by Mark Stevens
Sometimes the most tragic events can unfold in an institution of several hundred people. Water, though a vital part of our ongoing existence, can also be an agent of demise for a mind bent on its own destruction. Since we opened a small handful of patients have fallen victim to the proximity of the river. Our first loss was a 50-year-old tailor who had been suffering from a severe bout of depression. Invited to join a walking party, he used his new freedom to make for the water and plunge in. He floated on the surface for around 200 yards before disappearing from view, and when he did not emerge attendants were obliged to dredge the river in order to retrieve his body. Nor is the river the sole risk on our estate: a few years ago, a male patient fell into one of the shallow gutters which channel rainwater away from the buildings and drowned in only a few inches of water.
In such cases artificial respiration may be practised. If you have swallowed water, then you will first be placed on your front to allow the fluid to escape, then placed on your back with a pillow underneath your head, and your arms brought up until they meet above you. The arms are then brought down again and pressed against your chest. This piston motion is repeated up to fifteen times a minute for as long as is necessary.
A similar routine is practised in cases of suspected strangulation, though with the addition of cold water as a stimulant. But the sad truth is, as we have stated previously, that it is sometimes very hard to protect someone from themselves. The current male patient who has taken to hiding in the evergreens is one example. Every day he remains behind in the airing court, hoping that he will be forgotten by the staff so that he may try to hang himself from the nearest tree. An attendant is now detailed especially to check for him. And our suicidal female patient with the destructive lust for hair pins has become wont to rip them from the heads of female staff who visit her.
As we discuss the possibility of life being extinguished, it may be appropriate also to say a word about the commencement of it. Although the asylum is a medical establishment, it is not seen as a desirable place in which to usher in a newborn. Nevertheless, we are from time to time obliged to admit female patients who are pregnant. We do so only if there is no other option for their safe care. If an expectant patient is admitted, one of the female attendants will keep a close watch to ensure that no harm comes to the woman or her baby. The attendant is detailed to look out for signs of labour too, as the patient may be unaware of its onset or unable to communicate its approach.
These cases can cause great sorrow. As an example of the extremity required for admission, several years ago one patient was brought in from a local workhouse in the early stages of labour. She had begun gesticulating wildly and pulling at her hair, so much that the workhouse staff had shorn it to prevent her from injuring herself. This poor woman was held down in the female padded room until she gave birth to a stillborn child. The result of the restraint was that the mother’s wrists were greatly swollen and we were unable to detect her pulse – or the absence of it. We failed to notice her own crisis, and she died later that day from complications of the birth.
Fire
A final safety warning must be raised against this great destroyer. Precautions against fire are not, of course, limited to asylums, and much effort is made within all institutions to curb the effects of unwanted conflagrations. Yet the hearth in every home is a constant source of danger, and the practices we adopt here are ones that could be projected sensibly into any domestic arrangement. Clothing is the usual culprit, and this is a particular concern for the female patients. Long dresses or hanging shawls are always at risk of ignition from a spark when a stove is opened. Such incidents usually occur in one or other of the day-rooms, and many a rug has become a blanket in which to wrap a burning patient.
As a large institution, we also recognise that we owe our patients a duty to take more formal precautions against fire. Some asylums have begun to invest in alarm systems – whereby a glass protector is broken in order to access an alarm bell – and additional staircases. Though these costs are outside our current range, they emphasise a concern for fire safety that shows no sign of decreasing. Instead, we hang a list of instructions in every attendant’s room, stressing the importance of making sure that stoves are refuelled safely, closed at all other times, and put out at the end of every day. Each attendant has also been issued with a Metropolitan Police whistle to be blown in the event of fire to summon help.
We have recently constituted an asylum fire brigade from the ranks of the unmarried male attendants, who sleep within the main building. We have the latest Merryweather fire hoses, ten of which are connected to the plumbing and stowed in cupboards throughout the asylum block. Two additional portable fire pumps have been purchased from Merryweather’s. This equipment was invaluable when soot from a chimney fell recently and caught fire in one of the female day-rooms; the swift application of water resulted merely in damage to a small patch of flooring.
Chapter 9
Patient Rights
Thus far our attempt to create an accurate picture of asylum life has outlined the tasks in which you must acquiesce. This suggests strongly a life of custody. You may well think of your admission as an evil that deprives you of your liberty; that gives you no say in your treatment or in your eventual disposal; and that renders you mute with others unable to hear your desires or wishes. Yet, while it is inevitable that the detained lunatic must to some extent submit, a framework does exist in which you can articulate your concerns.
