 detained in asylums (12.66 per 10,000) and 139 private madhouses. More than 80% of those considered insane were classified as paupers. Only 15 counties had built asylums. Of these 5 contained more than the recommended maximum of 200 patients - Kent (300, built 1833), Surrey (360, built 1841), Wakefield (420, built 1818), Lancaster (611, built 1816) and Hanwell, Middlesex (975-1,000, built 1831). At Hanwell there were only two resident medical officers. Other asylums included Nottingham (1812), Bedford (1812), Norfolk (1814), Staffordshire (1818), Lincoln (1820), Cornwall (1820), Gloucester (1823), Suffolk (1829), Chester (1829), Dorset (1832), Leicestershire (1837), Shropshire and Montgomery (1845), Devon (1845) and Oxfordshire and Berkshire (1846).
In 1844, Wharburton's Red and White Houses in Bethnal Green contained 562 inmates. In that years report of the Metropolitan Commissioners in Lunacy to the Lord Chancellor, they noted that Wharburton's houses in Bethnal Green "which were among the worst, now rank with the best receptacles for the insane."
In 1845 John Perceval formed the Alleged Lunatics' Friend Society "for the protection of the British Subject from unjust confinement on the grounds of mental derangement and the redress of persons so confined." His father, Spencer Perceval, was MP for Northampton from 1796 and Prime Minister from 1809. On 11th May 1812, he was shot at point blank range in the lobby of the House of Commons by John Bellingham who blamed the government for his bankruptcy. John wrote "a narrative of the treatment experienced by a gentleman during a state of mental derangement" (1838), an account of his experiences as a patient in Brislington House and Ticehurst.
The Care and Treatment of Lunatics, and Lunatic Asylums Inspection Act 1842 extended the geographical jurisdiction of the commissioners to England and Wales as a whole, and the Care and Treatment of Lunatics Act 1845 renamed them the Commissioners in Lunacy. The Lunacy Commission was to consist of 3 doctors, three barristers, and up to five unpaid lay commissioners. A more detailed form of certification was devised which increased the safeguards against wrongful detention for both pauper and private patients. All asylums were required to keep a Medical Visitation Book and a record of the medieval treatment of each patient in a Medical Case Book. The Act empowered the person who signed the order for admission of a private patient to discharge the patient. This could be barred by the medical person in charge of the house or the registered medical attendant by certifying the patient to be "dangerous and unfit to be at large" which in turn could be overruled by the written consent of Commissioners in Lunacy.
The County Asylums Act 1845 made it mandatory for each borough and county to provide, within three years, adequate asylum accommodation at public expense for its pauper lunatic population. This led to a rapid building programme as funding arrangements encouraged local parishes to move the parish poor into asylums as they were funded by the county council and not the parish. Counties were also authorized, though not instructed to erect separate, less costly buildings for chronic lunatics. By 1847, 36 of the 52 counties had built asylums of their own or combined with others to open joint institutions. That year the East and North Riding of Yorkshire County Asylum opened, followed by Somerset (1848),Derbyshire (1851), Wiltshire (1851), Monmouth, Hereford, Brecon, and Radnor (1851), Warwickshire (1852), Lincolnshire (1852), Worcestershire (1852), Hampshire (1852), Buckinghamshire (1853) and Essex (1853).
The Journal of Psychological Medicine and Mental Pathology, published in 1848, was owned and edited by Dr Forbes Winslow, the proprietor of two Metropolitan Licensed Houses. Both this and the subsequent Asylum Journal emphasised that "Insanity is purely a disease of the brain. The physician is now the responsible guardian of the lunatic and must ever remain so."
The Colney Hatch Asylum or Middlesex County Pauper Lunatic Asylum was completed in 1849 and opened by Prince Albert. It was designed to accommodate 1,000 patients and promoted as the most modern in Europe. Within a decade it had been expanded to accommodate more than 2,000 patients despite opposition from the Lunacy Commission.
