Prestwich Hospital Births Lunacy Reform

Last year saw the centenary of a book by Doctor Montagu Lomax called The Experiences of an Asylum Doctor: with suggestions for asylum and lunacy law reform, which directly led to a public and media outcry about the treatment of people with mental health problems, and, eventually, a reform of the law.

Doctor Montagu Lomax was a retired GP who applied to work in asylums to fill the gap left by doctors who had been called up to the military during the First World War. He worked for a short while at Bracebridge Asylum in Lincolnshire, before moving onto Prestwich Asylum where he worked for two years between 1917 and 1919 gathering information for his whistle blowing book.

He wrote that “It was my bounden duty to call public attention to…the evils and abuses” of the institution. He wasn’t the first person to plead for reform of mental health treatment but, whereas previously, tracts were written for either an academic or medical readership, his work was written to inform the public so that “the public could take the lead”…

Lomax dedicated his book ‘To all the insane poor, in sympathy with their sufferings and in hope of alleviating their hardships’. He wrote… “I speak of the insane, at least in my experience, as housed in gloomy and often dilapidated barrack-asylums, more like prisons than palaces, badly fed, poorly clad, dirty and unkempt, mostly unoccupied, and certainly not amused…” and noted that “many paupers are not only sent to asylums, but are also detained in them, who ought never to have been so sent or detained…”

Lomax added that the “grave defects and abuses…could not be rectified without far-reaching administrative and legislative reforms… Our asylums detain, but they certainly do not cure…

“…To treat the insane as if they were criminals, to herd them together in huge barrack-like asylums, to make them wear a distinctive and humiliating garb, to restrict their liberty as forcibly and ostentatiously as possible, to punish them for faults for which they cannot justly be held responsible is irrational and barbaric…” he wrote, and listed some of the horrendous conditions.

These included…

Behind The Table – here, ‘difficult patients’ were sat all day on a long bench with a table pushed in front of them…“Of all forms of restraint this of being put ‘behind the table’ is resented more than any other by patients of every degree and type of insanity, except those who are past all feeling of resentment whatsoever, and who are reduced mentally to the condition of brute beasts” Lomax wrote.

“…Not only is this treatment reserved for refractory and quarrelsome patients, it is used as a method of punishment for minor offences as well…In my judgment there is no form of restraint so utterly uncalled-for…it is utterly barbarous and irrational, and as a ‘punishment’ it is often vindictive, and always brutalizing and degrading…”

Lomax described the scene of a ‘behind-the-table’ crowd of lunatics in the refractory”…“Bestialized, apathetic, mutinous, greedy, malevolent – often quarrelling fiercely with each other, at meal times snatching away each other’s food, or spitting into each other’s plates – they sit all day in their miserable corner…”

Croton oil – a powerful laxative which was supposed to make ‘lunatics’ so preoccupied with the movement of their bowels that they had no time or energy left to be difficult..

“Chloral, bromide, and croton-oil are the three sheet-anchors of all asylum medicinal treatment, and the worst in its effects of all three is possibly croton oil” Lomax wrote “This was the recognized method of ‘taming’ them or keeping them quiet. No doubt, in many cases, croton oil is a valuable purgative, it acts quickly and thoroughly, and if the patient is young and strong does no harm when occasionally used. But the cases are not carefully selected, the drug is used much too frequently and indiscriminately, and, worse still, often as a ‘punishment’…

“The reader may imagine its effects upon weak and elderly patients” he added “For no patient knows he is taking croton-oil, otherwise he would, in ninety-nine cases out of a hundred, refuse it. The capsule is dissolved without his knowledge in his food…

“…this routine employment of croton oil as a means of maintaining order is sheer cruelty” he emphasised “I have little doubt in my own mind that it is the indirect cause of more cases of colitis or asylum dysentery than is ever suspected…”

Medicinal or Chemical Restraint – as well as croton oil, the indiscriminate use of hard drugs on patients “with very little regard to their possibly injurious effects” peppers Lomax’s book, as he called it “one of the greatest evils in modern asylum treatment in England, and in my opinion is productive in many cases of the greatest harm…

“The wholesale employment of bromide, chloral, sulphonal, paraldehyde, veronal, etc., for all and every type of insane patient, irrespective of age, sex, mental state, or physical condition, seems to me hopelessly unscientific and irrational, as well as inhumane” he explained “As a matter of fact, these drugs are often used not only to keep the patients quiet, but, as I have said, to save the doctors the trouble of making a diagnosis, or finding out the cause of some intercurrent malady. But troublesome cases are not only kept quiet, they are kept drugged, a very different thing…”

