In the day-to-day running of the asylum, it was not the work of the laboratory that was most immediately evident, but that undertaken by asylum attendants and nurses. By the late 19th century, this was a job that was increasingly codified as efforts to institute proper training and qualification began.
In 1890, the Medico-Psychological Association (MPA) recommended that attendants did two years training in an asylum; the following year saw the introduction of the Certificate in Attendance and Nursing upon Insane Persons. This official qualification was complemented by other developments such as the introduction of the MPA’s Handbook for the Instruction of Attendants on the Insane. The Handbook’s contents ranged from an overview of legal matters concerning insanity, to the importance of setting a good example for patients, to best practice in matters such as bathing and ward ventilation.
Non-restraint and asylum care
In both the Handbook and elsewhere, the issue of restraint was paramount as asylums were required to carefully record any instances of patient restraint in a central register. There was a sense that the disappearance of mechanical restraint (such as straitjackets) increased the potential for injuries, as attendants struggled to subdue patients or manually convey them to seclusion in an excited state. Florence Hale Abbot, writing in The American Journal of Nursing, suggested that in many cases being manually restrained by an attendant made a patient more excitable than they might be when mechanical means were used.
Ellen Dwyer, examining American asylums in her book Homes for the Mad, argues that such problems tended to occur on male rather than female wards, citing ‘general patient-staff tensions [which] were exacerbated by male attendants’ need to defend their masculinity’ (p.181). This was also hinted at in the MPA’s Handbook which cautioned: ‘Inexperienced attendants often think it a weak thing to get assistance, and pride themselves on managing a troublesome patient without aid from others. This is a grave mistake.’ (p.112).
Nurses at Claybury Asylum, Essex, 1890s. © Wellcome Library, London
This sense of gendered attendant experiences was evident in moves towards the formal qualification of staff and worries about mistreatment. Some commentators laid much of the blame for violence at the feet of male attendants. The Nursing Record & Hospital World noted that abuse was usually ‘brought to notice first from the men’s wards, where there [were] men attendants’, whilst the Male Nurses’ Temperance Cooperation (yes, there was such an organisation) lambasted the ‘drunken male attendant [who was] a greater terror to [the] inmates than his insane patients’. Though female nurses were said to have a more calming influence on male wards, it was difficult to do away with male attendants entirely. Geertje Boschma, writing on Dutch asylums, says that men remained necessary due to their greater strength, for example. The usefulness of male attendants had been earlier recognised by the 1839 Select Committee investigating Hereford Asylum, who criticised the scarcity of male staff, and noted that male patients tended to fight amongst themselves as a result of the lack of supervision.
Alongside the issue of restraint, a related point of concern was how attendants were to identify injuries sustained by patients. Many handbooks set out the symptoms that might indicate fracture, for example. The MPA’s Handbook instructed the attendant to report any complaints of pain or a ‘shrinking away’ from contact that suggested its presence, as well as any bruises or other abrasions noticed during dressing and bathing. Bathing had a double function as a means of maintaining basic hygiene and method of inspection. At admission the patient was:
… carefully undressed, and any bruises, marks, injuries, or eruptions on his person … looked for and noted. … When a Patient [was] very dirty, the Relieving Officer, Relative, or other person accompanying him to the Asylum, [was] to remain until he [had] been washed and cleansed with soap, as bruises [were] often concealed by dirt, and revealed by washing.
Male patients being washed by attendants at Epsom’s Long Grove Asylum, c.1930.
© Wellcome Library, London
Attendants might also be reminded of bathing regulations on the wards themselves. A wall-mounted sign at the West Riding Asylum reminded nurses that bathing was to be supervised by the Chief Female Officer and Chief Nurse, and that ‘Hip, Cold, Turkish, and all kinds of Special Baths [were] only to be given or allowed in accordance with special orders from a Medical Officer.’
The concern that a Medical Officer provide permission for ‘Special Baths’ was mirrored in the advice that, if any injuries were suspected, a Medical Officer was to be called upon to provide a definitive diagnosis. This reflected the view that, for asylum attendants, ‘a little learning [was] a dangerous thing’ as one asylum Superintendent put it. By the time that the fifth edition of the MPA’s Handbook was published in 1908, it was criticised for its increasing focus on anatomy rather than psychiatry. For many commentators, then, there was a sense that – despite the introduction of official certification and training – asylum staff remained if not morally, then intellectually, inferior.
 West Yorkshire Archive Service. SRH C85/1/16/3 Regulations and Orders. Relating to the Male Department (1909).
 West Yorkshire Archive Service SRH C85/1/16/2 Bathroom regulations. Relating to the Female Department (1874).
Anon., ‘Nursing Echoes’, The Nursing Record & Hospital World 27 (17 Aug. 1901).
Anon., ‘Reflections from a Board Room Mirror’, The Nursing Record & Hospital World 14 (20 Apr. 1895).
F.H. Abbot, ‘Feeding and the Use of Restraint in Caring for the Insane’, The American Journal of Nursing 4 (Oct. and Nov. 1903).
W. Bevan Lewis, ‘On the Formation of Character: An address to the nursing staff at the Retreat, York, delivered November 1st, 1906’, Journal of Mental Science 53 (Jan. 1907).
G. Boschma, ‘The Gender Specific Role of Male Nurses in Dutch Asylums: 1890–1910’, International History of Nursing Journal 4 (Summer 1999).
N. Brimblecombe, ‘Asylum Nursing as a Career in the United Kingdom, 1890–1910’, Journal of Advanced Nursing 55 (Sept. 2006).
J. Crammer, Asylum History: Buckinghamshire County Pauper Lunatic Asylum – St. John’s (London: Gaskell, Royal College of Physicians, 1990).
E. Dwyer, Homes for the Mad: Life inside Two Nineteenth-Century Asylums (New Brunswick, NJ: Rutgers University Press, 1987).
L. Monk, ‘Working in the Asylum: Attendants to the Insane’, Health and History 11 (2009).
P. Nolan, A History of Mental Health Nursing (London: Chapman & Hall, 1993).
The Royal Medico-Psychological Association, Handbook for the Instruction of Attendants on the Insane (Boston: Cupples, Upham and Co., 1886 [first published 1885]).
J. Sheehan, ‘The Role and Rewards of Asylum Attendants in Victorian England’, International History of Nursing Journal 3 (Summer 1998).
L.D. Smith, ‘Behind Closed Doors; Lunatic Asylum Keepers, 1800–60’, Social History of Medicine 1 (Dec. 1988).
D. Wright, ‘The Dregs of Society? Occupational Patterns of Male Asylum Attendants in Victorian England’, International History of Nursing Journal 1 (Summer 1996).