Introduction
The rise of the asylum system during the 19th century is well documented, but there are divergent views on its nature and purpose. On the one hand, the asylum is presented as an enlightened and humanitarian response to the problem of madness; embodying an attitude of therapeutic optimism and providing a ‘place of refuge in a very harsh world’ (Jones, Reference Jones1993, p. 40). It also offered the possibility of specialist attention and a better-funded alternative to the cruel and austere regimes of the Victorian Workhouse (Bartlett, Reference Bartlett1998). Thus, communal living, sheltered work, sports and excursions replaced the punitive measures of earlier periods as the means of restoring asylum residents back to health and competence (Bartlett, Reference Bartlett1998; Bynum, Reference Bynum1974). According to this view, the noble ideals of the early asylum movement were thwarted in the late 19th century by over-crowding and under-funding (Shorter, Reference Shorter1997).
On the other hand, thinkers such as Michel Foucault and the historian Andrew Scull have highlighted the segregative nature of the asylum system and its political and economic functions. Based on the French experience of institutionalisation, Foucault held that the mass-confinement of the mentally ill consisted of an enterprise in social control that equated cure with conformity, and helped to establish and reinforce the discipline required in an emerging industrial economy (Foucault, Reference Foucault and Howard1988). Scull (Reference Scull1977, Reference Scull1993) has further argued that the growth of an interconnected capitalist system necessitated the delineation of ‘categories of deviance’, and the channelling of each category (e.g. criminal, non-able bodied poor, able-bodied poor) towards either the support most appropriate for their sculpting into models of ‘bourgeois rationality’ and ‘proper work habits’, or else towards a more permanent segregation in the interests of maintaining order in the workhouse or factory (Scull, Reference Scull1977, p. 341).
Thus Foucault and Scull suggest the asylums existed principally as removal grounds for people unable to fit into the new social and economic system. A related view claims that psychiatry emerged as a means of neutralising political opposition and unconventional behaviour in line with the interests of capitalism (Cohen, Reference Cohen2016). Some feminist writers have also suggested that there was an entirely moral basis to much female incarceration, with allegations of lunacy a response to such deviancies as lesbianism, illegitimate pregnancy or espousing political opinion (Chesler, Reference Chesler2005; Russell, Reference Russell1995). Other feminist thinkers have suggested that the elevated rates of female incarceration observed during much of the 19th and early 20th centuries are better explained as genuine mental illness provoked by women's ‘legally powerless and economically marginal’ social position (Showalter, Reference Showalter1985, p. 73). Beliefs have accumulated, however, about asylums being used to incarcerate people, and especially women, for moral and political transgressions, masturbation or harmless eccentricity (Eloise, Reference Eloise2017).
The stereotype of late 19th and early 20th century asylums also suggests that, once admitted, few people ever left. They have been described as ‘dustbin[s] of the incurable’ (Porter, Reference Porter1987, p. 20), ‘in which any hope of therapy was illusory’ (Shorter, Reference Shorter1997, p. 65; see also Rollin, Reference Rollin2003). Indeed, even at the time, some commentators viewed the asylums as little more than ‘prisons for the mentally sick’ (Hollander, Reference Hollander1905, p. 117).
Analyses of case notes provide contrary evidence, however, with studies showing that between 49% and 55% of patients were discharged, mainly recovered or improved, from asylums at the end of the 19th century (Doody, Beveridge, & Johnstone, Reference Doody, Beveridge and Johnstone1996; Renvoize & Beveridge, Reference Renvoize and Beveridge1989; Turner, Reference Turner1992). In a study comparing service outcomes in North West Wales in 1896 and 1996, Healy et al. (Reference Healy, Harris, Michael, Cattell, Savage, Chalasani and Hirst2005) found that not only were rates of institutional care higher in 1996, but that, excluding patients retrospectively identified as suffering from organic disorders, recovery rates remained stable across the 20th century.
The current study presents an analysis of case notes from the Essex County asylum in 1904. We used the data to reflect on the stereotypes of asylums during this period and to contribute to the discussion about the functions of the asylum. We also explored differences between men and women in terms of presentations and outcomes.
