Mental Illness and Asylums

Welcome to blog post number 7, the last on the subject of health issues.
 
Writing historical fiction involves a lot of research which informs the story but is not necessarily included in it. This blog is for sharing some of the interesting and fun facts I discovered while researching my novel, Shakespeare Cliff.

Two 'feeble-minded cretins' aged twenty-two and twenty-one, Dartford. (Wellcome images)

Sarah’s brother, Arthur, returns from the Boer War in 1902 seriously wounded and suffering from recurrent nightmares. He has shell-shock or PTSD, a condition unrecognised at the time. (See my blog post number 5 on the subject of shell-shock.)
 
Barely a night passed without a nightmare, in which he relived the battle of Bakenlaagte five months previously, and the farm clearances before that. Transported back to the Transvaal, he slaughtered animals and burned buildings, hearing children crying and women screaming.
And:
Arthur could not close his eyes without visions of the war: nightmares of lying wounded near dead and dying comrades, the sniper shooting off his fingers, the blindfolded deserter peppered with bullets.
 
Arthur and Sarah both understand he is having nightmares because of the terrible events he witnessed during the war. One day, while he is looking after his two-year-old niece, Annie, he experiences something that is not a nightmare. They had been playing together with wooden bricks.
When she had enough, he encouraged her to return the bricks to the box. Desperate for a cigarette, he set her on her feet, before rummaging in his jacket pocket for his tobacco pouch. Annie stood on tiptoes, reached for the box of bricks and pulled it off the table. A resounding crack split the air as it hit the quarry-tiled floor. For Arthur, it was the crack of a rifle shot.
He leapt for cover under the rock overhang, dragging his mate out of the gunshot and shelling. Screams and cries engulfed him. With eyes closed and hands over his ears, he cringed at the sound of pom-pom shells whining towards him.
 
This was the first time that Arthur had experienced visions of the war while awake. It made him question his sanity.
While Sarah was upstairs, Arthur considered what had happened. ‘A funny turn’ Sarah had called it. She was right. He was used to visiting the battlefield in nightmares, but this was different—he had been awake. What did this mean? Was he losing his mind?
 
Sarah also questions his mental state:
“Arthur, what is going on? Nightmares I can understand—we all have them, though you have more than normal. That’s no surprise after what you’ve been through. But how do you explain what happened, if it wasn’t a nightmare?”
“I can’t explain it.” Arthur rubbed his eyes with his forefingers. “Look, don’t worry. Tomorrow, I’ll be out of your hair. You won’t have to deal with it again.”
“That’s not what I meant.” Sarah bit her lower lip. “I’m concerned for you.”
“You mean you wonder if I’m going mad.”
“I’m not sure what to think, but shouldn’t you consult a doctor?”
“What, and end up an inmate at Chartham?”
 
Chartham was the local Kent mental asylum, three miles south of Canterbury. It had been founded in 1875 following the Lunacy Act of 1845. Prior to the beginning of the 19th century, all asylums were privately run with a few hundred people living in nine small charitable asylums. The wealthy provided for mentally ill family members in private “madhouses”, while the poor with mental illness and the criminally insane usually ended up in prisons and workhouses.
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The 1845 Lunacy Act and County Asylum Act obliged authorities to build county asylums for the poor and criminally insane, and established the Lunacy Commission to oversee both private and public asylums. By 1900, more than 100,000 ‘idiots’ (defined as ‘natural fools from birth’) and ‘lunatics’ (defined as persons who were ‘sometimes of good and sound memory and understanding and sometimes not’) resided in 120 county asylums. A further 10,000 were in workhouses. By the beginning of the Great War, an average asylum in England and Wales had 1000 beds and over 100,000 people were certified as ‘pauper lunatics’.

St Augustine's Hospital, Chartham, Kent

Situated high on the North Downs, Chartham asylum fulfilled the requirements laid down by the Lunacy Commission for ‘a site on elevated ground with cheerful prospects and enough space to provide employment and recreation for inmates while preventing them being overlooked or disturbed by strangers’.1 High risk patients were looked after in single sex locked wards in the main building, while low risk residents lived in houses within the grounds and had the freedom to wander around.
 
By the 1920s it had become a self-contained village, with its own farm, workshops, baker, butcher, fire-brigade, church, graveyard, gasworks, cricket team, band, etc. Male patients worked on the farm, while female patients worked in the laundry or as seamstresses.2 It doesn’t sound too bad, does it? So why did Arthur dread the idea of living in an asylum so much?
That night Arthur lay awake, analysing the implications of the day’s events. Was he losing his mind? He could imagine no worse fate than ending up in a lunatic asylum.

