Why was someone with dementia called a ‘lunatic’?

Many people are surprised and troubled to find that a person with a diagnosis of senile dementia was labelled a ‘lunatic’. But this was actually quite common.

lunatic census

The word lunatic had a legal meaning. Anyone who was admitted to a lunatic asylum was, by definition, a lunatic. And lunatic asylums were often the only institutions which were prepared to accommodate older people with dementia.

The word lunatic conjures up a horrific stereotype of a raving madperson: a term which stigmatises and dehumanises the mentally ill.* But like many such terms which now exist only as unacceptable insults, the word lunatic was widely used in the nineteenth century, as a general word for someone who was insane (another term which has disappeared from official language).

If a person was to be admitted to an asylum, they had to be legally certified as a ‘lunatic’. This certificate was filled in by a doctor, who had to record evidence that the person was really insane. He signed it, usually along with another doctor and a local magistrate. Without this certificate, properly completed, the patient could not be admitted to the asylum. This policy was strictly enforced. No one could be admitted to the asylum without being certified.

So, entering an asylum also involved being legally designated a ‘lunatic’.

This then begs the question: why was someone with ‘senile dementia’ admitted to an asylum?

There were no dementia care homes in the nineteenth century. We can assume that most people living with dementia never entered an institution. They were supported by their families, friends and communities. Unfortunately, without official documentation, it is very hard for us to find out anything about these people.

However, if someone had no family or friends to support them, or if the family didn’t have enough money, time or space to provide that support, then the asylum was one of the only places they could go.

Workhouses provided a certain amount of support for older people who were too poor, or too infirm to look after themselves. But for the most part, workhouse inmates slept on large wards. People who wandered at night, made noise in distress or confusion, or mistakenly got into other people’s beds, were seen as a disruptive presence.

There were also a small number of charitable homes for ‘the aged poor’, but they too were not prepared or able to look after people whose behaviour disrupted the smooth running of the institution.

The asylum was the only public institution which could, and would, take in people whose behaviour made them a disruptive presence elsewhere. In practical terms, this was the very definition of a ‘lunatic’. People with dementia were admitted to the asylum for the same reason as anyone else: their behaviour – usually that which make them a danger to themselves or others, or at the very least an extreme disruption to the lives of those around them – could not be managed by the people they were previously living with or near.

There’s a strong element of unexamined prejudice against mental illness in the shock reaction to people with dementia being labelled lunatics: lunatics are ‘crazy’, but people with dementia are just ‘old’ or ‘ill’. This is underpinned by a seemingly clear distinction in our own culture between ‘mental illness’ and ‘dementia’.

As I discussed in my last post, dementia was very much viewed as a form of insanity in the nineteenth century: a disease which could come on at any age, characterised by progressive mental disintegration, usually brought on by physical or mental exhaustion.

So people with senile dementia were considered to be lunatics 1). Because their condition was explained using the same language and theories as other forms of insanity and 2). Because, when they entered asylums because of their unmanageable behaviour, they had to be legally certified as such.

At the same time, the status of senile dementia as a form of insanity was by no means assured. As the asylums filled up, asylum doctors became more determined to limit the definition of insanity, and thus to limit the number of people entering the asylum. Older people suffering from dementia were particularly unappealing patients: they were seen as incurable, and were often suffering from physical ailments as well as mental ones. Asylum doctors started to argue that ‘the senile’ should be excluded from the asylum because they were not truly insane, but suffering ‘simply from decay of nature‘ (even the cause of a patients disruptive behaviour had never really been a factor in determining whether they were sent to the asylum).

In spite of these objections, there were no genuine attempts to provide more suitable alternative provision for older people with dementia. They continued to be sent to asylums, or remained warehoused on crumbling workhouse infirmary wards, until well into the twentieth century.

*That’s not to say it was a value neutral term: the derogatory and dehumanising usage was also very present in this period.

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The History of Senile Dementia: FAQ

If you watched Secrets from the Asylum on ITV1, you will have seen me chatting away to actress Claire Sweeney about her ancestor, John Sweeney.  He was admitted to Ballamona Asylum on the Isle of Man with a diagnosis of ‘senile dementia’ in 1902.  She was surprised to find out that old people with dementia were admitted to lunatic asylums, and so are many other people.

Over the next few days I’m going to be answering some of the questions I commonly get asked about dementia, old age and the asylum.

1.  How old is the term ‘senile dementia’?

The term senile dementia was first used in English in 1835, in a book called A Treatise on Insanity by doctor James Cowles Prichard.

