On the State of Lunacy and the Legal Provision for the Insane
The following practical suggestions, calculated to improve the condition of the insane poor, are deducible from the foregoing remarks on workhouses considered as receptacles for lunatics.
1. The County Asylums should afford aid to all insane persons unable to procure proper care and treatment in private asylums; and 2, such patients should be directly transmitted to them; the circumstance of their entire or partial liability to the poor-rates being, if necessary, subsequently investigated. 3. As a corollary to the last suggestion, the primary removal of patients to a workhouse should, save in very exceptional cases, such as of distance from the asylum and unmanageable violence at home, be rendered illegal; or, what is nearly tantamount to it, for the future no alleged lunatic should be suffered to become an inmate of a workhouse, except with the written authority of the District Medical Officer or Inspector proposed to be appointed. 4. Without the sanction of this officer, likewise, no lunatic should be permitted to be discharged or removed from a workhouse. This is necessary for the patient’s protection, for securing him against confinement in any house or lodging under disadvantages to his moral and physical well-being, to check improper discharges, and to protect the asylum against the transfer to it of unfit cases, a circumstance which will presently be shown to be of frequent occurrence. 5. No person should be detained as a lunatic or idiot, or as a person of unsound mind in a workhouse, except under a similar order as that required in the case of asylum detention, and a medical certificate to the fact of his insanity. 6. If workhouses need be used, whether as temporary or as permanent receptacles for the insane, they should be directly sanctioned by law, placed under proper regulations, and under effective supervision, not only of the Lunacy Commissioners, but also of a Committee of Visitors, and of the District Medical Officer, whose duty it would be to watch over the welfare of the insane inmates, their treatment, diet, occupation, and amusement. The Visitors should be other than guardians or overseers of the poor of the union or parish in which the workhouse is situated, although every union should be represented on the Committee; and they might be selected from the magistrates, and from the respectable classes among the rate-payers. If the county were large, it might be advantageously divided into districts, a Committee of Visitors of Workhouses being appointed in each district. 7. Every workhouse containing lunatics should be licensed as a place of detention for them by the Committee of Visitors, who should have authority to revoke the license. This power of revoking the license should be also vested in the Commissioners in Lunacy. 8. Every such workhouse, and the number of its insane inmates, should be reported to the Lunacy Commissioners. According to our scheme, the District Medical Officer would do this, as well as report generally to the Lunacy Board, the condition and circumstances both of the workhouse and of its insane inmates. 9. For the future, the erection or the appropriation of distinct lunatic wards to workhouses should be interdicted by law.
By the preceding suggestions reforms are, indeed, proposed to render confinement in workhouses legal; to make it more satisfactory; to provide for effectual supervision, and in general to assimilate the wards of union-houses more closely to those of asylums. Yet all this is done only on the ground of the necessity for some legislation on these matters, and more particularly under the pressing circumstances of the time. The present state of lunacy compels acquiescence in the Lunacy Commissioners’ statement, that workhouse-wards must for some time longer be used for the detention of insane paupers; and this fact alone supplies an apology for making suggestions to improve them. Moreover, apart from it, the workhouse will at times necessarily be the temporary refuge for some few cases, and may be occupied as a permanent dwelling by those rare instances of imbecility of mind which can be allowed to intermingle with the other inmates, and be usefully occupied; and for these reasons it need be rendered both a legal and not unsuitable abode. At the same time, it is most desirable that the Lunacy Commissioners should be able not only to discourage, but also to veto the construction of lunatic-wards for the future, on the grounds already so largely pointed out; and for this reason, moreover, that where such wards exist, they are thought good enough for their poor inmates, and are looked upon as asylums over which the county institution has little preference. The existence, therefore, of any specially erected or adapted ward, may always be urged against the proposition for further expenditure in providing for pauper lunatics elsewhere in suitable asylums; – a plea, which should consequently be set aside by overturning the foundation whereon it rests.