Methods
Setting, location and sample
The current study utilised casebooks of male and female admissions to Essex County Asylum in 1904–1905. These were selected as they were the latest available clinical records when the study was initiated in 2004. Notes were obtained on the first 100 male admissions recorded in the casebook – from 27 August 1904 to 2 January 1905 – and the first 100 female admissions – from 5 August 1904 to 10 November 1904. Background information on the Essex Asylum was obtained from an unpublished history originally compiled in 1953, and other contemporary documents.
Data
Male and female case notes were written in separate ‘casebooks’ and included descriptions of the circumstances of admission and subsequent progress. Despite the constraints of legibility, in the overwhelming majority of cases it was possible to gather some demographic data, outcome of the current episode and details of the nature of the disorder.
Patients' presentations were retrospectively classified into broad categories of disorder based on descriptions of psychopathology and behaviour, and other information available, such as alcohol use or the presence of syphilis. Where there was uncertainty as to how to categorise a particular case, the authors reviewed relevant notes together and made a collective decision. Presentations were assumed to be manifestations of an organic disorder if the notes used specific terms such as ‘dementia’, ‘senility’, ‘imbecility’, syphilis or named other organic conditions (e.g. head injury, alcohol withdrawal) in conjunction with a clinical picture suggestive of organic aetiology, or alternatively if recorded physical signs (e.g. fits, abnormal gait, balance problems) suggested an organic disorder. Individuals who died of natural causes shortly after admission were also assumed to have had an organic condition.
Statistical tests were performed using the SPSS statistical package.
Results
Essex County Asylum, 1904
Like other asylums of the Victorian–Edwardian era, Essex County Asylum circa 1904 existed as a self-contained community (Nightingale, Reference Nightingale1953). It opened in 1853 for a total of 450 patients, but by the turn of the century provided lodgings for around 2000 patients. By this time it had a chapel, agricultural land for the patients to work on, and lawns for cricket, bowls and billiards. In 1874 the medical superintendent described the institution as ‘really and truly an Asylum, a place of refuge and retreat from pain and trouble and sorrow; a hospital and a home’ (n.p., preface). Entertainment evenings, and particularly dances, were a regular event, though the policy of serving gin at these evenings, along with that of giving patients a pint of beer every day, was discontinued in 1892. As early as 1860, it was noted that there was insufficient accommodation for women and in 1870 a new female ward was opened which almost doubled the places available for women. Further wards for both sexes were erected in the 1890s in response to overcrowding.
The medical superintendent in 1904 was Dr Amsden, who was in post from 1884 to 1911. There were three other doctors on the staff by 1904 and around 200 ‘attendants’, who were encouraged to take some nursing qualifications (Nightingale, Reference Nightingale1953). The nearest available Lunacy Commission inspection report written in the 1890s raised no major concerns, but recommended that a larger number of attendants would improve conditions for residents (The Commissioners in Lunacy, 1894).
The patients
In the current sample, women were admitted to the asylum more frequently than men, with a mean of 1.02 female admissions per day compared to 0.78 male admissions, a statistically significant difference (t = 2.04; p = 0.04). Table 1 shows the demographic characteristics of the sample. The average age of admission was 42 years (s.d. 17.7 years). Women were younger than men at the time of admission by an average of seven and a half years (t = 3.07, p = 0.002). Most patients were married, with no evidence for a gender difference in patients' marital status. Men were employed mostly as unskilled manual labourers in agriculture, the docks or factories, though some were skilled labourers (e.g. a carpenter and a draper), and a few worked in non-manual jobs, including a butler, a policeman, two clerks and some shopkeepers and salesmen. Almost half of the female admissions were classified as being ‘housewives’ with others mostly unemployed or working as unskilled domestic servants, and a few working as higher skilled servants such as a cook and two governesses.
Table 1. Demographic characteristics of male and female admissions
Retrospective classification of disorders
Table 2 shows the retrospective classification of disorders. Notably, no patients in our sample were admitted without evidence of a mental and behavioural disturbance that would, at face value, meet the threshold for clinical significance in the 21st century. In particular, there were no records of behaviour that might have been deemed morally or politically deviant in the absence of a more general mental and behavioural disturbance.
