The  Asylum  Years 1917 -19

                                           

Prior to the First World War, Montagu Lomax had spent two decades moving from town to town, country to country. There are great gaps in his narrative, but for certain, he had used the time to develop his writing skills and his interest in theosophy and spiritual healing. Montagu claimed that he had retired at the start of the war, although between 1915 to 1916, the trade directories record him working as a physician in London. He was living in Brighton by 1918, but it is difficult to know exactly when he moved out of London. At any rate, in 1917 he did something very strange. He applied to work in an Asylum.

In April 1917 Lord Derby announced that he was calling up all medical men under 41 years of age for military service. Several hospital ships had been sunk by that stage with great loss of life, so there was a desperate shortage of medics. Even so, he made this pronouncement with little consultation  and the medical profession was incensed. The pages of the BMJ were littered with letters of complaint. The BMA surveyed its members and then wrote to Lord Derby on 25th April 1917 to point out that there would be some towns left entirely without medical cover. Lord Derby asked the BMA for a list of names of 850 suitable doctors to be supplied by 1st May but his language was aggressive ‘In the event of the number so asked for not being forthcoming, I must reserve to myself the right at any time to reconsider my position’. In other words he would proceed with a general conscription of all medical men of military age if the BMA didn’t cooperate. There was only one solution to backfilling the vacant doctors posts, and that was to ask retired medics to return to work.

  By the summer of 1917, Lord Derby’s medical call-up would have significantly depleted the numbers of GPs around the UK, and civilian health care was already compromised. Montagu would have been well aware of the situation because of the letters and articles published in the weekly BMJ. He was an experienced GP and only 57 years old. Wherever he was living, whether it was London or Brighton, GPs would have been required for the civilian population. Yet  in the summer of 1917, he applied for and was appointed as an asylum medical officer at the Bracebridge Asylum in Lincoln. He stayed at Bracebridge for two months, but decided he didn’t enjoy the work there so on 1st October 1917, he went to work as an asylum medical officer at the Prestwich Asylum in Lancashire.  He had heard that ‘there was a great dearth of asylum doctors’, and that he had been ‘a life-long student of psychology’(1).  Montagu claimed that he had chosen to work as an asylum medical officer because he wanted to do his bit for National Service.

This is odd behaviour on several counts. If he had returned to work as a GP, he could have lived at  home. Instead of which, he moved into a doctor’s mess many miles away from his wife and his home for long periods. He chose not to work as a GP, the job he would have been able to do with his eyes closed, and which was relatively well respected and reasonably well paid by 1917. Choosing to work as an asylum officer might be considered  professional suicide – the post was widely regarded as the pariah of the medical profession at the time. It was poorly paid with onerous responsibilities – one medical officer might have been responsible for upwards of  500 patients. The nature of the asylums meant that they were usually situated in the countryside miles from any forms of entertainment, so Montagu would have been unable to attend masonic meetings, play golf or tennis and there would have been little company except for the other three medical officers.  Finally why did Montagu choose to go to Lincolnshire and Lancashire when there were 97 asylums in the UK, and many of these were situated around the outskirts of London where the railways would have made it easy for him to get home from time to time.

At this point, it is worth considering how the asylums came into being. The  origins of the  madhouse in Britain date back to the 15th century when the Bethlem Royal Hospital began to treat  the insane  of  London. However, provision of care for the mentally ill was patchy, and most would have been looked after by their own families. The Asylum movement began in the 18th century with the aim of offering humane treatment for those too ill or  too dangerous to be kept at home. Hospital facilities began to spring up across the country but institutional care was the exception rather than the rule. Then came the the Poor Law Amendment of 1834 which corralled the poor and those unable to work into the workhouses, and provided a legal definition for  ‘pauper lunatics’.  In 1845 the government passed the the County Asylum Act  which made it compulsory for every county to build an asylum. The next few years saw a massive building program across the country with the number of county asylums in England increasing from 9 in 1827 to 91 in 1910.

