“What is the most desirable situation for an hospital for the insane?
We may presume, without further question, that the same circumstances, in regard to situation, which are found by a person who is free from any morbid tendency, to have a beneficial influence on his mental feelings, will generally, in some degree, contribute to the restoration of a mind diseased.
The establishment should be situated, then, under a mild sky, in an agreeable, fertile, and sufficiently dry part of the country, where the surrounding scenery, diversified with mountains, valleys, and plains, is calculated to enliven the spirits of the beholder…there should be an unfailing spring of good drinking water…and easy communication with some large market town.” [1]
The location of the North Wales Lunatic Asylum, opened in 1848 to serve the five counties of North Wales, almost perfectly realised Jacobi’s vision. Nestling amongst the rolling hills which mark a border between the fertile Vale of Clwyd to the east and the rugged Hiraethog moors and Snowdonia to the west it also lay within easy walking distance of the thriving agricultural market town of Denbigh which, by the 1860s, was to become the main centre of the Vale with rail connections to London, the Midlands and the North West.
In the autumn of 1874 Dr George Turner Jones, who had been Medical Superintendent of the asylum since its opening, was terminally ill. He had supervised the care of more than 2700 patients during his 26 years in post and it seems he had adhered as closely as possible to the philosophy of humane treatment for the insane which underpinned the 19th century asylum building programme.
Dr Jones would have employed the limited medications available to him, along with wine and brandy, as part of a therapeutic regime. However, in 1869, he was keen to investigate the curative properties of the Turkish bath and made arrangements to visit asylums at Cork and Limerick where baths had been installed and were apparently effective, with Dr Thomas Power claiming that half of his patients at Cork were improved or cured after using the bath.[2]
After this visit to Ireland, Dr Jones strengthened his recommendation for a Turkish bath at Denbigh by adding that “as a means of cleansing it is found to be the cheapest mode adopted” and the Committee of Visitors approved its immediate construction.[3]
The Lancet had insisted in 1861 that the medical properties of the Turkish bath were unknown and denounced the literature on the subject as “for the most part, either puffs or long descriptions of baths, ancient and modern, with a few instances of cures affected”. The journal had called for “a fair and scientific trial” to be made at a metropolitan hospital under the direction of medical officers.[4] It appears that no such trial had been conducted by the time the Committee of Visitors at Denbigh made their decision because Dr Jones was condemned in 1870 for making an extravagant claim as to the percentage of cases cured by the Turkish bath and failing to produce any exact statement of its real scientific value.
In a letter to the Lancet in February 1871, Dr Edgar Sheppard, Medical Superintendent at Hanwell Asylum (the only asylum in England to have a Turkish bath at this point), wrote in defence of Dr Jones. While agreeing that his statement regarding cures was probably an error, he argued that:
“It is probable that… 74 per cent of “recovered” cases had been treated by the Turkish bath with markedly good effect, rather than that 74 per cent of insane cases had been absolutely cured by it.”
And in criticising the Lancet for insulting medical superintendents generally:
“We can afford to bear, and smile at the abuse. We may not be doing much for what you and others call science, but we may still be labouring hard, and not unsuccessfully, to bring about the cure and well-being of our patients”.[5]
In 1871, in the midst of these professional disagreements, the asylum at Denbigh became the fourth asylum in Britain to install a Turkish bath and Dr Jones was soon reporting a marked beneficial effect in several cases of acute mania, adding that: “I am fully persuaded of the superiority over the ordinary warm bath in its cleansing power. The peculiarly disagreeable odour which is emitted from the secretion in the skin of the insane is perceptibly modified by the Turkish bath”.[6] The association of insanity with a particular smell appears to have been widely accepted in the 19th century and is discussed in medical journals of the period. An article in the London Lancet of 1830 describes the “maniacal odour” as “a pathognomonic symptom so unerring, that if I detected it in any person I should not hesitate to pronounce him insane, even though I had no other proof of it”. [7]
Regardless of this, patients also approved the Turkish bath – it was much less objected to than the ordinary warm bath water – and the Commissioners in Lunacy observed in 1872 that they used it generally instead of the baths in the wards.[8] By 1874 the average number of patients taking the bath weekly amounted to 170 men and 180 women representing about 85 per cent of the inmates.[9]
Dr Sheppard’s robust response to the Lancet’s criticisms of the scientific shortcomings of medical superintendents – that their work was more focused on the wellbeing of their patients than on research – is borne out in the records from the North Wales Lunatic Asylum during this period.
While the therapeutic value of a limited drugs armoury and Turkish baths remained unclear, the need to provide meaningful employment for patients and opportunities for recreation was never questioned. Male patients worked on the asylum farm or in the garden. Skilled craftsmen were able to work with the joiner, tailor, shoemaker, blacksmith, painter or butcher and some of the better educated patients assisted the steward or clerk with clerical duties. Female patients knitted or sewed, others worked in the laundry or kitchen or on the wards. All patients capable of occupation were employed in some way.
