The Patient Workers Inside Hospital

Abstract

Freebody explores how a patient’s class, gender, age, physical health and mental condition influenced the allocation of occupation in French and English institutions. Class was an important consideration since manual labour was considered unsuitable for the middle classes, particularly for women, despite its alleged benefits as a therapy. Whether a patient’s condition was perceived as curable or incurable made a difference to the type of occupation prescribed in England, and to whether it was prescribed in France. The reasons why curable patients at the acute stage of their illness were more likely to be prescribed occupational therapy in England, or unoccupied and treated biologically in France, are examined. In both countries, incurable patients, and those whose condition had deteriorated into chronicity, were allocated work around the hospital, provided they were physically fit, for the benefit of both institution and patient. Freebody compares the material conditions of English and French, rural and metropolitan institutions, that provided the context for patient work, and the varied approaches towards offering incentives to work.

This chapter focuses on the patients who were prescribed (or not prescribed) occupation in French and English mental hospitals. The extent to which class, gender, age, physical health and mental condition influenced whether patients were allocated some form of work or occupational therapy, is examined. The matter of patient choice—whether or not they wanted to be occupied—is difficult to ascertain, but the existence of incentives to work indicates that some encouragement was necessary. This raises the question of what happened to patients who were unable or unwilling to work, such as the elderly, who may have been too frail, and the middle classes, for whom manual work was something of an anathema in both France and England. Were these patients presented with alternatives to work? The influence of the psychiatrists prescribing occupation, discussed in chap. 6, is also relevant here since psychiatrists’ views on the appropriateness of occupation for acute cases is fundamental to the allocation of work or the prescription of occupational therapy. The combination of these influences contributed to the experience of patient work, and to the overall experience of life in each of the mental hospitals examined.

Patient Class

Before the emergence of new methods of occupational therapy, a patient’s class affected whether they were expected to carry out work around the hospital, irrespective of their physical or mental condition. Establishments catering for a middle-class clientele, such as Bethlem and the private section of the Asile de la Sarthe, had fewer working patients than public institutions, because manual work was not considered appropriate for the middle-classes. Bethlem, as a registered hospital, catered for the “deserving poor”, who were “received gratuitously” (that is, they paid no fees) and the poorer middle classes who could not afford the high fees of a private institution, but could still afford to pay for all or part of their treatment at Bethlem.¹ Manual work was unlikely to be considered appropriate for these paying patients. Physician superintendent John Porter-Phillips noted that admissions in 1921 included “many professional men, officers of Her Majesty’s Forces and civil servants”.² In the early 1920s, c.70% of patients paid no fees; the group of professional men referred to by Porter-Phillips were probably among the remaining 30%. By the late 1930s, the proportion of fee-paying patients to those paying no fees had reversed, with only around 20% of patients “received gratuitously”, suggesting that the profile of Bethlem patients became progressively middle class during the interwar period. It is plausible to assume that the numbers of patients engaged in work decreased as a result, while those of patients occupied with occupational therapy (introduced at Bethlem in 1932), leisure activities and entertainments increased.

Between 25% and 31% of Bethlem’s patients were recorded as “usefully employed” by the Board of Control’s inspectors between 1920 and 1928 (after 1928 figures for “useful employment” ceased to be recorded).³ These working patients were most likely to have been selected from the non-paying cohort, but even when this is taken into account, the figures are considerably lower than the average of 57% of public mental hospital patients who worked, as identified by the Cobb Report of 1922.⁴ This can be explained by the fact that Bethlem’s admissions policy was to accept only curable cases. Those at the acute stage of their illness, who were most likely to respond to treatment, were sedated at Bethlem and would not have been prescribed work, which was allocated to convalescent patients. The fact that some of his patients worked, was not something that Porter-Phillips wished to publicise, since, as Andrews et al. have suggested, “work did not agree with the Hospital’s bourgeois character”.⁵ Porter-Phillips preferred to emphasise Bethlem’s provision of sport, leisure and entertainment activities (in which between 34% and 49% of patients participated), and occupational therapy after 1932, which were designed to appeal to a middle-class clientele. Class was an issue at Bethlem. In 1911, the physician superintendent noted that although the “social status of patients has been rather better in recent years”, he had been obliged to admit out of “common humanity”, several patients on a voluntary basis who were “not of the educated classes”. He was relieved to note that once “the new hospital on Denmark Hill” (the Maudsley) had opened, he would be able to refuse such patients.⁶

The Maudsley was a public mental hospital, but it was unique among public mental institutions in that it specialised in patients at the early, acute stage of their disease when their symptoms were not so severe as to warrant certification; and admission was voluntary. Other English public mental hospitals accepted a mix of curable, acute, incurable and chronic patients but only patients who were certified were admitted before the Mental Treatment Act of 1930. At the Maudsley c.75% of patients were “rate-aided” (a term that carried less stigma than pauper) and c.25% paid fees.⁷ There was no indication that work or occupational therapy was allocated differently between the private patients and those whose care was paid for by the London County Council. All patients (with the exception of children under 14 years, who comprised 3–7% of Maudsley patients) were obliged to undertake some form of ward work as soon as they were able to get out of bed. Patients were occupied with craft activities whilst still in bed.⁸ Although admission was determined solely on medical grounds, and not by “social or financial considerations”, Maudsley patients included a high proportion of middle-class individuals, including educated professionals, such as doctors, clergymen and school teachers.⁹ In 1925, the largest professional group were artisans (26%), while the next most highly represented group were the unemployed (15%) [see Table 8.1 above].¹⁰ Medical superintendent Edward Mapother was aware of the wide range of social classes and educational attainment amongst patients, although he observed that such “social differences have never given rise to difficulties”.¹¹ Class therefore appeared to have less relevance to the type of activities allocated to patients at the Maudsley than it did at Bethlem. The high proportion of middle-class patients at the Maudsley might be explained in economic terms—patients who were insecure economically were less likely to seek voluntary treatment than those who had more of a financial “cushion” and could afford to spend time in hospital without working.

