Asylumscience: future plans

Some of you may have noticed that it’s gotten a little quiet here at asylumscience recently. This is chiefly due to two exciting developments: the first being that I submitted my thesis last month, and the second – rather more exciting – being Mike’s appointment as Lecturer in History of Science at the University of Leeds! Both causes for congratulation, but also causes that have led to the blog being a little neglected as we get to grips with a new term of teaching, publication plans, and new roles.

Science in the Asylum © David KerekesIt’s just over a year now since we held our ‘Science in the Asylum’ conference at the site of the old West Riding Lunatic Asylum in Wakefield, Yorkshire. Since then, Mike has continued to work alongside staff at the Stephen Beaumont Museum of Mental Health, and we’ve had a range of blog posts expanding on the themes we addressed at the conference. We’ve considered surgery in the asylum, if the weather might affect our mental health, even the role of horses in the history of neurology.

The blog has also led to some fantastic opportunities for collaboration. In July Simon Tombs, a teacher of Psychology at Devonport High School for Girls, wrote a guest post for us on how he and his colleagues had put together a project on King George III for a group of the school’s pupils and exchange students. Simon’s project was a brilliant example of how the history of psychiatry can be incorporated into the curriculum. Earlier this year, I participated in some research being undertaken by journalism students at London’s City University for a short documentary they were making on modern ‘psychosurgery’. Alongside this, we’ve had a number of interested queries from students researching the field, showing that the history of psychiatry and neurology holds an enduring fascination for many people.

As 2013 comes to a close, asylumscience will remain online as a resource – though posts won’t be as regular as they were previously, we still hope to be able to offer some new posts as our own research progresses (and we’d still love to hear from you if you’d like to write something!). Mike will keep you updated on the work he’s doing with the Stephen Beaumont Museum, and in the not-too-distant future we expect to have a permanent published record of several of the papers given at ‘Science in the Asylum’ – so please watch this space!

Communicating Mental Health, University of Birmingham, 16-17 September 2013

‘Communicating Mental Health, c.1700–2013′ was a workshop held at the University of Birmingham’s Institute of Advanced Studies, aiming to bring together researchers from a range of backgrounds to consider the communication of mental health and illness, both in the past and in the present. Communication took many forms in the papers presented – verbal, written, and visual.

L0028860 Case notes: Holloway Sanatorium Hospital for the InsaneKicking off the proceedings, Louise Hide from Birkbeck, University of London examined letters written by 19th-century asylum patients. Letter-writing by patients was a significant activity, with around 100 letters a day written at London’s Claybury Asylum in 1895. Such letters are complex both in their contents and the ways in which they might be read by the historian – Hide particularly emphasised patient’s use of metaphor as a way of communicating their experiences within the asylum. This was a trend also evident in the spoken words of patients, as I briefly noted in a paper on the role of the patient in diagnosis. As the asylum admission process in the 19th century didn’t involve the input of an asylum doctor (rather, general practitioners and Poor Law authorities), the information provided on admission documents was often re-assessed in the asylum in light of the patient’s own story. One man, who had told the general practitioner certifying him that the ‘flesh was dropping off his bones’, explained to the asylum doctor that he didn’t really think this, but had employed the phrase to describe his feelings of numbness in the toes.

Letters sent by patients were also examined by Jane Hamlett (Royal Holloway University of London), who described how demands for goods from families may have been a way for the patient to assert authority after being placed in an institution. One patient at Bethlem wrote an astonishingly long list of goods that he ‘required’, asking his father to send him – amongst other things – a harmonium and an alarm clock. That letters were a means of maintaining one’s position as head of the household was evident in the letter written by a man to his wife, who declared that she ‘need not send the cake [she had mentioned], as he did not care for it’, but she might send some rashers of bacon instead. In their provision (or not) of foodstuffs and domestic items, then, we can see families engaging in a form of object-based communication.

Inside the padded cell in the Stephen Beaumont Museum of Mental Health.

Inside the padded cell in the Stephen Beaumont Museum of Mental Health.

That objects might be communicative was a possibility also explored in Rob Ellis’s (University of Huddersfield) talk, which examined the Stephen Beaumont Museum of Mental Health – previously discussed on this blog, here. Ellis argued that museum collections are very much bound up with who ‘owns’ the history of psychiatry (the closure of asylums in the late 20th century, for example, prompted some curators to highlight the ‘progressive’ nature of psychiatry).

This much broader issue of ownership was a concern that ran throughout the two days of the workshop. Towards the end of the first day, we were already asking ourselves if historians were part of ‘myth-making’ about mental illness and, if we were, what we could do about it. But was ‘myth-making’ too simplistic a label to put on the issue? Was there, asked Peter Bartlett (University of Nottingham), any area of life where – as humans – we weren’t constantly constructing myths about history, the present, and ourselves? Many of the papers presented at the workshop had highlighted how there was rarely a single narrative of mental health or illness that enjoyed relative hegemony at any one time. In the stories we were telling about past and present mental health practice, we were also adding other voices to an already varied narrative.

Poster from the Birmingham campaign, ‘Don’t Turn Your Back on the Symptoms of Psychosis’.