Weekly dances had been introduced in 1864 which, apart from being enjoyed by patients, provided a useful opportunity for the medical staff to observe behaviours. Around 220 patients of both sexes regularly danced to music from the asylum band and in the summer there were dances on the bowling green. Case notes suggest that a patient’s conduct at the weekly dance could be taken to signify the likelihood of recovery or relapse. Elizabeth Phelps Gapper, a young governess employed at Dolgelley, was admitted onto the refactory ward with acute mania but after a few weeks was permitted to attend the dances and once it had been observed that ‘she conducts herself in an orderly manner’ she was soon discharged.[10] There were concerts, ‘private theatricals’, a brass band and in 1873 it was reported that:
“Every object for the amusement of the patients has been resorted to. Several dramatic performances and amusements were attended by many of the most excitable patients and their conduct has been so encouraging that in future we hope to extend these entertainments”.[11]
The asylum was surely a cold, uncomfortable place with its stone floors and poorly lit corridors but the vast majority of its patients were paupers whose lives outside the institution may have offered no greater physical comfort and in some cases a great deal less. Not infrequently, patients admitted in a malnourished condition left the asylum ‘quite stout’ and there are examples of recovered patients who asked to be kept a little longer, like WO who, on his second admission, did not want to miss the Christmas celebrations he had enjoyed the previous year.[12]
Christmas festivities were a highlight of the year when patients helped staff to decorate the asylum in preparation for an annual feast of roast beef and plum pudding. “On Christmas Day, over a hundred of each sex sat down together in the large room to their annual feast” when “the cheering and soothing effects of occasionally mingling the sexes are very observable.”[13]
Prior to being discharged, all patients were required to appear before the Committee of Visitors where they would be questioned as to the treatment they had received in the asylum. The Committee reported in 1873 that: “In every instance the patients have expressed their gratitude for the considerate manner in which they have been cared for”.[14]
Dr Jones’ deteriorating health forced him to resign in October 1874 and he died the following year. Dr William Williams, assistant medical officer at Hanwell Asylum under Dr Edgar Sheppard, was appointed his successor but until he was able to take up his post on 1st January 1875, Dr Evan Powell served as acting medical officer in charge.
It was therefore Dr Powell who presented the medical superintendent’s annual report for 1874 and it is clear from this that cracks were beginning to appear in the system. He described patients admitted during the year as being “of a most unfavourable class on account of their advanced ages, bodily infirmities and the form of their mental diseases” and regretted that so many chronic and imbecile patients were being sent to the asylum.[15] This Dr Powell attributed to a government subsidy which made it cheaper for Poor Law Unions to maintain paupers in the asylum rather than in the workhouse:
“The crowded state of the asylum, especially on the female side, will very shortly become an important subject for the consideration of the committee. We would recommend as a temporary remedy the removal of the chronic and harmless patients to the workhouses.”[16]
Dr Powell also expressed his disappointment that, because family members had objected, so few post mortems had been carried out during the year. “It would be very desirable if a rule could be established by which a post mortem examination could be made in every case.”[17]
Dr Powell’s frustration was shared by his successors and the need for more post mortem examinations is frequently mentioned in subsequent annual reports. There are hints of a progressive approach to medicine in Dr Powell’s diagnoses. In earlier reports these fell into four basic categories – mania (acute, puerperal and chronic), melancholia, dementia, epilepsy and idiocy. But in Dr Powell’s report mania could also be recurrent, melancholia could be acute or chronic and idiocy had a sub group ‘with epilepsy’. Kleptomania appeared on his list, also monomania with and without suspicion, and delirium tremens. Dr Powell left his post at the asylum[18] soon after delivering his report and diagnoses generally returned to the more conservative groupings of previous years.
In January 1875, when Dr Williams took up his post at Denbigh, the asylum was almost full, with a large proportion of beds occupied by chronic long stay patients who had been accumulating year upon year since the asylum’s opening. The need to make provision for curable cases of insanity demanded that the problem of providing alternative accommodation for these long term chronic cases be addressed. It was a problem which would dominate Dr Williams’ time at the North Wales Lunatic Asylum and become an even more pressing problem for his successors.
Footnotes
[1] Jacobi CWM (1841) On the Construction and Management of Hospitals for the Insane.
[2] Kandela, Peter (2001), The rise and fall of the Turkish bath in Victorian England, International Journal of Dermatology, Vol 39, Issue 1.
[3] DRO AR 22, 1870
[4] Lancet, February 23rd 1861: 198
[5] Lancet, February 25th 1871: 287
[6] DRO/1/4, 23rd Annual Report 1871
[7] The London Lancet 1830
[8] DRO/1/4, 24th Annual Report 1872
[9] DRO/1/4, 26th Annual Report 1874
[10] DRO/HD/1/Adm.no. 2520
[11] DRO/HD/1/4, 25th Annual Report 1873
[12] DRO/HD/1/360/Adm no. 2507
[13] DRO/1/4, 25th Annual Report
[14] DRO/1/4, 25th Annual Report
[15] 1874 AR
[16] 1874 AR
[17] 1874 AR
[18] The Medico-Pharmacological Association lists Evan Powell as Medical Superintendent at the Borough Asylum Nottingham in 1888.