Abstract
Deaths in the asylum could be interpreted as a sign of failure, particularly if they were related to the poor condition of those admitted, the spread of disease among patients, or the direct consequences of severe mental disorders. County asylum superintendents lamented the bad physical state in which many were sent to the asylum and the consequences for death rates. Due to limited consideration of environmental and sanitary matters before the 1830s, there was great risk of contracting fatal diseases in the asylum. Combined with the deteriorated physical condition of many patients, and the growing overcrowding, this had a notable influence on mortality. For some individual patients, death came about as a direct consequence of a profound mental disorder. Without effective treatments to confront manifestations of disordered thinking, mental symptoms might precipitate physical deterioration to the point of death, while severe distress led some to kill themselves in the asylum.
Death accounted for a significant proportion of the departures of patients from the early group of English county asylums developed following the enabling legislation of 1808 (48 Geo. III, 1808). John Thurnam, the statistically inclined medical superintendent of the York Retreat, calculated in 1845 that the mean annual mortality in county asylums accepting only pauper lunatics had been almost 14 per cent since their establishment (Thurnam, 1845: 137–8). 1 Nevertheless, the phenomenon received comparatively little contemporary notice. Asylum managers and medical officers were more interested in projecting the effectiveness of their institutions in the achievement of patient turnover by the more favourable means of recovery and discharge. The concept of the asylum as a place of ‘cure’ had been enshrined in the legislation (51 Geo. III, 1811, Section 1). The operating principles of the new asylums were ostensibly based, at least in part, on the discourses of ‘moral treatment’ and a humane system of care (Jones, 1972; Mellett, 1982; Scull, 1993; Smith, 1999). They were intended as medical institutions, where the restoration of physical and mental health were closely interlinked. Within those parameters, the deaths of disproportionate numbers of people could constitute something of an inconvenience.
If the ideal of ‘cure’ was pre-eminent, death could be deemed a sign of failure requiring explanation (Thurnam, 1845: 2–3; C Smith, in this issue). Mortality rates differed markedly between asylums, as highlighted in 1844 (Metropolitan Commissioners in Lunacy, 1844: 187–90; Thurnam, 1845: 17–21, 137–44). The percentages of deaths to average numbers resident over the previous five-year period ranged from 9 per cent at the Middlesex and Nottingham Asylums to 19 per cent at Norfolk Asylum. Figures comparing proportions of cures and of deaths to overall outcomes were even more striking. At Gloucester Asylum (opened 1823), ‘cures’ amounted to 65 per cent of people departing, while deaths were only 14 per cent. However, at the huge Middlesex Asylum (opened 1831) ‘cures’ stood at 37 per cent and deaths at 56 per cent. Other county asylums fell somewhere between (Metropolitan Commissioners, 1844: 189). Various reasons were adduced to explain these differences. Thurnam (1845: 84–97) suggested a strong correlation between death rates and the quality and quantity of dietary provision, as well as factors such as ventilation and levels of overcrowding. John Conolly, based on his experience as medical superintendent at Hanwell Asylum, also emphasized the importance of good food, noting that ‘a very low diet conduces to a high mortality’, while deaths diminished when the diet was improved. He thought this not surprising, considering the poor physical state of most people admitted (Conolly, 1847: 65–7). Whatever the identified causes, large numbers of deaths certainly did not give a favourable impression of an asylum, presumably accounting for the widespread reluctance to explore the issues in any depth (see also Michael and Hirst, in this issue).
The perception of a definite link between insanity and a reduced life expectancy had been growing from the early part of the nineteenth century, to judge from the writings of practitioners (C Smith, in this issue). Joseph Mason Cox, a prominent private madhouse proprietor, noted the danger of ‘extinction of life itself’ in maniacal patients who ‘resist every remedy, strive against every shackle and mean of coercion, use the most violent gesticulations, and rend the air with vociferations’ (Cox, 1806: 172–3). In the case histories of people admitted to Bethlem Hospital in the 1790s, cited by its influential apothecary John Haslam (1809: 87–112), several had died from emaciation or exhaustion directly attendant on their mental symptomatology. Another leading ‘mad-doctor’, George Man Burrows, was particularly concerned with the proneness of asylum patients to physical disorders that could bring about an early death, such as consumption, dysentery, diarrhoea, apoplexy and convulsions. He insisted that ‘whenever the intellectual functions of the brain are deteriorated, the vital functions are also deteriorated’. Insanity, he concluded, ‘tends to the shortening of human life’ (Burrows, 1828: 226–34, 552–3, 559). The epidemiological studies of the statistician William Farr (1841) served to confirm the high mortality of lunatic asylum patients in comparison with the general population. Lockhart Robertson later argued the case even more strongly, suggesting that the statistics showed ‘the prognosis, as to the expectancy of life, is directly and materially reduced by the mere presence of mental disease’, and that the mortality rate among the insane was twice that of the general population (Robertson, 1859: 280).
