Infrastructure: Rules, Walls, Obstacles and Opportunities


This chapter discusses the organisational underpinning of the asylums during the war. The Board of Control oversaw the asylums but could neither enforce best practice nor prevent low standards. Local tiers of management ran the asylums day-to-day. Government, professionals and public influenced asylum management, but patients’ voices were barely audible or credible. The system prioritised obeying rules and stifled innovation. Twenty-four asylums (23,000 beds), one quarter of the total, were vacated for military purposes. Widespread negativity about mental disorders and their treatment discouraged expenditure on anything other than the cheapest custodial regimes. People who attempted to make improvements faced many hurdles.


Introduction
Lunatic asylum practice shifted, arguably for the worse, in the first decade of the twentieth century. Sir George Savage informed his fellow psychiatrists in 1912: Fifty years ago we were proud in thinking that we English were the great protectors of the insane. We introduced humane treatments and were content that the patients should be protected, while also society was safeguarded from injury. 1 In early 1914, the Lancet published a letter from psychiatrist Dr. Lionel Weatherly, concerned about declining rates of recovery in the asylums, and the problem of "large asylums for the insane, wherein individualism is so much lost and where, to a very large extent, patients are herded in large numbers together." 2 The asylums were submerged under countless pressures, partly stemming from the Lunacy Act 1890, and associated with long-term detention, overcrowding, and larger institutions having a diminished sense of community. 3 The Board of Control ("the Board"), the central government authority responsible for supervising and regulating the asylums, praised those which managed to preserve patients' individuality and make their lives meaningful, 4 but their praise suggests that high standards were noteworthy rather than universal. The Medico-Psychological Association (MPA, the asylum doctors' professional body, forerunner of the Royal College of Psychiatrists) discussed how to overcome the "grave defects" in British psychiatry. Its recommendations, made in July 1914, 5 vanished amid the turmoil when war broke out a few weeks later.
Outside the asylums, a shifting landscape of national political, social and economic change preceded the war. 6 The Labour Party was formed in 1900. Some movement towards social reform emerged under the Liberal government which came to power in 1905. A state old age pension was first paid in 1909, and the National Insurance Act 1911 created health and unemployment benefits for the workforce, although not for their dependents. The poverty of working-class people more generally, however, received little practical attention. Society was still largely divided by class and functioned in a duty bound, paternalistic, conservative, gender segregated and moralising way. New knowledge and ideas, such as about science, belief in God, the unconscious, the global village and gender, affected outlooks, social interactions and behaviours. 7 However, regarding the asylums, well entrenched older attitudes persisted. In the view of psychiatrist Bernard Hollander in 1912: It is difficult to get rid of antiquated notions on the subject of lunatics. The popular impression would seem to be that the insane are generally raving and desperate people, whose actions resemble those of beasts and whose language is that of Billingsgate; that consequently they ought to be deprived of their liberty and kept in specially built places of safety where they are protected from doing harm either to themselves or others. 8 Limited information passed between institution and community, creating a restricted and often unbalanced view of life inside, open to speculation by the general public and contributing to Hollander's "popular impression". The separate world of the asylums fitted with Erving Goffman's model of a "total institution", a place of residence and work where a large number of like-situated individuals, cut off from wider society for an appreciable period of time, together lead an enclosed and formally administered round of life. 9 The London County Council (LCC) managed nine lunatic asylums of the total institution pattern, altogether comprising about 19,000 patents and 3500 staff. 10 The LCC aimed to achieve a ratio of about 1 staff member to 10 patients during the day and 1-70 at night, in accordance with the Board's advice. Montagu Lomax, however, based on his wartime work as an asylum medical officer, regarded these ratios as insufficient to manage patients humanely 11 : they were scarcely enough to allow staff to know all the patients' names, let alone to develop therapeutic relationships.
The staffing situation deteriorated dramatically within weeks of the outbreak of war due to many male asylum workers volunteering or being called up as army reserves. 12 Whether any, let alone suitable, other staff could be obtained partly depended on competition with local industries which might pay better wages and have more desirable hours and conditions of employment. 13 Medical staff levels, already low because of a "shortage of qualified practitioners willing to enter this branch of their profession" worsened. 14 Reduced staffing, accompanied by financial constraints and problems obtaining supplies, risked prejudicing patient care. 15 The LCC had oversight of staffing and other aspects of its asylums, although it generally delegated implementation to each asylum's lay management, or "visiting", committee (VC). One of the LCC's proposals in 1914 to improve the lives of asylum patients was to provide cinematograph lantern appliances to screen films for them. 16 The course of events goes someway to demonstrating the bureaucracy and complexity of making constructive changes in the asylums. Pre-war, noting that public audiences were reported to panic more frequently at "picture theatres" than in other places of entertainment, the LCC pondered over the likelihood that low levels of lighting required to watch the films might make patients panic. 17 However, the asylum engineers and medical superintendents agreed that lights "sufficiently bright for attendants to see their patients" with the hall having as many exits as public picture theatres, would suffice. 18 The war halted implementation, but the plan re-emerged post-war. A few VCs regarded film-shows as a therapeutic form of recreation and supported their introduction, but others opposed the idea, reiterating the pre-war rhetoric that patients would panic in the dark. 19 Their argument disregarded the fact that, during the war, asylums were bound by the same rules for low-level indoor lighting as domestic households, and they ignored the evidence that patients did not panic more than the general public in the dark, during air raids or if fires broke out at night. 20 Post-war, Herbert Ellis, a VC member who was also a magistrate, declared that he did not want patients "more mad than they are. I hope they won't have cinemas. I think that is what drives many patients in." 21 As well as VC discussions influenced by personal opinions rather than evidence, other factors thwarted implementation, including the poor state of the economy and the Board's preoccupations about licences and legalities of film-shows more than their contribution to normalising patients' lives. 22 Rules, regulations and personal opinions influenced decision making, contributing to a mismatch between evidence, ideals of care and experiences of asylum patients who remained virtually voiceless. 23 Sometimes, the Board admitted, rules were too rigid, 24 and, inequitably, the patients and lowest tiers of staff, comprising the largest groups in the institution, had the least say in decisions and bore the brunt of the mismatch.
