WHEN introducing his Metropolitan Poor Bill in 1867, Gathorne Hardy had declared that he intended to initiate his workhouse classification scheme by building special establishments for poor law ‘lunatics and imbeciles’. At this time, the terms’ lunacy’ and ‘insanity’ were loosely used for the whole of what is now termed ‘mental disorder’, whether of the nature of mental illness or of mental subnormality. Further, the terms ‘imbecile’ and’ defective’ were used, equally loosely, for conditions associated with weakness of mind, and therefore applied to states of senile dementia and the end-results of mental illness, as well as to congenital defectiveness. Only the term’ idiot’ was reserved definitively for the more severely subnormal.
Before Gathorne Hardy’s Act, the different methods of disposal of persons of unsound mind – in county asylums, poor law institutions, private licensed houses and voluntary hospitals – had resulted more from expediency than from statutory disposition. One of the main purposes of the 1867 Act had been to provide special hospitals for a particular group of the mentally afflicted – those ‘idiotic, chronic and harmless patients’ for whom the workhouses of London were the only available refuge.
The first attempt to regulate the institutional care of persons of unsound mind was the passing of an Act in 1774. (The Act for Regulating Private Madhouses, 1774.) At that time, lunatics – to use the terminology of the period – were to be found in pitiable conditions in prisons, workhouses, public hospitals such as Bethlem, and private ‘madhouses’. Nevertheless, the Act applied only to the private institutions. These were to be inspected and licensed by five Commissioners – all Fellows of the Royal College of Physicians – in the metropolitan area, and by Justices of the Peace in the provinces. The Act further required that admission should be on a medical certificate, and that notification of cases received, both in London and elsewhere, should be made to the Commissioners. Paupers, however, were excluded from the Act.
During the next four decades, standards of care in institutions for the mentally disordered failed to improve, and it became necessary for their regulation to be examined. A select Committee was accordingly set up in 1815, and re-appointed in 1816. By this time, thirty-four private licensed establishments functioned in London and upwards of forty in the counties. The Retreat at York, founded by the Quaker, William Tuke, had been opened in 1796; Guy’s Hospital had a new lunatic ward; and a new Bethlem hospital had just been completed in Lambeth. In the provinces, there were a few other hospitals of ancient foundation, such as the York Asylum, where abuses had given rise to the enquiry. Twelve county asylums had been built under ‘Wynn’s Act’ of 1808, but only one – that at Nottingham – was as yet fully in operation. The 1808 measure had empowered, but not compelled, Justices of the Peace in every county to provide establishments for the care of pauper lunatics, so that they might be removed from workhouses and prisons. Evidence received by the 1815-16 Committees revealed a generally noisome picture of the mentally disordered still suffering neglect in wretched conditions in workhouses, ‘madhouses’ and voluntary hospitals. Only in a few institutions were standards of care and treatment regarded as praiseworthy. These included the Nottingham Asylum (financed partly by the rates and partly by voluntary subscription), the York Retreat, and some of the licensed houses founded by medical men at the end of the eighteenth century. During the decade following the 1815-16 enquiry, however, most of the private institutions remained as bad as ever, despite the Committees’ urgent demands for remedial measures.
Another Select Committee sat in 1827, largely as a result of agitation on the part of a new twenty-six-year old Member of Parliament, Lord Ashley (later Lord Shaftesbury) and Robert Gordon, a Dorsetshire magistrate. Their work on the Committee and subsequent publicity led to the passing of two Acts in 1828, one dealing with county asylums – their erection and management, and the care of pauper and criminal lunatics; and the other with private ‘madhouses’. Under the Madhouse Act, a new Metropolitan Lunacy Commission was appointed consisting of fifteen members. Five were physicians paid at the rate of £1 an hour, and the remainder, including Ashley, Gordon and Wynn, were honorary. The Commissioners had greatly extended powers of inspection and licensing, and they made a significant improvement in the London area. Similar powers were bestowed on the Justices of the Peace, but progress in the provinces was less apparent. While private asylums were thus controlled, public institutions for the mentally disordered remained exempt, and single patients in care in the community continued to be unprotected.
