In 2009 the European Working Time Directive restricted the working week to 48 hours. There was a measure of protest from the medical profession, particularly surgeons who felt that their training would be adversely affected. However, many doctors who spent their early years working 140 hour weeks were genuinely pleased that their successors would be able to maintain a normal life outside of their career. They celebrated the luxury of working life with its 30 days paid annual leave, guaranteed study leave and a national pay and pension structure allowing them to move relatively freely around the country. Their predecessors were not so fortunate. It is a sobering exercise to study the letters pages of the early British Medical Journals where grievances over doctors’ working conditions feature frequently. The plight of the asylum medical officer at the turn of the 19th century is particularly distressing. It is the purpose of this article to record their struggle for recognition as a profession, a career structure and adequate rest and remuneration.
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 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 coraled the poor and those unable to work into the workhouses and legally defined ‘pauper lunatics’. The workhouses were an important filtering stage in the assessment of the pauper lunatics. In 1845 the government passed the the County Asylum Act which made it compulsory for every county to build an asylum and the Lunacy Act which established the The Lunacy Commission responsible for asylum supervision. The Poor Law guardians seized on the 1845 Act as an opportunity to pass on their pauper lunatics to the new asylums and relieve the ever mounting pressure on the workhouse beds. The next few years saw a massive building programme across the country with the number of county asylums in England increasing from 9 in 1827 to 91 in 1910.
The intent behind the County Asylum Act was to provide humane conditions conducive for rest and recovery. The Report of the Commissioners in Lunacy to the Lord Chancellor 1847 laid out careful recommendations for the situation and architecture of the buildings. The report specified that ‘the site of an Asylum should be of a perfectly healthy character’, which meant that most asylums were built in the countryside but close to the urban conurbations. The commissioners recommended that there should be ‘healthful employment out of doors and should as far as possible be of a ration of one acre to ten patients’ .. 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. 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. 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 a self contained 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 were chaotic and so that by 1918, there were 142,000 pauper lunatics incarcerated within the British asylum system. The reasons for the astonishing growth of the pauper lunatic asylums in the 19th century has been a subject of vigorous debate in the literature. It is a fact that the proportion of paupers classified as lunatics rose from one in one hundred in 1842 to one in eight in 1910, with subsequent overcrowding in the Asylums. – 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….’ . It was standard practice to lock wards until well into the 20th century. What were envisaged as curative hospitals became ‘mere vessels of containment’.
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. These ‘mad doctors’ or ‘alienists’ were keen to improve their status, and to encourage the scientific study of mental illness . The Association of Medical Officers of Asylums and Hospitals was formed in 1841, changing its name to The Medico-Psychological Association (MPA) in 1864 (eventually becoming the Royal College of Psychiatrists in 1972). The MPA published the Journal of Mental Science and was responsible for a sense of community amongst the asylum doctors. It was however a ‘cosy gentleman’s dining club’ with a small membership in the early years being largely confined to the Medical Superintendents. Moreover, the MPA had little impact beyond its membership and had almost no influence on public attitudes towards mental illness, relying on the more powerful voice of the British Medical Association .
The Asylum medical officers were unlikely to have formal training in their chosen profession. Dr John Connolly, in his presidential address to the MPA of 1858 and again in 1860, called for a compulsory course of clinical instruction for all asylum medical officers. It wasn’t until 1885 that the GMC added mental disease as a separate item on the medical curriculum for the final MB examination. Leeds medical students were invited to visit the West Riding Asylum for lectures and clinical experience under the great Dr James Crichton-Browne, superintendent from 1866 to 1876, although this practice was not commonplace outside of Yorkshire and London. The MPA introduced a Certificate in Psychological Medicine in 1865, but this was not a compulsory qualification for would-be asylum medical officers and the take-up was poor. By 1894, only 8 asylums were recognised for training purposes, although the BMJ commented that there were several postgraduate lectures given in London, and each provincial medical school ‘has a lecturer on Psychological Medicine who gives clinical instruction in a neighbouring asylum’. However, for the majority of medical officers, ‘training’ consisted of the acquisition of experience through working in the asylums.
In 1894 the BMJ reported that ‘It is almost as easy for a woman to get a complete medical education in England, Scotland or Ireland as it is for a man’. Membership of the MPA was restricted to ‘gentlemen’ by vote at the annual general meetings of 1865 and 1872. Women were working as asylum medical officers by the late 1880s and the Certificate in Psychological Medicine was awarded to a woman in 1888. However, it was another six years before the MPA finally agreed to accept women members in 1894 and even then the vote was not unanimous. By 1900, only 14 women were or had been members of the MPA.
