In this guest blog, Caroline Nielsen describes how vulnerable patients were displaced from hospitals to make way for the casualties of war.
In a recent post for this blog, Dr Jessica Meyer discussed how wounded and sick soldiers were evacuated from the frontlines to large specialized hospitals in Britain. Images of these war hospitals and their military patients have appeared in publications as part of the centenary commemorations. These institutions have even been the subject of popular TV dramas, such as Downton Abbey, The Wipers Times, and The Crimson Fields. But the creation of these life-saving institutions had a hidden cost: the forced displacement of around 12,000 of the most vulnerable people in British society. This was because twenty-four of Britain’s largest war hospitals were requisitioned asylums for the mentally ill and those with learning disabilities.
Asylums and the War
The British military authorities were under considerable pressure in late 1914. There were simply not enough hospital beds in Britain to accommodate the ever-growing number of allied war casualties. Numerous patriotic individuals and organisations voluntarily opened their doors to soldier-patients, donating their time, money, and property to the war effort. But it was simply not enough. A drastic and ambitious scheme was developed to ensure that the nation remained fighting fit. Recovering soldiers needed beds but they also needed spacious grounds, recreational areas and sports fields to aid their recovery. Only a small number of institutions had all of these facilities already in place: residential schools, workhouses and the largest of them all, lunatic asylums. There were only two problems: the pre-existing large population of vulnerable patients and the stigma attached to them.
Every county in England and Wales had a lunatic asylum. Run by local committees overseen by the Government’s centralized Board of Control, these institutions offered residential care to a large population of men, women and children. There were over 102 psychiatric asylums in England and Wales in 1914. Over 108,000 men, women and children lived permanently in these institutions. This meant that each county and borough asylum cared an average of 1000 patients at any one time (Sarah Rutherford, The Victorian Asylum, 2011).
Asylum patients had a wide range of conditions, many of which would not fit with modern understandings of mental illness. As well as caring for those with depression, anxiety and delusions, asylums nursed those with long-term or degenerative conditions like epilepsy, tuberculosis, liver disease, alcoholism, and syphilis. A significant proportion of patients were elderly and frail, moved from out of their homes when they started to experience the disorientating symptoms of dementia. It was not uncommon to find those with learning disabilities living permanently in asylums (for example those with Down’s syndrome or who would now be placed on the autistic spectrum). It is important to stress that the majority of those with learning disabilities in the early twentieth century continued to live with their extended families. While some patients were sent by their families to these institutions, others were referred there by social welfare authorities: by doctors, charity workers, the Board of Education, or by the Guardians of the Poor who oversaw workhouses. Going into a workhouse or insane asylum carried a huge social stigma. But for the most impoverished, sick and desperate, they offered the only chance of free medical care.
The Asylum War Hospital Scheme, 1915-1919
Faced with mounting casualties, the British War Authorities approached the Board of Control for permission to empty a small number of asylums. Patients were either to return to their families or be transferred into different institutions. 9 asylums were initially selected, with others gradually added into the scheme whenever more beds were needed. All selected asylums were swiftly renamed as “war hospitals” so that soldier casualties would not be tainted with the stigma of receiving treatment in a lunatic asylum.
The most incredible aspect of the scheme was the speed with which it was carried out. Within 5 weeks of the scheme being confirmed, the selected asylums had been emptied of all but a few of their patients. The official estimate was about 12,000. Only the “gravely ill” [dying] and a few “quiet useful insane” men were allowed to stay on. The “useful” patients were to work as gardeners. (Board of Control, Official History of the War Asylum Hospitals, 1920). The insane were not even given the reassurance of familiar staff. Asylum nursing staff were requisitioned for the war effort along with the furniture.
Unsurprisingly, the immediate effect on the patients was severe. The official report of the Medical Officer of Norfolk County Asylum (later Norfolk War Hospital) is so shocking that it is worth quoting at length;
The scenes on departure aroused varying emotions in myself, my medical colleagues and the nurses. It was all interesting, some of it most amusing and much sadly pathetic. To not a few the asylum had been their home for many years, some for over fifty years, some since childhood; many even had never been in a railway train … so it will be readily believed that the whole gamut of emotion was exhibited by the patients on leaving, ranging from acute distress and misery, through gay indifference, to maniacal fury and indignation.
Casualties of War
That the Asylum War Hospitals Scheme saved lives is beyond dispute. By 1920, the hospitals had offered specialist care, pioneering treatment and friendship to over 440,000 men from all over the world. Approximately over 38,000 (9%) of these men were psychiatric cases; those suffering from shell-shock, nervous breakdowns, delusions, and sheer terror.
But the War Hospitals came at a terrible cost to the mentally ill and their families. Within 1 year of the first transfers, the Board of Control noticed that patients were dying at a higher rate than usual. Overcrowding had resulted in some of the remaining asylums, facilitating the spread of influenza, pneumonia and tuberculosis. The asylum patients were also subject to rationing and food shortages, weakening an already sickly population. A series of cold wartime winters and a shortage of psychiatric medical professionals only exacerbated the problem.
In its official 1920 inquiry on the War Hospital’s Scheme, the Government reported that the transferred insane should be viewed as quasi casualties of war. Their suffering during the war was immediately and irrefutably comparable to that of “normal” military casualties. The insane deserved respect and sympathy irrespective of the stigma attached to their condition.
This was never to be. In spite of the report-writer’s best efforts, the wartime experiences of the civilian insane were almost immediately forgotten by their communities. The stigma surrounding mental illness and disability meant that discussing their experiences became taboo. No war memorials were raised in the name of these men, women and children. But as the centenary passes, they too should be remembered.
The AHRC and BBC “World War One at Home” project will explore the asylum transfers further in the autumn. Detailed descriptions of the individual asylums can be found in the Board of Control’s official report, entitled “History of the Asylum War Hospitals in England and Wales”, 1920. Regional asylum death statistics can be in Lewis Krammer’s article “The Extraordinary Deaths of Asylum Patients, 1914-18” in the journal Medical History (1992).