Civilian Lunatic Asylums During the First World War

Front matter

Civilian Lunatic Asylums During the First World War A Study of Austerity on § Londons Fringe

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Foreword

I am delighted to provide a foreword for this detailed and insightful book exploring the life of London’s asylums during the First World War. It is a compelling but also harrowing read for all those interested in the history of psychiatry and mental health services. The book explores the structural, legal, relational and procedural side of asylum life in the First World War with a particular emphasis on the experience of patients. It draws on a breadth of source material reflecting their experiences.

In England and Wales there were 100,000 patients in asylums and whilst it might be tempting to think, when exploring the horrors of military life, that asylum life might be a welcome respite, the experiences of patients were quite the opposite. The book shows us that mental health care never existed outside the context of culture, politics and world events and was particularly prone to adversity when resource and workforce pressures abounded. There were huge staff shortages and general goods were in short supply but what was particularly obvious was the deficit in terms of innovation that had made some headway prior to the First World War.

There were some enlightened voices urging a focus on what would benefit patients, but treatment could be harsh and there was disregard for personal dignity along with poor hygiene and high death rates. It did make me feel grateful for our safeguarding procedures, mental health law that prioritises and protects patients and for regulators with real teeth, along with encouraging the externalising of complaints and concerns, rather than suppressing them.

vil vill FOREWORD

An important reason to explore the past is to learn lessons for the future and Claire Hilton’s book does that. Some challenges are still very much present 100 years on: stigma, human rights, power imbalances, resources, workforce, research, regulation and organisational structure remain part of our current discourse.

Read on with an open mind, a thirst for knowledge and with gratitude for what we can do for our patients. Continued self-reflection and challenge are vital. We could still do so much more.

Dr. Adrian James President of the Royal College of Psychiatrists London, UK

Preface

Bombarded by historical analyses of First World War “shell shock” and the suffering of military casualties left me wondering how 100,000 “pauper lunatics” fared in the wartime civilian lunatic asylums. Asylum patients were low priority on the scale of social welfare, regarded as a burden on the economy and unable to contribute to the war effort. Standards of care and treatment fell, discharge rates plummeted, and death rates due to infectious diseases escalated far in excess of those in the community. The neglect was particularly disturbing because the asylum leadership knew what should be done in the interests of the patients, but too often failed to act on that knowledge.

This book centres round the patients who were the raison d'ètre of the asylums. It explores how individuals helped them and hindered them and how the system let them down. It is an un-told story, about real people, which deserves to be heard.

London, UK Claire Hilton ix

ACKNOWLEDGMENTS

Many people have helped, cajoled, criticised, supported and guided the research and writing of this book. Librarians and archivists, particularly at the Wellcome Collection, London Metropolitan Archives, Royal College of Psychiatrists and the National Archives at Kew have helped sort endless requests for documents. The Wellcome Collection generously provided the funds to publish this book open access. Matt Smith and Cathy Coleborne, series editors, and Molly Beck, Joe Johnson and Meera Mithran at Palgrave, have been a supportive team to work with. Two anonymous peer reviewers, one who read the synopsis and another who read the entire manuscript offered valuable feedback and helped shape the final text. Rhodri Hayward read chunks of the work and his comments were much appreciated. Advice from Nicol Ferrier about post-mortems was most welcome and discussions with Louise Hide are always thought provoking and fruitful. Adrian James found time to write the foreword, and I am grateful for his continued interest in the history of psychiatry. Hugh and Gus Fowler-Wright and library staff at King’s College London provided invaluable copyright information about illustrations. My husband Michael has allowed me to disappear into lengthy anti-social hibernation with my laptop, and he has continued to explore former asylums and asylum cemeteries with me. I am particularly indebted to David Jolley for his enthusiasm and encouragement and valuable comments after reading the entire manuscript, some parts more than once.

xi

Contents

Food, Farm and Fuel: An Inequitable Supply Chain Patients and Their Daily Life

Difficult Diseases: Tuberculosis and Other Infections Accidents, Injuries, Escapes and Suicides

Index al xiii

Chapter 1

Britain declared war against Germany on 4 August 1914. For the next four years military priorities overrode those of civilians. The entire population faced hardships, but for those 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, the failed dreams of social reformers and psychiatrists. They had become “vast warehouses for the chronically insane and demented.”! Richard Hunter and Ida Macalpine, in their history of Colney Hatch Asylum, commented about the gloomy picture: “Custodial care was forced on asylums as a way of life....paralysed by sheer weight of numbers of patients” and financial constraints.7 “Nothing”, they said, showed “more blatantly how relentless pressure for more and more beds forced the asylum further and further away from the idea of a hospital.”°