When the 1834 Poor Law Amendment Act provided for the erection of large workhouses by the union of parishes, it was not intended that these institutions should become permanent refuges for pauper lunatics. Section XLV of the Act expressly prohibited the detention in a workhouse of ‘any dangerous lunatic, insane person or idiot’ for more than fourteen days. This wording, however, was taken by the guardians to imply that the detention of any who were not dangerous was allowable-an interpretation of doubtful legality. As the cost to the guardians of maintaining insane paupers in the workhouse was less than paying for their care elsewhere, (In 1844, the average annual cost per head in a workhouse was £40; in a county asylum it varied from £100 to £350) these patients were retained in the poor law institutions, despite the absence of suitable accommodation and care, and in disregard of central recommendations, injunctions and statutory directives.
In 1838, a Select Committee of Enquiry into the operation of the poor law recommended the fusion of several unions for the purpose of maintaining a common lunatic asylum distinct from the county asylums. An attempt was made to implement this recommendation in a poor law Bill in 1839, but it was defeated by medical opposition on the ground that pauper patients would be deprived of what was regarded as superior treatment in the county asylums.
In 1842, the Poor Law Commissioners issued a directive to boards of guardians deprecating the improper retention in workhouses of any curable lunatics. It was urged that ‘with lunatics the first object ought to be their cure by proper medical treatment, which can only be obtained in a well-regulated asylum’. But, at this time, not more than twenty county asylums had been established. In 1844, there were some 20,600 lunatics in all forms of care in England and Wales. Of this total, less than 3,800 were private patients, while over 16,800 were classed as paupers. These poor law patients were admitted without certification, and, once in care, were subject to no form of official inspection. For nearly twenty years, Ashley had been fighting to improve the lot of these patients in workhouses, while another champion of the rights of the mentally disordered, Dorothea Dix (1802-87), a former American schoolteacher, was agitating for improved conditions in asylums both in this country and the United States. Further light was brought to bear on the pressing need for reform by the results of a two-year survey carried out by the Metropolitan Lunacy Commissioners. Their report, published in 1844, showed that some 9,000 (about 75 per cent) of the total number of lunatics in the metropolitan area were still in workhouses, boarded out or in licensed houses, often in appalling conditions.
The following year saw the passing of ‘Shaftesbury’s Act’, which became the basis for subsequent legislation. Under the 1845 Lunacy Act, a permanent Board of Lunacy Commissioners was created, and Justices everywhere – in counties and boroughs – were compelled to erect lunatic asylums to be financed by the local rates. Committees of Visitors were to regulate and superintend the asylums, which would be visited regularly by the Lunacy Commissioners in the London area and by the Justices elsewhere. The Commissioners were also obliged to visit all other establishments in which lunatics were in care. Safeguards governing admission and discharge were rigorously imposed. It was intended that all lunatic paupers should be transferred to the new asylums when built. Meantime, new procedures for the care of these patients in workhouses and licensed houses were to be observed. These included certification for admission, the keeping of records for the information of the Lunacy Commissioners, annual inspection by legal and medical Commissioners and the supervision of care and accommodation by special Visitors.
During the next decade, the system of licensing and methods of certification were tightened up; single patients were brought under supervision; and lunatics in workhouses and on outdoor relief were visited periodically and reported on by the union medical officer.
As the new county asylums gradually came into being, the guardians sent in, not only their mentally ill patients, but also their incurable defective cases, although the new institutions were intended to be places of treatment and cure. Delays in building the county asylums and the crowded state of those in operation rendered it necessary by the late’ fifties for the parochial authorities to take back their harmless chronic patients – by far the largest category of the mentally disordered. By 1859, there were some 36,000 lunatics in all forms of care in England and Wales – about 31,000 classed as paupers and 5,000 private patients. Over 17,000 of the paupers were in county asylums or on contract in licensed houses; about 7,000 were in workhouses; while a similar number were living ‘with friends or elsewhere’. From the numbers recorded at this time, it is impossible to know how many patients were suffering from what we now call mental illness and how many from subnormality. When the Lunacy Commissioners made a study of mental patients in workhouses in 1847, they recognized three categories: ‘the defectives from birth; the demented and fatuous; and the deranged or disordered’. In the late ‘fifties, many such patients were still being warded with sane inmates and attended by fellow paupers. Although forbidden by the Lunacy Commissioners, the use of mechanical restraints was tolerated because workhouse staffs could not manage without them. A number of parochial boards, particularly in the metropolitan area, provided what they called ‘insane wards’, but these were generally ill-equipped and poorly staffed, and were created merely to avoid the extra expense of sending mental cases to other institutions. Later, however, in a few large provincial towns, including Liverpool, Manchester and Birmingham, special mental wards came to be developed in the poor law infirmaries with their own nurses and medical officer. Mental wards in small workhouses were not encouraged by the Lunacy Commissioners. They felt that to segregate the imbeciles from the other inmates deprived them of whatever cheerfulness, sense of protection or means of making themselves useful they might have in the body of the house.
