How to Cure Insanity: Treatment in the Lunatic Asylum

Sometime in 1857 a young, unidentified woman, left her home at 4.00 a.m. on a wet morning and, keeping close to the railway line, walked fourteen miles to the door of the Derby Asylum where she requested admission. This young lady had previously been a patient in the asylum and had been discharged, cured, to her home. Whilst at home she began to experience a relapse in her mental state. She reported afterwards that she feared becoming unwell at home because “they treated me badly when mad”; and she regarded the asylum as much as a home as a hospital and so hurried to get there so that she could get help in good time. When she arrived she was allowed to stay for a few days by the superintendent, not detained under the law, but able to rest and to “take a little medication”. After that she felt better and so returned to her home and to her friends where she subsequently remained.

It was an essential claim associated with the establishment of County Lunatic Asylums in the first half of the 19th Century, that many of those admitted to the asylum would be cured and then discharged. Estimates provided to the Select Committee on Lunacy in 1807 led them to believe that “at least” 50% of those admitted would be cured and returned to active employment, making their rudimentary cost-benefit analysis clear and convincing. Their estimates were not simply plucked out of thin air, but rather were driven by the data they had received from the Retreat in York and St Lukes in London. The spirit of optimism and a belief in an invigorated medical science was enough to convince parliament and public that here was a path of progress, a humanitarian and proper means to cater for those unfortunate enough to be afflicted by mental derangement.

Not until the second half of the century was there any significant increased concern about the operation of asylums. Fuelled by scandal, by polemic accounts of wrongful detention such as that by Louisa Lowe, by an increasingly influential and critical media, by gripping portrayals from novelists such as Wilkie Collins (The Woman in White), and Charles Reade (Hard Cash), a more widespread questioning of the value of the asylums began to permeate society and to a more general view from the 20th century that asylums were indeed “bastilles” in which the wrong people were detained, often without due legal processes, for long periods of time, to little or no effect. The lunatic asylum, in this view, was not just a place to be avoided at all costs, but a gothic horror palace to be demolished at the earliest possible opportunity.

Perhaps inevitably there is another reality that lies beyond these views. That amidst the harshness and the cold of the asylum there was warmth and care. That the detention of the insane did bring peace, improvement and even cure to some troubled individuals. That after the degradation of being shackled in the workhouse, or after being roped and hidden at home by family members at a loss to manage a loved one, there was a kind of freedom and meaning within the asylum walls. That an improved diet and sociable activity might provide the energy and purpose with which to face the world again.

It looks as though truth lies in both and in neither of these extremes. That for some the asylum was a place where life and hope effectively ended, whilst for others it offered new opportunity. For some a place of degradation and death; for some a chance to play a new role and see the world in a different light. For some a kind of home. For many probably no more or less than somewhere to live, a place neither of fear or hope. Merely different surroundings to pass long days with little stimulation.

Somehow, inside the arc of physical construction, and the belief in the possibilities of treatment, something was lost. Rates of cure rarely came close to those estimated, either by the select committee, nor by the admitting physicians. Yet some people did recover and resume their former lives. So, questions arise: How could the insane be cured? What can be garnered from the asylum regime that might shed light on approaches to mental illness in the present?

One way to understand the descent from early hopes of proponents into the defensive diatribes of the later Victorian specialists is by examination of the beliefs about who might be cured and how such cures might be effected.

As each new County Asylum opened its doors to the insane poor of the area, medical superintendents made efforts to distinguish the curable from the incurable. It seems to have been a fairly easy task. If you were old, or feeble, or if your mental derangement was of long standing, and especially if all three of these conditions were met, then it did not augur well for your chances of leaving the asylum. You would in all likelihood be classed as incurable. The logic to this decision rested on two assumptions. The first was that physical and mental wellbeing, intimately linked, meant that old and feeble individuals would simply not have the energy needed for recovery and the pursuit of an active life. Many of those classed as feeble were indeed diagnosed as also suffering corporeal ailments or diseases. Workhouse or family diets were often so meagre that it would take considerable time for improved nutrition to have any impact.

The second assumption was more particular to the length of the episode of mental infirmity. This was because the essential diagnosis behind symptoms of mental derangement was that of inflammation of the brain. Once the inflammation had become established it would be exceedingly difficult, if not impossible, to reduce. It was this assumption that lay behind the complaints of medical superintendents, year after year, that the “wrong” patients were being admitted. That recovery of a high proportion of patients could not be expected when so many of those entering the asylum were chronic cases for whom little more could be provided than lodgings, practical care and structured activity. An additional problem was that of “intemperance” — usually through drink — which also offered a poor prognosis.

There was a further, somewhat bizarre and certainly discriminatory reason for regarding a person as incurable: If the patient was Irish. In his discussions of the experience of treatment at Cumberland and Westmorland Asylum in ?? the superintendent is quite clear that such persons would not benefit from treatment. Wiltshire asylum report and Saxons or Vikings (see below).