The introduction to this chapter sketches out some of the organisational challenges faced by the asylums in 1914, including: staffing difficulties; falling standards of care; bureaucratic and uninformed decision making; and the public keeping the asylums at arm's length. The rest of this chapter will explore in more depth aspects of asylum management which maintained the total institutions, exerted control over them and shaped the lives of patients and staff within them. The Lunacy Act was a fait accompli. Heavily legalistic and created with the needs of the general public rather than the patients in mind, it stipulated asylum rules which constrained practice in ways which some said made it unfit for purpose. In Kathleen Jones' view it was "out of date before it was passed." 25 The Act shaped the asylum organisational hierarchy, with the Board at the top and local tiers of lay management which coordinated the asylums day-to-day in association with senior asylum employees, particularly the medical superintendent. National and local government and professional organisations interacted with and influenced this hierarchy. As the war progressed, the asylums made compromises to meet military requirements, providing accommodation for both mentally and physically injured soldiers. These compromises revealed, and added to, the poor standards of care provided to civilian patients. Moving forward into the plans for post-war reconstruction, the government prioritised physical health over mental health. that his wife Mary petitioned for a judicial separation, raising suspicion that perhaps, vindictively, she tried to have him "put away". 27 Although wrongful confinement appeared rare, and as with James W, the decision could be overturned, when it occurred it frightened the public and jolted the authorities into considering ever more legalistic measures to avoid repetition. 28 Thus lawyers had played a major part in creating the Lunacy Act 1890, whereas asylum physicians with practical experience of treating insane people had little influence. 29 The outcome was an Act which prescribed everything in great detail with nothing left to chance or to professional discretion and provided little scope for future development. 30 It undermined the flexibility required for rehabilitation and compromised therapeutic interventions for patients. 31 It set penalties for infringements, 32 which fostered a risk-averse culture and created fears of punishment for staff and loss of reputation for the leadership. Mary Riggall, a patient, provided an example of the defensive, risk-averse stance in her memoir. She described how one woman was discharged then readmitted a week later after she hurled a knife at her family doctor. The medical superintendent told Riggall: "If people have to come back again as quickly as this, the doctors outside will say I don't know my job." 33 Some psychiatrists openly criticised the Act. Daniel Hack Tuke, a psychiatrist at the time it became law, commented that "the great evil of the Act was that it was red tapism from the beginning to the end". 34 Some red tape was undoubtedly necessary, but administrative minutiae and bureaucratic form filling could detract from caring for patients and inhibit innovation. Sir Frederick Needham, a senior member of the Board, also reflected on the Act which may have suited the public but hardly worked in the patient's best interest: let the public feel the inconvenience of this Act which they demanded and has been passed in obedience to this demand, and as soon as the public have sufficiently felt the inconvenience of the Act, which we always objected to, I think they will demand a public remedy. 35 Lionel Weatherly (Fig. 2.1), one of the most outspoken psychiatrists of his generation, regarded the Act as "obnoxious" and "To tinker with [it] is no use. It should be burnt on the rubbish fire of pernicious Acts." 36 Weatherly's book on lunacy law reform, A Plea for the Insane, was welcomed by his colleagues. 37 Tuke, Needham, Weatherly, Hollander and Lomax all challenged the value of the Act and its consequences for asylum practices and patient wellbeing. The Act prohibited public expenditure on out-patient clinics or on using asylums as hospitals for voluntary patients who required treatment for their early, mild, or "borderland" (uncertain) mental disturbance. 38 Thus, only people who had the means to pay privately could consult a psychiatrist in the early stages of their mental disorder, a clinically unreasonable situation. 39 Psychiatrists regarded the private-public divide as invidious. They wanted more flexible access to their services. They alleged that mentally disturbed people sought help from alternative, ill-trained and inexperienced practitioners, such as "psycho-therapeutists", hypnotists, faith healers, occult magnetic healers, quacks who made money from selling cheap medication, and physicians "who not infrequently recommend a sea voyage for an early suicidal melancholic, who returns to trouble them no more." 40 Hollander viewed delays caused by the Act's restrictions on early treatment as scandalous: "In no other form of disease is 'appropriate' treatment so tardily initiated and so difficult of attainment." 41 Drawing on his experience of continental clinics and private practice in London, he wrote that delaying treatment worsened outcomes, patients "becoming confirmed lunatics by neglect". 42 He wanted facilities for advice and early treatment for lower classes as well as the more wellto-do "which would do away with half of the difficulty we experience in treating the insane to-day." 43 Dr. Wolsely-Lewis of the Kent County Asylum, Barming Heath, argued that a less restrictive Act could prevent much suffering a wife who has a husband subject to attacks of recurrent insanity, with intervals of mental health, is obliged when the attacks are coming on and before the law can intervene to endure the misery of living with him as his wife, of seeing daily the evil influence he exercises on the home, and of watching his reason tottering to its fall -perhaps in constant dread for the safety of her children and herself; or, again, a husband whose wife suffers from recurrent attacks -finds his home and children neglected while he is away at work, well knowing from past experience what harm can be done before his wife again becomes certifiable. 44 The Board agreed with Wolsely-Lewis, commenting that "the medical side of insanity was to some extent sacrificed to the legal". 45 A certificate for admission was binding on an asylum to accept a patient, and without it, the asylum would turn a patient away. At one asylum: "A former patient came back in pouring rain and asked to be admitted, but had to be refused". 46 At another, the porter recognised a former patient when she arrived by taxi in a distressed state. He told the driver to take her to the police station and informed the medical superintendent about his action. 47 Under the Lunacy Act, "certifying" patients for admission usually fell to doctors who were general practitioners or workhouse medical officers who lacked specific expertise or post-graduate training in psychiatry, and to magistrates, more often associated with making judgments in criminal cases. Concurring with public concerns, the magistrate's role was to ensure that no one was unjustly deprived of their liberty. Delegating certification to non-psychiatrists aimed to prevent asylum doctors from admitting patients into their own institution which might provide them with personal or pecuniary advantage.
As a result, asylum doctors who had the specialist knowledge and experience of treating mental disorders were excluded from deciding who might be best placed in an asylum. The asylum admission process was closer to prison detention than an admission to a general hospital for a physical ailment, which was under the control of the patient and hospital doctor. Since asylum certification could be prolonged indefinitely, it could create more fear than a prison sentence of finite duration. Discharge from an asylum was also cumbersome. A medical officer and two VC members had to approve it for each patient. Coordinating this often delayed discharge, inadvertently increasing bed occupancy and overcrowding.