The Lunatics Asylums Act 1853 required the medical officer to make a special note in the medical journal of patients under restraint and seclusion, its means and duration, and the reasons for it or face a £20 fine. Bethlem was brought under the jurisdiction of the Lunacy Commission. The rules of every asylum were to be submitted to the Home Secretary (in practice the Lunacy Commission) for approval and were to be "printed, abided by and observed".
Invention of the hypodermic syringe in 1854.
By 1854, 41 counties had made public provision for the insane. There were 181 private madhouses. In 1857, the asylum superintendents estimated that only 1,890 (12%) of the 15,194 patients in the county asylums of England and Wales were considered curable.
The Medical Registration Act 1858 provided the basis for uniting the medical profession. Medical practice had previously been provided by three separate professions - physicians, surgeons and apothecaries. A proposal by the Secretary of the Alleged Lunatics' Friend Society won official endorsement by the Select Committee on Lunacy 1859-60 for the extension of the requirement of the order of a magistrate for detention as a lunatic from pauper to private cases, as a protection of "the liberty of the subject" and a check on medical opinion. The Select Committee displayed some anxiety about pauper lunatics still confined in workhouses. It focused on private not public asylums and reported that the system was largely free of abuse. It recommended Emergency Certification and the "terminability of orders" to reduce asylum populations.
The Criminal Lunatics Asylums Act 1860 created Broadmoor, specifically under Home Office control, for mentally disordered offenders.
The Association of Medical Officers of Asylums and Hospitals for the Insane became the Medico-Psychological Association in 1861.
An Act to Amend the Law relating to Lunatics 1862 rendered lunatics chargeable upon the common fund of the union of parishes instead of the individual parish. In 1867, the asylum superintendents estimated that out of 24,748 pauper patients in county and borough asylums and in registered hospitals, no less than 22,257 were past all medical cure. That year saw the creation of the Metropolitan Asylums Board to administer relief to the capital's non-ablebodied paupers with the aim of freeing the workhouse to sanction the "less eligible" ablebodied.
The Annual Report of the Lunacy Commission of 1862 indicated that mechanical restraint, although still used, was employed in very few places and on very few occasions. Seclusion was used in the majority of asylums with varying degrees of frequency.
In 1870, the Lunacy Commissioners reported that 122 attendants had been dismissed from asylums during the preceding year, 46 for being violent or rough towards patients. This included two attendants from Lancaster Asylum who were sentenced to seven years penal servitude for manslaughter.
The 1871 census showed that whilst the ratio of women to men at large was 1,056: 1,000, in asylums it was 1,182:1,000 and among pauper lunatics, the ratio was 1,242: 1,000.
The Lunacy Law Reform Association was founded in 1871. An offshoot, the Lunacy Law Amendment Society was formed in 1876. In 1874, the government granted each parish a subsidy of four shillings a head per week towards the cost of every pauper lunatic confined in an asylum. The Commissioners in Lunacy 30th Annual Report in 1876 reported that 23 of the 49 county asylums were officially described as overcrowded while most others were clearly up against the upper limits of their accommodation.
The Select Committee on the Operation of the Lunacy Law in 1877 was set up following highly publicised cases of wrongful imprisonment, noted that a JP's signature was currently only required in pauper cases (the majority of admissions), dismissed its extension as the JP would "find the position intolerable if he really attempted to go seriously into every case."
The Northampton County Lunatic Asylum opened in 1878 with a capacity of less than 500 patients. The superintendent was soon forced to resign after a press campaign alleging extravagance in the way the asylum was administered. The following year, the asylum reported that local ratepayers would not be asked for further money for additions and alterations as they had attracted 128 out of county and private patients as well as patients chargeable to Northampton and Peterborough.
In 1879, only 13 of the 44 metropolitan and 12 out of the 60 provincial licensed houses contained 30 patients or more.
An 'asylum for idiots' was established at Park House, Highgate which later became known as Earlswood Asylum. By 1881, it had 561 inmates.
Paraldehyde was developed in 1882.
