Permeable Walls: Historical Perspectives on Hospital and Asylum Visiting (Clio Medica Wellcome Institute Series in the History of Medicine)

PERMEABLE WALLS HISTORICAL PERSPECTIVES ON HOSPITAL AND ASYLUM VISITING

THE WELLCOME SERIES IN THE HISTORY OF MEDICINE Forthcoming Titles:

The Imperial Laboratory: Experimental Physiology and Clinical Medicine in Post-Crimean Russia Galina Kichigina

The Stepchildren of Science: Psychical Research and Parapsychology in Germany, c.1870–1939 Heather Wolffram

The Wellcome Series in the History of Medicine series editors are M. Neve, V. Nutton, R. Cooter and E.C. Spary. Please send all queries regarding the series to Michael Laycock, The Wellcome Trust Centre for the History of Medicine at UCL, 183 Euston Road, London NW1 2BE, UK.

PERMEABLE WALLS HISTORICAL PERSPECTIVES ON HOSPITAL AND ASYLUM VISITING Edited by Graham Mooney and Jonathan Reinarz

Amsterdam – New York, NY 2009

First published in 2009 by Editions Rodopi B.V., Amsterdam – New York, NY 2009. Editions Rodopi B.V. © 2009 Design and Typesetting by Michael Laycock, The Wellcome Trust Centre for the History of Medicine at UCL. Printed and bound in The Netherlands by Editions Rodopi B.V., Amsterdam – New York, NY 2009. Index by Merrall-Ross International Ltd. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from The Wellcome Trust Centre for the History of Medicine at UCL. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978-90-420-2599-8 E-Book ISBN 978-90-420-2632-2 ‘Permeable Walls: Historical Perspectives on Hospital and Asylum Visiting’ – Amsterdam – New York, NY: Rodopi. – ill. (Clio Medica 86 / ISSN 0045-7183; The Wellcome Series in the History of Medicine) Front cover: Comical scenes of grand ladies visiting hospital patients with gifts of cigarettes and cakes. Coloured lithograph after Louise Catherine Ibels, 1916. Courtesy of the Wellcome Library, London. © Editions Rodopi B.V., Amsterdam – New York, NY 2009 Printed in The Netherlands All titles in the Clio Medica series (from 1999 onwards) are available to download from the IngentaConnect website: http://www.ingentaconnect.co.uk

Contents

1

2

3

4

5

6

List of Figures

1

List of Tables

3

Acknowledgements

5

Hospital and Asylum Visiting in Historical Perspective: Themes and Issues Graham Mooney and Jonathan Reinarz

7

Receiving the Rich, Rejecting the Poor: Towards a History of Hospital Visiting in Nineteenth-Century Provincial England Jonathan Reinarz

31

‘Family-Centred Care’ in American Hospitals in Late-Qing China Michelle Renshaw

55

Care, Nurturance and Morality: The Role of Visitors and the Victorian London Children’s Hospital Andrea Tanner

81

Pariahs or Partners? Welcome and Unwelcome Visitors in the Jenny Lind Hospital for Sick Children, Norwich, 1900–50 Bruce Lindsay

111

Visiting Children with Cancer: The Parental Experience of the Children’s Hospital of Pittsburgh, 1995–2005 Robin L. Rohrer

131

7

8

9

10

Infection and Citizenship: (Not) Visiting Isolation Hospitals in Mid-Victorian Britain Graham Mooney

147

Stage-Managing a Hospital in the Eighteenth Century: Visitation at the London Lock Hospital Kevin Siena

175

‘The Keeper Must Himself be Kept’: Visitation and the Lunatic Asylum in England, 1750–1850 Leonard Smith

199

‘A Disgrace to a Civilised Community’: Colonial Psychiatry and the Visit of Edward Mapother to South Asia, 1937–8 James H. Mills and Sanjeev Jain

223

11

‘In View of the Knowledge to be Acquired’: Public Visits to New York’s Asylums in the Nineteenth Century Janet Miron 243

12

‘Amusements are Provided’: Asylum Entertainment and Recreation in Australia and New Zealand c.1860–c.1945 Dolly MacKinnon

267

Challenging Institutional Hegemony: Family Visitors to Hospitals for the Insane in Australia and New Zealand, 1880s–1910s Catharine Coleborne

289

Notes on Contributors

309

Index

313

13

List of Figures

2.1

The Duchess of York at the Woodlands

46

2.2

The Prince of Wales at the Woodlands

47

3.1

A Family Witnesses an Orchidectomy

68

4.1

Adrian Hope, HSC Secretary, Escorts Lady Visitors Around the HSC

96

The Prince and Princess of Wales’s Visit to the HSC, 22 March 1902

97

The Lock Hospital, Hyde Park Corner, Westminster

184

4.2

8.1

12.1 Collingwood Lunatic Asylum Ball, Victoria, Australia, 1868

271

12.2 Mr Tucker’s Bay View Private Asylum, New South Wales, Australia, 1869

277

1

List of Tables

4.1

7.1

7.2

Distinguishable Male Visitors to the Hospital for Sick Children, London, 1856–60 to 1876–9

85

Isolation Hospital Admissions by Age, Sanitary Authorities in England and Wales, c.1881

156

Admissions, Deaths and Visitors to Dangerously Ill Patients, London MAB Hospitals, 1878–81

162

3

Acknowledgements

The idea for an edited collection on hospital and asylum visiting emerged from two conference sessions. The first, ‘Institutional Visiting’, took place in 2004 at the Annual Conference of the Social Science History Association (SSHA) in Chicago. The second was ‘Children in Hospital’ at the 2006 Annual Conference of the American Association for the History of Medicine, Halifax, Canada. We are grateful to the organisers of both conferences for placing these sessions on the respective programmes. We have accrued a number of other debts along the way, and it is our pleasure to acknowledge them. Barbra Mann Wall (School of Nursing, University of Pennsylvania) served as chair and commentator at the SSHA conference in Chicago. Her comments and interest in the presentations were very encouraging to us. Judith Young (Margaret M. Allemang Centre for the History of Nursing, Toronto) provided Jonathan Reinarz with a tremendous amount of information and advice. Professors Anne Hardy and Roger Cooter extended an invitation to Jonathan Reinarz to present a version of Chapter 2 at The Wellcome Trust Centre for the History of Medicine at UCL. Carolyn Strange alerted us to other researchers working on institutional visiting and Marta Hanson pointed us to the contemporary significance of visiting for equity and rights. The reader for Clio Medica: The Wellcome Series in the History of Medicine provided helpful comments, while Mike Laycock and Esther Roth have steered the project skilfully to completion. Finally, our contributors have been a delight to edit and we thank them for their patience, promptness and enthusiasm. Graham Mooney and Jonathan Reinarz

5

1 Hospital and Asylum Visiting in Historical Perspective: Themes and Issues

Graham Mooney and Jonathan Reinarz

Compared to doctors, patients and institutions, visitors are an understudied constituency in medical history. The collection of essays in this book situates the historical practice of hospital and asylum visiting in broad social, cultural and geographical perspectives. This introduction loosely categorises visitors into four groups: patient visitors, including family and friends; public visitors, such as entertainers, tourists and the clergy, who have no direct formal ties with the institution or the patients; house visitors involved with the management and government of the hospital; and official visitors, who have inspectorial responsibilities. Discussion of the wider historical significance of visiting draws attention to issues such as urban governance, philanthropy, the public sphere, civil society and citizenship.

Guy Browning’s droll advice on ‘How to… Visit a Hospital’ in The Guardian’s Weekend 2 April 2005 edition satirises some of the experiences historicised in this book.1 Browning warns today’s potential hospital visitor that the ‘smart, middle-aged woman in a uniform… dishing out words of comfort’ is the cleaner, while the ‘young girl in casual clothing visiting the old man in the next bed’ is, in fact, the senior consultant; on gifts of food, visitors should be aware ‘that people who don’t like fruit at home are unlikely to have developed a taste for it in hospital’; and in the realm of infection prevention, Get Well Soon cards are to be avoided as they have been identified as major carriers of the hospital ‘superbug’ MRSA. Of course, Browning’s spoof would carry little comedic weight if his audience could not instantly recognise and understand the basis of his lampoon in the first place. The same applies to the work of the Cornish poet, Charles Causley, who addressed the subject of institutional visiting three decades earlier in his 7

Graham Mooney and Jonathan Reinarz poem ‘Ten Types of Hospital Visitor’.2 Causley, like Browning, banks on the vast majority of his readers having visited a friend or a relative in a hospital. We would further wager that probably most people’s experience with a health institution, historically, is as much as a visitor as it is a patient. The collection of essays in this book is intended to situate the historical practice of hospital and asylum visiting in broad social, cultural and geographical perspectives. From them we learn that the scope of visiting extends far beyond the familial context. It is hoped that these essays will deepen our sketchy understanding about who visitors were, what visiting involved and how the practice has evolved from the mid-eighteenth century to the present day. In a variety of national contexts, visiting in its widest sense emerges as an intricate set of disputed arrangements and interactions. Scrutiny of visiting promises, at least partially, to deflect attention away from patients and doctors, and from the glorification or demonisation of the institutions themselves. Rather, consideration is given over to a constituency that is not so much part of the institution as periodically and momentarily drawn into its ambit. Historical studies of visitors and visiting promise to tell us much about the changing relationship between institutions and the communities they serve, particularly at a time when it is becoming more common to find visitors themselves as the topic of academic research.3 Who were visitors and what did they do? The answers to these questions are, in fact, complex and encourage us to categorise types of visitor in order better to understand them. As we shall see, visiting involved the comings and goings not only of relatives and friends, but also of administrators, managers, philanthropists, lay care-givers, priests and ministers, entertainers, and tourists. For the purposes of simplicity, in this introduction we consider four categories of visitor that form the basis of the studies in this book. First, family and friends or ‘patient visitors’. Second, ‘public visitors’, under which are classed members of the public not associated with the direct administration of the hospital or with familial ties to the patients. Such visitors might include entertainers, tourists or members of the clergy. We identify a third group as ‘house visitors’, individuals who were usually involved in the formal management and government of the hospital by way of a donation or subscription. Such individuals commonly performed, for want of a more historically appropriate term, quality control tasks. Historians have already argued that these visitors took an active interest in patients who entered the institution on their subscription ticket.4 The final category is that of ‘official visitors’ who were usually, but by no means always, salaried inspectors of the state, and were responsible for monitoring and reporting on the performance of, and conditions inside, institutions. Often, though again not always, run by local and central governments, such inspections were, of course, carried out on behalf of the wider community. 8

Hospital and Asylum Visiting in Historical Perspective They were, and indeed continue to be,5 normally a feature of institutions funded by taxation, though that is not to say private voluntary institutions escaped the roving eyes of surveillance at times. Though below we consider each of these categories of visitor separately, it is important to recognise that their roles and functions often overlapped. Sources of emotional support could come from a priest as well as a family member; monitoring was undertaken by both house visitors and official visitors and, it must be said, by family and friends acting in the patient’s interest. Patient visitors Patient visitors, namely family and friends, offer emotional and practical support for the institutionalised, and provide an intimate link to a familiar world that is temporarily, or even permanently, beyond reach. Given the significance of visiting for today’s experience of health care, it is perhaps surprising how little has been revealed about the historical evolution of this seemingly universal practice. Case studies of general and specialist hospitals in this volume, and a scattering of references elsewhere in the literature, illustrate the complexity of the institution–patient visitor relationship. At various points in time and across a wide range of hospitals, visiting by relatives and friends has been prohibited, discouraged, policed, or positively welcomed. Evidence from the early voluntary hospitals in England and its colonies suggests that by providing food, clean clothes and linen for relatives, visitors sometimes offset the institution’s operational costs. But such visitors were little more than tolerated. Like English hospitals, those in late nineteenthcentury America tended to be rule-bound institutions where visitors were discouraged outside prescribed visiting hours. In the context of American hospitalisation, Charles Rosenberg has noted how visiting regulations were part and parcel of creating a highly ordered community that encompassed patients and staff as well as outsiders. Violations of visiting rules were frowned upon: the overriding concern of hospital authorities in this context was the potential hygienic and moral contamination brought into the ordered hospital environment.6 Of course, the maintenance of a moral quarantine predates the late nineteenth century, as Kevin Siena’s study of the London Lock Hospital in this volume illustrates. Not unlike the contemporaneous penitentiary movement, the Lock Hospital kept watch over those wanting to visit patients. Such control was connected to the moral reform of the patients, especially those women who, it was feared, might return to a life soliciting sin once they had achieved respite from their ailment and then discharged. The hospital had a system of total quarantine in place by the end of the eighteenth century and visits were forbidden. 9

Graham Mooney and Jonathan Reinarz Sequestration sought to purge the Lock’s women both spiritually and physically. As Jonathan Reinarz demonstrates in this volume, though the visits of patients’ families were often restricted in the early nineteenth century, they continued to be ‘a necessary evil’ at all hospitals, especially those with least funding, given the goods and services they provided. Wealthier institutions, such as London’s Great Ormond Street Hospital for Sick Children, could afford to dispense with such concerns and reduce patient visiting to just a couple of hours each week. Bruce Lindsay shows in his chapter that the Jenny Lind Hospital for Sick Children, a small charitable institution in Norwich, England, initially seized the opportunity of family visits to educate parents in hygiene and childcare in the late 1890s. The Jenny Lind’s acceptance of visitors in this way, however brief the episode, provides a significant counter-balance to the overwhelming portrayal of children’s hospitals that they more-or-less universally excluded visitors up to the 1950s. However, using evidence from microbiology and psychology, the Jenny Lind followed the example of Great Ormond Street and began to curtail family visits so that, by the 1920s, children’s parents were largely prevented from entering the hospital. Patients’ visitors at most institutions were increasingly identified by name and address, issued with passes, and their periods of access similarly regulated. Occasionally, their discussions with patients were observed, especially when involving vulnerable groups, such as women and children. In most cases, visiting days were clearly advertised in publicity material and sometimes adjusted to suit patients’ families. But why did this shift to greater restriction occur? It seems apparent that it was the result of a gradual increase in medical control over all aspects of the institutional experience. In many children’s hospitals, visits from parents came to be regarded as traumatic for their offspring, and disruptive of the daily routines that were determined for them by medical staff.7 Patient visitors were possibly the victims of professional nursing turf wars.8 Bruce Lindsay argues that the exclusion of parents, and especially mothers, would have enhanced the status of Registered Sick Children’s Nurses in the eyes of general nurses, who regarded children’s nursing as somewhat inferior. More widely, it was not uncommon for fears to be articulated about the biological exchange of infection between the hospital and the wider community, and the possible moral contagion introduced by ‘undesirable’ visitors, especially ‘strangers’.9 Debate about cross-infection within general hospitals, which characterised these places as ‘gateways to death’, raged for much of the nineteenth century.10 Concern mainly was with the admission of infectious patients and not with the role of visitors in transmitting infection. But as the infected were increasingly catered for in specialist isolation hospitals towards the end of the nineteenth century, Graham 10

Hospital and Asylum Visiting in Historical Perspective Mooney detects that families and friends of patients – the overwhelming majority of patients being children – were identified as potential exporters of infectious disease from the hospital to the local neighbourhood. As a result, strategies were adopted to discourage visiting, if not ban it outright. When visiting was permitted, visitors were often given guidelines for the most appropriate behaviour to reduce the possibility of infection. This demonising of visitors as biological fetchers-and-carriers undoubtedly played into the policies of infection prevention at general and children’s hospitals in the early twentieth century. Yet any discussion about using the restriction of visiting to non-infectious disease hospitals as a tool of infection control by the medical staff is thrown into dispute – if not revealed as grossly hypocritical – when class distinctions are considered. In the case of Toronto’s Hospital for Sick Children, semi-private (paying) parents in the 1920s were granted daily access to their children, whereas patients receiving care on the public’s dollar were restricted to one hour per week.11 Similarly, visitors to adults residing in the public wards of other Canadian hospitals were invariably subjected to shorter visiting hours when compared with those to the private wards.12 One may also point to the American mission hospitals in China as a point of departure from the visiting regimes of Western general hospitals. Michelle Renshaw’s chapter reveals how it was not uncommon for family members, friends and servants to live with the patient in American-run hospitals. Renshaw identifies a number of reasons to account for this: a lack of resources to employ staff; Chinese cultural norms concerning the inappropriateness of women nursing men; customary familial involvement in caring for the sick; and the fact that missionaries were prepared to make concessions to these norms and customs so that Chinese patients would agree to come into hospital to undergo unfamiliar procedures and perhaps even receive a dose of religious instruction. Visitors in the missionary hospitals assumed responsibilities of both nursing and nutrition. So integrated were visitors in hospital life that this may even have helped reduce the rates of cross-infection in missionary hospitals, something not recognised in British hospitals until well into the twentieth century. Renshaw argues persuasively that the centrality of dietetics in Chinese medical practice ultimately served to do the hospital patient both physical and psychological good: foods would be selected and prepared by family members according to their knowledge of dietetics and the patient’s symptoms; patients presumably believed that the food would help restore their health and complemented any medical treatment; and, they would feel cared for and valued.13 It would seem that in the mid-twentieth century hospital, visiting in the West came to be encouraged again for the psychological benefits it conferred 11

Graham Mooney and Jonathan Reinarz on the patient. The work of numerous psychologists began to draw attention to the damage caused by ‘hospitalisation trauma’.14 Initially resisted by health professionals, further research was disseminated widely, stimulating both government reform and much public debate. Now associated with the Tavistock Clinic, founded in 1920, and the work of James Robertson and John Bowlby, the recognition of ‘separation anxiety’, initially disputed within the medical community, helped unlock hospital doors once again and liberalise visiting hours. By the 1940s, new perspectives from developmental psychology and changing societal views on childcare were influencing the return to centrality for the family of the sick child. Additional work in this area will presumably develop the uneven and regional pace of change at specific institutions. There has been relatively little new research on visiting hospitals in the intervening half century or so. Robin Rohrer’s chapter brings us up to date with a survey of parental involvement with the diagnostic and treatment regimes at the Children’s Hospital of Pittsburgh from 1995 to 2005. Besides shifting to a contemporary American context, the chapter examines the families’ involvement in many aspects of patient care. Contact with medical and psychosocial staff and relationships with family visitors of other hospitalised children with cancer are explored. Issues of psychosocial support, treatment decision roles and the emotional care of the children are at the heart of Rohrer’s study. The degree of family participation is reminiscent of, if not identical to, that of the American missionary hospitals in China. Rohrer alerts us to the sense of psychological isolation that characterises institutional settings, noting that frequent and often unpredictable hospital admissions and treatment side-effects including hair and limb loss undeniably contribute to the feeling of seclusion. Rohrer’s study provides a crucial departure for this volume in that she assesses not only how the expectations of family visitors in the realm of psychosocial support from hospital staff match up to reality, but also what it is that the child’s treatment team expects or requires from family visitors. Consequently, the families of young cancer patients are very much engaged in the formation of new communities. In considering the benefits and drawbacks in-patient family members have on the experience of cancer treatment for the child and his/her quality of life, Rohrer’s findings depict a sea change in the views of healthcare professionals that one hopes will bring lasting benefits to patients. Rohrer’s chapter provides an important counterpoint for much of the evidence presented in this volume and elsewhere on the long-standing resistance of medical staff to patient visitors. In addition to reiterating the encouragement of visiting at the Jenny Lind in its early years and the example of the American mission hospitals in China, we want to conclude 12

Hospital and Asylum Visiting in Historical Perspective this section with four more observations that complicate this issue, at least over the long run of history. The first is the importance of visiting to therapeutic regimes at asylums, as argued by Catharine Coleborne in her study of visitors in New South Wales, Victoria, Queensland and New Zealand in the nineteenth century. Coleborne’s analysis of a rich array of source materials makes the point that, in private at least, the asylum medical staff recognised the psychological benefits that patient visiting accrued. Even before admission, asylum authorities involved relatives and friends, requesting and compiling family histories and acquiring advice about incoming patients.15 Second, as Coleborne’s chapter also indicates, occasionally patients exercised their right not to be visited. This is probably less of an issue for children than for adults, and perhaps more relevant for mental than for physical illness. But whatever the circumstances, we should be sensitive to the possibility that for some patients, isolation, seclusion and solitude were what they themselves recognised as being appropriate for their stability and recovery above and beyond the ‘intense resentment against their families for having committed them to an asylum’.16 Third, this volume gives prominence to the important roles played by families and friends of patients during periods of institutionalisation. Nevertheless, Reinarz extends our understanding even further to include visitors to medical, nursing and ancillary staff, many of whom lived on hospital premises well into the twentieth century. Finally, we have been unable to say anything at all about the identity, motivations and views of relatives or friends who did not attempt or wish to visit the sick or infirm in hospital. Public visitors The visiting of medical institutions by members of the wider public is a long-standing tradition. One of the main purposes of allowing members of the public inside the walls of the institution was to court potential financial donors and we consider these in the section below on house visitors. But public visitors, in fact, played a remarkably diverse set of roles, from religious and moral rejuvenation of the patient, through the provision of entertainment, to institutional tourism, if not voyeurism. In the case of military hospitals, unfortunately not addressed in this volume, well-timed visits, often by celebrities, were certainly important historically in boosting morale during the least successful episodes of military campaigns.17 Traditionally, nineteenth-century asylums for the insane have been portrayed as institutions that existed on the social and physical margins of society. The characterisation of mental asylums as isolated and segregated from the local community has been dismantled gradually.18 Various chapters in this volume continue this process of revision. Somewhat ironically, by placing the experiences of asylums and other healthcare institutions side by 13

Graham Mooney and Jonathan Reinarz side, the former appear to have been comparatively open to interaction with those who did not have a direct interest in their operation. Sometimes the physical fabric of the institution was the focus of attention. In the late eighteenth century, for example, visitors came to peruse the paintings that adorned the walls at London’s Foundling Hospital, arguably England’s first art gallery.19 As with the first voluntary hospitals, the opening of a new hospital or asylum in subsequent decades remained cause for a mass invasion. Tens of thousands of people trooped through the new isolation hospitals in Oldham, Nottingham and Edinburgh for their openings in the 1870s, 1890s and 1900s respectively, though well before the patients themselves were admitted. Indeed, Graham Mooney notes that visiting restrictions meant that such an occasion might have been the only opportunity for the community to view the inside of the local isolation hospital, paid for by their own taxes. Hospital administrators, on the other hand, regarded such visits as ideal fundraising opportunities, some having even contemplated the introduction of admission charges.20 In any case, the opening of a new institution, ward or wing was an important event in the annals of a town or city, and many considered themselves fortunate to be granted a royal visit to commemorate the occasion. While the closely supervised nature of royal visits is evident, it is worth noting that practically all forms of visits were subject to a greater or lesser degree of stagemanagement by the hospital authorities. Celebratory openings emphasised the benefits that new configurations of bricks and mortar – or wood and corrugated iron – would bring to the patient. The grandeur of institutional buildings, as physical expressions of a donor’s largesse or the modernity of local government, continued to be a draw for visitors as tourists beyond the opening ceremonies. By and large, however, patients tended to be the primary focus of public visiting, as made famous by excursions into Bethlem in the eighteenth century. So, too, in Britain’s unreformed gaols, where the insane served as ‘sport to idle visitants’.21 In her chapter, Janet Miron similarly examines the lay visitors to psychiatric institutions in the north-eastern United States in the nineteenth century. While information about asylums could be had from the contemporary media, a tour in person was also possible. Visitors came from across the social spectrum and Miron draws upon the records left not only by the administrators and medical staff but by people who believed that asylums were a remarkable development in modern society.22 Dolly MacKinnon’s chapter equally demonstrates the permeability of the asylum’s walls. MacKinnon explores the varieties of official ‘entertainment’ for inmates in Australian and New Zealand asylums between c.1860 and c.1945. The range of entertainments on offer was impressive, from singing and dancing, through sports and indoor games, to the provision of 14

Hospital and Asylum Visiting in Historical Perspective newspapers, magazines, radio and films. Not uncommonly, participation resulted in the commingling of patients, staff and visitors as either spectators or participants. These activities were provided by paid professionals, volunteers and, in the case of live music, the asylum band. One interesting product of the interaction with public visitors is that over time their demands prompted the reconfiguration of institutional space. Wards, dining halls and airing yards gave way to purpose-built recreation halls and grounds, a testimony of bricks, mortar and open space to the importance of recreation. The introduction of silent films in the early twentieth century was followed by the installation of centralised radio sets in the 1930s. While these media required censoring, they nevertheless connected the patients to the outside world and counteracted the effects of institutionalisation. Yet it is equally plausible to observe that they reduced the necessity of arranging for visiting entertainers, even if the community continued to be involved with extravagant annual asylum balls, and cricket and football competitions. Recreation doubtless served a rehabilitative medical function and, as James H. Mills and Sanjeev Jain show, they were incorporated into psychiatrist Edward Mapother’s blue-print for Ceylon’s improved mental health system in the late 1930s. Institutions could also be places of religious and moral rehabilitation. This was no more evident than in London’s Lock Hospital. Salvation could not be achieved in the absence of contact with the outside world and visitation was crucial to the hospital’s unique dual medical and moral mission. Kevin Siena demonstrates how the hospital increasingly emphasised spiritual visitation, arranging for ministers to attend patients in the hope of reforming sinners who had caught the nefarious ‘Foul Disease’. Three broad points can be made in relation to these public visitors, be they tourists, entertainers or reformers of the soul. The first concerns the management of the institutional visit. Often resembling choreographed theatrical performances, the institutional visit has been theoretically unpacked by the sociologist Erving Goffman.23 The chapters in this volume tend to confirm Goffman’s observations that hospital and asylum governors historically had clear motives for trying to control, or stage-manage, the way in which their institutions were represented to the public. Given the potential financial implications of many visits, most staff and administrators engaged techniques that conveyed certain impressions to visitors. Loyal and disciplined members of an institution’s staff were employed to guide distinguished guests and sight-seeing parties. As a result, visitors frequently did not see entire institutions, but only new, clean or prized, state-of-the-art portions of buildings; occasionally, even patients’ families did not enter wards, but only purpose-built meeting rooms. Often staff had time to 15

Graham Mooney and Jonathan Reinarz prepare for visits, in which case they properly rehearsed their parts, members being schooled as to what to wear, how to curtsey and what to say.24 With repetition, even the worst-prepared staff developed their own acceptable visiting routine. Disruptions or ‘inopportune intrusions’ by the least respectable or ungrateful patients might weaken performances, if not the exaggerated claims of institutional staff. Whether due to an open door, as described in Siena’s chapter, or an unexpected visit, unmediated views of buildings and patients were discouraged at most institutions. Even today, the ‘intrusion’ of family members in the emergency room is a topic of popular debate.25 Our second point relates to issues of identity. The chapters in this volume provide indications of how the general public used visiting encounters to shape the identity of the institutionalised. Their impressions of patients were recorded in diaries, letters and newspaper reports, even if we must question how far such testimonies were conditioned by stage management. What is perhaps less obvious, and only rarely retrievable, is how visiting shaped the identity of the visitor as well as the patient. Janet Miron uses the patient newsletter from the Utica Asylum, The Opal, to gauge inmate reactions to visitors there. But what can be said of the public visitors themselves? Surely visiting an institution provoked self-reflection at some level? Did a tourist’s visit to an asylum serve to reaffirm his or her own normality? Perhaps it provoked a reaction along the lines of ‘there but for the grace of God go I’, blurring visitors’ notions of what it meant to be mentally stable? Similar questions of identity might be posed when the issue of ‘leave’ is raised. As described by Dolly MacKinnon, patients well on the way to recovery were granted leave from the asylum for periods of hours, a day or a weekend to attend dances and films in nearby local towns. Clearly these recreational outings further dissolved the barriers between the institution and the community. But, and this is our third point, they also turn the whole notion of visiting around. No longer is it the outsider coming in to the asylum, but it is the institutional insider negotiating the outside world. The patient becomes a visitor to the wider public, preparing for integration into a new or former community. House visitors In this section on house visitors and in the next, on official visitors, we consider the role of visiting in monitoring the management and operation of healthcare facilities. Though sharing certain traits, a crucial distinction needs to be made between two quite separate groups. Official visitors were independent of the institutions themselves, whereas house visitors tended to be associated closely with the hospital or asylum administration. 16

Hospital and Asylum Visiting in Historical Perspective From their establishment, medical institutions frequently deployed visiting as a promotional tool to generate charitable donations, and it was not uncommon for lay-visiting to become enmeshed with the administrative fabric of hospitals and asylums. As such, many of those who eventually became house visitors began their relationship with the hospital as a public visitor. Institutions paid a great deal of attention to securing this transition in status, no more so than with the London Lock Hospital where administrators were acutely sensitive about the visitors who crossed the carefully managed threshold of the institution’s doorway. Kevin Siena notes that hospital governors invested much time and energy drumming up financial support – an unenviable task given that many potential benefactors would need to be persuaded that paupers with syphilis were the most deserving cases for charitable donations. The hospital’s governors were placed in a delicate position: on the one hand, publicity for the hospital and its patients had to cast them in the best possible light in order to attract gifts; on the other, such portrayals risked exposure as less than accurate if visitors were allowed unfettered access to the wards. As we mentioned above, hospital administrators carefully stage-managed the circumstances under which possible donors visited the wards. Acting as administering governors, donors to the Lock Hospital could monitor how their money was being spent and regularly visited the wards to inspect the quality of care and provisions. Their reports also gave disgruntled patients the opportunity to register complaints and marked an important form of institutional selfpolicing. Both Andrea Tanner and Bruce Lindsay show that children’s hospitals restricted visits for families and friends of patients on the grounds of discipline and order, but, at the same time, encouraged open daytime visiting ‘of a better sort’ to come and see for themselves everyday life on the wards. Exploring the motives and actions of these so-called ‘disinterested’ visitors helps us to understand the complex web of interactions the hospital management and staff had with a benevolent public. Enhancing the image of the hospital in Victorian and Edwardian public opinion, they represented free publicity, spread the gospel of the institution’s ethos and attracted donations and additional support. While a form of house visiting tends to be recognisable in most hospitals and asylums, there were significant shades of difference between institutions. Jonathan Reinarz describes how donors and governors in the English Midlands would visit hospitals in their official capacity to monitor various aspects of institutional life and propriety, expenditure, and the compliance of patients and practitioners to house rules. Lady visitors were also a common presence in the wards of Birmingham’s women’s and children’s hospitals, as was the case at Great Ormond Street. 17

Graham Mooney and Jonathan Reinarz Sources of funding clearly shaped the role played by house visitors. This is perhaps best exemplified in the British case. One might expect that the transition to a hospital system funded by central taxation and management in 1948 eliminated the need for house visitors and threw the onus of responsibility for monitoring onto a salaried inspectorate, but the transition began earlier. From the early twentieth century, family membership in contributory schemes reduced hospitals’ reliance on charity.26 As with the Jenny Lind in the 1920s, the funding mix was further diversified as hospitals contracted with local councils for the treatment of patients. Such developments meant that while donations and endowments from individual or corporate supporters continued to be gratefully received, there was less need to court them explicitly. Hospital visits for public relations purposes, and the participation of donors in the administration of the hospital, consequently diminished. Official visitors Clearly then, many charitable hospitals performed a certain degree of selfmonitoring using the system of house visiting. But such internal surveillance was, by and large, exercised to uphold standards set by the institutions themselves. This is not to say that institutions were remorselessly insular. Indeed, institutional visiting can also be interpreted as a relatively underresearch topic in the history of knowledge acquisition and technological transfer. It was often the first step, an information gathering expedition, carried out by those managing change, whether at a hospital, asylum, or elsewhere.27 Compared to factories, whose managers traditionally viewed visitors with suspicion,28 staff at hospitals and asylums frequently welcomed guests and openly assisted them in their attainment of knowledge. Dorothea Dix, for example, travelled indefatigably across America and Europe in the 1840s and 1850s to visit asylums, prisons and poorhouses, collecting information on the conditions and treatment of the mentally ill and used this information to lobby for improvements.29 She was just one in a long line of visitors who toured institutions for the purposes of enlightenment and, ultimately, reform. Prior to the establishment of more modern avenues of instruction, and whenever it was permitted, visiting was a crucial way for individuals – whether medical staff, members of the public or foreign dignitaries – to acquire information about new or alternative treatments, as well as the general organisation of institutions.30 Today, visits by pharmaceutical sales representatives and equipment technicians are an important, not to mention ethically problematic, means of communicating new developments to medical professionals. Though their educative function declined in importance, institutional visits remained important to the instruction of healthcare professionals throughout our period. Edward 18

Hospital and Asylum Visiting in Historical Perspective Mapother sought to encourage this particular type of visit in order to raise the standards of medical staff at asylums in India and Ceylon, as suggested by James H. Mills and Sanjeev Jain. Though promoted enthusiastically in the eighteenth century, official visiting at medical institutions was initially undertaken haphazardly, as Leonard Smith’s and Jonathan Reinarz’s chapters both indicate. The emergence of for-profit madhouses in England in the first half of the eighteenth century was accompanied by concerns over malpractice. None other than Daniel Defoe suggested that visitation to and inspection of private madhouses would help curtail potential abuse.31 Public concern about the issue led eventually to state intervention and an Act of Parliament in 1774. Whether this law had any discernible effect is open to question, though as Smith notes, it served to highlight that the care of the insane was worthy of regulatory attention. Smith shows that while the idea of madhouse and asylum inspection had gained currency by the early nineteenth century, the methods of carrying it out were disputed. Staff from both public and private asylums rejected outside interference, while proprietors of private madhouses also invoked their privileges as property owners and business men. It was represented also that the patients themselves had an entitlement to privacy and anonymity. The oversight of publicly funded county lunatic asylums by magistrates was covered in Wynn’s Act of 1808, though visitation became an important part of lunacy reform following the findings of the Select Committee on Madhouses of 1814–15. Legislation in 1828 and 1845 finally established a system of inspection of public lunatic asylums, first in London and then nationwide. The Commissioners in Lunacy had a remit to visit, report on and regulate the care of lunatics in all forms of public and private institutions. The primary source of Graham Mooney’s chapter on infectious disease hospitals in England and Wales is a government inquiry made in the late 1870s and early 1880s, ostensibly carried out to gauge provision across a country that was developing services in a piecemeal way. This patchwork of isolation hospital provision was the result of permissive legislation through which local authorities exercised their autonomy. With a team of peripatetic inspectors, the medical department of the Local Government Board sought to monitor activities across a wide range of public health-related activities, of which isolation hospital provision was but one aspect.32 Although a central inspectorate of hospitals was never set up in Britain, by the first decades of the nineteenth century, official visitors to healthcare institutions appear to have been carrying out their work with greater vigour. While this may have been fuelled by an explosion in visiting culture more generally (see below), transparency was also encouraged by political ideals. An important unwritten chapter in the history of complaints, visits were undertaken more 19

Graham Mooney and Jonathan Reinarz regularly, eventually by trained professionals, and critical comments grew more extensive. Certainly this was evident in Mapother’s visits to South Asia immediately before Second World War. A professor of psychiatry at the Maudsley Hospital in London, Mapother was asked, in 1937, to make an assessment of the colony’s local mental hospitals. Despite his initial critical findings, Mapother was brought back by the Government of Ceylon in a formal capacity to report officially on the state of its asylums. In the end, Mapother’s investigations took in a tour of British India as well as Ceylon. The deficiencies exposed by Mapother in British India paled in significance when compared to Ceylon. Yet his report also exploded the myth that the provision of psychiatric facilities in the former was evidence of an enlightened British empire. Mapother’s visit to the mental hospitals of South Asia clearly depicts the dynamics of the official visiting process. While regarded as valuable administrative tools, providing insight to both governors and medical students, not all hospital administrators were eager to open their institutions to public scrutiny. Neither was each institution, in the eyes of investigators such as Mapother, worthy of a visit. Whether influenced by race, gender or class, this particular case additionally emphasises that, depending on context, some visitors have been more prepared to be critical than others. The wider context of visiting By the Victorian period it could be argued that a culture of visiting had begun to develop in bourgeois civil society.33 Prisons, workhouses, schools, and institutions devoted to healthcare were all focal points. As one early embodiment of this burgeoning culture, John Howard reputedly travelled upwards of fifty thousand miles throughout the 1770s and 1780s, interrogating authorities at prisons, hospitals, lazarettos, schools and workhouses in England and on the continent. Like many of the house visitors mentioned in this volume, his visits often involved reading rules and regulations, ‘measuring the rooms, weighing the loaves and nibbling the provisions’.34 Howard was by no means the first and only authority to call attention to the reform of prisons using surveillance. As early as 1701, the Society for the Propagation of Christian Knowledge sent a committee to visit Newgate, among other prisons. In Panopticon (1791), Bentham’s sketch for a penitentiary, both prisoner and guard were placed under the surveillance of an inspector situated at a central tower.35 As this suggests, inspection was to be democratic, members of the public being granted free entry to the elevated block. In this way, the prison’s design and the appointment of visitors promised to restore the legitimacy of a legal system that had been jeopardised by the severity of a previous penal code. These ideas were very quickly incorporated into the approach of Howard’s successors, not least, 20

Hospital and Asylum Visiting in Historical Perspective John Neild, the London merchant and philathropist, who duplicated the former’s census of prisons.36 Elizabeth Fry formed the Prison Discipline Society in 1817, shortly after leading an apprehensive committee of wives of Quaker businessmen through the women’s wards at Newgate. So popular were Fry’s Sunday services at Newgate chapel that there were frequently as many visitors watching from the galleries as there were prisoners in the pews.37 Official and quasi-official visiting proliferated in other realms of government. The English created a factory inspectorate in 1833 and poor law commissions in 1834; Louisa Twining commenced her tours of workhouses in the late 1850s, establishing her Workhouse Visiting Society and its associated journal shortly afterwards; and school inspection became commonplace in the late nineteenth century.38 Institutional visiting in all its guises was designed to limit custodial discretion – read abuse – and ensure the accountability of keepers, who, in both prisons and asylums, were often private contractors as well as public servants.39 Many of the chapters in this volume implicitly take up with themes connected to the role of institutions in shaping bourgeois public life, particularly philanthropy. Using the work of Jürgen Habermas on the public sphere as a framework,40 Steve Sturdy has summarised much historical scholarship on the relationship between philanthropy and voluntary medical institutions as follows: Involvement in the organisation and management of the new voluntary hospitals [in the eighteenth and nineteenth centuries] was based less on older forms of social identity than on the ability to contribute financially to the philanthropic enterprise. As a result, the hospitals provided a site where the aristocracy and gentry could combine with the emerging bourgeoisie in pursuit of a common social project, namely the relief and domestication of the poor… reconciling hitherto divergent social, political and religious interests within a single institutional endeavour.41

This ‘relief and domestication’ of the poor, it has been emphasised, was based on what might be termed ‘deep philanthropy’, in which the financial donation was predicated by a certain watchfulness on the donor’s part.42 Such scrutiny ensured the suitability of the deserving patient on the one hand, while offering personal involvement and gratification for the donor on the other.43 The foundation of this deep philanthropy came through committee participation, canvassing for donations, and house visitation.44 Yet the extent of such meaningful engagement has been exposed, in some places at least, as remarkably shallow. More often than not, all-male governing committee meetings were sparsely-attended. Management 21

Graham Mooney and Jonathan Reinarz decisions based on notably small quorum were characteristic of even the most famous of voluntary hospitals.45 In his study of the English Midlands, Jonathan Reinarz argues that the time between governors’ visits might occasionally be measured in years rather than weeks or months. When they did appear, comments recorded in surviving ledgers and visitors’ books were characterised by their cursory nature. Women were often excluded from a governing role and the decisionmaking process, and their participation as fund-raisers and visitors represents a marginalisation of their participation.46 As Sturdy notes, however, medical institutions served up a plurality of roles in the public sphere and it was arguably among women visitors that the reciprocity of deep philanthropy found its most concrete expression. In the case of Great Ormond Street Hospital, men and women tended not to visit at the same times, and the sexes played different roles in the monitoring and publicising of the charity. As with house visitors elsewhere, male visitors fulfilled a policing function. For middle-class women, institutional visiting became part of the London philanthropic social round. Women were far more visible in the frequency and length of their visits. They performed tasks for the patients – such as teaching prayers – that replicated domestic life, and they were by far the most successful conduit for financial donations and other forms of support. Great Ormond Street allowed women to experience and influence workingclass life without the unpleasantness associated with visiting the homes of the poor. In most cases, lady visitors were deemed to accelerate the transformation of hospitals into homes, organising musical events and educational programmes, among many other activities. Often these took on a moralistic and religious patina. Prohibited from other forms of public service, women threw themselves into their visiting roles, gradually extending their duties and authority. Frequently described as meddling busybodies, many staff rightfully feared that female efforts would only further expose the abuses in medical institutions.47 As Tanner indicates, though female visitors allegedly spent much of their time tormenting nursing staff and servants, the psychological benefits of their initiatives – as patient advocates, if not surrogate mothers – have yet to be fully explored by historians. The visiting practices of civil society might be appropriately considered part of the wider concept of governance. Under the rubric of governance, urban historians have sought to delve into the sites and practices of voluntary, professional and business activities that took place in the urban sphere, uncovering ‘patterns and processes which’, in the words of Robert Morris, ‘create and organise authority, provide access to resources, provide for the delivery of services, and generate and deliver policy’.48 Studies of governance thus aim to reach beyond the formal structures of ‘government’ 22

Hospital and Asylum Visiting in Historical Perspective in explaining the shape and form of historical life, or, as Morris again puts it, ‘the ordering of order’.49 In terms of modern liberal state power, a correlate to Morris’s ‘ordering of order’ would be the ‘conduct of conduct’, one strand of Michel Foucault’s work on governmentality.50 While studies of governance are not bound to the state as an analytic focus, certainly they are concerned with the ways in which various realms of urban power – governmental and non-governmental – interact, abrade or are mutually constitutive with it. Many of the contributions in this volume demonstrate that visiting was one procedural element associated with institutions through which the ordering of the urban community was realised and the conduct of citizens was regulated. Our broad panorama of visiting intersects with the ideas of governance at various junctures. Official and house visits strove to bring order, standardisation and accountability to institutional regimes, sometimes with the imprint of government, though often without. Public visits by tourists and entertainers could be highly regulated and stage-managed events, doubtless presenting, in many cases, the mere façade of ‘order’. To undertake a patient visit was to submit to a certain degree of behavioural conditioning, and it is striking that some hospitals took the opportunity to inculcate in visitors norms of conduct – in parenting and dietary habits, for example – intended to be taken beyond the walls of the institution and into public life. Whereas Foucauldian studies of medical power have emphasised isolation, exclusion and how institutions sought to return patients to their ‘normal’ role in the community, this book emphasises that visitors were subjected to such forces as well. A further point to be made about the conduct of visitors is its role in citizenship formation. Ensuring ‘appropriate’ behaviours in visitors, both within and without the institutional walls, was indicative of the way in which an individual’s duties and responsibilities were made clear.51 The requirement to fulfil the role of disciplined visitor was traded with expectations that hospitals and asylums would protect local communities – either from infection or the mad – and restore the health of patients. Interestingly enough, rarely before the mid-twentieth century was the ‘right’ of patients to receive visitors the subject of much discussion. In a fascinating ethnographic study of patients dying in hospital that was undertaken in the USA in the 1960s, David Sudnow makes it clear that in ‘public’ hospitals, patient visitors were excluded as much as possible from the usual hospital regime and made to feel far less welcome than they were in private hospitals.52 This contrasts markedly with the current climate. Equality groups at the state and national level in the USA point out that hospital visitation is an important and significant right that is denied same-sex couples who are unable to obtain a civil marriage licence.53 In 2004, the 23

Graham Mooney and Jonathan Reinarz Human Rights Campaign launched an online advertisement, ‘What if it was a gay world?’ to encourage signatories to its petition for marriage equality.54 With the advert depicting a distraught straight man being deprived access to his female partner in a coma, the Campaign chose hospital visiting as a bulwark issue to underline that heterosexual couples in the USA enjoy more than one thousand federal rights, benefits and obligations that same-sex couples do not. The Campaign advises gay, lesbian, bisexual and transgendered couples to complete a Hospital Visitation Authorisation document to instruct healthcare personnel on who should be allowed and given priority to visit should they be hospitalised. The power of this campaign was bolstered in North America when a recent episode of The L Word featured a storyline in which access was denied a cancer patient to her same-sex partner who was left stranded in a hospital corridor. Notably, the visitor endured a hostile reception both from the attending physician and the patient’s parents.55 Here, hospital visiting was being used to explore the very definition of ‘family’ in modern society. The examination of a host of additional contemporary issues related to visiting would benefit from a deeper engagement with historical perspectives. The openness that was characteristic of the final third of the twentieth century has been threatened by the need to protect child patients from abduction and a perturbing rise in hospital-acquired infections – namely methicillin-resistant Staphyloccus aureus (MRSA) and other ‘superbugs’.56 In the face of MRSA, Gill Morgan, the Chief Executive of the NHS Confederation (an organisation representing hospital trusts), said in 2005 that hospitals were experimenting with stricter visiting hours, so that patients could recover in peace and germs might be kept out of the hospital. Her comment that ‘Patients are tired and unwell, and ten family members sitting on the edge of the bed doesn’t seem a good idea’ certainly would not look out of place in a hospital report from the mid-nineteenth century.57 A pertinent link can be made here to the reception of animals in hospitals. The use of pets, dogs in particular, as therapeutic agents in healthcare settings did not garner serious interest from the medical profession until the 1970s.58 Since that date, however, pet therapy has gradually moved into the mainstream of primary healthcare.59 Charities in various countries organise networks of volunteer pets and their human companions.60 One perverse indication of the popularity of the practice is that, as potential carriers of MRSA, which might be transmittable to humans, pet therapy dogs are likely to be future subjects of infectious disease surveillance.61 Dolly MacKinnon reminds us that, historically, it was not uncommon for asylums to keep a selection of pets for inmates to care for. In relation to visiting, however, pets seem to have been prohibited entry to most hospitals in other circumstances. In January 1780, the committee of the 24

Hospital and Asylum Visiting in Historical Perspective General Hospital in Birmingham ordered that a board be hung near the front gates stating ‘no dogs will be admitted’.62 Visitors to North American hospitals in the later nineteenth century were known to flaunt such rules and bring them anyway.63 Given that animals now have a place in histories of scientific and medical research,64 and that there has been an explosion of historical and sociological interest in human–animal interactions,65 perhaps the moment has arrived for a serious historical study of pet therapy, if not the non-human animal aspects of health institutions altogether. Conclusion Taken together, the chapters in this volume concern themselves with all the types of visitor mentioned in this introduction and cut across many of the larger historiographic themes mentioned above. These multiple layers of subject matter and context presented us with an intriguing task of organisation. Broadly we have grouped the contributions by type of institution. Thus, general hospitals are first up, from the English Midlands by Jonathan Reinarz to late-Qing China by Michelle Renshaw. Specialist children’s hospitals form the next category, comprising chapters on Great Ormond Street by Andrea Tanner, on the Jenny Lind by Bruce Lindsay, and on Pittsburgh by Robin Rohrer. Graham Mooney’s chapter on isolation hospitals in Victorian Britain also deals predominantly with child patients, but, with a focus on infectious disease, it also provides a stepping stone to Kevin Siena’s chapter on the London Lock Hospital. In the remainder of the book, attention turns to mental institutions. Officially sanctioned inspectorial visits to asylums in markedly different contexts are the topic of Leonard Smith’s chapter on modern England, while James H. Mills and Sanjeev Jain take a trip with Edward Mapother to parts of Britain’s South Asian empire. Janet Miron considers aspects of public asylum tours in North America, before we wind up in the colonial setting of Australia and New Zealand with Dolly MacKinnon’s exploration of entertainment and Catharine Coleborne’s assessment of family visits in antipodean mental institutions. Notes 1. G. Browning, ‘How to...Visit a Hospital’, The Guardian Weekend, 2 April 2005 and online at http://www.guardian.co.uk/lifeandstyle/2005/apr/02/ weekend.guybrowning, accessed 12 January 2009. 2. C. Causley, ‘Ten Types of Hospital Visitor’, in C. Causley, Collected Poems (London: Macmillan, 1992), 232–7. 3. See Robin Rohrer’s chapter in this volume.

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Graham Mooney and Jonathan Reinarz 4. W.B. Howie, ‘The Administration of an Eighteenth-Century Provincial Hospital: The Royal Salop Infirmary, 1747–1830’, Medical History, 5, 1 (1961), 34–55: 44–5. 5. Indeed, the proliferation of inspection in the UK prompted the creation of a voluntary system called Concordat that strives to co-ordinate the myriad bodies responsible for the regulation, audit and/or review of healthcare institutions, http://www.concordat.org.uk/homepage.cfm, accessed 12 January 2009. 6. C.E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (Baltimore: Johns Hopkins University Press, 1987), 286–7; see also David N. Livingstone, Putting Science in its Place: Geographies of Scientific Knowledge (Chicago: University of Chicago Press, 2003), 66. 7. H. Hendrick, ‘Children’s Emotional Well-being and Mental Health in Early Post-Second World War Britain: The Case of Unrestricted Hospital Visiting’, in M. Gijswijt-Hofstra and H. Marland (eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 213–42. 8. J. Young, ‘Changing Attitudes Towards Families of Hospitalised Children from 1935–1975: A Case Study’, Journal of Advanced Nursing, 17 (1992), 1422–9. 9. P. Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 158; M.J. Vogel, The Invention of the Modern Hospital, Boston, 1870–1930 (Chicago: University of Chicago Press, 1980). 10. J.H. Woodward, To Do the Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London: Routledge and Kegan Paul, 1974), 123–42 and 251–66; S. Cherry, ‘The Hospitals and Population Growth, Part 1: The Voluntary General Hospitals, Mortality and Local Populations in the English Provinces in the Eighteenth and Nineteenth Centuries’, Population Studies, 34, 1 (1980), 59–76. 11. J. Young, ‘“A Necessary Nuisance”: Social Class and Parental Visiting Rights at Toronto’s Hospital for Sick Children 1930–1970’, in C.D. Naylor (ed.), Canadian Health Care and the State (Montreal: McGill-Queen’s University Press, 1992), 85–103. 12. D.P. Gagan and R.R. Gagan, For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890–1950 (Montreal: McGill-Queen’s University Press, 2002), 165. 13. One 2006 UK survey of ninety-seven NHS trusts revealed that forty per cent of patients had their hospital meals supplemented by food brought in by relatives and friends. J. Carvel, ‘Wide dissatisfaction with NHS hospital food’, The Guardian, 16 October 2006, http://www.guardian.co.uk/ society/2006/oct/16/hospitals.health, accessed 12 January 2009.

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Hospital and Asylum Visiting in Historical Perspective 14. J. Spence, ‘The Doctor, the Nurse and the Sick Child’, Canadian Nurse, 47 (1951), 13-16; Hendrick, op. cit. (note 7). 15. P.E. Prestwich, ‘Family Strategies and Medical Power: “Voluntary” Committal in a Parisian Asylum, 1876–1914’, Journal of Social History, 27 (1993–94), 799–818; D. Wright, ‘Getting Out of the Asylum: Understanding the Confinement of the Insane in the Nineteenth Century’, Social History of Medicine, 10 (1997), 137–55; J.E. Moran, Committed to the State Asylum: Insanity and Society in Nineteenth-Century Quebec and Ontario (Montreal: McGill-Queen’s University Press, 2000). 16. A. Digby, Madness, Morality, and Medicine: A Study of the York Retreat, 1796–1914 (Cambridge: Cambridge University Press, 1985), 194. 17. M.A. Crowther and M.W. Dupree, Medical Lives in the Age of Surgical Revolution (Cambridge: Cambridge University Press, 2007), 329. 18. R. Porter and D. Wright (eds), The Confinement of the Insane: International Perspectives, 1800–1965 (Cambridge: Cambridge University Press, 2003); P. Bartlett and D. Wright (eds), Outside the Walls of the Asylum: The History of Care in the Community, 1750–2000 (London: Athlone Press, 1999); M. Kelm, ‘Women, Families and the Provincial Hospital for the Insane, British Columbia, 1905–1915’, Journal of Family History, 19 (1994), 177–93. 19. R.K. McClure, Coram’s Children: The London Foundling Hospital in the Eighteenth Century (New Haven: Yale University Press, 1981), 66–72; A. Levene, ‘Left to the Mercy of the World’: Childcare, Health and Mortality at the London Foundling Hospital, 1741–1800 (Manchester: Manchester University Press, 2006), Ch. 7; See also the Foundling Hospital Museum website, http://www.foundlingmuseum.org.uk, accessed 12 January 2009. 20. Gagan and Gagan, op. cit. (note 12), 23. 21. J. Howard, The State of the Prisons in England and Wales (London: J.M. Dent & Sons, 1929), 6. 22. C. Vanja, ‘Madhouses, Children’s Wards, and Clinics: The Development of Insane Asylums in Germany’, in N. Finzsch and R. Jütte (eds), Institutions of Confinement: Hospitals, Asylums, and Prisons in Western Europe and North America, 1500–1950 (Cambridge: Cambridge University Press, 1996), 117–32. 23. E. Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (Chicago: Aldine, 1962). 24. E. Goffman, The Presentation of Self in Everyday Life (Woodstock: Overlook Press, 1973). 25. J. Groopman, ‘Being There: Should Patients’ Families See What Happens in the Emergency Room?’, The New Yorker, 3 April 2006, 34–9. 26. M. Gorsky, J. Mohan and T. Willis, Mutualism and Health Care: Hospital Contributory Schemes in Twentieth-Century Britain (Manchester: Manchester University Press, 2006); S. Cherry, ‘Beyond National Health Insurance: The

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27.

28. 29. 30.

31. 32. 33.

34.

35.

36. 37. 38. 39. 40. 41.

42.

43.

Voluntary Hospitals and Hospital Contributory Schemes, a Regional Study’, Social History of Medicine, 5 (1992), 455–82. One online resource devoted to these kinds of visits by psychiatrists to asylums in Europe can be found at European Journeys, http://www.europeanjourneys.org/home.htm, accessed 12 January 2009. J.R. Harris, Industrial Espionage and Technology Transfer: Britain and France in the Eighteenth Century (Aldershot: Ashgate, 1998). D.L. Gollaher, Voice for the Mad: The Life of Dorothea Dix (New York: Free Press, 1995). Digby, op. cit. (note 16), 256, mentions how the York Retreat ‘was considered the alma mater of moral treatment’ and was visited by Elizabeth Fry, J.J. Gurney and Robert Owen, among others. D. Defoe, Augusta Triumphans; Or, the Way to Make London the Most Flourishing City in the Universe (London: Roberts, 1728). C. Bellamy, Administering Central Local Relations, 1871–1919 (Manchester: Manchester University Press, 1988). R.J. Morris, ‘A Year in the Life of the British Bourgeoisie’, in R. Colls and R. Rodger (eds), Cities of Ideas: Civil Society and Urban Governance in Britain 1800–2000 (Aldershot: Ashgate, 2004), 121–43: 129. R. Porter, ‘Howard’s Beginnings: Prisons, Disease, Hygiene’, in R. Creese, W.F. Bynum and J. Bearn (eds), The Health of Prisoners: Historical Essays (Amsterdam: Rodopi, 1995), 5–26: 7. M. Foucault, Discipline and Punish: The Birth of the Prison (London: Allen Lane, 1977); M. Ignatieff, A Just Measure of Pain: The Penitentiary in the Industrial Revolution, 1750–1850 (New York: Pantheon Books, 1978). J. Neild, State of the Prisons in England, Scotland and Wales (London: John Nichols & Son, 1812). Ignatieff, op. cit. (note 35), 144; J. Kent, Elizabeth Fry (London: B.T. Batsford Ltd, 1962), 56–80. T.R. Bone, School Inspection in Scotland, 1840–1966 (London: University of London Press, 1968). Ignatieff, op. cit. (note 35), 77. J. Habermas, The Structural Transformation of the Public Sphere: An Inquiry into a Category of Bourgeois Society (Cambridge: MIT Press, 1989). S. Sturdy, ‘Introduction: Medicine, Health and the Public Sphere’, in S. Sturdy (ed.), Medicine, Health and the Public Sphere in Britain, 1600–2000 (London: Routledge, 2002), 1–24: 9. S. Sturdy and R. Cooter, ‘Science, Scientific Management, and the Transformation of Medicine in Britain, c.1870–1950’, History of Science, 36 (1998), 421–66. R. Porter, ‘The Gift Relation: Philanthropy and Provincial Hospitals in Eighteenth-Century England’, in L.P. Granshaw and R. Porter (eds), The

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44. 45. 46. 47. 48.

49. 50.

51.

52.

53.

54.

Hospital in History (London: Routledge, 1989), 149–78; H. Marland, Medicine and Society in Wakefield and Huddersfield, 1780–1870 (Cambridge: Cambridge University Press, 1987); A. Borsay, Medicine and Charity in Georgian Bath: A Social History of the General Infirmary, c.1739–1830 (Aldershot: Ashgate, 1999). A. Borsay, ‘“Persons of Honour and Reputation”: The Voluntary Hospital in an Age of Corruption’, Medical History, 35 (1991), 281–94. K. Waddington, Charity and the London Hospitals, 1850–1898 (Rochester: Boydell Press, 2000), 137–9. Marland, op. cit. (note 43). F.K. Prochaska, Women and Philanthropy in Nineteenth-Century England (Oxford: Clarendon Press, 1980). R.J. Morris, ‘Governance: Two Centuries of Urban Growth’, in R.J. Morris and R.H. Trainor (eds), Urban Governance: Britain and Beyond since 1750 (Aldershot: Ashgate, 2000), 1–14: 1. Ibid. M. Foucault, ‘Governmentality’ and ‘The Subject and Power’, in J.D. Faubion (ed.), Michel Foucault: Power (New York: The New Press, 1994), 201–22 and 326–48; M. Dean, Critical and Effective Histories: Foucault’s Methods and Historical Sociology (London: Routledge, 1994), Ch. 9. See also L. Murdoch, Imagined Orphans: Poor Families, Child Welfare, and Contested Citizenship in London (New Brunswick: Rutgers University Press, 2006), Ch. 4. D. Sudnow, Passing On: The Social Organization of Dying (New Jersey: Prentice-Hall, 1967). The two subjects of Sudnow’s study were a large, urban west coast charity (that is, ‘public’) hospital and a mid-west private, general hospital. Misrepresentative though these might possibly have been, the reader today is struck by how patient treatment and care in the former are portrayed as being indicative of the potential perils of a wider socialised medicine in the USA. Human Rights Campaign, Opening the Door to Equal Protection Under the Law for America’s Same Sex Couples and their Families (Washington: Human Rights Campaign, 2003); Equality Maryland, The Issues: Marriage Equality, http://www.equalitymaryland.org/issues/marriage/marriagerecog.htm, accessed 12 January 2009. Human Rights Campaign, What if it was a Gay World? http://www.youtube.com/watch?v=pzx66q9kO1Y, accessed 12 January 2009. In his acceptance of the Democratic nomination for President on 28 August 2008, Barack Obama promised to grant equality of hospital visiting rights to partners of gay and lesbian patients. See http://www.youtube.com/ watch?v=kv8eiDvrHJ4&, reference at 34 minutes 56 seconds, accessed 12 January 2009.

29

Graham Mooney and Jonathan Reinarz 55. The L Word, ‘Lifesize’, season 3, episode 6, 12 February 2006, http://www.imdb.com/title/tt0623871/, accessed 12 January 2009. 56. G.A.J. Ayliffe and M.P. English, Hospital Infection: From Miasmas to MRSA (Cambridge: Cambridge University Press, 2003). 57. G. Hinsliff, ‘MRSA Checks Before Patients go in’, The Observer, 12 June 2005, http://www.guardian.co.uk/society/2005/jun/12/uknews, accessed 12 January 2009. 58. S.D. Hooker, L.H. Freeman and P. Stewart, ‘Pet Therapy Research: A Historical Review’, Holistic Nursing Practice, 16 (2002), 17–23. 59. A. Shanahan, ‘What’s up, Dog?’, The Guardian, 9 August 2005, 8–9; L.M. Behm, Human–Animal Bond, Animal Therapy, and Service Animals (Chicago: Medical Library Association, 2004). 60. V.V. Harris, Velma’s Pets as Therapy, http://www.velmaspetsastherapy.com.au, accessed 12 January 2009; Pets as Therapy, Pets as Therapy, http://www.petsastherapy.org/, accessed 12 January 2009 61. D.A. Enoch et al., ‘MRSA Carriage in a Pet Therapy Dog’, The Journal of Hospital Infection, 60 (2005), 186–8. 62. J. Reinarz, The Birth of a Provincial Hospital: The Early Years of the General Hospital, Birmingham, 1765–1790 (Stratford: Shakespeare Birthplace Trust, 2003). 63. Rosenberg, op. cit. (note 6), 286–7. 64. K.A. Rader, Making Mice: Standardizing Animals for American Biomedical Research, 1900–1955 (Princeton: Princeton University Press, 2004); D.P. Todes, Pavlov’s Physiology Factory: Experiment, Interpretation, Laboratory Enterprise (Baltimore: The Johns Hopkins University Press, 2001). 65. B.M. Levinson, ‘Pets: A Special Technique in Child Psychotherapy’, Mental Hygiene, 48 (1964), 243–8; B.M. Levinson, Pet-Oriented Child Psychotherapy (Springfield: Charles C. Thomas, 1969); S.A. Corson, E.O. Corson and P.H. Gwynne, ‘Pet-Facilitated Psychotherapy’, in R.S. Anderson (ed.), Pet Animals and Society: A B.S.A.V.A. Symposium Held at the Zoological Society of London, Regents Park, London, 30th and 31st January 1974 (London: Baillière Tindall, 1975), 19–36; J.A. Serpell, In the Company of Animals: A Study of Human–Animal Relationships (Cambridge University Press: Cambridge, 1996); A. Franklin, Animals and Modern Culture: A Sociology of HumanAnimal Relations in Modernity (London: Sage, 1999); International Society for Anthrozoology, ISAZ Newsletter, http://www.isaz.net/newsletter.html, accessed 12 January 2009.

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2 Receiving the Rich, Rejecting the Poor: Towards a History of Hospital Visiting in Nineteenth-Century Provincial England

Jonathan Reinarz The changing perceptions of visitors to hospitals in provincial England during the long nineteenth century are examined in this chapter. In particular, it discusses the experience of visitors to hospitals in nine general and specialist hospitals in Birmingham, England's 'second city'. Though the history of visitors in this provincial setting supports the general assumption that hospital governors received the rich and rejected the poor, this chapter demonstrates that attitudes to visitors were not always straightforward. Views of hospital governors and medical staff varied with medical specialism, hospital finances, and a host of other factors.

The history of hospital visiting has been a strangely neglected theme in the history of medicine. Though rarely appearing in hospital histories, visitors were regularly admitted to the first voluntary medical institutions in England. Most medical charities appointed subscribers and members of governing bodies to inspect facilities and to inquire into the treatment of patients. Regarded as some of the grandest and innovative of public institutions when they began to appear in the eighteenth century, voluntary hospitals in England also regularly attracted numerous national and international visitors, who subsequently publicised the novel features they encountered on their tours. Patients’ families also entered the wards, often bringing with them food, drink and a change of bed linen. Nevertheless, while celebrity visits were enthusiastically welcomed, poorer guests were variously regarded as agents of infection and disorder, many bringing with them less welcome items, such as dirt and germs. Consequently, visits from patients’ friends and families were gradually restricted over the nineteenth century, or such is the generally accepted historical trend. This chapter seeks to examine changing perceptions of visitors to hospitals, as well as changes in patterns of hospital visiting in provincial 31

Jonathan Reinarz England during the long nineteenth century. In particular, it will discuss the experience of visitors to hospitals in eight general and specialist hospitals in Birmingham, England’s ‘Second City’. These include the General (1779) and the Queen’s (1841), Birmingham’s two main general hospitals, as well as the town’s main nineteenth-century specialist institutions: the Royal Orthopaedic Hospital (1817) [hereafter Orthopeadic Hospital]; the Birmingham and Midland Eye Hospital (1823) [hereafter Eye Hospital]; the Birmingham and Midland Ear, Nose and Throat Hospital (1844) [hereafter Ear Hospital]; the Birmingham Children’s Hospital (1861) [hereafter Children’s Hospital]; the Birmingham and Midland Hospital for Women (1871) [hereafter Women’s Hospital]; and the Birmingham and Midland Hospital for Skin and Urinary Diseases (1881) [hereafter Skin Hospital]. Though the history of visitors in this provincial setting can be seen to follow the relatively neat trend outlined above and in various hospital histories, it seeks to demonstrate that attitudes to visitors were not as straightforward as might be expected. The views of hospital governors and medical staff in Birmingham during this period varied with medical specialism, hospital finances, as well as a host of other factors. Though this chapter will consider hospital visiting in the widest sense, to an eighteenth or nineteenth-century public, ‘visitors’ as referred to in hospital minute books, rules and annual reports denoted a particular individual selected from among an institution’s subscribers whose job it was to investigate the management of the medical charity. As such, it is with the official ‘hospital’ or ‘house visitor’ that this investigation will commence. It will then broaden its perspective to include a number of other, less official visitors, including the friends and family of inpatients, guests of resident medical staff, as well as members of the general public, both ordinary and extraordinary, who occasionally toured medical institutions in these years. A final section will briefly discuss the way in which the various visiting practices addressed in the early sections of this chapter evolved in the first decades of the twentieth century. Enforcing rules and overseeing expenditure: The appointment of house visitors Drawn from a hospital’s subscribers, the ‘house visitor’ was one of the original officers appointed at all English voluntary hospitals in the eighteenth and nineteenth centuries. Usually living locally, and therefore able regularly to visit the institution, the house visitor essentially ensured charitable funds were carefully spent and the hospital managed efficiently. Visitors’ functions in these years were all the more necessary given that surgeons and physicians at voluntary hospitals usually attended the sick wards only once or twice a week, generally leaving the daily running of an 32

Receiving the Rich, Rejecting the Poor average institution to an apothecary and matron. Besides transforming medical institutions following brief inspections, many people in towns and cities throughout England, while fulfilling the duties of this particular charitable office, simultaneously transformed their economic capital into social and cultural capital, taking on ever more important posts in local charities, if not political posts, local as well as national.1 Often possessing little medical knowledge, most house visitors applied their skills of business administration, or simply their familiarity with managing a large household and its serving staff, to the administration of England’s first hospitals. Unusually, despite comprising approximately ten per cent of subscribers over the next half century,2 not a single woman was officially appointed to inspect Birmingham’s very domestic-looking General Hospital in its first decades. The first men to inspect the institution were William Russell and Francis Parrott, who were appointed house visitors for a week at the town’s new General Hospital on 2 October 1779.3 Expected to visit the institution twice during its first week of operation, the surgeon and gilt-toy maker were accompanied by the matron or apothecary on an initial visit, guiding them through the institution’s four floors and various departments. At many provincial hospitals a white wand was prepared for such officers in order to denote them as official hospital visitors, though many holders of this post would have been recognised by staff and patients as important local men of status.4 Visitors to the General Hospital in its first years tested the quality of the bread and beer, commented on the building’s overall suitability as a hospital, ensuring primarily good drainage and ventilation, while also inquiring into patients’ experiences of hospitalisation. This final task was usually undertaken on the wards in the absence of medical staff, who, according to hospital rules, were to withdraw while house visitors carried out their inquiries.5 Patients, on the other hand, were expected to stand alongside their beds ready to answer any questions that the visitors put to them.6 Occasionally ward visits involved registering complaints, or ensuring orderly behaviour among patients, often by securing religious texts for the general or venereal wards. Following their tours, house visitors’ observations and suggestions were recorded in a special ledger, usually kept locked away, until presented at hospital committee meetings. While such meetings undoubtedly covered every aspect of hospital administration, in general, entries in minute books list little more than attendance at meetings, the clergyman selected to read prayers, numbers of patients admitted and discharged and, of course, each week’s newly appointed house visitors. While the General Hospital appears to have been administered efficiently in its first years, one gets the sense this had very little to do with the hospital’s house visitors, despite the efforts of some very dedicated and capable officers. For example, in the hospital’s seventh year (1786), its 33

Jonathan Reinarz committee determined that the apothecary keep a list of all those visitors who had not attended since the institution’s anniversary.7 A decade later, it was also resolved that Law No. XXVII of the hospital’s rules and regulations be sent to all house visitors in order to ensure that each officer understood his responsibilities.8 Despite their occasional foresight, committee members on many other occasions forgot to appoint weekly visitors and subsequent reports appear to have concerned primarily educating the visitors of their functions, if not obtaining additional Bibles for the wards. By the early nineteenth century, when a string of other voluntary hospitals emerged, house visitors at all voluntary hospitals appear to have understood their roles more clearly and regularly undertook their duties more confidently. While reports grew as suggestions multiplied, most house visitors still concerned themselves primarily with the management of their particular hospital. In general, this involved weighing the quartern loaves supplied by local bakers and assessing the quality of meat delivered by a number of local butchers. Besides being expected to be good judges of quality, most visitors also possessed some familiarity with markets and advised staff on the best times to purchase supplies, ideally before prices began to advance. Having frequently possessed the latest modern conveniences in their own homes, they were particularly knowledgeable when it came to assessing the state of hospital plumbing or simply instructing staff on the correct way to fill a bath.9 At times, the first house visitors also appear to have concerned themselves with the treatment of patients, occasionally offering very useful suggestions, not always grounded in medical evidence. In August 1823, for example, house visitors at the General Hospital reported that two patients, a man and a boy, were found in a single bed, a situation the apothecary was asked to rectify and in future prevent on moral grounds.10 On other occasions, visitors reported on the damp state of staff bedrooms,11 or advised the porter against washing three or even four patients in the same bath water.12 In general, visitors’ concerns appear to have translated into a preoccupation with cleanliness, if not that of a single patient, then a section of the building or even the neighbourhood in which the hospital was situated. As such, it was house visitors who frequently recommended the implementation of appropriate sanitary measures after detecting bad smells arising from hospital water-closets and piggeries. So too did they oppose the proliferation of steam engines and rubbish heaps among the hospital’s industrial neighbours.13 It is in their report books, not surprisingly, that concerns with miasma or disease-causing smells survived longest at all hospitals. As a result, they also appear to have meddled in hospital affairs in ways that promised to hinder progress. For example, on one such occasion in 1824, upon discovering that the General Hospital’s iron bedsteads were 34

Receiving the Rich, Rejecting the Poor coming apart and destroying the plaster walls, house visitors suggested a return to wooden beds, which were regarded as superior and cheaper.14 Above all, however, house visitors aimed to safeguard the hospital’s finances. If this did not include weighing all products entering the building, it involved regulating their consumption. This extended to monitoring the economical use of surgical lint and the correct usage of hospital equipment in order to prevent costly instruments from being damaged. An abhorrence of waste equally led them in 1833 to determine who threw bread into the hospital’s hog tub and subsequently admonish the nurses.15 More importantly, it regularly involved interviewing each patient and determining whether they were appropriate candidates or ‘deserving’ recipients of charity.16 Inappropriate cases at the General Hospital included Richard Fenn, who when presented to the house visitors on 5 September 1823 was regarded ‘an idiot’ and discharged the same day.17 Others included a female patient admitted with ulcers on the legs and delivered of a female child following a week in hospital. On this occasion, the patient was to be removed to the poorhouse as soon as possible and the subscriber who issued her ticket was encouraged in future to ascertain the fitness of charitable objects before facilitating their admission to hospital.18 Other patients, such as John Jones, though deserving cases, were discharged for committing various offences, such as using bad language.19 Should patients have satisfied house visitors’ detailed inquiries into their backgrounds, their progress in subsequent weeks was scrutinised as carefully in order that beds should not be occupied longer than necessary. While this policy was introduced at all institutions, it was exercised less rigorously at specialist hospitals where patients paid a fee towards their treatment, as well as at the Queen’s Hospital, which benefited most from workplace collections, which were undertaken systematically in Birmingham from the early 1870s.20 At times, visitors appear to have been entirely pre-occupied with the behaviour of patients, leading them quite literally to construct the moral universe of the hospital. In 1831, house visitors reported a political sermon containing injurious and blasphemous doctrine. In future, it was determined no political sermons of any description were to be read on the hospital’s wards and only those pamphlets approved by the chaplain were distributed to patients.21 Weeks later the importance of religious instruction was only confirmed when house visitors found patients gambling in the hospital’s smokehole.22 Similar concerns led visitors to draw attention to an increase in the number of venereal patients in the hospital.23 In 1834, a visitor even questioned whether venereal patients should not be placed in a separate ward ‘as one depraved female is sufficient to influence detrimentally the morals of the patients in the same ward.’24 As one might expect, these concerns were equally common at the Skin Hospital, especially during years when venereal, 35

Jonathan Reinarz as opposed to dermatological, cases comprised a greater percentage of the inmates. For this very reason, in the 1890s, when clergymen were disappearing from the corridors of other local medical institutions, they were making weekly visits to the Skin Hospital’s in-patients.25 So, too, were ladies and gentlemen visiting the patients in order to lend, if not read them, books.26 Given their pre-occupation with patients’ morals, it is easy to forget that house visitors were also early patient advocates; most of them carefully investigated any complaints made by patients during their periods of hospitalisation. Should they have uncovered any supporting evidence, house visitors readily reprimanded staff for neglecting patients, as when those at the General Hospital discovered that John Allen had been visited only once by a surgeon despite being confined to his hospital bed for more than eight weeks with erysipelas, a bacterial skin infection, of the left foot.27 At other times, staff were reprimanded for speaking to patients with disrespect, or even abusing defenceless victims. Even in those cases where no abuse had been perpetrated, house visitors were often the only people who attended the funerals of those dying in hospital, should this have occurred during their period of duty.28 Though not always possessing expert medical knowledge, official hospital visitors were influential and their comments not surprisingly often caused offence to both hospital patients and practitioners. Conflict with medical staff only escalated as the medical profession increased in status through the first decades of the nineteenth century. This is perhaps best demonstrated by an incident recorded in the minute book of the General Hospital in 1841. Following a meeting on 18 June 1841, the board ordered that leaves written on were not to be removed from the minute book, ‘persons having too quickly taken offence to comments of visitors who suggested mismanagement’.29 Rather than bring about the end of hospital visitors, their duties were taken over by house committees, comprising both lay and medical men, who were expected to visit the wards before each weekly meeting.30 In some cases, however, house committees reported that members needed a much more intimate knowledge of the hospital in order to perform functions adequately. As a result, some hospital boards recommended reviving the custom of two of their number being appointed as house visitors each fortnight to report on the workings of the institution. On such an occasion in 1875 at the Queen’s Hospital, as so commonly noted in the past, Reverend Halsted and Mr A.N. Hopkins reported views ‘most unfavourable with regard to the cleanliness of the Hospital’.31 They found the wards, corridors, ‘in short, all parts of the Hospital extremely dirty, the floors insufficiently scrubbed and the windows filthy.’32 The lady superintendent was in no way to blame, but she was now given direct control 36

Receiving the Rich, Rejecting the Poor over each ward cleaners’ appointment, dismissal and general superintendence. By the late nineteenth century, however, many hospitals were beginning to report financial difficulties and facilities at even the bestrun institutions were rarely described as up-to-date and admired by visitors. Visitors to the Children’s Hospital in 1907, for example, regarded the institution as out of date, reporting that a ‘feeling of depression came upon one in going over it’.33 In such cases, reconstruction was required, in which case a different form of hospital visit was undertaken. Educational visits: hospitals as sites of knowledge transfer During these years, many individuals visited English hospitals to view their technological and architectural features, or, occasionally, their patients. Like factories, hospitals incorporated many of the newest innovations of the industrial age and were therefore often included in the grand tours of visiting foreign dignitaries. One of the first general hospitals to utilise hollow pot and iron-frame technology, the Derby Infirmary was visited by, among others, Grand Duke Nicholas (1796–1855), later Nicholas I, who, in 1816, was conducted through the entire building, even before visiting any of the town’s other sites and landmarks.34 Before touring the institution in Derby, the Duke had made a similar expedition in Birmingham, where he visited the town’s General Hospital, donating £100 at the conclusion of his rounds.35 Many other individuals, from intellectuals to industrialists, made similar excursions to the country’s medical institutions. Though not always presenting such generous donations in exchange for their acquired knowledge, the appearance of an unusual personality, if not an unusually large donation, in a hospital subscription list is usually associated with such an institutional visit. Due to the permeability of hospital walls, the question of innovation at such institutions also appears very different from that occurring in the British industrial sector at this time. From their first appearance, the flow of information between these medical institutions, regardless of region, was particularly fluid. This specific characteristic contrasts greatly with models advanced by economic historians, who suggest that the details of innovation at British firms, for example, were typically kept secret before 1914.36 Despite often competing for patients, prestige and funding,37 hospitals throughout the United Kingdom, as revealed in the pages of ledgers and minute books, also regularly and freely shared technological and organisational information with one another. In general, Victorian charities do not appear to have viewed themselves as competing businesses.38 Secrecy in medicine after all ‘smacked’ of quackery.39 For example, when discussing the most suitable bed for patients during the construction of Birmingham’s original General Hospital, its committee corresponded with and visited a 37

Jonathan Reinarz number of Midland hospitals, including institutions at Worcester, Stafford and Leicester.40 Only after undertaking very thorough investigations did most hospital managerial boards attempt to implement new methods or techniques. Similar inquiries were made of hospitals from London to Aberdeen in order to determine diets, rates of pay, the organisation of laundry and kitchen facilities, as well as the ideal space between patients’ beds, similar tales being recounted in almost every hospital history.41 Often such visits and inquiries stimulated further unintended technological transformations, as when staff at the Queen’s Hospital organised an outing to the general hospital in Nottingham in order to inspect the institution’s disinfecting oven, only to discover a superior wringing machine in its laundry.42 As one might expect, this free flow of ideas led to considerable uniformity in the way hospitals developed in England, a fact not always commented upon by hospital historians. Nowhere is this more evident than in the printed rules used to govern these institutions, which defined, among other things, the duties of house visitors and hospital visiting hours. The pattern repeated itself throughout the nineteenth century with the establishment of specialist institutions, whether children’s, eye or skin hospitals. Those in Birmingham, for example, based much of their organisation on a local dispensary, and on the General Hospital once they commenced admitting inpatients.43 Soon afterwards, governors looked to leaders in their particular area of specialism for guidance, staff at the Eye Hospital, for example, modelling their institution on the Royal London Opthalmic Hospital at Moorfields.44 The Children’s Hospital, on the other hand, very clearly looked to London’s Hospital for Sick Children at Great Ormond Street when instituting change.45 Often this process of research substantially slowed reconstruction, as when the governors of the Queen’s Hospital visited the General, as well as the ‘beautiful new West Bromwich hospital’, before beginning work on their new outpatient department.46 Unlike firms where members of staff or apprentices were often encouraged to sign contracts certifying that they would not disclose what they saw or learned during their periods of service, hospital walls were particularly pervious barriers.47 Evidence of innovation at British hospitals appears not only in their annual reports and minute books, but often in local newspapers and medical periodicals. Given the transparency of this particular sector of society, historians might even justifiably question whether the individual firm is the most appropriate context for the study of innovation.48 A necessary evil: friends and families visiting patients While royal visits were always welcomed at all voluntary hospitals, other types of visitors were particularly discouraged. This included visitors to patients, especially those arriving unannounced. As a result, in 1833, staff at 38

Receiving the Rich, Rejecting the Poor the General recommended a wire lattice be placed before the lower windows in the building ‘that communication from without may be prevented’.49 Though permitted to visit patients, guests were restricted to two per inmate on Tuesday and Friday between 2pm and 4pm, while those residing a considerable distance from the institution were also tolerated on Sundays and Thursdays. Though medical staff in the 1850s regularly spoke of the great inconvenience caused by visitors attending four days a week, the matron encouraged such visits as they usually brought clean linen. At some of the less well-supported voluntary hospitals, patients’ friends were even permitted to stay the night, as it dispensed with the expense of hiring night nurses.50 They also introduced many other goods into the hospital, such as tea, sugar and butter. However, they also brought many prohibited items, such as liquor. As a result, porters at some hospitals were instructed to be vigilant, limiting visitors to two, recording all guests’ names and addresses, and searching, if not retaining, all baskets during visiting hours.51 Nevertheless, many banned articles made their way into hospitals, often with the connivance of the gate porter, who, as at the General Hospital in the 1830s, was reprimanded and repeatedly admonished for the dereliction of his duties.52 Night nurses were regarded as similarly weak gate keepers.53 Regulations governing patients’ visitors were much the same at the specialist institutions. At the Eye Hospital for example, in the first half of the nineteenth century, friends of patients could visit Wednesday and Friday between 3pm and 5pm.54 Interestingly, operations were performed at 11am, when visitors were absent. On visiting days at the Children’s Hospital during its first decade of existence, the matron ensured all guests brought a change of linen.55 Nevertheless, here too they brought many banned items, described by medical officers as ‘an evil which increases every visiting day’, staff being requested in 1870 to prevent visitors from bringing cakes, apples and other ‘indigestible’ food to the children.56 As a result, a line of defence was organised, commencing with the housemaid, who stood at the entrance door and ‘question[ed] and examine[ed] every one as they enter[ed]’. Nurses were to be present in each ward, ‘and the beds [were] searched when… friends le[ft].’57 Despite these efforts, children still obtained food and were said to be the worse for it several hours later, although this was also attributed to the excitement of seeing family and friends. Perhaps surprisingly, staff at the Children’s Hospital were generally more tolerant of visitors given the age of patients. Besides being admitted on fixed visiting days, guests were permitted to attend when inmates’ wounds were dressed, and, occasionally, mothers were permitted to reside in the hospital with their children, though sometimes charged as paying patients.58 By the 1880s, however, work on disease causation revealed that infection could be introduced by guests from 39

Jonathan Reinarz outside hospital walls, leading governors once again to revise their policy regarding visitors. Control over visiting became more vigilant in the last two decades of the nineteenth century. Visitors to the Queen’s Hospital now entered through the outpatient waiting hall, not a separate gate as previously. To avoid unlawful communication with patients, a slag wall was built at the rear of the detached wards, and proper passes were designed for guests.59 In contrast to earlier years, food was no longer the prime threat. In fact, patients unable to eat hospital food were permitted delicacies sent by friends with permission of staff.60 At the Children’s Hospital one visiting day was abolished entirely to prevent diseases from being introduced to the hospital, while at other institutions, guests were not to enter children’s departments during epidemics.61 Reducing visitors was also seen as a way to reduce noise and expenses associated with cleaning institutions, much dirt having accompanied guests at the Children’s Hospital. Only at the Eye Hospital did the financial benefits of visiting days clearly outweigh any perceived threats, collection plates having been placed in day rooms on such occasions.62 This approach was also eventually adopted by the governors of the Women’s Hospital, who, in 1905, opened their new building to visitors each afternoon from 2pm to 5pm,63 a decision which also appears to have converted a number of those most critical of the hospital’s redevelopment.64 As this suggests, while a good way to improve hospital finances, in some provincial towns hospital visits proved an important way to overcome a community’s initial suspicions of medical institutions and maintain public confidence.65 Regulating the residents: visitors to hospital staff Hospital governors’ concerns were not limited to patients’ visitors, given that many members of staff, including junior surgeons, students, nurses and porters, lived within English hospital premises up until the introduction of the National Health Service (NHS) in 1948. Their primary concern, as one might expect, were ‘vulnerable’ groups, such as nurses and the youngest members of staff. At the General Hospital it was the duty of the gate porter to ensure that nurses received visitors on visiting days and during visiting hours only. Occasionally, rules were violated, as when the Secretary reported in April 1841 that a visitor to Nurse 12 had been detected ‘scaling the boundary wall’ after she had been admonished ‘on the impropriety of her keeping her visitors so late’.66 Soon after, the top of the wall was covered with glass and mortar. As one would expect, despite such extreme measures, visiting rules would continue to be violated during the next decade and surely helped 40

Receiving the Rich, Rejecting the Poor convince governors of the need to recruit nurses of a higher social status in the second half of the nineteenth century. One of the repercussions of recruiting ‘ladies’ into nursing was the expense of providing them with better accommodation. No longer expecting nurses to sleep in or adjacent to the wards, governors further demonstrated a need to better protect the decency of their new recruits. As a result, when nurses’ homes were built alongside hospitals in the 1860s, no male visitors were permitted to enter this exclusively female space. Resident medical officers themselves only ever entered nurses homes in case of illness and when accompanied by the lady superintendent.67 When organising evening entertainments and dances, senior staff equally scrutinised all visitors to the nurses, no ‘strangers’ having been admitted to functions organised at the Queen’s Hospital in the 1870s.68 Given the control exercised over female members of staff, one might question whether historians are omitting an important element in their focus on the inmate alone when considering the total institution.69 Governors were equally anxious when it came to medical apprentices and students, given their age and, not least, their portrayal as drunk and disorderly youths during an age of medical professionalisation.70 Unlike in an age of apprenticeship, responsibility for a hospital pupil’s conduct in the nineteenth century was no longer in the hands of a single master, or medical instructor. Consequently, hospital governors ‘endeavoured to assume the moral function of a master–apprentice relationship’, concerns that led certain benefactors to regulate the hospital much like the master formally managed the apprentice’s home life.71 No longer residing with a master, apprentices were nevertheless subjected to house rules, which regularly addressed the issue of visitors. In general, medical apprentices were permitted visitors only with the permission of the house surgeons. Neither were such visits to interfere with their studies. At the General Hospital, Birmingham’s largest teaching hospital, all guests were to leave at ten in the evening.72 At the town’s other main teaching hospital, the Queen’s, strangers or visitors were in no case permitted to remain in hospital after 11pm.73 As a precaution, the Hospital Secretary paid ‘surprise visits at various hours of the night’.74 On one such visit in these years, it was reported that Dr Wood, a resident medical officer, ‘had from time to time improper female characters visiting him in the Physician’s Rooms’.75 Given the conduct of resident medical staff at this particular institution, it is not surprising that governors continued to take the lead when it came to providing students with moral guidance throughout these years. While visitors to students were carefully regulated, students’ own visits to hospital wards were also strictly governed. If not resident, students were to leave the General Hospital at 1pm and not permitted to attend evening 41

Jonathan Reinarz rounds into the last decades of the nineteenth century.76 As theories of contagion were gradually being worked out and gaining greater credibility, their access to wards at other institutions became equally constrained. At the Queen’s Hospital in the 1870s, for example, students were not to perform post mortems or attend fever cases when visiting patients. In case of an outbreak, students, as well as officers, were not to attend another case for a fortnight.77 Governors at the Women’s Hospital were even more concerned with access to their wards, given the delicacy of the hospital’s cases. At the Women’s Hospital, students could visit the wards only when accompanied by a medical officer.78 Soon after, student visits were discontinued entirely, although some members of staff had originally stressed that diseases peculiar to women could be treated without ‘annoyance caused by students’ visits’.79 In general, student visits had always been less frequent than at other hospitals, given the institution’s distance from the city centre, where Birmingham’s medical school was located. A female inspector calls: the introduction of lady visitors The delicacy of many female cases had, of course, always made it difficult for many official house visitors to inquire into the full details of all the hospitalised cases they encountered on the wards. Given that so many male house visitors made only superficial inquiries of female patients, female visitors, or ‘lady visitors’, appeared at all hospitals in Birmingham, though more quickly at some than others. Lady visitors to the women’s wards were first discussed at the General Hospital in 1802, some twenty years after the hospital admitted its first patients. A decade later, institutional visiting by ladies was introduced at hospitals and asylums in York, Worcester and London.80 Other institutions took longer to extend similar welcomes to their female donors. Governors at the Queen’s Hospital, for example, first discussed the matter of appointing lady visitors in 1882 – four decades after its foundation81 – as official lady visitors to the women’s wards ‘could give more valuable suggestions than any gentlemen could offer’.82 At the same time, given that women were not burdened with other forms of employment, governors could expect these charity workers to improve the attendance record of hospital visitors at all institutions. In turn, such ladies brought ‘the nation’s sick, poor, and outcast into contact with their more fortunate neighbours, who would call forth their better feelings and lead them back to the fold.’83 Often this included the housekeeper and other inferior hospital servants. Representing virtually every sect or religion, lady visitors shared the fundamental belief ‘that contact between inmates and the benevolent was wholesome and essential’.84 For many religiously motivated women, such philanthropy was rooted in the belief that ‘God’s progressive plan for the improvement of the world was to be effected through human 42

Receiving the Rich, Rejecting the Poor agency’.85 Only in this way might all people ‘live in mutual friendship and dependence, united to one another by the ties of gratitude and love’.86 At the very least, female house visitors offered hospitals capable inspectors of the household economy. In the process, many also replaced the ‘barracks’ atmosphere of charitable institutions fashioned by men with a more domestic family system.87 In turn, the experience of serving as house visitors promised to transform female volunteers into better wives and mothers.88 While six lady visitors were soon appointed by the governors of the Queen’s Hospital, female house visitors appeared more quickly on the wards of the Children’s Hospital. At this specialist institution, however, they were requested to confine their investigations to the wards.89 The Skin Hospital also appointed several lady inspectors to investigate female lock, or venereal, cases in 1890,90 many more being welcomed by the matron three years later.91 The Women’s Hospital, on the other hand, only ever appointed lady visitors, thirteen having been listed in 1893.92 Interestingly, though occasionally engaging the services of institutional visiting societies, such as the Charity Organisation Society, female visitors at the Birmingham hospitals, as elsewhere, tended to be spouses of governors and senior medical staff.93 Despite first appearing at the same institutions that first welcomed female medical practitioners,94 by the end of the nineteenth century, the female house visitor became the dominant image of the hospital visitor nationally, a situation reflected in William Henley’s poem, ‘In Hospital’, written between 1873 and 1875 when the Gloucester-born poet was a patient at the Old Infirmary, Edinburgh. Furthermore, while the average age of female hospital staff, especially nurses, was noticeably in decline during these years,95 only the visitor appears to have become older. Her little face is like a walnut shell With wrinkling lines; her soft, white hair adorns Her withered brows in quaint, straight curls, like horns; And all about her clings an old, sweet smell. Prim is her gown and quakerlike her shawl. Well might her bonnets have been born on her. Can you conceive a Fairy Godmother The subject of a strong religious call? In snow or shine, from bed to bed she runs, All twinkling smiles and texts and pious tales, Her mittened hands, that ever give or pray, Bearing a sheaf of tracts, a bag of buns: A wee old maid that sweeps the Bridegroom’s way, Strong in a cheerful trust that never fails.

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Jonathan Reinarz Besides her old age, the poem once again reinforces the house visitor’s association with religion and moral guidance, though still emphasising her role as patient activist. At the same time, lady visitors remained popular with hospital governors, as at the Children’s Hospital in 1907, where they were often thanked in official publicity material for ‘visiting and amusing the children’.96 While such accolades and the perfunctory ‘thank you’ in annual reports clearly minimised their roles at voluntary hospitals, their work involved far more than simply entertaining patients. Given that their duties within hospitals had been curtailed in the last decades of the nineteenth century, many lady visitors attempted to expand their work outside the hospital’s walls by shifting their attention to the discharged patient. For example, in 1899, when the Birmingham and District Crippled Children’s Union was established, much of its work was undertaken by lady visitors, who provided systematic mental and manual instruction of children under their care. When the Union – among whose officers were many ladies – took over visiting of in-patients from female volunteers in 1900,97 the hospital’s lady visitors directed their energies to other ventures. Miss Bartleet, a visitor to the Children’s Hospital, for example, organised an ‘after care’ committee, which comprised five women and twelve visitors.98 The committee commenced work in February 1911, when seventeen children were placed under their care, the children having received weekly visits from these lady volunteers and received milk and eggs according to hospital instructions. Many other medical institutions equally attempted to extend the benefits of the hospital by visiting the homes of patients. The Women’s Hospital commenced home visits in 1872.99 The Queen’s Hospital also paid followup visits to their patients in order to assess their financial status. While this was resented by some families, who ‘refused admission to [the] Visiting Agent’,100 such visits were particularly useful for research at the Women’s Hospital. However, by 1893, the District Nursing Association was already beginning to visit cases of the Women’s Hospital,101 a similar arrangement having been made with the Queen’s Hospital in 1884.102 Concluding remarks: the twentieth century and beyond Despite their functions having been appropriated by other more professional organisations, house visitors continued to be appointed at Birmingham’s medical charities in the last decade of the nineteenth century and even into the twentieth century. Those who survived generally outlived their welcome. They were, however, on the way out, many having been replaced by house committees, others by professional almoners and, eventually, social workers. Some lasted into the interwar period, as at the Women’s Hospital, where female subscribers had long taken an interest in the charity’s administration. 44

Receiving the Rich, Rejecting the Poor Taking too keen an interest in hospital affairs in this case only increased prejudices against ‘feminine meddling’ and proved to hasten the decline of the hospital visitor at this institution as at many others. In 1916, governors reported that ‘grave difficulties’ were caused by the actions of the ladies’ visiting committee, who managed to upset the matron and nurses by crossexamining them on their duties, and even reduced some of the patients to tears by ‘their want of tact and their injudicious and thoughtless remarks’.103 As a result, the medical committee insisted on the cessation of visiting as at present conducted and, as at other institutions, lay female volunteers were replaced by a house committee with female representation. Hospital medical personnel, on the other hand, continued to visit other medical institutions in order to gather information. By the late-nineteenth century, however, these visits became far less concerned with standard issues of housekeeping and furniture, as in an earlier age, and were specifically organised to aid the implementation of the latest medical innovations. Surgeons at the Skin Hospital, for example, visited medicinal baths at London University in 1890 before offering their own bathing facilities.104 On another occasion, staff at the Orthopaedic Hospital were sent to visit the best hospitals in Britain and on the Continent to investigate the latest techniques and technologies.105 In 1912, when staff at the Skin Hospital decided to introduce the Wassermann reaction, Dr Green was sent to London to view the manner in which this new method of diagnosing syphilis had been implemented at institutions in the capital.106 A similar journey was organised approximately a decade later when a new Erlangen apparatus – an instrument using X-rays to treat deep-seated cancer – was installed at the Skin Hospital for the purposes of cancer treatment. On this occasion, however, Cranston Walker visited the manufacturers in Erlangen, Germany.107 On rare occasions staff would even visit an institution in order to assess new recruits. This was the case at the Queen’s Hospital in 1907 when two members of staff visited Rotherham Hospital and Dispensary to see how it was managed by Miss Maude G. Buckingham before appointing her as their new matron.108 Other times, experts were occasionally invited to give their opinions of innovations and redevelopment. For example, in 1907, Sir Alexander Simpson was invited to visit the Women’s Hospital and assess the hospital’s method of treatment.109 Invited in the capacity of a consultant, Simpson was also paid for his services. Visits by foreign dignitaries may have become very rare in the twentieth century, but appearances by members of the nation’s royal family became more regular at numerous hospitals, especially at those bearing a regal title or named in honour of the family’s members. Some hospital governors even organised such visits in an effort to add the Royal prefix to their institution’s name.110 Other members of the nobility had long patronised these medical 45

Jonathan Reinarz Figure 2.1 The Duchess of York at the Woodlands HRH the Duchess of York visits the Woodlands branch of the Royal Orthopaedic and Spinal Hospital, Birmingham, 6 November 1929. Source: Birmingham Central Library, Local Studies, Royal Orthopaedic and Spinal Hospital Annual Report, 1929. Reproduced with Permission from Birmingham City Archive.

institutions, though commenced regular visits more recently. For example, when the Women’s Hospital appointed the Countess of Dudley their first ever woman president, she confessed to not yet having visited the hospital.111 Alternatively, when Prince Albert opened the Victoria Hospital in Burnley in 1886, his official duty occasioned the town’s first royal visit.112 In the first decades of the twentieth century, many more members of the aristocracy toured these institutions, such visits often coinciding with anniversaries, the opening of new wards, wings or even a new building.113 In Birmingham, this reached a climax in March 1938 with a royal visit to the new buildings of the Queen Elizabeth Hospital.114 46

Receiving the Rich, Rejecting the Poor Figure 2.2 The Prince of Wales at the Woodlands HRH the Prince of Wales signs the Visitors’ Book at the Woodlands branch of the Royal Orthopaedic and Spinal Hospital, Birmingham, 1927. Source: Birmingham Central Library, Local Studies, Royal Orthopaedic and Spinal Hospital Annual Report, 1927. Reproduced with Permission from Birmingham City Archive.

