Shell Shock And Lunacy Reform

Wilfred Owen (1883-1918), Treated for shell shock Craiglockhart hospital.

By the time Dr Montagu  Lomax wrote The Experiences of An Asylum Doctor (1) in 1921, the campaign for lunacy reform had been ongoing for over half a century. There had been some successes such as the 1890 Lunacy Act, designed to reduce the number of unregulated madhouses.  However, little had been achieved to improve living conditions for pauper lunatics in the asylums. This was partly because the campaigners were often ex-patients as in the Alleged Lunatics Friend Society, so had little status, and partly because  psychiatrists were resistant to change. Dr Lionel Weatherly published his ‘Plea for The Insane’ in 1918. This book was aimed at the medical profession and was largely ignored. Lomax’s book was written for the public. His writing style was clear, and direct, perhaps with an overtone of sensationalism. However, it could be understood by any lay person and more importantly, by members of the Press. The book set in motion a wave of public outrage. 

Cleverly, Lomax keyed into public concern over the treatment of shell shocked soldiers. He wrote about the plight of these young men who had been sent back from the trenches with shattered minds only to find themselves incarcerated within the lunatic asylums. Lomax allied himself with the Ex-Services Welfare Society (ESWS), and was a guest speaker at a number of the Society’s public meetings. The aim of the ESWS was to raise public awareness and funds to help these veterans, some 5000 of whom were still in the asylums five years after the end of the war. Lomax was a good public orator and the national press reported his speeches. The wave of public outrage became a tsunami.

It is worth considering what a diagnosis of ‘shell shock’ meant. On 12 December 1914, the British Medical Journal published an article on functional paralysis following shell explosions (2). The author noted that although there was no obvious physical injury, the proximity to explosions was seen as a causative factor and from the winter of 1914/15 ‘Shell Shock’ became a valid medical diagnosis (2). 

There was a running debate between the top psychiatrists of the day as to whether the diverse collection of signs and symptoms which contributed to the diagnosis of shell shock were functional (psychological) or had an organic (physical) origin. The psychiatrist, Dr Frederick Mott noted the presence of microscopic brain hemorrhages in post mortems of men with shell shock, and hypothesised that the condition was due to blast trauma. This lead him to believe that shell shock had an organic cause (3). The Maudsley psychiatrists believed that shell shock was due to a breakdown of psychological mechanisms. Doctors could find no identifiable organic pathology in 38% of admissions for shell shock (2). This dichotomy between psychodynamic and physiological explanations for shell shock was never resolved (3). There was however a military classification which attempted to distinguish between men who were physically damaged, categorised as ‘Shell Shock (Wounded)’ and a second category of ‘Shell Shock (Sick)’ (4). The Shell shock (W) cases were entitled to a wound stripe and a pension. If a soldier’s neurosis did not follow a shell explosion, he was to be labelled Shell shock (S) and was not entitled to a wound strip or pension. Many of the 306 British soldiers shot for cowardice would probably have fallen into this latter category, now recognised as Post Traumatic Stress Disorder (PTSD).

At the start of the Great War, the military hospitals absorbed psychologically damaged men, who could be treated by specialist doctors without the stigma of certification. As the war progressed, casualty number rose and young soldiers with shell shock were increasingly shunted into the County Asylums (4). Estimates vary, but one study found 63% of shell shock cases in 1916 were placed within the asylum system (3). These men were officially classified as private patients, so that their fees were paid by the government, but their private status was effectively meaningless in times of war and carried no special privileges  for the soldiers. The asylums were understaffed, and overcrowded with patient food reported as ‘starvation rations’ (5). The asylum medical staff were overworked, and had no facilities or specialist skills to treat broken soldiers. For those young men who weren’t insane, there was a significant risk that they would be made insane by their surroundings.

For relatives, there was a very real stigma to having a soldier son in a County Asylum. The asylums were viewed as the domain of the pauper lunatic. Admission was by ‘certification’ under the 1890 Lunacy Act, and a certified pauper lunatic in the family carried with it great shame. This was partly because poverty was a frightening spectre for the working class, but also because of the  strongly hereditarian discourse of mental health which dominated through the 1920s (4). 

