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

by Mark Stevens

  Moral Insanity

  Like monomania, moral insanity is a modern concept. It is a condition where the patient’s powers of reason work efficiently, and it is often considered to be a disease free from all delusion. Instead, the symptoms of the disease are based around deficiencies of moral sense. Reason has not been lost but has instead been perverted. Of course, variations in morality will be found amongst all men. Although as a society we try to attain virtue and avoid sin, it is inevitable that as individuals we may take subtly different views about what sort of behaviours are normal practice in these pursuits. Where the sufferer from moral insanity differs is that his behaviour is of such great variance from the rest of society that it becomes intolerable.

  The current medical conclusion is that the patient’s will has been subsumed by a desire. Sometimes a patient labours under an irresistible impulse, unable to prevent their actions, however harmful. In other cases all emotional normality is jettisoned, and the sufferer acts without the usual fear of consequence. This renders them reckless, and the result can be inappropriate behaviour that is merely alarming or more obviously destructive. The erotic vanity of an old woman apt to colour her face and adorn herself in tinsel may be unnerving, but the unchecked libido of a young man can be a source of danger. Both individuals might be considered to be suffering from moral insanity, and both might be suitable cases for treatment.

  Some form of callousness, masked by plausibility, is a typical feature of moral insanity. Friends and family of such patients often put up with their perverted behaviour for years, constantly reassured by the sufferer that no wrong has been done, before they find that their companion can no longer be managed or that the local magistrates have become involved. For the morally insane are able to commit atrocities and then justify them, removing the blame elsewhere. They may also express themselves seized with the wish to change their ways, while still working to subvert the very cures on which they claim salvation.

  Moral insanity is perhaps the hardest of our acknowledged illnesses of the mind to diagnose. These cases are also rare: the only one in memory here was A.H., a young woman who was a compulsive thief. Though she was admitted to our care it was clear that mentally, she suffered no apparent defects and she was discharged within weeks of her arrival. Her case relates to characteristics of personality rather than identifiable illness. Cases like this have led to a further classification of ‘moral imbecility’ being considered by alienists.

  Neither prolonged conversation nor physical observation is guaranteed to bring about a clear diagnosis of moral insanity, as for much of the time it is a concealed disease, becoming apparent only when an outburst can be witnessed. Because of this we are reluctant to diagnose it unless certain that there is no other underlying condition.

  General Paralysis

  The general paralysis of the insane is usually considered a disease in its own right, even if its early symptoms can sometimes be confused with other states of lunacy, meaning that it is often undiagnosed until its final stages. What causes general paralysis is still a mystery to physicians, though it is worth noting that the disease is seldom, if ever seen in those of less than 30 years of age. It is an adult affliction with distinct physical symptoms.

  These symptoms can sometimes appear subtle to the untrained eye, but gradually all tend towards a loss of function and co-ordination of the muscles. Speech may be affected and the paralytic patient slurs or droops like a drunken wretch; reflexes are gradually lost; and added to the rolling speech and gait is an inability to swallow or control the bowels. Sores may appear on any part of the body and are impossible to heal. These are the later stages of the disease, and a full paralysis is quite obvious by its physical effects.

  We must warn you that the prognosis in such cases is not good. J.Hr., a police constable, was sent to us five months ago with a vacant gaze, listlessness and indistinct speech. This dullness has increased along the lines described above and it is apparent that his death is close at hand.

  Feigned Insanity

  It is our duty to be sure that your case is one of genuine insanity. It is rare, but occasionally we encounter patients who evidently have the desire to be thought of as insane, though in truth they are not. This is a particular route taken by some felons who wish to avoid the more exacting rigours of the gaol, though it is also a ruse that some tramps use to escape harsh conditions on the road.

  Fortunately, the sane man stands out amongst the rank and file of lunatics. An ex-patient, J.Ht. was admitted having been spotted loitering outside a bank. In the local cells he claimed at once that he was aide-de-camp for the Crown Prince of Prussia, as well as the son of King George III and the Governor of the Bank of England. But these statements were entirely random, and did not tend towards any subsequent belief or action. In contrast, each lunatic has a particular system to his madness, a system that the sane are quite unable to replicate. J.Ht. was an imposter, and information was soon received to that effect from a neighbouring asylum. When confronted, J.Ht. admitted his malingering tendency and explained that when he gets a little drink he ‘goes wrong’.

  Amentia, or Idiocy and Imbecility

  Amentia, or absence of mind, is not a disease as such; rather, it is a state of development. Sufferers are those whose intellectual faculties were never fully established – reason has not been lost because it was never there. Patients affected by amentia are usually described as idiots, imbeciles or the mentally defective, and the condition itself is wont to be classified according to the degree of helplessness from which the patient suffers. The true idiot finds himself unable to function on his own: incapable of either gaining sustenance or reproduction. Some idiots are also mute, deaf or blind. As one moves up the scale the higher forms of imbecile are capable of eating, bathing and dressing themselves; while some even converse in simple terms.