Patient visiting, on the other hand, was no longer the ceremony it had been in previous decades. Though still conducted according to its own unique rules, the act of visiting friends and family members in hospital generally became more relaxed. At first, additional visiting days were introduced, as at the Women’s Hospital in 1918 when patients were permitted guests three days a week for two hours daily.115 A year later, lady volunteers – many of whom were former house visitors – provided tea to those visiting the hospital each Sunday.116 In general, visitors became far 47

Jonathan Reinarz more common at all institutions, the Skin Hospital having thrown its doors open to visitors, and not only because charity had become democratised, ever greater sums of hospital charity coming from the working classes since the 1870s.117 By the interwar period, a growing awareness of patients’ psychological needs had also begun to emerge. As a result, visiting hours only liberalised further. Efforts to humanise the hospital went furthest in children’s hospitals, where rooming-in became a viable option for mothers in the last decades of the nineteenth century. Similar facilities were introduced to infant wards at specialist hospitals within and without Birmingham in the early twentieth century.118 In contrast to an earlier era, medical staff in the post-war period began to direct their attention to the emotional and social impact of hospitalisation. In some cases, family visits even began to be regarded as vital diagnostic and therapeutic tools.119 By this time, however, an army of specialised visitors had also made its appearance with that of the NHS. This had been first apparent in the early years of the twentieth century when factory inspectors began to visit hospital laundries in order to ensure the presence of automatic safety guards on machinery.120 Ironically, wringers and other innovations in laundering themselves had been the direct result of an earlier round of hospital visits – as described earlier in this chapter. Over the course of the twentieth century, such inspections multiplied with increases in government intervention, leading many hospitals to be tied up by dozens if not hundreds of red-tape visitors. Most depressing of all, while visitors had formerly been associated with fund-raising and charity, today’s hospital visitors, or at least those employed by the government, are more frequently described as oppressive burdens, not potential donors. The inauguration of the NHS also witnessed the disappearance of the old collection boxes which appeared at every ward door on visiting days.121 Though recently regarded as liabilities, hospital visitors in a previous century had epitomised the country’s thriving voluntary medical service. Originally drawn from an institution’s male subscribers, house visitors effectively bought into the eleemosynary enterprise and carefully monitored the expenditure of charitable funds. Often successful men of business, these vigilant volunteers had much to offer English hospitals, not least of which was their grasp of financial matters. As house visitors’ commitments to their respective charities grew, however, their advice, especially when coming from a woman, frequently conflicted with medical knowledge, leading to the formation of house committees which promised to dilute their influence on hospital affairs. Less welcome than official hospital visitors, families and friends of patients also offered considerable support to medical institutions through their periodic visits by providing, among other things, food, clean linen and 48

Receiving the Rich, Rejecting the Poor moral support. In fact, at the majority of voluntary hospitals it was often those without friends who ate least well and perhaps in the long term fared worst of all. Rarely remembered by historians, visits to hospital staff in these years were also regular occurrences and deemed equally in need of regulation. While the fear of infection became the primary motive for restrictive visiting at most hospitals in the late nineteenth century, the work of some influential women, including Catherine Cappe, Elizabeth Fry and Florence Nightingale, did more than anything else to stimulate institutional visiting during this period. While this particular avenue of women’s work was only the best-known form of institutional visiting, by the close of the nineteenth century, hospitals attracted ever more guests, with only foreign dignitaries becoming less common over time. Foreign students, on the other hand, like all other visitors, only increased in the twentieth century. As a result, in most cases, institutional visitors to hospitals easily began to outnumber their inmate populations, a phenomenon which at the very least should stimulate further research into this hitherto overlooked subject. Notes 1. P. Shapely, Charity and Power in Victorian Manchester (Manchester: The Chetham Society, 2000), 8. 2. Birmingham Central Library Archive (BCLA), General Hospital, GH/1/3/1. Annual Reports, 1779–1827. 3. Ibid., GH/1/2/4. Minutes of the General Committee, 1766–84. 4. Ibid., GH/1/2/5. Minutes of the General Committee, 1784–93; F.H. Jacob, A History of the General Hospital near Nottingham Open to the Sick and Lame Poor of Any County (Bristol: John Wright and Sons Ltd, 1951), 52. 5. Ibid., GH/1/4/510. Hospital Rules, 1779. 6. Jacob, op. cit. (note 4), 52. 7. BCLA, General Hospital, GH/1/2/5. Minutes of the General Committee, 1784–93. 8. Ibid., GH/1/2/6. Minutes of the General Committee, 1793–1803. 9. BCLA, Queen’s Hospital, HC/QU/1/2/3. House Committee Minutes, 1869–71. 10. BCLA, General Hospital, GH/1/2/9. Minutes of the General Committee, 1819–23. 11. Ibid., GH/1/2/11. Minutes of the General Committee, 1831–7. 12. Ibid., GH/1/2/9. Minutes of the General Committee, 1819–23. 13. Ibid., GH/1/2/5; GH/1/2/7. Minutes of the General Committee, 1784–93; 1803–15. 14. Ibid., GH/1/2/10. Minutes of the General Committee, 1823–31. 15. Ibid., GH/1/2/11. Minutes of the General Committee, 1831–7.

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Jonathan Reinarz 16. For more on the subject of such interviews, see J. Reinarz, ‘Investigating the “Deserving” Poor: Charity, Discipline and the Voluntary Hospitals in Nineteenth–Century Birmingham’, in A. Borsay and P. Shapely (eds), Reconfiguring the Recipient: Historical Perspectives on the Negotiation of Medicine, Charity and Mutual Aid (Aldershot: Ashgate, 2007). 17. BCLA, General Hospital, GH/1/2/9. Minutes of the General Committee, 1819–23. 18. Ibid., GH/1/2/11. Minutes of the General Committee, 1831–7. 19. Ibid., GH/1/2/13. Minutes of the General Committee, 1843–51. 20. Reinarz, op. cit. (note 16); and M. Gorsky, J. Mohan and T. Willis, Mutualism and Health Care: British Hospital Contributory Schemes in the Twentieth Century (Manchester: Manchester University Press, 2006). 21. BCLA, General Hospital, GH/1/2/10. Minutes of the General Committee, 1823–31. 22. Ibid., GH/1/2/11. Minutes of the General Committee, 1831–7. 23. Ibid. 24. Ibid. 25. University of Birmingham Special Collections (UBSC), Skin Hospital, Annual Report, 1890. 26. Ibid., 1891. 27. BCLA, General Hospital, GH/1/2/11. Minutes of the General Committee, 1831–7. 28. Tyne and Wear Archives Service, Newcastle Royal Infirmary, HO/RVI/48/2. Infirmary House Visitors Book, 1824–35. 29. BCLA, General Hospital, GH/1/2/12. Minutes of the General Committee, 1837–43. 30. Ibid., Queen’s Hospital, HC/QU/1/2/1. Minutes of the House Committee, 1863–6. 31. Ibid., Queen’s Hospital, HC/QU/1/2/6. Minutes of the House Committee, 1874–6. 32. Ibid. 33. Ibid., Children’s Hospital, HC/BCH/1/14/8. Annual Report, 1907. 34. P. Elliott, ‘The Derbyshire General Infirmary and the Derby Philosophers: The Application of Industrial Architecture and Technology to Medical Institutions in Early-Nineteenth-Century England’, Medical History, 46, 1 (2002), 65–92: 75. By travelling to England, Nicholas was very much continuing a Russian tradition of educational tourism that can be traced back to Peter the Great. See, for example, A. MacGregor, ‘The Tsar in England: Peter the Great’s Visit to London in 1698’, The Seventeenth Century, 19, 1 (2004), 116–47. 35. BCLA, General Hospital, GH/1/3/1. Annual Report, 1816.

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Receiving the Rich, Rejecting the Poor 36. J. Harris, Industrial Espionage and Technology Transfer: Britain and France in the Eighteenth Century (Aldershot: Ashgate, 1998); D. Edgerton and S. Horrocks, ‘British Industrial Research and Development Before 1945’, Economic History Review, 47 (1994), 213–38: 215; W.J. Hornix, ‘From Process to Plant: Innovation in the Early Artificial Dye Industry’, British Journal for the History of Science, 25 (1992), 65–90: 86; E. Homburg, ‘The Emergence of Research Laboratories in the Dyestuffs Industry, 1870–1900’, British Journal for the History of Science, 25 (1992), 91–111: 93. 37. K. Waddington, Charity and the London Hospitals, 1850–1898 (Woodbridge: Boydell Press, 2000), 121. 38. P. Shapely, op. cit. (note 1), 21. 39. W.F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994), 167; Elliott, op. cit. (note 34), 88. 40. J. Reinarz, The Birth of a Provincial Hospital: The Early Years of the General Hospital, Birmingham, 1765–1790 (Stratford: Dugdale Society, 2003), 10–12. 41. G. Haliburton, The History of the Newcastle Infirmary (Newcastle-upon-Tyne: Andrew Reid, 1906), 35, 54; W.H. McMenemey, A History of the Worcester Royal Infirmary (London: Press Alliances, 1947), 55, 104–5, 231; M. Bewick, The History of a Provincial Hospital (Burton-upon-Trent: David Whitehead, 1974), 26; M. Railton and M. Barr, The Royal Berkshire Hospital, 1839–1989 (Reading: Royal Berkshire Hospital, 1989), 16; Elliott, op. cit. (note 34), 89. 42. BCLA, Queen’s Hospital, HC/QU/1/2/6. House Committee Minutes, 1874–6. 43. Ibid., Eye Hospital, MS 1919. General Committee Minutes, 1823–57. 44. Ibid., MS 1920. General Committee Minutes, 1857–66. 45. Ibid., Children’s Hospital, HC/BCH/1/4/1. Medical Committee Minutes, 1861–8. 46. Ibid., Queen’s Hospital, HC/QU/1/1/1. Minutes of General Committee, 1870–2. 47. See, for example, Hornix, op. cit. (note 36), 82; and J. Reinarz, ‘Fit for Management: Apprenticeship and the English Brewing Industry, 1870–1914’, Business History, 43, 3 (2001), 33–53: 47. 48. D.E.H. Edgerton, ‘Science and Technology in British Business History’, Business History, 29 (1987), 84–103: 85. For a more comprehensive discussion of the process of innovation at voluntary hospitals in the nineteenth century, see J. Reinarz, ‘Mechanising Medicine: Medical Innovations and the Birmingham Voluntary Hospitals in the Nineteenth Century’, in C. Timmermann and J. Anderson (eds), Devices and Design:

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49. 50. 51. 52. 53. 54. 55. 56. 57. 58.

59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69.

70.

Medical Innovation in Historical Perspective (London: Routledge, 2006), 37–60. BCLA, General Hospital, GH/1/2/11. Minutes of the General Committee, 1831–7. Ibid., Eye Hospital, uncatalogued. Minutes of the Medical Committee, 1884–1900. Ibid, General Hospital, GH/1/2/12. Minutes of the General Committee, 1837–43. Ibid., GH/1/2/11. Minutes of the General Committee, 1831–7. Ibid., GH/1/2/12. Minutes of the General Committee, 1837–43. Ibid., Eye Hospital, MS 1919. Committee Minutes, 1823–57. Ibid., Children’s Hospital, HC/BCH/1/4/2. Medical Committee Minutes, 1869–77. Ibid. Ibid. Ibid., HC/BCH/1/4/3. Medical Committee Minutes, 1877–93. See also, J. Pickstone, Medicine and Industrial Society: A History of Hospital Development in Manchester and its Region, 1752–1946 (Manchester: Manchester University Press, 1985), 162, 166. Ibid., Queen’s Hospital, HC/QU/1/1/2. General Committee Minutes, 1873–6. Ibid., HC/QU/1/2/6. House Committee Minutes, 1874–6. Ibid., Children’s Hospital, HC/BCH/1/4/4. Medical Committee Minutes, 1893–1906. Birmingham Central Library, Local Studies (BCLLS), Eye Hospital. Annual Report, 1887. Ibid., Women’s Hospital, HC/WH/1/10/5. Annual Report, 1905. Ibid., Annual Report, 1906. Pickstone, op. cit. (note 58), 166. Ibid., General Hospital, GH/1/2/12. Minutes of the General Committee, 1837–43. Ibid., Queen’s Hospital, HC/QU/1/1/5. General Committee Minutes, 1886–96. Ibid., HC/QU/1/2/6. House Committee Minutes, 1874–6. F. Condrau, ‘“Who Is the Captain of All These Men of Death?”: The Social Structure of a Tuberculosis Sanatorium in Postwar Germany’, Journal of Interdisciplinary History, 32, 2 (2001), 243–62; P. Michael, Care and Treatment of the Mentally Ill in North Wales, 1800–2000 (Cardiff: University of Wales Press, 2003). K. Waddington, ‘Mayhem and Medical Students: Image, Conduct and Control in the Victorian and Edwardian London Teaching Hospital’, Social History of Medicine, 15 (2002), 45–64.

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Receiving the Rich, Rejecting the Poor 71. Ibid., 46; S. Lawrence, Charitable Knowledge: Hospital Pupils and Practitioners in Eighteenth-Century London (Cambridge: Cambridge University Press, 1996), 123–7. 72. BCLA, HC/GHB. Medical Committee Minutes, 1868–76. 73. Ibid., HC/QH/1/2/5. House Committee Minutes, 1873–4. 74. Ibid., HC/QU/1/1/4. General Committee Minutes, 1880–6. 75. Ibid., HC/QU/1/2/2. House Committee Minutes, 1866–8. 76. Ibid., HC/QU/1/2/4. House Committee Minutes 1871–3. 77. Ibid., HC/QU/1/2/8. House Committee Minutes, 1879–83. 78. Ibid., Women’s Hospital, HC/WH/1/5/1. Medical Board Minutes, 1871–92. 79. Ibid., HC/WH/1/10/4. Annual Report, 1897. 80. F.K. Prochaska, Women and Philanthropy in Nineteenth-Century England (Oxford: Clarendon Press, 1990), 141–3; H. Plant, Unitarianism, Philanthropy and Feminism in York, 1782–1821: The Career of Catherine Cappe (York: Borthwick Publications, 2003), 18. 81. BCLA, Queen’s Hospital, HC/QU/1/1/4. General Committee Minutes, 1880–86. 82. Ibid., HC/QU/1/2/8. House Committee Minutes, 1879–83. 83. Prochaska, op. cit. (note 80), 138. 84. Ibid., 139. 85. Plant, op. cit. (note 80), 20. 86. N. Cappe, Discourses on the Providence and Government of God, edited by Catharine Cappe (London, 1811), 99–100. 87. Prochaska, op. cit. (note 80), 158, 179. 88. C. Cappe, ‘Thoughts on the Desirableness and Utility of Ladies Visiting the Female Wards of Hospitals and Lunatic Asylums,’ The Pamphleteer, 8 (1816), 376–7. 89. BCLA, Children’s Hospital, HC/BCH/1/14/2. Annual Report, 1870. 90. BCLLS, Skin Hospital. Annual Report, 1890. 91. Ibid., 1893. 92. BCLA, Women’s Hospital, HC/WH/1/10/4. Annual Report, 1893. 93. Prochaska, op. cit. (note 80), 142. 94. H. Marland, ‘“Pioneer Work on all Sides”: The First Generations of Women Physicians in the Netherlands, 1879–1930’, Journal of the History of Medicine and Allied Sciences, 50, 4 (1995), 441–77. 95. S. Wildman, ‘Fitness for Practice, Fitness for Purpose: The Changing Nature of Hospital Nursing in the West Midlands, 1841–1914’, in J. Reinarz, (ed.), Medicine and Society in the Midlands, 1750–1950 (Birmingham: Midland History Society, 2007), 98–114. 96. BCLA, Children’s Hospital, HC/BCH/1/14/8. Annual Report, 1907 97. Ibid., HC/BCH/1/14/7. Annual Report, 1900. 98. Ibid., HC/BCH/1/14/8. Annual Report, 1911.

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Jonathan Reinarz 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113.

114. 115. 116. 117. 118. 119.

120. 121.

Ibid., Women’s Hospital, HC/WH/1/5/1. Medical Board Minutes, 1871–92. Ibid., Queen’s Hospital, HC/QU/1/1/2. General Committee Minutes, 1873. Ibid., Women’s Hospital, HC/WH/1/10/4. Annual Report, 1893. Ibid., Queen’s Hospital, HC/QU/1/2/9. House Committee Minutes, 1883–7. Ibid., Women’s Hospital, WH/1/5/2. Medical Committee Minutes, 1893–1928. BCLLS, Skin Hospital. Annual Report, 1890. Ibid., Orthopaedic Hospital. Annual Report, 1907. BCLA, Skin Hospital, MS 1918. Medical Committee Minutes, 1890–1928. BCLLS, Skin Hospital. Annual Report, 1921. BCLA, Queen’s Hospital, HC/QU/1/1/6. General Committee Minutes, 1896–1907. Ibid., Women’s Hospital, HC/WH/1/10/5. Annual Report, 1907. Bewick, op. cit. (note 41), 130. BCLA, Women’s Hospital, HC/WH/1/10/4. Annual Report, 1893. Pickstone, op. cit. (note 58), 151. F.W. Law, The History and Traditions of Moorfields Eye Hospital: Volume 2, Being a Continuation of Treacher Collins’ History of the First Hundred Years (London: H.K. Lewis and Co., Ltd, 1975), 27. BCLLS, United Birmingham Hospitals. Annual Report, 1938. BCLA, Women’s Hospital, HC/WH/1/10/7. Annual Report, 1918. Ibid., 1919. BCLLS, Skin Hospital. Annual Report, 1935. Law, op. cit. (note 113), 43. A.D. Hunt, ‘On the Hospitalization of Children: An Historical Approach’, Pediatrics, 54, 5 (1974), 544–5; J. Young, ‘Changing Attitudes Towards Families of Hospitalised Children from 1935–1975: A Case Study’, Journal of Advanced Nursing, 17 (1992), 1422–9: 1424. BCLA, Queen’s Hospital, HC/QU1/2/14. House Committee Minutes, 1908–12. Bewick, op. cit. (note 41), 164.

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3 ‘Family-Centred Care’ in American Hospitals in Late-Qing China

Michelle Renshaw Today, patients’ families in the West are regaining the access to hospitals that they lost when hospitals emerged as the primary site for medical treatment, research and training at the beginning of the twentieth century. In China, however, families were never excluded from American mission-run hospitals, in fact, they were indispensable. Families were in the waiting rooms, consulting rooms, wards and operating theatres. They provided more than reassurance and comfort: they fed and nursed their sick relatives, acted as advocates and middlemen and may even have lowered the incidence of cross-infection, the scourge of the contemporary hospital in the West.

Inspired by the consumer-led movements of the 1960s, and encouraged by research from psychologists who wrote about ‘maternal deprivation’ of institutionalised children, American parents had started to campaign against restrictions on visiting their children in hospitals.1 In Massachusetts they formed ‘Children in Hospitals’, an organisation which, in 1973, started to conduct and publish bi-annual surveys of visiting hours in the state’s hospitals. It is unlikely they could have foreseen their activism leading to the widespread adoption of an entirely new approach to patient care that pertains in American hospitals today.2 This new policy approach goes by the name of ‘family-centred’ care. Developed originally with children in mind, one of the first concrete moves in its direction was legislation passed in Massachusetts in 1980 requiring hospitals to institute twenty-four-hour family access to paediatric wards.3 Today it is a well-developed system with an agreed set of principles and protocols.4 Over the years it has extended its reach and is increasingly being adopted by hospitals for the aged as well as for adults in acute care hospitals.5 Like fathers wanting to be present at the birth of their child – including those carried out by caesarean section – family members are expecting to be present even during invasive and emergency procedures.6 55

Michelle Renshaw The cornerstone of the family-centred policy – emphasised in many hospital advertisements – is a belief that ‘health care providers and the family are partners, working together to best meet the needs of the child.’7 Of course, neither the idea nor the practice of families caring for their sick is new and, before the advent of hospitals for other than the very poorest of them, patients were routinely cared for at home with occasional visits from a physician. What is new in America is the idea that the family should take on a significant, if not central, role in patient care within the hospital setting. But, there have been manifestations of the American hospital from which the family was never excluded – those established by Protestant missionaries in nineteenth-century China, for example. There, the presence of family and friends was commonplace well into the twentieth century and continues in the Chinese successors of these hospitals today.8 So, the questions addressed in this chapter include: what economic, political and cultural factors operated in China to distinguish the American hospital in China from its counterpart at home, particularly in relation to the presence of patients’ family and friends? To what extent and in what capacities were these ‘visitors’ involved in the actual operation of mission hospitals? What were the possible consequences of the families’ involvement, so far as outcomes were concerned, for the Chinese patients, their families and for hospital staff? Lacking first-hand contemporary accounts by either Chinese patients or their families, this chapter relies upon annual reports published by a wide range of hospitals operated by various missionary societies and articles in missionary journals, particularly those written for and by medical missionaries. For the history of hospitals and present-day practices in America, secondary sources are used. Background: medical missions When the first of the Protestant medical missionaries arrived in China in the mid-1830s what few public hospitals there were in America had been established primarily to serve the poor.9 Those who could afford it were still treated at home by a physician and cared for by family members. The state of medical knowledge, practice and technology – before anaesthesia and the germ theory – meant that specialised equipment and nursing were not deemed to be necessary; the middle or upper-class home was thought to provide a perfectly adequate environment in which to care for the sick. So it would have been considered unremarkable when the first American medical missionary, Peter Parker, arrived in Canton, the warehouse he chose for his hospital, in 1835. Equally unremarkable was the fact that he had no nurse; caring for the forty in-patients he could accommodate was undertaken by their relatives, friends or servants.10 56

‘Family-Centred Care’ in American Hospitals in Late-Qing China Following Parker, Protestant medical missionaries established themselves in China, slowly at first until the rate picked up from the 1880s to reach a peak after the Boxer Rebellion in 1900 of almost twenty new arrivals per year for the following five years. By the end of 1905, some 450 medical missionaries had arrived in the country since 1869.11 In 1906, according to the China Medical Missionary Association, there were 241 dispensaries and 166 mission hospitals operated by 207 male and 94 female medical missionaries.12 Much was changing, however, in hospitals in America throughout this period. Anaesthetics such as ether and chloroform, discovered in the 1840s, enabled surgeons to contemplate more radical, particularly abdominal, surgery with its attendant danger of infection. In the 1860s, Lister pioneered the performance of antiseptic surgery and, in the 1870s and 1880s, Pasteur’s and Koch’s experiments established the germ theory of disease. The causative agents of wound infections were identified and the idea of aseptic surgery was advocated and eventually universally adopted. Sanitation studies influenced the design of hospitals and the need for trained nurses was recognised. Both general and specialised hospitals were opened to cater specifically for the middle-classes and trained medical personnel – physicians, nurses, surgeons and technicians – largely usurped the role of the family in caring for the sick. Medical missionaries kept abreast of these changes, via study trips home and reading medical journals, and were quick to assimilate much of the new knowledge and implement many of the techniques. The economic and cultural conditions in China, however, were such that the development of mission hospitals did not completely mirror the changes taking place in hospitals at home. In the dispensary In America, free-standing public dispensaries, which had arisen in the late eighteenth century, gave way to the emerging hospitals as the principal sites for physicians to learn, practise diagnosis and advance their careers.13 However, no study of mission hospitals in China can avoid discussing the operation of dispensaries; it was through these out-patient institutions that the vast majority of Chinese continued to come into contact with Western medicine. Dispensaries always preceded the building of mission hospitals; large numbers of patients could be catered for at little cost and the missionary could start work as soon as he or she had acquired sufficient Chinese language. It also provided a way to break down barriers because it was easier to persuade potential patients to visit a physician than to enter a foreign hospital. After all, the set-up of a public dispensary – a doctor sitting in a room, examining and questioning a patient and prescribing medicine – 57

Michelle Renshaw had been familiar to Chinese people since at least the Tang Dynasty (618–907 AD).14 In 1906, medical missions reported that only 3.7 per cent of the 913,200 new and returning patients treated during the year had been admitted as inpatients.15 The rest had been seen in dispensaries, by missionaries who periodically travelled throughout the countryside proselytising and holding ‘clinics’ wherever people gathered at fairs and markets or in their homes. But the hundreds of thousands of patients who were treated in dispensaries did not come alone: they were invariably accompanied by friends or relatives. For example, when the Methodist Episcopal Mission (South) (MEM(S)) Women’s Hospital at Suzhou opened in 1887, the ‘number of friends [coming to the dispensary was] usually double that of patients’.16 Similarly, the Southern Presbyterian Mission (SPM) reported in 1905 that their outpatients at Qingjiangbu in Jiangsu, were invariably accompanied by ‘at least one friend’.17 Understandably, children would have been accompanied when visiting the dispensary but so too were most women and many men. As Elizabeth Reifsnyder, the physician-in-charge of the Margaret Williamson Hospital (est. 1885) at Shanghai observed in 1887, ‘[a]t home the woman is a free moral agent, so far as going to the dispensary is concerned… here, the husband invariably comes with the wife, the father with the daughter, and it is the father, too, very often [who] brings the baby, or comes with it and the mother or nurse.’18 As the medical missionaries’ stated ‘prime’ purpose in establishing dispensaries and hospitals was ‘to propagate the Christian religion and make it a power in the hearts and lives of these people’, they welcomed the opportunity to influence patients’ families and friends.19 In addition to introducing them to the Gospel by preaching in waiting rooms, missionaries also sought to persuade the Chinese of the ‘superiority’ of Western – which the missionaries equated with ‘Christian’ – ‘scientific’ medicine. So, patients and visitors were encouraged to observe medical consultations and minor procedures carried out in the dispensary. When their turn came a patient might enter a separate examination area, partitioned off but often remaining in full view. Many doctors advocated this arrangement and designed their dispensaries so that patients who were still waiting and any friends or relatives who had accompanied them could see what the doctor was doing.20 They hoped that this would inspire confidence, allay fears and prevent rumours from arising. To this end, one doctor went so far as to call patients into the consulting room in groups of ten at a time. They would sit on a bench until being called individually to take a chair next to his desk to be examined.21 The large number of people who thereby became familiar with dispensaries associated with missionary hospitals would presumably have 58

‘Family-Centred Care’ in American Hospitals in Late-Qing China come to view the foreign-run hospital as a ‘public’ space where both patients and visitors were welcome. It was so common for visitors to crowd Parker’s hospital that on one occasion, in 1838, he was only able perform a potentially dangerous operation by seizing the opportunity afforded when, ‘during the time of the attempted execution of an opium dealer, and the consequent riot… all was quiet at the hospital’.22 In the wards Up until the 1870s, American hospital patients had, according to Rosenberg: [H]oped and expected to find relatives and friends a source of emotional support in strange and threatening surroundings. Their visitors had smuggled in food and drink and paid little attention to stipulated visiting hours.23

But the physical conditions within American hospitals were transformed with the advent of trained nurses to replace untrained staff or the convalescent patients who were required to help care for others. By the earlytwentieth century a new-style regime had become firmly established and ‘the patient became subjected to a routine which was in the main unnatural and largely determined by the nurse and her needs.’24 The familiar photographs of hospital wards with highly polished wooden floors, two rows of ironframed beds arranged facing into a central aisle, tightly tucked white sheets, patients either in bed or sitting in a chair next to it and attendant nurses in starched uniforms and caps began appearing in hospital reports.25 There may have been visitors in these hospitals but, presumably, hospital administrators who wished to paint their hospital in the best possible light considered it imprudent to have them appear in photographs. Along with the emergence of the trained nurse and the ordered ward came a tightening of rules and regulations devised to try to govern the behaviour of patients and their relatives. Thus, visiting hours were restricted and limits were placed on the number of visitors a patient could have at any one time. Family and friends, however, thought that bringing food for a patient was the one caring task they could continue to perform and hospital rules were written in an effort to control this aspect of the patient–visitor relationship: generally, they forbade bringing in any food for patients, even going to the extent of searching visitors before they were allowed in.26 Medical missionaries on the other hand, were not in a position to institute rigid rules for either patients or their visitors. In the 1830s, Peter Parker’s lack of even untrained nurses meant that he alone was responsible for ‘[t]he prescribing, the principal part of the labor of administering the prescriptions, and the supervision of house patients by day and night’.27 Sixty 59

Michelle Renshaw years later, in 1902, another missionary, operating in Shandong, explained to his patients, ‘we have no staff of nurses; if you are going to need attendance, you must bring some one from your home.’28 Mission hospitals in China in 1910, according to Jefferys, of the American Episcopal Mission’s St Luke’s Hospital at Shanghai, were ‘far more homey and far more human than eleven-tenths of our rule-trodden institutions in the dear homeland, and it suits the Chinese patients very well indeed.’ He advised medical missionaries that they would save themselves ‘endless trouble’ and their patients ‘endless ingenuity’ if they were to limit their ‘rules to the bare necessities and extend [their] elasticity to the utmost degree short of, and sometimes past, the breaking point’. His patients ‘could smoke and talk all night’ and friends could come and go, or not go, as they pleased.29 By the turn of the twentieth century in America trained nurses had come into their own: the number of students enrolled in professional nursing schools had increased from a mere 323 in 1880 to 11,164 in 1900 with graduates increasing from 157 to 3,456 per annum.30 But in China, according to a survey of sixty hospitals undertaken in 1904, some 80 per cent were operated by a single physician. In 1923, 69 per cent of mission hospitals in China were ‘one-man’ hospitals with a single physician and ‘his or her Chinese helpers’; a further 18 per cent were described as ‘two-man’, which meant they had two doctors and a foreign nurse; and only 8 per cent had more than two foreign-trained physicians.31 So far as nursing staff were concerned, Balme and Stauffer found in 1919 that 34 per cent of the hospitals did not have a trained nurse on the staff; a further 26 per cent of hospitals had but one trained nurse. They summed up the situation thus: ‘in one third of all these hospitals there is no sort of skilled nursing whatever, and in 60 per cent of them there is no more than can be attempted by a single graduate nurse.’32 The lack of nursing staff in China was due to a confluence of forces: lack of money to employ foreign-trained nurses; the Chinese custom of family members taking an active role in caring for the sick; and the reluctance of Chinese women to be attended by a man. There were few Chinese women trained as nurses and the small corps of trained nurses was overwhelmingly male. As late as 1918, there was a widespread belief among physicians and nurses that it was not yet appropriate for Chinese women to nurse men.33 In America, once trained nurses were in place, under certain circumstances – in cases where the patient was ‘dangerously ill’ for example – a hospital would allow a friend, relative or nurse to accompany a patient.34 The privilege was not generally extended to patients in wards.35 In China, the situation was very different. Margaret Polk of the MEM(S) hospital at Suzhou, one of the relatively few women who contributed regularly to the China Medical Missionary Journal and spoke at medical conferences, 60

‘Family-Centred Care’ in American Hospitals in Late-Qing China commented in 1901, ‘two or three servants’ frequently accompanied private patients and family members – husbands, sons, daughters, sisters, fathers and mothers – attended patients in wards.36 This led to the chronic overcrowding which characterised mission hospitals. In 1906, Arthur Peill, of the London Missionary Society (LMS) Roberts’ Memorial Hospital in Hebei, proposed restricting in-patient numbers to the number of beds in the wards ‘instead of allowing them to pack in like sardines as heretofore’. He had tried to solve his problem two years earlier by building a ‘commodious and very convenient inn’,37 but his wards had remained ‘very full’. One day he had found 103 people in quarters intended for 50; of these, 75 were actual in-patients and the rest were ‘so called “nurses”’, that is, family and friends.38 Another doctor, writing in 1912, described the situation in hospitals’ wards in China: [B]esides the patients are to be found their relatives, with one and all practicing their natural unhygienic habits. Any attempt of nursing is done by the relatives or glorified coolies and is of the most primitive and disgraceful character.39

Things were much the same in 1919 when Gibson declared that: [N]o more can be tolerated wards which are dirty and disorderly, patients who are clad in their own ‘questionably clean garments’ and cared for by their own ‘questionably capable’ friends or hirelings.40

Peill announced his intention to tackle the overcrowding in his hospital by appointing ‘regular nurses… men chosen for their Christian character and reliability, to act as ward evangelists, to do dressings, and be responsible for the cleanliness and order of the wards’.41 Even if Peill and his fellow medical missionaries had had the appropriate staff, it would have still been necessary to allow patients’ families to accompany them into hospital. They were keen to admit as many patients to hospital as they could because it was universally believed that in-patients offered the maximum opportunity to influence the Chinese with respect to religion. Patients could be persuaded to both enter and stay longer when they would not be separated from their family and friends. When Balme conducted his survey in 1919, 37 per cent of hospitals required that all patients be accompanied while a further 51 per cent allowed family, friends or servants to live in with patients. In other words, 88 per cent of hospitals had to be able to accommodate friends and family. In the early days, as Balme explained, it had been a matter of cultural sensitivity: it had been ‘neither easy nor polite to induce patients to come into the hospital unless they were allowed to bring their friends to live with them.’42 John A. 61

Michelle Renshaw Anderson, who was working in Western Yunnan in 1901, went further: he rather liked his patients to bring their friends or servants with them. It helped to keep the patients from being homesick, and it brought more people under the influence of the Gospel.43 It would seem that some patients were extremely well catered for, at least in terms of the number of attendants. A little girl of eight years whom Parker operated on in 1838 to repair a hare-lip was apparently the ‘the idol of her wealthy parents’ and had four people in ‘constant attendance’ for the ten days she was in hospital. At the other end of the age scale, a 56-year-old former ‘district magistrate’, was attended by two or three servants, his ‘personal servant’ being described as being ‘as old as himself, with a flowing jet black beard… unwearied in his attention to his blind master’.44 Sixty years later, the fact that patients were still being routinely accompanied in hospitals excited no particular comment. Josephine Bixby, bringing her readers’ attention to the lack of space in her hospital, described a room ‘scarcely large enough for two’ having to accommodate three women. What she does not say is that it actually had to hold at least six – each patient had at least one attendant.45 The practice of requiring or allowing all patients to be accompanied, while extremely common, was not universal. Lillie Saville at Beijing was a rare exception among medical missionaries: she appears to have succeeded in her quest to rid her hospital of live-in visitors. In preparation for introducing clinical training for Chinese nurses, she reported in 1906 that she had ‘almost entirely abolished the heretofore prevalent practice of allowing mothers and friends to live with the patient in the hospital’.46 Family and friends: multiple roles Important as reassurance, companionship and even nursing were to patients, the responsibilities of family and friends went much further. They were so ubiquitous and commonplace in these mission hospitals, however, that many writers of hospital reports appear to have considered their roles unworthy of detailed attention. As we have already noted, some of these reports included sweeping generalisations that decried Chinese family members’ perceived ineptitude, ignorance or lack of hygiene. Others welcomed and, indeed, expected family and friends to participate in caring for patients. Naturally, in some instances, attendants used the methods of traditional Chinese medicine; for example, Parker described a servant, alarmed at her mistress’ vertigo which had been brought on by a dose of laudanum, ‘engaged in pinching the patient’s nose and violently rubbing the temples with green ginger, which she had first masticated’.47 On another occasion a pregnant woman who had been accidentally shot was brought to the hospital. She was attended by a Chinese nurse and midwife; the nurse 62

‘Family-Centred Care’ in American Hospitals in Late-Qing China swathed the new-born ‘hand and foot [with its] face only remaining exposed’ and fed it its first food which was ‘a little paste prepared from cakes composed of sugar and rice flour, with which fare the little one seemed quite satisfied’. Parker was told that ‘this is the common nourishment, the infant not being put to the breast for one or two days.’ He tells us that the Chinese midwife made: [A] great objection to the application of cold water to the abdomen to produce contractions of the uterus, and to stop the haemorrhage, and, on being asked what means the Chinese adopted, the reply was, we ‘let the patient alone’.48

In such passing asides one can glean something of the variety and depth of the families’ involvement in the life of the hospital and sometimes, the missionary’s attitude towards his patients and their customs and beliefs. Since Peter Parker made frequent mention of family members in his published cases, much of the remainder of this chapter relies upon his reports. His hospital was not unique, however, and all of the relevant events he described had their parallels in other mission hospitals for at least the next sixty years. When he first opened the hospital in Canton, Parker had anticipated difficulty ‘in receiving females as house patients’ because, he noted, it was ‘regarded as illegal’ for a woman to enter the foreign factories area where he was situated. The difficulty, though, had proved more imaginary than real. Women whose condition meant that they should remain in hospital had been ‘attended by some responsible relatives, – wives by their husbands, mothers by their sons, daughters by their brothers.’ He found it ‘truly gratifying to see the vigilance with which these relatives’ duties have been performed.’49 In 1839, for example, when the first death occurred following surgery in his hospital, he reported that the ‘husband was asleep by the patient’s side’.50 The attendance statistics Parker quotes seem to bear out his observation that women were not deterred from consulting him. He does not tell us how many of the 925 patients he saw in the first three months of operation in 1836 were admitted as in-patients, but we do know that 270 of them were female. An analysis of Parker’s statistics reported between 1836 and 1849 reveals that the rate of admission for patients suffering from obviously ‘female’ complaints accelerated over that time.51 By allowing relatives and servants to live-in with patients, Parker had access to, and thus the opportunity to influence, Chinese women as well as men. Friends and family acted as advocates on behalf of their sick relatives. Parker decided after his first three months to try to limit his workload by 63

Michelle Renshaw ‘nominally’ closing the doors to new patients for one month. In this, he failed. He estimated that at least one third of the 358 new patients who had managed to gain admittance did so by ‘importunity and the combined influence of their friends’.52 Equally, a family’s desire to protect their relative could frustrate the physician’s desire to admit a patient. In the experience of Dr Margaret Polk, women would often be surrounded by ‘people whose unreason will prevent her yielding herself to treatment’. Frequently she had had to turn away from: [A] case begging to be relieved after trying to reason with the father-in-law, the mother-in-law, two or three of the older sisters-in-law, the woman’s own family, and last but no means least in a Chinese family, the servants.53

Family members could also be valuable sources of information about the course of the patient’s illness and any past treatment. It was relatively common for the literati to provide Parker with a written patient history which might include their understanding of the cause of the illness. Less often, it seems, family members sought to be actively involved in deciding the treatment regimen. One such was the father of a 22-year-old woman who suffered from cataracts. In a note, he requested that Parker ‘couch the cataract’ or at least adopt a ‘quick and easy method of cure’ because it was going to be inconvenient for her to have to stay in hospital.’ He stressed that if this course was followed but the cure was not successful and ‘she should not be able to see’ he would still be ‘satisfied’.54 From Parker’s arrival in 1836, in contrast to America and Britain, most Western medical practices in China were weighted in favour of surgical, over medical, cases.55 There were two reasons for this. Firstly, Western medical therapeutics were not demonstrably more efficacious than traditional Chinese. Secondly, surgery was ‘almost without tradition in China’56 and missionaries believed that ‘the superiority of scientific surgery [was] more easily demonstrated to the Chinese than that of scientific medicine’.57 But surgery was risky and, to safeguard his reputation, Parker always required at least one family member or friend of the patient to consent before he would operate. His insistence on this policy was demonstrated when a 23-year-old man presented in November 1839 with an arm in such a state that Parker – and the colleagues he consulted – decided that his only chance of life was to have it amputated at the earliest possible opportunity. As the young man’s friends were not present to give permission, the operation was delayed until the next morning when consent could be obtained.58 Whenever Parker was persuaded to take into the hospital any patient whose prognosis was poor, he required, in addition to consent to operate, someone to indemnify the hospital in the event of the patient’s death. Such 64

‘Family-Centred Care’ in American Hospitals in Late-Qing China a case occurred during the first half of 1836 when a 13-year-old girl was brought in suffering from extreme ascites. He told her friends that if they insisted on leaving her at the hospital, instead of taking her home, they must be ‘satisfied’, after he had done his best to help, if she should die in the hospital. They agreed: she stayed, and was relieved of her abdominal swelling.59 Frequently, before a patient was admitted to the hospital, physicians would require them to name a ‘middleman’ who could act as an intermediary and, if necessary, on the patient’s behalf. Duncan Main, who had established his Church Missionary Society (CMS) Hospital in Hangzhou in 1885, insisted upon having an intermediary whose role included taking care of the patient’s clothing when it was exchanged for hospital garments. Many medical missionaries went so far as to require all in-patients to find a ‘local man to go surety for them’. This was firstly to cover burial costs in case no one would ‘come and claim the body’; secondly, to compensate the hospital for the loss of any property the patient might steal – the physician-in-charge of the CMS hospital at Ningbo recommended this practice because he believed that the ‘police are of little use’; and thirdly, to guarantee any unpaid fees.60 The requirement would not have struck Chinese patients as odd because it was common, in a society based on reciprocal relationships, for transactions to be effected through contacts. The roles of family and friends of Chinese patients were not limited to acting as companions, advocates, intermediaries or nurses: they were often also responsible for the patient’s nutrition. They collected fuel and brought, prepared and cooked patients’ meals. Just as the doctor referred to earlier was unable to provide his patients with nursing neither could he provide them with food: ‘[W]e have not money to feed you. You must bring your own grain.’61 This meant that the type of hospital rules so common at home could not be applied to diet in the hospitals in China. Some doctors wished they could be. It was, said one, a ‘very important thing with people who are so prone to over-eat, under-eat, to eat dead or half decayed food rather than see it thrown out, and to eat at any and all hours of the day or night.’62 A few tried. One doctor, in 1899, despaired of his Chinese patients who ‘almost invariably… refuse to take beef tea, or milk, or chicken broth... [t]hey prefer nothing, or peanuts, or raw pears, or pig’s stomach, and all sorts of sweetmeats and smuggle them in and eat them.’63 One of Parker’s patients was found five days after her arm had been amputated ‘with a bowl of oily sausages, which she was devouring even without rice.’64 Apparently, it did her little harm as her wound healed and she was discharged a month later. It was probably fortunate for them that the majority of patients in missionary-run hospitals ate Chinese food prepared by their own family 65

Michelle Renshaw members. Had this been the case in the MEM(S) hospital at Suzhou, in the 1890s, Anne Fearn’s young patients might not have died. She acknowledged that it was her ‘desire for cleanliness… and anxiety to provide only the best foods [that] inadvertently were responsible for bringing two dread[ed] diseases into the compound, tuberculosis and beriberi.’ By providing the more expensive polished rice, the hospital had: [U]nknowingly taken away the very vitamins they needed because, aside from their… three bowls of rice, they ate little else save a flavouring of cabbage, pork, chicken, or fish. First one girl and then another was sent home to die.65

In China, the role of the family in providing food to patients has rather more significance than it might in another setting. Dietetics had always been an integral part of Chinese medicine and moreover, knowledge of the role of diet in medical treatment and recuperation was not confined to medical practitioners but was widespread among all classes of society. Foods were classified in the same way as drugs were and could be prescribed – or proscribed – according to their supposed interaction with the person, their disease, their temperament, the season, and so forth, to re-establish ‘balance’, that is, health. ‘Warming’ foods could be used to compensate for problems classified as ‘cool’, ‘cool’ foods to help reduce heat symptoms and foods classified as ‘strengthening’ recommended following trauma, surgery or birthing.66 Medical missionaries were aware of the place of dietetics in Chinese medicine and one, Daniel MacGowan, thought that just as ‘the materia medica of China has merited and received attention from foreigners, their materia alimentaria [was] worth investigating’. He had observed that ‘culinary and dietary regulations abound’, particularly ‘selecting edibles for the same meal that are not incompatible’ because ‘articles which when taken separately are wholesome become noxious when in combination, so much so that such cases are classed among poisons.’67 The advantage to the patients’ psychological health is self-evident. They would not only have had evidence that their family cared about them, they would also have believed that the specific foods chosen would benefit them. The family would have also felt better, as Anderson puts it, ‘when they could do nothing else, as was all too often the case, they could at least make the patient feel that family, neighbors, and community cared and were acting to help.’68 But Margaret Polk’s complaint would be familiar to those in today’s hospitals wanting to introduce a ‘family-centred’ approach who encounter resistance from professional staff. As she put it, ‘women… usually bring two or three servants, which not only complicates the relations with the patient but complicates the housekeeping arrangements.’69 At Anne Fearn’s hospital 66

‘Family-Centred Care’ in American Hospitals in Late-Qing China ‘another factor contributing to our disorganisation was the special kitchen we were forced to maintain for our Mohammedan patients, who brought along special food and their own cooks to prepare it.’70 One hospital thought it worth the extra work and expense to take control of the provision and preparation of food but the patients obviously disagreed and, in 1888, the in-patients had had to be allowed ‘to return their custom of bringing their own food and cooking for themselves’, resulting in ‘its constant attendant – perpetual untidy wards’.71 As well as parents accompanying children, some children accompanied their parents. They were not always there in the capacity of carer but because the parent had no choice. In 1922, a woman suffering burns brought her ‘daughter and little boy with her’ to the Baptist hospital at Ningbo because ‘their home was burned and they didn’t have any place to stay’.72 Some, though, were there in a caring capacity, for example, a 54-year-old man whom Parker treated for ‘cataract of both eyes’ was attended by ‘his son twelve years of age, and two servants’.73 Another patient, an apparently ‘amiable’ 43-year-old woman, on whom Parker operated for cancer of the breast, came with her 12-year-old daughter.74 One father particularly impressed Parker. Lew Akin was 12 years old when her father signed the ‘usual indemnity’ for Parker to remove a seven-pound tumour from her hip: the ‘strength of [the father’s] natural affections’ was demonstrated by his ‘vigilance in his attention to his only child, continually, day and night’. Akin’s father, along with other ‘spectators’, was in the room when Parker operated but the ‘unsightly wound that presented as the integuments retracted ten or twelve inches apart, the incision being about ten inches, was too much for [him] to witness without tears’. He left the room but the girl’s cries, when Parker stitched the wound, ‘soon recalled him’.75 It was not unusual for family members to be present in the operating room in mission hospitals (such as in Figure 3.1, overleaf ). The most obvious reason for allowing them in was to comfort the patient in an alien, frightening, painful and often dangerous situation. In 1837, Parker performed what he described as the ‘first instance of the extirpation of the female breast from a Chinese’. The patient was a courageous 48-year-old woman, a maker of artificial flowers, who had had a ‘cancerous breast’ for six years. It seems her family was equally brave, both her husband and her son being present during the ground-breaking operation. She endured the procedure with ‘the fortitude characteristic of her sex’ while her family ‘commanded their feelings remarkably, and spoke cheerfully to their suffering friend.’76 When Parker performed a similar operation on a 26-yearold woman, the ‘several European and Chinese witnesses’ included her ‘devoted mother and sister [who] on seeing the poor sufferer as she fainted, all covered with her blood… could not refrain from weeping.’ 77 67

Michelle Renshaw Figure 3.1 A Family Witnesses an Orchidectomy Having been summoned to sign an indemnity for the hospital, the wife and son of the patient look on. The British doctor’s assistant weighs the diseased testicle which has been removed under anaesthetic. Source: Dianshizhai Hua Bao, Vol. Chen, No. 3 (1888), 14. Reproduced with permission of the Library, School of Oriental and African Studies, London University.

Family were not the only people who witnessed operations. When Parker made an incision to remove a fist-sized hydatid cyst from the breast of a 62year-old money-changer he ‘unluckily’ opened the cyst and he and the ‘bystanders [were] spattered with its foul contents, which resembled dark venous blood’.78 Parker was happy to accommodate this level of scrutiny of his work as he felt sure that it would serve to overcome ‘prejudice’ and lead to a wider acceptance of Western medical techniques and thereby to more Chinese coming under the influence of his Christian mission.

68

‘Family-Centred Care’ in American Hospitals in Late-Qing China Benefits to missionaries and consequences for patients Observing operations did more than reduce Chinese anxiety about what medical missionaries were doing. Parker thought it was also the best form of advertising. As he put it, ‘few operations could exhibit in a stronger light their confidence in foreign surgery’ than the one he had just performed for breast cancer.79 Simple procedures, such as separating the eyelids of a little girl of seven years, provided the opportunity to demonstrate his skill to larger numbers. He used a pair of curved scissors and the: [F]ine black eye, which had neither seen nor been seen for seven long years, was in a moment unhooded [which] impressed the spectators more than a successful treatment of half a dozen pulmonary affections would have done.80

In the first year of operation, Parker had received 2,152 patients but estimated that ‘not less than 6,000 or 7,000’ Chinese had visited his hospital: They have witnessed the operations, and have seen the cures. They are from nearly all parts of the empire; they carry with them the intelligence of what they have seen and heard. Consequently, from provinces more remote applications are made, new and anomalous diseases are presented, and the desirableness is daily increasing.81

When anti-foreign sentiment was high and rumours of foul deeds – such as Western doctors stealing the eyes of children to make medicines or to use in photography, and extracting ‘the fetus and placenta from pregnant women for medicinal and alchemical purposes and for sorcery’82 – were rife, it was essential that they welcomed visitors and acted as openly as possible. Without first-hand accounts from patients or their families it is difficult to be certain about the psychological benefit of having their family and friends care for them. But, if the recent research carried out in American hospitals is any guide, it would have been considerable for both patients and their families.83 From Parker’s and others’ accounts, we know that the mission hospital in China in the nineteenth century was a safer place for a patient undergoing major surgery than a hospital in America or England. An analysis of the results of the 144 surgical cases Parker published between 1835 and 1849 reveals a low death rate from amputation of a limb (5.6 per cent) and removal of tumours (3.2 per cent).84 By contrast, when Lister arrived at Glasgow Infirmary in 1860 ‘eight out of every ten amputations died [and] pyaemia almost always followed a compound fracture’.85 Half a century later another physician, J. Thomson, was to write about the ‘remarkable recuperative power’ of the Chinese after surgery, often major. According to him, it was ‘unanimously testified by all who have had 69

Michelle Renshaw to deal with them’ and his experience in Hong Kong had confirmed the ‘generally received opinion [that] recovery and convalescence are very much more rapid and complete in the average Chinaman than in the average Englishman’. To illustrate, he provided details of four of his patients who had recovered ‘in circumstances that one can scarcely believe would have been other than fatal in Europeans’.86 To what extent, if at all, Chinese powers of recuperation could be attributed to the presence of family in the hospital is debatable. But one can conjecture from the vantage point of present-day knowledge. Firstly, in Western hospitals of that period, death following surgery was mainly due to the high rate of infection and cross-infection associated with hospitals. As Robert Liston, a contemporary of Parker’s, described the situation at Edinburgh in 1835: No patient was admitted with a breach of surface, an ulcer, or a wound of any kind, without suffering erythema or erysipelas; and scarcely a single operation was performed, seldom even bloodletting, without the same results.87

In contrast, Parker records having seen erysipelas in only nine of the 32,600 patients who entered his hospital in the fourteen years to 1849.88 Similarly, John Kerr, who succeeded him at the Canton Hospital, met his first case of erysipelas in 1874, after twenty years of practice in China, and Thomson had never had an instance following an operation. Given that these medical missionaries agree that most of their Chinese patients who submitted to surgery did so only after prolonged illness, treatment by Chinese physicians and healers, and often as a ‘last resort’ – not the best case scenario for success – their recovery rate is even more remarkable. Could it have been the fact that friends and family were providing the nursing that contributed to the comparative safety of Chinese patients? Liston described the ‘foolish practice of washing every sore indiscriminately… with the same sponge’ in British hospitals, with the result that ‘a patient with a putrid sore, or labouring under an attack of erysipelas, soon became the means of spreading erysipelas throughout the ward.’ In a mission hospital in China, this was less likely to happen where all patients had their personal attendants.89 Also, knowing the patient intimately and being with them constantly would surely have improved the quality of observation above that of a harried, overworked nurse.90 Further, the surgical success rate would have been enhanced by the widespread policy, discussed earlier, of reluctance to operate on anyone without good prospects of recovery. Family and friends were instrumental in the implementation of that policy. The physician in charge of the LMS 70

‘Family-Centred Care’ in American Hospitals in Late-Qing China hospital at Xiaogan attributed the fact that no death had occurred in his hospital during 1902 to this approach. In the first instance, if he considered a patient to be a poor risk he would try to dissuade him or her from proceeding with the operation. But ‘should he still beg for it’ the physician would insist that he send for some friends or relatives to talk it over with them before deciding. ‘Much talking and arguing’ would ensue with the physician calling in ‘friend after friend’ until, usually, the patient concluded that the ‘advantages to be gained by operation [were] too small to warrant the risk’. If this failed and the patient insisted that the operation proceed the hospital had made it ‘sine qua non that there shall be one or more friends present at the operation, in order to see fair play.’ The plan, apparently, worked ‘splendidly. There is afterwards no suspicion that we have plucked out an eye or mysteriously extracted blood or “virtue” or what not. The Chinese are wonderfully suspicious and inventive and we need on that account to do everything quite openly.’ This vigilance did not end when the operation was concluded because after the patient was placed in a ward the physician demanded that a ‘friend shall remain with him until all danger of a relapse is past’.91 Conclusion In the United States today, family members might not think it necessary to be observers in hospitals to be assured that the physician is not removing organs to use in some arcane medicine, nevertheless, ‘vigilance’ is the term used by researchers to describe the role of family members who accompany patients in hospitals. ‘Vigilance’, in this context, has been defined as ‘the close protective involvement of family members with hospitalised relatives’.92 It is manifest as a ‘commitment to care’ involving wanting to protect the patient, acting as the patient’s advocate, watching for any changes, monitoring treatment, providing company and reassurance and demonstrating love. In a study of the ‘day-to-day experience of vigilance’, Carr and Fogarty report observing family members in a range of caring activities including feeding and bathing patients, moving them from bed to chair, providing exercises to increase mobility as well as providing ‘general comfort’.93 As the concept and practice of family-centred care spreads from paediatric to adult wards, acceptance is growing among health professionals and research suggests that it enhances the hospital experience and outcomes for both patient and their families. For children, these outcomes have included being less anxious, recovering and being discharged earlier and requiring less pain medication.94 Their parents experience less stress and ‘procedure related’ anxiety and feel that their presence has helped the child.95 In some hospitals, relatives of adult patients have been able to help with feeding, washing and allaying patient fears and have, themselves, felt useful 71

Michelle Renshaw and more confident about being able to care for the patient when they return home.96 Patients have told of feeling ‘comfort, strength, and support’ because family members were present; they felt that their family had acted as their advocates and, by interpreting and explaining information, had helped them to ‘understand, cope with, and reframe painful and stressful events’.97 There is no reason to suppose that these benefits would not have accrued to patients and their families in mission hospitals in China where, as has been shown, the involvement of families was even more extensive and included being responsible for the patient’s nursing and diet as well as being present for all procedures. It is somewhat ironic that the practice of families accompanying their relatives to hospital, being so enthusiastically embraced in Western hospitals, is now under threat in China. As China moves away from centralised planning to a regionalised, privatised market economy, few Chinese still have access to the free, or low cost, medical care they enjoyed before 1980. Costs have been shifted from the government to individuals, so that 90 to 95 per cent of total hospital income is now derived from ‘direct user charges’ and less than 15 per cent of the population is covered by medical insurance.98 Hospitals charge patients on a fee-for-service basis and separate fees cover such things as registration, the bed, laboratory tests, scans, food, nursing, operations, treatments and drugs. Families unable to meet these multiple expenses have no option but to accompany and cook and care for their sick relative. In 1998, an American medical student who spent time in a teaching hospital in the remote city of Jiamusi, in the Heilongjiang Province, described the infectious diseases ward as having: ‘five nurses, and 20 to 30 patients whose family members usually cared for them’.99 But smaller families – as a result of China’s one-child policy – and many elderly people – rising due to the increase in life expectancy, with more now living alone as workers are able to move between cities – are combining to put pressure on the diminishing number of offspring available to provide care for the growing number of aged parents and grandparents. A colleague from Beijing tells me that today the greatest concern he and his friends have is not being able to raise the money if their parents need to be hospitalised: ‘If they can raise the money to cover the medical expense [but] do not come to see them, even once, that is fine – [their parents will say] their children are still good.’100 Notes 1. For a summary of the history of hospital visiting policies, see A.W. Giganti, ‘Families in Pediatric Critical Care: The Best Option’, Pediatric Nursing, 24, 3 (1998), 261–6: 261–2. See also H. Hendrick, ‘Children’s Emotional WellBeing and Mental Health in Early Post-Second World War Britain: The Case of Unrestricted Hospital Visiting’, in M. Gijswijt-Hofstra and H. Marland

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2.

3. 4.

5.

6.

7.

8.

9.

10. 11.

(eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 213–42. For a comprehensive summary of the development of family-centred care in America, including a review of the literature, see B.H. Johnson, ‘FamilyCentered Care: Four Decades of Progress’, Families, Systems, and Health, 18, 2 (2000), 137–56. For a cross-cultural perspective, see L. Shields and J. Nixon, ‘Hospital Care of Children in Four Countries’, Journal of Advanced Nursing, 45, 5 (2004), 475–86. Johnson, op. cit. (note 2), 139. American Academy of Pediatrics Committee on Hospital Care, ‘Policy Statement: Family-Centered Care and the Pediatrician’s Role’, Pediatrics, 112, 3 (2003), 691–6. See J.M. Carr and P. Clarke, ‘Development of the Concept of Family Vigilance’, Western Journal of Nursing Research, 19, 6, December (1997), 726–40: 726. For example, see K.S. Powers and J.S. Rubenstein, ‘Family Presence During Invasive Procedures in the Pediatric Intensive Care Unit: A Prospective Study’, Archives of Pediatric and Adolescent Medicine, 153 (1999), 955–8; T.A. Meyers et al., ‘Family Presence During Invasive Procedures and Resuscitation: The Experience of Family Members, Nurses, and Physicians’, American Journal of Nursing, 100, 2 (2000), 32–43; D.J. Eichhorn et al., ‘During Invasive Procedures and Resuscitation: Hearing the Voice of the Patient’, American Journal of Nursing, 101, 5 (2001), 48–55. Cincinnati Children’s Hospital Medical Center, Family-Centered Care Philosophy and Core Concepts, 2005, http://www.cincinnatichildrens.org/ about/fcc, accessed 26 January 2009. Medical missions to China were predominately sponsored by British and American Protestant churches. For new medical missions established between 1890 and 1910, American out-numbered British, two to one. M. Renshaw, Accommodating the Chinese: The American Hospital in China, 1880–1920 (London: Routledge, 2005), 11. There were only three in 1810, a number that had increased to 129 by 1873, of which a third were for the mentally ill. See J. Bordley and A.M. Harvey, Two Centuries of American Medicine (Philadelphia: W.B. Saunders Company, 1976), 57; C.E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (New York: Basic Books, 1987), 118–9; G. Rosen, ‘The Hospital: Historical Sociology of a Community Institution’, in E. Freidson (ed.), The Hospital in Modern Society (London: Free Press of Glencoe, 1963), 1–36: 25. ‘Walks About Canton: Extracts from a Private Journal’, Chinese Repository, 4 (1835), 44–5. Renshaw, op. cit. (note 8), 11.

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Michelle Renshaw 12. C.J. Davenport, ‘Secretary and Treasurer’s Report for 1906’, China Medical Journal, 21, 3 (1907), 146. 13. Many dispensaries lived on as out-patient departments of hospitals. See, P. Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 182–4. 14. Renshaw, op. cit. (note 8), 113–14. 15. The survey was carried out by the China Medical Missionary Association, ‘Medical [Mission] Statistics for 1906’, China Medical Journal, 21, 3 (1907), Endpaper. 16. ‘Letter to the Editor: Woman’s Hospital in Soochow’, Chinese Medical Missionary Journal, 1, 2 (1887), 73. 17. ‘Hospital Reports: Tsing-Kiang-Pu (Qingjiangbu) Hospital’, Chinese Medical Missionary Journal, 19, 1 (1905), 32–4: 33. 18. E. Reifsnyder, ‘Methods of Dispensary Work’, Chinese Medical Missionary Journal, 1, 2 (1887), 67–9: 69. 19. ‘Why Medical Missionaries are in China?’, Chinese Medical Missionary Journal, 14, 4 (1900), 278–80: 279. 20. Renshaw, op. cit. (note 8), 95–6. 21. O.L. Kilborn, Heal the Sick: An Appeal for Medical Missions in China (Toronto: Missionary Society of the Methodist Church, 1910), 189. 22. P. Parker, ‘Ophthalmic Hospital at Canton: The Ninth Report, Being for the Quarterly Term Ending December 31st, 1838’, Chinese Repository, 7 (1839), 569–88: 577–8. 23. Rosenberg, op. cit. (note 9), Ch. 12, 286–309. 24. R. Hawker, ‘A Day in the Life of a Patient’, Nursing Times, 12 June 1985, 43–4: 44. 25. Sisters of Mercy, Annual Report of St John’s Hospital and Training School for Nurses: October 1913–September 1914 (St Louis: 1915), 18–19. 26. R. Hawker, ‘Rules to Control Visitors, 1746–1900’, Nursing Times, 21 March 1984, 49–51: 50. 27. P. Parker, ‘Ophthalmic Hospital at Canton: Third Quarterly Report, for the Term Ending on the 4th of August, 1836.’ Chinese Repository, 5 (1836), 185–92: 185. 28. A.P. Peck, ‘The Development of the Medical Department of a Mission Station’, Chinese Medical Missionary Journal, 16, 1 (1902), 13–15: 14. 29. W.H. Jefferys and J.L. Maxwell, The Diseases of China (Philadelphia: P. Blakiston’s Son & Co., 1910), 7. 30. United States Bureau of the Census, Historical Statistics of the United States, Colonial Times to 1970, bicentennial edn (Washington: U.S. Department of Commerce, 1975), 75–6. 31. J.H. Snoke, ‘Administration of Mission Hospitals in China’, China Medical Journal, 37, 10 (1923), 860–6: 862.

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‘Family-Centred Care’ in American Hospitals in Late-Qing China 32. One-hundred and ninety-two hospitals provided information with reference to nurses: H. Balme and M.T. Stauffer, An Enquiry into the Scientific Efficiency of Mission Hospitals in China, paper presented at the Annual Conference of the China Medical Missionary Association (Peking, 1920), 31. 33. Paper read to Biennial Conference of the Nurses’ Association of China, Fuzhou: E.J. Haward, ‘Is China Ready for Women Nurses in Men’s Hospitals?’, Chinese Medical Missionary Journal, 33, 2 (1919), 174–7: 177. 34. In America, most educated nurses were employed by families who worked for them, both at home and when they went to hospital, as ‘Private Duty Nurses’. Student nurses provided hospital labour: E. J. Halloran, personal Communication, 2 December 2005. 35. See for example, ‘Rules for Companions to Patients’ in Sisters of Mercy, op. cit. (note 25), 21. 36. See, for example, M.H. Polk, ‘Women’s Medical Work’, Chinese Medical Missionary Journal, 15, 2 (1901), 112–19: 114. 37. A.D. Peill, ‘Roberts’ Memorial Hospital, T’sang-Chou’, Chinese Medical Missionary Journal, 18, 2 (1904), 99–100: 100. 38. A.D. Peill, ‘Hospital Reports: Roberts’ Memorial Hospital, T’sang-Chow’, Chinese Medical Missionary Journal, 20, 1 (1906), 44–7: 44. 39. W.A. Tatchell, ‘The Training of Male Nurses’, China Medical Journal, 26, 5 (1912), 269–73: 269. 40. D.M. Gibson, ‘The Old-Time Hospital and Assistants’, China Medical Journal, 33, 5 (1919), 475–6: 475. 41. Peill, op. cit. (note 37), 15. 42. Balme and Stauffer, op. cit. (note 32), 15–16. 43. ‘Medical Discussions in Shanghai: Following Dr Polk’s Paper on “Women’s Medical Work’’’, Chinese Medical Missionary Journal, 15, 4 (1901), 299–300: 299. 44. P. Parker, ‘Ophthalmic Hospital at Canton: The Eighth Report Including the Period from January 1st to June 30th, 1838’, Chinese Repository, 7, 2 (1838), 92–106: 94–5. 45. J.M. Bixby, ‘Kieh-Yang Hospital Report’, Chinese Medical Missionary Journal, 19, 6 (1905), 261–3: 262. 46. L.E.V. Saville, ‘Hospital Reports: London Mission Women’s Hospital, Peking, Annual Report, 1905’, Chinese Medical Missionary Journal, 20, 4 (1906), 188–91: 188. 47. Parker, op. cit. (note 22), 582. 48. This was the first baby born at the hospital: P. Parker, ‘Twelfth Report of the Ophthalmic Hospital at Canton: From 21st November, 1842, to December 31st, 1843’, Chinese Repository, 8, 6 (1844), 301–20: 305.

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Michelle Renshaw 49. P. Parker, ‘Ophthalmic Hospital at Canton: First Quarterly Report, From the 4th of November 1835 to the 4th of February 1836.’ Chinese Repository, 4, 10 (1836), 461–73: 462. 50. Parker, op. cit. (note 22), 571. 51. Parker, op. cit. (note 49), 463. Parker recorded but did not report numbers of female patients, see M. Renshaw, ‘The Nineteenth Century Hospital: Europe’s Gateway to Death – China’s Safe Haven?’ (Honours, University of Adelaide, 1998), 25–7. 52. P. Parker, ‘Ophthalmic Hospital at Canton: Second Quarterly Report, from the 4th of February to the 4th of May, 1936’, Chinese Repository, 5, 1 (1836), 32–42: 32. 53. Polk, op. cit. (note 36), 141. 54. Parker, op. cit. (note 52), 37. 55. As Rosenberg pointed out, in relation to antebellum hospitals in America, many ‘surgical’ patients were admitted but few operations undertaken. Treatment more often consisted of ‘diet and rest, the regular changing of dressings, and the healing powers of nature’, Rosenberg, op. cit. (note 9), 28. 56. I. Veith, The Yellow Emperor’s Classic of Internal Medicine: Translated with an Introductory Essay (Berkeley: University of California Press, 1972 [1949]), 2. 57. Kilborn, op. cit. (note 21), 197. 58. P. Parker, ‘Ophthalmic Hospital in Canton: The Fourth Quarterly Report, for the Term Ending on the 4ht [sic] of November, 1836’, Chinese Repository, 5, 7 (1836), 323–32: 229–31. The patient was seated in a chair, ‘supported around the waist by a sheet’ and less than a minute after the ‘application of the scalpel… the arm was laid upon the floor’. Po Ashing, was as far as Parker knew, ‘the first Chinese… who has ever voluntarily submitted to the amputation of a limb.’ 59. Ibid. 60. Twenty-Sixth Annual Report: CMS Hospital, Ningbo (Ningbo: C.M.S. Medical Mission, 1912), 198. 61. Peck, op. cit. (note 28), 14. 62. Bixby, op. cit. (note 45), 263. 63. ‘Hospital Reports’, Chinese Medical Missionary Journal, 13, 1 and 2 (1899), 56–7. 64. Parker, op. cit. (note 22), 578. 65. A.W. Fearn, My Days of Strength: A Woman Doctor’s Forty Years in China (London: Robert Hale Ltd., 1940), 64–5. 66. For discussion of Chinese Traditional Medicine and dietetics, see, E.N. Anderson and M.L. Anderson, ‘Folk Dietetics in Two Chinese Communities, and its Implications for the Study of Chinese Medicine’, in Arthur Kleinman et al. (eds), Medicine in Chinese Cultures: Comparative Health Care in Chinese and Other Societies (Washington: U.S. Department of

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67.

68. 69. 70. 71. 72.

73. 74.

75.

76. 77.

78. 79. 80.

81.

Health, Education and Welfare, 1975), 143–76. See also, ‘Legacy of China’, Part 3 of Louis E. Grivetti, ‘Nutrition Past, Nutrition Today: Prescientific Origins of Nutrition and Dietetics’, Nutrition Today, 26, 6 (1991), 6–17. For a more general study of the place of food in Chinese culture, see K. C. Chang and E.N. Anderson, Food in Chinese Culture: Anthropological and Historical Perspectives (New Haven: Yale University Press, 1977). Linda Koo has demonstrated the extent of lay knowledge and use of food to prevent and treat disease in Hong Kong in 1981, see L.C. Koo, ‘The Use of Food to Treat and Prevent Disease in Chinese Culture’, Social Science and Medicine, 18, 9 (1984), 757–66. For a recent case study, see also E.N. Anderson, ‘Fishing People’s Medicine: Variations on Chinese Themes’ (2002), http://mcel.pacificu.edu/aspac/papers/scholars/anderson, accessed 26 January 2009. D.J. MacGowan, ‘Report on the Health of Wenchow for the Half-Year Ended 30th September 1881’, in Customs Gazette: Medical Reports, No. 22 (Shanghai: Imperial Maritime Customs, 1881), 14–50: 45. See Anderson, ‘Fishing People’s Medicine’, op. cit. (note 66). Polk, op. cit. (note 36), 114. Fearn, op. cit. (note 65), 65. ‘Report of the Mission Hospital and Dispensary, Taiwanfu, Formosa’, Chinese Medical Missionary Journal, 2, 1 (1888), 94–5: 94. H.N. Smith, ‘Nurses Training School’, Hwa Mei Hospital (Ningpo, China) Report for 1921 (Shanghai: American Baptist Foreign Missionary Society, 1922), 11–14: 12. Parker, op. cit. (note 49), 469. P. Parker, ‘Ophthalmic Hospital at Canton: Seventh Report, Being That for the Term Ending on the 31st of December, 1837’, Chinese Repository, 6, 9 (1837), 433–45: 439. P. Parker, ‘Ophthalmic Hospital at Canton: The Sixth Quarterly Report, for the Term Ending on the 4th of May, 1837’, Chinese Repository, 6, 1 (1837), 34–40: 38–9. Parker, op. cit. (note 74), 437–8. She was discharged five weeks later. P. Parker, ‘The Fourteenth Report of the Ophthalmic Hospital, Canton, including the Period from 1st July 1845, to 31st December, 1847’, Chinese Repository, 17, 3 (1848), 133–50: 136, 137. Parker, op. cit. (note 48), 307. Parker, op. cit. (note 74), 438. P. Parker, ‘Ophthalmic Hospital in Canton: The Fifth Quarterly Report, for the Term Ending on the 4th of February, 1837’, Chinese Repository, 5, 10 (1837), 456–62: 461. Parker, op. cit. (note 58), 332.

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Michelle Renshaw 82. P.A. Cohen, History in Three Keys: The Boxers as Event, Experience, and Myth (New York: Columbia University Press, 1997), 165–6. 83. J.M. Carr and J.P. Fogarty, ‘Families at the Bedside: An Ethnographic Study of Vigilance’, Journal of Family Practice, 48, 6 (1999), 433–8. See also Giganti, op. cit. (note 1); Powers and Rubenstein, op. cit. (note 6); Meyers, op cit. (note 6); and Eichhorn, op. cit. (note 6). 84. Renshaw, op. cit. (note 51), 57–62. 85. R. Traux, Joseph Lister: Father of Modern Surgery (London: George G. Harrap & Co. Ltd, 1947), 56. 86. J.C. Thomson, ‘Surgery in China (Continued)’, Chinese Medical Missionary Journal, 6, 2 (1893), 69–79: 70. 87. R. Liston, ‘Clinical Lecture on Erythemia and Erysipelas’, Lancet (1835), 324–31: 325. 88. Renshaw, op. cit. (note 51), 62. 89. Liston, op. cit. (note 87), 325. 90. There are too many other contributing factors for a direct comparison to be made between the infection rate in a missionary hospital in China, which more closely resembles the ‘cottage’ hospital found, by Simpson in 1872, to be a safer place for patients, and a major ‘teaching’ hospital in the West where all patients were ‘material’. For example, see Rosenberg, op. cit. (note 9), 122. The fact that post-mortem examination and dissection were forbidden in China until 1913, I contend, would also have contributed to the low rates of cross-infection in hospitals. Renshaw, op. cit. (note 51), 67–9. 91. ‘L.M.H., Hiau-Kan Annual Report’, Chinese Medical Missionary Journal, 17, 3 (1903), 124–5. 92. Carr and Fogarty, op. cit. (note 83), 433. See also Carr and Clarke, op. cit. (note 5). 93. Carr and Fogarty, ibid., 435. 94. American Academy of Pediatrics, op. cit. (note 4), 692–3. 95. Powers and Rubenstein, op. cit. (note 6), 958. 96. E.J. Garton, ‘In Praise of Open Visiting’, Nursing Times, 11 October 1979, 1747. 97. Eichhorn, op. cit. (note 6), 53. 98. Q. Meng et al., ‘The Impact of Urban Health Insurance Reform on Hospital Charges: A Case Study from Two Cities in China’, Health Policy, 68, 2 (2004), 197–209: 198. 99. S. Eigles, ‘Medicine in China and the U.S.: Observations from an American Medical Student’, Oberlin Alumni Magazine, Spring (1998), http://www.oberlin.edu/alummag/oampast/oam_spring98/medicine.html, accessed 7 January 2009.

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‘Family-Centred Care’ in American Hospitals in Late-Qing China 100. My thanks to Zhang Dapeng whose first-hand account helped me understand the situation in China today.

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4 Care, Nurturance and Morality: The Role of Visitors and the Victorian London Children’s Hospital

Andrea Tanner Visitors at the Hospital for Sick Children, Great Ormond Street, fulfilled an economic, social and marketing role at an institution which, in its earliest years, struggled against significant opposition from medical and charitable critics. Men and women from the respectable classes found a function that reflected well their philanthropic credentials, and that also opened up social and professional opportunities. The parents and families of the patients, however, found themselves marginalised by the hospital, and granted little scope to influence the hospital experience of their children or to interact with the supporters of the institution.

Children’s hospitals in Britain were a late specialist institution. The first were not founded until the 1850s, against considerable opposition from the medical establishment and lay opinion that decreed children were not suitable objects for hospital treatment.1 Once established, the management of these specialised institutions was largely in masculine hands, as was the clinical care of the patients, and the all-important fundraising.2 Visiting rights and opportunities, however, were open to both sexes, and visitors were an important factor in a hospital’s relationship with its supporters and in the creation of its wider profile. A bad visit for a member of the public – for example, where staff were deemed to be rude or unprofessional – could result in adverse publicity and a drop in donations; a successful one, by contrast, might attract support of a family or church congregation for more than a generation.3 As witnessed by the foremost Victorian publication on hospitals, ‘[v]oluntary hospitals live by popular favour, and to take away that is to deprive them of the breath of life’.4 The following is a consideration of the role of visitors in the life and growth of the Hospital for Sick Children, Great Ormond Street (HSC), the first and most influential of the British children’s hospitals, from 1852 until 1879. 81

Andrea Tanner There were, in essence, three different types of visitor to the HSC: male management committee members who took turns to inspect the establishment on behalf of the hospital governing body; women – and less commonly, men – who acted as formal, but more often informal, commentators on the cleanliness and nursing standards of the institution; and the friends and families of the patients. This last group was subjected to high levels of regulation and frequent exclusion from the wards, and was regarded as something of an irritant to the smooth running of the institution.5 Although presumably the most important group to the patients, it occupied the lowest rung in the visitor ladder as far as the hospital was concerned, although there were contradictions. Without parental consent there would be no patients, and it was important to ‘sell’ the hospital’s services to the families. This was no mean feat for the HSC; London’s poor housewives had well-established networks of local support in times of family sickness, and removing a sick child to this new institution could upset the delicate balance of neighbourhood dependence.6 In order to induce them to proffer their children to the hospital for treatment, it had to offer a level of care and range of services that made the transaction worthwhile. Once the child was admitted, however, his or her family was subject to intense regulation and periods of exclusion. Subscribers to children’s hospitals were wooed with tales of parents as decent hard-working people who could not afford to pay for the medical care of their children, and thus, worthy of assistance. However, in contrast, parental neglect or vicious behaviour was also seen as the cause of their children’s sickness. The General Hospital and Dispensary for Children, Manchester claimed its justification for existing was: In counteracting the thousand nameless evils which attend bad feeding and bad nursing, or the neglect and vices of the parents; and which either nip in the bud the precious lives of these ‘little ones’, or cause them to grow up sickly and diseased men and women – their lives too often a burden to themselves and others!7

In the earliest days of the hospital’s life, certain maternal responsibilities were still expected to be fulfilled. For example, mothers of in-patients were charged with undertaking their child’s laundry. Every in-patient was supplied with slippers and a wrapper by the HSC, but parents were expected to supply decent clothing for all but the eruptive fevers, and to take away the dirty clothing and linen for washing. Measles and scarlet fever cases were put in fever wards, separated from the rest of the hospital, and in these cases the HSC supplied all clothing, and returned the patients’ own clothes, disinfected, on discharge.8 As the hospital grew, however, and the dangers of 82

Care, Nurturance and Morality risking the export – or import – of infection through clothes and bedding became appreciated, this task was gradually assumed by the hospital itself. Once mothers were no longer required as washerwomen, it was relatively simple to employ the fear of infection as the reason for their increased exclusion from the wards.9 Among the non-family supporters, men and women rarely visited the hospital at the same times, and the sexes played differing roles in the monitoring and publicising of the hospital. Men primarily acted as unpaid inspectors, reporting on everything from ward discipline to accuracy in record keeping, and their reports became part of the official life of the hospital. Women, or, to give them their Victorian nomenclature, ladies, were split into two camps; the official visitors – who were there at the request of the matron or lady superintendent – and the casual afternoon callers for whom a few hours at the children’s hospital was a respectable and appealing part of the metropolitan social round. Male visiting governors and casual visitors Male visitors were the official face of the hospital visiting system, although numerically they were far less significant than female official visitors. From the hospital’s opening on 14 February 1852, members of the management committee agreed to be placed on a monthly rota of hospital visiting once a week, with their comments recorded in a special ledger that was presented at each committee meeting. This system of regular official inspections by visiting committees was already well-established in the workhouses created by the Poor Law Amendment Act of 1834, when specific guardians were charged with visiting the institutions to ensure that the terms of the Act were being adhered to, and the ratepayers’ money was not being wasted.10 The principle of having official visitors had long been accepted by the voluntary hospitals, but their roles represented opposing advantages for the boards of guardians of the Poor Law unions and the committees of management of the hospitals. For the former, the fact that they had a visiting committee, made up of elected, unpaid guardians enabled them to deflect requests from outside bodies – in particular charitable visiting societies and the press – to enter the workhouses to inspect arrangements and talk to the inmates.11 The exclusion of outside visitors to workhouses and other Poor Law institutions was mainly directed at women, who made up over eighty per cent of the supporters of the Workhouse Visiting Society.12 For the hospitals, on the other hand, the visitors offered not concealment, but the opportunity to claim total transparency in matters of financial management and patient care. In order to cultivate and keep support, voluntary hospitals had to be perceived as open institutions. 83

Andrea Tanner Perhaps because they were ultimately responsible for raising and authorising the expenditure of the funds to keep the hospital running, the principal concern of the official visitors was the state of the fabric of the buildings. Most of the male visitors made no mention of the patients or the staff, preferring to restrict their recommendations to the guttering, ventilation, and, above all, the water closets of the hospital. The men who undertook this task – which, like all their work for the institution, was voluntary and unpaid – were among the most distinguished in the land. They included the co-founder of the hospital, royal physician Sir Henry Bence Jones, rector of St Martin in the Fields Sir Henry Dukinfield, and leading barrister Edward Futvoye.13 No doubt the nurses and the patients were grateful that they concentrated on the drains, and not on them, during their perambulations. Having said that, any absence of order, particularly with the nurses’ dress, was noted, and the matron reprimanded for allowing slackness. The experience of going round the ward, however, could affect the sensibilities of the novice visitor, as exemplified by governor John B. Owen, who was moved to flights of Dickensian prose when he first began his inspection duties, remarking, ‘the dear babes seem tranquil and at home.’14 The purpose of the visiting governor was to act as a direct conduit to the management committee from the hospital. The committee was made up of busy men with pressing professional and charitable lives, and a direct report of a faulty drain meant that it was dealt with quickly.15 It also ensured that the maintenance staff was kept on its toes. At the Annual General Meeting, management committee members could report, with some credibility, that they knew every brick of the building and were guarding the physical environment of the hospital and, by extension, the investment of the donors. The visiting governors themselves could gain benefit from this voluntary activity. As Sandra Cavallo has noted, ‘participation in the management of hospitals… favoured the creation of networks of interest allowing the establishment of contacts, business links and influence over work and career opportunities.’16 This is perhaps best seen in the creation and involvement of business elites in provincial hospitals, as detailed by Anne Borsay and Martin Gorsky.17 However, London’s wealth and significant philanthropic cadre provided the opportunity for association with hospitals to an unrivalled scale, with over forty new specialist hospitals alone having opened in the capital between 1820 and 1860.18 Involvement in a London hospital arguably could bring the male volunteer better social and business contacts, and personal cachet, than a lifetime of membership of a livery club or the Oddfellows. The cream of British society was happy to have their involvement with metropolitan hospitals advertised in published subscription lists, and in the accounts of attendees at annual fundraising dinners that so liberally populated the pages of The Times and the weekly 84

Care, Nurturance and Morality Table 4.1 Distinguishable Male Visitors to the Hospital for Sick Children, London, 1856–60 to 1876–9 Doctors 1856–60 1861–5 1866–70 1871–5 1876–9

6 17 46 54 38

Titled Male 5 8 17 15 14

Military 5 10 26 35 22

Clergymen 7 30 87 71 101

Other Unspecified 14 101 233 325 325

Source: Great Ormond Street Visitors’ Books.

press of the capital. At these jamborees, speeches were given by members of the Royal Family, by the aristocracy, lords temporal and spiritual, and by senior politicians. A subscription of one hundred guineas and a filled silk purse might be the gateway to a few words over the port with the Duke of Connaught, Lord Rosebery or Lord Salisbury. It is hard to imagine a more open admission into London society than that offered by the hospitals, all of which enjoyed aristocratic, if not Royal, patronage.19 As Keir Waddington has observed, the philanthropic psyche, as exploited by London hospitals, ‘could be both altruistic and intrinsically selfish’.20 While the majority of the male official visitors were acting in their official capacity on behalf of the hospital management, the visiting books from 1852 to 1879 do contain references to more casual supporters, who could turn up at the door any afternoon to be shown round. Table 4.1 shows that they can be divided into distinct groups. The most prominent identifiable group of unofficial male visitors were Church of England clergymen, many of whom accompanied small groups of ladies. They tended to leave comments approving of the Christian atmosphere of the hospital and the apparent happiness of the children. Their visits often resulted in the hospital being mentioned in future sermons, and donations being sent to the hospital from their congregations. Men who described themselves as doctors are included in the visitors’ books, but not in the numbers one might have expected, and roughly half of those so described came from Continental Europe or North America. It is possible that these foreign medical visitors came to see first hand the work of this pioneering paediatric institution, and reported back to their peers, although the author has been unable to discover any published proof of this. Military gentlemen are surprisingly prominent, most visiting with their wives, but occasionally coming in small groups of 85

Andrea Tanner officers, the Navy outnumbering the Army by two to one. Significant among those men who gave addresses, but no profession, were members of Oxbridge colleges and heads of banking and insurance companies. Those men who did not identify themselves by vocation or profession tended to visit the hospital with their wives and, on occasion, their children. Although they rarely comment on what they thought of the institution, their names can be found among the sponsoring governors in the patient admission registers. Whether they were already subscribers and were checking their investment, or became supporters as a result of visiting the hospital, is impossible to say. The visitors’ books would tend to confirm that the casual callers were of the more respectable and affluent classes, with banking, business and political surnames being prominent. These men were economically successful, but arguably influenced by the prevailing evangelical censoriousness that demanded self-denial and virtuous action. Mid-nineteenth-century London demanded public proof of Christian belief and practice, but offered unrivalled opportunities for aggressive economic profiteering. Charity offered escape and reassurance. In the words of Boyd Hilton, ‘public service was less the outcome of spiritual assurance than a means by which convinced sinners, ever conscious of Satan at their elbows, sought release from guilt and a buttress for precarious faith.’21 The profile of the male visitors, both official and casual, would indicate that the Victorian imperatives of compassion, concern for the poor, ambition and social pressure, might be identified in the supposed motivation for their involvement in the charity. One name missing from the visitors’ books, but which is important in the annals of the hospital’s history is that of Charles Dickens. Dickens’ involvement with charities of all kinds has been well documented, and his relationship with the HSC in particular has been the object of study in recent years.22 The portrait of the hospital in Our Mutual Friend is one of the few flattering accounts of a specific charity to appear in his fiction.23 This, and his journalism, certainly stressed the good work that the hospital was doing for the helpless sick poor children of the capital, but it also highlighted the need within this institution for his most favoured form of philanthropy, namely individual benevolence borne of goodness of heart.24 In his writings and his speeches, Dickens provided a template for how individuals could actively support the hospitalised child.25 The role of women supporters The part female hospital supporters were allowed to take was firmly rooted in the central maternal role considered best suited to their sex by the patriarchal tenets of the time. The hospital’s male medical and governing bodies did not countenance their presence on the board of management, or even the nursing committee. The subordinate role of educated women at the 86

Care, Nurturance and Morality HSC, as opposed to other children’s hospitals, was noted and challenged by at least one female journalist: Surely if woman’s quick and ready sympathy, woman’s tenderness of heart and hand and voice, woman’s ingenuity in soothing pain and devising a thousand ways and means of adding inexpensively to comfort, order and regularity, be anything more than a poet’s dream or a lover’s fancy, here, of all places in the world, is her ministering presence needed, here, in virtue of the maternal qualities of her nature, should she surely be found. And we cannot help thinking that the benevolent men who form the management committee would find their hands strengthened, their hearts comforted, and the funds of the hospital enlarged, by admitting women side by side with them as fellow-labourers in the same field of love and charity, which has for its harvest here the succour of those of whom Christ says, ‘Of such are the kingdom of Heaven’.26

Her protest was in vain. The middle and upper class women’s role at the hospital was a mirror of that in society at large. They were permitted to sit by the beds of the sick, but could not direct the politics, finances, or administration of the institution. Their function – as in the world outside the hospital – was to provide personal social service. The attitude prevailed, as evidenced by the comments on the innovation of women board members in the late 1940s by one of the senior consulting staff, [Women committee members] are absolutely indisposable [sic] in many matters of detail, the detail occupies the same perspective as some major issue. Some are strangely unaware of the fact that it is the doctors and nurses who actually hold up the hospital and incline to think they are the based metal rather than the gilt edge security.... [But] we cannot do without them, this sums it all up.27

Most women supporters of the HSC were involved in day-to-day fundraising. They were barred from attending the annual fund-raising dinner as full guests – it was strictly a men-only affair – but were allowed in to sit in the gallery to listen to the speeches.28 While this jamboree was the principal fund-raising event for most of the nineteenth century, it was women who organised year-round bazaars, collections and tea parties in support of specific cots, or for the general running of the hospital.29 They knitted vests and jackets for the children, and sent in the outgrown clothes of their own offspring for the patients, along with books – the majority of which were spiritual in character – toys, fruit and flowers. In this, they were in the very best of company. The patron of the hospital, Queen Victoria, and her daughters were renowned supporters of the institution, and often sent in 87

Andrea Tanner consignments of fruit and items of clothing sewn by the female members of the royal household.30 On one occasion, the Queen sent hundreds of toys, ordered from a toy factory she had visited while on holiday in Germany.31 Victoria’s gifts were not only a publicity dream, but her example encouraged her lesser subjects to give to the institution. However, while fund-raising and making clothes for the patients were important aspects of the hospital’s economy, women supporters were a more significant presence within the building than were their male counterparts. The lady visitor was a vital part of the hospital structure, and, as such, was cultivated by the management and senior staff. Official lady visitors In British paediatric hospitals in the second half of the nineteenth century, lady supporters – usually relatives of governors: [W]ould… exert an often powerful influence indirectly as members of ladies’ committees, who visited hospitals, talked to patients and nurses, took stock of complaints, general morale, and the state of the wards, then communicated their opinions to the hospital secretary or board of management.32

The relationship was not always easy; barred from the boardroom, some ladies’ committees strove hard to mould the institution into the image of the perfectly-run middle-class home, and treated the matron and staff as they did their own servants.33 At the Liverpool Infirmary for Children, the ladies’ committee not only inspected the institution regularly, but also had direct control over the matron, and was especially forceful in the dismissal of unsatisfactory nurses.34 In 1862, the ladies’ committee of the Birmingham Children’s Hospital began in the same vein as that in Liverpool, but their interference vexed the lady superintendent so much that, by 1869, their role was restricted to ward visiting, soon after which the committee was dissolved altogether.35 The hospital secretary acknowledged that his board was reluctant to lose their financial support, and, as such, allowed a group of lady visitors to visit periodically to look over the wards, but with no power over the authorities, stating emphatically, ‘[t]he object of appointing them is to secure their interest in the Hospital.’36 The role of official lady visitors at Edinburgh Children’s Hospital, by contrast, was controversial and emphatic. They dealt with the hospital female staff as they would have dealt with refractory domestic servants and demanded a high level of attention from the doctors and the secretary. The committee’s secretary engineered a campaign against the matron of the hospital that ended in the latter’s resignation, emphasising the difficulties the earliest children’s hospital matrons – who were hired for their housekeeping, 88

Care, Nurturance and Morality and not nursing or managerial, abilities – had in negotiating with committees of middle- and upper-class women.37 The women who inspected the hospital at the invitation of the lady superintendent of the HSC did not begin their work until 1860; before that date, all women who visited the hospital did so on an unofficial basis. The first lady inspector was Mary West, the wife of Dr Charles West, the founder of the hospital, and later lady inspectors included the wives of other physicians, and the redoubtable Louisa Twining. The quality of observation, from the first, was of a different order to that of their male counterparts. These women were looking over the hospital as if it were their own home and the nurses their domestic servants. They criticised every aspect of the nurses’ appearance, manner and working practices, not scrupling at personal comments, ‘Eliza (the nurse in charge of teaching convalescing patients) has good teaching skills and conducts her activities well, but it’s a great pity E is too indolent to keep this up…’.38 One constant point of censure was the amount of food the nurses wasted, both that served to the children, and their own rations. The official visitors did not seem to appreciate that very sick children might not have been able to eat the dietaries prescribed by the medical officers, and that, at ten minutes for dinner the nurses did not have time to make a proper meal. One suggested a system of fines for carelessness, which, given the paucity of the wages, would have guaranteed a mass exodus of the nurses to other institutions.39 As they went from ward to ward, the ladies chatted to the nurses, picking up gossip, and using it to check on specific complaints; for example, where one lady visitor had been told about a nurse’s unkindness to the patients, she watched the nurse covertly in order to make a report on how she dealt with them.40 Although one lady visitor claimed that the nurses looked forward to their inspections, stating, ‘[I]t was excitement and encouragement for them’, it is hard to believe that their role brought harmony to the institution.41 The role of the official lady visitor came to an abrupt end at the HSC – although other children’s hospitals retained them – with the appointment of Miss Isabella Babb as unpaid lady superintendent in 1862, in the place of the matron-cum-housekeeper and the supervisor of nurses. Exuding an air of quiet dignity and natural authority, it was clear that under her the nurses would receive better training, they would have a powerful figure to look after their interests, and she would act as their champion in relations with the allmale management committee. As a social equal to the supporters of the hospital, Isabella Babb, and her successors, could placate, and even ignore, the lady visitors.42

89

Andrea Tanner Louisa Twining The one official lady visitor who was in any way a professional in such matters was Louisa Twining.43 Scion of the Workhouse Visiting Society and the pauper infirmary reform movement, interested in philanthropic causes world-wide, Miss Twining brought an expertise and degree of impartiality to her role that was lacking in her fellow official visitors. Her deep Christian faith was allied to an unsentimental clear-sighted vision of institutional best practice.44 At the end of the 1850s, she had considered making sick children’s nursing a career, and attended the hospital every morning to be instructed by Elizabeth Mooney, an elderly Irish nurse.45 Louisa decided quickly that her vocation lay elsewhere, ‘I was impressed then with a conviction that I have never lost – that it is far more sad and trying to witness disease and suffering amongst little children than in adults.’46 Within a few years, however, she was very experienced in making institutions work – especially those run mainly by women – and in using the power wielded by the outside institutional visitor. The HSC had experienced great problems with the senior nursing staff. Mrs Rice, the first matron, was often ill, and did not get on with the new superintendent of nurses, Mrs Cross, who had been employed in 1859. The nursing establishment was in danger of complete collapse, and the management committee decided to call in an expert to review the situation.47 The invitation to her to inspect the hospital on behalf of the ladies’ committee was both a gamble and an astute political judgement. By the 1860s, Louisa Twining was not only an expert in a field of amateurs, she embodied the movement to open up Poor Law medical facilities to public scrutiny. By asking her to inspect and comment upon the children’s hospital, a deep contrast was being drawn between this homely institution and the ‘Bastilles’ of the workhouses. Once through the doors, she was not afraid to express her views in the harshest terms.48 She looked into everything – no cupboard or locker was safe from her eagle eyes and her unforgiving fingers – and it was the nurses who bore the brunt of her criticism. She accused them of being slovenly, jealous, disloyal and irreligious. This judgement was in stark contrast to the habits, mores, morals and manners of the lady visitors. The lack of a proper nurses’ uniform in the first ten years of the hospital’s life came in for particular criticism, and she advocated the introduction of standard dress: ‘[It] might go some way to engendering a unified spirit, and it would be far more pleasing and suitable for a Christian woman than the present style of independent bad taste.’49 Louisa Twining may have spoken with greater authority than her peers, but she was not a disinterested observer. She had ambitions for the hospital, and she had something to sell. In 1861, she had established a home for training pauper teenage girls to be domestic servants. It proved difficult to 90

