Robert Gardiner Hill

Robert Gardiner Hill MD  (26 February 1811 – 30 May 1878) was a British surgeon specialising in the treatment of lunacy. He is normally credited with being the first superintendent of a small asylum (approximately 100 patients) to develop a mode of treatment whereby the reliance on mechanical restraint and coercion could be made obsolete altogether, a situation  he finally achieved in 1838. Nevertheless, the debate concerning its merits continued  for many years.

As so little is written of him, much of what follows is from a contemporary account of a visiting doctor.

Early career
Hill born in Louth, Lincoln, England, of parents engaged in trade. He was apprenticed to an apothecary at Louth, and passed his examination in London. He afterwards was appointed surgeon to the Lincoln Dispensary with Dr. Edward Parker Charlesworth, who, marking the young man's merit and worth, and being a daily witness to his indefatigable exertions, as well as attention to his duties, befriended him. As his health was not of the best, and the duties of the Dispensary became very laborious, Mr. Hill, with Dr. Charlesworth's assistance, watched for a vacancy in the office of house surgeon to the lunatic asylum, and when it occurred he was unanimously elected.

His introduction to 'non-restraint'
Charlesworth had already experimented with reducing the dependence at the asylum on mechanical restraint. Being of a turn of mind given to statistics, Mr. Hill, soon after his appointment, looked into all the registers of the asylum, and began to tabulate the facts therein contained. In doing this it is probable that he hail seen how progressively the coercive system in the asylum had been reduced to a very low degree without any injurious effects, and hence he was induced to think that he might dispense with it altogether.

Mr. Hill has the merit of having succeeded in completely abolishing that system among the patients in the Lincoln Asylum. In justice, however, to the medical officers and boards, who have been very active and zealous in the discharge of their respective duties during a series of years previously to Mr. Hill's appointment, it is right to state that that gentleman found the plan of non-coercion more than two-thirds adopted already, measures of restraint and the use of restraining instruments having been reduced very considerably before his connexion with the asylum. This he himself very candidly puts forth in his book, by transcribing from the register of the asylum the various resolutions passed from time to time, and the measures adopted accordingly for the utmost possible diminution in the employment of coercion, and for substituting simpler and less aggravating modes of coercion when such was deemed absolutely necessary. Thus it appears from a comparison of the table of restraints for 1830, with the table for 1835, given in the appendix to Mr. Hill's book, that whereas, with a number of patients in the house, during the first of these years, amounting only to 92 (male and females included), the total number of instances of restraint had been 2364; in the latter of these years, with a number of patients greater, namely, 108, the total number of instances of restraint had only been 313; being a diminution of five-sixths of the number in the former year.

Mr. Hill, too, had the good fortune of finding the senior physician. an experienced and able practitioner, not only friendly disposed, but a warm advocate of the little or no restraint system; and with him some benevolent and philanthropic clerical members of the weekly board, dignitaries of the Lincoln Cathedral, who showed a praiseworthy readiness in co-operating for the adoption of a system which had humanity to recommend it.

At this point in time Hanwell Asylum in Middlesex had approximately 700–900 patients.

Results
Taking as a guide Mr. Hill's own tables and statements, it would seem that the recoveries under the coercive system have exceeded those under the non-coercive system by nearly 35%. If then, the usefulness and advantage of a mode of treating lunatic patients is to be determined by the number of recoveries effected, the three years' experiment by Mr. Hill has proved that his system is not so good as the one followed during the years antecedent to his appointment.

The grounds for such an assertion are these: During the years 1829-30-1-2-3-4-5, while the coercive system was pursued in the asylum there were treated 264 patients, including those already in the asylum on the first of January, 1829: of whom 117 were discharged recovered, being one in two and not quite 1/9. But during the years 1836 7–8, while the non-coercive system invaded, 195 patients. including those who remained in the asylum on the first of January, 1836. were treated, and of those 65 only were discharged recovered, being one in three. The total number of patients treated under this system have been omitted, the patients reported in the statistical tables as having been re-admitted in consequence of relapses, as such patients to average nearly the same number in each year, under both systems, so that their omission cannot vitiate the relative proportion of recoveries. This then, it appears, is nearly 35% in favour of the coercion system. But if the non-coercion system does not exhibit yet a vantage ground when examined in reference to the number of recoveries it produces, the rate of mortality under it (which is, after all, a better conclusion) proclaims its superiority over the opposite system, inasmuch as we find it in the latter to have been nineteen and a half, while in the former it was only 15%; the suicides being almost always checked by it.

It remained to be seen whether this superiority is obtained at a much higher rate of expense; and for this purpose it would be important to ascertain the average cost of each patient treated in the asylum, from the time of his admission to that of his discharge, under the former and present system. For this calculation, there was not sufficient materials. It would be necessary to include in the expenditure entailed by the system, the interest of the money employed in enlarging the premises, and altering them to suit the views of the promoter of the system.