In April 1859, while yet another Select Committee on lunacy was sitting, the Lunacy Commissioners published a special report on the insane in workhouses. They had decided that the time had come to publicize the problem and so pave the way to reform. In the course of this 8o-page report, the Commissioners declared that any attempt to remedy the defects radically incident to the workhouse system would be impracticable so long as insane patients were detained in poor law institutions, whether mixed with other inmates or placed in distinct wards. Of the 655 workhouses in England and Wales in 1859, 10 per cent provided separate insane wards. They recommended, as an alternative to extending the already overlarge county asylums, “the erection of inexpensive buildings adapted for the residence of idiotic, chronic and harmless patients, in direct connexion with, or at a convenient distance from, the existing institutions. These auxiliary asylums. . . would be intermediate between union workhouses and the principal curative asylums. . . .” As with most of the Lunacy Commissioners’ recommendations, this suggestion was left in abeyance.
Following the report of the 1859-60 Committee of Enquiry (July 1860), the Lunacy Act of 1862 was passed. The 1862 Act is particularly noteworthy as pioneering, in a limited way, voluntary admission. It empowered any person who had been a patient in any type of mental hospital during the previous five years to enter a licensed house as a voluntary boarder, provided that he wrote personally for permission to two of the Lunacy Commissioners. This was soon afterwards extended to the registered hospitals. While empowering the Lunacy Commissioners to remove lunatics from workhouses to county asylums when considered necessary, the Act legalized the transfer of the harmless chronic insane from the overcrowded curative institutions to the workhouses. The Poor Law Board subsequently explained to guardians that it had not been contemplated that chronic patients should be generally received into workhouses, thereby constituting them all small lunatic asylums. Application to the Lunacy Commissioners for such transfers had to originate with the statutory Asylum Visitors, who would select only those poor law institutions which provided adequate accommodation, care and attendance. But of these there were relatively few.
In their early days, the Lunacy Commissioners had been hopeful of relying on the co-operation of the central destitution authority, but, as they found their recommendations constantly discarded and they had no power to enforce their suggested reforms, they came to voice their displeasure and alarm. Gathorne Hardy, during his first months at the Poor Law Board in 1866 was no less alarmed when he discovered that, as President of the Board, his authority was blunted by an absence of effective sanctions for compelling guardians to act upon such directives as were addressed to them. His powers thus limited, he was faced with the problem of remedying workhouse evils which stemmed from overcrowding, a situation which was aggravated by the presence of numerous inmates whose mental condition warranted their being in specialized care. The public asylums in the London area, as elsewhere, were also suffering from similar pressures. The number of county asylum beds was never sufficient to meet the demand. In addition to the 7,000 pauper lunatics which the metropolitan guardians maintained at this time in county asylums and licensed houses, there were in the London workhouses over fifty children and nearly 2,000 adults classed as ‘insane’. These mentally afflicted adults formed part of the group designated ‘Old and Infirm’, which totalled upward of 14,000 and undoubtedly included, in addition, numerous senile dements and other weak-minded persons.
When presenting his case for removing the insane from the London workhouses to new establishments, Gathorne Hardy approvingly endorsed the Lunacy Commissioners’ recommendation for ‘auxiliary asylums’. The new institutions which he was proposing were to accommodate the same broad category of ‘harmless chronics” but they would not be administered by the same authorities as the existing curative institutions, but by a new body. As we have seen, this was to be the MAB.
To carry out its duties under the 1867 Act, the Asylums Board erected two large establishments at Leavesden and Caterham on sites which had been chosen for cheapness well out in the country. Originally designed for some 1,500 patients each, they were as nearly as possible identical in construction and consisted of three-storied blocks, each floor forming one enormous ward. These were opened in October 1870.