 The intent behind the 1845 County Asylum Act was to provide humane conditions conducive for rest and recovery so most asylums were built in the countryside. Healthful employment was to be provided for all patients. Each asylum was almost self sufficient with its own pig and dairy herd and farms for vegetables and wheat. They had their own bakeries, workshops, linen rooms, and laundries mostly staffed by inmates under supervision.  Each ward was to have access to an airing court where the patients could take outdoor exercise in a safe contained space.  As in the workhouse, men and women were completely segregated, often on separate wings of the asylum. Burial grounds were purchased close to the asylums, and since most patients were paupers, they were buried in unmarked graves often three or four to a plot. The Asylum was intended to be a self-sufficient community, designed for containment and care, often over many years from admission to discharge or death.

Despite the original good intentions of the 1845 County Asylum Act, the admissions policies to the asylums proved to be chaotic. The Poor Law guardians seized on the 1845 Lunacy Act as an opportunity to pass on their pauper lunatics to the new asylums, thus saving money for the parish. Overcrowding soon became a problem so that one hundred patients to a ward was common.The beds became clogged with  an assorted rag bag of social misfits, people with varying grades of learning disability, those addicted to drugs and alcohol, either acutely or chronically disturbed, vagrants’ (2).  It was standard practice to lock wards until well into the 20th century. What were envisaged as curative hospitals became places of containment for inconvenient people. Asylums were considered to be deeply unattractive places to work, and psychiatrists were viewed with suspicion and held to be of low status in the ranks of the medical profession.

The Prestwich Asylum was described by Sir Aubrey Symonds in his 1921 initial briefing paper for the Minister of Health as ‘a large asylum with nearly 3000 patients. The buildings are antiquated and the medical superintendent is not conspicuously efficient. It may therefore be safely said that Dr Lomax saw the English asylum system at its worst, the normal defects of Prestwich being aggravated by shortage of staff and strict rationing of food” (3). It was also noted by an aide to Symonds ‘The ratio of staff to patients (at Prestwich) was 1:10 when it should have been 1:7. There was no operating theatre and a surgeon was brought from Manchester if required. Nursing training fell into abeyance during the war and has not yet been reinstated. Prestwich was still using earth closets in 1921 – the only British asylum still to do so’ (3). 

 It is possible that Montagu wanted to indulge his hobby of psychology, although this would have been an extreme way of doing so and at the cost of his personal comfort and professional respect. To my mind, it is hard to escape the suspicion that he was armed with an agenda for lunacy reform  before he started work as an asylum medical officer. Indeed he wrote in his introductory chapter ‘..as my object was to gain as much information as I could , in order to make the best use of it when the proper time came’ (1). Montagu also took great care to explain why he had not simply discussed his concerns with the superintendent at Prestwich whilst he was working there. He said that he was only ‘an obscure and negligible person, a locum tenens’ and at risk of being dismissed with a week’s notice. He had been well advised where and how he could obtain ammunition to make the greatest impact. Lomax already had a good track record as a medical writer. He was articulate, accustomed to public speaking and giving lectures to a non-medical audience. Montagu enjoyed a good battle with authority, he had a strong sense of justice and wasn’t afraid to speak out to right wrongs. He was at the end of his career and was not dependent on references for advancement. He could act as a truly detached observer, and report his findings without bias. He knew how to use the press. He could criticise without fear of repercussions. He also had a tragic family secret which gave him a personal insight into the workings and failures of the asylum system – Armine, his middle son was feeble-minded and had died of asylum dysentery in The Earlswood Asylum 1910, aged only 18 years.

 Montagu was in many ways, an ideal front man.