The Idiots Act 1886 was the first time the needs of the mentally handicapped were specifically addressed by legislation. People with learning difficulties were often admitted to workhouses, lunatic asylums, and prisons. The Act introduced registration, inspection and admission to specialised asylums.
The Lunacy Act 1890 favoured public over private provision. It provided for four methods of admission.
- The Summary Reception Order was the usual way of receiving pauper patients. A police officer or Poor Law Relieving Officer, with a medical certificate, petitioned a JP to order admission. One of these officers could also, in an emergency, detain a wandering lunatic in a workhouse for up to 3 days.
- A Reception Order was the usual way of admitting non-pauper patients. A relative, the husband or wife if possible, supported by two medical certificates, one from the patient's usual medical attendant if this was practicable, petitioned a magistrate or county court judge to order admission. The relative was required to visit the patient at least every 6 months.
- Under an Urgency Order, private patients could be admitted by petition from a relative to the asylum authorities in an emergency for up to 7 days. At the end of this period, either a Reception Order was obtained or the patient was discharged.
- Admission following inquisition applied to Chancery lunatics.
Reception orders expired at the end of the first year unless the institution manager furnished a special report and certificate to the Lunacy Commission. Acceptance of the report by the Commission would renew the order for a further year, and it would be renewable for first two, then three, and thereafter for successive periods of five years. The Lunacy Commission retained its power to direct discharge of patients from asylums if they were not satisfied with the report. Also two commissioners (one medical and one legal) could discharge a patient from any hospital or licensed house after only one visit. Managers of licensed houses were allowed, with the permission of the Lunacy Commission or the licensing justices, to receive as boarders "any person who is desirous of voluntarily submitting to treatment". Boarders had to be produced to the Commission and the justices on their visits. They could leave on giving 24 hours' notice and detention beyond the 24 hours rendered the proprietor liable to a fine of £10 per day. The admission of voluntary boarders remained confined to licensed houses and only extended by implication to registered hospitals. The consent of the commissioners or licensing justices was still required.
Claybury County Asylum was completed in 1894 for 2,000 patients. The hospital covered 12 acres and had a gothic chapel, elaborate jacobean recreation hall and water tower. By 1900 there were 77 public asylums each with an average population of 961 patients.
The National Association for the Care of the Feeble-Minded was founded in 1896.
The new Rampton State Asylum opened at the village of Woodbeck in North Nottinghamshire in 1912. The 300-bed institution comprised three central wards, and was initially home to 88 men and 40 women, all transfers from Broadmoor. It was staffed by just 8 male attendants and 13 nurses.
The Mental Deficiency Act 1913 established four classes of mental deficiency (idiot - unable to guard themselves against common physical dangers such as fire, water or traffic; imbecile - could guard against physical dangers but were incapable of managing themselves or their affairs; feeble-minded - needed care or control for protection of self or others and moral defectives - who had vicious or criminal propensities (use of this category developed into unmarried women with babies). The Act founded the Board of Control and transferred to it the powers and duties of the Lunacy Commissioners and placed on local government responsibility for the supervision and protection of defectives, both in institutions and in the community.
The Ministry of Health Act 1919 transferred responsibility for the Board of Control from the Home Office to the newly formed Ministry of Health.
The Medico-Psychological Association received a Royal Charter in 1926 to become the Royal Medico-Psychological Association.
The Report of the Royal Commission on Lunacy and Mental Disorder (MacMillan) in 1926 recommended redefinition of madness in medical terms. Compulsion was considered less appropriate in the new spirit of enlightenment. The Annual Report of the Board of Control that year saw the first official use of the term "Community Care".
The Mental Deficiency Act 1927 gave Local Authorities statutory responsibility for providing occupation and training. Mental defiency was "a condition of arrested or incomplete development of mind existing before the age of 18 years whether arising from inherent causes or induced by disease or injury."
