Madness: A Brief History (10 page)

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A mentally ill patient in a straitjacket attached to the wall and a strange barrel-shaped contraption around his legs. Many different modes of restraint had been tried; most were found counterproductive, triggering the ‘non-restraint’ movement; photograph after a wood-engraving, 1908.

An early champion of the asylum as a therapeutic engine was William Battie. Physician to London’s new 
St Luke’s Asylum and owner of a private asylum, Battie conceded in the 1750s that a fraction of the insane did indeed suffer from ‘original insanity’, which, like original sin, was incurable. Yet far more common was ‘consequential insanity’—i.e. insanity resulting from events—for which the prognosis was favourable. To maximize cures, argued Battie and his many followers, what was required was early diagnosis and confinement (before the condition grew confirmed), and then a regime tailored to the individual case. Blanket therapeutics, like the annual spring bloodletting meted out at Bethlem, were useless; surgical and mechanical techniques would avail little; and ‘medicine’ would accomplish far less than ‘management’, by which was meant close person-to-person contact designed to treat the specific delusions or delinquencies of the individual. Contradicting the therapeutic gloom which typified Bethlem, Battie instilled a new enlightened optimism: ‘madness is ... as manageable as many other distempers.’

The decades around 1800 brought surging faith in the efficacy of personal treatment in sheltered asylum environments. In England, such doctors as Thomas Arnold, Joseph Mason Cox, and Francis Willis (called in to treat George III in 1788) followed Battie’s watchword that ‘management did more than medicine’ and pioneered a ‘moral management’ through which the experienced therapist would outwit the deluded psyche of his patient. A visitor was impressed by the tone of Willis’s Lincolnshire madhouse:

all the surrounding ploughmen, gardeners, threshers, thatchers, and other labourers, attired in black coats, white waistcoats, black silk breeches and stockings, and the head of each
bien poudrée, frisée,
and
arrangée.
These were the doctor’s patients; and dress, neatness of person and exercise being the principal features of his admirable system, health and cheerfulness conjoined toward the recovery of every person attached to that most valuable asylum.

Summoned to treat his royal patient, Willis deployed a mix of psychological bullying, morale boosting, and fixing with the eye (to obtain dominance), all supplemented by such routine medication as blistering. George improved, to the nation’s relief, although today his recovery is attributed to the natural remission of the acute intermittent porphyria (an inherited metabolic disorder, causing chronic pain and delirium) from which it is believed the monarch was suffering.

Shortly afterwards, the York Retreat developed ‘moral therapy’, with its emphasis upon community life in a domestic environment designed to recondition behaviour. The York Asylum, a charitable institution, had become bemired in scandal. By way of a counterinitiative, the local Quaker community, led by a tea merchant, William Tuke, established an alternative, the Retreat, opened in 1796. It was modelled on the ideal of bourgeois family life, and restraint was minimized. Patients and staff lived, worked, and dined together in an environment where recovery was encouraged through praise and blame, rewards and punishment, the goal being the restoration of self-control. In his
Description of the Retreat
(1813), Tuke’s grandson Samuel noted that medical therapies had initially been tried there with little success; the Retreat had then abandoned ‘medical’ for ‘moral’ means, kindness, mildness, reason, and humanity, all within a family atmosphere— and with excellent results.

Comparable developments occurred elsewhere. In late-Enlightenment Florence, Dr Vicenzo Chiarugi (further discussed in Chapter 6) repudiated custodial-ism, medication, and restraint, and promoted therapies which treated the mad as human beings—‘it is a supreme moral duty and medical obligation to respect the insane individual as a person.’ Most highly publicized, however, were the reforms initiated at the Salpetriere and Bicetre Hospitals in Paris by Dr Philippe Pinel. Inspired by the Revolutionary ideals of liberty, equality, and fraternity, in 1793 Pinel figuratively (and perhaps literally) struck off the chains from his charges.

Pinel embraced the progressive thinking of the Enlightenment. If insanity was a mental disorder, it had to be relieved through mental approaches. Physical restraint was at best an irrelevance, at worst a lazy expedient and an irritant. Treatment must penetrate to the psyche.

During the Reign of Terror, a Parisian tailor challenged the execution of Louis XVI. Misconstruing a conversation he overheard, he then became convinced he was himself about to be guillotined. This delusion grew into a fixation necessitating his confinement. By way of psychotherapy, Pinel staged a complicated demonstration: three doctors, dressed up as magistrates, appeared before the tailor. Pretending to represent the revolutionary legislature, the panel pronounced his patriotism to be beyond reproach, ‘acquitting’ him of any misdeeds. The mock trial, Pinel noted, caused the man’s symptoms to disappear at once.

