The Story of Nursing in British Mental Hospitals

Echoes from the Corridors

Niall McCrae, Peter Nolan

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9780415738958
• eBook ISBN: 9781317812388
• Edition: 1
• Topic: Medicina
• Subtopic: Storia sociale

From their beginnings as the asylum attendants of the 19th century, mental health nurses have come a long way. This comprehensive volume is the first book in over twenty years to explore the history of mental health nursing, and during this period the landscape has transformed as the large institutions have been replaced by services in the community. McCrae and Nolan examine how the role of mental health nursing has evolved in a social and professional context, brought to life by an abundance of anecdotal accounts.

Moving from the early nineteenth to the end of the twentieth century, the book's nine chronologically-ordered chapters follow the development from untrained attendants in the pauper lunatic asylums to the professionally-qualified nurses of the twentieth century, and, finally, consider the rundown and closure of the mental hospitals from nurses' perspectives. Throughout, the argument is made that whilst the training, organisation and environment of mental health nursing has changed, the aim has remained essentially the same: to develop a therapeutic relationship with people in distress.

McCrae and Nolan look forward as well as back, and highlight significant messages for the future of mental health care. For mental health nursing to be meaningfully directed, we must first understand the place from which this field has developed. This scholarly but accessible book is aimed at anyone with an interest in mental health or social history, and will also act as a useful resource for policy-makers, managers and mental health workers.

1
The pauper palace and its servants

In the beginning, there was care in the community. Homo sapiens has always been a social animal, whose bonds stretch beyond blood relations to tribe or townsfolk. Throughout the Middle Ages feudal communities looked after their own. The Church preached compassion for the mad as for the sick, and the ‘village idiot’, a medieval caricature of the odd or mentally impaired person, received parish alms. The term ‘lunatic’, derived from the legendary belief in mental derangement provoked by full moon, applied to people with temporary or permanent 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 ducking pool.

Since the fifth century monasteries had been established in Britain. The monastic life demanded unquestioning obedience, self-restraint, humility and commitment to improving one’s spiritual life through service to the community, asceticism and celibacy. As in secular enslavement, monks’ heads were shaved to confirm their capitulation to God’s will. In a frugal existence, devotees sought to overcome the desires of the flesh by fasting, manual work, prayer and study. They laboured in the fields, the mill, kitchen and gardens; skilled ‘brothers’ were deployed as smiths, leatherworkers, masons or carpenters, and a scribe produced the chronicle of the monastery.¹ By around the twelfth century Benedictine monasteries began to reach out to people with sickness or disability in the community. Peripatetic monks visited sufferers of mental disorder in their homes 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 the monastery until able to return home.²

Despite such caring provision, some people of wayward mind and spirit were seen as a danger to society, drawing not sympathy but severe penalty. In the religious turmoil of the late Middle Ages, insanity and evil were often conflated. The omnipotent Catholic Church responded to deviance and dissent with the Malleus Maleficarum (Hammer of the Witches), a missive credited to two celibate Dominican theologians, Heinrich Kramer and Jacob Sprenger. The Malleus asserted the dangers of witchcraft, and guided magistrates on interrogation and torture.³ Witches were known as libidinous women who copulate with incubi, casting spells in cahoots with the Devil to spread evil throughout the land. While some men were also persecuted, the misogynistic Malleus asserted that women, due to their vanity, proneness to lying, weak intellect and lust, were most prone to diabolical possession. Between 1580 and 1650 there were 200,000 prosecutions in Europe; the guilty were burnt at the stake, thereby destroying both body and spirit.⁴ The sixteenth and seventeenth centuries were dangerous times for anyone behaving oddly.

