History has, among its many purposes, that of exploring and explaining how the pasthas shaped the present. Closely aligned to this is assisting us to resolve themystery of who we are.1 In takingan active interest in our background, we come to appreciate that while wedon’t live in the past, the past lives in us.2 A major benefit of history is in enabling us tounderstand our reality, and its limitations and possibilities. To become more awareof the dimensions of that reality is especially important when seeking to understandthe lives of those who are marginalised, by social class, gender, culture orethnicity, or anyone on the lowest rungs of a hierarchy. Those who ignore what thepast has to teach us have a very restricted vision. Although the discipline of history can be described in many ways, it should not beconfused with nostalgia, rose-tinted reminiscence or mourning for the dead. It can,however, reveal the resourcefulness of the human spirit and inspire, and perhapswarn, the living. Studying history helps us to lament what should be lamented, tohonour what should be honoured and to celebrate what should be celebrated.3 ‘Doing history’requires open minds and hearts and a refusal to allow others to predetermine thefindings. Historians tend to be cautious in accepting the interpretations of otherhistorians, regardless of the evidence they cite and what they claim to know. It isan endless quest for ‘truth’, a quest that can never fully berealised.4 As well as being acontinuous dialogue between the present and the past,5 it is also our best means of challenging ourtaken-for-granted concepts of institutions and practices and of the assumptions thatunderpin them.6 Conscientious historians, committed to guarding the integrity of their discipline,strive to abide by methodological conventions. Careful selection of sources,objectivity of analysis and the formulation of valid conclusions are required toensure a rigorous enquiry. Philosopher RG Collingwood saw history not as a luxuriousindulgence to fill hours of leisure, but a means by which reason is maintained andthe human mind acquires knowledge of itself.7 For Collingwood, the study of history shows us not onlywhat has been achieved in the past, but also the diverse potential of human beings.Understanding the motives that drove people to behave in certain ways expands ourcollective memory and enables us to appreciate how the political, economic andsocial values of the past have shaped the world that we inhabit today.8 History is a job never done,because interpretations of the past areconstantly being reconsidered in the light of new evidence and the formulation ofnew questions. As no authoritative truth exists for the past, revisionism isnecessary and meaningful. Otherwise we would lose that sense of a human civilisationthat is constantly evolving and never fixed. While traditional approaches to history have tended to focus on the great and thegood, revisionist historians have a much broader gaze; uppermost in their minds istheir responsibility to ensure that some stories are not lost or deemed toounimportant to record.9 Psychiatryhas been criticised for over-emphasising certain aspects of its past while ignoringothers, endorsing the observation that ‘there is a history that remembers anda history that forgets’.10History of ‘ordinary people’ seeks an understanding of the lives ofthose who have been denied authorship and are consequently in danger of beingforgotten, thus redressing that most final and brutal of life’s inequalities:whether or not you are remembered in the pile of historical debris left tomodernity.11 Contrasting withtraditional top-down approaches, history from below is largely the history of thedisadvantaged. EP Thompson12posited four fundaments of social history: History must be our collective conscience It tells the stories of as many people and as many ways of being in theworld, as it can reasonably do It presents the complexity and context of human experiences in the pastto the readership of the present It is the engine of our collective social maturity Until recently, the history of mental health services was largely presented as thehistory of psychiatry, written by psychiatrist-historians who depicted theirpredecessors as working inside a unified system of thought and practice thatrepresented a benign progression towards the alleviation of human suffering. It was,in essence, a history from the perspective of doctors and in attempting to own thepast, they were laying down their claim to the future. These medical authors werearticulate, had access to a substantial corpus of primary data and found itrelatively easy to publish their material. They had a vested interest in conveying afavourable image of institutions and of the influence that they exercised insidethem. They monopolised credit for ‘advances’ in the care and treatmentof the mentally ill, giving the impression that all progress was essentiallymedical progress. In taking this position, they did disserviceto those who were closely involved in the day-to-day lives of patients, consigningtheir stories to a footnote in the history of psychiatry.13 Like researchers in other disciplines, historians are obliged to be scrupulouslyhonest about their sources, transparent in their analyses and logical in theconclusions they draw from their data. Readers should be wary of any tendencies toresort to myth-mongering or peddling fantasised versions of the past.14 Those who set out to paint apositive picture of psychiatric care and treatment were either deluding themselvesor hoped to delude their readers, as many mental hospitals throughout the world wereterrifying institutions in which people were subjected to extreme and unproven treatments, and where their rights and dignitywere disregarded.15 Berrios andPorter16 concluded that themajority of the early histories of psychiatry were no more than poorly collatedcollections of opinions and conjecture, betraying an ignorance of historical method.As Healy17 explains, conscious orunconscious distortions of the past have exaggerated the knowledge and skills ofasylum doctors, inflated the effectiveness of treatments and ignored thecontributions of other members of staff, consequently overlooking the inadequaciesand abuse within the system. Cannadine18 condemns the ‘lazy approach to history’ thataccepts unquestioningly the conclusions of others and is satisfied with simplisticexplanations. Change grabs our attention, but stability is ignored because it istaken for granted at the time, and it appears less interesting than the story ofseminal events and innovations. However, the astute historian accepts nothing asread.19 Indeed, such eventsand innovations may have had limited impact on the everyday reality of institutionallife, and only years later are they honoured as historical milestones or turningpoints. In recent decades there has been tremendous development in the history of psychiatryand mental health care, inspired by the likes of social historian Roy Porter.Launched in 1990, the History of Psychiatry journal is a richresource of critical accounts of the evolution of psychiatric theory and practice,with a plethora of fresh insights Meanwhile, other mental health professions havebeen examining their past. This embryonic activity has not evolved in synchronicitydue to disparities in availability of educational and research opportunities,accessibility of archival resources and whether the discipline has an interestedreadership. Early studies of the nursing in mental hospitals demonstrate theproblems of naïve enquiry. In his book The Waiting Room to Hell,Cubbin20 described conditionsin Shelton Hospital (the former Shropshire asylum) in the 1950s, while admittingthat his desire to tell the story outweighed his ability to do so. Such humility isadmirable, and should be more widely acknowledged in the annals of psychiatry andits associated disciplines. Since the closure of mental hospitals at the turn of the century, numerous books havebeen written on these defunct institutions. Many are flimsy in their sources andwriting, but there are also some exemplars of scholarly but accessible accounts.Diana Gittins,21 for example,applied sociological critique in her book on Severalls Hospital in Essex; whiledeservedly highlighting the exploits of medical superintendent Russell Barton, shealso brought patients, nurses and other underlings to the fore. Nonetheless, despitetheir vital role, nurses remain marginalised not only in the history of mentalhealth care, but also in the present multidisciplinary system. Boschma22 attributes this to a lack of roleclarity and a lack of robust history to underpin nurses’ professional status.Disciplines with clearly demarcated boundaries are able to confine themselves torewarding areas of work, leaving everything else to nurses, whose role in mentalhealth care is consequently amorphous. Boschma suggests that if nurses felt moresecure in their role, they could work as equal partners with other professions inimproving mental health services, ensuring that theory and practice are informed bynursing experience. Professional confidence is necessary to challenge mediocrity andto shape new ways of working, and to nurture a professional culture that allowschange to occur. Playing their part inexpanding the therapeutic imagination is important in a climate in whichnurses’ humanistic values are trumped by financial targets andbureaucracy.23 Figure 0.1 A portrait of Peter Nolan, drawn by a West Park patient in 1973 Perhaps neglect of its history has contributed to the decline of mental healthnursing in recent years.24Knowledge of professional background confers an understanding of how we got where weare, and where we may be heading, but nurses have tended to be dependent on otherswho purport to know more about it then we do ourselves. Mental health nurses areinsufficiently assertive in drawing attention to the factors that are threateningtheir existence, such as poor recruitment, inadequate training, high levels ofattrition among both students and qualified staff, and underfunding. Warelow andEdward25 argue that currenttraining and education of mental health nurses is culpably deficient in failing totransmit an identity with the history of the profession. Hence, they argue,historians of nursing have an important responsibility: To account for the endurance of traditions, understand the complex interplaybetween continuity and change and explain the origins, evolution and declineof institutions and ideas.26 Researching and writing this book has been a labour love for both authors. From ourown professional practice, we appreciate how much valuable information and insightis lost when nurses with vast experience leave the profession, retire or die. Wewant to help nurses to examine their past and learn from it; to tell the stories ofthose who spent whole careers caring for people shunned by society. In the course ofour research we have interviewed many ex-nurses whose perspectives were neverpreviously sought or valued, in a process of triangulation with documentary records and published literature. Undoubtedlythere are many stories still waiting to be told and our wish is that these should beheard before they disappear into the ether. However, we have guarded againstselective portrayal, following the principle of EP Thompson that if history iscomforting, it is not doing its job. This book has four main objectives: to contribute to the growth of historical enquiryinto mental health care in general and mental health nursing in particular; toexamine the many and varied influences that have shaped the evolution of mentalhealth care; to reveal hitherto unexplored material; and, finally, to assure mentalhealth nurses of their rightful place in history. Peter Nolan and Niall McCrae July 2015 Notes Carr EH (1990): What is History? Phillips UB (1968): The Slave Economy of the Old South. Schama S (2009): A History of Britain (volume 1): At the Edge of theWorld. Popper K (1976): Unended Quest: An IntellectualAutobiography. Carr EH (1990). 6 Porter R (1992, ed.): Myths of the English. London: Harris EE (1957): Collingwood’s theory of history.Philosophical Quarterly. Thompson P (1978): The Voice of the Past: Oral History. Rowbotham S (1992): Women in Movement: Feminism and SocialAction. Marx OM (1970): What is the history of psychiatry? American Journalof Orthopsychiatry. Hitchcock T, Sharpe P (1997, ed.): Chronicling Poverty: The Voicesand Strategies of the English Poor 1640–1840. Thompson EP (2002): The Making of the English WorkingClass. Walk A (1961): The history of mental nursing. Journal of MentalScience. Porter R (1992, ed.). Willmuth LR (1979): Medical views of depression in the elderly: historicalnotes. Journal of the American Geriatrics Society. Berrios G, Porter R (1995, ed.): A History of Clinical Psychiatry:The Origins of Psychiatric Disorders. Healy D (2001): The dilemmas posed by new and fashionable treatments.Archives of Psychiatric Treatment. Cannadine D (2013): The Undivided Past: History Beyond ourDifferences. Berrios GE (1995): Research into the history of psychiatry. InResearch Methods in Psychiatry: a Beginner’sGuide (eds C Freeman, P Tyrer). Cubbin JK (2006): The Waiting Room to Hell. Gittins D (1998): Madness in its Place: Narratives of SeverallsHospital, 1913–1997. Boschma G (2012): Community mental health nursing in Alberta, Canada: an oralhistory. Nursing History Review. Holmes C (2006): The slow death of psychiatric nursing: what next?Journal of Psychiatric and Mental Health Nursing. Crowther A, Ragusa A (2011): Realities of mental health nursing practice inrural Australia. Issues in Mental Health Nursing. Warelow P, Edward K (2007): Evidence-based mental health nursing inAustralia: our history and our future. International Journal ofMental Health Nursing. Leishman J (2004): Back to the future: making a case for including history ofmental nursing in nurse education programmes. International Journalof Psychiatric Nursing Research. Acknowledgements The following nurses discussed their experiences in mental hospitals with theauthors: The female side Angela Ainsworth (St Luke’s) Annie Altschul (Royal Edinburgh) Joyce Archer (All Saints) Kay Baggins (Gartloch, Napsbury) Yvonne Beaumont (Parkside, Lancaster Moor) Ruth Benbow (Claybury) Brenda Billings (Graylingwell) Jo Brand (The Maudsley) Patricia Burdett (Coney Hill) Imelda Bures (Netherne) Alison Bussey (Hill End) Val Canty (Fairmile) Louise Clark (Parkside) Fiona Couper (Tooting Bec) Bridget Dickson-Wild (Netherne) Mary Everett (Cane Hill, Netherne) Sharon Frood (Carlton Hayes) Morah Geall (Hellingly) Velvendar Godfrey (Runwell) Beryl Hepworth (St Bernard’s) Janet Herd (Warlingham Park) Mary Hicks (St Lawrence’s) Louise Hide (Fulbourn) Irene Jones (St Bernard’s) Jayne Love (St Augustine’s, Fair Mile) Judy Lunny (Graylingwell) Fiona Nolan (Banstead, Horton) Ann O’Donnell (Netherne) Carmel Piris (Netherne) Olive Slattery (Gartnavel, Highcroft, All Saints) Mary Slevin (All Saints) Sophie Slevin (All Saints) Felicity Stockwell (Holloway Sanatorium, Whittingham) Judith Watson (Goodmayes, Warneford) Brenda Wild (Graylingwell) The male side Philip Barton-Wright (High Royds, Scalebor Park) Neil Brimblecombe (Hill End) Paddy Carr (Parkside) Tom Chan (Park Prewett, Brookwood) Eric Chitty (Moorhaven) Alistair Clark (Ravenscraig) Bryn Davis (The Retreat, Holloway Sanatorium) Carlos Forni (Bexley) John Greene (Moorhaven) Kevin Halpin (Oakwood) Dermot Hennessy (Banstead, Netherne) Allan Hicks (St Lawrence’s, Goodmayes) Tom Hopkinson (Rubery Hill) Barone Hopper (Graylingwell) John Kelly (Hartwood) Jack Lyttle (Gartloch) Andrew McCrae (Denbigh, Hill End) Tim Mosses (Bexley) Jim Newlands (Hartwood) Ronnie Newman (Roundway) Ian Norman (Long Grove) Mike O’Connor (Park Prewett) John Pay (Graylingwell) Tony Quinn (Tooting Bec) Teerenlall Ramgopal (St George’s Stafford) Peter Robinson (Cane Hill) Mark Rudman (Whitecroft) Charlie Russell (Hartwood, Cane Hill) Iain Tulley (Hartwood, Exminster) Jim Vaughan (Barrow) Peter Walsh (Woodilee, Banstead, Horton) Tom