Table 2. Retrospective classification of presentations
Many of those admitted had an organic condition, including dementia, learning disability, delirium, epilepsy and other non-specific conditions characterised by physical symptoms alongside psychological symptoms or behavioural disturbance, and often resulting in early death following admission. When the categories that represent an organic condition were combined, they made up 44% of all admissions. The next most common category was psychotic disorders representing 22.5% of all admissions, followed by mania (13.5%) and then non-psychotic and psychotic depressive disorders. A small number of admissions appeared to be in the context of an acute personal or situational crisis, such as might be classified as an ‘adjustment disorder’ in today's terms.
Five patients showed disturbed behaviour that could not easily be classified on the existing information using modern concepts. They included a 27 year old labourer, who took his clothes off and attacked nurses in the Workhouse infirmary from which he was transferred; a 31 year old housewife, who had ‘daily attacks of shrieking’; a 27-year-old domestic servant, who could ‘give no sensible account of herself’, was ‘simple and childish’ and ‘apathetic’; an 18-year old domestic servant, who was noted to be ‘grimacing’, showing ‘choreic movements’ and was ‘dull and apathetic’; and a 23 year old woman who was constantly laughing, ‘childish’ and ‘unfit to manage herself’. All recovered and were discharged except for the last patient who was transferred to a unit for people with chronic conditions in 1906.
Analysis reveals evidence for a differential effect of gender on diagnosis, χ2(12) = 27.2, p = 0.007. The more notable gender differences were observed in elevated rates of organic disorders, including dementia and syphilis in men, and of psychosis and mania in women. Among female admissions, 29% were diagnosed with psychosis and 16% with mania. An additional five women had an episode of mania or psychosis during pregnancy or the postnatal period. No women were recorded as having had an illegitimate child prior to admission. One young single women, Ada, who worked as a dressmaker and appeared to have a psychotic depression initially, gave birth to a baby shortly after admission. She subsequently showed signs of having a chronic psychotic disorder, being described as ‘hearing voices’ and ‘deluded’, and she remained in the asylum until at least 1910 when she was transferred to another unit.
Outcomes
Table 3 shows outcomes of admission for men and women. Overall, 45.5% of the sample were discharged from the asylum as ‘recovered’, ‘improved’ or, in rare cases, ‘not improved’ in the judgement of the medical author of the case notes. Just under 30% died in the asylum, usually shortly after admission. Twenty-six percent remained in care, some remaining in the Essex asylum, where notes lasted up until 1913 in some cases, and others being transferred to other asylums or to annexes for the accommodation of ‘chronic’ patients. Differences between men and women in terms of death rates and discharge are due to the different pattern of diagnoses. There was a significant difference in the outcomes of those classified as having an organic condition v. those with a non-organic or psychological complaint (χ2 = 62.8, df = 2, p < 0.001; Fig. 1). Among those with a psychological disorder (psychosis, mania, depression, perinatal conditions, behavioural crisis and ‘abnormal behaviour’), 62% were discharged either recovered or improved (51.8% recovered and 9.8% improved). A third remained in the asylum or were transferred elsewhere. For those with a diagnosis of psychosis, the rate of discharge either recovered or improved was 33.3%, with 62.2% remaining in the asylum. Among those with mania, 85.2% were discharged recovered or improved and 11.1% showed a chronic course and stayed in the asylum (one of whom was initially discharged and then readmitted shortly after). Among those with an organic disorder, almost 59.8% died in the asylum, but 21.8% were discharged recovered or improved.
Fig. 1. Outcome of psychological and organic disorders.
Table 3. Outcome of admissions
The total length of admission was not known for most of those who remained in the asylum due to being transferred to other units or outliving the end of the casebook. For those who were eventually discharged, length of admission was approximately normally distributed, with a mean of 6.4 months (s.d. 9.8; range 0.25–70). Women who were subsequently discharged stayed 8.3 months on average (s.d. 12.3; range 0.25–70), whereas men stayed only 4.0 months (s.d. 3.9; range 0.25–16), which was a statistically significant difference (t = 2.6; p = 0.02).
Some female patients admitted with non-organic psychotic disorders showed evidence of recovery after protracted periods of disturbance. Agnes, for example, a 52-year old married woman, was admitted with psychotic depression and continued in an agitated state for almost 2 years but then improved and was discharged recovered. Chrissy, a 27 year old barmaid, was admitted with delusions and rambling and incoherent speech. Two years after admission she was still described as symptomatic, but after 3 years she was discharged recovered. Thirty year old Harriet was admitted with ‘melancholia’ and delusions and was later described as hearing voices and looking ‘perplexed’. Over subsequent years she became ‘excited and violent’ and required seclusion, yet she was discharged recovered 5 years after admission.
