13.16 per cent. higher than the average per centage of other public asylums-that, while only 38.86 per cent. of the patients admitted were cured in these, as many as 52 02 per cent. were cured in the much abused hospital. But that is not all; while there is an average of 13.54 per cent. of deaths in the public asylums, there is only 5.05 per cent. in Bethlehem, or, in fact, 8.49 per cent. in favor of the hospital. With a trusting confidence, sublime in its simplicity but terribly misplaced in its object, it is contended that "these facts distinctly show that the situation of Bethlehem Hospital cannot be unhealthy, and that its natural advantages are very great." The surprising part of the matter is, that any one so entirely ignorant of the simplest elements of statistical science as the author of those figures is proved by them to have been, should have ventured to put forward results so extravagant; but it is more surprising still that any body of men should have covered themselves with ridicule by thoughtlessly accepting them. Such marvelous results might well have startled the most ignorant or the most credulous. A mortality of 13.5 per cent. is a mortality of 135 in the 1000, while the supposed Bethlehem mortality of 5.02 per cent. is a mortality of 50 in the 1000; so that the outrageous claim made for the hospital, as against other public asylums, is that it positively saves 85 lives in 1000. The mortality of the British army on the deadly Gold Coast is, as Dr. Robertson, the successful defender of the public asylums, has aptly observed, only 37 in the 1000 more than in England; and yet, deadly as the service on the Gold Coast is deemed, yet deadlier in their influences on the recently insane, in the ratio of 85 to 37, stand the asylums of the home counties as compared with Bethlehem.* Such figures cannot be treated seriously; they have been arrived at simply by ignoring every principle of statistical science as relating to the comparative death rate of any given population or disease. The death rate has moreover been calculated on the admissions instead of, as is always rightly done, on the number resident. So again with regard to the recoveries. No notice whatever is taken of the several important circumstances in the character of the 'cases admitted, which, independently of place or method of treatment, materially influence the results. For example, there is no consideration given to the important question of age, although it is established that, under the age of twenty-five, as many as three

* On a recent attempt at the Comparative Statistics of Bethlehem Hospital and the English County Asylums. By C. L. Robertson, M. D.—Journal of Mental Science. October, 1865.

fifths of the insane recover, while, after sixty, scarce more than one in six recovers. And yet the very erroneous table given in the Bethlehem report shows that as many as ten public asylums, receiving all sorts and conditions of cases, attained a higher percentage of cures than Bethlehem Hospital. The "Eighteenth Report of the Commissioners of Lunacy," which gives the correct statistics of different asylums, shows that the proportion of cures in Bethlehem, notwithstanding the careful selection of cases for admission, is exceeded by other public asylums; and that its mean annual mortality, notwithstanding its systematic rejection of every case that seemed likely to die, and every case that seemed not likely to get well, was 57 in the 1000, while at the Warneford Asylum, Oxford, the annual mortality was 21 only in the 1000, at Coton Hill, 52, and at the Retreat, 52. As far as any argument in such case can be founded on figures, it assuredly strengthens the general condemnation of the site, structure, and management of the hospital.

Does not the history of Bethlehem Hospital reveal only too plainly how vast are the difficulties in the way of practical reform, even when its principles are universally accepted? Ever as the course of progress takes a different direction, and as new questions arise, does the old spirit reassert itself, and as it resisted advance in the past, so again resists the impulses of present progress. Were it not that nature has happily put a period to human life, it may be doubted whether any great reform would ever be accomplished. But as the old men, imbued with the spirit of bygone thought, drop away, younger men, inspired with the spirit of progress, take up the work and carry it on until they, in their turn, become old and petrify in cold obstruction. In some of the large London hospitals, it has recently been found necessary to enact that the officers should retire after reaching a certain age, so much had these noble charities suffered by the tenacious clinging to office of those whom age had rendered incapable of fulfiling their duties. Had this excellent rule been always in force at Bethlehem, how much obloquy would it have escaped-how much cruel suffering might have been spared to numbers of unfortunate patients-how great a reproach might have been spared to England! Had the rule been in force even during the last few years, it cannot be doubted that some response would have been made to the humane and scientific views of the age, that something would have been done to make this wealthy charity meet the pressing claims for the benefits which it was so well capable of supplying. To point

out what these needs are is to pass the severest condemnation on the administration of the hospital, and to present the most conclusive evidence of its inefficiency.