Poster from the Birmingham campaign, ‘Don’t Turn Your Back on the Symptoms of Psychosis’.

The languages spoken by these voices seemed diverse – historical, medical, psychoanalytical – but displayed some important similarities. That there was an easily discernible line between ‘normal’ and ‘abnormal’, or ‘health’ and ‘illness’, was complicated by many of the speakers present. Katherine Chisholm and Sarah-Jane Fenton both addressed the importance of identifying mental ill-health in adolescence – the point at which many serious psychiatric disorders began and often manifested themselves in ways that made it difficult to determine the lines between ‘mental illness’ and ‘typical’ teenage behaviour. The language used to talk about mental health issues was also a rapidly changing one, so that – as one current practitioner pointed out – an individual might be diagnosed with something that meant little as a diagnostic label years later. How language and the labels we assign to disorders could profoundly affect an individual’s sense of self, then, was a consideration that came through in papers both by historians and current practitioners.

Methodology also turned out to be an area of common experience: though we might lack a methodology that can properly capture the experience of mental illness at different points in time (as Joseph Melling [University of Exeter] noted), there was a clear similarity across the disciplines in terms of research methods employed. Thematic analysis was central for many speakers, whether analysing the letters of 19th-century asylum patients, or in working with young autistic adults (Susy Ridout, University of Birmingham).

300px-Speech_bubble.svgFittingly, the workshop ended with participants reflecting on how we had communicated with each other. Fostering interdisciplinary study was a laudable aim, but something that involved more than simply delivering papers together at the same event. How could the discussion continue beyond that context, and how far were historians, practitioners, and service users really integrated? Whilst we’d been using the same languages and methodologies, there was still a sense of a divide within the room at times – almost that historians were distanced, detached observers with little direct experience of mental health issues. How could we bridge that divide?

This was a big question that I had the chance to explore a little further a few days later, at the Wellcome Trust’s Engaging Science Day, a workshop for grantholders about public engagement. In our session, ‘Are historians human? Communicating medical history’, we talked about the mental health issue directly. Should we, as historians, communicate our own experiences of mental health and illness to make our field of study more accessible to others? The general consensus was no, unless you felt strongly about doing so. There was, though, a case to be made for engaging with medical and psychiatric history on a more personal level as a way of capturing other’s imaginations. Appealing to people’s preconceptions about the history of psychiatry and medicine as a starting point for discussion was one suggestion. Opening up a talk with an appeal to the audience – such as ‘What do you think the first drug treatments used in psychiatry were?’ – was a way in to a subject that the speaker specialised in, but which the audience might also have some knowledge of, going a small way to bridging that gap between speaker and audience, or historian and service user. Maybe the issue wasn’t one of language, of methodology, even of different disciplines, then, but in the very simple way we communicated with others.

‘Communicating Mental Health’ ended with a discussion amongst University of Birmingham participants about taking the dialogue opened up at the workshop further, and we look forward to hearing more about this in due course. You can view the full timetable of speakers and papers here, and Vanessa Heggie (@HPS_Vanessa) has kindly Storified (or Storify-ed?) live tweets from the two days here.

Horses and humans in the history of neurology

Towards the end of the 19th century, there was increasing interest in comparative pathology, comparative neurology or – let’s use this one for simplicity’s sake – comparative neuro-pathology. This was the idea that, by studying the brain and nervous system of an animal, one could extrapolate the knowledge gained in such investigation to human subjects. The Journal of Comparative Neurology, for example, published its first issue in 1891. In an era captivated by evolutionary theory, an animal’s brain offered to reveal something of cerebral development, demonstrating ‘by what steps the lower faculties of animals may have passed by natural process of development into the higher faculties of man’. The use of animals in scientific research at this time has previously been discussed on this blog by Mike Finn, who highlighted popular responses to the cerebral localisation work of David Ferrier (often using monkeys or cats), whilst Liz Gray has examined the work of William Lauder Lindsay, who was interested in the ‘psychopathology’ of animals.

From C. Watson, 'The Pathogenesis of Tabes and Allied Conditions in the Cord' (1901).

From C. Watson, ‘The Pathogenesis of Tabes and Allied Conditions in the Cord’ (1901). The horse’s hind legs assume an unusual position and the right rear knee joint is prominent.

Animals might also be used to reveal something of the nature of neurological disorders which had distinct physical symptoms. In 1901, Chalmers Watson of the Scottish Asylums tried to advance existing knowledge about tabes, a degenerative condition of the spinal cord: ‘If the etiology of tabes were accurately determined,’ he said, ‘a large and important chapter in neurology could be written’. In setting about this task, Watson presented a clinical case study not of a human patient, but of a horse. He had seen a horse that exhibited tabes-like symptoms, with an unusual gait and prominent knee-joint that recalled the Charcot’s knee seen in humans. The horse went on to suffer a seizure, afterwards developing the signs of ‘Stringhalt’. Stringhalt is a condition affecting horses in which the hind legs flex whilst walking. It may be most marked when the animal is frightened, turns, or has to back up slowly. (You can see a video of a horse with the condition here.)