Table 8.1 Table to show the occupation of patients at the Maudsley Hospital, London, prior to admission in 1925. [Source: Report of the Superintendent, Maudsley Hospital, 1925. BMM/MSR-01]

The Asile Clinique in Paris was also a public mental hospital where the majority of patients were paupers.¹² Details regarding the previous occupations of patients passing through the Admissions Service (15% of whom were admitted to the Asile Clinique) reveal that between 1919 and 1926, 56%-77% of patients had no previous profession [see Table 8.2 above]. Patients of public asylums were expected to work to contribute to the costs of their care if they were sufficiently fit, whether or not they had worked outside the institutions prior to admission. However, the acute nature of patients admitted to the Asile Clinique after 1927, meant that very few patients in the treatment divisions were prescribed occupation, despite their pauper status, because doctors did not consider work a suitable treatment for patients at the acute stage of their illness. The ability of patients to work, as discussed in chap. 5, was one of the factors that delayed the transformation of the Asile Clinique to an acute hospital. The authorities were concerned about the budgetary implications of focusing on acute cases, since this would result in a significant reduction in the number of patient workers, upon whose economic contribution they relied. Before the transformation of the hospital to an acute service in 1927, an average of just 25% of patients worked. The figure of 25% was already considerably lower than the national average for French public asylums serving pauper patients, which stood at between 50% and 55%.¹³ Patient health, discussed below, may have been influential in lowering the proportion of patient workers at the Asile Clinique prior to 1927. The asylum’s city location was also a factor, since this limited the availability of land for cultivation (although vegetable and flowers were grown in the gardens). After 1927, it was the acute nature of patients’ mental condition that kept numbers of workers numbers from the treatment divisions very low.

Table 8.2 Table to show the sectors in which male (M) and female (F) Seine patients were employed prior to admission to one of the Seine’s six asylums (of which the Asile Clinique was one) during the period 1918–1926. [Source: Reports to the General Council, 1919-26. ADP-D.10K3 26-34]

The Asile de la Sarthe provided care for both private patients who were able to pay for their care, and pauper patients whose fees were paid by the local authority. In 1919, 27% of patients paid for their care; this figure decreased to 25% by 1928 and to 19% by 1939. There was a marked difference between the classes in terms of the proportions of working patients. Only 18%–33% of male private patients worked, compared with 46%–63% of male pauper patients. Private patients were divided into four classes. The top three classes of patients, some of whom had their own personal servants in the asylum, would not have been expected to work, due to their middle-class status. Patients in class four, who comprised an average of 50% of the private patients [see Table 8.3, below], shared the same regime (le régime en commun) as the publicly funded patients. Relatives of private patients belonging to this fourth tier were charged roughly the same rates as the local authorities for the maintenance of pauper patients, who were expected to work.

Table 8.3 Table to show the class divisions, based on average numbers of patients resident per year, of paying patients at the Asile de la Sarthe Sarthe [Source: Report of the Asylum Director, Asile de la Sarthe, 1919-39. ADS-1X964/5]

The Littlemore Hospital was a public asylum, catering for predominantly pauper patients. Patients were referred by one of the Oxfordshire Poor Law Unions, or by local authorities from outside Oxfordshire [see Appendix A.14]. The hospital was under contract with the London County Council to receive 20 patients per year, and with the Middlesex local authority (c.125 patients). These patients, as well as those coming to the Littlemore from Croydon, Nottingham, Buckinghamshire and East Ham, would have had quite different backgrounds to patients coming from rural Oxfordshire, but all were pauper patients. The only private patients were Service, or ex-Service, patients who were classed as “private” in order to avoid the stigma of certification. There were 20–23 such patients between 1923 and 1935. As at the Asile Clinique, the suitability of work for middle-class patients therefore was not an issue at the Littlemore. Here, as in all the asylums, mental condition, gender, age and physical health played important roles in the type of occupation prescribed.

Patient Gender

The patient populations at Bethlem, the Maudsley and Littlemore hospitals showed a consistent female bias during the interwar period, with an average of c.45% men and c.55% women.¹⁴ This bias was typical of English mental hospitals in the early twentieth century. In 1915, of the 137,188 cases of notified mental illness in England and Wales, 54% were women. This proportion remained fairly stable until 1946.¹⁵ As the Board of Control noted in 1934, following the introduction of voluntary treatment in 1930, female voluntary admissions were increasing faster than male. The Board felt this was to be expected since “the man is generally the breadwinner of the family, and therefore is compelled by economic considerations to defer applying for treatment”.¹⁶ Just 32% of British women in 1921 and 34% in 1931 were in paid employment.¹⁷ Women comprised c.30% of the British labour force in 1921. Paid employment for women was concentrated in five sectors: domestic service; commercial, financial and insurance occupations; clerical work; textiles and clothing.¹⁸

There are no details regarding the gender split of occupations at the English mental hospitals during this period, as the recording of the numbers of patients who were “usefully employed”, and at what tasks, ceased at public mental hospitals when war broke out in 1914. It was noted, however, that at the Maudsley in 1925 the new carpentry and upholstery workshops “greatly increased opportunities for the employment of suitable male patients”, while “both sexes of patient” had been engaged in gardening and clerical work.¹⁹ At the Littlemore, in 1913 (just before such details ceased to be recorded and prior to the introduction of occupational therapy), 38% of male patient workers cleaned the wards; 34% worked in the gardens; 12% were engaged in hair picking and another 12% in bed-making. Amongst the female patient workforce, cleaning occupied 43% of women; needlework 37%; laundry 13% and work in the kitchen 4%, revealing a clear split between the genders [see Table 2.1]. In 1937 the Board of Control inspectors noted in that although occupational therapy on the wards was well organised for the female patients, very little was being done for the men. Dr. Good explained that many of the male patients came from rural areas where they were “not accustomed to hand-crafts”, but this explanation was not accepted by the inspectors who felt that with some encouragement, many of the male patients from both urban and rural backgrounds, would benefit from “this form of employment”.²⁰ These remarks indicate that occupational therapy, as well as work around the hospital, was gendered.