People certified under the Act and admitted to public asylums were designated by the doubly stigmatising term "pauper lunatic". The word "pauper" was associated with poverty and destitution and the demeaning epithet of "undeserving". It came to signify any financial dependence on the Board of Guardians ("the Guardians"), the locally elected body which oversaw welfare in its neighbourhood, payed for by local taxation. The Guardians had direct responsibility for social welfare, public health and the workhouse infirmaries which functioned as local general hospitals. For the asylums, the Lunacy Act delineated the Guardians' obligations: to fund the treatment of patients usually resident in their locality, and to delegate the asylum's management to the VC. 48 Typically, when an asylum sought funding from the Guardians to support a patient, the Guardians would assess the patient's finances to determine if they were able to make means-tested contributions to their care. Despite the contributions, the patient was still designated a pauper lunatic. This was raised by Labour Member of Parliament (MP) John Clynes in the House of Commons in 1910, on the grounds that the term pauper lunatic was misleading and offensive to their relatives. The Home Secretary disregarded the emotional distress, blamed the Lunacy Act, 49 and stated that relatives' contributions did not cover the full cost of the patient's stay, so patients were still dependent on the Guardians. 50 The combination of lunatic and pauper designations with "undeserving" implications, plus the need for a magistrate to oversee admission to an asylum, created a multiple whammy of indignity. It also contributed to deterring people from seeking psychiatric help until they, or their family, could cope no longer. 51 In the context of overcrowded asylums during the war, some leniency appeared in the way the Lunacy Act was interpreted, such as responding to requests from relatives of patients for the patient to be discharged into their care. Some of these requests, refused shortly before the war on the grounds that the patient remained too unwell, were suddenly agreed when the war began, despite no clinical improvement. Other patients, less helpfully, were discharged from asylums, still unwell, into the care of relatives who had previously been unable to manage them. 52 By interpreting some sections of the Lunacy Act more flexibly, asylum admissions could be limited to the most disturbed civilian patients, while those considered, dependent, harmless or senile were placed in workhouses. 53 Marriott Cooke, who may have had some conflict of interest as a Board member delegated to work with the War Office, stated that long-term workhouse placements suited many asylum patients: they worked well, became attached to the Master and Matron, and had social networks in the local community which would not have been feasible had they stayed in the asylum. An additional motivation was that placements in workhouse were cheaper than in asylums. Conveniently for the Board and the budgets, as Cooke reassured the social welfare reformer Beatrice Webb, former patients "need never be returned to the more expensive asylum accommodation". 54 Occasionally, contingency plans necessitated ignoring the Lunacy Act altogether, such as when considering how to manage the worst scenario, that of a German invasion into Essex: for Severalls asylum near Colchester, the Board and medical superintendent agreed that helpless and violent patients would remain in the asylum under the Red Cross flag and the remainder would "take their chance with other inhabitants" of the area, free to leave without formality. 55 The Lunacy Act stipulated the maximum amount that a VC could charge the Guardians for each patient: 14s (shillings; 70p) a week. This covered staff salaries and related expenses, some maintainance of the buildings and estate, and allowed for expenditure on consumables, such as food and clothing, at around the level of the poorest of urban households. 56 Asylum fees could only be raised above 14s if the proposal was first published in a local newspaper. 57 In the context of negative pubic perspectives and fear about mental disorder and its treatment which discouraged expenditure on anything other than the cheapest containment in asylums, the Guardians were reluctant to take steps which might make them unpopular with their electorate. 58 In Lomax' words, the "welfare of patients is pitted against the cost to the ratepayers". 59 With almost no inflation between 1890 until 1914, the 14s maximum was tolerable, but fear of exceeding it ensured that many VCs strived to minimise their expenditure. With wartime inflation, the asylums tried to remain within the 14s stipulated, despite having to increase staff salaries to cover the higher cost of living. 60 In mid-1915, the LCC was relieved to find that costs of care had risen slower than expected mainly due to economies in the asylums. It did not refer to the possibility that economies might be detrimental to patients, but warned that war time inflation would continue to rise and that asylums must comply with public retrenchment directives, 61 a tall-order for an already cash-strapped system. Financial constraints contributed to friction between VC members and medical superintendents who objected to being told to reduce standards which were "the result of many years of thought and experience" with the warning that "a lowering of standard does not necessarily lead to a saving". 62 Psychiatrist and pathologist Richard Gundry Rows berated the asylum authorities for their financial preoccupations. He expected that if mental disturbance was treated in the early stages (in line with provision for private patients) and that treatment was founded on science, the public would grumble less about expense, in the same way as they accepted rising costs of treating physical disorders. 63 Another psychiatrist, John Keay, then president of the MPA, put asylum expenditure into perspective: the war cost £6.8 million a day compared to £4.6 million annually for the entire UK asylum system. Keay argued that the country could afford better if it wished: prevention was preferable, for both mental disorder and war, but otherwise, like the war, care and treatment for mentally unwell people was a necessity. 64 As well as minimising expenditure, the asylums tried many ways to subsidise their budgets, with practices established pre-war including recycling, selling or otherwise putting surplus asylum material to good use. These practices continued during the war, but with austerity and material shortages, lower standards were permitted when considering what should be repaired, condemned or recreated. 65 The LCC enquired of their asylums how they economised, such as whether they cooked potatoes in their jackets, and how many garments nurses were allowed to send to the laundry. 66 Some measures showed ingenuity and skill: Colney Hatch, for example, installed tanks in the sculleries to collect grease for making soap, and Hanwell sold hundreds of empty jam tins for 2d (old pence; 1p) each. 67 Colney Hatch also advertised tar, a by-product from the asylum gas-works, at 6d (2½p) a gallon and invited tenders for tons of unwanted lead which had accumulated. 68 Lead was used in munitions manufacture, so was in demand, but it was also a constituent of paint.
Asylums required permission to use their own stocks of paint, but only for essential maintenance, such as repainting rust-prone, out-door iron emergency staircases ( Fig. 2.2). 69 Lunacy law in England and Wales contrasted with that in Scotland which permitted less legalistic approaches to treating mental disorders in publicly funded institutions, ideas which the Board and other psychiatrists were keen to follow. 70 One manifestation of Scottish innovation was the "psychiatric observation unit" established in 1887 at Glasgow's Barnhill Hospital, the local "poorhouse", by John Carswell, a psychiatrist committed to improving public health. 71 Similar units followed in Edinburgh and Dundee. Their wards ran under psychiatric leadership, in contrast to similarly named "observation wards" in England which were led by non-psychiatrically trained workhouse infirmary physicians, and although they aimed to provide initial assessment of mental disturbance, this was often cursory. Standards varied and at times were "disquieting." 72 The model of having psychiatrist-led units outside the asylums and associated with universities was also part of the scene in Germany and Austria and much admired by psychiatrists in England. Emil Kraepelin, a physician, led one of these, a university-funded, research and teaching focussed, psychiatric "clinic" in Munich which allowed admission of patients with early stages of mental disorders on their own volition without legal procedures. 73 Kraepelin's clinic admitted over 1500 patients a year for early treatment. 74 It comprised 120 in-patient beds and out-patient facilities. Wards were quiet and un-crowded with no more than 10 beds in each, contrasting with wards of 50 or more beds in many English asylums. It was well-staffed, with 16 doctors and 53 ward staff plus out-patient physicians, compared to an English asylum, typically with 4 doctors and around 120 ward staff for 1000 patients. 75 High staffing levels were inevitably costly, but with thorough medical assessment and active treatment many patients were discharged, although local long-stay asylums backed up clinics when that was not feasible. Overall, avoiding long-term admissions meant that the clinics were financially sound. Rows commented that Kraepelin's model would enable psychiatrists in England "to take a more honourable position amongst those engaged in the conflict with disease." 76 Psychiatrist Adolph Meyer in Baltimore was also an advocate of the clinic model. When Meyer addressed the seventeenth International Congress of Medicine in London in 1913. 77 he expressed hopefulness about the treatment of mental disorders, compared to the "pessimism and helplessness" of his English colleagues. 78 He recommended that clinics should be in hospitals familiar to local people, not in asylums. He noted the clinics' goals of "service to the patient rather than to an administrative system" and compared them to "wholesale handling" in asylums. 79 Placing psychiatrists in clinics alongside physicians and surgeons in major centres of clinical practice, teaching and research, could provide opportunities for better psychiatric training, help alleviate some of the professional isolation and acquired stigma of working in a typical rural asylum, and promote exchange of ideas across disciplines. Meyer attributed the slow rate of up-take of the clinic model in Britain to the moralising attitude of Anglo-Saxon communities, which aimed to regulate and remove, rather than to understand psychiatric conditions. 80 Although the observation wards in Scotland were superior to those in England, none of them provided the intensive assessment or treatment of their German counterparts. 81 A few German-style psychiatric clinics emerged in the USA, founded on the understanding that they were as necessary to psychiatry as to any other medical discipline. 82 In England, Hollander criticised the inhumanity associated with the lack of similar facilities: The want of such an establishment in every great urban centre in the country is an expression of passive cruelty and indifference which can only be described as a blot upon our much vaunted civilisation. 83 University teaching hospital psychiatric facilities were not alien to England, 84 but their value was debated, with particular concern that they might encourage neglect of incurable patients in asylums. 85 Teaching hospital facilities would be permitted under the Lunacy Act because these hospitals were funded from voluntary or charitable sources, rather than drawing on local authority public funds. By 1913, several London teaching hospitals had some sort of out-patient department, but still no in-patient facilities. 86 Frederick Mott, a dedicated physician and researcher in psychiatry who directed the LCC's Central Pathological Laboratory, proposed the first publicly run German-style psychiatric clinic in England after visiting Kraepelin's clinic in Munich. A gift of £30,000 to the LCC in 1907 by another psychiatrist, Henry Maudsley, kick-started the project, with Mott facilitating the protracted negotiations behind it. 87 Negotiating and building this new "Maudsley Hospital" took eight years. 88 Planned for civilian patients, it became a military mental hospital in which Mott took a significant lead, and only when no longer required for that purpose, in 1923, were its doors opened to its original target population.