Care, Nurturance and Morality place her protégées in respectable homes, and Twining alighted on the hospital as a suitable place of training and employment for them. An arrangement had been made whereby her girls would attend the hospital as probationers and train in the short-lived HSC nursery for poor local children, but she had been disappointed in the lack of training and the jealousies between ward staff that she felt hampered the effectiveness of the institution. By the 1880s, the lady superintendents – women of impeccable breeding and the social equal of the members of the ladies’ committees – had superseded the old-fashioned matron. Many of them established training systems for the nurses, a clear demarcation of the lines of responsibility within the hospital, and also declined to make obeisance to the ladies’ committees, many of which withered away. The disbanding of ladies’ committees of at least one other children’s hospital left a core of women who remained attached to the institution as friends of the children, to act as casual visitors and providers of treats for out-patients.50 At the HSC, there had been such women from the hospital’s foundation. Casual lady visitors The HSC, from the very beginning, encouraged middle- and upper-class women to support the hospital.51 There were no British women medical doctors at that time, and, as has been mentioned, women were not allowed to sit on the management committee. Subscribers – no matter how much they gave each year – received no guarantee that any child they nominated would be accepted for treatment, as admission was based on clinical need alone. This was in sharp contrast to the majority of voluntary hospitals at this time, where the larger the donation or subscription, the more patronage a supporter enjoyed.52 The philosophy was taken up by the Bristol Children’s Hospital in 1866 and expressed by a new committee member: ‘Enough that a child be sick and poor, it will be admitted, provided there be a vacant bed and that medical officers consider the case a suitable one for the hospital.’53 Assuming the policy was put into practice, it might be taken that the vast majority of visitors were not going to the HSC to check up on their nominated patients, but had another agenda altogether. Barred from the boardroom, women were welcomed on the wards as agents of maternal socialisation, bringing the breath of the well-ordered and comfortable Christian home to the working-class patients. Hospital visiting fulfilled the Christian moral imperative of personal philanthropy that had been so much a part of the evangelical revival of the 1830s and 1840s, and whose expression was found in the publicised charitable activities of the Royal Family.54 If charitable involvement was an imperative for the successful and/or ambitious Victorian gentleman, it was the only feasible outlet for 91

Andrea Tanner what one woman’s magazine called ‘the unemployed energies of women’.55 The following plea, written by the HSC’s Honorary Secretary, H.A. Bathurst, in February 1859, reveals what was expected from female supporters: The kindly feelings of every Lady must be with the children of the poor in infancy and sickness, whilst the interests of the rich must ever be associated with the advancement of Medical knowledge, in respect of children’s diseases, and with the growth of a class of highly qualified nurses... If children, in poverty and sickness, find not friends in the Ladies of England, whence can help be expected for those who most require it.56

Over the course of twenty-seven years (1852–79), 10,497 casual visitors are recorded in the visitor books as having come into the hospital. Despite some minor annual variations in the volume of visitors, females usually outnumbered males by 5:1. Thirty per cent of the women were the wives and daughters of known hospital governors and management committee members, some of whom were pioneers in their own right in charitable works. They included Mary Jane Kinnaird, whose husband, Arthur, Baron Kinnaird, was a member of the management committee, and who visited regularly with her daughters and female friends.57 Titled ladies were well represented, including Lady Laura Palmer58 and Lady Dorothy Nevill,59 although more than one aristocratic patroness sent someone else to visit the hospital on their behalf. Others noted were Mary Kingsley, wife of the evangelical rector of St Luke’s Chelsea, and mother of Charles Kingsley, the clergyman and author of The Water Babies. Only one visitor identified herself as attending the institution to see how a specific patient was progressing. Mrs Sweeting of Kilburn visited the hospital on 11 October 1853: To visit a little girl belonging to the Sailors’ Orphan Girl’s School. Much pleased with the apparent order and cleanliness of the Establishment, and highly gratified to find such an Excellent Institution in existence. May it greatly grow and increase!60

Until 1869, there is a bias in the identifiable visitors of men and women of evangelical convictions, perhaps indicating that the hospital visit was an extension of the growing domestic visitation movement. The addresses given by women visitors are notable for the predominance of rectories and vicarages. The women rarely visited alone; there was usually a small party, which often consisted of a mother and daughters, but never a mother and her adult sons. The comments of the visitors were rather formulaic, with judgements such as ‘much pleased with the institution’, and, ‘an excellent 92

Care, Nurturance and Morality charity’, which might indicate that they were already subscribers or were considering becoming such.61 Before committing their own money – or their husbands’ – a visit to check on the running, cleanliness and Christian values of the institution was required. The children’s hospital was a safe place for women to visit. Their presence was cultivated by the institution, so they could be assured of a warm welcome, and it was easier – from the point of propriety – for groups of respectable women to experience the sight of sick children than of adults, especially male patients. The children were unlikely to object to their attention, and their answers to enquiries as to the nature of their ailments might be more suitable for ladylike ears than might have been heard in an adult hospital. As the 1860s progressed, the groups visiting included more and more schoolgirls, accompanied by their female teachers. Were these girls thinking about becoming nurses, or of adopting the hospital as a favourite charity, or being exposed to those less fortunate than themselves, in the spirit of Christian humility? Apart from offering a new place to visit on long outof-season afternoons, going along to the HSC gave middle-class women of little status the opportunity to rub shoulders with women of much greater social standing. The socially conscious lady visitor – particularly if she lived in the suburbs – might hope to encounter women of high status on afternoons when the wards were open to casual visitors.62 Titled men accounted for twelve per cent of all male visitors, while identifiable medical men made up less than one-eighth.63 A steady five per cent of male visitors were military gentlemen, and clergymen, unsurprisingly, accounted for up to one quarter. As has been mentioned, women far outnumbered men. However, identifying the class and occupation of female visitors is much more difficult. While this is not uncommon in primary sources of the time – the census is a good example – it also highlights the development of the charitable endeavour as natural women’s work in the Victorian era. Titled ladies – that is, women married or born to the peerage, baronetage and the wives of knights – made up ten per cent of all female visitors. One curious aside is that titled women tended to visit in pairs or small groups and they were rarely accompanied by nonaristocratic friends.64 The two per cent of visitors identified as children is an unreliable figure, as only those visitors specifically described as children are included, and the signatures of some of the visitors might indicate a higher number of juvenile visitors than are given here. Visitors were encouraged to write their impressions of the HSC in the visitors’ book. As indicated above, the comments are generally restricted to ‘much pleased’, ‘very much pleased’, and ‘highly gratified’, but, occasionally, a longer entry reveals the attitude of visitors to the patients and staff. Those at the higher end of the social scale tended to comment on the apparent 93

Andrea Tanner happiness and contentment of the children, but their more humble sisters were a little more exacting in their requirements. Mrs David Lewis of Liverpool – apparently a seasoned institutional visitor – recorded her impressions after her visit on 8 February 1869, in the same manner as that of her titled counterparts: Cannot express too highly her admiration and the excellent manner in which the inmates of the Hospital are cared for. The arrangements seem to be perfect – the dear little children have a contented and peaceful appearance quite different from the countenances of such sufferers in similar establishments which Mrs Lewis has visited.65

She does not say whether the ‘similar establishments’ were in London or in Liverpool, but the fact that she chose to spend time at the HSC and record her impressions indicates the draw that viewing working-class sick children in a controlled environment had for the female visitor to London. One visit could result in a longer-term relationship with the hospital, as in the case of Mrs Lee of Grove Hall in Yorkshire. Having been shown around the wards, and having made enquiries as to the conventions for supporters, she endowed a cot, named ‘the Alice Cot’ in memory of her dead daughter. Mrs Lee claimed no right to fill the cot continuously, but desired to send Patients occasionally only, as other Governors of the Charity do, so long as in accordance with the Rules of the Hospital. She also desires to be made acquainted from time to time, [with] the name, age, and nature of the cases placed in the cot, also requests leave to provide the children with clothes, toys and books.66

Thus, one mother’s grief was assuaged by her support of a cot, and by keeping in touch with its occupants. To the hospital, the unofficial visits of female supporters were a vital part of the publicity and fund-raising profile. It was hoped that the majority of them would become subscribers at a few shillings, or perhaps even a few pounds a year, but, perhaps more importantly, the hospital depended on them to act as unpaid advertisers for the ethos of the hospital. The ideal lady visitor would enthuse to her friends about her visit, encourage them to emulate her, and would be prepared to assist with the never-ending fundraising. One of the most important visitors in the influence she wielded among potential supporters was Margaret Gatty, a vicar’s wife from Sheffield and editor of a children’s newspaper called Aunt Judy’s Magazine, which was published in various forms from 1859 to 1882.67 Mrs Gatty wrote about the patients in her publication, concentrating on their suffering and Christian 94

Care, Nurturance and Morality fortitude, and reminding her readers of their own good fortune in enjoying the benefits of comfortable Christian upbringings. The tactic worked, and children began to send her their pocket money to give to the hospital. She eventually launched an appeal among her readership to sponsor a cot in perpetuity, promising tales of the occupants of ‘their’ cot in the magazine. The venture was so successful that three cots were sponsored, and the stories of the occupants of these cots provided much editorial copy over the years.68 The role of casual visitors The hospital did not underestimate the value of the visitors. Casual visitors of both sexes were welcome to tour the wards every afternoon, except that designated for parental visits. In practice, this meant that the lady superintendent or the hospital secretary operated an open house five afternoons a week, conducting groups of donors, and would-be supporters, round the wards, and offering them tea before their journey home. This was a crucial part of the interface between the institution and the public, and the impression had to be given that no trouble was too great in accommodating the ladies, who comprised the vast majority of this class of visitor. The nursing staff was expected to wait on the guests at teatime, and were made to act and dress in a way pleasing to them.69 The nurses were not seen as the social equals of the visitors, and their cleanliness, attitude and competence were viewed critically by the ladies who came into the wards. One reason for this scrutiny was that the ladies were looking at the nurses as potential employees, for not only was the training at the HSC viewed as an excellent grounding for privately employed children’s nurses, but, for a weekly fee, the HSC nursing staff could be hired to look after the sick offspring of the middle- and upper-class hospital supporters.70 A close inspection of a nurse’s skills, personal hygiene and demeanour would hold a mother in readiness for the application to the HSC for paid help.71 The disruption caused to ward routines by visitors was often resented by the nursing staff. A book of cartoons by Ada Bois, a late nineteenth-century nurse, illustrates such interruption. In one double spread, the HSC Secretary Adrian Hope shows society ladies round the hospital while nurses act as maids, carrying the tea and cakes.72 One panel, reproduced overleaf in Figure 4.1, reads: ‘We greatly enjoy waiting on the distinguished visitors and Adrian Hope’, while the other says that the nurses ‘found the novelty of directing them delightful’.73 Management thought nothing of accommodating unannounced visitors – including royalty, as shown in Figure 4.2. The committee clearly felt that it was worthwhile upsetting the nurses for the sake of the benefits the visitors brought. Nevertheless, the role played by lady volunteers in knocking off the rough edges of the paid nurses, thereby making them more fitted for their position within the hospital and as 95

Andrea Tanner Figure 4.1 Adrian Hope, HSC Secretary, Escorts Lady Visitors Around the HSC The caption reads: ‘We greatly enjoy waiting on the distinguished visitors and Adrian Hope’. Reproduced with permission of Great Ormond Street Hospital for Children NHS Trust, Museum and Archive Service. Source: GOS/11/18/9. Nurse Ada Bois’s sketchbook.

ambassadors for the HSC, understandably was resented by at least some of the nurses.74 For the visitors, what might begin as an afternoon outing with friends to view the children as exhibits – as they might have visited the zoo or an art gallery – could turn into a regular commitment to visit the patients, and undertake tasks that the nurses had no time to perform. In this way, visiting the hospital became a rarefied form of that iconic activity for the middleclass Victorian women of Christian conviction: domestic visitation.75 Organised and systematic visiting of the poor in their own homes had begun 96

Care, Nurturance and Morality Figure 4.2 The Prince and Princess of Wales’s Visit to the HSC, 22 March 1902 The caption reads: ‘The sittingroom HSC on the unexpected visit of the Prince and Princess of Wales’. Reproduced with permission of Great Ormond Street Hospital for Children NHS Trust, Museum and Archive Service. Source: GOS/11/18/9. Nurse Ada Bois’s sketchbook.

in the late eighteenth century, and had become the favoured method of directing charity to the poor by the mid-nineteenth century. Most Anglican parishes and Nonconformist congregations had their own district visiting societies, and, by the late 1850s, there were nearly eighty district visiting societies in London affiliated to the Metropolitan Visiting and District Relief Association, with a total of over one thousand committed regular volunteers.76 The term rarefied is used deliberately. Unlike true domestic visitation, the ladies were spared the sights, sounds and, above all, smells of the homes of the poor. They came to the hospital on days when the parents 97

Andrea Tanner of the patients were excluded, so could not interact with them, and did not have to engage with the concerns of the families. The children were presented in a clean and tidy state within the sanitised frame of the hospital ward. They wore cast-off middle-class children’s clothes and played with cast-off middle-class children’s toys. The world of the street, the poor child’s playground, was banished, and all was calm and ordered. The visitors observed their care, directed by the medical profession, but undertaken by women who might otherwise have been domestic servants in their own homes, and with whom, by extension, they felt socially and morally superior. The hospital acted as a filter through which the women could vicariously experience metropolitan working-class life without the attendant dangers of reality. Many visitors came once, and returned to their usual lives, perhaps becoming subscribers or agreeing to support hospital fund-raising events. They would donate cast-off clothing of their own children, send in surplus apples in the autumn, and take their friends in turn to the wards for afternoon visits. For a significant minority of lady visitors, however, visiting the children’s hospital became their vocation. Described by one management committee member as ‘Samaritanesses’, the women committed themselves to regular and significant work with the patients. They performed the same duties with them as they might have done for their own children; teaching them to read, write and most especially, pray. They discouraged rowdiness and strong language, and inculcated the merits of quiet cleanliness in children who might have had no access to running water and clean clothes at home. They sat with critically ill patients, displaying, it was hoped, the best aspects of middle-class Victorian family values. This ad hoc education was resolutely Christian in character and content. Much of the reading and teaching matter was supplied by the Religious Tract Society and similar organisations, and many of the afternoon visitors quizzed the children on their knowledge of the Scriptures.77 These volunteers not only provided services ancillary to the work of the nurses, but acted as sponsors of rehabilitation and social progress through the medium of the child patient. The value of the lady volunteers was not lost on the hospital management, but they were not expected to get above themselves, as this gentle reminder of their place in the grand scheme of things by one of the HSC management committee illustrates: [The lady volunteers] are doing a work, both external and internal in the hospital, which we could not afford to dispense with. They assert a voluntary position; they assert woman’s rights in the most emphatic way. I hold that it is a woman’s right to be kind to man, and above all to her little ones; and I am sure that it is the right that they would most earnestly vindicate for

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Care, Nurturance and Morality themselves. We all of us feel that women occupy a position sacred to humanity - a position on which we need not expatiate in complimentary terms, because all our hearts are ready to acknowledge it.78

The message could not be clearer. The HSC needed their labours, but the male establishment did not want them to occupy any official management role within the institution – unlike other children’s hospitals in the United Kingdom and in North America. The financial benefit of the lady visitors was not underestimated by the matrons of the main hospital and the convalescent home. The lady superintendent at Cromwell House, convalescent home from 1869 to 1924, complained about the consequences to the HSC’s reputation by lack of consideration shown by the doctors: It is most perplexing to arrange our hours when some of the Medical Officers come in the morning and some in the afternoon… The visitors are told that they may come in the afternoon after 2 o’clock, but I am sorry to say that owing to the presence of the MOs, we are frequently obliged to hurry the visitors through the wards, or perhaps not let them in except for a moment, or pain them with the cries of children who have just been examined. For the Visitors and the Ladies who come to read to and amuse the children the inconvenience is obvious to all who know how much benefit is done to the Hospital by Visitors being able to see the children pleasantly, and talk to them, thus exciting very frequently great sympathy in our work.79

In 1879, the Bishop of Winchester gave the chairman’s speech at the annual dinner, and dwelt on the debt that the HSC owed their volunteers. He emphasised the disinterestedness of the ladies’ motives, for, where no payment was extracted, no accusation of greed could be made.80 Given the low level of the paid nurses’ wages, this compliment seems like an insult to them, but it does raise the question: what was the motivation of these women? As has been argued, working with the children might be seen as domestic visiting without the dangers of encountering the adult poor in their own homes. As patients’ mothers were rarely present at the same time as the lady volunteers, the latter had free rein to educate the children in middle-class manners and mores away from the doubtful influence of the parents. In the words of Seth Koven, this voluntary labour, untainted by commercialism, had a powerful subtext: It channelled middle-class women’s activism into a traditionally female area of expertise, while providing mechanisms by which middle-class women could impose their domestic ideals on working-class women and children….

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Andrea Tanner ‘Lady’ social welfare workers invariably represented the exercise of their authority as demonstrations of their motherly love for impoverished children and their sisterly solicitude for unfortunate or feckless working-class women.81

The work provided an opportunity for some women to ‘be mother’ at a time when their own children either were grown up or had been lost to an early death or for others who, husbandless, were unlikely ever to experience motherhood first hand.82 The hospital provided a safe and socially acceptable environment for occupying their time, and offered the opportunity to meet women of their own class and those of higher social standing. It gave respectability, and a certain seriousness of purpose to educated women, for whom getting a paid job was out of the question, and social delicacies outlawed them fulfilling similar functions in adult hospitals.83 The work was also educational; the example of the ladies would provide templates of domestic hygiene and childcare to nurses and mothers, and, it was hoped, would create a demand for higher standards of mothering in the children.84 In this, they provided the three elements identified by Koven and Michel in the Victorian maternalisation of society: care, nurturance and morality.85 Their work was firmly in the tradition of the personal social work that was deemed an acceptable occupation for the Victorian woman who had no need to seek paid employment.86 Parents and families This most important group of visitors is almost invisible in the hospital records, except in strictures on their behaviour and in unflattering descriptions in fundraising speeches. Parents were not required to sign visiting books, and were not asked for their opinion of the hospital, or the treatment given to their children. They feature strongly in the first pages of the surviving case-notes, as their witness as to the patient’s medical prehistory was vital for the admitting doctor, but, thereafter, little notice is taken of them in the surviving archives. In the first few years of the hospital’s life, mothers were expected to provide much of the nursing – and do all of the laundry – of their sick child. From 1858, however, visiting hours for parents were strictly controlled. From 1880, mothers were allowed to visit on Thursday afternoons, Sunday thereafter being known as ‘fathers’ day’, as it was the one day in the week when fathers were expected to be free to call at the hospital.87 The only exception to this rule, until the early 1960s, was when a child was dying, at which point parents were allowed free access to the ward. No quarter was given for work commitments or difficulties in travelling, and the assumption was that the mothers did not have external work commitments. This 100

Care, Nurturance and Morality assumption seems not to have been based on reality. While the surviving case notes do not give occupations for the mothers of the patients, a recently discovered book of early out-patients indicates that most of the mothers of the London children being treated at the hospital had paid employment outside the home.88 Equally, little flexibility was allowed in terms of the length of visits. The grief of the children on their parents’ departure was dealt with by a different ward routine on visiting days; as soon as the visitors had gone, the children’s tea was brought in, with extra treacle or sugar on the bread.89 On Sunday afternoons, patients were hurried down to the chapel immediately after their parents’ departure, where hymns and prayers were the means by which tears were dried. Even the limited visiting rights were subject to further curtailment. Risk of infection and disruption to other patients were used as the reasons for banning the patients’ siblings from visiting. This rule was particularly harsh given the traditional role of older sisters – and also, to a lesser degree, brothers – in childcare among workingclass families. As a family grew, older sisters in London took over the watching of younger siblings, and the bonds between the so-called ‘little mothers’ and their charges were strong.90 Given the average length of stay at the HSC – usually three to four weeks – whether the patient was an older child or ‘her’ baby, this long separation must have been difficult for them to endure. Once access to the ward had been attained, visiting parents were subjected to a strict set of rules themselves. They were forbidden from bringing food in for the children, apart from sponge cakes, and were expected to behave with propriety at the child’s bedside.91 The hospital was strict about punctuality, but did not always make it easy for the mothers to comply. No allowance for family circumstances was made in setting the visiting times, and perceived misbehaviour on the part of the parents could result in the child being discharged. The hospital saw itself as an educator, as well as a place of healing. From the first, it produced a series of pamphlets for visiting parents to take home with them, advising on the care of the sick child. Diet, how to bathe a baby, medicinal routines, guidance on cleanliness and fresh air, and recipes for broth and beef tea were handed out liberally. The instruction also took place on the wards; in the interface between the hospital staff, visitors, patients and families. The children and their mothers were to be educated by the examples of the nursing staff who, in turn, had learnt the catechism of cleanliness and godliness from the female volunteers who interested themselves in the new institution. The arena for social change was the hospital ward, a neutral space compared to the homes of the poor families more familiar to the women volunteers of domestic visiting societies. The interface between the 101

Andrea Tanner ‘do-gooders’ and the poor mothers was managed and controlled by the medical function of the building, and by the presence and actions of an intermediate tier of women – the lady superintendent and her nurses – that might make the educative process more palatable to all.92 Conclusion When the hospital opened, it was important for its success that it gained the trust and acceptance of poor families, and, to that end, parental rights were observed and visiting encouraged. However, as the nursing establishment grew, the nurturing role of the mothers was gradually reduced, until they became hospital visitors, with fewer rights of access than the ladies for whom the HSC was part of their social round. Sunday afternoon, the one on which lady visitors were not allowed, was, until 1880, the best chance mothers and fathers had of seeing their hospitalised children. There was little opportunity for the ladies and the mothers to meet, and thus little chance for the women supporters to gain first-hand knowledge of the difficulties of raising a family in poverty in the great metropolis. The relationship between the HSC and its supporting visitors was entirely symbiotic. The hospital gained supporters, publicity and enhanced its reputation through the agency of the visitors. Staff were kept on their toes, and faults in the building and the quality of care to the patients were noted with little publicity. Visitors made business and social contacts they might not have made in their ordinary circles. The lady visitors, in particular, had the opportunity to meet in safe and clean surroundings the most affecting of charitable objects -– the sick children of the poor – and to influence them and their families through imparting some of their own values to the patients. All visitors fulfilled the requirements of the Charity, the cardinal Christian virtue, which, in the words of Roy Porter, ‘is the hallmark of humanity and of the gentleman’, not to mention the gentlewoman.93 Notes 1. While poor sick children were largely excluded from the wards of voluntary hospitals until the 1850s, children were the single largest group of beneficiaries of state welfare in London at that time. L.H. Lees, ‘The Survival of the Unfit: Welfare Policies and Family Maintenance in Nineteenth Century London’, in P. Mandler (ed.), The Uses of Charity: The Poor on Relief in the Nineteenth Century Metropolis (Philadelphia: University of Pennsylvania Press, 1990), 18. 2. Hospitals were not unique in the charitable world in being dominated by male supporters. See R.J. Morris, ‘Voluntary Societies and British Urban Elites, 1780–1850: An Analysis’, Historical Journal, xxvi (1983), 95–118.

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Care, Nurturance and Morality 3. The financial support for which London charities competed was vast. By 1885, it has been estimated that donations to metropolitan charities were worth more than the entire combined national budgets of Portugal, Sweden and Denmark. E. Ross, ‘Hungry Children: Housewives and London Charity 1870–1918’, in Mandler, op. cit. (note 1), 164. 4. The Hospital, 13 December 1890, 165. 5. The first set of rules for visitors, set out in April 1852, decreed that a maximum of two visitors per patient per day were to be allowed, and that anyone bringing in food or drink to the patients was to be excluded. Great Ormond Street Hospital Archive (GOS) GOS/1/2/1, 8 April 1852. Family visiting was banned during epidemics. By 1882, visiting days for parents and friends were restricted to an hour on Thursdays and Saturdays, ‘Rules for Patients’ leaflet, GOS/8/162. Four years later, only the parents of the patients were allowed to visit on Sunday afternoons; all other family members were excluded, GOS/8/162, 23 December 1886. 6. See E. Ross, ‘Survival Networks: Women’s Neighbourhood Sharing in London before World War One’, History Workshop, 15 (Spring 1983), 4–27, and A. Davin, Growing Up Poor: Home, School and Street in London, 1870–1914 (London: Rivers Oram Press, 1996). 7. Thirty-Third Annual Report of the General Hospital and Dispensary (Manchester, 1862), 62, quoted in E.M.R. Lomax, Small and Special: The Development of Hospitals for Children in Victorian Britain. Medical History, Supplement No. 16, (London: Wellcome Institute for the History of Medicine, 1996), 33. 8. R.A. Clavering, ‘Dr Charles West and the Founding of the Children’s Hospital in Great Ormond Street’, uncatalogued manuscript in GOS (1956), 37. 9. The exclusion of parents from the wards on the grounds of fear of infection was not challenged until the late 1940s, when the British Paediatric Association conducted a study of cross-infection in hospitals that showed there was no correlation between cross-infection and adult visitors. A.G. Watkins and E. Lewis-Faning, ‘The Incidence of Cross Infection in Children’s Wards’, British Medical Journal (17 September 1949) 2, 616–19. 10. M.A. Crowther, The Workhouse System 1834–1929 (London: Methuen, 1983), 30–4. The injection of bureaucratic values of the 1834 Act involved the unions themselves being subject to regular inspection by the Poor Law Assistant Commissioners. 11. The payment of poor rates was legally enforceable, and guardians were accountable to their electorate irregularly. Not having to attract subscriptions gave the Poor Law authorities far more powers of exclusion than voluntary hospital boards of management.

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Andrea Tanner 12. It has been posited that domestic visitation societies developed in practically every Anglican parish and Nonconformist chapel in London as a reaction to women’s exclusion from workhouse visiting. F. Prochaska, Women and Philanthropy in Nineteenth Century England (Oxford: Oxford University Press, 1980), 31 and 107–12. 13. The involvement of such men attests to William Lubenow’s judgement that private philanthropy ensured the persistence of aristocratic values and the continuation of noblesse oblige in the nineteenth century: W. Lubenow, The Politics of Government Growth: Early Victorian Attitudes Towards State Intervention, 1833–1848 (Newton Abbot: David and Charles, 1971) 20–1. 14. GOS/7/2/1, 13 June 1856. 15. Arthur Fitzgerald, Baron Kinnaird, who was a banker by profession, politician by inclination, and philanthropist by conviction, might exemplify the business and philanthropic commitments of the committee members. Among the causes with which he was intimately involved were the Church Missionary Society, the London City Mission, the Ragged School Union, the Ranyard Mission, the Destitute Children’s Dinner Society, the Lock Hospital, and Dr Barnardo’s. F. Prochaska, ‘Kinnaird, Arthur Fitzgerald, Tenth Lord Kinnaird of Inchture and Second Baron Kinnaird of Rossie (1814–1887)’, Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004). 16. S. Cavallo, ‘The Motivation of Benefactors: An Overview of Approaches to the Study of Charity’, in J. Barry and C. Jones (eds), Medicine and Charity Before the Welfare State (London: Routledge, 1991), 46–62: 52. 17. A. Borsay, Medicine and Charity in Georgian Bath: A Social History of the General Infirmary, c.1739–1830 (Aldershot: Ashgate, 1999) and M. Gorsky, Patterns of Philanthropy, Charity and Society in Nineteenth-Century Bristol (Woodbridge: Royal Historical Society Studies in History New Series, 1999). 18. D. Owen, English Philanthropy (Cambridge: Harvard University Press, 1964), 171. 19. Frank Prochaska has calculated that Edward VII, when Prince of Wales, was the patron of over seventy hospitals: F. Prochaska, Royal Bounty: The Making of a Welfare Monarchy (New Haven: Yale University Press, 1995), 104–10. 20. K. Waddington, ‘“Grasping Gratitude”: Charity and Hospital Finance in Late-Victorian London’, in M. Daunton (ed.), Charity, Self-Interest and Welfare in the English Past (London: Routledge, 1996), 181–202: 184. 21. B. Hilton, The Age of Atonement: The Influence of Evangelicalism on Social and Economic Thought, 1795–1865 (Oxford: Clarendon, 1988), 19. 22. J. Kosky, Mutual friends: Charles Dickens and Great Ormond Street Children’s Hospital (London: Weidenfeld & Nicolson, 1989). 23. C. Dickens, Our Mutual Friend (Oxford: Oxford University Press, 1987), 1–3.

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Care, Nurturance and Morality 24. Dickens himself, while acting as a willing publicist for the hospital in the 1850s and 1860s, also acted in a more direct way in recommending patients for the institution. The patient admission registers reveal that he sent fifty-six children as in-patients before his death. See, Small and Special: The Hospital for Sick Children at Great Ormond Street Historic Patient Admissions Database, http://www.smallandspecial.org, accessed 18 February 2009. 25. Apart from Our Mutual Friend, he published two pieces of journalism on the hospital, ‘Drooping Buds’, Household Words (February 1858) and ‘Between the Cradle and the Grave’, All the Year Round (February 1862). The hospital continued to publish off-prints of Dickens’ writings on the hospital for the rest of the century, see GOS/14/1. 26. The Englishwoman’s Journal (April 1860), 120. Most of the journalistic pieces written on the hospital were penned anonymously, and it has not been possible to tie-in names in the visitors’ books with press articles. 27. GOS/8/156, ‘Reminiscences of Dr F.J. Poynton’, 18. Women had been admitted to the Almoners’ Committee during the Great War, but it was another generation before they were allowed on the Board of Management. 28. This division of labour in the philanthropic world is dealt with in detail in Prochaska, op. cit. (note 12). 29. In 1888, this activity blossomed into a major social event, when a ladies’ committee – headed by Princess Frederica and composed entirely of titled ladies – organised a two-day Doll Show in aid of the hospital. GOS/8/1/ref. 71. The quality of the goods sold at such bazaars was satirised by Robert Louis Stevenson while he was a student at Edinburgh University, ‘The Charity Bazaar’, The Works of Robert Louis Stevenson (New York: Charles Scribner and Sons, 1925), xxiv, 171–4. 30. Twentieth Annual Report of the HSC, 1872. 31. For the Royal Family’s involvement with the hospital see Prochaska, op. cit. (note 19), 124, 193. In the mid- to late Victorian period, hospitals were favoured causes for royal support. In the case of Great Ormond Street, the male members of the family were as conspicuous as Victoria and her daughters and daughters-in-law. The Prince of Wales and his brothers took their turns as chairmen of the annual fund–raising dinner, and the future Edward VII gave a speech on his wife’s behalf at the stone-laying ceremony for the new hospital in 1873. 32. Lomax, op.cit. (note 7), 4. 33. In this, they were obeying Florence Nightingale’s exhortation to women who visited public and charitable institutions to treat them as if they were extensions of their own homes. Prochaska, op. cit. (note 12), 147. 34. Lomax, op.cit. (note 7), 64. 35. Ibid., 65.

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Andrea Tanner 36. Lawley Parker, Secretary of the Birmingham Children’s Hospital, 1869, quoted in ibid., 65. 37. Ibid., 65–6. 38. GOS/5/2/30, 4 July 1860. 39. GOS/7/2/1. 40. GOS/5/2/30, October 1860, report by Mrs Leonora G. Bell. 41. GOS/5/2/30, 13 August 1860, report by Mrs Shadwell. 42. Lomax, op. cit. (note 7), 66. 43. Louisa Twining (1820–1912) was the daughter of tea merchant Richard Twining. She is today best remembered for her influence on improving the lot of the pauper sick, but she had a wide variety of interests and enthusiasms, and was a member of the Society of Arts and a Fellow of the Royal Society. 44. Twining was a champion of empowering women by encouraging their involvement in visiting public and charitable institutions, telling the 1861 Select Committee on the Poor Laws, ‘service… is the only occupation they can follow in life’. Quoted in Prochaska, op. cit. (note 12), 155. 45. Nurse Mooney evoked strong reactions among the visitors; some thought her uniquely gifted and a source of maternal comfort to patients and younger nurses, while others were appalled at her low standards of cleanliness and unwillingness to discard the ragged clothes that some of the patients wore on admission. Kosky, op. cit. (note 22), 211, 215–19, 224. 46. Quoted in ibid., 216. 47. GOS/1/3/7, 5 June 1860, Management Committee Minutes. 48. It is likely that she had first encountered the hospital soon after it opened in 1852, as she was then teaching classes for women at the Working Men’s College, which was at that time in Great Ormond Street. L. Twining, Recollections of Life and Work (London: E. Arnold, 1893). 49. GOS/5/2/30, November 1860. 50. Lomax, op. cit. (note 7), 66. 51. The inaugural meeting to launch the hospital had more women in the audience than men, but, significantly, not one of them was mentioned by name in the press reports of the meeting. Morning Chronicle, 19 March 1851. 52. For an account of this, see F. Hart, The Roots of Service: A History of Charing Cross Hospital 1818–1974 (London: Special Trustees of Charing Cross Hospital, 1974). 53. Mark Whitwell, quoted in Gorsky, op. cit. (note 17), 157. 54. D. Roberts, Paternalism in Early Victorian England (London: Croom Helm, 1979). 55. The English Woman’s Journal, xi, 1 (May 1859), 196.

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Care, Nurturance and Morality 56. GOS/8/1, February 1859. 57. The couple – who were both from banking families – were noted evangelical philanthropists, and active in many Christian charitable concerns. Mary Jane’s involvement with recruiting nurses for Florence Nightingale’s mission to the Crimea resulted in her setting up a nurses’ home in London, which translated in the late 1870s into the YWCA. D. Fraser, Mary Jane Kinnaird (London: Nisbet, 1890), K. Heasman, Evangelicals in Action: An Appraisal of Their Social Work in the Victorian Era (London: Geoffrey Bies, 1962). 58. Second daughter of the Eighth Earl Waldegrave, Laura Palmer was the wife of Roundell Palmer, future Lord Chancellor. She was a committed evangelical Anglican and active in numerous good causes. D. Steele, ‘Palmer, Roundell, First Earl of Selborne (1812–1895)’, Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004). 59. Dorothy Fanny Nevill, née Walpole, was, in the early 1850s, gaining a reputation as an horticulturalist, but she also established an important political salon at her London home. W.R. Trotter, ‘Nevill, Lady Dorothy Fanny (1826–1913)’, revised by K.D. Reynolds, Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004). 60. GOS/7/1/1. 61. There was a template for the visitors’ book in a children’s institutional charity; informal visits by ladies had been welcomed at the London Infant Asylum, with comments being petitioned in the matron’s book. Prochaska, op. cit. (note 12), 143. 62. HSC Annual Reports, 1853–1875. 63. GOS/7/1/1 and 2. 64. In addition to the Great and the Good, the visitors’ books record attendances at the hospital by the wives of prominent politicians, journalists (male and female), foreign diplomats (including a delegation from Siam), industrialists and the families of such ‘Men of Letters’ as Dickens, Thackeray and Carlyle. 65. GOS/7/1/2, 8 February 1869. The use of the first person pronoun was not considered quite polite in such public documents, hence the writer referring to herself in the third person. 66. GOS/1/2/10, 7 January 1869, Management Committee Minutes. 67. C. Maxwell, Mrs Gatty and Mrs Ewing (London: Constable, 1949). 68. All members of the Gatty family were regular visitors to the HSC, always checking on the current occupants of ‘their’ cots. 69. In the summer of 1861, the nurses were persuaded to adopt a uniform, ‘to please the eye of visitors and ladies… at the hospital’, and to change their caps from black to white, a colour more suitable to the innocence and purity of their charges. GOS/5/2/30, July/August Visitations 1861.

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Andrea Tanner 70. John Walter, MP and proprietor of The Times, was chairman of the committee of management for some years. He suggested that the HSC should treat children from the upper and middle classes as well as the poor, emphasising the moral benefit to be gained from children from all classes being together in times of sickness. GOS/8/1, 22 March 1876. 71. Nursing sisterhoods founded in the 1830s and 1840s had been established to improve the quality of nursing in hospitals and to provide free nursing in the homes of the poor. By the 1850s, however, financial necessity meant that many of them had to offer home nursing for the better off. A. Summers, ‘The Costs and Benefits of Caring: Nursing Charities, c.1830–c.1860’, in Barry and Jones, op. cit. (note 16), 133–48. 72. GOS/11/18/9. The social climbing of the HSC secretary Adrian Hope was remarked upon by one of the senior physicians: ‘Well known in Society, it was an education to see him slightly bending and walking backwards with a tray of toys before Royalty’, ‘Reminiscences of Dr F.J. Poynton’, op. cit. (note 27). 73. There is some suggestion in the book that the lady visitors were extremely fastidious in not letting their skirts touch the hospital floors. The author gives her feelings about this full rein, ‘“Mind the germs, mind the germs! They stick for quite a week!” If it’s the germs on our floors they mean? We think it’s beastly cheek’, GOS B–INT 10964e, c.1904. 74. The volunteer middle-class nurse was a feature of many London hospitals, many of them trained by semi-religious nursing sisterhoods, such as the St. John’s House sisterhood, which had the monopoly of nursing at the highly Anglican King’s College Hospital. J. Moore, A Zeal for Responsibility: The Struggle for Professional Nursing in Victorian England, 1868–1883 (Athens: University of Georgia Press, 1988). 75. Lady visitors attached to the Manchester General Hospital and Dispensary for Sick Children did actually undertake domestic visits to check up on the progress of discharged patients. Lomax, op. cit. (note 7), 92. 76. D. Owen, English Philanthropy 1660–1960 (Cambridge: Harvard University Press, 1964), 142–3. In 1864, the Ladies Diocesan Association was set up to co-ordinate the vast amount of institutional visiting undertaken by women in London. Prochaska, op. cit. (note 12), 179. 77. See I. Bradley, The Call to Seriousness: The Evangelical Impact on the Victorians (London: Cape, 1976). 78. GOS/8/1, ‘Report of the Anniversary Festival, 1880, speech by Sir James Paget, Bt, FRS, Chairman’. By 1880, these women worked in the out-patient department, dressing wounds and putting on splints. They gave classes in household management to the mothers, and visited children at home. 79. GOS/8/Cromwell House Correspondence. No date.

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Care, Nurturance and Morality 80. GOS/8/1. Letters and press cuttings, Vol. 1, part 2. Ref. 71, ‘Report of the Proceedings at the Twenty-Seventh Anniversary Festival, held at Willis’s Rooms, St James’s Thursday 20 February 1879’. 81. S. Koven, ‘Borderlands: Women, Voluntary Action, and Child Welfare in Britain, 1840–1914’, in S. Koven and S. Michel (eds), Mothers of a New World: Maternalist Politics and the Origins of Welfare States (New York: Routledge, 1993), 94–135: 98 and 124. 82. See A. Summers, ‘A Home from Home: Women’s Philanthropic Work in the Nineteenth Century’, in S. Burman (ed.), Fit Work for Women (London: Croom Helm for Oxford University Women’s Studies Committee, 1979), 33–63; D. Epstein Nord, ‘“Neither Pairs nor Odd”: Female Community in Late Nineteenth Century London’, Signs, 15, 4 (1990), 733–54. 83. See K. McCarthy, ‘Parallel Power Structures: Women and the Voluntary Sphere’, in Kathleen McCarthy (ed.), Lady Bountiful Revisited: Women, Philanthropy, and Power (New Brunswick: Rutgers University Press, 1990). 84. One of these lady volunteers paid a high price for her commitment to the HSC. Helen Fergusson took over volunteer responsibility for the out-patient department in 1874. She distributed books and toys to the waiting children, and on two afternoons each week sat with the children undergoing galvanism for distorted and wasting limbs. She visited the out-patients in their own homes, and contracted bronchitis, which, in spite of going abroad for her health, eventually killed her. GOS/8/1, pamphlet, ‘In memoriam. Helen Fergusson and the Hospital for Sick Children’, 1891. 85. S. Koven and S. Michel, ‘Introduction: “Mother Worlds”’, in Koven and Michel, op. cit. (note 81), 1–42: 4. 86. J. Lewis, Women and Social Action in Victorian and Edwardian England (Stanford: Edward Elgar, 1991). 87. J. Greenwood, ‘Tiny Tim in Hospital’, pamphlet, 1880. At least the parents were permitted to see their children properly shod; at the Royal Hospital for Sick Children in Glasgow, they had to take their boots off and visit the wards in their stocking feet until 1909. E. Robertson, The Yorkhill Story: The History of the Royal Hospital for Sick Children, Glasgow (Glasgow: Board of Management for Yorkhill and Associated Hospitals, 1972), 33. 88. GOS/9/1/1 and GOS/9/1/3. 89. Daily Telegraph, 11 July 1872. 90. Davin, op. cit. (note 6). 91. This was not just in the case of the HSC, see Ruth Hawker’s study of the Exeter Hospital, R. Hawker, ‘For the Good of the Patient’, in C. Maggs (ed.), Nursing History: The State of the Art (London: Croom Helm, 1987), 143–51.

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Andrea Tanner 92. For women’s negotiation of power in welfare work, see J. Lewis, ‘Gender, the Family and Women’s Agency in the Building of Welfare States: The British Case’, Social History, 19 (1994), 37–55. 93. R. Porter, ‘The Gift Relation: Philanthropy and Provincial Hospitals in Eighteenth Century England’, in L. Granshaw and R. Porter (eds), The Hospital in History (London: Routledge, 1989), 149–78: 150.

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5 Pariahs or Partners? Welcome and Unwelcome Visitors in the Jenny Lind Hospital for Sick Children, Norwich, 1900–50

Bruce Lindsay The idea of ‘visitors’ when applied to hospitals may appear simple and uncontroversial: relatives or friends keeping the sick person company, lifting the spirits and offering support. The reality was more complex and challenging, particularly in the care of child patients. The Jenny Lind Hospital for Sick Children constantly evolved its relationship with visitors in the first half of the twentieth century. Two major variables are discussed in this chapter: the changing importance of the visitors themselves and the way in which the Jenny Lind defined and adapted its perspective on visitors and the nature of visiting.

The Jenny Lind Infirmary for Sick Children, the second hospital for children in Britain, was established at a public meeting on 30 May 1853 and opened to in-patients and out-patients on 3 April 1854.1 The hospital was named in honour of Jenny Lind, the Swedish singer, whose donation of the income from two charity concerts in Norwich, in 1849, paid for the initial running costs of the hospital. It was an independent voluntary hospital for seventyfive years, until its nursing management became the responsibility of the Norfolk and Norwich Hospital in 1929. In 1948, it became part of the new National Health Service. The Jenny Lind was at first housed in Pottergate Street, in the centre of Norwich, in a large converted residential property. In 1898, it moved briefly to 28 Tombland, another city centre property close to the Cathedral, due to the poor state of the Pottergate Street house. In 1900, it moved again, to a new purpose-built site at Unthank Road on the city outskirts, changing its name to the Jenny Lind Hospital for Sick Children in 1918. In the mid-1970s, it moved onto the site of the Norfolk and Norwich Hospital, becoming that hospital’s Jenny Lind Children’s Department.2 In the first decades of the Jenny Lind’s existence, medical treatment predominated with few surgical operations being performed. The majority of the child in-patients suffered from diseases or injuries resulting from 111

Bruce Lindsay poverty and insanitary living conditions. Rest, wholesome diet and good hygiene were central aspects of treatment and care. Parental education was seen as vital, and parents were encouraged to visit so that they could learn to be better carers. By the last quarter of the nineteenth century surgical treatments were increasing, the advent of anaesthesia and asepsis enabling more complex and invasive procedures to be carried out successfully.3 In 1885, twenty-nine children from a total of 194 in-patients underwent surgical procedures.4 Soon after the opening of the new Jenny Lind surgical admissions began to dominate. In 1909, surgical admissions exceeded medical admissions for the first time.5 Surgery soon became the dominant reason for admission.6 Throughout the nineteenth century the management and staff of the Jenny Lind encouraged visitors. The concept of ‘visitors’ encompassed both the relatives and friends of patients, to be referred to in this paper as ‘patients’ visitors’, and the supporters and potential supporters who were relied upon for finances and publicity, to be referred to as ‘hospital visitors’. The Jenny Lind’s differing expectations of each group meant that their access to the hospital and their roles within it were regulated differently. In the last decade of the nineteenth century and the first decade of the twentieth, ideas about visitors changed and developed. Hospital visitors lost much of their importance relatively quickly, retaining access for specific activities on limited occasions. Patients’ visitors rapidly became pariahs and were virtually excluded by the 1920s, but began to gain a prime place in the function of the hospital by the 1950s. Hospital visitors: attracting finance and influence In the nineteenth century, the Jenny Lind welcomed supporters and potential supporters as hospital visitors. The most influential group of supporters, both strategically and operationally, was the Ladies’ Committee. This committee was routinely involved in decisions regarding hospital policy and controlled the activities of the matron, who reported directly to it. In addition its members acted as lady visitors to the Jenny Lind. The lady visitors made regular inspections of the wards and departments and reported their findings to the Committee of Management (CoM). There is no evidence that lady visitors were involved in the direct care of in-patient children but they were responsible for maintaining a homely environment in the wards. The medical officers supported this work ‘by which the happiness of the inmates is so much increased and their recovery in so many instances materially assisted.’7 Governors or subscribers, potential supporters and other interested parties could also make visits to the hospital. These hospital visitors had access to the wards and departments, and therefore could see both the in112

Pariahs or Partners? patient children and the work being done to care for them. A record of their attendance was made in a visitors’ book. This book was used at Pottergate Street and was specifically designed, each page having columns for visitors’ names, date of visit and ‘remarks’.8 It covers the years from 1854–97 and contains approximately 1,400 separate entries. Many of these entries record a named visitor ‘and party’, indicating substantially more than 1,400 individual visitors in this forty-three year period. Jenny Lind made two visits to the infirmary, in 1856 and 1862.9 She remained in contact with the infirmary for the rest of her life and she and her husband, Otto Goldschmidt, were life governors of the institution.10 The power of the Ladies’ Committee gradually waned following the arrival of the first qualified nurse to be appointed matron: Miss Peter, who took up post in 1885. In 1896, the Ladies’ Committee was subsumed into the CoM.11 This helped to give the Jenny Lind’s female supporters more power over strategic management, but at the same time they were less involved with day-to-day activities. In 1901, the role of ‘housekeeping referee’, which had been held by a member of the Ladies’ Committee, was withdrawn.12 The new Jenny Lind was to be operationally managed without the assistance of a formal lay committee, relying instead on the abilities of the matron and senior nurses. In the early years of the Unthank Road Infirmary, there is some evidence that hospital visitors did have direct contact with in-patient children. In the Annual Report of 1905, for example, the CoM offers thanks to ‘the Misses Lefroy and to Mrs and Miss Thompson for their great kindness in giving so much of their valuable time to visiting the children in the Institution.’13 These references appear only in the reports for 1905–7 and there is no indication before or after these dates that such activities occurred. Other hospital visitors were still welcome in the early years of the twentieth century, but their numbers were markedly reduced as their importance to the hospital’s well-being diminished. Only one visitors’ book survives from the Unthank Road hospital.14 This book covers the period from October 1910 to August 1915. It contains no ‘remarks’, only visitors’ names and places of residence. The book was used again to record visitors to the Jenny Lind on 30 May 1953, the centenary of its establishment. Surviving documents offer evidence that hospital visitors still came to the Jenny Lind for specific activities or events, but there is no evidence to suggest that they were welcomed for casual visits or tours of the establishment’s wards and departments. The visitors’ book for 1910–15 contains 185 entries. At first this suggests that the Jenny Lind was receiving as many visitors annually as it had done in the nineteenth century. However, the entries refer only to individuals rather than to parties and many entries are made by a small number of individuals 113

Bruce Lindsay who were active in the work of the Jenny Lind in some way. Fifty-one of the entries refer to male visitors, twenty of them noting visits by the Reverend Douglas-Willans between April and October 1911, the year in which he acted as chaplain to the Jenny Lind. Of the remaining entries, nine refer to Annie Ranson, a CoM member for much of this time, and thirteen to a Miss Sheepshanks, whose activities in the hospital are not known. Eight visitors gave overseas addresses, including Robert Ranson from Florida, who may have been a relative of Annie Ranson, and a Mrs Morgan from Rome. Of the final nine entries for 1915, one is from Los Angeles, one from Canada, one from India, one from Los Angeles and two from Sweden. Visits were made by the Right Reverend Bishop Hamlyn, accompanied by the Reverend Douglas-Willans, Fleet Surgeon A.S. Nance RN, and Edward G. Glover Kt MD. Tours of the hospital were a public relations exercise aimed at encouraging people to become supporters and to make financial contributions to its work. In 1914, the Jenny Lind made its first contract for the treatment of children, with the Norwich Education Committee.15 By the 1920s, the Jenny Lind was agreeing contracts for the treatment of children with other education committees and with local councils. At the same time a growing proportion of its child patients were covered by their families’ membership of contributory schemes. In 1919, Mr John Howlings, representing the Great Eastern Railway Staff Hospital and Benevolent Fund, was co-opted onto the CoM.16 In 1926, two members of the CoM were coopted from the Norwich Hospitals and Medical Institutions Sunday and Saturday Fund, which was funded primarily through a contributory scheme.17 The Jenny Lind came to depend less and less on the financial contributions of individuals and so courtship of their support became unnecessary. Supporters remained important for their contributions of gifts and of money for the endowment of cots, for example, but their financial contributions were no longer the only source of income for the institution.18 The Jenny Lind’s in-patients continued to see regular visitors on the wards as a brief religious service was given every Sunday. In the 1930s, this consisted of ‘a blind man who came to play hymns on the piano and some ladies who sang. We all got a pretty printed text from them each week.’19 But it was only on special occasions that the Jenny Lind still encouraged visits from its supporters in order to entertain the in-patient children. Guy Fawkes Night on 5 November is traditionally celebrated with bonfires and fireworks. The Jenny Lind celebrated on at least one occasion with a ‘magnificent firework display…. We were allowed to watch it through the verandah windows.’20 Christmas was the most important occasion of the year, and Christmas celebrations were a consistent feature of the Jenny Lind even when parental 114

Pariahs or Partners? visiting was at its most tightly controlled. The first recorded Christmas celebration in the Jenny Lind took place in 1876, when a Mrs Hansell organised a ‘Christmas Tree Party’.21 By 1900, this celebration had developed its own tradition: Mr Bosworth Harcourt, a consultant dental surgeon, played Father Christmas for the eighteenth time in that year and would go on to play the role for another thirteen years.22 The Christmas festivities became increasingly complex during the early twentieth century and soon included the lighting of the Christmas tree ‘by electricity by Messrs Mann, Egerton and Co Ltd’, a musical play by junior pupils of the High School and, on New Years Day, a song and dance and a ‘Cinematographic Entertainment’.23 These entertainments were considered to be important enough for the CoM to declare, in 1914, that they would continue despite the outbreak of war.24 The Christmas entertainments became less complex over the years, but remained important and carried on throughout the Second World War. Christmas 1943, for example, featured visits to the wards by the Royal Air Force, fire services and the Salvation Army. The nurses went round the wards singing carols on Christmas Eve, and members of the United States forces, many of whom were stationed in Norfolk, visited with gifts.25 In contrast, parents continued to be prevented from entering the wards, even when other visitors were providing the Christmas entertainments, and outside the Christmas period restrictions continued. In 1944, the local Mothers’ Union proposed that a Mrs Oswald should act as a ‘Mothers’ Union Visitor’ to the Jenny Lind.26 The CoM’s response was emphatic: the Mothers’ Union was to be informed that ‘visitors to the Wards are not generally permitted and… parents are not allowed to visit their children unless the condition of the patient is serious.’27 Patient visitors The first policy for visiting, established in the autumn of 1854, stated that ‘Parents and friends of Patients’ could visit ‘on three days in the week between the hours of 2 and 4pm on Mondays, Wednesdays and Saturdays.’28 Patients’ visitors routinely ignored the policy and nursing staff and in-patient children were soon receiving visits from relatives and friends with little regard for agreed visiting hours.29 This more flexible approach to visiting resulted in a formal complaint from Mr Dalrymple, the consultant surgeon, who felt it necessary to report ‘unauthorised visits’ to the CoM, although seemingly without effect.30 While the Jenny Lind admitted children with the primary intention of curing illness, or at least stabilising the child’s condition, it had other intentions that required visits from relatives and friends. On a practical level, regular visits by relatives enabled them to keep their children supplied with 115

Bruce Lindsay fresh clean linen and to take away dirty linen for washing.31 This would help to reduce the staff workload and the hospital’s running costs. More importantly for the aims of the Jenny Lind, regular visits enabled parental education. The educational role was promoted strongly by the Jenny Lind, its medical officers and its supporters, including the local newspapers. The wards of the Jenny Lind were seen as model environments for parents to observe and learn from.32 The medical officers used the opportunities afforded by parental visits to educate the parents about the care of sick children.33 Children, as well as adults, were accepted as patients’ visitors. On occasion, such as the outbreak of infectious disease, patients’ visitors would temporarily be banned but even then this was not a decision taken lightly.34 Rules would be officially relaxed in special circumstances, such as when children were terminally ill. In such a case ‘the Parents of a child who is supposed to be dying shall be informed of its condition… and shall at all times have access to the child….’35 Towards the end of the nineteenth century, the Jenny Lind abandoned its role in educating the parents of in-patient children. The arrival of Miss Peter as matron, in 1885, resulted in the development of formal training for probationer nurses. These programmes, at first of only three to six months duration but eventually extending to a year, served to boost recruitment. Many probationers came from wealthy families and these ‘special probationers’ paid for their training, providing a welcome addition to hospital income.36 This new emphasis on the training of nurses left less time for senior nurses to educate parents. By the mid-1890s, the Pottergate Street building was no longer fit for use as a children’s hospital. The structure of the building was in need of major repairs and the state of the wards was resulting in problems with recruitment and retention of nurses as well as with the delivery of care. The Jenny Lind left Pottergate Street in 1898 and moved to a temporary home at 28 Tombland, adjacent to Norwich Cathedral. In 1897, Jeremiah James Colman donated land on Unthank Road and a new, purpose-built, hospital was opened in 1900.37 The Colman family, owners of the Colman’s mustard business, were well-known philanthropists and were active supporters of the Jenny Lind. J.J. Colman was a life governor.38 By 1900, the Jenny Lind had reduced its formal visiting hours, allowing visiting only on Mondays and Saturdays and by no more than one person at a time.39 When this revised policy was introduced is unclear, but it may have resulted in part from the move to 28 Tombland. This was a small building, containing two wards each of five beds, with limited space available.40 Shortly after the opening of the new Unthank Road hospital, Miss Wenlock, the matron, persuaded the CoM to ease the visiting restriction slightly. The 116

Pariahs or Partners? new policy changed visiting days to Wednesday and Saturday and allowed two patients’ visitors at a time.41 Less than two years later this minor liberalisation of the policy was reversed and the Jenny Lind began a process of restricting patients’ visitors which was to lead to their almost total exclusion from the wards. In March 1902, the CoM decided to reduce the risk of smallpox in the Jenny Lind by banning visits by adults from infected areas and by banning child visitors completely.42 The ban on child visitors was never formally rescinded. In 1903, the hospital was accused by Erpingham District Council of discharging two children who had become infected with scarlet fever during their admissions, resulting in an outbreak of the disease in the district. A local councillor asserted during the case that the Jenny Lind was known to be ‘a hotbed of infection’.43 In late 1904, visiting times were reduced to one hour, from 2pm to 3pm, on Wednesday and Saturday. More crucially, patients’ visitors were banned from entering the wards.44 No justification for this change appears in surviving records, but two local issues may have had an influence. Local concerns about infection risk, such as those from the Erpingham councillor, may have caused the CoM to reduce the amount of time visitors spent on the wards, giving the hospital two potential benefits. Less time on the wards meant less time for infection to spread between patients and visitors. It also meant less time for visitors to observe practices which may be open to criticism. In addition, there was much debate at this time over whether to appoint a resident medical officer (RMO). Miss Sutherland, the matron, had responsibility for dealing with emergency cases in the absence of a physician or surgeon.45 Visiting hours may also have been reduced to ease at least one pressure on the matron and nurses. Restricted visiting hours may have been intended to make the running of the hospital easier and the limitations attracted little comment in the Jenny Lind’s documents or in the local press. However, as the hospital grew and admission numbers increased, problems began to arise. Although patients’ visitors could no longer enter the wards and contact the children directly, many parents and friends still travelled to the hospital on visiting days, hoping to glimpse a child through the ward windows or on the verandahs. In 1918, visiting times were becoming problematic and the CoM was worried about the behaviour of the visitors who: [A]re very abusive and refuse to obey any requests made to them by our officials. The flower beds have been trampled down and the whole place over-run. It was decided that the Chairman should see the Chief Constable and ask his help and advice.46

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Bruce Lindsay The outcome of the discussion with the Chief Constable is not recorded, but, in 1924, the ‘problem’ of patients’ visitors again emerged. During September, the Honorary Secretary, Frank Inch, complained at the CoM about the ‘very large numbers of parents and relatives of the patients on visiting days… and the harm done to the patients themselves and to the garden and buildings.’47 The ‘harm’ is not clarified, but the CoM considered the issue to be so problematic that it arranged a special meeting and recommended that the Chief Constable be contacted for advice. The meeting heard evidence from the matron and the RMO about ‘disturbance owing to visits which, so far as can be ascertained, are not allowed in any other Children’s Hospital.’48 The source of this information is not known. However, at that time at least one other institution, Sheffield Children’s Hospital, allowed parental visits on a weekly basis.49 Again, the precise nature of this ‘disturbance’ is not recorded but the meeting proposed new restrictions for visiting, to take effect from January 1925.50 Visiting was limited to Saturday afternoons, from 2.30pm to 3.00pm. Visiting cards were to be issued to parents on the admission of a child, with each card admitting two adults only: the new regulations again emphasised that child visitors were not allowed. Parents could have access to their children only in cases of life-threatening illness or injury. In all other cases, parents were not allowed access to the wards, only to the ward sister in her office. The visiting cards were to include the statement that ‘Children are found to be happier and more contented when undisturbed by parental visits’. Restrictions were also placed on the gifts that patients’ visitors could bring for the children. Only eggs and flowers were permitted as gifts initially, and although this was relaxed shortly afterwards to include fruit, it was made clear that gifts of fruit would be collected by the ward sister and shared out to all children.51 This redistribution of fruit would have helped to ensure a healthy diet for all the in-patient children, at no additional cost to the institution. The 1924 regulations represent the nadir of parental access to the Jenny Lind. ‘Visiting’ was formally declared to be a problem for both the hospital staff and the young patients, obstructing the smooth running of the institution and the recovery of the children. Even this extremely limited access could be withdrawn without explanation. In 1930, the Jenny Lind cancelled at short notice, and without giving a reason, visiting on the Saturday after Christmas. A letter from ‘A Sufferer’ was published in the local newspaper, complaining that ‘No notice whatever was given to the parents… which caused many a tearful eye on the Unthank Road.’52 The letter was discussed by the medical officers, who were in agreement that ‘visiting should not be allowed except in those cases where the patient is dangerously ill.’53 In addition Mr Inch wrote a reply, also published in the newspaper, 118

Pariahs or Partners? making the Jenny Lind’s official position clear and re-emphasising the importance of a strict ban on visiting: For many years there has been a rule that parents should not be permitted to visit their children except in cases on the danger list… a) Because of the risk of bringing infection into the wards; and b) It has been found from experience that the progress of children is undoubtedly retarded by these visits. For some time now there has been some slackness in the application of this rule, as a result of which many parents, when making inquiries at the ward door, have entered the ward without permission. It has therefore been found necessary to adhere more rigidly to the regulation… printed on the cards given to the parents… as follows:‘This card admits two parents or guardians to interview the ward sister. Entrance at the out-patient department only. Children are found to be happier and more contented when undisturbed by parental visits. For this reason visiting is not allowed, but the sisters welcome inquiries on Saturdays from 2.30 to 3 p.m.’ I should like to point out that the rule prohibiting visiting is in force at most of the children’s hospitals throughout the country.54

This version of the visiting regulations remained in force for twenty years. While the administrators and medical staff were in favour of the regulations no evidence remains of the opinions of nurses or parents. However, ex-nurses and patients reflecting on the Jenny Lind in the late1990s held contrasting views. One ex-nurse remembered the ban on visits to the wards but commented that ‘the children didn’t seem so unhappy’. Another ex-nurse wrote of the exclusion of parents that ‘[i]t would be thought rather cruel now and indeed I thought so then,’ while an ex-patient, admitted as a 3-year-old in 1935, remembered ‘the heartbreak and anguish my parents went through which in today’s world would be classified inhuman.’55 Experiences of the visiting regulations varied. One ex-patient remembered her mother being able to speak to her through a ‘partition’ but not to touch her. Another remembered that when critically ill in 1935 his parents ‘were allowed to come to the entrance doors of the very long Ward and see from a great distance where I was laying.’ Other parents and relatives would attempt to catch a glimpse of the children from outside the hospital grounds, standing at the iron railings in the hope of seeing children in the gardens or at the ward windows.56 119

Bruce Lindsay While individual experiences were different, the official policy of the Jenny Lind was consistent. Regular contact with parents was not seen as important to the child’s treatment or psychological well-being. Indeed, parental presence on the wards was seen as a danger to the effective treatment and care of the in-patient children. When parental access to in-patients was again considered it was strictly in reference to infant patients. In 1939, discussions took place about the construction of a new ward for infants. Mrs Jackson, the matron, proposed that such a ward should include accommodation for nursing mothers. The medical officers agreed, proposing the building of two sets of rooms, each containing a sitting room, bathroom and lavatory.57 The reasons for supporting this idea are not recorded and the ward itself was not built. At first, support for resident mothers seems in stark contrast to a policy which declared that parents were an infection risk and obstructed the recovery of children. However, the Jenny Lind was not the only institution to support the admission of mothers with their infants. The argument in favour of resident mothers emphasised different underpinning theories than the one in favour of the exclusion of parents of older children. Encouraging mothers to be resident with their infants was intended to reduce the risk of crossinfection by reducing the contact between nursing staff and patients.58 By the late 1940s, children’s hospitals such as the Jenny Lind were finally resolving the conflict between preventing infection and responding to new psychological theory. New medications were proving to be effective against infectious disease, and this effectiveness was becoming recognised by the public as well as by health professionals. As the fear of infection receded a major medical argument against patient’s visitors lost its impact. Had new medications not appeared, this new perspective on meeting children’s emotional needs may have taken longer to win support. The Jenny Lind revised its visiting regulations in late 1948 or early 1949, allowing families to visit in-patient children at weekends. However, these visits were initially at the discretion of the ward sister. If she felt that a child was being upset by the visits then parents could again be excluded from the wards and allowed only to peer at their children through the windows of the ward doors. Even this activity could be refused if their child saw them.59 This revision coincided with the establishment of the National Health Service, but there is no indication that this was the driver for such a change to visiting policy. Other influences, such as evacuee studies, the child welfare movement, experiments with parental care that suggested its value in reducing infection, may all have influenced this development.60 More pragmatically, a potential shortage of nurses was predicted and care by mothers was seen as a way of alleviating this shortage.61 The new policy proved successful, and daily visiting was soon introduced. This initial 120

Pariahs or Partners? relaxation of the rules for patients’ visitors was small, but it was a change that placed the Jenny Lind in the vanguard of hospitals with regard to the issue. In the early 1950s, a survey of 1,300 hospitals that admitted children showed that only 300 allowed daily visits by parents and 150 allowed no visiting at all.62 The following years saw a relatively swift change in the Jenny Lind’s ideas about visiting and psychological care. In 1951, local art students painted Alice in Wonderland murals on the walls of Colman Ward, watched in a newspaper photograph by child patients in day clothes.63 Three years later Centenary Hall was opened in celebration of the hospital’s one-hundredth anniversary, to be used for children ‘able to get up from bed to continue their education, and for reading and recreation’.64 A mothers’ room was opened, suggesting that mothers were expected to stay on the wards for long periods, perhaps overnight, during their children’s admissions.65 By the mid-1950s, the Jenny Lind was presenting itself as a progressive children’s hospital, basing its care on the most up-to-date psychological theories of development. A newspaper report offered an insight into an institution that claimed that it put children and families first.66 The Jenny Lind was now emphasising out-patient care because of the ‘modern tendency’ to prevent admission if possible. The policy for in-patients included getting children up and into their day clothes as soon as it was safe to do so. Parents had, ‘[i]n the last few years’, been able to visit daily. Despite the occasional upset or over-excited child, daily visiting was now ‘by far the best thing in the long run’.67 The Jenny Lind’s approach to the care of children had changed almost completely and apparently with no internal or external opposition. This new orthodoxy focused on parental access and psychological care, replacing the previous orthodoxy of psychological and physical isolation with ease. Infection and upset: reasons for exclusion? The Jenny Lind publicly justified its gradual exclusion of parents and relatives on two grounds: the risk of infection they posed, and the upset they caused to the child in-patients.68 Neither accusation was ever levelled at hospital visitors, but this does not simply reflect social or economic stereotyping by the Jenny Lind’s managers and staff. The Jenny Lind recognised that parents and relatives were different from hospital visitors in their reasons for visiting the hospital, in their relationships with the inpatient children, and in their socio-economic backgrounds. Parents and relatives were familiar faces for the children. They were known and loved, and they were links to the child’s normal home environment. It was not their presence on the ward that caused upset in the children, but their leaving at the end of their visits. Hospital visitors were strangers, unfamiliar and 121

Bruce Lindsay unrepresentative of home life: in many cases they would have no contact with individual children. It is highly unlikely that many of these hospital visitors would cause upset to children by leaving the ward. For similar reasons, hospital visitors were not seen as an infection risk. By 1900, the germ theory of disease was fairly well accepted within the medical community and health professionals were beginning to understand how infectious disease could be transmitted from person to person. Poor hygiene and close personal contact both offered opportunities for infections to thrive and spread.69 The Jenny Lind’s patients were from the poorer populations of Norfolk and north Suffolk, and the medical staff was aware of the overcrowding and poor sanitary conditions that many of them experienced daily. Ideal conditions for the spread of infection were being created when parents and relatives visited from these areas and came into close physical contact with their children. Hospital visitors, drawn from the middle and upper classes, assumed to have higher standards of hygiene, and without close physical contact with the patients, were viewed as posing no such risk. The Jenny Lind’s perspective on infection and emotional upset is not articulated in any surviving material, and so it is impossible to know to what extent these two issues genuinely drove the hospital’s visiting policy. There is little reference to the emotional well-being of children in any Jenny Lind documentation that survives from this period. However, the risk of infection was often referred to in connection with other aspects of the Jenny Lind’s work. Parents were aware of the risk to their children posed by a hospital admission. Indeed, the CoM would remind parents of this risk themselves when justifying further restrictions to visiting times or when banning visitors completely during outbreaks of infectious disease.70 The benefits of admission would be believed to outweigh the risks, but if an infection did occur the Jenny Lind could find itself being called to account. Formal complaints about the Jenny Lind’s treatment of children were rare, but when they were made, infection was the commonest reason.71 Exclusion of patients’ visitors offered two advantages relating to the risk of infection. The risk of parents and relatives bringing infection to the wards was eliminated, and so too was the risk that such visitors would observe care practices which later give might cause for complaint should infection arise as a result of admission. Although drugs were being developed which offered prevention and treatment of an increasing number of infectious diseases, other infections remained impervious to pharmacology. Throughout this period, therefore, the Jenny Lind would regularly consider infection control measures based on the physical isolation of in-patients. The Jenny Lind was not an infectious disease hospital, and was not equipped to be one. Any outbreak of infection 122

Pariahs or Partners? was to be feared due to the risks it posed, in particular to post-operative patients. In 1934, Miss Helen C. Colman, a long-term supporter of the Jenny Lind, who was then serving on the CoM, suggested that screens should be erected between beds to prevent infection. The medical officers rejected this, agreeing instead that all parents would be asked during the admission interview if the child had been in contact with any infectious disease.72 The possibility of undertaking any microbiological tests for infectious disease was not considered. As late as 1946, Professor Alan Moncrieff, a leading paediatrician, recommended during a visit to the Jenny Lind that bed numbers should be reduced and glass panels should be used to separate the remaining beds.73 This suggestion was also rejected, but it demonstrates the strengths of concerns about cross-infection that remained within the medical profession and served as a strong argument for the continued exclusion of patients’ visitors. Infectious disease and emotionally upset children were both aspects of hospitalisation that could be easily demonstrated to professionals and parents alike. They offered readily understood reasons for strict visiting policies, but may themselves have covered other reasons for this restriction. Parental visits could disturb ward routines; parents could be disruptive and ‘difficult’.74 The role of the nursing staff in the development and continuation of parental exclusion demands further study. In the Jenny Lind there is some evidence that a few nurses felt concerned about the lack of contact in-patient children had with their families, but there is no evidence that nurses made any attempt to change the policy, or actively campaigned for the re-introduction of visiting.75 In the early twentieth century, children’s nurses struggled to achieve equality with the so-called ‘general’ nurses, who were trained mainly in the care of physically ill and injured adults. Children’s nursing was seen by many as an extension of mothering, with these nurses taking on a role that the mother would herself have fulfilled if other responsibilities had allowed her to do so. In the 1919 Nurses’ Registration Act, this belief was legitimated by the creation of a ‘supplementary’ register for the new Registered Sick Children’s Nurses (RSCNs). The RSCNs were criticised for their focus on sick children, which was seen as secondary to the skills needed to nurse adults, and even senior children’s nurses would sometimes leave their posts to undertake general nurse training.76 It is possible that RSCNs supported the exclusion of parents and relatives from children’s hospital wards, at least implicitly. The exclusion of parents and relatives from the children’s hospitals enabled the nursing staff to work away from the constant gaze of parents and relatives. It also enabled them to create a belief that parents were of no use in a children’s ward: that the skills required to care for the sick hospitalised child were beyond those held by the untrained parent. 123

Bruce Lindsay In the Jenny Lind, the skills of the children’s nurse came under regular criticism by the medical staff during the 1920s. Discussion about closer cooperation with the Norfolk and Norwich Hospital had first taken place in 1923–4. Miss Colman saw this discussion as a response to a general move towards co-operation between large and small hospitals and no agreement was reached.77 However, by the late 1920s, the medical officers were expressing concern about the standards of nursing care at the Jenny Lind. In 1929, the matron Miss Pratt retired. The medical officers took the opportunity to act on their belief that the nursing staff ‘should be made more efficient’.78 The medical officers agreed that the hospital should be staffed by nurses from the Norfolk and Norwich Hospital, and managed by that hospital’s matron. Nursing management became the responsibility of the Norfolk and Norwich Hospital and senior nursing posts required a general, rather than children’s, nursing qualification.79 The Jenny Lind’s nurse training school was closed, and the wards became part of the training circuit for pupil nurses from the general nursing school at the Norfolk and Norwich. The 1929 amalgamation resulted at least in part from the failure of the Jenny Lind’s children’s nurses to meet the needs of the medical staff. Physicians and surgeons clearly felt that RSCNs lacked the clinical abilities and knowledge required to assist doctors in their work. The general nurses trained mainly in adult wards and departments and their training courses had little room for any consideration of the emotional or psychological care of children and families. Their perspective on care, therefore, made the return of parents and relatives even less likely. A process that had been initiated with the tacit agreement of children’s nurses was to continue even though that group of nurses was itself disappearing from the wards of the Jenny Lind. The growth in, and eventual dominance of, surgical treatments also impacted strongly on the Jenny Lind’s management of care. Surgical dominance was due overwhelmingly to one procedure: tonsillectomy and adenoidectomy. The first instance of this procedure at the Jenny Lind was in 1887 when one ‘excision of tonsils’ was undertaken.80 In 1897, eighteen operations from a total of ninety-six were for tonsillectomy and adenoidectomy.81 This proportion grew rapidly in the Unthank Road hospital, with the procedure soon becoming the commonest reason for admission. In 1929, the Jenny Lind admitted 1,802 in-patients: 1,424 inpatient operations were undertaken, with 1,008 of these being tonsillectomy and adenoidectomy.82 The impact of tonsillectomy and adenoidectomy on the Jenny Lind was high. It affected the hospital’s working practices, its income, its relationship with local family physicians and the routines of its junior medical and 124

Pariahs or Partners? nursing staff. Its impact on visiting is difficult to judge accurately but warrants further exploration here. On one hand, tonsillectomy and adenoidectomy helped the Jenny Lind to justify its restrictions on visits by relatives and friends. Children admitted for this procedure had to be generally well at the time of admission and as the surgery was planned the family would have had time to make preparations for their child’s hospital stay. Hospitalisation was not the sudden result of an accident or acute life-threatening illness, and could therefore be viewed as less traumatic for both the child and the family. Hospitalisation was also relatively brief. In the 1920s, an admission for tonsillectomy and adenoidectomy routinely lasted for two days. In 1932, the medical officers revised their policy to ensure that they had time to evaluate each child’s need for the procedure and to better ensure post-operative recovery, extending the period of admission to five days.83 However, this was still well under the average length of stay of nineteen days for children admitted for other reasons.84 Tonsillectomy and adenoidectomy also intensified the concerns about risks of cross-infection. The nature of the surgery and the high number of children undergoing the procedure meant that some physicians considered the risk to be extremely high. In the late 1920s and early 1930s, the question of infection risk was regularly debated, particularly in relation to scarlet fever, with the local Medical Officer for Health advocating routine scarlet fever prophylaxis for every child admitted for tonsillectomy and adenoidectomy.85 Although the Jenny Lind’s medical officers did not always view infection as a serious risk, the concerns of local physicians did lend credence to the official Jenny Lind view that parental visits risked spreading infection. In contrast, other aspects of tonsillectomy and adenoidectomy may have helped to create a new climate in favour of visits by relatives. It became the standard treatment for persistent tonsillitis and this was not an illness confined to the children of the poor. The procedure’s popularity coincided with the rise in the funding of treatments by contributory schemes and contracts with local councils and education authorities. These two factors helped to change the characteristics of children’s hospital in-patients and, consequently, of their parents. In-patient children were increasingly likely to be from middle-class families, with parents who were socially closer to the physicians and more likely to be aware of new ideas in psychology and sociology. As this awareness gathered pace, parental expectations of care gradually moved to a greater emphasis on psychological and emotional needs. In the Jenny Lind, parents did not overtly articulate such changing expectations. However, this awareness was becoming apparent nationally by 125

Bruce Lindsay the early 1940s, when Lady Russell initiated a heated debate about parental visiting in the Lancet.86 In the 1940s and 1950s, the work of Donald Winnicott, John Bowlby and James Robertson, among others, was becoming well-known among professionals and parents alike. The detrimental effects of separation from parents and placement in clinical environments such as children’s wards were becoming recognised.87 The Jenny Lind’s changing attitudes to patients’ visitors were an early indication of the change in approach that would eventually impact on the care of sick children in the latter half of the twentieth century. Conclusion The Jenny Lind’s attitude to visitors changed markedly in the period from 1900–50. Hospital visitors lost their vital roles as supporters or potential supporters of the institution and their ability to access the buildings freely was no longer of importance to the institution’s survival. As a result, they were no longer welcome to tour the wards and departments at will, and were limited to visits on special occasions such as Christmas, and then only by invitation. Patients’ visitors found their access to the Jenny Lind was also reduced, so that by 1924, they were almost totally excluded. In contrast to the hospital visitors they regained the access they had enjoyed in the early years of the Jenny Lind’s existence. Parents and relatives of patients had been welcomed to the Jenny Lind in the 1850s because their visits offered opportunities for their education and for practical assistance with the cleaning of laundry, as well as enabling them to maintain links with the inpatient children. Access was regained when their importance for the psychological and emotional well-being of the children was recognised. The re-introduction of patient visitors in children’s hospitals and wards was a clear indication of the growing influence of new psychological theories on child development and well-being. Notes 1. All primary material from the Jenny Lind Hospital for Sick Children (Infirmary for Sick Children until 1918) referred to in this text is archived at the Norfolk Records Office, County Hall, Martineau Lane, Norwich. Material is part of the archive of the Norfolk and Norwich Hospital, NNH 67/1–NNH 110/3. 2. B. Lindsay, ‘The Jenny’: A History of the Jenny Lind Hospital for Sick Children, Norwich, 1854–2004 (Norwich: Norfolk and Norwich Hospital, 2004). 3. B. Lindsay, Who Cares? The Morphology of ‘Caring’ in Children’s Hospitals, 1852–1950 (unpublished PhD thesis, University of East Anglia, 2000), 120. 4. Jenny Lind Infirmary for Sick Children Annual Report (hereafter AR), 1885, 7. 5. AR, 1909, 20.

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Pariahs or Partners? 6. This shift in clinical emphasis may have happened later at the Jenny Lind than was typical. Cooter suggests that, by 1900, two-thirds of in-patients in children’s hospitals were surgical patients. See R. Cooter, ‘Introduction’, in R. Cooter (ed.), In the Name of the Child: Health and Welfare, 1880–1940 (London: Routledge, 1992), 1–18: 11. 7. Jenny Lind Infirmary for Sick Children Medical Officers’ Annual Report (hereafter MOAR), 1856, 3. 8. Visitors Book, 1854–97. 9. Lindsay, op. cit. (note 2), 10. 10. AR, 1873, 5. In 1885, two years before her death, Jenny Lind met J.J. Winter, the Chairman of the CoM, and Charles Noverre, the Honorary Secretary, on separate occasions, AR, 1885, 6. 11. AR, 1896, 2. 12. AR, 1901, 2. 13. AR, 1905, 6. 14. This visitors book (NNH 109/2) is a standard notebook of lined paper without headed columns, in contrast to the specially designed book used in the nineteenth century. 15. AR, 1914, 11. 16. AR, 1919, 11. 17. AR, 1926, 2. 18. Gifts were generally of linen, books and toys, or fresh produce but on occasions they could be more complex and more expensive. For example, a new ‘wireless set’ was donated in 1932 (AR, 1932, 11) and in 1955 three television sets were donated. See Eastern Daily Press, 22 March 1955, 6; and 7 April 1955, 7. 19. Lindsay, op. cit. (note 3), 274. 20. Ibid., 273. 21. Jenny Lind Infirmary for Sick Children Committee of Management Meeting (hereafter CoM), 4 January 1876. 22. AR, 1900, 5. 23. AR, 1908, .9. 24. AR, 1914, 12. 25. Lindsay, op. cit. (note 3), 272–3. 26. The nature of the Mothers’ Union Visitor’s role was not made explicit in any of the correspondence. 27. CoM, 27 September 1944. 28. CoM, 24 October 1854. 29. The exclusion of patient visitors in the early twentieth century was so complete that texts for medical and nursing students often assume that visitors were never present in children’s wards until the 1950s. These texts instead ascribe the appearance of visitors on children’s wards to the work of

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30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49.

50. 51. 52. 53. 54. 55. 56. 57.

James Robertson, the psychologist, in the late 1940s and early 1950s. See B. Lindsay, ‘Visitors and Children’s Hospitals, 1852–1948: A Reappraisal’, Paediatric Nursing, 13:4 (2001), 20–4: H. Hendrick, ‘Children’s Emotional Well–being and Mental Health in Early Post-Second World War Britain: The Case of Unrestricted Hospital Visiting’, in M.Gijswijt-Hofstra and H. Marland (eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 213–42. CoM, 27 February 1855. CoM, 5 July 1872. Norwich Mercury, 6 January 1855, 4. MOAR, 1864, 2. In the first years of the Infirmary, the medical officers produced their own Annual Report, separate from that of the management. CoM, 3 November 1871. CoM, 26 July 1859. Lindsay, op. cit. (note 3), 178. Lindsay, op. cit. (note 2), 6. AR, 1897, 12. J.J. Colman died in 1898. CoM, 9 May 1900. AR, 1898, 8. CoM, 9 May 1900. CoM, 12 March 1902. CoM, 13 July 1903. CoM, 12 December 1904. Lindsay, op. cit. (note 3), 172. CoM, 24 April 1918. CoM, 17 September 1924. CoM, 12 November 1924. Sheffield Children’s Hospital House Committee, minutes of the meeting of 6 February 1930, House Committee Minute Book 19 May 1927–19 March 1936. Accessible via Sheffield Children’s Hospital administration. This meeting also noted that from November 1925 visits were monthly, and restricted to children who had been in-patients for at least one month, unless children were on the ‘danger list’. This would have meant that visits were rare. CoM, 12 November 1924. CoM, 15 July 1926. Eastern Daily Press, 6 January 1931, 4. MOAR, 8 January 1931. Eastern Daily Press, 8 January 1931, 9. Lindsay, op. cit. (note 3), 266. Ibid., 266–9. MO meeting, 5 April 1939.

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Pariahs or Partners? 58. This approach was enacted in Britain during the 1930s by Professor James Spence in Durham, and in the early 1940s in New Zealand by the Pickerills. See the letter from J.C. Spence, Lancet, 1 (1933), 440; H.P. Pickerill and C.M. Pickerill, ‘Elimination of Cross-Infection, an Experiment’, British Medical Journal, 1 (1945), 159–60. 59. Lindsay, op. cit. (note 3), 270. 60. Ibid., 290–300. 61. J.C. Spence, ‘The Care of Children in Hospital’, British Medical Journal, 1 (1947), 125–30. 62. J. Robertson and J. Robertson, Separation and the Very Young (London: Free Association Books, 1989), 7. 63. Eastern Evening News, 7 June 1951, 12. 64. Eastern Daily Press, 9 December 1954, 6. 65. Eastern Daily Press, 27 December 1956, 2. 66. Eastern Daily Press, 30 May 1953, 4. 67. Eastern Evening News, 6 June 1958, 14–15. 68. Eastern Daily Press, 8 January 1931, 9. 69. A. Yankauer, ‘Pediatric History: Job Lewis Smith and the Germ Theory of Disease’, Pediatrics, 93, 6 (1994), 936–8. 70. Lindsay, op. cit. (note 3), 191. 71. Ibid., 195–8 and 240–1. 72. MOAR, 4 July 1934. 73. CoM, 23 October 1946. 74. Hendrick, op. cit. (note 29), 213–42. 75. Lindsay, op. cit. (note 3), 323. 76. Ibid., 176, 223. 77. Correspondence, NNH 93/25. 78. MO meeting 12 February 1929. 79. Lindsay, op. cit. (note 3), 223–4. 80. AR, 1887, 7. 81. AR, 1897, 8. 82. AR, 1929, 30. 83. AR, 1932, 6. 84. This figure is for 1929. If tonsillectomy patients are included in the figures, the average length of stay falls to twelve days, AR, 1929, 5. 85. See, for example, MO meeting 4 December 1929, MO meeting 1 March 1932. 86. Patricia Russell, ‘A Parent at Hospital’, Lancet, 1 (1945), 642. 87. For a detailed analysis of this shift in thought see Hendrick op. cit. (note 29), and B. Lindsay, ‘“A 2-year-old goes to Hospital”: A 50th Anniversary Reappraisal of the Impact of James Robertson’s Film’, Journal of Child Health Care, 7, 1 (2003), 17–26.

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6 Visiting Children with Cancer: The Parental Experience of the Children’s Hospital of Pittsburgh, 1995–2005

Robin L. Rohrer This chapter examines the unique role of parental visitors of children with cancer at the Children’s Hospital of Pittsburgh, 1995 to 2005. Using oral interviews with parents, medical and psychosocial staff, the study explores the experiences of parents while in hospital with their children and the social, emotional, financial and family issues they confronted during these admissions. Parents in their stories identified the various roles they assumed as their children experienced illness, treatment, side effects and psychosocial issues. The study also questions the relative importance of family dynamics, race, and socio-economic status as these related to parents’ roles and perceptions.