This begs the question of front man for whom – presumably by someone who knew the asylum system well and was keen to obtain national reforms? There are a number of possible candidates. Dr Fletcher Beach would have known Montagu well, having looked after his son, Armine for over ten years. Beach was over 70 at the outbreak of the war, but returned to work at Cane Hill Asylum and stayed there for the duration. He would have been well aware that Prestwich Asylum had a poor reputation. Fletcher Beach would have been able to introduce Montagu to other politically significant alienists (psychiatrists). It is known that Montagu corresponded with and visited Dr Helen Boyle, and Professor George Robertson (4).  Helen Boyle was  a prominent psychiatrist and who, like Montagu had an interest in spiritual healing. She was based in Brighton where she ran the Lady Chichester Hospital, and has been described as ‘ a leading ‘reformist’ amongst English psychiatrists’ (4). Montagu moved to Brighton in or before 1918, so it is possible that he wanted to be within easy reach of her, perhaps for her advice and assistance. Professor George Robertson was a leading academic psychiatrist in Glasgow. Montagu had been to visit Robertson as part of his research and later acknowledged Robertson’s work on the use of female nurses for male patients (1). All three alienists were presidents of the national MedicoPsychological Association during their careers. T.W. Harding reviewed Lomax’s work at the Prestwich Asylum in his 1990 paper ‘Not worth powder and shot’. Harding did not know about Beach’s connection to Montagu Lomax,  but  speculated that Robertson, Boyle and Lomax would have been ‘aware of the built in professional conservatism and inertia in the asylum system’. Harding noted that Robertson and Boyle had failed to support Lomax publicly, but thought that Lomax would have understood their position ‘in a spirit of conspiracy to bring about change’ (4).

The pattern of Montagu’s placements  at Bracebridge and Prestwich Asylums is also strange. He worked for two months at Bracebridge but decided not to stay since the work was purely clerical and he wanted patient contact. He moved to the Prestwich Asylum, working as an asylum medical officer between 1st October 1917 to 3rd June 1917, and went back again for second block between 5th September 1918 to 20th June 1919 (a total of 318 days). He wrote asking for a third term on 2nd September 1919, offering to return to work at Prestwich, but he qualified the offer by saying ‘It will not be worth my while to come unless you can guarantee my staying until at least the end of the year.’ (5). It was almost as if Montagu wanted to gather more information. September 1919 would have been an interesting time in the UK asylums because they were filling up with shell-shocked soldiers. The First World War had been over for nearly a year and the staffing crisis would be beginning to ease. It may be that Montagu wanted to study the soldier patients, and to experience life in the asylum under more normal conditions.

In the event, the Prestwich superintendent , Dr Perceval, did not renew his contract for the last quarter of 1919. It seems that Montagu had been able to gather sufficient material,  and he went home to Brighton to write a book – The Experiences of an Asylum Doctor. His strategy was as clever as it was simple. The book was written for the layman. It was an exposure  of the asylum system written in short chapters. Points were well argued using clear language. It was aimed at the educated middle classes who could be guaranteed to make a fuss about the shocking conditions described. It was also aimed at the relatives of the  shell-shocked soldiers, the ‘other ranks’ who had given up so much for their country, only to find themselves confined within the pauper asylums in the immediate aftermath of the war. He commented  in his book that he was aware that much had already been written about the necessity for asylum reform but most of the matters had been discussed through the pages of the medical journals, or discussed at medical meetings. However, as he pointed out ‘no attempt has been made hitherto to bring the subject to public notice,…….. for until the public realises the paramount interest it has in the matter, it is not likely that much will be done. All reforms of public institutions depend in the last resort upon rousing of public sentiment and the pressure of public opinion(1). Montagu went on to point out that the public were largely ignorant of the facts of the conditions within the asylums. He said that his book was an attempt to supply the facts so that the ‘public could take the lead’. Montagu was a whistleblower, but subsequent events showed him to be far more than just a whistleblower.

He was careful to point out that the problems he was describing were based on his own experiences within only two asylums, but he felt that the asylums in question  were ‘fully representative of their class’ (1). Moreover, he had read widely on the subject and had many conversations with medical officers from other asylums. He believed that his experiences were by no means unique. Montagu added that he had ‘stated nothing of which I was not myself an eye witness’. He emphasised that ‘it is the system I am attacking, not individual asylums; it is principles not persons’ (1). He finished his introductory chapter by reminding readers that he was not a mental specialist, and the book was not a psychiatric treatise but ‘a plea for asylum reform’ written for the general public.