Arthur’s idea of a lunatic asylum, like that of so many of the general populace, was based on the infamous ‘Bedlam’ asylum. Founded in 1247 as the Priory of St Mary of Bethlehem just outside the walls of the city of London, it was originally dedicated to the healing of sick paupers, but soon became England’s first hospital for the mentally ill. The name, ‘Bethleham Hospital’, was abbreviated to ‘Bethlem’ and later corrupted to ‘Bedlam’. Bedlam has entered the language as a word meaning uproar and mayhem, due to the disorder and chaos prevailing at the institution at the height of its notoriety in the eighteenth century. With its scandalous history, Bedlam came to represent all institutions of its kind in the public imagination.

James Norris at Bedlam

The general public was able to gain an understanding of what life was like inside Bedlam due to a scheme, which began in the seventeenth century, of allowing casual visitors access to the inmates. This display of madness was a popular entertainment. In 1689, Thomas Tryon, a merchant and author, described the ‘swarms of people’ that flocked to Bedlam on public holidays, and César de Saussure wrote an account of his visit to the asylum on his tour of London sights in 1725:
 
​You find yourself in a long and wide gallery, on either side of which are a large number of little cells where lunatics of every description are shut up, and you can get a sight of these poor creatures, little windows being let into the doors. Many inoffensive madmen walk in the big gallery. On the second floor is a corridor and cells like those on the first floor, and this is the part reserved for dangerous maniacs, most of them being chained and terrible to behold. On holidays numerous persons of both sexes, but belonging generally to the lower classes, visit this hospital and amuse themselves watching these unfortunate wretches, who often give them cause for laughter.
 
During these visits the inmates were subjected to many kinds of abuse, being taunted, poked with sticks, even sexually assaulted.
 
Conditions for many patients at Bedlam during the worst phases of its history were undoubtedly shocking. A famous example is that of James Norris, an American marine, who spent twelve years shackled to an iron pole by means of a contraption which severely restricted his movement.

​Appalling as this is, there is no evidence to suggest that the majority of asylums were such awful places, and iron shackles and chains, once used to restrain mentally disturbed patients, were replaced by leather and strong cloth many years before the First World War. In fact, there seems to have been a wide variation in the type of care and practices administered. In her excellent work entitled Civilian Lunatic Asylums During the First World War, Claire Hilton writes that ‘different standards of care were experienced from patient to patient, ward to ward and asylum to asylum. There was no such thing as an average ward.’

There is little evidence of what life was like in Chartham hospital at the beginning of the twentieth century, but various studies of a range of different asylums throughout the country paint a complex picture. At one asylum in Northumberland, the Commissioners in Lunacy issued a yearly report. The report for 1867 claimed that ‘the state of the inmates was satisfactory, their person and clothing were very clean and in general their conduct was orderly with nobody in seclusion. On the day of the visit dinner consisted of baked meat, potatoes, bread and beer. The wards were clean and properly ventilated but were said to have a bare appearance.’ 3
 
On the other hand, the report for 1873 for the same institution commented upon ‘a male patient who had died due to a blow to the head but who was also found to have his breast bone and five ribs fractured.’3 It was never discovered how these injuries were inflicted. A female patient was also mentioned as when out walking with a party of other females she committed suicide by jumping in the river. Due to this incident walks outside of the asylum were terminated.
 
Records for one asylum in Hampshire show it to be professionally managed with male and female patients kept in separate wards. No male attendant, servant or patient could enter the female wards, nor any female enter the male wards except in cases where the superintendent deemed it advisable. Patients of both sexes were employed, men in the garden and women in the laundry and kitchen. Women also undertook sewing, knitting and mending work, and men were taught trades such as shoemaking, tailoring, plumbing and painting. Reading was encouraged and an ample supply of books and publications of a moral and cheerful nature were supplied in addition to the bible and prayer books.
 
‘Every Wednesday evening there was a dance interspersed with songs, and on two occasions a conjuring entertainment was kindly provided by Mr Shute, the assistant surgeon. In the summer months the men played cricket, bowls, quoits and football while the women played croquet. The patients also enjoyed picnics at the seaside.’ 4

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Female patients exercising at Kew (Wellcome Images)

For desperately poor people living on the margins of society, life in an asylum could be preferable to life outside. Diet, clothing, and hygiene compared well with what was on offer in poorer private homes and in the workhouse, while heating, lighting and lack of privacy were similar. For asylum patients who worked during the day and took part in social activities in evenings and weekends, ‘it was a full life – often much more so than their life outside.’5

Not all patients admitted to asylums would nowadays be considered as suffering from mental illness. Moral degradation was seen as a valid reason for being certified: one woman was sent to Chartham for no other reason than that she had five children by five different fathers out of wedlock.