Parental visitors of children with cancer have a special experience in the larger schema of visitors to medical institutions. They are obviously not patients or staff but deal closely, even intimately, with both. The stakes for these visitors are exceedingly high – the life or death of their children. Most of these visitors will spend weeks or months at a time in the hospital, thus approximating many aspects of patient hospitalisation itself. Depending on many factors, including the hospital’s distance to home, and the family’s situation, many parents will spend this time of stress, crisis and hope alone in the hospital without significant family support or relief. This chapter examines the experiences of twenty-five parents whose children were being treated for blood or solid tumour cancers. Overall, the goal of the project was to capture and assess parental visitors’ feedback in the light of factors including the child’s diagnosis, type of treatment, family stresses and staff involvement. The chapter includes examples from parent interviews to highlight stressors, relationships with medical and psychosocial personnel and the development of the role of parent as advocate. For most parental visitors, the cancer diagnosis and treatment of their child was a turning point in family life that called for great emotional and even 131

Robin L. Rohrer financial reserves. The extent to which parental visitors had the support they needed depended largely on their pre-existing family and community support systems. Interaction with hospital staff would enable most of these visitors to weather their family’s crisis, adding or even substituting a hospital support system for their own.1 Paediatric acute care and, in particular, care for children with cancer was a development of the modern era, mainly in the last four decades of the twentieth century. Specialty care for children with cancer began in the 1930s with the establishment of a paediatric cancer ward at Memorial Hospital (later Memorial Sloan Kettering Cancer Center) in New York. Even in this time professionals realised that a team approach to treatment was critical in caring for children. Psychologists, social workers and teachers joined the ranks of doctors and nurses in Memorial’s Children’s Pavilion. This tradition was continued with the establishment of oncology units in institutions such as the Children’s Hospital of Boston and Children’s Hospital of Philadelphia. Built primarily for the treatment of children with cancer, St Jude’s Children’s Research Hospital in the early 1960s furthered the development of childcentred ‘total care’ for this population.2 This tradition of total care for children continued to change in response to the development of better and eventually curative therapies for cancer. By the 1980s, through chemotherapy, often along with surgical or radiation interventions, the care of these children included both acute (fast moving) and chronic (slow moving) phases as clinical trial protocols and more toxic drugs resulted in frequent hospital admissions and longer periods of treatment.3 It is into this setting of acute and chronic paediatric care that we place the visitors in this chapter. The chapter will examine their experiences as the outcome of medical research continues to increase the odds of survival for the child with a cancer diagnosis. It will explore the roles of their parents who will visit and leave the hospital, mostly with the support and strength they will need to survive this family experience. Several aspects of parents and families coping with a child’s cancer diagnosis and treatment have been explored in the fields of psychology, psycho-oncology and nursing oncology. These works have not focused on the in-patient or hospital experiences per se, although their findings are useful and interesting for this study. Young, Dixon-Woods and Heney explore the identity and role of parenting a child with cancer and of being an advocate for the child.4 Patterson, Holm and Gurney examine the coping behaviours of families and the extent of family resources in their ability to handle the cancer experience.5 Family reactions, including those of siblings and extended family, were explored by Martinson and Cohen.6 There have been several studies which have assessed the emotional impact of childhood 132

Visiting Children with Cancer cancer diagnosis and treatment.7 In contrast, the experience of children and their parents while in the hospital is an area virtually unexplored. Overview of childhood cancers and treatment According to the Children’s Oncology Group, today in the United States, one in 330 children will be affected by cancer before the age of twenty-one. It is estimated that in the next ten years, one in 250 adults will be childhood cancer survivors.8 Although cancer in children is a rare disease, it is still the number one killer of young children after accidental death. In the last fifty years the development of chemotherapy drugs – particularly through combination therapy – the work of national co-operative groups, clinical trials and the creation of supportive therapy have meant that most children will survive cancer. But living through the experience is painful, frightening and with no guarantee of cure. Some cancers have much better cure rates than others. Childhood cancers are typed into two basic categories: leukaemias and lymphomas, and solid tumours. Leukaemias include primarily acute (lymphatic and myeloid) and chronic. Lymphomas include Hodgkin’s and Non-Hodgkin’s. Solid tumours include those of bone and soft tissue, while tumours of the spine and brain are yet another type. Acute lymphoblastic leukaemia (ALL) is a cancer of the lymphatic system and is sometimes called ‘childhood leukaemia’ because it is the most common cancer in children. ALL may be pre-B – the most common type – or T-cell, but is always considered stage IV at diagnosis because it is a cancer of the blood. Children with ALL will usually have symptoms of fatigue, loss of appetite and bruising. The first and most successful advance in the treatment of children with cancer was chemotherapy accomplished with ALL, beginning in the late 1940s. This became the model for chemotherapy delivery and the cure rate for standard ALL now is eighty-five per cent or better. Yet children with high risk and very high risk ALL are often not that fortunate and must undergo more intensive and toxic treatment, including radiation and transplantation. Relapsed ALL is the second most common cancer in children today. The development of effective and later curative therapy for children with ALL is one of the great success stories in modern medicine. Both the process and the therapies produced for paediatric ALL have become the paradigm for cancer therapy and research for both children and adults. In the 1940s, Sidney Farber at Boston Children’s Hospital, who had worked on infectious diseases, was convinced that leukaemias in children could be treated with antifolates. Most of Farber’s haematology colleagues were sceptical of the idea that any effective therapy for leukaemia could be developed, even after 133

Robin L. Rohrer Farber’s antifolate, aminopterin, produced short remissions in several children in 1946. In the late 1940s, most clinicians who treated children with cancer believed that the introduction of ‘chemotherapy’ such as Farber’s aminopterin would only unnecessarily prolong the suffering of dying children with toxic drugs and side effects. Joseph Burchenal, however, was willing to use aminopterin and later its derivative, methotrexate, in his patients at Memorial Hospital. By the mid-1950s, he was seeing some longterm remissions in children, particularly when used in combination with prednisone. Gertrude Elion and George Hutchings at Burroughs Wellcome were also working in the 1950s on developing a therapeutic agent to treat leukaemias in children. Elion was a chemist who believed that a drug could be especially designed to attack leukaemia cells and who tested hundreds of possible substances before 6-mercaptopurine was developed. This drug, along with prednisone and methotrexate would firstly become the basis of leukaemia therapy and today leukaemia maintenance therapy in ALL. Elion received a Nobel Prize for her contribution to this work. Therapy for children with ALL took a great leap forward in the 1960s with the development of combination therapy, created in an attempt to overcome the drug resistance that inevitably occurred in cancer treatment. Combining drugs such as Vincristine, Doxyrubicin, prednisone and l’asparaginase produced a higher initial remission rate and pushed the long remission rate. The introduction of cranial radiation in the 1960s, to prevent central nervous system leukaemia, pushed the rate from about ten per cent to over fifty per cent by 1970. The concept of ‘total therapy’ advocated at St Jude Research Hospital under Donald Pinkel was the impetus for this. The addition of bone marrow transplantation in the 1980s, for refractory or relapsed disease, and the recognition of the importance of molecular disease and chromosomal study have, in 2009, driven the cure rate to nearly ninety per cent for children with standard risk ALL disease.9 AML, or acute myelogenous leukaemia, is not nearly as common as ALL and the cure rate is currently between twenty-five and fifty per cent. In the twenty-first century, AML continues to be a disease which has a poor response rate and for which very few therapies have only partial success. Children will spend the first month, including diagnosis in the hospital, with frequent hospitalisations because of their low white blood count and consequent susceptibility to infection. If remission is obtained, then these children most often will undergo transplantation either with a matched sibling donor or unmatched donor. About one half of the parents interviewed for this study had a child with AML. 134

Visiting Children with Cancer Childhood solid tumours include neuroblastoma, Wilms’ Tumour and tumours of the bone or soft tissue. Liver tumours also sometimes occur, although these are rarer, as are a variety of other tumours. Children seldom have the same types of tumours as adults because the causation is different and almost always unknown. Treatments for all childhood cancers are intense, toxic and come with significant side effects. Hospitalisations are required for many treatments including chemotherapy, radiation and surgery. Hospitalisations are also necessary for treatment of related issues such as fevers and infections.10 Today, although chemotherapy is used when surgery and radiation have limited value, solid tumours, as a group, are more resistant to treatment, and survival rates are closer to fifty and sixty per cent. Study design The goal of the study design was to elicit responses to key questions from the parents of hospitalised children, but also to provide room for them to give detailed examples of significant experiences and individuals. Overall, the project sought to identify the roles of the parent as visitor and their relationship with staff in determining these roles. Children’s hospitals traditionally have given the parents more roles in the care and support of the child, but this situation is a relatively new development over the last two decades. For much of the twentieth century, parents had more limited visiting hours and were told by medical staff to only comfort the child and not play a key role in treatment and support. The nurse’s role was more of a surrogate parent than it is today. Changes in healthcare and the concept of a team approach began to transform these roles over time and this is particularly seen in the area of childhood cancer care. The very serious nature of the disease and the growing realisation that psycho-social support to the child and family was critical has made the evolution of oncology parenting a modern model of ‘total care’ of the ill child. Keeping this model in mind, the survey for this study sought to begin with background information of the child and family regarding the child’s diagnosis, date of diagnosis, age at diagnosis and gender. The next set of questions concerned the first admission: was the child admitted through the emergency room or clinic, on a weekday or weekend? How long was the first admission and what contacts did the parents have with hospital staff? For the purposes of this study, staff included the following: oncologists, nurses and nurse practitioners, residents and fellows, consultants, social workers and child-life specialists. If the child was admitted to an intensive care unit, a section on their particular concerns was also included. The next study material focused on personal issues. The questions in this area dealt with the parents’ comfort and privacy, as well as eating and sleeping habits. Parents 135

Robin L. Rohrer were asked to comment on coping with family at home, finances and family support. Parents answered questions regarding other visitors to the child, including family and friends. Interviews of parental visitors focused on relationships with social work and child-life staff (see below for more details on child life). They examined the roles of these individuals in providing emotional support, direction to resources, educating parents, acting as a liaison with medical personnel and being an advocate for the family. Regarding child life, parents were interviewed concerning behavioural interventions, availability of the play room, toys/crafts and special programs. Parents were questioned about the types of procedures the child experienced during hospitalisation. The list of procedures and tests included blood draws, bone marrow aspirations and biopsies, tissue biopsies, lumbar punctures, surgeries, including line placements, scans, X-rays and echocardiograms, ECGs, EEGs and other diagnostic tests. Tests and procedures being an important treatment and psycho-social area, parents contributed many stories about how well the child tolerated tests and procedures and they were encouraged to relate specific instances of positive or negative experiences. Were parents able to stay with children during tests and procedures? Were tests performed in a timely manner? How well was the child’s pain and or anxiety controlled? How skilful were staff at performing these procedures? During the interviews, parents were asked specifically about the child’s treatment, which could last for several days or weeks at a time. Parental visitors discussed the types of treatment their child received, including chemotherapy, radiation, surgery or alternative therapies. They were asked to comment on their participation in decision making regarding these treatments and if they were dealt with respectfully in this process. Very key in this process was the child’s participation in a clinical research trial. Over ninety per cent of children with cancer are enrolled in clinical trials. Parents answered a series of questions regarding the informed consent process, the information they received on the trial and its possible benefits and side effects. The author asked parents to comment on whether they believed they had enough, too little, or too much information concerning their child’s clinical trial and the emotions they experienced around the decision for the child to participate. Particularly a key issue today, parents were asked if they felt they gave adequate consent.11 The relationship of parents with hospital staff was an important interview area. Questions dealt with both nursing and physician staff. Parents commented on discussions of treatment, privacy and psycho-social issues. They were asked if the child was admitted on 8 North which is the primary oncology floor, or 8 South, 9 North or 9 South, which are medical 136

Visiting Children with Cancer wards. Questions were included on issues such as attention to the child’s needs, the answering of call buttons and intravenous monitoring. Attitude of the nursing staff toward both parent and child, skill level and general quality of nursing overall were also addressed. Did nurses bring parents’ concerns to the physician promptly? Did nursing staff give correct and the ‘right amount’ of information to parents on the child’s condition or treatment? Was the quality of nursing different during the day or night, on weekdays or at weekend? Was there any interaction that stood out? Parents’ relationships with the child’s physicians, particularly the primary oncologists, was a key section of the survey. Did the physician make the parents part of the ‘team’? Did they trust his/her medical judgement and treatment decisions? Did the physician express concern for the child’s concerns? Was adequate time spent with the child? Did they feel that the physician truly ‘cared’ for the child and developed a bond with him or her? Did the oncologist always use language that was understandable and was he or she willing to answer questions? Parents were asked how they experienced the ‘team’ approach of the attending physician? Was the coming and going or rotating of ‘on call’ or ‘on service’ physicians confusing, frustrating or helpful? What about the role of fellows and residents in the child’s care? Were there mostly positive or negative interactions? The last set of study questions related to the child’s discharge from the hospital. Did the parent feel generally prepared to take care of the child at home? How did hospital staff prepare for discharge? Did the parent feel hope, overwhelmed, fear or other emotions at this juncture? Did they feel they were leaving a safety net behind? Did the child’s physician communicate his expectations for home care and next hospital admission?12 Study participants and findings The study included twenty-five participants whose children received treatment for cancer at the Children’s Hospital of Pittsburgh from 1995 to 2005. The Children’s Hospital of Pittsburgh sees a range of patients of various socio-economic and racial groups from the Pennsylvania, Ohio and West Virginia area. The aim of the study was to interview parental visitors whose children were not more than ten years from diagnosis, but not less than six months. It was thought that the longer time from diagnosis would probably dim some details which appeared to be true of the ‘longer out’ families. Many children more than five years from diagnosis can be ‘lost’ to follow up, mostly due to the family’s move outside the Pittsburgh area. All families contacted were willing to participate although roughly twenty-five per cent were not logistically able to do so. This study is part of an ongoing longitudinal study of families since the 1970s. 137

Robin L. Rohrer The Children’s Hospital of Pittsburgh celebrated its twenty-five year history of paediatric transplantation in 2006, and is a national leader in acute care for children with cancer and other diseases. The oncology programme at the hospital is decades old – some of the physicians on staff have given forty years of service and have witnessed pioneers at work in this branch of paediatrics. The Children’s Hospital is part of the University of Pittsburgh Medical Center and member of the Children’s Oncology Group, which creates and oversees co-operative North American clinical trials for all children with cancer. The institution is thus a major teaching hospital which includes several fellowship positions within the haematology oncology division. Paediatric haematology oncology has eight full-time attending oncologists/haematologists, several nurse practitioners and one physician assistant. The team also includes three oncology social workers and a childlife specialist who provides emotional and behavioural support to the children through activities and individual visits. The division also houses a premier blood and marrow transplant unit with an integrated staff. Some of the patients and families included in this study were transplant recipients. Parents were those of children with leukaemias or solid tumours, leukaemias representing seventy per cent and solid tumours thirty per cent respectively. They were interviewed while in hospital or clinic, at the parents’ home or another venue. Some interviews were conducted by phone or begun through email exchange. In roughly one-third of the cases both parents or guardians were interviewed. In all cases, the mother of the child participated in the study. Depending on diagnosis or relapse, some parents experienced as many as eight years of intermittent hospitalisation with their children. Parents of children undergoing blood or marrow transplantations had the longest single hospitalisation – over three months – with children with acute lymphoblastic leukaemia the shortest – several days to two weeks for a single stay. Parents were questioned regarding their child’s first admission and subsequent admissions, being asked to ‘generalise’ to some degree, but to recall specific incidents whenever possible.13 Diagnosis For all parents, the day they heard that their child had cancer was one of terror and shock, resulting in ‘an emotional roller coaster ride in the dark’.14 Parents experienced a variety of overwhelming emotions including confusion, numbness, denial, guilt, fear, helplessness, sadness, grief and anger. Parental loss of control is a prevailing issue. Having a child in the hospital, very ill and perhaps dying, with strangers making life-and-death medical decisions, makes every parent feel that they no longer have control over their child’s welfare and daily life. One parent interviewed recalled that they felt ‘like all parents, a feeling of complete devastation’. It has been well 138

Visiting Children with Cancer documented that most parents will experience symptoms of post-traumatic stress during their child’s treatment for cancer.15 All diagnosis stories are unique, yet have certain aspects in common, such as the feeling of shock and that ‘this really can’t be happening to us’. This study cannot recount each diagnostic narrative, but some examples from the parent interviews speak extremely well of the family’s grief and stress, the background to the first of many hospital stays with their child. For about two weeks Evan had seemed not quite himself, although he still would play periodically with his toys and his sibling. At this time he was just over two years old. Visits to the paediatrician told us nothing only that he probably had a virus. One morning however he got out of his bed and fell onto the floor. He couldn’t walk after that and we took him to the Emergency Room at the Children’s Hospital. There in the ER, the doctor told us that he had leukaemia and would be admitted onto 8 North and that an oncologist would come down to see us before long. It seemed like it wasn’t happening to us but somewhere inside of me I knew it was true. I thought he is going to die and I will never hold him again. We then went up to his room and a strange journey would begin for us.16

Another parent of a child diagnosed with neuroblastoma had a different view of her child’s diagnosis: It took about two weeks for us to know Kelsey’s diagnosis and at first we were told that the lump in her stomach was probably benign. So we didn’t know during her first admission to hospital that we were dealing with cancer. She had surgery and then we went home and waited. The doctor from oncology called and said we had to come back the next day and begin chemotherapy for her. It was malignant and very aggressive. I was very angry and didn’t want my baby (15 months old) to have poisonous drugs. Even later I felt guilt and anger at the doctors and myself for doing this to her. But they told me it was her only chance to live and so I had really no choice. But I kept having this feeling that they were all wrong and that she didn’t have cancer and we were killing her with these drugs.17

Usually, the time of a child’s symptoms to diagnosis is a few weeks, so this parent’s story is uncommon. In some ways, the parents had much less time to ‘digest’ that their child was sick, let alone had an advanced cancer. Kathy was four-and-a-half years old at the time and had seemed to have a slight cold and coughed, kind of a barking cough about once or twice a day. In retrospect, maybe she wasn’t eating as well the last couple of days before but she wasn’t generally a big eater anyway. That Friday we were at her brother’s speech therapy and she kept lying down on my lap and the floor so

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Robin L. Rohrer that the speech therapist who knew us for years said that she seemed not herself. We went out to lunch and I decided to call the paediatrician’s office. I thought perhaps she had strep throat and the weekend was coming up so we should go in. I’ll never forget the doctor, who was in the middle of telling a joke to her, stop and pull out a measuring tape and measured her abdomen. When he finished he said that he wanted us to go to the local hospital and get blood work and a chest X-ray right away. Then it seemed like I was numb and we drove there and the radiologist gave her about twenty stickers when he was done and I thought – this must be bad. In about half an hour they put our paediatrician on the phone while we were in radiology and he told us that she had a mass in her chest and to go home, pack and go right into Children’s Hospital (an hour away). On the way home he called my cell phone and said it was T-cell leukaemia and that she might need a bone marrow transplant. Somehow, by 5.30, we had found sitters for our other three children and were back into Pittsburgh. They took us right away onto 8 North and I remember thinking this must be a parent’s worst nightmare to be on the oncology floor but it seemed like the feeling didn’t really register and that’s how it was for a few days.18

Diagnosis, entry into treatment and the long road ahead of them were, of course, handled differently by each family, drawing upon family and usually religious supports. Of the participants surveyed, the one variable that made a major difference was socio-economic status. Loss of income was devastating to families already under pressure. Families with a higher income could more afford the loss of one parent’s income, and often only one parent worked outside the home before the child’s diagnosis. In recounting their experiences, parents cited their economic situation as a critical factor. The population of the Pittsburgh region is heavily working class and traditionally ethnic, and similar hardships were recounted among both African-American and white families. Entry into a clinical trial Parents of children with any type of cancer reported significant stress around the decision to enter their child into a clinical trial. In the United States, all research hospitals are part of the Children’s Oncology Group, which designs and oversees all paediatric oncology trials in the United States and Canada. Most children will be enrolled in clinical trials but it is a decision for the parents to make. The decision to enrol a child in a research study almost always had to be made in the child’s first hospital stay, often within the first two days. Unlike adults with cancer who are under-enrolled in research trials, over ninety per cent of children with cancer in the United States are enrolled in mainly Phase III trials.19 Phase III trials compare the standard 140

Visiting Children with Cancer treatment (Arm A) with Arms, B, C and D, which have different dose schedules, intensities or combinations. Randomised, national co-operative group trials over the last fifty years have moved forward the cure rate of childhood cancers from nearly zero per cent to over seventy-five per cent cure ratio.20 But parents are understandably fearful at the many possible side effects of treatment. In interviews, they commonly expressed their worries that their child would be a ‘guinea pig’, or the trial would be more toxic and dangerous than standard treatments – which were also at one point clinical trials. They also feared making the wrong decision or submitting their child to more ‘extreme’ therapy than perhaps necessary. Parents in this study related many different experiences of the consent process and attitudes toward clinical trials. The physician’s role, in particular, was seen as crucial in understanding and even ‘embracing’ the research study. Some physicians more than others invited questions and took a long time to explain the research protocol. Most parents believed they had ‘the right amount’ of information with some too much or too little. Overall, parents expressed that, ultimately, they ‘had no choice’ and that the clinical trial was their child’s best chance for a cure. General issues about the stay in hospital Parents encountered many common experiences, although there were key differences. Length of hospital stay was a key factor in parent recall. Children with solid tumours or acute myelogenous leukaemia or those undergoing transplantation were admitted to hospital for weeks or months, whereas hospitalisation for children with ALL generally lasted from several days to fortnight. Different issues emerged for longer admissions. Of the parents surveyed, all believed that they were treated with respect from support staff and shared numerous stories of specific staff, small and large kindnesses. As much as possible, the parents’ and child’s privacy was respected although inevitably round-the-clock patient care interrupted sleep, meals and general daily routines. Parents generally reported getting very little sleep, finding fold-out chairs very uncomfortable, and night-time patient monitoring sleep disruptive. During the child’s first admission, parents were too worried, stressed and fearful to sleep in any case. Even months into their child’s treatment, parents usually slept uneasily and reported being hyper-vigilant. One parent reported that trusting the nurses as she did, she was finally able to go right back to sleep when the staff came in to check her 18-month-old daughter’s vitals, give medication and change her nappy. They became like family, and after repeated requests that ‘I go ahead and sleep [when] I was able to do so’.21 141

Robin L. Rohrer Outside concerns While in the hospital with their child, parents had many outside concerns and stresses that often they had to manage alone or with the child’s other parent. Although difficult situations were made easier if the family had a strong support system, hardships remained. These outside concerns included financial worries, care of siblings at home, running of the household, concerns about other family members and concerns about other responsibilities. Some parents were clearly more fortunate than others in being able to focus only on their child in the hospital. Some parents were able to share parental visiting more than others because of employment or family issues. Financial issues were very high on the list of parent worries. While some employers were reported to be ‘very understanding and flexible’, many employers were not and there were eight cases out of twenty-seven where the father was ‘laid off ’ from his work, usually for ‘other reasons’. Mothers almost always had to leave employment, if employed outside the home, in order to stay with the child in the hospital on a full-time basis. On top of loss of employment, there were the extra costs of having a child in the hospital. These included travel, gas, parking, fast food, food for the family visiting or staying in the hospital, ‘treats’ for the sick child and baby-sitters for children at home. Parents estimated that about two-hundred dollars more a month was spent while their child was in the hospital; in fact, the amount was much more. Add to that the patient’s costs after insurance policies, for clinic visits and prescription drugs when the child was an outpatient, the monthly amount increased by another hundred dollars on average. Parents in the hospital with their child experienced a lot of stress managing for their children at home. Some parents were fortunate if they had extended family who could stay at the house and be with siblings, but many reported that they and the child’s other parent had to juggle this responsibility alone with perhaps occasional visits from out-of-town relatives. Parents of children who underwent bone marrow or cord blood transplantation experienced these stresses most severely. Loss of employment was common as the parent stayed for continuous months in the hospital with the child both pre- and post-transplant. Siblings were allowed only limited visits because of the risk of infection and, as a result, felt even more alienated from the hospitalised child and parent. This group reported the most significant long-term psycho-social side effects for the family, including depression, anxiety and post-traumatic stress.

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Visiting Children with Cancer Support and other visitors Most study participants reported strong family and community support systems while staying in the hospital. This was true even when families lived over forty miles from the hospital. Most of the time, the child’s father and mother stayed alternate nights at the hospital, and extended family often took turns spending time at the hospital with the parent and child. This was not always the case however, and some parents reported feeling greater isolation and stress if they did not have family and other visitors. The Children’s Hospital of Pittsburgh serves children in the tri-state area as the only children’s hospital in western Pennsylvania. Therefore, patient families may live up to three hours away from the hospital by car. Often a child’s grandparents, or other extended family members, were able to visit for a period of weeks. This was particularly so in families where the child was undergoing transplantation. Most visitors were very welcome by the child’s parent and not seen as an intrusion. Visits from friends and other members of the family were also generally welcome. Occasionally, this was not the case. Depending on the visitor’s own expectations and understanding of the family’s predicament, the visitor could add stress to the situation by questioning the treatment, diagnosis, or even the parent’s judgement.22 Social work and child life support In almost all families, the social-work staff and child life team played a strong positive role. In the United States, ‘child life’ is the department in a children’s hospital which provides play opportunities, play therapy and psychosocial support to the hospitalised child. Parents reported that social work and child life teams gave emotional support, coping strategies, education and advocacy. Rarely did a parental visitor find their service of lesser value; the overwhelming majority felt that they ‘could not have got through’ their family’s cancer experience without the support of these two areas. Sometimes the social work staff acted as advocates between the parent and physician. Two parents felt that the physician was ‘too blunt and offered little hope for their child’s treatment’. In such cases, parents requested that social workers ‘ask for a better bedside manner’ from the doctor. Relationships often improved after such interventions. Relations with medical staff Parents developed relationships with the nursing staff that lasted well beyond the child’s hospitalisations. Nurses became allies and friends. Parents offered many examples of not only the skill of the nursing staff, but their compassion and willingness to be involved and close to the child. Parents 143

Robin L. Rohrer told very emotional stories of how the physicians made them and their child feel special and that their oncologist ‘truly cared that their child lived and was happy’. Physicians developed strong trusting relationships, investing time, energy and compassion into the child’s care. Several parents told stories of the physician ‘tearing up’ when the news was bad. Physicians, without exception, formed a close bond with the child and family during years of treatment and follow up. Conclusion Although notionally visitors, parents, in fact, provided comfort, support and personal care to their children while staying with them in hospital. Both insiders and outsiders, parents were asked by their child’s medical team to be an integral part of the child’s treatment, hospital life and day-to-day journey through cancer. Primarily, parents had to cope with the emotional roller coaster of their situations, providing their hospitalised children with advocacy and care. Of the twenty-five families surveyed, only two were of African–American background – the twenty-three other families were Caucasian. This statistic basically corresponds to the lower national rate of African–American children with cancer. In this limited study, it appears that socio-economic status and single parenthood were more of a factor in determining the hospitalisation experience than race alone. Based on income, two families could be designated upper-middle class, three working class and the remaining families being solidly middle class. The two families of African–American background were middle class. The four families who had single parents were working-class households and were Caucasian. Whatever race and socio-economic status, worries about life at home, particularly the needs of siblings, were primary in this study. The emotional and practical needs of siblings and staying in close touch were issues with every family interviewed. Particularly poignant were the stories of five families who also had infants at home. In this study, the hospital staff reported their ongoing appreciation of the parents’ role, especially, but not only, as ‘extra hands’ and key input. Both physicians and nurses emphasised in interviews that the parent visitor was the key member of the child’s team. Parent interviews confirmed this as a reality and not just a sentiment. Staying with their child in hospital meant also that they were the most consistent part of the treatment team, as nurses, physicians and other staff rotated shifts and daily assignments. This study has provided a window into how children and their families as experience cancer and its treatment today. There is still much to observe and learn from what must be one of life’s hardest experiences: being the parent of a desperately ill child. This preliminary study reflects a solidifying of the role of parent as caregiver, even in this type of situation. Often alone 144

Visiting Children with Cancer with their child day-after-day in hospital, the parent is not an outsider but a key player in the battle against the most dreaded of diseases and killer of children. For these families, the fight continues outside the hospital, into the home and school, until the next hospital visit on the long road to cure. Acknowledgements The author wishes to thank Rakesh Goyal, MD, Director, Blood and Marrow Transplantation, Children’s Hospital of Pittsburgh, for his key participation in this study. The author is also indebted to A. Kim Ritchey, Chief, Division of Pediatric Hematology Oncology and the staff of the Marty Ostrow Outpatient Clinic and 8 North. Special thanks to Brigid E. Mannard of Duquesne University for research assistance. Notes 1. J. Culling, ‘The Psychological Problems of Families of Children with Cancer’, in A. Oakhill (ed.), The Supportive Care of the Child with Cancer (London: Butterworth, 1988), 204–37; H. Langton, The Child with Cancer: Family-Centred Care in Practice (London: Harcourt Publishers, 2000); J. Overholser and G. Fritz, ‘The Impact of Childhood Cancer on the Family’, Journal of Psychological Oncology, 8, 4 (1990), 71–85. 2. Children’s Oncology Group, CureSearch, http://www.childrensoncologygroup.org, accessed 12 March 2009; G. Krueger, ‘“For Jimmy and the Boys and Girls of America”: Publicizing Childhood Cancers in Twentieth-Century America’, Bulletin of the History of Medicine, 18, 1 (2007), 70–93; J. Patterson, The Dread Disease: Cancer and Modern American Culture (Cambridge: Harvard University Press, 1987). 3. Children’s Oncology Group, op. cit. (note 2); P.A. Pizzo and D.G. Poplack, Principles and Practice of Pediatric Oncology, 5th edn (Philadelphia: Lippincott Williams and Wilkins, 2006). 4. B. Young, M. Dixon-Woods and D. Heney, ‘Identity and Role in Parenting a Child with Cancer’, Pediatric Rehabilitation, 5, 4 (October–December 2002), 209–14. 5. J.M. Patterson, K.E. Holm, and J.G. Gurney, ‘The Impact of Childhood Cancer on the Family: A Qualitative Analysis of Strains, Resources, and Coping Behaviors’, Psycho-oncology, 13, 6 (June 2004), 390–407. 6. I. Martinson and M. Cohen, ‘Themes from a Longitudinal Study of Family Reaction to Childhood Cancer’, Journal of Psychosocial Oncology, 6 (1988), 81–97. 7. C. Binger, et al., ‘Childhood Leukemia. Emotional Impact on Patient and Family’, New England Journal of Medicine, 280, 8 (1969), 414–8; A. Faulkner, G. Peace and C. O’Keefe, When a Child had Cancer (London:

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8.

9. 10. 11.

12.

13. 14. 15.

16. 17. 18. 19. 20.

21. 22.

Chapman and Hall, 1995); Young, Dixon-Woods and Heney, op. cit. (note 4). K.W. Chan and R.B.J.R. Raney (eds), Pediatric Oncology (New York: Springer Science and Business Media, 2005); C.R. Pinkerton, A.J. Michalski and P.A. Veys, Clinical Challenges in Pediatric Oncology (Oxford: ISIS Medical Media, 1999); Pizzo and Poplack, op. cit. (note 3). Pizzo and Poplack, op. cit. (note 3); Children’s Oncology Group, op. cit. (note 2). Pizzo and Poplack, ibid. C. Eiser et al., ‘Mothers’ Attitudes to the Randomized Controlled Trial (RCT): The Case of Acute Lymphoblastic Leukaemia (ALL) in Children’, Child: Care, Health and Development, 31, 5 (September 2005), 517–23. L.M. Massimo and T.J. Wiley, ‘Randomization, Informed Consent and Physicians’ Communication Skills in Pediatric Oncology: A Delicate Balance’, Bulletin Cancer, 92, 12 (December 2005), E67–9. Living with Childhood Cancer: A Handbook of the Children’s Hospital of Pittsburgh (Pittsburgh: Children’s Hospital of Pittsburgh, 1998, repr. 2003). H. James-Hodder and N. Keene, Childhood Cancer: A Parent’s Guide to Solid Tumor Cancers. (Sebastopol: O’Reilly and Associates, 1999). S.A. Clarke et al., ‘Parental Communication and Children’s Behaviour Following Diagnosis of Childhood Leukaemia’, Psycho-oncology, 14, 4 (April 2005), 274–81; A.E. Kazak et al., ‘Posttraumatic Stress Symptoms During Treatment in Parents of Children with Cancer’, Journal of Clinical Oncology, 23, 30 (20 October 2005), 7405-10; P. Sloper, ‘Needs and Responses of Parents Following the Diagnosis of Childhood Cancer’, Child: Care, Health and Development, 22 (1996), 187–202. Interview no. 4, July 2005. All names have been changed to protect the identity of study participants and their children. Interview no. 21, November 2005. Interview no. 14, September 2005. K. Alecksa and G. Koren, ‘Ethical Issues in Including Pediatric Cancer Patients in Drug Development Trials’, Pediatric Drugs, 4 (2002), 257–65. F.M. Balis, ‘Clinical Trials in Childhood Cancers’, Oncologist, 5, 3 (2000), xii–xiii; O.B. Eden, ‘Therapeutic Trials in Childhood ALL: What’s their Future?’ Journal of Clinical Pathology, 53 (2000), 55–9. Interview no. 2, July 2005. Interviews no. 10, August 2005; no. 12, August 2005; no. 19, October 2005; and no. 23, November 2005.

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7 Infection and Citizenship: (Not) Visiting Isolation Hospitals in Mid-Victorian Britain

Graham Mooney Local authority provision for the sequestration of infectious people mushroomed in Great Britain from the mid-1860s. By the First World War, more than 750 isolation hospitals contained almost 32,000 beds for infectious patients, most of whom were children. Trips to an isolation hospital were problematic because visitors might contract infection there and spread it to the wider community. Various strategies sought to minimise this risk or eliminate it altogether. This chapter argues that the management of isolation hospital visitors was typical of Victorian public health’s tendency to regulate people’s behaviour. By granting rights to, and conferring responsibilities on, the relatives of patients, visiting practices enshrined notions of citizenship that sought to govern ‘through’ the family.

The isolation of people with infectious disease has attracted an increasing amount of attention from historians. The fundamental rationales for the institutional exclusion of the infected – namely the protection of the wider population, the prevention or stamping out of an epidemic outbreak – are practically self-evident. Yet scrutiny in a variety of metropolitan and colonial contexts also reveals a set of practices that, over the course of the nineteenth century, seemingly were ever more laden with undertones of coercion, moral and physical rehabilitation and normalisation. The removal of biologically dangerous individuals from their community surroundings and into confinement has been characterised as a strategy of government power. In common, then, with penal incarceration and confinement of the mentally ill, isolation of the infected demonstrates a central contradiction of liberal governance: freedom was a means to govern because practices such as isolation created, in the words of Nikolas Rose, ‘the conditions in which subjects themselves would enact the responsibilities that composed their liberties’.1 Taking this cue, Bashford and Strange have noted that ‘isolation was not an aberration from liberal governance but central to its internal 147

Graham Mooney logic’.2 Put simply, ensuring the liberty of the many necessarily meant restricting the freedom of the few. This chapter considers the isolation of patients with infectious disease in Victorian Britain. It begins with a very brief summary of scholarship on citizenship and public health in the Victorian period. Just how far isolation hospitals really were ‘isolated’ is explored next, by taking into account both physical location of hospitals and the movement of people in and out of them. This is followed by an attempt to enumerate those features of isolation hospitals that acted as obstacles to their acceptance in the local community. In the fourth section, the forced separation of children from their families is identified as a bone of contention between parents and the state. Finally, the state’s shaping of visiting regulations comes under scrutiny as an important aspect of this separation. Here, the spotlight is on the families and friends of patients who were visitors to isolation hospitals. Public health authorities took the opportunity visiting presented to inculcate behaviours in families that limited the possible transmission of infection outside the hospital. The argument is that isolation hospital visiting regulations were part-and-parcel with the liberal state’s desire to shape those activities in the domestic sphere that qualified people as being fit for citizenship. The consideration of visiting shifts the centre of attention away from diseased people – be they identified patients or carriers of disease as yet unidentified by a medical or state authority – towards those family members and friends who may be (or become) diseased, and spread disease, by the irresponsibility of their actions. In this way, the family – and not simply individuals with disease – comes into view as the locus of intervention. As one of the foremost authorities on the history of child welfare notes, one of the crucial questions for liberal democracies has been how the state relates to the private family in shaping ‘duties, responsibilities, rights and “needs”’.3 The ‘duties and responsibilities’ under investigation in this chapter are those imparted to family members who were visiting patients in isolation hospitals, while ‘rights and needs’ refer to the level of access that families were granted. The ‘costs to individual liberty and convenience’4 families underwent because of isolation were transformed by the state into an opportunity to underline the dangers of infection and encourage behaviours that would prevent its spread beyond the walls of the hospital. The critique presented in this chapter therefore tends towards an interpretation that the state increasingly sought to govern ‘through’ the family,5 an interpretation that sits comfortably alongside studies that, in the realm of health, have examined domestic visiting, the infant welfare movement, child protection and school welfare. To develop these lines of thought, three pivotal government inquiries are used, which were undertaken in the late 1870s and early 1880s. The first is 148

Infection and Citizenship a survey of hospital isolation facilities written by Richard Thorne Thorne (hereafter his surname will be truncated to just Thorne), an inspector of the medical department of the Local Government Board (LGB). In addition to distributing a questionnaire to all English and Welsh sanitary authorities, Thorne personally visited a total of 82 authorities and 67 hospitals. The second is a report by another LGB inspector, William Power, on the influence of the Fulham Smallpox Hospital as a focus of infection. The third is the Royal Commission on Smallpox and Fever Hospitals (RCSFH) which took evidence in 1881 and 1882 and was set up to consider the implications of Thorne’s and Power’s reports for the hospitals of the Metropolitan Asylums Board (MAB) in London. Interpretations of visiting that emerge from these central government documents are augmented by commentaries on the practices of local hospitals that can be found in Medical Officer of Health (MOH) reports, the archives of administrative bodies such as town council health committees, and accounts of isolation that occasionally surface in local newspapers written by the people who experienced it. Citizenship and public health The intersection of freedom, citizenship and health is proving to be fertile ground for historians of Great Britain. The production and maintenance of a healthy population in the twentieth century through primary health care, physical fitness, health education and army propaganda relates particularly well to the idea of ‘social’ citizenship put forward by T.H. Marshall in the mid-twentieth century.6 According to Peter Baldwin, the emphasis on individual responsibility and ‘internally accepted restrictions’ that was characteristic of some of the responses to the AIDS epidemic signified a ‘democratic public health’ in which the contract of health citizenship assumed that ‘individuals would curb harmful behaviour and develop healthy habits’.7 Isolation and exclusion are policies through which health and citizenship are seen to interact, notably in the leper colony and the tuberculosis sanatoria.8 In the latter, patients were rehabilitated, educated and inculcated into behaviours that were ‘appropriate’ to functioning and productive members of the citizenry.9 Rights are crucial in liberal democracies if individuals are to be free to pursue legitimate interests in the absence of interference from either other individuals or the state.10 Citizenship is an expression of the relationship between an individual in possession of rights, and the community, to which that individual has responsibilities, duties and obligations – and which, of course, grants those rights. Fluid and dynamic, citizenship is subject to constant redefinition as individuals find new ways of articulating their rights and obligations (in this case, as visitors) and as new institutions (in this case, 149

Graham Mooney isolation hospitals) are ‘constructed to give form to the changing needs and aspirations of the citizen and community’.11 No discussion of citizenship in Victorian Britain can avoid the issue of nationhood as a crucial component of state formation.12 National identity was the concept through which the ‘improvement’ of individuals and thus citizenship was articulated.13 Pamela Gilbert has recently elaborated on this theme in relation to public health between the 1830s and 1860s. Franchise reform in this period focused increasingly on the ‘fitness’ of the electorate to contribute to the social well-being of the nation as a whole. As qualification for the vote shifted from property ownership in 1832 to property rental in 1867, ‘fitness’ came to mean not simply the ability to pay taxes, but the capacity of working-class individuals to ‘procure’ and maintain a home and demonstrate a degree of prudent household economy that resonated with middle-class norms.14 At around about the same time, the rhetoric of sanitary reform was linking the physical degradation of urban places to the immorality of the inhabitants.15 While this seemingly ‘confirmed the vision of the poor as incapable of exercising citizenship’, Gilbert writes that ‘it also implied a remedy that might bring such creatures within the pale of those who could develop into citizens over time’.16 The ‘remedy’ was an environmentally based public health: cleaning up public space – the removal of sewage, the supply of water and so on – also secured the conditions under which individuals might achieve domestic propriety. As Mary Poovey points out, Edwin Chadwick’s sanitary report in the early years of Victoria’s reign concentrated on domestic as much as public space.17 Alongside the school, the home was the crucial site of liberal governance; the place where, through the agency of the family, moral character was built in order that individuals would behave rationally, as responsible citizens of a national community. Gilbert’s focus is on housing and the charitable efforts of Octavia Hill. In her book Bodily Matters, Nadja Durbach has revealed how citizenship was a crux of the debate over compulsory infant vaccination in England in the nineteenth century. Anti-vaccinationists argued for their rights as parents to withhold their children from vaccination; pro-vaccinationists saw vaccination as a way to ‘incorporate working people into the national community as citizens through participation in maintaining the public’s health’.18 Gilbert’s homes and Durbach’s infant bodies are both spaces of risk over which the role of family was contested.19 This chapter discusses yet another: isolation hospitals that were provided by local governments to sequestrate people with infectious disease.

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Infection and Citizenship The isolation of isolation hospitals Although the early years of the nineteenth century witnessed the founding of a small number of private isolation (fever) hospitals in England, it was not until the second half of the century that such institutions began to proliferate nationally.20 Both the 1866 Sanitary Act and the 1875 Public Health Act gave local government the power to build an isolation hospital, and allowed them to borrow money for the purpose. By the end of the 1870s, the LGB estimated that 296 local authorities made some form of provision for the reception of patients suffering from an infectious disease, representing about one quarter of all provincial sanitary authorities.21 The Isolation Hospitals Act of 1893 enabled County Councils to build an isolation hospital and, if necessary, force local authorities under their jurisdiction to do so. Between this date and the eve of the First World War, more than 300 local authority isolation hospitals were constructed; as a result almost 32,000 beds were available nationally for infectious diseases, and isolation hospitals (755) outnumbered both Poor Law infirmaries (700) and general hospitals (594). Local authorities were not compelled to provide a permanent isolation hospital and this might explain why a significant minority of these facilities – about one-fifth – were buildings that had been converted from other uses, such as Poor Law institutions, private houses and even factories. Under such conditions, much of the local provision for epidemic outbreaks was rudimentary at best, and often of a temporary nature. The LGB, of course, was instrumental in imposing a greater degree of uniformity. It issued model hospital plans on a regular basis and it also withheld loans for proposed hospital buildings considered to be architecturally inferior.22 Isolation hospitals came to be an integral component of the panoply of public health measures that Peter Baldwin has dubbed ‘neo-quarantine’ and Michael Worboys has characterised as ‘exclusive’.23 Focusing on the transmission of disease between people, leading lights of public health considered the institutional isolation of infectious patients as vital to the successful control of epidemics when used in combination with infectious disease notification, disinfection and domestic quarantine.24 Noting the amount of human traffic coming out of and going into these institutions, however, Logie Barrow recently lamented ‘how prematurely historians label these institutions as “isolation” hospitals’.25 The immediate rationale for isolation lay with the state of knowledge about the communicability of diseases. In general, the diseases that accounted for the largest proportion of cases admitted to fever hospitals – scarlet fever and, increasingly from the late 1880s, diphtheria – were acknowledged to be contagious.26 Smallpox came to be exceptional because of the controversy about whether the disease 151

Graham Mooney also could be carried in the air over long distances or not, a clear problem if the hospital was located amidst a populous district.27 This possibility sparked allegations that smallpox hospitals were foci for infection. Those for whom more proximate and intimate channels were required to pass on the disease rejected this. More crucial for them was the hospital’s endless traffic of people: There are the milkman, the baker, the butcher, the greengrocer, and their assistants who call daily. To those who attend daily have to be added those who attend less frequently; contractors of various kinds, provision merchants, vendors of patents and disinfectants, the friends of the dead, inquirers after situations, the wine merchant, the brewer, the grocer, the cheesemonger, the oilman, the soap merchant, the crockery merchant, the brush man, &c., &c.28

Notwithstanding omission of the candlestick maker, this remains an extensive list. It does not even begin to enumerate the movements of the nursing and medical staff, ambulances and visitors to patients. Indeed, in one six-day period in January 1881, LGB inspector William Power recorded that 439 interactions of the sort mentioned above took place at the Fulham smallpox hospital.29 In accepting the case for long-distance smallpox transmission, the RCSFH also admitted that ‘personal communication’ between patients and individuals entering the hospital was a significant factor in raising the incidence of smallpox in the immediate neighbourhood.30 Following his extensive survey into isolation hospital provision, the Commission heard from Thorne that disease might, on occasion, have spread as the result of ‘illicit’ visits to patients or when patients were ‘so placed’ as to be able ‘to communicate with others outside the hospital’.31 The Commission clearly felt the weight of evidence was heavy enough to tighten the authorities’ grip on all possible routes of transmission between people and it made a series of recommendations intended to minimise the risks involved with these interactions. Tradespeople and contractors were to use a separate entrance; nurses’ and attendants’ leave should be less frequent, though of a longer duration; the ambulance service should be more closely managed and under the complete control of the hospital authority; and, significant in the context of this chapter, regulations for visitors to patients should be ‘strictly enforced’.32 The poor man’s spare bedroom? Both the popular perception and the reality of exclusion that surrounded isolation hospitals presented a tricky problem to public health officialdom, 152

Infection and Citizenship since it militated against the isolation of all cases that, ideally, was required to arrest an epidemic. Local authorities used hospitalisation rates as a roughand-ready means of assessing community acceptance of, and satisfaction with, the isolation hospital. It is instructive that in 1891, Sheffield’s MOH regarded the city’s scarlet fever hospitalisation rate of twenty-nine per cent as a dismal figure.33 Although hospital accommodation in the city was ‘exceedingly well adapted to the requirements’, the MOH puzzled at parents’ reluctance to utilise the city’s hospital at Winter Street.34 By the late 1880s and early 1890s, some other local authorities were hospitalising as many as eighty per cent of all scarlet fever cases that were notified to them.35 This intensification of isolation hospital provision in the final quarter of the nineteenth century must have represented a real, sometimes troubling, shift in the community experience of institutionalisation.36 The overwhelming impression is that isolation hospitals tended to serve the working classes and poorest members of the community. For the most part, this is undoubtedly true, since legislation that sanctioned compulsory removal to hospital – the 1866 Sanitary Act – stipulated that it need only take place in instances where domestic isolation was not feasible – that is, in homes that were overcrowded. This was achieved by reformulating the definition of a nuisance to embrace ‘any house, or part of a house so overcrowded as to be dangerous or prejudicial’ to the residents. The link between the lack of domestic space and hospitalisation is significant in the context of the mid-century formulation of citizenship: the criteria of ‘fitness’ included a family’s ability to secure a dwelling that would promote moral and physical wellbeing;37 since ‘overcrowding’ itself evaded official technical definition until the 1890s, there was considerable leeway in the interpretation of this term.38 The opinions of public health officials, who tended to regard the working classes as either far too ignorant to understand the requirements of domestic isolation or unable to secure isolation of a patient in an overcrowded home, did much to foster the impression that isolation hospitals existed to serve primarily the needs of the poorer sections of society. The following quote from the Sheffield MOH indicates precisely why isolation hospitals came to be portrayed as the ‘poor man’s spare bedroom’: It is quite impossible that proper isolation can be carried out in small houses where there are several members of a family, and where the room containing the patient is in close proximity to that used by others, or where the mother, no matter how careful in the use of disinfectants, has both to nurse the patient and superintend domestic arrangements. Efficient isolation consists in completely cutting off the sick room with all it contains, including the

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Graham Mooney nurse, from the rest of the house and family, and, except in special cases, this is quite impossible in private houses.39

The need to hospitalise all but the wealthiest patients created barriers to acceptance, particularly over the thorny issue of pauperisation. In London, where the MAB was a constituted authority of the Poor Law, those unable to secure domestic isolation and submitting to hospital admission were immediately pauperised – and thus disenfranchised.40 Though MAB hospitals could in fact admit any person without a relieving officer’s certificate if they were deemed to present a danger to the public, the legal status of pauperism was not removed until the Diseases Prevention (Metropolis) Act of 1883.41 The spectre of pauperisation might have prejudiced the domestically overcrowded working classes against isolation hospitals in London; everywhere else, the spectre of paupers prejudiced the well-to-do. In the provinces around this time, some isolation hospitals contracted with the local guardians to admit paupers with an infectious disease, especially where separate accommodation did not exist in the workhouse infirmary. In the late 1870s, four per cent of Salford’s isolation hospital patients were drawn from the middle and upper classes (tradespeople, clerks, professionals) and fifty-four per cent from the ‘wage-earning classes’. The remainder – a little over forty per cent – were paupers, a figure similar to that in neighbouring Manchester’s Monsall Hospital in 1880. A minority of hospitals reported that no troubles were encountered with the admission of out-door paupers, particularly if their ragged or dirty clothing was replaced with hospital-issue uniform, as was the case in Salford.42 In Oldham, where the hospital outfits came in a variety of patterns ‘so as to avoid the appearance of a uniform’, newly arrived patients were also issued a numbered bag containing a clean brush and comb. Bathing, the cutting of hair and the sorting and disinfection of clothing became routine for patients everywhere.43 While these rituals of standardisation certainly can be interpreted as the inculcation of desirable hygienic behaviours, within the hospital itself they also aimed at dissolving the separation of the pauper ‘anti-citizen’ from the respectable working class.44 Despite this, securing the isolation of patients unwilling to co-habit wards with paupers was a recurring problem in places such as Blackpool, Carlisle, Manchester, Newcastle and Nottingham. Some local authorities administering isolation hospitals refused to admit paupers altogether.45 Most hospitals had private rooms that the better-off families living in detached houses might pay for. This saved their children from having to commingle with the hoi polloi, a state of affairs wealthier parents quite ‘naturally refuse to allow’.46 Birkenhead’s MOH encouraged the provision of such rooms by tantalising his council with the prospect of 154

Infection and Citizenship recovering at least some of their costs through charging wealthier patients ‘double or three times the ordinary’ rate.47 Elsewhere, such patients were further induced into the hospital by being allowed, again at their own cost, to call in their own general practitioner.48 Isolating children Pamela Gilbert’s recent contribution on citizenship and public health recognises that children ‘are of particular interest within liberalism because they represent the limit case of individual freedom and responsibility’.49 Children’s status as dependents and their future potential to act as autonomous citizens legitimated the provision of free education by the state on the one hand and interference in the domestic sphere on the other. Isolation hospitals are important in this respect because infectious diseases most afflict immunologically unprotected young members of the family. There are two points to consider here. First, the separation of children from their domestic environment raises the question of where responsibility for children’s health lies: is it with the government or with the family? This echoes the vehement anti-vaccination debates in which infants’ bodies were fought over by parents and the state. Second, removal of a diseased family member to hospital placed the regulation of home life firmly into the social realm.50 Through the body of the infected child, parental competence in domestic hygiene was being put on display in the isolation hospital.51 In London in the 1870s, every tenth death of a child aged between 5 and 9 years old was caused by scarlet fever – for every age above twenty years it was less than one in a hundred. Data for morbidity is harder to come by, though evidence from Nottingham around the turn of the century indicates that around ninety per cent of all scarlet fever cases occurred in children under 14 years old.52 As Thorne discovered, isolation hospital admissions rapidly came to reflect this age-specific incidence and he seemed genuinely impressed and pleased that parents were so willing to relinquish their children to the care of the hospital authorities (Table 7.1 overleaf ).53 Thorne’s report gave official credence to the idea that isolation hospitals were gaining in popularity, though instances of local resentment and resistance suggest this was a partial view. Hostile feelings were expressed more or less covertly, and not without the occasional connivance of the family physician. Leicester’s Sanitary Inspector, Sergeant Braley, reported on one couple who were in the habit of sending their sick children to their grandmother, and had initially refused to allow their child to be taken to hospital after the family practitioner had advised them that it would be treated equally well at home.54 It was also in Leicester around this time that one newspaper letter-writer with the pseudonym ‘An Englishman’ observed: 155

Graham Mooney Table 7.1 Isolation Hospital Admissions by Age, Sanitary Authorities in England and Wales, c.1881 Alcester Bradford Grantham Huddersfield Isle of Thanet Leeds Leicester Maidstone Manchester Oldham Salford Warrington

All Patients 220 812 66 452 138 523 346 48 500 200 1,263 190

Patients <=10 yrs 179 485 49 303 83 183 251 24 166 118 710 122

% 81 59 74 67 60 35 72 50 33 59 56 69

Source: R. Thorne Thorne, ‘On the Use and Influence of Hospitals for Infectious Diseases’, Tenth Annual Report of the Local Government Board 1880–81. Supplement containing Reports and Papers submitted by the Board’s Medical Officer on the Use and Influence of Hospitals for Infectious Disease (Cd 3290, London, 1882), 27. [W]ho amongst us would think of running to the Sanitary Inspector and saying, ‘Please, sir, my child has the whooping cough; come and fetch it from its mother, and take it to the fever hospital; it will be quite safe under Dr Johnston [Leicester’s Medical Officer of Health], for they say he can cure all diseases.’55

It was believed by some that the concealment of disease to avoid hospital admission was as likely amongst the wealthy as it was among the poorer classes.56 Some agitation took place on a scale that might be noticed by a local authority. The 16,000 signatories to Nottingham’s ‘Rights and Liberties Defence League’ petition reacted in this way to the Council’s resolution to adopt the 1890 Infectious Diseases (Prevention) Act: We the undersigned inhabitants and ratepayers of the town of Nottingham, pray that your honourable Council will take such steps as may be necessary to rescind the resolution recently passed by the Council, which converts our hospital into a prison and deprives us of our right to nurse our sick and claim

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Infection and Citizenship our dead. We consider that the power conferred upon certain officials under this resolution are greatly in excess of any that ought to be granted, that they are absolutely uncalled for, certain to be abused, and calculated to create a spirit of prejudice against an institution which has cost the ratepayers very dear.57

This issue brought a great deal of raw emotion to the surface and re-opened old sores for at least one parent. ‘As a ratepayer of Nottingham I am diametrically opposed to any further compulsory powers being granted to our town officials’, wrote C.J. Welton, recounting his own child’s death but ten hours after hospital admission: What would the world be without sentiment? What can be better than kindness and happy endearing surroundings for a person who is suffering from some foul disease? Your cold, callous doctrine of isolation and separation from all friends, even if directed against all adults, is unbearable when applied to children, who are to be dragged away from their parents, perhaps never to see them alive again… I would suffer imprisonment sooner than I would allow another child to be cruelly dragged from its parents to die in a hospital.58

Similar examples of protest and resistance are gradually being recovered in public health histories.59 That isolation procedures could be coercive is difficult to deny, though not all public health authorities were unsympathetic. In Leicester, one family doctor demanded to know why the Sanitary Inspector – a Mr Buxton on this occasion – had refused to remove a child immediately to the isolation hospital one evening in May 1880.60 He met with this reply from the Health Committee, relayed by the city’s town clerk: I am directed to inform you that the Sanitary Office closes at 6 o’clock: I am directed however to say that it is the wish of the committee that the inspectors should give every facility for and assistance in the removal of cases to the hospital after their usual business hours. With regard to this particular case it appears that the delay was caused by the difficulty Buxton felt in removing an infant of such tender age into the hospital and therefore separating it from the mother, especially as he was informed that it was in a very critical condition. Not being able to consult Dr Johnston [the MOH], Buxton went to the chairman [of the Health Committee] for advice and on the following morning the child was removed into the hospital. I understand the child died the next day after it was received into the hospital.61

Returning to Nottingham, we might contrast Mr Welton’s experience with that of local surgeon, Thomas Burnie: 157

Graham Mooney Without any compulsion, I was glad to avail myself of the opportunity of sending to the Bagthorpe Hospital one of my boys who, some three months ago, began with scarlet fever. He has recently come home in good health and excellent condition, and no other member of the family has taken the disease. During his stay in the hospital he was treated with the utmost care and kindness by everyone connected with the institution, and everything that could conduce to his recovery or well-being was provided for him without stint… I am fully conscious of the grave objections there must always be to a parent parting with his or her child, especially when the child is seriously ill, but I am able, from my own experience, to assure my fellow townsmen that if they do send their children when ill to one of these institutions they will be tenderly and gently cared for, and will have provided for them everything necessary to their comfort and welfare.62

As a surgeon and member of the local medical élite, we might treat Burnie’s account with a larger pinch of salt than if he were, say, one of the city’s lace-makers. But personal accounts such as this probably did have a positive impact on the regard in which isolation hospitals were held. Thorne himself believed that admission rates were aided by ‘the steady diffusion of the reports made by previous patients as to the comforts and excellence of nursing obtained with the several hospitals.’63 In advocating the extension of its isolation hospital, Birmingham’s Health Committee used patient evidence to show the hospital was ‘becoming increasingly popular’. The committee told the City Council in 1884 that the hospital had ‘received letters from discharged patients, thanking them for their kindness and attention’, arguing they had little difficulty ‘inducing the relatives of the sufferers to send them to hospital’.64 Mostly, it seems, medical officers and hospitals relied on word-of-mouth to increase the popularity of isolation hospitals and they were confident that any unwillingness would dissipate once parents realised that by sending their child to the hospital they would be free to go to work or to keep their businesses running.65 Some hospitals were more proactive and practiced what would now be termed ‘outreach’. Four cottages served as the isolation facilities in the Kent town of Maidstone. The medical superintendent there adopted the practice of sending out a nurse from the hospital not only ‘to assist in washing linen and to superintend any measures of disinfection’, but also to ‘use her personal influence to secure the removal of patients’. The nurse encouraged mothers to consult with neighbours as to the ‘comforts which other children enjoyed when in hospital’.66 This section of the chapter has sought to illustrate some of the issues at stake in the isolation of children. The official creed was that popular opposition to isolation hospitals was on the wane and that parents gradually 158

Infection and Citizenship acquiesced to the state’s requirement that they act out their duty towards community well-being by giving up their children for removal. The apparent success of gentle moral persuasion and self-enlightenment – that is, individuals realising for themselves the benefits of isolation – carries a whiff of delusion, since local authorities had recourse to legal powers in the face of a recalcitrant patient. While instances to the contrary were not infrequent, the sparing use of compulsory removal orders was cited by contemporaries as evidence that the working class were readily submitting to the increasingly clear benefits of isolation hospitals.67 But the underlying threat of coercion is of equal importance to its legislative enforcement. Thorne pointed to numerous occasions when simply initiating the process of obtaining a magistrate’s order for removal was enough to induce admission; the order itself rarely required enacting. Parents were faced with relatively little choice than perhaps to protest at the state’s interference with traditional modes and spaces of familial care-giving, yet ultimately submit to it. Below is considered how hospital authorities circumscribed parents’ rights to visit their children whilst in hospital, and the discipline they attempted to inculcate in familial behaviours. Regulating visitors The regulation of visiting in many institutional contexts was about preserving the moral and hygienic order of the hospital.68 While this was also an issue for the administrators of isolation hospitals,69 the connection with public health meant that of equal, if not greater, concern was that visitors might unwittingly contract a disease in hospital and contaminate the outside world by taking it with them into the local community. Isolation hospitals were spaces laden with infectious risk. Visitors were dangerous not because, like patients, they had contracted a disease with visible signs; nor even because they harboured a disease asymptomatically. Rather, visitors constituted a danger because they were susceptible to the biological threat of the isolation environment. Consequently, visitors were expected to submit to rules and regulations that acted as strategies to underline the exclusionary nature of infectious disease isolation both to them and the patient. In his report, Thorne could point to no examples where ward visiting by family and friends was freely allowed in isolation hospitals. As we shall see, visiting did take place in most isolation hospitals under tightly controlled conditions, conditions that probably became more stringent in the aftermath of the Royal Commission.70 Nowhere, at least in the official rhetoric, was it possible for a parent to turn up, walk onto a smallpox, scarlet fever or diphtheria ward and take a seat next to their sick son or daughter. If daily, weekly or even monthly ward visiting times were ever posted, they never made their way into Thorne’s report. In fact, Thorne only came across two 159

Graham Mooney provincial locations where the visiting rules were committed to paper (Alcester and Bradford; the MAB also published visiting regulations). Perhaps this in itself reflects a reluctance to entertain the idea of visitors: there was no need to produce a set of rules for a constituency that was not supposed to exist in the first place.71 Typically, given the feminised character of the social body, mothers were portrayed as problematic. The author has already alluded to the ways in which mothers became the hospital authorities’ focus of outreach activities. The need for tactful handling of parental feelings extended to allowing mothers to accompany children in the ambulance and make sure that they were settled in bed. Thorne’s review of his evidence indicated that it was ‘general policy’ to admit a mother along with her child ‘if isolation could not be secured domestically’.72 Except in cases where the mother was breastfeeding, the length of stay ranged between a few hours and three days. The picture was more complicated than Thorne’s summary of his own survey would have us believe. To begin with, in at least one hospital (Aberdare, south Wales), mothers were expressly forbidden from accompanying their children. This policy was also adopted in 1881 at the MAB Homerton Smallpox Hospital, much to the apparent regret of William Gayton, a medical superintendent there.73 In Aberdare’s case, Thorne was prepared to admit that this practice probably caused resentment among the local population and contributed to the perceived failure of the hospital. At the other extreme, parents in Sunderland were admitted with their children if they so desired and if their occupation was ‘of such a nature as to facilitate the spread of infection from their homes or shops’.74 Alternatives were adopted elsewhere. One was the introduction of a financial charge that served to reclassify accompanying parents not as visitors but as inmates. In Blackpool, mothers were billed at the same daily rate, 3s 6d, as paying patients. In Carlisle, it was the ‘custom’ to admit a parent, relative or nurse along with the patient and a weekly payment of 10s 6d.75 These costs were clearly prohibitive for the average working family, particularly when lengths of confinement for scarlet fever were between six and nine weeks.76 Not surprisingly in Carlisle – where the 10s 6d payment also procured a private room – only the better-off could afford these fees, so the ‘arrangement is thus not applicable to the lower classes’: no money, no mother.77 In addition to these financial disincentives, hospital officials were confident that the rituals of isolation were enough to discourage parents from wanting to stay in hospital for any length of time. In Oldham, parents were permitted to go in with their children, but ‘the restrictions to which such parents are necessarily subjected when in the hospital soon induce them to leave their children, and there are but few who have not within a few days 160

Infection and Citizenship returned to their own homes’. Being required to take a bath and have their clothes disinfected may have proved deterrent enough for many parents wanting to remain with their child – the author will return to these rituals below.78 While the presence on the ward of parents and close relatives was not necessarily an unusual occurrence, it was a portentous one. In nearly all the instances where visiting rules and practices are known, visitors were only permitted when a patient was deemed to be so ‘dangerously ill’ as to be close to death.79 For Mancunian patients, the chance of this final comfort was slight, since ‘visitors have only in one or two very special cases been admitted even when fatal results were anticipated’.80 According to the oral testimony of one nurse who worked at the London Fever Hospital, as late as the 1930s, there was no visiting at all except for patients in the private wards.81 In Alcester, dangerously ill patients were allowed to see only one of their ‘nearest relatives or intimate friends’ for no more than fifteen minutes, although in very urgent cases two visitors were allowed and the time was extended.82 A one-time 4½-year-old patient at a Kent isolation hospital during the First World War, later recalled that when one girl died ‘the gardener had to walk to her house to inform her parents’.83 The terms of hospital rules were open to interpretation and ultimate authority lay at the top of the hospital hierarchy. The medically qualified staff deemed when a patient was dangerously ill or not. Evidence also suggests that it was not lodge-keepers or junior nurses who decided whether visitors met the bloodline or intimacy criteria. At the Queen’s Memorial Infectious Diseases Hospital, Australia, this gate-keeping power extended to the matron.84 In Edinburgh, no visitor entered the City Hospital’s wards without a pass issued by the Medical Superintendent himself, and this was the case at the MAB’s smallpox hospital in Fulham. Also at Fulham, the name of each visitor was recorded, presumably to prevent multiple visits by the same person on the same day.85 One piece of evidence presented to the RCSFH, in 1882, provided a thumbnail sketch of visiting to three of the MAB’s hospitals, from January 1878 to the end of 1881 (Table 7.2 overleaf ). Taking all three hospitals together, the vast majority (eighty-seven per cent) of the dangerously ill patients in both the smallpox and fever hospitals were, in fact, visited. On average, those dangerously ill patients who were visited received two visitors and each visitor came to the hospital about three times. The number of visitors was not insignificant, especially in the one fever hospital represented here. It seems fairly clear that the fever hospital tended to be more receptive to visitors than the two smallpox hospitals – perhaps reflecting popular fears of infectiousness and subsequent fatality – but there are nonetheless intriguing variations between the Stockwell and Fulham smallpox hospitals. 161

Graham Mooney Table 7.2 Admissions, Deaths and Visitors to Dangerously Ill Patients, London MAB Hospitals, 1878–81

Admissions Deaths Dangerously Ill Dangerously Ill Visited Number of Visitors Number of Visits Visitors Subsequently Admitted

Stockwell Fever 3,833 587 1,474 1,407 3,911 11,553 0

Stockwell Smallpox 2,283 205 825 721 1,103 3,947 1

Fulham Smallpox 3,368 530 710 479 683 1,391 14

Total 9,984 1,322 3,009 2,607 5,697 16,891 15

Source: Royal Commission on Smallpox and Fever Hospitals (Cd. 3314, London, 1882) 91; deaths and admissions from MAB statistical reports.

For whatever reason, patients in the latter were far less likely to be visited than those in the former. This may have been due to a localised prejudice against the Fulham smallpox hospital, which was the subject of Power’s inquiry in 1881.86 But one should not discount that differences between any hospitals might have been due simply to differences in the opinions of medical superintendents about the propriety of allowing visitors. Once admitted, the behaviour of visitors was highly circumscribed. In almost all the hospitals where details of visiting are known, relatives and friends were required to wear some form of special clothing, typically described as a ‘wrapper’, an ‘overall’, a mackintosh or some other ‘impervious covering’.87 Such rituals existed well into the twentieth century.88 Visitors were allowed to sit at the bedside, but at ‘some little distance from the patient’ in order ‘to avoid touching the patient, or exposing themselves to the breath or to the emanations from the skin’.89 Contact with bedding was also forbidden. Unless every visitor was closely monitored by the staff, it beggars belief how these strictures on non-bodily contact could be enforced in all cases, especially when hospital wards teemed during an epidemic outbreak. One witness to the RCSFH cited a flagrant breach of the rules at the MAB’s Deptford Hospital, where a wife in borrowed items of clothing spent the afternoon with her infected husband’s head on her breast.90 According to the rules, in the absence of infection-proofing garments, visitors were required to remove their clothing for fumigation once the visit was over and, 162

Infection and Citizenship regardless of attire, all visitors were requested to wash hands, face and head with a disinfecting agent, usually carbolic soap.91 In Huddersfield, this cleansing stage extended to a full bath.92 The epidemiological rationale behind these procedures was obvious. The most pressing need was to minimise the possibility of visitors acquiring infection – though the otherwise unacknowledged point was made by Alexander Collie, medical superintendent at the MAB’s Homerton Hospital, that it would be highly unlikely that the most common visitors, mothers and wives, would not already have been exposed to the disease in the domestic environment.93 This explains the wrappers and the prohibition of contact with the patient. Nonetheless, the chance of infection remained, and the cleansing of garments and bodies provided an additional hurdle in the way of infection’s escape from the hospital. However, these regulations were also employed as a management tool to deter visiting in the first place. Huddersfield’s respondent to Thorne’s survey observed that the tiresome rituals associated with visiting had served practically to do away with any demand to enter the wards.94 Thorne himself admitted that the wearing of distinctive garments, the disinfection of clothing and the washing procedures had ‘the unquestionable advantage of indicating to the public the views which are entertained by the hospital authorities as to the danger likely to result from needless visits.’95 The pointed use of ‘needless’ betrays Thorne’s attitude; the ordeal of entering the ward should take place only when the patient was perilously close to death. It is also striking that in the few instances where visiting regulations were formalised, various attempts were made to condition the behaviour of the visitors well beyond the boundary of the hospital, both before and after their encounter with isolation. Entry as a patient visitor into the MAB smallpox hospitals required physical evidence of successful vaccination.96 With the warning that ‘they run a great risk when entering the hospital’ still ringing in their ears, visitors to both metropolitan and provincial isolation facilities were advised not to enter the wards if they were ‘in a weak state of health, or in an exhausted condition’. This stipulation certainly can be understood in relation to a visitor’s potential susceptibility to infection when in a compromised physical state, but for reasons the author is unable to fathom, eating food before entering the hospital was also frowned upon.97 A further exhortation not to use a train or any other form of public transport ‘immediately after leaving the hospital’ is, at first glance, wise advice. However, given the state of knowledge regarding incubation periods of infectious disease, allied to the relative inaccessibility of many isolation hospitals by any means other than public transport, the dispensation of such advice was practically pointless. Once again, the laying down of these rules served more than just an epidemiological purpose. Since the hospital was 163

Graham Mooney doing all in its power to reduce the possibility of infection being exported, and since families were openly warned of the risks of entering such a contaminated environment, responsibility for an epidemic outbreak subsequent to a visit could be legitimately directed at the visitors themselves. As such, a variety of alternative management strategies evolved that allowed relatives and friends to see patients but further served to underline the exclusionary nature of isolation. One concession was the operation of what can be termed ‘window appointments’. Here, relatives and friends were allowed to view the patient through the ward windows for brief periods, at set times, on specified days of the week. Alcester hospital set aside one hour for this activity on Tuesday and Friday afternoons.98 One hour per week was the norm at Broadstairs.99 It is not clear whether the windows were open or closed during such visits. On one occasion in Broadstairs, a window appointment was thought to have caused scarlet fever to spread in the district, so it might be guessed that the windows were open that time. In Aberdeen, the stated practice was to keep the windows shut.100 Systems of window appointments endured until after the First World War. Quoted in Margaret Currie’s book on fever nursing, this is Jean Bell’s list of the worst aspects of her job at West Lane Fever Hospital, Middlesborough in the late 1950s: Deaths in young and small children; looking after septic abortions, and VD. Seeing a dead foetus. Doing loads of sluicing and emptying mugs from TB patients. Seeing children upset when relations could just look through the window at them when visiting.101

During the war itself, visitors were unable to see much inside one hospital because sandbags were piled up to protect the windows!102 Many authorities successfully kept potential visitors at arms’ length simply by providing daily updates on the welfare of each patient. In Nottingham, Leicester and London, parents and relatives were told that information could be had at the hospital lodge. At the Fulham smallpox hospital, a daily list of dangerously ill patients was kept by the gate porter and appearance on the list qualified patients to receive visitors.103 For most working-class parents and relatives in places where isolation hospitals were located on the outskirts of the communities they served, such information was quite literally beyond their reach.104 As James Gray has described, a system of daily newspaper bulletins was developed in Edinburgh within four years of the city isolation hospital opening. This involved ascribing a number to each patient on admission. The number was known to the family of the patient but otherwise preserved anonymity. Each patient’s number was then

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Infection and Citizenship classified into one of four categories, according to his or her condition, as follows: Dangerously ill, friends requested to come out Seriously ill, no immediate danger Ill, making satisfactory progress Not quite so well, no cause for anxiety

The list then was published in the daily newspapers.105 As well as providing an indication of the well-being of all patients, the list acted as a signal to relatives of dangerously ill patients to come and visit. Accessibility to patient information was solved in some places by the introduction of new technology. At Monsall Hospital, Manchester, where ward visiting was practically unheard of, the isolation hospital’s telephone connection with the more centrally located Royal Infirmary acted as a line of communication to the outside world and saved some inquirers a journey of several miles. Thorne witnessed this system in operation and was highly impressed: Whilst at the hospital I could not fail to note that the answers sent to inquirers, instead of being merely formal or limited to monosyllables, afforded some detailed information as to the progress of the patients in question, and to this is probably due to the fact that the arrangement has to a very great extent done away with the difficulties which might otherwise have attended the rule which prohibits visiting.106

Thorne’s official rubber stamp of approval can be read alongside John Burdon Sanderson’s recommendation to the RCSFH that telephones should link the ‘interior and exterior of each ward’ to ‘render the visits to patients of their friends as seldom as possible’.107 All these channels of information provision were designed to prevent visiting and conferred privilege on those in possession of the means of transport and communication. Conclusion Isolation in a variety of penal and health-related settings has been described as a technique by which states came to know the populations they sought to govern.108 Strange and Bashford remark that: The ‘dangerous’ became those who did not deserve, or those who could not be trusted with, the freedoms that responsible and healthy citizens enjoyed. In both liberal and totalitarian regimes, experts and government bureaucrats stretched the definition of ‘dangerousness’ to capture individuals who had not yet committed offences.109

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Graham Mooney This point of view is both complemented and complicated by forefronting visitors. To be sure, the interpretation offered here is sympathetic to Strange and Bashford’s observation in the sense that the net of dangerousness also captured the potentially diseased. But visitors to isolation hospitals also blurred the line that unequivocally marks the non-diseased and non-isolated as ‘responsible and healthy citizens’. Visitors, it seems, were cast in a somewhat ambiguous role, one that might be best described as that of compromised citizens. Flirting with infection in and around the isolation hospital, visitors teetered on the precipice of disease. As such, their health was vulnerable to risk in ways that for ‘free’ citizens it was not. What is more, the sub-standard domestic hygiene practised by parents was expressed through the infected status of their children and brought the adults’ fitness as citizens into question. The sequestration of children ran against traditional ways of treating sickness in the home and drew families into unavoidable contact with a state that, not untypically, infantilised them. Visiting was an opportunity that public health grasped to mould ‘selfmanaging citizens capable of conducting themselves in freedom… according to norms of civility’.110 Once inside the hospital, parents, other relatives and close friends were pressed on their responsibility to engage in behaviours that would not facilitate the spread of disease. This advice was not restricted simply to how visitors should act inside the hospital, but also to what they should or should not do before and after crossing the hospital boundary. Acknowledgements I am grateful to the Wellcome Trust for financial support. Additional research was facilitated in 2003 by a Visiting Fellowship to the University of Nottingham’s Institute for the Study of Genetics, Bio-risks and Society. Earlier versions of this chapter were presented to the 2004 Social Science History Conference in Chicago, the 2006 conference of the American Association for the History of Medicine in Halifax, Canada and a colloquium in the Johns Hopkins Program in the History of Science, Medicine and Technology. I am thankful to these audiences and to Harry Marks, Matthew Newsom Kerr and Jonathan Reinarz for their perceptive comments. Notes 1. N. Rose, Powers of Freedom: Reframing Political Thought (Cambridge: Cambridge University Press, 1999), 72. See also P. Joyce, The Rule of Freedom: Liberalism and the Modern City (London: Verso, 2003); U.C. Mehta, ‘Liberal Strategies of Exclusion’, Politics and Society, 18 (1990), 427–54. These studies, of course, flow from the writings of Michel Foucault: M. Foucault, Discipline and Punish: The Birth of the Prison (London: Allen

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2.

3.

4.

5. 6.

7. 8.

9.

10. 11.

Lane, 1977); J.D. Faubion (ed.), Michel Foucault: Power (New York: The New Press, 1994). A. Bashford and C. Strange, ‘Isolation and Exclusion in the Modern World: An Introductory Essay’, in C. Strange and A. Bashford (eds), Isolation: Places and Practices of Exclusion (London: Routledge, 2003), 1–19: 3. H. Hendrick, Child Welfare: England, 1872–1989 (London: Routledge, 1994). Child welfare is further explored by L. Murdoch, Imagined Orphans: Poor Families, Child Welfare, and Contested Citizenship in London (New Brunswick: Rutgers University Press, 2006). Chapter 4 is most relevant to the question of visiting. Royal Commission to Inquire Respecting Smallpox and Fever Hospitals in Metropolis. Report, Minutes of Evidence, Appendix (Cd. 3314, London, 1882) (henceforth RCSFH), x. J. Donzelot, The Policing of Families (New York: Pantheon Books, 1979). A. Beach, ‘Potential for Participation: Health Centres and the Idea of Citizenship c. 1920–1940’, in C. Lawrence and A.K. Mayer (eds), Regenerating England (Amsterdam: Rodopi, 2000), 203–30; B. Harris, ‘Educational Reform, Citizenship and the Origins of the School Medical Service’, in M. Gijswijt-Hofstra and H. Marland (eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 85–101; J. Welshman, ‘Child Health, National Fitness, and Physical Education in Britain, 1900–1940’, in Gijswijt-Hofstra and Marland, idem, 61–84; M. Harrison, ‘Sex and the Citizen Soldier: Health, Morals and Discipline in the British Army during the Second World War’, in R. Cooter, M. Harrison and S. Sturdy (eds), Medicine and Modern Warfare (Amsterdam: Rodopi, 1999), 225–49; P. Gruffudd, ‘“Science and the Stuff of Life”: Modernist Health Centres in 1930s London’, Journal of Historical Geography, 27 (2001), 395–416. P. Baldwin, Disease and Democracy: The Industrialized World Faces AIDS (Berkeley: University of California Press, 2005). A. Bashford and M. Nugent, ‘Leprosy and the Management of Race, Sexuality and Nation in Tropical Australia’, in A. Bashford and C. Hooker (eds), Contagion: Historical and Cultural Studies (London: Routledge, 2001), 106–28; W. Anderson, ‘Leprosy and Citizenship’, Positions, 6 (1998), 707–38. A. Bashford, ‘Cultures of Confinement: Tuberculosis, Isolation and the Sanatorium’, in Strange and Bashford, op. cit. (note 2), 133–50; S. Craddock, ‘Engendered/Endangered: Women, Tuberculosis, and the Project of Citizenship’, Journal of Historical Geography, 27 (2001), 338–54. For an accessible summary of citizenship theory, see K. Faulks, Citizenship (London: Routledge, 2000). Ibid., 5–6.

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Graham Mooney 12. P. Corrigan and D. Sayer, The Great Arch: English State Formation as Cultural Revolution (Oxford: Blackwell, 1985), Ch. 6. 13. M. Poovey, Making a Social Body: British Cultural Formation, 1830–1864 (Chicago: University of Chicago Press, 1995), Ch. 3. 14. P. Gilbert, The Citizen’s Body: Desire, Health and the Social in Victorian England (Columbus: Ohio State University Press, 2007), 55; See also C. Hall, K. McClelland and J. Rendall, Defining the Victorian Nation: Class, Race, Gender and the Reform Act of 1867 (Cambridge: Cambridge University Press, 2000); K. McClelland and S. Rose, ‘Citizenship and Empire, 1867–1928’, in C. Hall and S. Rose (eds), At Home with the Empire: Metropolitan Culture and the Imperial World (Cambridge: Cambridge University Press, 2006), 275–97. 15. Poovey, op. cit. (note 13), Ch. 2; C. Hamlin, Public Health and Social Justice in the Age of Chadwick: Britain, 1800–1854 (Cambridge: Cambridge University Press, 1998). 16. Gilbert, op. cit. (note 14), 18–24; Corrigan and Sayer, op. cit. (note 12), 150–1. 17. Poovey, op. cit. (note 13), Ch. 6. 18. N. Durbach, Bodily Matters: The Anti-Vaccination Movement in England, 1853–1907 (Durham: Duke University Press, 2005). 19. On sites of risk, see D.N. Livingstone, Putting Science in its Place: Geographies of Scientific Knowledge (Chicago: University of Chicago Press, 2003), Ch. 2. 20. H. Richardson, English Hospitals 1660–1948: A Survey of their Architecture and Design (Swindon: Royal Commission on the Historical Monuments of England, 1998). There were, of course, fever wards in Poor Law institutions. M.R. Currie, Fever Hospitals and Fever Nurses – A British Social History of Fever Nursing: A National Service (London: Routledge, 2005), 13, notes fever hospitals were founded in Liverpool, London, Manchester and Newcastleupon-Tyne between 1800 and 1804. In this chapter I use the term ‘isolation hospital’, which came to replace ‘fever hospital’, a notable shift in title that receives some attention in Currie’s work, but perhaps would repay closer scrutiny. 21. R. Thorne Thorne, ‘On the Use and Influence of Hospitals for Infectious Diseases’, Tenth Annual Report of the Local Government Board 1880–81: Supplement Containing Reports and Papers Submitted by the Board’s Medical Officer on the Use and Influence of Hospitals for Infectious Disease (Cd 3290, London, 1882). 22. Richardson, op. cit. (note 20), 139, although bed provision in the Poor Law Infirmaries (94,001 beds) outstripped all other types of institution combined. See S. Sheard, ‘Reluctant Providers? The Politics and Ideology of Municipal Hospital Finance 1870–1914’, in M. Gorsky and S. Sheard (eds),

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23.

24. 25.

26.

27. 28. 29.

30. 31. 32.

Financing Medicine: The British Experience Since 1750 (Abingdon: Routledge, 2006), 112–29. P. Baldwin, Contagion and the State in Europe, 1830–1930 (Cambridge: Cambridge University Press, 1999); M. Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain, 1865–1900 (Cambridge: Cambridge University Press, 2000). See also M. Pelling, Cholera, Fever and English Medicine, 1825–1865 (Oxford: Oxford University Press, 1978), Ch. 6. Some aspects of isolation and hospitals are dealt with in the following: P. Weindling, ‘From Isolation to Therapy: Children’s Hospitals and Diphtheria in Fin De Siècle Paris, London and Berlin’, in R. Cooter (ed.), In the Name of the Child: Health and Welfare, 1880–1940 (London: Routledge, 1992), 124–45; J.M. Eyler, ‘Scarlet Fever and Confinement: The Edwardian Debate Over Isolation Hospitals’, Bulletin of the History of Medicine, 61 (1987), 1–24. J.M. Eyler, Sir Arthur Newsholme and State Medicine, 1885–1935 (Cambridge: Cambridge University Press, 1997). L. Barrow, ‘Victorian “Pest-Houses” Amid London’s March of Bricks and Mortar’, Recherches Anglaises et Américaines, 36 (2003), 127–37: 134. Barrow does not directly name the historians he has in mind. ‘Isolation hospital’ was of course, a commonly used term by the late-nineteenth century. For qualifications to this generalization, see Worboys, op. cit. (note 23). Diphtheria occupied a dual position as both a filth disease (sewer gas continued to be identified as a culprit) and a disease that was infective. Isolation of enteric (typhoid) fever cases was advocated to ensure that patients’ excreta could be dealt with safely. RCSFH, op. cit. (note 4), question 2,485. Barrow, op. cit. (note 25). RCSFH, op. cit. (note 4), question 4,494. W.H. Power, ‘Influence of the Fulham Smallpox Hospital on the Neighbourhood Surrounding it’, Tenth Annual Report, op. cit. (note 21). See M.L. Newsom Kerr, Fevered Metropolis: Epidemic Disease and Isolation in Victorian London (Unpublished PhD: University of Southern California, 2007), Ch. 12. RCSFH, op. cit. (note 4), xxv–xxvii. Ibid., question 1,037. Ibid. In addition, all letters were to be disinfected and the exposure of bedding and clothing was to be minimised as far as possible. Although the commission was concerned with the situation in London, and in particular the duplication of authority between the Poor Law and the MAB, the majority of these recommendations were, of course, applicable to other places.

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Graham Mooney 33. H. Littlejohn, Annual Report on the Health of the Borough of Sheffield for the Year 1892, 53. 34. H. Littlejohn, Annual Report on the Health of the Borough of Sheffield for the Year 1891, 34. 35. Publication of hospital admissions was uneven. Scarlet fever hospitalisation rates can be calculated from MOH reports in all the following cities from 1892. In that year, Birmingham hospitalised 80% of cases notified, Edinburgh 46%, Leicester 55%, and Nottingham 88%. On infectious disease notification, see G. Mooney, ‘Public Health Versus Private Practice: The Contested Development of Compulsory Notification of Infectious Disease in Late-Nineteenth-Century Britain’, Bulletin of the History of Medicine, 73 (1999), 238–67. 36. Not dealt with here are the mass invasions by a curious public of newlyconstructed isolation hospitals that took place before they began admitting patients. On Edinburgh, see J.A. Gray, The Edinburgh City Hospital (East Lothian: Tuckwell Press, 1999), 135; on Oldham see Thorne, op. cit. (note 21), 217; and on Nottingham, see Nottingham City Archives (henceforth NCA), CA.CM/Health/14, Borough of Nottingham, Health Committee Minute Books, 8 May 1891, 44. 37. Gilbert, op. cit. (note 14), Ch. 3. 38. J. Burnett, A Social History of Housing, 1815–1985, 2nd edn (London: Methuen, 1986), 144–5. 39. Littlejohn, op. cit. (note 33), 53. See also F.M. Hardy, ‘The Infectious Diseases Question’, Nottingham Daily Express, 11 April 1891, 6. 40. RCSFH, op. cit. (note 4), questions 2,853–4. 41. G. Ayers, England’s First State Hospitals: The Metropolitan Asylums Board (London: Wellcome, 1971), 81–2. 42. Ibid., 230. 43. Thorne, op. cit. (note 21), 174–8, 218 and 230. 44. Gilbert adopts the term ‘anti-citizen’ to describe paupers, reflecting their lack of both political rights and domestic attachment. Gilbert, op. cit. (note 14), 46. 45. Thorne, op. cit. (note 21), 30. 46. Littlejohn, op. cit. (note 34), 34. 47. F. Vacher, Report on the Sanitary Condition of Birkenhead and Claughton-cumGrange for the Year 1874, 28. 48. Thorne, op. cit. (note 21), 49. See also NCA, CA.CM/Health/6, Borough of Nottingham, Health Committee Minute Books, 16 April 1875, 154. 49. Gilbert, op. cit. (note 14), 18, note 1. Gilbert does not pursue this theme in any great detail. 50. Here, I take ‘social’ to mean that which mediates between the private and the public spheres. Ibid., Ch. 4 and Poovey, op. cit. (note 13).

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Infection and Citizenship 51. For the recreation of middle-class domesticity in an isolation setting (the London Fever Hospital), see Newsom Kerr, op. cit. (note 29), Ch. 6. 52. Calculated from P. Boobyer, Nottingham Annual Health Reports for 1899–1901. 53. Thorne, op. cit. (note 21), 27. 54. Leicester City Archives (henceforth LCA), CM32/8, Borough of Leicester, Minute Book of the Sanitary Committee, 7 March 1879, 377–86. 55. An Englishman, ‘The Proposed Compulsory Registration of Infectious Diseases’, The Leicester Chronicle and Leicestershire Mercury (18 January 1879), 6. It was not usual for local authorities to hospitalise whooping cough and I have come across no evidence that it ever was in Leicester. 56. RCSFH, op. cit. (note 4), questions 500 and 1,191. 57. Nottingham Daily Express, 3 March 1891, 6. 58. C.J. Welton, ‘The Infectious Diseases Question’, Nottingham Daily Express, 16 April 1891, 6. 59. M. Sigsworth and M. Worboys, ‘The Public’s View of Public Health in MidVictorian Britain’, Urban History, 21 (1994), 237–50; Durbach, op. cit. (note 18); Barrow, op. cit. (note 25). 60. LCA, CM32/9, Borough of Leicester, Minute Book of the Sanitary Committee, 4 June 1880, 314. 61. LCA, 22D57/74, Borough of Leicester, Town Clerk Correspondence (Out), 10 May 1880. 62. T. Burnie, ‘The Nottingham Hospital for Infectious Disease’, Nottingham Daily Express, 6 April 1891, 6. Burnie’s profession is listed in Wright’s Directory of Nottingham, 1894–95. 63. Thorne, op. cit. (note 21), 27. 64. Birmingham City Archives, Borough of Birmingham, Birmingham Health Committee Minute Book, 26 March 1884, 76. 65. Littlejohn, op. cit. (note 34), 34. 66. Thorne, op. cit. (note 21), 168. 67. J. Tatham, Seventeenth Annual Report on the Health of Salford for the Year 1885, 61; Thorne, op. cit. (note 21), 28, who stated that in the course of his inquiry he came across no more than three dozen cases where patients were removed to hospital by force. 68. C.E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (Baltimore: Johns Hopkins University Press, 1987), 35, 286–7. 69. Gray, op. cit. (note 36), 158. 70. Newsom Kerr, op. cit. (note 29), Ch. 10. 71. In 1881, Sheffield’s Health Committee proposed appointing a non-resident medical officer to its newly opened hospital. Of course, this was cheaper than having a resident medical officer, but also was seen as necessary since the Committee assumed that otherwise it would be ‘impossible for friends,

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72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86.

87.

88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101.

visitors or charitable persons to visit the patients’. Sheffield Local Studies Library (henceforth SLSL), 352.042.SQ, City Council of Sheffield, Minutes of the Council, 7 June 1882, 344. Thorne, op. cit. (note 21), 27. See also NCA, CA.CM/Health/7, Borough of Nottingham, Health Committee Minute Books, 4 April 1878, 332. RCSFH, op. cit. (note 4), evidence of William Gayton, questions 2,680–1. Thorne, op. cit. (note 21), 257, citing a case of mother who worked in a pawnbrokers being admitted with her children. Ibid., 83 and 92. Eyler, op. cit. (note 24), 111. Thorne, op. cit. (note 21), 92. Ibid., 150, 217. RCSFH, op. cit. (note 4), question 1,260. Thorne, op. cit. (note 21), 176. See Currie, op. cit. (note 20), 81, testimony of Sarah England (Hicks). Thorne, op. cit. (note 21), 51. See Currie, op. cit. (note 20), 63. W.K. Anderson, Fever Hospital: A History of Fairfield Infectious Disease Hospital (Melbourne: Melbourne University Press, 2002), 33. Gray, op. cit. (note 36), 158. RCSFH, op. cit. (note 4), question 1,260. Power, op. cit. (note 29). At the time of the Royal Commission, the Fulham smallpox hospital was closed to all cases except those occurring within a mile of it. Thorne, op. cit. (note 21), 27 and 52; Gray, op. cit. (note 36), 158; I.A. Porter and M.J. Williams, Epidemic Diseases in Aberdeen and the History of the City Hospital, No. 2 (Aberdeen: Aberdeen History of Medicine Publications, 2001), 48. See Currie, op. cit. (note 20), 81, testimony of Sarah England (Hicks). Exceptions commonly were made in the case of erysipelas and enteric fever wards. Barrow, op. cit. (note 25), 134. Thorne, op. cit. (note 21), 294. Porter and Williams, op. cit. (note 87), 48. Thorne, op. cit. (note 21), 134. RCSFH, op. cit. (note 4) question 2,057. Thorne, op. cit. (note 21), 134. Ibid., 27. Ibid., 294. Ibid., 51 and 294. Ibid., 51. Ibid., 89. Porter and Williams, op. cit. (note 87), 48 Currie, op. cit. (note 20), 86, testimony of Jean Bell (Hall).

172

Infection and Citizenship 102. Ibid., 99, testimony of Olive Dodd (Cowley), Dunstable and District Joint Isolation Hospital, 1942–4. 103. Thorne, op. cit. (note 21), 150, 209 and 294. RCSFH, op. cit. (note 4), evidence of John Ashton Bostock, question 1,260. 104. Thorne, op. cit. (note 21), 8. 105. Gray, op. cit. (note 36), 149. 106. Thorne, op. cit. (note 21), 176. The health committee in Sheffield also argued that a telephone would reduce the time and inconvenience that the MOH incurred when seeking out cases to induce them to come to the hospital. See, City Council of Sheffield, op. cit. (note 71), 344. 107. J. Burden Sanderson, ‘Memorandum on the Administration of Urban Hospitals for Smallpox’, RCSFH, op. cit. (note 4), 315. 108. M. Dean, ‘Liberal Government and Authoritarianism’, Economy and Society, 21 (2002), 37–61. 109. Bashford and Strange, op. cit. (note 2), 3–4. 110. Rose, op. cit. (note 1), 242.

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8 Stage-Managing a Hospital in the Eighteenth Century: Visitation at the London Lock Hospital

Kevin Siena London’s Lock Hospital, established in 1747 to treat venereal diseases, depended heavily on charity. Its administrators tried valiantly to project a positive image of the hospital in spite of the pervading moral assumptions about its patients and doubts about whether they deserved charity. Policies governing visitation were bound up in the hospital’s attempts to police itself and promote its cause to benefactors. Visitation policies served numerous ends, including policing patients, introducing moral reform, monitoring the staff, and obscuring the reality of the wards from public view, ensuring that prospective donors only saw what administrators wanted them to see.

London’s Lock Hospital was unique. Founded in 1747, it was the first English hospital devoted exclusively to the care of venereal disease. The royal hospitals of St Bartholomew’s and St Thomas’s also provided treatment for the scourge often called the ‘Secret Malady’ or the ‘Foul Disease.1 But the Lock was the only hospital in England to make its sole purpose caring for victims of the ‘wages of sin’ – another cliché from the period. This unique mission meant that the Lock had to tread cautiously. Many were the critics who argued that the hospital encouraged sin by allowing the justly punished to escape their plague. As a result, hospital authorities were acutely aware of the need to handle certain policies carefully. Rules governing visitation were among the most important of those policies. At the Lock, the issue of visitation concerned much more than merely whether to allow patients’ friends and relatives to enter the hospital. That question was important, but in addition to this meaning of the term, visitation at the Lock Hospital also demonstrates how older notions of the concept continued well into the Enlightenment. As it had throughout the mediaeval and early modern period, visitation also constituted, on the one hand, an important form of institutional surveillance and, on the other, a strategy for moral reformation. One can only fully understand visitation at 175

Kevin Siena the Lock if one appreciates the influence of these older legacies of the term. Moreover, policies governing all three forms of visitation were bound up in the hospital’s vital and carefully managed public relations campaign.2 The Enlightenment is now characterised as witnessing the birth of the allimportant public sphere, or the rise of what some simply choose to term ‘public opinion’.3 As public opinion became increasingly influential in most every endeavour – whether in politics, culture or the economy – so too did it take on new importance for hospitals. Public opinion was essential to the survival of the Lock Hospital, and, we will see, visitation policies were essential to public opinion. Finally, visitation policies can also provide a gauge of the direction of the institution itself, for after 1780, the charity intensified its efforts to reform patients, and visitation policies changed dramatically. The Lock Hospital emerged from the voluntary charity movement in eighteenth-century England. That movement witnessed a flurry of charitable activity driven by private initiative. Unlike parish institutions such as workhouses, funded by the state through the Poor Law, or the Royal hospitals like St Bartholomew’s, St Thomas’s or Christ’s, which had been endowed by the crown and had ties to the city government, voluntary charities were funded exclusively by private donation. Groups of urban mercantile élites applied the principle of the joint stock company, whereby many investors could join together in a charitable endeavour. Most benefactors were unlike Thomas Guy, the London bookseller so fabulously wealthy he could launch the hospital that still bears his name largely from his own fortune. Unable to give such enormous lump sums, most contributors to eighteenth-century voluntary charities ‘subscribed’ a set amount each year. Through collective organisation and steady contribution, members of the urban middle class could finally take some pleasure in the rewarding act of conspicuous contribution, something which – as the term noblesse oblige suggests – was traditionally a luxury of the landed nobility.4 Hospitals were among the most important examples of this new charitable form.5 By the time the Lock opened its doors in the late 1740s, London could already boast of such institutions as the Westminster Infirmary, the Middlesex Infirmary, the London Hospital and St George’s Hospital.6 The voluntary charity model was particularly popular, not just because it offered an opportunity for giving to a new class, but because of particular advantages the voluntary charity structure seemed to provide. For one thing, these polite and commercial people wanted good value for money. One of the most attractive features of the voluntary hospital was that participation in the administration of the institution accompanied subscription. Donors who gave the annual subscription fee – five guineas at the Lock – became governors of the hospital with all the rights and privileges 176

Stage-Managing a Hospital in the Eighteenth Century therein. Subscribers thus had the chance to involve themselves in the actual running of the house. Not only could they attend and vote at all meetings, but benefactors could see first-hand that their money was put to good use. The voluntary hospital model thus promised efficient and transparent operation, something about which London merchants were particularly keen.7 Voluntary charities also provided important networking opportunities, as membership brought with it the chance to mingle with other urban élites, including the titled nobles who frequently leant their names to such endeavours as chancellors – usually along with generous donations. Importantly, a policy altogether novel saw governors acquire the power to nominate patients. This may have been the voluntary hospital’s particular genius, for aspiring patients could only access care through a personal appeal to a governor, who held the proverbial keys to the institution in the form of the crucial nomination letter. Roy Porter made a convincing case that this admissions policy appealed to prospective benefactors because it guaranteed donors the chance to restrict their benevolence to ‘worthy objects of charity’.8 The attitude that indiscriminate charity bred sloth and immorality was intensifying.9 Handpicking the recipients of care guaranteed subscribers that the inmates of their hospitals truly deserved it. This practice allowed donors to puff themselves as good Christians while subtly turning their institutions towards the end of social discipline. The immoral and the unworthy could find their relief in the workhouse while the honest poor would be saved from such a fate, rewarded for their good character in one of these new infirmaries. This link between morality and charitable worthiness spelled bad news for syphilitics. London’s voluntary hospitals routinely banned them. The Westminster Infirmary provides the clearest, though hardly the only, example. Its language could not be more obvious: That no person having the venereal disease shall be admitted into this Infirmary. That if any person having the venereal disease and not discovering the same shall obtain Admission under pretence of some other distemper such person upon discovery afterwards made thereof shall be immediately discharged without cure.10

However, it seems likely that the omnipresence of the disease among the London poor11 pressured some governors to try to amend the policy in 1738. Those suggesting that the hospital start admitting syphilitics met intense opposition. Emphasising that the charity was intended only for ‘honest, Sober, [and] Industrious poor Sick persons’ angry governors argued that 177

Kevin Siena ‘persons infected with the Venereal Disease do generally bring it upon themselves by their own lewd and vicious Habits.’ Moreover, the hospital had a limited amount of spaces, so admitting the poxed would mean having to exclude others more deserving of care.12 No fewer than thirty-seven of the hospital’s subscribers signed an open letter, published as a pamphlet, opposing the motion and calling the admission of venereal patents ‘a Subversion of the Charity, or a Misapplication of the Money given in trust for the Poor.’ The society had consistently rejected such patients ‘for the very reason of Being Venereal’.13 The London Hospital would fight the same fight a decade later.14 In both cases, proponents who suggested extending care to venereal patients backed down when they saw the reality of what such a policy might mean for their institution’s public image and hence its fundraising campaigns. These pressures likely drove the same policies of exclusion at St George’s Hospital and the Middlesex Infirmary as well.15 A tangible result of these policies was a dire need for hospital beds for syphilitics by the middle of the eighteenth century. William Bromfeild, a surgeon at St George’s Hospital with a highly lucrative private practice built on a significant noble clientele, moved to address the crisis by organising a new voluntary hospital in 1747, this one devoted entirely to these frequently neglected patients.16 However, the new Lock Hospital found the crowded world of London charity extremely competitive. It managed to soldier on, but as Donna Andrew has noted, it competed quite poorly for subscribers.17 Londoners of means had no dearth of charities from which to choose. Foundlings, orphans, impoverished mothers – benefactors contributed much more eagerly to the institutions bestowing care upon these recipients than to the hospital treating the repugnant ‘foul disease’.18 It was hard not to view an institution like the Foundling Hospital or the Lying-In Hospital as simply more worthy than the Lock Hospital. Thus, the Lock faced an uphill battle in the world of eighteenth-century charity. It had to work hard for every pound and penny it dug out of the pockets of the well-heeled. For this reason, I contend, the hospital had to be particularly vigilant of its operation, its patients, its staff and, especially, its public image, and that this coloured visitation policies in a number of ways. Visitation as institutional self-policing For starters, it was imperative for the Lock, as it was for all voluntary hospitals, to avoid any accusations of mismanagement. One strategy was to constitute a committee of ‘house visitors’ charged with visiting the wards to oversee operations and report problems to the administrative board. This policy assumed a definition of visitation in its essentially mediaeval and early modern sense; in the tradition of ecclesiastical visitation, it referred to an act of authoritative inspection.19 In this way, the concept of visitation in the 178

Stage-Managing a Hospital in the Eighteenth Century eighteenth century still carried with it a strong sense of surveillance. Such committees remained common at voluntary hospitals. For example, the ‘house visitors’ committee at the London Hospital kept a separate report book to document abuses,20 as in 1754, when the surgical apprentice Thomas Dunckly was dismissed for ‘endeavouring to commit indecencys with One of the Women Patients’.21 These house visitors policed both the employees and the patients,22 and while they were not members of the medical staff, they even weighed in on medical issues, as in 1759, when they reported that several patients seemed well enough to be discharged to make room for new patients. On this occasion, the visitors were also vigilant to prevent abuse of the charity by the unworthy, in this case unemployed women trying to use the hospital for food and shelter rather than medical care: And as your Committee have great reason to believe that Several Persons received into this Hospital come here for a Maintenance (particularly Several Women out of place) we are of opinion that such Visitation once in three weeks or a Month would be of a great use to the Publick, therefore have desired the above said Three gentlemen to make another Visitation, and Report to your Committee how they find the State of the Patients, by which means we hope to get the House clear of such improper People, and Consequently Room be made for those who are real Objects of the Charity.23

The London Hospital was hardly unique; the records of Guy’s, St Bartholomew’s and St Thomas’s Hospitals all demonstrate regular inspection–visitations by governors.24 The Lock Hospital employed visitation in this manner roughly from its inception. The earliest list of hospital rules (1754) stipulated regular visitation by a committee of house visitors. Two governors sitting on the Weekly Committee (overseeing admissions and other day-to-day business) formed a subcommittee for visitation, charged with weekly inspection of the wards. As at the London Hospital, this was as much an inspection of the staff as of the patients. The Lock’s inspection also seems to have been quite thorough. At the time of visitation the house visitors cleared the wards of all staff in order to question the patients candidly about the quality of their care. Likewise, the house visitors were instructed to question the nurses about the patients, the matron about the nurses, the surgeons about their apprentices, and so on.25 The Lock’s administration was compelled to do this because it was not infrequent that its board of management received angry communiqués from governors complaining about the treatment their nominated patients had received. Letters like that of John Major, in November 1759, threatened to suspend subscription ‘on account of some ill 179

Kevin Siena treatment’ that his recommendations met with at the hospital.26 The personal interest in patients that the voluntary model afforded governors like Major meant that stories from the wards could easily make their way to benefactors’ ears. It was to prevent just such complaints that the hospital utilised visitation. Problems addressed by the house visitors ranged greatly. Food figured prominently. On several occasions patients complained about the quality of their meals.27 In 1760, the matron and cook were both fired when provisions were found to be ‘so extremely bad they were not fit to be given to a Christian.’28 While in June 1789, porter John Oram narrowly escaped the same fate when the weekly visitors discovered that he had emptied his chamber pot into the patients’ gruel.29 If this were not bad enough, visitation also revealed instances when the staff took advantage of the female patients. Years before soiling the oatmeal, Oram tried to use his position to gape at women’s bodies. Telling incoming women that it was his job to conduct physical examinations – which, of course it was not – Oram: [E]xamined them… as to their wounds, & if they had any discharge upon them &c. that he took up the cloths of some of them, & actually examined them, that he attempted it in others, but was resisted.30

With a somewhat precarious moral reputation already, the Lock could hardly afford such practices to go unpunished, especially since patients might easily report such abuse when they returned thanks to their nominating governor after discharge, which policy required them to do.31 Controlling the doorway The policy of weekly visitation, then, was aimed at keeping good order in the house and thereby maintaining a good public reputation. But this was difficult to do. In part, harmony on the wards was difficult to keep because of the visitors who came into the hospital from the outside. Policy regarding this second form of visitation also points at an attempt to keep stern order. The hospital’s walls were indeed permeable, so governors strove to manage the flow of people in both directions. Patients’ movements outside the house, and visitors’ movements into the house, were strictly policed. Visitors coming to the house were clearly viewed as problematic. House rules instructed the porter ‘that he shall not suffer any stranger to come into the house without giving notice to the matron,’ who would vet them before admission.32 Moreover, nurses were charged with clear instructions to limit strictly the amount of time visitors who gained access could stay. Even family members could only visit sick relatives for a few minutes. Nurses were ordered to let visitors stay a mere ‘20 minutes or half an hour at most’.33 It 180

Stage-Managing a Hospital in the Eighteenth Century is clear that governors policed visitation in part because visitors were constantly smuggling alcohol into the house. Governors were adamant ‘that no patient presume to send for victuals or drink of any sort into the Hospital’ and complained that visitors represented a means ‘whereby liquors & Provisions were brought in, contrary to the Rules & orders of this Hospital.’34 Surgeons, by contrast, seemed more concerned that visitors might retard patients’ treatments by bringing them the wrong kinds of food. In 1764, the surgeon complained that the matron and porter were doing a poor job of guarding the door, because a woman had been observed entering the wards to sell tarts and cakes to the patients ‘which greatly hurt them’.35 Perhaps due to the aforementioned concern for appearances of respectability, the governors seemed especially concerned with policing entry to the female wards. Women who contracted the pox were already viewed as morally loose, and the need to quarantine them seems to have been intense. One of the first motions passed while the hospital was still under design emphasised this concern; the Board unanimously agreed: [T]hat no Man be admitted on any Pretence whatsoever into the woman’s ward in this Hospital, except Governors & Officers of the House, or Persons introduced by a Governor or Officer.36

This concern was as much about men from outside the hospital as from within it. Nurses of the female wards were repeatedly instructed ‘never [to] permit the Men Patients to enter their [ie. female] wards on any pretence whatever.’37 Such anxiety was common in eighteenth-century hospitals like St Thomas’s, where male and female patients could not ‘talk suspiciously’ nor enter each other’s wards.38 Evidence suggests that control of visitors to the women’s wards, even by women, was taken so seriously that it could lead to conflict. In the autumn of 1794, the porter refused visiting privileges to a woman who applied to see a female patient in the Lock. The reason she was denied is not known, but she clearly went away angry. She brought charges against the hospital porter, for whose legal defence the hospital had to pay. On 4 November 1794, the minutes record: [T]hat Jn. Oram the Porter be paid six Guineas on account of the Expence he was at in defending a prosecution brot. agt. him by a Woman for opposing her going up into the Womans Ward contrary to the Rules of the house.39

As this incident suggests, the anxiety surrounding the female wards did not merely stem from worries that the women might be abused by men. Most women who arrived at the Lock Hospital were assumed to have been prostitutes, or at the very least, women who had been debauched by the low 181

Kevin Siena company they kept. Governors thus frequently viewed their friends and acquaintances as denizens of London’s seedy underbelly and found visits from them extremely worrisome. The minutes of 2 May 1765 recorded the kernel of their concern: This court receiving information that Bawds & disorderly persons had found means to get into the Women’s Patients Ward and endeavor’d to Decoy or prevail upon sevl. of the Women Patients who were nearly Cur’d to return to their former evil courses.40

What use was their hospital if the women they cured could be lured back into a life of sin? Such visitors had to be banned. Fanny Finley was just such a character. Finley ran a brothel in Fleet Market. One of the women she employed was Ann Hook. Ann was still a teenager when she contracted the pox and was treated for the disease in the Lock in 1764. When she was about to be discharged the governors questioned her about her circumstances; they must have been moved by Ann’s story because they recorded it in great detail. With a tale so typical Ann could have stepped from the plates of Hogarth’s Harlot’s Progress. Ann told the board how she had come to London hoping for work as a domestic servant, but she was unable to secure a job. Unemployed, she took her first step down a slippery slope when she befriended a woman who gave her ‘great Quantities of Liquor’ and when she was ‘quite insensible’ put her to bed with a man who slept with her and infected her. Soon deserted by these new ‘friends’, Ann was convinced by some street walkers to apply to the bawd, Fanny Finley. Finley agreed to provide her with room and board for fifteen shillings a week, which Ann was expected to earn ‘by Walking the Streets & bringing Men & bad Company to her House, whom she us’d to sell Liquor to & extort money from.’ This she did until her disease worsened. Finley agreed to arrange to get Ann a governor’s nomination for the Lock on the condition that she promise to return to the bawdy house when discharged. The governors must have been infuriated to learn that Finley coached her to lie, telling her to enter the house under the pseudonym Ann Lamb, to claim to be younger than she was, and to tell the admissions committee that she had been infected through a rape by a stranger, all of which Ann related when she was first admitted. But Finley’s gall went even further; she regularly visited Ann in the hospital, pretending to be her mother. She habitually came to see Ann with gifts of tea and sugar ‘in order to keep her in the mind to return to her.’ Ann pleaded with the Board to help her. She shuddered to think of returning to Finley, but she was penniless, homeless and unemployed. Upon hearing Ann’s story the Board resolved to enquire into prosecuting Finley for keeping a bawdy house. In the meantime they agreed 182

Stage-Managing a Hospital in the Eighteenth Century to keep Ann out of the reach of Finley and her cohort, allowing her to stay in the house and emphasising to the staff ‘that [neither] the said Fanny Finley nor any person from her be suffer’d to come into the House, or speak with the said Ann Lamb [sic].’41 Given its clientele, it was imperative for the Lock to monitor who came into the hospital. But they also had to control who left. Early house rules ordered patients ‘not [to] stir out of their respective Wards’ while in the house. Employees were warned never to send patients out of the house on errands.42 The matron was instructed to keep the door locked, especially at night, and the porter was ordered to keep all patients from leaving the premises.43 Exceptions were made for patients given specific written permission by the board to leave, as well as for patients in need of fresh air who were allowed to walk in St James’ or Green Parks. However, such exceptions were to be limited. It is immediately discernable that this drive to corral patients linked up with the hospital’s aforementioned public relations campaign. When emphasising why patients should not be seen on the streets – patients who, it should be remembered were suffering from rather odious symptoms – the governors exclaimed that the policy of quarantine was intended ‘to prevent offence’.44 This admission strikes at a vital truth concerning a venereal disease hospital. It was, to most polite eighteenth-century eyes, disgusting. Try as they might to keep the house orderly, governors knew deep down that their hospital was not for the faint of heart. Its patients suffered from one of the most repellent diseases then known, their bodies riddled by open sores. Some lost their noses when the cartilage deteriorated, and the main treatment – mercurial salivation, in which patients were given large doses of mercury and kept warm as they sweat and spit copious amounts – was painful for those enduring it and shocking for those witnessing it.45 Indeed, the control of visitation had as much to do with keeping the reality of these wards out of public view as with maintaining order among patients’ working-class visitors. Governors demonstrated considerable anxiety about members of polite society glimpsing the inside of their hospital for fear that potential benefactors, if they saw the wards first hand, might be turned off the idea of giving. So it was that the porter was given strict instructions never to allow fashionable visitors onto the wards. This policy had to be handled delicately, however. While he might easily exclude some people out-of-hand, as in the case of the aforementioned woman who sued when she was barred from the wards, the lowly porter could hardly bar a gentleman who wished to see the house. In these cases, he was carefully instructed to steer them. He was to guide them away from the wards full of rank, ulcerated patients, and into the one respectable room in the building, the board room. The porter had to be constantly on the lookout: 183

Kevin Siena Figure 8.1 The Lock Hospital, Hyde Park Corner, Westminster Engraving, drawn by Thomas Hosmer Shepherd and engraved by W. Wallis. Source: Wellcome Library, London.