Walsh (West Park) Herman Wheeler (Rubery Hill) Other informants Julia Brooking (professor of nursing, University of Birmingham) Maureen Gomez (laundry manager, Netherne) Mary Gutierrez (nursing assistant, Netherne) Tom Harrison (psychiatrist, Hollymoor) Jean McFarlane (professor of nursing, University of Manchester) Alan Packham (estates foreman, Horton) Bill Reavley (psychologist, Graylingwell) Peter Scarrett (social worker, Netherne) George Townsend (electrician, Horton) Tony Tramalgini (nursing assistant, Netherne) William Trethowan (professor of psychiatry, University of Birmingham) Bob Wycherly (psychologist, Middlewood) 1 The pauper palace and itsservants DOI: 10.4324/9781315817026-1 In the beginning, there was care in the community. Homosapiens has always been a social animal, whose bonds stretchbeyond blood relations to tribe or townsfolk. Throughout the Middle Agesfeudal communities looked after their own. The Church preached compassionfor the mad as for the sick, and the ‘village idiot’, a medievalcaricature of the odd or mentally impaired person, received parish alms. Theterm ‘lunatic’, derived from the legendary belief in mentalderangement provoked by full moon, applied to people with temporary orpermanent loss of mental faculties. Some lunatics wandered from town to town– their liberty to roam only curtailed if they became troublesome,when they might be punished at the stocks, whipping post or duckingpool. Since the fifth century monasteries had been established in Britain. Themonastic life demanded unquestioning obedience, self-restraint, humility andcommitment to improving one’s spiritual life through service to thecommunity, asceticism and celibacy. As in secular enslavement, monks’heads were shaved to confirm their capitulation to God’s will. In afrugal existence, devotees sought to overcome the desires of the flesh byfasting, manual work, prayer and study. They laboured in the fields, themill, kitchen and gardens; skilled ‘brothers’ were deployed assmiths, leatherworkers, masons or carpenters, and a scribe produced thechronicle of the monastery.1 By around the twelfth century Benedictinemonasteries began to reach out to people with sickness or disability in thecommunity. Peripatetic monks visited sufferers of mental disorder in theirhomes and gave practical and spiritual guidance to their family and friends.Anyone who did not recover was invited to submit to the ordered life of themonastery until able to return home.2 Despite such caring provision, some people of wayward mind and spirit wereseen as a danger to society, drawing not sympathy but severe penalty. In thereligious turmoil of the late Middle Ages, insanity and evil were oftenconflated. The omnipotent Catholic Church responded to deviance and dissentwith the Malleus Maleficarum (Hammer of theWitches), a missive credited to two celibate Dominicantheologians, Heinrich Kramer and Jacob Sprenger. TheMalleus asserted the dangers of witchcraft, and guidedmagistrates on interrogation and torture.3 Witches were known as libidinous women whocopulate with incubi, casting spells in cahoots with the Devil to spreadevil throughout the land. While some men were also persecuted, themisogynistic Malleus asserted that women, due to their vanity, proneness to lying,weak intellect and lust, were most prone to diabolical possession. Between1580 and 1650 there were 200,000 prosecutions in Europe; the guilty wereburnt at the stake, thereby destroying both body and spirit.4 The sixteenth andseventeenth centuries were dangerous times for anyone behaving oddly. As society recoiled from witchcraft hysteria, theological interpretations ofmadness began to be eclipsed by the advance of medicine. Dominating Westernmedicine was the ancient Greek system of four humours: blood, yellow bile,black bile and phlegm. These humours governed behaviour: mania was due tobile boiling in the brain, while excessive black bile caused melancholia;imbalances were treated by purging, blood-letting and sudden plunging in hotor cold water. A more humane treatment of madness was promoted by maverickSwiss physician Paracelsus in the sixteenth century. Having observed healingpractice in Tibet, Constantinople, Arabia, Egypt and the Holy Land,Paracelsus rejected harsh physical methods and medicinal concoctions asguesswork, emphasising instead the moral virtue of the lunatic’s careror physician.5 Eventuallyhumoural medicine was undermined by revelations in anatomy and physiology,and discovery of the nervous system relocated the seat of insanity fromvisceral organs to the brain.6 However, this was not readily followed by advancesin treatment: Thomas Willis, reputedly the first neurologist, saw torture asthe most reliable means of imposing order on unruly minds. Insanity,according to medical opinion, needed robust treatment: I do advertise every man the whiche is madde or lunatyke or frantykeor demonyacke, to be kepte in safegarde in some close house orchamber where there is lytell light; and that we have a keeper thewhiche the madde do fear.7 From alms to the madhouse The only institution specifically for care of lunatics was the BethlemHospital in London. Built in 1247 as a priory dedicated to St Mary ofBethlehem, this establishment moved in 1676 from its monastic buildings to alarger site beyond the city wall at Moorfields, with accommodation for 120lunatics. Public viewing was offered for a small fee, and‘Bedlam’ (a truncated name that became synonymous with madness)was as popular as the zoological gardens; inmates were encouraged by theirkeepers to growl like wild beasts for their audience. The governorsextracted donations from affluent visitors, in whom pity might be aroused;this was a major source of profit until the notorious parade was abolishedin 1770.8 Although thehospital was run by a religious organisation, the mostly male staff was notaverse to brutality. Treatments included bleeding, blistering and beating,but as insanity eluded cure, Bethlem rested on the assumption that the bestthat could be done for the insane was to restrain them. A corrective to Bedlam was Robert Burton’s The Anatomy ofMelancholy, published in 1621.9 An Oxford don and celibate priest, Burton wasafflicted with physical and mental maladies throughout his life. He sawmelancholy as an imbalance of body, mindand spirit, which could be corrected by the restorative powers ofblood-letting, exercise, good diet and country air. It was theresponsibility of the medical profession to help people whose afflictionalienated them from their fellow beings. Sufferers needed a calm and restfulenvironment, supported by kindly, tolerant people. For Burton, lastingrecovery depended not on the quantity of medicinal concoctions but on thequality of human relationships. Since 1634 the Bethlem keepers had been subordinated to a salaried physician.Nepotism was evident in a 125-year medical dynasty beginning with theappointment of James Monro in 1728.10 The Monros refused to take medical studentsand were intolerant of anyone who doubted their methods. Despite itsworsening reputation, Bethlem had a lengthy waiting list. James wassucceeded in 1751 by his son, John, in the same year that a rivalinstitution opened across the road. Appointed as physician in charge of StLuke’s Hospital for Lunatics was William Battie. Son of a vicar,Battie’s commitment to improving conditions for the mentally ill wasinspired by the Enlightenment philosophy of Hobbes, Rousseau, Voltaire andLocke. Hobbes’ Leviathan, published in 1651,presented the ideal of a social contract whereby the State would controlgreed and protect the weak from brutishness and misery. Battie’sTreatise on Madness, published in 1758, criticised thecoercive and barbaric treatment and cramped cells at Bethlem Hospital. Monrowas infuriated by this slur from a commercial rival. While differentiating lunatics from other itinerant outcasts, the VagrancyAct 1744 could only enforce their removal to a house of correction, but inthe eighteenth century various institutions for the insane emerged. Some ofthe general hospitals that opened in larger cities, funded by publicsubscription schemes, included an annexe for lunatics (as at Guy’s inLondon). The Manchester Lunatic Hospital of 1766 was administrativelyattached to the general infirmary, an arrangement followed in Liverpool in1792. Meanwhile private madhouses proliferated. Typically owned by clergymenor doctors, these establishments catered for private lunatics or recipientsof Poor Law assistance. Unsurprisingly, the latter class got the worst deal;head-shaven inmates were perpetually shackled to the walls of dank and dingycells. Concern at abuses led to appointment of a parliamentary committee toenquire into care of lunatics; the resulting Madhouse Act of 1774 required alicence for owners, and in the London environs madhouses were to beinspected by a body of five commissioners from the College of Physicians. Asthe only sanction was that details of irregularities were displayed at themadhouse entrance, proprietors remained a law unto themselves. It was therough treatment meted to King George III during his episodes of madness thatbrought the plight of the insane to public attention. Philanthropists’ stone Exempt from the Madhouse Act was the care of pauper lunatics. In 1806 HighSheriff of Gloucestershire and prison reformer Sir George Onesiphorus Paul,after visiting several madhouses, highlighted the dreadful plight of theinsane poor to the Secretary of State for the Home Department. This led tothe appointment of a Select Committee,chaired by Charles Williams-Wynn and comprising several members of theClapham Sect, an influential society for humanitarian reform.11 At this time the numberof identified lunatics was small: only 2,248 in England and Wales (2.26 per10,000 population), of whom 1,765 were in workhouses and 140 in gaols. Inits report in 1808 the Parliamentary Committee presented a catalogue ofcruel and degrading treatment, demonstrating urgent need to protect lunatics– particularly paupers, who had no choice in where they were sent. Alaw was subsequently passed for the provision of county pauper lunaticasylums. To understand these developments, we must consider the political and socialcontext of Britain at the beginning of the nineteenth century.Parliamentarians at this time were aristocrats, and parochial authorityrested with the landed gentry: the few governed the many. Men (rarely women)of high social standing were selected as magistrates by the county’sLord Lieutenant for formal appointment by the Home Secretary (a system thatcontinued until local government legislation in 1888). Any transfer of powerto the State was likely to be opposed as a threat to local autonomy. TheCounty Asylums Act of 1808 was a tentative step, merely giving English andWelsh county justices the option to build an asylum at ratepayers’expense. The 1808 Act recommended that asylums be built on an airy, south-facing sitewith good water supply. They would be located on the outskirts of a markettown, thus within reach of medical assistance. The reformers were inspiredby a model establishment in York founded in 1792 by William Tuke, a teamerchant and philanthropist. The Tuke family were Quakers, a minor religiousgroup whose basic tenets were peace and simplicity. The ethos of The Retreatwas moral management, based on the notion that even the most frenziedlunatic could return to lucidity if treated well. Each of the thirtyresidents was allocated a personal attendant, and troubled minds werediverted by fulfilling occupation, prayer and recreation. The spaciousgrounds were aesthetically pleasing, with gardens offering views over thesurrounding countryside, and domesticated rabbits and fowl in the airingcourts. The Retreat was not only a haven but also a therapeutic environment,and its recovery rate impressed the humanitarian reformers. As presented in Samuel Tuke’s Description of TheRetreat,12published in 1813, the principles and practice of moral management requiredlittle medical input; visiting physicians merely treated bodily illnesses(not until forty-two years after its opening was a medical superintendentappointed). By contrast, patients in other lunatic hospitals and asylumswere subjected to regular purgatives and cold baths, phlebotomy of thearteries of the head and neck, and contraptions such as the gyratory chair.The Tukes saw such interventions as distasteful. As eloquently discussed byMichel Foucault in Madness and Civilisation,13 it was incidental to thedevelopment of the medical profession that a system of institutional carewas founded for the insane. In the guise of ‘alienists’, doctorsappointed to manage the new county asylums had more appeal in social staturethan in clinical expertise. However, the asylum movement sowed the seeds ofa medical monopoly of madness, in which the scope of practice expanded fromindividual treatment to an overall therapeutic regime. Alongside the Tukes the greatest pioneerin the institutional care of lunatics was physician Philippe Pinel, who in1792 was appointed head physician at the Bicêtre, a large hospital for theinsane in Paris. This was a time of turmoil in France, as Robespierrepursued his Grande Terreur against the aristocracy and30,000 died at the guillotine. An erudite humanist, Pineltook no part in the political upheaval, but he implemented the revolutionarydoctrine of liberté at the Bicêtre, where he was shocked bythe brutal treatment of lunatics. Freeing inmates from fetters,blood-letting and ducking, Pinel practised le traitementmoral, emphasising individualised care and meaningfuloccupation. Like the Tukes, he believed that care of inmates depended on thecharacter of attendants. Jean-Baptiste Pussin and his wife Marguerite wereemployed as head attendants, with whom Pinel visited each patient daily toreview progress, carefully recording their observations. The Tukes and Pinelindependently devised similarly enlightened therapeutic approaches, but thelatter attracted doctors with its emphasis on ‘treatment’,unlike the non-medical language of The Retreat. Public asylums did not suddenly appear on the horizon after the permissive1808 Act. The first, in Nottingham, began to receive patients in 1810; itwas built on a site of five acres, with a lawn in front and two airingcourts behind (additional land was later purchased for growing crops).Unlike The Retreat, the architecture of the first generation of publicasylums prioritised confinement over comfort, with custodial manifestationsthroughout. Walls were of great thickness, in locally quarried stone, as inthe imposing bastion of the Kent Asylum at Barming Heath. Of some influencewas the ‘Panopticon’ model for institutions devised in the lateeighteenth century by philosopher-jurist Jeremy Bentham. This circularstructure had cells or wards radiating from the centre like spokes of acartwheel, thereby maximising surveillance and reducing the need forphysical restraint. Although applied at the Glasgow Asylum of 1814 and inamended form in the Cornwall and Devon asylums, Bentham’s model wasgenerally deemed too oppressive for county asylums, being favoured insteadfor the prison-building programme.14 The typical linear structure comprised a series of wards each side of acentral administration block, where the office and residence of the medicalsuperintendent were situated. Contrasting with the grand facade, thecorridors to the male and female sides led to a Spartan interior of barewalls, asphalt floors and minimal furnishing. Each ward consisted of a widegallery and adjacent sleeping quarters, where patients slept in wooden boxeswith straw bedding. Heating was by open fires, quite inadequate for largedormitories in winter, while oil lamps effected modest illumination. Narrowiron casement windows afforded little daylight and fresh air, resulting inpersistent stale odours. Yet the asylum was an improvement on the hovels towhich many patients were accustomed. From the outset of the public asylum system, power of admission was investedneither in physicians nor Poor Law officers. Parish overseers were legallybound