The Board of Control, Asylum Leadership and Their Challenges
The Lunacy Act delegated oversight and regulation of the asylums to the Commissioners in Lunacy. This body was reformulated as the Board of Control by the Mental Deficiency Act 1913, but the leadership remained largely unchanged, maintaining stability and expertise, but hardly introducing new blood. The Mental Deficiency Act stipulated Board membership: salaried lawyers and doctors; unpaid lay-commissioners; at least two women, one paid and one unpaid; and at least one member able to undertake inquiries in Welsh. 89 The Board had no direct health-related ministerial-level oversight but was accountable to the Lord Chancellor for some legal matters, and to the Home Office for many other duties under the rubric of protecting the public and safeguarding rights and liberties of individuals. Within the asylums it worked with the medical superintendents, other senior asylum officers, and the VCs. The VCs were appointed annually 90 and consisted of well-meaning lay people of relatively high social standing in the local community but with little expertise in subjects on which they were expected to make decisions.
In addition to monitoring and regulating public lunacy and mental deficiency institutions, the Board directly managed the criminal lunatic asylums and oversaw many small private establishments which consumed a disproportionate amount of its time. Its lunacy, mental deficiency and criminal asylum roles developed separately, reflecting public understanding. The public regarded mentally deficient people as unfortunate and generally harmless, thus worthy of compassion and philanthropic co-operation with the statutory services. By contrast, according Kathleen Jones, "emotions aroused by the thought of mental illness were so painful that the whole subject tended to be blocked". The public offered little support for mentally disturbed people, for whom care was largely provided by statutory organisations and salaried workers. 91 One small charity, the Mental After Care Association (MACA), functioned mainly in the London area and aimed to assist people regain their confidence and independence after discharge from lunatic asylums. 92 As a further indication of the pecking order of sympathy, philanthropic support was more readily available to criminals on release from prison than pauper lunatic patients on discharge from asylums. 93 A time-consuming and prolonged dispute about a single patient greeted the Board at its first committee meeting in April 1914, just four months before the war: which institution, a workhouse infirmary or a lunatic asylum, should provide care for 80-year-old Ellen Q? The stalemate was attributed to an invalid Lunacy Act certificate. 94 Since a certificate was normally binding on an asylum to accept a patient, questioning its legality was a convenient way to allow the asylum to refuse to do so, but the deadlock allowed other more fundamental concerns to surface.
The Barnet Guardians approached the Board to intervene in the dispute between them and Napsbury's VC who refused to admit Ellen Q from their workhouse infirmary. Ellen's disturbed behaviour had necessitated the Guardians employing two nurses specifically to look after her over several months "at a cost of Two Guineas a week for salaries besides rations and other expenses." 95 From Napsbury's perspective, a shortage of female beds meant that "senile" women should not be admitted for care; vacant beds "were to be reserved for patients obviously requiring Asylum care and treatment," a recurrent theme in the twentieth century, of excluding older people on the assumption that they would not benefit from care and that younger people were automatically more deserving of expert attention. 96 The Board objected to this discriminatory stance, stating that Ellen's on-going disturbed behaviours meant that she required admission and should not be "deprived of such care merely on the score of age." 97 Napsbury's VC did not budge. 98 The Board expressed "grave dissatisfaction" 99 stating that the VC showed "a callousness and indifference to the welfare of the insane, which the Board cannot consider creditable to any lunacy authority." 100 Eventually Dr. Rotherham from the Board, and Dr. Rolleston, medical superintendent at Napsbury, jointly assessed Ellen, but we are not privileged to know their opinions: minutes at Napsbury and from the Board fell silent on the matter as the country moved into war. 101 Bed shortages, monetary concerns, rejection of older people from hospitals and asylums, and rigid but opposing perspectives of different players in the fragmented healthcare system were among the tension-creating issues looming large when war broke out.
Visiting committee minutes chiefly recorded practical problems of asylum management and attempts to solve them. Minutes at Colney Hatch demonstrated a range of wartime challenges, such as: providing for refugees, enemy aliens and military patients; managing staff sickness, vacancies, salaries and "war bonuses"; and dealing with infestations of rats, mice and beetles and an outbreak of typhoid fever. 102 Minutes which reported more problems and the actions taken to remedy them could be interpreted in several ways, including that those asylums had higher, rather than lower, standards. The VC's minutes rarely mentioned individual patients, except in the context of discharge or untoward incidents, although occasionally they recorded gifts from former patients, their relatives and staff, grateful for care and support given. Overall, however, since the management hierarchy assumed that asylum care was humane, good practice and kindnesses received little direct comment. Minutes also give insight into activities arranged for patients, and asylum practices such as arranging trial leave before discharge and providing a monetary allowance to assist the patient during it. The Lunacy Act recommended this leave plus the allowance, but VCs often overlooked it, even if the patient had no other means of support, reinforcing the impression that VCs cut corners on short-term expenditure, even if that might hamper recovery in the longer term. 103 The Board desired to solve problems in asylums and to ensure good standards, to promote innovation, staff education, research into mental disorders and more liberal lunacy legislation, but it only had authority to advise and lacked power to mandate change. 104 It relied on naming and shaming, suggestion, cajoling and using "informal tactics of persuasion". 105 It did not shy away from criticising medical superintendents and VCs. The Board, for example, pointed out that the medical superintendent at Colney Hatch needed to keep a close eye on ward safety and "impress upon the nurses the absolute necessity of refraining from anything in the nature of rough treatment", with the implication that rough treatment had occurred under his leadership. 106 The Board described another superintendent as "able and energetic in the discharge of his duties" but he needed to develop his asylum "on enlightened modern lines", 107 implying that he was behind the times. The Board could be precise and targeted, verging on harsh, with their criticism sometimes rejected hostilely by the recipient. 108 To help monitor asylums the Board undertook annual inspections of all the institutions in its charge. However, without formally defined or agreed concepts and criteria for standards of care, Board members judged quality against ideals and expectations inferred from the annual reports, and letters and circulars giving guidance, and from their own experience, including from previous inspections and discussions in their regular team meetings. The effect of subjective, non-standardised values for determining standards could be moderated when two inspectors worked together, but it was problematic when an inspector worked alone. Aware of this, pre-war, the Board delegated two people, usually a doctor and a lawyer to undertake inspections together, but, by 1915 staff shortages reduced this to one. 109 That a lawyer could undertake an inspection alone indicated the emphasis placed on law, rules and regulations, rather than the care and treatment provided and the patients' mental and physical wellbeing. Lawyers were confident that they could undertake the task, although it is hard to believe that they could advise on clinical matters, make judgements on patterns of illness or death statistics or judge conclusively that a patients' complaints were "evidently based on a delusional condition of mind" 110 so that they could justify ignoring them.