That if any Persons of Fashion Distinction or Quality shall desire to see the house he do immediately shew him into the board room & acquaint the Matron therewith that she may attend them.46

The governors had select forums for communicating with propertied Englishmen. They were happy to have such men and women read their carefully worded fundraising pamphlets or attend one of the many fundraising sermons.47 But unfettered access to the wards was something else entirely. This is why we see so many instances of tension surrounding the issues of windows and doors. Not only were the Lock Hospital’s walls permeable, at times they were transparent. Traditionally, hospitals for odious patients had been purposefully situated on the outskirts of towns, hence the location of most leper houses. Indeed, because the earliest hospitals to deal with 184

Stage-Managing a Hospital in the Eighteenth Century syphilitics in England were transformed leper houses, these unpleasant operations tended to fall far from the city centre, in neighbourhoods like Southwark, which already had a dubious reputation.48 The Lock Hospital broke with this tradition. Hardly in the seedy boondocks, it was in Hyde Park. As a result the well-to-do walked by the hospital every day. As a gauge of its neighbourhood, consider that in 1761 the hospital’s neighbour, Lord Grosvenor, sent his attorneys to meet with the Lock’s board of govenors, challenging the institution’s right to install windows that faced his property, lest the sight of patients become visible to his estate.49 Indeed, Thomas Sheperd’s sketch of the hospital that survives from the early nineteenth century nicely illustrates how the respectable strolled by the hospital daily (Figure 8.1). The proximity of the hospital to polite Londoners meant that it had to do everything it could to create the illusion of respectability. For example, the hospital was greatly concerned about its street-front façade. It did its best to keep the walkway in front of the hospital as respectable as possible. Unfortunately, in eighteenth-century London, rife with homelessness and unemployment, this was difficult to do. Evidence that the well-to-do indeed frequented the neighbourhood is the fact that beggars consistently set up shop right outside the hospital’s door.50 Twice, the governors contacted the magistrates in attempts to clear their doorway of them. In 1764, and again in 1766, the hospital complained about: [T]he Numbers of Vagrants and other idle persons that assembled themselves near this hospital at the time of Divine Service, and that Mr Upton had been so kind as to order the Beadles of the Parish to attend and apprehend them, by which means the Avenues leading to the Hospital were much cleared of those Nuisances.51

Governors must have been acutely aware that prospective benefactors might easily mistake these beggars for patients, which would have reflected terribly on the charity. As that passage illustrates, hospital authorities were especially concerned that such beggars harassed the respectable citizens who supported the hospital by renting pews in its chapel. Built in 1761, the chapel quickly became singularly important to the charity. Because its subscription income was so low, the hospital took a chance on the evangelical preacher Martin Madan, who proposed that the charity build a chapel that he would lead, providing all the income from pew rentals and hymnal sales to the hospital. Madan emerged as one of the leading evangelical preachers in London, attracting a large and wealthy following, and it was not long before the chapel income outstretched the donations of all the governors’ subscriptions combined, making it immediately the lifeblood of the charity itself.52 185

Kevin Siena Chapel-goers were undoubtedly the most important guests the institution ever received, visiting the hospital grounds each and every Sunday. We can therefore understand why the administration was so upset by the ‘poor persons infesting the avenues of the Chapel [who] begg Alms of the people as they pass.’ It was not just that paupers accosted hospital supporters on their way to chapel, when refused, panhandlers frequently ‘behav[ed] ill to them, using very indecent Language’.53 Beggars were bad enough. But it was even more important to manage the circumstances under which these visitors saw actual patients. The hospital’s founder and surgeon, William Bromfeild, was livid in July 1764 when he discovered that one of the hospital’s main doors had been left open. For one thing, it was a security breach that might allow in undesirables such as Fanny Finley. However, the real problem was that it opened the world of the ‘foul wards’ to public view. The surgeon expressed shock when he arrived at the hospital to find patients, possibly just hoping for a bit of fresh air in muggy July, actually standing in the doorway. Bromfeild made plain the nature of the problem, emphasising how such public exposure of the nasty reality of the hospital’s wards might damage the fiscal health of the hospital. But besides many other inconveniencies that might arise therefrom, he apprehended the Patients standing at the Door and exposing themselves to publick view was so Disagreeable a sight that it might Prejudice Ladys and gentlemen (who frequently pass by there) in their good opinion of the Hospital, and the Charity might Loose Considerably thereby.54

The Board called in the entire staff and issued a stern lecture about the rules governing the locking of the door. Windows were almost as big a problem as doors. In 1772, the house received complaints that the patients leaned out of opened windows and spat upon pedestrians’ heads as they passed. Predictably, the windows were ordered locked; while in July 1783, the house received repeated complaints that male patients looked out the windows, and ‘behave[d] indecently in sight of People, passing & repassing the Road’. In this instance, even a locked window was too transparent; the house ordered that the window be covered to block sight.55 Such concerns clearly increased in frequency in the period after the establishment of the chapel, when Madan’s all-important flock began visiting the hospital grounds on Sundays. After which, it became imperative to keep the hospital tightly locked.56 Visitation and moral reform It is telling that the immediate response to breaches in the visual quarantine of patients was to sweep them out of view by locking doors or covering 186

Stage-Managing a Hospital in the Eighteenth Century windows. It betrays that the hospital’s attempts to keep the patients orderly met with only limited success. It simultaneously raises the issue of patients’ moral reform, bringing us to the third role played by visitation at the Lock Hospital. As in the case of visitation as a form of surveillance, this view of visitation also suggests the continued currency of mediaeval and early modern usages of the term – namely, clerical visitation.57 The Lock’s clientele were a dubious bunch. The charity thus saw itself as charged with a mission not only to tend to their bodies, but to tend to their souls as well, and clerical visitation played a central and revealing role in this project. However, this moral mission was one that was rather lacking during the hospital’s first few decades. From its inception, the Lock’s minister was supposed to visit the patients on the wards in the name of effecting in them a lasting reformation. Such visitation had long been common practice in London hospitals. St Thomas’s Book of Government (1556) stipulated the importance of clerical visitation, and the records of Bart’s and St Thomas’s each show the practice upheld throughout the seventeenth and eighteenth centuries.58 However, it became clear during a conflict over the issue in 1780 that this had not happened at the Lock for decades – to the shame and damage of the hospital, some argued, in a highly public and vitriolic debate.59 Once Madan’s chapel had been built, the hospital chaplain turned his attention to his wealthy flock and stopped visiting patients on the wards. In a telling admission, Madan confessed that he lacked the stomach to face the reality of the wards. In the preface to a short prayer book that he edited to act as the patients’ ‘private visitor in my stead’, Madan exclaimed: The cure of your disorder is of such a nature as it renders it often impossible for me to converse with you in private, and a stay of any long continuance in the wards, tho’ the House where you are is so neatly and carefully kept, is what I have attempted, but cannot bear.60

During a heated debate on the issue in 1780, the governors were forced to acknowledge that neither Madan, nor his replacement Charles de Coetlogan, visited the wards at all, admitting that visiting the patients ‘became so exceedingly offensive, that so long ago as 1760 Mr Madan found it impracticable,’ and that from that point forward clerical visitation had been discontinued altogether.61 This was about to change. The 1780s witnessed a significant transformation in the makeup of the Lock’s governing board. Madan’s chapel linked the Lock to London’s evangelical community, influential members of which increasingly joined the ranks of its governors in the 1760s and 1770s. More than just subscribing and nominating patients, evangelicals took an active role in administration and they steered the institution on a course of much more 187

Kevin Siena intensive soul-saving. They made regular clerical visitation their number one priority. Unfortunately, finding a chaplain who was willing to take on this task proved difficult. Two ministers attempted it initially but they both quickly gave up. One cited his ‘fearful apprehensions’ of completing ‘so disagreeable business’. The other submitted a lengthy letter detailing his failed attempts to visit the patients. It is notable that he considered the effort ‘in vain’, not because he couldn’t stomach it – although he does use terms like ‘offensive’ to describe the experience – but because the patients resisted his efforts, hiding beneath their sheets and doing everything they could to ‘evade [his] attention’.62 De Coetlogan eventually found a minister named Twycross willing to take on the job. Even though he visited the patients less frequently than the board had hoped, just twice a week, the hospital still made the point to emphasise the new development in its fundraising literature. The text of the hospital’s Annual Account had remained virtually unchanged for more than three decades, but the charity now added a new paragraph broadcasting their visitation policy.63 The admission that the hospital had not witnessed clerical visitation for decades was a public relations and fundraising disaster. Donors expected their hospital to make an effort to reform these wayward patients, so the charity swiftly moved to perform damage control. But the new policy was hardly mere stage-managing to placate donors. From the 1780s onwards, the hospital developed several policies to increase its efforts to reform patients and enhance the charity’s moral respectability, and frequently these efforts focused on stricter visitation policies. Indeed, two different forms of visitation quickly intersected. Anxious to gauge the impact of renewed clerical visitation on patients’ reformation, the board ordered the inspecting house visitors to look into the success of clerical visitation in their weekly reports. In addition to looking out for abuses or complaints by patients or staff, the administration now ‘recommended to the weekly Visitors to enquire particularly into the good Effects of the constant visitation of the Patients in their Wards, by the Chaplain or his Assistants’ and to include in their reports ‘such signs of Penitence & Reformation in the patients occasioned thereby’.64 The board also called in Reverend Twycross to give his own report of his success. Twycross was less than sanguine, but he gave some cause for optimism, stating that his labours were ‘not entirely in vain’ and that there was at least some hope of penitence and reformation in several of the female patients. Governors again instructed the weekly visitors to keep an eye out for progress on this front.65 Despite a rather lukewarm report of success, the administration penned a report to donors in which they crowed about the terrific effects of their new visitation policies, stating that ‘they have the greatest reason to believe’ that through 188

Stage-Managing a Hospital in the Eighteenth Century clerical visitation many patients had been ‘brought to a proper sense of their former evil courses, and from that time become useful members of Society.’66 This momentum picked up steam. By 1785, the hospital succeeded in finding a minister who was much more enthusiastic about the idea of salvation in the foul wards. Reverend Thomas Scott applied to become the new assistant chaplain, the main task of which was visiting the wards. In his interview he proclaimed ‘that he would feel a peculiar satisfaction in visiting the unhappy Patients in the House’. The committee enthusiastically supported him for the job, exclaiming – probably with some measure of relief – ‘that the patients will be again visited with Zeal & Attention’.67 Within six months, the administration patted Scott, and itself, on the back for the clear transformation clerical visitation seemed to be having on the patients. The ‘zeal, piety and unremitted attention with which the patients were now visited’ must account for the ‘visible reformation’ they all agreed was taking place. Patients were said to be much more ‘orderly and tractable’, thanks to the ‘warnings and exhortations’ Scott meted out daily, transforming patients’ stay in the hospital from a largely medical experience to a sombre period of reflection.68 Patients’ physical pain and the torments of mercury now merely underscored a more ominous punishment that Scott assured them lay ahead if they failed to heed his warnings to change their lives. However, strangers on the wards endangered this new mission. In 1787, Scott complained that visitors entering the house threatened to undermine his efforts to reform patients. The liberty of visitation had been very much abused, he claimed, because ‘very improper persons who come for the worst purposes’ frequently gained admission to the wards. Because of them ‘the grand object of reformation, is thereby much prevented, & many bad consequences, both to the Charity and to the Patients themselves, are thereby occasioned.’ The board heeded his warning and dramatically limited access to the wards. Now visitation was restricted to merely one day a week, Mondays and then for just a window of two and a half hours. Moreover, the hospital made visitation procedures more stringent. Members of the public could not enter the wards unless they applied to visit a specific patient and ‘give a satisfactory account of their Business with such patient.’ Other dramatic new policies followed. Visitors and patients could no longer speak privately. Now all conversation had to take place with a nurse present. Moreover, visitors were prohibited from conversing with any but the patient they applied to meet. Further still, all parcels coming into the house for patients were to be inspected by the matron or nurse and only delivered if thought proper. Finally, the new policies were to be posted in large signs ‘in such places, where all who come may read them’.69 Reformation was possible, it seemed, but it required strict cloistering. 189

Kevin Siena Scott and the evangelicals were not done here. However, as they moved forward with even more intense reforming passion it became apparent that they were far more concerned with the reformation of the hospital’s women than its men. Warnings to enforce the new visitation policies tended to emphasise the need for vigilance in the female wards. Women, they feared, were forever vulnerable to the influence of ‘improper conversation [passing] between the female Patients & Visitors’, something about which Scott repeatedly complained, reminding nurses not to allow any private conversation on visiting day.70 This anxiety had long been present in the hospital, as the story of Ann Hook and Fanny Finley showed earlier. However, it was now renewed and intensified. In fact, Scott and the Evangelicals soon proclaimed that the job of reforming loose and debauched women was too difficult to accomplish under the current conditions in the hospital. Yet the task was too important to accept failure; thus Scott proposed his boldest suggestion yet. In 1787, he convinced the Board of Governors to establish an entirely separate institution to save the hospital’s women, the Lock Asylum for the Reception of Fallen Women.71 The Lock Asylum would incarcerate women who had been treated in the hospital and keep them for additional reformation. Their regimen of mercury would now be followed by one of prayer and work.72 The asylum was in keeping with the evangelicals’ well-documented views on gender.73 Above all, women needed to be protected from the public sphere, which only promised to corrupt and ruin them, as it had these women. Their faith in the power of domesticity was such that they believed even these women might be saved if safely returned to their proper place in a household, perhaps as a wife and mother, but failing that, at least as a servant in a gentleman’s home. The asylum also demonstrates the influence of another powerful force in the late Enlightenment, the movement to use institutions to improve human beings. The Lock Asylum was, in many ways, simply another example of the penitentiary movement at work.74 As its etymology suggests, such penitentiaries emerged from homes for penitents, most notably the fallen women’s asylums of sixteenth-century Italy – which often also grew out of VD hospitals.75 London had recently witnessed its own first outlets of this movement in the Magdalen Hospital for prostitutes of 1758 and more recently the Misericordia Hospital of 1780.76 Scott clearly fashioned the Lock Asylum on these institutions. Moreover, it is clear that one of the signature elements of the penitentiary model at the Magdalen and Misericordia was the intense control of visitation. Penitent women had to be quarantined from the outside world as much as possible. Their reform hinged on an internal reformation, in which women must come to loath themselves, to detest how they had lived and, finally, to reject their former lifestyle completely. This, penitentiary proponents emphasised, 190

Stage-Managing a Hospital in the Eighteenth Century could only be effected through long periods of intense personal reflection, reflection which could only take place in solitude. In addition to the intense regimens of prayer and work (which, of course, had their own redemptive power) women at the Magdalen and Misericordia were cut off from society in an attempt to cut them off from their former selves. For example, the staff at the Misericordia were forbidden to carry messages into or out of the house unless vetted by the board, and visitors were similarly policed.77 Women in these institutions were even restricted in their discussions with other inmates. Women were threatened with discharge if they dare ‘mention a word relating to [their former] vicious ways of life’.78 Miles Ogborn’s study of the Magdalen similarly emphasises the cloistering that was central to its reforming mission. Women had to be cut off from their former acquaintances for a prolonged period if there was to be any hope that they would turn over a new leaf.79 This was the model Scott proposed to the Lock administration in 1787. Women in the Lock Asylum were to receive religious instruction every morning and daily clerical visitation became routine. The chaplain restricted all reading material to officially vetted religious books. The solitude was intense. Inmates were not permitted to speak, even to one another, save in the presence of the matron. They were confined to the premises.80 Laxity on this last issue was immediately condemned; one of the asylum’s first inmates, Ann Nunn, was permitted to leave the asylum to visit her sick mother. However, Ann’s symptoms soon returned. Rather than attribute this to the failure to cure the disease the first time – the disease was notoriously difficult to treat and such return of symptoms was common – the board assumed the worst: namely, that ‘during her absence (which was only for one Afternoon) [she] had behaved in such a manner as again to be infected with the Venereal Disease. It is resolved that the said Ann Nunn be expelled.’81 Such day-passes quickly became extremely rare. As at the Magdalen, all parcels and letters at the asylum were inspected, whether coming in or leaving the house.82 Above all, the women had to be isolated from their previous friends. Policies forbid not just visits but even letters from women’s former acquaintances. The asylum’s Annual Account emphasised the importance of quarantine. More than anything, reformation hinged on preventing these women from contacting friends; they must be ‘preserved from ever seeing or conversing with their former abandoned companions’.83 The Lock’s new mission of social engineering required a far more intense quarantine than ever before. However, that quarantine was, to a great extent, an institutionalised double standard. While men in the Lock Hospital now certainly received more frequent visits from the chaplain than did male patients of previous decades, their regimen differed dramatically from their female counterparts, who not only underwent physical treatment on the 191

Kevin Siena wards, but were then transferred to an altogether separate institution for much more intense moral therapy. This two-tiered regime betrays the stark gender anxiety that would drive policies on venereal disease well into the nineteenth century.84 Conclusion People visited the Lock Hospital for a multitude of reasons in the eighteenth century, and thus visitation came to mean many things. Policy and practice often hinged more on who a visitor was than anything else. Working-class associates of patients hoping to visit a friend in the hospital met with a vastly different welcoming than did prospective donors or wealthy chapel attendees. Moreover, the hospital’s visitation policies convey that older conceptions of visitation still mattered. Clerical visitation formed a vital tool in the struggle to reclaim patients from sin; indeed, the underlying goal of human perfectibility that drove late-Enlightenment institutionalisation hinged on it. Visitation simultaneously represented a crucial form of selfpolicing, as authorities took turns ‘visiting’ their own hospital in the name of assuring donors – and prospective donors – that their charity was well run and provided good value for money. Understanding visitation at the Lock means understanding how it meant so much more than merely the establishment of hours when the wards were open. Successful visitation policies formed key components in the Lock Hospital’s survival strategy during its first few decades. They worked to enhance the Lock’s reputation by keeping undesirables out, maintaining order, ensuring quality of care, guarding against institutional abuses, keeping patients out of polite company’s sight, and turning the charity towards a more reputable mission of attacking the pox at its true source – not merely the physical cause of disease, but the deeper moral failings that middle-class Londoners were sure were responsible for this awful scourge. Notes 1. On the care provided by these hospitals see Chapters Two and Three in K. Siena, Venereal Disease, Hospitals, and the Urban Poor: London’s ‘Foul Wards’ 1600–1800 (Rochester: University of Rochester Press, 2004). 2. The use of the term ‘stage-managing’ in this article’s title warrants reference to Erving Goffman’s use of theatrical principles to analyse self-presentation: E. Goffman, The Presentation of Self in Everyday Life (Garden City: Anchor, 1959). 3. The concept, of course, stems from J. Habermas, Structural Transformation of the Public Sphere: An Inquiry into a Category of Bourgeois Society, T. Burger (trans.), (Cambridge: MIT Press, 1991); For useful introductions to the period emphasising Habermas’ core insight see D. Outram, The

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4.

5.

6.

7. 8. 9.

10. 11.

Enlightenment (Cambridge: Cambridge University Press, 1995), and J. van Horn Melton, The Rise of the Public in Enlightenment Europe. (Cambridge: Cambridge University Press, 2001). For application of Habermas’s idea to medicine see S. Sturdy (ed.) Health and the Public Sphere in Britain, 1600–2000 (London: Routledge, 2002). The standard work on the voluntary charity movement remains D.T. Andrew, Philanthropy and Police: London Charity in the Eighteenth Century (Princeton: Princeton University Press, 1989). On voluntary hospitals see R. Porter, ‘The Gift Relation: Philanthropy and Provincial Hospitals in Eighteenth-Century England’, in L. Granshaw and R. Porter (eds), The Hospital in History (London: Routledge, 1989), 149–78; A. Borsay ‘“Persons of Honour and Reputation”: The Voluntary Hospital in the Age of Corruption’, Medical History, 35 (1991), 281–94, and ‘“Cash and Conscience”: Financing the General Hospital at Bath, c.1738–1750’, Social History of Medicine, 4 (1991), 207–29; A. Wilson, ‘Conflict, Consensus and Charity: Politics and the Provincial Voluntary Hospitals in the Eighteenth Century’, English Historical Review, 111, 442 (1996), 599–619. Institutional histories include A.E. Clark-Kennedy, London Pride: The Story of a Voluntary Hospital (London: Hutchinson Benham, 1979), and T. Gould and D. Uttley, A Short History of St George’s Hospital (London: Atlantic Highlands, 1997). Andrew, op. cit. (note 4), 29. Porter, op. cit. (note 5), 164–6. For an overview that explores this drift of attitudes towards the poor, see R. Jütte, Poverty and Deviance in Early Modern Europe (Cambridge: Cambridge University Press, 1994). This sentiment found its most important institutional manifestation in the workhouse movement, which increasingly replaced the parish dole with a bed in a workhouse as a key form of poor relief. On the workhouse movement, see T. Hitchcock, ‘The English Workhouse: A Study in Institutional Poor Relief in Selected Counties, 1696–1750’, (unpublished PhD dissertation, Oxford University, 1985), and idem, ‘Paupers and Preachers: The SPCK and the Parochial Workhouse Movement’, in L. Davison et al. (eds), Stilling the Grumbling Hive: The Response to Social and Economic Problems in England, 1689–1750 (New York: St Martin’s Press, 1992), 145–66. ‘Resolutions and Orders of the Westminster Hospital’, London Metropolitan Archives (hereafter LMA) H2/WH/A1/64, 119. Consider that well over twenty per cent of patients in London’s royal hospitals entered their VD wards throughout the seventeenth and eighteenth centuries. Siena, op. cit. (note 1), 70–2 and 110–11. Randolph Trumbach’s research similarly suggests extremely high rates of infection: R. Trumbach, Sex and the Gender Revolution, Volume I: Heterosexuality and the Third Gender

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12. 13.

14.

15.

16.

17.

18.

19.

in Enlightenment London (Chicago: University of Chicago Press, 1998), 198–201. Westminster Infirmary, Trustees Minutes, LMA, H2/WH/A1/5, 175–7. Some Reasons of a Member of the Committee, &c. of the Trustees of the Infirmary in James Street Westminster, near St James Park, for his dividing against the Admission of Venereal Patients: In a Letter to a Lady (London, 1738), 1–3. Proponents at the London Hospital succeeded in convincing the Board of Governors to open special wards for venereal patients, but these lasted less than a decade. For the bulk of the century the hospital excluded venereal patients. See Siena, op. cit. (note 1), 221–3. Policy at the Middlesex held ‘to guard in future as much as possible against the admission of persons ill of that disease’: M.W. Adler, ‘History of the Development of a Service for the Venereal Diseases’, Journal of the Royal Society of Medicine, 75, 2 (1982), 124; St George’s held the same policy, though evidence suggests that the hospital may have made some exceptions. Gould and Uttley, op. cit. (note 6), 5. On Bromfeild’s career, see D. Innes Williams, The London Lock: A Charitable Hospital for Venereal Disease 1746–1952 (London: Royal Society of Medicine Press, 1996), 11–15. On the Lock’s establishment, see Williams, idem., 19–24; Andrew, op. cit. (note 4), 69–70; and L. Merians, ‘The London Lock Hospital and Lock Asylum for Women,’ in L. Merians (ed.), The Secret Malady: Venereal Disease in Eighteenth-Century Britain and France (Lexington: University of Kentucky Press, 1996), 129–30. D.T. Andrew, ‘Two Medical Charities in Eighteenth-Century London: The Lock Hospital and the Lying-In Charity for Married Women’, in J. Barry and C. Jones (eds), Medicine and Charity Before the Welfare State (London: Routledge, 1991), 82–97. Bronwyn Coxson’s study of the Middlesex Infirmary similarly points to the competitive charitable atmosphere in Enlightenment London and the importance of a hospital’s – perceived – moral balance sheet; she suggests that the Middlesex’s lying-in service gave it a distinct advantage when fundraising: ‘[I]n the competitive charitable market-place, providing lying-in services was used by the Middlesex to differentiate itself from other voluntary hospitals and to attract benefactors.’ B. Coxson, ‘The Foundation and Evolution of the Middlesex Hospital’s Lying-In Service, 1745–86’, Social History of Medicine, 14 (2001), 29 and 38–40. According to the Oxford English Dictionary (OED): ‘The action, on the part of one in authority, or of a duly qualified or authorised person, of going to a particular place in order to make an inspection and satisfy himself that everything is in order.’

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Stage-Managing a Hospital in the Eighteenth Century 20. London Hospital, House Visitors Book, 1749–1756, London Hospital Archive (hereafter LH) LH/A/16/1. 21. London Hospital, Report Book 3, LH/A/4/3, 18. 22. For example, the house visitors commonly recommended the discharge of ‘unruly’ patients like Richard Atkinson ejected from the house on 13 March, 1745/6, London Hospital, Report Book 1, LH/A/4/1, 107. 23. London Hospital, Report Book 3, LH/A/4/3, 235–6. 24. Guys Hospital, Court of Committees Minutes, LMA, H9/GY/A3/1/1, 4 April 1726; St Thomas’s Hospital, General Court of Governors Minutes, HI/ST/A1/6, ff.73-5, 223 and 233; St Bartholomew’s Hospital, Governor’s Journal, St Bartholomew’s Hospital Archive (hereafter SBH) HA 1/8, f. 125. 25. Royal College of Surgeons Library (hereafter RCS) Lock Hospital, General Court of Governors Minutes, Book 1, 1. 26. RCS, Lock Hospital, Board of Governors Minutes, Book 2, 3 November 1759, n.p. 27. See for example, RCS, Lock Hospital, Board of Governors Minutes, Book 10, 161. 28. RCS, Lock Hospital, General Court of Governors Minutes, Book 2, 12. 29. RCS, Lock Hospital, Board of Governors Minutes, Book 12, 11 June 1789, n.p. 30. RCS, Lock Hospital Board of Governors Minutes, Book 9, 62 and 64. Original emphasis. 31. RCS, Lock Hospital, Board of Governors Minutes, Book 2A, 6 March, 1662, n.p. 32. RCS, Lock Hospital, General Court of Governors Minutes, Book 1, 142 33. Ibid., 140–1. 34. Ibid., 136–7, and Lock Hospital, Board of Governors Minutes, Book 10, 179. 35. RCS, Lock Hospital, Board of Governors Minutes, Book 3, 176–7. 36. RCS, Lock Hospital, General Court of Governors Minutes, Book 1, 28. 37. RCS, Lock Hospital, Board of Governors Minutes, Book 1, 140–1. 38. LMA, St Thomas’s Hospital, General Court of Governors Minutes, HI/ST/A1/6, ff.73-5. See also LMA, St Thomas’s Hospital Rules, c. 1752, H1/ST/A25. 39. RCS, Lock Hospital, Board of Governors Minutes, Book 14, 4 November 1794, n.p. 40. RCS, Lock Hospital, General Court of Governors Minutes, Book 2, 59. 41. RCS, Lock Hospital, Board of Governors Minutes, Book 3, 140–2. 42. RCS, Lock Hospital, Board of Governors Minutes, Book 10, 239–40. 43. RCS, Lock Hospital, Board of Governors Minutes, Book 3, 138–9 and 142. 44. RCS, Lock Hospital, Board of Governors Minutes, Book 1, 136–7.

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Kevin Siena 45. On the conspicuous nature of the disease’s symptoms and treatment see Siena, op. cit. (note 1), 18–24. 46. RCS, Lock Hospital, Board of Governors Minutes, Book 1, 142. 47. For the charity’s official fundraising pamphlet, see Account of the Proceedings of the Lock Hospital near Hyde-Park Corner (London, 1749). Examples of fundraising sermons include M. Madan’s, Every Man our Neighbour: A Sermon Preached at the Opening of the Chapel, of the Lock-Hospital near HydePark Corner (London, 1762), and A Sermon Preached at the Parish-Church of St George, Hanover-Square, For the Benefit of the Lock-Hospital (London, 1777). 48. N. Orme and M. Webster, The English Hospital, 1070–1570 (New Haven: Yale University Press, 1995), 41–8; and M.B. Honeybourne, ‘The Leper Hospitals of the London Area’, Transactions of the London and Middlesex Archaeological Society, 21 (1963), 6. On Southwark’s reputation, see J.A. Browner, ‘Wrong Side of the River: London’s Disreputable South Bank in the Sixteenth and Seventeenth century,’ Essays in History, 36 (1994): 34–71. 49. RCS, Lock Hospital, Board of Governors Minutes, Book 2A, 17 October 1761, n.p. 50. On begging strategies see T. Hitchcock, Down and Out in Eighteenth Century London (London: Hambledon and London, 2004). 51. RCS, Lock Hospital, General Court of Governors Minutes, Book 2, 32–5. 52. RCS, Lock Hospital, General Court of Governors Minutes, Book 1, 270–1. On the chapel see Williams op. cit. (note 16), 37–9; Merians, op. cit. (note 16), 136; and Siena, op. cit. (note 1), 187–9. 53. RCS, Lock Hospital, Board of Governors Minutes, Book, 4, 126. On the place of intimidation in begging strategies see Chapter Four, ‘Menaces and Promises’ in Hitchcock, op. cit. (note 50), 75–96. 54. RCS, Lock Hospital, Board of Governors Minutes, Book 3, 176–7. 55. RCS, Lock Hospital, Board of Governors Minutes, Book 11, 10. 56. Yet another example came in 1791 with the renewed order ‘that the Street Door and Hall Door at the foot of the patients stairs be always shut when service is over’ to prevent exposure of the wards to chapel attendees. RCS, Lock Hospital, Select Committee Book, 22 March 1791. 57. The OED’s third definition of the noun ‘visitation’ reads ‘3. a. The action or practice of visiting sick or distressed persons as a work of charity or pastoral duty,’ and ‘3. b. The action of pastoral visiting on the part of a clergyman.’ 58. LMA, St Thomas’s Hospital, The Book of the Government of the Hospital, HI/ST/A24/1; St Thomas’s Hospital, General Court of Governors Minutes, HI/ST/A1/6, ff.73-5; SBH, St Bartholomew’s Hospital, Governors’ Journal, HA 1/5, f. 118; HA 1/8, f. 242, HA 1/10, ff. 65, 98, and 285. 59. Bromfeild first criticised the minister for not visiting the wards as a counter attack to earlier criticism that he had poached hospital medicines for his

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60.

61.

62. 63.

64. 65. 66. 67. 68. 69. 70. 71. 72. 73.

74.

75.

private practice. The ensuing feud was quite hostile, splitting the governors into camps. For details see Siena, op. cit. (note 1), 197–200; and Williams, op. cit. (note 16), 43–8. M. Madan, ‘Preface’ to J. Reynolds, Compassionate Address to the Christian World… Revised, Corrected and Published for the Use of the Patients in the Lock-Hospital, near Hyde-Park Corner (London, 1767), iii–iv. An Address to the President, Vice-Presidents, and the other Governors of the Lock Hospital near Hyde Park Corner on Behalf of that Charity (London, 1781), 20–1. RCS, Lock Hospital, Select Committee Book, 11 June 1781, n.p. Ibid., 10 August 1781. This passage remained in the fundraising pamphlet for the rest of the century. See, for example, Account of the Proceedings of the Lock Hospital near Hyde-Park Corner (London, 1789), 5–6. RCS, Lock Hospital, General Court of Governors Minutes, Book 3, 139–40. Ibid., 115. Ibid., 169–70. Ibid., 198. Ibid., 204–5. RCS, Lock Hospital, Board of Governors Minutes, Book 12, 17 May 1787, n.p. RCS, Lock Hospital, General Court of Governors Minutes, Book 3, 334. Ibid., 311–13. On the Lock Asylum see especially Merians, op. cit. (note 16), 136–43. The classic study is L. Davidoff and C. Hall, Family Fortunes: Men and Women of the English Middle Class (Chicago: University of Chicago Press, 1987), 149–92. See also, C. Hall, ‘The Early Formation of Victorian Domestic Ideology,’ in her White, Male, and Middle Class: Explorations in the History of Feminism (New York: Routledge, 1992), 75–93; A. Clark, The Struggle for the Breeches: Gender and the Making of the British Working Class (Berkeley: University of California Press, 1995), 92–118; and R. Shoemaker, Gender in English Society, 1650–1850: The Emergence of Separate Spheres? (London: Longman, 1998), 217–25. Andrew, op. cit. (note 4), 187–94. On the penitentiary movement see especially M. Ignatieff, A Just Measure of Pain: The Penitentiary in the Industrial Revolution, 1750–1850 (London: Macmillan, 1978); and M. Foucault, Discipline and Punish: The Birth of the Prison, A. Sheridan (trans.), (New York: Vintage, 1979). On these institutions in Italy, see S. Cohen, The Evolution of Women’s Asylums Since 1500: From Refuges of Ex-Prostitutes to Shelters for Battered Women (Oxford: Oxford University Press, 1992); and L. McGough, ‘Quarantining Beauty: The French Disease in Early Modern Venice’, in K. Siena (ed.), Sins of the Flesh: Responding to Sexual Disease in Early Modern

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76.

77.

78. 79. 80. 81. 82. 83. 84.

Europe (Toronto: Centre for Reformation and Renaissance Studies, 2005), 226–34. What we know about the Misericordia, a venereal disease hospital that seems to have lasted less than a decade, comes mainly from founder Jonas Hanway’s fundraising pamphlet, J. Hanway, An Account of the Misericordia Hospital for the Cure of Indigent Persons, involved in the Miseries Occasioned by Promiscuous Commerce. With Moral and Religious Advice to the Patients (London, 1780). On the Magdalen, see S. Nash, ‘Prostitution and Charity: The Magdalen Hospital – a Case Study’, Journal of Social History, 17 (1984), 617–28; S. Lloyd, ‘“Pleasure’s Golden Bait”: Prostitution, Poverty and the Magdalen Hospital in Eighteenth-Century London’, History Workshop Journal, 41 (1996), 51–72; and Chapter Two ‘The Magdalen Hospital’ in M. Ogborn, Spaces of Modernity: London Geographies, 1680–1780 (New York: Guilford Press, 1998), 39–73. Hanway, op. cit. (note 76), 66, 69 and 77. On similar policies at the Magdalen, see Nash, op. cit. (note 76), 621; and Ogborn, op. cit. (note 76), 60–70. Hanway, op. cit. (note 76), 79. Ogborn, op. cit. (note 76), 66–70. RCS, Lock Asylum Committee Minute Book 1, 10–17; Merians, op. cit. (note 16), 139–40. RCS, Lock Asylum Committee Minute Book 1, 44–5. Ibid., 15–17. An Account of the Institution of the Lock Asylum (London, 1793), 7–8. Siena, op. cit. (note 1), 210–18; on the nineteenth century, see J. Walkowitz, Prostitution and Victorian Society: Women, Class and the State (Cambridge: Cambridge University Press, 1982), 11–148; M. Spongberg, Feminizing Venereal Disease: The Body of the Prostitute in Nineteenth Century Medical Discourse (New York: New York University Press, 1998); P. Baldwin, Contagion and the State in Europe, 1830–1930 (Cambridge: Cambridge University Pres, 1999), 355–523; and R. Davidson and L. Hall (eds), Sex, Sin and Suffering: Venereal Disease and European Society since 1870 (London: Routledge, 2001).

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9 ‘The Keeper Must Himself be Kept’: Visitation and the Lunatic Asylum in England, 1750–1850

Leonard Smith There was a growing disquiet in eighteenth-century England about the activities of private madhouses. Early legislation, in 1774, gave limited powers of registration and inspection to local magistrates. The exposure of flagrant abuses in both private and public institutions by a parliamentary select committee, in 1815, brought the question of visitation to the centre of the lunacy reform agenda. Subsequent legislation extended the responsibilities of magistrates and also established the principal of centralised oversight. An effective national system of regulation was finally created in 1845, with Commissioners in Lunacy required to provide formal visitation to all public and private asylums.

Two enduring images have tended to dominate the mythology of the treatment of mentally disordered people in eighteenth-century England. The first is that of the unjust confinement in a private madhouse of people declared insane by close relatives with an ulterior motive. Writers like Daniel Defoe exposed the alleged practice,1 reflecting a fear that it and other abuses might be pervasive. The second image was that of Bethlem Hospital, or ‘Bedlam’, as a place of public resort where the ignorant and the voyeuristic could view, deride and laugh at the antics of the lunatic inmates.2 In both these scenarios there was at least some element of truth, but in neither case did they represent the whole story. Whether myth or reality, they provided the basis of differing strands of discourse on the issues of whether and how the care and treatment of the insane might be monitored by external visitors. From these discourses there emerged a fundamental tension between conflicting interests. There was a growing acceptance of the need to ensure that people were not incarcerated without justification, and that abuses did not take place behind the closed doors of the madhouse or the asylum. At the same time, it became acknowledged that it was desirable to protect the individual patient from the distress that might be caused by the prying eyes 199

Leonard Smith of unsympathetic interfering outsiders. There were also issues concerning the rights and the integrity of those who controlled the institutions. The proprietor of a private madhouse could be seen to have an entitlement for his property rights to be upheld, whilst the governors and medical officers of public institutions were likely to consider themselves benevolent men whose gentlemanly status provided sufficient guarantee against any malpractice. In the century following 1750, a complex pattern of institutional provision for the insane developed, based on three elements – private, voluntary and publicly funded.3 A growing network of private madhouses in London and the provinces initially catered for insane members of the wealthier classes. Increasingly, however, entrepreneurial proprietors were meeting the demand for placement of the insane poor, whose parishes were prepared to meet the cost rather than attempt to contain disturbed and disorderly people in the community or in the workhouse.4 In the voluntary charitable sphere, Bethlem’s origins went back to the fourteenth century. Its magnificent building of 1676 remained emblematic both of insanity itself and of the public duty to minister to its victims.5 Bethlem, however, was inadequate to meet the growing demand. In 1751, a second lunatic hospital was established in London at St Luke’s. Its governors utilised the mechanism of public subscription that had proved so effective in creating general hospitals. Other provincial cities, like Newcastle, Manchester and York subsequently followed the example and established lunatic hospitals.6 The third, and ultimately the most significant, element of provision were the rate-funded asylums that followed the enabling County Asylums Act of 1808.7 By 1845, there were around twenty county asylums in operation. In that year, legislation made it compulsory for counties to provide a pauper lunatic asylum, and over the next three decades the national network was completed.8 The oversight and monitoring of conditions in these institutions received increasing attention, reflected by periodic investigations and legislative intervention. By the early nineteenth century, concerns among reformists about aspects of the management and treatment of the insane were gaining influence. Their efforts brought about a parliamentary select committee in 1807, which led directly to the Act of 1808.9 Perhaps of equal significance were the investigations and reports of the Select Committee on Madhouses of 1815–16.10 These exposed some of the worst abuses and excesses prevalent in both private and charitable establishments. Although visitation, or its absence, was not a key area of investigation, its importance figured quite prominently among the remedies advanced. Indeed, the whole visitation movement was given a major boost by the example of the select committees themselves, their work having clearly demonstrated the value of effective 200

‘The Keeper Must Himself be Kept’ monitoring and oversight. The year 1815, in effect, marked a watershed and provides a suitable divide in the narrative. 1750–1815: a gentlemanly activity Concerns about possible abuses occurring in private madhouses were being increasingly voiced by the mid-eighteenth century. In particular, these focused on the idea of the designing husband seeking the removal of an inconvenient wife, either for financial gain or for the indulgencies that Daniel Defoe alluded to as ‘the sending their Wives to Mad-Houses at every Whim or Dislike, that they may be more secure and undisturb’d in their Debaucheries’. One of the remedies proposed by Defoe in 1728, was that there should be licensed madhouses, ‘subject to proper Visitation and Inspection’.11 The anxieties about what became known as wrongful confinement were aired in organs like the Gentleman’s Magazine and articulated in a parliamentary select committee enquiry in 1763.12 No formal intervention followed at that stage, but it remained an issue of interest in polite circles, eventually leading to legislation in 1774. The Act for Regulating Madhouses provided for the licensing of madhouses by the justices of the peace. Most significantly, it laid down requirements for their visitation. Different arrangements were made for London and the provinces. In London, where there was a well-established network of madhouses, regular inspection was to be provided by members of the Royal College of Physicians. Elsewhere, the responsibilities were placed in the hands of the local justices, a committee of whom were to visit in conjunction with a medical man. Their powers were fairly limited, however, for they did not have the authority to withdraw a licence. They were to have access to patients to check that they were appropriately detained, and could report accordingly. However, visits could only take place in daylight hours and by arrangement.13 The 1774 Act has been generally construed as having had only limited effectiveness.14 In practice, compliance with the legislation varied markedly. In some localities, madhouses were registered under the Act and inspections took place on a regular basis. Elsewhere, houses were not licensed and inspections never occurred, as in the case of the large Droitwich Lunatic Asylum, opened in 1790 for almost a hundred patients. By 1815, it had still not been licensed by the Worcestershire justices, who had displayed little interest in the matter due, presumably, to having other priorities.15 The more usual situation was for registration and licensing to occur, followed by infrequent visits of inspection. For example, the house kept by George Chadwick at Lichfield in Staffordshire was licensed by the city’s magistrates. The first recorded visit was in December 1779, conducted by two justices and Dr Erasmus Darwin. Several years elapsed before another visit in 1788, 201

Leonard Smith with the next in 1796, and then 1802. Thereafter, the visits became more frequent, taking place every year or two.16 The Staffordshire magistrates registered no fewer than three madhouses in the Black Country town of Bilston from 1774 onwards, as well as another at Abbots Bromley. No records have survived of any visits, though this does not mean that they did not take place.17 Thomas Bakewell’s house at Spring Vale near Stafford was licensed in 1808, but he told the select committee, in 1815, that official visits had been very irregular, though one magistrate sometimes called in informally.18 In Warwickshire, Henley-in-Arden also became a centre for madhouse provision. William Roadknight’s house was licensed in 1774. By 1797 there were three in the town – each apparently visited at least once a year.19 The reports submitted by official visitors, where these have survived, indicate that inspections were often fairly cursory, recording routinely that all was well and the patients properly looked after. This was certainly the attitude of the Warwickshire visitors who repeated annually, after 1800, that the patients in Thomas Burman’s houses in Henley-in-Arden were ‘well accommodated and duly attended to’. An innocuous appraisal was perhaps to be expected where the visitors were likely to be directly acquainted with the proprietor.20 The potential difficulties were noted by Dr John Conolly, who acted as a medical visitor in Warwickshire before he became a noted specialist in the treatment of insanity. The magistrates could be very reluctant to criticise a madhouse proprietor who was ‘a most respectable man, a neighbour, a friend perhaps, and the asylum is his fortune’, for the damage to his reputation might prove ruinous.21 William Ricketts, the owner of the Droitwich Lunatic Asylum, candidly acknowledged the issue to a select committee in 1828: There was a Visiting Magistrate about a Year and a Half ago, who was a Neighbour of mine, and he used to come frequently; he was a Friend of mine, and he used to dine at my Table, and at that Time he used to go round and visit the Patients. He was appointed under the Act.22

In circumstances like these, objectivity and thoroughness were hardly to be expected. However, reports did sometimes reveal a more rigorous approach. The visiting magistrates in Lichfield, by 1788, were observing that George Chadwick accommodated more patients than permitted in his licence. They also noted that his wife was ‘confined to her room as a Lunatic & appears to be insane’.23 At their visits, they were evidently interviewing the patients and ascertaining if they had any complaints, checking that they were properly fed and clothed, and that their rooms and bedding were clean and comfortable.24 202

‘The Keeper Must Himself be Kept’ Some of the official visitors’ comments became politely critical. In 1802, they commented that the house and beds were ‘tolerably clean’. The following year, it was observed that the patients were ‘in general’ satisfied with their treatment and were ‘not under the influence of fear’.25 In 1808, the visitors ascertained that ‘those capable of giving rational answers said they had been well used and had plenty of food’.26 They began to note how many patients were being kept under restraint.27 In 1811, they were overtly critical and confronted the proprietor directly: [T]hat the straw of such patients as required close confinement is small in quantity, short, and dirty, and their rooms are dirty – which grievances Mr Chadwick promised immediately to remedy, and endeavoured to excuse himself, by saying the visit was made on a Saturday morning, the usual day of cleaning, and a few hours before they would have been cleaned.28

Later entries reverted to the more equivocal comment that the house and beds were ‘tolerably clean’.29 In the voluntary sector, oversight remained firmly in the hands of the institution’s governors and they were likely to guard their privileges jealously. The archetype was St Luke’s Hospital, founded with the deliberate intention of providing alternative approaches to those of increasingly discredited Bethlem.30 One of the practices to which the St Luke’s governors took particular exception was the open public access allowed to Bethlem’s inmates. The Gentleman’s Magazine, in 1748, had published a letter condemning the practice in the strongest terms: But those are fallen yet lower, who resort to an hospital, intended for the reception and for cure of unhappy lunatics, purely to mock at the nakedness of human nature, and make themselves merry with the extravagances that deface the image of the Creator, and exhibit their fellow creatures in circumstances of the most pitiable infirmity, debility, and unhappiness.31

The St Luke’s rules pointedly excluded such practices, pronouncing ‘That the Patients in this Hospital be not exposed to publick View’.32 Similar principles were adopted at the provincial lunatic hospitals. Public access, however, could at least provide for some protection against abuses carried out by staff, and the governors of lunatic hospitals acknowledged that arrangements were required to guard against these. A balance had to be drawn between the entitlement of patients to privacy and confidentiality and the need to ensure the maintenance of proper standards. The early provincial lunatic hospitals were of two types. Those at Newcastle (1764), York (1777) and Exeter (1801) were established as independent institutions like St Luke’s. Others were built as annexes to 203

Leonard Smith existing voluntary hospitals, as at Manchester (1766), Liverpool (1792), Leicester (1793) and Hereford (1799).33 Requirements for visitation and inspection varied accordingly. Where there were intimate links to a general hospital, the arrangements would normally be comprised within the overall rules. At the Manchester Lunatic Hospital, for example, it was laid down that the infirmary’s house visitors would visit daily, noting down ‘the Behaviour of the Governor and Servants to the Patients, or any particular Occurrences’. In addition, two of the trustees (governors) of the infirmary would visit on the day of the weekly board.34 In the independent lunatic hospitals, the governors tended to adopt a less systematic approach, with responsibilities for visitation shared between governors and medical men. At the Newcastle Lunatic Hospital, according to the early rules, the physician and surgeon were each expected to visit the patients at least three times per week. In addition, a governor would be appointed each week to make two visits ‘to enquire into the Conduct and Management of the House’.35 Some years later, the Exeter Lunatic Asylum’s governors, in an endeavour to promote high standards, laid down clear stipulations. Regular visits by members of the house committee were required on the first Tuesday of each month and, judging from the governors’ minutes, these were carried out conscientiously.36 In practice, expectations, whether or not expressed in rules, were not always fulfilled. The amount of attention paid by individual governors could vary considerably. Some took their duties seriously, combining attendance at weekly board or house committee meetings with a perambulation of the galleries and day rooms, whilst others never attended board meetings unless there was some critical occurrence in the affairs of the hospital.37 Even where visits did take place, these could be quite cursory. At more than one lunatic hospital, the physician acquired a position of dominance over the institution’s affairs, leading the governors to lose interest in exercising any powers of oversight. The most blatant example occurred at the York Lunatic Asylum, where Dr Alexander Hunter held sway for thirty years. Arrangements for regular visits initiated in 1782 had fallen into disuse by 1794.38 The 1815 select committee heard that, for many years, the physician had been ‘sole visitor, and sole committee, and had the whole management of the Institution’, that the governors only visited the asylum quarterly for meetings, and then they did not ‘examine into the conduct and management of the house’ or ‘the state and condition of the lunatics’.39 Dr Charles Best, Hunter’s successor, confirmed that the governors seldom visited. They would ‘examine the beer and the bread’, but little more as ‘there was a repugnance on the part of the Governors to enter the rooms where the patients were confined.’40 The lack of visitation was, however, just one symptom of a much wider malaise in the York Asylum.41 204

‘The Keeper Must Himself be Kept’ A not dissimilar situation had also developed at the Leicester Lunatic Asylum. Even though it was attached to Leicester Infirmary, Dr Thomas Arnold managed to exclude the governors from having any role in monitoring and inspecting the asylum. The ostensible rationale was the protection of the patients from unwelcome intrusion that might impede their recovery. The rules were quite explicit: No person shall enter the Lunatic Asylum, or be permitted to see, or converse with the Patients, but the Physician, Apothecary, or Servants of the Asylum, excepting by the permission of the Physician. The Governors of the Infirmary and Asylum, shall only enter the Asylum on special occasions, by express order from the boards, and with the advice and approbation of the Physician, who is the only proper judge when, and in what manner they may safely be visited; so that they may not be disturbed, nor their cure impeded, by improper, and unseasonable, visitations.42

It took many years for the infirmary governors to challenge the exclusion and to exercise their entitlement to visit with the approval of the board and the physician. Quarterly visits commenced in March 1814, and the concerns highlighted led to a wide-ranging internal investigation.43 In the county lunatic asylums, clear arrangements for visitation and inspection were initiated from the outset. The 1808 Act gave a key role to ‘Visiting Justices’, appointed to superintend first the construction and then the management of the asylum. They were required to report regularly to the Quarter Sessions.44 The earliest counties to provide specifically pauper lunatic asylums were Bedfordshire (1812), Norfolk (1814), Lancashire (1816) and the West Riding of Yorkshire (1818), each with committees of visiting magistrates. The Act also enabled county justices to combine with voluntary subscribers to provide a joint asylum, an option adopted in Nottinghamshire (1811), Staffordshire (1818), Cornwall (1820) and Gloucestershire (1823), with management oversight by committees of visitors comprised both of magistrates and governors of the charity.45 In all these pioneering institutions proper monitoring arrangements were established, though the frequency of meetings or the structure of management committees varied.46 However, although the records demonstrate the assiduity of attendance at meetings, they tend to be less explicit about the extent to which there was inspection of the facilities and the standards of care, with little indication of visitors conversing or directly interacting with the patients. By 1815, taking institutions for the insane as a whole, the regulatory situation was somewhat mixed. The projectors and founders of the new county asylums had the advantage of being able to learn from the best 205

Leonard Smith practices in operation, and were well aware that proper monitoring was essential for the promotion and maintenance of high standards in what were expected to be model institutions. They could avoid some of the difficulties that had become apparent in the voluntary lunatic hospitals. The serious deficiencies in visitation that had become apparent at York and Leicester were indicative of a tendency toward complacency, based on a conception that an institution’s charitable origins, and the benevolent motives of its governors ought to be sufficient guarantee of satisfactory standards. In the private sector, there were proprietors like Joseph Mason Cox, Edward Long Fox and Thomas Bakewell attempting to operate their madhouses on enlightened principles, notwithstanding the need to run a profitable business.47 Some others were less scrupulous, but the makeshift visitation arrangements that emanated from the 1774 Act were in no manner adequate to maintain standards or protect patients from abuses. 1815–50: from voluntarism to centralism The Select Committee on Madhouses of 1815–16 concentrated its critical investigations on Bethlem Hospital and the York Lunatic Asylum, as well as some private madhouses in London. The mass of published evidence reflected the widely varying standards of care and treatment, with the favourable coverage given to the York Retreat, the Nottingham Asylum and some provincial madhouses set against the appalling conditions and flagrant abuses revealed elsewhere. The lack of visitation and inspection was highlighted in several cases. The reform lobby, led by George Rose and Charles Williams-Wynn, was galvanised into action, and attempts were made to introduce legislation. They concentrated their efforts on proposals to establish an inspectorate to deal primarily with private madhouses. Several bills were introduced and passed through the House of Commons, only to founder in the Lords, largely because of the perceived threat to property rights.48 Representatives of vested interests, including the governors of voluntary lunatic hospitals, had lobbied strongly for exclusion from any encroachment on their privileges or freedom of action.49 Although the concrete results were limited, the select committee’s revelations continued for some years to provide ammunition to the reformers and remained influential in opinion formation among those who advocated the correction of abuses. Within the county asylum sector, the desirability of proper oversight and inspection had already been accepted and the necessary structures adopted. The lessons of the select committee were not lost on the governors of the subscription lunatic hospitals and asylums. They were certainly acknowledged to have been influential in Leicester, where an enquiry by the infirmary governors uncovered the sort of maladministration and neglect in 206

‘The Keeper Must Himself be Kept’ the asylum that was becoming familiar elsewhere. Most prominent among the changes they initiated was the rectification of: [A]n error, which has been found to be not less injurious in practice, than it is exceptionable in principle. The Asylum has been hitherto for the most part closed against public inspection; and the authority of some of the officers has been left undefined.

To remedy this, the governors accepted that they had to ensure ‘careful, watchful, and vigorous inspection which is consistent with prudence’. This was to be achieved by taking the asylum back under the direct management of the infirmary, with monthly inspection by a committee of governors. Judging from the criticisms that continued to emanate regularly from the visiting committee, their duties were taken seriously.50 The governors of the York Asylum, whose numbers had been augmented by reformers such as Samuel Tuke, Samuel Nicoll and Jonathan Gray, had not waited for the strictures of the select committee, having been goaded into action in 1813 by exposures of serious deficiencies and gross abuses. A series of sweeping reforms was implemented, alongside a purge amongst the management and staff.51 A comprehensive system of visitation was at the centre of the changes, with some innovatory arrangements implemented. Two visiting governors were to be appointed each month and they were given wide powers. They were called upon to ‘visit unexpectedly and as often as possible’, during the night as well as the day. Perhaps more significantly, and in response to some untoward incidents exposed during the scandals, three lady visitors were appointed specifically to ‘notice whatever regards the Female Patients’.52 Samuel Tuke, who became one of the regular official visitors, was in little doubt as to the significance of the new arrangements: The appointment of visiters [sic] in the York Lunatic Asylum, has afforded me an opportunity of accurately observing, the general effects of visitation on deranged persons, who had not previously been subjected to it... it has materially promoted the comfort of the patients, many of whom have become acquainted with the visiters [sic], and express great pleasure on seeing them enter their apartments.53

As a result of the various improvements and reforms implemented, conditions within the York Asylum were transformed within the space of a few years.54 There were significant developments in visitation arrangements at other voluntary lunatic hospitals. At the Exeter Lunatic Asylum, where a system of monthly visits had been operational from the outset, the rules were amended to allow governors to visit as and when they chose. They were encouraged to 207

Leonard Smith enter observations or complaints into the visitors’ book and to make suggestions for reforms. However, the physician could still withhold permission for them to have access to any patient ‘improper to be visited’.55 At the new Lincoln Lunatic Asylum, opened in 1820, visitation was made integral to its management, it being made explicit from the outset that proper inspection had to be reconciled with the need to protect the patients: That it is desirable that every proper facility be given to inspect this Establishment, so that its real state may be at all times ascertained, and its regulations carried into effect; but at the same time care must be taken, that it be not exposed, for the gratification of idle curiosity, to the interruption of order, and the prejudice of the Patients.

At each weekly board meeting a ‘House-Visitor’ was appointed for the coming week, with a brief to visit and inspect daily ‘if convenient’. Facilities were also made available for visits by clergymen, as well as by interested outsiders.56 The governors’ policy of encouraging regular scrutiny was maintained and was a significant element in Lincoln Asylum’s subsequent emergence as a centre of innovatory and progressive practices.57 The implementation of effective visitation arrangements taking place in the voluntary and statutory sectors in the 1820s was not being matched for private establishments. The provisions of the 1774 Act, to which adherence was patchy and erratic, remained in force. Ongoing concerns about practices in some of the large east London madhouses, and in particular the situation of pauper lunatics, led to another parliamentary select committee in 1827.58 It produced a damning report that exposed, in particular, Warburton’s White House in Bethnal Green, highlighting the excessive use of mechanical restraint and the squalid conditions.59 Although the London madhouses had been subject to visitation by members of the Royal College of Physicians since 1774, the ineffectiveness of the arrangements was clearly apparent. Two main conclusions emerged from the select committee’s work. The first was the urgent necessity for a pauper lunatic asylum for the county of Middlesex, which became a reality within four years.60 The second was the need for a more effective system of visitation and inspection. Many of the recommendations of the 1827 select committee dealt with visitation.61 Reforming legislation followed in 1828, and the Madhouse Act particularly addressed the issue.62 In the provinces, the licensing requirements were tightened, and the Quarter Sessions were to appoint two justices and a medical man to visit each house within their jurisdiction four times per year and to forward a report to the Home Office. In the London area, the role of the Royal College of Physicians was superseded by the establishment of a statutory body, the Metropolitan Commissioners in 208

‘The Keeper Must Himself be Kept’ Lunacy, who were required to undertake visits to each licensed madhouse or asylum four times annually.63 With the various other provisions contained within this Act and the accompanying County Asylums Act,64 the state, under the auspices of the Home Office, had clearly accepted a broader responsibility for the regulation of institutional provision for the insane. To establish a system of visitation on its own was not necessarily enough, however, as pointed out in a polemic published in 1828 by Samuel Nicoll, a York lawyer prominent in the exposure of the scandals at the York Asylum and in the upheavals that had followed.65 Nicoll reiterated the arguments why the regular and careful inspection of all areas occupied by the patients, and the meticulous oversight of their keepers, were essential. He pointed out the severe pressures under which the staff carried out their duties and the influences and temptations to which they were open. In order to prevent the development of reciprocal violence between ‘the prisoner and the gaoler’, it was essential that ‘the keeper must himself be kept’.66 The principle, however, was also applicable to governors themselves, for they were only too liable to fall into a complacent and cursory fulfilment of their perceived duties.67 There were comparable temptations for magistrates who directed county asylums and for the medical men who inspected private madhouses.68 A centralised system of regulation was required, Nicoll argued, in order to ensure that all carried out their functions effectively.69 The sweeping reform of the Poor Law in 1834 had incidental consequences for the development of visitation. Although the Poor Law Amendment Act was not primarily concerned with the insane, section fortyfive stipulated that dangerous pauper lunatics ought not remain in the workhouse longer than fourteen days, but should be removed to a lunatic asylum.70 In localities with access to a county asylum, this would be their likely destination. Elsewhere, guardians contracted with the proprietors of private asylums either locally or further afield.71 The main concern was usually the rates of payment, but some boards accepted a wider responsibility for their paupers, and would send delegations on visits of inspection. The Birmingham guardians, for example, in 1835 and 1836 received reports on visits to their patients in the Stafford County Asylum.72 The Aston guardians, in 1837, sent a delegation to Duddeston Hall private asylum and were given a favourable report on ‘the cleanliness good order and Management of the House and… the comforts of the patients’.73 The Warwick guardians proved particularly assiduous in monitoring their lunatics placed at the Sandfield Asylum in Lichfield.74 In July 1839, their workhouse master, whilst accompanying a pauper for admission, took the opportunity to visit the other Warwick inmates, and reported back on the dreadful conditions to which they were exposed. The outraged guardians demanded explanations from Dr Thomas Rowley, the proprietor, and 209

Leonard Smith protested to the Lichfield magistrates, who investigated and found the charges proven. The Warwick guardians removed their lunatics forthwith.75 The sort of diligence shown in the Sandfield case was not regarded as typical by the reformers, led by Lord Ashley. In a context of growing state intervention in issues of social welfare and public health, they were convinced that central direction was also required with regard to the care of the insane.76 They secured legislation in 1842, empowering the Metropolitan Commissioners in Lunacy to conduct a national survey.77 Over the next two years they traversed the country, visiting numerous asylums as well as workhouses, many on several occasions. They lodged reports locally, some of which were relatively favourable and some critical. For example they visited both the private Droitwich and Hereford Lunatic Asylums respectively four times in 1842–4. Their reports described in some detail the asylums’ facilities and the types of patients confined, commenting particularly on cleanliness, ventilation and signs of ‘offensive smells’, as well as on the use of mechanical restraint.78 The Metropolitan Commissioners were equally methodical in their inspections of county asylums, and could be quite forthright in their criticisms. At the Norfolk Asylum, whilst approving its cleanliness and order, they were less impressed with the paucity of the dietary fare, the bad quality of the beer, the absence of tables at which patients could eat, the lack of facilities for employment, and the widespread presence of chains and leg locks.79 On their visits to other county asylums, such as those for Suffolk and Cornwall, there was more general approval.80 Indeed, the Metropolitan Commissioners showed a definite ideological bias toward promoting the model of the county asylum, illustrated in their appraisal of the Lancaster Asylum: That so large a number of persons, from the lowest & most ignorant classes of society, should be kept in a state of such perfect order & quiet affords abundant proof of the skill, zeal, & attention of the Medical Officers, & of the excellent regulations laid down for the conduct of the Attendants in the performance of their duties.

Their enthusiasm was tempered, though, by expression of regret at the confined nature of the asylum’s airing grounds and the lack of sufficient land for patients’ employment, which meant that the ‘improved system of treatment’ could not be carried out.81 The criticisms bore early fruit, for a year later the Metropolitan Commissioners could report that there had been a large addition to the amount of land attached to the asylum.82 The painstaking work of the Metropolitan Commissioners in Lunacy was all brought together and crystallised in their seminal report of 1844.83 210

‘The Keeper Must Himself be Kept’ This invaluable historical document, with its three hundred pages of detail, heralded the great triumph of the principle and practice of visitation of institutions for the insane. A comprehensive picture was presented of the actual state of provision in all the different types of institution. The commissioners sought to fairly evaluate the existing situation: The Asylums thus brought before our view, exhibit instances of almost every degree of merit and defect. Some are constructed on an extensive scale, and combine most of the advantages and comforts of a wealthy establishment. Others are mean, poor, confined within narrow bounds, and almost wholly without comforts or resources of any kind….84

The report concentrated its attention on asylums that received the ‘lunatic poor’. Numerous examples were cited of conditions and practices in particular places, some complimentary, but many highly adverse. By and large, county asylums and charitable asylums received approving coverage, though there was much criticism of the defects of some that had been longestablished, particularly as regards their gloominess, their lack of space for recreation and employment, and the perennial problem of overcrowding.85 Much of the more damning evidence was in relation to private asylums, in some of which appalling conditions were exposed.86 The Metropolitan Commissioners had not, however, adopted a universally condemnatory approach to the private sector, providing favourable descriptions of several establishments.87 The report’s findings proved as significant as those of any select committee. The mass of published evidence presented a virtually incontrovertible case for state intervention, both by regulation of existing institutions and by the compulsory development of publicly funded facilities. Major legislation followed in 1845. The Asylums Act mandated counties to provide a pauper lunatic asylum, either on their own or in conjunction with other counties, whilst also enabling boroughs to build an asylum.88 The Lunatics Act dealt comprehensively with visitation and inspection, empowering a national body of Commissioners in Lunacy, composed of legal, medical and lay representatives, to supersede the Metropolitan Commissioners.89 They were given wide powers, which included inspection, regulation and reporting, though licensing was still confined to the London area. Their inspectoral duties covered all lunatic hospitals, asylums and private licensed houses, with discretion also to visit other institutions including workhouses, prisons and places where ‘single lunatics’ were confined.90 Although there were some limitations to the Lunacy Commission’s powers, they were still considerable. From the outset it adopted a thorough 211

Leonard Smith approach toward its tasks of visitation and inspection. Commissioners clearly saw their remit as being to encourage and disseminate good practices, whilst seeking to place obstacles in the way of institutions or proprietors seen not to be meeting suitable standards. The commission’s first major report was published in 1847, and annual reports then followed.91 These recorded visits to different establishments and the commissioners’ observations. Special reports covered particular topics such as treatment methods, the use of mechanical restraint, occupational activities and religious observance. There were also extensive statistical tables, containing information on numbers of patients, admissions and discharges, staffing levels, dietary tables, and so on. The commissioners, under the leadership of Lord Ashley,92 demonstrated a particular interest in exposing and confronting the deficiencies of private lunatic asylums. Even their agenda to encourage implementation of the law requiring counties to build asylums was partly motivated by the wish to remove pauper lunatics from the hazards of private care. To that end, the commissioners were energetic in their exposures and were prepared to employ or threaten to use their powers to require licence removal. For example, Sandfield Asylum excited their critical attention during 1846: [T]hey observed no tables in any of the Paupers’ sitting-rooms (where, however, they dine and take their meals): that the bed clothes were quite insufficient during that inclement season; that in the various beds which they uncovered they found only one rug and a blanket for the upper covering, many of the blankets being old and several consisting of fragments only; that a Patient in bed complained of being starved with cold: that the patients of both classes, with scarcely an exception, were unemployed; and that they (the Commissioners) saw no book nor any means of amusement provided for them.

A letter was sent to the proprietor threatening to recommend removal of his licence if the defects were not remedied.93 The remonstrations brought some improvements, but the problems subsequently recurred to an even greater extent and Sandfield was closed down at the behest of the Lunacy Commission in 1856.94 Conditions in private institutions catering primarily for paupers were almost invariably subjected to particular scrutiny. The Hereford Lunatic Asylum, which had been the subject of a parliamentary select committee in 1839,95 was regularly on the receiving end of the commissioners’ disapproval. They made it clear that it was only the impending prospect of a county asylum that prevented them from seeking closure.96 Similar considerations brought leniency toward the privately run Kingsland Asylum, situated 212

‘The Keeper Must Himself be Kept’ within the precincts of the Shrewsbury workhouse, which provided for seventy paupers and a few private patients. In 1850, the commissioners condemned the ‘dirty and offensive condition of the gutters, privies, and airing courts; the dampness of the walls, the defective drainage, and the deficiency of the clothing and bedding provided for the paupers’. Their remonstrations pushed the Shrewsbury borough authorities to join with the county of Shropshire which had already built an asylum, thus enabling removal of the paupers from Kingsland and its closure in 1851.97 Even previously well-regarded asylums, like Droitwich, now received the commissioners’ disapproval. By 1849, reports were describing its pauper accommodation as ‘indifferent as well as incurably defective’. The proprietor’s response, to immediately initiate improvements, demonstrated the frequent effectiveness of their criticisms.98 The Commissioners in Lunacy’s most significant early intervention in the affairs of a private asylum was at the massive Haydock Lodge in Lancashire.99 Established in January 1844, it was accepting pauper lunatics transferred from workhouses throughout the Midlands, the North and Wales, and within a few months it was licensed for four hundred paupers and fifty private patients. By 1845, there were growing concerns regarding physical conditions, the treatment of patients, and various aspects of its management, and both commissioners and local magistrates were visiting frequently. Finally, in 1846, the Lunacy Commission mounted a special investigation into the running of Haydock Lodge, which upheld some of the charges whilst acknowledging mitigating circumstances.100 Lord Ashley was careful to point out that the level of external supervision had served to check possible abuses. He took the opportunity, however, to highlight the limits of visitation in the face of commercial forces: But the result, we think, indisputably proves how difficult it is by any system of visitation, however vigilant, to prevent the possibility of abuse in pauper lunatic asylums, like Haydock Lodge, which are set on foot and maintained merely as trading speculations, with a view to pecuniary profit….101

The information provided by the published report was, nevertheless, an example of what could be achieved by visitation. One of the concerns about Haydock had been the unusually high level of mortality. The commissioners investigated each case in detail and included their findings in a lengthy appendix. Within a few months, the management had responded to the various strictures with some significant measures of improvement.102 The commissioners adopted an unashamedly partial approach toward the idealised county lunatic asylums. They commented favourably on aspects of their operation and management, seeking to encourage further 213

Leonard Smith improvements in line with current thinking, for example on the implementation of non-restraint and the provision of employment for patients. However, they showed a more sceptical attitude to charitable asylums, demonstrated in an early confrontation with the governors of the Lincoln Lunatic Asylum, notwithstanding its reputation as the pioneer of ‘non-restraint’.103 Commissioners conducted a thorough two-day investigation in September 1846, after receiving representations regarding practices in the asylum and its management systems.104 They were extremely critical on several aspects, particularly the abandonment of a system of patient classification, the open access to outside visitors, the singular treatment methods and the medical supervision arrangements. Their forthright comments brought a trenchant response from the Lincoln governors, who refuted the criticisms one by one, accusing the commissioners of a lack of knowledge and experience and of having been duped by local opponents of progress.105 The exasperated commissioners, who may indeed have been unduly influenced by critics of the asylum’s regime, responded by denouncing the governors as ‘discourteous’ and intemperate. They claimed the last word, insisting that practices at the asylum were ‘erroneous’ and that ‘they require imperative amendment’.106 Eventually an accommodation was reached, with the governors adopting many of the commissioners’ suggestions in response to a more conciliatory subsequent report.107 The importance of the work of the Commissioners in Lunacy in the development of visitation was greater than the actual results of their investigations and reports, significant as they were. They were also instrumental in bringing about improvements in the practices of other visiting bodies, the ‘visitation upon visitation’ that Samuel Nicoll had called for in 1828.108 It was noticeable that local magistrates and committees of visitors became more diligent in the performance of their duties. Minute books would intersperse commissioners’ reports with those of the visiting magistrates, and they were likely to be fairly similar in content.109 Adverse reports by commissioners on particular private asylums might propel the magistrates into activity, with the local visitors’ reports explaining the improvements that had taken place, as at the Droitwich Asylum.110 Magistrates could be just as censorious as commissioners, as at Hunningham Hall Asylum in Warwickshire, where they conducted a special investigation in 1849, after criticisms by commissioners and complaints from interested parties.111 In other instances, visiting magistrates might take issue with commissioners in defence of a proprietor under attack, as happened at Oulton Retreat in Staffordshire in 1852. Several years of criticism from both bodies culminated in a recommendation by the commissioners that the licence be withdrawn. However, the official visitors resisted and were 214

‘The Keeper Must Himself be Kept’ evidently justified, for within a few months reports had become much more favourable.112 Nevertheless, although magistrates could disagree with the commissioners, they clearly could not ignore them. Conclusion Prior to the dispensation of 1845, the whole system for the provision of institutional care and treatment of mentally disordered people had developed in fairly ramshackle fashion, with the balance between the three elements of public, voluntary and private provision very much related to local circumstances. The arrangements for visitation and inspection had reflected that local diversity in both nature and quality. The 1845 Acts represented the ascendancy of central direction in provision for the insane, particularly with regard to the universal requirement to construct public lunatic asylums. The establishment of the Commissioners in Lunacy was a key element in the centralisation. Whatever the limitations of the commission, the principles of visitation and inspection were now at the heart of the developing tapestry of care and treatment. The commissioners used their not-inconsiderable powers of influence and of direct intervention to achieve a significant raising of standards in the worst-performing asylums, particularly in the private sector. Indeed, they were instrumental in the elimination of some of them, and those that remained were subjected to continuing close scrutiny in a context of thinly veiled disapproval. In their efforts to regulate the private sector, whilst urging ever higher standards on the voluntary and public sectors, the Commissioners in Lunacy had, within the space of a few years, translated the ideals of visitation into reality. Notes 1. D. Defoe, Augusta Triumphans: Or, the Way to Make London the Most Flourishing City in the Universe (London: Roberts, 1728), 30–4, cited in R. Hunter and I. Macalpine, Three Hundred Years of Psychiatry 1535–1860 (London: Oxford University Press, 1963), 265–7. 2. J. Andrews et al., The History of Bethlem (London: Routledge, 1997), Ch. 13; K. Jones, A History of the Mental Health Services (London: Routledge and Kegan Paul, 1972), 12–17. 3. R. Porter, Mind Forg’d Manacles: A History of Madness in England from the Restoration to the Regency (Cambridge: Cambridge University Press, 1987); L.D. Smith, Lunatic Hospitals in Georgian England, 1750–1830 (London: Routledge, 2007). 4. W.L. Parry-Jones, The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries (London: Routledge and Kegan Paul, 1972).

215

Leonard Smith 5. C. Stevenson, ‘The Architecture of Bethlem at Moorfields’, in Andrews, op. cit. (note 2), 230–59. 6. Porter, op. cit. (note 3), 129–36; Smith, op. cit. (note 3), Chs 1 and 2. 7. L.D. Smith, ‘Cure, Comfort and Safe Custody’: Public Lunatic Asylums in Early Nineteenth-Century England (London: Leicester University Press, 1999), 20–51. 8. A. Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (London: Allen Lane, 1979). 9. British Parliamentary Papers (hereafter BPP) 1807, II, Select Committee on the State of Criminal and Pauper Lunatics; 48 Geo. III, cap.96. 10. BPP 1814–15, IV, Report of the Select Committee on Madhouses in England; BPP 1816, VI, Third Report of the Committee on Madhouses in England. 11. Defoe, op. cit. (note 1), 30–4. 12. Gentleman’s Magazine, xxxiii (1763), 24–5, 126; Journal of the House of Commons, 27 January 1763, 413–14; Journal of the House of Commons, 27 February 1763, 486–9. 13. 14 Geo. III, cap. 49; Hunter and Macalpine, op. cit. (note 1), 451–6; ParryJones, op. cit. (note 4), 9–18, 296–300. 14. Hunter and Macalpine, op. cit. (note 1), 452–3; Jones, op. cit. (note 2), 32–3. 15. Parry-Jones, op. cit. (note 4), 31, 264; Select Committee on Madhouses (1814–15), op. cit. (note 10), 169. 16. Lichfield Joint Record Office (hereafter RO), D25/1/1; D25/3/3, 29 December 1779, 21 February 1788, 29 December 1796, 6 March 1802, 9 July 1803, 24 July 1806, 2 June 1808, 24 July 1810, 13 July 1811, 16 November 1812, 20 August 1814. The 1774 Act had not stipulated that visits be recorded, and so it may well be the case that they took place more often. 17. Staffordshire County Records Office (all County Records Offices hereafter CRO), Q/FAa/1/1, Q/FAa/1/2. For the Bilston madhouses, see L.D. Smith, ‘Eighteenth-Century Madhouse Practice: The Prouds of Bilston’, History of Psychiatry, 3 (1992), 45–52. 18. Select Committee on Madhouses (1814–15), op. cit. (note 10), 121. 19. Warwickshire CRO, QS 24/6/1–2; QS 92j/35/5. 20. Warwickshire CRO, QS 24/6/2. Burman had taken over the house formerly owned by Roadknight. 21. J. Conolly, An Inquiry into the Indications of Insanity, with Suggestions for the Better Protection and Care of the Insane (London: Taylor, 1830), 6, cited in Parry-Jones, op. cit. (note 4), 265–6. Conolly practised in Warwick for several years; for his medical career, see A. Scull, C. Mackenzie, and N. Hervey, Masters of Bedlam: The Transformation of the Mad-Doctoring Trade (Princeton: Princeton University Press, 1996), 48–83.

216

‘The Keeper Must Himself be Kept’ 22. ‘Minutes of Evidence Taken Before the Select Committee to Whom Were Referred the Bill, Intituled “An Act to regulate the Care and Treatment of Insane Persons”’, Journal of the House of Lords, LX (1828), Appendix 2, 721. 23. Lichfield Joint RO, D25/3/3, 21 February 1788. 24. Ibid., D25/3/3, 29 December 1796. 25. Ibid., 6 March 1802, 9 July 1803. 26. Ibid., 2 June 1808. 27. Ibid., 24 July 1810. 28. Ibid., 13 July 1811. 29. Ibid., 16 November 1812, 20 August 1814. 30. For the establishment of St Luke’s Hospital, see Smith, op. cit. (note 3), 7–16. 31. Gentleman’s Magazine, 18 (1748), 199. Jonathan Andrews has pointed out that public visiting at Bethlem did serve some beneficial functions, by encouraging charitable giving as well as providing a check on some of the more blatant abuses that could be carried out by staff: Andrews et al., op. cit. (note 2), 181–94. 32. Reasons for the Establishing, and Further Encouragement of St Luke’s Hospital for Lunaticks: Together with the Rules and Orders, for the Government Thereof (London: J. March & Son, 1790), 22. 33. See note 6. 34. An Account of the Rise and Present Establishment of the Lunatick Hospital, in Manchester (Manchester: J. Harrop, 1771), 17. 35. Newcastle City Library, Local Tracts, 111A, ‘Rules of the Hospital for Lunaticks, for the Counties of Northumberland, Newcastle Upon Tyne, and Durham’ (c.1764), 3. 36. Devon CRO, 3992/ F/H1/1, Committee of Governors, Minutes, 18 August 1801, 6 July, 7 December 1802, 3 July 1804: ‘This being the first Tuesday of the Month the house was visited by the Chairman & Dr Daniell, who reported everything in good Order.’ 37. P. Langford, Public Life and the Propertied Englishman, 1689–1798 (Oxford: Clarendon, 1991), 497. 38. Report of the Committee of Inquiry into the Rules and Management of the York Lunatic Asylum (York: Thomas Wilson and Sons, 1814), 10, 35; J. Gray, A History of the York Lunatic Asylum (York: W. Hargrove, 1815), 22–3. For Dr Alexander Hunter, see A. Digby, From York Lunatic Asylum to Bootham Park Hospital, Borthwick Papers No. 69 (York: St Anthony’s Press, 1986), 1–13. 39. Select Committee on Madhouses (1814–15), op. cit. (note 10), 8–9, evidence of Godfrey Higgins. 40. Ibid., 144. 41. Gray, op. cit. (note 38); Digby, op. cit. (note 38).

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Leonard Smith 42. Staffordshire CRO, QAIc, Box 1, Leicester Lunatic Asylum, Rules (1794), 6. For Arnold, see P. Carpenter, ‘Thomas Arnold: A Provincial Psychiatrist in Georgian England’, Medical History, 33 (1989), 199–216. 43. Leicestershire CRO, 13 D 54/2/2, 1 February, 17 March 1814, 13 D 54/3, 29 August, 22 September 1815. 44. 48 Geo III, cap. 96, Sections II–VI. 45. Smith, op. cit. (note 7), 25–30, 53–7. At Nottingham Asylum, they were called the ‘Visiting Governors’. See Nottinghamshire CRO, SO/HO/1/2/1, Minutes of Proceedings of Visiting Governors, 1810–45. 46. Bedfordshire CRO, LB/1/1, Minutes of Visiting Magistrates; Norfolk CRO, SAH 2–3, Visitors’ Minute Books, 1813–22; Staffs CRO, D550/1, Minute Book of Visitors; West Riding CRO, C85/1, Order Book, Pauper Lunatic Asylum; Cornwall CRO, DDX 97/1, Minutes of Subscribers and Visiting Justices; Gloucestershire CRO, HO 22/1/1, Minute Book of Visiting Justices and Subscribers. 47. Parry-Jones, op. cit. (note 4), 91–3, 112–15; Porter, op. cit. (note 3), 136–47, 175–225; L.D. Smith, ‘To Cure Those Afflicted with the Disease of Insanity: Thomas Bakewell and Spring Vale Asylum’, History of Psychiatry, 4 (1993), 107–27. 48. Jones, op. cit. (note 2), 86–7. 49. St Luke’s Hospital Archives, General Committee Book, 24 May 1819. In fact the St Luke’s governors were lobbying against any prospect of legislation even before the select committee met – General Committee Book, 12 August 1813, 12 May 1814. 50. Leics CRO, 13 D 54/3, 17 November 1815 (quote), 15 March 1816, 3 June, 2 December 1817. 51. Digby, op. cit. (note 38), 15–24; A Complete Collection of the Papers Respecting the York Lunatic Asylum, Published Originally in the York Newspapers, During the Years 1813, 1814, and 1815 (York: York Herald, 1816). 52. University of York, Borthwick Institute, RET 8/1/1/1, York Lunatic Asylum, Annual Report, 1818; The Rules and Regulations of the York Lunatic Asylum, With a List of the Governors (York: Thomas Wilson and Sons, 1820), 12–13; C. Cappe, On the Desirability and Utility of Ladies Visiting the Female Wards of Hospitals and Lunatic Asylums (York: Thomas Wilson and Sons, 1817), cited in Hunter and Macalpine, op. cit. (note 1), 729–30. 53. S. Tuke, Practical Hints on the Construction and Economy of Pauper Lunatic Asylums (York: William Alexander, 1815), 28. 54. Digby, op. cit. (note 38), 24–6; Borthwick Institute, RET 8/1/1, Annual Reports, 1815–23.

218

‘The Keeper Must Himself be Kept’ 55. Statutes and Constitutions of the Lunatic Asylum, in the Parish of St Thomas, Near Exeter, with the Rules and Orders for the Government and Conduct of the House, &c, 4th edn (Exeter: S. Hedgeland, 1824), 12. 56. Rules for the Lunatic Asylum at Lincoln, as Settled and Arranged at a Public Meeting of the Subscribers Holden at the County Hospital, Nov. 4, 1819 (Lincoln: William Brooke, 1819), 6–7. 57. See Smith, op. cit. (note 7), Ch. 8. It was at Lincoln that the policy of ‘nonrestraint’ was pioneered in the late 1830s. 58. BPP 1826–7, VI, Report of Select Committee on Pauper Lunatics in the County of Middlesex and on Lunatic Asylums. 59. Jones, op. cit. (note 2), 101–8; E. Murphy, ‘Mad Farming in the Metropolis. Part 1: A Significant Service Industry in East London’, History of Psychiatry, 12 (2001), 245–82. 60. Smith, op. cit. (note 7), 7, 26. 61. Select Committee on Pauper Lunatics in the County of Middlesex, op. cit. (note 58), 5–8. 62. 9 Geo. IV, cap. 41; N. Hervey, ‘A Slavish Bowing Down: The Lunacy Commission and the Psychiatric Profession 1845–60’, in W.F. Bynum, R. Porter, and M. Shepherd (eds), The Anatomy of Madness, Vol. 2, Institutions and Society (London: Tavistock, 1985), 98–131. 63. Jones, op. cit. (note 2), 108–9. 64. 9 Geo. IV, cap. 40. 65. S.W. Nicoll, An Enquiry Into the Present State of Visitation, in Asylums for the Reception of the Insane: And into the Modes by Which Such Visitation May be Improved (London: Harvey and Darton, 1828). Nicoll had become one of the governors of the asylum, and was chairman for several years between 1819 and 1830, see Digby, op. cit. (note 38), 26. He had been responsible for at least one of the influential pamphlets published at the time of the asylum’s difficulties: A Vindication of Mr Higgins from the Charges of Corrector: Including a Sketch of Recent Transactions at the York Lunatic Asylum; Addressed to Earl Fitzwilliam by a New Governor (York: William Hargrove, 1814). 66. Nicoll, ibid., 3. 67. Ibid., 6–12, 60–3, 86–7. 68. Ibid., 65–71. 69. Ibid., 79–80, 88–90. 70. Jones, op. cit. (note 2), 125; P. Bartlett, The Poor Law of Lunacy: The Administration of Pauper Lunatics in Mid-Nineteenth Century England (London: Leicester University Press, 1999), 84–5. 71. L.D. Smith, ‘The Pauper Lunatic Problem in the West Midlands, 1815–1850’, Midland History, 21 (1996), 100–18.

219

Leonard Smith 72. Birmingham Archives, Birmingham Union Board of Guardians, Minutes, 7 April 1835, 20 April 1836. 73. Birmingham Archives, Aston Union Board of Guardians, Minutes, 16 May 1837. 74. Sandfield House had replaced the original Lichfield madhouse in 1820 – Lichfield Joint RO, D25/3/3, 25 May 1820; L.D. Smith, ‘Sandfield House Lunatic Asylum, Lichfield, 1820–1856’, Staffordshire Studies, 10 (1998), 71–4. 75. Warwicks CRO, CR/1581, Warwick Union: Minute Book, 20, 27 July, 3, 10, 17, 24, 31 August, 7 September 1839. 76. D. Fraser, The Evolution of the British Welfare State: A History of Social Policy Since the Industrial Revolution, 3rd edn (Basingstoke: Palgrave Macmillan, 2003), 1–84; B. Harris, The Origins of the British Welfare State: Society, State and Social Welfare in England and Wales 1800–1945 (Basingstoke: Palgrave Macmillan, 2004), 1–124. 77. 5 & 6 Vict. cap. 87; Jones, op. cit. (note 2), 132–4; Bartlett, op. cit. (note 70), 92–3. 78. Worcs CRO, b 125 BA 710(1), Droitwich Lunatic Asylum, Visiting Magistrates’ Committee Minute Book, 17 June, 30 September 1843, 15 July, 14 October 1844; Hereford City Library, ‘Book of Entry of House for Reception of Lunatics’, 20 September 1842, 19 July, 27 September 1843, 7 July 1844. 79. Norfolk CRO, SAH 137, Governors’ Book for Entry of the Visitations, 1814–44, 9 September 1842, 29 August 1843. 80. Suffolk CRO, ID 407/B16/1, Visitors Book, 4 September 1843, 24 October 1844; Cornwall CRO, DDX 654/246, Visitor’s Book, 5 October 1843, 4 September 1844. 81. Lancashire CRO, QAM/1/33/11, Magistrates Visiting Book, 25 October 1842. 82. Ibid., 13 September 1843. 83. Report of the Metropolitan Commissioners in Lunacy to the Lord Chancellor (London, 1844). 84. Ibid., 6. 85. Ibid., 12–31, 83–93, 132–5. 86. Ibid., 46–56; Parry-Jones, op. cit. (note 4), 253–5. 87. Report of the Metropolitan Commissioners in Lunacy, op. cit. (note 83), e.g. 41, regarding the Droitwich Lunatic Asylum. 88. 8 & 9 Vict. cap. 126. 89. 8 & 9 Vict. cap. 100. 90. Jones, op. cit. (note 2), 145–7; Hervey, op. cit. (note 62), 103–4; D.J. Mellett, ‘Bureaucracy and Mental Illness: the Commissioners in Lunacy 1845–90’, Medical History, 25 (1981), 221–50; E. Murphy, ‘The Lunacy

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91. 92. 93. 94. 95.

96.

97.

98.

99.

100. 101. 102.

103. 104.

Commissioners and the East London Guardians, 1845–1867’, Medical History, xlvi (2002), 495–524. Further Report of the Commissioners in Lunacy to the Lord Chancellor (London, 1847). Ashley became Earl of Shaftesbury in 1851. Further Report, op. cit. (note 91), 103–4. Smith, op. cit. (note 74), 72–3; Tenth Report of the Commissioners in Lunacy (London, 1856), 22–3; Eleventh Report (London, 1857), 44. BPP 1839, IX, Report from Select Committee on Hereford Lunatic Asylum With Minutes of Evidence. It was the remonstrations of former visiting county justices, who had removed the asylum’s licence due to concerns about its management and conditions, that had led to the establishment of the select committee after it was re-licensed by the city magistrates whose own visitors were quite satisfied with conditions. Hereford City Library, ‘Book of Entry of House for the Reception of Lunatics’, 14 February, 6 December 1846, 9 March, 6 October 1848, 24 November 1849. Further Report, op. cit. (note 91), 107; Fifth Annual Report (London, 1850), 7–8; Sixth Annual Report (1851), 12–13; Seventh Annual Report (London, 1852), 7; Parry-Jones, op. cit. (note 4), 255. Worcestershire CRO, b125 BA 710(1), 8 July 1846, 5 July, 11 December 1847, 25 May, 21 November 1849, 1 July 1850. Parry-Jones noted this tendency of the commissioners to change their attitudes towards private asylums they had formerly regarded favourably in the cases of the houses at Hook Norton and Witney, op. cit. (note 4), 144–51. BPP 1847, XLIX, Report of the Commissioners in Lunacy Relative to the Haydock Lodge Lunatic Asylum; Parry-Jones, op. cit. (note 4), 58–9, 277–80; D. Hirst,‘“A Ticklish Sort of Affair”: Charles Mott, Haydock Lodge and the Economics of Asylumdom’, History of Psychiatry, 16 (2005), 311–32. Report of the Commissioners in Lunacy Relative to the Haydock Lodge Lunatic Asylum, op. cit. (note 99), 3–14. Ibid., 14. Ibid., 15; Parry-Jones, op. cit. (note 4), 279–80. In several instances magistrates and guardians sent their own representatives to Haydock to investigate the condition of their patients and of the asylum as a whole, see Warwickshire CRO, CR51/1583, Warwick Guardians, Minutes, 18 July 1846; Birmingham Archives, Board of Guardians, Minutes, 15 September 1846, 11 November 1847; Coventry City RO, CUMB/1/1, Coventry Union Parishes Board of Directors, 9 September 1846. Smith, op. cit. (note 7), Ch. 8. Further Report, op. cit. (note 91), 150–4, Appendix H, 353–82. The Lunacy Commissioners’ investigation and the subsequent report took place in a

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105. 106. 107. 108. 109. 110.

111.

112.

context of bitter in-fighting among governors and medical officers at the Lincoln Asylum, see Lincolnshire Archives, LAWN 1/1/5, Lincoln Lunatic Asylum, Committee Minutes, 26 October 1846–14 July 1847. Further Report, op. cit. (note 91), Appendix H, 363–78; Hervey, op. cit. (note 62), 109–10. Further Report, ibid., 379–82. Lincolnshire Archives, LAWN 1/1/5, 29 November 1847. Nicoll, op. cit. (note 65), 5. Warwickshire CRO, QS 24/8/1/4, Reports of Visitors and Commissioners in Lunacy, 1845–54. Worcestershire CRO, b125 BA710 (1), Droitwich Lunatic Asylum, Visiting Magistrates’ Committee Minute Book, 21 November 1849, 27 March, 1 July, 25 September 1850, 15, 20 March, 16 July, 12 September 1851. Warwickshire CRO, QS 24(a)/I/1/viii, letter from Alfred Carr MD to Lunacy Commissioners and Official Visitors 30 January 1849, ‘At a Special Meeting of the Visitors of the Lunatic Asylum’ held 5 February 1849, Draft Special Report of Visitors, 5 March 1849; QS 24/8/1/1, 21 January 1848 to 28 February 1850. Staffordshire CRO, Q/AIp, Administration – Lunacy – Private Asylums, 19 August 1847–18 October 1852.

