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Senility Before Alzheimer: Old Age in British Psychiatry, c. 1835-1912 Emily Stella Andrews History Department, University of Warwick Thesis submitted for the degree of Doctor of Philosophy in History April 2014 ii Contents List of Figures………………………………………………………………………………vi List of Tables………………………………………………………………………………..vi Acknowledgements……………………………………………………………………….vii Declaration………………………………………………………………………………...vii Abstract……………………………………………………………………………………viii Introduction……………………………………………………………………………1 Defining the Object of Study…………………………………………….......2 Defining the Locus of Study…………………………………………………6 The History of the Asylum …………………………...…………………….12 The History of Old Age……………………………………………………...23 Sources, Approaches and Arguments……………..……………………….28 Chapter One: Senility, Dementia and Dissolution in Psychiatric Theory….…...34 The Classification of Senility and Dementia in Nineteenth-Century Psychiatry…………………………………………………………………….38 James Cowles Prichard, and Dementia as Loss………………….……39 David Skae and Somato-Aetiological Classification………………….44 Dissolution, Dementia and Senility…………………………………..51 The Symptoms of Dementia and the ‘Cognitive Paradigm’…...………...62 Sensation, Attention and Memory…………………………………....65 Dementia and Emotion………………………………………………..68 Dissolution and the Cognitive Paradigm……………………………..70 The Localisation of Dementia………………………………………….71 Models of Ageing…………………………………………………………….75 The Bodily Economy; the Exhaustion of Life…………………………..75 Old Bodies: Arteries and Atrophy…………………………………….85 Second Childhood and the Phylogenic Metaphor……………………..….91 The Lebenstreppe……………………………………………………….91 Second Childhood………………………………………………………94 Ontogeny and Phylogeny………………………………………………97 Ontegenic and Phylogenic Memory…………………………………….99 iii Conclusion: The Natural and the Pathological……………………………...101 Chapter Two: The Politics of Lunacy and the Exclusion of Senility……..………...107 The Lunacy Commissioners, Incurables and the Senile……………..………110 The Enumeration of Senility………………………………………..……113 Explaining the Increase: the Four-Shilling Grant………………….…...116 The Meaning of Insanity and the Exclusionary Discourse of Senility……………………………………………………………….......119 The Commissioners’ Solution…………………………………………….123 Senility at Hanwell………………………………………………………….…..128 Senility and the Metropolitan Asylums Board…………………………….…131 The MAB Response to the Problem of the Senile………………………...135 The View from the Workhouse…………………..…………………………….142 Conclusion………………………………………..……………………………...145 Chapter Three: Older Patients’ Journeys to Hanwell………………………………..147 The Historiography of Asylum Admission…………………………………..150 Old Age in the Family…………………………………………………………..155 Relationships and Care Before Institutionalisation………………………….161 Troublesome Husbands, Troubled Wives………………………………...161 Adult Children and the Extended Family………………………………..165 Friendship, Neighbourhood and Charity Networks……………………...173 Care and Management in the Home..…………………………………………178 Order in the Workhouse………………………………………………………..182 Conclusion……..………………………………………………………………...187 Chapter Four: The Emergence of the Senile Patient at Hanwell……………………189 The Aged Subject………………………………………………………………..190 The Structure of the Patient Records…………………………………………194 The Form of Insanity…………………………………………………………...199 The Patient’s Body……………………………………………………………...207 Describing and Examining the Body…………………………………….208 The Senile Body…………………………………………………………..211 Aetiology and the Lay Narratives………………………………..…………....214 iv Economic Anxiety………………………………………………………...215 The Marginalisation of the Lay Voice…………………………………….219 Recording the Lay Narratives…………………………………………….220 Senility as a Cause of Insanity…………………………………………...224 Conclusion……………………………………………………………………….226 Chapter Five: Leaving the Asylum; The Death and Discharge of Aged Patients……………………………………………………………………………………228 Dying and Death………………………………………………………………...229 Discharge…………………………………………………………………………242 Conclusion………………………………………………………………………………..253 Understandings and Categories……………………………………………….253 Reponses………………………………………………………………………….259 Bibliography……………………………………………………………………………...266 Appendix 1: The 1882 Medico-Psychological Association ‘Form of Insanity’ Classification……………………………………………………………..296 Appendix 2: The Format of the Case Books at Hanwell…………………………….297 v Abbreviations LCC (London County Council) MAB (Metropolitan Asylums Board) MPA (Medico-Psychological Association) vi List of Figures Figure 1. (Artist Unknown) ‘Life and age of man: stages of man's life from the cradle to the grave’ (New York: Currier and Ives, between 1856 and 1907), Library of Congress, cph 3a04025……………………………………93 Figure 2. Detail from ‘The Stages of Life’ (London: James Catnach, c. 1830), British Museum, 1992,0125.31, AN347203……………………………………………..94 Figure 3. Detail from Bernard Van Oven, On the Decline of Life in Health and Disease (London, 1853), p. 36. ………………………………………………………95 Figure 4. Annual admissions to Hanwell Asylum, 1850-1910……………………....115 Figure 5. The proportion of annual admissions to Hanwell Asylum reported to be aged 60 or over on admission, 1850-1910………………………….