Montagu said  that the asylums detained and restrained, but they did not cure. Moreover, he found that the administrative system for the asylums which had been set by Act of Parliament, ‘permitted occurrence of grave defects and abuses’. He quoted from Dr Charles Mercier’s book written a quarter of a century earlier which described  the gloomy, dilapidated barracks used to house the insane as being more like prisons and where patients were badly fed, poorly clad, dirty and unkempt. Montagu noted that there had been no improvement in these conditions in the last quarter century. He saw little point in herding lunatics into asylums unless there was a recognised treatment for them, and he noted that some patients who had the chance of recovery were made permanently insane by being incarcerated with chronic lunatics. There was no attempt made to classify lunatics , and other than divide them into male and female, epileptics were placed with psychotic and suicidal depressives. Staff shortages meant that disruptive patients were either put into solitary confinement cells for long periods, or put ‘behind the table’ with their backs against the wall, held in place by a table and watched  by a single member of staff. Montagu found this to be a brutalising, degrading  form of restraint where men sat all day with no form of entertainment except to quarrel with each other and to spit into each others food. Exercise would be taken in the airing courts attached to  wards which was a walled yard open to the elements. No overcoats were supplied and patients were forced to go out for a set period each day in all weathers. Upwards of 150 patients would be trying to exercise in the space of around 1/3rd of an acre, all dressed in asylum garb and asylum boots. Montagu commented that the insane poor had many difficulties to cope with but the ill-fitting boots, lack of spectacles, poor dentition and chronic constipation due to the appalling food were all easily remediable for a small investment. 

He went on to describe forms of chemical restraint, mechanical restraint and punishment which he felt was used too freely and often without justification since the essence of insanity was loss of self-control. In his opinion, the use of the strong purgative, croton oil as a method of punishment was utterly barbaric.It was usually added to a patient’s food so that they were unaware that they had been dosed. He thought that the use of croton oil predisposed patients towards asylum dysentery, which he acknowledged was due to an infection, but one which might take hold in a patient weakened by violent purging. The ‘germ’ which caused asylum dysentery was a good reason for having proper plumbing in each asylum. Prestwich had not installed any plumbing in an attempt to save money and by 1921 was still using earth closets, and a ‘closet gang’ of patients to empty them. Montagu reported that the members of the closet gang were frequently ill, and had a much higher death rate than the rest of the inmates at Prestwich. 

He  described the slave labour of the asylum patients who worked in the laundries, sewing rooms, boot makers, the kitchen, the farms and the gardens for little more than an extra plug of tobacco. He suggested that payment could be by tokens which could be exchanged in the asylum shop, a system which was already working well at the criminal asylum at Broadmore. He thought that management would resist this change since free inmate labour kept administrative costs down.

A whole chapter covered the issue of asylum food which was shockingly bad. Montagu acknowledged that things were difficult during war time. However the asylum managed to feed its medical officers well enough but the diet for the insane poor was barely adequate. The death rate in the asylums had risen alarmingly during the war and this had been attributed to tuberculosis, dysentery and pneumonia along with ‘senility’.  Montagu commented that “senility’ was a new and mysterious disease which the leader writer in The Times (Sept 7th 1919) had hinted might be a euphemism for ‘starvation’ (1). Crammer’s 1992 paper confirmed that the calorific value of food supplied to asylum patients during the war was below the accepted minimum for sedentary life (6). Crammer thought that the rise in tubercular deaths at this time was due partly to overcrowding in the asylums, but was also consistent with food deprivation. The Board of Control were aware that there was malnutrition in the asylums, (some having colossal death rates of over 30%) but did nothing to change the status quo. Crammer estimated that the war time conditions in the asylums resulted in excess of 17,000 pauper lunatic deaths (6). 