Of course, this wasn’t the first time that someone recognised that people in old age sometimes showed signs of mental disorder and deterioration:  terms like dotage and fatuity had a long history, and were often used to describe mental decline in old age.

Prichard took the term ‘senile dementia’ – or démence sénile -  from French psychiatrists Phillipe Pinel and Jean-Étienne Esquirol.  For them, and for psychiatrists throughout the nineteenth century, ‘dementia’ was not just a disease of old age.  It was a form of insanity which was characterised by progressive cognitive impairment, which was usually incurable, and which could be brought on at any age by mental exhaustion or shock.

By the same token, senile dementia was not the only ‘senile’ diagnostic label used by British psychiatrists.  Senile mania, senile melancholia, senile epilepsy…pretty much any form of insanity could have the word ‘senile’ attached to it when the disease appeared in an older person.  However, as the nineteenth century wore on, the association between senility and dementia became increasingly tight.  By 1904 – the year John Sweeney died – senile dementia was the only officially recognised form of senile insanity in the UK.

At the same time, in Germany, a new disease category was being formed which would have a huge impact on the understanding of dementia.  In 1901, a German psychiatrist and neurologist called Alois Alzheimer met a patient, Auguste Deter, in an asylum in Frankfurt.  She was losing her memory, and was confused.  After she died in 1906, he examined her brain, finding lesions which he identified as neurofibrillary plaques and tangles – the pathological hallmarks of the disease which would later bear his name.  In 1910, the term ‘Alzheimer’s disease’ appeared for the first time.

In the mid-nineteenth century, the term ‘senile dementia’ was replaced with more precise and supposedly less stigmatising terms.  The term ‘senile dementia’, it was argued, suggested that all old people were potentially demented.  It reinforced the idea that dementia was caused by a general, irreversible, ‘natural’ process of ageing, rather than a disease.  Now, there have even been moves to replace the 250-year-old word ‘dementia’ with new terms:  major and mild neurocognitive disorders.

Coming up…How and where were older people cared for in Victorian England, when they needed looking after?  Why was senile dementia described as a form of lunacy?

 

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‘A ghastly absurdity’: The Senility of Dickens’ mother

Elizabeth Dickens (1789-1863) has been named as the primary inspiration for both Mrs Nickelby and Mrs Micawber, fixing her in the popular mind as a flighty and confused woman, with an unending devotion to her financially inept husband.  Dickens’ biographers have been similarly unforgiving, with some recognition of her good nature and cheerful manner.  Dickens (like most people?) had a complicated relationship with his mother.  They were close in some ways, yet it seems he could never forgive her for removing him from school to put him to work in a blacking factory during his youth.1

The adult Dickens financially supported his parents to a large extent, and this continued following Elizabeth’s widowhood in 1851.  Ten years later, when she was 71, it became clear to Dickens that his responsibilities towards his mother would have to extend beyond sending an occasional cheque:

When I got home last night, I found a note from the lady with whom my mother lives, who is terrified by the responsibility of her charge, and absolutely relinquishes it.

Dickens now had to find some new ‘good hands’ to take care of his mother, a task he felt ‘at great loss to settle’.2 A few months later, his brother Alfred died.  Financial responsibility for the widow and her five children fell to Charles, but with it came a solution to the problem of his mother.  Elizabeth was moved in with Helen Dickens, and Helen was paid to nurse and support her until her death.  This was to come only three years later, but in the intervening time, the elder Mrs Dickens was to prove a worrisome charge.  In August 1860, Dickens described his mother’s condition thus:

My mother…is in the strangest state of mind from senile decay: and the impossibility of getting her to understand what is the matter, combined with her desire to be got up in the stables like a female Hamlet, illuminates the dreary scene with a ghastly absurdity that is the chief relief I can find in it.3

 Dickens, now at the height of his fame, had friends in high places.  He engaged William Charles Hood, medical superintendent of the great Bethlehem Hospital (known in the popular imagination as ‘Bedlam’) to treat his mother, lamenting that she was ‘on the whole…rather worse than I had supposed her to be’.4  The doctor’s ministrations did not, apparently, make Elizabeth any easier to deal with, but Dickens did not wish to hear Helen’s complaints on the matter:

I really cannot bear…the strife she gets up in my mind about the whole business.  I was completely disgusted and worn out by her on this last occasion.5

In an earlier letter detailing his mother’s mental ailments, Dickens had concluded that ‘Life is a fight and must be fought out’.6  The end to Elizabeth Dickens’ fight came in September 1863, and was no surprise to Dickens, who felt that she had ‘long been in a terrible state of decay’.7

The case of Dickens’ mother gives me a small, but useful, insight into the management of old-age mental change in the upper echelons of society, something I am finding hard to get a sense of.  The desire to ‘keep it in the family’ prevailed, as was often the case with upper-class mental illnesses, especially at a time when the hereditary nature of insanity was just beginning to gain attention.  The solicitation of advice from Hood adds weight to my argument that ‘senility’ and ‘insanity’ were (<academic caveat> in some ways </academic caveat>) much more closely associated in the nineteenth century than they are today.