Public lunatic asylums in England and Wales changed in the decades before the war, arguably for the worse. Reflecting Hunter and Macalpine’s dismay, earlier good intentions such as implementing “moral treatment”, a social intervention involving trust, sympathy and group activities, alongside good food, fresh air, occupation and exercise, disappeared, even though the approach benefitted patients with reversible disorders of recent onset and those chronically unwell on long-stay wards.* Alongside moral treatment, principles of “non-restraint” were valued, but not uniformly implemented. Both these methods were effective and gained

© The Author(s) 2021 1 C. Hilton, Civilian Lunatic Asylums During the First World War, prominence in smaller institutions through the work of enthusiastic lay leaders, such as the Tuke family at the Retreat in York, and medical leaders such as John Conolly at Hanwell and Robert Gardiner Hill at Lincoln. The methods worked less well in larger asylums, and never achieved widespread implementation, remaining as an ideal rather than reality.

Many other aspects of the asylum changed, influenced by stakeholders with different opinions, including doctors, lawyers, social reformers and the general public. Sometimes they agreed on priorities, but often not. The role of the medical profession became more dominant, in part due to legislation which stipulated that every institution of more than 100 lunatics must have a resident physician. No other profession vied for the leadership. New lunacy laws became more rigid and complex, tending to focus on the safety of the public rather than on the wellbeing of those suffering from mental disorders.

By 1870, public asylums had an average of 500 beds. Total annual admissions rose steeply after 1890, associated with the new Lunacy Act, but then stayed roughly in line with demographic trends (Fig. 1.1).” The death rate remained stable, but the discharge rate declined. There is no evidence that the type or severity of mental disorders accounted for the changes. The increasing size of asylums, beyond that which could be accounted for by demographic changes, is likely to have been due to the decades-long mental disability caused by chronic psychotic disorders, such as schizophrenia,’ accompanied by a changing balance of therapeutic interventions and custodial care. By the beginning of the war, in England and Wales, an average asylum had 1000 beds!° and over 100,000 people were certified as pauper lunatics. Wartime shortages of staff and material goods, and overcrowding after the War Office requisitioned asylums to use as military hospitals, were associated with a calamitous fall in standards of care for mentally unwell civilian patients. The situation was a sad commentary on the low social priorities attached to people identified as suffering from mental disorders.!!

A substantial historiography exists on “shell shock”, the syndrome of mental disturbances suffered by war-traumatised soldiers during the First World War.!? By contrast, the historiography of civilian asylums and their patients at the same time is meagre, featuring in a few academic journal articles and chapters in some general asylum histories.!* No in-depth historical studies have specifically drawn together the various elements of the story to provide a contextualised and detailed analysis, as this book sets out to do. It tells the story of four asylums on the periphery of o a o a Ce a © ` © a ssssseoirse: 2 o s © SIRFID no

Fig. 1.1 Percentage change in “insane” patients relative to population of England and Wales (1869-1915). From top to bottom: Patients resident (“total insane”); Annual admissions; Population of England and Wales; Ratio of patients to population; Ratio of admissions to population. (First Annual Report of the Board of Control, for the Year 1914 (London: HMSO, 1916), between pp. 8-9).

London to the north of the River Thames at a time of national turmoil, when intense austerity, deprivation and competing priorities affected those within them. The narrative overlaps with the direct effects of war on the mental health of military personnel and civilians living in the community, material which is used here to help contextualise and explain what happened in the asylums. The asylum story may also contribute to debate and shed light on the mechanisms and processes underlying standards of mental health services in other periods of austerity, including in the first decades of the twenty-first century.

This study covers the period from just before the conflagration through to the beginnings of post-war reconstruction. It tries to put the raison d’ètre of the asylum—the patients and their mental health—in the foreground, with the people caring directly for them close behind. It explores the decision making and actions of those in authority over the asylums and the work of staff looking after the patients. It focusses on how the public asylum system provided care and treatment, how standards were envisaged and whether or not they were achieved. It brings together knowledge, ideas and attitudes about mental illness at the time, including political, scientific, medical, economic and popular cultural aspects.