The Lunacy Act of 1845 made it mandatory that each County Asylum should have a resident medical officer and gave official recognition to the dominant position of the medical profession in the diagnosis and treatment of mental illness. The Lunacy Acts of 1845 and 1890 established the supremacy of the asylum Superintendent giving him ‘paramount authority’ in each asylum subject only to that of the asylum sub-committee. The autocratic superintendent was provided with a house, servants, free provisions and coal and a good salary. On February 17th 1894 the British Medical Journal published an editorial entitled ‘Asylum Superintendents’. The author was pleased that the standard of applicants for the superintendent of the Whittingham Asylum was so low that the post had been withdrawn. The editorial believed this was result of the progressive erosion of salaries and pensions of the asylum medical officer so that men of quality would not apply for a job with responsibility for 2000 patients where the pay was equivalent to that of a country village GP. The editorial recognised the huge pressures that asylum medical officers worked under, and recommended that the asylum superintendents should be paid at least the equivalent of a successful urban practitioner and should have the help of one or two experienced deputy superintendents. This single paragraph unleashed the floodgates and there was an outpouring of discontent through the letters pages of the BMJ almost every week for the next six months.
There was general agreement that the work was relentless and that there was little energy or time left for research or ‘original observations or even any industrious survey of the the rich material at hand. One commented that the career of the assistant medical officer ‘is one of the saddest pictures our profession affords‘. He complained of the boredom of the job, the inability to marry, inadequate pay, and the absence of a home or independence. The lack of career progression was a common complaint and that only a small proportion of assistants achieved a superintendency. The power of the superintendent’s position was an abiding grievance ‘The truth is that the superintendent is absolute master, and the assistant is, to the extent of abasement, his serf, his man Friday’. Many of the correspondents used pseudonyms for fear that they would be identified and jeopardise their jobs. ‘If the cases in which the professional careers of assistants have been injured beyond repair by superintendents were made known, the revelation would be startling and shameful’. The same correspondent described how a paper had been read before the Medico-Psychological society on the status of assistants in 1890. He said that it had been ‘pitiful to note the cowed and apologetic tone in which the assistants pleaded for some amelioration of their lot, for fear of arousing the displeasure of the superintendents’. One thought that the system of autocratic medical superintendents had killed scientific research in the asylums. He described the experience of stinging humiliation which taught him ‘never to cross the bar of “established usage”, and how this demoralised and destroyed his energy and individuality.
A long letter from ‘Hopeful’ complained that the prevailing asylum spirit was one which makes for maximum comfort, exaltation and glorification of the Superintendent. He admitted that the superintendent’s duties were primarily those of an administrator and all his training and professional experience was wasted since the medical duties had to be delegated to his assistants. He complained that superintendents visited the wards rarely and never in the company of the ward doctor, but were prone to change treatment regimes without discussion which was ‘tantamount to a snub,…..and a deterrent to the confidence of the patient in the medical officer under whose treatment he is’. Hopeful noted that there was little reward or incentive to become an asylum medical officer since the wages were a pittance, there was no private practice and he was unable to marry. The poor conditions in the asylum service ‘scotches the profession of our best men and draws into the service a lower class of medical men than average’.
Many commented that since such a system was enshrined in the legislature and enforced by laymen who ‘only understand a maintenance sheet’, there was little hope of change. There were thought to be too many vested interests in maintaining the status quo from superintendents who needed the assistants to do the routine clinical work to the county council who were reluctant to raise wages while there were still doctors who would accept the terms offered. The implication was that the MPA was controlled by the asylum superintendents who had a vested interest in maintaining the status quo. Eventually, it was proposed and heartily endorsed that the question of assistant medical officers should be brought before the the annual meeting of the British Medical Association. Yet even when this proposal had been agreed, the sense of hopelessness conveyed in a letter from ‘Experientia Docet’ was palpable. ‘Assistants will look forward with interest if with little hope, to the realisation of the scheme of a discussion at the next meeting of the British Medical Association’ .