Towards the end of the war, the British public were growing increasingly uneasy that ex-soldiers were being treated as ‘ordinary lunatics’ (4). The Ex-Services Welfare Society (ESWS) was founded in 1919 to support the ex-servicemen who were effectively trapped within the County Asylum system. The aim of the Society was to set up residential homes for traumatised veterans so that they could be released from the totally unsuitable environs of the lunatic asylums. It was an ambitious project which required enormous financial input. Fundraising and a prominent public profile was therefore crucial to the success of the ESWS. The Society appointed Captain Charles Loseby, to speak on its behalf. He was a lawyer by training and had a distinguished military service record. As an MP between 1918 to 1922, he concentrated on veteran welfare, eventually taking a keen interest in the plight of shell shocked veterans detained within the lunatic asylums. He took the ESWS under his wing, organising and speaking at a number of public meetings on their behalf. Dr Montagu Lomax used the ESWS public platforms as an opportunity to drive forward his case for lunacy reform. Unfortunately, the ESWS’s association with the  campaign for lunacy reform was subsequently viewed as controversial, and after a series of financial scandals, the Society’s supporters quietly distanced themselves. By the mid 1920s, the British Legion had assumed responsibility for much of the practical support required by veterans including liaison with the Ministry of Pensions, and the ESWS was sidelined. 

It is heartbreaking to read Lomax’s account of the shell shocked soldiers in his book The Experiences of An Asylum Doctor. Men such as these were usually ‘other ranks’, whilst the officer class with shell shock were sent to exclusive military hospitals such as Craiglockhart. For the interested reader, Pat Barker’s Regeneration trilogy portrays shell shock amongst the officer class at Craiglockhart.

Bibliography

1. Lomax M. The experiences of an asylum doctor : with suggestions for asylum and lunacy law reform. [S.l.]: Allen and Unwin; 1921.

2. Linden SC, Jones E. ‘Shell shock’ revisited: an examination of the case records of the National Hospital in London. Med Hist. 2014;58(4):519-45.

3. Jones E. Shell shock at Maghull and the Maudsley: models of psychological medicine in the UK. J Hist Med Allied Sci. 2010;65(3):368-95.

4. Reid F. Broken Men: Shell Shock, Treatment And Recovery In Britain 1914-30: Bloomsbury Publishing; 2011.

5. Crammer JL. Extraordinary deaths of asylum inpatients during the 1914-1918 war. Med Hist. 1992;36(4):430-41.

Hospital Scandal

JH Murray-Aynsley

In the spring of 1895 The Christchurch Hospital was in trouble. A series of complaints about the standards of care at the hospital had resulted in an inquiry which dragged on for several long months. It was covered in excruciating detail in the local press, and syndicated across New Zealand. Amongst the many complaints from the citizens of Christchurch was the callous attitude and rudeness of the house surgeon, a certain Dr J.H. Murray-Aynsley. It was alleged that he had often arrived on the wards drunk, sometimes in his slippers and dressing gown if he was called at night. He  smoked during his ward rounds. He was accused of insisting that  the prettiest probationer nurses assist him in theatre and was prone to peculiar behaviour such as placing patients on a bread and water diet, and squirting water in the face of an injured  child to stop it screaming. The inquiry drew to a close  in August 1895, and for lack of convincing evidence, Dr Murray-Aynsley was cleared of all charges.

However, that was not the end of the story.

John Henry Murray-Aynsley was born in Lyttleton, New Zealand but studied at Christ’s College Cambridge , and St Georges Hospital, London before returning to Christchurch, to work as the house surgeon at the hospital. His job was to look after patients who had been operated on by the honorary  surgeons including those of Dr Montagu Lomax-Smith (later Montagu Lomax).

The two doctors shared the same year of birth – 1860 – but they had little else in common. Lomax-Smith came from three generations of tanners, Murray-Aynsley  had an English aristocratic background, his great, great grandfather was the third duke of Athol. Lomax-Smith’s father was a Church of England Vicar. Murray-Aynsley’s father was a wealthy business man who kept a string of race horses and was a member of the New Zealand Parliament. Lomax-Smith was raised to service and duty, Murray-Aynsley had little sense of the professionalism that his role required. It is not difficult to imagine that Murray-Aynsley would have rubbed Lomax-Smith up the wrong way.