HISTORIOGRAPHY OF THE ASYLUMS

To comprehend how the asylums coped with the crisis of the Great War, it is necessary to understand their development, and disentangle fact from fiction. Mid- to late twentieth century historical interpretation of the lunatic asylums was contentious and damning, including the persuasive and influential analyses by Andrew Scull and Michel Foucault. Scull took as his starting point that the asylums, mainly established in the nineteenth century, were associated with defining a problem population and incarcerating them “in a specialised, bureaucratically organised, state-supported asylum system which isolated them geographically and symbolically from the larger society.”!4 Foucault also attributed asylums’ rural locations to the public desire to segregate “mad” people from the majority of the population, drawing analogies between asylums and leper houses of the middle ages.!5 Even though, like leprosy, mental disorders were tainted by fear and stigma, in the nineteenth century there was also a public perception that people with disturbed minds required protection, care and compassion. These notions contributed constructively to new lunacy legislation, asylum building and asylum care in England.!° Despite good intentions of the reformers, as sometimes revealed verbatim in their reports in Hansard,'” Scull and Foucault identified the underlying ethos of the asylums as inherently and inevitably damaging to those within. Their conclusions linked to the theoretical and ideological standpoints which they held. Scull took a Marxist perspective in his analysis,!® which fits with his description of asylums as “Warehouses of the Unwanted”, “largely receptacles for the confinement of the impossible, the inconvenient and the inept”,!? the economically unproductive sector of the population. Foucault’s analysis was cotemporaneous and convergent with that of the anti-psychiatry movement, which regarded mental illness as socially fabricated and those afflicted as wrongfully confined and medicated. Anti-psychiatry activists who wrote at the same time as Foucault included RD Laing and Thomas Szasz who expounded on social causes of insanity, and Erving Goffman, who scrutinized regimes of institutional living, with particular attention to their harmful effects.?? David Cooper, the psychiatrist said to have coined the term “anti-psychiatry”, wrote the introduction to Foucault’s Madness and Civilisation when published in England, endorsing its link to anti-psychiatry ideology.”

So contentious were the writings of Scull, Foucault and others in the second half of the twentieth century, that historians since then have criticised their methodologies.?? Joseph Melling and Bill Forsythe argued that Foucault displayed some “extravagant historical inaccuracies”, such as in his analysis of confinement of the insane in early modern Europe.?? Louise Hide described Foucault’s study as “brilliant but flawed”, such as his arguments about industrial society being increasingly intolerant of its non-productive members so beginning to lock them away in institutions.?* Jonathan Andrews and Anne Digby regarded some twentieth-century historiography as too divorced from wider historical issues and “overly ideologised and unconvincingly theorised” in its approaches to asylums and psychiatry, lacking a firm and comprehensive grounding in archival sources.?° Hugh Freeman found no evidence to support Scull’s economic and social exclusion model of the asylums. Instead, he found severely ill patients whose relatives had done all they could to contain the situation before seeking admission.2° Edward Shorter also criticised historians of the 1960s and 1970s, who constituted a kind of lost generation in that they have chosen to pursue puffs of smoke, displaying no interest in the question of just what happens historically to make mind and brain go awry. If we wish to tell the story of psychiatry empathetically, we must deal with the story of illness rather than arguing that it is a nonstory or that it is unknowable.27

Paul Tobia also argued that understanding asylums in depth can only be done by uncovering detailed source material, although that risks creating studies overly detailed and too divorced from wider historical issues.7°

Another sort of historiography, which has coloured our understanding of psychiatric history, comprises accounts written by medical professionals about their own institutions.?? These authors also conveyed biased perspectives, often as culprits of “whiggish” research, according to Juliet Hurn, adopting a “style of history-writing in which it is assumed that scientific progress can be charted through the approach towards an objective scientific truth.”*° Their work tended to be founded on hindsight, comparing the past with scientific evidence and medical standards to which they had aspired during their clinical careers.*! They were also judgmental, praising the work of those perceived to have aided “progress” and dismissing others.*? They tended to focus on the leadership rather than the patients and on what happened, rather than on analysing processes of why and how things occurred in broader contexts. John Crammer, a psychiatrist who wrote the history of the Buckinghamshire Asylum summarised: “the history of psychiatry was left to medical men with a fondness for anecdote, a reverence for pioneers, and a belief in ‘progress’.”33

Aware of the many concerns about the nature of the evidence and analysis used in historical studies of mental disorder and institutional care, this study uses standard historical methodology,** and draws extensively on archival and published sources, aiming to achieve a balanced understanding of the asylums, contextualised in the circumstances of the day.