Cells or single rooms – difficult patients were also confined to single rooms, or ‘cells’ as Lomax calls them…“The stench at times is so great that I have been unable to remain in the room more than a few minutes” he wrote, adding that the rooms resembled “the lairs of wild beasts”, in which patients could be locked up for three months at a time with only one hour’s daily exercise…

“Let the reader imagine, if he can, the existence of an inmate of one of these rooms, in almost pitch darkness night and day, clad only in a canvas shirt, lying on a thinly-stuffed and noisome coir mattress spread on the floor, and covered with two or three dirty canvas rugs, with a permanent draught blowing under the door, and if in winter time, with the temperature possibly several degrees below freezing-point; for most of the cells are not heated” he wrote “Is it any wonder that patients confined in these rooms often rave and blaspheme, and hammer on the doors with naked feet and hands in their fruitless efforts to get out?”

And when they did get out for exercise, it was in a secure area “like a wild animal in a pen”. And all patients had to exercise outside in all weathers without proper clothing; even their overcoats were confiscated on arrival at Prestwich, without any replacement…

“The consequence is that in wet and cold weather the unhappy patients, with health already undermined by their malady in many cases, and by the coarse and innutritious food supplied in most asylums, suffer grievously in winter time. Should they get wet while at exercise, as they often do, they have no change of clothes, and little chance of drying those they have on…

“Tuberculosis, in particular, is a deadly scourge in most asylums” he wrote “In 1915 the asylum death-rate from this disease was 161 per 1,000, while the mortality for the same year among the general population was only 6 per 1,000. And though exposure to wet and cold, and improper diet, do not of themselves produce consumption, they are the most potent accessory factors in its production among those predisposed to it.”

Montagu Lomax Experiences of an Asylum Doctor

Meanwhile, patients felt like prisoners as they were not allowed to wear their own clothes…“Nothing is so destructive to an insane patient’s self-respect as his deprivation of his own clothes” Lomax wrote, calling it a an “indignity” and a “scandal”.

“To treat sick paupers as criminals, to make them wear a distinctive garb, to deny them proper treatment and to stint them in medicines and surgical appliances because of their cost, to withhold from them the best medical and surgical skill, in a word to punish them for being sick, would excite the severest public censure” Lomax concluded “Yet what are insane paupers but the mentally sick? Why should these be punished any more than those? Why should they be degraded, ill-clothed, stinted of nourishing food and medical comforts, exposed to humiliations and insults, because they are mentally, but not physically, sick, though they are often both?

“To mix all classes of the insane indiscriminately together with no attempt at classification, and careless of the bad effect some types have upon others, or from the medical point of view to purge and drug them while denying them such forms of exercise, amusement, and employment as would conduce most readily to their recovery. To crowd lunatics into asylums is worse than useless unless we have some recognized principles of treating them when once we have got them there. Merely to confine the insane is not to treat them…Detention and restraint, as cheap and effective as possible, sum it up…

“Might not the best treatment for such cases be in reality an improvement of asylum conditions, such as more fresh air, exercise, employment, amusement, and, above all, liberty” he pleaded.

The Fall Out From The Book…

“In 1921, one man published a book which crystalised for the public a dreadful picture of the suffering lunatic, acted as a catalyst for lunacy reform, and provided the basis for our modern mental health services” writes Dr Clare Groves on her excellent website about Lomax…*

Just ten days after the book’s publication, questions were being asked in Parliament, and, after a Board of Control report on the matter was rejected by the Ministry of Health as being ‘disappointing’ and too defensive of asylums, and an independent Cobb Inquiry was boycotted by Lomax, the Government set up an inquiry, the Royal Commission on Lunacy and Mental Disorder 1926, which led to the 1930 Mental Treatment Act...

“This Act of Parliament replaced the term ‘asylum’ with ‘mental hospital’, and laid down the principle that mental illness treatment should be conducted as nearly as possible on the lines of physical illness treatment” writes Dr Groves “For the first time, local authorities could establish out-patient clinics and mental hospitals could admit voluntary patients. GPs as well as specialists were encouraged to share the care of mentally ill patients.

“The Act was designed to demystify madness and to ensure that patients were treated with dignity and respect” she adds “Harding noted that ‘many of Lomax’s suggestions made in 1921 were curiously similar to the provisions of the 1930 Mental Health Act, the single most important legislative reform affecting psychiatry in England and Wales’…”

* For lots more details see https://montagulomax.org/