Religion as an index of the rise and fall of ‘moral treatment’ in 19th century lunatic asylums in England

“…; and the tone of the chapel bell, coming across the Valley of the Brent, still reminds me, moming and evening, of the well-remembered and mingled congregation of the afflicted, and who are then assembling, humble yet hopeful, and not forgotten, and not spiritually deserted.”


Prologue
As a function of the Christian ethic, monasteries in Britain from the Middle Ages onwards set aside a section for the care of the sick. The monastic tradition ensured that the spiritual needs of the physically sick were well taken care of: chapels formed an integral part of the building complex and chaplains were, of course, con stantly on tap. The mentally sick were less well served, however. For example, the second build ing to be occupied by St Luke's Hospital, London, opened in 1787, did not even boast a chapel, a distinction shared with Bethlem, the other major charity asylum, then occupying a purpose-built structure in Moorgate in the City of London.
The reasons for this are not immediately clear, but it is conceivably linked to the belief, prevalent at that time, that lunacy was equated with the loss of reason and that this deprivation rendered lunatics on a par with brutes, incapable or unworthy of communion with the Deity. This hypothesis began to lose ground at the end of the 18th century and during the first decades of the 19th century, due in large measure to the rise in influence of the English Evangelicals who had infiltrated the Established Church and whose voices could be heard in every Corridor of Power in the Establishment.
Included among the tar gets of 'Vital Christianity' were the abolition of slavery (William Wilberforce was a prime example of an Evangelical), prison reform, child labour, corporal and capital punishment, cruelty to ani mals, and most important in the context of this paper, the treatment of the insane incarcerated in asylums or elsewhere (Lord Shaftesbury was yet another vitally important Evangelical). It was seen as an instrument of Christianity to bring lunatics within the compass of the Established Church in order that their personal salvation could be guaranteed. This could not possibly be achieved without an accessible place of worship, so that chapels within the curtilage of the asylum became a prominent feature of asylum architec ture in the 19th century, particularly after the Act of 1845 (8 & 9 Viet, clOO) when the Counties were compelled rather than permitted to build asylums.
Tacit legislative recognition of the change in status of lunatics and the assumed palliative effects of religion on their minds is conveyed in the Treatment of Insane Persons Act 1828 9 Geo rv c41 (Madhouse Act). Para 38 states: "And whereas the Hopes and Consolations of Religion may soothe and compose the Minds of Patients, and subdue the Malady under which they are suffering; be it further enacted. That the Com missioners and Visitors . . . shall inquire whether and at what Times Divine Service is read and performed for the Benefit and Consolation of any of the Patients, or what Religious Aid they receive The Act goes on to instruct "such Com missioners and Visitors to enter into a Book or Register the results of such enquiries and, fur thermore, that if it appeared that Divine Service was not performed, or not permitted, then the keeper shall state the Reason or Reasons thereof." Stripped of all the bureaucratic verbiage, the message conveyed is that, although there was no actual compulsion for Divine Service to be avail able in asylums, the non-availability of such services would meet with official disapproval.
Although the legislators, spurred on no doubt by the reformers, were convinced of the benefits of religious practices on the minds of lunatics, their conviction was not completely shared by the medical men in whose care they were. John Conolly (1794Conolly ( -1866, that most benevolent and Christian of men, who clearly regarded divine worship as part and parcel of the "moral treatment" of the insane, had, nevertheless, his reservations. He writes: "I believe the experience of all chaplains of asylums has taught them, that there is great difficulty in ascertaining to what extent their most anxious endeavours are really serviceable, and that all their attempts should be characterized by moderation." Indeed, he goes much further and gives due warning of the malevolent effects of certain kinds of religious literature on the fragile minds of lunatics. "There are, however, kinds of exhorta tion and descriptions of books and tracts, so mischievous, that the physician should have power to protect his patients from their influence". He recommends that all books should be submitted for medical inspection before being circulated. Furthermore, he insists that the list of patients wishing to receive the sacrament should first be submitted to the physician for approval so that, "none should be admitted whom the ceremony might disturb, or who might in any way interrupt its solemnity." Dr David Uwins (71780-1837), physician inter oÃ-Ã-a, to Peckham House Asylum, Surrey, is downright sceptical. He writes: "In regard to reli gious instruction of lunatics, where the mind is completely alienated, I am of the opinion also that the anticipations of those who, in the best spirit, proposed it, will be miserably disap pointed. Even the daily reading of prayers is nugatory, if not farcical, before an indiscriminate assembly of mad persons .... Beyond these probable and by no means certain benefits, it has appeared to me, in fact, as I confess I should beforehand have expected, that the legislative provision of a spiritual instructor for a mad house has been founded rather upon benevolent feelings, rather than much knowledge of the constituents of insanity." Despite the scepticism of some medical men, the provision of religious services gathered pace during the 19th century. The Report on Lunacy 1843^14 (pp 159-163), is particularly illuminat ing in this respect. Chapter VI, Religious Ser vices, goes into some detail as to the provision of such facilities.