 I also see some resonance with the debate over the public responsibility for the ‘senile poor’ in nineteenth century London (probably because that’s what I’ve recently been writing about).  ‘Senile dements’ presented significant challenges for the institutions in which they often ended up – be they workhouses, infirmaries, or lunatic asylums.  The managers of these institutions made no secret of the problems of managing these cases, and clamoured to have them removed.  The ‘senile’ were passed – rhetorically and literally – from institution to institution, and they were only ever admitted begrudgingly.  Elizabeth Dickens’ behaviour clearly posed a huge challenge for those who provided her primary care, and yet the person who bore ultimate responsibility for her – her son – did not want to hear about these practical issues.  He did not want to bear the ‘strife’ it caused him.  Perhaps this is a little unfair to Dickens, whose relationship with his parents was coloured by years of disappointments and difficulties, and whose position as a successful Victorian man precluded him from expectations of taking on that caregiving role himself.  I really need more examples to see how this case fits into the wider picture of upper and middle class responses to the needs of mentally changing aged relatives.  Any leads appreciated!

All letter references are from Graham Storey, Margaret Brown and Kathleen Tillotson (eds.), The Letters of Charles Dickens (Oxford, 1997)

1Fred Kaplan and Norman and Jeanne MacKenzie are quite critical of Elizabeth Dickens’ character and abilities as a mother, and emphasise the coolness of Charles’ attitude towards her.  Peter Ackroyd’s more psychoanalytically inflected biography is rather more forgiving, and describes Dickens’ ‘hopeless love’ for his mother.  Claire Tomalin’s recent biography makes very little reference to Elizabeth.  Norman and Jeanne Mackenzie, Dickens:  A Life (Oxford, 1979), pp. 5, 8, 16, 211, 216, 325; Fred Kaplan, Dickens:  A biography (London, 1988), p. 104; Peter Ackroyd, Dickens (London, 1990), pp. 6-7

2CD to WHW, 28March 1860, vol. ix, p. 227

3CD to FD, 19 August 1860, vol. ix, p. 287

4CD to WCH, 21 June 1860, vol. ix, p. 266

5CD to GH, 24 January 1862, vol. x, p. 22

6 CD to FD, 19 August 1860, vol. ix, p. 287

7CD to EdlR, 13 September 1863, vol. x, p. 288

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“Simply from decay of nature”

“These patients are imbecile simply from decay of nature, and quiet in manners, and should, in the opinion of the committee, have been allowed to spend the little time left for them in the respective Workhouses, without compelling them to run the risk attending the journey to Caterham.”

- Report from the Committee for Caterham Asylum, sent to the Metropolitan Asylums District, 9th December 1871

This is taken from a report written by the Governors of Caterham Asylum in 1871.  Caterham had been opened a year earlier in an attempt to relieve the burden on the main county lunatic asylums by taking on some of the ‘incurable’ cases who were thought to be unsuitable for mainstream asylum care.  Its main purpose was supposedly to manage and train people diagnosed as ‘idiots’ (broadly, people who were thought unable to learn or process information properly, but who were not deluded or violent).

Training the inmates, producing useful members of society, and maintaining an orderly and efficient institution were the key aims of the Caterham governors.  They were, however, confounded by the number of elderly and infirm cases sent to them from workhouses across London.  Such people were not only unsuitable for training and education, but needed a level of care and attention which the asylum was not able (or prepared) to provide.

This was a problem in most, if not all, lunatic asylums, but Caterham was particularly vocal in its objections.  The quotation above is one example of the many passive-aggressive appeals made to the powers-that-be to admonish the individual Poor Law Unions who acted in this way.

Caterham administrative block, c.1914Caterham administrative block, c.1914.
© Peter Higginbotham

Often, objections were raised on the grounds of  the physical condition of the patients when they arrived at the asylum – clearly unfit for travel (quite an ordeal in mid-Victorian London, even across short distances) and so affected by the journey that they died shortly afterwards.  In this example, the dignity of the patient is also invoked, asking that they be allowed to “spend the little time left for them” in the Workhouse, without suffering the stigma of asylum admittance.  However, I cannot help but feel that these reasons were used by the asylum to make their argument more compelling, and that the heart of their objection is that they felt that these cases simply did not belong in their institution.