to report a lunatic, who would be examined by a justice of the peaceand, if certifiable, sent to the asylum. A visiting committee was appointedby county magistrates to oversee the management of the institution. Theofficial visitors were distinguished gentlemen, and some ladies, ofphilanthropic bent; they held monthlymeetings at the asylum, scrutinising the accounts and offering patients anaudience for any grievance.15 Meanwhile, dreadful conditions persisted in private madhouses and lunatichospitals. Magistrate Godfrey Higgins found that a patient he had sent toYork Asylum, a charitable establishment founded in 1777, had been repeatedlyflogged. The asylum governors denied any wrongdoing, but Higgins pursued thematter and an investigation began in November 1813. On 26 December there wasa serious fire at the asylum, when most of the staff members were absent:two male attendants were taking Christmas leave and the doctor was attendinga private patient thirty miles away. Four patients perished in the blaze.Higgins subscribed to become a governor of the asylum and in this capacityhe was able to see the conditions for himself. Squalid cells housed severalincontinent lunatics, with walls daubed in excrement, the stench causingHiggins to vomit. A single airing court was provided for each sex, where themeek melancholic mingled with the agitated maniac. Male and female patientswere inadequately segregated with the result that ten women were impregnated(in one case a child was fathered by an attendant named Backhouse, who wasrequired to pay maintenance to a poorhouse).16 These atrocious conditions led to appointment of a Select Committee in 1815to enquire into regulation of the care of lunatics. The investigators werenot easily fooled, and at York they found handcuffs and chains concealedunder filthy straw. Bethlem Hospital was indicted by the notorious case ofWilliam Norris. An educated man, Norris had allegedly tried to killattendants; for twelve years he had been continually chained so that hecould barely stand, with an iron ring around his neck. John Haslam,apothecary to Bethlem, was asked by an investigator about the treatment ofinmates:17 Would you treat a private individual patient in the same wayas has been described in respect of Bethlem? No, certainly not. What is the difference of management? In Bethlem, the restraint is by chains, there is no such thing aschains in my house. What are your objections to chains and fetters as a mode ofrestraint? They are fit only for pauper lunatics; if a gentleman was put inirons, he would not like it. Social class division was pronounced in treatment of the insane, with ahierarchy of care from the comfortable private asylums, where moneyedpatients were waited upon by servants, to the windowless dens for paupers,staffed by illiterate ‘keepers’. Bethlem was far from perfect,but Haslam drew a distinction between the staff at such charitableinstitutions and the private madhouse: With respect to the persons, called keepers, who are placed over theinsane, public hospitals have generally very much advantage. Theyare better paid, which makes them anxious to preserve theirsituations by attention and good behaviour: and thus they acquire some experience of diseases. Butit is very different in the private receptacles for maniacs. Theythere procure them at a cheap rate: they are taken from the plough,the loom, or the stable; and sometimes this tribe consists ofdecayed smugglers, broken excise-men, or discharged sheriff’sofficers. If anything could add to the calamity of mentalderangement, it would be the mode which is generally adopted for itscure. Although an office of some importance and greatresponsibility, it is held as a degrading and odious employment, andseldom accepted but by idle and disorderly persons.18 Keepers maintained order and attended to basic needs, but these poorly paidworkers received little guidance from proprietors, who were mostly ignorantof therapeutic endeavour. Indeed, perpetual incarceration was profitable.Despite damning evidence of mistreatment of pauper lunatics, a proposedinspection regime was rejected four times by the House of Lords between 1814and 1819. Local magistrates did not see statutory control as the solution.However, the shameful revelations caused growing unease in the ruling classand in 1827 another enquiry was conducted, which led to two Acts ofParliament. There was no public asylum serving the London conurbation, wherepaupers went to one of many private madhouses or to Bethlem or St Lukes.Some licensed houses were large: Hoxton House, Peckham House, CamberwellHouse, Grove Hall in Bow, and the Red House and White House in Bethnal Greenheld between 200 and 400 inmates. The Select Committee led by Dorsetmagistrate Robert Gordon told the House of Commons of miserable conditionsin madhouses containing Middlesex paupers, particularly at DoctorWarburton’s madhouse in Bethnal Green. Violent inmates were kept in a‘crib room’, each chained to a box of straw where they were leftfor entire weekends without attention, until Monday morning when they weretaken into the yard and doused by pails of cold water to wash them ofexcrement. The Madhouse Act of 1828 tightened regulation of private madhouses andcharitable lunatic hospitals. In the London area, the ineffectual College ofPhysicians inspectors were replaced by the Metropolitan Commissioners inLunacy, a new inspectorate appointed by the Secretary of State, despiteopposition from the College and madhouse-owning doctors as an infringementon medical practice. Five of the fifteen commissioners were to be medicallyqualified, and the legal profession secured representation in an amendmentin 1832, requiring at least two barristers. The Metropolitan Commissionerscould revoke a licence and discharge anyone improperly detained.Commissioner Lord Ashley, who had seconded the legislation, became chairmanin 1834. A tireless campaigner for the care of lunatics, Ashley19 was spurred to socialactivism by an unhappy upbringing relieved only by the housekeeper, whoseaffectionate care taught him that compassion conquers all. His day wouldcome. While the new public asylums were exempt from inspection, the County AsylumsAct 1828 imposed new requirements, including a resident medical officer,whose order was necessary for any use of restraint. Annual reports ofadmissions, deaths and discharges were to be sent to the Home Office.Alongside statutory obligations, a codeof practice was prepared by parliamentary reformers as a blueprint for moraltreatment. However, merely nine of the fifty-two counties of England andWales had opened asylums: Nottingham, Bedford, Norfolk, Lancaster, Stafford,West Riding of Yorkshire, Cornwall, Lincoln and Gloucester. The averagecapacity was 116, well within the maximum of 300 recommended by the 1808Act. The largest was the West Riding Asylum at Wakefield; having opened in1818 with 150 beds, its capacity had expanded to 250. Elsewhere, countyjustices eschewed such a costly venture, arguing that their number of pauperlunatics was negligible. Parish guardians were required to keep record ofall lunatics receiving indoor or outdoor relief. By this time 9,000 pauperlunatics were registered in England and Wales – a substantial increaseon 1807. For them, the foundations had been laid for a proper system ofcare. Forward and back The men and women drawn to work in the county asylums were a mixed bunch.Ideally recruits were of good physique, practical ability, basic literacy– and deference. Previous experience could not be expected, althoughsome may have worked in private asylums or workhouses. The asylums lureddomestic servants, whose pay was considerably lower. Young women wereinitially posted as kitchen maids or laundresses, before promotion to acaring role. As well as employees of the gentry, previous occupations ofmale staff included farmhands, artisans, soldiers and sailors. Male wardswere thus staffed by stout labourers who could be relied upon to keep order,and men with skills such as carpentry or tailoring who could practise theirformer trade in the service of the institution. As in the madhouses, the term ‘keeper’ was initially used incounty asylums, until this was replaced by the more humanitarian‘attendant’. Some matrons referred to their care staff as‘nurses’. The three job titles were used interchangeably by WCEllis,20 residentmedical officer at Hanwell Asylum, in his treatise on the treatment oflunacy. A convenient arrangement was for the institution to be run by ahusband and wife partnership, as at Hanwell, where Ellis was in overallcharge but the matron effectively managed the female wing; she wasconsequently paid more than the head attendant on the male side. As described in LD Smith’s21 study of attendants in the early years at StaffordAsylum, incentives were introduced for continual service. Keepers in theprincipal gallery and in the basement storey both received £25, and on thetwo upper galleries £20 each. In 1825 annual increments began for staff onthe lower rate: an additional £1 per year, until they reached parity withthose on £25. Volunteers for a weekly night shift gained an extra £5, butthis was seen as an unnecessary expense by the Stafford visiting committeeand in the 1840s night duty was included in the employment contract for newrecruits. Attendants on the night rota were not excused from the normalshift starting at 6 a.m. At the Surrey Asylum, which opened in 1841, male attendants received from £25to £31, and female counterparts from £12 to £16.22 Such differential was the norm at atime when a man’s wages supposedly covered his family upkeep. However, only the most senior maleattendants were allowed to marry and to live with their wives and childrenin the asylum. Otherwise, marriage was deemed incompatible with therequirements of the job; attendants lived in rooms off the patients’dormitories, and could be summoned to duty at any time during the night. Themarriage bar was a major factor in the attrition of younger female staff,but spinsters or widows tended to stay. Attendants enticed their relativesto asylum service, thus beginning the intergenerational continuity andinformal power bases that became prominent features of life in the mentalinstitution. Attendants were expected to keep the patients occupied, both for therapeuticbenefit and for the self-sufficiency of the asylum. Wards were emptied inthe daytime as female patients went to work in the laundry, kitchen orsewing room, and the men in the workshops or outdoors. The derogatory term‘funny farm’ originated in the scene of supervised gangs ofpatients toiling in the fields. Asylum land was fruitful, with sufficientacreage and livestock for ample crops, meat and dairy produce. Alongside thefarm account, asylum reports listed the clothing, bedding and tools producedover the year. Some patients remained on the wards, cleaning and polishingthe dormitories and galleries. Ellis described Hanwell as a veritable houseof industry:23 There are two keepers to each ward, one of whom is a mechanic. Beforebreakfast, both are employed in the getting up, waking and shavingthe patients. After breakfast the mechanic leaves the ward in chargeof the other, and he selects from his own ward, and from the othermale wards, such patients as are able to work with him at his trade.The keeper who is left in the ward, attends to the patients, takescare that the beds are made, the rooms and the gallery thoroughlycleaned, and employs the patients in picking coir, twine-spinning,or any other in-door employment … Each female ward has twonurses: at nine o’clock the junior nurse, whenever the weatherpermits, collects those patients in her ward who are to be employedout of doors, and assists and watches over them whilst in thecultivation of the ground. The necessary ward duties, mending theclothes for the male and female patients, the making the whole ofthe house linen, and assisting in sewing the men’s clothes,the superintending the twine-spinning, basket-making, pottle-makingand other works, afford sufficient occupation to the nurse who isleft in charge. Many inmates were unable to work, such as the acutely disturbed and thesenile infirm. In reality, managing large groups of insane patients, somewith proclivity for violence, suicide or escape, was difficult withoutrecourse to physical methods of control. Moral management may have worked atThe Retreat, but the large pauper asylum was not so amenable. Thedangerousness of lunatics was demonstrated by a dreadful incident in theannals of the Kent County Asylum:24 John Nicols Thom, a Cornishman, was admitted to the Asylum withdelusions that he was Sir William Courtenay, King of Jerusalem,Knight of Malta, etc. His wife, having some influence, obtained anorder for his release, notwithstanding the protests of the Medical Officer, with theresult that he organised a riot among the poor ignorant hop-pickersin the neighbourhood of Canterbury; obtained arms for them andfought the King’s troops in the Blean Woods, where LieutenantBennett and 16 soldiers were killed, and Thom and a number of hisfollowers also lost their lives. Violent inmates were strapped into chairs fixed to the wall, or chained tobeds. Among various items of restraint was the straitjacket, which was madeof strong material tied from behind, binding hands and arms to the torso.Manacles were used to lock the patient’s wrists together. Suchrestraint was excessively applied by the untrained and unsupervisedattendants, and consequently the county asylums were in danger of becominglittle different from penal institutions. This was a trend that offendedsome medical superintendents: they had qualified as doctors, not prisongovernors. Yet medical treatments were no more beneficial, as WC Ellis explained: Very copious evacuations and profuse bleeding from the system areresorted to, and after the animal strength of the patient isexhausted, he becomes quiet, but the mental delusion stillremains.25 In his book on the treatment of insanity, Ellis presented the following asone of several examples of individualised moral management: A female, discharged as incurable from an hospital near London, was,on her admission at Hanwell, one of the most distressing patientsamong the six hundred. The wringing of her hands, with her constantmoaning, almost night and day, rendered her unfit to be amongst theother patients. Liberty and confinement, indulgence and privationwere tried without effect; she still persevered in the deplorablenoise and wringing of her hands. As she seemed to dislike the openair, she was ordered to be taken out of doors every morning, andkept there the whole day. For a long time no alteration seemed totake place; but the plan was still continued. In about two monthsher bodily health had greatly improved, and, although she refused towork, her noise was diminished, and she expressed her dislike of thegoing out of doors. This was a great point gained. She was told,that if she should conduct herself so as not to annoy the otherpatients, and amuse herself with a little work, she should remain inthe house. On the promise of good behaviour, the experiment wastried, and it succeeded. She has, for weeks, daily occupied insewing. She has little indulgences, the fruits of her labour; andshe rarely attempts to wring her hands or to repeat her moaning:when she does, a hint that she be removed from her nurse – towhom she is much attached – and again sent into the garden, isquite sufficient to recall her to order.26 Appointed as house surgeon to the Lincoln Asylum in 1835, Robert GardinerHill continued the work of visiting physician Doctor Charlesworth, who hadconsiderably reduced instances ofrestraint. Regarding its use as unjustifiable in any circumstances, GardinerHill entirely abolished mechanical restraint by 1838. Against the doubts ofthe visiting committee, this was a courageous strategy which could not havesucceeded without cooperation of the attendants. Staffing was increased anda night watch was posted. Selected for physical strength, attendants wereallowed to restrain a violent or disturbed patient