Book Review by Peter Tyrer

Claire Hilton. Palgrave MacMillan, 2021. ISBN 978-3-030-54870-4

The moral status of a country can be determined by its treatment of the mentally ill. On this count Norway and Sweden do well, Russia and the US do badly, and the United Kingdom is in between. But was it always thus? This historical account, complete with detailed references, describes the fate of the mentally ill residents of four asylums all within the London area during the First World War. These all differed; Colney Hatch (subsequently Friern Barnet), had many insane prisoners of war, Claybury was famous for its pathological laboratory established by Frederick Mott; yet it deteriorated in the war and the laboratory was closed; Hanwell, made famous by John Conolly for removing physical restraint, received patients from other hospitals all over the country that had been taken over by the military; and Napsbury Hospital gradually increased its complement of military patients with over 1000 of these accommodated in the hospital by the end of the war.

What stands out in this scholarly account are three lessons that were subsequently learnt and led to mental health reform:

• physician superintendents were all powerful in asylums and could change or neglect policies at will without demur,
• The Board of Control for Lunacy and Mental Deficiency, created in 1913 just before the war, had good intentions but no real power and so too often was seen as bleating from the side lines when things went wrong,
• Patients were at the very bottom of a rigid hierarchical system that virtually deprived them of rights.

Just to give one example, Sir Robert Armstrong-Jones, whose grandson, Antony, married Princess Margaret, was a grandee of the physician superintendent system. He ran Claybury Hospital like a private company, often with good intent, trying to ensure that all the patients had the minimum of creature comforts. But when extra ration happened to arrive, mainly from the productive farms tilled by patients at the hospital, it became a different matter. Senior asylum personnel were permitted to purchase up to 7 lbs of fruit a week and unlimited quantities of milk and vegetables from the farm shop and on one occasion in 1915, Armstrong-Jones bought goods to the value of £25. Later in the summer, when 400 lbs of strawberries were harvested just over half was shared between the 2000 patients, with the rest distributed amongst the 200 staff.

The Board of Control was established in 1913. It had well-qualified staff, a Chairman, two Senior Medical Commissioners, one Senior Legal Commissioner, six Commissioners including lawyers and doctors, six Inspectors and administrative staff (with one, interestingly by law, required to be a woman). Its purpose was primarily to establish that those under the various mental and mental-deficiency Acts were legally in custody, that ‘care was proper’ and that the money and property of patients was not stolen or misused. But these requirements only touched the surface of mental health care; the Commissioners were powerless to intervene in the high mortality of patients at Claybury Hospital in 1917 (almost 70 deaths each month compared to an average monthly death rate of 20 during the previous two decades). The causes of death included TB and Spanish flu but why were other hospitals spared?

What I would have liked to see more about in the book is the reaction of mental hospitals to the military mental casualties of the war, the new diagnosis of shell-shock and the interaction between the new military and old asylum patients. The important work of Montagu Lomax, a junior psychiatrist at Prestwich Hospital, could not be part of this book as Prestwich is in Manchester, but could have been interleaved with the debate about patients’ voices, most commonly noted by their absence in Hilton’s account.

How much of what happened in the First World Ware led to subsequent reform is also difficult to quantify. The MacMillan Commission report of 1924, that directly followed from Lomax’s criticisms at Prestwich Hospital stated the case clearly:

‘There is no clear line of demarcation between mental illness and physical illness. The distinction is commonly based on symptoms and is in practice no doubt convenient, but it has had an undue influence on the development of the lunacy system. The modern conception of mental illness calls for a complete revision of this attitude. The key-note of the past had been detention; the key-note of the future should be prevention and treatment.’ (Royal Commission on Lunacy and Mental Disorders, 1926.)

This Commission report led directly to The Mental Treatment Act of 1930. This Act of Parliament replaced the term ‘asylum’ with ‘mental hospital’, and laid down the principle that mental illness and physical illness were entwined, perhaps the most important statement in any reform of mental health acts; one that still has to be repeated today. Did the First World War experiences adumbrate this; I think they did.

Works Cited

Royal Commission on Lunacy and Mental Disorders: Summary of Report (1926). British Journal of Nursing, 74, p. 200.

Peter Tyrer is Emeritus Professor of Community Psychiatry, Imperial College, London.