Life in the Victorian Asylum: The World of Nineteenth Century Mental Health Care

by Mark Stevens

  This is not to say that institutional care necessarily generated a better outcome than the gaol. Inside the few private asylums of the Georgian period, the outlook for a lunatic was often dramatically worse than for those subsisting outside, with custody and neglect the sole routine provided by physicians seeking financial bounty. Only a desperate case indeed would surrender itself for admission.

  One unfortunate young pauper woman, Hannah Mills, was taken to the York County Asylum in 1790. She had been widowed and was suffering from an acute case of melancholy. Within weeks, Hannah was dead, the victim of a callous regime which spared all expense in managing its charges. Patients at York were dirty, malnourished and kept under restraint in an exercise of containment rather than care. Visitors were banned, and no physicians would attend the patients unless contracted by the governors; an untrained rogue was the patients’ keeper. Profit had been put before people and with devastating effect. Public outrage ensued when Hannah’s friends discovered the truth of the conditions that had caused her death. How could such abuse be permissible in prosperous eighteenth century England?

  The remedy arrived by applying the new science of reason. Hannah Mills was a Quaker, and it was clear to all her friends that those who ran the York Asylum had not followed any basic teachings from that religion. For Quakers believe that God is in all of us, even those who have become insane. It follows that the lunatic is no different from the rest of men, and that they should be treated like any other neighbour. This starting point for rational thought heralded in an entirely new system of care. By 1796, Hannah’s fellow Quaker William Tuke had opened a new asylum in York. The Retreat would be completely different from any English asylum that had gone before it.

  Within twenty years, The Retreat had transformed the management of those who were mentally ill and the way that they were perceived. Rather than condemn the lunatic like an unreformed prisoner, William Tuke’s regime sought to treat him as an innocent, and to boost the morale of all those who crossed its threshold by providing a uniform kindness. Tuke’s ‘moral treatment’ offered the hope of a cure and the certainty of compassion, and, above all, it reduced the stigma of insanity.

  Of course, it took some time for these new ideas to become widely accepted. The authorities running Bethlem, London’s oldest asylum (known also as Bedlam), were found guilty in 1815 of much the same practices as the York County Asylum had been in 1790. One patient, William Norris, was discovered by inspectors unable to move, his arms fastened to his sides and his neck chained to an iron bar. Norris’ treatment met with widespread condemnation, and slowly the medical establishment adopted Tuke’s reforms. Finally, in 1839, John Conolly, physician in charge at the Hanwell Asylum, tore up all his attendants’ mechanisms of restraint. His action was a symbolic declaration that all the country’s lunatics should be free.

  Today, the scandals of the past have been left behind; neglect, mistreatment and bondage are gone; in their place we offer attention, treatment and refuge.

  How Public Asylums Came into Being

  For centuries, the care of lunatics was of no interest to the state. Such provision as there was came about through the auspices of private charities or private speculators. It is well-known that any alienist, or mind-doctor, was obliged to turn a surplus if he wished to continue in his business, and if that surplus did not come about through benefaction, then it had to be encouraged through careful management. There was no incentive to cure; indeed, the reverse was often of greater pecuniary value.

  It is easy to see in retrospect that an unregulated system of care is no system at all; to engineer abuse one may just as well let any profession moderate itself. Abuse certainly followed, reported in cases such as that of Mrs Hawsley, a woman tricked into confinement in a Chelsea madhouse for no other reason than that her mother considered her a drunk. There, she discovered that a fellow inmate, Mrs Smith, displayed no obvious symptoms of madness. The latter woman had been incarcerated solely because her husband wished to be rid of her and could afford to pay the requisite fee.

  The discovery of many similar cases led eventually to statute. The Madhouses Act of 1774 began a system of licensing and inspection for the various private asylums operating throughout the country. Bad practice, such as admitting sane people who were merely inconvenient to their families, or treating patients inhumanely could result in the refusal of a licence. For the first time, British lunatics had someone to watch over them.

  This was just as well, for the turn of the century led to a dramatic rise in patient numbers. One key event raised the public consciousness of the mad within society: the assault by James Hadfield on King George III. Hadfield, a young soldier who fired two pistols at His Majesty in May 1800, was unusual in that he ended up in Bethlem. It must be said, with great regret, that at this time a far larger number of the insane were placed within parish workhouses and county gaols. This was an expensive and ultimately fruitless outcome, as no lunatics were being cured by custody.

  A select committee of the House of Commons was created to suggest a solution to this problem, and in 1808, all the counties of England and Wales were empowered to build public asylums. Few chose to do so. Many of the county justices were not convinced that money spent on asylums was money well spent. The counterargument, of course, is that their residents will inevitably find themselves inside one institution or another, and that respite care in an asylum is no more expensive than providing extra beds in a workhouse or prison, though with the greater possibility of a beneficial outcome. In the end, not spending money on public asylums became a false economy.

