On the State of Lunacy and the Legal Provision for the Insane
TekstBy 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.”
The notions of parish authorities of the very great comparative economy of workhouses over asylums rest, say the Commissioners, on a false basis; and to place the question fairly before them, “it is essential that the mode of keeping the accounts should be assimilated in each, and that in the asylum only food and clothing should be charged to the parishes, and all other expenses to the county. In such case, we believe it would be found that the charges in each would be brought so nearly to a level, that there would exist little or no inducement on the plea of economy to tempt the guardians to keep their insane patients in workhouses, instead of sending them at once to a county asylum.”
To provide proper accommodation for the insane poor in workhouses, inasmuch as many asylums are on “so large a scale as not to admit of the necessary extension, whilst some are of a size much beyond that which is compatible with their efficient working,” the Commissioners propose “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, which should be under the management of the present visiting justices, would be intermediate between union workhouses and the principal curative asylums. The cost of building need not, in general, much exceed one-half of that incurred in the erection of ordinary asylums; and the establishment of officers and attendants would be upon a smaller and more economical scale than those required in the principal asylums.”
“Whether or not such additional institutions as we recommend be provided, we think it essential that visiting justices of asylums should be invested with full power, by themselves or their medical officers, to visit workhouses, and to order the removal of insane inmates therefrom to asylums at their discretion. They should also be empowered, upon the report of the Commissioners, to order the removal into the asylum of pauper patients boarded with strangers.”
“And in the event of our obtaining your Lordship’s approval of such suggestions for legislative enactment, we would further recommend that it should include the following provisions: —
“No lunatic, or alleged lunatic, to be received into or detained in a workhouse, unless he shall have been duly taken before a justice or officiating clergyman, and adjudged by him as not proper to be sent to an asylum.
“In any case, however, wherein an order for a lunatic’s reception into an asylum shall be made by a justice or officiating clergyman, it shall be competent to him, if, for special reasons to be set forth in his order, he shall deem it expedient, to direct that such lunatic be taken, pro tempore, to the workhouse, and there detained for such limited period, not exceeding two clear days, as may be necessary, pending arrangements for his removal to the asylum.
“A list of all inmates of unsound mind to be kept by the medical officer of a workhouse, and left accessible to the Visiting Commissioners.
“The medical officer to specify, in such list, the forms of mental disorder, and to indicate the patients whom he may deem curable, or otherwise likely to benefit by, or in other respects proper for, removal to an asylum.
“The Visiting Commissioner, and the Poor-Law Inspector, to be empowered to order and direct the relieving officer to take any insane inmate before a justice, under the provisions of the 67th Section of the Lunatic Asylums’ Act, 1853.
“In all cases of inmates of unsound mind temporarily detained in workhouses, the medical officer to be invested with full powers as respects classification, diet, employment, and medical and moral treatment, and otherwise.”
Of some of these suggestions we shall take a future opportunity to speak, and at present pass from the consideration of the state and wants of lunatics in workhouses to notice, briefly, the condition of those living with their friends or elsewhere.
§ Pauper Lunatics living with their relatives or with strangers
In the previous chapter “On the state of the present provision for the Insane,” some remarks have been made on the class of lunatic poor living with their relatives or strangers, calculated to arrest attention to their numbers and their neglected position. The Commissioners in Lunacy have as a rule, and in the absence of particular information, calculated that they are about equal in number to those resident in workhouses. Considering the imperfect nature of the statistical records of them, and the fact that they escape official observation and inquiry to a much greater extent than even the lunatic inmates of workhouses, we have assumed them to be more numerous, and that there are 8000 so distributed in the homes of our industrial classes.
Of these 8000, more or less, poor persons, dependent, on account of distinct imbecility or idiocy, upon others for protection and support, no one outside their abodes, it may be generally said, thoroughly knows their condition, although a partial knowledge may be possessed by the parochial authorities of the union or parish to which they are chargeable. To these authorities, however, they possess no interest; they are regarded as burdens upon the public purse, to be arranged for on the cheapest terms. The only person at all responsible for their condition is the parish medical officer, who is required by sect. 66 (16 & 17 Vic. cap. 97) to visit them quarterly, and to certify “whether such lunatics are or are not properly taken care of, and may or may not remain out of an asylum.”
In the first place, the matter of deciding what pauper reported as insane, imbecile, or idiotic is actually so, is not by law given to any parochial officer; hence it frequently happens that differences of opinion and divisions arise between the medical officer on the one hand, and the poor-law guardians on the other, as to the chargeability of this and that pauper to the parish as insane; and the decision acquires intensified importance from the fact that one half-crown per quarter is at stake on each pauper chattle in dispute; for if the medical man gain the day, just that sum has to be squeezed out of the rate-payers to compensate him for his quarterly call upon the admitted lunatic. We leave the reader to imagine the battlings of the vestrymen on the knotty point; sane or not insane, that is the question, the solution of which must cause the consumption of much time and breath yearly to many an honourable board of guardians, to animated discussions, bold definitions and fine-drawn distinctions, lost to the profanum vulgus enjoying no seat in the conclave.
Here, then, appears a duty which, in our opinion, should be performed by a duly appointed officer, such as a district medical inspector or examiner; for we would deprive the guardians of the poor of all voice in deciding on the sanity or insanity of any individual. The law might with equal or with greater propriety leave the decision of the success or non-success of the operation of vaccination to a vestry, as that of the question under remark. Further, since many might argue, that to leave the determination of the question to an officer like the parish medical man, directly interested in settling it in one way, and who might saddle the parish with an annual charge for every poor person in it who did not come up to his standard of mental strength, would be unfair to the rate-payers; an independent opinion, given by an officer in no way interested in the decision of the point at issue, would seem to afford the very best means of settling the point, and a sufficient guarantee against any supposable irregularities. We would suggest, therefore, that the district inspector should visit every poor person wholly or partially chargeable, or proposed to be made chargeable to any parish, as being of unsound mind, and make a return to the parochial authorities and to the Poor-Law Board, and that the certificate of this officer should be held to be a sufficient proof of the insanity of the individual.
But the duties of this officer, in relation to the lunatic poor under consideration, would not stop here. In his visit we would require him to investigate more narrowly than a Union medical officer can be expected to do at the remuneration offered, and amid his many other arduous engagements, – into the condition and the circumstances by which the poor patient is surrounded, to report thereon to the Lunacy Board and to the proper Union officials, and in general to state, in the words of the Act, whether he is or is not properly taken care of, and is or is not a fit subject for asylum care. The officer we propose, would approach the inquiry independently of the parish authorities, and indifferent to their censure, having no position and no pay to lose by his decision; whilst as an experienced physician, understanding the varying features of mental disorder, and the conditions necessary to its amelioration or cure, his opinions would claim greater respect.