Mental deficiency in 1868 was primarily defined as “idiocy”. According to John Langdon Down, this was not a scientific term, but a convenient term to include a class of maladies that differ essentially from insanity both as to their nature and treatment. He wrote that “the term idiocy covers such a large area, and includes a great variety of cases, that there is endless gradation in its manifestation, from slight departures from a normal condition, to the state of profound idiocy in which the unfortunate subject thereof sees nothing, feels nothing, does nothing and knows nothing”.
In practice, however, some distinction was made when assessing the degree of mental deficiency exhibited by a patient. The worst cases were classified as idiocy and those of a lesser degree as imbecility. 98 per cent of patients entering Normansfield were initially classified in one of these two categories in the Admission Registers. No contemporary definition of the boundaries of these classifications was found, but a later classification indicated idiocy to reflect an IQ in the range 0 to 20 with imbecility an IQ of 21 and over.
John Langdon Down describes, in some detail, the characteristics of someone with an ‘average’ condition. Generally, there are distinctive physical characteristics affecting posture and appearance. A weak circulation is common giving a susceptibility to low temperatures. Lungs are very liable to inflammatory attacks and prone to tubercular disease. Puberty is generally delayed and often sterility exists. Motor functions are abnormal, usually with defective co-ordination and a tendency to produce purely rhythmical and automatic movements. Often there is a diminished sensitivity to pain. Speech, sight and sense of smell may also be defective. Memory is frequently good, however, and there are often instances of remarkable powers in this respect. There is very little power of imagination or abstract thought, while judgement and reasoning powers are almost entirely absent.
John Langdon Down proposed that there were three important groups, based on when and how the idiocy became apparent:
- Congenital – pre natal causes and present from birth.
- Developmental – causes influencing the embryo during the intra-uterine stage but condition becoming evident after birth usually during dentition phase or at puberty.
- Accidental – caused by an illness or shock after birth and arising at any time up to puberty. The subjects may have “no appearance of idiocy in their faces or bodies, that, in fact, the prognosis is often inversely as the patient is winsome, fair to look upon and comely”.
It was believed that congenital cases, which would include all Mongol types, were the most responsive to treatment.
The basis of John Langdon Down’s philosophy was that treatment should consist of a judicious combination of medical, physical, moral and intellectual agencies.
“The patient should be removed from his solitary life and have the companionship of his peers. He should be surrounded by influences, both of art and nature calculated to make his life joyous, to arouse his observation and to quicken his power of thought”.
At Normansfield, the intent was to create a ‘domestic’ atmosphere. Patients were not accommodated in large wards, but in smaller bedroom groups. A nurse or attendant slept in each room with the patients and ate with them at mealtimes to help create a bond with those in their care.
It was believed the basis of all treatment should be ‘medical’ in an enlarged sense, success being only achievable if the patient was maintained in the best possible health. It is interesting that Dr Langdon Down does not stipulate or prescribe any specific medication whatsoever for the treatment of the mental condition. Presumably, it was accepted, however, that any illness or physical problem arising would be treated in the most appropriate manner in line with current medical practice.
Directions given for Treatment by John Langdon Down:
- Diet should be liberal and well-balanced and food should be served in a form suited to the masticary power of the patient.
- Rooms should be well-ventilated and kept warm.
- There should be daily baths with shampooing.
- Physical training is important – muscles need to be exercised to fulfil their functions.
- Automatic and rhythmic movements are to be replaced by others that are the product of will.
- The simplest movements are to be taught first, then the more complex to promote development.
- Moral education is of paramount importance. The patient has to be taught to subordinate his will to that of others.
- Obedience has to be learned and awareness engendered that right is productive of pleasure and that wrong is followed by deprivation thereof. Corporal punishment should be forbidden. Instead, the patient should be led to believe that deprival of the love of one’s teacher/nurse is the greatest punishment and its manifestation the greatest reward. (It was noted that the records for the period studied indicate that, in all those years, there was only one occasion when a patient was even restrained because of violent behaviour. In rare cases, where violent behaviour could not be controlled, the patient, as a last resort, would be certified and transferred to another institution).
- Intellectual training had to concentrate on the cultivation of the senses. Teaching should engender an appreciation of the qualities, form and relationship of objects by sense of touch. Similarly, the colour, size, number, shape and relation of objects needed to be understood by sight and their qualities by sense of smell. Lessons should be simple at first then becoming progressively more difficult. Nothing should be left to the imagination and teaching must be directed to the concrete, not the abstract. The aim should be to build up reasoning and reflective faculties.
- Simultaneously, improved physical ability should allow the teaching of dressing/undressing; inculcate habits of order and neatness; the use of cutlery, walking with precision; the handling of objects with care. Speech could be improved by a course of ‘tongue gymnastics’ followed by the cultivation of imitative powers.
The care and treatment of patients in Normansfield closely followed the foregoing recommendations.
Reports following regular visits by the Lunacy Commissioners at various times uring the period of study confirm aspects of care. The diet was considered to be very good and it was observed that nurses and attendants ate with the patients. It was reported that great importance was attached to neatness and personal hygiene and that patients were well-behaved. Patients appeared to be well-dressed, happy and in good health. The accommodation arrangements generally were “on a very superior order” and the establishment was adequately staffed for the care of patients.
There was a policy that all patients, able to do so, should be taken for walks beyond the grounds at least twice a week. The extensive grounds also provided opportunity for sports, exercise and recreation. Cricket, football and tennis were played by patients.
In 1877 a farm was established in the grounds. This not only led towards self-sufficiency, but also provided occupational opportunities for more able patients.
In 1879, a theatre was opened in the main building and this was used for a variety of entertainments and for Sunday services. To promote theatrical activity, there was an active policy to recruit care staff and teachers who had additional talents that could be harnessed for the entertainment and stimulation of the patients. There were frequent theatrical performances and, for a period, even a staff band.
In 1884 a boathouse was built providing opportunities for water-based activities on the River Thames.
In 1889 a drill hall was built to improve physical training.
Formal schoolwork was tailored to the ages and abilities of patients (see later section on teaching) and encompassed not only academic subjects, but also life skills.
John Langdon Down practiced what he preached! His sons, Reginald and Percival, continued in the same vein following their father’s death. It is perhaps somewhat surprising that Reginald readily embraced his father’s philosophies given that he was a prominent member of the Eugenics Society.
In his lifetime, John Langdon Down was recognised for his enlightened and progressive views on the treatment of mental deficiency and many of his peers came to visit Normansfield. His ideas, however, did not meet with universal agreement or approval. Even in the early 20th century there were still those who held the pessimistic ‘degeneration theory’ – this implied that the treatment of psychiatric illness was an unrealistic aim and that downhill progress was inevitable.