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10 ‘A Disgrace to a Civilised Community’:1 Colonial Psychiatry and the Visit of Edward Mapother to South Asia, 1937–8

James H. Mills and Sanjeev Jain In 1937, Edward Mapother, Medical Superintendent of the Maudsley Hospital in London, took a trip around the mental hospitals of Britain’s dominions in South Asia. The result was a series of documents that provide a snapshot of psychiatry in India and Ceylon in the twilight years of the British Empire. This chapter will consider Mapother’s reports from a number of perspectives in order to assess the politics and the impact of an expert ‘visitor’ to a colonial medical system.

Professor Edward Mapother, the medical superintendent of the Maudsley Hospital in London, was the oldest of seven siblings, and the son of an ENT surgeon. Mapother had his initial training in Dublin, and after the First World War, he had been entrusted with reforming psychiatric services in London. He set about pushing through changes in legislation and developing the wards of the London County Asylum, establishing neuropsychiatric clinics and placing the emphasis on early treatment. The result was perceived as a shift from a legalistic and custodial system to a clinical one that emphasised the latest in psychiatric theory. Chief among his innovations was the Institute of Psychiatry at the Maudsley Hospital in London.2 This was designed as a remedy for what Mapother described as the ‘absurd situation that if English-speaking psychiatrists want to specialise they have to go to Germany or Austria, especially Vienna (since they teach in English)’ and his vision was of ‘an institute to provide for research and for the very advanced training of psychiatrists and of most English speaking psychiatrists on leave from India and from the various British Overseas Dominions.’3 Mapother was invited to Ceylon by Dr S.T. Gunasekara, who, by 1936, was the first Ceylonese Medical Director of the island.4 He wrote, in 1937, that in a meeting: 223

James H. Mills and Sanjeev Jain [W]ith the minister for health I mentioned your name knowing your reputation and how keenly you are interested in the subject. I am writing this demi-officially to enquire whether you could see your way to come out to Ceylon, and if so, when and for what length of time. I shall be glad if you would also let me know the terms under which you could come.5

Gunasekara was the recipient of a Rockefeller Foundation scholarship which he spent in London6, and Mapother enjoyed a long relationship with the Foundation that stretched from the 1920s until his death in 1941.7 It is likely that it was this connection which put the Maudsley psychiatrist uppermost in the mind of the new Medical Director of Ceylon when he turned his attention to the mental health of the island. The result of this trip was to be a series of documents that provide a snapshot of psychiatry in South Asia in the years before the Second World War and the subsequent end of the British Empire. This chapter will consider Mapother’s reports from a number of perspectives. Firstly, it looks at the politics and the impact of an expert ‘visitor’ to a colonial medical system. It seems clear that his inspections and reports were organised as a direct challenge to the colonial state, and were intended to force it into policy decisions it was unlikely or unwilling to take of its own accord. Secondly, it examines the evidence of psychiatric practices in South Asia in the period before decolonisation. Psychiatry had often been lauded as one of the benefits of imperialism and its introduction of modern scientific and medical techniques. Mapother’s observations allow the historian to assess how effectively the British had implemented psychiatric practices. Finally, the chapter considers the significance of this outsider’s glimpse of hospitals in South Asia for other accounts of the region’s medical systems under colonial rule. Psychiatry in South Asia British colonial administrators had established specialist institutions for those they considered ‘insane’ in both local and European communities from the eighteenth century onwards in South Asia. At first, these seemed to be little more than places of segregation and isolation, but as the nineteenth century progressed attempts to provide therapy based on European models became more complex and concerted. By the 1860s, it was common to find superintendents expressing the opinion that, ‘I hope that we shall be able to carry out still further improvements, and in time bring the Asylum as near to the English standard as the circumstances of the country admits’,8 while those nearer the top of the colonial bureaucracy also recognised that ‘everything that constitutes a remedial institution on the modern European footing has to be introduced and exercised for the first time’.9 Throughout 224

‘A Disgrace to a Civilised Community’ this period, the asylum system was funded by the colonial state and each hospital was headed by a European doctor working for the Indian Medical Service, although the staff at the hospitals were usually drawn entirely from the local community.10 This began to change in the twentieth century. The state-run hospitals of the colonial system experienced a lack of European medical personnel during, and in the wake of, the First World War. The effect was the ‘Indianisation’ of the health services so that it was now doctors of local origin who took control of facilities.11 Outside of these institutions, Christian Hartnack has shown that modern Western theories of mental health and therapy were beginning to circulate in society and that even such innovations as Freudian analysis found a local market.12 The period in which Edward Mapother arrived in South Asia in the 1930s was a particularly complex one that has been relatively neglected in accounts of colonial medicine. The latter has been accused of simply serving as a ‘tool of empire’,13 where ‘the history of medicine in empire refers to the... history of medical regimes as participants in the expansion and consolidation of political rule.’14 Such an impression usually relies on evidence from the nineteenth century and the focus here on Mapother’s visit in the decade before the end of Empire in South Asia provides an insight into the rather more complicated power relations of medicine in this period. Mapother in Asia Edward Mapother provided the following account of the circumstances of his visit in the official report submitted to the Government of Ceylon in 1938: The inadequacy of the provision for mental disorder in Ceylon and the deficiencies of such treatment as has been provided has been a subject of criticism for a number of years. During a visit to Ceylon in January 1937 some of those who felt strongly about the matter asked me to visit Angoda Asylum. The impression produced was such that when subsequently I received from the Government of Ceylon an invitation to give an opinion upon necessary reorganisation, I was glad of the opportunity.15

While this is the only account of the origins of his trip to Ceylon, other sources written after the journey provide some other details. Mapother himself noted in a letter in 1937: I am venturing to send you another copy of my Ceylon Report in the hopes that you might get Dr Gregg to look over it at his leisure. It has raised hell in the Island (vide cuttings from local press) and various parties from the Ministry of Health downwards are briskly engaged in passing this from one

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James H. Mills and Sanjeev Jain to the other. What is more important they seem agog to do something quick. It seemed to me one of the cases where forcible methods seemed most likely to be successful.16

Another letter in his correspondence provides more information. In a letter to Mapother, written in September 1938, John Pye, a member of the European Association of Ceylon, wrote: There can be no doubt whatever that your report has done splendid work in making the Government and the country realise the terrible state into which the Department dealing with mental cases had fallen. I am afraid that until your report, which has now been published as a Sessional paper, none except the one or two of us who had to visit the place, including the Government themselves, really knew how terrible was the treatment afforded to mental cases.17

When taken together, these details provide glimpses of a picture of the circumstances of his involvement in Ceylon. It seems that while visiting the island, those living locally who felt strongly about the provision of psychiatry there – probably those involved in some capacity as ‘visitors’ – took the opportunity to avail themselves of an ‘expert’ to assess what they had encountered. Mapother thereafter seems to have taken it upon himself to create a fuss about the facilities, a fuss was reported in the newspapers and which had pressured the colonial government to act. Whether Dr Gunasekara was in collusion with those critics of the colonial government is unclear, but it was certainly the case that his relations with British superiors had been uneasy in the past.18 He acted by approaching Mapother to return to the island in a demi-official capacity and to make recommendations as to how the system might be improved. From the above, at no point does the impression form that it was the colonial government itself which took the initiative to have Mapother visit the island in the first place. It seems as if the government had little interest in the psychiatric facilities under their control, and were simply responding to criticism in their eventual strategy.19 While the visit of Mapother to Ceylon had forced the colonial government to act and to appoint him in an official capacity as an ‘expert’ assessor and inspector, it had further unforeseen consequences in unleashing him on the rest of South Asia. Having been asked back by the island’s government, he decided that ‘in order to qualify myself for giving advice of a practical kind, I suggested that I should make a preliminary inquiry into the mental arrangements of various Provinces of India.’20 As such, he took off to Ceylon’s neighbour, packing in visits to hospitals as far apart as Bombay, Madras, Lahore and Ranchi. As well as visiting seven of India’s psychiatric units, he attended the Indian Science Congress in Calcutta and interviewed 226

‘A Disgrace to a Civilised Community’ a number of officers in the Colonial Medical Service, including the DirectorGeneral of the Indian Medical Service himself. Significantly, however, the Government of India was careful to make it clear that, while it was happy to help him out in whatever ways it could, his was not an official visit. Mapother had agreed in a meeting with the President of the Medical Board at the India Office that ‘the information which I obtained was not for publication, but for personal use in relation to the report which I was preparing for the Government of Ceylon as to the reorganisation of the Island.’21 Indeed, this was emphasised in newspaper reports, one clipping stating that ‘Dr Edward Mapother in an interview to The Hindu, stated that he was in India on a holiday tour’.22 It seems that the Government of India was not about to be caught out as had its equivalent in Ceylon. While the latter was forced to publish his criticisms and recommendations, and to commit itself to reforms, the assessment of Mapother of India’s system remained a private typescript that remains unpublished in his private papers to this day. Mapother’s reports Edward Mapother was unequivocal in his assessment of the psychiatric facilities of the Government of Ceylon, and in his view of the implications of this assessment. He made it plain that the ‘inquiry in Ceylon reveals such a state of affairs that to acquiesce in its continuance would imply callous indifference to suffering and mortality.’23 His criticisms were wide-ranging. The buildings had ‘the air of a prison that is neglected and dilapidated,’24 despite the fact that they had only been built in 1926. They had been erected as an exact replica of the older hospital they replaced, and the only reasoning behind this was to move the institution out of the capital city, Colombo. The hospital was dangerously overcrowded, so that 3,000 patients were packed into buildings designed for only 1,830. This was thought to be behind the high death rates at the institution, largely accounted for by tuberculosis and dysentery. In 1936, this had been 137 per thousand inmates, almost double the average in India. Verandahs had been converted into bed-space, and patients slept on mats; by day, they crouched there ‘immobile and unoccupied in two long rows containing 45 apiece’.25 The solitary confinement cells were condemned as ‘unfit for human habitation’.26 Only the female side came in for any praise, thanks to the efforts of Miss Robinson, the matron, but even here Mapother observed that there was no real attempt at treatment, ‘the sight of nearly 1,000 women sitting in orderly squares on the ground doing nothing or giggling without reason, hardly represents an ideal state of affairs.’27 It was not just the hospital itself that came in for his scrutiny. Mapother argued that there was no reason to suspect that there were differences in 227

James H. Mills and Sanjeev Jain incidence in mental disorder and mental defect between Asian and Western societies. As such there was no excuse for the low ratio of psychiatric accommodation to the local population. He pointed out that in London there was a bed in a public mental hospital for one in every two hundred of the capital’s inhabitants, while in Ceylon this figure was about one for every three thousand – a total of 1,830 beds for all 5.4 million of the island’s inhabitants. Expenditure was similarly critiqued; Mapother concluding that, in London, spending on mental health facilities was about twenty-five per cent of that on hospitals for physical ailments, while in Ceylon it was only four per cent. This demonstrated to the author that ‘those in authority in the East have not yet reached a modern standpoint with regard to the relative importance of mental disorder and its treatment.’28 The outcome of this low expenditure was not simply overcrowding. The provision for patients was poor quality, largely because allowances per patient were almost half that of the average in India. The number of doctors at Angoda had not been increased to take account of the large patient population, with the effect that the doctor–patient ratio was one-fifth of that allowed in India. The scene painted by Mapother of his arrival at the hospital suggests that the outcome of this was very little treatment for the inmates at all: The garden was densely packed with a turbulent mob of men, a few of them entirely nude, the majority naked except for a loin cloth. Many were shouting remarks at the sky and waving their arms, while others shrieked insults above the din and shook their fists in each other’s faces. Now and then when actual violence seemed imminent a couple of male attendants would dart into the thick of the mob and extricate one of those quarrelling by dragging on one arm. Their manner of handling patients in the presence of the Medical Superintendent and myself was not reassuring as to what might happen in our absence.29

His prescription for improvement was far reaching, and was composed of thirteen recommendations which tackled the provision of psychiatry in Ceylon, root-and-branch. In the first instance, legal reform was necessary. The historical origins of the Lunacy Ordinance of Ceylon were obscure, but it seemed to hark back to an age when mental illness was a legal rather than a medical matter. The individual had to be presented to a judicial authority, who would make the decision as to whether a doctor should be consulted or not. Once the doctor had been consulted, the judicial authority could order detention in the asylum; only the magistrate responsible for this order could authorise the subsequent release of the patient. The regulations seemed to be concerned mainly with those dangerous to others, and with those who might 228

‘A Disgrace to a Civilised Community’ be falsely presented as insane, as part of a plot, and Mapother noted that ‘the law does not seem to have contemplated treatment as a contingency to be considered’.30 He suggested that new legislation be modelled on the English Mental Deficiency and Mental Treatment Acts, and that certification should be the last resort in a system where the emphasis was on voluntary patients seeking legally authorised therapy. As a separate note, he urged the authorities to devise new regulations for dealing with mothers who had killed their recently born child. He argued that these should not be tried as murderers, but rather should be admitted to psychiatric hospitals for treatment as civil rather than as criminal cases.31 He then tackled the institutional aspect of the system. He clearly felt that the reliance on one institution for the whole island resulted in the muddling together of different types of patient. In the first instance, he suggested that those admitted to the facilities through the penal system ought to be separated out. The custody of those awaiting trial for, or serving sentences for serious crimes consisted of measures, which Mapother felt were quite unsuitable in an environment where civil patients were under treatment, and, as such, he thought a separate hospital needed to be built. He then suggested that the existing hospital at Angoda could be adapted to house what he called the ‘chronic insane’. This involved measures such as pulling down its forbidding walls, painting the wards and other buildings, replacing bars on windows with ‘armour plate glass’, using impermeable flooring in the lavatories and building a new recreation hall. Mapother devoted much detail to the latter: This hall could be used daily for drill and gymnastic classes, it should be furnished with newspapers and books, with indoor games, and a gramophone and wireless set… here there should be given occasional concerts either organised by the staff of the institution, or provided by companies from outside if sympathisers could be found to do this. Display of sound films is usual nowadays in English mental hospitals and at some in India.32

He was similarly enthusiastic about ‘outdoor games such as cricket and tennis and football’, picnics and ‘carefully supervised occupation’ in the new regime he proposed. With Angoda rescued, Mapother turned his attention to a range of new institutions. The first was a neuropsychiatric clinic, to treat ‘neurological cases of the clearly organic type’ such as schizophrenia and ‘general paralysis’.33 Patients would only be admitted there on a voluntary basis, and it would have one hundred beds for inpatients and would offer an outpatient service. Complementing this was the psychopathic hospital, with a capacity 229

James H. Mills and Sanjeev Jain of 1,500 beds. This would deal with patients likely to recover within two years, who would benefit from being separated from the chronic cases at Angoda but who were not suffering from conditions likely to respond to the treatments on offer at the neurological hospital. The regime would be similar to that at Angoda, consisting of recreation halls and occupational therapy opportunities.34 Then there would be an observation home, to deal with those who may well be perfectly sane but who were, at the time, plunged into Angoda regardless of condition. This was essentially a clearing house, in which those in recent contact with the psychiatric system could be assessed, and then directed to the correct institution from the number above, once it was clearly established that they were suffering from a mental illness. This would contain three hundred beds, and patients were to remain there a maximum of six weeks, by which time a decision could be made about their ailments. He concluded his plans for this set of hospitals by pointing out that ‘in order to cope with the future number of unavoidable cases plans will probably have to be made for another Mental Hospital’.35 While Mapother concerned himself with the institutional system, he did not neglect the issue of who would run it. He proposed that existing staff be sent to India to observe best practice there at Bangalore, Madras and Ranchi. He then suggested a ‘special service of medical officers devoting themselves to psychiatry as a career’. He observed that only two of the five medical officers currently serving at Angoda had any sort of psychiatric training, and was sure that the hospital was seriously understaffed when compared with India, where the ratio of patients to staff was between five to one and nine to one, whereas in Ceylon it was sixteen to one. He anticipated a system with twenty-one doctors at various levels of seniority and argued that: [T]he necessity to create a permanent and separate service of psychiatrists must involve the provision of a career with such a rate of pay and chance of promotion as will render this specialty attractive to the suitable type of man.36

Alongside these doctors, Mapother saw the need for ‘a service of well trained mental nurses’ arguing that at present ‘there prevails a complete ignorance of the standards customary in modern institutions for the care of the insane.’37 European nurses were to be sent out to Ceylon to supervise the hospitals and the training of local staff, and the best of the latter were to be sent to England for specialist training that would qualify them to return to take up senior positions. Furthermore, he advocated the recruitment of ‘young women of suitable education’ to be trained as social workers to work with the local community to learn more about the circumstances of particular patients and to provide a means of ‘aftercare’ for those released 230

‘A Disgrace to a Civilised Community’ from hospital. He was also keen to provide ‘occupational therapists’ trained to the standards that he had seen in India at Ranchi. Finally he urged the addition of psychiatry to the syllabus of medical students on the island, so that even those who did not go on to become psychiatrists ‘would profit by an elementary knowledge of normal and morbid psychiatry’, emphasising that ‘the relation of psychiatry to neurology should be persistently stressed’.38 Ceylon was not simply to have a new cadre of specialist doctors and nurses running its mental hospitals, it was to have a network of amateur psychiatrists spread throughout its clinics and general practices. The plan was grand and the response, at first, seemed vigorous. His report was submitted to the Government on 9 May 1938, and, by 25 August, the Executive Committee of Health met to approve a strategy. All of the suggestions that were cheap were approved. The law was to be modernised, the syllabus at the Medical College was to be altered to incorporate instruction on ‘special treatment of mentally defectives’, senior staff were to be sent abroad to ‘familiarise themselves with recent practice’ and new staff were to be specially trained. However, there were no clear or definite instructions on the number of new staff to be recruited and the vague statement that ‘the principle of the creation of a special service of Medical Officers devoting themselves to psychiatry as a career should be accepted’ suggests that the Government was in no rush to commit itself to rapid expansion in the number of specialists. Indeed, when it came to giving effect to Mapother’s plans for a new institutional network, there was a considerable downsizing of scale: a neuropsychiatric clinic at the General Hospital to be staffed by a specially qualified medical officer was provided, along with a psychopathic hospital at Maharagama for three hundred patients with a house of observation for one hundred patients attached, and a separate institution for housing inmates who were committed to detention at an asylum by order of the courts at Angoda, which was to have three hundred inmates.39 Mapother had wanted his neuropsychiatric clinic to have five ‘specially qualified medical officers’, his psychopathic hospital to have 1,500 beds and the house of observation to have three hundred beds. The Government made it explicit that ‘it is, however, realised that all his proposals cannot be undertaken immediately on account of the heavy cost involved in carrying them out’. Tellingly, there is no mention of giving effect to another of Mapother’s proposals. He had suggested the ‘establishment of a Visiting Committee for each institution’ to ‘meet at the hospital, carry out inspections, and make recommendations’.40 It would appear that the Government of Ceylon had learned its lesson; allowing visitors into its asylums and inviting them to report back could be a costly and troublesome business. Indeed, when news of the Government’s alteration of his scheme 231

James H. Mills and Sanjeev Jain filtered back, Mapother was furious. He wrote to John Pye at the European Association as follows: I have been rather disturbed by the indications in the newspapers that the fulfilment of my recommendations was likely to be distorted. I had thought of bringing the whole matter to the notice of the Secretary of State. However, the international crisis intervened and made the raising of all minor questions inopportune. The crisis will presumably have subsided shortly and if it appears that the programme proposed diverges entirely from my recommendations it may seem advisable that I should ask the Sec. of State to interest himself in the matter. I think this would be better than that I should deal with the situation by a comment on inadequate proposals in the Ceylon newspapers.41

There seems to have been no approach to the Secretary of State, and no recourse to the newspapers. Mapother was dead within eighteen months of writing the above letter, and the collection of his correspondence reveals that his interest in South Asia in that time was limited to trying to persuade the Rockefeller Foundation to fund fellowships for Indian students to study at the Maudsley.42 Indeed, the international crisis he mentioned was the prelude to the 1938 Munich Agreement between Chamberlain and Hitler, which, of course, did not subside but escalated into the Second World War – followed by rapid decolonisation by the British in South Asia. Mapother’s grand plans for psychiatry in Sri Lanka were never realised. Mapother in India ‘It would be difficult for the most jingoistic to affirm that, in the matter of provision for mental disorder in India, the British “bearing of the white man’s burden” has been quite adequate.’ The opening declaration of Mapother’s report on his travels in India accurately set the tone of what was to follow, and he made sure that readers did not miss the point by emphasising that the state of affairs there ‘sets an awkward task for the holders of the moderate view [that] British rule has been a benefit’.43 The report was severely critical of the facilities, noted the demoralisation of many of the staff, and was gloomy about the scale of the problem and the difficulties of undertaking any attempt at improvement. Mapother had worked hard to arrive at his conclusion, as he took full advantage of the freedom given to him by the India Office: I had a conversation of nearly an hour with Sir John Megaw. He was quite alive to the deficiencies of psychiatric arrangements in India, but convinced that other needs must have priority and that economic reasons forbade these

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‘A Disgrace to a Civilised Community’ defects being rectified. He arranged that I should have every possible facility to meet those whom I wished to see in India, and to visit all institutions.44

As noted earlier, he made visits to hospitals as far apart as Bombay, Madras, Lahore and Ranchi, in all, seeing for himself seven of India’s psychiatric units. He also attended the Indian Science Congress in Calcutta and interviewed a number of officers in the Colonial Medical Service, including the Director-General of the Indian Medical Service himself. He compiled a ‘who’s who in relation to psychiatry in India’ in his report that recorded his observations on those he had met. Of the Surgeon-Generals of Bengal and Madras he recorded that they were ‘extremely friendly and expressed appreciation of the situation coupled as usual with an almost excessive clarity of vision as to the difficulties.’45 Of Lt Col. O. Berkeley Hill, who had served as Superintendent of the Ranchi Hospital, he wrote that he ‘is by far the ablest man that there has been in psychiatry [but] he is a bitter controversialist with a dangerous wit who scored so successfully off his official superiors that they retired him as soon as possible’.46 He was equally critical of the Indians he encountered. Of Lt Col. L.E. Dunjibhoy in Calcutta he observed that, ‘his annual reports include reference to his wide travels and the closeness of his acquaintance with psychiatrists in Europe and America. But he did not seem to have equal intimacy with psychiatry itself.’47 In Bombay he noted, ‘the young man in charge of the psychiatric out-patient clinic is a young Parsee whose name I have mislaid. He is a psychotherapist trained at the Tavistock Clinic with an ingenious and credulous mind and little knowledge of solid psychiatry.’48 He explained that Dr G. Bose in Calcutta was ‘devoted to psychoanalysis’ and as such was ‘a danger to psychiatry in India’.49 Some did not come in for such strong judgement, so that ‘Dr Banarsi Das was trained at the Maudsley… his hospital is deplorable but it is probably not his fault.’50 Lt Col. Lodge Patch of the facility in Lahore was described as ‘with intelligence and keenness nearly equal to that of Berkeley Hill, he unites stability and balance,’51 and Venkata Subba Rao at Madras had ‘a real knowledge of psychiatry and its needs [and] an unselfish enthusiasm’. It was in them that Mapother saw some cause for optimism, and of the latter he noted that ‘he seemed to me the best Indian in British India to support if the Rockefeller Foundation were disposed to foster psychiatry there in any way.’52 Having travelled widely and assessed the key men, his overall judgements were damning. The asylums of India were ‘a permanent monument of brutal stupidity and of a refusal to look at the rest of the world with any hope of learning from it’, and he spoke readily of ‘the wretched provision for the insane in India.’53 The buildings were shaped by ‘the conception held by the 233

James H. Mills and Sanjeev Jain Public Works Department as to the nature of lunatics and the accommodation proper for them, unchecked by any such experience as could be borrowed from a psychiatrist’, and he described ‘one single ward in which I saw a female patient [that] was an exact replica of the accommodation for tigers at the Regents Park Zoo.’54 The availability of services in British India was compared to that in London, in which there were ten institutions with 22,000 beds serving a population of 4.4 million, as compared to nineteen institutions, and 9,608 beds in the whole of British India, for 276 million people. In London, there was a psychiatric bed for every two hundred individuals, while in India there was one bed for 30,000. He identified wide divergences in provision within India; in the Bombay presidency there was one bed for every 12,000 of the population, as compared with Bengal, Bihar and Orissa, where there was only one bed for every 57,000 individuals. While there were five psychiatric beds for every eight beds for ‘physical disease’ in London, there was only one bed for psychiatry to every seven for bodily ailments in India. Thus, even allowing for differences in economics and poverty, it was obvious that the shortage of beds for mental capacity was four times that of the UK. The London County Council spent £2.2 million per annum on the mental health services – twenty-five per cent of the total health budget – while all the mental hospitals of India accounted for just Rs.3.6 million – £250,000 – or less than ten per cent of the total medical spending.55 This shortage of provision partly explained the problem he identified of overcrowding, which in turn emphasised the lack of staff. He noted that where there was no overcrowding, as in Bengal, this was a result of ‘a deliberate refusal to fill institutions beyond capacity’.56 The situation in Bombay was the worst, and he drew out the consequences of overcrowding; the confinement of both civil and criminal lunatics in the same institutions, the inability to separate out the chronic from the acute patients, an official disinclination to admit cases in the early stages of illness who might most benefit from treatment, and the rapid discharge of those who, while not cured, had moderated their behaviour. The outcome of all this was ‘the growth of a well founded tradition that the asylum is a place fit only for the segregation of such dregs, and that it is inhuman to send or keep there any persons who are not either indifferent or anti-social.’57 Indeed, what provision was available was then analysed in terms of cost. Mapother discovered that there were enormous disparities within India on what was spent per patient; in Lahore this was as much as Rs.553 per patient, while in Agra it was less than half that as Rs.264. The direct result of this was that ‘the death rate of the mental hospitals is in proportion to their cheapness’,58 so that at Ranchi, where Rs.116 was spent on diet, the hospital death rate was about the same as the death rate in the community 234

‘A Disgrace to a Civilised Community’ around it, at about twenty-five per thousand per annum. At Agra, where only Rs.63 was spent on food, the death rate in the hospital was almost five times greater than that in the local population. The report made the obvious conclusion that ‘it is futile to expect that any material improvement in the arrangements for dealing with mental disorder in India can be made without a very large increase in cost.’59 Blame for the problems lay in the lack of leadership shown in the matter of medicine in India according to Mapother. The British officers of the Indian Medical Service (IMS) were settled into what Mapother called ‘a long tradition that anything but passive acceptance was grousing, and that the way to acquire merit was to avoid grousing’.60 Indeed, this had been exacerbated in the 1930s by the peculiarities of the period, and Mapother thought that ‘the higher officers of the IMS strike one as having a sense that their whole Service is under notice to quit’, a reference to the Nationalist campaigns of the 1930s against the British and to the Indianisation of medical provision in India that had been gathering pace since the end of the First World War.61 Mapother therefore argued that ‘the whole situation in India cries aloud for a crusade’,62 and saw the leaders in this to be both Indians and Americans. The Indians could draw on the example of the independent state of Mysore. Mapother had visited the mental hospital there and called it: [A] monument to the vision and wisdom of all those responsible for the mental defectives in the East. The Institution is almost unique among mental Hospitals in India… it is quite evident that modern methods of diagnosis and treatment are available and freely used.63

Though established in the 1840s, when Mysore was ruled by the British, the hospital had been extensively and recently improved. A new building, wellmaintained grounds and laboratory facilities had been provided in the 1920s by the local Maharajah, whose family had ruled Mysore as a state independent of British India since 1878. It had been modeled on the Maudsley by its first Superintendent, Frank Noronha, an Indian doctor who had studied psychiatry in London. As for the Americans, Mapother was hopeful that ‘the Rockefeller Foundation could even by the loan of its name and at very little cost give to such a crusade the influence which no private person could exert.’64 As already stated, Mapother had a longstanding relationship with the Foundation, and he took it upon himself to raise the issue of India with its representatives. He closed a letter to his contact with a paragraph that read: [S]ome day I hope your Foundation will take a serious interest in psychiatric arrangements for four hundred million people in India. At present they are

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James H. Mills and Sanjeev Jain primitive but I believe the situation is such that great development is possible.65

In other correspondence, he noted that: I told the Rockefeller people that… it would be an excellent plan if they could see their way towards helping with the finance in India of a psychiatric clinic at which Indians could get the sort of education in their own country that would enable them to deal with early and minor cases.66

However, it does not seem as if he managed to spark interest in the crusade that he wanted to inspire in India; ‘I had rather hoped for a beginning of at least a few fellowships in India, but this and many other hopeful ideas must now be infinitely postponed’ was the position of his correspondent at the Foundation by the end of 1939.67 The shape the crusade was to have taken was based on the same principles as those he proposed in Ceylon. He advocated changes in the law relating to civil cases so that the power to admit to psychiatric hospitals lay with patients and doctors rather than magistrates, and a strengthened Visiting Committee needed to be appointed to each institution. All medical students were to receive an elementary education in psychiatry, specialist colleges in north and south India were to be established for the training of psychiatrists, finance was to be made available to send the best abroad to study recent developments, and a cadre of mental health nurses and social workers was to be nurtured. In a note on the syllabus to be studied by this new generation, he wrote ‘emphasise need for education of medical students in neuropsychiatry’.68 To pursue these reforms and to oversee their operation a psychiatrist should be appointed to the Public Health Commission for the Government of India. Finally, a programme of survey and public information was to be devised, so that the problems of mental illness in India could be studied and the benefits of early treatment at the hospitals could be conveyed to local communities.69 Any attempt to dispute this scheme on grounds of cost was dismissed in advance in the opening paragraphs of his introduction, in which Mapother pointed to the grand project of the time, where the British were erecting an imperial capital at New Delhi. He wryly noted that ‘it serves only for the work and ceremonial entertainment of the representatives of the British Raj, its more fortunate officials, and the native Princes who support it’, before reminding readers that it had cost £18 million to date. It is unclear that anyone ever saw this plan or read his recommendations. Mapother wrote in July of 1938 that ‘I am hoping shortly to get together a note of my impressions on the situation in India’,70 so it is clear that he did not get round to writing his notes within a year of his visit. In his notes, he 236

‘A Disgrace to a Civilised Community’ laid out a plan for the report he was to write and included a list of those to be contacted about it, including Sir John Megaw, the President of the Medical Board at the India Office in London, and the Viceroy himself. There is no evidence that they received the report as no copy remains in the India Office collection at the British Library. Indeed, it is not clear what they would have done with it even had it ended up in their offices, because Mapother had committed himself to the deal that gave him access to India, but which meant that ‘the information which I obtained was not for publication’. He had visited India, and been appalled by what he saw of the psychiatric services of the colonial administration there, but it was that very administration that prevented him from doing anything about the state of affairs he had found. Conclusion The tale of Mapother’s travels in India points to a number of conclusions. The first is that many of those involved in the process of his visits seemed convinced that the psychiatric systems of South Asia needed to be opened up to the outside world, and that visiting in various forms would be an important part of the improvement of mental health institutions in the region. Those who found themselves so concerned about the hospital in Ceylon that they needed to take action were themselves visitors to the institution, and they saw the arrival of an expert visitor as central to their response. When Mapother took on the role, he incorporated visiting into many aspects of his blueprint for reform. His institutions were each to have a Visiting Committee, staff were to be sent from the institutions to hospitals and colleges elsewhere for training and education, and the patients were to be entertained by companies and films from the outside world. The insularity and isolation of so much of the psychiatric provision was seen to be a problem, and the solution was to be provided through various forms of visit. A cursory reading of the evidence brings to mind the post-colonial critiques of medicine in colonial contexts mentioned earlier. It might be argued that Mapother was simply seeking to re-establish an Orientalist colonial order in recommending greater engagement between psychiatric institutions in south Asia and the wider world. After all, this was a period in which psychiatry was increasingly ‘Indianised’, and his appearance as a British expert who gave full voice to harsh criticism could be read as an act of colonial paternalism; the superiority of the European was being asserted over the incomplete or childlike efforts of the Asian.71 Indeed, the idea that Indian doctors needed to be sent to London for training seems to emphasise the colonial relationship, in which those on the imperial periphery are directed to the metropole to be civilised.72 Such a reading would be 237

James H. Mills and Sanjeev Jain ahistorical and overly determined by theory. In reality, Mapother was as critical of the British and European individuals he encountered on his travels as he was of Indians, and commended as few of the former as he did of the latter. He used imperial rhetoric only where it could be employed against British colonial administrators in order to shame them into greater action, not in order to subject Asians. The sole hospital in South Asia he lauded was that established and run entirely by Indians in the independent state of Mysore. He did not recommend training in London per se, but at the Maudsley, the hospital that was his life’s work and which he regarded as a model for psychiatric training, treatment and administration in general. Indeed, the blueprint he exported to South Asia drew heavily on the one he had already imposed on London, and which he clearly considered to be the solution to the problems of social psychiatry the world over. If he was empire building, it was for his institution and his ideas, not his nation.73 The circumstances of Mapother’s visit to South Asia also point to the value of visitors’ reports to the historian. His observations suggest that visitors can provide crucial assessments of medical systems, crucial because they emanate from outside of the internal logics and cultures of those systems. When working with sources from within the system it may be difficult for this historian to escape the working of these mechanisms, and as such when an assessor arrives who has no experience of the logic or the culture, and who has no material or professional attachment to them, a fresh and often disruptive perspective is provided. Mapother certainly falls into this category in this case, as his is a set of documents which throw an interesting light on the psychiatry of colonial South Asia. The picture he presents rather undermines the lofty rhetoric of imperial medicine in the region, which had boasted since the nineteenth century of its benefits to the subject populations; ‘the establishment of lunatic asylums is indeed a noble work of charity, and will confer greater honour on the names of our Indian rulers than the achievement of their proudest victories.’74 Coming towards the end of British rule in South Asia, Mapother provides a clear sense that when viewed from outside the region and its corridors of power, the mental health services of the imperial regime conferred little honour on the colonisers and brought few benefits to the local population. The final set of conclusions relates to the broader theme of this volume about medical visitors. Those who organised his trip to South Asia intended Mapother to act as an expert witness in a one-off capacity. There was never any suggestion that he was to become a regular monitor of the system in South Asia, rather it was hoped that he would stir matters up; his professional prestige and experience would allow him not only to identify problems and to offer solutions, but also to demand the attention of the bureaucrats and politicians whose apathy had stifled action. In Ceylon, he 238

‘A Disgrace to a Civilised Community’ succeeded up to a point, as the evidence suggests that he had managed to force the issue of the mental health services of the colony into public debate to the extent that the Government was compelled to act. However, the correspondence also points to the limitations of his achievement, as it seems that the Government was determined to reform at its own pace and in ways that fell some way short of Mapother’s recommendations. Indeed, the story from India only emphasises the ways in which his role as expert visitor could be circumscribed, as he was limited to observing and noting while specifically shorn of any power to publicly condemn or report. In short, it may be the case that historians can find much in the reports of visitors to medical institutions and systems, as they can provide important perspectives and information often missing from accounts written from within those institutions and systems. However, historians need to be alive to the swirling political circumstances of appointment before considering the career and the achievements of any expert visitor. Notes 1. British Library, C.S.B. 24/3. E. Mapother, ‘Report on Present Arrangements for the Treatment of Mental Disorders in Ceylon and Suggestions for Reorganization’, in Papers laid before the State Council of Ceylon during the Year 1938 (hereafter ‘Ceylon Report’), (Colombo: Government of Ceylon Press, 1939), 1. 2. This summary of his career is based on A. Lewis, ‘Edward Mapother and the Making of the Maudsley Hospital’, British Journal of Psychiatry, 115, 529 (December 1969), 1349–66. 3. Royal Bethlem Hospital Archive, EM–01, Report on Psychiatry in India File (hereafter ‘India File’), to The Rockefeller Foundation, March 1931. 4. M. Jones, Health Policy in Britain’s Model Colony: Ceylon 1900–1948 (Hyderabad: Orient Longman, 2004), 76. 5. PRO CO 54/950/4, from S.T. Gunesekara to E. Mapother, 21 July 1937. 6. Jones, op. cit. (note 4), 262. 7. See R. Hayward, ‘Mapother, Edward (1881–1940)’, Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004), http://www.oxforddnb.com/view/article/58394, accessed 3 March 2009. 8. Annual Report on the Lunatic Asylums in the Punjab for the Year 1879, 3. 9. Minute by President of Madras, 29 October 1865, Government of India (Public) Proceedings, 27 February 1869, 105–107A 10. For more on the nineteenth century see J. Mills, Madness, Cannabis and Colonialism: The ‘Native-Only’ Lunatic Asylums of British India, 1857–1900 (Basingstoke: Palgrave, 2000); W. Ernst, Mad Tales from the Raj: The European Insane in British India 1800–1858 (London: Routledge, 1991);

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11. 12. 13.

14.

15. 16.

17. 18.

19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

S. Kapila, ‘The Making of Colonial Psychiatry, Bombay Presidency, 1849–1940’ (unpublished thesis: University of London, 2002). J. Mills, ‘The History of Modern Psychiatry in India: 1795 to 1947’, History of Psychiatry, 12 (2001), 431–58. C. Hartnack Psychoanalysis in Colonial India (Oxford: Oxford University Press 2001). A phrase taken from D. Headrick, The Tools of Empire: Technology and European Imperialism in the Nineteenth Century (Oxford: Oxford University Press, 1981). R. MacLeod, ‘Introduction’, in R. MacLeod and M. Lewis, Disease, Medicine and Empire: Perspectives on Western Medicine and the Experience of European Expansion (London: Routledge, 1988), 2. ‘Ceylon Report’, op. cit. (note 1), 3. Royal Bethlem Hospital Archive, EM–01, Papers of Edward Mapother, Treatment of Mental Disorders in Ceylon File (hereafter ‘Ceylon File’), to Dr O’Brien, 26 February 1937. ‘Ceylon File’, ibid., from John Pye, 23 September 1938. In 1931, Ceylon had been granted some limited self-government, but senior officials such as the Governor remained British and the Colonial Office in London remained the distant source of authority. The Colonial Office and the Medical Advisor Dr Stanton had opposed the appointment of Gunasekara as the first local Medical Director in October 1936. See Jones, op. cit. (note 4), 76. For a contrast in state approaches see the chapter by Leonard Smith in this volume. ‘Ceylon Report’, op. cit. (note 1), 3. ‘India File’, op. cit. (note 3), 33. Ibid., ‘Growing Interest in Psychiatry, Dr Mapother Interviewed, Visit to Madras’ (undated newspaper clipping). ‘Ceylon Report’, op. cit. (note 1), 3. Ibid., 6. Ibid., 7. Ibid., 8. Ibid. Ibid., 4. Ibid., 7 Ibid., 12. Ibid., 9. Ibid., 11. Ibid., 17. Ibid., 20.

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‘A Disgrace to a Civilised Community’ 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61.

62. 63. 64. 65. 66. 67. 68. 69. 70.

Ibid., 21. Ibid., 23. Ibid., 25. Ibid., 27. Ibid., 28. Ibid., 16. ‘Ceylon File’, op. cit. (note 16), to John Pye, 4 October 1938. ‘India File’, op. cit. (note 3), to Dr O’Brien, The Rockefeller Foundation, 8 July 1938. ‘India File’, op. cit. (note 3), ‘Report on Psychiatry in India’, 1. Ibid., 33. Ibid., 34. Ibid., 37. Ibid. Ibid., 38. Ibid., 37. Ibid. Ibid., 38. Ibid., 39. Ibid., 1. Ibid., 31. Ibid., 3–4. Ibid., 5. Ibid. Ibid., 9. Ibid. Ibid., 10. For more on this process see M. Harrison, Public Health in British India: Anglo–Indian Preventive Medicine 1859–1914 (Cambridge: Cambridge University Press 1994), 233; Mills, op. cit. (note 11), 449–51. ‘India File’, op. cit. (note 3), ‘Report on Psychiatry in India’, 10. Sir Mirza Ismail, My Public Life: Recollections and Reminiscences (London: George Allen and Unwin, 1950). ‘India File’, op. cit. (note 3), ‘Report on Psychiatry in India’, 10. ‘India File’, op. cit. (note 3), to Dr O’Brien, The Rockefeller Foundation, 8 July 1938. Ibid., to Lieutenant Colonel Owen Berkeley Hill, Ranchi, 23 February 1937. Ibid., from A. Gregg, The Rockefeller Foundation, 3 December 1939. ‘India File’, op. cit. (note 3), ‘Report on Psychiatry in India’, 1. Ibid., (note 43), 18–26. ‘India File’, op. cit. (note 3), to Dr O’Brien, The Rockefeller Foundation, 8 July 1938.

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James H. Mills and Sanjeev Jain 71. Orientalism is an analytical device that draws heavily on the work of E. Said, Orientalism (New York: Pantheon, 1978) and idem, Culture and Imperialism (London: Chatto and Windus, 1993). The paternalistic ideology of British imperialism in South Asia is mapped in A. Nandy, The Intimate Enemy: Loss and Recovery of Self under Colonialism (New Delhi: Oxford University Press, 1983). 72. For recent discussions of this relationship see H. Fischer-Tine and M. Mann (eds), Colonalism as Civilizing Mission: Cultural Ideology in British India (London: Anthem, 2004). 73. This view seems to be corroborated by Mapother’s DNB entry, which emphasises that ‘he never abandoned his commitment to the Maudsley [which] provided the institutional space and intellectual opportunity for Mapother to realise his own vision of psychiatry’, Hayward, op. cit. (note 7). 74. F. Winslow, ‘Review of “Practical Remarks on Insanity in India”’, Psychological Medicine and Mental Pathology, 6 (1853), 356–67.

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11 ‘In View of the Knowledge to be Acquired’: Public Visits to New York’s Asylums in the Nineteenth Century

Janet Miron This chapter examines asylum tourism in nineteenth-century New York. It argues that the popularity of visits by the public undermines the notion that asylums were segregated from greater society, and instead, suggests that these institutions were deeply embedded within the social and cultural landscape of the time. While challenging many of our assumptions regarding the relationship of asylums with their greater communities, the phenomenon of visiting enhances our understanding of both popular attitudes towards the mentally ill and the experiences of patients themselves. As people believed asylums represented something remarkable in society, visiting provides new perspectives on the social role of these institutions and nineteenth-century cultural practices more generally.1

Introduction In a mid-nineteenth-century issue of Harper’s, a writer described in detail his visit to the New York City Lunatic Asylum on Blackwell’s Island, established in 1839 on the East River and located about six miles from City Hall. The writer began the piece with the statement, ‘Among the numerous charitable institutions founded by the benevolence of our City and State, we know of none of which New York can be more justly proud than the Lunatic Asylum on Blackwell’s Island.’ He proceeded to describe the institution’s location, charming grounds, elegant architecture, clean interior, therapeutic practices, amusement programmes, and the people confined inside its walls. Writing for the ‘benefit of those who may have a curiosity to see the interior of a lunatic asylum,’ the author discussed the exchanges that took place with ‘the gay and the melancholy’, the ‘reasoning’, the ‘matronly’, and the ‘benevolent’, and remarked on the ambiguity that existed between the sane and the insane. One patient who captured his attention in particular was fluent in several languages. According to the writer, if learning were ‘the one 243

Janet Miron thing needful, [the patient] would certainly be better entitled to the professor’s chair than many who occupy that position in our first-class colleges.’ While the narrative tone of the article fluctuates between meticulous observation and anecdotal story, the interactions that took place with patients clearly captivated the writer’s eye more than any other feature of the asylum. However, as if to reassure those who might dismiss the tour as cruel spectatorship, the writer claimed that the patients ‘did not seem to be disturbed by our visit; but, with a very few exceptions, they were rather pleased than otherwise.’2 The people who read the piece, had they not visited the Blackwell’s Island asylum already or another in their community, may have been inspired to follow the author’s example and see for themselves the changes taking place in the treatment of mental illness. Indeed, this writer was merely one of the thousands of visitors who toured this New York City institution every year in the nineteenth century, a phenomenon that characterised most publicly funded asylums in the United States.3 From the 1830s to the end of the century, people traipsed across the gardens, strolled through the wards, and spoke with patients confined inside the asylums of New York State, believing that these institutions represented something exceptional in society that needed to be seen in person. Drawn especially to the asylums in Utica and on Blackwell’s Island, ‘lay’ visitors represented a broad spectrum of society: they were men, women, and children from different socio-economic and ethnic groups who either lived in the communities surrounding the asylum or travelled from abroad to be part of the growing endeavour to study insanity. Albeit not without certain restrictions, asylums opened their doors to the general populace, attracting attention from farmers, leisure travellers, aboriginal leaders, labourers, teachers and botanists. One superintendent of the New York State Lunatic Asylum at Utica, John P. Gray, claimed, in 1884, that ‘more than 10,000 people visit and go through the wards yearly, and no week day is without this public visitation.’4 Nevertheless, in spite of the significant number of ‘casual’ tourists to asylums between the 1830s and 1880s, scholars have tended to overlook their presence and significance. Traditionally, when their existence has been acknowledged, lay visitors have been portrayed as indulgent voyeurs who annoyed institutional employees and treated the asylum as nothing more than a human menagerie. In his 1945 study of the history of psychiatric practices at the New York Hospital, William Logie Russell wrote, ‘in some places in Europe and also in America a visit to the “Lunatic Asylum” was considered a means of entertainment, and an admission fee was sometimes charged.’5 In the 1980s, Anne Digby argued that the presence of the public in England’s Bethlem Asylum rendered the institution a ‘human zoo’, while Patricia Allderidge 244

‘In View of the Knowledge to be Acquired’ claimed, ‘there is no doubt that a very large number of people did visit the hospital in the late eighteenth century, that many of them abused the patients shamefully, [and] that it was a most degrading spectacle.’6 Further denouncing the presence of the public in asylums, Ellen Dwyer presented visitors to Utica as insensitive, harmful to patients and vexing to administrators.7 More recently, with regard to the eventual exclusion of visitors to the St Louis Asylum in the nineteenth century, Jennifer A. Crets stated, ‘one of the more shameful Gilded Age St Louis attractions closed its doors to tourists.’8 Focusing on the New York State Asylum at Utica and the New York City Lunatic Asylum on Blackwell’s Island, this chapter challenges these conventional interpretations by situating asylum visiting within the cultural context of its time and within the framework of nineteenth-century sensibilities.9 Analysing how visits were represented by institutional officials, the public and patients, this chapter presents New York asylums as sites of social and civic activity that were closely connected to the communities surrounding them and argues that asylum visiting was imbued with multiple layers of meaning and complex motivations. Furthermore, the study of asylum tourism not only enriches our own understanding of popular views of the asylum and mental illness, but also reveals important features concerning the place of the asylum in nineteenth-century society. Whereas scholars have argued that the asylum ‘remained as aloof as possible’ from greater society and that there was ‘relatively little public interest in readily available but mundane information about asylum[s]’, visiting illuminates the need for a more nuanced interpretation of the relationship between the asylum and the public world.10 Asylums and the broader community Public tours of convents, orphanages, prisons, workhouses and asylums – where they existed – had been established as a tradition in many Western countries prior to the nineteenth century, but a number of changes took place that made asylum visiting especially relevant in the context of the United States. From the perspective of many Americans, exciting changes were taking place in the treatment of insanity in the nineteenth century that reflected the maturation of their young country. In particular, the modern asylum, with its programme of moral therapy, seemed to offer a panacea for the supposedly increasing rates of insanity accompanying industrialisation, and thus, would grip the attention of the public mind. Seeing insanity as an inevitable result of progress that stemmed from the ‘intense civilisation of modern times,’ many people believed the rise of the asylum with its humane principles to be further evidence of society’s advancement.11 Assessing the 245

Janet Miron asylum on Blackwell’s Island, one newspaper article highlighted the positive changes that were taking place in the care of the mentally ill: In olden time, it is true that lunatics in civilization… were treated with great barbarity, and made to suffer physical privation and outrage. But, thanks to the philanthropy ever generated by science and intelligence, all this has disappeared. In the handsome and comfortable home provided for these beings, by New York – one of the noblest of all her long list of noble public charities – the utmost peace and harmony reigns….12

Another writer who visited Utica enthused: Nothing illustrates our age and country more than the lively interest manifested in human institutions; and among them all, the asylums for the insane may be considered as perhaps the most interesting and striking.13

As institutions promised to not simply house the insane but cure them, asylums were constructed with great vigour and optimism across the country and, by mid-century, almost every state could boast of a public insane asylum.14 Superintendents who presided over these new institutions generally exerted great power within their asylums, and overall, experienced little intervention in their practices. Nevertheless, they were often subject to government inspections and, at least in theory, to the dictates of state legislation. In 1836, the legislature of New York passed ‘An Act to Authorize the Establishment of the New York State Lunatic Asylum’, whose construction would be presided over by three commissioners appointed by the government. In 1842, another Act was passed by which nine managers were appointed and the principal officers chosen to oversee the new state institution at Utica. Shortly after the construction of Utica began, in 1839, the asylum on Blackwell’s Island was opened and would fall under the same legislation. Supervision of New York’s asylums was modified again in 1867; the governor now appointed eight commissioners of public charities to oversee state-funded social welfare institutions, thereby creating the Board of State Commissioners of Public Charities. This arrangement was further changed in 1872, when the legislature authorised the appointment of a special state commissioner in lunacy, who would supervise the internal affairs of both state and local asylums. In 1889, the legislature would replace the solitary commissioner with a commission of three people.15 Through these various pieces of legislation and the establishment of offices to conduct inspections, the government was attempting in part to gain the tax-payer’s confidence in asylums; however, superintendents also struggled to foster the

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‘In View of the Knowledge to be Acquired’ trust of the general populace and achieve widespread social support for their institutions. While asylums were touted by supporters as a progressive and humanitarian solution to contemporary problems, faith in, or social acceptance of, these institutions was often tenuous and, in spite of government inspection and official visiting, popular responses could oscillate between fear and respect. As a result, although asylum superintendents faced a number of challenges in their efforts to develop well-managed institutions – ranging from problems with staff to overcrowding – institutional authorities also had to contend with public scepticism. As was pointed out in the Journal of Insanity: [T]he prejudice against such institutions is great…. [T]hey are regarded by a large part of the unenlightened portion of the community, as prisons and dungeons, where men and women are confined in cells, chained and abused. It is this prejudice that has caused the large number of incurable cases of insanity in the country.16

Furthermore, both government officials and ordinary citizens expressed concern over the cost of institutions, and the comment made by one commissioner to New York’s State Board of Charities that ‘one cannot visit the Asylum buildings without being impressed with the idea of enormous and unnecessary expenditure’ likely stimulated unease amongst asylum managers.17 Consequently, throughout much of the nineteenth century, many recognised that the public needed to be convinced or, at the very least, reminded of the efficacy of asylum care. As speculated in an early report of the Blackwell’s Island Lunatic Asylum, ‘to do the greatest amount of good to the insane, the mind of the tax-paying community must be trained to understand and admit the necessity of expensive arrangements.’18 Institutional authorities and the practice of visiting Amariah Brigham, the first superintendent at Utica, was one of the more prominent superintendents, who sought to diminish the social stigma surrounding the asylum and, in his own words, ‘labored to diffuse a more extended knowledge of the subject of insanity’. His means for this were public lectures and printed material, such as the Journal of Insanity, which first appeared in 1844 with the objective of ‘popularis[ing] the study of insanity.’19 However, he did not wish to educate the population merely through writings and lectures alone, but also endeavoured to make the asylum itself a hub of social activity and community involvement. Brigham welcomed regular visits by the public, especially on civic holidays, and clear rules for visitors were established as a means of ‘affording [to the public] 247

Janet Miron suitable opportunities for visiting it and inspecting its internal arrangements’. Although not all superintendents agreed with his receptivity to the public, Brigham argued visiting served an important function with regard to both public legitimacy and patient therapy, and claimed that widespread ‘interest [was] generally felt in its prosperity’.20 While daily tours of the institution by the public ensured a certain fluidity of the asylum walls – although it was only members of ‘free’ society who could permeate them – dances, entertainments, plays, and even a few performances by magicians further drew the general populace into the realm of the institution. In the nineteenth century, many alienists argued that if they were to cure mental disease effectively, then they had to have the capacity to shield their patients from stressful situations and the gaze of the public. One commentator claimed that to ensure the ‘recovery and restoration of the insane to society’, asylums had to ‘strictly exclude visitors’ as part of the therapy under moral management.21 However, rather than advocate segregation, many other alienists employed the same measures as Brigham and emphasised the advantages that could be gained by integrating the asylum into the broader community. Even Thomas Kirkbride, who was appointed Superintendent of the Pennsylvania Hospital for the Insane when it opened in 1841 and often complained of the ‘gaze and impertinent curiosity of visitors,’ realised public trust was necessary for the asylum to function, and thus, recommended people tour his institution in order to witness its therapeutic programme in person.22 Additionally, some asylum officials found that public visiting served an important purpose in times of controversy. In the mid-1880s, public faith in the care provided by Utica asylum was shaken by the death of one patient ‘caused by injuries received at the hands of his attendants’ and by other ‘charges of a grave nature’ against the institution and its management. Owing to the fact that the public had ‘lost confidence in the management’ of the asylum and ‘regard with horror the atrocities alleged to have been there committed’, Superintendent Gray, who had earlier been opposed to visiting, attempted to pacify society’s fear by citing the institution’s accessibility to visitors and his willingness to accommodate daily tours of the institution.23 Aside from the desire to gain the public’s trust, visiting also served a financial role in asylum management. Chronically under funded, asylums could, and did, benefit financially when their doors were opened to the public through donations from visitors or the sale of items manufactured by patients. Claiming to be motivated by the interests of the patients, asylum officials argued that visiting stimulated feelings of benevolence and provoked acts of charity. M.H. Ranney, the resident physician for the asylum on Blackwell’s Island, speculated in the early 1850s: 248

‘In View of the Knowledge to be Acquired’ Who would not be willing to contribute something if fully conscious of its beneficial tendency? Let any one visit the Asylum from pure motives of benevolence instead of mere curiosity and view this wreck of reason: it will teach a lesson that will be likely not only to improve the heart but give a practical direction in contributing substantial aid for alleviating the sufferings of humanity.24

Even more creative measures to increase an institution’s annual revenue through public participation were devised, which further fostered ties between the community and asylum. Both Utica and Blackwell’s Island asylums held annual fairs, often topped with spectacular firework displays, and raised money for the purchase of many items, including magic lanterns, pianos, and books.25 The first fair at the New York State Lunatic Asylum at Utica was held in January of 1844, where an array of articles manufactured by the patients were sold to the public. According to Brigham, this inaugural fair was so popular that it generated approximately $200, a tidy sum that was used to expand the library collection, purchase musical instruments, provide every patient with entry to the museum in Utica for one year, and erect a greenhouse. In spite of a winter storm, the second fair proved to be equally successful, drawing in hundreds of eager shoppers, and again, bolstering the institution’s revenue.26 New York asylums – like many others in North America – did not exclude the public entirely from their establishments, even if doing so was preferable to some employees. One visitor to the asylum on Blackwell’s Island alluded to this when he pointed out, ‘visitors, though always treated with politeness, are not at all desired by the physicians of the place.’27 Instead, asylum officials tolerated and often encouraged the engagement of society with the practices surrounding and study of mental illness. Indeed, owing to the importance of public support, all employees of the New York State Lunatic Asylum at Utica were ‘expected to show marked respect and attention to strangers and visitors’.28 While rules were often carefully laid out in detail, they were intended to manage, but not prohibit, visitors. As one officer of the Utica asylum explained to a visitor in 1887: We have been compelled to deny admission to the general public at any other hours than between 2 and 5pm. The managers were forced to adopt this rule, because we were actually overwhelmed with visitors. Public curiosity and interest about the condition and care of the insane is largely on the increase. Before the adoption of this rule people came here in such crowds and at such unreasonable hours that our duties were seriously interfered with.29

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Janet Miron Parameters may have been set, but the fact that officials promoted entry by the outside world into the corridors of asylums reveals a relationship that ultimately entailed significant interaction between the asylum and the broader community in the mid-nineteenth century. Lay visiting and the asylum Whether owing to the efforts of superintendents or simply word-of-mouth from a neighbour, a substantial number of people in the nineteenth century took great interest in the asylums around them, thereby rendering these institutions important and familiar sights in the social and cultural landscape of New York. Frequently touted as ‘enlightened’ and ‘noble’ institutions by those who visited them, asylums regularly appeared as a topic in the popular press. Newspapers, including the New York Times, reprinted the annual reports of asylums and announced special events, while magazines, such as the North American Review and Harper’s, provided details of asylum architectural design and innovative therapeutic practices. Not only did people read about asylums in contemporary newspapers, periodicals and guide books, but they also were encouraged in the printed press by newspaper reporters, travellers and asylum officials to tour and inspect these institutions for themselves. As one newspaper article propounded, ‘No more interesting or profitable expedition can employ a day than a visit to the Lunatic Asylum.’30 Even the patient-edited magazine of the Utica asylum, The Opal (1851–60), informed its readers that ‘visitors occasionally take Asylumia in their route’.31 The popular press admonished readers to ‘[w]alk through the wards of an insane asylum, and talk here and there with a patient,’ urging them to educate themselves on a topic of ‘vital interest to humanity’.32 Such calls for engagement did not go unheeded and an ‘endless throng of visitors’ characterised both Utica and Blackwell’s Island asylums.33 In part related to officials’ desire to ensure the committal of family members was not hampered by distance, most asylum superintendents concurred that ‘a reasonable proximity to a large town, always offers many advantages that may be made available in the management of a hospital for the insane, and used to add to [the] enjoyment and improvement of the patients.’34 Some even argued that the location of an asylum for the insane ‘should be central, and in the neighborhood of a city or large village.’35 This desire for proximity to urban centres also had the effect of ensuring that casual visitors had relatively easy access to local asylums. Blackwell’s Island asylum, for example, could be visited after a fifteen- to thirty-minute ferry journey from the mainland, a voyage that was described by one visitor in the 1870s as a ‘delightful ride’.36 However, while asylum superintendents promoted visiting 250

‘In View of the Knowledge to be Acquired’ for specific reasons, visits were interpreted and portrayed by the public in ways that both intersected with and deviated from ‘official’ views. As sites where leisure time could be spent, asylums competed for the attention of the public with a growing roster of popular entertainments that characterised the nineteenth-century urban landscape, especially in New York City where dozens of dancehalls, theatres, museums, and exhibitions sought to attract customers from the working or middle classes. However, many forsook the lure of other entertainments and delights, and instead chose to spend their day sleigh-riding to the Utica asylum for a tour of its grounds or hopped on a ferry to attend the annual fair at the asylum on Blackwell’s Island. The individuals who visited asylums recorded their experiences in an array of media, including travel narratives, diaries, newspapers and magazines. Reflecting the inequalities that pervaded nineteenth-century American society, tales of asylum tours were most often written by white, middle-class males. Often carefully crafted and shaped by contemporary narrative conventions, these accounts nevertheless shed light on how many perceived the asylum and its place in nineteenth-century society. While asylum tourism had multiple, fluctuating and often contradictory meanings in popular accounts, certain commonalities emerge in these narratives.37 In particular, visitors often portrayed asylums, not as mysterious or impenetrable institutions that existed in isolation, but as centres of self-education and ‘scientific’ study. Connected to the broader context of nineteenth-century visual culture, the spectatorship that asylum visitors engaged in was, for many, part of a wider process of education, whereby seeing was the vehicle through which insanity and its treatment could be better understood. Visitors certainly heard, smelled and touched, yet they tended to emphasise the act of ‘seeing’ in their accounts and presented their tours as investigations into the ‘reality’ of asylum life. When situated within the context of nineteenth-century visual culture, visiting can be seen as not simply an anachronistic tradition of spectatorship, but part of a wider cultural movement whereby people – especially the emergent middle class – actively sought to uncover and understand the world around them. Far from being an eccentric pastime in the 1800s, visiting existed alongside a panoply of activities that emphasised spectacle, such as exhibitions and the urban reform movement – as one visitor to Blackwell’s Island asylum noted, New York City itself was a ‘city of observations’.38 In particular, asylum tourism was part of a broader context of visiting the ‘other’ that included sight-seeing tours of prisons, convents and aboriginal communities, activities that were indicative of a society that was enthralled with the human spectacle and embodied the idea that the gaze facilitated understanding.39 Celebrating the visual and upholding ‘ocular demonstrations’ for their educational value,40 visitors to these various 251

Janet Miron ‘sights’ were also seeking reassurance of their own place within society. By seeing the ‘other’ in clearly demarcated spaces, visitors could have their own status in the ‘normal’ world affirmed, even if at times these distinctions were often ambiguous, as some visitors confessed during asylum tours. Occasionally interpreting what they saw according to pre-existing assumptions, members of the middle class could use asylum visiting as an opportunity to reinforce fears surrounding immigration and the ‘foreign born’, primarily the Irish, and to reinforce prejudices concerning the labouring poor. In addition, the growing interest in visual consumption and representation – linked to developments such as the explosion of print culture and advancements in photography and anatomy – helps to explain why asylum visiting captured the attention of so many people. Inventions, such as the daguerreotype in 1839, resulted in what Baudelaire has termed the ‘cult of images’ and led to the scopic regime that became dominant during the nineteenth century, infiltrating all spheres of society and changing the relationship between subject and object.41 With explorations into physiological optics and a growing culture of exhibition, the encapsulation and recreation of reality became a prominent feature of social, intellectual, and cultural life. As Martin Jay has argued in his book, Downcast Eyes: Whether or not one gives greater weight to technical advances or social changes, it is thus evident that the dawn of the modern era was accompanied by the vigorous privileging of vision. From the curious, observant scientist to the exhibitionist, self-displaying courtier, from the private reader of printed books to the painter of perspectival landscapes, from the map-making colonizer of foreign lands to the quantifying businessman guided by instrumental rationality, modern men and women opened their eyes and beheld a world unveiled to their eager gaze.42

Much like the men and women described by Jay, those who toured asylums ‘opened their eyes and beheld a world’ that they felt was, or at least should be, ‘unveiled to their eager gaze’. Owing to this broader cultural milieu, the ways in which visiting was rationalised by the populace hinged on faith in the value of visually-based education or study and it was this very element that helped to render the pastime so popular and instilled it with meaning – at least for the visitor – beyond mere prurient voyeurism. Based on the idea that knowledge lay within the grasp of all visually astute individuals, visiting, like many other popular pastimes, could be justified through the guise of scientific enlightenment and the idea that visual investigation could unravel the mysteries of life.43 252

‘In View of the Knowledge to be Acquired’ Many theories surrounding mental illness in the nineteenth century centred on the act of looking, such as popular phrenology, and paralleled visitors’ tendency to equate the act of viewing with ‘scientific’ study.44 Reflecting almost a democratisation of knowledge and a rejection of exclusive expertise, writers repeatedly emphasised the need for members of the general populace to witness the asylum in person in order to acquire understanding of mental illness. It was through seeing that education could be acquired, not reading or formal schooling, for, as most asylum visitors suggested, what could ensure accuracy more than seeing with one’s own eyes? One visitor, titled his visit to the Utica asylum a ‘Tour of Observation’,45 while another proclaimed: The confidence, the good order, the busy and cheerful activity which prevail in this institution, are really one of the most touching and beautiful spectacles we ever witnessed, and constitute a more effective eulogy on the officers than any which we could write.46

A visitor to the Utica asylum further commented that ‘to a sensitive and reflecting person [visiting] can be a privilege only in view of the knowledge to be acquired,’ thereby echoing the assumption that seeing fostered understanding.47 Visiting and the act of seeing allowed the public to feel as if it could engage with reform-oriented debates – such as those surrounding moral treatment – and evaluate the efficacy of specific experimental therapies, a topic that tended to generate much speculation. For example, one New York Times writer remarked: The experiments made recently upon insane persons in the asylums on Blackwell’s and Ward’s Islands, to determine the value of music as a therapeutic agent, have excited a great deal of interest not only among scientific men, but also among the general public.48

Although voyeurism inevitably underlay asylum tourism, the manner in which visitors represented their activities speaks of a society that valued, for a variety of reasons, first-hand experience and observation. In light of the fascination people had with asylums, nineteenth-century Americans and tourists from abroad refused to be mere passive receptacles of the ideologies espoused and practised by the medical profession. Instead, they were active participants in the endeavour to understand and study mental illness through visual observation. When physicians and natural scientists visited ‘freaks’, according to historian Robert Bogdan, their comments fanned widespread interest in the nature and origin of these creatures and fostered the notion that seeing them was linked to scientific inquiry.49 Likewise, the interest of many asylum visitors was provoked by the 253

Janet Miron popular press which described contemporary approaches to mental illness and emphasised how pressing issues of the day were being worked out in these institutions. One newspaper article exclaimed: In no field of modern scientific inquiry has there been a greater extension of the active humanities than in that which pertains to the treatment of the insane. This domain… wherein ignorance and superstition vied with each other in the infliction of barbaric cruelties, is now thoroughly informed with the spirit of the age.50

Visitors to asylums often commented upon the ways in which their tours had enhanced their understanding of both mental illness and institutional care, portraying their experiences as intellectually meaningful. Refuting any possible charges of prurient voyeurism, one writer explained: My visit was dictated by what may be styled an intelligent and reasonable curiosity, and a desire for information upon a subject as to which, as the doctor said, public curiosity and interest are largely on the increase…. There is a popular and ignorant belief that all lunatic asylums are places of unmitigated horror…. Possibly this delusion will account for much of the curiosity that the doctor referred to. A visit would dispel such a fancy.51

For many, the ‘optics of visiting’ represented an active search for comprehension, an opportunity to engage in meaningful contact with the people inside the institution and to study therapeutic regimes of asylums.52 Straddling the intersection between ‘science’ and ‘spectacle’, asylums were thus central to, rather than at odds with, a growing visual culture in the nineteenth century. In the minds of many in the nineteenth century, visiting constituted an opportunity to evaluate asylums and was predicated on the idea that the power to see abuse, success, or failure lay within the scope of the visitors’ vision, an attitude likely perpetuated in part by the occasional discovery of abuse.53 One visitor to Utica encapsulated the attitudes many held regarding asylum tourism when he explained: I left the asylum and went out through its high stone-pillared portals and under its great trees to the larger ferment and agitation of life beyond its walls, wondering as to how many of the people who think and talk and write about insanity really know anything about it…. We should see for ourselves what class of people [asylum workers] have to deal with.54

Also, responding in a manner similar to many others, a visitor to Blackwell’s Island asylum determined that through ‘actual observation’ the public could see that the institution was based on ‘humanitarian principles’.55 Fearing 254

‘In View of the Knowledge to be Acquired’ corruption would prevail if society did not serve as a watchdog, visitors who passed through asylums often expressed mistrust of the state and opposition to the removal of such activities as executions from the public sphere. One traveller claimed that corruption inevitably arises when ‘the public eye is not present to control’,56 while Isaac Ray remarked that asylums have an ‘air of mystery which stimulates the imagination and excites the apprehensions of the ignorant and credulous.’ He further noted, ‘[a]ny appearance of concealment very naturally gives rise to the suspicion of something wrong.’57 Furthermore, the presence of the public eye fostered the impression that instances of abuse were less likely to occur, for, as Samuel Tuke speculated, ‘the uncertainty of visitors arriving would be some check upon neglect, or improper conduct.’58 One visitor to Blackwell’s Island asylum – who claimed to have been a patient there – stated at the end of his tour: The public mind, filled with the fictions of novel writers, indulges the notion that in all insane asylums persons of perfect sanity are unjustly imprisoned against their will…. I am confident that no instance of the kind exists in the Institution....59

Similarly, a visitor to the State Lunatic Asylum at Utica concluded, ‘my mind has been prejudiced against the Institution… but my visit has very happily removed every doubt.’60 Often representing their tours within a framework of democratic rights, visitors emphasised the notion that they were serving a civic role by ensuring humane treatment of the insane within the asylum. Consequently, in many ways, lay visitors can be seen as playing a role in the growing state apparatus designed to manage deviant behaviour by endowing new institutional methods of regulation with legitimacy and public approval. The tendency to portray visiting as an important educational or civic service was a prominent feature of nineteenth-century accounts, yet there certainly were other incentives behind the practice as well. While some visitors appeared to be motivated by nothing more than a desire to catch a glimpse of those less fortunate, others claimed to be propelled by religious sentiment and a sense of ‘Christian duty’. However, regardless of individual motives, the recorded impressions of visitors and the focus on the act of seeing is indicative of a society that was actively engaged with the topic of mental illness. This involvement stemmed in large part from the conviction that people had an obligation to tour these institutions for themselves and not blindly accept the views and opinions of others. Through visiting, the viewing public was exercising what it believed to be its right – often framed as a democratic right – to reason alongside alienists, state commissioners, and other authorities on the nature and treatment of mental illness. Of 255

Janet Miron course, not all authority figures supported this attitude, and instead, dismissed the active interest of the public in insane asylums. In particular, at one point Superintendent Gray expressed little faith in the public’s ability to comprehend the nature of insanity or its treatment, portraying this knowledge as the reserve of the trained medical élite, and criticised the ‘talk of inexperienced, self-styled “alienists”, who are without practical knowledge of the disease – people whose eyes, by an occasional visit to an asylum, serve them in the place of knowledge and experience.’61 Nevertheless, the public refused to adhere to Gray’s demarcations between ‘experienced’ and ‘inexperienced’ and insisted upon their right and ability to evaluate, condemn or condone, and study contemporary treatment of mental illness through asylum tourism. Patient responses to the public Officials and the public had their own views of visiting; however, patients also played a role in determining the relationship that would be forged between the asylum and the outside world. Whereas many historians have portrayed the institutionalised as entirely silenced, as ‘so completely removed from view that their presence could not speak for them’,62 the insane refused to be mere passive bystanders during visits from the public and sought to benefit from these interactions with the ‘free’ world. In their collection, Isolation: Places and Practices of Exclusion, editors Alison Bashford and Carolyn Strange discuss the complexities of institutionalisation, colonisation, and other processes of marginalisation, arguing, ‘[p]eople forced into isolation are rendered objects through exclusionary practices, yet they remain subjects, who claim and remake spaces through patterns of accommodation and resistance.’63 Similarly, patients, although restrained, refused to be either controlled completely by their keepers or contained by the gaze of strangers. Instead, many used the presence of the public as a means to improve the condition of their confinement. Unfortunately, sources that shed light on patient experiences and views are rare and those that do exist are often problematic. For example, The Opal was a magazine edited, written, and printed by patients at the Utica asylum.64 A monthly journal for most of its existence, The Opal garnered a respectable number of paying subscribers; in 1851, it had nine hundred paying subscribers and, in addition, was exchanged for ‘two hundred and twenty-seven weeklies, four semi-weeklies, eight dailies and thirty-three monthlies’.65 However, in spite of patient involvement, The Opal was ‘censored by Physicians and assistants’ in theory, and thus may not accurately depict patients’ attitudes and experiences.66 Moreover, those who wrote for the periodical did not necessarily represent a wide range of patients. As Maryrose Eannace’s examination of the journal and patient case files 256

‘In View of the Knowledge to be Acquired’ suggests, the majority of contributors were residents in the first halls of the asylum and were ‘of better than average education… and the majority were private patients rather than wards of the country’.67 Furthermore, in light of the paucity of sources written by the institutionalised, it is often the words of others, found primarily in institutional records, popular magazines and travel narratives, that must be relied upon by the historian. Visitors were not always upfront about their identities and may have ‘tricked’ some patients into providing them with personal information. Nevertheless, while the stories of patients were influenced by a variety of factors and often filtered through the eyes of visitors, the writings by both visitors and patients help to reveal the psychological and material experiences of asylum confinement and the role patients saw the public playing in institutional affairs. The asylum imposed profound physical and mental restrictions on those confined within it and also posed innumerable dangers. However, in addition to the threat of abuse from attendants and other patients, the daily realities of institutional life could entail boredom and loneliness. Feelings of isolation were particularly exacerbated by the fact that superintendents usually restricted visits from family members and intercepted all mail moving in and out of the institution.68 Strangers may have contributed towards this sense of social alienation, yet the receptivity of patients to strangers and the extensive interactions that took place suggests something more complex. Indeed, records written by patients indicate that many did not perceive themselves as mere objects of the visitors’ gaze, and instead, derived some satisfaction from the public’s presence. One writer in The Opal stated, ‘[t]he monotony of our every-day life is broken by receiving company,’69 while another writer for the magazine felt heartened by the interest people had in the asylum and was pleased with the large numbers who attended the annual fair in 1858. Although sarcasm is always a possibility, he or she described the people of Utica who frequently toured the institution as ‘constant, so true hearted, so respectable, and so intelligent’ and concluded that visitors to the annual fair must have learned ‘what charming, and funny, and ingenious people lunatics are’.70 Furthermore, even if some visitors were not honest with patients, for many institutionalised people, the fact that there was an outsider to whom they could tell their story could often provide temporary comfort or distraction from the hardships of their confinement. Consequently, patients frequently engaged in conversations with strangers passing through their institutions, occasionally ‘buttonholing’ visitors in order to voice their grievances or share their experiences and opinions.71 Aside from the opportunity for conversation, many patients associated the presence of outsiders with those institutional therapeutic practices that emphasised socialisation and entertainment. Musical concerts, plays and 257

Janet Miron athletic games often took place at Utica and generally included the participation of the public. One patient at the Utica asylum implicitly defended the involvement of the outside world by highlighting the enjoyable nature of these amusements for all participants. While realising few citizens are ‘aware of the entertainments, which are got up at the Asylum – and none would think of finding amusements there,’ the author argued that on those occasions in which the public interacted with patients, joy ‘abounded’. He or she described one event in which ‘ladies and gentlemen from the city’ were invited to an evening of entertainment that included ‘a display of mesmerism, which was... a capital burlesque in that science.’ According to the writer, all members of the audience were ‘convulsed with laughter’.72 Not only could visitors help to relieve the monotony and loneliness associated with institutional life through social interaction, but they themselves unwittingly provided patients with a source of entertainment. The misconceptions or ignorance of visitors to Utica asylum provided contributors and readers of The Opal with much amusement, and stories of bumbling strangers were frequently recounted in its pages. The female visitors who questioned whether patients understood the moves of a checkerboard game led to ‘a pretty sonorous roar of laughter’, while another visitor was ‘somewhat “taken in”’ by one inmate – a ‘youngster with intelligence in one eye, and mischief in the other’ – whose claim that the steam register was actually a mechanical device for steam therapy led to the speedy departure of the anxious visitor and provoked ‘manifest amusement’ amongst the patients.73 As well, tales of visitors unable to leave at the end of their tour was a recurring theme in The Opal. One writer warned, ‘I came here a visitor… I am insane now’, while another was even more direct in highlighting ‘the dangers’ of asylum tours.74 He or she stated: It might be as well, by way of warning, to say that the Superintendent is obliged by every consideration of persons, who, though supposing themselves to be visitors, yet act in such a way as to justify the conclusion that they will derive benefit from the sanative discipline of such an Institution as this. Great circumspection therefore should be maintained by all visitors – especially young men.75

Through such thinly veiled threats, patient–writers were perhaps warning visitors that a certain decorum and respect was expected of them and that the line between sane and insane, visitor and patient, could become dangerously blurred at times. Visitors also distracted patients from the tedium of institutional care in more direct and material ways. In fact, if asylum managers were benefiting financially through donations and sales, then patients seemed equally 258

‘In View of the Knowledge to be Acquired’ determined to exact their own fees. Consequently, many visitors were aware of patients’ expectations and came prepared on their tours with items for the institutionalised. Tobacco and liquor were common items that visitors reportedly gave patients behind the backs of asylum employees, and undoubtedly many patients felt that having to tolerate strangers was well worth such treats in an otherwise bleak environment. As one visitor remarked, a female patient in the asylum on Blackwell’s Island: [A]ttacks every man who may happen to be a few yards off with demands for tobacco. If her request is complied with she pockets her treasure, pats the donor on the back or cheek, in token of thanksgiving, and rejoins her companions.76

Consequently, a flourishing trade often developed between patients and visitors77 – a ‘problem’ that vexed not only administrators but even the ferry department responsible for transporting employees and visitors to the institutions on Blackwell’s Island. The ferry department complained that not only were the increasing number of visitors to the institutions on Blackwell’s Island ‘unusually arduous’, but that their work was burdened by having to search visitors for ‘bottles of spirituous liquors’, a ‘considerable number’ of which had been confiscated.78 While some of the institutionalised may have ‘appeared much gratified when spoken to by any of the visitors’, for others, the presence of visitors offered little consolation. One contributor to The Opal believed asylums should ‘be retired’ from ‘the gaze of idle curiosity’,79 and another patient complained, ‘Oh the rapid and superficial glances of scrutinizing observers! Oh the monster gaping crowd of the curious!’80 One rare in-depth account written by a person who had been institutionalised in an asylum refers to the phenomenon of visiting, and highlights the opposition many patients may have felt towards the presence of the public. In 1868, the Reverend H. Chase published a memoir of his experiences in New York’s State Asylum at Utica, entitled, Two Years and Four Months in a Lunatic Asylum, From August 20th, 1863, To December 20th, 1865. Chase began his narrative by condemning the public’s ignorance of the conditions inside asylums, arguing that he wrote his book ‘for the purpose of opening the eyes of the people… that they may enquire more strictly into the nature and workings of these institutions of benevolence, so called.’81 Chase was critical of the treatment patients received at Utica and hoped his book would: [W]arn the good people of the State of New York to never send their wives, their children, or any of their dependents to a State institution for the cure of any disease of body or mind, where the patient is confined by bolts and

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Janet Miron bars by legal sanction, and where the sole power over the patient is vested in one man.82

However, in spite of his strong feelings about the asylum and his hope that the public would become better educated as to the conditions inside its walls, Chase never explicitly recommended public tours, and indeed expressed great dislike for the practice while a patient there. Nevertheless, a number of years after being discharged, Chase went on a tour of the asylum himself and thus may not have been entirely opposed to the practice, only to the fact that visitors were not seeing the normal workings of the asylum.83 When so few accounts such as Chase’s are available to the historian, it is difficult to discern the reactions of patients to visitors. Whereas some clearly disliked their presence, others either paid them no heed or eagerly interacted with them. In contrast to Chase, one ex-patient of Blackwell’s Island asylum wrote an article about the institution after being released and did not express any hostility towards members of the public who toured asylums. This writer emphasised the variety of reactions to visitors amongst patients and the toleration of them by physicians, and explained to readers of Harper’s how admission as an ‘ordinary pleasure-seeker’ could be gained.84 Clearly, whether it be from the perspective of the patient, visitor or official, there was no consensus regarding the implications of public tours of asylums. Rather, the practice could serve a variety of interests and be interpreted, represented, used, and manipulated by the parties involved in manifold ways. Conclusion Although riddled with constraints, assumptions and competing interests, the practice of visiting nevertheless reveals the fact that asylums were deeply embedded within the broader social and cultural milieu of the nineteenth century. The fact that interaction took place between asylums and the communities surrounding them is in itself important, even if it is possible to discern only how the asylum and its relationship to the world beyond its walls was represented by officials, the public and patients. Furthermore, when the widespread phenomenon of visiting is included in asylum histories, the idea that the isolation or privatisation of mental illness occurred with the construction of edifices to house those labelled insane becomes problematic. Although segregation manifested in both spatial and psychological ways and the walls of the asylum were never erased, isolation was never complete nor was it even an objective embraced unilaterally by either asylum officials or the public in the nineteenth century. Asylums did not exist simply to hide the insane from greater society, but instead, were sites that were familiar to and visited by large numbers of people, people who sought engagement with contemporary approaches to and treatment for 260

‘In View of the Knowledge to be Acquired’ mental illness. Nevertheless, by the end of the century, rules surrounding the visiting public would become more and more stringent, and increasingly, commentators would lament ‘the mystery which now constitutes the atmosphere of the asylum’ and its ‘inaccessibility to the general public’.85 Notes 1. I would like to thank the support given to me by the Associated Medical Services, Inc. in the form of a Hannah General Scholarship and Travel Grant, which facilitated much of the research behind this chapter. 2. ‘A Day in a Lunatic Asylum’, Harper’s New Monthly Magazine, 9, 53 (1854), 653–9. 3. Visiting by the public was not unique to New York State, nor did it characterise only asylums. For a broader study of asylum and prison visiting in nineteenth-century Canada and the United States, see my ‘“As in a Menagerie”: The Custodial Institution as Spectacle in the Nineteenth Century’ (unpublished PhD dissertation, York University, 2004). 4. Testimony Taken by the Special Committee to Investigate the Affairs and Management of the State Lunatic Asylum at Utica (Albany: Weed, Parsons and Company, 1884), 1233. Unfortunately, when this research was being conducted, the visitors’ book for Utica could not be located by the New York State Library and Archives. 5. W. Logie Russell, The New York Hospital: A History of the Psychiatric Service 1771–1936 (New York: Columbia University Press, 1945), 76. 6. A. Digby, Madness, Morality and Medicine: A Study of the York Retreat, 1796–1914 (Cambridge: Cambridge University Press, 1985), 3; P. Allderidge, ‘Bedlam: Fact or Fantasy?’ in W.F. Bynum, R. Porter and M. Shepherd (eds), The Anatomy of Madness: Essays in the History of Psychiatry, Vol. II (London: Tavistock Publications, 1985), 24. 7. E. Dwyer, Homes for the Mad: Life Inside Two Nineteenth-Century Asylums (New Brunswick: Rutgers University Press, 1987), 26–7. 8. J.A. Crets, ‘“Well Worth the Visitor’s While”: Sightseeing in St Louis, 1865–1910’, Gateway Heritage, 20, 3 (Winter 1999–2000), 18. 9. There were important differences between Utica and Blackwell’s Island asylums; in particular, whereas Utica contained both paying and non-paying patients, the New York City asylum served only non-paying. Nevertheless, their histories followed a similar trajectory. Both institutions were founded on similar ideals yet were plagued with serious problems as the century progressed, such as overcrowding. Although Blackwell’s Island asylum has garnered little attention from scholars, Utica asylum is explored in Dwyer, op. cit. (note 7). 10. Ibid., 28 and 7.

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Janet Miron 11. W.I. Cole, ‘Boston’s Insane Hospital’, New England Magazine (old series), 25 (September 1898–February 1899), 253. 12. ‘Sketches From the Life School: Number Three’, New York Daily Times, 27 September 1852. 13. ‘Insanity’, Christian Inquirer, 3, 23 (17 March 1849), 90. 14. D.J. Rothman, The Discovery of the Asylum: Social and Disorder in the New Republic, rev. 2nd edn (Boston: Little, Brown, 1971), 130. 15. Dwyer, op. cit. (note 7), 37–8. 16. ‘“Journal of Prison Discipline” and Lunatic Asylums’, Journal of Insanity, 2, 2 (October 1845), 177–8. 17. W.P. Letchworth, Commissioner, Extract from the Eleventh Annual Report of the State Board of Charities of the State of New York Relating to the Charities of the Eighth Judicial District (Albany: Argus Company, Printer, 1878), 37. See also, Report of the Commission Appointed to Inquire into the Expediency of Revising the System of Administration of the Public Charities of the Commonwealth (Boston: Rand, Abery, 1878), 20. 18. ‘Blackwell’s Island Lunatic Asylum’, Journal of Insanity, 4, 3 (January 1848), 272. 19. ‘Amariah Brigham, MD’, Journal of Insanity, 6, 2 (October 1849), 188–9. 20. Testimony Taken by the Special Committee to Investigate the Affairs and Management of the State Lunatic Asylum at Utica, Exhibit no. 1, ‘Rules, Regulations and By-Laws of the New York State Lunatic Asylum’, 1167–9. 21. New York Public Library, Cp v 1711. T. Romeyn Beck, An Inaugural Dissertation on Insanity (New York, 1811), 27–34. 22. Cited in D.H. Trezevant, Letters to His Excellency Governor Manning on the Lunatic Asylum (Columbia: R.W. Gibbs, 1854), 31, 44–5, and 53. 23. NYSLA LEG 493.1-4. Testimony op. cit. (note 4), 1233. 24. Third Annual Report of the Governors of the Alms House, New York, For the Year 1851 (New York, 1852), 106. 25. Eleventh Annual Report of the Governors of the Alms House, New York, for the Year 1859 (New York, 1860), 186. 26. A. Brigham, ‘Brief Notice of the New York State Lunatic Asylum, at Utica’, Journal of Insanity, 1, 1 (July 1844), 6; ‘Second Annual Fair at the N.Y. State Lunatic Asylum’, Journal of Insanity, 1, 4 (April 1845), 348. 27. W.H. Davenport, ‘Blackwell’s Island Lunatic Asylum’, Harper’s New Monthly Magazine, 32, 189 (1866), 276–94: 278. 28. Testimony Taken by the Special Committee, op. cit. (note 20), 1167. 29. ‘The State’s Insane Wards’, New York Times, 4 July 1887. 30. ‘Sketches From the Life School: Number Three’, op. cit. (note 12). 31. ‘Editor’s Table’, The Opal, 6 (1856), 269.

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‘In View of the Knowledge to be Acquired’ 32. S. Osgood, ‘Mental Health’, Harper’s New Monthly Magazine, 28, 166 (1864), 494–500: 494; ‘New York State Lunatic Asylum’, Tribune, 13 February 1869. 33. ‘Governor Hoffmann’s Visit to the State Lunatic Asylum at Utica’, The World, 1 October 1870. 34. T.S. Kirkbride, ‘Description of the Pleasure Grounds and Farm of the Pennsylvania Hospital for the Insane’, Journal of Insanity, 4, 4 (April 1848), 251. 35. ‘Lunatic Asylums in the United States’, Journal of Insanity, 2, 2 (October 1845), 174. 36. ‘Local Intelligence’, New York Times, 8 July 1866. 37. For a broader discussion of visitor motives, see J. Miron, ‘“Open to the Public”: Touring Ontario Asylums in the Nineteenth Century’, in J.E. Moran and D. Wright (eds), Mental Health and Canadian Society: Historical Perspectives (Montreal: McGill-Queen’s University Press, 2006), 19–48. 38. ‘A Day With Lunatics’, New York Times, 27 December 1870. 39. On aboriginal communities as sites of tourism, see P. Raibmon, Authentic Indians: Episodes of Encounter from the Late-Nineteenth-Century Northwest Coast (Durham: Duke University Press, 2005). 40. See J. Crary, Techniques of the Observer: On Vision and Modernism in the Nineteenth Century (Cambridge: MIT Press, 1990); and M. Jay, Downcast Eyes: The Denigration of Vision in Twentieth-Century French Thought (Berkeley: University of California Press, 1993). 41. Jay, ibid., 435. 42. Ibid., 69. 43. On the place of science in American society, see J.C. Burnham, How Superstition Won and Science Lost (New Brunswick: Rutgers University Press, 1987). 44. On the popular appeal of phrenology in the United States, see: M.M. Sokal, ‘Practical Phrenology as Psychological Counseling in the NineteenthCentury United States’, in C.D. Green, M. Shore and T. Teo (eds), The Transformation of Psychology: Influences of 19th-Century Philosophy, Technology, and Natural Science (Washington: American Psychology Association, 2001). 45. ‘The State’s Insane Wards’, New York Times, 4 July 1887. 46. ‘Sketches From the Life School. Number Three’, op. cit. (note 12). 47. New York Tribune, 13 February 1869. 48. ‘The City’s Pauper Insane’, New York Times, 25 March 1878. 49. R. Bogdan, Freak Show: Presenting Human Oddities for Amusement and Profit (Chicago: University of Chicago Press, 1988), 27. 50. ‘The City’s Pauper Insane’, New York Times, 24 August 1883. 51. ‘The State’s Insane Wards’, op. cit. (note 45).

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Janet Miron 52. This idea parallels the work of Rudy Koshar, who writes of the ‘optics of tourism’ in ‘“What Ought to Be Seen”: Tourists’ Guidebooks and National Identities in Modern Germany and Europe’, Journal of Contemporary History 33, 3 (1998), 339. 53. For example, see the discussion of a newspaper reporter who uncovered a ‘series of disasters’ at Blackwell’s Island asylum, which were ‘undetected’ by the New York State Board of Charities, in W.A. Hammond, ‘The Treatment of the Insane’, The International Review (March 1880), 229–30. Suspicion of what went on behind the asylum walls and public interest in these institutions was so extensive that a number of stunt reporters had themselves committed to experience patient life. The most famous of these was Nellie Bly, who feigned insanity and was committed to Blackwell’s Island asylum for ten days. For a discussion of Bly, see: J.M. Lutes, ‘Into the Madhouse with Nellie Bly: Girl Stunt Reporting in Late Nineteenth-Century America’, American Quarterly, 54, 2 (2002) 217–53. 54. ‘The State’s Insane Wards’, op. cit. (note 45). 55. ‘The Insane Asylum’, New York Times, 29 October 1873. 56. Serjeant W. Ballantine, The Old World and the New: Being a Continuation of his ‘Experiences’ (London: R. Bentley, 1884), 82. 57. I. Ray, ‘The Popular Feeling Towards Hospitals for the Insane’, Journal of Insanity, 9, 1 (July, 1851), 38. 58. S. Tuke, Description of the Retreat: An Institution Near York for Insane Persons of the Society of Friends [1813], repr. (London: Dawsons of Pall Mall, 1964), xii. 59. Davenport, op. cit. (note 27), 293. 60. ‘Visit to the State Lunatic Asylum’, The Cobleskill, 25 January 1873. 61. Testimony Taken by the Special Committee to Investigate the Affairs and Management of the State Lunatic Asylum of Utica (Albany: Weed, Parsons and Company, 1884). NYSAL LEG 493.1–4 Appendix, Exhibit No. 37, 1232. 62. M. Eannace, ‘Lunatic Literature: New York State’s The Opal, 1850–1860’ (unpublished PhD dissertation: State University of New York, 2001), 24. 63. A. Bashford and C. Strange, ‘Isolation and Exclusion in the Modern World: An Introductory Essay’, in C. Strange and A. Bashford (eds), Isolation: Places and Practices of Exclusion (London: Routledge, 2003), 1–19: 12. 64. Eannace, op. cit. (note 62), 90. For additional discussion of The Opal, see: B. Reiss, ‘Letters from Asylumia: The Opal and the Cultural Work of the Lunatic Asylum, 1851–1860’, American Literary History, 16, 1 (2004), 1–28. 65. ‘Ninth Annual Report of the Manager of the State Lunatic Asylum at Utica’, (1852), 32–3. 66. ‘On the Claims of the Insane’, The Opal, 2 (1852), 242. While censored by institutional officials, it is impossible to gauge how much the magazine was actually interfered with. Criticisms of the asylum and staff were not

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‘In View of the Knowledge to be Acquired’ common, yet they nevertheless occurred occasionally. In an article titled, ‘Life in the Asylum’, the female author wrote: Now comes the power of man, with his scaffoldings and hammer sounds. I try to pass his boundary and my fate is declared. The master, man, makes me a lunatic in these walls… The Doctor is the champion knight here, and his process is one of bitter pills. [The Opal, 5, 1 (1855), 5.] That such a harsh description of the doctor could be published suggests that the censorship practised was not necessarily severe. Moreover, writers for the magazine frequently referred to their autonomy and insinuated that, in practice, officials did not exercise any authority. According to one patientwriter: We deem it proper to say, here, that its [The Opal’s] articles are all written by patients, and under no other ‘supervision’ or restraint than their own genii. The beloved and honored Superintendent, nor either of his estimable assistants interpose any control or direction in the production of the brains or pens of the contributors to the OPAL. [The Opal, 5 (1855), 188.] 67. Eannace, op. cit. (note 62), 90. 68. For a nineteenth-century discussion of the censorship of mail in asylums, see: Hammond, op. cit. (note 53), 234–5. 69. The Opal, 11 (1861), 347. 70. The Opal, 8 (1858), 181. 71. Ibid., 281. 72. ‘Schools in Lunatic Asylums’, Journal of Insanity, 1, 4 (April 1845), 327–8. 73. ‘The Editor’s Table’, The Opal, 2 (1852), 26–7. 74. ‘Life in the Asylum’, The Opal, 5 (1855), 4–5. 75. ‘Editor’s Table’, The Opal, 2, 4 (1852), 122. 76. Davenport, op. cit. (note 27), 280. 77. ‘The Work-House – Blackwell’s Island’, Harper’s New Monthly Magazine, 33 (1866), 692. 78. NYCPL, *z-6416. Eleventh Annual Report, op. cit. (note 25), 172–3. 79. ‘The Ladies Fair’, The Opal, 5 (1855), 82. 80. The Opal, 3 (1853), 291. 81. H. Chase, Two Years and Four Months in a Lunatic Asylum, From August 20th, 1863, to December 20th, 1865 (Saratoga Springs: Ban Benthuysen & Sons Steam Printing, 1868), 9. 82. Ibid.

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Janet Miron 83. Ibid., 93. 84. Davenport, op. cit. (note 27), 278–9. 85. Hammond, op. cit. (note 53), 236.

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12 ‘Amusements are Provided’: Asylum Entertainment and Recreation in Australia and New Zealand c.1860–c.19451

Dolly MacKinnon This chapter examines the official ‘entertainment’, in all its forms, provided to inmates in Australian and New Zealand asylums – later mental hospitals – between c.1860 and c.1945. Visitors came into asylum grounds and patients were permitted periods of leave, all for the purposes of entertainment and recreation. Surviving recreation buildings, their grounds and institutional archives, bear silent witness to the noisy and lively recreational activities of past patients, staff and visitors. This chapter reconstructs these practices in twenty public and three private asylums from this period by examining a diverse range of sources, including archives, histories of asylums and newspaper articles.

