On the State of Lunacy and the Legal Provision for the Insane / With Observations on the Construction and Organization of Asylums

by J. T. Arlidge

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.”