Whether life in any particular asylum was tolerable or even pleasant, or whether it was harsh and brutal, depended to a large extent on the staff. The superintendent in charge of an asylum was required to be a legally qualified medical practitioner. Below him, a matron was responsible for female patients, attendants and servants, and a clerk or steward for male patients and staff.

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Charles Mercier

Charles Mercier, a leading psychiatrist and president of the Medico-Psychological Association in 1908, wrote that ‘the asylum exists for the benefit of the patients’ and urged staff to be kind, courteous, sympathetic, tactful, and not overbearing or bullying. Staff must never threaten, tease or frighten, mock, jeer, insult, disparage or deceive a patient, lose their temper with, strike a patient or punish one in any way. ‘Under no circumstances whatever should a patient be knelt on. More broken ribs and broken breastbones are due to this practice than to all other circumstances put together’. This best practice was recognised but not always emulated, and the treatment meted out to asylum inmates spanned a huge range from the admirable to the appalling.
 
Sadly, in the majority of asylums, ward staff had little training in therapeutic methods and were paid at the level of unskilled workers. Most asylums were overcrowded and understaffed resulting in a stressful environment in which employees were undervalued and working under intolerable pressure. The fact that their seniors could summarily dismiss them often led to distrust between the lower ranks of the workforce and their masters, and encouraged attendants to conceal their harsh treatment of inmates. Staff struck patients, but according to one wartime staff member, ‘the attendant who knows his business seldom leaves a mark on the patient he abuses’. 6  ‘One former patient reported that when he dared to criticise his attendants, they punished him with concealable torments, including giving him strong laxatives, placing a live earwig in his porridge and heavily over-salting his soup then laughing when he spat it out.’4

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Nurses at Starcross asylum (Wellcome images)

Rachel Grant-Smith wrote about her experiences as an asylum patient, republished in 1922 by Montagu Lomax. She alleged brutality and degrading nursing practices, such as being forced to take laxatives, for her bad behaviour. Unless she cooperated ‘it meant my being forcibly laid down and three or four nurses pulling my mouth open and pouring it down.6  She observed distressing scenes: ‘Fanny Black and Miss Hurd were made to sit out of bed on the chamber utensil many hours in the night, quite naked, often for an hour at a time. Miss Hurd has lately died from consumption.’ 6
 
On the other side of the equation, an analysis of 1000 letters written by patients at the Royal Edinburgh Asylum between 1873 and 1908 reveals a complex picture with many patients speaking warmly of the asylum and its staff and thanking the medical superintendent for his kindness and concern. Some patients, rejected by family and friends, made a life for themselves within the asylum which was more tolerant of their behaviour than the society outside.

During the Cobb Inquiry into asylums set up by the Ministry of Health in 1922, asylum inmates described their attendants’ behaviours in a variety of ways which suggest that physical abuse was neither an inevitable nor daily part of a patient’s experience. One patient recalled that he ‘never saw the attendants use more force on a man than was absolutely necessary for the way the man was acting.’ Another described them as ‘decent Englishmen who do their best for everybody’. Others noted variable degrees of benevolence: ‘some I found good,…did what they thought best for the patients; they are the salt of the institution. Then there is a second class who…do as little work as possible and do anything to make it a comfortable job.…And the third class, who are frankly brutal.’
 
Obviously accidents could happen and manual handling of patients could be inadvertently harsh. But excessive force could also be applied deliberately, disproportionate to the patient’s needs. ‘Too often the leadership turned a blind eye to the possibility of malicious injury. Medical-scientific explanations attributing injury to a patient’s inherent predisposition were acceptable to public and professionals and allowed the asylum leadership to exonerate staff, reassure the public of the adequacy of the care provided, and preserve the reputation of their institution, even when treatment was detrimental to the patients.’ 7

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Given the complexity of the evidence, it is difficult to reach a conclusion about the treatment in general that asylum inmates received in the late 19th and early 20th centuries. Perhaps it is reasonable to say that patients were not victims of physical brutality most of the time, but that standards fell far short in comparison with modern notions of acceptable care for the mentally ill.   

Footnotes:
1 1844 report of Metropolitan Commissioners in Lunacy, quoted in J. Taylor 1991 Hospital and asylum architecture in England, 1840-1914
2 J. Taylor 1991 Hospital and asylum architecture in England, 1840-1914
3 Northumberland archives
4 Civilian Lunatic Asylums During the First World War by Claire Hilton
5 Kathleen Jones, “The Culture of the Mental Hospital,” in 150 Years of British Psychiatry ed. Berrios and Freeman
6 The Cobb Inquiry, March 1922
7 W Sullivan, “Haematoma Auris in the Insane,” JMS 53 (1907)
 
Sources:
Historic England website.
Wikipedia
Northumberland archives
Allan Beveridge, Life in the Asylum: Patients’ Letters from Morningside, 1873–1908, History of Psychiatry 9 (1998)