Stereotypical views of the asylum conjure up images of isolation and confinement. Remote from the community, the asylum is cut off from everyday life. But it is clear from the evidence contained in institutional records and contemporary newspaper accounts, that the walls of the asylum were permeable. Visitors came into the asylum grounds and patients were permitted periods of leave, all for the purposes of entertainment and recreation. Using a diverse range of sources, including archives, histories of asylums, and articles published in newspapers from the period, we are able to explore ‘entertainment’ in its many forms in twenty public and three private asylums – later mental hospitals. These records reveal that entertainment could cover a vast range of activities. There were various forms of physical exercise including dances and balls, walks, boat rides, as well as indoor and outdoor sports. Indoor recreation included films, music making, and the provision of newspapers and magazines for individual amusement. Entertainments might involve patients, staff and visitors as either spectators or participants. Family and friends also provided informal entertainment in the form of parcels of newspapers and magazines, as well as fruit and tobacco sent on a regular 267

Dolly MacKinnon basis. In the more isolated asylums, the provision of recreation fell to the staff and certain patients, who had to rely upon their own resources in order to entertain each other. The provision of recreational activities for asylum inmates came from three main sources: paid professional groups, volunteers – from both inside and outside the asylum – and the asylum band. The economic imperative for public and private asylums in Australia and New Zealand was to pay for only those services that could not be obtained through voluntary work by individuals, community groups or by staff and patient labour. Asylums made strenuous efforts to include the community by holding extravagant annual asylum balls, and by the involvement of staff in community cricket and football competitions, all of which brought visitors into the asylum. Initially, dining halls, day wards or airing yards were used to hold entertainments. As asylum complexes grew, purpose-built recreation halls and grounds were constructed. The asylum buildings and grounds, like the forms of employment, entertainment and recreation, were gendered. Music was deemed particularly appropriate for women, while outdoor sports proved especially advantageous for men. Providing entertainment combatted the effects of institutionalisation. Entertainment and recreation gave select inmates normal experiences of the outside world ‘inside’ the asylum walls. Although asylums came to have purpose-built recreation buildings, they were never intended to accommodate the entire asylum population. Equally, gramophones, pianos and games were only placed in some wards. Technological advancements such as film and radio – while they were subject to censorship – were considered beneficial as they created an interactive and realistic link to the outside world. From 1910 onwards, silent films, with piano accompaniment provided by either an inmate or a member of staff, were shown as the main form of patient entertainment.2 From the 1930s, centralised radio sets were installed in wards.3 Also, patients who were considered well on the way to recovery were granted ‘leave’ – for a period of hours, a day or a weekend – from the asylum to attend dances and films in nearby local towns. Recreation and amusements as a treatment regime Australia and New Zealand looked to the practices of recreation and amusement that developed from the non-restraint movement in the first half of the nineteenth century in Britain. Much, but not all, of this recreation was provided inside the asylum buildings and grounds. Indoor and outdoor recreational activities were gendered, and often incorporated the employment of the free labour of patients in activities common outside the asylum.4 Dr Attfield of the Fremantle Asylum, Western Australia, stated that 268

‘Amusements are Provided’ ‘all rational amusement and indulgence that is possible under the peculiar circumstances of this asylum’ is provided and that: Books are regularly supplied, and a good proportion of men read daily; several games at ball, such as fives or cricket, together with draughts in the evening, constitutes their chief amusement. Washing, sewing, and housework constitute the chief employment for the women….5

At Yarra Bend Asylum, Victoria, male patients made ‘Cricket and Footballs’ as a form of employment.6 Medical staff in Australia and New Zealand from the 1870s onwards increasingly called for the incorporation of asylum spaces specifically set aside for recreation, namely chapels, halls and sports grounds. Initially, space for Divine service was requested, as this was considered essential in the treatment of the mentally ill as ‘something is wanted even with insane people to mark distinctly the Sunday, and without such an adjunct as this to the institution the attempt at a line of demarcation will ever be impossible.’7 Hymn singing was considered especially beneficial for women.8 The constant pressure on available space meant that buildings fulfilled a number of functions. The use of day wards and airing yards for entertainments highlighted the need for recreation halls. But there was often a considerable delay in the actual building of these facilities. At New Norfolk Asylum, Tasmania, a concerted effort over a twenty-year period had been made to build a recreation hall. Dr Lalor pressed again in 1919 that: Fully 18 years ago the late Medical Superintendent, Dr MacFarlane, advocated the erection of, and the necessity for, this building, on account of all religious services and amusements etc., having to be carried out in the female dayroom, which arrangement necessitated the male patients having to be conveyed frequently at night into the female division, which practise, apart from being objectionable, caused great anxiety continually to the female nursing staff… and, as such entertainments are recognised an important part in the mental recovery of patients, it should be considered a matter of importance that such a building be erected as soon as possible.9

When not in use, recreation halls were often used as workrooms, or even as dormitories to accommodate overcrowding. The Board of Official Visitors (1879) for Kew Asylum, Victoria, stated that they: [C]annot but regret the idea of the large hall… being appropriated for sleeping accommodation for female patients, as it will thereby prevent the use of it for religious and amusement purposes, so essential in many cases for the recovery of the inmates.10

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Dolly MacKinnon The constant increase in patient populations meant that, by 1937, New Norfolk’s recreation hall was considered ‘far too small, and owing to the low ceiling, the acoustic properties were very poor. This hall was really a day room, and often patients had to be turned out of it to make provision for functions which were held there.’11 The most well-known indoor amusement was the iconic asylum ball, a prominent feature of the nineteenth-century popular press in Britain, Australia and New Zealand, as well as in published histories of psychiatry. The ball served a number of functions both inside and outside the asylum walls. It provided an excellent, highly controlled public relations opportunity between the asylum and the broader community, official visitors and invited guests, as it demonstrated the success of the new treatment regimes through the interactions of well-behaved female and male patients and institutional staff. It also reflected the institutions’ obligation to rehabilitate patients back into society by socialising them through their participation in everyday activities.12 The famous illustration of the ‘Twelfth Night Entertainments at the Hanwell Lunatic Asylum’, from the Illustrated London News, 5 January 1848, championed the reforms in treatment, and was matched by similar images from the 1860s for Australia and New Zealand. Asylum balls and entertainments were designed to be amusements for select patients and the broader community, as well as revenue raisers for specific asylum projects (Figure 12.1). They contained some paid performers, as well as voluntary performances by attendants who were expected to provide their sporting, musical and dramatic abilities for free for the greater good of the asylum. In order to accommodate the different tastes of patients, staff and visitors, the entertainments provided were diverse, ranging from concert programmes of classical chamber music, folk music as well as popular songs through to popular culture spectacles. At New Norfolk Asylum, the Queen’s Birthday celebrations of 1866 comprised ‘fireworks’, an ‘Amateur Performance by the Attendants’, followed by ‘Refreshments’ and ‘dancing’.13 The proceeds went towards purchasing ‘materials for slips and scenery to form a stage’.14 The following year, a lengthy list of entertainment, including the ‘Exhibition of the Performing Elephant’, funded the ‘Prince Alfred’s Decoration Fund’ and went ‘towards purchasing a Piano’.15 The Woogaroo Lunatic Asylum, Queensland (later known as Goodna Hospital for the Insane, and then Brisbane Special Hospital – this chapter will use contemporaneous titles) held weekly balls, and had ‘an extra entertainment… at Christmas’ and ‘an exhibition of performing dogs and monkeys’.16 The Auckland Mental Hospital, New Zealand (also known as the ‘Whau’, hereafter Auckand Hospital) during the 1870s, ‘with the aid of subscriptions and supplementary assistance from the… Provincial 270

‘Amusements are Provided’ Figure 12.1 Collingwood Lunatic Asylum Ball, Victoria, Australia, 1868 Source: ‘Collingwood Lunatic Asylum Ball’, Illustrated Melbourne Post, 12 October 1868, 156. Reproduced by kind permission of the La Trobe Picture Collection, State Library of Victoria.

Government’ was able ‘to purchase a suite of theatrical scenery’, erect a temporary stage ‘in the dining hall’, and hold ‘dramatic and musical entertainments’ that ‘seemed to afford much gratification to the patients.’17 At New Norfolk, the lack of a recreation hall prior to 1937 meant that entertainments were held in the female section and ‘only the best behaved male patients’ were ‘being admitted’.18 The division of entertainments for the better behaved patients is a constant feature of the descriptions of asylum balls. The Illustrated Melbourne Post (1868) reported that regular dances held on ‘alternate Thursdays… are well attended by those living in the neighbourhood, and 271

Dolly MacKinnon the best behaved of the patients are allowed to join’.19 The broader community was able to see the benefits of their government-funded asylums through the ‘normal’ social activities of the better behaved patients. Less elaborate entertainment was also provided for some of the back wards. At New Norfolk Asylum, in 1880, the Patients’ Ball was accompanied by the ‘Asylum Fife Band’, and ‘those patients not attending the above [were] Dancing to the Hand Organ in [the] Back Yard’.20 The use of music as an amusement in institutions served a number of functions: it offered light relief from the monotony of institutional life; it provided a link to the outside world through the visiting groups of musicians who came inside the asylum walls; the sound of the musical performances offered an alternative soundscape to the everyday noises of asylum life; and it must have lifted the spirits of many of the patients and staff who attended. Entertainments forged important political and social links between the invited guests and the institution. Charity concerts were one of the oldest methods by which medical institutions raised large sums of money within the community, by skilfully ‘combining pleasure with use, [and] private entertainment with public utility’.21 In 1868, the New Zealand Herald reported a performance by an amateur group The Whau Minstrels, in the dining room at the Auckland Hospital. The ‘object for which the concert was given… could never fail to recommend itself to the sympathy and warm support of the philanthropic portion of the people of Auckland’ with ‘a large and highly respectable audience’ numbering a hundred and fifty. At the conclusion, Dr Fischer ‘thanked the Minstrels on behalf of the officers and patients, for the liberal and kind manner in which they had come forward to assist them,’ and added ‘that the proceeds would be something handsome.’22 Prominent members of this community ‘would never hesitate to come forward whenever their services could be of any use to that or any other charitable institution.’23 Not all amusements provided by visitors were a success. The ‘Magic Lantern Exhibition’ at New Norfolk Asylum was described as ‘the most miserable exhibition ever given in the Hall.’24 Good intentions may have driven this ‘miserable’ performance, but the reluctance on the part of some visitors to provide the mentally ill with an adequate standard of entertainment was not missed by Queensland authorities. At Goodna Hospital the Salvation Army Brass Band rehearsed rather than performed in front of the patients. The staff – clearly not impressed by this – in the Annual Report publicly thanked the band members for their ‘disinterested efforts’.25 Financial constraints meant that institutions were adept at only paying for those services they could not otherwise obtain through free patient 272

‘Amusements are Provided’ labour or the services of voluntary community groups or individuals. Room was made within the regimented world of the institution to: [I]nvite the assistance of any persons willing to contribute to the amusement of the patients by music, singing, reading on amusing subjects… and that the cost of conveying such persons to and from the Asylum, [would] be defrayed by the Government, if necessary.26

As Dr Robertson, observed for Victoria, ‘By such means the inside and outside world are brought, as it were, together.’27 A constant feature of provision of recreation for patients between c.1860 and c.1945 in Australia and New Zealand, was the ebb and flow in levels of voluntary contributions either in cash or in kind for the provision of recreation for patients within the institution. It was difficult for institutions to maintain a constant supply of entertainers. Woogaroo Asylum, lamented that entertainments ‘have generally dwindled into a perfect parody’ as there was ‘no piano… no [asylum] band in existence, and the dancers have to do their best to the strains of a concertina’.28 This was considered to be a direct result of a lack of strong links between the community and the asylum, as there was no organised programme of entertainment. These asylums were unlike ‘other places’, where ‘it is usual for lady and gentleman amateurs to patronise such entertainments.’29 The entertainments that did take place ‘suffered much from the lukewarm manner in which they have been attended and supported by the better classes...’.30 Two world wars within twenty-five years had serious implications for institutions in Australia and New Zealand, resulting in staff shortages and the inevitable redirection of resources. What occurred in Australia and New Zealand was a temporary cessation during the wars of voluntary groups providing regular entertainment. This was coupled with a redirection in the aims of those limited entertainments that could be mustered away from forms of patient recreation within the asylums, towards the broader patriotic endeavours of the community.31 The First World War curtailed much of the voluntary entertainments provided to institutions ‘owing to outside people being busy with war and patriotic work’.32 The Recreation Hall at Goodna Hospital, in addition to ‘patients’ entertainments… has been frequently used for patriotic entertainments, and sums of not inconsiderable amount have been sent from there to various war and patriotic funds’.33 When, in 1940, the staff of the Porirua Hospital, New Zealand, requested permission to hold their annual staff ball, ‘the inspector general replied; “I am not going to approve of a staff dance under the present circumstances, and trust the staff will not pursue the matter.”’34 Instead, staff efforts were to be redirected towards ‘a social evening with the proceeds devoted to Patriotic funds’ which 273

Dolly MacKinnon ‘would be more in keeping with the times’.35 Dr Brown of Seacliff Mental Hospital, New Zealand, regretted in 1945 ‘as during the other war years’ that the levels of entertainment had ‘not been what I would have liked’ as ‘petrol and travel restrictions have prevented the many concert parties and bands… as in the past from visiting.’36 Bands, records, the wireless and cinematographs Voluntary groups – some amateur and some professional – offered musical and dramatic entertainment for patients in New Zealand and Australian asylums. Beechworth Asylum, Victoria, thanked ‘some ladies and gentlemen of Beechworth’ for a concert ‘much enjoyed by the inmates who were able to attend’.37 At Willowburn Asylum, Queensland, when the Austral Band played ‘on the lawn’ at the asylum, ‘a large number of townspeople also went out’.38 Asylum bands, later known as hospital orchestras, were to be found in institutions across Australia and New Zealand in the nineteenth and twentieth centuries. Staff members were automatically expected to volunteer their musical, dramatic and sporting talents, where possible.39 Dr Childs thanked ‘the Hokitika Band [New Zealand] for playing for the dances’.40 The quality of the band depended on the musical ability of the staff available. For Ararat Asylum, Victoria, Dr McCreery stated ‘he expects little or no results, as there is want of musical talent in a large portion of the staff ’.41 Some asylum bands lapsed only to be revived again in a new era of enthusiasm by staff. Asylum attendants and nurses were drawn predominantly, although not exclusively, from the working class. The most valuable attendants in the asylums, however, were those who, in addition to their routine duties, were also able to contribute to asylum recreation by playing sport, and either singing or playing a musical instrument. New staff members were often quizzed about their sporting and musical abilities, the aim being to utilise these skills as part of the moral therapy regime. The asylum bands comprised combinations of brass, string, and woodwind instruments, with the additional accompaniment of a piano. These instrumental combinations reflect the musical practices of the broader community, and the asylum repertoires spanned both working class and middle-class musical tastes ranging from popular songs, national airs and anthems, to classical works by Gioacchino Antonio Rossini and Sir Arthur Sullivan.42 While the band members were predominantly male, nurses could also be members of the asylum band. The Goodna Hospital band in Queensland, c.1910 comprised male attendants, the medical superintendent and one nurse. They met ‘twice a week to practise between 2 and 4 o’clock, and they play[ed] at all the dances’. The medical superintendent, H.B. Ellerton, observed that while there was ‘one [nurse] in the band… generally the nurses do not play anything outside the piano’.43 274

‘Amusements are Provided’ The introduction and installation of sound technology in recreation halls from the 1930s onwards revolutionised the quality of music being heard. The 78rpm recordings provided a consistently more flexible and better quality of music for entertainments than even the best amateurs could previously have provided. Technology may have also assisted in the demise of voluntary musical groups performing for patients in the years after the First World War. Philanthropic endeavours also brought visitors to the hospitals for the insane. In the early 1930s, new technologies such as wireless radio and the cinematograph were installed in hospital recreation halls and wards. The publishers of the Herald newspaper in Melbourne presented Mont Park Hospital with a Krupp film projector, complete with Cinesound, enabling them to show ‘talkies’ on a regular Friday-night basis for patients.44 Thanks to the ‘generosity of Mr D. Stern and members of the Grey Lynn Ladies Committee’ two ‘cinema machines’ were installed at the Auckland Hospital in 1945.45 The technological ability to bring the outside world inside the hospital walls was embraced by general hospitals and specialist hospitals alike.46 At Goodna Hospital, ‘in order to buy Wireless sets for each of the wards at this hospital, the staff arranged entertainments in aid of the Fund. Some of the patients also expressed their willingness to subscribe a few shillings towards this fund’, and also the installation costs of £447 15s.47 The Ipswich Mental Hospital, Queensland, ‘chiefly raised [funds] through the voluntary efforts of staff and their friends’ and had installed a wireless system that was ‘accepted… on behalf of the patients’ by the Honourable J.C. Peterson, MLA who ‘performed the opening ceremonies at a social afternoon held at the institution.’48 How the staff controlled the opening ceremony, Peterson’s visit, and any interaction he had with patients, is not recorded. But the radio programmes heard by patients do reflect the musical content heard across the broader community when they too turned on and tuned in their radiograms in their own homes. The centralised nature of the Queensland asylum radio systems meant that staff were technically able to censor what patients could and could not listen to, but unfortunately no evidence survives to indicate either exactly when this occurred, or what form this censorship took. Frustratingly, the levels of staff control regarding radio broadcasts in particular, and entertainment more generally, remains beyond our grasp, but as American writers on the shifting practices of psychiatry in another context observed: In hospital… [the] radio seems to be appreciated not only for its entertainment and educational value, but because it provides a stimulus to interaction and a realistic link to the outside world.49

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Dolly MacKinnon Monitoring of recreation by Official Visitors Across Australian and New Zealand institutions, one of the many responsibilities of lay and medical staff was the provision of suitable recreation for patients. It was also a legislated consideration of ‘Official Visitors’ to public and private asylums. In the 1873 ‘Rules for the Management of the Fremantle Asylum’, that operated in accordance with the Lunacy Act (1871), official visitors appointed by the governor ‘may enter and inspect the Asylum at any hour, day or night’, and their ‘duty’ was to ‘visit the Asylum at least once a week’. They were to ‘make themselves acquainted with the nature of the occupation and amusements provided for the patients’, and ‘if dissatisfied’ to ‘note the same in the Visitor’s Book for the information of the Superintending Medical Officer.’50 ‘If their suggestions’ were ‘not attended to’ then they were to bring them to ‘the notice of the Colonial Secretary’ through the provision of ‘a copy of their minutes and of the “Book of Admission”… at least once every three calendar months.’51 The official visitors to Bay View Private Asylum, New South Wales (Figure 12.2), and Ashburn Hall Private Asylum, New Zealand, also reported on the provision of amusements for patients.52 An official visitor reported, ‘I have found the Asylum, after careful examination of each inmate, to deserve the confidence of the public. It is a pleasure to visit it.’53 Situated in ‘extensive grounds of over 100 acres’ which incorporated a dairy farm, Ashburn Hall comprised ‘buildings specially constructed’ for the care of the mentally ill.54 Ashburn Hall, like Bay View Private Asylum, and the government asylum at Kew, Victoria, had a ‘waggonette for the use of inmates’ both inside and outside the asylum grounds.55 ‘Suitable patients’ were taken on escorted excursions outside the confines of the institution. At Goodna Hospital, ‘trips are given to suitable [government] patients in the motor launch, up and down the river, whenever possible.’56 ‘The visitor’ to George Tucker’s Bay View Private Asylum ‘on walking through the different parts of the asylum… cannot fail to notice the discipline maintained by a little gentle management.’57 Tucker’s ‘creed [was] to please and amuse the patients in every way he possibly can, and thus make them feel more as if at home than in confinement,’ and the improvement of the buildings and plantings in the grounds would be beneficial as ‘nature will second the efforts of man.’58 J.T. Harcourt’s Cremorne Private Asylum, Victoria, was formerly a pleasure garden. The Argus (1865) described the nature of the amusement and recreation facilities provided: The place is admirably adapted for the use to which it has been applied. For instance, the dance rotunda is the place where the patients can play at ropes,

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‘Amusements are Provided’ Figure 12.2 Mr Tucker’s Bay View Private Asylum, New South Wales, Australia, 1869 Source: ‘Mr Tucker’s Bayview Private Asylum’, Illustrated Sydney News, 23 December 1869, 316. Reproduced by kind permission of the State Library of New South Wales.

quoits, and indulge in other past times: the pagoda furnishes accommodation for reading, chess-playing etc.: the bowling saloon supplies another source of diversion, and the fountain is an object of interest. Such instrumentalities for amusement, combined with the most approved mode of treating lunacy, are no-doubt calculated to facilitate the restoration of the mind to its proper balance.59

An interstate advertisement for Bay View in the Year Book of Australia (1896), stated that the asylum’s ‘proximity to Sydney enables friends of patients to visit the Hospital with a minimum amount of trouble, inconvenience, or loss of time.’60 Patients could also, on day release, attend entertainments in the neighbourhood, or even in Sydney.61 277

Dolly MacKinnon Official visitors often, but not always, commented favourably on the levels of recreation made available to patients, but their accounts should also be treated with some caution. The New South Wales Inspector General of the Insane, on a visit to Bay View Private Asylum, cautioned that recreation had not been observed as ‘it was a somewhat showery and bleak afternoon interfering with outdoor exercises and the patients were confined to the buildings.’62 New South Wales government asylums appeared to give some warning of impending visits by official visitors as well as ‘friends and relations’. 63 Visitors never come ‘straight into the wards and see the patients’ as between twenty to thirty minutes ‘notice [was]… given’ to staff ‘to enable them to clean up and, in many cases, dress patients who were in a state of disorder or undress’.64 At a Queensland asylum, friends and relations did not come into the wards at all, rather patients were brought out to meet relatives and friends at a purpose-built pavilion. Voluntary organisations, relatives and friends Asylum archives demonstrate that institutions always relied upon gifts from families and friends of patients as well as those of a philanthropic nature. In an 1886 annual report, the Medical Superintendent of Gladesville Hospital for the Insane publicly thanked Mrs Barton for ‘£6 to provide amusement for the patients’, as well as ‘those [5 groups in all] who kindly gave entertainments, theatrical performances and concerts’.65 The institutional thanks offered in 1952 could equally have been applicable one hundred years earlier across institutions in Australia and New Zealand: ‘Thanks are extended to the many societies and people who contribute towards the added entertainment and welfare of the patients.’66 The Ipswich Mental Hospital thanked ‘the local branch of the C[ountry] W[omen’s] A[ssociation who] visited the patients’ at ‘Christmas and distributed fruit, cakes, icecream, sweets and presents’.67 Ice-creams were also distributed to the children at the hospital once a month. In addition, a ‘Miss Hinton and party made available a small “merry-go-round” to entertain the children.’68 But institutional amnesia meant that often ‘new innovations’ were, in fact, simply lapsed practices reinvigorated. The Brisbane Mental Hospital expressed its ‘appreciation… for help given by the Red Cross Society, the Country Women’s Association, the Salvation Army, the Friends and Relatives Association’ and other named individuals.69 The hospital also congratulated the staff for their ‘enthusiastic efforts’ as ‘the patients’ fancy dress ball was revived at Christmas and was a brilliant success,’ and ‘should ensure that this function becomes an annual entertainment.’70

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‘Amusements are Provided’ Pets as pastimes Apart for the range of farm animals tended by patients and kept on the asylum farm grounds as part of its economic drive for self-sufficiency and the useful employment of patients, other animals designed purely for the purposes of recreation were also to be found inside institutions. The provision of pets was the only institutionally sanctioned recreation that actively encouraged physical and emotional connections for patients. This also may have combatted some of the isolation felt by patients due to the infrequent or unwanted visits from family and friends, and further exacerbated by the highly regulated and stage-managed social interactions of asylum life and recreation. The famous image in the Illustrated London News, 31 March 1860, of the Gallery for Men at the Royal Hospital of Bethlehem, depicts two dogs and a bird cage and demonstrated the attempts to make some wards, at least, like a home. One Queensland asylum made a public appeal for pets ‘for the amusement of the patients’ and received ‘three magpies and two monkeys’.71 While Gladesville Asylum, New South Wales was given ‘two swans’.72 Gifts of reading materials and games Australian and New Zealand institutions also relied heavily upon the gift of books, magazines and newspapers. Gladesville Asylum thanked the proprietors of twenty-four newspapers from across New South Wales for ‘a copy of each issue throughout the year free of charge’, adding ‘the large majority of the newspapers… have been forwarded to me for nearly seven years’.73 Individual men and women who gave magazines, fruit, plants and cuttings were also thanked.74 The Inspector’s book for the Auckland Hospital, reported ‘one or two newspapers’ but ‘no books’ and suggested ‘a special grant for these objects would be money well spent’.75 But some gifts were considered too valuable just to be given to any patients. The Queensland Colonial Secretary, Arthur Hodgson, ‘presented’ a ‘handsome bagatelle board and table’ to the Woogaroo Asylum.76 But ‘for want of a suitable room to place it in’ patients were not able to make use of it ‘for if placed in the ordinary wards, it would soon be destroyed.’77 Cricket and football teams As asylums were set in large grounds, cricket/football ovals, and gardens set out by patient labour were also considered important additions to the treatment regime. Australian and New Zealand institutions, like their British counterparts, recognised the value of outdoor sports as a form of amusement and entertainment. In the late 1860s, Woogaroo Asylum stressed these advantages: 279

Dolly MacKinnon [W]eather permitting, a game of cricket serves, at least for some, to while away for an hour or so the weariness of life. The bagatelle and draughts fail to inspire either a lively or general interest; cricket is held in greater esteem, less perhaps for the pleasure of the game than the chance it affords for a passing glimpse of the outer world.78

Cricket provided one of the better means of integrating the asylum into the community, as through exhibition matches as well as hospital teams, institutions became part of the fixtures of community cricket matches played on asylum ovals. Made up predominantly of staff, asylum sporting teams also reinforced the institutional hierarchy that openly and contentiously allowed certain staff time away from the arduous work on the wards, at the expense of their workmates. Where teams also included patients, the institutional favouritism directed to certain patients who either participated or watched these matches was also evident. From the 1870s onwards, cricket ovals were being established in asylum grounds. The Medical Superintendent at Gladesville stated, ‘[t]he new cricket ground, which the drought rendered quite useless last year, has this season been in excellent order, and afforded a great amount of play.’79 Cricket, like football and tennis, was supplied as ‘spectacular and partly where possible for the patients to participate.’80 Visiting cricket teams, including ‘the Hibernians, The Paper Mills, the Irish National Foresters and Carlton and United Brewery (CUB)’, came to Mont Park Hospital, Victoria, in the 1930s to play social games against the staff and patient team.81 Competition to get into the hospital team was extremely intense when a match involved the CUB team, as the brewery ‘team always brought a nine gallon keg of beer’ to the game.82 But like all asylum spaces, sports grounds could also provide a perfect spot for the ‘annual picnic’ that ‘was successfully held in the cricket oval instead of as hitherto in the paddocks, and with marked advantage’ to the patients at Kew in 1909.83 In 1931, the Goodna Hospital reported that ‘Patients’ sports, and athletic sports days organised by the patients for the patients’ had been held and were ‘a great success’. The patients’ sports days had been an annual event ‘for some four years or more’ and ‘many firms and businesses in Brisbane supply the prizes’.84 But criticism was often levelled at institutions, and within institutions, regarding exactly who benefited from these recreation facilities, staff or patients? There was a fine line between official staff duties and staff liberties. Regarding an attendant who was accused of playing draughts with a patient, Dr Attfield’s journal entry for the Fremantle Asylum of 5 January 1859 noted that ‘this officer considered it part of his duty to amuse the patients but has been told that he must in future overlook, but not engage in 280

‘Amusements are Provided’ anything of this sort’.85 But the records show that the staff did initiate and participate in much of the recreation for patients. Patients leaving the grounds The asylum walls were permeable, and while there was a clear perception that these institutions should provide recreation for patients within the asylum, there was also room for excursions under supervision beyond the boundaries of the asylum grounds. These excursions enabled certain patients who were issued passes for hours, a day or even a week to visit the outside world.86 That patients, where possible, should visit the outside word is reflected both in the practice of the patients’ pass system, as well as in the criticism levelled at those institutions that failed to take suitable patients on excursions beyond the asylum grounds. At the Auckland Hospital in 1882, [T]he amusements of the patients receive some amount of attention here, but they are never taken for walks beyond the asylum grounds, nor are any excursions or picnics organised. This is a matter for regret. If these amusements are practicable in London and its suburbs there can be no insuperable obstacle to their being enjoyed here in a sparsely-populated district.87

But for the asylum, those patients that did go on excursion, were automatically on public display, no longer hidden away behind asylum walls or in private homes.88 These patients then, through their actions and behaviour, reflected the medical success or failure of the institutions they represented. These excursions by patients enabled the community to observe the asylum and its inmates without ever having to actually enter the asylum grounds and buildings. Excursions by patients beyond the grounds of the asylum may have raised fears in the community, but they also were a cause for some concern for the asylum staff. In defence of his management of the Auckland Hospital, T. Aickin, MD, in a letter (1878) highlighted the difficulty in allowing ‘a large number of male patients to enjoy excursions outside the asylum grounds, owing to the then limited staff of attendants’.89 Smaller numbers of patients went on excursions, and in the ‘summer several patients were sent to bathe in a safe and convenient place adjacent to the Asylum’ without incident.90 Female patients left the Auckland Hospital on day trips and ‘enjoyed picnics on the picturesque sites’ on the private property ‘bordering the Waitemata’ of ‘Mr P. Dignan’. 91 The visitors from the asylum were ‘kindly received’ by his family, and the party included ‘one or two musicians [and] also a few respectable residents in the neighbourhood’. Aickin reflected, ‘I can safely state that these days were about the pleasantest I passed during a dreary residence of nearly nine years.’92 281

Dolly MacKinnon Kew Hospital for the Insane gives one of the few references to the actual costs incurred in providing the annual picnic. When ‘the fine Police Band again gave their much appreciated services’ the ‘annual grant for this function’ proved ‘inadequate since we discountenanced the custom of accepting presentations from the contractors to the institution’ and ‘it is scarcely possible to organise a successful outing for so many people under at least £20.’93 When annual reports made general statements about recreation, they were including activities that happened within and without the asylum grounds. In New Zealand, Christchurch Asylum reported that ‘the amusements of patients are well looked after’, while at Hokitika Asylum ‘all opportunities of visiting places of amusement in the neighbourhood are taken advantage of ’.94 Nelson Asylum held weekly dances ‘attended by both sexes of patients, and also by a limited number of visitors’, and some patients ‘constantly attended’ entertainments ‘in the town’ and were taken on ‘walks… in the neighbourhood’.95 Newspapers covered positive accounts of the asylum balls, as well as negative stories about institutions.96 In 1903, the Sydney Mail ran an illustrated article of ‘Callan Park: A Great State Institution’, including pictures of the ‘Church and Concert Hall’.97 But the press also reported on the often-tragic failures of the patient day-release system. A private patient on day-release from Bayview Private Asylum, New South Wales, committed suicide at a nearby railway station. The newspaper report of the inquest into the ‘Shocking Railway Fatality’ was pasted into the patient’s casebook entry.98 The press made much of these failures, and instances from individual states were reported in interstate newspapers. A day outing for two groups of patients accompanied by attendants from Kew Asylum and Mont Park Hospital ran into trouble at the 1913 Melbourne Cup, held at Flemington Race course, Victoria, and was reported in the Queensland Toowoomba Chronicle as ‘Lunatics at the Cup Race: Some Strange Happenings’. The attendant, with the Mont Park group of ‘10 men who work on the farm… and… are harmless’, got into a fight with a carter because ‘a patient… [had] surreptitiously abstracted a bottle of beer from the [carter’s] coat pocket’.99 The attendant was accused of failing ‘to carry out his duties while under the influence of liquor’, while another patient from a Kew Asylum party ‘strayed away and was lost, and he had not yet been found’. 100 The Medical Superintendent of Ipswich Asylum defended allowing six male patients ‘to attend the Brisbane Exhibition’ because they ‘are well behaved, and have private funds which they desired to expend in this way’.101 Ninety-five patients were allowed to attend the Ipswich Show to which ‘patients were given free entrance’ and ‘the Hospital provided each patient with 1/- to 2/- shillings as pocket money’.102 According to a former patient 282

‘Amusements are Provided’ from Victoria, in place of the ‘idleness’, institutions could actively encourage ‘patients who have the prospect of going out of the institution’ in order to ‘have the chance to keep themselves fit for life’.103 But the newsworthiness of madness, coupled with community unease, made stories like these popular. Conclusion Australian and New Zealand practices of providing entertainment inside and outside the walls of these institutions drew on the asylum culture of Britain and North America. Entertainment and recreation formed part of the earliest therapeutic regimes in the treatment of the mentally ill, and from the mid-nineteenth century onwards comprised designated architectural spaces within asylum complexes. Evidence of the permeable nature of asylums for the purposes of recreation is also to be found in the broad range of sources discussed in this chapter. The analysis of recreational activities for Australia and New Zealand demonstrates how visits to and from the asylum formed an integral part of the medical and social rehabilitation of patients, at first within the walls of the asylum, but ultimately within the community. That these practices were in accordance with the views of certain sections of society is also evident in the support and positive press some of these activities attracted. Entertainment formed an important part of the asylum’s public relations with the broader community, and was a constant feature of annual reports, local newspaper articles, and descriptions and illustrations in institutional histories. Recreation was one of the few asylum activities that attempted, albeit in a highly regulated way, to encourage patients to respond and interact in appropriate ways in a social, physical, as well as an emotional sense. Thus, surviving recreation buildings and grounds for Australia and New Zealand, and the archives these institutions generated, are the silent witnesses to the noisy and lively recreational activities inside and outside the asylum of past patients, staff, and visitors. Acknowledgements This research was possible through the support of the following: History Department, University of Waikato, New Zealand, Visiting Fellowship (2003); the Royal Society of New Zealand’s Marsden Fund for my research into private asylums, part of a larger project entitled ‘Family Strategies Involving “Madness” in Colonial Australia and New Zealand, 1860–1914’, with Catharine Coleborne, University of Waikato; the New South Wales Health Department for permission to use the Bay View Private Asylum records held at the NSW Archives Office; and Ray Osborne who generously forwards anything relating to madness.

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Dolly MacKinnon Notes 1. Sir James Crichton Browne (1889) quoted in H. Burdett, Hospitals and Asylums of the World, Vol. II (London: J. and A. Churchill, 1891), 182. 2. D. MacKinnon, ‘“A Captive Audience”: Musical Concerts in Queensland Mental Institutions c.1870–c.1930’, Context: Journal of Music Research, 19 (2000), 43–56: 54. 3. Ibid., 54–6. 4. For a detailed consideration of gender, indoor and outdoor work, and recreation in Victoria see C. Coleborne, ‘Space, Power and Gender in the Asylum in Victoria, 1850s–1870s’, in C. Coleborne and D. MacKinnon (eds), Madness in Australia: Histories, Heritage and the Asylum (St Lucia, Queensland: University of Queensland Press, 2003), 49–60; and for England see M. Levine-Clark, ‘“Embarrassed Circumstances”: Gender, Poverty, and Insanity in the West Riding of England’, in J. Andrews and A. Digby (eds), Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry (Amsterdam: Rodopi, 2004), 123–48: 126–8, and A. Shepherd, ‘The Female Patient Experience in Two LateNineteenth-Century Surrey Asylums’, in Andrews and Digby, idem, 223–48: 241–2. 5. British Parliamentary Papers, 8, (1862), 120, cited in A.S. Ellis, Eloquent Testimony: The Story of the Mental Health Services in Western Australia 1830–1975 (Nedlands: University of Western Australia Press, 1984), 19–20. 6. Report of the Inspector of the Asylums (1877), 23, cited in Coleborne, op. cit. (note 4), 56. 7. Queensland Votes and Proceedings (hereafter QVP) (1873), Lunatic Asylum Woogaroo Report, 1306. 8. MacKinnon, op. cit. (note 2), 43–56; D. MacKinnon, ‘Jolly and Fond of Singing: the Gendered Nature of Musical Entertainment in Queensland Mental Institutions c.1870–c.1930’, in Coleborne and MacKinnon, op. cit. (note 4), 157–68. 9. R.W. Gowland, Troubled Asylum: The History of the Invalid Barracks, New Norfolk, Colonial Hospital, New Norfolk, Madhouse, New Norfolk, Her Majesty’s Lunatic Asylum, New Norfolk, Mental Diseases Hospital, New Norfolk, Lachlan Park, New Norfolk… Royal Derwent Hospital (Tasmania: Gowland, 1981), 144. 10. Victoria Votes and Proceedings of the Legislative Assembly and Papers (hereafter VVPLAP) (1880), Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1879, Kew, 20. 11. Gowland, op. cit. (note 9), 155. 12. D. MacKinnon, ‘“The Trustworthy Agency of the Eyes”: Reading Images of Music and Madness in Historical Context’, in D. MacKinnon and C.

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‘Amusements are Provided’

13. 14. 15. 16. 17.

18. 19.

20.

21.

22.

23. 24. 25. 26. 27. 28. 29. 30. 31.

Coleborne (eds), Health and History: Deinstitutionalisation Special Issue, 5, 2 (2003), 123–49: 135–42; D. MacKinnon, ‘Music, Madness and the Body’, History of Psychiatry, 17, 1 (2006), 9–21. Gowland, op. cit. (note 9), 196. Ibid. Ibid. QVP (1873), Lunatic Asylum Woogaroo Report 1872, 4. Extract from New Zealand Herald, 5 October 1878, Letter To the Editor, Archives New Zealand, Auckland, YCAA Carrington Hospital 1083/5b, Newspaper Reports 1851–78. I am grateful to Catharine Coleborne for this reference. Gowland, op. cit. (note 9), 144. ‘Collingwood Lunatic Asylum Ball’, Illustrated Melbourne Post, 12 October 1868, 159. For similar findings regarding visitors’ experiences of asylum balls in Ontario, Canada see J. Miron, ‘“Open to the Public”: Touring Ontario Asylums in the Nineteenth Century’, in J.E. Moran and D. Wright (eds), Mental Health and Canadian Society: Historical Perspectives (Montreal: McGill-Queen’s University, 2006), 19–48: 40. ‘Entertainment Book’ [Private collection of Mrs Grace Curtain], quoted in Gowland, op. cit. (note 9), 143; For a detailed discussion of images of music in asylums, see MacKinnon, ‘The Trustworthy Agency...’, op. cit. (note 12), 123–49. Some of the earliest and best known examples of these types of annual benefit concerts were those conducted by George Frederick Handel for medical charities such as the Charitable Infirmary in Dublin, and the London Foundling Hospital. See J. Brewer, The Pleasure of Imagination: English Culture in the Eighteenth Century (London: Harper Collins, 1997), 375. ‘The Whau Minstrels: Concert at the Lunatic Asylum for the Benefit of the Patients’, Extract from New Zealand Herald, 6 March 1868, Archives New Zealand, op. cit. (note 17). Ibid. Gowland, op. cit. (note 9), 198. Queensland Parliamentary Papers (hereafter QPP) (1903), Goodna Mental Hospital Annual Report 1902, 13. QVP (1869), Lunatic Asylum Woogaroo Report 1868, 918. Kew Asylum Inquiry (1876), cited in Coleborne, op. cit. (note 4), 57. QVP (1873), Lunatic Asylum Woogaroo Report 1872, 1306. Ibid. Ibid. Interestingly, American published accounts of institutional visiting in nineteenth-century newspapers during the Civil War period and after

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32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

43.

44. 45. 46.

47. 48.

suggest, in general, that the practice of visiting continued regardless of any disruptions caused by conflict. For Australia and New Zealand, while some visitors still came to the asylum during the First and Second World Wars, they did not provide concert or entertainments for groups of male or female patients. QPP (1918), Goodna Mental Hospital Annual Report 1917, 10. Ibid. W.H. Williams, Out of Mind Out of Sight: The Story of Porirua Hospital (New Zealand: Porirua Hospital, 1987), 106. Ibid., 106. New Zealand, Appendices to the Journals of the House of Representatives (hereafter AJHR) (1945), H–7, 13. VVPLAP (1880), Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1879, Beechworth, 27. Toowoomba Chronicle, 3 May 1908, 3. MacKinnon, op. cit. (note 2), 49–51. AJHR (1945), H–7, 11. VVPLAP (1880), Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1879, Ararat, 23. For a detailed discussion of music programs in Queensland asylums see MacKinnon, op. cit. (note 2), 48–9, and 51–3, and MacKinnon, op. cit. (note 8), 65. MacKinnon, op. cit. (note 2), 50. For a comprehensive study of attendants in asylums in Victoria see, L.A. Monk, ‘Artisans of Reason: Crafting a Gendered Occupational Identity in the Asylum in Victoria, 1848–1886’ (unpublished PhD Thesis: La Trobe University, 2001) and idem, ‘Gender, Space and Work: The Asylum as Gendered Workplace in Victoria’, in Coleborne and MacKinnon, op. cit. (note 4), 61–71; regarding the employment process of attendants in England and the importance placed upon sporting and musical skills see D. Gittins, Madness in its Place: Narratives of Severalls Hospital, 1913–1997 (London: Routledge, 1998), 173–4, and 176–7. I. Bircanin and A. Short, Glimpses of the Past: Mont Park, Larundel, Plenty (n.p.: Campus Design, 1995), 15. AJHR (1945), H–7, 6. ‘Wireless in Hospitals: Its Uses and Advantages Toowoomba’s Appeal’, Toowoomba and Darling Downs Gazette, 12 October 1926, 8; and ‘Wireless in Hospitals: Its Beneficial Aspects Appeal for the “General”’, Toowoomba and Darling Downs Gazette, 12 October 1926, 3. Queensland State Archives (hereafter QSA) A/31775 Correspondence, 26 June 1935 and 5 March 1935. QPP (1931), Vol. 1, Annual Report, Ipswich, 842.

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‘Amusements are Provided’ 49. M. Greenblatt et al., From Custodial to Therapeutic Patient Care in Mental Hospitals: Exploration in Social Treatment (New York: Russell Sage Foundation, 1955), 109; for a discussion of concert programs performed, and radio programmes broadcast in Queensland asylums see MacKinnon, op. cit. (note 2), 43–56. 50. Rules of the Management of Fremantle Asylum 1873. Colonial Secretary’s Office, Perth, 22 August 1873, cited in Ellis, op. cit. (note 5), 193–4. 51. Rules cited in Ellis, ibid., 193–4. 52. NSW Archives Office (hereafter NSWAO), CGS 5166 5/143–4 Medical Journals, 1881 and 1893. 53. New Zealand Medical Journal (hereafter NZMJ) 8, 1 (1 January 1895), advertisement for Ashburn Hall. 54. Ibid. 55. Ibid.; NSW AO, CGS 5166, 5/144, Medical Journal, 1894. 56. QPP (1918), Goodna Mental Hospital Annual Report, 10. 57. ‘Mr Tucker’s Bayview Private Asylum’, Illustrated Sydney News, 23 December 1869, 312 and 316. 58. Ibid., 312. 59. Argus, 18 March 1865, 4 and 5. 60. Year Book of Australia (1896), Section for Victoria, 35. 61. NSW AO, CGS 5166, 5/144, 1894. 62. NSW AO, CGS 5167, Kingswood 5/146, Inspector Generals’ and Visitors’ Book 1908–45, 16 October 1914. 63. NSW Votes and Proceedings (1894–5), Vol. 6, 1156, ‘Alleged Preparation for Official Visits and the Visits of Friends and Relations’. 64. Ibid. 65. Journal of the Legislative Council of New South Wales (hereafter JLCNSW) (1885–6), Vol. 11, Part 3, Inspector-General of the Insane Report 1885, 648. 66. QPP (1952) Vol. 2 Part 2, Annual Report, 860. 67. Ibid., 862. 68. Ibid. 69. Ibid., 861. 70. Ibid. 71. QVP (1870), Lunatic Asylum Woogaroo Report 1869, 45. 72. JLCNSW (1875–6), Vol. 27, Part I, Gladesville Report 1876, 911. 73. JLCNSW (1876–7), Vol. 27, Part I, Gladesville Report 1875, 890. 74. Ibid., 909. 75. AJHR (1883), Vol. 3, H–J, Report on Lunatic Asylums… for 1882, H–3, 5 Auckland. 76. QVP (1870), Lunatic Asylum Woogaroo Report 1869, 44. 77. Ibid.

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Dolly MacKinnon 78. QVP (1869), Woogaroo Lunatic Asylum Special Report, 905. 79. JLCNSW, op. cit. (note 73), 890. 80. QPP (1932), Vol. 1, Annual Report Toowoomba, 788; For the Canadian context, Janet Miron observed that sports were also intended to be open to all visitors, op. cit., (note 19), 40. 81. Bircanin and Short, op. cit. (note 44), 14. 82. Ibid., 14. 83. Victoria Papers Presented to Parliament (hereafter VPPP), (1910), Vol. 2, Hospitals for the Insane, Report of the Inspector-General, 1909, Kew, 912. 84. QPP (1932), Vol. 1, Annual Report 1931–2 Goodna, 775. 85. ‘Journal of the Fremantle Asylum 1858–1860’, in T. Bignold, ‘Lunatic Asylum 100 Years Ago’, Medical Journal of Australia , 21 Sepember 1963, 506, cited in Ellis, op. cit. (note 5), 190. 86. P. Bartlett, The Poor Law of Lunacy: The Administration of Pauper Lunatics in Mid-Nineteenth Century England (London: Leicester University Press, 1999), 135. 87. AJHR, op. cit. (note 75), 6, Auckland. 88. P. Bartlett and D. Wright (eds), Outside the Walls of the Asylum: The History of Care in the Community 1750–2000 (London: Athlone Press, 1999), 86–114. 89. New Zealand Herald, 5 October 1878, Letter to the Editor. 90. Ibid. 91. Ibid. 92. Ibid. 93. VPPP, op. cit. (note 83). 94. AJHR, op. cit. (note 75), 7–9, Christchurch and Hokitika. 95. Ibid., 10, Nelson. 96. MacKinnon, ‘The Trustworthy Agency...’, op. cit. (note 12), 123–49. 97. ‘Callan Park: A Great State Institution’, Sydney Mail, 12 August 1903, 409–12. 98. NSW AO, CSG 5165 Bayview 5/134 Medical Casebook (1891–1900), Book 5, folio 267. 99. Toowoomba Chronicle, 22 November 1913. 100. Ibid., 22 November 1913. 101. QSA, A/31775 Correspondence 1935–7, 26 July 1935. 102. Ibid. 103. R.G.M. MacLachlan, The Case for Patients in Public Mental Hospitals (Melbourne: F.J. Hilton, 1944), 15.

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13 Challenging Institutional Hegemony: Family Visitors to Hospitals for the Insane in Australia and New Zealand, 1880s–1910s

Catharine Coleborne Historians have increasingly come to identify that there was considerable traffic between nineteenth-century psychiatric institutions and the world beyond, with official visitors recording details of their regular forays inside asylum walls, and sometimes family members visiting the institution to check on treatments, patients’ progress and welfare. This chapter explores the broad array of experiences of asylum visitors in colonial Australia and New Zealand, focusing on families and their responses to the institution. It draws upon a range of materials to show that visitors found their way inside the hospital for the insane, both in their letters and through their actual physical presence. Through these glimpses, it suggests that the asylum itself should be unsettled as the locus of all the meanings of insanity and its cure.

In the spring of 1867, Mrs Annie G. wrote to the asylum on the banks of Woogaroo River in Queensland about her husband. She explained that his father had also been confined in an asylum in England, a point the medical authorities noted in his case record. She was ‘very sorry’ that her husband was ‘worse’: ‘Please let me know’, she wrote, ‘if I should come and see him’.1 This letter, and others like it over subsequent decades, is a highly suggestive fragment of evidence from the asylum archive. Asylums, later known as hospitals for the insane, were often removed from centres of population in colonial Australia and New Zealand. Yet such evidence suggests that asylum authorities were keen to involve ‘relatives and friends’, often seeking family histories at committal, and that family members engaged with the asylum. This chapter is primarily concerned with an exploration of family visitors to colonial asylums in order to investigate the institution in its complex relationship to the outside world, emphasising the extent to which families actively negotiated asylum care for the insane. 289

Catharine Coleborne Historians have increasingly come to identify that the boundaries between the asylum and the extra-institutional world in the nineteenth century were highly porous and not impenetrable. In particular, this has been expressed in recent scholarship about families and their interactions with nineteenth-century asylums in different contexts. James Moran, David Wright and Matt Savelli offer a set of possible interpretations of the ways that families used institutions in Victorian Ontario, arguing that families were, in part, ‘strategic’ about institutional confinement, perhaps seeing asylums as alternatives to the household stress caused by mental breakdown.2 Writing about the Provincial Hospital for the Insane in British Columbia between 1900 and 1915, Mary-Ellen Kelm has argued that ‘relatives mediated the controlling environment of the asylum, adding their voices to the psychiatric discourse on the wards, and contributing to an institutional environment that was conflictual and negotiated’.3 Two key ways in which families maintained contact with patients were visits and correspondence. This is also true for other places, including parts of Britain and the Australasian colonies.4 In fact, there was considerable traffic between the institutions and wider society, with official visitors recording details of their regular forays inside asylum walls, some patients frequently on trial absences, and family members visiting the institution to check on treatments, patients’ progress and welfare. Yet, despite the scholarly interest shown in family strategies and interactions with the asylums, the very act of ‘visiting’ has not been examined in any depth. Perhaps this is one result of the relative paucity of sources relating to community responses to asylum confinement, as Wright has noted.5 However, the asylum’s rich archive does offer historians evidence, albeit partial and incomplete, of the family’s encounters with the institution as it brushed up against colonial authorities, and colonial institutional record-keeping. This chapter explores the broad array of experiences of official and unofficial asylum visitors to four public asylums in the late nineteenth and early twentieth centuries in New South Wales, Victoria, Queensland and New Zealand. It focuses on family visiting, and on families’ responses to the institution, and also comments on institutional responses to their presence. It draws upon official visitors’ books and annual reports, family and patient letters, patient casebooks, and one visitors’ book at Auckland between 1891 and 1911, to suggest that interactions with institutions were far more dynamic than previously suggested. Many letters written by relatives and friends of asylum inmates to hospital authorities, together with official asylum sources, remind historians that institutions responded in a variety of ways to the web of relationships surrounding patients. 290

Challenging Institutional Hegemony Background Scholarship about eighteenth-century charitable hospital visiting in Britain shows that visiting the sick was a tradition of some long standing. W.B. Howie has written about the administrative history of ‘house visitors’ and visiting clergymen to a provincial hospital, the Royal Salop Infirmary in Shrewsbury. The role of these visitors was both to inspect and possibly intercede on patients’ behalf.6 However, arguably lunatics were not merely ‘the sick’, and occupied a different social and institutional space. At the eighteenth-century hospital for lunatics known as the Bethel in Norwich, visits to lunatics were restricted.7 The fact that asylum visits from family and friends took place at all prior to the nineteenth century, by which time reforms shaped by the growing adherence to codes of ‘moral therapy’ had taken hold, indicates the lengthy relationship between such visiting and other charitable activities.8 This tradition of visiting the sick was continued in the nineteenth century asylum. By this time, visiting was seen as potentially therapeutic, with family visitors even encouraged to stay at some private institutions, including Holloway Sanatorium, where they would participate in amusements and meals.9 Family visits were also encouraged at the Royal Edinburgh Asylum, while in private practice, families were sometimes excluded from contact with women suffering from puerperal mania.10 Family visits to asylums have rarely been explicitly explored by historians, but Kelm’s study of women patients in British Columbia in the early decades of the twentieth century is one in a number of exceptions. Kelm argues that although the asylum sometimes blamed the family for the condition of the insane, constructing it as both a site of hereditary insanity and of domestic disorder, families inserted themselves into its activities as far as possible. Those who were permitted to visit were able to see patients in sitting rooms or on wards, and to walk around the asylum’s grounds. Although strictly supervised, sometimes visits resulted in family dissent over treatment or conditions.11 Another Canadian study, by Geoffrey Reaume, explores family visits to Toronto Hospital for the Insane in the latter part of the nineteenth century as another means of gaining a perspective on the relationships between asylums and communities.12 In her study of Thomas Kirkbride in Pennsylvania, Nancy Tomes has suggested that families came into direct physical contact with the asylum, sometimes complaining about the accommodation and the noise.13 Historical studies of colonial asylums in Australia and New Zealand have also explored relationships between families and the insane. The provocative article by Mark Finnane in 1985, which suggested that historians might look more closely at family agency and asylum committal in both the Irish and 291

Catharine Coleborne New South Wales contexts, began a new generation of historical inquiry.14 In his study of insanity in New South Wales, Stephen Garton drew upon patient and family letters, exploring gender and class profiles of asylum inmates, and described the culture of the mental hospitals.15 In New Zealand, similar problems of family agency, gender, class, ‘race’ and committal to Auckland Mental Hospital have been explored by Bronwyn Labrum.16 While none of these historians explored family visits, or attempted comparisons of family strategies across Australia and New Zealand, their work opened up areas of inquiry pertinent to this chapter and the larger project on which it is based.17 Colonial asylums In each of the four colonies, asylums, along with public hospitals and, later, industrial schools and primary education, were considered the responsibility of the state.18 In the Australian colonies and in New Zealand, early laws, including the 1846 Lunatics Ordinance, put in place the expectation that asylums should be supported by government.19 As all the colonies enacted new legislation in the nineteenth century, the meanings of the ‘public’ insane asylum were further defined. The 1868 Act in New Zealand gave power to justices to seek maintenance payments from relatives. The 1878 Lunacy Act in New South Wales empowered the Master-in-Lunacy to seek legal assistance to collect maintenance fees from families or inmates’ estates; this was also true in Victoria. In Queensland, the Curator of Insanity was granted similar powers under the terms of the 1881 Insanity Act. Legislation articulated both economic concerns, and also questions about social regulation; it enshrined the meanings of the family’s role in relation to the asylum. Families were expected to make reasonable contributions towards costs, based on their means. In practice, full maintenance fees were rarely collected from families and the colonial governments effectively fully subsidised public patient care, with very few wealthy patrons making significant or minor donations to asylums.20 There were several small licensed houses operating in Victoria and New South Wales towards the end of the nineteenth century. Only one private institution existed in New Zealand.21 The four public asylums discussed in this chapter shared certain characteristics. All were established by the 1860s in relatively young English colonies, and were located near or just outside centres of population. Woogaroo in Queensland, later Goodna Hospital (this chapter will use its contemporanous titles), for the Insane, was more distant from towns than the other institutions: Gladesville Hospital for the Insane, Sydney, New South Wales; Yarra Bend Hospital for the Insane, Melbourne, Victoria; and the ‘Whau’, or Auckland Mental Hospital, New Zealand. In both New 292

Challenging Institutional Hegemony South Wales and Victoria, the population grew rapidly from the 1860s, and the cities of Sydney and Melbourne became centres of commerce, manufacturing and migration by the 1880s. Both Gladesville and the Yarra Bend were relatively large institutions, and while they were not the only asylums in their respective colonies, they catered for around one third of all the insane patients in their geographical areas by the early 1900s. Many patients came from the urban areas, but many others also from beyond the city, travelling long distances from remote towns or stations, and sometimes even from neighbouring colonies. Goodna Hospital for the Insane, located between Brisbane and Ipswich, was more isolated. It was removed from towns, making it too far for visits from some ‘relatives and friends and entertainers’ which became part of asylum treatment.22 Over time, this impediment of distance was tackled, so that by the 1930s, free rail passes were granted to families in need so that they could visit hospital inmates.23 Some groups of patients were ‘friendless’, including the Chinese male admitted after 1868.24 Indeed, asylum inspectors worried about the relative lack of family and friends for the insane because of the nature of colonial populations across each of the colonies discussed here. New migrants arrived in successive decades, creating new patterns in family relationships, but the lack of extended family in the colonies was apparent until the late nineteenth century. Even in the more populated colonies of Victoria and New South Wales, this problem received significant attention. One of several asylums across the colony of New Zealand by the end of this period, the Auckland Mental Hospital (hereafter Auckland Hospital) was established in 1853 in the grounds of the Auckland Hospital, and later moved to new buildings at Point Chevalier in the 1860s. From 1854, the asylum was administered by the Auckland provincial government and by 1876, the asylum came under the control of the central government of New Zealand.25 Like other asylums in the colony, and like those in Australian colonies, the asylum was inspected annually, with reports tabled in Parliament. Its population was mostly drawn from the north of the North Island and from Auckland suburbs, with some Maori patients among those committed in this period.26 Colonial society was a place and time of rapid change and invention. Some institutional frameworks, including medical and legal measures, were adapted from the old world. Asylum superintendents were often medical men trained in Britain. Their successes and failures were tracked in annual asylum inspectors’ reports to colonial parliaments in all four colonies – and in the Australian state governments after Federation in 1901. The role of individual superintendents and inspectors is also part of this history. In New South Wales, Frederick Norton Manning created an important relationship 293

Catharine Coleborne between the asylum at Gladesville, and asylums more generally. He also reached out to the wider public through his persona and reforming zeal.27 He was Medical Superintendent at Gladesville until 1879, and then became Inspector General in New South Wales. Medical experts were among a growing community of professionals, and many were involved in local politics. They ‘achieved legitimacy’ in the field of managing insanity as a ‘social problem’; increasingly the asylum, too, became ‘legitimate’ in the eyes of public observers, including families seeking to utilise its services.28 The charitable context of the colonies was also distinctive, as this chapter goes on to explore briefly below. By the late nineteenth century, approaches to the management of mental illness had already begun to address the perceived dangers of institutionalisation. At the Intercolonial Medical Congress in 1889, Eric Sinclair, then Medical Superintendent at Gladesville, gave an address about the extension of ‘hospital methods’ to asylums. Sinclair suggested: The asylum of the future should be a hospital, with powers of detention… the insane person should be treated altogether as a sick person; and… the main idea of the hospital for the insane should be medical treatment of disease, not mere detention and separation from society.29

This belief, discussed before a large gathering of medical men involved in colonial asylum management, no doubt helped to shape new institutional cultures in the colonies. Yet, as this chapter explores, official visitors and family visitors were already part of asylum life, and continued to play a role into the early twentieth century. Official visitors Laws governing the confinement of the insane in nineteenth-century colonial asylums, derived from British practices, set out the expectation that official visitors would keep a close eye on the workings of the institutions. Legislative measures in all four colonies established the expectation that official visitors would be appointed by government and be drawn from the ranks of medical and legal men. They were to play a role as quasi inspectors, with at least one of the Acts describing this role under the heading of ‘inspection of patients’. Other persons could also be appointed as visitors on an ad hoc basis.30 Official asylum inspectors also played a vital role. But as the official visitor to Auckland Hospital noted in 1901, official visitors, perhaps more than inspectors, created a ‘valuable link between the patients, attendants, and the public’.31 Their work was an extension of existing charitable and welfare measures in the colonies relating to the needy and the

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Challenging Institutional Hegemony institutionalised. They could also intercede for families, as historians have shown in other contexts.32 There was no poor law in any of the Australasian colonies, but as detailed above, public asylums were among the only state-funded institutions, and as such, resembled welfare institutions. Systems of indoor and outdoor relief also existed, taking the form of benevolent homes and charitable aid, with historians arguing that a ‘persistent ideal’ of ‘family responsibility’ shaped public responses to the needy in colonial life.33 Middle-class female charity workers interacted with the poor through their visits to benevolent asylums and private homes in the colonies. Some of these women, whose work was voluntary, were ‘indomitable’, and they were cast within the gendered framework for colonial life as the appropriate people to ‘visit, “rescue”, counsel or relieve working class women’ of their burdens.34 These activities extended to the asylum. In the 1870s and 1880s in New South Wales, ladies visited the asylum to play the harmonium and to run a weekly choir, and in Victoria, a ‘lady visitor’ presented a pianoforte to the female receiving ward.35 It was crucial that the institution avoided having a ‘prison-like aspect’.36 An article in the New Zealand Herald, in March 1868, described a concert at the lunatic asylum ‘for the benefit of patients’. An audience of philanthropic Aucklanders sat down with a group of ‘decent, orderly and respectable’ patients to enjoy the amateur performers, the Whau Minstrels.37 Dolly MacKinnon’s chapter in this volume demonstrates that asylum entertainments can be read as one aspect of the history of institutional visiting. In addition, persons designated as official visitors also often sought to improve the cultural lives of confined patients. From the 1860s, the official annual asylum inspectors’ reports for the colonies commented on the duties of official visitors, their ‘care and attention’ to their tasks, indicating that, at times, they intervened in cases of maltreatment or poor conditions.38 The reports detailed the official visits of a number of people, including charitable women, and also provided extracts of official visitors’ own reports. What did visitors see around them when they encountered colonial asylums? There were often quite serious matters to report. Visitors to Gladesville found serious overcrowding among the female patients in 1879. Similarly, that year at the Yarra Bend, official visitors noted that ‘unsatisfactory’ buildings and structures needed improvement, in particular, verandahs and fencing.39 Those coming into contact with Auckland Hospital saw a ‘modern’ building, according to reports in the 1870s.40 Located about three miles from Auckland city on twenty-two acres, much of which was taken up by a garden and farm, it included two large airing-yards, surrounded by ‘lofty’ brick walls, and it separated male and female patients into distinct yards. It had a large church that could accommodate two hundred and fifty people. Large dining rooms, a kitchen, 295

Catharine Coleborne a bakehouse and cellars, as well as dormitory spaces, defined the lives of patients and staff. From 1897 to about 1904, Mrs Sada Russell Hendre was an official visitor to the Auckland Hospital, visiting patients at least monthly. She was appointed to the role in 1897.41 In this period, Hendre was also matron at the Castley Training Institution, a home for orphan and delinquent boys and was active in welfare activities around Auckland.42 She was a well-respected member of the community, as the Inspector of Asylums Duncan MacGregor reported in 1898.43 Interested in the institutional spaces made available to asylum patients, she returned to the theme of outdoor exercise frequently in her reports. By the 1880s, the initial optimism in the new buildings had become despair: an inspector commented that he felt ashamed of the place, since it had ‘a poverty-stricken appearance’.44 On wet days she found patients cooped up inside in often overcrowded indoor spaces. She advocated a women’s garden in April of 1898, having spoken to some women patients about how they liked being outside. She noted that some ‘quiet and industrious’ women patients preferred to stay in, but wished that ‘a small plot of ground, as an old fashioned flower garden’ could be laid out to be cultivated by female patients who would otherwise either remain inside, or pace up and down the dull courtyard.45 Some female patients reminded her of this wish on subsequent visits.46 By 1899, a year later, Hendre noted with ‘satisfaction’ that her suggestion for the garden was to become a reality: the ground was being broken in preparation.47 Hendre was right: some women patients were restless and needed regular exercise, such as Elizabeth Ann P. who was ‘daily exercised in the airing yard’ in 1894, while many were listless and needed their spirits revived.48 Her notes reveal that Hendre treated her role of official visitor with some seriousness. She arrived early one day, in 1901, to surprise staff before they set off to take some patients on their asylum picnic, to make sure that adequate ‘comfort and security’ were in place for the many patients who stayed behind.49 Satisfied, she noticed, too, that the picnic had created a ‘joyous’ atmosphere at the institution. Even rain, seemingly frequent in Auckland, did not dull the spirits of the asylum patient ‘picnicers’. Hendre knew that not all patients were deemed ‘able’ or ‘fit’ to attend the picnics. Despite the usefulness of such events and entertainments, not to mention, she remarked, their ‘humanity’, she knew that many patients, male and female, would remain behind.50 The asylum’s medical journal (extant 1902–5) recorded the numbers of patients confined, secluded, engaged in employment, attending recreation or sick at the end of every week.51 Many patients were noted as being ‘wet and dirty’ or not adequately dressed. Some patients were ‘disobedient’, ‘troublesome’, ‘threatening’ or ‘abusive’. They were most likely to be secluded for periods of time. Yet, about two-thirds of 296

Challenging Institutional Hegemony patients, both male and female, were consistently employed in wards, the workshop, the laundry, in the grounds, in the dining hall, in the kitchen or at needlework. As in other colonial asylums, there was a distinctly gendered division of labour.52 Hendre was one official asylum visitor who left behind her a mark of her activities and what she saw in the asylum. Other visitors left more fleeting traces of their contact with institutions. The following section of this chapter explores less official visits to colonial asylums. ‘Unofficial’ visitors: families ‘inside’ the asylum The official annual asylum inspectors’ reports made almost no mention of family visitors. Although inspectors noted that asylums needed to be accessible, and lamented colonial geographical distances, considering that ‘the visits of friends are in many cases good for the mental health’, they were silent on the presence of family members and friends inside the institution itself.53 Despite their near obsession with all manner of quantifiable data, official reports never tabulated visits made to patients by family and friends.54 This is possibly because legislation in all of the colonies, except New Zealand, made no mention of the role of family visits. In that colony, the Lunatics Act of 1882 set out rules for the ‘Admission of friends of lunatics’ in sections 141 and 142 and detailed the penalty for refusing admission, which was up to £20, unless asylum authorities were acting upon written instructions to prevent visitors from entering the asylum. Therefore visits were still at the permission of asylum authorities including the Asylum Inspector, the Colonial Secretary, or the superintendent.55 Other evidence from New Zealand reveals the nature and extent of family visiting to Auckland’s asylum, as this section of the chapter later explores. Family members often physically encountered institutions at the point of committal, and also at the point of discharge. In 1896, the Goodna Hospital case book entry for 25-year-old Ethel S., who was being discharged after a short time in the institution, recorded that she was ‘today for Brisbane with her mother’.56 When patients were granted a trial release or absence, family members came to escort them away, or to return them. Sometimes, during a patient’s period of absence, family members were responsible for bringing the patient to the asylum for a quick check, to ensure they were still fit to stay outside the institution.57 Mary B., who was a 29-year-old domestic servant confined at Goodna from 1902, was given three months trial leave at the end of that year. In January 1903, she ‘was brought up for inspection… by her mother who gave a very good account of her and she was accordingly discharged’.58 Ada Jane B. was visited by her husband at Yarra Bend in 1899, who wrote to the medical superintendent to negotiate her leave of absence. He remarked that she appeared ‘quite sensible and 297

Catharine Coleborne rational, the same as she always has been except when she happens to get a fit’.59 These fits had happened over a period of thirteen years, and she had always conducted her housework despite her illness. When family or friends of inmates visited, they sometimes discussed the patient with the superintendent or medical officer. The son of Abigail M., a widowed hotel keeper in North Melbourne, mentioned his interview to discuss his mother’s case with the Medical Superintendent Dr Watkins in correspondence to Yarra Bend in 1900.60 This type of discussion also took place in writing, usually following visits and physical contact with the institution. In Robert W.’s case, several relatives were listed at the time of his committal to the asylum in 1901. Only a few weeks after his arrival in March, a member of the family wrote to Dr Watkins claiming Robert had made ‘rapid progress’ over six weeks, and offered to collect him the following week. The case notes reveal that this request was granted, and, safely dispatched to his sister’s seaside home, Robert was deemed well and discharged by October that year.61 Cases like these demonstrate that as in other contexts, contact with family could speed recovery and lead to discharge.62 The visitors’ book at Auckland tells us more about the presence of family and friends in the institution. Hundreds of visits were made to patients at the Auckland Hospital over the period 1891–1911.63 When visitors signed in, they were obliged to note their name and address, the name of the patient being visited and their relationship to that person. Some patients were visited regularly by the same person, others by different family members. In a number of cases, both parents of a patient visited together, perhaps providing support during the visit and over the distance travelled. Small family groups also arrived in parties. Some addresses indicate that visitors came from distances of over one hundred miles, including the far north of the North Island, Whangarei, north of Auckland, and the north-eastern coastal towns of Coromandel and Thames. There were also visitors from other colonies, such as the friend of Alfred T., who came from Melbourne to see him in 1902.64 Some families sent friends, and it was noted that they visited at the request of a family member: ‘Friend at father’s request’. If any visitor refused to give their address, this was duly noted in the book.65 Visitors could take a patient out for the day, if that person was deemed able to go beyond the asylum grounds, and the visitors’ book details a few such instances. As in Kelm’s study, some patients were visited on the wards, with one woman remaining with her husband in his ward for over two hours in 1901.66 It is not clear whether any of these asylums had large spaces for visitors; it does seem that specific days of the week were advertised to visitors from the public, including patient’s families and friends, and that they were not admitted at any time they chose. Letters written to medical 298

Challenging Institutional Hegemony superintendents reveal that people negotiated to visit on days other than those designated. Requesting leave for her daughter Ethel, one mother notified Dr Beattie at the Auckland Hospital that she would need to change the day she came to collect her, explaining that otherwise she would lose a day’s wages; her employment ‘was only day work’.67 Family visits very rarely occasioned mention in the patient’s case record, but were sometimes noted in other records including maintenance investigations and payment ledgers. This lack of attention in the patient case record is perhaps a result of the detail required on other matters, including bodily health and the regular recording of medical notes. More attention was paid to family history at the time of committal. However, Catherine B., a young woman confined at Auckland in the 1890s, and described in her case record as a ‘congenital idiot’, received very little attention from medical observers. Like other patients labelled as ‘imbecile’ or ‘idiot’ in this period, her case was perhaps regarded as hopeless. She was the daughter of a farmer at Mahurangi, some distance north of Auckland, and their surname indicates that they were European immigrants. Her sister stated that she had been ‘an idiot all her life’.68 Her case record reveals very little about her family’s interest in her. Yet her father made significant attempts to contact the asylum. In September 1892, he visited the asylum with details of his financial situation, contrary to the negative views of the police, who claimed he would ‘not worry himself to get money’ to cover the cost of her maintenance.69 He also pledged to make regular payments.70 He also visited his daughter, her name noted by him in the visitors’ book as ‘Kitty’. He visited again later that year.71 Patients whose behaviour before committal had been the source of some distress for families also received visits. Fifty-four-year-old Barbara L. suspected her husband of infidelity with an imaginary woman, had delusions and was violent towards her children, threw stones at people and annoyed the neighbours in 1894.72 Despite being ‘afraid of her’, her son visited her shortly after her committal in January.73 Elizabeth P. was confined with puerperal mania in January 1894, and would ‘not have the child near her’.74 Her husband first visited her in February when she had begun to improve, although she was still ‘restless’ and prone to ‘throw herself down’, and had to be controlled by attendants.75 Peter A.’s wife, who said he had threatened her and turned against their child, still visited him on several occasions before his death in 1904.76 For some patients, asylum committal, trial absence and discharge became a pattern, with family support an important factor in their experiences. The many visits over time to Stephen H. at Auckland illustrate this use of the institution. Stephen was a 41-year-old tinsmith who had been ‘acting strangely’ for some time, drinking too much, and who had become 299

Catharine Coleborne melancholic and withdrawn at the time of his committal in May 1900. His wife gave copious information about his state, including that he ‘became timid and was frightened to go out of the house imagining people were watching him’.77 He was admitted and discharged several times over the next two years. In 1900, he was visited several times by his wife and father until his discharge in September. The following year he was visited at the asylum again, this time by his wife and daughter, by his sons together, then by a son with his daughter, his father, and so on, with a shifting pattern of family responsibility over many months suggested by the range of arrangements. Stephen’s family lived in Auckland’s inner city, making their visiting more possible, since the asylum was accessible to them. Their visiting also suggests an understanding of the importance of its therapeutic value, with evidence that his initial committal was only a short stay in the asylum. At committal in 1900, he had been concerned about ‘disgracing his family’. These visits show a distinct determination on the part of family to ensure his eventual complete recovery. Although the visitors’ book shows that other patients received regular visits, there were many others, including some mentioned here, who received only one or two visits during their confinement at the Auckland Hospital. This paltry record of visits seems likely to have been partly the result of difficulties with distance. Perhaps mindful of this problem, some visitors to the Auckland Hospital did not go to visit specific patients, but went simply ‘to visit the patients’. This type of compassionate visiting was sometimes conducted by those from religious communities. Kevin Siena’s chapter in this volume explores this type of visiting in more detail. In August 1892, William M. was visited by a Priest, Father Hackett, from St Patrick’s Church Parish in Auckland. Father Hackett was named as a ‘friend’ in the visitors’ book.78 Records show that visits by nuns and priests were relatively common. When family members came to visit patients in colonial asylums, they often negotiated more than one distance. Both physical and symbolic separations between asylums and the outside world shaped their interactions with the institution. Margaret C., described as a ‘young widow’, was admitted to the Auckland Hospital in 1891. Although her condition was said to be caused by the loss of her husband and child, the brief medical case notes suggest she was suffering from a brain disease which made her appear ‘demented’ and like an ‘imbecile’. She did no work, and died in 1899.79 Margaret was visited twice, once by her sister from Mangawai, a small settlement north of Auckland in 1892, and once the previous year by a young woman who proclaimed ‘an interest’ in her, also from Mangawai, and possibly a former charge from Margaret’s work as a nursemaid.80 What did these two women see when they visited? Margaret sat ‘with her eyes closed’ and answered no questions, at least in the presence of medical staff; she 300

Challenging Institutional Hegemony moved ‘her fingers round and round her face’. The distressing nature of such visits, together with their distance from the asylum, may have deterred these women from any further contact with Margaret. As the following section of the chapter explores, both family and asylum responses to visiting also shaped the asylum experience, and provide another view of the relationships between the institution and the world beyond it. Patient, family and asylum responses to family visiting In the 1880s, when his wife Catherine was taken to the Yarra Bend Asylum on the fringes of the city of Melbourne, John Currie began writing in her diary. The Curries lived on a farm east of Melbourne, and had struggled with the worries of farming life, including bushfires, accidents and drought. In 1881, their youngest child drowned in a well on their property. Catherine’s sanity was severely tested. She succumbed to a breakdown, and at the asylum, began a slow process of recovery. John was agitated, visiting her regularly and then writing about it in the diary. He was not impressed by Yarra Bend, commenting ‘what an establishment!’ He worried that his wife seemed more ill in the institutional setting, and noticed that asylum staff seemed eager for him to leave; ‘they gave me the hint to go away’, he wrote.81 Yet he made more than one visit, and other diary entries indicate that family and friends also visited her at the asylum. This episode opens up a number of potential themes for historical analysis, including patient and family emotional reactions to asylum confinement, and the asylum’s own reaction to family visits. Reaume has argued that while visits could be ‘occasions of great anticipation for patients eager for familial contact’, these meetings could also ‘be a source of distress, igniting painful feelings of resentment and hurt’.82 The institution might then restrict or discourage such visits. As Kelm has pointed out, ‘medical staff… did not part with their hegemony easily’ and controlled the nature of family visits, and to varying degrees, the exchange of correspondence.83 It is difficult to find out very much about what family visitors thought about their interaction with the asylum. Visitors’ books did not collect pleasantries or reflections. But it seems fair to speculate, as in the case of Margaret C., above, that some visits were harrowing for family. One woman made several visits to her son at Auckland but each time she came, he was experiencing some kind of episode: she ‘did not wish to see her son [when] he had a fit’.84 The sister-in-law of another patient ‘did not wish to see him to speak to’ in June 1901.85 Visitors were sometimes themselves excited and agitated by their contact with the patient. Visiting her husband John P. at Goodna in 1885, one woman became upset; she ‘gave him a very bad character for violence then declared she would never live with him again’.86 In other cases, it was patients who exercised their right not to be visited. One 301

Catharine Coleborne patient ‘refused to speak to his wife’, while another ‘did not wish to see her husband’. Another ‘refused to leave the airing court’ to see his parents.87 There were conflicts within families: one entry read: ‘mother not allowed to see him by wish of patient’s wife’ in 1900.88 Medical superintendents were also cautious, as Kelm also suggests, about too much contact between families and patients. ‘Not seen by order of medical superintendent’, was occasionally entered in the visitors’ book at Auckland.89 This extended to correspondence. Just as visits were controlled, letters between patients and those outside were regularly inspected and sometimes destroyed. This was paralleled in British institutions. In 1907, reports from the London County Council asylums detailed some anxiety about the suppression of patients’ letters.90 In the colonies, legislation determined that patients’ letters be reviewed by the asylum inspector and destroyed if they contained questionable content. Official criteria were not outlined but archival research shows that this content might include hostile communications to family members, or incomprehensible letters that were simply evidence of mental deterioration. Official reports regularly described this process. In his 1880 report on Gladesville, Manning noted that he had ‘looked over with some care all the patients’ letters detained by the Superintendent, and ordered their destruction, considering their detention reasonable and right’.91 At issue here was the improper treatment of patients’ letters. Family correspondence did reach patients, but was also reviewed. It seems likely that the contents of some letters were also checked for their potential impact on patients. However, as I have argued elsewhere, visits and letters from family could also become valuable to the diagnostic process.92 In some cases, the asylum incorporated family or lay testimony in very deliberate ways, or it simply became part of the clinical record. In the case of Alfred T., a patient at Auckland in the 1890s who received several visits from his wife, who lived at a distance, the family observations, did, in fact, have some kind of ‘medical’ significance. When she visited him in October 1895, his wife commented that she felt something was ‘wrong’, or changed, since her last visit, but she was unable to define this; she also noted that his memory was failing.93 Family visitors could provide the type of insight into cases that medical staff were unable to; in this case, the patient’s memory was better tested by someone who knew him. Conclusions Visitors found their way inside the institution of the hospital for the insane in Australia and New Zealand. Exploring their presence should remind historians of the significance of this under-examined aspect of the social and cultural history of medicine and the asylum. Visitors were not only part of 302

Challenging Institutional Hegemony the official monitoring of such institutions, but unofficial, family visitors also played their part in the culture of the hospital. This interplay between the ‘inside’ and ‘outside’ worlds challenges some views, at least in the public historical imagination, of the institution as a closed or sealed place of confinement. Elsewhere, I have commented on the way that watching asylum patients through the fences became a colonial weekend ‘sport’ in Victoria.94 In different ways, this chapter extends that vignette and demonstrates that colonial asylums were sites with multiple points of contact between families, patients and medical staff. Overall, this contact was a source of some anxiety for asylum managers who were working to build their hegemony over the problem of mental breakdown. Yet, they also relied upon the family as they attempted to return convalescent patients to their homes in the communities beyond the institution. In the newly forged colonial societies of Australia and New Zealand, where families were fractured by distance and migration, these attempts arguably shaped the relationships between medical professionals and the families of the insane. Family visits could disrupt the asylum’s order and control over patients. They were also sometimes distressing for both patients and their families who struggled to cope with the visible effects of mental breakdown and subsequent institutionalisation. The very presence of families inside the asylum unsettled the asylum’s separation of the ‘insane’ from the ‘sane’. At the same time, a growing discourse of ‘the family’ as the site of cure and control underscored asylum management. The evidence provided by family visiting and lay observers, including official visitors, suggests that the asylum itself should be unsettled as the locus of all the meanings of insanity and its cure. Notes 1. Queensland State Archives (hereafter QSA), Wolston Park Hospital, A/45600, Medical casebooks, folio/letter 237, 3 September 1867. 2. J. Moran, D.Wright and M. Savelli, ‘The Lunatic Fringe: Families, Madness, and Institutional Confinement in Victorian Ontario’, in N. Christie and M. Gauvreau (eds), Mapping the Margins: The Family and Social Discipline in Canada, 1700–1975 (Montreal: McGill-Queens University Press, 2004), 277–304. 3. M. Kelm, ‘Women, Families and the Provincial Hospital for the Insane, British Columbia, 1905–1915’, Journal of Family History, 19, 2 (1994), 180. 4. Kelm, op. cit. (note 3), 181; M. Finnane, ‘Asylums, Families and the State’, History Workshop, 20 (1985), 134–48. 5. D. Wright ‘Getting Out of the Asylum: Understanding the Confinement of the Insane in the Nineteenth Century’, Social History of Medicine, 10, 1 (1997), 155.

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Catharine Coleborne 6. W.B. Howie, ‘The Administration of an Eighteenth-Century Provincial Hospital: The Royal Salop Infirmary, 1747–1830’, Medical History, 5, 1 (1961), 34–55. 7. M.Winston, ‘The Bethel at Norwich: An Eighteenth-Century Hospital for Lunatics’, Medical History, 38 (1994), 27–51: 42. 8. On moral therapy see N. Tomes, ‘The Anglo–American Asylum in Historical Perspective’, in C. Smith and J.A. Giggs (eds), Location and Stigma: Contemporary Perspectives on Mental Health and Mental Health Care (Boston: Unwin-Hyman, 1988), 3–20. 9. A. Shepherd, ‘The Female Patient Experience in Two Late-NineteenthCentury Surrey Asylums’, in J. Andrews and A. Digby (eds), Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry (Amsterdam: Rodopi, 2004), 223–48: 242. 10. H. Marland, Dangerous Motherhood: Insanity and Childbirth in Victorian Britain, (Basingstoke: Palgrave Macmillan, 2004), 159. 11. Joseph Melling and Bill Forsythe include a short discussion about asylum visiting for pauper lunatics at Exminster; see J. Melling and B. Forsythe, The Politics of Madness: The State, Insanity and Society in England, 1845–1914 (London: Routledge, 2006), 100. Kelm, op. cit. (note 3) 181–2. 12. G. Reaume, Remembrance of Patients Past: Patient Life at the Toronto Hospital for the Insane, 1870–1940 (Oxford: Oxford University Press, 2000), especially 188–91. 13. N. Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840–1883 (Cambridge: Cambridge University Press, 1984), 116. 14. Finnane, op. cit. (note 4). 15. S. Garton, Medicine and Madness: A Social History of Insanity in New South Wales, 1880–1940 (Sydney: University of New South Wales Press, 1988). 16. B. Labrum, ‘Looking Beyond the Asylum: Gender and the Process of Committal in Auckland, 1870–1910’, New Zealand Journal of History, 26 (1992), 125–44. This has recently been republished as ‘The Boundaries of Femininity: Madness and Gender in New Zealand, 1870–1910’, in W. Chan et al. (eds), Women, Madness and the Law: A Feminist Reader (London: Glasshouse Press, 2005). 17. This project is focused on families and public colonial institutions for the insane in Australia and New Zealand, 1860–1914. It is funded by the Royal Society of New Zealand’s Marsden Fund. It will culminate in a book-length study called Madness in the Family: The Australasian Colonial World, Insanity and Institutions, 1860s–1914. 18. M. Tennant, Paupers and Providers: Charitable Aid in New Zealand (Wellington: Allen & Unwin, 1990), 39. 19. Ibid., 13.

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Challenging Institutional Hegemony 20. Asylum maintenance has not been explored in any detail by historians of Australian and New Zealand asylums and will form part of the wider study from which this chapter is derived. Official asylum reports from all four colonies throughout the nineteenth century comment on rising costs of patient care, and lament the inability to improve upon maintenance fee collection rates. By the 1880s, the average weekly cost per patient had decreased to just over eleven shillings, and this was constant into the twentieth century for the four colonies discussed here. 21. Associate investigator to this research project, Dolly MacKinnon, is examining private institutions in New South Wales and Victoria. There is very little scholarship about the Australian private institutions. On New Zealand’s Ashburn Hall, see A. Somerville, ‘Ashburn Hall, 1882–1904’, in B. Brookes and J. Thomson (eds), ‘Unfortunate Folk’: Essays on Mental Health Treatment 1863–1992 (Dunedin: Otago University Press, 2001), 83–103. 22. M. Finnane, ‘The Ruly and the Unruly: Isolation and Inclusion in the Management of the Insane’, in C. Strange and A. Bashford (eds), Isolation: Places and Practices of Exclusion (London: Routledge, 2003), 89–103: 92. 23. Ibid., 98–9. Finnane provides no indication of the costs incurred but points out that only indigent families could apply for rail passes. 24. Ibid., 98. 25 See also R.M. Hunter, ‘Historical Notes on the Auckland Psychiatric Hospital’, The New Zealand Nursing Journal (February 1957), 15–21; and M.S. Primrose, ‘Society and the Insane: A Study of Mental Illness in New Zealand, 1867–1926, with special reference to the Auckland Mental Hospital’ (unpublished MA thesis: University of Auckland, 1968). 26. On Maori patients, see L. Burke, ‘“The Voices Caused him to Become Porangi”: Maori Patients and the Auckland Lunatic Asylum, 1860–1900’ (unpublished MA thesis: University of Waikato. 2006). Labrum has also discussed Maori patients in her work, op. cit. (note 16). 27. On Manning, see D.I. McDonald, ‘Manning, Frederick Norton’, Australian Dictionary of Biography, Vol. 5 (Melbourne: Melbourne University Press, 1974), 204–5. 28. Garton, op. cit. (note 15), 55; Finnane, op. cit. (note 4), 143; See also M. Philip, ‘Scientific Pastors: The Professionalisation of Psychiatry in New Zealand 1877–1920’, in Brookes and Thomson, op. cit. (note 21), 185–99. 29. E. Sinclair, ‘The Extension of Hospital Methods to Asylum Practice’, Intercolonial Medical Congress of Australasia Second Session (1889), 895. 30. See the following: Lunatics Act, 1882 (New Zealand); Lunacy Act, 1898 (New South Wales); Insanity Act, 1881 (Queensland) and Lunacy Act 1890 (Victoria). 31. ‘Report on Lunatic Asylums for the Colony’, Appendices to the Journal of the House of Representatives (hereafter AJHR), H–7, 1901, 4.

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Catharine Coleborne 32. C. Krasnick Warsh, Moments of Unreason: The Practice of Canadian Psychiatry and the Homewood Retreat, 1883–1923 (Montreal: McGill-Queen’s University Press, 1989), 134. 33. Tennant, op. cit. (note 18), 14. 34. C. Twomey, Deserted and Destitute: Motherhood, Wife Desertion and Colonial Welfare (Melbourne: Australian Scholarly Publishing, 2002), 92, 97. 35. ‘Report of the Inspector General of the Insane’, New South Wales Legislative Assembly Votes and Proceedings, 1879–80, 12; ‘Report of the Inspector of Lunatic Asylums’, Victoria, Parliamentary Papers (hereafter VPP), 1888, 43. 36. ‘Report on Lunatic Asylums in New Zealand’, AJHR, D–29, 1870. 37. ‘The Whau Minstrels’, New Zealand Herald, 6 March 1868. Located in the Archives New Zealand, Auckland, at YCAA Carrington Hospital 1083/5b, Newspaper Reports 1851–1878. 38. ‘Report of the Inspector General of the Insane’, op. cit. (note 35); ‘Report on the Yarra Bend Lunatic Asylum’, VPP, 1860–61, 5. 39. ‘Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane’, VPP, 1879, 18. 40. ‘Report on Lunatic Asylums in New Zealand’, AJHR, D–29, 1870, 1. 41. The appointment was reported in the New Zealand Gazette, 30 April 1897, 779. 42. Information obtained from the Dictionary of New Zealand Biography online, in development, http://www.dnzb.govt.nz/dnzb/. 43. MacGregor had a reputation for being fierce. His praise of the ‘lady Official Visitor’ is notable in his comments about Auckland. See ‘Report on Lunatic Asylums of the Colony’, H–7, AJHR 1898, H–7, 12. 44. ‘Report on Lunatic Asylums of the Colony’, AJHR 1886, H–6, 6. 45. YCAA 1049/1, 18 April and 28 May 1898. 46. Hunter, op. cit. (note 25), 20. Hunter collapses the notes by official visitors together; these are undated and not referenced. I was able to check these against the original source. 47. YCAA 1049/1, 1 April 1899. 48. YCAA 1048/6, Patient Casebooks 1853–1916, 17 January 1894, 207. 49. YCAA 1049/1, 13 March 1901. 50. YCAA 1049/1, 12 March 1902. 51. YCAA 1100/1, Medical Journal, 1902–5. 52. See C. Coleborne, ‘Space, Power and Gender in the Asylum in Victoria, 1850s–1870s’, in C. Coleborne and D. MacKinnon (eds), ‘Madness’ in Australia: Histories, Heritage and the Asylum (St Lucia: University of Queensland Press, 2003), 49–60. 53. F.N. Manning, ‘Report on Lunatic Asylums’ (Sydney: Thomas Richards Government Printer, 1868), 125. 54. As Reaume also notes for Canada, op. cit. (note 12), 188.

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Challenging Institutional Hegemony 55. Lunatics Act, 1882 (New Zealand) s. 141, s. 142. 56. QSA A/45627, 22 September 1896, 37. 57. The ‘boarding-out’ of patients in the colonies is outside the scope of this chapter, but will be discussed elsewhere as part of the wider project. It took a different form in the colonies. International studies of boarding out practices include: H. Sturdy and W. Parry-Jones, ‘Boarding-Out Insane Patients: The Significance of the Scottish system 1857–1913’, in P. Bartlett and D. Wright (eds) Outside the Walls of the Asylum: The History of Care in the Community 1750–2000 (London: Athlone Press, 1999), 86–114. 58. QSA A/45639, January 1903, 81. 59. Public Record Office of Victoria, VPRS 7400/P1, Yarra Bend Patient Casebooks, Unit 12, 19 June 1899, 228; 7570/P1, Applications for Leave of Absence, Unit 1, File 99/1789, Bundle 2, 2 July 1899. 60. VPRS 7570/P1, Unit 1, File 1900/1870, Bundle 4, 19 October 1900. 61. VPRS 7399/P1, Unit 13, 20 March 1901, 46; 7570/P1, Unit 1, File M01/1584, Bundle 5, 24 April 1901. 62. Kelm, op. cit. (note 3), 180. 63. This visitors’ book is not paginated, but could easily contain a record of twenty visits per page, in a book of around two hundred pages or more, over this time period. It is only a fraction of information about visiting which most likely occurred throughout the nineteenth century in a similar pattern. 64. YCAA 1075/1, Visitors’ Book 1891–1911, 23 June 1902. 65. Refusal to provide an address might suggest one of two things: transience or lack of a permanent address, or a wish to evade maintenance collection. Efforts were made to trace families for maintenance payments. This subject falls outside the scope of this chapter but is dealt with in my wider project. 66. YCAA 1075/1, 25 October 1901. 67. YCAA1026/12, Patient Case Files, Case 4112, 17 October 1911, letter to Dr Beattie. 68. YCAA 1048/5, 13 February 1892, no page. 69. YCAA 1044/1, Record Book of Maintenance Investigations, 38. 70. YCAA 1045/1, Maintenance Payment Ledger, 1885–99, 133. 71. YCAA 1075/1, 6 September 1892; 15 December 1892. 72. YCAA 1048/6, 18 January 1894, 209. 73. YCAA 1075/1, January 1894. 74. YCAA 1048/6, 17 January 1894, 207. 75. YCAA 1075/1, February 1894; YCAA 1048/6, 6 February 1894, 207. 76. YCAA 1048/9, 15 June 1900, 20. Several mentions in the visitors’ book covered the period of his committal. 77. YCAA 1048/9, 10 May 1900, 2. 78. YCAA 1075/1, 26 August 1892. 79. YCAA 1048/5, September 1891, 641; YCAA 1044/1, 49.

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Catharine Coleborne 80. YCAA 1075/1, 27 November 1891; 8 January 1892. 81. 9 October 1881, Ann Catherine Currie, Farm Diaries, 1873–1916, La Trobe Australian Manuscripts Collection, State Library of Victoria, MS 10886 MSB 623, 7 vols. 82. Reaume, op. cit. (note 12), 115. 83. Kelm, op. cit. (note 3), 180–1. 84. YCAA 1075/1, 15 June 1900. 85. YCAA 1075/1, 5 June 1901. 86. QSA A/45611, June 22 1885, 39. This was followed by a letter to the asylum in 1905, when she was still concerned about his release. 87. YCAA 1075/1, 30 August 1901; 18 September 1901; 18 October 1901. 88. YCAA 1075/1, 28 February 1900. These examples are echoed by Melling and Forsythe, op. cit. (note 11), 100. 89. For example, YCAA 1075/1, 7 March 1900. 90. Reports from London County Council Asylums, Journal of Mental Science (January 1907), 204. 91. ‘Report of the Inspector General of the Insane’, op. cit. (note 35), 11. 92. C. Coleborne, ‘“His Brain was Wrong, his Mind Astray”: Families and the Language of Insanity in New South Wales, Queensland, and New Zealand, 1880s–1910’, Journal of Family History, 31, 1 (January 2006), 45–65. 93. YCAA 1048/6, 12 October 1895, 439. 94. C. Coleborne, ‘Passage to the Asylum: The Role of the Police in Committals of the Insane in Victoria, 1848–1900’, in R. Porter and D. Wright (eds), The Confinement of the Insane: International Perspectives (Cambridge: Cambridge University Press, 2003), 129–48: 131.