Since the preceding observations on the detention of pauper lunatics in workhouses were in print, a most important supplementary Report on the subject has been put forth by the Commissioners in Lunacy (Supplement to the Twelfth Report; ordered to be printed 15th of April, 1859). We have read this Report with pleasure, so far as it confirms the views we have taken, but with surprise and pain at the details it unfolds of practices the most revolting to our better feelings, and, in general, of a state of things discreditable to a civilized and christian country. By being confirmatory of the opinions and statements advanced by us, it may be said to give an official sanction to them; and as it is one of the most important documents ever issued by the Board, we shall attempt an analysis of its contents.
In the first place, the Commissioners resort to some recent corrected returns of the Poor-Law Board, and discover that the number of pauper lunatics in workhouses was, on the 1st of January, 1858, 7555, i. e. upwards of 500 above that returned in the Tenth Report of the same Board, and referred to in the foregoing pages; and on the 1st of July in that same year it amounted to 7666. They then proceed to describe the “character and forms of insanity most prevalent in workhouses,” and show that their insane inmates all require protection and control; that “some, reduced to poverty by their disease, are of superior habits to those of ordinary paupers, and require better accommodation than a workhouse affords. Many are weak in body, and require better diet. Many require better nursing, better clothing, and better bedding; almost all (and particularly those who are excitable) require more healthful exercise, and, with rare exceptions, all require more tender care and more vigilant superintendence than is given to them in any workhouse whatsoever.”
On turning to the “Design and Construction of Union Buildings,” they rightly point out that the stringent conditions to ensure economy, and to check imposition and abuse, the “reduced diet, task labour, confinement within the narrow limits of the workhouse premises,” the plan of separating the inmates into classes, the scanty means of out-door exercise, &c., are inimical to the well-being of the insane residents. In the “Modes of Workhouse Direction and Administration” there is great unfitness. The rules under which the officers act “are mainly devised to check disorderly conduct in ordinary paupers; and it is needless to say with how much impropriety they are extended to the insane. Any increase of excitement, or outbreak of violence, occurring in the cases of such patients, instead of being regarded as a manifestation of diseased action requiring medical or soothing treatment, has subjected the individual to punishment, and in several instances led to his imprisonment in a jail. In addition to these hardships, the lunatic patient is for the most part precluded from leaving the workhouse at his own will. In effect he becomes a prisoner there for life, incapable of asserting his rights, often of signifying his wants, yet amenable to as much punishment as if he were perfectly sane, and a willing offender against the laws or regulations of the place. Nor, as will hereafter be seen, is his lot much bettered in the particular cases where it is found convenient to the authorities to relax those restrictions, and give him the power at will to discharge himself.”
Rural workhouses of small size are generally preferable abodes for the insane than those of larger dimensions, since their “arrangements have a more homely and domestic character, and there are more means of occupation and of free exercise in the open air;” and where their imbecile inmates can be associated with the ordinary paupers, and regularly employed, their condition is not unfavourable; “but these form only the exceptions.” Workhouses in the metropolis and in large towns generally, are for the most part “of great size, old, badly constructed, and placed in the midst of dense populations. The weak-minded and insane inmates are here generally crowded into rooms of insufficient size, sometimes in an attic or basement, which are nevertheless made to serve both for day and sleeping accommodation. They have no opportunity of taking exercise; and, from the want of space and means of separation, are sometimes associated with the worst characters, are subjected unnecessarily to seclusion and mechanical restraint, and are deprived of many of the requisites essential to their well-being.”
“Of the 655 workhouses in England and Wales, somewhat more than a tenth part are provided with separate lunatic and idiot wards.”
