Dickens’s choice to visit St. Luke’s on Boxing Day (the day after Christmas) of 1851 reflects in part an appropriate seasonal desire to concern himself, and urge others to concern themselves, with the poor and suffering, as was traditional on this day in British culture. He concludes the sketch with the injunction to readers, "if you can do a little in any good direction--do it," which may be why the Governors of St. Luke’s reprinted this piece for many years as part of a fundraising pamphlet. But with Dickens’s keen eye for issues of popular concern, this sketch also deftly places itself in a tradition of documents on "asylum reform" as well, as is clear in his informed, repeated retrospectives to discredited, cruel treatments.

Dickens’s visit to St. Luke’s Hospital followed a century-long process of reform, sparked by the efforts of those who, like Samuel Tuke, Sir Andrew Halliday, John Connolly, W. A. F. Browne, William Charles Ellis, and Robert Gardiner Hill, drew attention to the often cruel treatment of the mentally ill and called for a more humane approach. Although there were earlier efforts to regulate asylums, the Act of 1845 ensured that an independent team of Commissioners in Lunacy would inspect, license, and report upon institutional conditions annually.

Dickens’s 1852 sketch of St. Luke’s supplements the shocking revelation of abuses in the "Parliamentary inquiry into madhouses of 1815-16," or the impressively detailed report of partial success in the 1844 "Report of the Metropolitan Commissioners in Lunacy." Like Dickens’s ambivalence about conditions at St. Luke’s, the Commissioners also record mixed responses in the annual visitation report recorded in the Visitors Book of St. Luke’s Hospital for 1850. They warn, for example, that while "the Hospital [was] generally clean," the "warming rooms . . . are cheerless and uncomfortable," and they note "a deficiency of tables in the day rooms." The Visitors Book for January 1858 also records Dickens’s response upon a return visit, in which he was "Much delighted with the great improvements in the Hospital."

Dickens critiques several specifics of the old-style treatment in a series of memorable passages arguing that "nothing was too wildly extravagant, nothing too monstrously cruel to be prescribed by mad-doctors"--like "spinning in whirligigs," for example. Joseph Mason Cox, in his landmark treatise, "Practical observations on insanity" (1804), popularized the swing as a treatment for the mentally ill. In his 1828 treatise, "Cases of mental disease," Alexander Morison proposed a "Rotatory Machine" much like the one Dickens describes, although it is possible that St. Luke’s used a swing with multiple seating like W. S. Hallaran’s circulating swing, constructed for the asylum in Cork and described in his "Practical Observations on Insanity" (1818). This could rotate four patients simultaneously at a hundred times a minute.

Similarly, Dickens offers an extended critique of John Haslam’s "key" to open rebellious patients’ mouths, as discussed in his 1809 treatise Observations on Madness and Melancholy. Dickens quotes at length from "the amiable practitioner" to illustrate Haslam’s horrific treatment of the mentally ill, although the quotations, taken from an 1809 review of the book in The Quarterly Review, actually paraphrase Haslam.

Finally, Dickens describes the immobilizing chairs, no longer in use but "preserved in a lumber-room," as "hideous curiosities indeed." Although Benjamin Rush proposed "the Tranquillizer" Chair in order to immobilize and blind an uncontrollable patient (see The Philadelphia Medical Museum, 1811), the chairs at St. Lukes were less extreme in restraining only the lower body and preventing backward or sideways movement of the upper body.

Dickens’s blunt sarcasm about the "Good Doctor" of the "good old times" does not prevent him from noting more nuanced ironies about the era of what were called "heroic" (extreme) remedies for illnesses that were then often incurable. He notes how the urge to control patients’ bodies as a way of calming wayward minds inspired a remarkable inventiveness in the profession. Dickens neatly inverts the usual hierarchies by mocking mad-doctors for themselves suffering from a "monomania" for curious prescriptions.

Similarly, he calls the "practitioners of old" "early homeopathists" who cure a disease with its cause; thus, inflicting "the most violent and certain means of driving a man mad" in hopes of "restoring him to reason." Dickens’s self-affiliation with what he sees as the more enlightened, humane, and modern methods of treatment is enhanced by his recourse to statistics, at the time generally hailed as a signifier of progress and science in medicine.

The sketch as a whole is punctuated by Dickens’s usual memorable characterizations. He peoples the asylum with a "pippin-faced old lady," an "old-young woman" he calls "Weird-Gentility," a "wry-faced tailor," and assorted others, and includes approving sketches of some popular attendants and the angel-like wife of the resident physician. This piece offers an interesting counterpoint to many of his novels, with the opportunity to discuss Dickens’s characters, social conscience, and mix of humor, sentiment, and realism. Readers in a medical-humanities setting might discuss his evident ambivalence over the institution, its inhabitants, and their place in Victorian society.