Nature and content of psychological conditions
Descriptions of people classified as having mania were distinctive and easily recognisable in today's terms. Thus, Elizabeth, a 42 year old single waitress was described on admission as talking ‘incessantly and volubly, incoherent nonsense, makes grimaces and gestures, very excitable, sings and laughs, cries and swears … climbed onto roof and into neighbours garden’ and a day later as having ‘no sleep’. She was discharged recovered approximately 4 months later. Lily, a 25 year old married woman was described on admission as ‘continually raving in an incoherent manner, violent and troublesome’, and a few days later as ‘noisy, excited and incoherent. Keeps chattering’. She was discharged recovered within 2 months. George, a 45 year old warehouseman, was said on admission to be ‘suffering from religious mania and is very excited and delusional that the almighty has ordered him to sing and pray continuously which he does by shouting’. He was discharged 2 weeks later, but was noted to have been showing symptoms for three months prior to admission.
Those classified as having ‘psychosis’ were more varied in their presentations and outcomes. Amy, a 44 year old unemployed single woman who was diagnosed with ‘delusional insanity’ at the time, was described as ‘restless, excited and delusional’ on admission, thinking that ‘people have injured her internally with suffocating vapours and electricity’ and experiencing ‘auditory hallucinations’. She was also said to be ‘depressed’. She showed no improvement throughout her four and a half year stay in the asylum and was transferred to another asylum in 1909. In contrast, Emily, a 43 year old married housewife, was admitted with delusions that she was being poisoned by her relatives and was described as hearing voices. Within 2 months she was said to have improved: she had ‘lost her delusions’, and was discharged a month later.
Alfred, a 32 year old single clerk, was admitted with the delusion that his neighbours were suing him for libel and was said to be experiencing hallucinations of his neighbours talking about him. He was also described as ‘somewhat depressed’, but was diagnosed as having ‘delusional insanity’. He improved initially, then deteriorated before improving again and being discharged recovered after 5 months. Thirty-nine year old farm labourer, James, was admitted for the first time and described as being ‘in a state of melancholia, delusive he has been bewitched and that Christ has visibly appeared to him’. He was also noted to have ‘no interest in anything’. By the following year he had improved slightly and was described as ‘industrious’, ‘well-behaved’ and ‘cheerful’, but was ‘still subject to auditory hallucinations’ and was ‘deluded he is sent here by divine order’. He remained in the asylum until at least 1911 when the last entry is made at which point he was described as having ‘secondary dementia’ and being ‘dull, stupid with impaired memory’.
The nature of psychotic experiences, such as hallucinations and delusions, also offer a window into the preoccupations of the Victorian–Edwardian age. Eight people were worried about having been poisoned and five were concerned about being manipulated by machines or electricity. John, for instance, complained of ‘atmospheric electricity’ in his head, and Agnes of hearing ‘voices through telephones’. Eight people thought they were being harmed by relatives or others including the same Agnes who had the idea that ‘the man who lives with her is Jack the Ripper’. Florence was preoccupied with the thought that ‘she is a steam engine’, while the manic delusions of Frederick, a 52-year-old house decorator, stretched from a belief that he was the world's ‘champion swimmer and jumper’ to the conviction that he ‘could earn a million pounds by playing the organ at the Crystal Palace’.
Discussion
Functions of the asylum
Despite the variation between individual asylums, the present study replicates and geographically extends findings from previous research showing that asylum patients were admitted with severe neurological or mental disorders. Even the five patients whose presentations were unclassifiable using current diagnostic conceptions displayed evidence of unusual and disturbed behaviour. The vast majority of admissions had signs of an organic brain disease or what would today be considered a ‘severe mental disorder’ (psychosis, mania or severe or psychotic depression). This is consistent with a retrospective study of asylum admissions from a similar period (Healy et al., Reference Healy, Harris, Michael, Cattell, Savage, Chalasani and Hirst2005) and with the presentations of people admitted to the local asylum from a general hospital in Sweden at the beginning of the 20th century (Appelquist, Bradvik, Ottosson, & Asberg, Reference Appelquist, Bradvik, Ottosson and Asberg2019). These studies together suggest that people with less severe forms of mental disorder – the sort that would nowadays be diagnosed as depression or anxiety and would previously have been referred to as ‘neurosis’ – were rarely admitted to the asylum (Appelquist et al., Reference Appelquist, Bradvik, Ottosson and Asberg2019). Moreover, as other asylum studies have noted (Melling & Forsythe, Reference Melling and Forsythe2006), none of the admissions were described as vagrants, prostitutes or criminals, suggesting that other forms of social deviance were addressed in different ways.