The “Objections to Intermixture of Inmates” are briefly stated. “There is no mode of complying with suggestions for” the peculiar benefit of insane inmates, “without disturbing the general economy of the house, – a fact which shows how important it is that no lunatic or idiot should be retained for whom any special arrangements are necessary.” Separate lunatic wards are declared to be more objectionable than the intermixture of the pauper inmates. Only occasionally are such wards found at all tolerable; and even then, the constant medical supervision, proper attendants and nursing, sufficient diet, exercise, occupation, and other needful provisions, are deficient. The majority are thus sketched: – “In some of the wards attached to the old workhouses the rooms are crowded, the ventilation imperfect, the yards small and surrounded by high walls; and in the majority of instances the bed-rooms are used also as day-rooms. In these rooms the patients are indiscriminately mixed together; and there is no opportunity for classification. There is no separation where the association is injurious; and no association where such would be beneficial. In fact, patients of all varieties of character, – the weak, the infirm, the quiet, the agitated, the violent and vociferous, the dirty and epileptic, – are all mingled together, and the excitement or noise of one or more injures and disturbs the others. The restless are often confined to bed to prevent annoyance to the other patients, and the infirm are thus disposed of for the want of suitable seats. Their condition when visited in the daytime is obviously bad, and at night must be infinitely worse. Even in workhouses where the wards are so constructed as to provide day-rooms, these are often gloomy, much too small in size, and destitute of ordinary comforts; while the furniture is so poor and insufficient, that in some instances, there being no tables whatever, the patients are compelled to take their meals upon their knees. Other cases to be hereafter mentioned will indeed show that it is reserved for lunatic wards of this description, and now happily for them only, to continue to exhibit some portion of that disregard of humanity and decency, which at one time was a prevailing characteristic in the treatment of insanity.”
Not only, again, are there no sufficiently responsible authorities in the house, and no qualified responsible attendants, but also no records of restraint, of seclusion, of accident, or injury, or of medical or other treatment. “Above all, there is no efficient and authoritative official visitation. The Visiting Justices never inspect the lunatic wards in workhouses, and our own visits are almost useless, except as enabling us to detect the evil that exists at the time of our visit, and which, after all, we have no power to remove.” The “Results of Neglect in Deteriorating the Condition of Patients” of all classes are ably portrayed. In the absence of attentive and experienced persons to watch and to supply their wants, many of the insane suffer unheeded and without complaint, to the prejudice of their mental and bodily state; or become inattentive to natural wants, and prone to violence and mischief. “In a very recent case of semi-starvation at the Bath Union, when the frauds and thefts of some of the attendants had, for a considerable time, systematically deprived the patients of a full half of their ordinary allowance of food, the only complaint made was by the wan and wasted looks of the inmates.”
In the two next sections the Commissioners insist that the duty of distinguishing the cases in workhouses to be classified as “Lunatics, Insane Persons and Idiots,” should be performed by the medical man independently of the master; and that, without examination and sanction from that officer, no person of weak mind should be discharged, or allowed to discharge himself. Very ample cause for this latter proposition is shown in the illustrations appended, particularly in the case of imbecile females, who not unfrequently become, when at large, the prey to the vicious, further burden the parish by their illegitimate offspring, and often by an idiotic race.
“The diet necessary for the insane” is required to be more liberal than for other inmates; yet the Commissioners have “in very numerous instances” animadverted upon its inadequacy, both in quantity and quality, but without result, except “in very few instances:” for, notwithstanding that “the medical officer of a Union has full power” (by the Consolidated Order 207, art. No. 4) “to give directions, and make suggestions as to the diet, classification and treatment of the sick paupers, and paupers of unsound mind,” yet, we are sorry to learn, that “the power thus given, although backed by our constant recommendations, is rarely exercised by the medical officer.”
This circumstance is so far confirmatory of a view we have above taken, that the medical officer of a parish or union is neither sufficiently independent, as the paid employé of the guardians, to carry out measures that may be necessary for the alleviation of the condition of lunatics in workhouses, where such means involve increased cost (we regret to entertain the notion); nor always sufficiently acquainted with the wants of the insane.