Lomax-Smith must have been appalled that Murray-Aynsley was vindicated by the hospital Inquiry in August 1895. Less than two months later, Lomax-Smith brought further charges against Murray-Aynsley, alleging that he was drunk on duty and neglected the care of his patients. The Hospital Board was reluctant to get involved in another inquiry. Lomax-Smith resigned as honorary surgeon, claiming that Murray-Aynsley had systematically neglected his surgical cases. A series of vicious letters were published in the local and national press with both sides making claims about the other which would be considered libellous today. Lomax-Smith was accused of unethical behaviour for complaining about a brother doctor. Two doctors resigned in support of Murray-Aynsley. Eventually, the Hospital Board agreed to another investigation.

In April 1896, The Hospital Board found Murray-Aynsley guilty as charged and asked for his resignation. Lomax-Smith subsequently withdrew his own resignation. 

The outcome of this poisonous dispute was poor for both men. Murray-Aynsley left Christchurch for a small bush town where he worked for a short time as a GP. He tried to work in the UK, but never really established himself and returned  to New Zealand where he died aged 57. Lomax-Smith left New Zealand in the summer of 1896 to return to the UK. He left behind a prosperous, comfortable existence, and never really recovered the standard of life he had had in New Zealand. However, Lomax-Smith did learn about the personal difficulties faced by whistle-blowers.  He learned that attacking a person rather than ‘the system’ which allowed an incompetent to work within it, was  was personally devastating. Finally, he learned how to harness the power of the Press. These tribulations were  to stand him in good stead some thirty years later when he wrote his book: The Experiences of an Asylum Doctor, with suggestions for asylum and lunacy law reform in 1921.

More at: 

  1. https://en.wikipedia.org/wiki/The_Experiences_of_an_Asylum_Doctor
  2. The New Zealand years.
  3. Montagu Lomax – montagulomax.org 

Why Montagu Lomax matters.

Montagu Lomax (1860-1833) was a British general practitioner  who wrote The Experiences of an Asylum Doctor, with suggestions for asylum and lunacy law reform in 1921[1]. The book was an exposé of conditions within two English lunatic asylums based on Lomax’s experiences as an asylum medical officer between 1917 and 1919. 

The book became a cause célèbre [2]. The national press was outraged by Lomax’s revelations, with The Times publishing an article entitled “Asylum Horrors – A Doctors Indictment’ [3]. Within ten days of the book’s publication, questions were being asked in Parliament [4]. Whilst many attempts at asylum reform had been made previously, it was Lomax’s book and the associated newspaper articles that alerted public opinion on a wide scale [2]. The Ministry of Health decided to use Lomax’s book to start the process of lunacy reform, and to subsume the mental health services, previously managed by the Board of Control [2]. The Lomax affair was a significant prelude to the 1926 Royal Commission on Lunacy and Mental Disorder [5]. The recommendations of the Royal Commission were incorporated into the Mental Treatment Act of 1930 which opened the way to many developments in mental health services over the next thirty years [2].

Lomax had a successful publication which ensured him a place in the tradition of British social reportage [5]. It was an important book because it directed public attention to the defects of the asylum system which had hitherto been taken on trust [2]. Lomax’s vivid descriptions of patients’ behaviour and mental state in asylums and of the institutional process produced insights which were to be rediscovered 30 years later by researchers who themselves went on to influence mental health care from 1959 onwards [2]. However, Lomax did more than contribute to a process of mental health reform. His willingness to write frankly and to criticise provide an example to all mental health professionals who find themselves in settings where abuses occur [2].

More information at montagulomax.org

Bibliography

1. Lomax, M., The experiences of an asylum doctor : with suggestions for asylum and lunacy law reform. 1921, [S.l.]: Allen and Unwin.

2. Harding, T.W., “Not worth powder and shot”. A reappraisal of Montagu Lomax’s contribution to mental health reform. The British Journal of Psychiatry, 1990. 156(2): p. 180-187.

