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

by Mark Stevens

  Not only are you curtailed here through your loss of liberty, but also through the limits placed on your freedom of choice. Your choice of diet is controlled and so too how you fill your day. Your favourite chair or bench is no longer solely yours; on hot days the shady spot outside may be already taken and in winter there may be many already warming themselves before the fire. However generous the floor space, this is a crowded, communal place and the enforced proximity to others can lead to frustration. Familiarity causes irritation and small gestures assume weighty gravity, while repetitive habits may annoy.

  Some patients have additional restrictions forced upon them by the nature of their delusions. To worry about being poisoned is to become agitated by food; to hear insulting voices close at hand is to suspect your neighbour. Nevertheless, these incidents pale when compared to those brought about by the ordinary pressures of shared living. For this reason, the first response to violence is usually one of dispersal. The disturbed patient must be set free to wander in the grounds with an attendant for company, and, once calm, induced to engage in some sort of occupation. Application of the moral treatment works wonders in many cases of aggression.

  If you are inclined toward aggression then you will probably be moved into a refractory ward with other patients who share that tendency. Great care is taken in these wards to remove items that may be used as weapons, though once a patient has employed a particular means of assault, this is likely to become his method of choice and opportunities can be taken to prevent similar circumstances arising: clothing can be searched for tools or cutlery; pockets may be emptied of stones.

  Should you mount a physical attack you will be restrained from behind by an attendant, while if you have a weapon, an attempt is made to disarm you. It may be necessary to take away your balance with a back-heel, forcing you to fall. Once the attendants have control, you will then be restrained.

  The greatest risk of harm in asylums is not, however, from other patients, but from yourself. For it is suicidal patients who exercise us more than any other, not least because of the great difficulty in accurately predicting the fatal impulse. The outward appearance of melancholia is no barometer for the true state within, and if we asked our attendants merely to watch those patients who appear sombre then we should fail to miss the carefree appearance of one who has resolved to destroy himself.

  Around half our patient group will have been considered suicidal at one time or another. Those who have attempted self-murder over the past month, or before their admission, are placed in a ward where it is possible to observe them closely. What is harder to watch is whether a patient is collecting harmful items such as stones, cord, wood or metal, and for this reason bedding is regularly inspected.

  The impulsive nature of suicide makes it almost impossible to guard against fully. Whilst any patient who has ever attempted it will be considered at risk of relapse, successful suicides often occur amongst those patients who have been here many years and recently shown no sign of felo de se. Sometimes a suicide attempt is brought about by an external factor and sometimes there is no known cause. One of our ladies could not bear to have her husband see her in her disordered condition and, as he arrived in the waiting room one day, she took herself off to the top floor of the female side, where she successfully hanged herself from a metal coat hook in the corridor. Other cases comprise another lady who swallowed a quantity of hair pins, and a man who waited until the airing court was clear before tying a noose to one of the trees.

  Mercifully, we thwart the majority of attempts at destruction. Of those that succeed, perhaps the saddest case in recent years was of a young woman whose condition had improved until she was considered to be convalescing. Soon after her move to the trusted sewing ward, she took a knife from the scullery and made off into a water closet, where she cut her throat.

  If you are considered to be actively suicidal, then you will be accompanied everywhere by a dedicated attendant, even to the water-closets, and one of the medical officers will visit you daily. A form, known as a caution ticket, is also issued to all attendants looking after you, stating that you are suicidal and they must sign it to acknowledge that they have read that statement. This is usually repeated day and night at the change of each shift.

  As another precautionary measure, you will be searched in the morning and evening, and helped to dress and undress. However, you will not usually be restricted in what activities you can undertake because some trust is required to encourage self-reliance. Nevertheless, we must still carefully observe you; one patient allowed to attend chapel decided to scale the holy roof, then jump; happily his fall was broken by an attendant.

  Once you have recovered enough for this exceptional care to be removed, you will spend the next few months sleeping in a dormitory that is watched at all times, and you will be forbidden from being in the workshops or to work alone in the wards or gardens. It takes considerable time to regain sufficient trust for you to work with tools again.

  As much as possible, the temptation to end your life is removed by deliberate design and the vigilance of staff. Attendants are instructed never to carry knives or scissors around the building; if they wish to shave, they do so away from the wards. Points of suspension are not generally found within the building: hooks, holes, poles or bars are kept to a strict minimum, and even the window shutter handles and the fittings for the gas lamps in the dormitories and day-rooms are recessed to such a high degree that no purchase can be found. Your safety is paramount.

  Children in the Asylum

  One of the less well-known aspects of our institution is that a small number of children are resident here, and at any time you may find a handful on our books. The juvenile patient usually stands upon the cusp of adulthood, but one or two are under ten, while our youngest was admitted at the tender age of five.

  These children have come from the same place as you: a family home. They are, almost without exception, suffering from a defect in their evolution rather than a defect in their thinking. Their disabilities were usually apparent from an early age, when their parents noticed that they remained unable to control their bladders or their bowels, lacked physical co-ordination or the ability to communicate and socialise. A significant proportion are also afflicted by epilepsy.