However, some curious facts and philosophical deductions may be obtained, by the consideration of the statistical reports, regularly made for the last fifteen years, of the state of this asylum. In looking over the data furnished by such reports, of which Mr. Hill availed himself in his lecture on the management of lunatic asylums, delivered at Lincoln in June, 1838, when the author was only twenty-six years of age and which he subsequently published: The total number of patients subjected to restraint, male, and female, amounts to 311; being 184 males, who were confined 4918 times, or 55,592 hours; and 127 females, who were confined 3696 times, or 40,255 hours.

From which it appears that every female, relatively speaking, had required to be restrained fourteen hours and a half more than any of the male patients. The proportion of the patients restrained during the eight years, compared to the total number of patients admitted or re-admitted in the course of that time, has been 311 of the former to 344 of the latter, which is the total of ad missions during the eight years, in the relative proportions of 190 males to 154 females.

Other innovations
One of the improvements introduced by Mr. Hill in pursuance of his system is the dormitories, almost entirely established for the prevention of suicides, so frequent under a former regimen. On being asked whether it was the apprehension of such cases being likely to be numerous, that had led him to place so many beds in dormitories instead of cells, Mr. Hill answered—" Yes; and that the larger proportion of lunatics in the asylum were disposed to suicide."

The cells on one side of the dormitories, all of which have excellent beds and beddings, and clean sheets, are for such lunatics as arc dangerous to others, and are locked up, but not restrained, at night. At the end of the dormitories is a square sleeping-room, containing seven or eight beds, for ordinary quiet or convalescent patients. In this the night-guardian has to register the time, at every quarter of an hour of his watch, by pulling the string of a clock, so constructed, that one of many steel pegs projecting from the circumference of the dial-plate is pressed in by a spring, put in action by the string, when pulled by him at the proper period, which is every quarter of an hour. That period past, without the string being pulled by the guardian, who may be asleep, the dial turns round the space between two pegs, the peg passed over being left out in consequence. This cannot be pushed in by the hand afterwards, and remains, therefore, an irrefragable proof of the want of watchfulness on the part of the attendant.

Some causes of Lunacy and treatments
Mr. Hill attributes the greater number of bad cases to the frequent and inordinate use of ardent spirits, and the next largest number to religious enthusiasm, devotion, or perplexity of mind on religious doctrines. Dr. Charlesworth, in the course of his conversation, broached a doctrine of his own, to which Mr. Hill assented, namely, that all mental diseases are diseases of atony, requiring strength, good food, air, and exercise. He abjures and abominates every species of depletion, and places no reliance on remedies of any sort for such maladies. Lunacy is a complaint that must have its course. If at the commencement of the disease all sources of irritation, excitement, &c. &c., be removed, the course will be of short duration, and so in proportion to the length of time that has elapsed between the attack and the removal of the patient to a retreat away from friends and familiar objects. The late eminent Dr. Willis partook very much of this opinion, but could not be prevailed upon to believe that the total absence of coercion, even to the abolition of the long-sleeved smock-frock for patients who were inclined to do harm to themselves and to others (all of whom Mr. Hill allowed to be at full liberty), would ultimately prove so beneficial as its advocates expected.

Setting aside this important question of the abolition of every species of restraint from a lunatic asylum, which in that of Lincoln had so far succeeded, though not without much struggle, and some schism in the councils of the institution: and unwilling to enter the lists with Dr. Charlesworth upon the subject of a non-medical treatment of insanity, there remained in the minds of some, another question with regard to another branch of the moral management of patients in the Lincoln Asylum, and which consists in mingling together purposely, and upon principles. the private with the ordinary patients, when they are all out in the airing-grounds.

Separation by social class
Within doors, the private patients have separate apartments,' which, though well arranged, and usefully furnished, are not equal, for the charge of a guinea, or even fifteen shillings a week, to those in the York Retreat. But when out of doors, no distinction is made among the patients; and the reason given by Mr. Hill was this, namely, that they would not be separated in the streets were they not confined, and that, though made to live together with the pauper patients in the asylum, the better class are not bound to converse or hold intercourse with them.