3. Asylum Horrors, in The Times. July 23rd, 1921.

4. Soanes, S., REFORMING ASYLUMS, REFORMING PUBLIC ATTITUDES: J. R. LORD AND MONTAGU LOMAX’S REPRESENTATIONS OF MENTAL HOSPITALS AND THE COMMUNITY, 1921-1931. Family & Community History, 2009. 12(2): p. 117-129.

5. Towers, B.A., The management and politics of a public expose: the Prestwich Inquiry 1922. J Soc Policy, 1984. 13(1): p. 41-61.

A Doctor in Victorian Britain.

P1000545
1891 medical directory

The medical profession at the beginning of the 19th century was in disarray. Most doctors were trained through apprenticeship, often within their own families which saved money in tuition fees. The  medical schools, particularly in Edinburgh, and London offered lectures in a wide range of subjects  as well as practical training in anatomy but attendance was by no means compulsory for aspiring doctors. The need to standardise training and exclude quacks was seen as imperative. The 1815 Apothecaries Act and The 1858 Medical Act defined curriculum content and prescribed the routes to medical qualification. The medical apprenticeship was taken away from the family setting and transplanted into the hospital system where established physicians and surgeons headed ‘firms’ of doctors in training. Examinations became the only method to obtain a license to practice. By the mid 19th century, medicine had become a true profession and its practitioners were an intelligent elite who had earned their position in society on merit not through accident of birth. 

The rise of the medical profession during the Victorian era paralleled the rise of the middle classes whose new money came from the industrial revolution. Montagu Lomax was a perfect example of this new professional class whose training was paid for from profits his father’s family had made through the leather industry. 

Unfortunately, by the time Lomax qualified in 1883, the profession was overcrowded. The vast majority of medical graduates followed the path of general practice at this time. It was possible with enough money to buy into an existing general practice, but most new doctors ‘set up their plates’ on their own. Some newly qualified men took on salaried appointments with local dispensaries, occupational schemes or within the poor law hospitals and asylums. This ‘club practice’ provided an income as they began to build their own lists of paying  patients. However, club practice was perceived as low status work, poorly paid and  with the added disadvantage that doctors were supervised by laymen (Peterson 1978).

There is no doubt that some doctors found it hard to make a decent living and were forced to look for other options. Some joined the military where they signed on for a set period and were able to accumulate funds to buy a practice at the end of their service. The pay was reasonable, there was usually travel and sport in every posting and much less drudgery than general practice at home. Astonishing numbers of young Irish graduates (around 20%) signed up for the Indian Medical Service between 1860 and 1905 (Jones 2010). This allowed retirement on half pay after 20 year’s service, and a severance honorarium which would pay for the purchase of a practice. Others went to the colonies, often to Australia where prospects were considered to be better than Britain, and  society to be less hierarchical (Peterson 1978).

It is a fascinating exercise to browse through medical directories of the late 19th century – doctors are listed under ‘London’; ‘Provincial’, ‘Hospitals, Dispensaries and Lunatic Asylums’,‘Local Government Medical Services’, ‘Scotland’, ‘Ireland’, Practitioners Resident Abroad’, and ‘Services and Mercantile Marine’. Of the many practitioners registered abroad in the 1891 edition, British doctors were working all over the world including Uruguay, China and Tasmania. The majority of Irish doctors who went abroad settled for good  in their adopted country, but around 40% returned to set up practice at home after ten years (Jones 2010). This was certainly the case for Dr Montagu Lomax whose six years spent as a GP in New Zealand were both lucrative and personally challenging. (see New Zealand 1890-1896).

P1000548 copy
The Medical Directory 1891

Bibliography

Jones, G. (2010). “”Strike out boldly for the prizes that are available to you”: medical emigration from Ireland 1860-1905.” Med Hist 54(1): 55-74.

Peterson, M. J. (1978). the Medical Profession in Mid-Victorian London. Berkley, Los Angeles California, University of California Press.