In ‘On “Stringhalt” and “Shivering” in Horses’, Watson presented his horse much as one would present a human case study, setting out the animal’s age, appearance, and occupation:

The subject was a light-legged, well-bred horse, 15½ hands, aged 15 years or more, that had been able for work up to three months before the date at which he came under observation. His work was light, that of going in a fishmonger’s cart in a level country. His owner informed me that the animal had occasionally been off work for a few days or so from “lameness.”

Detail from a Muybridge study of a horse and its rider. © Wellcome Library, London.

Detail from a Muybridge study of a horse and its rider. © Wellcome Library, London.

Watson had earlier presented a cinematograph film of this horse to a meeting of the British Medical Association, which documented the animal’s unusual movement (and which also recalls the motion studies of Eadweard Muybridge). The horse’s physical symptoms – ‘spastic movements of the hind limbs’, elevated and quivering tail, inco-ordination – were observed for a few days by Watson, at the end of which the case took a rather different course than that of a human case study: ‘the animal was shot’.

Watson was particularly keen to conduct a post-mortem on the horse in the hope that the pathological appearances found would reveal something about the progress of disease. The advantage of using animals was that their ‘tissues … [exhibited] evidence of nervous disease … at an early stage of the morbid process when the pathological picture [was] as yet unobscured by the secondary and non-essential changes which so frequently complicate[d] the picture in the human subject’. The post-mortem and subsequent microscopical examinations led Watson to conclude the horse’s Stringhalt had been caused by ‘a chronic interstitial neuritis with secondary degeneration of the nerve fibres in the main nerves of the hind limbs’, with the ‘shivering’ symptoms explained by nerve fibre degeneration.

Appearance of the (human) spinal cord in advanced tabes. This was interestingly presented beneath the photograph of the horse in Watson's 'Pathogenesis of Tabes' article.

Appearance of the (human) spinal cord in advanced tabes. This was interestingly presented directly beneath the photograph of the horse in Watson’s ‘Pathogenesis of Tabes’ article.

Whilst Watson recognised the difficulty of formulating any general conclusions from a single case, he considered his findings to be of interest to both the veterinary and human sciences. He concluded that the post-mortem exam both threw light upon ‘common diseases of the horse’, and held some ‘suggestive lessons for the student of pathological processes in the human subject’. On the latter point, he pointed to the importance of vascular lesions (such as thickened blood vessels) in the horse, suggesting this might also be at the root of tabes in human subjects. He further suggested a possible cause for such changes, ‘toxaemia, probably of bacterial origin’, reflecting the interest in bacteriological matters that ran through much of his work. (Watson’s obituary demonstrates that his interests in bacteriology and animals often complemented one another: ‘in [his] later years [he] devoted himself to rearing cattle for [the] production of pure and safe milk’.)

By using animal case studies, then, investigators could make deductions about neurological development, but also neurological disease. Such studies reveal the often surprising scope of asylum-based research at this time, with Watson thanking the President of the Royal College of Veterinary Surgeons and referencing publications such as the Veterinary Record in his research. In addressing degenerative conditions like tabes, animals offered doctors and pathologists a way in to uncovering the ‘truth’ of diseases that caused many asylums to fill up with chronic (human) cases.

Reading

C. Watson, ‘The Pathogenesis of Tabes and Allied Conditions in the Cord’, BMJ (1 Jun. 1901).

C. Watson, ‘Cinematograph and Lantern Demonstration upon Nervous Diseases in the Lower Animals’, BMJ (27 Sept. 1902).

C. Watson, ‘On “Stringhalt” and “Shivering” in Horses. A Study in Comparative Neuro-pathology’, Brain 26 (1903).

A musical interlude

V0007684 A woman plays music to a stag; God condemns Adam and Eve to

With things winding down over summer, we thought we’d do a rather more light-hearted post this fortnight. Taking a cue from (perhaps even directly copying…) the Wellcome Library, who have begun to compile some medically-themed Spotify playlists for library readers to listen to during the Wellcome’s building works, we’ve put together our own Spotify playlist based (very loosely) around the theme of mental health.

You can access the playlist here. Some tracks are a bit tongue-in-cheek, others more serious, but I think they’re all quite uplifting in their own way. You’ll notice, though, that our own musical tastes have strongly influenced our choices!

Basket Case – Green Day

Emotion Sickness – Silverchair

Out of Mind – The  Cure

Schizophrenia – Sonic Youth

Black Eyed Dog – Nick Drake

Insomnia – Feeder

Melancholia – The Who

Hysteria – Muse

Agoraphobia – Incubus

Perfect Blue Buildings – Counting Crows

Disorder – Joy Division

Still Ill – The Smiths

Can the weather affect our mental health?

Firmly cementing the notion that the British are obsessed with the weather, this fortnight’s post considers how far climate might affect our mental health. Usually, when we think about the links between our external environment and how we feel, we think of Seasonal Affective Disorder (SAD), or ‘the winter blues’. But what about our mental wellbeing at other times of year? Over the last few weeks, Britain has been hit by heat waves interspersed with some impressive thunderstorms, both of which have been identified as possible influences upon mental health.