  At this higher end of amentia, many patients may have happily taken care of themselves, held down basic work, and displayed a range of emotions. T.S. is one such example. Now aged 44, he was born the illegitimate son of an agricultural labourer and for years he had found seasonal work, interspersed with periods in the workhouse. Though he can only answer ‘yes’ or ‘no’ to any question put to him, he has managed to get by. His removal here was due to a sudden inclination to commit unnatural offences with other workhouse inmates. We have found him hard to manage, as he wets and soils himself, and is liable to annoy the other patients by shouting noisily at them or by trying to steal their food at mealtimes.

  However, we will not give up on his recovery merely because he is one of our more challenging patients. Dr Down’s recent work at Earlswood Asylum on Mongolian syndrome has proved there is the potential for such patients to benefit from the asylum regime, to take part in activities and be trained for employment. This suggests that there is little reason why some amentia sufferers should not make their own way in society. That men and women like this end up here instead is probably because a source of work is denied them or their family is not able to support them. They have probably also displayed some petty behaviour that makes them unsuitable for the workhouse.

  Many idiots can be diagnosed by visual observation. They have large heads, malformed faces or disproportionate limbs. Similarly, epilepsy can provide a clue to idiocy, as each fit observed is liable to damage the brain and render it less productive. E.H., an 11-year-old girl, has been an epileptic idiot since birth. She was supposed for years to be also deaf and dumb, but we have found her capable of uttering a few words even though she does not understand what is said to her. She is powerless to wash or feed herself and needs help with both procedures. When she was first admitted she was violent too and would throw her clothes around, though over time she has become a little calmer and is being taught to sew.

  It perhaps seems odd that idiots and imbeciles are considered to be suitable asylum patients, given that their conditions cannot be alleviated. The reason for this is that the condition of idiocy has long been given over to the alieni
sts to study. Nevertheless, the differences between lunatics and the disabled are widely noted and there is increasing encouragement to give them alternative arrangements according to their different needs.

  Chapter 5

  Staff

  For the purpose of your stay, the staff at the asylum can be neatly grouped into two communities: those whom you will see around on a daily basis; and those who work behind the scenes. Within both communities is an order of command and a series of duties carefully defined so that everyone may know his task. Stepping outside those duties, or performing them incorrectly, is considered a noteworthy misdemeanour. There is also a natural division between the different classes of staff, reflecting their rank within the asylum.

  Ultimate power rests, of course, in the committee of visitors, but as these men are unable to offer more than the occasional period of time, they must, of necessity, delegate the responsibility for running the asylum to their appointees, and here the true hierarchy begins. We shall consider each of them in turn: officers, attendants, and servants.

  The Asylum Officers

  The Medical Superintendent

  As any army needs its general, so too does the asylum require its superintendent. For the superintendent directs all that goes on – he is the head of medicine, as well as of staff management – and his control extends to every aspect of life in the institution. He is by some distance the best paid member of staff (let us suggest a salary in the region of £400 per annum), and also enjoys a generous allowance of six weeks’ leave. He is appointed solely by the committee of visitors – from whom he must seek permission for any absence – and acts as their representative during daily operations.

  Asylum superintendents are very rare birds. They combine a forensic aptitude for scientific analysis with the decision-making skills of the brightest administrators. It is a given that, when appointed, they should already be of high standing in their profession: a member of one of the colleges of surgeons or physicians and a former student of one of the universities. In addition, they are highly practical exponents of the art of the mind-doctor. Superintendents have first to hone their skills as assistant medical officers before they can be considered suitable to run an asylum. This does not mean that they are necessarily aged, for a medical man’s career can progress quickly. Our first superintendent was appointed while in his early thirties and the present one assumed control at the age of 29.

  The superintendent commands respect, but is also able to listen carefully to both his staff and patients. He exercises a benevolent control over his institution based on experience of his situation and a confidence in its handling. Yet this is not an arrogant or inaccessible man, and you will see him every day in his smart suit as he makes his rounds. He is also expected to make unannounced visits to the wards at any time of day or night so that he can see that all is well. On any of these occasions you may ask to speak to him, and he shall be happy to hear you; equally, you must obey his instructions.

  One of the ills resolved by the modern asylum is the previous tendency for superintendents to undertake external paid work. Often these men were in private practice, and saw their public income as merely another part of their personal receipts, to be treated as with any other contract. This merger of the public purse with private business led to poor medical standards, and patient care became a barrier to profit rather than a central tenet. The filth and restraint in which many patients found themselves was detailed in the 1844 report by Parliament which led to the reforms of the following year. The lawmakers insisted that the modern superintendent devotes the whole of his time to the office from which the ratepayers expect so much.