It deals first with Private Asylums. The Report illustrates the haste with which facilities were provided, and the remarkably motley crowd deemed fit to undertake the solemn responsi bilities of conducting the services which in them selves cannot have lacked variety, and at times, a certain black humour. "We have found in some instances," it records, "that the Proprietor of the Asylum, or one of his Superintendents, or Keepers, or even one of the Patients, has been the only person in the habit of reading Church Service, or other Prayers, to the Inmates. In one House (at Box) a Patient, obviously Lunatic, was permitted to exhort his fellow patients every Sunday, in reference to their Religious Duties, in an extemporaneous address. In other places, a Keeper, or Nurse (without any apparent qualifi cations for rendering the subject as impressive as it ought to be) has been the only person delegated to read the service to the assembled Patients." It goes on to report that at Gateshead Fell Asylum, the rector of the parish attended once a month on Sunday evenings and performed Divine Service which was read on the intermedi ate Sundays by the proprietor. At Nunkeeling, the incumbent of a neighbouring parish had been licensed as chaplain to the asylums; and at Gate Helmsley, a clergyman from an adjoining parish attended regularly every Wednesday and read the Evening Service as well as reading a short discourse to the assembled patients, male and female. The paragraph ends, "We adduce these cases ... as examples of these arrange ments made voluntarily by Proprietors of Asylums, which we think desirable, wherever there are any considerable number of Patients capable of benefitting by the assistance of a Clergyman." The Report then turns its attention to the "County and other Public Asylums". The provi sion of religious services, it found, was mixed as, indeed, were those who provided the service. With few exceptions, chaplains had been ap pointed, or the duties performed by the chaplain to the County Gaol {!).At Chester, for example, there was no chaplain and the service was read on Sundays by the Head Keeper and Matron on the Male and Female sides. At Lincoln Asylum, where no chaplain had been appointed, prayers were ready daily, and twice on Sunday, by the House Surgeon. At St Luke's where, as already noted, there had been no chapel, it was found, even more surprisingly, that prayers had never been read to the inmates. However, this grievous omission was about to be put right: a chapel was "in progress of being fitted up and a Chaplain about to be appointed". Finally, the Report noted that at the Warneford Asylum, Oxford, a chapel had been recently built for the inmates.

Status of the chaplain
Corresponding with the rapid growth in the num ber of asylum chapels came a rise in the number of chaplains appointed. An insight into the status of chaplains can be found in John Crammer's illuminating history of Buckinghamshire County Pauper Lunatic Asylum -St John's, opened in 1853 (Crammer, 1990). The chapel, he writes, was built as an integral part of the asylum, and that as the patient population grew and exten sion became necessary, a bigger chapel was one of the first priorities. A chaplain was appointed from the very beginning: he was non-resident 628 Roi/in and, as a measure of his importance, paid one of the top salaries, the same, in fact, as an assistant medical officer. At St John's the chaplain was required to do much more than to hold one or two services on Sundays. He was obliged to pay frequent visits to all the wards, to read and pray with the patients and, in addition, he was expected to keep a journal of all his activities for the inspection of the monthly committee meetings as well as contributing his own section to the annual reports. St John's, incidentally, seems to have enjoyed a well above average ration of the odour of sanctity in that for the first 25 years after its inception there were four or five Anglican clergy (a third of the membership) on the Committee of Visitors of whom, the Rev Ouvry was chairman from 1869 to 1886.