  Every family tries at first to manage these children at home, and for some this is entirely practicable, as either elder siblings or relatives nearby may provide a little extra supervision. The children here have come to us either because there are no older siblings, nor a helpful extended family, or because it has become impossible to control them in domestic life. Please do not judge their parents too harshly.

  We offer these children the same treatment we offer our adult population and they are able to take a full part in the moral regime. Every attempt is also made to educate them, if their disabilities allow, from the chaplain’s lessons in reading, writing, maths and scripture to opportunities for apprenticeship. Additionally, the attendants make an effort to teach everyday intercourse, as the use of a spoon or fork, or the ability to control their temper can make an appreciable difference to a child’s quality of life.

  Recording Your Treatment

  Whatever medical treatment you undergo will be noted, beginning with admission. A new page in one of our casebooks is begun for you. Your first notes include some description of complexion, stature and gait, together with remarks on any notable facial expressions. An observation is then made of any symptoms noted before or at admission, and this maiden summary allows later comparisons to be made.

  As time goes by, your case notes will be built with further observations from the medical officers, noted down during their rounds and later formally written up. The Commissioners in Lunacy suggest that notes should be made on a case once a week for the first month; thereafter once a month will suffice for convalescing cases, with one note every quarter for cases remaining unchanged. These rules are mostly adhered to, though a chronic case that has continued without variatio
n for many years may warrant only a solitary annual note: ‘No change’.

  Some behaviours or occurrences may require an additional note. One of the principal features we observe is your own conduct and response to the daily necessities of life, so that any peculiarities regarding eating, social contact, speech or work will be worthy of recognition. These are the tools required if you are to successfully re-enter the community. It is important to know if you wet or soil yourself; if you reject some foods but not others; if you fail to speak in company but will speak to yourself when alone; if you hoard things or throw them away. Equally, how you respond to staff, to other patients and to your friends and family is of interest to us. Does a male patient quarrel every time he is asked to work in company? Does a female patient with infants of her own engage with children?

  There is also the matter of your interest in your personal appearance and in that of others. Any fascination regarding dress will be keenly noted. The enhancement of ourselves is a key natural urge and a loss of interest in neatness or cleanliness is a symptom of an unwell mind. Similarly, inappropriate dress will be noted, as will the desire to discard items of clothing.

  To these observations we add others that reflect upon your feelings and your thoughts. Though we separate those concepts, the two are much intertwined. Your disordered feelings about things such as religion, food or even people often follow from your disordered thoughts. We are always keen to observe your powers of memory and reasoning, as well as your perceptions. Of course, every man and woman in society will occasionally filter the evidence of their senses and reach conclusions that are false. Yet the difference between the sane man and the insane is the ability of the sane man to recognise and then correct his mistake. The insane patient is doomed to hunt within a false world for a truth that must elude him.

  These reflections form the narrative of your case. They allow us to see how the moral regime benefits you and how your illness is progressing. They are referred to whenever your case is discussed by the medical officers or with your friends and family. They form the evidence for our actions, and the basis of our decisions.

  Chapter 8

  General Health and Patient Care

  Although the asylum is not a general hospital, it is still concerned with bodily health and renders appropriate medical attention to its patients, usually falling under three headings: cleanliness, comfort and safety. Each one has a role to play in the running of a good asylum. As your cleanliness and comfort have already been discussed at length previously, this chapter deals with the third aspect of care: safety, and its various elements.

  Medical Practice Within the Asylum

  Though this is a hospital for the sick in mind, our patients are just as likely as the sane population to suffer from physical ailments. We therefore need to create suitable conditions to prevent outbreaks of disease.

  Certain illnesses are more prevalent in large institutions than in other places. The first is phthisis, also described as consumption or tuberculosis, which affects the lungs, causing breathing difficulties. Phthisis is commonly found in towns where the density of population is at its greatest. This disease is airborne, which is another reason why we encourage ample ventilation throughout the asylum. For the microbes to be airborne, they must first be projected from a carrier and so attendants will forbid patients to spit into any of the ventilation grilles within the wards or onto the ward floor. Spittoons filled with sawdust are provided in each male ward and used by the patients who chew tobacco, but they are regularly emptied, then rinsed with boiling water.

  The early symptoms of phthisis include a persistent cough and loss of weight. If you are found to be suffering from the condition, then you will be issued with rags to wipe your nose or mouth. These rags are destroyed once used. If your symptoms are slight you will be allowed to remain on your usual ward, but should your symptoms worsen, then you may be placed within a single room at the end of the ward corridor or even moved to the infirmary.

  Persistent cleaning of the wards is the chief method by which we prevent contagious diseases such as smallpox, scarlet fever or measles. Washing and disinfecting surfaces constantly is our best defence against an epidemic. This is also true of erysipelas, the disease most prevalent within asylums, which brings with it fever, sickness and skin eruptions. Nevertheless, no amount of cleanliness is guaranteed to provide an impermeable barrier and intermittent outbreaks are inevitable. Earlier this year we had a sudden outbreak of scarlet fever, which was traced to one of the attendants’ cottages.