manually, but only withuse of the hands. Solitary confinement was also permitted, but cold bathsand drugs were regarded as mechanical restraint in disguise. The most celebrated reformer of asylum care was John Conolly, who hadabandoned his professorship in medicine at University College London, wherehis efforts to integrate the mind and its disorders in medical training werefrustrated. On succeeding Ellis as resident physician at Hanwell Asylum,Conolly visited Lincoln in 1839 to assess whether non-restraint could beapplied at a large pauper lunatic asylum, then housing eight hundredlunatics. Conolly regarded physical coercion as detrimental to recovery, asit made patients morally indifferent. Within seven months he removed allinstruments of restraint, including hundreds of leglocks and handcuffs.Conolly had no doubt about the crucial factor in the proper care of lunatics: Everything that a judicious committee wishes to be carried intoeffect – every comfort that the benevolence of the officerswould wish to confer – every appliance of daily treatmentevery curative means, will be either realized or withheld, accordingto the character of the attendants. They are the instruments bywhich every great and good intention is brought into hourlypractice. It is not necessary to say more, to prove how important itis that they should be well chosen, well governed, well taken careof, well supported in their duty, and well paid.27 Within a year of his appointment as medical superintendent at LancasterAsylum in 1840, Samuel Gaskell abolished manual restraint and removed theiron bars and gates. Gaskell emphasised classification of patients bybehaviour, separating the quiet and compliant from the dirty and turbulent,so that moral reinforcement replaced physical coercion. The non-restraintdoctrine became a new focus for reformers, although arguably thisovershadowed the positive goals of moral treatment. Draconian devices couldbe withdrawn, but attendants could abuse their power in other ways.Occasionally attendants were sacked for mishandling of patients, althoughsometimes they were excused by circumstances. The Hanwell regulations statedthat ‘any keeper striking or ill-treating a patient will, for thefirst offence, be fine five shillings, and be dismissed for thesecond’.28 Improving the quality of attendants was the key to proper care of the insane,asserted prominent Scottish alienist WAF Browne in his book WhatAsylums Were, Are, and Ought to Be. Browne, having once takenadvice that he must fix the attendants before proceeding to cure thepatients, was not impressed by the general standard of such workers: Keepers are the unemployed ofother professions. If they possess physical strength, and atolerable reputation, it is enough: and the latter quality isfrequently dispensed with. They enter upon their duties altogetherignorant of what insanity is, fully impressed with the idea that thecreatures committee to their charge are no longer men, that they areincapable of reasoning or feeling, and that in order to rule ormanage, it is necessary to terrify and coerce them.29 Browne wrote this treatise while at the Royal Montrose Asylum. Having openedin 1781, this was the oldest of the chartered asylums in Scotland. Othersgranted royal charter had opened at Aberdeen (1800), Edinburgh (1813),Glasgow (1814), Dundee (1820) and Perth (1826). These privately ownedestablishments received two classes of patient: private and rate-aided.While paying ‘boarders’ benefited from superior accommodation,the principles of moral treatment were earnestly applied throughout. A Billfor provision of district lunatic asylums in 1818 was vehemently opposed asa needless imposition when institutional provision already existed. Thelatest of the chartered asylums opened at Dumfries in 1839, where thewealthy benefactor enticed Browne to take charge of the Crichton Institutionfor the insane poor, which stood adjacent to the asylum for privatepatients. Under Browne’s direction, a hundred lunatics benefited froman exemplar of humane care. In 1842 the foundation stone was laid for the new Glasgow Royal Asylum, whichmoved to larger premises at Gartnavel. Inscribed in stone above the entrancewas the legend: ‘Employing no mechanical restraint in the treatment ofpatients’. Five hundred patients were accommodated, with the affluentclass in the west wing, and paupers and lower-rate boarders in separatewards to the east. There was limited space for exercise, or for expansion.In a rapidly growing city, the number of insane was growing, and many wereconfined at unregulated private premises. Despite progressive ideals,Scottish lunacy provision was slow to respond to the social turmoil wreakedby the Industrial Revolution. The sweeping drive As Parliamentary reformers continued to press for a national, regulated system for lunacy, an Act of 1842 empowered the Metropolitan Commissionersto visit asylums and madhouses throughout England and Wales. Written by LordAshley, the detailed report in 1844 described much variation in care and conditions. The benefits of inspection were confirmed by dramatic improvements at Warburton’s madhouse: in 1828 up to two hundredinmates were held in leg-locks and chains at night, whereas in 1844 onlyfive of the 582 patients were so restrained. Overall, despite somedeficiencies in design, county asylums were found superior to other institutions housing the insane. Yet half of English counties lacked anasylum, and there was none in Wales. The population of England had doubled from 7.4 million in 1790 to 14.8 million by 1840, and susceptibility toinsanity appeared disproportionately high among the labouring class. The number of registered lunatics was six times greater than in 1807, although this was partially explained by better recording. Table 1.1 County asylums, 1844 County Location Year of opening Nottinghamshire Nottingham 1811 Bedfordshire Bedford 1812 Norfolk Thorpe, near Norwich 1814 Lancashire Lancaster 1816 Staffordshire Stafford 1818 West Riding, Yorkshire Wakefield 1818 Cornwall Bodmin 1820 Lincolnshire (for private patients only) Lincoln 1820 Gloucestershire Gloucester 1823 Suffolk Woodbridge 1829 Cheshire Chester 1829 Middlesex Hanwell 1831 Dorset Forston, near Dorchester 1832 Kent Barming Heath 1833 Leicestershire Leicester 1837 Surrey Wandsworth 1841 The asylum movement was driven by two contrasting socio-political motives,leading to the same destination. The unsavoury conditions for the teemingmasses in mill towns offended the sensibilities of radical idealists such asLord Ashley, who channelled their Christian faith into social reform.Alongside this evangelical zeal was the philosophy of utilitarianism, asexpressed by Jeremy Bentham’s tenet of the greatest good for thegreatest number. In a burgeoning capitalist economy that required a largesupply of labour, a rationally organised system for the non-productiveelements of society supported the progress of society. With philanthropy onone hand, and the utilitarian goal of order on the other, a consensus formedfor a centrally controlled institutional response to lunacy. By 1844 only a quarter of the 16,000 lunatics and idiots chargeable toparishes in England and Wales were accommodated in county asylums. Ninethousand were in workhouses, where they cost parishes about 2 shillings perweek, compared to 9 shillings at an asylum. Benthamite ideology spurred thePoor Law Amendment Act of 1834, which imposed the principle of lesseligibility: no able-bodied recipient should live better than thelowest-paid worker. Handouts were perceived as encouraging idleness andthereby perpetuating pauperism. The shift from outdoor to indoor reliefrequired substantial expansion of the workhouse system. Although explicitlydesigned to discourage destitution, union workhouses shared by neighbouringparishes rapidly grew as depositories for all kinds of society’s rejects, but they were not designed forcare of the insane. Workhouse masters found insane inmates disruptive toproductivity and discipline, and in the larger institutions a separatelunatic ward was provided, typically in the worst part of the buildings. TheMetropolitan Commissioners visited five such establishments during theirtour and were not impressed. Overall the Metropolitan Commissioners’ report demonstratedinadequacies in the care of the insane, reinforcing the case for statutoryprovision for pauper lunatics and a national inspectorate. Consequently,lunacy legislation was consolidated by two statutes passed by RobertPeel’s government. Building of county asylums was mandated by theLunatic Asylums Act of 1845, while the Lunatics Act of the same yearintroduced a national body of Commissioners in Lunacy to inspect everypublic asylum, licensed madhouse and hospital for the insane in England andWales. At last, the reformers had triumphed. The Lunacy Commissioners included five lawyers, three medical commissionersand five laymen. As chairman, Lord Ashley doubted whether the medical andlegal professions could be relied upon to protect the welfare of pauperlunatics, and he continued to argue that lay people could understandinsanity as well as a doctor. In his experience medical inspectors oftentolerated or defended substandard conditions. Indeed, the reforms pursued byAshley had been consistently opposed by a profession with pecuniaryinterests in the madhouse business. While having no statutory authority overasylum management, the Lunacy Commissioners wielded power through theirrigorous inspection and reports that could name and shame a medicalsuperintendent and his employing authority. Their recommendations led to aproliferation of rules governing all activity in the asylum; for example,each use of mechanical restraint was to be documented and justified by adoctor. The Lunacy Commissioners tended to focus on occupation and materialcomfort, and often enquired into attendance at religious services. Theypersisted with their notion that the insane could recover, given the rightenvironment and care. An important role of the Lunacy Commission was to oversee the construction ofcounty asylums. There was much to learn, as serious defects had arisen withventilation, water supply and drainage. At the recently built Surrey Asylum,patients were endangered by the flawed central heating system: Iron pipes had been laid to carry steam throughout the wards but theyproved too thin, and explosions throughout the wards were frequent,as the pipes burst and the patients were injured. Within a fewyears, almost the entire system had to be removed and new fireplacesinstalled.30 Frugality was regarded by the Lunacy Commissioners as a false economy thatdemoralised patients. Richard Eager described the austere Devon Asylum,which opened in 1845: The original building was in the form of a semicircular corridor withgalleries 150 feet long radiating from the convexivity like thespokes of a cartwheel. The walls were rough brick, painted withwhitewash, and the floors black asphalt. The furniture consisted of heavy tables screwed down tothe floor and wooden forms built into the walls so that they couldnot be moved. There were no chairs and the beds were made of woodwith wooden ‘stretchers’ on which to lie. Mattresseswere stuffed with coir, no upholsterer being appointed before1893.31 Unlike official visitors to county asylums, patients did not enter the frontporch and wood-panelled reception hall, but were swiftly processed at a sideentrance to the male or female side. For the class of patient in countyasylums, according to WC Ellis, solidity trumped comfort. In asylums designed for paupers only, it is unnecessary to have anyplaster on the walls: lime-wash on the bricks is all that isrequired…in a large building the saving of money isconsiderable. The doors, both of the galleries and the rooms, shouldbe made substantially strong; none of them panelled. Doors of thisdescription are burst open by a madman without the slightestdifficulty.32 The average size of the twenty-four county asylums in 1850 had crept up to297, and demand was rising. A spate of asylum building resulted from theAct, but justices of some counties continued to drag their heels. There weredifficulties in purchasing a site that fulfilled the requirements of theLunacy Commissioners, and landowners were wary of the impact of a lunaticasylum on their estate. Gardner described the prevarication of theauthorities in Sussex, who had prioritised the building of a gaol at Lewes.The last county in England to plan its asylum, Sussex eventually erected animpressive structure at Haywards Heath in 1859.33 Lord Ashley had specifically criticised the absence of lunacy provision inWales. The registered insane were widely dispersed in the undevelopedcounties of the Principality; most lived in private dwellings supported byparish relief, but unmanageable lunatics, of whom many spoke only theirnative language, were sent to asylums in England. When the first asylum inWales opened in 1848, the founders made the first rule that all officersmust be conversant in Welsh. While official records were written in English,Denbigh Asylum was a preserve of Welsh culture in Anglicisedsurroundings.34 As atDenbigh, smaller counties combined to fulfil their obligations: Brecon,Radnor and Monmouth established the United Counties Asylum at Abergavenny in1852, with a capacity of 250. Meanwhile urban authorities in England beganto build their own institutions, beginning with the Birmingham BoroughAsylum at Winson Green in 1850. The mid-nineteenth century was the zenith of asylum architecture. Countyauthorities responded to their obligations with decorous expressions ofcivic pride: this was caring intent cast in stone. Modelled on the pleasuregrounds of the gentry, the landscaping would have impressed the visitor, whopassed through an ornate gate lodge to a sweeping drive flanked by evenlyspaced trees, leading to a stately reception block with columned porch.Unlike the picturesque gardens to the fore, aft were fields for farming andsewage. Vast sites were necessary for the recommended maximum of fourpatients per acre. The Derbyshire Asylum at Mickleover opened in 1853 on an estate of 79 acres for its 360patients, a ratio of 0.21 acres per head, compared to 0.07 acres at HanwellAsylum. Elevated sites were chosen, several miles from the nearest largetown, affording fresh air and a pleasant aspect, albeit exposed to theelements. Each ward had access to an airing court, with benches andshelters. The perimeter wall was built on a decline, which reduced itsheight on the outside, while on the inside a ha-ha (a ditchdug on the inside perimeter) prevented escape without spoiling the view. Architectural embellishment was eschewed by the Lunacy Commissioners, whowere more concerned with therapeutic milieu than aesthetic extravagance.Nonetheless, while they could reject indulgent designs, the LunacyCommissioners approved a degree of tasteful stonework to relieve themonotony of a very large building. Among the masterpieces of craftsmanshipwere the Warwickshire Asylum at Hatton with its Dutch gables and ornatebelfry, the lengthy Byzantine yellow-brick range of the Sussex Asylum, andthe neo-Gothic Essex Asylum at Brentwood with its steep gables, turrets andgargoyles. In older asylums large tanks in the roof had sufficed for watersupply, but as asylums grew, greater gravitational pressure was necessary.Ready availability of a large volume of water was vital for tackling a fire,which might rapidly envelop buildings of combustible material. Piercing thehorizon, the lofty water tower became the indelible image of the Victorianasylum. Medical masters and their minions Asylum doctoring was not a prestigious pursuit. Although the medicalsuperintendent was in charge of the day-to-day management of theinstitution, ultimate power rested with the visiting committee. Barred fromemployment elsewhere, he needed permission to spend a night away from theasylum. Asylum doctors had no say over who was admitted, and patients couldbe discharged by the visiting committee as they saw fit, although this wasrarely done against medical advice. Supported by