It was perhaps because the evangelical influ ence at St John's was so strong that the chaplain was able to far exceed his clerical brief. For example, the Rev J.B. Reade, the first chaplain to be appointed, wrote, somewhat presumptuously, in his last annual report for 1859: "1 seldom fail to receive from newly-admitted patients, when not absolutely unimpossible and obviously silent, some account of the state of their minds as well as the causes which led to their ill ness. The most common causes are religious melancholy, loss of health, loss of property and drunkenness. I have given such advice and reproof as the cases seemed to require, and generally the reproof was well received and richly deserved." His successor, the Rev Charles Lowndes, was more circumspect: in 1860 he wrote in his report: "Although I have stated that the patients are generally attentive, it must not be supposed that all who attend Chapel worship God in spirit and in truth, far from it . . ." The high esteem in which the clergy were apparently held at St John's was by no means universal. Further north, for instance, at the Lancaster Asylum, John Walton writes: "The Chaplain thus saw himself as an important com ponent of the 'moral treatment' system, and his high salary and new chapel (opened in 1866) might seem to endorse this view. In practice, however, he was firmly subordinated to medical control, to such an extent that he had to obtain (as John Conolly at Hanwell had also insisted) the superintendent's permission before a patient could receive Holy Communion, and by the mid-60s his reports were not deemed worthy of being forwarded to the Clerks of the Peace for printing".
A further broadside was delivered by a Mr R. Hindle who published an attack on county rates in 1843. He, although not finding fault with the asylum in general, took exception to the annual salary of Â£300 paid to the chaplain when, he alleged, "some needy curate in the neighbour hood would have done the job for Â£50".

Exclusivity of religious services
It is a matter of both interest and importance to note that all the organised provisions for reli gious services in asylums during the 19th cen tury were designed exclusively for patients who were members of the Church of England. This reflects in the main the relative homogeneity of the population at that time: Queen Victoria in mid-century could, surveying her loyal subjects, take pride in the Englishness of the English. John Crammer (1990) writes that in the early years following the opening of St John Asylum in 1853: "about three quarters of the patients were Anglican, and the rest Methodist or Baptist with an occasional Roman Catholic or Quaker".
However, arrangements were made on an ad hoc basis for the spiritual needs of non-Anglicans and in this regard it is apropos to quote John Conolly again (p. 127) who wrote in mid-century: "The patients who do not belong to the Church of England should, of course, be permitted to see their minister. Except the Irish Catholics, how ever, I have scarcely ever found a patient, not of the English Church, desirous of seeing a minister or priest." No account of the provision of religious ser vices in asylums would be complete without a mention of that unique and epoch-making insti tution, The Retreat at York. It was formally opened in May 1796 and has continued to pro vide an enlightened service to this day. It was founded, however, exclusively for the treatment of Quakers, although not all Quakers were, or are, treated at The Retreat. Those who are, how ever, have the good fortune to enjoy the religious benefits peculiar to that denomination.
With the waves of immigration into England in the last quarter of the 19th century and the beginning of the 20th century, England lost its homogeneity. It had become increasingly a pluralist and multi-faith society and denomi nations other than Anglican had to be catered for. Thus, at Horton Asylum, Epsom, Surrey, opened in 1902, the patient population in 1904 was 1,968 of whom 221 (11 %) were Roman Catholics. Even so, there was no provision originally for Roman Catholics, although it is noted in the Commissioners in Lunacy Report for 1904 that a "portion of the Chapel will be specially set apart." By 1911 provision had been made for Jews admitted from the London area to attend Jewish service at Colney Hatch, Friern Barnet, London.

The decline in the role of religion in 19th century asylums
The role of religion in the overall treatment of patients in asylums appears to have reached its zenith in mid-century and then to have steadily declined. The reasons for this decline are com plex, but certain determinants stand out as important.
First, the Evangelical movement, which had played such an important part in promoting "religious therapy" in the first place, had lost its dynamism and its influence. Secondly, the men of genius and goodwill who had put into practice the precepts of "moral treatment" in the 19th century asylums, such as Dr Gardiner Hill (1811-1878) and Dr Samuel Gaskell (1807-1886), Dr E.P. Charlesworth (1782-1853), Sir William Ellis (1780-1839) and Dr John Conolly (1794-1866), had retired, or died, and had not been replaced by men of comparable calibre or conviction. Thirdly, the mental hospitals that had been built in the 19th century, despite end less additions to their accommodation, had become swamped by the unstoppable flow of admissions of the old and of the intellectually subnormal, for whom the asylums were a conve nient receptacle, plus the inexorable build-up of long-term chronic patients. The dream that a cure for mental illness could be found in careful management and humane treatment alone had evaporated to be replaced as the century wore on by the nightmare of gross overcrowding and under-staffing, particularly in terms of physi cians and attendants: the less-than-merry quip that ". . .a gigantic asylum is a gigantic evil ..." had become more than justified. Fourth, there had been an increasing flight from religion in society at large which was reflected in the micro cosm of the asylum. Finally, as has been shown, there was nothing like universal conviction among asylum doctors that "religious therapy" was worthwhile, and therefore, lacking press ure from without and leadership from within, religious practices were allowed to decline by default.