FROM BROAD THEORIES AND GENERALISATIONS TO SPECIFICS AND DIVERSITY

Despite some historical analyses suggesting that the segregation and exclusion of mentally disturbed people was a key rationale for building asylums in rural areas, there are alternative explanations. One was the belief, in line with moral treatment, that the location would provide a healthy environment to benefit recovery and recuperation. Similar principles applied to building rural sanatoria for treating tuberculosis in the pre-antibiotic era. Asylums were frequently located on the best sites— on a hillside and above urban pollution, and south-facing to maximise sunshine and give shelter from the prevailing winds—to allow employment and leisure in the fresh air. The building of many asylums in the early to mid-nineteenth century was also concurrent with the founding of specialist hospitals, each dedicated to a group of related diseases or a single bodily organ or organ system. In the London area, for example, specialist hospitals opened for eye and ear diseases, bowel problems, cancer and neurological conditions. They raised interest in the diseases on which they focussed, and the knowledge and expertise in treatment which developed in them were gradually adopted by general (physical illness) hospitals, thus becoming part of mainstream medicine and surgery.*° There are parallels in the asylums, where the medical leadership sought to better understand the disorders they diagnosed and to find effective treatments, preferably cures.

The architecture of the asylums, the palatial façade of Colney Hatch (Fig. 1.2) or the prison-like central towers at Hanwell (Fig. 1.3) were emblematic of the diversity of the asylums in terms of practices and

Fig. 1.2 Colney Hatch Lunatic Asylum, Southgate, Middlesex: panoramic view, undated (Wellcome Collection CC BY licence)

Fig. 1.3 Hanwell Asylum (Photograph by author, 2017)

standards within them. These varied despite the Lunacy Act 1890. The Act mandated legal, financial and organisational structures, and the hierarchy of authority, oversight and regulation stemming from the central government body, the Commissioners in Lunacy until 1914 and the Board of Control (“the Board”) thereafter, which had responsibility for civilian asylums in England and Wales. The rigid, legalistic approach of the Lunacy Act also reflected increased societal and legal concerns about public safety, ensuring detention of “dangerous” lunatics while preventing wrongful incarceration of “sane” people. Beyond these requirements, the public generally distanced themselves from happenings inside the asylums, their perspectives reinforced by novels about lunacy which tended to emphasise the frightening and the macabre, and rarely encouraged sympathetic interest in the asylums or their occupants.*°

Historian Roy Porter wrote in 1991 that many dimensions of recent psychiatric institutional history “remain a blank”.*” Since then, understanding of the philosophy, uniformities and diversity of the asylums, has been enhanced by in-depth “hospital biography” investigations into individual asylums, or small groups of them, including in Hampshire, Norfolk, Bristol, Essex, and on the London borders.*® These institutional biographies give nuanced insights into asylum organisation, patients, staffing, care and treatment within the wider societal context. In exemplary asylums shortly before the First World War, many patients reportedly undertook manual work appropriate to their pre-admission employment, participated in leisure activities, sports and entertainments, and had leave off the premises, including trial leave before discharge with a meaningful monetary allowance to help cover their personal expenses. Some asylums endeavoured to model their clinical approaches on practices in general hospitals. They placed patients on different wards according to whether they were deemed curable or chronic, used the most up-to-date treatments to ameliorate symptoms, and educated and professionalised their staff.°? Diane Carpenter, however, in her comparison of two Hampshire asylums, described the “postcode-lottery” of variability of care and treatment, from custodial to rehabilitative.

Hospital biographies challenge many generalisations made by Scull and Foucault, but they also demonstrate troubling variation, conflicts and mismatches between ideals and reality, intention and implementation, and numerous facets which came together to influence the functions of the asylums and the outcomes for individuals inside them. Mathew Thomson highlighted how individual and collective factors inside and outside the asylum system influenced policy and provision.*! Knowledge, understanding and value systems of the medical profession, lawyers, architects, reformers, national and local government, macro- and micro- political networks, and the broader public, all interacted. Together they affected asylum practices and contributed to maintaining the status quo or pacing the speed and mapping the route of any significant change. In histories of psychiatry dedicated to a particular aspect of science, philosophy, psychopathology or individual mode of therapy, “single-issue mythologies” have evolved to explain change or stagnation.4* To avoid these mythologies, the multiplicity of threads indicate the need for a multifaceted historiographical approach, digging deep into a range of archives and published sources, to reach an understanding about whether, how and when aspects of asylum care altered.