A special and most urgent want at the present time, repeatedly and earnestly insisted on by the Commissioners in Lunacy, individually and collectively, and by every one whose experience has made known to him the great necessity, is that of suitable asylum accommodation for the poorer members of the middle-class-those who are poor, but not poor enough to be paupers. For such persons, as Lord Shaftesbury truly says, "nothing worthy of the name of treatment or accommodation can now be obtained, except at a cost which is ruinous to clerks, tradespeople, and hard laborers in various professions. The misery that follows affliction of this kind in families such as I have mentioned is indescribable." What is to become of the father of the family, and of the family dependent for support upon his daily exertions, when he is struck down with insanity—the most expensive of diseases? At the same moment he becomes a terrible expense, and the means of livelihood cease. Or, what shall he, with an income on which he can just contrive to maintain his family, do when his wife or one of his children is so miserably afflicted? As a matter of fact, the suffering caused by insanity amongst the lower middle-class is beyond description. Repeated attemps have been made to furnish asylum accommodation suitable to their means, and with partial success. There are eleven middle-class public asylums in England, receiving between 500 and 600 patients; but they are mostly situated in the northern and middle counties, and are not sufficient for the demands made on them there-for the southern and home counties there is no similar provision at all. In Scotland there is excellent provision of the kind; there are seven chartered asylums, built by private benevolence; and which are now self-supporting. Now the want felt everywhere in England is, as may be supposed, most grievously felt in the metropolis, where the high pressure of active competition leads to frequent mental failures, where so many persons are day by day entirely dependent on the work they do, where health is capital, where not to go forward in the race is to go back. For the insane poor there is everywhere the most ample and satisfactory provision made in the different county and borough asylums; but these admirable institutions cannot admit any but paupers. The true mission of Bethlehem Hospital is therefore plainly marked out-to supply the asylum accommodation so pressingly needed for the lower middle-classes. With its magnificent income of more

than £22,000 a year rightly applied and faithfully managed, it has funds enough to provide for at least 400 insane persons, without making any charge whatever for maintenance. But it is not necessary, nor is it perhaps well, that it should receive all patients entirely charitably; those who could afford to pay for their maintenance might pay a moderate sum, and those who could only afford to pay a little towards their maintenance, might pay that little. Thus would the revenues of the hospital be considerably increased, and its capacity of doing good be largely extended; instead of receiving only 200 patients, there might be accommodation provided for 600 insane persons. Thus would one of the most urgent wants of the day be met, and thus would the hospital best fulfill the charitable aim of its foundation.

Another want sorely felt in the metropolis is the opportunity of clinical instruction in mental diseases for medical students. With the exception of Dr. Conolly's lectures, delivered at the Hanwell Asylum thirteen years ago, when he was physician, there never has been available means of gaining a knowledge of this most important branch of medical practice; year after year men enter on practice, never perhaps having seen a single case of insanity. And yet they not only have to treat this most serious disease as they have to treat other diseases, and to treat it at that early stage when there is always the best and sometimes the only chance of success, but they are called upon in courts of justice to give evidence with regard to it that may affect both property and life. "On them, again, is imposed by law the duty of signing certificates of unsoundness of mind, under which an insane person is deprived of his liberty. Considering the serious and sacred interests involved in a medical opinion respecting insanity, and the grave responsibility incurred by the medical man, it is plainly most desirable that mental diseases should receive particular attention, and be a necessary branch of medical education, instead of being entirely neglected, as they are at present. But it is only within the last year that the Senate of the University of London, recognizing the importance of a knowledge of mental diseases, and willing to insist on such knowledge from the candidates for degrees, has been compelled to refrain from issuing any compulsory regulations to secure that most desirable result, solely because of the absence of means and opportunity of instruction; it was impossible to enforce on the student a knowledge which it was impossible for him to get. How much the public interests and the medical profession have suffered by the long neglect of the study

of insanity may easily be imagined by any one who calls to mind the great scandals that have occurred in regard to cases of insanity, and reflects on the outrageous character of the evidence frequently given in courts of justice. Whether an insane person who has committed murder is hanged as a criminal, or confined as a lunatic, is notoriously very much a matter of accident; and it is beyond question that persons really sane are sometimes acquitted as insane, while others really insane are executed. And what else can happen so long as men are called upon to give scientific evidence respecting a most obscure disease which they have never had any opportunity of studying, and perhaps, as may happen, of which they have never seen an example? By affording clinical instruction in mental diseases at Bethlehem Hospital, by instituting a course of lectures, and by making the hospital, like other metropolitan hospitals, a school for the scientific study of disease, the governors would not only supply a grievously felt want, but they would greatly advance the interests of medical science, and confer much real benefit on the public. But if they should persist in ignoring those claims and duties arising out of the interests entrusted to them; if they refuse to give the needy insane the full benefit of the vast revenues of which they have the charge; if they persevere in closing the doors of the hospital in the face of the afflicted rightly demanding its charitable help, and in the face of those who may justly claim the opportunity of clinical study which it is so well fitted to supply; then the importance of the subject is so great, and the public interests concerned so grave, that it may be hoped, and confidently expected, that parliamentary interposition will take place, and secure for the future the just application of the funds and the good government of the hospital. It is impossible that a lunatic hospital so strongly condemned by those who are the official guardians of the insane, and by public and scientific opinion, can be allowed to continue to be, as it has unhappily hitherto for the most part been, an ever recurring scandal and disgrace. It is impossible that those entrusted with the administration of a wealthy public charity can be allowed for ever to deprive the public of the full benefit of its magnificent income, and to frustrate the aim of its foundation. If the many excellent and benevolent men whose names are found in the list of governors would but cease to be only nominal governors, and begin to take a real earnest. interest in the government of the hospital, then assuredly would enlightened views prevail, and a reform, proceeding from within, obviate the necessity of a public interference otherwise inevitable.