You may recall that there is a statutory structure to your detention, which is overseen by the Commissioners in Lunacy, a body of august gentlemen who include members of the House of Lords, as well as experienced doctors and lawyers. We are obliged to pay heed to the rules and guidance issued by the Commissioners. The Lunacy Act ensures that they inspect every asylum annually. For two full days, a party of these gentlemen follow our rounds, inspect the wards, eat at our table and talk to patients. They then report their findings, giving a valuable evaluation of how we operate. Their reports are published so that our patient care may be scrutinised by the public.
This system of inspection does not automatically guarantee a patient voice, but it does allow for our decisions to be questioned. The Commissioners have wide experience of public and private asylums; they are able to spot poor practice and to exhort better. While their reports may offer only simple oversights – and it would be rare indeed for them to intervene in the treatment of an individual pauper lunatic – the medical officers appreciate that following the Commissioners’ advice is likely to win favour.
The Commissioners judge our performance against the standards Parliament has intended or approved. A simple legal statement defines your position: you are described as a ‘proper person to be confined’. There are two aspects of this definition, and both provide some ability for a patient to challenge the asylum. That you are such a ‘proper person’ is first evidenced by the certificates and order that brought you here. The existence of these papers, accurately completed by a qualified person, provides sufficient authority for your confinement. The medical officers at the asylum are not empowered to query this judgement and your only grounds for appeal is that the papers are incomplete or were prepared by an unqualified person.
Subsequent to your admission, this paperwork is copied and sent to the Commissioners. Unless they have reason to query your detention, the judgement as to whether you remain a ‘proper person’ passes to the medical superintendent here. Despite some current debate suggesting that admission should be subject to an annual continuation order, there is at present no need for the superintendent to reaffirm your suitability for care, and he is able to continue with your confinement for as long as he sees fit. At this point the nature of your confinement becomes relevant. The Commissioners’ guidance suggests that you should be ‘detained under care and treatment’ and not for any other reason. Public protection from a lunatic is not a suitable reason for your safekeeping; rather, we are tasked with helping you to regain yo
ur health. If we fail to meet this definition then you have a right to challenge us.
Whether you choose to do so is likely to depend on your confidence. You would have to tackle the professional and class hierarchy which has already judged your interests best served by your admission here. For someone of lowly station this can be intimidating, as you must confront your fate before a rank of educated men. This rank constitutes both the medical officers of the asylum and also an extra, local level of scrutiny in the form of our committee of visitors.
The Lunatic Asylums Act of 1845 provides each public asylum with a committee of visitors: men of a certain social standing, drawn from the ranks of the local magistrates, landowners, clergy and businessmen. There is no fixed number, but our current committee numbers twelve. The chairman is also the vice-chairman of the county court of quarter sessions and he owns a large agricultural estate thirty miles south-west of the asylum.
The visitors receive an annual report from the superintendent; every two months a few of their number also make a tour of this place. Such visits are unannounced, but the visitors must see every patient, unless circumstances such as illness make it impossible to do so. They will look about your day-room, inspect your dormitory and taste your food. However, they may not necessarily speak to you unless you make effort to address them. At the end of each visit a record is made in the visitors’ book, and if you made petition for your case it will be noted. The visitors will also glance at the case books and other medical records before they leave; regrettably, this is a privilege that we cannot offer you.
The committee meets more formally once a month in the board room above the asylum entrance. At these meetings it receives a shorter written report from the superintendent, which lists the patients admitted, discharged, transferred or deceased, as well as information about changes in the staff and notable incidents, accidents or enforcements of discipline. The committee members ask questions, check the accounts, and see that the rules of the Commissioners are adhered to. They act on behalf of the patients as well as for the local ratepayers.
It is to these meetings that complaints can be brought: either by patients or by friends and family on their behalf. You must inform the medical superintendent in advance if you wish to be seen by the committee. He will speak to you first, in an attempt to better understand what concerns you, but if he feels unable to resolve the problem then he will notify the committee that you wish to see them. This might be appropriate if you allege an assault by one of the attendants, or wish to criticise your treatment by the medical officers.
You will be heard by the committee at the end of their deliberations. You will be brought through the great corridor to the front of the building and taken up the staircase to the first floor. A heavy wooden door will open and behind it you will see the visitors, seated round a long table and resplendent in their fine tailored suits. South-westerly light streams brightly through the windows and onto the panelled walls, while these interested men let you stand before them and make your case.
In a recent charge of assault, a male patient stated that an attendant struck him on his chest in full view of his ward, which was assembled in the airing court. Though no bruise could be found on the patient, and the majority of the thirty-seven witnesses had seen nothing, two other patients agreed that they had seen the attendant land a blow. The patient, the attendant and three witnesses were brought before the visitors for inquisition; the attendant was cleared of any wrongdoing.