  The care and treatment of his patients must be the primary concern for any superintendent. Thus the provision of comfort, accommodation, occupation and amusement are all ultimately laid at his door. While he may delegate some matters to his supporting officers, it should be remembered that there is a medical element to every aspect of hospital care, even the lines on the cricket pitch and the linen on the beds.

  Each morning, the superintendent will arrive at his desk to find a series of reports from his officers and senior attendants, describing anything of note that should be queried or examined on his rounds. As well as the condition of all patients, both male and female, the superintendent is additionally responsible for the cleanliness and presentation of the male wards, and this is a further object of his daily inspection.

  The devotion to duty required can lead some superintendents to attempt control of every detail in their charge. The tale of our first superintendent is a salutary one. He was appointed as the building was still under construction, and made many helpful suggestions as to its fittings and fixtures. But in time this focus on the minutiae of his empire became his undoing.

  He had always been an obsessive character, a lifelong bachelor, whose circle of friends dwindled as the years wore on and he became ever more anxious about his work. He was reluctant to take holidays and seldom was seen at meetings with his professional colleagues. Gradually, his standards were set so high that none could achieve them, and after fifteen years of trying to fulfil his exacting strictures two of his senior staff decided that they could work with him no longer. They resigned. His own health broke down while he tried to recruit their successors, and he died exhausted some five months later.

  This demonstrates the strain that is placed upon those in high office. Here is the man of whom all requests must be made. The superintendent interviews patients who wish to see him, or who are presented as suitable for discharge on trial. More unpleasantly, so too falls to him the duty of carrying out post mortems on patients who pass away while in our care.

  It is the superintendent also who decides where each patient should be placed within the asylum, and no movement between the wards is undertaken without his express order. The superintendent assesses whether any patient requires a change in diet and updates the attendants on the numbers in the wards and the rations to allow. He oversees the keeping of records, of movements in or out of the asylum or other incidents, of staff appointments and behaviour, details of receipts, expenditures and stock; and these are collated and in due course form the basis of his reports to the committee of visitors.

  The superintendent is additionally the link between the patients and life outside the asylum. He is obliged to decide whether letters written by patients may be forwarded or, alternatively, received by them; to keep patients’ friends and family informed of any concerns or the sickness of a patient. He is assisted in his work by the proximity of his abode, which is adjacent to the asylum block. Thus he is always close at hand and able to deal directly with any need. His omnipresence provides reassurance that a familiar face will be continually present during your stay.

  The Chaplain

  You may have encountered many different characters of priest; those who hold strongly to one or other interpretation of the scriptures, and whose wish is that others may have their eyes opened to this particular interpretation; some for whom the words of God lay heavy, like a sombre beam that supports the soul; and others who believe that only they can channel the mysteries of the divinity.

  Such men are not to be found in an asylum, where propensities to fanaticism, guilt or exclusivity are not useful traits. Rather, our chaplain provides a broad church and he can also raise spirits and turn his hand to many secular pastimes without brooding on the delicacies of religion. He plays cricket and helps out with the entertainments. He is one of us.

  Any asylum chaplain will have graduated from the universities of Oxford, Cambridge, Edinburgh or London, before being ordained in holy orders. Like all the officers his work at the asylum is his only calling, though he may also be found teaching scripture at the local village school, where the children of our attendants and servants receive their own instruction. Within the clergy the post has a junior air, and as a result the chaplain is often a novice embarking on his career. This leads to a rather high turnover of chaplains, as the role compares unf
avourably with the benefits available to a rector, and twice already we have lost our clerics to better offers from a local parish.

  Our present chaplain has previously been a curate at various places across the country, including a rural poor law union. He joined us from a church in Hackney, where he had published some works about the area’s local history – an achievement for which he was made a fellow of the Royal Historical Society. We hope that he turns out to be a greater success than his predecessor, a married man with seven children, who had been given a second chance after he formed a most unwise extra-marital liaison with the village school mistress. Following months of intrigue the pair eloped to Uxbridge, returning, allegedly contrite, a few days later. Relieved of his parish duties and sent to us instead, he disappeared last autumn without notice. It transpired that he had gambled his way into substantial debt. When one last horse failed to triumph, he resolved to escape his creditors by boarding the next boat for Montevideo. He has not been heard of since.

  That these things can happen demonstrates how the chaplain exists somewhat separately from much of what goes on in the asylum. Although nominally under the control of the superintendent, the role of chaplain has much independence, and he is in some respects of equal standing to the senior man. The chaplain is the only other officer granted the maximum of six weeks’ leave, for example, and he is also second (if a rather distant second) in salary only to the superintendent. This enhanced standing reflects the other-worldly qualities of spiritual direction; it would be a rash superintendent indeed who would interfere with the content of morning prayers or Divine Service.