Considering the disadvantages of workhouses as receptacles for them, the general statement follows naturally, that as a class of workhouse inmates, the lunatics “are manifestly lower in health and condition than the same class in asylums. Hence,” add the Commissioners, “the patients’ bodily health and mental state decline upon removal from asylums to workhouses – an effect chiefly due to the inferior diet.” There are great “variations in workhouse dietaries,” – from one spare meat dinner in the week to a meat dinner daily. This latter provision is furnished “in a very small number of houses.” These dietaries are indeed much inferior to those considered necessary for criminals in jails; a fact that affords a sad comment on English consistency, which is thus found dealing with more favour and consideration towards those who have transgressed the laws of their country, than to those whose only crime is poverty, or poverty complicated with disease or infirmity.
Medical treatment would, in truth, seem to be not legally provided at all for lunatics in workhouses: no clause makes a visit of the union medical officer to the lunatic-ward of a workhouse imperative. As examples of the slight esteem in which medical supervision is held, the Leicester and the Winchcombe houses are quoted. In the former, the visits of the medical officer were only made quarterly; in the latter, by stipulation three times a week, but in practice very irregularly. Attendance and nursing are, as might be expected, on a par with medical treatment. Even imbeciles have been found exercising the functions of nurses, and, generally speaking, the selection of attendants is made from old and feeble people, having no experience, no aptness for the duties, no particular qualities of intellect or temper to recommend them, and receiving such a mere pretence, if any at all, in the way of remuneration for their trouble, that no painstaking efforts can be looked for from them. “Yet to such individuals, strait waistcoats, straps, shackles, and other means of restraining the person are not unfrequently entrusted; and they are, moreover, possessed of the power of thwarting and punishing at all times, for any acts of annoyance or irregular conduct, which, although arising from disease, are nevertheless often sufficient to provoke punishment from an impatient and irresponsible nurse.”
The interior accommodation, fittings, and furniture are, if not abominably bad, excessively defective: and on reaching this part of the Report, where the details of internal fittings and management come under review, the impression derivable from its perusal is akin to that gathered from the revelations of madhouses made by the Parliamentary Committees of 1814 and 1815. The sketch of the evils suffered by lunatics in workhouses, which we have ourselves attempted in past pages, tells a flattering tale compared with the realities unfolded to us by the Commissioners, and adds a tenfold force to the arguments against the detention of lunatics in such places. To continue the practice would be to perpetuate a blot upon the internal polity, the philanthropy and the Christianity of the country. Let those who would know the whole case refer to the Report in question; it is sufficient for our purpose to attempt a mere outline of its revelations. Patients are frequently kept in bed because there are no suitable seats for them; a tub at times answers the double purpose of a urinal and a wash-basin; a privy is partitioned off in a small dormitory; baths are almost unknown; a trough or sink common to all supplies the want of basins for washing, and an outhouse or the open air furnishes the appropriate place for personal ablutions. Clothing, again, is often ragged and insufficient; in an unwarmed dormitory, a single blanket, or only a coverlet, is all the covering afforded by night; loose straw in a trough bedstead usually constitutes the bed for wet and dirty patients to nestle in; and whether the bed be straw or not, the practice of using it night after night, when “filthy with dirt, and often rotting from frequent wetting, has been many times animadverted upon.” In some workhouses two male patients are constantly placed in the same bed; nor is the character of the bedfellows much heeded; for a sane and insane, two idiots, one clean and one dirty, and even two dirty inmates, have been found associated together in the same bed, occasionally in a state of complete nudity.
Further, the want of exercise and employment, the absence of supervision and control, and the entrusting of means of coercion to irresponsible and unfit attendants, lead to the most shocking abuse of restraint, and to cruel seclusion.
“The requirement occasionally made by the Visiting Commissioner, that the Master shall make a written record of such proceedings, is utterly neglected. The dark, strong cells, constructed for the solitary confinement of refractory paupers, are used for the punishment of the insane, merely to prevent trouble; quiet helpless creatures, from whom no violence could be apprehended, are kept in bed during the daytime, or coerced; and even the dead-house has been made to serve the purpose of a seclusion-room.”