Poor Law Board regulations for the MAB imbecile asylums-as they were called at this time-had stipulated that admission required a medical certificate to the effect that ‘the pauper is a chronic and harmless lunatic, idiot or imbecile. . .’. But, despite this rule, Leavesden and Caterham were soon filled with patients of all ages suffering from every type of mental disorder, acute and chronic. A large number of chronic insane were sent in from Hanwell and Colney Hatch, the county asylums of Middlesex. Heavy and sudden demands had been made upon nearly all the mental institutions near London following the 1867 Act. The Metropolitan Common Poor Fund, established under the Act, provided for the maintenance, not only of the ‘insane poor’ in the MAB asylums, but also of London rate-aided ‘lunatics in asylums, registered hospitals and licensed houses’. Guardians who were keeping patients in special insane wards in the workhouse were at a disadvantage, since they were paying for them out of the local poor rate, while those who had no segregation transferred to other institutions all cases for whom they could get medical certification, and claimed for their maintenance from the new common poor fund. The indiscriminate demands made by the guardians on the imbecile asylums at Caterham and Leavesden continued for some years, notwithstanding the protests of the Lunacy Commissioners and the Asylums Board.
Lord Shaftesbury, who had been chairman of the Lunacy Commissioners since 1853, had foreseen some of the problems likely to arise in the running of the M A B asylums. While the Metropolitan Poor Bill was passing through committee in the House of Lords, he urged that the type of patient should be specifically defined and, further, that the same protection against the detention of sane persons in the new buildings should be provided as was the case in the county asylums. When the regulations governing all MAB establishments were revised in 1875, the Local Government Board (which had absorbed the Poor Law Board) attempted to make the imbecile asylums’ admission rules more explicit by adding the directive: ‘No dangerous or curable person such as would. . . require to be sent to a lunatic asylum shall be admitted’. The amended regulations also stipulated that no pauper should be prevented from quitting the asylum, either by himself or in charge of a relative or friend, unless the medical superintendent certified that he was ‘not in a proper state to leave the asylum without danger to himself or others’, a proviso which appeared to be at variance with the rule excluding dangerous cases.
So great was the demand for beds at Leavesden and Caterham during their first five years that extensions had to be carried out. By 1876 about £172,000 had been spent on Leavesden (1,995 beds) and £183,000 on Caterham (2,052 beds) – a much lower cost per bed than that of any contemporary county asylum.
Outside London, the institutional care of the vast majority of the mentally disordered continued to be divided between the county asylums and the workhouses. By the beginning of 1870, the number of poor law mental cases – acute and chronic – in England and Wales had risen in a decade by about 36 per cent to over 46,500. Of this number, approximately 25,500 were in county asylums, 1,500 in registered establishments, and 11,500 in workhouses. The remainder were boarded out or resided with relatives. The opening of the MAB asylums in the autumn of 1870 reduced the total number of insane patients in workhouses by about one-third, but it soon began to rise again and maintained a steady upward trend in step with the general increase in the number of mental patients in other institutions. The actual increase in ‘insanity’ may well have been slight. The rise in the numbers of the registered insane was due to a variety of reasons, including the diminishing death rate, the discouragement of outdoor relief, improved systems of registration, the growing disinclination of the community to tolerate irregularities of conduct, and the relegation of the victims to institutions for family convenience. By 1876, there were nearly 65,000 mentally disordered persons in England and Wales. Pauper lunatics totalled 57,400: of these 15,000 were in workhouses and upwards of 4,500 in the MAB asylums.
For much of the remainder of the century, the reform of lunacy legislation was pursued on two fronts. On the one hand, were those who demanded increasing safeguards for the liberty of the subject, and were represented by the Lunacy Laws Amendment Association. On the other hand, were those who were convinced that the inspection system effectively removed the risk of improper incarceration, and were concerned primarily that complicated certification procedures should not deprive the patient of early diagnosis and treatment. The medical view, endorsed by Lord Shaftesbury, was voiced by Dr. Henry Maudsley before the Select Committee set up in 1877 to study anew the lunacy laws. Maudsley told the committee that mental ill health should be treated in the same terms as other illness without the stigma of certification and pauperism. But fears for personal liberty overshadowed the progressive approach.