Despite the fact that women were admitted more frequently than men, there was also no evidence in our sample of women being incarcerated for ambiguous reasons or without clear semblance of significant emotional, cognitive or behavioural disturbance. Thus the myth that Victorian and Edwardian asylums confined people for social or political non-conformity, or women who behaved in ways that ‘male society did not agree with’ (Pouba & Tianen, Reference Pouba and Tianen2006), is not substantiated by the current evidence.
The proportion of admissions with organic conditions was even higher than in studies of other public asylums where they accounted for 26% to 34% of admissions in the 1890s (Doody et al., Reference Doody, Beveridge and Johnstone1996; Healy et al., Reference Healy, Harris, Michael, Cattell, Savage, Chalasani and Hirst2005). In 1904, the asylum authorities complained to the local Poor Law Unions about the admission of so many people with ‘loss of memory or infirmity’ and questioned the ‘desirability of using the asylum as an infirmary’ (House Committee, 1901–1904). These concerns may have reflected a national situation as suggested by the Lunacy Commission in 1901 which expressed concern that asylums were ‘congested with aged, infirm and broken down persons’ who crowded out more acute cases (The Commissioners in Lunacy, 1894). The admission of such cases, together with the fact that the data long predates the introduction of anything that might now be considered a specific sort of treatment, suggests the asylum essentially functioned as a repository for those who were temporarily or permanently incapacitated or socially disruptive, providing care and containment for those who could not be managed at home or in other institutions. .
Gender
The current study found a higher admission rate among women, as well as longer length of stay among women who were eventually discharged. This is not explained by the sex ratio of the general population of Essex at the time, which was approximately even (University of Cambridge, 2019). Women were also 1.6 times more likely to be diagnosed with psychosis or mania, whereas men outnumbered women among those diagnosed with organic conditions. This differs from today when severe mental disorders, such as schizophrenia and manic depression (bipolar disorder), are found to be more, or equally, common among men (Anderson, Fuhrer, Abrahamowicz, & Malla, Reference Anderson, Fuhrer, Abrahamowicz and Malla2012; Diflorio & Jones, Reference Diflorio and Jones2010). In contrast to the present findings, and to Showalter's claims that 19th and early 20th century madness was a predominantly ‘female malady’ (Showalter, Reference Showalter1985), studies of other asylums in North Wales and Devon at the same time do not show an excess of female admissions (Healy et al., Reference Healy, Harris, Michael, Cattell, Savage, Chalasani and Hirst2005; Melling & Forsythe, Reference Melling and Forsythe2006), although one noted a high rate of admissions among young women, especially domestic servants (Melling & Forsythe, Reference Melling and Forsythe2006).
On the basis of overall figures for England, it has been argued that the excess of women in asylum populations during the 19th and early 20th centuries was due to their greater longevity and did not reflect higher admission rates (Busfield, Reference Busfield1994). However, there is variation between institutions and periods in the gender ratio of admissions (Busfield, Reference Busfield1994). Though it may be a chance finding in a relatively small sample, the current study suggests there may have been an increased tendency for women to be institutionalised in the early 20th century in the Essex area. This would be consistent with feminist scholarship that highlights women's status as a socially and economically marginalised group in Edwardian society (Gibson-Brydon, Reference Gibson-Brydon2016). Further research is needed to clarify the replicability and interpretation of the current findings.