Moral reformers like the Tukes and Pinel viewed madness as a breakdown of internal, rational discipline on the part of the sufferer. Their moral and psychological faculties needed to be rekindled, so that external coercion could be supplanted by inner 
self-control. Psychiatry must reanimate reason or conscience. For this the closed environment of the asylum was tailor-made.

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Philippe Pin el (1745-1826) pioneered moral therapy in revolutionary Paris and supposedly struck off the chains from the lunatics at the Salpêtrière and Bicêtre asylums; engraving after Mme Mérimée, 1810.

These reformist ideals chimed with the socio-political optimism of the revolutionary era. Progressives wished to sweep away the relics of the
ancien régime
madhouse. As citadels of repression, mindless coercion, and hopeless confinement, benighted bastilles like Bethlem must be purged. A House of Commons committee heard that one patient there, James Norris, had been shockingly restrained for many years:

a stout iron ring was riveted round his neck, from which a short chain passed through a ring made to slide upwards and downwards on an upright massive iron bar, more than six feet high, inserted into the wall. Round his body a strong iron bar about two inches wide was riveted; on each side of the bar was a circular projection; which being fashioned to and enclosing each of his arms, pinioned them close to his sides.

Bethlem’s physician Thomas Monro lamely reassured the Committee that such gothic fetters were ‘fit only for the pauper lunatics: if a gentleman was put in irons he would not like it’. Tuke’s
Description
offered, by contrast, a shining model for reform. As with Pinel, moral therapy was justified in England on the twin grounds of humanity and efficacy.

The idealized asylum

Criticism thus led not to the abolition of the madhouse, but to its rebirth, and institutionalization was transformed from a hand-to-mouth expedient into a positive ideal. In France the reforms of Pinel and the new legal requirements of the Napoleonic Code were further codified in the key statute of 1838. This formally required each
departement
either to establish public asylums, or to ensure the provision of adequate facilities. It guarded against improper confinement by establishing rules for the certification of lunatics by medical officers—though for paupers a prefect’s signature remained sufficient. Prefects were also given powers to inspect. Similar legislation was passed in Belgium twelve years later.

A comparable reform programme was put through in England, despite opposition from vested medical interests. Scandals revealing the improper confinement of the
sane
had already led to the Madhouses Act of 1774. Under its provisions, private madhouses had to be licensed annually by magistrates; a maximum size for
each asylum was established; renewal of licences would depend upon satisfactory maintenance of admissions registers. Magistrates were empowered to carry out visitations (in London the inspecting body was a committee of the Royal College of Physicians). Most importantly, certification was instituted. Henceforth, although paupers could continue to be confined by magistrates, for all others a letter from a medical practitioner would be required to make confinement lawful.

Further reforms followed. The 1774 legislation was strengthened in a series of Acts passed from 1828, above all establishing the Commissioners in Lunacy, first for the metropolis and then for the whole country. The Commissioners constituted a permanent body of inspectors (made up of doctors and lawyers) empowered to prosecute unlawful practices and to deny renewal of licences. They also took it upon themselves to improve and standardize care and treatment. The Commission ensured eradication of the worst abuses, for example, by requiring that all cases of the use of restraint should be documented.

Safeguards against improper confinement were extended. Under an influential consolidating Act of 1890,
two
medical certificates were required for the detention of
all
patients. In the long run, these legalistic scruples may have proved a mixed blessing. For by insisting that only formally certified lunatics be detained in an asylum, it delayed its transformation into a more ‘open’ institution, easier of access and exit. Rather it was confirmed as a closed location of last resort, and certification became associated with protracted detention. The result was a failure to provide institutional care tailored for the temporarily or partially disturbed, and to isolate the asylum from the community.

Similar developments occurred in the United States, where the asylum arrived in the nineteenth century. The success of the York Retreat was the impulse behind the Frankford Asylum in Pennsylvania (1817), the Friends’ Asylum near Philadelphia (1817), the McClean Hospital in Boston (1818), the Bloomingdale Asylum in New York (1821), and the Hartford Retreat in Hartford, Connecticut, founded in 1824. Most early American asylums combined private (paying) and public (charity) patients. As in France, the early asylum era in America was spearheaded by physicians specializing in mental disorders, notably Samuel B. Woodward at the Worcester State Hospital and Pliny Earle of the Bloomingdale Asylum in New York, both of whom integrated medical and moral therapies in a climate of Pinelian therapeutic optimism. They were among the thirteen originators of the Association of Medical 
Superintendents of American Institutions for the Insane, established in 1844—it later became the American Psychiatric Association.

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Lunatic Asylum, New York. In the nineteenth century it became customary to build lunatic asylums in the countryside, since it was believed that natural surroundings had healing properties.

The asylum as panacea