“The Examples of Restraint practised,” as adduced in the Report, recall to mind all those barbarities which civilized men of the present day are in the habit of congratulating themselves as matters of the past, and the subject of history. The catalogue of appliances for restraint reappears once more on the scene; and we read of straps, leather muffs, leg-locks, hobbles, chains and staples, strait-jackets, and other necessary paraphernalia, as of yore, worn for days, or weeks, or months. Excellent matter, indeed, in all this, to garnish a discourse on the advancement of civilization, on the prevalence of improved notions respecting the treatment of the insane, or on some similar topic addressed to the vanity of the present generation!
But the chapter does not end here. “It would be difficult to select places so entirely unfit for the purpose of exercise, or so prejudicial to the mental or bodily state of the person confined,” as the yards or spaces set apart for it; and yet “of all the miseries undergone by this afflicted class, under the manifold disadvantages before described, and of all the various sources of irritation and discomfort to which we have shown that they are exposed, there is probably none which has a worse effect than the exclusion from all possibility of healthy movement. Nothing more powerfully operates to promote tranquillity than the habit of extensive exercise; and in its absence, the patients often become excited, and commit acts of violence more or less grave, exposing them at once to restraint or seclusion, and not unfrequently to punishment. In not a few instances the outbreak has been looked upon as an offence or breach of discipline, and as the act of a responsible person; and the patient has been taken before a magistrate and committed to prison.
“A very grave injustice, it is hardly necessary to add, is thus committed, in punishing by imprisonment individuals who are recognized and officially returned as being of unsound mind. These persons in no respect differ from the class of the insane usually met with in asylums, and are equally entitled to the same protection, and the same exemption from punishment. Instead of such protection, however, the patient is exposed to double injury: – first, he is subjected to various sources of irritation while confined in the workhouse, directly occasioning excitement; and, secondly, the mental disturbance resulting therefrom is regarded as a crime, and is punished by imprisonment.”
The Commissioners in Lunacy next direct attention to the principal cause of the evils described, which they discover in the neglect and evasion of the duties imposed by the law on the officers of parishes and unions, in the interests of the pauper insane. Thus, as remarked in previous pages, – “Instead of causing the patient to be dealt with as directed by the 67th and 68th sections of the Lunatic Asylums’ Act, 1853, and immediate steps to be taken for his direct removal to the asylum, workhouses have been to a great extent made use of primarily as places for the reception, and (in many instances) for the detention of recent cases of insanity.
“The workhouse is thus illegally made to supply the place of a lunatic establishment, and the asylum, with its attendant comforts and means of cure, which the law has provided for the insane poor, is altogether disregarded; or it comes into operation only when the patient, by long neglect, has become almost hopelessly incurable. We should remark that this occurs most frequently in the larger workhouses, and in those having insane wards.”
… “How totally unfit even workhouses having insane wards are for the proper treatment of recent curable cases, we have endeavoured to exhibit in some detail. Nevertheless, the practice of making use of them for all classes of insane patients is rapidly increasing, and our efforts to check it have proved hitherto quite ineffectual.”
After further adverting to the influence of the neglect of the laws in increasing pauper lunacy, they very briefly discuss the comparative cost of lunatics in workhouses and in asylums, but their examination adds nothing to what we have much more fully put forward on this subject.
Their “conclusion” contains some valuable suggestions, more or less identical with those we have ourselves independently advanced, and which may be briefly summed up as follows: —
“To remedy many of the evils adverted to would, in our opinion, be impracticable, so long as insane patients are detained in workhouses, whether mixed with other inmates or placed in distinct wards.
“The construction and management of workhouses present insurmountable obstacles to the proper treatment of the disease of insanity; and therefore the removal of the majority of the patients, and the adoption of stringent measures to prevent the admission of others, have become absolutely necessary.”