Outcomes
Our findings are consistent with other studies that have shown that, once admitted, patients with a non-organic disorder stood a reasonable chance of recovery and discharge. This was largely due to high recovery among those diagnosed with mania. Those diagnosed with a non-affective psychotic disorder, such as would include schizophrenia in modern taxonomy, showed a recovery rate of only 31%, although this statistic may have been negatively distorted by the misidentification of some people with undetected organic conditions (such as syphilis). Such a statistic is not necessarily any worse than modern rates of recovery, however. A European study of people with schizophrenia published in 2000 found that, after 15 years, fewer than 20% showed a complete functional recovery (Wiersma et al., Reference Wiersma, Wanderling, Dragomirecka, Ganev, Harrison, An Der Heiden and Walsh2000). Other research suggests that the current outlook for people with schizophrenia and bipolar disorder has not surpassed outcomes achieved in the early 20th century before modern treatments were introduced (Harris, Chandran, Chakraborty, & Healy, Reference Harris, Chandran, Chakraborty and Healy2005; Hegarty, Baldessarini, Tohen, Waternaux, & Oepen, Reference Hegarty, Baldessarini, Tohen, Waternaux and Oepen1994).
The high mortality is unsurprising given the frequency of organic conditions and is in line with statistics from another public asylum where it was 36% overall in the late 19th century (Doody et al., Reference Doody, Beveridge and Johnstone1996).
Limitations of study
‘Retrospective diagnosis’ is controversial (Schmidt, Wlhelmy, & Gross, Reference Schmidt, Wlhelmy and Gross2019). Our interest in the past is to shine a light on the present, however, and therefore we agree with the position that the process can be justified if done carefully (Healy et al., Reference Healy, Harris, Michael, Cattell, Savage, Chalasani and Hirst2005). In line with other such projects, we have used only broad, descriptive categories that summarise particular patterns of behaviour and provided case summaries that illustrate the nature of that behaviour for some of the main categories of mental disorder. Nevertheless, our reading of the case notes is undoubtedly influenced by modern preconceptions, including the distinction between schizophrenia and affective disorders, established by Kraepelin, and recent concepts such as depression (Moncrieff, Reference Moncrieff2008).
Furthermore, the amount of information recorded about individual patients was often brief and sometimes illegible. In some cases we made inferences about the nature of the disorder from the fact that the patient died shortly after admission, or from descriptions of physical symptoms suggestive of an organic disorder. However, we cannot be certain that physical symptoms were reliably recorded or that, when present, they would necessarily exclude the presence of a psychological disorder. Some cases of protracted mania or psychosis may have had an organic cause that was not identified or noted at the time. The symptoms and behaviours described among people identified as having syphilis, for example, which included excitability, delusions, hallucinations and apathy, overlapped with those classified as persistent non-organic psychosis or mania. On the other hand, descriptions of some disorders, such as mania, were clear and consistent and reminiscent of the sort of behaviour that would characterise a florid episode of mania today. This supports research that suggests the syndrome of mania was well-characterised by the time that Kraepelin was working at the end of the 19th century (Kendler, Reference Kendler2018).
Although a few patients in our sample were recorded as being readmitted in the same case notes, we cannot be certain that all readmissions were recorded in this way, or that patients were not admitted to other asylums in Essex or London during future episodes. Therefore we have not attempted to look at the pattern of subsequent admissions. This precludes us from classifying patients as having manic depression (bipolar disorder), who would likely be admitted in different states at different times, or from assessing the ultimate outcome of people who were discharged.
Conclusions
The present study of the Essex asylum at the beginning of the 20th century suggests there is some truth in both of the opposing views of the old asylum system. Although we found no evidence of admission being used as a mechanism to repress political dissent or enforce moral conformity, the asylum can be understood as part of a social system of care and control that formed an integral part of the wider social and economic order. In line with this view, the higher rate of female admissions in this particular study may be a reflection of the greater economic dependency of women. On the other hand, it is clear that the asylum had a therapeutic orientation, aiming to support people back to health and functionality where it could, and that it was often successful in this endeavour. Where this was not possible, the system provided long-term care and containment. Evidence that, despite the closure of the old asylums (Healy et al., Reference Healy, Harris, Michael, Cattell, Savage, Chalasani and Hirst2005; Priebe et al., Reference Priebe, Badesconyi, Fioritti, Hansson, Kilian, Torres-Gonzales and Wiersma2005), the proportion of people in a form of institutional care has changed little over recent years, suggests that the original functions of the asylum persist in the modern day.
Financial support
The research received no specific grant from any funding agency in the public, commercial or not for profit sectors.
Conflict of interest
The authors have no conflicts of interest.