The Mental Treatment Act 1930 amended but did not replace earlier legislation. Lunatics became "persons of unsound mind" and asylums became "mental hospitals". The Act introduced voluntary admission by written application to the person in charge of the hospital. Magistrates continued to be involved in overseeing compulsory hospital admissions. The Act authorised local authorities to set up psychiatric out-patient clinics in general and mental hospitals and to organise a system of aftercare for people who left hospital but few services were established in the community and so the mental hospital remained the focal point for psychiatric provision.
Insulin Coma Therapy, invented by the Austrian psychiatrist Manfred Joshua Sakel in 1935 enjoyed a period of popularity in Britain from the late 1930s well into the 1950s.
Psychosurgery as a treatment for mental illness was started by Egas Moniz in Portugal in 1935 and was first used in Britain in Bristol in 1940.
Convulsive therapy by drugs was introduced in 1934 in Hungary by Ladislas von Meduna and in Britain in 1937. In 1938, the Italians Ugo Cerletti and Lucio Bini produced the first electrically induced convulsion in man. It was first used in Britain in 1939.
The National Health Service Act 1946 ended the distinction between paying and non-paying patients.
The National Association for Mental Health (NAMH) was established in 1946 by the amalgamation of three major mental health organisations: the Central Association for Mental Welfare (1913), The Child Guidance Council (1927), and the National Council for Mental Hygiene (1922). The amalgamation was recommended by the Feversham Committee on voluntary mental health associations (1936-39). The formal merger had to wait until the end of the second world war, but the associations worked together during the war through the Provisional Council for Mental Health. The Government asked the Council to take on the additional task of providing a national aftercare service for people discharged from military service on psychiatric grounds.
The National Assistance Act 1948 abolished the distinction between paying and non-paying patients. Policies of the 1930s and 1940s had resulted in some wards being unlocked. In 1949, a whole hospital, Dingleton Hospital, Melrose, Scotland was unlocked. In 1952, Sandoz supplied Powick Hospital, Worcestershire with LSD for a therapeutic trial.
Chlorpromazine (Largactil / Thorazine) was marketed in Britain in 1954.
The Royal Commission on the Law relating to Mental Illness and Mental Deficiency (Percy Commission) was appointed in 1953, reported in 1957 and formed the basis of a new Mental Health Act.
The Mental Health Act 1959 repealed all previous legislation. Informal admission was to be the usual method of admission and no longer required the positive statement of willingness on the part of the patient. For the first time since 1774, there were to be no judicial controls prior to compulsory admission. The Act provided an application for admission to be made by a mental welfare officer (social worker) or the patient's nearest relative:
- for observation - up to 28 days, two medical certificates, not renewable, if there is a need for further detention, the person will need to be reassessed for admission for treatment;
- in an emergency - up to 72 hours, one medical certificate; may be converted, by the addition of a further medical certificate, into an order for observation
- for treatment - up to 12 months in the first instance, two medical certificates, renewable for 12 months and thereafter for periods of two years. Able to apply for a Mental Health Review Tribunal hearing, once in the first period of detention and once in each period for which detention was renewed.
Enoch Powell, Minister of Health, in 1961 announced that "in fifteen years time, there will be needed not more than half as many places in hospitals for mental illness as there are today. Expressed in numerical terms, this would represent a redundancy of now fewer than 75,000 hospital beds ... ".
Haloperidol was introduced in 1959.
The White Paper, Hospital Plan for England and Wales, published in 1962 proposed the creation of large District General Hospitals. No provision for long-stay patients.
The Seebohm Report (1968) noted that the "widespread belief that we have 'community care' of the mentally disordered is, for many parts of the country, still a sad illusion, and judging by published plans, will remain so for years ahead."
The Royal College of Psychiatrists received its charter in 1971.
In 1971, its 25th anniversary, the National Association for Mental Health launched the MIND campaign to clarify its policy and aims, and to attract much needed funds, under the leadership of the new Campaign Director, David Ennals. It was so successful that in 1972 NAMH adopted the new name, MIND.
