Difficult Diseases: Tuberculosis and Other Infections

The pre-war annual asylum death rate of under ten per cent rose to 12 per cent in 1915–1916, and 20 per cent in 1918. There was little alarm, because causes of death were the same as pre-war, often infectious diseases, so it did not indicate staff failing in their duty of care, such as if the rise been attributed to “accidents” or suicide. Little was done to stem the rising death rate. A parallel rise did not occur in community dwelling civilians. Numerous practices, known to be unhygienic, risked spreading infection. They included: treating healthy and infectious patients together in open wards; lack of hand washing by laundry and kitchen workers and by patients after using the lavatory; lack of measures to prevent inhalation of mycobacterium tuberculosis; and drying soiled underclothing in the ward to be worn again without washing. Overcrowding, understaffing and war time austerity aggravated the situation.

Shackles and Chains: Some Concluding Thoughts

Many of the themes running through this book have parallels today, associated with stigma, austerity, deaths from preventable causes, and under-provision of services from which mentally unwell people could benefit. Metaphorical shackles and chains link then and now. At the beginning of the war, speculation and hope that victory would be within easy reach informed asylum planning. Decisions justifiable on that basis, but without compensatory adjustments later in the war, created harsher asylum regimes. Public support and special provision for mentally disturbed soldiers was heartening, but it highlighted the undignified standards of care provided for mentally disturbed civilians. Despite the problems in the asylums, there were also many dedicated and kind staff. Kindness was assumed so it was not noteworthy: it usually only came to light incidental to some other matter.

Food, Farm and Fuel: An Inequitable Supply Chain

Within days of war breaking out, the country faced extraordinary chaos in the food market. Many foods considered nutritious, such as meat, were prioritised for the soldiers. The large contracts for food required by the asylums became particularly vulnerable, with food diverted into military supplies. Within the asylums, food and fuel distribution was also inequitable, depending more on status than on health need. Alongside asylum managers’ goals of lowest possible expenditure, they often had little grasp of emerging nutritional science, a potentially disastrous combination. In 1919, the Times concluded: “Have we been sending some of our lunatics into the Army and starving the others?” It called for the Board of Control to account.

Introduction: Civilians, Lunacy and the First World War

Britain declared war against Germany on 4 August 1914. For the next four years military priorities over-rode those of civilians. The entire population faced hardships, but for people designated “pauper lunatics” in public asylums, life became very harsh. At the beginning of the war, the asylums were a story of good intentions gone awry, “vast warehouses for the chronically insane and demented,” the failed dreams of social reformers and psychiatrists. A substantial historiography exists on “shell shock”, the syndrome of mental disorder suffered by war-traumatised soldiers. By contrast, the historiography of First World War civilian asylums and their patients is meagre. This book tells the story of four asylums to the north of London at a time of national turmoil, when intense austerity, deprivation and competing priorities affected those within them.

Certified Insane: Concepts and Practices

This chapter explores psychiatric concepts and clinical issues relating to patients in the asylums, including classification of disorders; research; nature and nurture hypotheses; and treatment and convalescence. From medical and legal standpoints, definitions of insanity were vague, subjective and their value debated. Physical illness and mental disturbances overlapped and there was little consensus on the relative contributions of heredity, brain disease, psycho-social, spiritual and other non-medical factors to causing mental disorders. Treatment became more custodial, often relying on sedative medications, restraint and seclusion. Individually focussed treatment was an ideal but hard to implement in large impersonal, overcrowded and inadequately staffed asylums. Particularly during the war, the asylums lost the precious commodity of staff time to build therapeutic relationships and provide psycho-social treatments to assist recovery and manage the most disturbed patients humanely.

Infrastructure: Rules, Walls, Obstacles and Opportunities

This chapter discusses the organisational underpinning of the asylums during the war. The Board of Control oversaw the asylums but could neither enforce best practice nor prevent low standards. Local tiers of management ran the asylums day-to-day. Government, professionals and public influenced asylum management, but patients’ voices were barely audible or credible. The system prioritised obeying rules and stifled innovation. Twenty-four asylums (23,000 beds), one quarter of the total, were vacated for military purposes. Widespread negativity about mental disorders and their treatment discouraged expenditure on anything other than the cheapest custodial regimes. People who attempted to make improvements faced many hurdles.

Accidents, Injuries, Escapes and Suicides

This chapter aims to bring together components of asylum life—the law, the leadership, staff, patients and public—to create a broad picture about what happened when things went wrong: accidents, injuries, escapes and suicides. There are drawbacks, in that much of the material is necessarily anecdotal with inconsistencies and contradictions. However, cases provide enough evidence to identify repeated patterns of attitudes, behaviours and decision making, from which conclusions can be drawn. The Board of Control indicated that it knew about asylum rough handling, but it did little to try to remedy the situation. Despite their rhetoric of good intentions, the asylum leadership frequently rationalised or denied maltreatment, thus failing to secure the most humane conditions for patients.

Personnel: Staffing the Asylums and Serving the Colours

A vast staff served the asylums: doctors, nurses, attendants, artisans, clergy, kitchen and laundry workers, and other who maintained buildings, farm, gardens and cemetery. Ward work was particularly demanding, with long hours, and poor conditions of employment. A regimented and punitive culture and distrust between management and lower ranks of staff, contributed to “a general feeling of insecurity” among them. They had high rates of sickness and a high turnover, sometimes over 75 per cent annually, resulting in an inexperienced workforce. The asylum leadership contributed to creating a dysfunctional system in which the patients, whom the asylum was meant to serve, were far from central to it.

Patients and Their Daily Life

This chapter includes many aspects of patients’ personal care and wellbeing, including the provision of basic amenities; interactions between patients, staff and the outside world; and the work which patients undertook and the rewards they received. Ensuring patients’ personal dignity and providing appropriate employment, social diversions and as much freedom as possible was known to help alleviate their distress, lessen untoward behaviours and enhance wellbeing. However, some asylums ignored advice from idealistic psychiatrists about good practice. Knowing what needed to be done but failing to do it, was negligence of a particularly distressing kind. Although some patients’ relatives and friends had no concerns about standards of care, others feared repercussions on the patient should they complain. Staff and patients who spoke up about the deficits, usually did so after leaving the asylum.