Opinions on this arrangement differed. Dr. A B Granville felt strongly and wrote: "With deference, I hold this to be an extremely bad reason for the practice, while, at the same time, I contend that there are many good reasons for its non-adoption. True, a wealthy lunatic, or even a sound man, as he walks through the streets. mingles with beggars, is passed by the filthy, and may at every step find himself among bad characters; and yet he neither feels insulted, nor derives injury from the admixture. But that admixture is transitory, and of short duration. Moreover, the man who is desirous of avoiding it. may choose another street, another walk, another part of the town; and may change his course as often as he pleases to eschew such company: nor can the man of low degree, even where the medley is inevitable, come up and elbow you, stand still when you stand still, follow you persecutingly when you walk away, stare you in the face, mock, and spit at you,—which I have seen, and every body has seen, to occur a hundred times in an assembly of men bereaved of their nobler faculties. The reason therefore is a bad one, because it is inapplicable, and the two conditions of circumstances are quite distinct. Buy for not adopting the practice of mixing the private with the pauper patients, there are many excellent reasons. First. The man of education, and who has been brought up as a gentleman, mad as he may be, may retain his feelings of delicacy and pride; he will be better dressed, and be shocked (how do we know he is not inwardly so ?) at being associated with those whose coarse garments, coarse habits, rude manners, filthy tricks, and want of cleanliness, mark them out as of an inferior class. And if so, then the perpetual association, the inevitable company of such, their obtrusion on the same path, or along the same walk, must inwardly offend and irritate, and thus far impede the recovery of the man of a superior caste. Secondly. The sight of persons bereaved of their wits by hard inebriation from potent liquors, inducing the worst species of insanity, can ill accord with any anticipation of cure in the ease of a gentleman or gentlewoman afflicted probably only with melancholy, or an aberration of a refined sort, as most of the mental disorders of that class of people are. The latter, therefore, will probably be irritated at, and ultimately, perhaps, (through constant association,) be driven to imitate, the grosser ravings of the low-born. Thirdly and lastly. As the progress of recovery in all in. sane persons greatly depends on their power and means of conversing upon the very topics respecting which their reasoning faculties have been damaged; but so that they who are to converse with the patient as a means of cure, shall, by gentle and cunning gradation, turn his thoughts into a sounder channel: it is manifest that such a progress towards recovery will be retarded, and the damaged faculties be damaged still farther, if other patients, themselves in the worst state of low and coarse ravings, are to have a daily opportunity of forcing their conversation on the less afflicted and more refined invalids. On the whole, and under every aspect therefore, the admixture of the better with the worse, of the low-born with the educated class, of the gentleman and the pauper, which obtains in the open airing grounds at the Lincoln Lunatic Asylum, is injudicious, uncalled for, arid calculated to retard, if not altogether to mar, the recovery of the superior and private classes of patients."

This was a situation pauper asylums would not have need to address.

The experiment's main obstacles
It is very evident that Hill had much trouble maintaining a non-restraint system due to the custom of asylum governors in those times to employ people of the lowest caliber to act as the patients' attendants, who were naturally inclined to be 'reactive' than proactive in there interaction with their charges. With the benefit of hindsight it could well be this that was responsible for the unpromising recover rate. However, without clear convincing results the governors would not offer better pay to attract better staff nor give him their support and as it was begrudged the extra staff required for non restraint.

If the medical superintendent himself be not also or ever present and watchful over the keepers, the system sill assuredly not work continuously and successfully. The causes for irritation from the conduct of patients, and the temptation to resent them by a stretch of authoritative interference and severity on the part of their keepers, are unfortunately too frequent ever to justify the hope that, without the watchful eye of a superior officer, or the fear of it, subordinate officers will strictly and invariably execute their trust in harmony with the views and intentions of the head of their department.Accordingly I found that Mr. Hill hardly ever left the house, and was at all hours of the day mingling with the patients, watching them and their guardians at the same time.

Its legacy
Despite the problems Hill experienced, his system won admirers. One such, was Sergeant John Adams, who was an assistant judge. He took an interest in the asylum when circuit duties took him up to Lincoln. In his other capacity as chairman of the Middlesex magistrates and member of the Visiting Justices to Hanwell Asylum, he encouraged the newly appointed superintendent Dr. John Conolly to visit Lincoln Asylum and witness Hill's methods. This, Conolly did in the month before taking up his appointment. It is recorded in the asylum's visitors' book that he admired Hill's system.

Eventually Hill tired of this and in 1840 Hill resigned from his post. This left the further development and popularization of non-restraint to Dr. John Conolly at Hanwell Asylum.

Career after Lincoln Asylum
For the rest of that decade he stayed in general practice. The he opened a private asylum for women in 1851.

Some of Hill's publications

 * Hill Robert Gardiner. Total Abolition of Personal Restrain in the Treatment of the Insain.
 * Hill Robert Gardiner (1857) Concise history of the entire abolition of medical restraint.
 * Hill Robert Gardiner (1870) Lunacy: its Past and its Present.

Lectures

 * Hill Robert Gardiner (1839) A lecture on the Managemnet of Lunatic Asylums and the Treatment of the Insane.