In France, numerous laws passed between 1874 and 1919 were aimed at encouraging women to remain at home and become mothers, rather than seeking paid employment outside the home.²¹ The promotion of motherhood was explicit in the maternity laws of 1909–1913 amid concerns regarding France’s low birth-rate and high level of infant mortality.²² That said, women comprised nearly 40% of the French labour force in 1921. Even though this figure had decreased to 36% by 1936, the female proportion of the workforce was higher in France than in Britain, where, paradoxically, there was less emphasis on women’s role as mothers.²³ At the Asile Clinique, the proportion of male and female patients was more evenly balanced than in the English institutions, with a slight male bias.²⁴ Work for the female patients was associated with their domestic roles, as it was at the Littlemore, and included mending and making clothes, cleaning, ironing, working in the laundry and kitchen. The majority of working female patients were employed as cleaners on the wards or in the sewing (couture) workshops. Opportunities for men were much more diverse, and included work in the gardens, plumbing, decorating, electrical or mechanical work, shoemaking, carpentry, building, road mending, working in the wine cellar, library, pharmacy or the surgical wing. Some roles were divided between men and women, such as housework, scrubbing floors, kitchen and laundry work because these tasks were performed in their respective quarters. Male patients were not allowed in the female quarters and vice versa. At the Henri Rousselle Hospital, the proportion of male and female patients fluctuated, with a higher proportion of female admissions in the 1920s and becoming more evenly balanced in the 1930s as the Depression took its toll on the mental health of men unable to find employment. Patients of both sexes were encouraged to keep busy, but they were not obliged to work in the hospital. A sewing room was available for use by the female patients. A piano and gramophone were also provided, and patients could play tennis or boules in the hospital grounds. Artists visited the hospital free of charge to give art classes to the patients.²⁵

In the provincial Asile de la Sarthe, the proportion of female patients was even higher than in the English institutions. The proportion of male patients (both pauper and private) gradually increased from 32% in 1921 to 41% in 1939. Amongst the paying patients, a higher percentage of men than women worked (an average of 26% of men, and 18% of women, worked, as indicated in Table 8.5). This might be explained by attitudes towards middle-class women, around whom a “cult of domesticity” had been created that emphasised middle-class women’s reproductive, maternal and homemaking activities.²⁶ In contrast, an average of 54% of pauper women, and 51% of pauper men worked within the asylum, which was close to the average for French asylums observed by Dr. Lautier in 1929 [see Table 8.4]. Thus, three times as many female pauper patients than their private counterparts worked, and twice as many male pauper patients than male private patients, worked. Class and gender were therefore significant influences on the prescription of patient work in provincial France, despite its alleged therapeutic benefits for all classes and both genders. As in England, manual work was considered unsuitable for middle-class men, and the fact that patients were paying for their care meant that they were not expected to contribute to asylum maintenance costs with their labour. This exemption from work for middle-class patients was made explicit in the regulations of 1857.²⁷

Table 8.4 Table to show the number and percentage of male and female pauper patients working at the Asile de la Sarthe, 1923–1937. [Source: Reports of the Asylum Director, Asile de la Sarthe, 1923-37. ADS-1X964/5]

Table 8.5 Table to show the number and percentage of male and female paying patients working at the Asile de la Sarthe, 1923–1937. [Source: Reports of the Asylum Director, Asile de la Sarthe, 1923-37. ADS-1X964/5]

Table 8.6 Table to show rates of cure (‘recovered’) and improvement (‘relieved’) amongst male (M) and female (F) patients at the Littlemore Hospital, 1923–1939. [Source: Littlemore Hospital Annual Reports, 1923-39. OHA-L1/A2/1-17]

The Mental Condition of Patients

Whether a patient’s condition was perceived as curable or incurable, and whether the condition was at its early, acute stage (when it was most likely to respond to treatment) or well established (and more likely to become chronic), influenced the likelihood of the patient being prescribed occupation, and of what type. What was not clear from the records, was the influence of different types of mental disorder on the prescription of occupation. Hermann Simon, the originator of MAT, believed that patients with all types of condition, from mania to melancholia, could be employed in some capacity if they were physically fit. This view was shared by the Swiss psychiatrist Eugen Bleuler (1857–1939), who maintained that “every mental institution” should be able “to offer every patient some kind of work at all times”.²⁸ Mary Macdonald’s textbook of occupational therapy distinguishes between the therapeutic occupation “definitely prescribed as treatment with a view to improving the patient’s condition” and the non-therapeutic work assigned to chronic cases. Work for the chronic and incurable, she maintained, was valuable because it kept patients happier, healthier and able to live as “normal” a life as possible.²⁹ Macdonald’s book outlined the different types of therapeutic occupation that might be suitable for patients suffering from various types of mental disorder, such as depression (for example, a past hobby), schizophrenia (rug-making, weaving, basketry) or confusional insanity (winding yarn, polishing brass).³⁰ She advised that “the work chosen should demand the patient’s whole attention and the standard must be raised as the patient improves” which resonated with the different grades of occupations outlined by Simon.³¹ Macdonald recommended that the calm chronic and incurable patients were occupied in supervised work around the hospital, and the more turbulent in simple tasks on the wards that kept them busy and “out of mischief”.³² But it was not clear from the institutional records how specific diagnoses influenced the types of occupation prescribed in each of the hospitals examined. This issue was further complicated by changing nosology during the interwar period. Psychiatrists of the same nationality used different classification systems, which changed over time, and a comparison of French and English disease categories was impeded for the same reasons. Much clearer was the influence on occupation of the perceived curability of the patient.

Metropolitan Hospitals

All four metropolitan hospitals discussed in this chapter specialised in acute cases, but they treated these acute cases differently. Before World War I patient work had been considered unsuitable for acute patients and was reserved for chronic, incurable and convalescent patients. Bed-rest (l’alitement), sometimes for several weeks, had been the main treatment for acute patients at the Asile Clinique since 1896 when it was first advocated by the influential chief medical officer of the Ste. Anne’s Admissions Service, Valentin Magnan.³³ His ideas were widely supported in Francophone psychiatric circles. Reporting at the First Belgian Congress of Neurology and Psychiatry in 1908, Dr. Cuylitz, speaking on the alleged therapeutic benefits of work for the acutely mentally ill, claimed that “the best exercise was rest”. He rejected on scientific grounds any possibility that work might be therapeutic.³⁴ Although not all Magnan’s colleagues in Paris agreed with him,³⁵ his views set the tone for the treatment of acute patients at the Asile Clinique, none of whom were prescribed occupation at the acute stage of their illness. In this, the Asile Clinique patients were treated similarly to those at Bethlem. Most patients, on admission to Bethlem, were sedated, often for several months, and therefore unoccupied.³⁶ Doctors at the Asile Clinique and Bethlem did not respond positively to the new theories concerning patient occupation, discussed in chap. 4, that emerged after World War I. The new theories put forward by Hermann Simon and advocated by Adolf Meyer challenged the view that prolonged, complete rest was the most effective treatment for acute cases. The continued use of bed-rest at the Asile Clinique was indicated in 1929 by chief medical officer Dr. Capgras’ observation of the difficulties of supervising patients undergoing bed-rest in the Asile Clinique’s overcrowded wards.³⁷