The position at the beginning of the 20th cen tury was that the facilities and personnel were in place for those who sought or benefited from the comfort of the Church, but little or no attempt was made to spread the gospel.
A good example of the state of affairs at this particular time is to be found at Horton Asylum. The hospital was based on plans drawn by G.T. HiÃ±es, a noted institutional architect of the late 19th century. Included was a handsome chapel in the classical, pavilion style, standing in its open spacious grounds. The chapel (now a listed building) is well appointed and boasts, as an added attraction, a splendid organ, reputed to have been bought from Winchester College, circa 1903. In accordance with the recommendations for asylums of this era, the chapel was built "large enough to hold fully one-half of the inmates" (Burdett, 1891). The anticipated patient population was approximately 2,000 so that the chapel as built would comfortably seat Above and below: Chapel, Horton Hospital, Epsom 1,000 patients plus the requisite number of medical and nursing staff.
Yet the Commissioners in Lunacy, 1906, note, somewhat woefully, that the "number attending weekly services in chapel is small, i.e. 25%"; and in the Report for 1913 that the number "attend ing Sunday services is still rather low." By con trast the attendance at weekly entertainments is given as 56%.
Just in case Horton might be considered un representative it is as well to compare it with other asylums in and around London. The Com missioners Report for 1911, for example, invari ably makes some remark about attendances in chapel which, for the most part, is somewhat despairing. At Claybury (London: patient popu lation 2,473) the Report notes that, "The propor tion attending the Sunday services in chapel during the year was low, amounting to only about half the average attendance in institutions of this class." At Colney Hatch (London: patient population 2,488) it is written that, "The morning and afternoon Sunday Church of England ser vices are only fairly well attended . . . being 34% and 32% respectively." Napsbury (Middlesex: patient population 1,288) comes in for severe censure, ". . . we notice that the proportion of patients attending the church services on Sundays and the weekly entertainments is very much below average. We think it would be in the interests of the patients that these numbers be largely increased." Cane Hill (London: patient population 2,190) brought a little cheer to the Commissioners. They write, 'The good propor tion of 42% of the patients are present at Sunday Church of England Service, which service the Noncomformists also attend: and for those of the Roman Catholic faith there are services twice a month, which are well attended." However, the most severe admonition is re served for Hanwell (London: patient population 2,531). "The returns for 1910 show that the attendance at the Church of England services was very poor, and the same may be said as to the weekly entertainments." In the same vein the Commissioners castigate Hanwell for the below average proportion of patients usefully employed, and the numbers of patients confined to bed. What is even more disturbing is the note that since their last visit mechanical restraint had been used for 11 patients on 108 occasions for an aggregate of 2,066 hours, and that, "seclusion is recorded to have been employed for 31 patients on 116 occasions for 329Ã•hours in all." The grim irony of this deplorable indictment is inescapable if it is remembered that it was at this selfsame hospital under the superintendency of Dr John Conolly from 1839 to 1844 that the "moral treatment" of the insane took such firm root. Hanwell, at that time, shone like a beacon, giving guidance in the treatment of the insane not only in the British Isles, but throughout the civilised world. Sad it is to reflect that in the course of half a century or so the beacon he had lit was virtually extinguished. This betrayal of each and every article of faith woven into the tapestry of "moral treatment" was not of course peculiar to Hanwell, but common to all asylums in varying degrees towards the end of the 19th century and well into the 20th. The decline in the role of religion must, therefore, be considered not as an isolated phenomenon, but as part and parcel of a much greater tragedy, that is, the resurgence of inhumanity in the treatment of the insane. That this was brought into high relief at Hanwell of all hospitals merely adds poignancy to that tragedy.