only one or two assistantmedical officers, the medical superintendent’s work was moreadministrative than clinical. With his residence in the main block, he hadlittle respite from the noise and smell of the wards. At Hanwell, forexample, the medical superintendent’s garden was between male andfemale airing courts. Yet the asylum offered alienists a platform on which to develop theirprofessional expertise and authority. At a meeting in 1841 at GloucesterAsylum, the Association of Medical Officers of Asylums and Hospitals for theInsane was founded, with the aim of promoting asylum doctoring as aspecialised discipline, to develop its scientific discourse and to setstandards for treatment. In 1853 this association started its professionalbulletin The Asylum Journal, edited by John Bucknill ofDevon Asylum. With its case studies, pathological investigations andphilosophical discourse, this monthly publication was renamedJournal of Mental Science in 1858. At the inauguralmeeting it was agreed that the terms ‘lunatic’ and‘asylum’ should be replaced by ‘patient’ and‘hospital’. While Lord Ashley was sceptical about doctorsrunning asylums, he was persuaded by the therapeutic optimism of alienists such as Browne, who promised much ofthe asylum as a place of cure. Unintentionally, Ashley’s emphasis ontreatment (albeit moral rather than medical) gave impetus to medical claimsof jurisdiction. Tension often arose between medical superintendents and the Commissioners inLunacy. None of the medical commissioners had asylum experience, untilSamuel Gaskell’s appointment in 1848. Some medical superintendents sawthe Lunacy Commissioners as an ally against their parsimonious layemployers, but others resented the perceived interference and pettycriticisms of the inspectors, and broadsides were frequently fired from thepages of the Asylum Journal. A recurring controversy wasthe use of restraint. Most asylum doctors deemed this a necessarycontingency for violent or disturbed patients, but the Lunacy Commissionersqueried its wide variation in usage. A case at the Surrey Asylum in Wandsworth showed how treatment could overlapwith discipline. A mole-catcher admitted in 1855, Daniel Dolley had a strongphysique for his age of sixty-five. On one occasion when he became excitablethe medical officer for the male side Charles Snape ordered a shower-bath.As Snape was departing from the scene he was violently struck on the back ofhis head by Dolley. The shaken doctor demanded that the patient be showeredfor at least half an hour, followed by a dose of antimony. Shivering afterthe prolonged onslaught of cold water, Dolley had a seizure and died. Hisdeath was attributed to a diseased heart, but after an inconclusivepost-mortem examination, medical superintendent Hugh Diamond secretly sentthe heart to two London surgeons who found no pathological cause. The heartwas returned to the asylum where Diamond burnt the evidence. The LunacyCommissioners decided to investigate, and on hearing from alienists CharlesHood and John Conolly that such use of the shower-bath was dangerous, theyinstituted a charge of manslaughter against Snape. The jury found no case toanswer and Snape was reinstated, but the debacle showed that the LunacyCommissioners would not shirk from confronting dubious medical practice, andthe case led to a decree that the shower-bath should never be used for morethan three minutes. The medical superintendent could be held to account not only for his ownactions but also those of attendants. At the pinnacle of a rigid hierarchy,he hired and fired, while delegating supervision of junior staff to the headattendant and matron. Each supported by a deputy, the head attendant andmatron inspected the wards in their respective departments daily, andcompleted a summary of the number of patients, staffing changes and anyuntoward incidents. At some asylums, annual reports featured contributionsby the matron and head attendant, but this input was dropped in the laternineteenth century when the standard format comprised reviews by the medicalsuperintendent, chaplain, steward and chairman of the visiting committee.For positions of such responsibility, asylum committees sometimes lookedbeyond their county for candidates experienced in care of the insane. Themanagers of the North Wales Asylum at Denigh prepared resident medicalofficer George Turner Jones, matron Nichols and head keeper Robinson bysending them to Gloucester Asylum for instruction by reputable medicalsuperintendent Samuel Hitch.35 To the dismay of libertarian doctors suchas John Conolly, men and women of desirable character were not readilyfound. Turnover was high, as many attendants found the work too demandingand the conditions of service too restrictive. Any breach of discipline byattendants was reported by their superior to the medical superintendent, whomight summon the miscreant to his office for a reprimand if not summarydismissal. Asylum reports provide copious detail on staff discipline; forexample, John Blewer and David Jones, two of the five male attendantsinitially appointed at Denbigh Asylum, were sacked after being seen climbingover the perimeter wall for an evening in town.36 In crowded and understaffed wards without recourse to effective drugs,inevitably there was rough handling by nurses, sometimes causing seriousinjury to patients. Signs of abuse were sometimes found by medicalexamination. The head attendant and matron were expected to report bruisingor other injury detected while supervising the bathing of patients. Bathingwas a potentially violent situation, with numerous shivering and agitatedpatients standing in line, and harried attendants trying to complete thetask as quickly as possible. Occasionally criminal proceedings againstattendants were initiated by the Lunacy Commissioners, if they were notsatisfied that the medical superintendent had taken appropriate action. Asthe asylum system expanded, some attendants moved from one institution toanother, and the Lunacy Commissioners proposed a national register toprevent the incompetent or troublesome from gaining employmentelsewhere. Some medical superintendents faced insurgency. In 1854 Doctor Grahamsley atWorcester Asylum responded to female attendants’ objection to revisedstaff rules by dismissing them all. He then rejected a pay rise for thematron, who was his sister-in-law. Amidst the unrest, Grahamsley took hislife in the retort room of the gasworks, and the matron was subsequentlysacked for insubordination. The Asylum Journal regrettedthe ‘melancholy end of this promising physician’;37 the same edition of thejournal carried an advertisement for Grahamsley’s successor. At theBuckinghamshire Asylum, the libertarian approach of medical superintendentJohn Millar dissatisfied the visiting committee.38 Millar let the matron take his youngdaughter around the female wards, believing that this stimulated a maternalinstinct in patients. Long before parole was introduced at other asylums, heallowed male patients to visit the Aylesbury Fair. When attendant HenryBrown arrived for night duty intoxicated, he was replaced by Millar and hiswages for the shift forfeited, but the chairman of the committee insistedthat Brown be dismissed. Struggling to recruit locally, Millar appointed ashead attendant Thomas Lissaman, who he knew from a private asylum in London.Lissaman took liberties with the relaxed regime and after several incidentsof impropriety the visiting committee demanded Millar’s resignation.This provoked action by the Association of Medical Officers of Asylums, witha petition signed by eighty-five members sent to the Lord Lieutenant of thecounty, but to no avail. This battle against lay control was lost, but theprofessional body of asylum doctors was beginning to assert itself. To improve discipline and quality of care, attendants needed guidance fortheir demanding role. In 1841 Doctor Kirkbride, head physician at thePennsylvania Hospital for the Insane andan honorary member of the British asylum doctor’s association,produced a manual for attendants; he later recommended that the associationintroduce a formal qualification.39 Other pioneers were Alexander Morison at theSurrey Asylum, who began lectures in the 1840s on humane principles of carefor the insane, and WAF Browne in Dumfries, who introduced the firsttraining course for attendants in 1854. A silk purse, however, could not bemade from a sow’s ear. Men and women of suitable disposition wereneeded, as described by a French alienist in the Journal of MentalScience. Berthier, physician at Bourg Asylum, suggested thatthe job might be best suited to members of religious orders who hadcultivated reflection, self-denial and generosity of spirit. He alsoemphasised obedience: only by following the doctor’s ordersmeticulously would successful outcomes be achieved. He needs to apprehend not only the duties of his calling and theinstructions given to him, but must realise his true position as oneraising him above that of servant, or prison-warder, to that ofcontroller and yet withal, the benefactor and friend of hispatients.40 So much for the expectations of their masters, but what did attendants seekin return? Here was a stable job with board and lodgings, but the wageshardly compensated for the arduous work, strict discipline and limited timeoff duty. At the Warwickshire Asylum, for example, attendants worked from 6a.m. to 8.30 p.m. They had one evening off per week, finishing duty at 6.30p.m. There were no full days off, but they had two half days in eachthree-week period, finishing at 2.30 p.m.41 Arriving late on duty incurred a fine. Atnight the attendants retired to their rooms with perhaps twenty minutes toread a book before the strictly applied ‘lights out’ athalf-past ten. A good sleep could not be guaranteed due to their proximityto the patients, as in this description at the Lincolnshire Asylum: The attendant’s bed room is placed between two of thedormitories, from which it is only separated by a swing door withperforated zinc panels, and the under attendant sleeps with the mosttranquil patients in the third dormitory.42 Wards were staffed at night, the daytime attendants being required to dealwith any nocturnal disturbance. Special duty was sometimes ordered to watcha disturbed or suicidal patient overnight. In 1861 medical superintendentLockhart Robertson reported the benefits of a dedicated night staffintroduced at the Sussex Asylum; he described the attendant’s role inchecking epileptic patients, changing the bedding of the incontinent, and ifnecessary removing a disruptive patient to a side-room.43 Each side of the asylum was covered byone attendant, who visited each ward at two-hourly intervals. As urged bythe Lunacy Commissioners, hourly visits later became standard. This was agradual development; Devon Asylum, for example, managed without a nightwatch until 1878.44 Discipline was symbolised by uniform. Attendants on the female side wore darkpetticoats with white aprons and cloth caps, the apparel of domestic servicethat evolved as the uniform of the nurse(by around the 1860s female attendants were ordinarily known as‘nurses’). The men wore a blue serge suit of jacket, waistcoatand trousers, with brass buttons and a number on the jacket sleeve. Thissmart but custodial garb was completed by a peaked cap bearing the countyarms. Both male and female attendants had a bunch of keys and whistledangling from a belt. Losing this set of keys was the swiftest route to thegate. Bread and beer In 1851 the Middlesex justices opened a colossal second asylum. Hanwell hadbecome the largest in the country with over 1,000 patients, and despiteConolly’s humanitarianism, an accumulation of chronic cases with noprospect of discharge inevitably detracted from the therapeutic atmosphere.Asylum managers were fighting a losing battle and had no choice but toextend buildings, which consequently bore little resemblance to the homelymodel of The Retreat. Proposals to double the size of Hanwell were rejectedin favour of the new institution, built six miles north of central London.With its majestic Italianate frontage, crowned by an imposing dome withcupolas and campaniles, Colney Hatch was showcased at the Empire Exhibitionas the most modern asylum in Europe. Although the grounds were mostlyenclosed by a wall ten feet high, a stretch of railings alongside therailway allowed passengers to marvel at the great edifice. Beside the gate lodge was stabling for the horses of magistrates andvisitors. A straight drive led to the main entrance, with lanes left andright leading to the male and female wings and respective medical quarters.The chapel, with capacity for 600, was next to the reception lobby; to therear was a vast hall with orchestra, waiting room, committee room, a diningroom for magistrates, servants’ quarters, steward’s office,general store and dispensary, kitchen and bakehouse. The boilers for laundryand kitchen were served by a huge steam engine. An artesian well bored to adepth of 330 feet had a daily yield of up to 120,000 gallons of water. Offthe corridor leading to the male side were the brewhouse and workshops ofthe tinman, plumber, upholsterer, printer, tailor, shoemaker, turner andcarpenter; the laundry and sewing rooms were towards the female side. Thefarm had a livestock of twenty-eight cows, one bull, two calves, 152 pigs,forty sheep and seven horses.45 With the largest workforce of any asylum, Colney Hatch was staffed on themale side by a head attendant, fourteen senior attendants each in charge ofa ward, and twenty-five ordinary attendants; on the female side the matronand deputy matron supervised forty-none attendants. The perambulatory nightstaff was supplemented by two stationary attendants on each side watchingover a dormitory of epileptic and suicidal patients. Male wards werenumbered 1 to 14, each holding thirty patients; female wards 15 to 32, withthirty-four patients. Each ward comprised a wide gallery, dining room,washroom, bathroom, scullery, store and two water closets, and rooms forattendants. The Lunacy Commissioners soon found faults in the Colney Hatch fabric. Theyinsisted that the asphalt ward floors be replaced by wooden boards. As theonly corridor was on the ground floor, doctors passed through the gallery ofeach ward to get to the next, althoughsuch throughput may have kept attendants on their toes. In 1857, a lessimpressive aspect of Colney Hatch was presented in the QuarterlyReview: Its façade, of nearly a third of a mile, is broken at intervals byItalian campaniles and cupolas, and the whole aspect of the exteriorleads the visitor to expect an interior of commensurate pretensions.He no sooner crosses the threshold, however, than the scene changes.As he passes along the corridor, which runs from end to end of thebuilding, he is oppressed with the gloom; the little light admittedby the loop-holed windows is absorbed by the inky asphalte paving… the staircases scarcely equal those of a workhouse; plasterthere is none … whitewash does not conceal the rugged surfaceof the brickwork. In the wards a similar state of things exists:airy and spacious they are without doubt, but of human interest theypossess nothing. Upwards of a quarter of a million has beensquandered principally upon the exterior of the building; but not asixpence can be spared to adorn the walls with picture, bust or eventhe commonest cottage decoration.46 Asylum patients were bathed on admission and weekly thereafter. During watershortages (a frequent problem before connection to the public water main),bathing was often postponed; in hot summers, body odour pervaded the wards.Reminders of the bathing regulations by the Lunacy Commissioners suggestthat the practice of using the same water for several patients persisted.Patients’ clothes and other belongings were removed on admission,including dentures, spectacles and jewellery. Items were recorded andstored, to be returned to the patient on discharge or to the family ondeath. Many patients arrived in workhouse clothing, which was returned onadmission. Clothes were pooled for each