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Notes on Contributors

Catharine Coleborne is an associate professor in history at the University of Waikato in New Zealand. She has published Reading ‘Madness’: Gender and Difference in the Colonial Asylum in Victoria, Australia, 1848–1880s (Perth: Network Books, 2007). She is the co-editor (with Dolly MacKinnon) of ‘Madness’ in Australia (Queensland: University of Queensland Press, 2003). Her key research interests are in histories of psychiatry, patients and institutions, and histories of gender, law and colonialism. Sanjeev Jain is a professor at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India. In addition to being an active researcher exploring the molecular genetics of psychiatric and neurological disorders, he has been documenting the history of mental health services in India, from the colonial to the contemporary period. He has authored several papers, and edited an issue of the International Review of Psychiatry devoted to the history of psychiatry. He has also used molecular approaches to understand the cultural and historical aspects of population admixture and consequent gene flow as part of the Portuguese and British interactions with the Indian population. This has helped understand the interface between science, medicine and social responses to mental illness in India. Bruce Lindsay is based at the School of Nursing and Midwifery, University of East Anglia, Norwich, where he is a senior lecturer. His PhD thesis was on the development of children’s hospital care in the UK and he has published a variety of papers on the history of children’s hospitals, child health care and hospital visiting. He is a child care nurse and also undertakes clinically-focused research, particularly in the field of epilepsy. He is a member of the Cochrane Collaboration of health care researchers. Dolly MacKinnon is a senior fellow at the School of Historical Studies, and a career enhancement fellow, Faculty of Music, both at the University of Melbourne. An interdisciplinary historian, Dolly co-edited with 309

Notes on Contributors Catharine Coleborne, ‘Madness’ in Australia (Queensland: University of Queensland Press, 2003) and a special issue of the journal Health and History: Histories of Psychiatry after Deinstitutionalisation, 5, 2 (2003). She co-edited with Ros Bandt and Michelle Duffy, Hearing Places (Newcastle-upon-Tyne: Cambridge Scholars Publishing, 2007). She is also the author of Revealing the Early Modern Landscape: Earls Colne, Essex (Aldershot: Ashgate, forthcoming). With Professor Elizabeth Malcolm and Dr John Waller, Dolly holds an Australian Research Council Grant for a project entitled ‘A History of Psychiatric Institutions and Community Care in Australia, 1830s–1990s’. James H. Mills is currently senior lecturer in modern history at the University of Strathclyde and was the founding director of the Centre for the Social History of Health and Healthcare, Glasgow. His publications include the monographs Cannabis Britannica: Empire, Trade and Prohibitions, c.1800–1928 (Oxford: Oxford University Press 2005) and Madness, Cannabis and Colonialism: The ‘Native-Only’ Lunatic Asylums of British India, 1857–1900 (Basingstoke: Palgrave Macmillan, 2000) and the edited collections (with Satadru Sen) Confronting the Body: The Politics of Physicality in Colonial and Post-Colonial India (London: Anthem Press, 2004) and (with Patricia Barton) Drugs and Empires: Essays in Modern Imperialism and Intoxication (Basingstoke: Palgrave Macmillan, 2007). Janet Miron is an assistant professor in the History Department at Trent University. Her PhD dissertation at the University of York, 2004, examines prison and asylum visiting in Canada and the United States in the nineteenth and early twentieth centuries. She has published a chapter on asylum visiting in James E. Moran and David Wright’s Mental Health and Canadian Society (London: McGill-Queen’s University Press, 2006) and a monograph based on her doctoral research is forthcoming with University of Toronto Press. Also, she has edited a forthcoming collection of articles, A History of Human Rights in Canada: Essential Issues (Toronto: Canadian Scholars’ Press, 2009). Her current research explores the history of firearms cultures and regulation in Canada. Graham Mooney is an assistant professor in the Institute of the History of Medicine, Johns Hopkins University. He has published widely on the history of public health, historical demography and historical epidemiology and is currently writing a book on infectious disease surveillance in Victorian Britain. 310

Notes on Contributors Jonathan Reinarz is the director of the Centre for the History of Medicine, University of Birmingham. His research addresses the history of hospitals and medical education, and he also continues to undertake research on the social and economic history of England from 1750 to 1950, with a particular interest in the history of alcohol. He has authored The Birth of a Provincial Hospital: the early years of the General Hospital, Birmingham, 1765-1790 (Stratford-upon-Avon: Dugdale Society, 2003) and edited Medicine and Society in the Midlands: 1750-1950 (Birmingham: Midland History Occasional Publications, 2007). His latest monograph is Health Care in Birmingham: The Birmingham Teaching Hospitals, 1779–1939 (Rochester: Boydell Press, 2009). Michelle Renshaw is a visiting research fellow at Adelaide University in the Faculty of Health Sciences, Public Health. Her earlier academic associations were with the Centre for Asian Studies at Adelaide University, the School of Aboriginal Administration at University of South Australia and Politics and Accounting Schools at Flinders University. Research interests include the comparative history of medicine and its institutions, particularly in the United States and China. She is currently writing a book exploring the cultural, political, legal and medical reasons for the extraordinary surgical success of the first American medical missionary to China, Peter Parker. She is the author of Accommodating the Chinese: The American Hospital in China 1880-1920 (London: Routledge, 2005). Robin L. Rohrer is a professor of history at Seton Hill University in Greensburg Pennsylvania where she teaches history of western medicine and American medicine and culture. She received her PhD from the Catholic University of America and her research focus is on the history of childhood cancer, particularly since 1970. Her current projects include a monograph on the development of therapy for children with leukaemia and a longitudinal study of the family experience of childhood cancer at the Children’s Hospital of Pittsburgh from 1970 to the present. Dr Rohrer has received a Pisano Grant from the National Institutes of Health and Wellcome Travel Grants to support this research. Kevin Siena is associate professor of history at Trent University, Canada. He has authored Venereal Disease, Hospitals and the Urban Poor: London’s ‘Foul Wards 1600-1800 (Rochester: University of Rochester Press, 2004) and edited Sins of the Flesh: Responding to Sexual Disease in Early Modern Europe (Toronto: Centre for Reformation and Renaissance Studies, 311

Notes on Contributors 2005). His current research explores poverty and illness in London during the long eighteenth century. Leonard Smith is an honorary research fellow at the Centre for the History of Medicine at the University of Birmingham. He trained as a psychiatric social worker in the 1970s and currently works in a community mental health team. He has researched and written extensively on the historical development of lunatic asylum provision in England in the eighteenth and nineteenth centuries. His publications include, ‘Cure, Comfort and Safe Custody’; Public Lunatic Asylums in Early Nineteenth-Century England (London: Leicester University Press 1999) and Lunatic Hospitals in Georgian England, 1750-1830 (London: Routledge, 2007). Andrea Tanner works at the Great Ormond Street Hospital for Children and at Kingston University. Most recently, she has helped create an online database of the pre-1914 admission registers at the hospital (http://www.smallandspecial.org), and is involved in extending this to other London children’s hospital registers, with a view to applying the same techniques to Scottish children’s hospitals. Research interests include the health of the poor urban child in Victorian Britain, social and economic philanthropic networks and (thanks to a post as honorary archivist at Fortnum and Mason), the history of shopping.

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Index

A Abbots Bromley, madhouse 202 Aberdare (south Wales), mothers forbidden in isolation hospitals 160 Aberdeen, window appointment at isolation hospital 164 abuse in asylums England see asylums (England) New York State Lunatic Asylum (Utica) 248, 255 by staff house visitors’ concern 36 official visitors to reduce 19, 21, 203, 255 prevented by house visitors at Lock Hospital 179 Act for Regulating Madhouses (1774) 201 acute lymphoblastic leukaemia (ALL), children 133–4 parental experience of diagnosis 139–40 symptoms 133 treatment 133–4 acute myelogenous leukaemia (AML) 134 adenoidectomy, Jenny Lind Hospital for Sick Children 124–5 advertising for Bay View Private Asylum (Australia) 277 scrutiny of surgery in China and 69 visiting days/hours to children’s hospitals 10 advocates of patients (family/friends as) in China 63–4

see also family and friends house visitors as, at General Hospital, Birmingham 36 social workers as, children with cancer 143 ‘after care’ committees 44 Aickin, T. 281 Akin, Lew (child operated on) 67 Albert, Prince, HRH the Prince Consort 46 Alcester, visiting in isolation hospital 161, 164 alcohol brought into New York asylums 259 smuggled into London Lock hospital 181 Allderidge, Patricia 244–5 Allen, John 36 ambulance service, isolation hospitals and 152 America see USA American Episcopal Mission, St Luke’s Hospital (Shanghai) 60 American mission hospitals, China see China, medical missions aminopterin 134 amputations death rates (UK vs China) 69–70 mission hospitals in China 64, 65 anaesthetics 57 Anderson, John A. 61–2 animals, in hospitals 24 see also pets apothecary, list of visitors and visits 34 Ararat Asylum (Victoria, Australia) 274 art gallery, London’s Foundling Hospital 14

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Index Ashburn Hall Private Asylum (New Zealand), official visitors reporting on entertainment 276 Ashley, Lord 210, 212, 213 Asia, South see South Asia asylums as alternative to household stress from mentally ill 290 Australian/New Zealand see Australian and New Zealand asylums balls 268, 270, 271–2, 273–4 bands 15, 268, 272, 273, 274–5 buildings Australian and New Zealand asylums 268, 269, 295–6 Ceylon 227, 228 India 233–4, 235 cultural context (nineteenth century) 13–14, 245–7, 251–2 England (Victorian era) see asylums (England) family blamed for condition by 291 family visitors 13, 291–2 Australian/New Zealand asylums 289, 297–301 patient’s rights not to be visited by 13, 301–2 restricted in New York asylums 257 therapeutic value 13, 298, 300 views on asylums 290 see also Australian and New Zealand asylums importance of visiting 13 New York see New York asylums official visitors 19 Australia/New Zealand see Australian and New Zealand asylums Ceylon 18–19, 20, 226 England see asylums (England) India 236

New York asylums 246 proximity to towns as benefit to visitors 250 public visitors 13–14 Australian/New Zealand asylums 268, 270, 273, 278 South Asia 224, 225 see also Ceylon, psychiatric institutions; India, asylums asylums (England) 199–222 1750–1815 201–6 1815–1850 (from voluntary to central oversight) 206–15 abuses in 199, 200, 206 Commissioners in Lunacy reports 212, 213 inspections needed to prevent 201 for ‘pecuniary profit’ 213 private madhouses 201, 203 protection by visitation 201, 203 reforms in 1813 (York Asylum) 207 centralised system of regulation needed 209, 211 county asylums 1750–1815 205–6 1815–1850 206–7 Commissioners in Lunacy approach 213–14 guardians and responsibility for paupers 209 magistrates directing 205, 209 Metropolitan Commissioners’ inspections 210 as model 205, 210 Select Committee (1815-16) recommendations 206–7 visitation/inspections 205–6 for-profit see private asylums (below) governors/official visitors complacency 209 conflicts of interests with proprietors 202

314

Index Leicester asylum 206–7 lobbying against 1815–16 Select Committee 206 private madhouses 201, 202 provincial asylums 204 York Asylum 207 images and myths 199 inspections 19 balance of needs for/against 19, 199–200, 203 need to prevent abuses 19, 201 Madhouse Act (1828) 208 need to inspect but need to protect patients from distress 19, 199, 203 overcrowding 211 oversight/monitoring 19, 200 pauper lunatics and 208, 209, 211 Asylums Act (1854) requirement 211 physicians role of dominance 204 private asylums 19, 199, 200 1750–1815 201–3 1815–1850 208 abuse for ‘pecuniary profit’ 213 Commissioners in Lunacy concerns 212 condemnation by Metropolitan Commissioners 211 conflict of interest of official visitors 202 criticisms of 202, 203 for-profit basis 19, 206 limited effectiveness of 1774 Act 201–2 Metropolitan Commissioners’ inspection 210, 211 paupers, concerns over c onditions for 212–13 proprietors 206 unjust admission by relatives with motive 199, 201 unregistered houses 201 visitation by local justices 201 provincial asylums

1750–1815 203–5 1815–1850 207 established as annexes to hospitals 203–4 need for oversight of keepers 203 visitation/inspection deficiencies 203–5 publicly funded 19, 200 Select Committee (1815-1816) 206–7 Select Committee (1827) 208 staff/governors rejecting inspection/interference 19, 203, 205 state responsibility 209 temptations for staff/visitors 19, 202, 209 visitation by Commissioners in Lunacy see Commissioners in Lunacy visitation requirements 1774 Act 201 1827 Select Committee 206–7, 209 best practices in county asylums 205–6 county asylums 205 Poor Law reforms and 209–10 private asylums 202, 203 provincial asylums 204 variations in fulfilment of 204 voluntary asylums 203, 206 ‘visitation upon visitation’ 214 Visiting Justices, for county asylums 205 voluntary sector 200 1750–1815 203 1815–1850 207–8 visitation deficiencies 203, 205 see also Commissioners in Lunacy Asylums Act (1854) 211 asylum tourism cultural context (nineteenth century) 13–14, 245–7, 251–2

315

Index asylum tourism (cont...) New York asylums 243–66 see also New York asylums Attfield, Dr 268–9, 280–1 Auckland Mental Hospital (New Zealand) (‘Whau’) 270, 272 administration/control and inspections 293 excursions for patients 281 family visits frequency 300 laws/Acts affecting 292 location and size 292 newspaper provision 279 official visitors 294–5 Hendre, Mrs Sada Russell 296–7 patient profiles 292 radio use 275 state of buildings 295–6 visiting day changes 299 visitors’ book information on visitors 298 women’s garden 296 Aunt Judy’s Magazine 94–5 Australian and New Zealand asylums administration/control and inspections 293, 294–5 asylum ball 268, 270, 271 for better behaved patients 271–2 permission declined during world war 273–4 asylum band 15, 268, 272, 273, 274–5 band members 274–5 buildings/spaces 268, 269, 296 overcrowding and poor state 295–6 Christmas celebrations 278 compassionate visiting 300 confined/secluded patients 296 contributions (financial) to from families 292 by visitors 278 correspondence/letters to patients 290

control by inspectors 302 employment of patients 268–9, 297 entertainment/recreation 14–15, 267–88, 295 annual picnic 280, 281, 282, 296 bands see above books/newspapers 269, 279 charity concerts 272, 295 cricket and football 269, 279–81 criticisms about 280–1 film/cinematography 268, 275 financial constraints affecting 272–3 First and Second World Wars 273–4 fundraising by 270, 272 games 269, 279 involving family/friends 267, 278 involving staff and visitors 267, 270 links between guests and asylum 272 monitored by official visitors 276–8 music 272, 274–5 paid professional groups providing 268, 270 patients excluded from 296 patriotic, during world wars 273 provision difficulties 273 radio 268, 275 range of activities 267, 270 for select patients 270, 271–2 sports 268, 269, 279–81 sports days 280 as treatment regime 268–74 unsuccessful exhibitions/bands 272 volunteers providing 268, 273, 278

316

Index weekly/regular dances 271–2, 282 exercise for inmates 267, 269, 279–81 family history, at committal time 299 family support of importance to patients 299–300, 303 family visitors 289, 297–301 control by staff 297, 301, 302 correspondence/letters to patients 290, 302 discussion with superintendent/medical officer 298 distances travelled 298 distressing nature of visits 300, 301 effect on families 300–1, 301–2 financial circumstances of 299 friends sent in lieu of 298 history 291–2 information about 298 involvement encouraged 289, 297 lacking for migrants 293 medical superintendents’ cautions 302 mention in case records minimal 299 not wanted by staff 301 patient day-release 298–9, 299–300 patient response 301, 303 for patients causing distress 299 patients’ right not to be visited 13, 301–2 permission of authorities for 297, 301 role at discharge 297–8, 303 role at patient admission 289, 297, 299 role in diagnostic process 302

shifting responsibility by family members 300 sources of information about 290 staff responses/views of 301, 303 therapeutic value 13, 298, 300 visiting day changes 299 visiting on wards 298 female charity workers visiting 295 gifts from families/friends 278 history of 291–2 importance of visiting 13 inspectors 294–5 lack of mention of family visitors in reports 297 reports 295–6, 297 lady visitors 295 laws/Acts affecting 292, 297 ‘leave’ for patients 16, 268, 281–3 community able to observe patients during 281 day release 298–9 excursions outside 281, 282 failures and criticisms 282 passes 281 trial release/absence 297–8, 299–300 location and distance from towns 292–3 maintenance payments from families 292 mental illness management/therapy 294 newspaper/magazine reports about 270, 271, 272, 282 normal experiences of ‘outside’ world 268, 270, 272 normal social activities of patients 268, 270, 272 obligation to rehabilitate patients 270

317

Index Australian and New Zealand asylums (cont...) official visitors 276–8, 290, 294–7 appointment 294 duties 295–6 monitoring of entertainment/recreation 276–8 notes from Hendre (Mrs Sada Russell) 296 recording comments in Visitor’s Book 276 warning of visits 278 overcrowding and state of buildings 295–6 patient profiles 292 patients’ right not to be visited 13, 301–2 penalty for refusing admission 297 permeable walls 14, 267, 281, 283, 290, 303 pets for inmates 24, 279 physical and symbolic separation 300–1 recreation halls 268, 269 sound technology in 275 used as dormitories 269–70 release/absence, trial 297–8, 299–300 space for Divine service 269 staff censoring of radio 275 concerns over excursions for patients 281 musical abilities 274–5 shortages during world wars 273 on sporting teams 280 working class background 274 state-funding 295 superintendents 293–4 trial release of patients 297–8 see also New South Wales asylums; Queensland asylums; Victoria (Australia) asylums

B Babb, Isabella 89 Bagthorpe hospital 158 Bakewell, Thomas 202, 206 Baldwin, Peter 149, 151 bands, Australian/New Zealand asylums 15, 268, 273, 274–5 Barrow, Logie 151 Bartleet, Miss, ‘after care’ committee development 44 Bathurst, H.A. 92 Bay View Private Asylum (New South Wales) 276, 277 discipline at 276 Inspector General’s cautions on 278 location and friends visiting 277 official visitors monitoring entertainment 276 suicide of day-release patient 282 ‘Bedlam’ see Bethlem Hospital beds, hospital General Hospital (Birmingham) learning from other institutions 37–8 house visitors advising on 34–5 number Ceylon, psychiatric institutions 228 India, asylums 234 isolation hospitals (midVictorian Britain) 147, 151 Beechworth Asylum (Victoria, Australia) 274 beer quality, assessment by house visitors 33 beggars, near London Lock Hospital 185 behavioural conditioning 23 behaviour of patients, house visitors’ concerns 35–6 behaviour of visitors see conduct of visitors Bell, Jean 164 Bence Jones, Sir Henry 84

318

Index benefactors see subscribers beriberi 66 Berkeley Hill, Lt Col. O. 233 Best, Dr Charles 204 Bethel (Norwich) 291 Bethlem Hospital (London) 199, 206 open public access 203 origins and inadequate to meet needs 200 pets for inmates 279 public visiting 14 voyeurism (by visitors) 199, 203, 244 Bethnal Green, Warburton’s White House 208 Bilston, madhouse 202 Birkenhead, isolation hospital and private rooms 154–5 Birmingham General Hospital see General Hospital (Birmingham) hospitals in nineteenth century 32 isolation hospital ‘popularity’ 158 see also specific hospitals (below) Birmingham and District Crippled Children’s Union 44 Birmingham and Midland Eye Hospital 32 regulations controlling patients’ visitors 39–40 staff visits to London hospitals 38 Birmingham and Midland Hospital for Skin and Urinary Diseases 32 educational visits for staff and innovations 45 lady visitors 43 venereal disease and religious instruction 35–6 visiting hours 48 Birmingham and Midland Hospital for Women 32 home visits 44 house visitors 17, 44 lady visitors 43 royal visits 46 student visits to wards and roles 42

tea provision for visitors 47 visiting days for patient visitors 47 visiting hours 40 Birmingham Children’s Hospital 32 ladies’ committee 88 lady visitors 17, 43, 44 learning from Great Ormond Street hospital 38 out-of-date in 1907 37 regulations controlling patients’ visitors 39–40 tolerance of family visitors 39 visiting day control to limit infections 40 Bixby, Josephine 62 Blackpool, charges for visiting isolation hospital 160 Blackwell’s Island, asylum see New York City Lunatic Asylum (Blackwell’s Island) Board of State Commissions of Public Charities (USA) 246 Bogdan, Robert 253 books, Australian/New Zealand asylums 269, 279 Bose, Dr G. 233 Bowlby, John 12, 126 bread quality assessment by house visitors 33, 204 waste 35 breast cancer cases 67 Brigham, Amariah 247–8, 249 Brisbane Exhibition 282 Brisbane Mental Hospital 278 Brisbane Special Hospital 270 see also Goodna Hospital (Wongaroo Lunatic Asylum)(Queensland) Bristol Children’s Hospital 91 Broadstairs, window appointment at isolation hospital 164 Bromfeild, William 178, 186 brothels 182 Browning, Guy 7 Buckingham, Maude G. 45

319

Index buildings, institutional asylum see asylums opening, visits and fundraising 14 reconfiguration of space for recreation 15 temporary nature, isolation hospitals (mid-Victorian Britain) 151 Burchenal, Joseph 134 burden, of visitors 48 burial costs 65 Burman, Thomas 202 Burnie, Thomas 157–8 burns case, China 67 Burroughs Wellcome 134 business administration, by house visitors 33 business opportunities benefits of visiting at Hospital for Sick Children 84 of subscribing/donating to hospitals 177 Buxton, Mr (Sanitary Inspector) 157

C Callan Park (Australia) 282 cancer, in children 131, 132–5 emotional stress of parents 131–2, 138–9, 142, 144 employment loss by parents 142 family reactions 132–3 financial loss (by parents) 140, 142 hospitalisation number and duration 134, 135, 138, 141 Memorial Hospital 132 new community formation 12 parental fears and lack of sleep 141 prevalence 133 psychosocial support for 12, 132, 143 support for parents from staff 141 total care for children 132, 134 tumour types 133 see also Children’s Hospital of Pittsburgh

Carlisle, charges for visiting isolation hospital 160 Castley Training Institution 296 cataract surgery/management 64, 67 Causley, Charles 7–8 Ceylon, psychiatric institutions 226, 227 in Angoda, for ‘chronic insane’ 229, 230 bed number 228 buildings and overcrowding 227, 228 certification as last resort 229 criminal and civil inmates together 229 doctor–patient ratio 228 low expenditure 228 Maharagama psychopathic hospital 231 Mapother’s criticisms 227–32 Mapother’s recommendations 15, 227, 228–32 costs of 231 cut-back by Government 231–2, 239 institutional aspects 229 legal reforms (mental illness as medical matter) 228–9 new institutions 229–30 Mapother’s visit in demi-official capacity as ‘expert’ 226–7, 237, 238 mental nurses and training 230 neuropsychiatric clinic 229, 231 observation home as ‘clearing’ house 230 official visitors to asylums 18–19, 20, 226 patient numbers 227 psychiatric medical officers 231 psychopathic hospital 229–30, 231 solitary confinement cells 227 staff for institutions and learning from India 230 staff numbers 231 Visiting Committees 231, 237

320

Index see also Mapother, Professor Edward Chadwich, George 201 chapel Australian/New Zealand asylums 269 London Lock Hospital 185–6, 187 charitable donations for educational visits and knowledge transfer 37 house visitors providing 17, 18, 32 see also subscribers charitable role/work, casual lady visitors in children’s hospitals and 91–2 charities, medical 31 charity concerts, Australian/New Zealand asylums 272, 295 Chase, Reverend H. 259–60 chemotherapy, development for childhood cancers 133–4 childcare centrality of family 12 role of older siblings 101 children accompanying parents to hospital in China 67 benefits of parents helping with 71 campaign against visiting restrictions in USA 55 cancer see cancer, in children detrimental effect of separation from parents 126 hospitals for see children’s hospital(s) in isolation hospitals see isolation hospitals (mid-Victorian Britain) neglect, parents viewed as cause of child’s sickness 82 responsibility for health after admission to isolation hospital 155 status as dependents 155 views on parental visiting at Jenny Lind Hospital for Sick Children 119–20

visits to dispensary (China) 58 ‘Children in Hospitals’ (USA organisation) 55 children’s hospital(s) 81–110 casual visitors (female) 82, 83 education of parents (hygiene/childcare) see education of visitors house visitors 17, 82, 83 infection control see infection control inspectors and official visitors 82, 83 ladies committees 87, 88–9 disbanding 91 London see Hospital for Sick Children, Great Ormond Street (London) Norwich see Jenny Lind Hospital for Sick Children number with daily visiting (1950s) 121 oncology see Children’s Hospital of Pittsburgh, children with cancer parental visiting 82–3 rooming-in for mothers 48, 120, 121 subscribers and visiting by 82 types of visitors 82 visiting restrictions for parents 10, 17 see also specific hospitals Children’s Hospital of Boston 132, 133 Children’s Hospital of Philadelphia 132 Children’s Hospital of Pittsburgh, children with cancer 12, 131–46 admissions 135 child participation in clinical trials 136 parental fears and experiences 140–1 discharge of children 137

321

Index Children’s Hospital of Pittsburgh, (children with cancer) (cont...) duration of parent stay/hospitalisation 134, 135, 138, 141 experiences of families 131–46 conducting of interviews with 138 of diagnosis of cancer 138–40 emotional stress on parents 131–2, 138–9, 142, 144 on entry into clinical trial 140–1 family/community support 143 financial/employment concerns 140, 142 general issues on hospital stay 141 interviews with parental visitors 136 lack of sleep for parents 141 parents’ loss of control (feeling) 138 parents’ loss of income/employment 140, 142 social work and psychosocial support 143 staff relationships 136–7, 143–4 study design 135–7 study participants and findings 137–8 nurse’s role 135, 143–4 oncology programme 138 parent–hospital staff relationship 136–7, 143–4 parents’ roles (care/support) 135 procedures/treatment types 136 psychosocial support for family 12, 132, 143 socio-economic and racial groups attending 137, 144 staff appreciation of parents’ role 144

teaching hospital and staff types 138 total care for children 132 see also cancer, in children Children’s Oncology Group (USA) 133, 138 China 62 current threats to hospitals 72 dispensaries 57–9 accompanying family inspiring confidence 58 benefits 57 children attending 58 patient statistics 58 responsibilities of doctor 59–60 family/friends in mission hospitals 11, 61–2 as advocates of patients 63–4 benefits of families’ presence 62, 66–7, 69, 70, 72 children accompanying parents 67 comfort for patients 67 consent for surgery 64 consequences for patients 69–70 current threats/changes 72 female patients 63 high risk surgery only in presence of 71 indemnifying hospital against deaths 64–5 infant care/feeding 62–3 as intermediary and guarantors 65 numbers of relatives/servants 61, 62, 69, 72 in operating rooms 67, 68 overcrowding by 61 parents accompanying children 58, 62, 67 psychological benefits to patient 66–7, 69 responsibilities 11, 62–3

322

Index responsibility for nutrition/food 11, 65–6 roles 62–8 scrutiny of surgery 67, 68, 69 as sources of information on illness 64 variety and depth of involvement 63 fee-for-service basis of hospitals 72 foreign-run hospitals as ‘public’ space 58–9 medical missionaries benefits of families visiting 69–70 increase in number 57 reluctance to operate on poor risk cases 70–1 study trips and keeping up-todate 57 see also Parker, Peter medical missions 11, 56–7 families accompanying patients see above in-patient number restrictions 61 limiting of rules to essentials 60 nurses appointed 61 overcrowding by servants/families 61 patient statistics 58, 61 reasons for lack of nursing staff 60, 61–2 staff statistics 11, 60 surgical cases vs medical cases 64 USA hospital comparison 56 ward conditions and people 60–2 one-child policy, effect on care of elderly 72 public hospitals (mid-1830s) 56 recovery rate after surgery 70 recuperation and family role 69–70 surgery safer than in USA 69–70

traditional diet, concerns over 65–6 traditional foods 65, 66 China Medical Missionary Association 57 Christchurch Asylum (New Zealand) 282 Christianity education in children’s hospitals 91, 92 spreading, in China 58, 61 see also clergymen/clerical visits Christmas Australian/New Zealand asylums 278 Jenny Lind Hospital for Sick Children 114–15 Church Missionary Society (CMS) Hospital (Hangzhou) 65 cinematograph, Australian/New Zealand asylums 275 citizenship 149–50, 165–6 formation, conduct of visitors and 23 health, and democratic public health 149, 166 ‘social’ 149 class distinctions, private vs public hospital visiting 11 cleanliness house visitors’ preoccupation 34 Queen’s Hospital, Birmingham 36 visitor reduction for reducing costs for 40 women casual visitors’ role in children’s hospital 98, 99, 100 clergymen/clerical visits visiting Hospital for Sick Children (London) 85 visiting Lock Hospital see London Lock Hospital clinical trials, participation by child with cancer 136

323

Index clothing infection spread in children’s hospitals 82–3 laundering see laundering/laundry protective, for visiting isolation hospitals 162, 163 provision for children’s hospitals 82–3, 87–8 Coetlogan, Charles de 187 Coleborne, Catharine 13, 289–308, 309 collection plates 40 Collie, Alexander 163 Collingwood Lunatic Asylum (Victoria, Australia), ball 271 Colman, Helen C. 123, 124 Colman, Jeremiah James 116 colonial asylums see Australian and New Zealand asylums colonial medicine, South Asia see South Asia Commissioners in Lunacy 19, 211, 215 approach to county lunatic asylums 213–14 criticisms of private asylums 212–13 development of visitation system 214 effects of adverse reports 212, 213, 214 empowering, powers and duties 211–12 Haydock Lodge intervention 213 major and special reports 212 Sandfield Asylum criticisms 212 commitment to care 71 compassionate visiting Australian and New Zealand asylums 300 Hospital for Sick Children, Great Ormond Street 85 Lock Hospital see London Lock Hospital, clerical visitation compensation, against loss of property, China 65

complaints/criticisms 19 house visitors registering 33 Lock Hospital see London Lock Hospital by Mapother see Mapother, Professor Edward concerts, Australian/New Zealand asylums 272, 295 conduct of visitors 23 concerns at Jenny Lind Hospital for Sick Children 117–18 isolation hospitals (mid-Victorian Britain) 162, 163 confidence, of patients attending dispensaries in China 58 Conolly, Dr John 202 consent for surgery, mission hospitals in China 64 contractors, isolation hospitals and 152 correspondence see letters cots, sponsoring 94, 95 County Asylums Act (1808) 200 County Asylums Act (1828) 209 Cox, Joseph Mason 206 Cremorne Private Asylum (Victoria, Australia) 276 cricket, Australian/New Zealand asylums 269, 279–81 Cromwell House 99 Cross, Mrs (matron at Hospital for Sick Children, Great Ormond Street) 90 cross-infection 10 prevention 10–11 Jenny Lind Hospital for Sick Children 123, 125 see also infection control custodial discretion/abuse official visitors to reduce 19, 21, 203, 255 see also abuse

324

Index

D Das, Dr Banarsi 233 ‘deep philanthropy’ 21 Defoe, Daniel 19, 199, 201 Deptford Hospital 162 Derby Infirmary 37 Dickens, Charles 86 diet, traditional, concerns over in China 65–6 dietetics, mission hospitals in China 11, 65, 66 Digby, Anne 244 diphtheria, isolation hospitals 151 disinfection, after visiting isolation hospitals 160–1, 163 ‘disinterested’ visitors 17 see also house visitors dispensaries China 57–9 USA 57 District Nursing Association 44 district visiting societies 97 Dix, Dorothea 18 doctor–patient ratio, Ceylon psychiatric institutions 228 doctors Ceylon psychiatric institutions 230 Hospital for Sick Children, Great Ormond Street (London) 84–5 South Asian, training at Maudsley Hospital 238 training, for India’s asylums 236, 237 dogs, in hospitals/asylums 24, 279 domestic visitation 96–7, 99–100 Douglas-Willans, Reverend 114 Downcast Eyes (Jay) 252 Droitwich Lunatic Asylum 202, 210 Commissioners in Lunacy criticisms 213, 214 opening but unregistered 201 Duchess of York, HRH, visits to hospitals 46 Duddeston Hall, asylum 209 Dudley, Countess of 46

Dukinfield, Sir Henry 84 Dunckly, Thomas 179 Dunjibhoy, Lt Col. L.E. 233 Durbach, Nadja 150 Dwyer, Ellen 245

E Eannace, Maryrose 256–7 Edinburgh Royal Edinburgh Asylum 291 visiting passes for isolation hospital 161 Edinburgh Children’s Hospital, official lady visitors 88–9 educational visits to asylums 251–2, 253 self-education, New York asylums 251, 252, 253, 254 to hospitals 37–8 for staff, specialist hospitals (UK) 38, 45 education of children in hospital, women casual visitors’ role 98, 99, 100 education of visitors institutional visits 18 parents (hygiene/childcare) 10 Hospital for Sick Children (London) 101–2 Jenny Lind Hospital (Norwich) 112, 116 elderly, care of, in China 72 Elion, Gertrude 134 Ellerton, H.B. 274 emergency room visitors 16 emotional stress family visitors to Australian/New Zealand asylums 300, 301 Goodna Hospital 301–2 parents with child with cancer 131–2, 138–9, 142, 144 prevention at Jenny Lind Hospital for Sick Children 121–2 emotional support, sources 9

325

Index employment of inmates, Australian/New Zealand asylums 268–9, 297 loss, by parents of child with cancer 142 England children’s hospital visiting see Hospital for Sick Children, Great Ormond Street (London); Jenny Lind Hospital for Sick Children general hospital visiting nineteenth-century in Birmingham 31–54 see also house visitors; specific hospitals isolation hospital visiting see isolation hospitals (mid-Victorian Britain) lunatic asylum visiting see asylums (England) venereal hospital visiting see London Lock Hospital Enlightenment, visitation concept 175, 176 entertainment, ‘official’ 14–15 for asylum inmates Australian/New Zealand asylums see Australian and New Zealand asylums New York 257–8 for hospital staff 41 epidemics, visitors/family responsibility for 164 equipment technicians 18 erysipelas 36, 70 Exeter Lunatic Asylum visitation frequency and requirements 204 visiting by governors 207–8 expert visitors, Mapother’s visit to Ceylon 226–7, 237, 238

F factory inspectors 48 family and friends 9 accompanying patients to dispensaries in China 58 to medical missions in China see under China benefits of visits by 39 blamed for condition of insane 291 caring activities in hospitals 71–2 central role in patient care 56 duties/responsibilities of visitors 148 family definition, and gay couples 24 as ‘general inconvenience’ 39 infections spread by 9, 11, 39–40, 49, 148 isolation hospitals 159 provision of food/linen 31, 39, 40, 48–9 banned articles 39 restrictions on visiting 10, 31, 39–40 see also specific hospitals/types of hospitals rights/needs for access to hospitals 148 state governing through 148 visiting sick as tradition 291 visitors to asylums see asylums Birmingham hospitals in nineteenth century 38–40, 47 children’s hospitals see Hospital for Sick Children, Great Ormond Street; Jenny Lind Hospital for Sick Children isolation hospitals see isolation hospitals (midVictorian Britain) mission hospitals see China venereal disease

326

Index hospitals see London Lock Hospital see also patient visitors family-centred care benefits for patients 71–2 in China see China, family/friends in mission hospitals rationale and background to 56 staff resistance 66 in USA 55, 71 Farber, Sidney 133 ‘fathers’ day’, for visiting 100 Fearn, Anne 66 special kitchens 66–7 fee-for-service basis of hospitals, China 72 female nurses see nurses female patients Chinese mission hospitals 63 lady visitors introduction 42 London Lock Hospital 181–3 prevention from yielding to treatment (China) 64 female visitors 22 house visitors 17 roles 22 see also lady visitors ‘feminine meddling’ 45 Fenn, Richard 35 fights, by day-release patients 282 films Australian/New Zealand asylums 15, 268, 275 silent 15, 268 financial help Australian and New Zealand asylums from families 292 by visitors 278 collection plates and increased visiting hours 40 ‘deep philanthropy’ and 21 Hospital for Sick Children (Great Ormond Street) 81, 84 women casual visitors 99 house visitors providing 17, 18, 35

monitoring of spending of 17 public visitors providing 13, 14, 15 visitors covering costs 9, 10 visitors to New York asylums 248–9 see also fundraising; subscribers financial losses, of parents of child with cancer 140, 142 Finley, Fanny 182–3 Finnane, Mark 291–2 First World War, entertainment in Australian/New Zealand asylums 273 fitness to contribute to social well-being 150 to maintain a dwelling 150, 153 food inspected by house visitors at London Lock hospital 180 provision by patient visitors Birmingham hospitals 31, 39, 40, 48–9 Jenny Lind Hospital for Sick Children 118 mission hospitals in China 65–6 USA hospitals 59 wrong kinds, London Lock Hospital 181 responsibility by family/friends in China 11, 65–6 wastage at Hospital for Sick Children 89, 90 football, Australian/New Zealand asylums 269, 279–81 foreign dignitaries, visits by 45 foreign students, as visitors 49 foreign visitors Jenny Lind Hospital for Sick Children 114 medical visitors, at Great Ormond Street hospital 84 ‘Foul Disease’ 15, 175 Foundling Hospital, London 14 Fox, Edward Long 206

327

Index franchise disenfranchising of paupers in isolation hospitals 154 reforms 150 ‘freaks’ 253 Freemantle Asylum (Western Australia) 268–9 criticisms on amusements 280–1 official visitors and rules 276 friends see family and friends Fry, Elisabeth 21 Fulham smallpox hospital 161 list of dangerously ill patients 164 movements of staff/suppliers 152 visiting 161–2 funding see financial help fundraising Australian and New Zealand asylums 270, 272 Hospital for Sick Children see Hospital for Sick Children, Great Ormond Street (London) isolation hospitals (mid-Victorian Britain) 14 London Lock Hospital 17, 184 see also financial help; subscribers Futvoye, Edward 84

G gardens 279 for women in Auckland Mental Hospital 296 Garton, Stephen 292 gate porters duties, Birmingham hospitals 39, 40 roles at London Lock Hospital 180, 181, 183–4 Gatty, Margaret 94–5 gay couples 23–4 Gayton, William 160 General Hospital (Birmingham) 32 beds, learning from other institutions 37–8 house committees 36

house visitors advice on beds/washing 34–5 advice on hospital management 34 advice on treatment of patients 34 conflict with staff 36 first visitors appointed 33 male-only 33 as patient advocates 36 role and tasks 33, 34 lady visitors 42 patient visitors (family/friends) 39 benefits and provision of food/linen 31, 39, 48–9 restrictions 39 pets not allowed 24 visitors to staff 40 gate porters’ duties 39, 40 visiting hours 41 General Hospital and Dispensary for Children, Manchester 82 Gentleman’s Magazine 201, 203 Get Well Soon cards 7 Gilbert, Pamela 150, 155 Gladesville Asylum (New South Wales) concern over letters to patients 302 cricket for patient/staff 280 location and size 292, 293 overcrowding and state of buildings 295 superintendent 293–4 swans at 279 Goffman, Erving 15 Goodna Hospital (Wongaroo Lunatic Asylum)(Queensland) 270 band 274–5 cricket and football 279–81 entertainment provision difficulties 273 family role at admission/discharge 297 family visitors 289 distress caused by visiting 301–2 games at 279

328

Index location and distance from towns 292, 293 patriotic entertainment during world wars 273 rail passes for families 293 unsuccessful band practices 272 governance, concept/studies 22–3 governing committees all-male (England) 21 Hospital for Sick Children see Hospital for Sick Children, Great Ormond Street London Lock Hospital 178, 179 governors, hospital see hospital governors Gray, James 164 Gray, John P. 244, 248, 256 Great Ormond Street Hospital for Sick Children see Hospital for Sick Children, Great Ormond Street Grey Lynn Ladies Committee (New Zealand) 275 grief, parents of child with cancer 139 guarantors, against unpaid fees in China 65 guides, for distinguished visitors 15 Gunasekara, Dr S.T. 223–4, 226 Guy, Thomas 176 Guy Fawkes night 114 Guy’s Hospital (London) 176, 179

H Hackett, Father (Auckland) 300 Halsted, Reverend 36 Hanwell Lunatic Asylum (Middlesex, UK) 270 Harcourt, J.T. 276 Harper’s article on New York City Lunatic Asylum 243–4 article on response of inmates to visitors 260 Hartnack, Christian 225 Haydock Lodge (asylum), Commissioners in Lunacy intervention 213

healthcare professionals house visitors’ conflict 36 sea-change in views 12 see also doctors; hospital staff; nurses Hendre, Mrs Sada Russell 296–7 Henley, William 43 Henley-in-Arden, madhouse 202 Hereford Lunatic Asylum 210 Commissioners in Lunacy criticisms 212 Hilton, Boyd 86 Hodgson, Arthur 279 Hokitika Asylum (New Zealand) 282 Hokitika Band (New Zealand) 274 Holloway Sanatorium 291 Homerton Smallpox Hospital, MAB 160 homes overcrowded, compulsory removal to isolation hospitals and 153 as site of liberal governance 150 home visits, Birmingham hospitals 44 Hook, Ann 182–3 Hope, Adrian 95, 96 Hopkins, A.N. 36 hospital(s) administration, house visitors monitoring 33 admission controlled by governors (subscribers) 177 boards, development in Birmingham hospitals 36 governors see hospital governors maintenance, male management committee member role 84 for mental disorders see asylums opening fundraising opportunity 14 importance to town 14 as sites of knowledge transfer 37–8 transformation into homes by women visitors 22 uniformity 38

329

Index hospital(s) (cont...) voluntary charity model 176–7 see also individual hospitals Hospital for Sick Children (Toronto) 11 Hospital for Sick Children, Great Ormond Street (London) 81–110 admission based on clinical need 91 care, nurturance and morality roles 81, 100 clothing for children 82–3, 98 laundering 82, 100 provision by women supporters 82–3, 87–8 duration of stay (by patient) 101 family and friends 82, 100–2 see also parents and families (below) funding and fundraising 81, 84 male casual visitors 85 male official visitors 84–5 women casual visitors 93, 94–5 women supporters 87 house visitors 17, 82, 83 female 17, 22, 86–8 male 83–6 lady inspector 89 lady superintendent 89, 91 male casual visitors 85–6, 93 clergymen 85 compassion and Charles Dickens 86 doctors and military gentlemen 84–5 motivation for 86 social classes, with wives and reasons for 86 male management committee members 82, 83–6 benefits of visiting (business/philanthropy) 84 maintenance (of hospital) role 84

for transparency on finance/care 83 male official visitors 83–5 male vs female visitors 22, 92 management committee 83, 98 members and AGM 84 see also above management of hospital 81 maternal responsibilities (laundry/feeding) 82, 100 matron 90, 91 as model for Birmingham Children’s Hospital 38 nursing staff monitoring by official lady visitors 89 private hiring 95 problems with senior staff 90 resentment of causal visitors 95, 96 scrutiny of by lady casual visitors 95 official visitors 82, 83 men 83–5 women see below opening 83 parents and families 82, 100–2 child grief at departure of 101 educational role of hospital 101–2 exclusion from wards, infection control 83 lack of consideration for working mothers 100–1 limited records on 100 restrictions on visiting 10, 100–1, 102 siblings banned 101 visiting hours/days 100–1, 102 visiting rules 101 patron (Queen Victoria) 87–8 ‘selling’ services to families 82 subscribers 82, 84, 91, 98, 102 subscription (amount) 84, 85 toy provision 88

330

Index as training place for poor teenage girls 90–1 unannounced visitors 95–6 visiting governors (male) 83, 84 visiting times/days 95, 100–1, 102 visitors’ books 85, 86, 93 visitor types 82 women casual visitors 22, 82, 83, 91–5 as agents of maternal socialisation 91–2 avoidance of parents 95, 102 child visitors 93 domestic visitation 96–7, 99–100 educational and cleanliness roles 98, 99, 100 financial benefits of 99 hospital as safe place for 93, 100, 102 hospital as vocation 98 lack of consideration by doctors to 99 long-term relationship 94 middle-class 93, 98, 99 numbers and social groups 91, 92, 93 nurse resentment of 95, 96 opportunity to ‘be mother’ 100 publicity and fund-raising 94–5 roles 95–100 sanitised view of hospital 97–8 schoolgirls 93 titled ladies 92, 93 of value but limited role given 98–9 views and reports on 92–3, 93–4 visiting giving purpose to life 100, 102 visiting in groups 92, 93 women official visitors 83, 88–9 criticism of nurses and food wastage 89, 90

ending of role 89 monitoring of nurses 89 relationship with governors/staff 88 ward visiting role 88 women supporters 82, 86–8 function, personal social service 87 subordinate role challenged by 87 hospital for the insane see asylums hospital governors 17 asylums see asylums (England) concern over visitors to staff 40–1 inspection visitations 179 Lock Hospital see London Lock Hospital male vs female 22 opposition to admission of venereal patients 177–8 patient selection by 177 subscribers as 176–7 time between visits 22 visits to other hospitals 38 see also house visitors hospital orchestras (bands) 15, 268, 272, 273, 274–5 hospital staff abuse by see abuse China 60 see also China, medical missionaries educational visits to specialist hospitals 38, 45 female 43 see also nurses house visitors’ conflict with 36 outing to Nottingham hospital from Queen’s Hospital 38 parental relationship, children with cancer 136–7, 143–4 appreciation of parents’ role 144 preparation for visits 15–16 USA 60

331

Index hospital staff (cont...) visitors to/for 40–2 see also doctors; healthcare professionals; nurses; specific hospitals Hospital Visitation Authorisation 24 house committees 44, 48 development in General Hospital, Birmingham 36 house visitors 8, 16–18, 32–7, 48 Birmingham hospitals 32, 33 appointment 32–7 conflict with staff 36 roles 33, 34–5, 36 see also General Hospital (Birmingham) concern over abuse by staff 36 conflict with staff 36 decline 36, 45 financial help provided by 17, 18, 35 functions and roles 32–3, 48 advice on beds/washing 34 advice on patient treatment 34 bread and beer quality testing 33 business administration 33 fitness of patients for admission 35 hospital finances and consumption control 35 meat quality assessment 34 moral/religious instruction 35–6 as patient advocates 36 Hospital for Sick Children see Hospital for Sick Children, Great Ormond Street (London) Jenny Lind hospital see Jenny Lind Hospital for Sick Children, hospital visitors London Hospital 179 London Lock Hospital see London Lock Hospital lunatic asylums

New York see New York asylums private madhouses 202–3 provincial asylums 204, 208 voluntary sector 203 see also asylums (England) responsibilities, apothecaries advising on 34 role began as public visitors 17 Royal Salop Infirmary 291 see also hospital governors; subscribers Howard, John 20 Howie, W.B. 291 Howlings, John 114 Huddersfield, bathing after visiting isolation hospital 163 Human Rights Campaign, gay rights and 23–4 Hunger, Dr Alexander 204 Hunningham Hall Asylum 214 Hutchings, George 134

I identity of institutionalised 16 of visitors 16 Illustrated London News entertainment in asylums 270 pets in asylums 279 Illustrated Melbourne Post, asylum balls 271–2 Inch, Frank 118 India, asylums 233–4 bed number 234 buildings 233–4, 235 civil and criminal lunatics in same asylum 234 costs and expenditure 234 lack of leadership 235 Mapother’s criticisms 233–4 Mapother’s recommendations 236, 237 medical student training 236 Mysore as good example 235, 238 overcrowding 234

332

Index psychiatrist appointment 236 psychiatrists and staff 233 training of doctors 236, 237 Visiting Committee 236 see also Mapother, Professor Edward ‘Indianisation’ of health services 225, 235, 237 Indian Medical Service (IMS) 235 infant(s) care/feeding by family/friends in mission hospitals (China) 62–3 Jenny Lind Hospital for Sick Children 120 vaccination 150 infanticide, in Ceylon 229 infection(s) control/prevention see infection control death rates after surgery (UK vs China) 70 families/visitors spreading 9, 11, 39–40, 49, 148 Birmingham Children’s Hospital 40 in isolation hospitals 148, 159 hospital visitors not spreading 122 spread by washing wounds in UK 70 spreading in children’s hospitals 11, 83 Jenny Lind hospital 117 spread by clothes 82–3 transmission, and control methods 151 see also cross-infection infection control 9, 19, 151 children’s hospitals 11, 83 Hospital for Sick Children 83 Jenny Lind Hospital 117, 120, 121, 122–3, 125 parental exclusion from wards 11, 83, 117 visiting day control for (Birmingham) 40 visitors to isolation hospitals

160–1, 163, 164 non-bodily contact rule 162 protective clothing 162, 163 rituals/disinfection 160–1, 162–3 ‘window’ appointments 164 see also isolation hospitals (midVictorian Britain) see also cross-infection innovations at hospitals, visits for knowledge transfer 37–8, 45 insane/insanity care of 19 see also asylums; asylums (England) as result of intense civilisation of modern times 245 institutional buildings see buildings institutional visits, management 15 see also stage-managing visits; individual types of institutions institutions, official visiting see official visitors Intercolonial Medical Congress (1889) 294 interwar period entertainment/recreation in Australian/New Zealand asylums 273–4 visitors in Birmingham hospitals 44–5, 48 Ipswich Mental Hospital (Queensland, Australia) 275, 278 Brisbane Exhibition attendance 282 Ipswich Show, attendance by asylum patients 282 Isolation: Places and Practices of Exclusion (Bashford and Strange) 256 isolation hospitals (mid-Victorian Britain) 19, 147–73 access to patient information 164, 165

333

Index isolation hospitals (mid-Victorian Britain) (cont...) admissions by age 155, 156 bed number 147, 151 children in 155–9, 166 implication for regulation of home life 155 increasing hospitalisation rates 158 mothers staying/visiting 160 parental acquiescence 158–9 personal accounts 157–8 petitions and protests against 156–7 resentment against compulsion 155–6, 157 responsibility for health after 155 threat of coercion 159 citizenship and 149–50, 165–6 as component of public health plans 151 contractors/suppliers to and movements in/out 152 daily updates on patients 164–5 ‘dangerous’/’dangerousness’ of citizens 165–6 dangerously ill patients 161, 164 diseases requiring admission 151–2 establishment 151 government inquiries 148–9 hospitalisation barriers to acceptance 154 concealment of disease to prevent 156 increase in popularity (official view) 153, 155, 158, 159 lack of domestic/home space causing 153–4 pauper admission prejudicing against 154 reluctance to use 153 resentment against 155–6, 157 hospitalisation rates community acceptance

334

assessment by 153 increase 153, 158 illicit visits to patients 152 infection spread minimisation 160–1, 163, 164 isolation level/extent 151–2 Local Authority requirement 151 location on outskirts of towns 163, 164 model plans 151 number of hospitals 147, 151 nursing staff movements 152 opening, visits and fundraising 14 outreach’ facilities 158, 160 patient isolation as strategy of government power 147–8 patient number system, and status categories 164–5 pauperisation and 154 paupers, admission and refusal to admit 154 personal accounts of 157–8 as ‘poor man’s spare bedroom’ 152–4 private rooms for wealthy 154–5 rationale for 147 social class of patients 153, 154, 156 telephone use 165 temporary nature of buildings 151 visiting passes 161 visiting restrictions 14, 159–65 charges for visitors 160 to deter visiting 160–1, 163 on mothers/parents 160 non-bodily contact rule 162 protective clothing for 162, 163 rituals/disinfection 160–1, 162–3 ‘window appointments’ 164 visiting rules 160 visiting times 159–60 visitors 14, 166 behaviour 162, 163

Index funding mix (charity and contributory schemes) 18, 114 gifts (food) from patients’ visitors 118 hospital visitors (supporters) 112–15, 126 differences from parent visitors 121–2 hygiene levels and no infection risk 122 lady visitors 112–13 male visitors 114 reduced in early twentieth century 113 ‘housekeeping referee’ 113 infant patients, mother’s role 120 in-patient policy (1950s) 121 in-patients, characteristics 122, 125 Ladies’ Committee 112, 113 power reduced by matron appointment 113 lady visitors 112–13 management 112, 113 matrons 113, 116, 117, 120, 124 medical treatment emphasis 111–12 mothers’ room 120, 121 name change of Jenny Lind Infirmary to 111 nursing management 124 nursing staff role in parental exclusion 123 out-patient care emphasis (1950s) 121 parental expectations of care 125–6 patient numbers 112 patients’ visitors (parents/family) 112, 115–20, 126 ban on visits 118–19, 122 child visitors 116 concerns on behaviour of visitors 117–18 daily visiting (1949) 120–1, 126

as danger (infection spread) 159 to dangerously ill patients 161 illicit 152 mothers 160 numbers 161, 162 public transport use 163 state of health 163 vaccination evidence needed 163 window appointments 164 for working class and poor 153–4 Isolation Hospitals Act (1893) 151 isolation of patients, as strategy of government power 147–8

J Jackson, Mrs (matron at Jenny Lind Hospital for Sick Children) 120 Jain, Sanjeev 15, 19, 223–42, 309 Jay, Martin 252 Jenny Lind Hospital for Sick Children 10, 12, 111–29 admission interviews 123 admission of children 115–16 risk/benefits 122 amalgamation with Norfolk and Norwich Hospital (1929) 111, 124 Centenary Hall opening 121 children’s nurses vs general nurses 123–4 Christmas 114–15 Committee of Management (CoM) 112, 113, 117, 118, 122 criticisms of nurses 124 cross-infection prevention 123, 125 duration of stay 125 entertainment of/for children 114–15 foreign visitors 114 funding by subscribers 112–13, 114

335

Index early policy of 3 days per week 115 food brought by 118 hospital visitor differences 121–2 laundry role 116 parental education 112, 116 reasons for restrictions see below restrictions (1900s) 115, 116–17 sudden cancellations 118 viewed as danger to treatment 120 viewing children from distance 117, 118, 119, 120 views/experiences of nurses/patients 119–20 visiting days 115, 116, 117, 120 patients’ visitors, visiting restriction reasons 121–6 avoidance of nurse/practice scrutiny 122, 123 emotional distress prevention 121–2 infection control 117, 120, 121, 122–3, 125 planned hospitalisation for surgery 125 Pottergate street building 111, 113, 116 probationer nurse training 116, 124 psychological care of children 121, 126 purpose/aim of hospital 115–16 religious services 114 resident medical officer (RMO) 117 supporters 112, 114 surgical treatment development 112, 124–5 Tombland building 111, 116 tours of hospital (public relations activity) 114 unauthorised visits 115

Unthank Road building 111, 113, 116 visiting cards 118, 119 visitors’ book 113–14 Jenny Lind Infirmary for Sick Children establishment, opening and naming 111 locations 111 Jones, John 35 Journal of Insanity 247

K Kelm, Mary-Ellen 290, 291, 298, 301 medical superintendents’ cautions on visits 302 Kent isolation hospital, visiting 161 Kerr, John 70 Kew Asylum (Victoria, Australia) costs of annual picnic 282 excursions outside asylum 276, 282 recreation hall use as dormitory 269 Kingsland Asylum 212–13 Kingsley, Mary 92 Kinnaird, Mary Jane 92 Kirkbride, Thomas 248, 291 knowledge transfer hospital visits providing 37–8 between institutions 37–8 Koven, Seth 99–100

L ladies committees, children’s hospital(s) 87, 88–9 disbanding 91 lady visitors 22, 42–4, 45 age 43 Australian/New Zealand asylums 295 Birmingham and Midland Hospital for Skin and Urinary Diseases 43 Birmingham and Midland Hospital for Women 17, 43

336

Index Birmingham Children’s Hospital 17, 43, 44 children’s hospitals 17 charitable role/work and 91–2 criticisms of nurses 89, 90 Great Ormond Street hospital 17, 22, 89, 95 Jenny Lind Hospital for Sick Children 112–13 monitoring of nurses 22, 89 philanthropy and 91 expansion of role outside hospitals 44 General Hospital (Birmingham) 42 hospital transformation into homes 22 introduction into hospitals for female patients 42 Queen’s Hospital, Birmingham 42, 43 roles and beliefs 22, 42 York Lunatic Asylum 207 see also female visitors lady volunteers, tea provision for visitors 47 Lancaster Asylum 210 The Lancet 126 laundering/laundry innovations 48 by mothers, children in hospitals 82, 100 Jenny Lind hospital 116 ‘leave’ from asylums 16 Australian/New Zealand asylums see Australian and New Zealand asylums Leicester, child admission to isolation hospitals 155–6 Leicester Lunatic Asylum 205 Select Committee recommendations 206–7 visitation after Select Committee report 207 visitation by governors prevented 205 leprosy/lepers 149, 184

letters of complaint, London Lock Hospital 179–80 from family to asylum patients 290 control by inspectors 302 Mapother, Professor Edward 225–6, 232 leukaemia 133 acute lymphoblastic see acute lymphoblastic leukaemia (ALL) acute myelogenous (AML) 134 Lewis, Mrs David 94 Lichfield, lunatic asylum 201–2 visiting magistrate’s observations 202 Lincoln Lunatic Asylum Commissioners in Lunacy investigation 214 governor response to Commissioners’ criticisms 214 governor visitations 208 house visitors 208 Lind, Jenny 113, 115 Lindsay, Bruce 10, 17, 111–29, 309 liquor see alcohol Liston, Robert 70 Liverpool Infirmary for Children 88 Local Government Board (LGB) inspectors 149 Lock Asylum for the Reception of Fallen Women 190 Annual Account and quarantine of women 191 day-passes and restrictions 191 parcels/letters inspected 191 religious instruction and regimen 191 role/aims 190 Lock Hospital, London see London Lock Hospital Lodge Patch, Lt Col. 233 London, madhouses 208, 223, 302 see also asylums (England)

337

Index London Children’s hospital see Hospital for Sick Children, Great Ormond Street (London) London County Asylum 223 control of letters to patients 302 London County Council, mental health expenditure 234 London Fever Hospital, visiting 161 London Hospital house visitors committee 179 opposition to venereal patient admission 178 London Lock Hospital 9, 15, 175–98 admissions policy 177 Annual Account 188 beggars in doorway 185 board room, visitors guided to 183–4 chapel 185–6, 187 income for hospital 185–6 clerical visitation 15, 192 Coetlogan, Charles de 187 evangelicals 187–8 female patients 190 intense control of visitation 189, 190 Madan 185–6, 187 male patients 191–2 Scott, Reverend Thomas 189–90 stage-managed to placate donors 188 success assessed by house visitors 188–9 Twycross, Reverend 188 controlling of doorway/entry into hospital 180–6 critics 175 diseases, repellent features and treatment 183 engraving/picture 184 external visitors (family/friends) 9, 180–6, 192 control of visitors to female wards 181–3 parcels inspected by

338

matron/nurse 189 prevention of fashionable visitors to visit 183–4 reduced access to patients (1787) 189, 190 undermining moral reform of patients 189 visiting times 180–1, 189 founding (1747) 175, 178 fundraising 17, 184 governing Board 179, 186, 187 governors/house visitors (subscribers/donors) 17, 176–7, 188 committee 178, 179 concern over beggars in doorway 185 difficulty in obtaining subscribers 17, 178 forum for communicating with wealthy people 184 house visitors’ roles 179, 180 inspection of staff/wards 179 letters of complaint from 179–80 moral reform expectations 188 problems addressed by 180 reports and complaints 17, 179–80 stage-managing visits 17, 183–5, 188 Weekly Committee and roles 179 Hyde Park location 184, 185 illusion of respectability 185, 192 importance of public opinion for survival 176, 192 Lock Asylum establishment 190 see also Lock Asylum for the Reception of Fallen Women male patients 191–2 nurses, of female wards, instructions to 181 permeability of hospital walls 180, 184

Index policing entry to female wards 181–3 porter’s roles 180, 181, 183–4 quarantine policy to prevent offence 183 reason for establishment 178 staff taking advantage of women patients 179, 180 street-front façade 184, 185 visitation and moral reform 186–92 see also London Lock Hospital, clerical visitation visitation as institutional selfpolicing 175, 178–80, 192 visitation types 175–6 wards/patients kept from public view 183–4, 186 door left open concern 186 windows locked/covered and doors locked 186 women patients Ann Hook and Fanny Finley case 182–3 control of visitors to female wards 181–3 friends’ visits not allowed 181–2 moral reform methods 190 protection from public sphere 190 viewed as morally loose 181–2 London Missionary Society (LMS) Roberts’ Memorial Hospital (Hebei) 61 Xiaogan hospital 70–1 Long Fox, Edward 206 Lunacy Act (1878) New South Wales 292 Lunacy Ordinance of Ceylon 228 lunatic asylums see asylums The L Word 24

M MacFarlane, Dr (New Norfolk Asylum (Tasmania)) 269 MacGowan, Daniel 66 MacGregor, Duncan 296 MacKinnon, Dolly 14–15, 24, 267–88, 309–10 Madan, Martin 185–6, 187 madhouses see asylums Madhouses Act (1774) 201 Magdalen Hospital 190–1 magistrates county lunatic asylums visits 205, 209 criticisms of lunatic asylums 214 private madhouse visits and conflicts of interest 202 Maidstone, outreach isolation facilities 158 Main, Duncan 65 Major, John, complaint to London Lock Hospital 179–80 male governing committees 21 male hospital governors 22 male visitors 22, 33 asylums see asylums (England) General Hospital (Birmingham) 33–5 Hospital for Sick Children see Hospital for Sick Children, Great Ormond Street (London) Jenny Lind Hospital for Sick Children 114 see also house visitors; official visitors; subscribers management committee, children’s hospitals 84 Hospital for Sick Children see Hospital for Sick Children, Great Ormond Street (London) Jenny Lind Hospital 112, 113, 117, 118, 122 Manchester, isolation hospitals 161, 165

339

Index Manchester Lunatic Hospital, house visitors 204 Manning, Frederick Norton 293–4 Mapother, Professor Edward 223–42 Ceylon visit 225–7 1937 visit 225–6 criticisms 227–8 invitation by Gunasekara 223–4 letters/correspondence 225–6, 232 limitations to achievements 231–2, 239 official report in 1938 225 recommendations 15, 227, 228–32, 238 reports 227–32 visit in demi-official capacity as ‘expert’ 226–7, 237, 238, 239 see also Ceylon India visit 226, 232–6 call for ‘crusade’ 235, 236 criticisms and comments 233–4 deficiencies exposed 20 Mysore as example 235, 238 personal visit and information use 226, 237, 239 recommendations 236 report 232, 236–7 visit to hospitals 233 see also India, asylums value of visitors’ reports to historians 238 visits to South Asia 18–19, 20, 223–4, 225–7 criticisms of British/Europeans 238 Margaret Williamson Hospital (Shanghai) 58 Marshall, T.H. 149 master–apprentice relationships 41 maternalisation of society 100 matrons Ceylon asylum 227 Hospital for Sick Children 90, 91

Jenny Lind Hospital for Sick Children 113, 116, 117, 120, 124 London Lock Hospital, parcel inspection by 189 Maudsley Hospital (London) Institute of Psychiatry 223 medical superintendent 223 training of South Asian doctors 238 measles 82 meat quality, assessment by house visitors 34 medical apprentices, visitors for 41 medical charities 31 medical missions, China see China medical staff see healthcare professionals Memorial Hospital (New York) 132 Memorial Sloan Kettering Cancer Center 132 memory, asylum patient’s 302 mental asylums see asylums mental (health) nurses, Ceylon 230 mercurial salivation 183 methicillin-resistant Staphylococcus aureus (MRSA) 7, 24 Methodist Episcopal Mission (South) (MEM(S)) Women’s Hospital (Suzhou) 58 family role in food provision 65–6 overcrowding by servants/families 60–1 methotrexate 134 Metropolitan Asylums Board (MAB) 149 Homerton Smallpox Hospital 160 Metropolitan Commissioners in Lunacy 208–9, 210 1844 report 210–11 superseded by Commissioners in Lunacy 211 see also Commissioners in Lunacy Middlesex, pauper lunatic asylum 208 Middlesex Infirmary 178

340

Index Midlands, English house visitors to hospitals 17 time between governors’ visits 22 see also Birmingham midwife, Chinese 63 military gentlemen, visitors at Great Ormond Street hospital 84–5 military hospitals 13 Mills, James H. 15, 19, 223–42, 310 Miron, Janet 14, 16, 243–66, 310 Misericordia Hospital 190–1 mission hospitals see under China Mohammedan patients, special kitchen/food for 66–7 Moncrieff, Alan 123 monitoring roles 8, 9, 17 see also house visitors; official visitors Monsall Hospital (Manchester) 165 Mont Park Hospital (Melbourne, Australia) 275, 282 Mooney, Elizabeth 90 Mooney, Graham 10–11, 14, 147–73, 310 moral contamination 9, 10 moral instruction house visitors’ role 35–6 for students 41 morality, charitable worthiness link 177 moral reform/rehabilitation public visitors’ role 15 visitation at London Lock Hospital and 186–92 see also London Lock Hospital moral therapy, in asylums 245, 291 Morgan, Gill 24 Morris, Robert 22 mothers at Jenny Lind Hospital for Sick Children 120, 121 role at Hospital for Sick Children 82, 100 see also Hospital for Sick Children, Great Ormond Street

(London) rooming-in for, at children’s hospitals 48, 120, 121 visiting children at isolation hospitals (mid-Victorian Britain) 160 see also family and friends; parents Mothers’ Union Visitor 115 MRSA (methicillin-resistant Staphylococcus aureus) 7, 24 music Australian and New Zealand asylums 272, 274–5 bands 15, 268, 272, 273, 274–5

N national identity, concept 150 nationhood 150 neighbourhood dependence, imbalance, removal of sick child to hospital 82 Neild, John 21 Nelson Asylum 282 neuroblastoma 139 neuropsychiatric clinic, in Ceylon 229, 231 Newcastle Lunatic Hospital, visitation frequency and requirements 204 Newgate prison 20 New Norfolk Asylum (Tasmania) ball and band 272 fireworks celebration 270 ‘Magic Lantern Exhibition’ unsuccessful 272 recreation hall 269, 270, 271 New South Wales asylums 290 Bay View asylum see Bay View Private Asylum (New South Wales) Gladesville Asylum see Gladesville Asylum (New South Wales) history 291–2 inspectors and superintendents 293–4 lady visitors 295

341

Index New South Wales asylums (cont...) laws/Acts affecting 292 newspapers Australian/New Zealand asylums 269, 279 failures of day-release system 282 encouraging asylum visits (New York) 250, 253–4 reports about Australian/New Zealand asylums 270, 271, 272, 282 New York asylums costs, concerns over 247 daily tours 248 as entertainment venue (for visitors) 251 family visitors restricted 257 as hub of social activity and community involvement 247 increase (number), as evidence of society’s advancement 245 institutional authorities 247–50 lack of faith in visitors’ ability to understand 256 patient response to public 16, 256–60 comfort by telling story to visitors 257 entertainment provided by visitors 258 opposition to public visitors 259–60 social alienation reduced 257 tobacco and liquor provided 259 variety of responses, reports 260 physical/mental restrictions on inmates 257 practice of visiting 247–50 public scepticism about 247 reasons for visiting 252, 255–6 self-education/’scientific’ study 251, 252, 253, 254

to understand world 251–2 social stigma, reduction 247 visitors (‘lay’ visitors) 250–6 assured of their ‘normal’ status by visiting 252 benefits of, for patients 248, 256 benefits/stress to patients, balance 248, 256 dangers of tours for 258 fears on immigration 252 financial role 248–9 intersection of ‘science’ and ‘spectacle’ 253, 254 newspaper/media reports encouraging 250, 253–4 opposition to tours/visits by 259–60 proximity to town as benefit 250 recording of experiences of 251 tobacco and liquor brought in by 259 understanding of mental illness 253, 254 voyeurism 244, 253, 254, 255 welcomed and rule for 247–8 see also individual asylums below New York City Lunatic Asylum (Blackwell’s Island) 243 abuse less likely with visitors 255 annual fairs 249 article in Harper’s 243–4 cultural context of nineteenth century 245–7, 251–2 description and interactions 243–4 evaluation of, by visitors 254 ferry to, need to search visitors 259 financial role of visitors 248 government inspection 246 ‘lay’ visitors 244, 250–6 socio-economic and ethnic groups 244 positive changes for care of insane 246, 247 supervision and legislation for 246

342

Index tobacco and liquor brought into 259 tolerance/respect of visitors by asylum officials 249–50 transport to 250 see also New York asylums New York State Lunatic Asylum (Utica) 16 abuse prevention by visitors 255 accessibility to visitors, to reassure public 248 annual fairs 249 cultural context of nineteenth century 245–7 curing of the insane 246 entertainment for inmates 257–8 evaluation of, by visitors 254 government inspections 246 ‘lay’ visitors 244, 250–6 The Opal see separate entry patient death and abuse 248 patient reaction to visitors 16, 256 superintendents 246 Brigham, A. 247–8, 249 tolerance/respect by asylum officials 249–50 ‘Tour of Observation’ 253 understanding of mental illness by visiting 253 visitor number 244 visitors as harmful 245 see also New York asylums New Zealand asylums see Australian and New Zealand asylums New Zealand Herald 272, 295 Nicholas, Grand Duke (1796-1855) 37 Nicoll, Samuel 207, 209, 214 nobility, visits by 45–6 Norfolk and Norwich Hospital 111, 124 Norfolk Asylum 210 Noronha, Frank 235 Norwich, children’s hospital see Jenny Lind Hospital for Sick Children Norwich Education Committee 114

Nottingham positive account of isolation hospital by surgeon 157–8 protest/petition against isolation hospitals 156–7 Queen’s Hospital staff outing to hospital in 38 Nottingham Asylum 206 Nunn, Ann 191 nurses children’s vs general 123–4 criticism of at Jenny Lind Hospital 124 by official lady visitors to children’s hospitals 89, 90 female 41, 43 lack of, in China, reasons 60, 61–2 mental health and training, Ceylon 230 monitoring by official lady visitors to children’s hospitals 89 problems with, at London Children’s Hospital 90 resentment towards casual visitors in children’s hospitals 95, 96 role in care of child with cancer 135, 143 role in parental exclusion, Jenny Lind Hospital 123 student, numbers 60 support for parents of child with cancer 141, 143–4 trained realisation of need for 57 USA hospitals 59 training in China 62 Jenny Lind Hospital for Sick Children 116, 124 uniforms, lack of, children’s hospitals 90 USA, statistics 60 views on parental visiting at Jenny Lind Hospital 119

343

Index nurses’ homes 41 Nurses’ Registration Act (1919) 123 nutrition, visitors to missionary hospitals in China 11, 65–6

O occupational therapists, Ceylon psychiatric institutions 231 official visitors 8, 18–20 to asylums see asylums; asylums (England) to children’s hospitals 82, 83–6 see also Hospital for Sick Children, Great Ormond Street (London) Commissioners see Commissioners in Lunacy to isolation hospitals 19, 149 monitoring entertainment in Australian/New Zealand asylums 276–8 to reduce abuse by staff 19, 21, 203, 255 in South Asia see Mapother, Professor Edward workhouse vs hospital 83 Ogborn, Miles 191 Oldham’s isolation hospital 154, 160–1 Ontario, families visiting asylums 290 The Opal (Utica Asylum newsletter) 16, 250, 257, 258 censoring 256 opposition to visitors at asylums 259–60 subscribers 256 see also New York State Lunatic Asylum (Utica) operating rooms, family members present, China 67, 68 Oram, John 180, 181 orchidectomy, family witness 68 ‘ordering of order’ 22–3 Oulton Retreat, Staffordshire 214 Our Mutual Friend (Dickens) 86

overcrowding of asylums 211 Australian/New Zealand asylums 295–6 Ceylon, Mapother’s criticisms 227 England 211 India, Mapother’s criticisms 234 overcrowding of homes, compulsory removal to isolation hospitals and 153 overcrowding of hospitals, by servants/families, China 60–1 Owen, John B. 84

P paintings, London’s Foundling Hospital 14 Panopticon (Bentham) 20 parents benefits of accompanying children 71 as cause of child’s sickness 82 children accompanying, to hospitals in China 67 of child with cancer see cancer, in children; Children’s Hospital of Pittsburgh education during visits see education of visitors in isolation hospitals 160 visiting children’s hospital Children’s Hospital of Pittsburgh see Children’s Hospital of Pittsburgh children with cancer 131–46 Hospital for Sick Children see Hospital for Sick Children, Great Ormond Street (London) Jenny Lind Hospital see Jenny Lind Hospital for Sick Children restriction on visiting 10, 17 see also family and friends; mothers Parker, Peter 56–7

344

Index children accompanying parents 67 crowding of visitors 59 family consent for surgery 64 female patients consulting 63 hospital indemnified against deaths 64–5 patient and family statistics 69 responsibilities, in absence of nurses 59–60 responsibilities of families in mission hospitals 62–3 scrutiny of work by families 68, 69 Parliamentary Select Committee (1807), lunatic asylums and 200 Parliamentary Select Committee (1827), pauper lunatics 208 Parrott, Francis 33 passes for parents visiting children’s hospitals 10 for patients leaving Australian/New Zealand asylums 281 Lock Asylum for the Reception of Fallen Women 191 for visitors, isolation hospitals 161 patient advocates see advocates of patients patients, selection by governors 177 patients rights not to be visited 13, 301–2 to receive visitors 23 patient visitors 8, 9–13 Birmingham hospitals in nineteenth century 38–40, 47 Jenny Lind hospital see Jenny Lind Hospital for Sick Children see also family and friends pauperisation, isolation hospitals and 154 paupers in isolation hospitals 154 lunatics 208, 209, 211 see also asylums see also poor, the

Peill, Arthur 61 penitentiary movement, Lock Asylum 190 Pennsylvania Hospital for the Insane 248, 291 Peter, Miss (matron at Jenny Lind Hospital for Sick Children) 113, 116 Peterson, Hon. J.C. 275 pets in hospitals and asylums 24, 279 not allowed at General Hospital (Birmingham) 24 pharmaceutical sales representatives 18 philanthropy casual lady visitors in children’s hospitals and 91 lady visitors and 42 management committee members at children’s hospitals 84 voluntary medical institutions and 21 photographs, USA hospitals 59 physicians, dominant role in asylums 204 picnic, annual, Australian/New Zealand asylums 280, 281, 282, 296 Pinkel, Donald 134 plumbing, hospital, assessment by house visitors 34 poetry and poets 7–8, 43 political sermons 35 Polk, Margaret 60–1, 64, 66 poor, the removal from hospital 35 visiting in homes 96–7 see also paupers Poor Law Amendment Act (1834) 83, 209 Poovey, Mary 150 Porirua Hospital (New Zealand) 273 Porter, Roy 177 post-traumatic stress, parents of child with cancer 139 Power, William 149, 152 prayers

345

Index regimen in Magdalen and Misericordia hospitals 191 teaching of by women 22 Prison Discipline Society 21 prisons, reforms, surveillance leading to 20 private asylums England see asylums (England) New South Wales see Bay View Private Asylum (New South Wales) Victoria (Australia) 276 private rooms, in isolation hospitals 154–5 private vs public hospital visiting 11, 23 Provincial Hospital for the Insane (British Columbia) 290 psychiatric institutions South Asia 224–5 UK 14 USA 14 see also asylums psychiatry, in South Asia 223–42 see also Mapother, Professor Edward psychological benefits to patients (of visits) 11–12, 48 of families attending, in China 66–7, 69 psychological isolation 12 psychopathic hospital, Ceylon 229–30 psychosocial support, children with cancer 12, 132, 143 public health democratic 149 isolation hospitals role 151 sanitary reforms 150 public hospitals, visiting, private hospitals visiting vs 11, 23 public transport New York City Lunatic Asylum (Blackwell’s Island) 250 rail passes for families to visit Goodna hospital 293 visitors to isolation hospitals and 163

public visitors 8, 13–16, 23 to Australian/New Zealand asylums 268, 270, 273, 278 to British asylums see asylums (England) to New York asylums see New York asylums roles 13 stage-managing visits for 15, 16, 17, 23 Pye, John 226, 232

Q Quakers 21 quality control, house visitors 8 Queen Elizabeth Hospital (Birmingham), royal visit 46 Queen’s Hospital (Birmingham) 32 cleanliness, views on 36 control over patient visitors 40 fees paid by patients 35 governors’ visits to other hospitals 38 home visits 44 lady visitors 42 appointment 43 staff outing to Nottingham hospital 38 student visits to wards and roles 42 visitors to staff 41 Queensland asylums 290 Ipswich Mental Hospital see Ipswich Mental Hospital (Queensland, Australia) Willowburn Asylum 274 Wongaroo asylum see Goodna Hospital (Wongaroo Lunatic Asylum) (Queensland) Queen’s Memorial Infectious Diseases Hospital (Australia) 161

346

Index

R radio 15 Australian/New Zealand asylums 268, 275 benefits 275 censoring 275 rail passes, for families to visit Goodna hospital 293 Ranney, M.H. 248 Ranson, Annie 114 Rao, Venkata Subba 233 Ray, Isaac 255 Reaume, Geoffrey 291, 301 recreation 15 in Australian/New Zealand asylums see Australian and New Zealand asylums Ceylon psychiatric institutions 229 recruitment, visits to hospitals for assessment 45 Registered Sick Children’s Nurses (RSCNs) 10, 123, 124 children’s nurses vs general nurses 123 Reifsnyder, Elizabeth 58 Reinarz, Jonathan 10, 13, 17, 19, 31–54, 311 religion, spreading, in China 58, 61 religious instruction house visitors’ role 35–6 Lock Asylum 191 London Lock Hospital 15 Renshaw, Michelle 11, 55–79, 311 rice, polished 66 Ricketts, William 202 rights of family to access hospitals 148 in liberal democracies 149–50 of patients not to be visited 13, 301–2 of patients to have visitors 23 Roadknight, William 202 Roberts’ Memorial Hospital (Hebei), London Missionary Society (LMS) 61 Robertson, James 12, 126

Robinson, Miss (matron in Ceylon institution) 227 Rockefeller Foundation 224, 232, 233, 235–6 Rohrer, Robin 12, 131–46, 311 rooming-in for mothers 48 Jenny Lind Hospital for Sick Children 120, 121 Rose, George 206 Rosenberg, Charles 9 Rowley, Dr Thomas 209–10 Royal College of Physicians, visiting London madhouses 201, 208 Royal Commission on Smallpox and Fever Hospitals (RCSFH) 149 admissions, deaths and visitor numbers 161, 162 smallpox spread and movements to/from hospitals 152 telephones for patient information 165 visiting restriction on non-bodily contact 162 Royal Edinburgh Asylum 291 Royal Hospital of Bethlehem see Bethlem Hospital Royal hospitals, London 176 Royal Infirmary (Manchester) 165 Royal London Ophthalmic Hospital, Moorfields 38 Royal Orthopaedic Hospital (Birmingham) 32 educational visits for staff 45 royal visits 46, 47 Royal Salop Infirmary (Shrewsbury) 291 royal visits 45–6 to hospitals 38 Hospital for Sick Children 95, 97 Russell, Lady 126 Russell, William 33, 244

347

Index

S salesmen 18 Salford’s isolation hospital 154 Samaritanesses 98 same-sex couples 23–4 Sanderson, John Burdon 165 Sandfield Asylum 209–10 criticisms of conditions and closure 212 Sanitary Act (1866) 153 sanitary reforms 150 Saville, Lillie 62 scarlet fever 82, 117, 125 child incidence and mortality 155, 156 hospitalisation rate in Sheffield 153 isolation hospitals 151 window appointment at isolation hospital 164 Scott, Reverend Thomas 189, 190 Seacliff Mental Hospital (New Zealand) 274 Second World War, entertainment in Australian/New Zealand asylums 273–4 ‘Secret Malady’ 175 Select Committee on Madhouses of 1814–15 19 Select Committee on Madhouses of 1815–16 200, 206 Select Committee on the State of Criminal and Pauper Lunatics (1807) 200 self-reflection, by visitors 16 separation anxiety 12 Sheffield, scarlet fever hospitalisation rate 153 Sheffield Children’s Hospital, parental visits 118 Shrewsbury, Kingsland Asylum 212–13 siblings banned from hospital visits, Hospital for Sick Children 101

care, concerns of parent of child with cancer 142 older, childcare role 101 Siena, Kevin 9, 15, 17, 175–98, 300, 311–12 Simpson, Sir Alexander 45 Sinclair, Eric 294 singing, Australian/New Zealand asylums 269 Skin Hospital see Birmingham and Midland Hospital for Skin and Urinary Diseases smallpox 117 isolation hospitals 151, 152 evidence of vaccination before visiting 163 smells, in hospitals, house visitors’ concern over 34 Smith, Leonard 19, 199–222, 312 social alienation, of inmates 257 social status, benefits of subscribing to children’s hospitals 84–5 social welfare workers, ‘lady’ 100 social work staff, as advocates between patient and physician 143 Society for the Propagation of Christian Knowledge 20 solid tumours 135 children 133 solitary confinement cells, Ceylon 227 Mapother’s criticisms 227 South Asia colonial paternalism and training of doctors 237 criticisms of imperial medicine and British 238 official visitors to asylums 18–19, 20, 223–42 see also Mapother, Professor Edward psychiatric institutions 224–5, 237 European doctors leading 225 psychiatry (pre-Second World War) 224–5 state-run hospitals 225

348

Index see also Ceylon, psychiatric institutions; India, asylums Southern Presbyterian Mission (SPM) (Jiangsu) 58 specialist hospitals (UK) regulations controlling patients’ visitors 39–40 staff visits (educational) 38, 45 specialist hospitals (USA), cancer in children 132 sports, Australian/New Zealand asylums 268, 269, 279–81 Spring Vale (Staffordshire), madhouse 202 staff see hospital staff; nurses Stafford County Asylum 209 Staffordshire Oulton Retreat 214 private madhouses 202 stage-managing visits 15 for donors to London Lock Hospital 17, 183–5, 188 for public visitors 15, 16, 17, 23 Staphylococcus aureus, methicillinresistant 7, 24 St Bartholomew’s Hospital 176, 179 steam therapy 258 St George’s Hospital (London) 178 St Jude’s Children’s Research Hospital (USA) 132, 134 St Luke’s Hospital (London) 200 oversight by governors 203 public access benefits but restrictions 203 St Luke’s Hospital (Shanghai), American Episcopal Mission 60 Stockwell smallpox hospital 161–2 St Thomas’s Hospital (London) 176, 179, 181 clerical visitation 187 students, medical foreign, as visitors 49 visitors for 41 visits to hospital wards 41–2 Sturdy, Steve 21, 22

subscribers benefits of supporting hospitals/charities 176–7 children’s hospitals 82 Hospital for Sick Children 82, 84, 91, 98, 102 Jenny Lind Hospital 112–13, 114 see also Jenny Lind Hospital for Sick Children, hospital visitors as governors of hospitals 176–7 London Lock Hospital see London Lock Hospital to The Opal 256 to voluntary charities/hospitals 176 see also charitable donations; financial help; fundraising; house visitors Sudnow, David 23 suicide, of day-release patient 282 Sunderland isolation hospital 160 superbugs 7, 24 superintendents Australian and New Zealand asylums 293–4 lady, Hospital for Sick Children 89, 91 Maudsley Hospital (London) 223 New South Wales asylums 293–4 surgery causes of death (infections) 70 consent for, mission hospitals in China 64 death rates 69 development, Jenny Lind Hospital 112, 124–5 planned, visiting restriction reasons, Jenny Lind Hospital 125 recovery rate in China 70 safer in China than USA 69–70 scrutiny by families, in China 67, 68, 69 Sutherland, Miss (matron at Jenny Lind Hospital for Sick Children) 117

349

Index Sweeting, Mrs (of Kilburn) 92 syphilis diagnosis 45 rejection of admission to hospitals 177–8

U

T Tanner, Andrea 17, 22, 81–110, 312 Tavistock Clinic 12 telephones 165 ‘Ten Types of Hospital Visitor’ (Causley, Charles) 7–8 terminal illness of patients children, parental visiting 100, 116, 118 in isolation hospital, visiting 161 Thomson, J. 69–70 Thorne, Richard Thorne 149, 152, 159, 165 tobacco, brought into New York asylums 259 Tomes, Nancy 291 tonsillectomy, Jenny Lind Hospital for Sick Children 124–5 Toronto Hospital for the Insane 291 Toronto’s Hospital for Sick Children 11 toys, provision for children’s hospitals 88 traditional Chinese foods 65, 66 traditional Chinese medicine 62–3, 64, 66 transport to New York asylums 250 rail passes for families to visit Goodna hospital 293 visitors to isolation hospitals and 163 tuberculosis 66, 149 Tucker, George 276, 277 Tuke, Samuel 207, 255 Twining, Louisa 89, 90–1 home for pauper teenage girls 90–1 Twycross, Reverend 188

USA asylums in New York see New York asylums asylum tourism 243–66 see also New York City Lunatic Asylum Board of State Commissions of Public Charities 246 cancer in children, hospitals 132 see also Children’s Hospital of Pittsburgh family-centred care in 55 hospital comparison with medical missions (China) 56 hospital photographs 59 medical vs surgical case numbers 64 psychiatric institutions 14 public dispensaries leading to hospitals 57 restrictions on visiting children, campaign against 55 role of visitors to hospitals (up to 1870s) 59 state commission in lunacy 246 surgery safer in China 69–70 vigilance by families and commitment to care 71 visiting hours and rules 9, 59 Utica Asylum see New York State Lunatic Asylum (Utica)

V vaccination evidence of before visiting smallpox hospital 163 infants 150 venereal patients house visitors’ concerns, Birmingham General Hospital 35 Lock Hospital see London Lock Hospital

350

Index opposition to admission to hospitals 177–8 Victoria, Queen of England (18191901) 87–8 Victoria (Australia) asylums 290 Ararat Asylum 274 Beechworth Asylum 274 Collingwood Lunatic Asylum, ball 271 Cremorne Private Asylum, entertainment/recreation 276 Kew Asylum see Kew Asylum (Victoria, Australia) Yarra Bend Asylum see Yarra Bend Asylum (Victoria, Australia) Victoria Hospital (Burnley, UK) 46 vigilance, by families in hospitals 71 visitation, concept 175–6 visiting, scope of 8 visiting days/hours advertising 10 Australian/New Zealand asylums 299 Birmingham and Midland Hospital for Skin and Urinary Diseases 48 Birmingham and Midland Hospital for Women 40, 47 General Hospital (Birmingham) 41 Hospital for Sick Children 95, 100–1, 102 isolation hospitals 159–60 Jenny Lind Hospital for Sick Children 115, 116, 117, 118 London Lock Hospital 180–1, 189 USA hospitals 9, 59 Visiting Justices 205 visiting rules Hospital for Sick Children 101 isolation hospitals 160 see also isolation hospitals (midVictorian Britain) medical missions in China 60 USA 9, 59 violations 9

voluntary charity model 176–7 voluntary hospitals 31, 81, 176 asylums see asylums (England) Ceylon psychiatric institutions 229 house visitors to see house visitors voyeurs at/of asylums Bethlem Asylum 199, 203, 244 New York 244, 253, 254, 255

W Wales, HRH Prince and HRH Princess, visit by (1902) 97 wand, white 33 Warwickshire Hunningham Hall Asylum 214 pauper lunatics 209 private madhouses 202 Wassermann reaction 45 Watkins, Dr (Yarra Bend Asylum) 298 Welton, C.J. 157 Wenlock, Miss (matron at Jenny Lind Hospital for Sick Children) 116–17 West, Mary 89 West Lane Fever Hospital (Middlesborough) 164 Westminster Infirmary (London) 177 subscriber opposition to motion to include venereal patients 177–8 ‘Whau’ (Auckland Mental Hospital) see Auckland Mental Hospital (New Zealand) (‘Whau’) Whau Minstrels 272, 295 Williams-Wynn, Charles 206 Willowburn Asylum (Queensland, Australia) 274 Winchester, Bishop of (1879) 99 ‘window appointments’, isolation hospitals 164 Winnicott, Donald 126 women patients see female patients women visitors see female visitors

351

Index Wongaroo Lunatic Asylum (Queensland) see Goodna Hospital (Wongaroo Lunatic Asylum)(Queensland) Worboys, Michael 151 workhouse official inspections 83 patients not selected for hospitals 177 pauper lunatics in 209 tours 21 Workhouse Visiting Society 21, 90 working classes, in isolation hospitals 153–4 Wright, David 290 Wynn’s Act (1808) 19

Y Yarra Bend Asylum (Victoria, Australia) cricket 269 Currie family experiences 301 family role in leave of absence/discharge 297–8 location and size 292, 293 overcrowding and state of buildings 295 patient/family reactions to confinement 301 Year Book of Australia, advert for Bay View Private Asylum 277 York Lunatic Asylum (England) 205, 206 1813 reforms 207 control by physicians 204 lack of visitation 204 lady visitors 207 violence between patient and keepers 209 visiting governors and powers of 207 York Retreat 206

352

r o d o p i [email protected]–www.rodopi.nl Amsterdam/New York, NY, 2008 XXXI-222 pp. (At the Interface/Probing the Boundaries 53) Paper € 50 / US$ 73 ISBN: 9789042024915

Negotiating Sexual Idioms Image, Text, Performance Edited by Marie-Luise Kohlke and Luisa Orza Negotiating Sexual Idioms: Image, Text, Performance affords new theoretical approaches and insights into the complexity of sexual discourse pervading contemporary cultures, exploring sexuality’s role in dominant conceptualisations of self and society, in patterns of political belonging and exclusion, and in societal transformations. Opening with a substantial critical introduction, this collection of twelve essays and creative pieces contributes to significant current debates regarding sexual rights and their violation, queer theory and identity politics, sexual fantasy formations and strategies of pleasure, and the celebration of sexual diversity, topics explored through a variety of disciplinary frameworks, including gender and film studies, religious philosophy, neo-Victorian and postcolonial literature, sociology, pornography, and performance art. The volume positions the subjects of sex and sexuality as crucial to our ethical understanding of the human, both in individual and communal terms, exploring how claims for sexual subjectivity and citizenship are formulated and the entitlements they entail. The analytical insights offered signal important new directions for critical engagement with the socio-political construction of sexuality and its strategic deployment within the cultural imaginary. Designed to appeal equally to scholars, students, and general readers, Negotiating Sexual Idioms will prove essential reading for those interested in multi-disciplinary approaches to reading sex and sexuality within inter-cultural contexts, from the early modern period to the present-day.

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Hosting the Monster Edited by Holly Lynn Baumgartner and Roger Davis

Hosting the Monster responds to the call of the monstrous with, not rejection, but invitation. Positing the monster as that which defies classification, the essays in this collection are an ongoing engagement with that which lies outside of established boundaries. With chapters ranging from the monstrous mother or the deformed child to subjectivity in transition, this volume is not only of interest to film and gender scholars and literary and cultural theorists but also students of popular culture or horror. Its wide appeal stems from its invitation both to entertain the monster and to widen the call to and the listening for the monsters that have not yet, and perhaps must not yet, come calling back. This sense of hospitality and non-hostility is one guiding principle of this collection, suggesting that the ability to survey and research the otherwise may reveal more about the subjectivity of the self through the wisdom of the other, however monstrous the manifestation.

Amsterdam/New York, NY, 2008 X-260 pp. (At the Interface/Probing the Boundaries 52) Paper € 54 / US$ 78 ISBN: 9789042024861

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Social Studies of Health, Illness and Disease Perspectives from the Social Sciences and Humanities Edited by Peter L. Twohig and Vera Kalitzkus The studies of the human being in health and illness and how he can be cared for is concerned with more than the biological aspects and thus calls for a broader perspective. Social sciences and medical humanities give insight into the context and conditions of being ill, caring for the ill, and understanding disease in a respective socio-cultural frame. This book brings together scholars from various countries who are interested in deepening the interdisciplinary discourse on the subject. This book is the outcome of the 4th global conference on “Making Sense of: Health, Illness and Disease,” held at Mansfield College, Oxford, in July 2005. This volume will be of interest to students in the medical humanities, researchers as well as health care provider who wish to gain insight into the various perspectives through which we can understand health, illness and disease.

Amsterdam/New York, NY, 2008 VIII 243 pp. (At the Interface/Probing the Boundaries 49) Paper € 50 / US$ 75 ISBN: 9789042024052

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Seeking Environmental Justice Edited by Sarah Wilks

The 5th Environmental Justice and Global Citizenship conference was held at Oxford, UK in 2006. This decidedly transdisciplinary, international event attracted participants from traditionally separate academic perspectives; each ambassadors for their disciplines and each seeking and making connections with other disciplines and other understandings. Some of the presentations from this conference have been further developed for inclusion in this book, yielding 14 chapters of paradigmatic richness covering issues ranging from environmental education and the nature of global multinational corporations, to the role of environmental activism and consideration of how democratically representative some campaigns may be. This book will be of great interest to anyone working in these areas as well as an excellent introductory journey for those seeking to become pan-paradigmatic.

Amsterdam/New York, NY, 2008 VII-294 pp. (At the Interface/Probing the Boundaries 46) Paper € 60 / US$ 90 ISBN: 9789042023789 USA/Canada: 295 North Michigan Avenue - Suite 1B, Kenilworth, NJ 07033, USA. Call Toll-free (US only): 1-800-225-3998 All other countries: Tijnmuiden 7, 1046 AK Amsterdam, The Netherlands Tel. +31-20-611 48 21 Fax +31-20-447 29 79 Please note that the exchange rate is subject to fluctuations

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Territories of Evil Edited by Nancy Billias

Evil is not only an abstract concept to be analyzed intellectually, but a concrete reality that we all experience and wrestle with on an ongoing basis. To truly understand evil we must always approach it from both angles: the intellective and the phenomenological. This same assertion resounds through each of the papers in this volume, in which an interdisciplinary and international group (including nurses, psychologists, philosophers, professors of literature, history, computer studies, and all sorts of social science) presented papers on cannibalism, the Holocaust, terrorism, physical and emotional abuse, virtual and actual violence, and depravity in a variety of media, from film to literature to animé to the Internet. Conference participants discussed villains and victims, dictators and anti-heroes, from 921 AD to the present, and considered the future of evil from a number of theoretical perspectives. Personal encounters with evil were described and analyzed, from interviews with political leaders to the problems of locating and destroying land mines in previous war zones. The theme of responsibility and thinking for the future is very much at the heart of these papers: how to approach evil as a question to be explored, critiqued, interrogated, reflected upon, owned. The authors urge an attitude of openness to new interpretations, new perspectives, new understanding. This may not be a comfortable process; it may in fact be quite disturbing. But ultimately, it may be the only way forward towards a truly ethical response. The papers in this collection provide a wealth of food for thought on this most important question.

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r o d o p i [email protected]–www.rodopi.nl Amsterdam/New York, NY, 2008 XII-170 pp. (At the Interface/Probing the Boundaries 44) Paperback € 37 / US$ 56 ISBN: 9789042023475

War, Virtual War and Society The Challenge to Communities Edited by Andrew R. Wilson and Mark L. Perry

These papers contribute to a growing discourse among academics, scholars and lawmakers that is questioning and rethinking the nature and purpose of war. By studying the effects of war on communities we can more readily understand and anticipate the consequences of present and future conflicts. Such an understanding might well enable us to plan and execute military action with a more clearly defined set of post-war goals in mind. Whereas traditionally a government at war seeks the defeat of the adversary as its primary and often sole aim, through a clearer understanding of war’s effects other aims will also become prominent. War, like surgery, could gradually become more refined, could minimize damage in ways that are currently unimaginable, and could involve an increasingly heavy responsibility to prepare for and facilitate reconstruction. Projects such as this volume are, of course, only the beginning. The more we understand the evolving nature of war, the better prepared we will be to protect communities from its harmful effects.

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r o d o p i [email protected]–www.rodopi.nl Amsterdam/New York, NY, 2007 VI-229 pp. (At the Interface/Probing the Boundaries 43) Paperback € 47 / US$ 68 ISBN: 9789042023406

Clowns, Fools and Picaros Popular Forms in Theatre, Fiction and Film Edited by David Robb

By its very nature the clown, as represented in art, is an interdisciplinary phenomenon. In whichever artform it appears – fiction, drama, film, photography or fine art – it carries the symbolic association of its usage in popular culture, be it ritual festivities, street theatre or circus. The clown, like its extended family of fools, jesters, picaros and tricksters, has a variety of functions all focussed around its status and image of being “other.” Frequently a marginalized figure, it provides the foil for the shortcomings of dominant discourse or the absurdities of human behaviour. Clowns, Fools and Picaros represents the latest research on the clown, bringing together for the first time studies from four continents: Europe, America, Africa and Asia. It attempts to ascertain commonalities, overlaps and differences between artistic expressions of the “clownesque” from these various continents and genres, and above all, to examine the role of the clown in our cultures today. This volume is of interest for scholars of political and comic drama, film and visual art as well as scholars of comparative literature and anthropology.

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The Changing Face of Evil in Film and Television

Amsterdam/New York, NY, 2007 XXI-244 pp. (At the Interface/Probing the Boundaries 41) Paperback € 53 / US$ 80 ISBN: 9789042023246 Textbook Edition € 22 / US$ 33 ISBN: 9789042023253

Edited by Martin F. Norden

The popular media of film and television surround us daily with images of evil images that have often gone critically unexamined. In the belief that people in ever-increasing numbers are turning to the media for their understanding of evil, this lively and provocative collection of essays addresses the changing representation of evil in a broad spectrum of films and television programmes. Written in refreshingly accessible and de-jargonised prose, the essays bring to bear a variety of philosophical and critical perspectives on works ranging from the cinema of famed director Alfred Hitchcock and the preternatural horror films Halloween and Friday the 13th to the understated documentary Human Remains and the television coverage of the immediate post-9/11 period. The Changing Face of Evil in Film and Television is for anyone interested in the movingimage representation of that pervasive yet highly misunderstood thing we call evil.

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