In the 19th century, Sussex Asylum’s Chaplain ‘laboured assiduously at meteorological observations’, claiming to find a correlation between atmospheric pressure as measured by the barometer, and fits experienced by epileptic patients. In America in the 1930s, W.F. Peterson and M.E. Milliken suggested in The Patient and the Weather that the incidence of neurosyphilitic conditions could be mapped onto the major storm tracks of North America – an intriguing idea, but one that a reviewer regretted was ‘very hypothetical’. Storms, though, were also identified as possible factors in suicidal behaviour by C.A. Mills in 1934, who suggested that the pressure and temperature changes caused by large storms might produce ‘mental instability’. Excessive heat had long been identified as a factor in mental ill health – seen, for example, in those soldiers admitted to asylums whose condition was attributed to ‘sunstroke’ suffered in India or Africa.

Soldier treated for sunstroke in the Sudan. © Wellcome Library, London.

Soldier being treated for sunstroke in the Sudan. © Wellcome Library, London.

Heat waves

But what about today? When a heat wave occurs, we often hear warnings in the press about the need to pay special attention to the health of young children and the elderly. The Department of Health’s Heatwave Plan also identifies those with mental illnesses as another at-risk group – not in terms of the direct effect of heat on their mental wellbeing, but their increased susceptibility to heat stroke. This may be due to individuals living in an institutional setting where provisions for dealing with a heat wave are inadequate; being isolated in the community and less likely to seek help and/or have someone looking out for them; or taking antipsychotic drugs and suffering psychomotor agitation, both of which can raise the body temperature.

V0025766 Lightning striking a rural building during a storm: onlooker

Heat waves have also been said to be associated with an increase in suicide and suicide attempts. Page et al identified a 46.9% increase in suicide rates during the 1995 heat wave, and a number of commentators have pointed to a rise in suicidal behaviours during the spring and summer. Salib and Gray, examining fatal self-harm in Cheshire, found rates of death from fatal self-harm to be positively related to fine, rather than extreme, weather, whilst Deisenhammer et al found a higher risk of committing suicide on ‘days with high temperatures, low relative humidity or a thunderstorm and on days following a thunderstorm’. Barker et al also suggested that thunderstorms were ‘likely to be associated with an increased number of parasuicides [attempted suicides that may be conceived of as 'cries for help']’.

explaining a summer/suicide link

V0024719 Astronomy: a diagram of the sun, and various effects of sunlHow might we explain such patterns? Barker et al note the suggestion that suicidal behaviour may peak in spring and early summer due to the ‘discrepancy noticed by depressed persons viewing the external world bursting into life when their internal world is lifeless’. They also suggest – as Durkheim did in his 1897 book Suicide – that seasonal variations in suicide rates are due to levels of social interaction. Spring and summer, rather than proving a counter to the isolation of the winter months, bring with them increased socialising opportunities that may lead to more relationship problems. Others have put forward biological explanations: increased air ionisation that raises the levels of adrenaline and serotonin in the body may, argued F.G. Sulman in the 1970s (see Carney et al), lead to more cases of mania in spring and summer. In their study of mania in Galway, however, Carney et al emphasise social factors. As a large part of Galway’s population are farmers, they say, the ‘frequently wet and windy [weather] contributes substantially to their psychological disposition’. Thus, ‘a bright sunny day is very welcome. For some it induces euphoria’.

Studies such as those by Carney et al are ultimately cautious in making definitive links between weather conditions and mental health. As Barker et al (see above) note, several variables are likely to influence suicidality, meaning any strong conclusions would require a large sample – and getting a large sample from a wide geographical area means that you also begin to see different weather conditions. Pinpointing a single variable when many ‘biologic and behavioural variables … undergo a 12-month cycle’ (such as hormonal cycles) means, say Ajdacic-Gross et al, that seasonal patterns in such complex matters as suicidal behaviour should be interpreted extremely cautiously.

Further reading and external links

S. Tromp, Biometeorology. The Impact of the Weather and Climate on Humans and their Environment (London: Heyden, 1980).

NHS Choices, Suicide – Getting help. (Includes links to helplines and support groups)

Guest post: Does the madness of King George III matter?

One of the best things about running asylumscience is the queries that we receive about the history of psychiatry. Simon Tombs, teacher of Psychology at Devonport High School for Girls in Plymouth, recently contacted us about a project he was putting together on King George III. In this guest post, he tells us more.

At Devonport High School, we have a long tradition of working with schools from other countries on projects that promote international understanding. Last October, I was offered the chance to work on a project with the Käthe-Kollwitz-Schule in Hanover. The English participants were Year 9 students (13-14 year olds), the German students a year older. The plan was for the German students to come to Plymouth in June 2013 and the Plymouth students to Germany the following year. The working title for the project was ‘History Matters’ and the springboard for this European-funded partnership is the 300th anniversary (in 2014) of the accession of the Hanoverians to the British throne. There were a number of topics planned for the project. George III’s madness was one of them. We aimed to understand something about how ideas about mental health and illness were exchanged between England and Germany. A bit of internet research suggested that psychology and psychiatry as academic disciplines started around the time of George’s illness in Germany. We wondered how, if at all, these ideas might have affected his treatment and recovery. For this project, I worked principally with Gesa Wrage at the Käthe-Kollwitz-Schule, and Elspeth Wiltshire who co-ordinates international projects at Devonport.

L0025613 King George III. Mezzotint after T. Frye.The original plan was to devise a session called ‘Out Of Sight, Out Of Mind’. I got in touch with Jennifer at asylumscience. She was able to provide some leads about asylums in the early 19th century. I had a look at an account of life inside the Eberbach Asylum in Germany and a summary of what German doctors had discovered when they visited England in the mid-19th century. This seemed promising: we could show students images of asylums from both Britain and Germany and ask them to consider what was the same or different. The written sources might tell us something about what life was like. We could think about why people living with mental illness might be moved to the countryside. I found something about the debate between ‘somaticists’ and ‘psychisists’ whose ideas about the causes of mental illness seemed to prefigure current debates on biological and psychological explanations for mental disorders.

The Madness of King George

-The-Madness-Of-King-GeorgeOne of the experiences which transformed the project was watching The Madness of King George. I had a vague recollection of seeing the film when it was released almost 20 years ago, and remembered the brutality of some of the treatments given to George. I also remembered Alan Bennett having fun with the depiction of Francis Willis, the doctor who was thought to have cured George, as a dour Lincolnshire puritan (my wife is from Lincolnshire). I realised when I watched the film again how many powerful ideas were in it. George’s illness was public knowledge and was seen as everybody’s business, in part because of the political situation at the time. In this, he seemed to prefigure modern celebrities  who go public about their mental health.

I also caught an excerpt of Simon Schama speaking at the Hay Sessions, discussing the importance of the late 18th century in our view of the modern world. Schama was bemoaning the lack of emphasis placed on this period in the new National Curriculum for History. I realised that George’s story stood at the point at which people began to realise that mental illness was something that could be understood scientifically. Francis Willis may have lacked social graces but he was at the forefront of enlightened, scientific thinking. He was part of a broader movement for change in England, Germany, and elsewhere in Europe. He became a celebrity after George’s recovery, receiving a generous state pension, a series of portraits and a special commemorative coin. Willis believed that George could get better. With this in mind, we planned for the students to watch The Madness of King George before their visit. I put together a session for the students to look at sources and understand more of the background to George’s story.

Discussing taboo

The second transforming experience was getting some help from a small group of the German students. They had been to an exhibition about taboo at an art gallery in Hanover and made a 10-minute Powerpoint presentation about what they had seen. They explained the origins of the word ‘taboo’, what was seen as taboo in the 18th century, and what was taboo today. Their presentation  raised some important questions. They made a connection between taboo and religion and made me think more fundamentally about where the stigma around mental illness really comes from. We used their input to discuss some questions:

  • Should we be talking about what was wrong with someone who died a long time ago and is not here to speak for himself?
  • If someone famous or important today has a mental illness, do we have the right to know about it?
  • Should celebrities living with mental illness talk about their illness? Should journalists write about it?
  • Is there still a taboo about mental illness? If there is, who makes it a taboo?
  • Apart from celebrities, should the views and opinions of people living with mental illness be heard more?
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Mind’s Time to Change campaign has tried to break taboos around mental illness, with celebrities like Stephen Fry talking about their experiences.

Visiting Saltram House

The third part of the project was a visit to Saltram House, a National Trust property on the edge of Plymouth. With the support of Anida Rayfield, who leads the volunteer tour guides at Saltram, we found that George had stayed there for a fortnight in 1789 following his illness. The house still looks very much as it did when George was there. George’s visit was designed to show that he had recovered. The route of his journey from Weymouth was lined with well-wishers, he came into Plymouth to great public acclaim to review the fleet, and visited the houses of the local gentry. We started to wonder how well he really was and if his visit was a form of convalescence. The family who lived there and all but two of their staff were absent throughout his stay: George brought his own people with him. He was able to walk in the extensive grounds in what was then a rural setting. His staff and carers would have been able to establish a routine and keep things in the manner to which he was accustomed. There was no court business conducted during his stay. It looks as if his stay in Saltram exemplified the ‘moral treatment’ advocated by Francis Willis and others.

Students imagine how a modern newsreader might report on George III's visit to Saltram House. © Elspeth Wiltshire/Simon Tombs.

Students imagine how a modern newsreader might report George III’s visit to Saltram House. © Elspeth Wiltshire/Simon Tombs.

Outcomes and going forward

Our project is ongoing. At the end of their session, we asked students why they thought the madness of King George was important and what else they wanted to know. Some focused on historical questions about what happened next, others said they wanted to know more about the idea of taboo. Others raised questions about science and medicine, both in relation to what was wrong with George and how he was treated, and with regard to what is done for people who suffer from conditions like George’s today. Both English and German students had the opportunity on the final day of the visit to explain what some of these questions were in a presentation to an invited audience of students, parents, and others connected with the school and the project. We have a year to work out how to deal with these questions and share ideas before the English students visit Germany in 2014.

L0025614 King George III. Soft-ground etching by W. Daniell after G.For me, it has already become clear why the madness of King George III matters. Through his story, we can see the birth of ideas that we deal with in contemporary psychology. We can see how questions about taboo, historical diagnosis, and the voices of people living with mental illness emerge from his story. One of the things we have not yet got hold of is what George himself thought of how he was treated, both at Saltram and before and after his visit there. I hope that is something we will understand better in time. Before we started, we were concerned that we were exposing some of the younger students to material about mental illness which they might find difficult. To deal with this, we formulated a statement that set boundaries and explained where support might be found. History matters because it enables us to approach issues which we might have forgotten, or feel embarrassed by. The sources about George in the form of written accounts, images and – in the case of Saltram House – concrete objects give us a vivid and compelling insight into these issues. We finished our session by watching a scene towards the end of The Madness of King George. George acts out the scene from King Lear where Lear is reconciled with Cordelia and talks about himself and his illness. I know of no better portrayal of the pain, the resilience, and the hope that are at the core of the experience of people who live with mental illness.

Attending the insane

L0027370 Claybury Asylum, Woodford, Essex: a dormitory. Photograph by

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

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.

Detecting injury

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.[1]

Male patients being washed by attendants at Epsom's Long Grove Asylum, c.1930. © Wellcome Library, London

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.’[2]

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.

[1] West Yorkshire Archive Service. SRH C85/1/16/3 Regulations and Orders. Relating to the Male Department (1909).

[2] West Yorkshire Archive Service SRH C85/1/16/2 Bathroom regulations. Relating to the Female Department (1874).

Further reading

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).

Post-mortems in the asylum and issues of consent

Our last post explored why post-mortems were considered essential to the scientific study of mental illness in the 19th century, with the procedure establishing cause of death and gathering pathological information that could be correlated with clinical notes taken during life. How was consent for post-mortems obtained, though, and how much input did patients’ friends and families have on the practice?

Seeking consent

That the bodies of asylum patients were considered important repositories of knowledge can be seen in the efforts made by asylum doctors to secure them for post-mortem examination. Eric Engstrom, investigating German psychiatric clinics, describes how ‘valuable neuropathological specimens’ were offered free beds in order to obtain access to their bodies after death. In Britain, there were appeals during the 1870s for post-mortems to be made a universal, automatic practice within medical institutions. Despite the support of prominent alienist Sir James Crichton-Browne and others, efforts to institute ‘carte blanche post-mortems’ were rejected in 1877, though this did not mean that all asylums followed the same protocol with regard to the procedure. Jonathan Andrews summarises: ‘At some asylums post-mortems had become de rigueur, formal consent not even being sought. At a minority, prior consent was procured from patients while living. Whereas a few sought written consent using purpose-specific pro-forma, others relied merely on verbal consent’.

L0000838 Section of the brain, 19th century.

At the West Riding Asylum in Yorkshire, the intent to perform a post-mortem was made clear on the notice of admission sent to relatives: ‘In case of death the usual post-mortem examination will be made in order to certify correctly the cause of death. Relatives in any case objecting to this course are requested to communicate immediately upon receipt of this notice, personally, with the Medical Superintendent.’ It is impossible to know how many families responded – or indeed were able to respond, depending on literacy levels – to this specific advice. Towards the end of the 19th century it is clear that some relatives were voicing their objection to post-mortem. Casebooks kept during the patient’s life might be annotated ‘Post mortem objected to’, or alternatively ‘No objection to P.M.’

Sample of a post-mortem book, 1899. © WYAS, Wakefield.

Sample of a post-mortem book, 1899. © WYAS, C85/1132.

Determining the specifics of post-mortem

Post-mortem records show that some families had very specific ideas about where the boundaries lay, and Andrews notes that this might be particularly evident if families belonged to a religious denomination that emphasised resurrection. Even amongst people without such beliefs, though, the idea of a post-mortem was – and is – a difficult one to deal with. In Speaking for the Dead, the authors relate the case of a mother whose son was killed in a road accident. Two years after his cremation, she and her family discovered that her son’s brain had been removed, and that his body had thus not been intact at his cremation. “It was my son’s heart and brain that made him what he was,” she said, and this is a feeling that crosses many cultures – of the brain as intimately bound up with the self.

There is a sense of this in several 19th-century records too. Often the ‘[h]ead [was] not permitted to be examined’, though there were some exceptions in which the head only was specified, possibly if the potential value of the exam to the wider study of mental illness had been emphasised by the doctor. Usually, the thorax was the part viewed by the family as an acceptable area of investigation, with records noting ‘Chest only examined’, or ‘Thorax only permitted to be examined’.

From J.M. Beattie, Post-Mortem Methods, 1915. © Wellcome Library, London.

From J.M. Beattie, Post-Mortem Methods, 1915.
© Wellcome Library, London.

There were also moves towards making death a less harrowing experience for patients’ families, with separate chapels set up apart from the mortuary. Reporting on the arrangements at Claybury Asylum, the British Medical Journal reported:

‘Our representative was much struck by the care taken to save the feelings of the friends of the dead. There is a cheerfully-furnished waiting-room for their special use; when they wish to take their last look at the departed the coffin is wheeled into the central hall where there is no trace of anything unpleasantly suggestive.’

Whilst asylum staff were keen to examine the bodies of deceased patients, then, there was increasing awareness that friends and families had a place in decisions about post-mortem practices, even if this was a time at which consent procedures were still being elaborated.

Further reading

J. Andrews (ed.), History of Psychiatry 23 (Mar. 2012) – Special issue: ‘Lunacy’s last rites: dying insane in Britain, c.1629-1939′.

S.  Ferber and S. Wilde (eds.), The Body Divided: Human Beings and Human ‘Material’ in Modern Medical History (Farnham: Ashgate, 2011).

E.T. Hurren, Dying for Victorian Medicine: English Anatomy and its Trade in the Dead Poor (Basingstoke: Palgrave Macmillan, 2011).

R. Richardson, Death, Dissection and the Destitute (London: Phoenix, 2001).

M. Sappol, A Traffic of Dead Bodies: Anatomy and Embodied Social Identity in Nineteenth-Century America (Princeton: Princeton University Press, 2002).

Post-mortems in the asylum: What were they for?

DSCF1077Last month, the Idaho State Journal reported that 120 headstones had been placed on the graves of former patients at State Hospital South (previously Idaho Insane Asylum). The new markers were unveiled as just one stage in an ongoing project of placing headstones on over 1,000 unmarked graves in the area. The unmarked or numbered graves of the asylum cemetery provoke strong feelings for present-day observers, suggesting large numbers of people who were forgotten by relatives, as well as raising questions about past psychiatric treatment. Reports on the unveiling of the latest headstones noted that some patients underwent lobotomies and other procedures. The Hospital’s current administrator said that, in the treatments they had undergone, these patients could be considered ‘pioneers’ in the treatment of mental illness whose legacy can still be seen today. Commemorating the dead in a cemetery leads us inescapably to the body of the asylum patient, something that is present throughout my own research and that can’t be overlooked when considering the history of psychiatry.

In the 19th century, the physical body was at the heart of much psychiatric research, but it is the body at post-mortem that this and a subsequent post will focus upon. In the search for the origins of mental illness, the post-mortem was crucial for asylum doctors and was a practice increasingly encouraged by the Commissioners in Lunacy in order that the ‘scientific spirit’ of asylum research be kept up. At the West Riding Asylum for instance, an 1885 Commissioners’ report noted that ‘[t]he number of post-mortem examinations, 193, [was] very satisfactory’.

What were the purposes of the post-mortem?

Why were the Commissioners so interested in the amount of post-mortems being performed? Firstly, as in any other medical arena, the post-mortem was crucial in identifying the cause of death. The West Riding’s Regulations and Orders of the Committee of Visitors stated that ‘A post-mortem examination [would] be made of the body of every Patient dying in the Asylum, and a searching inquiry … instituted as to the cause of any bruise or injury found upon a body’. As well as establishing the immediate cause of death, then, the asylum post-mortem acted as a check on asylum care. In examining the state of the body at death – post-mortem books might remind the doctor to note things such as bedsores, fractures, or if the body was emaciated – the procedure mirrored the admission exam in which the patient was bathed and checked for physical injuries. Sometimes the post-mortem revealed injuries that had been overlooked during life (such as a broken bone), and in this way could be conceived of as a deterrent to any attendants who were tempted to use violence towards patients.

Brain dissection, seen from above. © Wellcome Library, London.

Brain dissection, seen from above. © Wellcome Library, London.

Secondly, the post-mortem was a means of gathering evidence about the pathology of mental illness. Unusual appearances within the skull itself – adhesions of the membranes to the surface of the brain, blood clots, or wasting away of the brain substance – were recorded and tabulated in order to establish any patterns. Francis O. Simpson’s The Pathological Statistics of Insanity (1900) collected together a staggering amount of post-mortem data, organised by type of mental affliction so that the reader could chart the appearances found in the brains of melancholic, maniacal, or epileptic patients. Post-mortem record books might have an index added by recording doctors, where one could look up all instances of ‘adhesion’ or ‘haemorrhage’ in order to identify any similarities between the cases.

Thirdly, such data could be matched up with the clinical information kept on a patient during their lifetime. That post-mortem books often allowed the practitioner to note the ‘Form of mental disorder at admission’ and ‘Form of mental disorder at death’ suggests that mental illness wasn’t necessarily viewed as a static condition, but also – as Gayle Davies notes in ‘The Cruel Madness of Love’ – that the post-mortem could sometimes lead to a ‘re-diagnosis at death’. Conversely, the post-mortem often confirmed the suspicions of the doctor about the root of a patient’s problem, with a tumour or other anomaly found in the region of the brain that corresponded to a motor disorder exhibited during life.

Asylum museums were often smaller versions of those like the Royal Free Hospital's, above. © Wellcome Library, London.

Asylum museums were often smaller versions of those like the Royal Free Hospital’s, above. © Wellcome Library, London.

Lastly, this focus on the physical fabric of the insane body as a site of knowledge about mental illness led to many body parts being preserved for asylum museums. These on-site museums were used for teaching purposes as well as forming a permanent ‘catalogue’ of brain anomalies. Some specimens might be ‘put aside for hardening for general purposes’ – likely for students to examine or practice their dissection skills upon – or even sent to a researcher at another asylum for study (a brain from a patient at the West Riding Asylum who died in the early 1870s was sent to fellow alienist John Batty Tuke to examine). Towards the end of the century, bacteriological research also began to draw upon the fabric of the body, with  a researcher in 1895 ‘[inoculating] slices of sterilized potato … with blood from [a] spleen … [A] pure cultivation of typhoid bacilli resulted’. The post-mortem was, then, bound up with several other practices evolving at the time, and was a site where doctors honed their pathological skills as well as accounted for the basic facts of death.

Within all this, it often seems that the patients themselves are worryingly absent. What were the rules governing consent for post-mortems? Did families know what precisely a post-mortem entailed? Did they voice their objections to the asylum doctor? These are questions I’ll be turning to in our next post. In the meantime, for a fuller discussion of all of these issues you might like to take a look at a special issue of History of Psychiatry journal, ‘Lunacy’s last rites: dying insane in Britain, c.1629–1939’.

Stop, look, and listen

It’s been a busy few weeks here with exam marking, thesis writing, and all manner of things in between (including being interviewed by some students making a documentary about the history of psychosurgery – we’ll keep you posted). As a consequence, the blog has felt a little neglected, but we’ve put together a list of some great reading, viewing, and listening for you over the next couple of weeks that should make up for it!

Read

New issues of History of the Human Sciences and History of Psychiatry journals. The former includes a brilliant piece by Felix Schirmann on ‘Badness, Madness, and the Brain’ in the late 19th century and a free-to-all article by Chris Millard on self-harm in 20th-century psychiatry. In History of Psychiatry, Torbjørn Alm and Brita Elvevåg explore ergotism in Norway, and there is a timely consideration (after recent criticisms by the British Psychological Society) of classification in the DSM by Massimiliano Aragona, as well as – ahem – a piece on bone disease and insanity by Jennifer Wallis.

Understandings of ergotism are examined in the latest History of Psychiatry. © Wellcome Library, London.

Understandings of ergotism are examined in the latest issue of History of Psychiatry.
© Wellcome Library, London.

Whether or not you’re attending this year’s very exciting iCHSTM conference (International Congress of History of Science, Technology and Medicine)  in Manchester, the iCHSTM 2013 blog is definitely worth keeping an eye on, with posts so far on the science of selecting soldiers in WWII, to autopsies and asbestos.

Also on the blogs, check out this excellent post by Lisa Smith on ‘The Moon and Epilepsy in the Eighteenth Century’ over at The Sloane Letters Blog.

Watch

For those of you based in London, there’s still time to catch some of the seminars in KCL’s History of Health and Medicine series. This Wednesday promises a fascinating talk by Julie Anderson and Carole Reeves on ‘Imaging the Abnormal Body’, and the final seminar on 5 June welcomes Carin Berkowitz and David Hay to speak on ‘Educating the Body – Eye, hand, and imagination in (bio)medical education’. The seminars are free and open to all, starting at 6pm.

Pauline Norris promises an interesting take on the humble lettuce. © Efraim Lev/Zohar Amar.

Pauline Norris promises an interesting take on the humble lettuce.
© Efraim Lev/Zohar Amar.

And if you’re looking for some intellectual stimulation this Friday, I’m intrigued by Pauline Norris’s seminar as part of the Institute of Historical Research’s History of Gardens and Landscapes History seminar series: ‘The Lettuce Connection: The Ancient Egyptian Cultivation of Lettuce, the God Min and Aphrodisiacs‘. The seminar starts at 5.30pm at Senate House, and is free to attend.

Next week, also at the IHR, Roberta Bivins will be speaking on ‘Domesticating Medicine: Medical Technologies and the Home‘. Again, the seminar is free to attend, with a 5.30pm start.

On 10 June the annual Freud Memorial Lecture will take place at London’s Freud Museum. This year, it’s given by Allen Frances, who asks ‘How well does Freud’s work stand the test of time?’ For more details, including how to book, see the Museum’s website.

Listen

Today sees the first episode of a ten-part series by BBC Radio 4, ‘Disability: A New History‘ presented by Peter White. Examining the history of disability in the 18th and 19th centuries, the series will cover everything from ‘the only dwarf in Liverpool’ (today’s episode) to the facial disfigurements caused by diseases such as smallpox. It promises to be a fascinating set of programmes, with contributions from several key historians in the field, that I’m really looking forward to listening to.

© Wellcome Library, London.

© Wellcome Library, London.

Over on BBC Radio 3, a recent programme examined the cultural history of syphilis, a disease that frequently raises its head here on asylumscience. You can listen to the programme here.

I think that’s enough to keep you busy for the next week or so – and we’ll be back with our normal blog service in two weeks time!