The mythology of 19th-century asylums portrays them as dark and inhuman gothic institutions. Historical research is beginning to shed new light onto this world, however, forcing us to re-examine long-held beliefs. Case note analyses have consistently shown high levels of psychiatric morbidity in the patients admitted to these institutions (Reference TurnerTurner, 1992; Reference BeveridgeBeveridge, 1995; Reference Doody, Beveridge and JohnstoneDoody et al, 1996). Patients' letters have been examined and confirm high levels of florid psychopathology (Reference BeveridgeBeveridge, 1997), they also reveal some aspects of the rich social and cultural life available to patients at the Royal Edinburgh Asylum. Such studies add to our understanding of the culture of mental hospitals described by Jones (Reference Jones, Berrios and Freeman1991).

The day-to-day working life of 19th century physician superintendents remains ill-defined, however. Biographies of illustrious academics such as Henry Maudsley (Reference Turner, Bynum, Porter and ShepherdTurner, 1988) and reformers such as John Conolly (Reference Scull, Bynum, Porter and ShepherdScull, 1985) often fail to give a sense of the routine clinical and administrative work that underpinned their careers. Contemporary Medico-Psychological Association presidential addresses referred to the excessive workload of asylum doctors and suggested that this acted as a disincentive to recruitment (Reference NormanNorman, 1894). This stemmed from the all pervading responsibility for patients combined with the mundane and trivial nature of many of their tasks (Reference Hayes NewingtonHayes Newington, 1889). Charles Mercier (Reference Mercier1894) suggested a timetable for superintendents that set aside 90 minutes a day for administrative work, though it is not known to what extent this timetable was followed by other physician superintendents.

The purpose of this study was to examine in detail the correspondence book of a physician superintendent at a Scottish pauper asylum. In particular, the contents of the letters were analysed to shed light on conditions for patients and staff in an asylum in its opening year.

Historical background

In 1888 a District Lunacy Board was formed for Lanarkshire that was to oversee the planning, building and eventual running of the new Lanark District Asylum (from the earliest days more commonly referred to as Hartwood Asylum). It was designed by a local architect with “the buildings… plainly and very substantially built… all architectural decoration having been kept subsidiary to the grouping of the buildings for the efficiency and convenience of administration” (The Herald, 11 May 1895). The cost of the project, which had a capacity of 500 beds, was £152 430 with a further £ 10 000 being spent on furnishings. The staff complement comprised three doctors, six administrative staff, 25 male attendants, 17 female nurses, 12 servants and seven artisans and tradesmen. Hartwood grew rapidly and by 1901, when Campbell Clark (its first physician superintendent) died, it housed 730 patients, of whom 44 were private.

Rising from humble beginnings to become one of the most influential of 19th-century Scottish psychiatrists, Campbell Clark was born in Lochgilphead in 1852 where he worked in an administrative capacity in the local asylum. He went on to work in a Glasgow warehouse before studying medicine in Edinburgh. He worked as an assistant to Thomas Clouston at the Royal Edinburgh Asylum before taking up the position of physician superintendent at the Glasgow District Asylum in Bothwell, which took patients from some Glasgow and Lanarkshire parishes. While carrying out his duties in this post he worked exhaustively to establish the new county asylum for the whole of Lanarkshire.

His obituary described him as a man who “worked incessantly and at high pitch, whatever he did he did with his whole might” (JTM, 1902). He published extensively throughout his career, including case studies (Campbell Clark, Reference Campbell Clark1879, Reference Campbell Clark1888, Reference Campbell Clark1899) and clinical research into puerperal insanity (Campbell Clark, Reference Campbell Clark1883, Reference Campbell Clark1887/8), dietetics (Reference Campbell ClarkCampbell Clark, 1887) and treatment with extract of spleen (Reference Campbell ClarkCampbell Clark, 1898). He was appointed McIntosh Professor of Psychological Medicine at Glasgow University and published a popular textbook The Clinical Manual of Mental Diseases (Reference Campbell ClarkCampbell Clark, 1897).

Perhaps his greatest and most lasting contribution, however, was in the training and welfare of attendants and nurses (Campbell Clark, Reference Campbell Clark1884a , Reference Campbell Clark b , Reference Campbell Clark1886, Reference Campbell Clark1894). He was one of the earliest physician superintendents to suggest that patient care would benefit from improvements in the training of attendants and nurses. He instituted a series of lectures for staff who had hitherto been looked down on as ruffians and servants. With Drs McIvor Campbell, Turnbull and Urquart he was commissioned by the Medico-Psychological Association to produce a compilation of these lectures to help attendants “to a due understanding of the work in which they were engaged”: The Handbook for the Instruction of Attendants on the Insane (Reference Campbell ClarkCampbell Clark, 1885) as this became was known affectionately as ‘the little red book’ and was in use in subsequent editions until the 1980s (Reference RollinRollin, 1986). Despite his pivotal role in the development of both mental health nursing and industrial therapy, Campbell Clark has not been afforded his due significance by writers on the history of nursing (Reference Nolan, Freeman and BerriosNolan, 1996) or occupational therapy (Reference Bennett, Freeman and BerriosBennett, 1996).

The study

Among the archives of Hartwood Hospital is a volume of copies of letters from 1895 written in longhand by Campbell Clark (typed, later in the year) or his assistant medical officers. The volume starts with the appointment letters of key staff some 3 weeks before the asylum opened. It spans just over a year and contains a total of 1500 letters.

All letters from 1895 were examined and a 16-item checklist completed. Legibility and authorship were noted as well as content. This was divided into administrative, clinical and personal. Other contemporary records and secondary sources were examined to provide background historical material and to help understand the context of the letters.

Findings

A total of 863 letters were examined, of these 308 (36%) were administrative and date mainly to the weeks before the opening of the hospital (Table 1). A further 503 (58%) relate to clinical matters (Table 2). The majority of letters were written by Campbell Clark himself, 131 (15%) were written by his assistant medical officers. Only eight (1%) letters were personal and 44 (5%) were illegible.

Table 1.

Administrative letters (n=308)

No vacancies	61
Letters of appointment/terms	51
Works/maintenance/furnishings	49
Meetings	40
Character references	27
Fire department/railways	12
Post/publishers/books/newspapers	11
Inspector of poor	10
Other doctors	10
General Board of Lunacy	3
Dismissal	3
Miscellaneous	9

Table 2.

Clinical Letters (n=503)

Family	238
Inspector of poor	115
General Board of Lunacy	81
Other doctors	51
Clinical meetings	6
Pharmacy	2
Procurator fiscal	2
Miscellaneous	8

Discussion

The content of the letters reveals the extent of a physician superintendent's responsibilities: it was Campbell Clark's job to ensure the water was drinkable, the trains stopped on time, the staff were suitable and the patients were occupied or entertained. The study confirms the high administrative and clinical workload described by senior 19th century psychiatrists. Red tape, bureaucracy and an unmanageable administrative workload are often cited as a cause of stress and early retirement by psychiatrists working today (Reference Kendell and PearceKendell & Pearce, 1997). That these stresses existed 100 years ago suggests a failure by the profession to manage these demands satisfactorily. The correspondence also reflects Campbell Clark's commitment to the training and welfare of attendants and nurses and his family- and community-oriented approach to the care of the ‘insane’ in the nineteenth century. As the centenary of his death approaches it is timely to re-examine his philosophy and approach to psychiatry, which anticipated many later developments.