It is noticeable that, as time progressed, the problem of incurables only increased. Associated also with those who were noisy, it becomes possible to see how a logical development took place — the creation of separate wards for chronic and acute patients. The Cambridge Asylum reports document this trend.

It was a key objective of the asylum superintendents that the asylum should, so far as possible, be a place in which patients (or inmates as they were sometimes referred to), should be quiet or, if not quiet, then controlled. Those who were raving were evidently unwell. Those who were under control might at least be judged as being on a pathway to recovery. This was the reasoning behind so called “mechanical treatment”. In the first of the County asylums, such as that at Lancaster, there were various forms of shackling to achieve this: uncontrollable patients were forced to sit in a system of chairs or stalls along the walls of the ward. Hands and feet were locked securely. The seats were effectively a long partitioned bench into which holes sufficient to allow for excretions had been made. Neither shoes or leg wear were to be worn and, apparently, because the floors were heated, they were in any case not required for warmth. Thus held for the whole of their waking hours the raving were unable to cause problems. The stench of the ward could be reduced by means of a tap which could be turned on to flush the sewerage. For sleeping purposes the locks would be transferred to the beds. In the morning it would be necessary to change the bedding and ensure that the patients were clean before they were returned to their day seats. Of course this control did not prevent shouting and so the use of a whip or stick to cow individuals into silence was considered appropriate.

(Patient at West Riding Lunatic Asylum, Wakefield, Yorkshire. Attributed to Henry Clarke. Wellcome Collection)

For some individuals additional treatments might be provided. These included warm and cold baths in which the individual would be held in the bath by means of a wooden cover to the bath itself, from which only the head could protrude. A variation on the cold bath was the “surprise bath” wherein the individual may be taken into a darkened room with some flooring removed, resulting in a fall into the bath. Alternatively a sudden shower — water thrown over the patient — might be the preferred option. Hot and cold bathing perhaps also owed its popularity to more ancient theories. John King, an Apothecary writing on the subject in 1737 asserts its value for people with melancholia and mania, basing the logic of that on the Greek ideas of the balance of humors which the water can influence. He draws on an influential essay by Sir John Floyer (an interesting character who contributed to the development of measurement in medicine and was so obsessed with cold bathing that he persuaded the Borough of Lichfield to build special baths for women and men…); In 1791 an essay by William Simpson, a Surgeon at Knaresborough,….. repeats these arguments, also drawing on Roman authority: “Celsus recommends cold bathing as the only remedy in hydrophobia, and further assures us that it is a true specific for all maniacs”

And another option, sometimes regarded as valuable, was the rotating chair. Initially suggested by Erasmus Darwin, prolific inventor and grandfather of Charles, the chair was used to induce dizziness then nausea and perhaps defecation, followed by sleep.

From roughly 1840 these and other forms of mechanical restraint began to be removed and soon considered by many — though not all — to have been “horrors”. It was discovered that removal of restraints usually resulted in an altogether more tractable individual with relatively little need for external control. Those patients who did require management due to dangerousness might be placed into a padded cell for a period, or perhaps just closely handled by well-built attendants. However, as this new era of treatment progressed the underlying logic bore similarity to the predecessor treatment. Thus, rather than control the lunatic patient by physical restraint, the emphasis was placed on structure, routine, activity and intellectual development. Such means would improve or at least distract the mind. It would ensure that the asylum was, overall, a place of quiet and of order. The maniac would be discouraged and the melancholic urged into engagement and activity.

The credit for developing and promoting non-restraint methods of treatment was shared between superintendents Gardiner Hill at Lincoln asylum and by Dr Connolly at Hanwell asylum. Connolly gained a strong reputation for his promotion of non-restraint, although Gardiner Hill, in a somewhat vituperative personal record wherein he excoriated some repulsive activities in various asylums, claimed credit for himself. Regardless of the actual merits attaching to the individuals themselves, the new philosophy of moral treatment clearly gained considerable ground in the middle part of the century. A well-regulated programme of supervised day work, suitable for each gender and the capabilities of the patient, good food (i.e. plenty of meat with the possible addition of a glass of beer to drink), regular evening amusements in the form of reading, weekly visiting speakers or magic lantern shows, walks, summer games of cricket, church services every week or even every day, were all regarded as essential features of such treatment.

By the latter part of the 19th Century further inroads into the harsher conditions of the asylums were being supported. At Prestwich in 1881 the Commissioners in Lunacy noted the plan to treat melancholia by means of installing a Turkish Bath, which they regarded as commendable. More widely, though, was an overall improvement (noted even as being “luxury”) being afforded to patients in some asylums. This, whilst being considered acceptable in itself was also seen as the cause of problems: many of the patients who were discharged as cured, being paupers, would be transferred to the union workhouse for the area from which they had formerly lived. This meant that they would have to live in conditions designed to ensure that no-one would really wish to be there at all. Re-admission to the asylum was hence an attractive option for some who — to the evident suspicion of asylum visitors, found themselves falling into mental ill-health again.