Asylum inspections were meant to be unannounced, to give a true understanding of practices within. However, a "mysterious telepathy" between asylums could provide a couple of hours warning during which time staff were stirred into action, getting patients up, sorting out bed covers, cleaning side rooms, tidying, and improving the visual impression to which the inspectors paid particular attention. A message from the porter's lodge, or a warning along a corridor of approaching senior people, or even an unexpected turn of the key in a locked ward door, could alert staff to their approach. 111 Inspections often lasted one or two days, providing ample time for further window-dressing. 112 Many Board members had previously worked as medical superintendents, so were likely to be aware of the mechanisms by which an asylum could demonstrate high standards during an inspection. If the Board challenged those practices it risked exposing past practices of its own elite membership. By not doing so, the Board contributed to perpetuating the inspection culture and its drawbacks which could undermine rather than enhance patients' wellbeing. Ultimately, a good rating mainly reassured the leadership and the public that all was well, fitting with Goffman's assertion that total institutions present themselves to the public as rational organisations designed "as effective machines for producing a few officially avowed and officially approved ends." 113 Beyond those endpoints, few questions were asked about asylum processes and outcomes.
Preoccupied with asylum safety and disasters which could generate adverse public opinion, the Board scrutinised management of dangerousness and risks of all sorts. 114 Inspectors might initiate a fire drill, 115 aware of the high fire risk with asylums typically having coal fires and gas lighting in wards with wooden floorboards shined with inflammable floor polish and where patients smoked. 116 In 1914, the Board was encouraging installation of central heating, electric lighting and electric fire alarms. 117 Later that year it added telephones and chemical fire extinguishers, both necessary in the event of bombing, with extinguishers essential in the event of a bomb destroying the water mains supplying the fire hydrants. 118 Asylums which lacked the new technologies devised their own fire and air raid warning systems: at Colney Hatch in the event of an air raid warning, the police informed the gate porter or the attendant manning the switchboard who informed the medical superintendent 119 ; at Hanwell, if the boiler house engine driver heard a local explosion, he sounded the hooter to summon attendants and workmen who were off duty. 120 Lomax described inspectors as hurried and blasé, ward staff as constrained and anxious, medical superintendents bored and indifferent, and lunatics composed and critical, realising that it was all staged. 121 Inspectors focussed largely on the fabric and facilities and what could be observed directly, and senior asylum staff generally accompanied them around the site. 122 This gave patients little chance to speak to inspectors in confidence. Officials who spoke with patients tended to accept their compliments but discount their criticisms, which they attributed to distorted judgement due to their mental disorder. This selectivity was illogical. It also meant that formal inspections were unlikely to detect abusive practices which left no visible bodily or documentary trace. In addition, quiet patients were interpreted as being well cared for, rather than intimidated into submissiveness. Although Lomax referred to the eminent psychiatrist Henry Maudsley using the term "asylummade lunatics", 123 there was little acknowledgement of the effects of institutionalisation on the behaviour and mental state of patients. That understanding developed several decades later, particularly from the work by Russell Barton in the UK and Erving Goffman in the USA. 124 As well as ignoring most criticisms by patients, the Board was intolerant of other negative comments, particularly from people of lower social or employment ranks. The Board received a report written by some temporary attendants during the war which mentioned harsh treatment of patients. In response, the Board justified cold-hearted practices and low standards as inevitable due to wartime constraints. 125 Attributing poor care to the war, passed the buck and alleviated pressure on the Board to attempt to advocate for the patients and remedy the situation. Abdicating responsibility was more comfortable psychologically than the uncertainty of having to deal creatively and effectively with substandard care. However, their responses were questionable ethically: physicianmembers of the Board would have been familiar with the medical ethics principle primum non nocere, first do no harm. Denying or hiding problems gave the outside world the impression that all was well. The leadership feared adverse publicity which might undermine the reputation of the asylums and their own status. When the press reported that food at Colney Hatch was "abominably cooked", and when Graylingwell Asylum appeared in the Times as "Graylingwell Hell", they responded with rebuttal rather than planning to investigate. 126 After the war, at the Cobb Inquiry, deeper probing into the standards of care and treatment provided in asylums revealed both evasiveness and ignorance of some of the leadership about the poor care they provided for patients. 127 As with other criticisms of the asylums by those of lower rank, when faced with Lomax's critique of wartime Prestwich Asylum, the Board maintained its usual tactic of downplaying the allegations. 128 This contrasted with the stance taken by Chief Medical Officer Sir George Newman, who acknowledged the variable asylum standards. Newman wrote that Prestwich was one of the least satisfactory asylums: buildings are antiquated, and the Medical Superintendent is not conspicuously efficient.…Dr Lomax saw the English asylum system at its worst, the normal defects of Prestwich being aggravated by shortage of staff and strict rationing of food….Broadly speaking it is true that our asylums are barracks rather than hospitals and the insane are treated more like prisoners than patients.
Newman attributed the difficulties to broader organisational factors prewar, including: the Lunacy Act; local funding without central government funding; penny-pinching VCs; and the Board being expected to undertake "police duties." He asserted that the issues Lomax raised were well known, an indictment of a government which failed to remedy them. He was pleased that Lomax's book "directed public attention to the defects of a system which has hitherto been taken on trust." 129 Another aspect of the Board's work concerned collating data, aimed to detect trends to help guide the asylums. Pre-war, asylum staff filled numerous registers and forms which the Board then examined, including about infectious diseases, suspicious deaths, suicides, disciplinary matters, finances, facilities and numbers of "escapes". 130 The Board's first annual report, for 1914, made information available concerning benchmarks, pitfalls to avoid and goals to emulate. The report included quantitative statistical tables and rich narratives of each asylum's inspection: strengths and weaknesses, innovation and stagnation, praise and criticism. Some asylums were good, others far from ideal, but overall, the Board described them as "creditable", even though, by the end of the year, the war had "affected the Asylums to a serious extent". 131 Unfortunately, the asylum narratives were omitted from the annual reports from 1915 until after the war due to staff and paper shortages. The Board also recognised the time-consuming nature of data collection and suspended much of it during the war. As with inspections undertaken by a lone nonmedical inspector, amid many other changes occurring simultaneously, it is unclear whether, or how much, these data and publishing cutbacks affected patients' wellbeing.
General histories of psychiatric services express divergent views about the Board, from Kathleen Jones' praise for their good work, to criticism, such as by Charles Webster, that under its "jealous eye…the system ossified." 132 Marriott Cooke, a member of the Board (and its chairman 1916-1918), 133 was cited as saying that it regarded itself as "the particular friends of the lunatics". 134 Sir Robert Armstrong-Jones, medical superintendent at Claybury until 1916 (knighted in 1917), concurred: It may be said without fear of contradiction or exaggeration, that the Board of Control are the best friends of the Insane, and it is to this Board that is due the credit for the high place that the treatment of the Insane is known to occupy in the mind of the informed public in this country. 135 Armstrong-Jones wrote this just after the Cobb Inquiry. He may have written it to counteract negative public opinion at that time, but it is difficult to justify his sentiments.