Two distinct strands of discourse around the causation of deaths of mentally disordered people in asylums had emerged by the 1840s. The first strand might be conceived of as encompassing the collective, or the overall mortality levels of patients and the contributing factors. The great majority of deaths were attributable to causes emanating from physical ill-health, which arose before or following admission. The second strand related rather more to individuals. Although less numerically significant, it was generally acknowledged that some asylum deaths occurred as a direct consequence of patients’ mental disorders. Prominent mad-doctors and alienists were arguing that the symptoms of mental disorders might be directly responsible for the physical decline and death of asylum patients, or for their suicide. The remainder of this paper seeks to address these two strands, using supportive evidence from contemporary reports and from patient case records.
Explaining mortality
One of the defences used by asylum medical officers to account for apparently high numbers of deaths was to blame others, not least the patients. By 1800, the principle was established that people should be removed as early as possible from the surroundings associated with the onset of insanity and sent to an asylum (Battie, 1758: 68; Porter, 1987: 155–6; Scull, 1993: 135–8). It became an almost unanimous complaint among asylum medical officers and official visitors, however, that ‘pauper lunatics are sent there at so late a period of their disease, as to impede or prevent their ultimate recovery’ (Metropolitan Commissioners, 1844: 80). Criticism was largely directed towards the responsible parish authorities or boards of guardians, who avoided expenditure by seeking the admission of patients only when their behaviour became completely unmanageable (Metropolitan Commissioners, 1844: 223–7). According to Paul Slade Knight, the house surgeon and superintendent of Lancashire County Asylum, parsimonious parishes kept lunatics and idiots in appalling conditions in workhouses until they became ‘permanently deranged’; only when ‘the poor man becomes outrageous or extremely offensive, or till impending Death threatens to close the scene’ would he be sent to the asylum (Knight, 1822: 11–15).
Asylum superintendents lamented the bad physical state of people sent to them. William Ellis, in accounting for 14 deaths out of 138 admissions during his first year as ‘Director’ of the West Riding Asylum at Wakefield, claimed that 95 were ‘old cases’ and some came ‘almost in a dying state’ (WRLA, 1st Report, 31 Dec. 1819). Little had changed by 1825, when many were ‘sent in such a state of emaciation and debility’ that they died within days or even hours (WRLA, 7th Report, 31 Dec. 1825). Ellis moved in 1831 to the new Middlesex Asylum at Hanwell, where he found a comparable situation (London Metropolitan Archives, 1832: 4; 1833: 6; 1834: 11; 1835: 16). His successor at Wakefield, C.C. Corsellis, was equally concerned, noting during 1837 that 15 people ‘admitted in a dying state’ had ‘expired within a few days’ (WRLA, 19th Report, 31 Dec. 1837).
Anguished complaints came from numerous quarters (see also Michael and Hirst, in this issue). At Norfolk Asylum, after several people were admitted ‘in a dying state’ during 1822, a protest went to the magistrates requesting them to ‘abstain from committing persons in such a dangerous state’ (NLA, SAH 4, 2 Oct. 1822). Four years later, the overseers of the poor were cautioned against sending the terminally ill, after 19 deaths of people admitted who were dying or had incurable diseases (NLA, SAH 4, 7 Feb. 1826). Following five deaths within a week of admission in 1842, Lancaster Asylum’s medical officers expressed deep regret that ‘parties, in such an advanced state of bodily and mental disease’ were kept in the workhouse, to be ‘consigned to a lunatic asylum only when there is no longer any chance of recovery’ (Reports of the Medical Officers, 1842: 3). Dr George Button was concerned that Dorset Asylum would become ‘merely a receptacle for the hopeless and dying’, and demanded an investigation by the visiting justices (DLA, Report of the Visiting Justices, Epiphany 1844: 14–15). John Kirkman of Suffolk Asylum complained about people brought ‘in almost a state of dissolution’, some dying within days (SLA, 6th Annual Report, 1844: 11). The Gloucester Asylum Visitors strongly objected to people sent ‘from distant parts of the county, almost in a dying state’, many of whom were not ‘proper objects’ for an asylum (Gloucester LA, Annual Report, 1841).