As had been promised, the status of the assistant medical officer in the lunatic asylums was discussed at the 1894 BMA annual general meeting. Dr Charles Mercier, lecturer on neurology and insanity at the Westminster Hospital outlined the complaints listed through the pages of the BMJ over the preceding six months. The low starting pay was not thought to be a significant problem since there were plenty of applicants for the posts. However, the lack of career progression and adequate remuneration after the initial probationary period was recognised to be a serious deterrent to remaining in the service. The salary of £200 per year was the equivalent of a city clerk but with responsibility out of proportion. Poor wages and accommodation of two rooms meant that a man could not marry. Dr Mercier recognised the ‘intolerable loneliness and isolation’ of the position. Others noted that the asylum medical officer had no way to safeguard his position and no board to appeal to when problems arose with their employment. He was completely reliant on the goodwill of his superintendent. Various solutions were proposed including short term contracts and examinations as a means to ensure a career ladder. The meeting seemed to take the attitude that although there were some genuine grievances, the problems were not widespread. No concrete proposals were put forward, and the whole subject of the asylum medical officers and their problems disappeared from the pages of the BMJ. It must have been desperately disappointing, and to add insult to injury a separate proposal put forward at the same 1894 BMA AGM to create a national civil medical service with a graded pay structure was rejected out of hand.
Nearly twenty years later, in 1913, an anonymous asylum medical officer commented that there were a large number of vacancies for asylum medical officers, and ‘until some action is taken to improve existing conditions, the asylum medical officer will remain a professional pariah’. The main complaint was still the absolute power of the superintendents to make or break a medical career and the complete lack of career progression. Less than one third of assistant medical officers were offered a superintendency, with promotion a gamble dependent on the goodwill of laymen. The asylum medical officer was obliged to live in at the asylum in close touch with his patients -‘a two-room life which socially, to all intents and purposes, means annihilation. He remains a lifelong house physician. He is allowed a little time off each week – which often is of little use as most county asylums are situated in remote country parts- and a month’s annual vacation. The work is often times more clerical than scientific‘.
Some attempts were made to improve conditions and by 1909, the Asylum Officers Superannuation Act was passed which allowed for retirement at 55 years and made the profession a little more attractive. Yet there were still many problems for the junior medical officers in asylums. The MPA appointed a committee to consider the poor opportunities available for teaching and research, and for keeping up to date with medical practice. The committee reported in 1914 and a copy was sent to the Home Office with various recommendations. By this time, the Government was occupied with the more pressing matter of the First World War and nothing much happened.
The workload for the junior doctors around the turn of the 19th century was inconceivable by today’s standards. It was common practice to be responsible for 400-500 patients and more than that if a colleague was on leave. All patients were required to be examined on admission when a standard form was completed by the admitting medical officer, and then at least every month for the first year and three monthly for chronic cases. Inspection of the casebooks formed part of the Commissioners in Lunacy reports and there was therefore considerable pressure on the medical officers to keep them up to date. This meant that each medical officer was each responsible more than 300 examinations per week, almost a physical impossibility. There was no private interview room available, with information obtained by casual interviews in the wards or airing courts and the medical notes being written from memory with the help of the head attendant. There was a ‘mass of clerical work to be done with filling in of endless returns’. Post mortems should have been carried out by the superintendents but they were usually delegated to the assistants. All patients’ letters, except those addressed to the Commissioners, were read by the medical officers with the implication that censoring was required. Registers of deaths and discharges had to be kept up to date, again these were inspected by the Commissioners. The doctors lived on site and were frequently disturbed at night because a troublesome patient needed sedation and the medical officers kept drugs in their rooms to avoid having to walk to the dispensary.
The workload was onerous but the working conditions were terrible. Montagu Lomax, writing in 1921 , described the conditions at the Prestwich Asylum where he had worked as a locum assistant medical officer for two years. The patients were mostly paupers, and often admitted through the workhouses under a Reception Order which effectively removed a patient’s liberty. All asylum wards were locked, and patients were only allowed off the wards when collected for work parties by a supervisor. They were housed 100 to a ward and clothed in boiled communal clothes which resembled ‘prison garb’. There were no overcoats in winter and no change of clothes available if patients got wet at exercise. They were no lockers so that anything valued had to be carried all the time. They were not allowed to handle money, so that any personal money for sweets or cigarettes had to be held by the Head attendants. Women had no make up and hair cuts were all alike. Lomax described how almost everyone suffered from boot trouble, teeth trouble and spectacle trouble which were a constant source of minor misery, and constipation due to the monotonous diet was widespread. Exercise was taken in the airing courts but these were often shared between wards so that 300 men might be attempting to walk around in half an acre of enclosed grounds.
