‘Above All a Patient Should Never Be Terrified’: Moral Treatment and Management in Hampshire,

U.K. 1845-1914.

Diane CarpenterUniversity of SouthamptonUniversity of Portsmouth

11

Hampshire, England, UK c.1851

22

METHODOLOGY

55

• DRAMAS OF MEDICAL HISTORY

• THE HEALER

• THE SICK PERSON

• DISEASES

• DISCOVERING & COMMUNICATING KNOWLEDGE

• MEDICINE & HEALTH INTERACTING WITH SOCIETY

DE-MEDICALIZATION

MEDICALIZATION

ANNALES

ALLTAGSGESCHICHTEHCLA and BPLA

NARRATIVE OF THE PATIENT JOURNEY

CASE STUDIES

66

Hampshire County Lunatic Asylum

(HCLA)

Borough of Portsmouth Lunatic Asylum

(BPLA)

SOURCES

• Reception Orders, Case Books, Administrative records (daily running including accounts and staffing), Maps, Plans, Photographs, Quarter Session Reports, Censuses, Newspapers, Original textbooks and journals, Personal letters, Contemporary fiction.

77

ETHICS

• 100 – Year restriction re Medical Records

• Permission sought and gained from the Local Research Ethics Committee (NHS Research Ethics Service) June 2008.

88

Historiography

• Focus on control and order (moral management)

• Other determinants of moral treatment involved improved diet, fresh air, exercise, entertainment, meaningful occupation – in an aesthetically pleasing environment.

• These have been the specific province of local historians

9

Focus of this Paper

• To what extent did the quality of asylum life compare with the main alternatives for pauper lunatics?

• To what degree was the quality of life consistent in all asylums nationally?

• Is there evidence to suggest that the quality of moral treatment improved or deteriorated between 1845 and 1914?

10

11

Figure 1: BPLA DIETARY, 1879.BREAKFAST DINNER TEA

Bread Butter Tea Meat Soup Bread MeatPie

Veg SuetPud

Ale Bread Butter Cheese

MON 8 oz ½ oz 1 pt 3 oz 1lb ½ pt 8oz ½ oz 2 oz

TUE 8 oz ½ oz 1 pt 5 oz 1lb ½ pt 8oz ½ oz 2 oz

WED 8 oz ½ oz 1 pt 2 oz 2 pt 5 oz 8oz ½ oz 2 oz

THU 8 oz ½ oz 1 pt 12oz 1lb ½ pt 8oz ½ oz 2 oz

FRI 8 oz ½ oz 1 pt 5 oz 1lb ½ pt 8oz ½ oz 2 oz

SAT 8 oz ½ oz 1 pt 3 oz 1lb ½ pt 8oz ½ oz 2 oz

SUN 8 oz ½ oz 1 pt 16-18oz ½ pt 8oz ½ oz 2 oz

TOTAL 56oz 3½oz 7pts 18oz 2 pt 5 oz 12oz 5lb 16-18oz 3pts 56oz 3 ½oz

14oz

Source: C.I.L. Report, 1880

12

Comparison of the Weekly Dietary for Male Patients at Five Asylums fluid /oz

Bread Porridge Suet Broth/Soup/Stew

Meat/Pie Fruit / Vegetables

Butter Cheese Beer Tea Coffee Cocoa0

50

100

150

200

250

B.C.L.A. (1865)B.P.L.A. (1879)H.C.L.A. (1853)N.L.A. (1853)S.L.A. (1859)

Sources: Crammer, Asylum History, p.110; P.C.R.O. PR/H8/1/7/1, BPLA, 1880, A.R.M.S., p. 34; H.R.O. 48M94/A9/1, HCLA, A.R.M.S., 1853, p.11; Cherry, Mental Health, p77; Gardner, Sweet Bells, p.51. Precise details were not available in all categories for the NLA. Butter and tea were more frequently given to female patients.

13

Males No. Females No.

Architect 1 Agricultural Servant 1

Boat Builder 1 Dairy-woman 1

Brick Burner 1 Domestic Employment 7

Cabinet Maker 2 Domestic Servant 17

Clerk 1 Dress-maker 1

Coach Maker 1 Game-keeper’s Wife 1

Cooper 1 Governess 1

Dyer 1 Inn-keeper’s Daughter 1

Gardener 3 Labourer’s Daughter 2

Hawker 1 Labourer’s Wife 18

Joiner 1 Laundresses 3

Labourers 32 Lodging-house Keeper 1

Land Surveyor 1 Paupers 4

Pensioner 1 School-master’s Wife 1

Polish Refugee 1 School-mistress 1

Ship’s Pilot 1 Seaman’s Wife 1

Shoe-maker 1 Tailor’s Wife 2

Tailors 2 Weaver’s Wife 1

Teacher of Navigation 1 Without occupation 5

Thatcher 1

Tramp 1

Without Occupation 5

Total 61 Total 69

Occupations of Patients Admitted to the HCLA, 1854.