SHELL SHOCK: HISTORIOGRAPHY AND CHANGE

Regarding mental disorders and psychiatric services at the time of the First World War, historians of psychiatry have focussed on shell shock. Public sympathy for soldiers who became mentally disturbed while serving their country contrasted with fear and stigma concerning mental disorders of civilian pauper lunatics in asylums. The socially entrenched pattern of moral judgement of dividing needy people into “deserving” and “undeserving” was reshaped into provision for war-torn soldiers compared to civilians.

Commentators Anne Rogers and David Pilgrim inferred that shell shock plus industrial fatigue at home combined to “change irrevocably the face of twentieth-century psychiatric services”. They proposed that shell shock encouraged environmental theories of aetiology and displaced bio-deterministic ideas: to describe soldiers—“England’s finest blood”— as biologically “degenerate” and predisposed to mental disturbance “was logically impossible and tantamount to treason.” They linked shell shock to the establishment of out-patient clinics and to neurosis becoming a focus of professional interest, although that was also associated with psychoanalytic theory developing pre-war.*%

Shell shock may have contributed to re-conceptualising some mental disorders, but overall it stimulated little change in asylum treatment.*4 If anything, learning arising from the treatment of shell shock could be detrimental to patients with other severe, disabling mental disorders. Methods used to treat shell shock could be harsh, such as “bullying” electric shocks.*° Psychological therapies for shell shock, such as cure by suggestion, promoted the idea that patients could control their symptoms, a view which would be inappropriate for people suffering from psychoses, such as schizophrenia, or from organic brain diseases such as general paralysis of the insane (GPI, brain syphilis).*° Goals of treating shell shock, to send soldiers back to the front line, meant that medical ethics, humanity and measures of “success” were abstruse when compared to ideals of conventional aims of treatment to promote the health and wellbeing of individuals.

In contrast to Rogers and Pilgrim, Jose Harris and Peter Barham were cautious about attributing change in psychiatry primarily to shell

1 INTRODUCTION: CIVILIANS, LUNACY AND THE FIRST WORLD WAR ll shock. Harris raised the question of how far the war itself transformed British society, or merely channelled and accelerated germinating seeds of change sown pre-war when “Britain appeared to be on the cusp of radical change”.*” Social welfare and universal suffrage, for example, had roots pre-war, but wartime priorities diverted good intentions away from peace-time objectives, and direct implementation ground to a halt. The war, however, generated debate on many aspects of life, including roles and opportunities for women, priorities for reconstruction and the meaning of “civilisation”,** which informed public attitudes and helped shape the course of post-war policy.

Regarding mental health policy and provision, shell shock was just one factor alongside others, including clinical and scientific research; the psychiatric clinics in Germany envied by psychiatrists in England; and the rise of trade unions and disenchantment with conditions of employment in the asylums. Arguably, The Experiences of an Asylum Doctor by Montagu Lomax, a retired doctor in his late 50s and temporary wartime asylum assistant medical officer at Bracebridge Asylum, Lincolnshire and Prestwich Asylum, Lancashire (1917-1919), had a profound effect on instigating change in the asylums.*? For this reason, and as we shall refer to the author, his book and its aftermath several times in the course of the present study, they deserve introduction here. Tim Harding and John Hopton appraised Lomax’s work and its outcome.®? Lomax was particularly critical of the conditions which he observed at Prestwich, although in his book he did not reveal the identity of the asylum. He advocated more active therapeutic interventions to secure the return of patients to the community, he called for wide-reaching changes in asylum management, and a complete reform of existing mental health legislation. Published post-war, when the public had more emotional energy for considering such matters, it raised public awareness and spearheaded further thought. The psychiatric establishment, however, rejected his descriptions of inhuman, custodial, and antitherapeutic conditions.>! Despite publication coinciding with competing economic struggles nationally, likely to deflate interest in asylum patients’ welfare, the aftermath of Lomax’s exposé was an inquiry into the “administration of public mental hospitals” chaired by Sir Cyril Cobb in 1922. This led to the appointment of the 1924-1926 Royal Commission on Lunacy and Mental Disorder and to the enactment of the more therapeutically orientated Mental Treatment Act 1930."