  In such cases, the infectious patient poses a grave risk to the others. Sufferers are immediately placed in isolation within the infirmary ward and all their clothing is disposed of. Each contagious disease also brings with it some peculiarities of management. Any discharge from the eyes, mouth or nose must be wiped away with a rag which is then incinerated, and a disinfectant solution sponged around the affected area, while a similar mouthwash is available for gargling. With skin diseases such as scarlet fever or smallpox, any crusts peeling from the body will be removed before the skin beneath is bathed in carbolic wash. Whatever the contagion, all bedding is changed regularly and disinfected before it is re-used.

  If you are suffering from a disease then the attendants will also begin to record your symptoms, noting points such as duration and frequency of coughing or vomiting, regularity of bowel movements, temperature and pulse rates. Any unusual discharges, and also possibly urine will be collected for inspection by one of the medical officers.

  Even if your illness is not catching, you may still find yourself removed to the infirmary wing, where you can be more closely observed and treated in a quiet place detached from the hurly burly of asylum life. Our infirmary is kept fully aired, but pleasantly warm, maintaining a temperature of around 60 degrees Fahrenheit. Your bedclothes will be changed regularly, while the sick rooms are also cleaned constantly, being scrubbed or wiped down with antiseptic solutions of carbolic acid diluted in water.

  From time to time, the medical officers may prescribe some medicine, or even surgery for sickly patients. Emaciated or debilitated patients are often given a nutritional fortification such as beef tea. Brandy or port wine are also used: one 87-year-old male patient currently in the infirmary has been taking spirits and a hot water bottle. Sedatives or emetics are offered for physical ailments where either rest or evacuation of the bowels is required. Like other medicines, these tend to be prepared in advance as mixtures for dispensing. The medical officer decants a bottle of the mixture for issue to an attendant, who shakes the bottle before a quantity is measured out into a glass, ready for drinking. Medicine is only rarely dispensed in pill form, and if so, the attendant will first crush the pill and mix it with some food or drink.

  Wounds are bathed with a diluted solution of iodine, which cleanses and also aids the healing process. If the wound is related to sores from a prolonged stay in bed or a skin complaint, then a poultice can be made from a mixture of linseed meal, water and mustard within a linen wrap. For breathing problems – such as those caused by phthisis – patients are asked to sniff steam or medicated vapours, placing their nose and mouth over a jug to inhale, and taking each alternate breath from the fumes. For patients with throat or mouth infections, gargling may be practised, though it is often lamented at how much time attendants spend teaching patients how to gargle.

  More invasive treatments include the application of catheters or enemas and suppositories. Catheters are only applied to those patients who are unable to rise to urinate; a hot sponge is applied first to relax the body before the catheter passes. Enemas – for patients who are constipated or whose health would be improved by an increased level of evacuation – are supplied through an injection. Should you require an enema, you will be asked to lie on your side and to draw your knees up before warm water – sometime mixed with a little soap or castor oil – is gently eased into you. Typically around one or two pints will be used in each operation. Suppositories are introduced by hand t
o patients similarly positioned.

  Surgical intervention is avoided unless considered absolutely necessary. If your complaint escalates, we will engage a surgeon on your behalf from amongst the local medical men and his fees will be borne by the ratepayers. The most common surgical procedures are amputations of infected limbs, or the removal of tumours found in the torso, yet a number of tracheotomies have also been performed here on patients who have attempted to cut their own throats.

  Your consent, if you are capable of giving it, will be sought before you undergo any surgical procedure. Most modern surgeons use ether or chloroform gas as an anaesthetic, to ensure that you will be wholly unconscious for the operation. Of course, surgery can never be completely without risk and a successful prognosis is not guaranteed. We lost one middle-aged patient after his leg was amputated above the knee; and patients with large tumours are often so unwell that a sustained recovery is unlikely.

  Emergencies

  During your stay, you may witness various sudden deteriorations or accidents. Please do not be alarmed if you are party to such an event; the attendants will immediately fetch one of the medical officers and prompt remedial action will be taken. The most common emergency is a loss of consciousness. Generally, a patient who has fainted will first have their throat checked for obstructions, before their clothing is loosened round the neck and waist. Most incidents are fleeting and patients soon recover.

  The greater proportion of accidents in asylums relate to falls, due to the high numbers of elderly, demented patients and also the number of patients who suffer from involuntary movements. Last year alone, a male epileptic suffered a broken leg when in a fit, while one of the female helpers in the kitchen lost her footing on a stool and broke her ankle. Falls can be upsetting to witness: cuts or haemorrhages may cause severe blood loss, while fractures may cause limbs to adopt unnatural angles. Any accident is attended to quickly, and a loss of blood dealt with either by raising the affected part of the body to let gravity take control, or else by the application of a tourniquet. With a fracture to the leg or leg joint, the patient will be comforted in situ until the medical officer arrives. If you have a fracture to the arms, wrists or hands, it may well be possible to place the limb in a towelled sling so that you can move around the ward until proper medical attention is obtained.