"Petty tyranny and soulless discipline”: Lunatic asylums in the headlines 100 years ago

Montagu Lomax was a retired general practitioner who opted to work as a locum doctor in lunatic asylums during, and just after, the First World War. He was appalled by the care he witnessed and wrote about it with a view to achieving improvements. His book, The Experiences of an Asylum Doctor¹,  was published in 1921. It attracted press attention. The Times commented on “petty tyranny and soulless discipline” and other inhumanities².  In the English Review, "Civis” wrote about asylums:

with their bad food, with pitch-dark, ill-smelling, unheated cells, where patients die of diseases often caused by the conditions of asylum life, where patients are "secluded" for no responsible reasons, are systematically purged and drugged as an added means of punishment, where the superintendents hardly have time for the medical treatment of their patients and leave this important matter to the whim of the attendants, where the cast-iron routine kills all hope of individual care and supervision – these are revelations which demand at once public attention and inquiry, for truly if this is Bedlam in our midst, it is a ghastly and pitiable tale.

Civis praised Lomax’s “timely public service by his exposure of an antiquated system” and asked: “What is the Government going to do about it?”³ 

What the government did

Ministry of Health memoranda indicate that senior civil servants were aware of the dreadful asylum standards:

It is unfortunate that nearly all [Lomax’s] experience was gained at one of the least satisfactory asylums…buildings are antiquated, and the Medical Superintendent is not conspicuously efficient. It may safely be said that Dr Lomax saw the English asylum system at its worst, the normal defects of Prestwich being aggravated by shortage of staff and strict rationing of food [because of the war].…the book is important because the main criticisms apply in a greater or lesser degree to all public asylums….

Broadly speaking it is true that our asylums are barracks rather than hospitals and the insane are treated more like prisoners than patients.⁴ 

In contrast to the Ministry, the Board of Control, the asylums’ regulatory body, concluded that Lomax’s criticisms were untrue, exaggerated and unjust.⁵  The Board employed classic techniques of undermining the complainant’s credibility, noting, for example, that since Lomax had no formal psychiatric training, he lacked the knowledge and authority to comment. Lomax was, it said, “confused in his ideas”, and publishing his allegations was “ungentlemanly” and “unprofessional”, as he ought to have discussed his concerns with the medical superintendent first. Lomax recognised the ethical dilemma of delaying raising the issues, which allowed inadequate practice to continue, but he also knew that employees who spoke up were usually dismissed and their concerns ignored. Dismissal would have hampered the gathering of ammunition for his campaign. 

The Ministry described the Board’s analysis as “disappointing” and decided that the only option was to have an independent inquiry.⁶  Sir Cyril Cobb was appointed to chair it. He was knowledgeable about asylums, having previously chaired the London County Council Asylum and Mental Deficiency Committee.⁷  But if, as the Ministry suspected, defects reported by Lomax were found to be applicable to many asylums, evidence of this might damage Cobb’s reputation. Cobb’s knowledge and experience may have made him fit to chair the inquiry, but might also have introduced a conflict of interest. Critics of the inquiry recognised this.⁸  

Like the Board, Cobb’s committee questioned Lomax’s credentials, and concluded that he had exaggerated and lied. It likewise gave little credence to allegations from patients and staff low in the asylum pecking order which supported Lomax’s analysis.⁹  The committee concluded that although some improvements could be made, “the present provision for the care and treatment of the insane is humane and efficient” and “compares favourably with that in any other country”, a meaningless statement in the absence of international comparative data. 

After the inquiry

The press labelled the inquiry report as a “whitewash” and supported Lomax’s call for a Royal Commission.¹⁰  The medical press, however, launched personal attacks on Lomax, but he was undaunted and continued his campaign. He continued writing and allied himself with the National Society for Lunacy Reform, crisscrossing the country giving lectures on their behalf. Eventually, in 1924, a Royal Commission on Lunacy and Mental Disorders was appointed. One outcome was the Mental Treatment Act (1930), which, for the first time, permitted voluntary admission to public mental hospitals. His campaign laid the foundations for more liberal and humane mental health services.