The problem was, of course, that such cases did not really belong anywhere.  As the nineteenth-century wore on, only the very toughest proponents of the doctrine of less eligibility (the idea that conditions for those receiving poor relief should be worse than the worst possible existence without poor relief) thought that those impoverished through old age belonged in the workhouse.

The governors of Caterham, like those in charge of most asylums at this time, felt that the aged did not belong in their institution because they were not really insane, they were not really ill, they were simply showing signs of the inevitable decay from advanced age.  Calls to remove the elderly from the asylum for this reason grew louder as the century wore on, and as asylum physicians were faced with increasingly crowded institutions which seemed far removed from the therapeutic ‘utopias’ they were originally conceived as.  One of the contentions of my thesis is that these practical considerations – the need for a manageable asylum population and the desire to show that they had the power to cure – played a role in changing medical conceptions of mental change in old age.

‘Senile insanity’, ‘senile dementia’, and a host of other old-age mental illnesses were described in books and articles about diseases of the mind, alongside other forms of insanity.  Such cases were sent to asylums by their families, and admitted to asylums by doctors.  Yet, as the consequences of public institutional care of ‘lunatics’ became apparent, the definition of what constituted ‘lunacy’ came to be more tightly defined.  These elderly cases were no longer suffering from ‘senile insanity’, an organic disease of the brain, but ‘simply from decay of nature’.

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Today’s tweet 5/4/11

“Senile insanity due to atrophy of the brain, or exaggerated dotage, is, I feel sure, far more common than it once was.”

This was said by the great Victorian psychiatrist James Crichton Browne in 1891, in an address to students of the medical school at Leeds. Unlike many similar comments which are made today, this was not spurred by concerns about the rising number of elderly people. In fact, Crichton Browne was worried about falling numbers of elderly people. He claimed that every age group in society was benefitting from the fall in mortality rates caused by improving sanitation and health, except[it] the oldest; the over-65s. A smaller proportion of people, he suggested, were reaching an advanced age than had done 50 years before.

Much like twenty-first century commentators, Crichton Browne thought that old age was increasing in length: but at the other end. ‘Premature senility’ (people ‘growing old’ at younger and younger chronological ages) was his primary concern. ‘Modern life’, in particular the life of affluent, successful, urban men, was commonly blamed by Victorians for almost any evil they encountered, and Crichton-Browne invoked it to explain his crisis of ageing. The ‘high pressure existence’ to which the urban population were subjected, he suggested, literally wore people out in both body and mind. ‘Social Darwinism’, the idea that only the fittest can and should survive in society, was very much in the air, and Crichton Browne did not like it: ‘the competitive dispensation under which we live’, he wrote, was present from earliest childhood, and it was thus in ‘the nursery’ that the eventual degeneration of the elderly mind began.

While this might seem like a very negative attitude, Crichton Browne was in fact attempting to counter the negativity which he felt this struggle for survival had engendered. If human activity was causing people to age too soon, then regulating this activity could preserve the body and mind far beyond current expectations. Like most of his contemporaries, Crichton-Browne believed that ‘it is in the autumn of life that wild oats ripen and come to fruition’. In other words, if someone lives a life of excess (in work and in pleasure) they can expect to suffer the consequences of that lifestyle in a decrepit old age – unless they have a handy portrait in the attic, of course. Moderation, variety and temperance (though not necessarily total abstention) were recommended by a wide variety of Victorian authorities, from the religious to the financial to the medical, as the keys to a long, healthy and happy life. This doctrine of self-control and self-determination, told that the individual could, through their own efforts, control their destiny, both in this life and the next.

In some cases this led to a surprisingly optimistic and upbeat portrayal of the ageing process. While great longevity is a cause of concern in the twenty-first century, 100 years ago it was thought that a trend of more people living longer would also see a great improvement in the health of the elderly, and was therefore nothing to fear. Crichton Browne insisted that it was realistic for the students he was lecturing to see their patients live to 100 healthy years, and that they should also accept nothing else for themselves. While this might seem naively optimistic, Crichton Browne himself lived in reasonably good health all the way until his death at 98. Maybe he was on to something after all….

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Today’s tweet 8/3/11

“On the 12th Sept she went for a walk. She went to the House of Lords and demanded admission.”