If one major problem was that some of those admitted to the county asylums were nearly dead when they arrived, another was that issues of health, hygiene and disease appeared to account for the demise of quite a few more. The requirement in the 1808 Act that county asylums be built in an airy, healthy location (48 Geo. III, 1808: Section XVI) reflected some awareness of the risks of disease in buildings where numerous people were congregated (see also Philo, in this issue). Matters of public health and the need for measures to counteract epidemic fevers had been highlighted as early as the 1790s by men such as Dr John Ferriar, physician to the Manchester Infirmary and Lunatic Hospital (Ferriar, 1792, 127–53; Hamlin, 1998: 18, 66–9; Pickstone and Butler, 1994). However, practical responses by the authorities remained limited in scope before the 1840s. Lunatic asylums, like prisons, workhouses and hospitals, were places with a significant risk of contracting fatal diseases (Hamlin, 1998: 31–3; Ignatieff, 1989: 59–63; Woodward, 1974: 97–122). When combined with the poor physical state of many admitted, this significantly influenced asylum mortality.
Most county authorities adhered to the locational guidance of 1808, with some notable exceptions (Philo, 2004: 526–86). Lancaster Asylum was built near boggy ground, identified by Slade Knight as a key reason for the high incidence of bowel complaints in 1823–4, when 71 patients out of 250 were attacked and a number died (Knight, 1827: 119). Lancaster had recurrent problems through the 1830s, and was struck hard by cholera in 1833, losing no fewer than 94 patients. Another 46 died in 1837 from ‘phthisis after influenza’ (British Parliamentary Papers, 1836, Vol. XLI: 10; London Metropolitan Archives, 1838: 35–6; Thurnam, 1845: 138, 144). When Samuel Gaskell and Edmund De Vitrie took charge in 1840, respectively as medical superintendent and visiting physician, they found diarrhoea ‘very prevalent throughout the house’, resulting in many deaths, and having ‘always assumed a formidable character’ in the asylum ( Reports of the Medical Officers, 1841: 4; Scull, Mackenzie and Hervey, 1996: 164–5, 168; Thurnam, 1845: 138; Walton, 1981: 171–2). The fundamentals of healthy location were also overlooked at Dorset Asylum, opened in 1828 in an adapted country mansion (DLA, Dorset Quarter Sessions, Forston House (3), 27 June 1828). Situated part-way up a valley, water flowed down from the hills in times of heavy rain or spring thaw, saturating the asylum’s brick floors. The pervasive dampness precipitated a dysentery outbreak at the end of the winter of 1840–1, greatly increasing the mortality before remedial measures were taken (DLA, Dorset Quarter Sessions, Easter 1841, Michaelmas 1842; Report of the Visiting Justices, Epiphany 1842: 3, 11; Thurnam, 1845: 85).
A healthy geographical situation did not prevent epidemics if there were other adverse circumstances, such as poor drainage, inadequate sanitary facilities or overcrowded wards. Each became prevalent at the West Riding Asylum. Its patients were always prone to bowel diseases, diarrhoea contributing materially to the ‘great mortality’ in the institution’s early years. By 1826 the frequency of dysentery constituted a ‘real cause of alarm’ (Gilbey, 1830–1: 92–3). The disorder reached its height in 1828, accounting for at least 15 deaths, followed by more in 1829 and 1830 (WRLA, 10th Report of the Director, 1828, 11th Report, 1829, 13th Report, 1832: 5; Gilbey, 1830–1: 92, 95; Wright, 1850: 13–14). In seeking reasons for delays in determining the cause of the sickness, and for its virulence, Dr Gilbey, the visiting physician, observed bluntly that lunatics could not give proper information on symptoms because ‘the sensibility to all impression is so much deadened, by the weakening of the cerebral influence’, while they lacked ‘the common feelings of human nature’. Prognoses were poor because ‘in lunatics the brain and nerves are so shattered and impaired, that maladies act on matter almost inert’ (Gilbey, 1830–1: 91–2). Gilbey identified the key causal factor as severe overcrowding, exacerbated by the high incidence of soiled beds. He cited also the proximity of the kitchen to the wash-house, with its ‘stench and abomination’ from the ‘mass of filthy linen’, and defective drainage through sewage tanks adjoining the wards (Gilbey, 1830–1: 193–4). Sanitary measures in 1830 remedied the worst defects, though overcrowding was not relieved until the partial opening of a new building in 1846 (WRLA, 12th Report, 1830; Wright, 1850: 11–12, 37). The asylum even escaped cholera in 1832, while the surrounding district was badly affected and 20 people died in Wakefield jail (WRLA, 14th Report, 2 Jan. 1833). An influenza outbreak in 1837, however, precipitated 16 deaths from consumption (WRLA, 19th Report, 1837). Dysentery also never really went away, causing deaths throughout the 1840s; in 1849, 10 patients died from dysentery and 21 from diarrhoea (Wright, 1850: 14–15).