Special Care? Service Patients and Other Groups
In contrast to lack of public interest in the welfare of mentally disturbed civilian patients in the asylums, public concern and sympathy was aroused by distressing mental symptoms presenting in soldiers fighting in the front line early in the war. In February 1915, Captain Charles Myers of the Royal Army Medical Corps described three soldiers suffering from mental and physical disturbances but without physical injury. Their symptoms were attributed to shells bursting close to them, but curiously, despite the noise of the blast, their hearing was not disturbed. This observation contributed to Myers concluding that the condition resembled hysteria. The term "shell shock" was already used by the soldiers, and Myers adopted it in his report. 136 The War Office intended to treat men with this condition in the "mental section" of Netley Military Hospital near Southampton and, when faced with growing numbers, in the 2000 beds allocated for the purpose within the war hospitals. 137 The challenges of providing care and treatment for shell shocked soldiers also inform us about patients and practices in civilian asylums and public perceptions of them. The public, and some members of the medical profession, opposed mentally disturbed soldiers being treated as, or alongside, pauper lunatics whose care could be demeaning: it would be disrespectful to men whose mental distress was caused by fighting for king and country. Dr. White, "a lady member of the profession", protested in 1917 against nerve-stricken soldiers being sent to lunatic asylums, "worse prisons", she said, than Germany provided for prisoners of war. An anonymous report in the Journal of Mental Science expressed outrage at her criticisms, describing them as "unjustified…likely to make a very unfavourable impression on the minds of the public, and [they] are not creditable to any person who makes them." 138 Dr. White's colleagues dismissed her comments, appearing more concerned about adverse publicity. Shooting the messenger for exaggerating or making unjustifiable comparisons allowed the message to be rebutted, the public to be reassured by those with greater authority, and the reputation of the institutions to remain intact.
Many others wanted to prevent traumatised soldiers from entering the asylum system. Robert Cecil MP argued that soldiers with "nerve strain" should "not be placed under asylum administration or in charge of officials connected with lunacy", 139 indicating his lack of confidence in a system regarded as tainted with stigma. Cecil Harmsworth MP proposed a Mental Treatment Bill, to facilitate treatment of mentally disturbed soldiers outside the authority of the Lunacy Act, 140 but it was dropped when it became clear that the Army Act 1881 covered these contingencies. 141 The Army Act gave soldier lunatics the special status of "service" patients, unencumbered by certification or the pauper lunatic label. Some medical superintendents argued that all patients should have the same status, and some VCs responded with objections to any patient having the opprobrious label of pauper. 142 According to Marriott Cooke and Hubert Bond, members of the Board who wrote a government endorsed report on the war hospitals, the Board approved avoiding Lunacy Act certification for soldiers as it was "a boon and a solace to the men and their relatives". Alongside this, they promoted the cause of civilian asylum patients, noting long-term problems of negative public attitudes "to be recognised and reckoned with," and that the standards for soldiers should "be extended at the earliest practicable moment to the civilian population." 143 Military hospitals and dedicated shell shock beds in the war hospital were insufficient to treat large numbers of soldiers so some were transferred to civilian asylums. In these cases, the Ministry of Pensions (created to handle war pensions for former members of the armed forces and their dependants) would pay the asylum charge, rather than the Guardians. 144 It also paid 3s9d (18½p) a week over and above the usual asylum charge-a third more than the average for a pauper lunatic-plus half-acrown (12½p) to the individual patient for extra comforts, plus financial support when on trial leave and a war disability pension. These benefits emphasised the meagre provision for civilian patients. On the wards, the special privileges could create jealousy and resentment. 145 For the Treasury, the care package was seen as too lavish and it proposed that the service patient status should expire after one year, to which the Board responded: "Do they then become "paupers" through no fault of their own, indicating the short lived nature of the country's gratitude to them?" 146 An assumed hopeless outlook for lunatics, and qualms about asylums syphoning off public resources which could be spent more constructively on non-psychiatric health and welfare needs, coloured the decisions of those in power.
Within the asylums, particularly Colney Hatch, refugees, prisoners of war (PoWs), "undesirable" aliens under the Aliens Act 1905, and enemy aliens were treated alongside service and pauper patients. For the authorities, the different groups created administrative work as each had a different legal standing with time-consuming bureaucratic technicalities and financial implications. Financing refugees in asylums was relatively simple as they were directly chargeable to Whitehall's Local Government Board, thus imposing no additional expenditure on local authorities. 147 Regarding PoWs, Swiss officials inspected to check their well-being 148 and Colney Hatch's medical superintendent resented the amount of Home Office paperwork associated with monitoring them, the need to liaise with the police who inspected their belongings and interviewed them, and the time spent making plans to ensure their safe departure. 149 Sometimes staff were required to escort them to the port of embarkation or to another destination, creating further demands on the asylum. 150 A different set of rules regarding residency and finance applied to patients who fell under the Aliens Act 1905. Prompted by concern over mainly Jewish immigration from Eastern Europe, this Act was the first attempt to establish a system of immigration control. 151 Under it, if an immigrant became dependent on poor law relief, which included asylum admission, within 12 months of arriving in England, they could be deported as an "undesirable" alien. 152 This aimed to avoid cost to ratepayers. 153 Mayer L, a patient at Colney Hatch, was Jewish and from Jerusalem, then under rule by the Ottoman Empire. Just before war broke out, the Home Office decided not to deport him 154 ; the VC appealed, but the Home Office stuck to its decision stating that it would be inhumane to do so as he was unlikely to receive adequate treatment in Jerusalem. 155 Mayer L remained in Colney Hatch for two years, and was discharged to the Jews Temporary Shelter, funded by the Jewish community, to avoid him becoming dependent upon poor law relief. 156 After war broke out, as well as being undesirable aliens, people from Germany, Austria-Hungary or Turkey were also designated enemy aliens.

Creating Military Hospitals from Asylums
The War Office requisitioned asylums for billeting soldiers and treating military casualties, creating challenges for the whole asylum system. 157 In 1914, 300 men, 400 horses and "a park of guns" arrived at one Kent asylum and Severalls billeted 4000 troops. 158 The Board transferred newly built but unoccupied asylums, including Moss Side State Institution, Liverpool, and the Maudsley Hospital, to the War Office for treating mentally traumatised soldiers. 159 With the intention of freeing initially 2000 asylum beds for military use, 160 the 97 county and borough asylums were divided geographically into groups, to facilitate the transfer of patients to alternative asylums as locally as possible. Eventually 24 asylums were vacated, comprising over 23,000 beds, almost one quarter of the asylum total. 161 The Board complied with War Office requests half-heartedly, with occasional rhetoric but little more forceful advocacy on behalf of their civilian patients. 162 Many asylums had to make space for patients transferred from others which were vacated when the War Office requisitioned them. The Board authoritatively stated that 20 per cent overcrowding (i.e. 120 beds in the space usually allocated to 100) would not incur "serious detriment" to the health of civilian asylum patients. 163 Their reassurance was speculative, if not fraudulent, but with their foremost priority being to support the country during the crisis. 164 In mid-1916 Sir William Byles MP asked in the Commons about the degree of asylum overcrowding, receiving the official response that no further reduction in accommodation was proceeding or contemplated. 165 That plan did not hold.