The problem of the shell-shocked patient within the asylum was also touched on within Montagu’s book although he was to make much more of this problem after the book was published. Shell-shocked officers were sent to luxurious establishments where they received the best available care. Other ranks were sent to the public asylums, and found themselves detained with no treatment for their stutters, nightmares, and movement disorders and where there was a significant risk they would eventually be driven insane. Montagu noted that the War Office had promised that no mentally afflicted soldiers should be treated as pauper lunatics, and no shell-shock cases sent to pauper asylums. However, the government refused to pay war pensions to these soldiers unless they consented to be  admitted to the asylums for ‘treatment’, so they had little choice in the matter. Reid estimated that by October 1921, there were 6,000 of these men held in public asylums (7). Montagu thought such cases had no place in an asylum but should be treated in military facilities.

Montagu’s book also covered the problems associated with having the medical superintendent as the pinnacle of the asylum and the abuse of power which arose from such a position in the absence of checks and balances other than the Board of Control. He covered the unhappy life of the asylum medical officer who was unable to marry, was poorly trained, overworked, under-paid and had no career structure as such. He talked about exposing the system of asylum administration which was “sanctioned by law, approved by custom and fortified by official apathy and neglect’ (1). He was convinced that simple adjustments to the system could produce great improvements to the lives of the insane poor. His recommendations included appointment of visiting surgeons, physicians and dentists and the provision of operating facilities, X-ray facilities and consulting rooms to improve patient’s general health; improved balanced meals to include fresh fruit and vegetables; and the separation of imbeciles and epileptics into colonies of their own kind away from the lunatics.

The asylum system begun with the best of intentions for the insane poor, had begun to crumble under the sheer weight of patient numbers by the late 19th century. The buildings were no longer asylums, places of refuge from the world, but had become barracks, places of detention where patients lost their liberties, their dignity and often their lives. The pressing need for asylum reform had been discussed for over a quarter of a century by the medical profession. There had been little progress in spite of a number of Acts of Parliament, and some have attributed this inertia to lack of appetite for change on behalf of the MedicoPsychological Association, the professional body representing the psychiatrists of the day. I believe  that  Montagu Lomax viewed the 1917 medical call-up as an opportunity to take asylum reform out of the hands of the medical profession and to put the public in the driving seat.   I believe that Lomax wasn’t acting alone, and probably had powerful advisors who shared his vision of asylum reform. His book had an astonishing effect. Questions were asked in parliament within weeks of its publication suggesting that strings were being pulled in high places. 

Finally what was Montagu’s motivation?. He dedicated his book “To all the insane poor in sympathy with their sufferings and in hope of alleviating their hardships this book is inscribed by the author’(1).  I am certain that he wanted to improve a system which had been failing its clients for many years because of apathy and vested interests amongst those in charge. TW Harding reviewed Lomax’s case notes at Prestwich for his 1990 paper, and found that Lomax examined his patients more frequently than the other medical officers. He noted that Lomax was ‘clearly a careful observer of  behaviour and symptoms’,  and that he talked to his patient’s families and friends to find out more about their backgrounds. Harding considered that ‘Lomax was sincere his efforts and his book reflected an authentic concern for his patients’(4). Harding was impressed by Lomax but didn’t speculate on his motivation for putting himself into the asylum system in the first place.

I suspect, but will never be able to prove, that Montagu committed himself to asylum reform as atonement for the death of his son Armine. 

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. Rollin HR. Psychiatry in Britain one hundred years ago. The British journal of psychiatry : the journal of mental science. 2003;183:292-8.

3. PRO. Summary Paper by Symonds. November 20th. MH58/2221921.

4. Harding TW. “Not worth powder and shot”. A reappraisal of Montagu Lomax’s contribution to mental health reform. The British Journal of Psychiatry. 1990;156(2):180-7.

5. PRO. Letter from Lomax to Dr Perceval, superintendant, Prestwich Asylum. MH58/2221921.

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

7. Reid F, Van Everbroeck C. Shell Shock and the Kloppe: war neuroses amongst British and Belgian troops during and after the First World War. Med Confl Surviv. 2014;30(4):252-75.

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