Nevertheless, in the perspective of a century of effort, substantial advances had been achieved, largely as a result of Shaftesbury’s personal endeavour and the patient work of his fellow Commissioners and associates. These gains were consolidated in the Lunacy Act of 1890, five years following the great reformer’s death. The Act fell far short of Shaftesbury’s hopes, since it perpetuated the close association between lunacy and the poor law and stressed the custodial as against the medical aspects. It survived in large measure, nevertheless, as the lunacy law of this country for another seven decades.
We have seen that, notwithstanding the overall confusion attaching to the terms’ lunatic’, ‘insane’ and ‘imbecile’ in the nineteenth century, it was recognized that ‘idiots’ (approximately the present’ severely subnormal’ group) constituted a separate class, with its own problems and needs. The distinction between mental illness and subnormality was recognized in the fourteenth century when different legal provisions were made for the control and disposition of the property of a ‘born fool’, or idiot, and that of a ‘lunatic’, that is, a person’ who hath had understanding, but by disease, grief or other accident hath lost the use of his reason’.
Before the advent of the MAB, relatively little provision. existed in this country for the care and training of idiots and imbeciles, as such. Attempts to improve severely defective children were first made in France, stimulated by the work of Dr. Jean-Marc Itard, who in 1798 initiated the practical study of the psychology of defect with a treatise on his attempts to educate the ‘wild boy of Aveyron’. By 1840, Dr. Seguin, a pupil of Dr. Itard, was directing a regular idiots’ department at the Bicetre in Paris. In 1844, the first German State institution for the training of idiots was set up in Saxony; while about this time other institutions for the same purpose were founded on a voluntary basis in Germany, Switzerland and elsewhere in Europe and the United States. In England, Samuel Gaskell, who as medical superintendent of the Lancaster Asylum had taken a special interest in the idiot children there, drew attention in 1847 to the work being done at the Bicetre. The Lunacy Commissioners in their second report, issued in the same year, also made a point of focusing interest on congenital mental defectives. They pointed out that’ though persons of this description are seldom fit objects for a curative asylum, they are in general capable of being greatly improved, both intellectually and morally, by a judicious system of training and instruction. . . .’ That same year, the first ‘asylum for idiots’ in this country was established at Park House, Highgate, through the efforts of the Rev. Andrew Reed, the philanthropist, supported by Samuel Gaskell and by John Conolly, the former medical superintendent of Hanwell Asylum and champion of ‘non-restraint’. Expansion was soon found necessary, and after a temporary stay at Essex Hall, Colchester, the patients were moved in 1855 to the purpose-built Earlswood Asylum, Surrey. Later, Essex Hall was reopened as the Eastern Counties’ Asylum (1859); and other charitable institutions for the care and training of the severely subnormal were founded at Starcross, Devon (1864); at Knowle, Warwickshire (1868); and at Lancaster (1870). In 1886, these establishments were accorded a recognized status when the registration of all charitable and private hospitals for idiots became compulsory.
Round about 1870, the county asylums of Hampshire, Warwickshire and Northamptonshire built separate ‘idiot blocks’, intended to provide training for subnormal children and young persons received under the Lunacy Acts. But, as we shall see in the next section, the M A B was the only public authority during the nineteenth century to establish a complete institution devoted exclusively to this class of patient.
At first, children as well as adults were admitted to the Caterham and Leavesden Asylums, where classification on a clinical basis was at best haphazard. After a year or two, however, the medical superintendents urged the Asylums Board to separate the children from the adults. This was agreed, and in 1873 the first children left Caterham and Leavesden for Hampstead, where they were housed in the Board’s temporary fever hospital. Teachers were appointed, and the experiment of educating idiot children began. In 1878, after a temporary move to a disused orphanage at Clapton in north-east London, the children were brought to Darenth, Kent, where the Board had established a new institution, complete with classrooms, to accommodate about 560 young patients. But when these children reached the age of 16, most of them were still unfit for discharge. In order to spare them from the detrimental effects of associating once more with the chronic adult patients, the Board erected a separate institution adjacent to the schools, with accommodation for 1,000. This was opened two years later, in 1880. The scheme was to receive into the schools children from 5 to 16 years; to subject them to a special course of education and manual instruction; to retain the ‘improvable’ after the age of 16 for training in the workshops set up in the adjacent institution; and to transfer the more severely handicapped older children – by far the larger group – to the remaining part of the new building.