The War Office was particularly keen to take over asylums which had their own railway sidings, useful for transporting wounded men, coal, stores and other essentials. Of the LCC asylums, the "Epsom cluster" of four, south-west of London, was linked by the Horton Light Railway to Ewell West main line station. It was an obvious location for a war hospital. The LCC negotiated with the Board about providing beds for injured soldiers, contingent upon the Board "giving definite assurance that they will not raise objection to the infraction of rules and regulations" particularly concerning overcrowding and omissions in routine paper-work. 166 Thus Horton Asylum became "The County of London War Hospital Epsom", mainly for soldiers with physical injuries, and the LCC was reassured that compromises were acceptable when providing for civilian patients in its other asylums.
The peace-time arrangement whereby asylums receiving out-of-county patients could demand a higher fee from the requesting authority, 167 ceased for transfers made when creating war hospitals. In theory, within the Epsom cluster, it should have been straight forward to empty one asylum by transferring patients to the others. In practice, many were transferred further afield, in open-top "motor char-a-bancs and by omnibuses." 168 Hanwell accepted 173 patients, using basements, halls and whatever other space could be found. 169 Colney Hatch took 300 patients who all arrived on one afternoon. 170 The influx of patients added to the worsening staff-to-patient ratios. 171 Decisions to transfer patients long distances, over 150 miles in some cases, were taken locally, a difficult task for the VCs, disapproved of by the Board, and resented by patients and their families. 172 However, where possible, asylums took account of people's personal circumstances before moving them: when James R was transferred from Cane Hill, a LCC asylum in Surrey, to Gateshead in County Durham, his brother requested his return so that he could visit him: the VC refused, on the grounds that no one had visited him since his admission 14 years previously. 173 Patients moved from their asylum lost their "home" and many familiar faces associated with it. The VC and medical superintendent usually remained at the vacated asylum, to equip the hospital, engage more staff and manage it under the direction of the War Office which also defrayed additional costs and provided "fully trained nurses". 174 Most asylum doctors and ward staff remained at their asylum, rather than accompany their mentally unwell patients elsewhere. 175 Ward staff retained their salaries, but were demoted: experienced nurses to probationer grade, and attendants to orderlies, reflecting the standards of their physical-disorder nursing skills. The War Office also agreed to make available additional surgical support for "serious operations", although routine surgical procedures and anaesthesia, as when pauper lunatics required comparable interventions, continued to be undertaken by the asylum medical officers based on their medical student training. 176 Many modifications, of various sorts, were made to convert asylums into war hospitals. Work undertaken improved the ward lighting and heating; introduced electricity (ostensibly for X-ray equipment); and provided more toilets and bathrooms and better internal décor. 177 This upgrading had the implication that mentally unwell civilian patients, and their staff, could cope with antiquated facilities but wounded soldiers and those tending them deserved better. Regarding asylum paraphernalia, "everything in the buildings which might be objectionably reminiscent of their normal purposes" had to go, such as padded rooms, blocks on windows to prevent escape, and the excessive number of doors locked with a key. Lunacy stigma might also taint soldiers in death: if they died in a war hospital they were to be buried with military funerals and "In no case should a soldier be buried in that part of a local cemetery which has been specially set apart for insane patients dying in the Asylum". 178 A rare glimpse of equality between asylums and war hospitals was indicated in the decision that labour-saving devices installed in war hospital kitchens and laundries would remain on site when the building reverted to civilian use. 179 Horton received mainly physically injured soldiers. Additional beds were required for those with mental disturbances. Napsbury Asylum, like Horton, had a dedicated railway siding so was favourable to the War Office. Napsbury also had 1500 civilian patients, with 1200 in its main building and 300 in a separate admissions unit. Initially, the War Office acquired the smaller building for mentally traumatised soldiers, its civilian occupants being transferred to the main asylum. 180 A high fence separated the new 300-bed Middlesex County War Hospital from the main asylum a few metres away, 181 protecting the sensibilities of the soldiers and their visitors from association with the pauper lunatics. The war hospital also provided a superior level of leisure facilities for the soldiers compared to the civilian patients: new purchases included 2 billiard tables with all accessories at a cost of £73, more than the annual salary of many asylum staff. 182 The rest of Napsbury was vacated to become a war hospital for physically injured soldiers in May 1916. 183 In line with the Board's guidance, Napsbury aimed to transfer its asylum patients as short a distance as possible. 184 However, many were transported 70 miles away to Severalls, with others scattered across at least 18 asylums, mainly in south east England. 185 Eighty civilian patients remained at Napsbury to work the 426 acre farm and gardens. 186 The Edgware Guardians queried this: surely if these patients were working, the Guardians need not pay for them? There was no flexibility when it came to these costs: the VC informed the Guardians that the standard fees covered all patients, whether usefully employed or not. 187 Almost half a million men received treatment in asylum war hospitals, more than one-sixth of the total number of those sick and wounded from all fronts, 188 including 38,000 with mental disturbances. 189 In April 1919, Napsbury still had over 1000 military patients, and VC minutes gave no clue as to when civilian patients might return. Staff were restless, still working wartime shifts, longer than their pre-war hours. 190 Contrary to promises earlier in the war, 191 the authorities planned to remove the kitchen and laundry labour-saving devices before the civilian patients returned, on the grounds that patients would otherwise be unable to take up their former roles, and because machinery would "reduce the useful work upon which patients can now be employed." 192 With a high turnover of civilian patients-admissions, discharges and deaths-in the intervening years, how many would actually return was unclear. Unrealistically, the authorities wanted to pick up where they had left off, bizarrely seeming to regard patients as a group whose insanity was so all-encompassing that it made them oblivious to the war and unaffected by the changes imposed on their lives.

Reconstruction
The Cabinet established a Reconstruction Committee in 1916 to plan for after the war. Demoralisation at home and devastation abroad made planning essential, for economic and social welfare recovery, and to convince people that things could get better. 193 The Committee sought advice from numerous statutory bodies, including the Board, but the Board was disturbed by its emphasis on physical health without mental health. The Committee's stress was probably due to competing priorities, with deep concern about maternal ill-health, high infant mortality and a declining birth-rate, and because between 40 and 60 per cent of recruits for the British Army were turned down as physically unfit for service. 194 Failing to mention mental health, however, suggested that the Committee did not appreciate the incapacitating nature of severe mental disorders, whether suffered by soldiers or civilians. The Board did not reply to the circular until prompted by the Committee to do so. 195 The Board's reply respectfully stated that it hoped the Committee's expression "health of the population" included both mental and physical health and that the Committee agreed that they were equally important. It informed the Committee of the benefits of admitting mentally disturbed soldiers without certification to allow early treatment which could facilitate recovery and it reiterated the need for similar admission procedures for civilian patients, which had so far only been achieved to facilitate admission to the Maudsley Hospital when it could eventually open its doors to them. 196 Alongside seeking advice for post-war health priorities, the Reconstruction Committee was interested in plans to create a Ministry of Health, to improve and coordinate health care and public health more generally, which, according Walter Holland and Susie Stewart, were "something of a patchwork of ramshackle and uncoordinated services". 197 Public opinion also favoured the creation of the Ministry, which came into being postwar after "much political machination". 198 The Board feared that the new Ministry might remove its independence, but it also envisaged advantages of mental health being part of a comprehensive national health scheme, giving opportunities for prevention and treatment, and reducing stigma. 199 The Board had insightful ideas to improve services and to counteract damaging public opinion, but its ability to implement them was questionable.