…116 Figure 6. Outcome of residence of patients reported to be aged 60 or over on admission to Hanwell, 1851-1912. ………………………………………………….….228 List of Tables Table 1. Senile forms of insanity in patients reported to be aged 60 or over on admission to Hanwell, 1851-1912………………………………………………………200 vii Acknowledgements First thanks go to my supervisor, Hilary Marland, for her calm and consistent faith in this thesis and its writer, and her considerable support along the way. Thanks also to members of the Warwick History Department for their input and encouragement at various stages of this project. Thanks to my CHM compatriots Jack Elliot, Gareth Millward, Martin Moore, Harriet Palfreyman, Stephen Soanes and Rebecca Williams for listening ears, good times, and useful suggestions. I could not have got through this without such thoughtful, intelligent and tolerant peers. Thanks also to Jennifer Wallis and Åsa Janssen. Thanks to Anamika Basu, Ruth Baker, Simone Cooper, Lauren Ding, Julia Lambeth, Charlotte Moss, Sarah Stevens and Jayne Yong for being inspirational women, and a light at the end of the tunnel. Thanks to Rosi and David Pitcher, for their kindness and interest. Thanks to my dad, David Andrews, for intelligent thoughts, encouraging words, and the occasional good feed. This project would not exist without my grandmother, Pat Nichols, 'my muse'. She has been a thoughtful and incisive listener, and a beacon of love. Final thanks go to Chris Pitcher, who has given me every type of support imaginable over the last few years, and in particular in the final months. I can't express in words how much that has meant to me, but I can start doing the washing up again. This thesis is dedicated to my mum, Debbie Andrews, whose determination to understand people on their own terms inspired this project. I hope some of that humanity speaks through these pages. Declaration I declare that this thesis is entirely my own work, and does not contain material submitted for examination for a degree at any other university. viii Abstract This thesis addresses the place of old age in British psychiatry, from 1835-1912. It asks: how were mental disorders in old age understood, categorised and responded to? It seeks answers to these questions in three sets of sources: theoretical published works written by professional psychiatrists, the official reports of the bodies charged with managing the asylum at a national and local level, and in the patient records of Hanwell County Lunatic Asylum. It argues that the ‘senile’ became more clearly defined in the latter nineteenth century, in politics and in medicine, as a residual category of person: too insane for the workhouse, too old for the asylum. It shows that, during this period, older people in the asylum were increasingly likely to be viewed as ‘old’. Through the increasing focus on internal pathology as an aetiological determinant of mental disorder, both engendered and reflected in changes to the asylum’s patient records, the inherent agedness of older people – with associations of inevitable decline, incurability and dependency – became central to the way that psychiatrists interpreted their mental disorders. The senile were a controversial group in nineteenth-century psychiatry. The administrators of Lunacy made attempts to exclude them from the asylum, but families and workhouse officials continued to send them there. The asylum played an important role in latter-nineteenth-century London as a pressure-valve for those whose behaviour made them unmanageable in other settings. Without more specialised provision, the asylum was often the only institution which could manage the elderly mentally disordered. Once there, aged patients worked and were cared for alongside the rest of the asylum population, usually until their death. 1 Introduction On July 19th 1900, three medical students sat down to take the examination for the Certificate in Psychological Medicine, accredited by the Medico-Psychological Association of Great Britain and Ireland