This is from the case notes of Mary Warren, a 66-year old former servant, who was admitted to Hanwell lunatic asylum on the outskirts of London in September 1891. She had been picked up by the local constabulary and taken to Fulham workhouse, where she was certified insane and sent to Hanwell. It was not the first time she had been committed. 11 years before, according to the niece who was called on to give an account of her, she had spent over three years in an asylum in Devon. Apparently the intervening decade was not passed in absolute health: “Although she was discharged recovered, the informant says she has always had strange delusions but was easily managed.” Those delusions included the belief that she was very wealthy, that she was only half her age, and that she had seen ghosts rise from the ground in front of the house of commons.

Asylum case notes are a wonderfully rich source, which has been mined extensively by historians trying to get close to ‘the patient’. Although the accounts are mediated by the doctors who recorded them, these records give us an opportunity to get detailed insights into the lives of individuals. Hanwell insisted on gathering, from family members or close friends, narratives on the patients’ lives up to then, and of their descent into illness. This did not mean that the families were automatically accorded respect as interpreters of the case: this doctor noted, “Informant is a silly simpering imbecile.”

The doctors at Hanwell diagnosed Mary with ‘senile dementia’. Their description of her condition contains many of the phrases common to cases of dementia, and which – though devoid of the tact and respect which we now rightly demand – are recognisable to us as elements of dementia: “Memory impaired. Is simple, childish, demented… Becomes very incoherent in prolonged conversation.” Yet other elements of her case do not seem so well to fit that brief, such as visions of people rising from the grave, and auditory hallucinations of “wonderful and difficult sayings by night and day”. She has spent many years experiencing phenomena which we would now consider akin to the symptoms of schizophrenia. So why were her doctors so sure that this was a case of “senile dementia”, something which we now associate primarily with memory loss and its consequences, and more importantly, with the organic changes in the aging brain?

I came across Mary Warren’s case very early on in my study of the history of old-age mental health, and it was one of the first things which alerted me to the fundamental differences between nineteenth and twentieth century conceptions of old-age mental illness. The nature of that difference is something I feel I am yet to have a satisfactory understanding of, although I have plenty of ideas. Maybe, as time goes on, I may feel confident enough in them to share them with you.

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Today’s tweet 10/3/11

“One has to just – I don’t know myself – I don’t know at all – oh goodness gracious, what is it all?”

This was spoken by a woman called Auguste D during an interview with a doctor at the Frankfurt lunatic asylum in 1901. They were recorded in her case notes, which still survive. The doctor’s name was Alois Alzheimer, and he was rather puzzled by Auguste’s case. She was presenting symptoms of memory loss and confusion, as well as agitation and delusions – her first symptom was reported to be irrational jealousy of her husband. He had seen such symptoms before, he thought, in cases of senile dementia, but not with such severity, nor in someone so young (Auguste was in her mid-50s).

When Auguste died, Alzheimer had already moved across the country to another job, but he sent for her brain so that he could dissect and analyse it. Using the latest microscopy and staining techniques he found, he thought, a new configuration of pathological lesions: “neurofibrillary plaques and tangles” were both present in Auguste’s brain and remain to this day the neuropathological hallmarks of the disease which was to bear his name. In 1910, just four years after Alzheimer had published the case of Auguste D, and when less than a dozen similar cases had been identified, the great psychiatric theorist Emil Kraepelin announced that a new disease had been discovered: Alzheimer’s disease.

There are many different ways to tell the story of the genesis of Alzheimer’s disease – the one recounted above is just one of them. Why I chose today’s quote was not so that I could get into the question of how Alzheimer’s disease came to be, but because I always find reading Auguste D’s case notes quite an emotional experience. As a historian of mental health, I think that the way that we understand and even experience mental illness is very much influenced by the context we are in. I have some sympathy with the idea that no one suffered from Alzheimer’s disease before 1910 because such a thing did not exist. However, when reading first-person narratives of mental illness, whether by someone living with mental illness or an observer, I sometimes come across things which seem so instantly familiar, which speak so directly to my own experiences with mental illness, that they seem to suggest eternal, universal forms of human suffering. I don’t think the two approaches are irreconcilable. We can be aware of how strongly the ideas which surround us shape our lives and our understandings of ourselves, while still allowing for the possibility that sometimes an experience or a story will reach across that historical language barrier. History, and perhaps the history of medicine in particular, has more than one job to do: the analytical task of showing how different categories and concepts came to be formed and accepted, but also a more humanistic task of connecting people with their ‘emotional ancestors’, and reminding them that, in their experiences of suffering and tragedy, they have never been alone.

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