An additional problem with the model ideals of a personalised moral treatment regime was the cost. Such an approach, requiring a close knowledge of each patient to properly administer, required higher levels of staff with skill, patience and aptitude for the work. Not only were such staff difficult to come by, but the economics of the asylum — and more especially the Boards of Guardians and Visitors overseeing matters, placed intense pressure on overheads. When asylums such as Colney Hatch, Hanwell and Lancaster increased inpatient numbers to more than 1,000 and even reaching 2,000, the costs could be kept under control by staffing ratios in the region of one attendant to 50 patients. But effective moral treatment, it was argued, required a ratio of something like 1:15. Asylum superintendents and finance officers published detailed accounts to ensure they could be favourably compared for economy with other similar establishments.

Thus developed a triangulated problem in the asylum approach: Moral treatment required high staffing and skilled management. Superintendents also wanted to develop and improve medical treatments and hence wanted fewer patients and those who were “of the right kind” — i.e. people they regarded as curable. And socially and administratively the public and the asylum guardians wanted control of the intemperate and the escape minded, and minimisation of expenditure. In its essence a problem recognisable today.

Solutions to this problem set were, it might be argued, soluble in the best of the asylums. This was down to the efforts of the most energetic and positively minded of the superintendents. Dr Kirkman at the Suffolk asylum gained a positive reputation. Dr Hitchman at the Derby asylum achieved a high international renown for the local asylum. People had frequently been admitted to Derby Asylum under restraint. He quotes a particular instance of man who was 6 feet tall and very well- built. On admission he was roped and manacled. He spent the first night shouting “Murder” at full voice, and had required 3 men to manage him. However, “In a few minutes all the manacles were removed; he has had the perfect use of every limb since he has been in the asylum, and has been fully controlled by moral means alone”.

Of course, as the profession of medicine and the introduction of new treatments for physical conditions progressed across the century, the enthusiastic alienist (as psychiatrists were still referred to) were keen for easy-to-administer medicinal cures for mental derangement. With no established guidelines for clinical research superintendents might proceed by individual experiment and observation. A wide range of “cures”, homeopathic and allopathic, were tried out. “Tinctures such as Sumbul and Extract of the Cotyledon Umbilicus” have been used but with no real success, reported one superintendent. Chloroform was administered to a patient who was pregnant and “in a prolonged state of maniacal frenzy” — “with great advantage”. Some were treated with constant use of the water bed. Suicidal patients were treated as well: Acetate of Morphia; opium; tartar emetic (containing the poisonous chemical antimony); also Battley’s Sedative with Tincture of Hyoscyamus”; digitalis and leeches were tried and dismissed. Many of these medicinal remedies were essentially a stab in the dark, a hit and run approach to cure where the logic might be summarised as the application of a possible cure which, if it seemed to work would be continued, and if it worked it might throw light on what was the real cause of the problem in the first place.

The positivist approach was undeterred by the lack of real results from any such treatments, and simply became more sophisticated. An experiment in 1894, for example, was reported from Derby in a more structured form. Thirty patients were treated with thyroid extract (administered as tablets) and the results assessed with regard both the physical effects and to mental recovery. The results were considered to be promising:

• Mania: 4 treated; 2 improved/recovered
• Melancholia 5 treated; 2 improved/recovered
• Syphilitic Insanity 1 treated; 0 improved/recovered
• Alcoholic Amnesia 1 treated; 0 improved/recovered
• Chronic Insanity: 7 treated; 3 improved/recovered
• Puerperal Insanity: 4 treated; all improved/recovered.
• Lactational Insanity: 2 treated; 1 improved/recovered
• Climacteric Insanity: 3 treated; all improved/recovered
• General Paralysis: 3 treated; 1 improved / recovered

Overall: 30 treated; 16 improved/recovered. (53.3%)

These results provided enough evidence for the researchers to recommend thyroid tablets as “a useful addition to our armamentarium in the treatment of certain cases of insanity”.

In the twentieth century the pharmacological revolution has resulted in the introduction of many new medications for the management and treatment of mental illness. The reality remains that many of those treatments have been discovered by accident rather than by design. When the asylums were first opened they swept significant numbers of problematic individuals out of public view and provided a testing ground for all sorts of cures. Cures that have now been dispensed with.

Those who recovered and who were able to return home almost certainly did so in spite of rather than because of the “treatment” provided. What seems to have been more valuable then, as now, was the presence of those staff and perhaps patients who provided time, personal attention, a caring approach, stimulation, a sense that the individual and his or her own life mattered.