ward, stamped with the wardnumber.47 Mangled atthe laundry, trousers and petticoats were often baggy or too short, andill-fitting boots caused sores and a hobbling gait. The Lunacy Commissionersfrowned upon regular use of a strong dress or jacket. Made of thick materialand buttoned at the back, this was a form of restraint that had reappearedat Hanwell: The patients who destroy their dresses are put into strong canvasgarments, bound round with leather and fastened with padlocks.48 Some individuality was permitted. Men were allowed a beard if they kept itclean, and female patients adorned themselves with their embroidery. Indeed,the Quarterly Review writer found the austerity relieved by patients: There is no more touching sight at Colney Hatch than to notice themanner in which the female lunatics have endeavoured to diversifythe monotonous appearance of their cell-like sleeping rooms with ragdolls, bits of shell, porcelain, or bright cloth in the light of thewindow-sill. The love or ornament seems to dwell with them when allother mental power is lost.49 Moral management was in tune with theProtestant work ethic later described by Prussian sociologist Max Weber, butinmate labour was not only for salvation of lost souls; it was vital for therunning of the asylum, and thus required incentives. Some inmates weredeployed as ward workers, cleaning the dormitories and making beds, andperforming basic care for other patients; for this they were rewarded withextra tobacco or a side-room. For patients, the most important factor intheir quality of life was the character of their room-mates. Wards werecategorised by conduct, as recommended by medical superintendent Robert Boydat the Somerset Asylum:50 It would be very desirable to make a subdivision amongst the curableand industrious patients, by separating those who are talkative andotherwise annoying from the quiet and convalescent, without placingthem with the idle or mischievous class. The females are at presentdivided into five classes, of which the curable and industrious formthe first class, or those who are chiefly employed at needlework orsedentary occupation, and amongst them are to be found many of themost useful patients but some of whom are excitable and at timesvery troublesome. The second class includes chiefly working patientswho are employed in the laundry, kitchens and out of doors,consisting principally of cases of mania, monomania, and imbeciles,some epileptics, and perhaps a few convalescents. The third classconsists of the noisy, violent, and those of disagreeable anddestructive habits, including maniacs, some epileptics and idiots.The fourth class includes the chronic and infirm, cases of dementia,melancholia, some epileptics and imbeciles. The fifth class, thesick or infirmary patients. The architect’s plans for Worcester Asylum, which opened in 1852,featured one airing court for ‘the violent and dirty’, a secondfor ‘the imbecile and epileptic’ and a third for ‘thetranquil and convalescent’ (the latter was nearest the medicalsuperintendent’s office).51 This organisation of living space motivatedpatients towards productivity and compliance. While exasperated by cheeseparing authorities, the Lunacy Commissionerspersistently sought to improve the lot of the powerless inmates of lunaticasylums. In the better institutions, male wards were furnished with abilliard table, and female wards with a piano. Reading materials wereprovided, although the Lunacy Commissioners often found nothing moreinteresting than discarded Latin school books. Patients’ relativeswere not allowed into wards, their visits restricted to an hour on Sundaysand perhaps a midweek session, in the main hall. Patients’ letterswere scrutinised and destroyed by the medical superintendent if likely tocause trouble. Nonetheless, efforts were made to bring normality to asylumlife. In summer there were walking parties and picnics; at Colney Hatchpatients enjoyed annual outings to places such as Crystal Palace, the zooand Epping Forest.52Winter gloom was lifted by a weekly dance, to the tunes of the asylum band.This rare opportunity for socialisation of male and female patients wasfirst introduced at a pauper asylum by Samuel Hitch at Gloucester in 1841.The Quarterly Reviewcontributor described how strictsegregation of sexes was relaxed for the Monday ball at Hanwell:

Shortly after six o’clock the handsome assembly room,brilliantly lit with gas, becomes the central point of attraction toall inmates, male and female, who are considered well enough toindulge their inclinations for festivity … In a raisedorchestra five musicians, three of whom were lunatics, soon struckup a merry polka, and immediately the room was alive with dancers… At nine precisely, although in the midst of a dance, ashrill note is blown, and the entire assembly, like so manyCinderellas, breaks up at once and the company hurry off to theirdormitories.53 Chapel services were attended by large numbers of patients and attendants.The chaplain had an important role in the asylum, with its emphasis on moralrectitude. As well as conducting services, he visited individual patients,and ensured adequate supply of prayer books in the galleries. In Englishasylums the chaplain was Anglican, but in counties with a large Irishimmigrant population, a Roman Catholic priest also held services. A highproportion of patients were of non-conformist faith. At the LeicesterAsylum, for example, alongside many Baptists, Congregationalists, Methodistsand members of the Salvation Army were patients declaring themselves as a‘Calvanistic dissenter from the Trinity Chapel’, a Russian Jew,a follower of the Latter Day Saints, a spiritualist and a ‘freethinker’54.Religious enthusiasm was a common factor in asylum admissions, some patientsbeing described in the Leicestershire records as ‘ranters’. Manypatients had a prominent religious theme in their madness, but ministrationswere restricted. At Lancaster the chaplain needed permission from themedical superintendent to administer Holy Communion to any patient.55 As the status of thechaplain declined, so did his remuneration. The chaplain also offered spiritual guidance to staff, from supporting thehomesick to giving succour to sick attendants, some of whom died inresidence at the asylum. For their work, there was perhaps no moreappropriate use of the Christian dictum ‘All things whatsoever yewould that men should do to you, do you even so to them’.56 Henry Hawkins, chaplainat Colney Hatch from 1854 to 1900, wrote several tracts for attendants oncoping with life in the asylum: After your duty has been done on the ward and the time for rest hascome, do not let your mind be in the wards still. Even though youmay remain in the Asylum during the remainder of the day, do not letyour thoughts and your talk be only about Asylum matters. Asylumgossip is poor conversation. Interest yourself in what is going onoutside. Form a habit of reading if only a page everyday, some bookof history, poetry, biography, wholesome fiction. Self-improvementshould never be neglected.57 Some asylums had private patients, who were allowed to wear their own clothesin a relatively comfortable block separated from the main buildings. Suchpatients were a source of income, but inthe rigid class structure of Victorian Britain, the county asylum wasprimarily for paupers. Sometimes a middle-class patient was admitted if nolonger able to afford the fees at a private sanatorium. Certificationinstilled fear in affluent society, as the lunatic asylum was dreaded notleast for the genteel person’s exposure to the lower orders, asconveyed in Mabel Etchell’s account of her transfer from a privateasylum:58 ‘I am to go to a county asylum, Ada.’ She burst intotears. ‘Now that’s what I call really wicked, amongstsuch a low set! O Miss, you will never be happy there …Don’t you know they are all paupers, and you will have nodrawing room, but all herd together in one ward, and anybody goesthere, the refuse of the workhouses even! O Miss Mabel! And the foodis only fit for pigs.’ The asylum diet was a morbid fascination to Etchell: On Saturdays there was a perfect army of meat pies all standing inrows, which, when cooked, were conveyed to the dining rooms inwheelbarrows or handcarts. I cannot say much of the quality of thesedishes, for the crust was very heavy and indigestible, and wheat ofcourse quality; but lunatics are supposed to be indifferent to theepicureanism of the table, and perhaps their internal organisationcan relish deleterious substances more readily than sane people. In most asylums the main meal of the day was served in the dining hall aroundone o’clock, after grace was recited. Cold meat, broth, suet puddingand pies were the staple fare, served with seasonal vegetables and washeddown with table beer. Food for epileptic patients was cut into small piecesto prevent choking during seizure. Mealtimes were arduous for attendants inthe sick and infirm wards, where many patients were spoon-fed. After thelast meal of the day at five o’clock, a humble repast of bread andbutter taken on the wards, there was a long wait until breakfast. The LunacyCommissioners tasted the food on their annual visits, commenting in theirreports. Great quantities of milk, eggs, pork and vegetables were produced,but it was insufficient for a rising population. Cheaper food was bought,and this was not always to satisfaction, according to LunacyCommissioners’ reports. Tinned corned beef from the Argentine,unpalatable to some patients, became a staple item in winter. Working patients also had a light ‘lunch’ around 11 a.m.,comprising bread and cheese with a half pint of ale. Produced on site, beerwas supposedly nutritious and a safer beverage when water supply was proneto contamination. Male patients typically received a daily pint in theordinary diet, plus another pint during breaks in the farm or workshops;women received half or two-thirds of the male ration. Attendants alsoreceived a share from the barrel. Buckinghamshire Asylum, for example,issued two pints daily to men, and one pint to female employees.59 The staff brew was ofsuperior strength and quality to that given to patients. MedicalSuperintendent Lockhart Robertson at the Sussex Asylum noted: ‘Thehome-brewed beer of the attendantsis the best I’ve ever tasted in an asylum.’60 Until its removal by Doctor Hood in1851, a hydraulic tap at the Bethlem Hospital was constantly accessible toattendants, according to Russell ‘making the fat and formidablekeepers look more satisfied than cheerful’.61 Rising tide By the mid-nineteenth century it became clear that Britain was experiencingan escalation in lunacy. Despite its capacity of 1,250 beds, Colney Hatchwas already being expanded in 1857, when it was subdivided into fivedepartments each supervised by a matron or head attendant.62 In the rapidlyindustrialised county of Lancashire, despite two additional asylums built atRainhill and Prestwich, demand continued to outpace supply. By 1865 therewere forty county and borough asylums, with a total population of 22,284.The London asylums were largest, with 1,945 inmates at Colney Hatch and1,609 at Hanwell. Lord Shaftesbury (Ashley having succeeded to earldom onhis father’s death in 1851) argued that new asylums should not bebuilt for more than 600 patients. In 1857 they were unable to prevent theSurrey magistrates adding 700 places to their asylum at Wandsworth; a siteinitially deemed sufficient for 500 patients would now hold 1,500. In 1864three-storey blocks were hurriedly erected at Prestwich Asylum, increasingthe capacity to over a thousand.63 While they disapproved of extension ofexisting asylums, the Lunacy Commissioners accepted this as the lesser evilto severe overcrowding. The cause of this ‘great confinement’64 has been much debated. For sociologistAndrew Scull, the asylum system was a conspiracy of capitalism andprofessional interests. His economic determinism and cynicism towards themedical profession has been criticised, yet his thesis is compelling: theincrease in insanity seems inextricably linked to the rise in pauperism, andit created an expanding empire for doctors. Rapid transformation from apastoral to urban society shattered the social equilibrium, and whereasclose-knit communities had traditionally looked after their own kind,economic hardship and social breakdown left families unable to support thesick or disabled. Whenever industries wallowed in the troughs of economiccycles, destitution pervaded the masses. As Scull explained inMuseums of Madness,65 responsibility for unproductive members ofsociety switched to an institutional mechanism of social control. Thefeeble-minded, frail elderly, epileptic and insane were a drain onrelatives, and could not avoid the clutches of the Poor Law or the pauperlunatic asylum. The latter became the last resort for those of no use in theworkhouse. The proportion of lunatics per 10,000 of population in Englandand Wales doubled from 12.66 in 1844 to 24.13 in 1870, an increase from20,893 to 54,713 registered cases.66 Although the largest asylums were in denselypopulated areas, the prevalence of lunacy was relatively higher in countiessuch as Wiltshire, where agricultural unemployment was rife. An emerging feature of lunacy was the disproportionate increase in femalepatients. Women were more vulnerable to institutionalisation due to theireconomic disadvantage, and a condescending attitude of the maleestablishment towards the ‘weakersex’, a notion given credence by the medical profession. In her bookThe Female Malady,67 Elaine Showalter showed how male doctorsimposed cultural ideas about ‘proper’ feminine behaviour.Governed by their reproductive system, women were regarded as primarilyemotional, unlike the male agent of reason. Hysteria was the classic femalemadness. Once roughly equal by sex, the asylum population became skewed, aswomen consistently accounted for three-fifths of the total. Accordingly,there was more building on the female side, and the number of nursesovertook that of male attendants. Although dozens of new asylums had opened since the 1845 Act, the workhousecontinued as a staging post for the insane. In 1857 there were 14,393lunatics in county asylums, and 6,800 in workhouses. To reduce costs, boardsof guardians were inclined to avoid admission except for the worst cases,which required an order by a justice of the peace and a medical certificate.By 1865, 104 of the 688 workhouses in England and Wales had lunatic wards,but this arrangement was more for maintaining order than providing care. Theoppressive workhouse environment contrasted with the spacious grounds andhealthful regime in asylums. Boards of guardians were often criticised fortheir lack of proper facilities, most notably in a scathing supplement tothe Lunacy Commissioners’ annual report in 1859.68 Inmates were forced to work, typicallypicking oakum, cutting their fingers on the tarred chunks of rope.69 Lunatics were sparedregular punishments such as birching, but physical restraint was common, andin one workhouse the mortuary was used for seclusion. The LunacyCommissioners decreed that any lunatic restrained in a straitjacket shouldbe removed to an asylum. Despite its horrors, the workhouse had advantages over the asylum, as shownby Peter Bartlett’s70 research in mid-nineteenth-century Leicestershire.There was more shame in being certified as a lunatic than to be destitute,and a workhouse inmate was free to leave.71 The Lunacy Commissioners did not opposeaccommodation of chronic harmless cases in the workhouse, and sometimes theypraised the care. In response to overcrowding, the Lunacy Amendment Act 1862permitted transfer of such patients from the asylum. In the late nineteenthcentury Poor Law institutions continued to house about a quarter of thelunatics in England and Wales. However, asylum doctors frequently complainedof being sent moribund senile patients, many of whom died within a few daysof admission, while potentially curable cases languished in the workhouse.Furthermore, infirm patients sent from workhouses were unfit to work,detracting from