This ongoing mortality at the Wakefield asylum was, nevertheless, greatly overshadowed by the disastrous cholera outbreak of late 1849. After the first case appeared on 17 Sep. in a patient admitted from Gomersal workhouse, the epidemic spread rapidly through the asylum, reaching its height on 27 Oct. when 19 people died in a single day. The final death toll reached 106 (Bolton, 1928: 622; Wright, 1850: 2–3, 21). In attempting subsequently to justify themselves, the asylum authorities pointed to several years of improving sanitary conditions. The root cause was identified in chronic overcrowding and inadequate accommodation, which had led to prolonged restrictions on admissions and accumulation of the excluded in workhouses. After completion of the new building in 1848, those finally admitted included an ‘unusually large proportion of enfeebled patients, and advanced and hopeless cases’, all particularly vulnerable to contagious disease (Wright, 1850: 10–12, 16, 38). Reflecting on the epidemic, the visiting physician Thomas Giordani Wright (1850: 3–4) offered reassurance in terms reminiscent of his predecessor Gilbey:
It may be somewhat consolatory to observe, that, with scarcely an exception, the patients carried off have been subjects of incurable mental derangement; and in a majority of instances so demented as to be unable to describe their symptoms; while many perversely refused alike food and medicine.
In this characterization, the chronically insane victims had been barely human or alive even before their actual deaths brought formal confirmation (see also Michael and Hirst, in this issue).
Death by insanity
Although bodily health problems accounted for most of the mortality in county asylums, the occurrence of death as a direct consequence of madness was an increasingly acknowledged risk, albeit subject to some controversy among practitioners (C Smith, in this issue). Those experiencing extremes of mood disorder were the most vulnerable. Melancholia was often accompanied by self-neglect and refusal of nourishment, while in mania gross over-activity and excitement could lead to complete exhaustion. Haslam’s Bethlem case histories provided graphic examples of both (Haslam, 1809: 87–8, 90–4, 110–12). Cox (1806: 172–3) also recognized that deaths could occur both through self-starvation and through excited, violent behaviour, unless interventions like the rotating chair were employed to counteract the symptoms. Alienists came to focus mainly on the danger of exhaustion from mania. As George Man Burrows (1828: 554) observed:
Insane persons may be said to die of sheer lunacy when they exhibit no marks of bodily disease; but in such cases death may be the simple effect of exhaustion, the patient being worn out by mere mental excitement, raving and violence. This sometimes actually happens; and I see no reason why it should not so happen, since great mental excitation, or excessive bodily fatigue, will bring on instant death.
He did concede, though, that mania still might not be as fatal as melancholia.
James Cowles Prichard also drew attention to the dangers of unchecked mania, contending that a ‘fatal termination’ could follow from ‘exhaustion arising from continual excitement’. There were ‘many cases of maniacal disease in which the ceaseless excitement of the feelings, the constant hurry of mind and agitation of body, the total want of rest and sleep, and the febrile disturbance of the system’ produced a ‘marked reduction of strength as well as of flesh’. In some cases, despite medical interventions, ‘maniacs die completely worn out and exhausted’ (Prichard, 1835: 147). The phenomenon of death from exhaustion consequent on mania was recognized by Daniel Hack Tuke, citing cases treated by John Conolly (Bucknill and Tuke, 1858: 231–3), and by Lockhart Robertson, who also drew attention to the risks associated with food refusal in acute melancholia, especially where complicated by delusional ideation (Robertson, 1859: 269, 280, 282).