The medical superintendent of the Maudsley, Edward Mapother, embraced the new approach to occupation for acute patients. While he believed that bed-rest (preferably in the open air) for “a considerable time after admission” was necessary for most acute cases, he recognised “the need of industries for those confined to bed, or … to the wards”.³⁸ Once patients were up, all were given some sort of work, either “household duties”, needlework, clerical work, gardening, upholstery or carpentry.³⁹ Patients made bed tables, letter boxes for the wards, wardrobe lockers, washstands and mortuary trolleys, among other items, and maintained the hospital furniture.⁴⁰ An occupations officer was employed in 1925 who taught “a large variety of handicrafts” including rug- and basket-making, leather, pewter, embroidery and raffia work to patients on the wards.⁴¹ The results were very successful and had an “undoubted beneficial effect”.⁴² Patients were less inclined to “morbid preoccupation with their troubles” and less vulnerable to “boredom and deterioration”.⁴³ Mapother was aware that because the average length of stay in hospital for Maudsley patients was short (usually around three months), occupational therapy had to be organised differently to that provided in an asylum or orthopaedic hospital where patients remained for long periods. The arts and crafts activities taught by the occupational therapy department had to be relatively simple, so the techniques could be grasped quickly to produce rapid but pleasing results.⁴⁴

All Maudsley patients were at the acute stage of their illness, but their symptoms were not certifiable at the time of admission.⁴⁵ The fact that patients’ symptoms were relatively mild, and their prognosis generally good, suggests that they were likely to be capable of work or occupational therapy as soon as they had undergone the initial rest period recommended by Mapother. The records do not indicate the numbers of patients occupied at the Maudsley, but Mapother suggests that everyone who was “up” was given work and those in bed or on the wards were occupied with occupational therapy except at the very beginning of their stay.⁴⁶ At Bethlem, on the other hand, a significant (if declining) proportion of patients were certified, indicating that their symptoms were more severe.⁴⁷ When occupational therapy was introduced in 1932, it was initially only provided in the occupational therapy workroom, suggesting that patients had to have recovered sufficiently to leave the wards.⁴⁸ It was only two years later that occupational therapy was provided to patients confined to the wards.⁴⁹

At the Asile Clinique, after its transformation to an acute service in 1927, the bulk of the work around the hospital was performed by chronic and incurable patients specially drafted in for the purpose, and accommodated in a separate “workers” block. Only a small percentage of patients from the treatment divisions worked. These were most likely to be convalescent patients, such as those in remission from GPI following malaria therapy or recovering alcoholics. Alcoholism and syphilis were rife in interwar Paris; alcoholics and those suffering from GPI featured prominently amongst male admissions to the Asile Clinique. Between 18% and 22% of male patients, and between 8% and 16% of female patients, were admitted with GPI between 1919 and 1925. The Women’s First Section became a centre for malaria therapy in 1931. Women diagnosed as suffering from GPI at other asylums were transferred to the Asile Clinique causing the number of female GPI patients to increase significantly after 1931 (GPI accounted for 83% of admissions to the Women’s First Section in 1933).⁵⁰

Alcoholism was acknowledged as a curable condition, as indicated by the fact that in 1933, alcoholics accounted for 70% of patients discharged cured.⁵¹ Work had long been recognised as an effective treatment for mental disorders associated with alcoholism; the Asile Clinique’s patient workforce in 1901 comprised “almost exclusively alcoholics and chronics”.⁵² In the past, work had not been considered suitable for patients suffering from GPI; they were too turbulent in the early stages of the disease, and likely to cause accidents, and too weak at the end.⁵³ But since the introduction of malaria therapy, which resulted in the recovery or partial recovery of some patients, many were able to work after receiving the treatment. Following its introduction in 1927, the prognosis for GPI patients improved. A convalescent quarter providing work for recovering GPI patients was established in the Women’s First Section, after it became a centre for malaria therapy. The number of women engaged in sewing rose from 33 in 1928 to 49 in 1934.

Provincial Asylums

Unlike the Asile Clinique in Paris, the provincial Asile de la Sarthe admitted patients with both curable and incurable conditions. Because incurable patients, and those with chronic conditions, tended to remain in the asylum for many years (and often for life), movement of the patient population was slow and opportunities to admit new, curable cases were limited. In the department of La Sarthe, there were no alternative institutions for incurable patients, as there were in the Seine department. As highlighted in the previous chapter, there was only one medical officer for the whole asylum; one individual could only do so much when treating c.800 patients. When Dr Henry Christy arrived at the Asile de la Sarthe in 1935, he made it clear where his priorities lay. He identified two main categories of patients: those who were intellectually impaired (les infirmes du cerveau) and had been so since birth, or on account of illness or injury, and were regarded as incurable; and those who had an “evolving cerebral illness” which was considered curable, either completely or partially.⁵⁴ Dr Christy prioritised the second group, whom he sought to treat biologically, and not with occupational therapy. He had been critical of the “exaggerated claims” of certain “Germanic methods” of work therapy (clearly those of Hermann Simon) which had been greeted with scepticism by many French psychiatrists, himself included, who sought “realistic, concrete objectives and not just words”, as he put it.⁵⁵

Christy, like most of his French colleagues, believed that work was for chronic, incurable and convalescent patients. He reported in 1937 that a significant number of intellectually impaired patients had been admitted, for whom the only treatment was re-education through the discipline of work.⁵⁶ It was not always clear from the annual medical reports, however, which of the conditions ascribed to patients were considered curable or incurable, as in the case of “degeneracy” and “chronic alcoholism”. Christy highlighted in 1937 that although few cases of “degeneracy” were being discharged, not all were incurable and that many more would be curable if identified and treated earlier, and if more staff were at his disposal to treat them.⁵⁷ The categories of “mental debility”,” idiocy”, “cretinism” and “imbecility” were evidently incurable conditions associated with intellectual impairment. Intellectual impairment was attributed to 16% of male residents in 1921 and 24% in 1931. The admissions records suggest that significantly more pauper than private patients suffered from intellectual impairment (between 11% and 15% of pauper patients, compared to between 2% and 9% of private patients admitted in 1921–1931) and were deemed incurable.