the asylum’s self-sufficiency. In popular imagination, the asylum was a fearsome place, holding the wildestmadmen at the outer margins of humanity. Such perceptions were occasionallychallenged, as in this positive portrayal in the QuarterlyReview: The furious maniac who arrives at Colney Hatch or Hanwell in a cart,or handbarrow, bound with ropes like a frantic animal, the terror ofhis friends and himself, is no sooner within the building whichimagination invests with such terrors, than half his miseries cease.The ropes cut, he stands up once more free from restraint, kindwords are spoken to him, he is soothed by a bath, and, if still violent, the padded room… calms his fury, and sleep, which has so long been a strangerto him, visits him the first night which he spends in the dreadedasylum.72 Yet alleviation of acute disturbance did not always lead to recovery. Intheir report of 1844, the Metropolitan Commissioners had warned that ifadmission was delayed until lunatics were in an advanced state of insanity,the therapeutic potential of the asylum would decline. Finding that 85 percent of the 4,356 in county asylums had been resident for more than twoyears, the report had expressed concern about the accumulation of incurablecases, and pressure was mounting. Ward 19 at Colney Hatch, for example, heldninety patients – three times its initial capacity.73 As more patients were crammed intowards, the asylum became not a place of sanctuary but an environment hostileto recovery. The cure rate plummeted from around 15 per cent in the 1840s to8 per cent in the 1860s. In Scotland, meanwhile, the seven Royal Chartered asylums were rapidlybecoming unfit for purpose. Lord Ashley had told the House of Commons in1845 that Scottish facilities for lunatics were worse than anywhere inEurope or America. A Bill renewed the push for public asylums in 1848, butwas rejected as an excessive burden on ratepayers. The catalyst for changewas an American campaigner for the insane.74 In 1855 retired schoolteacher Dorothea LyndeDix came to Britain to recuperate after President Pierce rejected herproposal for federal aid for lunatics. Staying in Yorkshire with heracquaintance Daniel Hack Tuke, Dix heard that all was not well north of theborder, and so she embarked on an impromptu tour. Althoughwelcomed at Gartnavel, she had difficulty in gaining access to many privateasylums, but saw enough to raise urgent concern with Lord Shaftesbury. ARoyal Commission was rapidly established, and this led to the Lunacy(Scotland) Act 1857. Scotland was divided into districts for lunacy administration, with eachrequired to build an asylum for pauper patients. In 1863 the first districtasylum opened at Lochgilphead for the county of Argyll. The first report ofthe Scottish Lunacy Commissioners75 noted that the entire Highlands, far north andHebrides lacked provision apart from a few cells in the basement atInverness Infirmary and a pauper institution in Elgin. Opening in 1864,Inverness District Asylum had the largest catchment area in Britain. Castinga wide shadow, it took patients from outposts such as Barra or Benbecula, orfrom remote crofts in northern Sutherland or Caithness, who might never seetheir families again. For the populous industrial belt, much largerinstitutions were necessary. In 1875 the Barony Parochial Asylum, the firstof several public asylums on the outskirts of Glasgow, opened at Lenzie with400 beds; soon the second city of the Empire would be ringed by mentalinstitutions. Renowned for its medical schools, Scotland produced manyprominent alienists, who were libertarian in their management of asylums. Aradical change was the ‘open door’ system; at Lochgilphead, forexample, all wards were unlocked from 9 a.m. to 6 p.m.76 Parole was widely permitted, andboarding out was introduced, whereby patients were taken into privatedwellings for lengthy periods. Such innovations were scarcely applied inEngland, where an overwhelmed system was stagnating. As expectations ofasylum care lowered, so did staff morale. Working a ninety-hour week,attendants herded inmates to and fro in an unbending routine, with aconstant jangle of keys as doors were locked and unlocked. The priority wascontainment, preventing escape or access to potential weapons or implementsfor suicide. Cutlery was counted before and after each meal. Patients werecounted in and out of the airing court and dining hall, and frisked beforereturning from workshops. This did not prevent serious incidents, andsometimes a cunning patient slipped away, resulting in a fine for thecareless or unfortunate attendant. Suicide was also seen as a failing ofduty, but a determined patient could find the means. At the Sussex Asylum,for example, there were hangings from a towel in the bathroom and from abranch in the shrubbery, and fatal ingestion of poisonous berries in onecase, and nails and shoelaces in another. Incidents led to tightening ofprocedures, reinforcing the custodial atmosphere. The patience of the mostcaring attendants was tested in wards of up to a hundred inmates. Livingcheek-by-jowl in packed dormitories, patients squabbled and sometimesfought. Noting the number of black eyes during their inspection visits, theLunacy Commissioners disapproved of too many refractory patients beingplaced in the same ward. In 1863 a popular novel by Charles Reade presented a vivid account of asylumlife. Hard Cash: A Matter of Fact Romancewas not a fully accurate portrayal, drawing on earlier madhouse scandals,but it highlighted how patients had minimal contact with medical officersand were at the mercy of attendants. Responding to criticism that he hadexaggerated abuse, Reade was unrepentant. In 1870 he wrote to thePall Mall Gazette on ‘How lunatics’ ribsget broken’:77 Late in July 1858, there was a ball at Colney Hatch. The press wereinvited, and came back singing the praises of that blest retreat.What order! What gaiety! What non-restraint! Next week or so, OwenSwift, one of the patients, died of the following injuries:breast-bone and eleven ribs broken, liver ruptured. Varney, a fellow patient, gave evidence against an attendant who Swift hadannoyed, as Reade described:78 Slater threw the poor man down, and dragged him into the padded room,which room then resounded for several minutes with a ‘greatnoise of knocking and bumping about’, and with thesufferer’s cries of agony till these last were checked, andthere was silence. Swift was not seen again till Saturday morning;and then, in presence of Varney, he accused Slater to his face ofhaving maltreated him, and made his words good by dying thatnight. After the accused walked free, Reade explained how attendants evadeddiscipline for physical abuse:79 The keepers know how to break apatient’s bones without bruising the skin. The refractorypatient is thrown down, and the keeper walks up and down him on hisknees, until he is completely cowed. Should a bone or two be brokenin the process, it does not matter much to the keeper: a lunaticcomplaining of internal injury is not listened to. He is a being sofull of illusions that nobody believes in any unseen injury heprates about. In his letter Reade offered a £100 reward to anyone producing evidence toconvict whoever had killed a patient at Lancaster Asylum in 1863 (twoattendants were imprisoned for seven years for manslaughter). Yet the impactof Hard Cash was not so much in raising concern at thetreatment of patients, but in contributing to public fears of wrongfuldetention. This was an issue that dominated lunacy policy in the mid- tolate nineteenth century. To the consternation of Lord Shaftesbury, the focusshifted from care of patients inside, to protection of people outside. Shades of brown Perhaps the only benefit of the swollen asylum population was the opportunityit created for classification of patients. There was no standardnomenclature for the various types of insanity, but by the mid-nineteenthcentury alienists were using similar categories in their reports, withdiagnostic tables typically including: mania (acute or chronic) melancholia (acute or chronic) general paralysis of the insane dementia (primary, secondary, organic or senile) amentia (with or without epilepsy) epilepsy (acquired). A typology of moral and physical causes was also applied, with differingindications for treatment. Physical aetiology included intemperance,privation, fever, sunstroke, head injury, epilepsy and idiocy; prognosisdepended on the degree and permanence of the bodily insult. Moral insanity,a term first used by Bristol physician James Cowles Pritchard in his 1833Treatise on Insanity, was a disorder of the passionsoften without impairment to the intellect. Monomania, whereby the suffererpresented madness in one faculty only, epitomised alienists’therapeutic optimism in the early years of the asylums. As explained bySamuel Tuke at The Retreat,81 this partial form of insanity was fully reversibleby moral management, but such a regime was becoming less feasible in thecounty asylum. Nonetheless, about one-third of patients with first episodeswere discharged within a year; in the absence of specific medicalinterventions, probable factors in spontaneous recoveries were respite froma stressful situation, and the orderly asylum routine. In staking their claim as medical experts, asylum doctors sought moreeffective physical methods of treatment. The pharmacopeia at this time wassparse, with no drugs of any lastingbenefit. Natural substances such as opium and cannabis began to be replacedin the 1860s by chemical agents such as bromide of potassium and chloralhydrate. However, bromides required an increasing dosage to maintain thesedative action, causing confusion, and disturbed patients emerged from afug with their delusions intact. The more powerful hyoscine, which could beinjected for rapid action in a frenzied patient, was prescribed sparinglydue to its toxicity. Crude sedatives were prescribed sparingly, as indicatedby the Lunacy Commissioners’ report at Colney Hatch in 1882, statingthat merely thirteen male and fifty-one female patients in a population ofover 2,000 were sedated at night, and only two men and seventeen women indaytime.82 Drugsgradually became more prominent in asylums, as doctors experimented withvarious plant extracts and reported their findings in the Journal ofMental Science. Following the invention of the dynamo byMichael Faraday, electrical power was harnessed as a potential treatment,Turner Jones at Denbigh Asylum purchasing a galvanic shock machine in1850.83 In the 1860s,impressive results with the Turkish bath were recorded by Edgar Sheppard atColney Hatch. The temperature for this prolonged bathing was adjusted forcalming or stimulating effect. From 6 a.m. to 8 p.m., relays of six patientswere taken to the bathing suite; thus half of the male population could betreated in one day. The category ‘dementia’ (literally loss of mental faculties)included patients who would now be diagnosed as schizophrenic, for whomprospects were poor. The monotonous asylum regime was coloured by thedelusional idiosyncrasies of such patients, as in this remarkable casedescribed in the medical report for 1870 at Fishponds Asylum inBristol:84 Among the deaths was that of one of the celebrities of the Asylum,known to the Visitors as the ‘Man with the Wheel’. Hehad been an inmate from the first opening of the establishment in1861. His delusional ideas related principally to his having a wheelperpetually working within his body, the revolution of the wheelgiving him no rest night or day so that he had not slept for manyyears. He said, ‘Tomorrow at ten o’clock the wheel willstop and I shall be in Heaven’. As the Asylum clock wasstriking ten the following morning his Spirit took its flight. Epileptic patients presented considerable management problems for attendants.Longitudinal records maintained by RG Rose at Colney Hatch revealed that inone year the 300-plus epileptics suffered an astonishing average of eightygrand mal fits daily (excluding nights when no recordswere made).85 Leather capswere worn to prevent head injury during a convulsion. At Fishponds, medicalsuperintendent Henry Stephens conducted a trial of concentrated juice ofheathbed straw, a common plant that some French alienists had promoted as acure for insanity; only one of the six epileptic patients showed anyimprovement.86Bromides could reduce the frequency and severity of epileptic seizures, butwithdrawal effects were hazardous. With a minimal night watch, sometimespatients suffocated from a seizure in bed. Statusepilepticus, a continuous series of major seizures, was a common cause of death in asylums.Physical labour was believed to be particularly important for epilepticpatients, whose behaviour was unpredictable and sometimes violent, as inthis medical commentary: Of all the various classes of cases found in our County LunaticAsylums, none give so much trouble and annoyance, and have so littleinterest connected with them as the Epileptic Maniacs. If a blackeye is given, it is sure to be by an Epileptic – if twopatients fall to fisty-cuffs, the chances are, one or bothEpileptics. If furniture is broken, the probability is, an Epileptichas been the cause of the mischief. Joined to this they areirascible to a degree, always dissatisfied, quarrelling, andfighting; they half fill the list of wet and dirty cases; theycannot be trusted day or night without fear of some contretempsoccurring. Purgatives only relieve them for a time; anodynes areworse than useless; no remedy has ever been brought forward that hasbeen productive of any permanent benefit.87 With a relentlessly rising population, medical superintendents argued thatmany patients were inappropriate for a lunatic asylum. Most undesirable wasthe suspected or convicted criminal, who could be removed to an asylum ifbelieved insane. The Lunacy Commissioners frequently expressed concern aboutthe impact of criminal patients on the therapeutic milieu,and in the House of Lords in 1852 Lord Shaftesbury proposed a stateinstitution similar to Dundrum Central Criminal Asylum in Ireland. An Actwas passed and in 1863 Broadmoor State Asylum opened for male and femalecriminal lunatics. Although necessarily built for security, with barredwindows and inspection slits in the doors, no mechanical restraint was used.Moral management, however, faltered after several escapes and an attemptedmurder of the medical superintendent, who was struck by a large stone in asling while attending the chapel with his family, inflicting a severe headinjury. Among the incurable patients in asylums were those with congenital mentaldefect, known as ‘amentia’. The Lunacy Commissioners wereconcerned about mixing of mentally defective children with adult lunatics,and recommended special institutions for their care. Inspired by the work ofFrench physician Édouard Seguin, philanthropic campaigners in themid-nineteenth century believed that mentally defective children could beeducated to live with a modicum of independence, In 1848 anidiot asylum was opened at Highgate in London by Reverend Andrew Reed, whowas impressed by a training institution for ‘cretins’ (personswith mental and physical underdevelopment caused by an inactive thyroidgland) at Abendberg in Germany. About seventy ‘pupils’ wereaccommodated, with fees paid by their families, and a similar number weresupported by charity at Essex Hall, a disused hotel nearby. The Highgatebranch moved to a magnificent purpose-built institution with 500 beds atEarlswood in Surrey in 1855. Charitable institutions for the mentallydefective of private and pauper classes were planned on a regional basis. In1859 Essex Hall moved to become the Eastern Counties Asylum at Colchester;this was followed in 1864 by the Royal Albert Asylum for Idiots and Imbeciles of the NorthernCounties in Lancaster, and the Royal Western Counties Institution in Exeter;in 1866 Dorridge Grove Asylum near Birmingham catered for the Midlands.88 The Scottish NationalInstitution for the Education of Imbecile Children at Larbert inStirlingshire opened in 1862. These institutions were