This was the first attempt by a statutory body in this country to develop the potentialities of subnormal children: it owed much to the energy of the medical superintendent, Dr. Fletcher Beach. Sir Henry Burdett, the authority on hospitals, was so impressed with the scheme that he advocated the creation of such training establishments throughout the country as special county asylums under the existing laws. Similar vision was, unfortunately, obscured in Whitehall by the accumulation in the metropolitan workhouses of large numbers of adult imbeciles. As Leavesden and Caterham were filled to capacity, the central authority in desperation ordered the MAB to admit these cases into the Darenth institution. The original purpose of the training experiment was suspended, while the schools and the new work centre were filled with helpless and hopeless cases.
Meantime, a movement had been set afoot in this country to press the need for statutory provision for the mentally subnormal under the local authorities. In 1876, the Charity Organization Society initiated a study of the problem, and the attention of the Government was drawn to its findings by Lord Shaftesbury. However, the only action taken was the passing of the Idiots’ Act in 1886. This provided a simple procedure for the admission of defective patients to the existing charitable institutions, and authorized local destitution authorities to place in these institutions idiots for whom they were responsible.
It was generally accepted at this time that the primary object of institutional care for the mentally subnormal was the prevention of their perpetuation by segregation. But the policy of the Asylums Board had a wider intention. It aimed to develop the potentialities of patients and to train them towards a measure of self-support. By stimulating their interest in activity, it was hoped to increase their satisfaction in living. Attempts were made to occupy adult patients, according to their capacity, in supervised tasks connected with the upkeep of the establishments, the gardens and farms. This progressive aim proved for the most part an unattainable ideal, mainly because only a minority of patients were able to participate. A large number were senile, paralytic, or too severely handicapped to cooperate. For eight years following the suspension in 1880 of the training and classification schemes, the Asylums Board attempted to resurrect these plans, but was thwarted by the ever-increasing flow of helpless chronic cases from the workhouses. By 1888, however, it had been possible to build ten pavilions at Darenth for five hundred children of school age and to acquire a site at Tooting Bec on which to erect an infirmary for sick and aged patients.
Results at the new Darenth establishment for children, though not spectacular, were more encouraging than the outcome of the occupational schemes for adults. All the children were unpromising subjects on entry; few had had previous experience of systematic instruction. Within two years of the opening of the school in 1888, only a small proportion of the five hundred were found to be totally ineducable. The majority made a degree of progress; some even attained fair standards in the elementary subjects they were taught; while over sixty deaf and dumb children were instructed to read and speak on fingers.
During the 1890s – twenty or so years after the first attempts of the M A B to educate mentally defective children – a few local education authorities were beginning to provide for the instruction of children with physical and mental disabilities. In 1893, following the recommendations of the Royal Commission on the Blind, Deaf and Dumb, appointed in 1889 the Elementary Education (Blind and Deaf Children) Act empowered school authorities to pay for the education and maintenance of blind and deaf children in residential schools. As a result of a study by the Education Department in 1898 of systems of instruction for mentally defective children, the 1899 Elementary Education (Defective and Epileptic Children) Act empowered school authorities to organize special classes for feeble-minded children, and, where necessary, to board them out and provide transport. By the end of the nineteenth century, these two permissive measures, together with the Idiots’ Act of 1886, were the extent of State intervention, outside the poor laws on behalf of the mentally defective as a class.
By 1900, the MAB asylums at Caterham, Darenth and Leavesden were providing for nearly 6,000 patients. During the three-decade period since their inception, they had admitted nearly 24,000 cases. Of these, approximately 6,000 were discharged: about 1,400 of these were described as ‘recovered’, about 1,500 as ‘relieved’, and a similar number as ‘not improved’. Most of the other discharges were transferred to county asylums. All adult patients were certified under the Lunacy Laws, whether demented, chronic insane or subnormal. Admission to the M A B asylums was through the metropolitan guardians, who made application, not only for patients who were actual paupers, but also for former self-supporting citizens who required poor relief because of their mental incapacity. All were pauperized by admission, whatever their status or means on entry. Originally, the main object of the M A B imbecile asylums was that they should serve as ‘receptacles for harmless chronic insane paupers’. It had not been envisaged that they would be anything more than custodial. The special treatment and systematic training provided at Darenth, and to a lesser extent in their other institutions, were due entirely to the independent and progressive approach of the Asylums Managers and their medical staff.