As society recoiled from witchcraft hysteria, theological interpretations of madness began to be eclipsed by the advance of medicine. Dominating Western medicine was the ancient Greek system of four humours: blood, yellow bile, black bile and phlegm. These humours governed behaviour: mania was due to bile boiling in the brain, while excessive black bile caused melancholia; imbalances were treated by purging, blood-letting and sudden plunging in hot or cold water. A more humane treatment of madness was promoted by maverick Swiss physician Paracelsus in the sixteenth century. Having observed healing practice in Tibet, Constantinople, Arabia, Egypt and the Holy Land, Paracelsus rejected harsh physical methods and medicinal concoctions as guesswork, emphasising instead the moral virtue of the lunatic’s carer or physician.⁵ Eventually humoural medicine was undermined by revelations in anatomy and physiology, and discovery of the nervous system relocated the seat of insanity from visceral organs to the brain.⁶ However, this was not readily followed by advances in treatment: Thomas Willis, reputedly the first neurologist, saw torture as the 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 frantyke or demonyacke, to be kepte in safegarde in some close house or chamber where there is lytell light; and that we have a keeper the whiche the madde do fear.⁷

From alms to the madhouse

The only institution specifically for care of lunatics was the Bethlem Hospital in London. Built in 1247 as a priory dedicated to St Mary of Bethlehem, this establishment moved in 1676 from its monastic buildings to a larger site beyond the city wall at Moorfields, with accommodation for 120 lunatics. 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 their keepers to growl like wild beasts for their audience. The governors extracted donations from affluent visitors, in whom pity might be aroused; this was a major source of profit until the notorious parade was abolished in 1770.⁸ Although the hospital was run by a religious organisation, the mostly male staff was not averse to brutality. Treatments included bleeding, blistering and beating, but as insanity eluded cure, Bethlem rested on the assumption that the best that could be done for the insane was to restrain them.

A corrective to Bedlam was Robert Burton’s The Anatomy of Melancholy, published in 1621.⁹ An Oxford don and celibate priest, Burton was afflicted with physical and mental maladies throughout his life. He saw melancholy as an imbalance of body, mind and spirit, which could be corrected by the restorative powers of blood-letting, exercise, good diet and country air. It was the responsibility of the medical profession to help people whose affliction alienated them from their fellow beings. Sufferers needed a calm and restful environment, supported by kindly, tolerant people. For Burton, lasting recovery depended not on the quantity of medicinal concoctions but on the quality 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 the appointment of James Monro in 1728.¹⁰ The Monros refused to take medical students and were intolerant of anyone who doubted their methods. Despite its worsening reputation, Bethlem had a lengthy waiting list. James was succeeded in 1751 by his son, John, in the same year that a rival institution opened across the road. Appointed as physician in charge of St Luke’s Hospital for Lunatics was William Battie. Son of a vicar, Battie’s commitment to improving conditions for the mentally ill was inspired by the Enlightenment philosophy of Hobbes, Rousseau, Voltaire and Locke. Hobbes’ Leviathan, published in 1651, presented the ideal of a social contract whereby the State would control greed and protect the weak from brutishness and misery. Battie’s Treatise on Madness, published in 1758, criticised the coercive and barbaric treatment and cramped cells at Bethlem Hospital. Monro was infuriated by this slur from a commercial rival.

While differentiating lunatics from other itinerant outcasts, the Vagrancy Act 1744 could only enforce their removal to a house of correction, but in the eighteenth century various institutions for the insane emerged. Some of the general hospitals that opened in larger cities, funded by public subscription schemes, included an annexe for lunatics (as at Guy’s in London). The Manchester Lunatic Hospital of 1766 was administratively attached to the general infirmary, an arrangement followed in Liverpool in 1792. Meanwhile private madhouses proliferated. Typically owned by clergymen or doctors, these establishments catered for private lunatics or recipients of Poor Law assistance. Unsurprisingly, the latter class got the worst deal; head-shaven inmates were perpetually shackled to the walls of dank and dingy cells. Concern at abuses led to appointment of a parliamentary committee to enquire into care of lunatics; the resulting Madhouse Act of 1774 required a licence for owners, and in the London environs madhouses were to be inspected by a body of five commissioners from the College of Physicians. As the only sanction was that details of irregularities were displayed at the madhouse entrance, proprietors remained a law unto themselves. It was the rough treatment meted to King George III during his episodes of madness that brought the plight of the insane to public attention.