In a recent claim of ill-treatment, a young female patient - who had led a dissolute life prior to her admission - protested bitterly and unsuccessfully to the visitors for many months that she was not given medicine, before she began to accuse the medical officers of performing the most vile and immoral acts upon her. When she wrote to the visitors detailing the same accusations, they decided to interview her. They found her fantasies to be groundless.
Regardless of the nature of your own complaint, please be prepared to answer the visitors’ questions; they will want to build a picture of your concerns and to examine any evidence presented. The superintendent will be in attendance to represent the asylum, and perhaps other staff or patients might be sent for. If you are female, the housekeeper will be asked to provide an opinion on your case. After all the evidence is heard the visitors will come to a conclusion. Should this go against your desires, be assured that no ill-feeling will be borne by the medical staff. A note will be made in your records; asylum life then moves on.
The Legal Status of Certain Classes of Patient
Most patients here are poor law lunatics. However, there are a handful of patients whose stay is governed by additional rules or regulations.
Private Patients
We are allowed to admit a small number of patients on a fee-paying basis. Our fees are sixteen shillings a week, slightly in excess of the amount allocated to each poor law patient. This makes private status an attractive option for families who may wish to seek respite care for a relative, or who wish to avoid the stigma associated with pauperism but cannot afford the higher fees charged by the private hospitals. Such people are mostly in the more affluent working class, and it might be said that the ravages of insanity sit more harshly on those who have some standing to protect, but limited financial choices. At the present time our private patients include a baker, a horse dealer and a brewer’s apprentice; a carrier’s wife, a farmer’s sister and a draper’s daughter.
There are limits on the number of private patients we can take. Restricted space means that there are never more than twenty at a time – a small fraction of our patient group. At times when we are full to capacity with pauper patients, those private payers must be removed to other places or returned home.
Private patients must still be admitted with the requisite paperwork, which guards against them being brought here for familial advantage instead of medical need. During the day they take part in the normal run of activities, though with the presumption that they have a choice between work or leisure. At night, they occupy single rooms. In the matter of their discharge, the medical officers may offer advice but cannot insist that a paying patient remains within our care, and a simple request from family is usually enough to grant relief.
If you are admitted as a private patient and your family subsequently find themselves bereft of funds, then you will not necessarily be removed from us. Providing that you are still afflicted by your illness, arrangements can be made to readmit you as a pauper.
Chancery Lunatics
Chancery cases are concerned almost entirely with patients possessed of significant property, and even within private madhouses they account for but a tiny fraction of those detained. We have had two Chancery patients since we opened: a pauper patient who subsequently inherited £2000 and was removed to Bethlem; and a local servant girl whose employer, an elderly blind spinster, bequeathed her an estate. If you are a Chancery patient, then you have significant protection in law. You were found insane by a committee appointed by the Lord Chancellor for the sole purpose of considering your health. This committee then oversees your affairs in society as well as your medical care, and it is to them, and the Lord Chancellor’s visitors, that you must make appeal regarding your confinement.
Criminal Lunatics
Each year, some of our patients come to us via the judicial system, which makes allowance for patients suffering from mental illness to be sent to asylums rather than prisons. Such patients are termed ‘criminal lunatics’ by the relevant statutes.
You may occasionally have read in the newspapers or popular journals about patients ordered to be detained indefinitely ‘at Her Majesty’s pleasure’. The appropriate place of detention is usually Broadmoor, the national Criminal Lunatic Asylum for England and Wales. However, if these ‘pleasure’ patients are considered harmless then they may be received in asylums such as ours. On the books currently are several of them: a gardener who stole some wine bottles and some hearth rugs; a shoemaker who committed an assault; and a
lady dressmaker who attempted suicide. They join two men transferred after spending many years in Broadmoor, both now elderly and quiet, neither of whom had committed a capital offence.
The more usual criminal lunatics that we receive have been given gaol sentences measured in months or weeks. They are petty thieves or vagabonds and are often vastly experienced in the penal system. We have a housebreaker at present; also a soldier who struck his superior officer and a widowed laundress who stole a pair of shoes. Whatever their crime and whatever their sentence, all these patients are admitted under warrant from the Secretary of State for the Home Office.
If you are a criminal lunatic, then the Prison Commissioners will pay for your stay during your gaol sentence. If you become well again then you may be transferred back to prison; however, it is common for many patients to reside with us long after their custodial warrants have expired. In these circumstances the Home Office asks the magistrates to transfer you to the pauper ranks, and you may stay here or be moved to an asylum closer to your place of origin.