At the Asile de la Sarthe, those diagnosed with mania, melancholia and delusions of persecution or paranoia, accounted for 57% of all female residents in 1921 and 54% in 1931. From the admissions data, it appears that such diagnoses were particularly common amongst the female private patients. The condition was ascribed to 54%–71% of female private patients between 1921 and 1931, while to just 37%–38% of female pauper patients. Hermann Simon, who developed MAT, advocated work for such conditions, including mania, but as his methods were dismissed by Christy, it is unlikely that these patients were prescribed work. GPI was not nearly as common in rural asylums as in city establishments; syphilis was more prevalent in urban areas. GPI affected c.3% of male patients resident at the Asile de la Sarthe between 1921 and 1931, and an even smaller percentage of female patients. Nevertheless, it was a fatal condition before the (relatively late) introduction of malaria therapy at the asylum in 1933.⁵⁸ Before this date, GPI was the attributed cause of death in a quarter of male patients dying between 1921 and 1931. By 1937 GPI did not feature as a cause of death in the records.⁵⁹ It can be assumed that GPI patients would not have been considered capable of work before 1933, but thereafter, successful malaria treatment may have enabled convalescent patients, or those in remission, to work.

Although the Littlemore cared for curable, incurable and chronic cases, Dr. Good did not regard a mental hospital as an appropriate locus of care for the intellectually impaired, who comprised a growing proportion of admissions to the Littlemore each year. Good did not believe that these patients could benefit from the expensive treatment offered at a modern psychiatric hospital.⁶⁰ He acknowledged, however, the “extreme difficulty of obtaining vacancies for this class of case among the feeble-minded institutions in this country which are now practically full”.⁶¹ As Kathleen Jones has pointed out, even in the 1950s there were still many patients in mental hospitals whose primary condition was intellectual impairment, rather than mental illness, due to lack of provision for the intellectually impaired in colonies.⁶² In 1927, Good highlighted the number of “mental defectives” who had been admitted, and in 1930 he noted that the proportion of individuals suffering from “organic physical diseases and congenital mental defect” had increased.⁶³ The Board of Control inspectors also noticed the large number of “mental defectives” they encountered on their visit to the Littlemore in 1931 whom they felt would be better placed in a colony.⁶⁴ In 1932, the medical superintendent noted that there were 77 intellectually impaired male patients and 84 females in residence.⁶⁵ This was both costly for the local authority, and, “owing to their habits [the intellectually impaired] are detrimental to the acute cases”.⁶⁶ “Occupational training”, Good observed, was of “great value in constantly employing many feeble-minded patients who [were] otherwise mischievous and troublesome”.⁶⁷ This suggests that many of the Littlemore’s intellectually impaired patients were given some sort of work or occupation, if only to keep them out of mischief.

Senile dementia was suffered by a significant proportion of new patients during the interwar period (between 15% and 21%). This is in keeping with Good’s comments regarding the high proportion of elderly admissions. Patients suffering from senile dementia would have been unlikely to work due to their age but they may have benefited from some form of occupational therapy. ‘Confusion’ was also a significant category (23%–41%); these patients would probably have been allocated simple taks, such as winding yarn, on the wards. GPI was also an important category amongst the male patients; work would not have been appropriate for GPI patients until malaria therapy had been introduced. Good’s 1926/1927 report mentions that research was being conducted into malaria therapy as a treatment for both encephalitis and GPI, although he does not refer to the results or whether patients were able to work after treatment.⁶⁸ Dr Robert Armstrong reported in 1938/1939 that malaria therapy was being continued with some successful results, but again, he did not mention patients’ ability to work following treatment, nor whether they were prescribed occupational therapy.⁶⁹

The numbers of acute cases, or patients exhibiting the first signs of mental disorder, admitted to the Littlemore gradually increased after the passing of the Mental Treatment Act in 1930. Voluntary admissions grew from seven patients in 1931 to 1947 in 1935 and 1991 in 1939. These acute-stage patients would have been given craft activities on the wards after an initial rest period. They were likely to have worked, or to have continued with occupational therapy during convalescence, prior to discharge, like patients at the Maudsley. Good expected all patients who were physically fit enough to be kept busy, whether on the wards or around the hospital. As one nurse put it, “We weren’t allowed to let them do nothing!”.⁷⁰ Between 50% and 100% of these voluntary patients were discharged within the same year of admission. This should have had the effect of increasing the annual rate of recovery or improvement, particularly towards the end of the 1930s when the proportion of voluntary admissions was c.30% of all admissions [see Table 8.6]. There was no significant change, however, probably because of the increasing number of incurable and elderly patients who were accumulating in the hospital. This is indicated by the increase in the number of patients who were discharged “not improved” (presumably to an alternative institution, such as a colony) from an average of 14 patients per year before 1931 to an average of 30 patients between 1932 and 1939.

The Physical Condition of Patients

Patients in a weak physical condition would have been exempt from work. The poor physical health of patients admitted to the Asile Clinique, many of whom suffered from tuberculosis and other respiratory conditions, may help to explain the relatively small number of patient workers prior to the hospital’s transformation to an acute service. As Dr. Marchand of the Men’s First Section highlighted, many patients arrived at the Asile Clinique in a “very grave condition”.⁷¹ A healthier patient population at the Maudsley and Bethlem hospitals, in comparison to that of the Asile Clinique, is indicated by the relative patient death rates. These were much higher at the Asile Clinique and a high percentage of the deaths occurred within the first month of arrival. One explanation may lie in the class of patients. Many of the patients admitted to the Maudsley, and particularly to Bethlem, were middle-class or from amongst the employed working classes. Those admitted to the Asile Clinique were destitute; many had been attracted to Paris, “like nocturnal insects to a lamp”, seeking a better life than that which they had endured elsewhere, but had been unable to find work. Destitute in an unfamiliar and unforgiving environment, many succumbed to alcoholism and ended up in one of the Seine asylums.⁷² Poverty, as Parisian psychiatrist Édouard Toulouse emphasised, was one of the social scourges responsible for mental disorder.⁷³ In 1900, over half of those who died in Paris were buried in pauper graves, even though the city generated around a quarter of the nation’s wealth.⁷⁴ After World War I, migrant labourers continued to be attracted to the impoverished working-class suburbs of Paris, where the population grew from c.1.5 million inhabitants in 1920 to two million in the late 1930s.⁷⁵ Accommodation in the suburbs was dirty, damp and cramped and those who found work were forced to spend most of their meagre wages on rent.⁷⁶

Poverty was also a significant factor in the rural regions of Oxfordshire and La Sarthe, where wages were particularly low and work was often seasonal. Many Littlemore patients were admitted in a poor physical state, leading Good to comment that “so many of the admissions now are found to be suffering from severe physical illness and quite incapable of being employed in any hard or continuous occupation”.⁷⁷ Oxford was not severely affected by the General Strike of 1926, but the latter caused prices to rise, resulting in hardship for many.⁷⁸ The incidence of tuberculosis at the Littlemore was higher than the average for English mental hospitals. This often fatal disease was “overwhelmingly a scourge of the labouring poor”.⁷⁹ In 1929, the Board of Control inspectors noted that the average number of notifications of new cases of tuberculosis for all mental hospitals was 8.5 per thousand, while for the Littlemore it was 27.4 per thousand.⁸⁰ Deaths from the disease were 12.3 per thousand at the Littlemore, compared with the average of 6.9 for all mental hospitals in England and Wales.⁸¹ Pneumonia, heart and kidney disease and “organic brain disease” were other major causes of death among patients. Littlemore patients were also subject to epidemics of encephalitis (1924–1925) and German measles (1934) and regular outbreaks of influenza, such as during the minor epidemic of 1927.⁸² All these conditions would have weakened patients and compromised their ability to perform work around the hospital, but they may have been given occupational therapy, an opportunity denied patients of the Asile de la Sarthe.