The White Paper, Better Services for the Mentally Ill, was published in 1975. Although overcrowding had been reduced and resident populations had decreased, no single hospital had closed. The volume of work was greater than ever with rising admission rates.
The Butler Committee report on Mentally Abnormal Offenders and MIND's "A Human Condition" were published in 1975.
Report of a Committee of Enquiry, St Augustine's Report (1976) not only criticised conditions but also the use of unlawful restraint and treatment without consent.
"A Human Condition Volume II" and BASW document "Mental Health Crisis Services - A new philosophy" were published in 1976. Also that year the publication of DHSS Circular "Joint Care Planning: Health and Local Authorities".
Publication in 1980 of the Boynton Report "The Report of the Review of Rampton Hospital" following allegations of abuse made in the Yorkshire TV documentary "The Secret Hospital". Publication by DHSS in 1981 of "Care in Action: A Handbook of Policies and Priorities for the Health and Personal Social Services in England".
The Mental Health (Amendment) Act 1982, introduced as a bill in November 1981, paved the way for The Mental Health Act 1983. The Act contained similar provisions to 1959 Act with informal admissions continuing to be encouraged but was a moderate swing back towards a more legal approach to mental health. Its three primary areas of change may be characterised as: setting limits on the exercise of compulsory powers (definitions, treatability test, widening of scope of Mental Health Review Tribunals, clarification on Consent to treatment provisions, establishment of the Mental Health Act Commission, changes to Guardianship, appointment and training for Approved Social Workers), maintaining the civil and social status of patients (voting, access to the courts) and the right to services (provision of aftercare).
Publication in 1983 of DHSS Consultative Document "Care in the Community".
Publication in 1985 of House of Commons Social Services Committee "Report on Community Care with special reference to adult mentally ill and mentally handicapped people".
Publication in 1986 of Audit Commission report "Making a Reality of Community Care".
Publication in 1988 of report by Sir Roy Griffiths "Community Care: Agenda for Action" whose recommendations included the appointment of a Minister of State for community care.
Publication in 1989 of Government White Paper "Caring for People: Community Care in the Next Decade and Beyond" were enacted in the National Health Service and Community Care Act 1990.
Ashworth Special Hospital was formed in 1989 when Moss Side and Park Lane hospitals were amalgamated.
In 1989 a new authority, the Special Hospitals Service Authority, took charge of Broadmoor, Ashworth and Rampton Hospitals.
Publication in 1990 of House of Commons Social Services Committee "Report on Community Care: Services for People with a Mental Handicap and People with a Mental Illness".
Publication in 1990 of Mental Health Act Code of Practice.
Publication in 1990 of Care Programme Approach Circular - to take effect from April 1991.
Publication in 1990 of Mental Illness Specific Grant Circular - to take effect from 1991 -1992.
Christopher Clunis, who suffers from schizophrenia, killed Jonathan Zito at Finsbury Park tube station in December 1992.
On New Year's Day 1993, Ben Silcock, aged 27, who suffers from schizophrenia, climbed into the lions' enclosure at London Zoo and was severely injured.
Publication in January 1993 of report from Royal College of Psychiatrists advocating introduction of a Community Supervision Order.
Publication in 1993 by Department of Health of "Key Area Handbook - Mental Illness". Also the 5th Report from the House of Commons Health Committee who considered proposals from Royal College of Psychiatrists for the introduction of Community Supervision Orders to be "fundamentally flawed".
Publication by Department of Health of an internal review "Legal powers on the care of mentally ill people in the community".
Publication in August 1993 of a revised Mental Health Act Code of Practice which came into effect in November. Also Virginia Bottomley, Secretary of State for Health introduces her 10 point plan.
Publication, in April 1994, of HSG(94)(5) re introduction of Supervision Registers by October 1994.
"Building Bridges, a guide to Inter-agency working", published by Dept. of Health in November 1995.
The Mental Health (Patients in the Community) Act 1995, with its provisions for After-Care under Supervision / Supervised Discharge, commenced in April 1996.
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