A Family of Tanners

 

Montagu Lomax’s father, Thomas Smith, came from a long line of Ashbourne tanners who can be traced back to the  18th century. Montagu’s grandfather had moved his family from Ashbourne in Derbyshire, down to Bermondsey in London in the early 1800s. Bermondsey, on the south bank of the Thames, was a busy leather processing centre, but contemporary descriptions of the area convey the horrific living conditions endured by the leather workers – Dickens’s Oliver Twist was based in Bermondsey. The Napoleonic wars were raging across Europe at the time, resulting in  a huge demand for boots, saddles and harness. There was money to be made in leather, and the Smith family acquired a great deal of it, investing it shrewdly in property. By today’s standards, Thomas Smith would have been a multimillionaire by the time he was thirty.

Thomas Smith married a cousin from the Ashbourne side of the family. Their first child died as an infant from an unspecified fever, perhaps due to the unhealthy climate of the Bermondsey tanning yards.  It seems that the loss of his child was a crucial moment for Thomas, and he decided to use his wealth to leave Bermondsey behind.  He  bought himself a place at Cambridge University to study theology, eventually becoming a Church of England vicar. An astute businessman, he kept the properties he had bought in London since they were providing rental income, and continued to buy land and property throughout his life.

Montagu Lomax and his siblings were the first generation of his family  to be raised within the emerging middle classes of the mid Victorian era, and to marry the children of  vicars, and solicitors. Their comfortable life styles, public school and university education were bought with money made from the  leather industry (see The Story of the Reverend Smith’s Wealth). So I want to fill in a little detail here, about an industry which in the 18th and 19th centuries was second only to the wool trade in Britain.  It was a crucial source of revenue for the government with taxes imposed on hides bringing in enormous amounts of money. As cities grew at the beginning of the industrial revolution, meat consumption and therefore leather production increased. 

 The new toll roads begun in the 18th century, encouraged the expansion of travel. The increased numbers of carriages created huge demand for saddlery and harness. Leather was needed for upholstery, and shoes while  leather belts powered the factories of the industrial revolution. The demand for leather was endless, pushing  prices up and increasing tax revenue even more. The government needed to protect this lucrative income stream, so they legislated that hides should not be damaged during the slaughtering process. Hides then had to be inspected for quality and stamped by government inspectors. This meant that hides had to be traded through a single outlet in most large towns – Leadenhall Market served this purpose in London, which subsequently set the price for leather across the whole country.

Tanning itself was a filthy, smelly trade. To make leather from hides, the hides had to be cured. They were salted to prevent decay, and then soaked in water to remove the salt and dirt. The hides were then laid in lime pits to loosen hair and soften the skin so that it was easier to scrape away hair and fat. This residue was sold off to manufacturers of glue and soap – also foul-smelling industries, and of necessity, situated close to the tanneries. The lime was then removed from the hides by agitating them in pits containing enzymatic ‘bate’,  which before the production of chemical bate, relied on dog faeces. Next the hides were soaked for several weeks in pits of tanning liquid of increasing strength, usually made from oak bark although human urine could also be added. The stinking process was the tanning  method for centuries and for this reason tanneries tended to be grouped by rivers and outside the city walls downstream of a town’s drinking water. So it was that Bermondsey became the site that the butchers of London deposited their hides from the 14th century onwards. By 1792, a third of the leather in the UK came from Bermondsey, and by 1879 a grand leather exchange had been built in the town.

Tanners and curriers were separate trades before 1813 with entirely separate Guilds and apprenticeships. Curriers  were highly skilled tradesmen who finished the leather prior to its sale to the shoe makers and saddlers. Curriers, of which Thomas Smith was one, made substantial profits, considerably more than tanners, and to protect their income, tanners were forbidden to do any currying by Act of Parliament. After 1813, the old divisions between the trades were abolished and the boundaries blurred, but the curriers continued to act as the middle men between the tanners and the end users of the finished leather, so that many of them became extremely rich.

I found a reference to a court case from 1810 where  Thomas Smith’s servant  was accused of having stolen two pounds of leather. He was initially sentenced to seven  years transportation, but this was commuted to imprisonment because it was his first offence. Seven years transportation does seem a little harsh for such a small quantity of leather, but it was a very valuable commodity.

It would be so interesting to know whether Montagu Lomax ever told his friends about his father’s first career in the leather industry.