As indicated in the medical report of 1927, many patients at the Asile de la Sarthe suffered from physical conditions unrelated to their mental disorders. These conditions varied but included migraine; rheumatism; digestive problems such as diarrhoea and vomiting; respiratory conditions, such as tuberculosis, pneumonia, bronchitis, laryngitis and influenza; heart problems; and lumbago.⁸³ Tuberculosis, for example, was responsible for between 15% and 23% of female deaths between 1927 and 1931. The most common physical ailments, according to the chief medical officer, were “always” those involving the digestive tract.⁸⁴ In 1927, 214 men (or 74% of the male patient population) and 327 women (70% of the female patient population) suffered from one or more of these complaints. 282 (36% of the total patient population) patients required some sort of surgery, such as a setting a fractured bone, tooth extraction or treating an abscess.⁸⁵ These conditions indicate the poor general health of patients which would have prevented many from working, either inside the asylum or outside it. In some cases, physical and mental conditions were linked, such as in the case of circulatory problems leading to the onset of senile dementia, as highlighted by the chief medical officer in 1937.⁸⁶ Circulatory problems were particularly prevalent amongst female patients, accounting for 19% of female deaths in 1931 and 27% in 1937. Again, these conditions would have compromised a patient’s ability to work.

Patient Age

Age, as well as mental and physical health, also influenced whether patients were ascribed work. Age was particularly relevant in the provincial asylums where a significant proportion of incurable patients remained for long periods, often for life, and whose ongoing presence limited the admission of younger patients. The numbers of young men aged under 35 years (and therefore of working age) being admitted to the Littlemore fell from 18 in 1923 to 12 in 1925.⁸⁷ Dr. Good attributed the decrease in admissions of the under-35 s in part to the successful early treatment of younger patients at the outpatient clinic.⁸⁸ The numbers of young people being admitted to the Littlemore continued to fall, leading Good to observe in 1935 that younger people tended to present themselves to the outpatient clinic more readily than the middle-aged.⁸⁹ The treatment received in the outpatients clinic helped to prevent patients’ needing to be admitted to hospital. This was a positive for both the local authority budget and the individual, but it also meant that the average age of inpatients increased, and the numbers of capable workers decreased.

In 1924, the average age on admission was 49 for men and 47 for women, but already resident in the hospital at that time were 59 males and 112 females over the age of 60 years.⁹⁰ In 1926, 10 male and 26 female admissions were over 60 years; the average age of the male residents was 68 and that of the females 75 years.⁹¹ In 1927, 40% of patient deaths were attributed to “senile decay”.⁹² The elderly, in Dr. Good’s view, should be looked after in Public Assistance Institutions or Infirmaries, and the intellectually impaired should be sent to specialist institutions, where they could receive appropriate care.⁹³ The Board of Control noted in 1933 that 163 (or 28.6% of the total hospital population chargeable to the Oxford City and Oxford County local authorities) of the Littlemore’s patients were over 60.⁹⁴ By 1936, 191 patients were over 65 years, most of whom were suffering from “gross organic disease”.⁹⁵ The same year, eight patients aged over 75 years were admitted, few of whom required “the skilled nursing and medical care of an up-to-date mental hospital”.⁹⁶ During 1937, another 17 men and 26 women over 65 were admitted, comprising 23% of admissions.⁹⁷ While these patients were unlikely to be able to perform useful work, they may have benefited from occupational therapy provided by the nurses on the wards.

A high proportion of elderly, particularly female, former workhouse inmates could be explained in part by the government’s policy of encouraging the employment of younger workers in British enterprises, exposing many older people to unemployment and poverty.⁹⁸ Employers’ reluctance to employ women over 55 on account of their alleged poor health led to older women being particularly vulnerable to pauperism. Many women gave up work early to care for elderly relatives and afterwards found themselves unable to re-join the labour market.⁹⁹ For these destitute older people, the only option during the interwar period was the workhouse until 1929, and thereafter Public Assistance Institutions.¹⁰⁰ If the latter were overcrowded, or if the older inmates were mentally disordered, they might be transferred to the local mental hospital. In the 1930s, the old were the largest group of inmates of Public Assistance Institutions.¹⁰¹

The profile of patients at the Asile de la Sarthe was also gradually ageing. Between 1921 and 1931, the proportion of male patients aged 35–44 years fell from 26% to 20%, while the proportion of males aged 55–65 years increased from 9% in 1921 to 17% in 1931. The proportion of women aged 55–64 increased from 20% in 1921 to 25% in 1931 and that of those aged 25–34 fell from 9% in 1921 to 3% in 1931. In 1937, 30% of male admissions, and 24% of female admissions, were over 65 years. Patients over 65 were unlikely to be expected to work, so this increasing age profile provides a plausible explanation for the decrease in the numbers of patient workers at the Asile de la Sarthe indicated in Table 8.4, above. The patient workforce was gradually contracting as older patients became too frail to work. The lack of movement in the patient population (that is, very few discharges as a result of cure or improvement) meant that new, potentially younger, patients were not being admitted in sufficient numbers to take the place of “retired” patients. The experience at the Asile de la Sarthe was therefore similar to that of the Littlemore in terms of the ageing patient profile and the diminishing numbers of patient workers. But at the Littlemore, less importance was attached to the financial contribution made by patient work. Although produce from the hospital farm continued to be evaluated, the precise numbers of working patients were no longer recorded and the priority in terms of patient occupation was on the provision of therapy.