For public opinion to benefit patients, the authorities had to take it seriously. Occasionally this happened. In 1917, the LCC noted that patients, their relatives and the wider public preferred the designation "hospital" over "asylum" and acknowledged their backing as "an important factor in the success or failure" of planning. LCC asylums thus became "mental hospitals". 200 A year later, other asylums followed. 201 For economy's sake, the Board insisted that supplies of old headed paper would have to be used before ordering new, and legal documents would retain the old designation until altered by law. 202 The law, by then almost 30 years old, was a stumbling block to fully implementing this change, as it was to allowing a more flexible system of admission.
Also linked to public opinion, the MPA was optimistic about the speed at which legal reform might materialise: public attention has been awakened by the mental cases resulting from the war, and that during the era of reconstruction that must inevitably follow when peace is finally declared….a more enlightened opinion may prevail which may lead to better provision being made for the treatment of certain types of mental disorder. 203 In 1920, however, the Board acknowledged its failure to achieve prompt amendment to the Lunacy Act to enable early and voluntary treatment and to establish psychiatric wards and out-patient clinics in general hospitals. The Board suggested other ways for VCs to fulfil their duty to ensure that patients received "treatment on modern lines". These included encouraging VCs to make postgraduate psychiatric training with paid study leave mandatory (a financial issue), and setting a maximum of 50 new patients to be under the care of a single medical officer (with both recruitment and financial implications). 204 These recommendations hardly reached the standard of Kraepelin's clinic established 15 years earlier, and the competing pressures meant that the reality of implementing them was far from certain.
In October 1918, with the expectation that the war was nearly over, the Board met with VCs from across the country. Much of their discussion consisted of reiterated, unimplemented ideas, such as: the need for more research; better public and staff education on mental disorders; administrative support for medical superintendents, as in general hospitals; standardised wages, terms of employment and hours of duty; and abolishing the stigmatising labels of pauper, lunatic and asylum. 205 Novel recommendations derived from wartime experiences were lacking. The Cabinet Committee on Post War Priority, and its successors, would help shape if, how and when the ideas could be taken forward. 206 Mental health had never been at the top of the national priority ladder and it seemed unlikely to reach that position soon, despite MPA optimism.
Lack of priority for asylum change was likely to have been associated with the fall in number of civilian patients during the war. Admissions fell from over 23,000 a year in 1914 to around 20-21,000 annually during the war. Lower admission rates were attributed to better population mental health linked to greater social cohesion and high employment rates, a notion which has some support from the international decline in suicide rates in countries directly involved in the conflict. 207 Alcohol related admissions also declined, associated with restricted licencing hours and reduced liquor consumption. 208 High asylum death rates also contributed (see Chapter 7), and doctors and magistrates may have interpreted the Lunacy Act more liberally, being reluctant to certify patients into overcrowded, understaffed and sub-standard facilities. Also, men who became mentally unwell while on military service were initially admitted to war hospitals, beyond the Board's statistical radar. 209 Optimistically, or perhaps naïvely, the Board did not envisage an more patients post-war, with the consequences that it took a laissez faire approach to seeking more resources in the reconstruction period. 210 Bedford Pierce, medical superintendent at the York Retreat and president of the MPA in 1919 wrote optimistically in the Journal of Mental Science: I cannot but think that the old days of autocratic management are over, and though some who think a beneficent autocracy is the best form of government may lament the change, we can nevertheless look forward without dismay to the new era of democratic control if the proletariat recognises its responsibility. 211 His political insights aligned with other social and political changes. From abroad came news of the Russian Revolution. 212 At home changes included the Representation of the People Act 1918, the Education Act 1918, the Ministry of Health Act 1919 and the Sex Disqualification (Removal) Act 1919. These changes had potential to expand social opportunities and wellbeing for people with the least voice, both inside and outside the asylums. On the other side of the coin, post-war, the government had to pay off an enormous national debt. Local authorities curbed spending in every direction and the Board only authorised capital expenditure for essential maintenance of the fabric of asylums or for "promoting the health of the patients and the staff." 213 "Geddes Axe", the outcome of Sir Eric Geddes' Committee on National Expenditure in 1922, further restricted public spending. Without public demand, despite being chronically underfunded, the asylums were "low-hanging fruit" whose fortunes were unlikely to improve. 214 Public support for mentally disturbed soldiers during the war dwindled, and provision for them gradually merged into the existing asylum system rather than leading to asylum reform. By 1922, 5000 soldiers resided in public asylums in England and Wales alongside the pauper lunatics. 215 The same year, the report of the War Office committee of enquiry into shell shock, made no recommendations about reform of civilian asylum law or practice. 216 A further eight years would elapse before the Mental Treatment Act 1930 which created a less legalistic approach to admission and discharge. Overall, the shell shock legacy added little to debate on post-war improvements for patients in civilian asylums and mental hospitals. Lomax's critique, the voice of a low status temporary member of staff whose views were typically discounted by the asylum leadership, ultimately proved more effective. 217

Conclusions
The process of creating the war hospitals and the military, political and public responses to shell shock indicated inadequacies of the asylums and the lunacy system, but did not directly trigger reform of asylum culture and practices. 218 The Board lacked authority to prevent low standards or enforce the best practices for which it and a few psychiatristreformers advocated. The tactics of persuasion allowed to the Board were insufficient to change a complex conservative culture where multiple stakeholders had divergent concerns, lay VCs were insufficiently trained to make the decisions expected of them, patients' voices were barely audible or credible and a moralising public was largely unsympathetic, including as ratepayers. The top-down hierarchical management structure meant that the Board obeyed, almost without question, the obligations placed on it by its task masters in central government and by the Lunacy Act, passed a quarter of a century earlier and criticised at the time by psychiatrists as unfit for purpose. The Board policed compliance with the Lunacy Act by its bureaucratic monitoring of all aspects of asylum practices. The importance of this legal role was demonstrated when lawyer Board members inspected asylums alone. Policing and legal compliance helped transmit an authoritarian culture into the asylums, which neither inspired nor encouraged lateral-thinking, creativity or innovation. A few chinks of flexibility appeared in the Lunacy Act, apparently without adverse consequences.
Occasionally the Board challenged its superiors, but it is debatable how much it could do this without threatening its own reputation as a compliant and effective body. Its position was particularly difficult when higher-ranked authorities, such as the Reconstruction Committee, lacked understanding of mental disorders and asylums. The hierarchical assumption within the asylum system that the most senior knew best, meant that criticism, especially from people lower in the hierarchy was explained away rather than evaluated. Despite rhetoric about tackling asylum problems, the top-down approach inhibited the leadership from engaging with lower ranks to understand what needed to be done.
In Peter Barham's view the Board was "squeezed between conflicting interests and visions of its objectives". 219 The Board and other leaders in the asylum hierarchy appeared satisfied to stick with what they knew best, which maintained the organisational status quo as far as possible. But as circumstances changed, the status quo was not necessarily fit for purpose.

Notes
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