Surgery in the asylum I: Which way to the operating theatre?

On our lunch break a few weeks back, fellow postgraduate student Emily Andrews and I started to compare notes about post-mortem procedures in asylums (these are the kind of conversations you get into as historians of medicine – to our fellow diners, I can only apologise). Whilst both of us had uncovered quite detailed reports about the appearances of bodies at post-mortem, we had less information about the spaces in which post-mortems were performed. This led us to consider other medico-surgical spaces within the asylum.

There are many accounts in both archival and secondary literature of operations being performed on asylum patients. Alongside narratives of psychosurgery (covered previously on this blog) are tales of other types of operation: for cataracts, for removing foreign bodies ingested or inserted by patients, or for the excision of tumours. Rarely, though, are the practicalities of these operations mentioned. Where did they take place? Who performed them? Who benefitted (and who didn’t)?

The operating theatre of London’s Metropolitan Hospital in 1896. © Wellcome Images. Is this perhaps what many asylum operating rooms looked like?

The need for surgical intervention within the asylum was graphically highlighted in an 1858 article by D.F. Tyerman, Colney Hatch Superintendent, in which he described various emergency situations involving suicide attempts by patients. In 1834, he had prevented the death of a male patient who cut his throat with a knife during dinner. Arriving at the scene, Tyerman ‘introduced into the wound [his] fore finger’ before plugging the wound with lint and tying the carotid artery. He was also called to attend situations in the immediate area beyond the asylum, including a man who had cut his throat in a nearby hotel. As institutions typically placed some distance from urban centres, Tyerman’s anecdote showed how basic medical skills possessed by asylum staff might be called upon by neighbours in an emergency.

This distance could be problematic for the asylum, however, especially if an institution lacked staff who were able undertake such heroic measures. J.H. Sproat, in 1899, related four cases of surgical intervention that had necessitated calling in outside help because staff at the Somerset and Bath Asylum lacked the necessary skills. In some cases, local doctors proved difficult to convince, being reluctant to operate in institutions lacking the usual facilities and no doubt fearing any ensuing coroner’s inquests. In large asylums, then, it was crucial to have, if not the staff, then at least the facilities to deal with medical emergencies, as well as to perform more routine operations. (Many asylum staff were able to perform minor procedures, though it appeared less common for them to undertake things such as amputation, as William Dudley had at the West Riding Asylum in the 1890s.) R.H. Steen, writing on asylum architecture, included an operating theatre in his plans of a model asylum; it should be located close to the wards and ‘centrally placed’.

Victor Horsley operating at Queen Square in 1906. © Wellcome Images

The importance of such facilities can be seen in accounts of the construction of Cardiff Lunatic Asylum, which opened in 1908 under the Superintendency of Edwin Goodall. Speaking at a meeting of the Medico-Psychological Association in 1908, he explained how ‘the object had been to give the Institution as much a hospital character as possible’ (indeed, he also considered the possibility of employing the term ‘mental hospital’ rather than ‘asylum’ – a change that did take place a few years later). In the original plans for Cardiff, an operating room was included at a cost of £600, then reconfigured to be accommodated within existing rooms for the lower cost of £500. A loan to cover the cost had been refused by the Commissioners in Lunacy, but ‘as the buildings were nearly completed at that time they went on with them, [reasoning that] the cost would have to be borne out of the rates’. The Commissioners, defending their refusal to provide the funds, ‘said the operations [undertaken in asylums] were few’ and ‘that operations were often done in private bedrooms’. Goodall countered by producing a telegram from Dr Bond at Long Grove Asylum ‘saying that he had an operating room, so that such had recently been allowed [by the Commissioners]’. Debates with the Commissioners aside, Goodall proudly reported that Cardiff now had a well-equipped operating room with ‘about £360 worth of … instruments’.

Though Cardiff still relied on outside expertise where necessary, the benefit of on-site facilities was soon evident: within two weeks of opening their operating room, ‘their Night Sister sustained a fracture of the base of the skull and … was operated upon [there]’. Evidently, then, staff as well as patients might be treated within the asylum. Many operations were described as urgent measures – to treat an injury or remove a life-threatening tumour – but for patients in particular, surgery might also be viewed as a route to improved quality of life. Robert Picqué in France considered this in a 1907 article ‘Ce que Doit Être à notre Époque La Chirurgie des Aliénés’ [‘The Needs of our Time in Respect of the Surgical Treatment of Insane Patients’]. As a review of his work related, Picqué suggested that ‘restoring the use of a limb [for example], may exercise an indisputable, though indirect, action towards the restoration of mental health’ by allowing the patient to resume a more active life.

All was not well, however. At the same time, doctors were increasingly expressing their concern about the often hasty recourse to surgery on asylum patients. A worrying faith in craniectomy as a ‘cure’ for idiocy was identified, as well as the phenomenon of post-operative insanity – insanity caused or exacerbated by surgery. Both of these though, will be stories for future posts…

- Jennifer Wallis

If you’ve found any information on surgical practices in an asylum you’re researching, we’d love to hear from you!