The Hospital Environment and Facilities

Contributing to the overall experience of patients in institutions, as Jane Hamlett has demonstrated, were the hospital environment and facilities.¹⁰² Since the early days of moral treatment, the asylum environment itself had been considered curative. Surroundings aimed to be cheerful and comforting and the décor to reflect that of a middle-class family home.¹⁰³ An impressive building surrounded by ample grounds and views of the countryside were considered crucial to the healing process.¹⁰⁴ Opportunities for patients to spend time in the fresh air were emphasised in the late nineteenth and early twentieth centuries when open-air therapies were in vogue for a variety of conditions from mental illness to tuberculosis.¹⁰⁵ But by the 1920s, overcrowding, the necessity of building on some of the institutional land, and the neglect of essential building maintenance work during World War I had taken their toll on the older hospitals. Édouard Toulouse had campaigned for improvements to patient living conditions since the early 1900s and lamented the dilapidated state of Parisian asylums in 1918.¹⁰⁶

Overcrowding was an ongoing problem at the Asile de la Sarthe in Le Mans. Patient numbers had increased from 604 in 1919 to 899 in 1939, compromising the quality of life enjoyed by patients in terms of physical space, the enforced proximity of other patients, whose behaviour could be threatening or antisocial, and less attention from staff. The existence of an outpatients’ clinic, which meant patients could receive treatment without admission to hospital, explained the lack of overcrowding at the Littlemore, according to its medical superintendent, but there was no such facility at the Asile de la Sarthe.¹⁰⁷ The grounds at the Littlemore were extensive compared with the relatively cramped outdoor space at the Asile de la Sarthe, which was surrounded by Le Mans town, the river and railway line [see Fig. 2.3]. Bethlem’s move in 1930, from urban South London to purpose-built premises in the relatively rural suburb of Monks Orchard, Kent, gave patients far more indoor and outdoor space, including landscaped gardens and an orchard where patients could enjoy occupations outside. The Maudsley was also purpose-built, with verandas enabling patients to be in the fresh air whilst confined to bed. When it was built in 1867, the Asile Clinique had been designed for 300 male and 300 female patients, but twenty years after its opening, the patient population had reached 900.¹⁰⁸ The interwar years saw the population stabilise at around 1000 patients. The impressive buildings and grounds at Ste. Anne’s (in which the Asile Clinique and the Henri Rousselle Hospital were situated) were designed by the architect, Charles Auguste Questel according to Baron Haussman’s brief. The covered walkways, manicured lawns and elegant statues could not, however, compensate for overcrowded wards and malfunctioning baths.

At the Asile de la Sarthe, central heating and electric lighting were only installed in 1922 and 1923 respectively. Until 1924, when washbasins were provided in all sections, patients had to wash at the pump in the mornings.¹⁰⁹ Work to replace the existing “slopping out” buckets for the disposal of human waste with flushing water-closets began in 1929 and was completed in 1932.¹¹⁰ The new chief medical officer appointed in 1933, Dr. Schutzenberger, was very critical of facilities at the Asile de la Sarthe. He was particularly appalled by the level of overcrowding, which denied patients the regulated amounts of space or air cubage, and by the lack of baths.¹¹¹ This was not only problematic from the perspective of personal hygiene (an average of only 10 baths were taken per year per patient) but meant that agitated patients were missing out on hydrotherapy, which was considered a valuable means of soothing them.¹¹² The financial crisis of 1931 limited expenditure on building maintenance and repairs, and new works had had to be postponed.¹¹³ The asylum director remarked that “more than one project has had to be cancelled in these difficult circumstances”.¹¹⁴ Plans to extend the central heating system and modernise the kitchens (reportedly in a “dangerous” condition) were shelved. Nonetheless, the asylum director professed to be committed to making the hospital a more agreeable and happier place for the “pauvres déshérités” in their care. By 1937, patients were able to have weekly baths or showers, and the interiors had been repainted.¹¹⁵

Standards of living for patients appeared to be higher at the Littlemore Hospital. The patients’ quality of life, indicated by measures such as the decoration of the wards and communal spaces, a more varied diet and personalised clothing, gradually improved during the interwar period. Being allowed to stay up until 10 pm was an unusual (at most English mental hospitals patients retired at around 7.30 pm) and welcome privilege for patients.¹¹⁶ The Board of Control noted that since women inspectors had been permitted to conduct “statutory visits” to mental hospitals, more attention was paid to the clothing of female patients. “Greater variety in dress helps to lessen the monotony which is the bane of institutional life,” they maintained, “and is a step towards recovery when a patient can be induced to take some interest in her appearance”.¹¹⁷ Following pressure from the Board, “suitable” female patients at the Littlemore were able to choose the colour of the dresses made for them and to have “clothing marked for their own personal use”.¹¹⁸ The women’s underclothing had shocked one nurse who joined the staff in 1936; she described the “calico drawstring drawers” as very old fashioned.¹¹⁹ The underwear was modernised in 1937, and patients’ boots began to be fitted individually.¹²⁰ Dentures “for the better types of patient” and glasses for those with defective vision were provided from 1937.¹²¹ A fish fryer was installed in the kitchen in 1938 so that fish and chips could be served once a week; a measure that was “much appreciated” by both staff and patients.¹²²

All these factors—the décor of patients’ quarters, the facilities for personal hygiene, the quality of shoes and clothing, the numbers of patients occupying the same space, the provision of something as simple as a fish fryer—contributed to the patient’s experience of asylum life. They gave context to the time spent working, engaging with occupational therapy or receiving some other form of therapy, taking exercise, enjoying a recreational activity, or being left with nothing to do. The ability to buy small luxuries with money earned from work (in French institutions), or to enjoy a few hard-earned privileges, also contributed to the patient experience. This study has not been able to ascertain what patients thought about the occupations they were given, but the potential of some form of reward may have encouraged the unwilling, or provided a boost to a patient worker’s self-esteem. At the Asile de la Sarthe, an ability to work was one of the criteria for discharge, so this too may have encouraged patients to work. One patient, Jean S. wrote to the asylum director in 1919 asking for permission to work in the gardens as he believed that this might ultimately lead to his discharge [see Fig. 8.1].