PLACING THE PATIENTS CENTRE STAGE

Some historians of psychiatry, as Roy Porter advocated, have succeeded in placing patients centre stage in their narratives.°? Louise Hide’s study about gender and class in asylums between 1890 and 1914 and Paul Tobia’s study of the Bristol Lunatic asylum were both bottom-up and top-down, valuing the lives and experiences of patients and those in direct contact with them, as well as those in authority in the asylum hierarchy up to national level.54 Allan Beveridge analysed 1000 letters written by patients at the Royal Edinburgh Asylum (1873-1908) which were retained by the authorities rather than sent to the addressee. A complex picture emerged in their accounts, which included both humanity and coercion. Many patients spoke warmly of the asylum and its staff and frequently thanked the medical superintendent for his kindness and concern. Some patients, rejected by family and friends, made some sort of life for themselves within the asylum which was more tolerant of their behaviour than the society outside. Letters, like many other single classes of document from the asylum world, have limitations, but Beveridge concluded that the contents should militate against painting too crude a picture of the asylum with staff in the guise of oppressors and inmates as innocent victims.°> His conclusions contrasted with studies which create an overwhelmingly negative image of the asylums, such as those by Scull.5°

Peter Barham also wove individual life stories into his history of shell shock, Forgotten Lunatics of the Great War. He placed the sufferers’ mental disturbances in the context of their lives and the lives of their families and community, giving voice to their personal experiences. In contrast to the forgotten soldier patients during the war, civilian patients in the lunatic asylums were almost invisible and usually without a voice. Barham described his research experience, that “fossicking in the archival undergrowth frequently yields scraps that, once juxtaposed, deliver startling insights into what was at stake” for individuals.5” The same was true when researching this study of civilians, which, like Barham’s and Beveridge’s work, aims to tell the patients’ stories and how their needs were, or were not, met.

A variety of bottom-up sources are available to historians of asylums in the early twentieth century. Within individual asylum records, material written by patients, their families and friends can be found pasted into clinical notes and committee minutes. Some documents are positive, including letters of thanks, but more relate to disputes about treatment, thefts, escapes, discharge and money, and other unfavourable aspects of asylum life. As in Beveridge’s study, some accounts by patients derive from un-posted, asylum-censored letters. Regarding patients’ letters to friends and family, staff had authority to read them. Staff justified their probing in this way as a means of finding out about their patients in order to help them, but this probably reflected, and caused, a lack of trust and face to face conversation between patients and staff. Patients who were aware of the censorship of their letters might also have adjusted their content and tone.

In contrast to personal letters, the Lunacy Act stipulated that letters from patients to the authorities who oversaw their certification and care should be forwarded unopened, but this correspondence was often destroyed after being dealt with.” A few patients wrote memoirs. Whereas letter writing is influenced according to who the recipient might be, memoirs can be shaped by time between the experience and the writing, affected by personal reflection, changing knowledge and social expectations giving new emphases. Diaries, generally written for the authors themselves, are the least likely to be tailored to an anticipated external readership. No diaries, however, were identified while researching the present study. Another source of patients’ views was their evidence to the Cobb Inquiry as a result of Lomax’s book.°?

Some of the patient vignettes used in this study were identified serendipitously in clinical records or committee minutes. Others derived from a sample I gathered of 600 civilian patients from the national registers of asylum admission and discharge (1913-1918).°° The sample consisted of every thirtieth patient (the last entry on each page) in the register. Each entry recorded the asylum’s name, and patient’s name, gender, dates of admission and outcome (recovered, relieved, not improved, died), but not age, date of birth, diagnosis or other clinical information. The method ensured that the sample was clinically, socially and demographically un-biased. In total, 58 of the 600 patients were admitted to Colney Hatch, Claybury, Napsbury and Hanwell. Detailed social and clinical data were sought for them, with the aim of analysing the reasons for their admission and their “journey” through the institution.

l4 C. HILTON

STANDARDS OF CARE AND HOW TO MEASURE THEM

Several historians have attempted to ascertain the standards of care achieved in asylums. Carpenter concluded that “basic determinants of the quality of life” for patients in the Hampshire asylums pre-war were “preferable to its alternatives”: diet, cleanliness, personal hygiene and clothing, all compared reasonably with poorer private dwellings and the workhouse. Other living conditions were similar to many poorer homes, such as gas lighting, open fires, no electricity and lack of privacy.°! Kathleen Jones, who investigated mainly social and legal aspects of mental health policy and practice, commented that for asylum patients who worked during the day and took part in social activities in evenings and weekends, “it was a full life — often much more so than their life outside.”® She did not state a particular period to which this referred, or whether it was reality at times of greatest austerity.