  When Nottinghamshire opened a building for sixty patients in 1811, it became the first county to pay for the upkeep of some of its lunatics through the parish poor rates. It is easy to forget just how recent this development was, but it has since become the standard model. Local taxation now pays for virtually all the patients in our mental health accommodation. The professional management of relief brought about through the poor law also made reliance on untrained volunteers a thing of the past. The future would be one of skilled public service.

  Nevertheless, it took time for universal care to be established and, unfortunately, fear was once again the spark. There was the case of Edward Oxford, the young boy who shot, attempting to gain notoriety, at our pregnant Queen in 1840; or Daniel McNaughten, the Scottish wood-turner who, convinced that he was persecuted by the government, killed the secretary of Sir Robert Peel in 1843. The actions of these two men, though at odds with the harmlessness of the vast majority of lunatics, were actions for which society demanded a response. Parliamentary inquiry was inevitable, and brought with it an insistence that every county or named borough should provide an asylum for its populace or establish a contract to house its lunatics with a neighbouring authority.

  The result was the framework that we have in place today, based on the two great statutes of Victorian health care: the Lunatic Asylums Act of 1845 and its companion, the Lunacy Act.

  The Present Statutory Framework on Lunacy

  Like every patient, your position has its roots in the Lunacy Act. This piece of legislation governs everything, from the means by which you came here to those by which you may leave; all the paperwork that controls your comings and going is contained within it.

  The Act also delegates many powers to the Commissioners in Lunacy, and they produce rules establishing precisely how we should build public asylums, how we should care for patients, how we should manage our affairs and how we should report our findings. From their offices in Whitehall, these highly-qualified legal and medical men exercise a tight control over the treatment of lunatics across the country. If you stay here any length of time, you may meet some of the Commissioners during one of their annual inspections.

  At a more local level, our own committee of visitors is also empowered to operate under the Act. These men are all appointed by the local justices and it is to them that the superintendent directly reports. They are men of property and status, use
d to committee work and to devoting themselves to public service. They are ideally placed to look after your interests while you are here. As their name suggests, the committee members are also regular visitors to the asylum, and you may see the superintendent escorting one or two of their number from time to time.

  The asylum that you are now in was established as a result of the 1845 Lunatic Asylums Act. This statute was designed to end the system by which a patient’s chance of treatment rested unfairly on the accident of where he or she lived. The Act finally created a national system of care for pauper lunatics (those relieved by expenditure from the rates) based on a uniform model. Henceforth, sufficient accommodation was to be provided by every county or city throughout the land – and asylums were soon everywhere.

  Before the introduction of the Asylums Act, only around 5,000 lunatic patients were cared for in publicly-funded asylum beds, in contrast with the 12,000 or so lunatics who could be counted among the inmates of the country’s workhouses and gaol. Many patients suffering insanity or imbecility were being denied proper care, and the most satisfactory way of providing places for them was by creating entirely new buildings. Because most workhouses did not have sufficient room on site for the additional space required, and the few existing public asylums were not placed equidistantly around the country, fresh establishments were used to bridge the gap. The result was an enormous undertaking of public works.

  Since 1845 some sixty new asylums have been built across England and Wales. These state-of-the-art facilities came to be provided more and more locally, so that patients do not have to travel miles from home to receive treatment and their friends and family are able to visit. These new institutions are usually placed in pleasant, rural surroundings – ‘fixed upon an airy and healthy situation’, to quote the original 1808 Act – and have rapidly become a fixture in Victorian society.

  You may be surprised to discover how much financial support the public purse provides to fund your treatment. The generous expenditure upon the lunatic is in contrast to the general parsimony of the poor law and the workhouse system. Some three times the weekly allowance for a pauper in the workhouse will be spent on you, in recognition that you are not responsible for the condition in which you find yourself. Your economic failings are innocent; you are the deserving poor. It would be a grave error to weaken you further when instead we might improve your health and return you to the workforce, ready to make a contribution to society once more.

  The result of this approach is that the pauper patient in our charge is somewhat different from the pauper of the workhouse. Many respectable working men and women become our patients; these are not people who have fallen slowly on hard times but individuals who have suddenly become ill. Insanity is something that compels the conscientious labourer or artisan as much as the shiftless vagabond or thief. If your family is unable to pay for the care you need, or you have not the means, then the ratepayers will intercede on your behalf. It is not our purpose to exclude sufferers, rather, our job is to cater for all.

  You may have previously read about the growth in asylum care during recent decades and marvelled at it. At the present rate of increase we shall have around 100,000 patients within asylums nationally by the turn of the twentieth century. That is a large number, and to anticipate it new asylums are built to house anywhere between 700 and 1,000 residents beneath their roofs. It is a significant change from the more modest intention of 1845 to find an extra 12,000 beds across the country.