Once a patient was considered well enough, then he or she would be allocated to work parties. They were paid with extra food or asylum shag (snuff). Work was considered to be a means of attenuating boredom and building a good character from the work parties was vital in the as a means of receiving liberty. Most asylums were self sufficient and had workshops on site. A coir-picking shop was used to make mattresses, there was a printers shop, a boot-maker’s and tailors shop and work parties could also be allocated to the farms, kitchens and laundries. Many asylums were not on mains drainage and did not have electricity until the 1930s so a ‘closet gang’ was vital with responsibility for emptying the asylum earth closets. The epileptic patients were thought to be particularly suitable for this type of employment being generally of good health. There was a farm gang, an engineers gang, scrubbing gangs, gardening gangs, laundry gangs and kitchen gangs. Asylum inmate labour saved the authorities thousands of pounds but was not perceived as slavery at the time, but rather as a vital step on the path to recovery.
Some patients were not fit to work. They were described as the ‘wet and dirties’ (incontinent), the ‘back ward patients’ (chronic cases) and ‘pads’ (kept in padded cells) and their conditions were truly dreadful, often with only one or two trained staff to a ward of 100 patients, much of the cleaning, heavy work and feeding was done by ‘ward workers’, who were also inmates, under the direction of the nurses. Difficult patients might be put ‘behind the table’ to sit all day on benches with their backs against the wall and wedged in by a table where one attendant could keep twenty or so men under control. They had nothing to do but get frustrated, fight and spit in each other’s food. Lomax described ‘thousands of so-called pauper lunatics on both male and female sides of the asylum crowded together in vast barrack-like constructions, with no attempt at classification or segregation: early mental cases, epileptics, general paralytics……..of every grade and type indiscriminately congregated in comfortless, badly constructed, unhygienic buildings’ He felt that ‘many recoverable patients are, under the present system, made permanently insane is beyond question. This was particularly the case for the young shell shocked soldiers, 6000 of whom were drafted into pauper lunatic asylums, despite assurances from the War Office that this would not happen.
Lomax thought that ‘treatment could be summed up in two words – drugging and purging, to which in war time was added a little discrete starvation‘. It certainly seemed that restricted rations was a recognised policy. Most of the food produced by the asylum farms was requisitioned for the troops, although some was kept back for the resident staff. A rising death rate in the asylums was recognised during the first world war and when it rose from 12.1% in 1915 to 20% in 1918, the Government Board of Control was puzzled. Crammer’s 1992 review of the records of the daily food allowances and expenditure on food in the asylum confirmed Lomax’s suspicion that patients were systematically starved. The army had requisitioned a third of countries workhouse, isolation hospitals and asylum beds to treat wounded soldiers and Crammer suggested that resultant gross overcrowding of asylum patients allowed TB and other infective diseases to sweep through the malnourished pauper lunatics.
It is hardly surprising that there was a ‘chronic pessimism which characterises asylum doctors and patients alike‘. The conditions for the assistant medical officers had not changed one jot since the first attempts to represent their grievances to the MPA thirty years previously, and may indeed have worsened since there was an interim rise in the numbers of inpatients in conjunction with a fall in the number of medical staff during and after the first world war. The massive overcrowding seen in the lunatic asylums of the early 20th century had made a travesty of the original intentions of the 1845 lunacy act where asylums were meant to be places of shelter where the insane could recover. Instead they had become part workhouse, part prison and the medical care was an exercise in zoo keeping. Lomax was careful to portray the Visiting Committees of the Board of Control and the medical profession as victims of a system of asylum administration which had been sanctioned by law but was not fit for purpose. He experienced first hand the ‘senseless drudgery of a cast iron routine, content to make men into machines and careless of how their work was done as long as petty rules were obeyed‘. His clear enumeration of the faults of the system were followed by an impassioned plea for change, not for himself as his predecessors had done, but for the sake of his patients.
The Lomax affair became a cause celebre, and Montagu Lomax, in common with many whistleblowers was castigated and disowned by his own profession. Many attempts were made to discredit him and minimise the damage to the establishment with furious rebuttals in the Journal of Mental Science. Much of this mud slinging has subsequently been discredited in an excellent article by Harding , who showed Lomax to be a caring and conscientious doctor whose only concerns were the well being of his patients. The newspapers of the time whipped up public outrage at the conditions for the pauper lunatics and questions were asked in parliament. Lomax asked for a Royal Commission, and in 1924, the MacMillan commission was appointed, and made far reaching recommendations that led to the Mental Treatment Act of 1930 and gradual improvement in the conditions of asylum patients and asylum medical officers alike.
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