Fig. 8.1

A letter dated 5 April 1919 from a patient to the asylum director of the Asile de la Sarthe requesting to work in the gardens, in the knowledge that work was a crucial step in his being allowed to leave the asylum. (© Arch. dép. Sarthe, 1 × 633)

Incentives to Work

In France, work around the hospital was incentivised with a nominal wage or “pécule” paid according to each day or half day worked. The legislation of 1839/57 stated that it was “the right” of pauper (but not private) patients to receive remuneration for their work.¹²³ In England, the Cobb Report of 1922 had recommended the monetary payment of English patients who worked, but this had not materialised.¹²⁴ Instead, patients were given an extra cup of tea with bread and butter or cheese, a custom that began in the nineteenth century. These additional workers’ rations were itemised in the “dietary” section of Bethlem and the Littlemore’s annual reports. In Victorian times, English patient workers had been rewarded with beer, but this practice had ended in the 1880s following growing awareness and concern over the harm to health and morals caused by alcohol.¹²⁵ Payment for work around the hospital (albeit just for food and drink in England), but not for occupational therapy, highlights the fact that this work was valuable to the hospital and may not have been perceived as beneficial to the patient by the patients themselves. Douglas Bennet’s distinction between the two forms of activity is useful here. He maintains that with work, “one is generally doing something for other people” while in occupational therapy “one is doing something for oneself”.¹²⁶ The aim of the arts and crafts activities that comprised occupational therapy (AOT) was to inspire creativity and to generate feelings of satisfaction and pride in the items created. These positive, self-enhancing emotions were considered curative. Patients were not paid for undergoing other forms of therapy such as shock treatments or hydrotherapy, so it seems logical that patients would not be paid for the arts and crafts aspects occupational therapy.

On the matter of patient choice, the Board of Control maintained in 1928 that employment had been restricted to “those patients whose readiness to work was spontaneous or needed only the urge of some small reward”.¹²⁷ The Board regarded occupational therapy as a means of occupying the many patients who had been considered “unemployable” provided that the tasks were appealing to the patient, suggesting a degree of choice.¹²⁸ A later remark that, “An idle patient ought to be regarded as a reproach to the hospital”, indicates an intolerance of idleness.¹²⁹ At the Ranchi asylum in British colonial India during the 1930s, patients were allowed to choose their occupation, as superintendent Dhunjibhoy was keen to point out, but they were not allowed to remain idle. Those who refused to work in the gardens or undertake domestic duties were given instruction in arts and crafts.¹³⁰ Nurses at the Littlemore hospital reported being very anxious to ensure that all patients were engaged in a task when the superintendent did his rounds; they got into trouble if patients were idle.¹³¹ Edward Mapother also expected his patients at the Maudsley to do some form of work as soon as they were capable. He maintained that “every effort has to be made to prevent loafing among patients capable of occupation” to prevent “the boredom and deterioration” that would result from remaining unoccupied.¹³²

A refusal to work to work at the Zwiefalten asylum in southern Germany incurred a loss of privileges and rewards during the nineteenth century, leading Thomas Mueller to question the allegedly ‘voluntary’ nature of patient work.¹³³ At the Hamburg-Langenhorn mental hospital during the Weimar period, the amount of food patients received depended on the work they did. Patients working in agriculture, the laundry and gardens, and as craftsmen, seamstresses or tailors were given more food than those engaged in mending clothes, housework or vegetable peeling.¹³⁴ This discrepancy was justified on the grounds of the energy requirements of patients engaged in certain activities, but the food allocation was also related to the perceived value of the patient’s work to the institution.¹³⁵ An ability to work became a matter of life and death for mentally ill or disabled patients in Germany under the national-socialist “T4 Euthanasia Programme”. Those who were unable to work were killed, while those whose work was perceived as valuable had a higher chance of survival.¹³⁶ These examples show that the boundaries between voluntary participation, incentivisation and coercion could be very fluid indeed.

Conclusion

This chapter has shown that although the treatment preferences of psychiatrists and the way certain institutions were managed held considerable sway over the nature of patient occupation, patient class, gender, physical and mental health, and age were also influential. The fact that it was considered inappropriate for the middle classes, and particularly middle-class women, to engage in any form of manual work, meant that middle-class patients had fewer options for keeping busy in France, where occupational therapy was not available. The arts and crafts activities that comprised the American style of occupational therapy (AOT) prescribed in English mental hospitals were well suited to the middle-class patient, particularly amongst the women, whose upbringing encouraged them to develop proficiency in arts and crafts as hobbies. When occupational therapy was eventually introduced at Bethlem, it proved extremely popular with the middle-class patients. That said, at the Maudsley, where a quarter of patients paid fees, there did not seem to be any discrepancy in the allocation of occupation between the classes. The Maudsley was run as a modern hospital, where issues of class were less relevant than at the very traditional Bethlem, where nineteenth-century values and the practices of a traditional asylum persisted. The rigid segregation of the sexes, characteristic of traditional asylums, was also less evident at the Maudsley, where there was even a female psychiatrist.¹³⁷

Whether a patient’s mental condition was at the acute stage, and perceived curable, or incurable was fundamental. Acute-stage patients were not given any form of work or occupation in French institutions (apart from the Henri Rousselle Hospital) as this continued to be perceived as inappropriate for all but the calm, chronic and incurable cases and convalescent patients. Most French acute-stage patients were treated with “bed-rest” and sedated. This might be followed by “aggressive biological treatment” prescribed by the more progressive psychiatrists, such as Henry Christy at the Asile de la Sarthe and the doctors at the Asile Clinique. Sedation of acute-stage patients was also the policy at Bethlem, which appeared slow to embrace new ideas. At the Maudsley, Henri Rousselle and Littlemore Hospitals, occupation was considered beneficial for acute-stage patients, after a short rest period. The precise nature of a patient’s condition (such as mania, melancholia, delirium or schizophrenia) was less influential than the stage of their illness, such as acute or chronic, and whether it was perceived as curable or incurable.

Poor physical health, that might prevent patients from working, was associated with the extremes of poverty found in Paris and the rural regions of Oxfordshire and La Sarthe. At the Asile Clinique, GPI (the result of tertiary syphilis) and alcoholism were common and debilitating problems, while tuberculosis and gastric diseases were characteristic of all three institutions. At the Maudsley and Bethlem Hospitals, where there was a higher proportion of middle-class and employed working-class individuals, patients were physically healthier and more likely to be able to undertake some form of occupation. The provincial institutions had a high, and increasing, proportion of elderly patients due to the long-term residency of incurable patients that limited the admission of younger, working-age patients. This resulted in the gradual contraction of the patient workforce of the Asile de la Sarthe and the Littlemore. At these provincial establishments, preparing patients for work outside the asylum was arguably less important than at the institutions for acute patients, because so few were likely to be discharged.¹³⁸ Whether curable patients gained useful work experience whilst in hospital is considered in the next chapter.