RESULTS: MORAL TREATMENT – THE QUALITY OF ASYLUM LIFE

• The basic determinants of the quality of life for the local asylum population appeared preferable to its alternatives

• Asylum diet was better than at the Workhouse, and often to what could be afforded at home

• Accidents and contagious diseases occurred, but probably, because of the precautions taken, less often than in the industrial or agricultural workplace

• Asylum provided safer environment than patients’ homes• Standard of cleanliness was variable, but frequently checked• High standards of personal cleanliness

1414

THE QUALITY OF ASYLUM LIFE

Continued.• Clothing was institutional, but of very good quality –

providing warmth. All patients were given shoes, boots and winter coats

• Opportunity for exercise (in the fresh air) was better in Portsmouth than in Hampshire. (In both cases this was better than it is today).

• Employment was aimed at developing skills or preventing de-skilling with the aim of rehabilitation and discharge

• A wide variety of amusements and entertainments was provided in both Asylums.

15

RESULTS: MORAL TREATMENT – CONTROL AND ORDER (MORAL MANAGEMENT)

• States of quietude were considered desirable by most (Medical Superintendents, Asylum Visitors and Commissioners in Lunacy)

• Physical control was achieved largely by secluding patients for short periods of time

• Occasional authorized mechanical restraint e.g. ‘strong dresses’

• More evidence of psychological control (than physical or chemical) e.g. daily routine

1616

17

Figure 2: BPLA DAILY REGIME, 1879Hours to be observed during weekdays On Sundays

6.00a.m. First bell rings. All Attendants and Servants to get up - Patients to rise, wash, dress, and prepare for breakfast.7.30 a.m. Bell - Attendant's breakfast.8.00 a.m. Bell - Patients breakfast.9.00 a.m. Patients all go to their work.10.00 a.m. Bell - Working men's ale.12.15 p.m. Bell - Preparation for dinner.12.25 p.m. Bell - Patients' dinner.1.00 p.m. Bell - Servants' first dinner.1.30 p.m. Bell - Servants' second dinner.2.00 p.m. Patients return to their work.6.00 p.m. Bell - Patients return from their work - Supper7.00 p.m. Bell - In Winter }7.30 p.m. Bell - In Summer }9.00 p.m. Servants' Supper.10.00 p.m. Servants go to bed.

6.00a.m. First bell rings. All Attendants and Servants to get up - Patients to rise, wash, dress, and prepare for breakfast.7.30 a.m. Bell - Attendant's breakfast.8.00 a.m. Bell - Patients breakfast.10.30 a.m. Bell - Chapel, to commence at 10.45 a.m.12.25 p.m. Bell - Patients' dinner.1.00 p.m. Bell - Servants' first dinner.2.15 p.m. Bell - Chapel, to commence at 2.30 p.m.6.00 p.m. Bell - Patients' Supper.7.00 p.m. Bell - In Winter }7.30 p.m. Bell - In Summer }9.00 p.m. Servants' Supper.10.00 p.m. Servants go to bed.

Source: PCRO, PR/H8/1/8/1 Rules for the Government of the Borough of Portsmouth Lunatic Asylum,1879.

MORAL MANAGEMENT – SOCIAL CONTROL

• Social control in both asylums - encouragement of patients to conform to social mores e.g. chapel attendance,

• strict segregation of sexes (except for organized entertainment such as asylum dances)

• Visiting by patients’ relatives was limited, yet encouraged once the ‘acute phase’ had passed

• Reliance on institution as surrogate family appears to have been encouraged

18

19

The offices of religion have a soothing and favourable effect on many: - I have found the use of evening service, and the calm and sober strain of piety which pervades the Liturgy, to be well adapted to these unfortunate beings. Religious excitement of the feelings is always bad and has brought a great number of patients to this, as well as to every other Asylum. A patient should never be terrified.

CONCLUSIONS

• In conclusion, despite criticism by many of the quality of care for the mentally ill during the period 1845-1914, the local evidence would suggest that

• Asylum life was preferable to its alternatives• Generalizations should not be made, and, • in Hampshire, England, the quality of moral treatment

did not deteriorate between 1845 and 1914 although it was poised for a considerable change.

20