It may well be the case that the treatment methods employed in early nineteenth-century asylums failed to reduce the risks of physical deterioration, and could even exacerbate them. Although the range of medical and ‘moral’ treatments utilized was perhaps more sophisticated than sometimes credited, there were limited means to confront extreme manifestations of behaviour or disordered thinking. Treatments such as emetics and purgatives, and cold or warm baths, might provide relief but were unlikely to produce speedy tranquillization. Moreover, depletive techniques could further weaken the patient’s constitution (Smith, 1999: 194–212). Mechanical restraint, widely employed in most county lunatic asylums into the 1840s, ostensibly to restrict or prevent behavioural excess, could also have unintended consequences. Although campaigners against restraint did not directly contend that its effects might prove fatal, Conolly (1856: 47–8) argued that forcible restraint could increase the patient’s agitation to render him ‘furious’, and Robert Gardiner Hill (1839: 24–35) advanced a similar case.
Asylum case records provide some evidence to support both the pathway from mania-related exhaustion to death and the possibility of exacerbation by mechanical restraint. Case material for the early county asylums is, however, relatively limited compared with the later nineteenth century, both in quantity and quality. This is due partly to the vagaries of survival of original records, but more to the lack of statutory requirement to keep specific records before the legislation of 1845 (Berkenkotter, 2008: 70–1). Even where case records have survived, these have to be treated with caution. As Berkenkotter (2008: 2, 72–4) points out, from a ‘discursive perspective’ the case history constitutes a ‘double narrative’, whereby the patient’s story is subsumed into the ‘thought-style’ of the clinician. In his interpretation of the patient’s symptomatology and presentation, the alienist was influenced by the legal, intellectual and conceptual considerations of a developing profession.
The Stafford Asylum case books 2 contain several examples of patients suffering from mania, admitted in an excited state, who were subjected to mechanical restraint and died soon afterwards. James Hawley, a pauper from Colton who had previously spent nearly two years in the asylum, was readmitted in October 1827. By 17 Nov. he was in mechanical restraint, which continued until he died on 13 Dec. from ‘mania and exhaustion’ (SGLA, Casebook, 5 July 1822, 17 Apr. 1824, 10 Oct., 13 Dec. 1827; Weekly Returns of Patients, 17 Nov.–15 Dec. 1827). Three men died from ‘mania and exhaustion’ in the week ending 17 Mar. 1827, each having been under restraint in the preceding period (SGLA, Weekly Returns, 24 Feb.–17 Mar. 1827). One of them, John Overton, aged 20 and the son of a Shropshire farmer, was admitted in January. His insanity was ‘in the low form’; he was ‘very hypochondriacal, imagining that he is at the point of death, that his liver is destroyed &c&c’. He was ‘so excessively agitated at times, as not to be able to control his actions’. His untimely death followed three weeks in mechanical restraint (SGLA, Casebook, 5 Jan., 15 Mar. 1827).
Grace Hemmings, a 55-year-old Bilston pauper, was admitted to Stafford on 11 Jan. 1825, having been deranged for 18 weeks ‘without any assignable cause’. John Garrett, the medical superintendent, concluded that ‘she is in a high & dangerous state of excitement, with great probability that she will sink under her malady’. She was immediately put in mechanical restraint, given medicines, wine, and a ‘generous diet’. Despite these measures she died after 10 days, the consequence of ‘mania and exhaustion’ (SGLA, Casebook, 11, 21 Jan. 1825; Weekly Returns, 15–22 Jan. 1825). Sarah Gordon, a 55-year-old Derbyshire pauper admitted in May 1827, had ‘the disorder in the high form, & has a great propensity to destroy her apparel – she refuses her food & is become very much emaciated’. She was placed under constant restraint and given ‘a generous diet with Wine &c’, but died three weeks later (SGLA, Casebook, 31 May, 22 June 1827; Weekly Returns, 2–23 June 1827). William Steel, 35, a Burton-on-Trent shoemaker admitted on 4 July 1826, having been ‘deranged about a fortnight without any assignable cause’, also had ‘the disorder in the high form’ and had been violent towards those looking after him. He ‘imagines himself to be in possession of immense wealth on which topic he is constantly raving’. He was kept in mechanical restraint, until his death on 3 Aug. (SGLA, Casebook, 4 July, 3 Aug. 1826; Weekly Returns, 8 July–5 Aug. 1827).
The unique journals kept by the long-serving, semi-literate Thomas Caryl, ‘Master’ of Norfolk Asylum (Cherry, 2003: 1, 37, 43, 48–50), illustrate several instances of the decline and demise of violent, manic patients. On the night of 15 Oct. 1823, Caryl reported that Jonathan Brunning ‘became violent in the night & completely distroy his shirt, waistcoat & Breeches also rent his bed blanketts’, and for punishment he was locked down to his bed. Two weeks later he was restrained in his cell after being ‘violent and noisy’. On 10 Nov. Brunning again destroyed his night-shirt and tore up his bedding. However, by now he was becoming worn out, sick and feeble; he died on 4 Jan. 1824 (NLA, Master’s Journal, 16 Oct. 1823 – 4 Jan. 1824).
A patient named Edmund Abbott proved a considerable challenge. On the night of 16 Feb. 1840 he got out of bed and broke his cell windows with his shoes, and was consequently strapped to the bed. Four days later, after attempting to cut his throat, his hands were placed in a muff. On 26 Feb. Caryl reported that Abbott had ‘rent one of his blankett all to pice and his stockings’, and the muff was again applied. By 18 Mar. he was openly defying order in the asylum. Having destroyed his clothes and hat, he ‘say he will distroy them all – they are his own and he will do what he like with them – without anybodys leave’. The following night he pulled off his muff and destroyed his bedding. This pattern of excitement, violence and restraint continued; on 24 Mar. Caryl exclaimed that ‘there is no depending on Abbott not one hour’. In early May he was injured in an attack by another patient, but on 16 May he again destroyed all his bedding and was ‘very abusive’ to a keeper. By now, though, Abbott was becoming exhausted. On 20 May he was reported to be sinking fast, and he died ‘of a decline’ on 29 May. According to Caryl, he had been ‘restless eversince admitted’ (NLA, Master’s Journal, 16 Feb.–29 May 1840). Around the same time, two other male patients, Henry Pile and Charles Pooley, were regularly exhibiting equally violent and destructive behaviours, the latter being described by Caryl as a ‘complete blackguard’ after he had kicked a keeper ‘over the privates’. Caryl’s response to each patient was the repeated use of mechanical restraint. Both exhausted themselves, became week and feeble, and died. Pile was described as having been ‘constantly restless day and night’ (NLA, Master’s Journal, 12 Mar. 1840 – 7 Apr. 1841).
These various examples of deaths apparently consequent on mental symptomatology bear out the observations of Burrows, Prichard and others. Medical officers and staff in asylums were evidently quite powerless to prevent a fatal outcome, with symptoms even exacerbated by the treatment measures applied. Mechanical restraint, although intended to contain dangerous or excited behaviour, could promote agitation, and physical resistance, accelerating the process of exhaustion. Similar treatment techniques were often employed for another significant group of patients whose mental states could prove fatal – the suicidal (Shepherd and Wright, 2002; York, 2009). Although not a frequent occurrence, a successful suicide caused consternation to asylum authorities, leading usually to an investigation followed by the imposition of additional safety precautions. However, the most determined patients could find a means, as the Gloucester Asylum Visitors acknowledged in 1843 after only its second suicide, when a man named Nash had ‘contrived, in a manner truly wonderful and with an ingenuity and perseverance peculiar to suicidal maniacs’, to hang himself (Gloucester LA, Annual Report of the Visitors, 1842; House Committee Minutes, 29 May 1843).
Dr William Ellis, based on extensive experience at Wakefield and Hanwell asylums, concluded that ‘the mode of self-destruction usually attempted by the patients’ was hanging (Ellis, 1838: 120). The recent study by Sarah York (2009: 87–90) has confirmed that most successful suicides in nineteenth-century asylums were by some form of strangulation. In Nottingham Asylum, five of six suicides in the two decades after it opened in 1812 were by self-strangulation. Two occurred in a month in 1814, followed by others in 1818, 1831 and 1833. The exception was a woman who burnt herself to death in 1828 (Crommelinck, 1842: 150). After the 1814 incidents the asylum authorities increased the level of precautions. Mechanical restraint, however, failed to prevent the death in 1818 of a patient, ‘known to entertain an habitual propensity to self-destruction’, who had supposedly been ‘deprived of all means or opportunities of effecting his purpose’. Despite one hand fastened to his bed frame, he managed to tear his sheet into a strip and twist it round his neck ‘so as to effect strangulation, by his own efforts, without suspension’. Such ‘obstinate determination’, it was concluded, could only be displayed by someone with a ‘perverted state of mind’ (Nottingham General LA, 8th Annual Report, 1818).
A determined suicidal patient would, indeed, use whatever means were at his disposal. Joseph Bridgewater, a Dudley shopkeeper, was admitted to Stafford Asylum in late December 1820, after having attempted to cut his throat. Financial difficulties had apparently convinced him ‘that his wife & 5 Children would come to poverty’. After four weeks in the asylum he had reportedly been ‘meditating suicide, & secreted a rope, which he had taken from the hay rick’. Despite being closely watched and having his hands confined at night, Bridgewater evaded the precautions. In the water closet the following evening he ‘inflicted on himself a very extensive lacerated wound’, using a small piece of slate ‘which he had secreted about his person’ while at work. He died from the wound two days later (SGLA, Male Casebook, 27 Dec. 1820, 23, 25 Jan. 1821).
At Norfolk Asylum, Thomas Caryl’s drastic methods may have restricted the numbers of completed suicides. In July 1815 Phoebe Land was locked into bed by both hands after trying to strangle herself with her apron strings. She nevertheless ‘say that she will do it the first opportunity’, and two days later tried with the bed sheet. She was then placed in a strait waistcoat and attempted to use its strings, so Caryl had her locked down by her wrists and legs. Phoebe, however, contrived to tear up her rug and got it round her neck, after which she was subjected to mechanical restraint day and night, with someone sleeping in her room (NLA, Master’s Journal, 23, 24 June, 4, 6, 7 July 1815). Two months later, Samuel Vincent was more successful. Showing no sign of intent, ‘he toke his dinner as usual’ in the day room. Half an hour later he was found ‘hanging in the necessary’ 3 with a knotted handkerchief (NLA, Master’s Journal, 19 Sep. 1815). In 1844 Jonathan Lawrence successfully hanged himself from the cell shutters (NLA, Visitors’ Minute Books, 28 May 1844). However, numerous other attempts, some quite dramatic, were thwarted and followed by restraint and seclusion (NLA, Master’s Journal, 7 July 1822, 15 Jan., 18 May, 5, 20 Oct., 13 Dec. 1823, 22 Feb. 1824).
Prior intent of suicide was often not evident. Three females hanged themselves in Dorset Asylum between 1832 and 1842, and George Button, the medical superintendent, noted that no suicidal disposition had been apparent in any of them. One was conversing with the nurse and other patients five minutes before the ‘fatal act’, while another was deemed ‘convalescent’ and assisted in the kitchen (DLA, Report of Visiting Justices, 1844: 35–6). There was a similar lack of previous indication in the disastrous spate of suicides that occurred in Lancaster Asylum during 1841–2. Indeed, Gaskell and De Vitrie had congratulated themselves in their 1841 report that, despite numerous attempts, there had been no suicides the previous year, following the implementation of a non-restraint policy ( Reports of the Medical Officers, 1841: 12; 1842: 8). However, a rude shock followed when four occurred within eight months.
The first instance was a 24-year-old engineer, S.N., admitted in September 1839 with various delusions and hallucinations, including perceptions that the sun’s appearance was changing and that he received commands from a voice in the air. In April 1841, after ‘grossly indecent conduct in the gallery’ and ‘other vicious propensities’, which had been ‘dictated by the fancied voice of a spiritual being’ threatening eternal punishment if he did not comply, he was moved to a single room. However, he displayed no suicidal intent and on 19 Aug. was reported cheerful and helping to clean windows. The next morning he was found hanging by a plaited cord made from a bed sheet (Reports, 1842: 8–9). In early November, B.C., an ‘Irish girl of a high hysterical temperament’, hanged herself from the bedhead using a strip of blanket, following arguments with her room-mate whom she had annoyed by incessant singing and talking. Her death was probably the unintended outcome of a dramatic gesture (Reports, 1842: 9–10). There were ‘strong suicidal propensities’ recorded in the case of A.H., the mother of 11 children, admitted in November 1841. She was ‘the subject of constant and anxious solicitude’. However, on 15 Feb. 1842, she was particularly cheerful and ‘worked with more than ordinary assiduity’, after a promise that she could attend a dance that evening. As it began, two magistrates entered and distracted the nurse’s attention. Minutes later A.H. was found ‘suspended to the iron bar of a bed-room window on the opposite side of the gallery’ (Reports, 1842: 10). By contrast, T.S., an elderly man of ‘irritable disposition’ admitted in October 1829, had never shown any suicidal tendency. An unremarkable patient, who sometimes worked in the kitchen, he had ‘exhibited no unusual symptoms’ prior to being discovered hanging from iron window bars on 3 May 1842. It was conjectured only that he might have been agitated by building upheavals accompanying the introduction of the non-restraint system (Reports, 1842: 10–11).
After four suicides, Gaskell and De Vitrie felt the need to justify their non-restraint policies, and contended that only A.H. would have been restrained under the old system. They emphasized the ‘tendency to imitation’ displayed, particularly while patients still had access to window bars. Endeavours by the authorities to conceal the occurrences had failed, for each time several people ‘attempted it in the same manner and some even without the most remote purpose of destroying life’ (Reports, 1842: 11–12). The Lancaster episode exemplified the complexities of suicidal behaviour and its management within an ordered asylum. The risk was ever-present that preventative measures, such as building adaptations, classification, surveillance, restraint and seclusion, would be insufficient. Nevertheless, as York (2009: 134–5, 182–278) has shown, effective prevention became a bench-mark for judging an asylum’s achievements. A low suicide rate illustrated the skills of medical superintendents and staff, and the quality of the institution’s practices. Successful suicides could promote uncomfortable questions and unfavourable comparisons.
Conclusions
Individual deaths in county asylums directly attributed to the consequences of insanity aroused considerable concern, and even alarm. Their numbers were, however, comparatively small. Moreover, there are clear difficulties in the post-hoc identification of death from insanity. In almost every case the ultimate cause of death was likely to be physical rather than mental, particularly where exhaustion or emaciation brought about the failure of vital organs or accelerated a pre-existing bodily ailment. Suicides perhaps offered the most evident linkage to mental disorder. Outside the asylum, by the early nineteenth century, as Houston has shown (in this issue), there was already a sophisticated and animated debate as to whether or not suicide should be deemed the product of insanity and thus a ‘medical’ problem. Within the county asylum’s walls, however, there was little equivocation, as the existence of severe mental distress could provide sufficient explanation for the suicide of a patient already defined as insane.
The overall mortality of asylum patients as a direct consequence of physical ailments or deficiencies was, numerically at least, of far greater significance. As time went on, the discourse on the issue gained more widespread attention and participation, for the reputations of institutions and of their medical officers were at stake. Although comparative ‘cure’ rates were the favoured standard for comparing the effectiveness of county asylums (e.g. Melling and Forsythe, 2006: 181), death rates also provided an important basis for practitioners and external parties to make judgements about the relative achievements of particular asylums (Metropolitan Commissioners, 1844: 187–90; Thurnam, 1845: 2–3, 13, 17, 137–44). The assumption was that a relatively low death rate was an indicator of a healthy environment, appropriate treatment practices and effective management. A high death rate, however, pointed to a combination of deficiencies in location, buildings, treatment systems and management practices.
One of the great problems of the public asylum system throughout the nineteenth century was the incessant increase in patient numbers and the consequent continuing cycle of overcrowding, building expansions, and construction of more and ever-larger institutions (Melling and Forsythe, 2006: 46–55, 72; Scull, 1993: 268–82, 364–6). The growth in numbers was based partly on an increasing proportion of people deemed appropriate for asylum admission, compounded by the continuing rapid rise in the nation’s population. The difficulties related to overcrowding had already started to manifest themselves in the early county asylums by the 1830s (Smith, 1999: 79–82, 172–4), accentuated by the steady accumulation of people whose condition was chronic or ‘incurable’, and who were never likely to be fit to leave. The ill-effects of overcrowding, when associated with the locational, structural and sanitary deficiencies of asylum buildings, and the consequent transmission of contagious diseases, acted in combination on the poor physical state of many patients to produce high mortality rates. Their deteriorated mental states doubtless reduced powers of resistance to bodily disease, as Burrows (1828: 553–4) had argued and Dr Gilbey (1830–1: 91–4) at Wakefield evidenced, rendering insanity a contributory factor at least in some asylum deaths attributed to physical causes.
Although recovery and discharge rates differed significantly between county asylums, these sometimes did not exceed 40 per cent of the number of admissions (Thurnam, 1845: 10–11, 136–7). Consequently, the continuing accumulation of chronic and immovable patients made the process of ‘silting up’ in the asylum inevitable. This created the stark paradox, though doubtless involuntary and unsought, that a substantial death rate was partly in the interests of the county authorities. It enabled them to retain sufficient capacity in their asylums to provide for the constant streams of people requiring admission. In other words, death could prove to be a ‘welcome release’ for the authorities as well as for the patients.