Philanthropists’ stone

Exempt from the Madhouse Act was the care of pauper lunatics. In 1806 High Sheriff of Gloucestershire and prison reformer Sir George Onesiphorus Paul, after visiting several madhouses, highlighted the dreadful plight of the insane poor to the Secretary of State for the Home Department. This led to the appointment of a Select Committee, chaired by Charles Williams-Wynn and comprising several members of the Clapham Sect, an influential society for humanitarian reform.¹¹ At this time the number of identified lunatics was small: only 2,248 in England and Wales (2.26 per 10,000 population), of whom 1,765 were in workhouses and 140 in gaols. In its report in 1808 the Parliamentary Committee presented a catalogue of cruel and degrading treatment, demonstrating urgent need to protect lunatics – particularly paupers, who had no choice in where they were sent. A law was subsequently passed for the provision of county pauper lunatic asylums.

To understand these developments, we must consider the political and social context of Britain at the beginning of the nineteenth century. Parliamentarians at this time were aristocrats, and parochial authority rested with the landed gentry: the few governed the many. Men (rarely women) of high social standing were selected as magistrates by the county’s Lord Lieutenant for formal appointment by the Home Secretary (a system that continued until local government legislation in 1888). Any transfer of power to the State was likely to be opposed as a threat to local autonomy. The County Asylums Act of 1808 was a tentative step, merely giving English and Welsh county justices the option to build an asylum at ratepayers’ expense.

The 1808 Act recommended that asylums be built on an airy, south-facing site with good water supply. They would be located on the outskirts of a market town, thus within reach of medical assistance. The reformers were inspired by a model establishment in York founded in 1792 by William Tuke, a tea merchant and philanthropist. The Tuke family were Quakers, a minor religious group whose basic tenets were peace and simplicity. The ethos of The Retreat was moral management, based on the notion that even the most frenzied lunatic could return to lucidity if treated well. Each of the thirty residents was allocated a personal attendant, and troubled minds were diverted by fulfilling occupation, prayer and recreation. The spacious grounds were aesthetically pleasing, with gardens offering views over the surrounding countryside, and domesticated rabbits and fowl in the airing courts. 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 The Retreat,¹² published in 1813, the principles and practice of moral management required little medical input; visiting physicians merely treated bodily illnesses (not until forty-two years after its opening was a medical superintendent appointed). By contrast, patients in other lunatic hospitals and asylums were subjected to regular purgatives and cold baths, phlebotomy of the arteries of the head and neck, and contraptions such as the gyratory chair. The Tukes saw such interventions as distasteful. As eloquently discussed by Michel Foucault in Madness and Civilisation,¹³ it was incidental to the development of the medical profession that a system of institutional care was founded for the insane. In the guise of ‘alienists’, doctors appointed to manage the new county asylums had more appeal in social stature than in clinical expertise. However, the asylum movement sowed the seeds of a medical monopoly of madness, in which the scope of practice expanded from individual treatment to an overall therapeutic regime.

Alongside the Tukes the greatest pioneer in the institutional care of lunatics was physician Philippe Pinel, who in 1792 was appointed head physician at the Bicêtre, a large hospital for the insane in Paris. This was a time of turmoil in France, as Robespierre pursued his Grande T...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of illustrations
• List of tables
• Preface
• Acknowledgements
• 1 The pauper palace and its servants
• 2 Professionalisation, or organised labour
• 3 Shocks to the system
• 4 Interregnum
• 5 A new dawn
• 6 Time is called
• 7 Irish days, Mauritian nights
• 8 Holding the fort
• 9 End of the asylum
• Appendix: mental hospitals in Great Britain
• References
• Index