primarily intended forchildren, but as few patients were discharged, adults soon accumulated.Meanwhile large numbers of mental defectives remained in lunaticasylums. The Lunatic Asylums Act 1845 had given counties power to build separateasylums for chronic cases, and eventually two institutions of this type werebuilt in London. The Metropolitan Poor Act 1867 made the maintenance costsof asylum inmates chargeable to a single body instead of the thirty boardsof guardians in the city. The Metropolitan Asylums Board (MAB) wasestablished to provide institutional care for incurable cases deemedinappropriate for workhouses but not needing costly asylum treatment. Twomatching institutions were built at Leavesden to the north and Caterham tothe south, each with a capacity of 1,600. They were designed on the pavilionplan, with three-storey ward blocks connected by corridors and overheadwalkways; this layout allowed better classification, hygiene andventilation.89Initially Caterham and Leavesden received a large number of patients fromexisting asylums: Colney Hatch offloaded 491 chronic cases. Althoughofficially known as Metropolitan imbecile asylums, their intake was mixed.Of the 448 admissions to Caterham in its second year of operation, 137 wereidiots or imbeciles, and 263 had dementia; more than half of admissions wereaged over fifty.90 Medicalsuperintendent James Adam complained of parish officers often bringing indebilitated elderly people at death’s door. For example, in 1875 a managed seventy-six was sent by the Wandsworth and Clapham Union, only to diewithin a week.91 Thecemetery was filling fast. Despite these challenges, the MAB asylums werepraised by the Lunacy Commissioners: children were placed in the care of aschoolmaster and his wife, and half of the adults were usefullyemployed. The austere MAB asylums rose from sylvan countryside, lacking any hint ofornament to relieve the drab expanse of chalk brick. Meanwhile the LunacyCommissioners, in their periodically updated guidelines on asylumconstruction, advised architects that superfluous features would not beauthorised. As a pragmatic decision, the maximum number of patients per acrewas increased from four to ten. With only one in eleven patients deemedcurable in the Lunacy Commissioners’ reports, county justices saw theasylum as a poor return on investment, and they were no longer prepared tospend ratepayers’ money on palatial pretensions and therapeuticidealism. In 1877 the first lunatic asylum exclusively for chronic cases wasopened by the Middlesex authorities at Banstead in Surrey, diverting 1,600patients from Hanwell and Colney Hatch. Comprising four male and sevenfemale blocks on the three-storey pavilion plan, Banstead Asylum receivedfaint praise in a Middlesex County Times report: ‘Theinterior is cheerfully coloured in three shades of brown.’92 Table 1.2 Size of county and boroughasylums80 Year Number of asylums Number of patients Average number of patients 1850 24 7,140 297 1860 41 15,845 386 1870 50 27,109 542 1880 61 40,088 657 Degeneration Asylum labour was cheap. Among the 130 subordinate workers at Caterham Asylumwere attendants of first and second class, with men’s annual salariesstarting at £25 and women’s at £15; a solitary night attendant waspaid £28.93 The male headattendant received £44 and his female counterpart £32. Matron Emma Moselyreceived a relatively high £160, £10 more than the assistant medicalofficer, as she was effectively in charge of the female department. Thechaplain was paid £200, the house superintendent (in charge of thebuildings) £300, and at the top of the tree was Doctor Adam, on £500. By the mid-1880s Caterham Asylum had three doctors, thirty-four maleattendants and thirty-nine female attendants during daytime, and a nightstaff of six men and seven women, but the inmate population had grown toover 2,000.94 In allasylums the strength of the workforce was failing to keep pace with theincreasing number of patients. To attract good staff, the Lunacy Commissioners urged visiting committees toimprove working conditions. The medical superintendent’s residence inthe main building was replaced by a comfortable villa away from the bustle.This also freed space for patients: at Sussex Asylum accommodation for onedoctor was sufficient for a dormitory for sixty-one patients!95 In some asylumssemi-detached houses were constructed for the head attendant and matron, andcottages were built on the edge of the grounds for married charge attendantsand their families. Such expenditure was justified by the need to retainvalued workers in an unattractive vocation, while also promising futureemployment to their offspring. Loyal service was rewarded by medicalsuperintendents, who ensured that deserving attendants received a small potof money on retirement. The Lunacy Commissioners related staff continuity toquality of care, as in their report at Denbigh Asylum in 1880: The attendants seemed to us to be kind to the patients, and evidentlymuch good feeling exists between them, and we have much pleasure inrecording that out of the 30 attendants on the male side, not onehas seen less than 2 years’ service, and 24 have been here formore than 5 years.96 Tight discipline was a major factor in the high staff turnover. Of 567attendants in the employ of West Riding Asylum between 1860 and 1880,ninety-one were dismissed.97 Typical reasons fordismissal were drunkenness, insubordination, brutality and theft. Pettypilfering was inevitable, as hungry young workers were tempted to forage inan institution with large stores of goods; black markets were created intobacco and other comforts. Gender segregation was tested by illicitrendezvous before the 10 p.m. curfew. Lockhart Robertson at Sussex Asylumexclaimed: ‘This house is a hospital for the treatment of disease nota matrimonial agency office!’ Illustrating the unbending regime, hissuccessor Samuel Williams sent this memorandum to nurse Annie Rolset in1872:98 In January last I posted a notice stating that any nurse found withher light burning, after 10.15 p.m. unless for a good reason wouldbe required to resign the situation. Notwithstanding this, you arereported as having a light burning at 10.23 p.m. on 20th inst. Youstate that this was an accident, and I am willing to believe you,and so will not enforce any threat of requesting resignation, but assuch accidents show carelessness, I fine you 2/-. In his patriarchal role, the medical superintendent kept a moral hold onasylum life, deciding what was best for patients and staff. According toLord Shaftesbury and some asylum doctors, intemperance was the foremostcause of insanity. Undoubtedly alcohol was causing major problems among themasses. In 1874 beer consumption reached a peak of 34.4 gallons per head(four times the level drunk today).99 Intoxication temporarily relieved harshrealities but exacerbated poverty, and fears of consequent moral declinespawned the Temperance Movement. To rescue the poor from squalor and vice,evangelical campaigners lobbied Parliament against ‘demondrink’, achieving shorter public house opening hours, and resumptionof tax on beer. Medical attitudes to alcohol were changing. Doctors hadtended to prescribe alcohol for a plethora of symptoms, but scientificevidence undermined its use as a stimulant. Meanwhile, it remained a dietary fixture in asylums (see Figure 1.1). When the Cumberland and WestmorelandAsylum opened in 1862, no beer was provided to patients. Initiallysceptical, medical superintendent Thomas Clouston found this experimentsuccessful. A decade later at Carmarthen, George Hearder was the first towithdraw alcohol from the diet of an existing asylum.100 Some asylum doctors were wary ofTemperance zealots, but a Journal of Mental Scienceeditorial in 1881 declared that beer was ‘quite unnecessary in countyasylums’.101 In1884 Daniel Hack Tuke102conducted a survey of all 129 mental institutions in Great Britain andIreland, finding that half had eliminated alcohol except for medicinalpurpose. While supporting this trend, Tuke sympathised with the view of theLunacy Commissioners that to deny a poor man of a lifetime habit waslamentable. At the recently opened Banstead Asylum, which housed patientswith no prospect of discharge, the daily ration was three pints of ale. Fora while ale continued as an inducement for working patients. However, totalabstinence was necessary for alcoholic patients, and this was awkward whenbeer was in general supply. Drunkenness in staff was also a problem. Somemedical superintendents feared that withdrawal would cause greatdissatisfaction in the ranks, but many workers (particularly nurses) were willing to accept cash in lieu. By theend of the decade beer was completely withdrawn at most asylums, with milk,tea or oatmeal water served instead. In the aftermath few problems werereported by medical superintendents, who observed better conduct in patientsand staff. Figure 1.1 Diet table at Nottingham Asylum, 1874103 Alcohol had already been strictly controlled in Scottish asylums, whereCalvinist tradition was evident in the strict rules governing staffbehaviour, as in this puritanical notice displayed at the Murray Royal Asylum: No Attendant, Servant, or other Officer, shall dance with any otherAttendant, Servant or Officer.104 While withdrawal of beer was presented as morally virtuous, it alsodemonstrated the changing power dynamics in the asylum. From the visitingcommittee’s perspective, the brewery was a profligate operation withthe expense of malt and the labour in producing, storing and distributingthe fermented brew. Yet more importantly, by defining alcohol as a drug,doctors were imposing their professional authority, as they slowly butsurely wrested control from their lay employers. Every aspect of the asylumregime became a clinical matter, including the issue of restraint. Publicly,alienists were keen to distance itself from punitive use of strong clothing,manhandling by attendants and the padded room, but David Yellowlees of theGlasgow Royal Asylum warned in The Lancet in 1872 againstsentimental aversion to restraint, which he regarded as a necessarycontingency for the safety of patients and staff.105 While opposing mechanical apparatus,Marriott Cooke at Worcester Asylum justified use of seclusion:106 I am sure that there are some cases, both curable and chronic, whichare greatly benefited by being isolated for a few hours in the quietof a single room. I believe also that it is far better, in theinterest of the patient himself, let alone that of the staff, toplace him, when he is very violent, for a short time in a paddedroom, rather than to keep him in the day-room fighting andstruggling with four or five attendants. In 1877 a commission appointed by The Lancet on care andtreatment of the insane, led by Joseph Mortimer Granville, reported oncounty asylums in the London area. They had found Hanwell resting on itslaurels, no longer the progressive institution of Conolly’s time.Aware that cases of abuse were tarnishing the reputation of asylums, thecommission drew attention to the quality and supervision of attendants. Themedical officers at the Surrey Asylum in Wandsworth were praised for theirvigilance in making unannounced visits to wards at night as well as indaytime. The message was that whenever attendants were left to their owndevices, patients were at risk.107 Surveillance, however, was not the onlysolution to the problem. This untrained body of men and women neededpositive instruction. Although lectures for attendants had been initiated at several asylums, theinstructors themselves had no specific qualification in their field ofpractice. Of course, asylum doctors weretrained in medicine, which had recently developed a professional frameworkwith registration by the General Medical Council.108 However, medical officers in asylumshad little prestige, and the label ‘alienist’ reflected theirmarginalisation in the wider profession. In pursuing their claim as arightful branch of medicine, asylum doctors clung to the coat-tails ofclinical science. In 1865 their organisation was renamed theMedico-Psychological Association (MPA). The Certificate in PsychologicalMedicine was introduced, later accredited by the General Medical Council,although this was not an obligatory qualification. Meanwhile theJournal of Mental Science was favouring articles onpathology and treatment over philosophical musings. Medical superintendentsattended professional meetings, such as James Crichton-Browne’srenowned conversaziones at the West Riding Asylum, whichdrew audiences from near and far. By the late nineteenth century the aetiology of insanity had crystallisedinto two prominent theories, with significant implications for the work ofattendants. The first entailed dirt and germs, with the conjecture thatinsanity resulted from continual breathing of air polluted by miasma, whichwere putative substances emitted by sick people or putrefaction. Asknowledge of pathogens advanced in the late nineteenth century, the culpritchanged to microbes. Laboratories were established at many asylums, wheremedical officers studied samples of blood, urine and sputum by microscope.The Lunacy Commissioners recommended routine autopsies, and in post-mortemexaminations of the brain, any abnormalities in size or shape of ventricleswere recorded. For the Holy Grail of a pathological cause of insanity, novisceral organ was excluded in the search for a putative toxin orlesion. Asylums dealt with the pauper class, and the snobbery of medicalsuperintendents is often apparent in their attitude to ‘the greatunwashed’, whose filthy homes and foul habits explained not only theirdisproportionate mortality in fever epidemics, but also the prevalence oflunacy. Many patients suffered from tuberculosis, which doctors speculatedas a late manifestation of insanity.109 Mortality from this contagious disease wasfar higher than in the general population, and with so many people in closecontact, it became obvious that the asylum was contributing to the problem.The Lunacy Commissioners urged isolation of patients with infectious diseasein an infirmary ward, but this was not always feasible. On all wards therewas great emphasis on bathing, fresh air, purgatives and scrubbing of floorsand walls. The second theory of insanity gained momentum in the light of CharlesDarwin’s theory of evolution, as presented in The Origin ofSpecies in 1859. It was known that many patients had a familyhistory of mental disorder, but this was now placed on a scientific footing.Henry Maudsley, son-in-law of John Conolly and leading alienist of the latenineteenth century, asserted the deterministic nature of insanity: Multitudes of human beings come into the world weighed with a destinyagainst which they have neither the will nor the power to contend;they are like the step-children of nature, and groan under the worstof all tyrannies – the tyranny of a bad organisation.110 While positing no distinct line betweensanity and insanity, Maudsley explained that in severe forms behaviouralsymptoms tended to arise long before the underlying corporeal fault wasapparent, as in senile dementia, general paralysis or epileptic mania. No one now-a-days who is engaged in the treatment of mental diseasedoubts that he has to do with the disordered function of a bodilyorgan – the brain … Insanity is, in fact, disorder ofbrain producing disorder of mind.111 Hereditary theory had a dramatic impact on care of the insane, as itundermined the assumption of moral treatment that nurture was the key torecovery. Darwin’s contemporary Herbert Spencer coined the phrase‘survival of the fittest’, expressing his view that the Stateshould not interfere with the process of natural selection. Theincapacitated, therefore, should be left to die to preserve the health ofthe population. There was growing fear in the Victorian Establishment of theurban poor ‘outbreeding’ the educated class, thwarting theprogress of society and potentially leading to degeneration of the humanspecies. Maudsley hinted at the eugenic ideas that would dominate psychiatryin decades to come: