Tag Archives: asylum attendants

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).

Bones, breaking strain, and the insane body in 19th-century asylum practice

In January 1870, author Charles Reade wrote to the Pall Mall Gazette to make some sensational claims about the conduct of asylum attendants. Whilst researching his book Hard Cash – in which a young man ends up confined in a lunatic asylum – Reade said he had seen alarming evidence of the tactics used by attendants to subdue the patients in their care. ‘The refractory patient’, he wrote, ‘is thrown down and the keeper walks up and down him on his knees, and even jumps on his body, knees downwards, until he is completely cowed.’ He thus suggested that he had hit upon the answer to a burning question of the day: how was it that so many patients in asylums seemed to sustain fractures?

Within the space of a few months, a number of cases were reported in which patients had been found to have extensive fractures at post mortem – one exhibiting an astonishing eight broken ribs and broken breastbone. The Pall Mall Gazette was not the only media outlet to voice its concerns about the care of the insane in Britain; an article in the British Medical Journal listed several instances of broken ribs, prompting a significant backlash from alienist members of the British Medical Association when it asserted that ‘rib-crushing, though the favourite, seems not to be the only mode in which lunatics are hurried out of existence … [In] 1869 a patient … was boiled in his bath’.

These were serious allegations, and the last quarter of the nineteenth century saw the issue of ill treatment in the asylum gain prominence. In the 1880s and nineties, with the development of training and certification for asylum nurses, handbooks advised staff on how to handle patients carefully, to spot the signs of fracture, and to subdue excitable patients who were especially vulnerable to injury.

The dialogue around broken bones also spread to the asylum laboratory, with some pathologists undertaking post-mortem tests to determine if the bones of the insane were inherently weak or brittle. Visual evidence of bone disease was mentioned in a number of articles on the topic: doctors and pathologists described bones that were ‘soft and boggy’ or ‘like sponge soaked in fat’. There was also a desire, though, to quantify such anomalous appearances more minutely. Theo Hyslop, when working as a Clinical Assistant at the West Riding Asylum, had used ‘an ordinary concrete testing machine’ to measure the strength of ribs at post-mortem. In 1893 Charles Mercier distributed a special instrument he had devised for the purpose. First, one ‘extract[ed] a certain length of the eighth pair of ribs’. Then, the lengths were put into the instrument, one tested against its concavity, the other against its convexity.The instrument ‘had a stirrup at one end and a screw at the other, and between these was a spring which registered the number of pounds pressure exerted. The bone … was put through the stirrup resting on the fork of the machine; the screw was then turned till the rib broke’. He sent this instrument to a number of asylums, as well as some London hospitals; though it is difficult to find much evidence of its use, it was certainly employed at length by Alfred Campbell at Lancashire’s Rainhill Asylum, who attempted to tabulate ‘breaking strain’ by type of mental illness.

Alfred Campbell’s results were most specific, confidently identifying an average breaking strain of 44.8lbs convex and 44.4lbs concave in his male general paralytic (neurosyphilitic) subjects, compared to 62lbs and 65lbs respectively in a healthy adult male. (Similar meticulous records of breaking strain can be seen in Francis Simpson’s Pathological Statistics of Insanity, where breaking strain by mental disease/sex etc. was recorded alongside brain weights.) Campbell’s second paper on the subject was more hesitant. Published only a few months later, this paper cast doubt on the link between fragile bones and insanity: ‘The difference between the average breaking strain of the ribs of the insane and that of the ribs of persons free from mental disease is not so great as one would anticipate’. In his comparative sample of 58 Rainhill Asylum patients and 50 Royal Southern Hospital patients, Campbell found very little difference between the rib breaking strain of the male asylum patient and that of the male general hospital patient. Explaining this, he theorised that wasting diseases had greater influence upon bone structure than mental afflictions – and indeed, many pauper asylum patients were in poor health.

Though the results of experiments like Campbell’s were often inconclusive and of little help to the living patient, the idea of bone fragility was incorporated into asylum administrative practices: at the West Riding Asylum, ‘breaking strain’ was consistently recorded at post-mortem from 1895 until around 1902.

Mercier’s instrument was not enduring in its impact: analysing 200 post-mortems at the West Riding, William Maule Smith in 1903 chose not to use it, instead basing his conclusions ‘on the ease with which fracture was produced by digital compression’ (Mercier, in the audience listening to Smith’s paper, unsurprisingly did not agree with Smith’s method!).

Bizarre as these experiments may seem to us now, the idea that the insane were peculiarly prone to bone disease and fracture was one that fitted logically alongside wider theories about both disease susceptibility and the general health of the asylum patient in the late nineteenth century. Quantifying rib strength did not, though, change the basic fact that patients were vulnerable individuals: the key figure remained the asylum attendant whose responsibilities were unchanged by the suggestion that some patients were especially liable to fracture. Via the lab then, the bones of the patient became capable of mediating not only asylum research, but also everyday practices and social relations – objects both constructed and constructing, and a sign that the insane body was not a merely passive one, even in death.

Further reading

Anonymous, ‘A social blot’, British Medical Journal (22 Oct. 1870).

Alfred W. Campbell, ‘The breaking strain of the ribs of the insane: an analysis of a series of fifty-eight cases tested with an instrument specially devised by Dr C.H. Mercier’, Journal of Mental Science 41 (1895).

Alfred W. Campbell, ‘A comparison between the breaking strain of the ribs of the sane and insane’, British Medical Journal (28 Sept. 1895).

W. Lauder Lindsay, ‘Mollities ossium in relation to rib-fracture among the insane’. Edinburgh Medical Journal 16 (1870).

Charles Mercier, The Attendant’s Companion: a manual of the duties of attendants in lunatic asylums (London: J & A Churchill, 1898).

George H. Pedler, ‘Mollities ossium and allied diseases’, in James Crichton-Browne (ed.) West Riding Lunatic Asylum Medical Reports 1 (London: J & A Churchill, 1871).

Charles Reade, ‘How lunatics’ ribs get broken’, Pall Mall Gazette 1541 (20 Jan. 1870).

Francis O. Simpson, The Pathological Statistics of Insanity (London: Baillière, Tindall & Cox, 1900).

William Maule Smith, ‘On the nature of fragilitas ossium in the insane’, British Medical Journal (3 Oct. 1903).

- Jennifer Wallis