  Although the scale of mental health treatment was previously unimagined by our forebears, it must be seen in context. Great men have argued convincingly that an evil can exist for many years without our knowledge of it, and insanity is one such evil, left unexplored and unexplained for far too long. Only now are we beginning to understand the full range of connected illnesses and so it is inevitable that diagnoses should increase. When compared to our total population, it is true that, proportionately, the incidence of lunacy has increased slightly, but even now, in the latter half of the nineteenth century, the number of lunatics contained within asylums accounts for only one in every 400 of Her Majesty’s subjects.

  Chapter 2

  Admission

  You have been admitted to the asylum because someone was worried about you. It is likely that you have exhibited behaviour that caused anxiety or alarm to those closest to you. Perhaps you have been very melancholy lately, or very excited; perhaps you have acted in a way that is unbecoming to a man or woman; perhaps you threatened someone with violence, or even hurt them; perhaps you have endured terrors, fearing that your food is poisoned, that you are being followed or otherwise persecuted. You may have said that you wished to undertake some grand scheme, deliver a message to an important personage or foil some conspiracy you have discovered.

  This behaviour may have come about after some traumatic event, such as a bereavement, shock or disappointment in love, but equally it may have emerged through no discernible factor. Of course, there may be another precursor to your admission: you may have been apprehended by the police, found wandering as a tramp or vagrant or even sent to gaol and found unfit to be released into society.

  Your behaviour may well have been observed for some time before any action was taken. Initially, your family and friends might have made suggestions for the improvement of your health and, if they were able to afford it, called a doctor to attend you. He would have offered practical advice such as a period of rest or a change of scenery, or suggested that you abstain from alcohol or religious activities, or avoid potentially upsetting situations.

  Almost inevitably, these interventions failed. Yet, if those for whom you care most have been unable to obtain respite for you, then they must not be blamed. The workings of the mind do not easily allow a non-professional interpretation. However desirous your family may have been of keeping you at home, when it became harder for them to do so their thoughts turned naturally to possible alternatives.

  Involving the Poor Law Officers

  The decision to ask for assistance was not taken lightly. Your family only took action once they reluctantly concluded that domestic care was no longer practicable. Perhaps they found it difficult to provide food or board for you, especially after the loss of your wages. They might also have struggled to find the time or safe environment required to offer care. It is possible too that they recognised your domestic surroundings were only likely to nurture your illness, rather than resolve it.

  At some point your behaviour was perceived as creating a burden. Having made this decision, your relatives or friends were obliged to speak to the relieving officer of the local poor law union to ask for help.

  The relieving officer makes recommendations as to whom shall receive relief from the union, and what form that relief should take, as well as assessing those persons who wish to enter the workhouse. He recognises that the public purse does not open for everyone who needs assistance, and that each case must be scrupulously examined. The relieving officer works closely with his chaplain and the workhouse medical officer when considering the matter of asylum care. That triumvirate of authority holds much power over the allocation of help for lunatics. Unless your family was able to afford a doctor, then the relieving officer ensures that for the first time you had the benefit of a learned, medical opinion on your case.

  Now that the doctors’ profession is regulated by the Medical Act of 1858, any union medical officer will be perfectly able to reflect on the symptoms of your case. Though it is unlikely that he attended a medical school, he will doubtless have served a thorough apprenticeship with an experienced physician and learned his trade on the job. Indeed, as he is almost certainly a private practitioner contracted to his local union, the medical officer will, most likely, have experience of lunatics as part of his commercial work.

  The medical officer is instructed by the relieving officer to visit any prospective asylum patients for a thorough examination. If the patient is a workhouse inmate, then the examination is h
eld within that institution. If visiting a lunatic patient at home, the medical officer anticipates the need to undertake the consultation in a domestic setting, within the living room or kitchen. They are not influenced by your class or status; by the appearance of your clothes or shoes or by the contents of your larder.

  Since the middle of the century, doctors attending lunatics have been asked to make direct observations of the patient’s symptoms, and usually base their opinion on the record of these observations. Observations that tend towards a diagnosis of insanity include, though are not limited to:

  Incessant chatter and the use of inappropriate or over-familiar language, laughing or singing without obvious cause or motive.

  A loss of strength or will, resulting in a failure to be active in chores or employment or to interact with those around you.

  A belief that fraudulent enemies unknown are depriving you of something that is rightfully yours, or are trying to poison or otherwise attack you. Typically, a patient in this condition may have made threats to harm someone they know or to destroy their property, believing them to be part of the conspiracy against them.

  Being found wandering without seeming to have an aim or direction, and usually in a state of inadequate dress.