Madness: A Brief History (11 page)

Throughout Europe, it was the nineteenth century which brought a skyrocketing in the number and scale of mental hospitals. In England, patient numbers climbed from perhaps 10,000 in 1800 to ten times that number in 1900. The jump in numbers was especially marked in new nation states. In Italy, no more than 8,000 had been confined as late as 1881; by 1907 that had soared to 40,000.

Such increases are not hard to explain. Positivistic, bureaucratic, utilitarian, and professional mentalities vested great faith in institutional solutions in general— indeed quite literally in bricks and mortar. Schools, workhouses, prisons, hospitals, and asylums—would these not contain and solve the social problems spawned by demographic change, urbanization, and industrialization?

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The Lincoln Asylum was partly private and partly charitable. It achieved fame as the institution in which non-restraint therapies were pioneered in the 1830s by Robert Gardiner Hill.

Keen attention was paid to fine-tuning the asylum and many innovations were pioneered. In England ‘non-restraint’ was introduced in the 1830s, by Robert 
Gardiner Hill at the Lincoln Asylum and independently John Conolly at the new Middlesex County Lunatic Asylum at Hanwell on London’s western outskirts. Taking moral therapy to its logical conclusion, Hill and Conolly renounced all forms of mechanical coercion whatsoever: not just irons and manacles but fabric cuffs and straitjackets too. These would be replaced by surveillance under ample trained attendants and a regime of labour, which would stimulate the mind and discipline the body. ‘In all cases of mental disorder’, wrote Conolly, ‘the regular life led by patients in asylums is to a great extent remedial.’ Hill demonstrated his impressive success at Lincoln, as shown in the table (p. 115).

Numbers spoke volumes, but Gardiner Hill also answered his critics:

But, it may be demanded, ‘What mode of treatment do you adopt, in place of restraint? How do you guard against accidents?’ In short, what is the substitute for coercion? The answer may be summed up in a few words, viz,—classification—vigilant and unceasing attendance by day and by night—kindness, occupation, and attention to health, cleanliness, and comfort, and the total absence of every description of other occupation of the attendant. This treatment in a properly constructed and suitable building, with a sufficient number of strong and active attendants always at their post, is 
best calculated to restore the patient; and all instruments of coercion and torture are rendered absolutely and in every case unnecessary.

 

Despite Pinel’s striking off of the chains, absolute non-restraint was seen by Continental reformers as a quixotically English
idée fixe,
a foible of doctrinaire liberalism, and it was little imitated. But French and German reformers made resourceful use of the asylum environment in their own ways. Work therapy was widely favoured. Planted in the countryside, the asylum typically became a self-sufficient colony, with its own farms, laundries, and workshops, partly for reasons of economy, partly to implement cures through labour. In France balneological treatments became a key feature of ‘asylum science’
(police intérieure).
In Germany, C. F. W. Roller spelt out detailed directives for such matters as non-slip, smell-proof flooring, good drains, apparel, diet, and exercise at the influential Illenau asylum in Baden, where music and movement therapies were also pioneered. Everywhere, the care and cure of the mad became the subjects of the new ‘science’ of asylum management, spread by professional organs such as the significantly named
Asylum Journal
.

Architecture was held of cardinal importance. Expert design had to ensure maximum security, ample ventilation, efficient drainage, and optimal visibility along the lines of Benthamite panopticism, though few asylums were actually built specifically according to Jeremy Bentham’s panopticon blueprint. Crucial was the classification of the different grades of lunatics: men had to be separated from women, incurables from curables, the violent from the harmless, the clean from the dirty; and
a ladder of progress established so that the improving could ascend towards discharge. Meticulous classification became the first commandment of asylum managers. And all these aims had to be achieved compatibly with order, economy, efficiency, and discipline.

Asylums had never lacked critics: Bedlam was long a byword for man’s inhumanity to man. A literature of patient protest gathered momentum in the eighteenth century, exposing brutality and neglect, and in the following century such campaigners as Louisa Lowe denounced ‘the bastilles of England’. Radical undercurrents within the medical profession itself moreover insisted that, with the best will in the world, asylums must prove counter-productive ‘manufactories of madness’: herded together, lunatics would be reduced to the lowest common denominator. For long advocates outnumbered adversaries, however, and the asylum movement was buoyed up on waves of optimism. In 1837 Dr W. A. F. Browne, a pupil of Esquirol and head of the Montrose Royal Lunatic Asylum in Scotland, pronounced on
What Asylums Were, Are, and Ought to Be.
Traditional institutions had been abominations; present ones were better, and the asylum of the future would be positively paradisiacal:

Conceive a spacious building resembling the palace of a peer, airy, and elevated, and elegant, surrounded by extensive and swelling grounds and gardens. The interior is fitted up with galleries, and workshops, and music-rooms. The sun and the air are allowed to enter at every window, the view of the shrubberies and fields, and groups of labourers, is unobstructed by shutters or bars; all is clean, quiet and attractive. The inmates all seem to be actuated by the common impulse of enjoyment, all are busy, and delighted by being so. The house and all around appears a hive of industry ... There is in this community no compulsion, no chains, no whips, no corporal chastisement, simply because these are proved to be less effectual means of carrying any point than persuasion, emulation, and the desire of obtaining gratification...

Such is a faithful picture of what may be seen in many institutions, and of what might be seen in all, were asylums conducted as they ought to be.

Many, like Browne, believed, or wanted to believe, that such institutions were entirely beneficent.

The asylum as problem

A new pessimism, however, made itself heard in the last third of the nineteenth century. Discharge figures showed that expectations that the asylum would become a panacea were grossly over-optimistic. Cure rates dipped as public asylums silted up with long-stay zombie-like patients.

To some extent, psychiatrists were victims of their own propaganda. They had insisted that many of the aberrant and antisocial behaviours traditionally labelled vice, sin, and crime were actually mental disorders in need of the doctor and the asylum. As a result, magistrates deflected difficult cases from the workhouse or jail, but superintendents then discovered to their dismay and cost that rehabilitation posed more problems than anticipated. Furthermore, the senile and the demented, along with epileptics, paralytics, sufferers from tertiary syphilis (GPI), and other degenerative neurological disorders were increasingly shepherded through the asylum gates. For all such conditions, the prognosis was gloomy, and the asylum became a dustbin for hopeless cases.

Psychiatry adapted in response. If ‘moral therapy’ did not work, did that not suggest that much insanity was, after all, chronic, indeed ingrained, constitutional, and probably hereditary? Investigation seemed to show that madness was passed down from generation to generation, that society harboured an ‘iceberg’ of atavistic degenerates and defectives. Confronted by these intractable problems, ‘degenerationist’ psychiatrists (discussed in Chapter 6) held there was little that could be done beyond shutting such threats away where they would at least be safe and prevented from breeding future generations of recidivists and imbeciles. The Irish inspectors of lunacy expressed this new pessimism as early as 1851, when they announced that ‘the uniform tendency of all asylums is to degenerate from their original object, that of being hospitals for the treatment of insanity, into domiciles for incurable lunatics’.

In this climate, public asylums grew larger—the average English specimen housed 116 patients in 1827 but nearly ten times as many in 1910, while Colney Hatch Asylum in north London held over 3,000—but degenerated into sites dominated by formal drills, financial stringency, and drug routines (like bromides and chloral hydrate) meant to pacify, sedate, and stupefy. In the USA there was a slide from the optimism of moral therapy to a preoccupation with security and sedation. Quality of care declined. Set up in the first half of the nineteenth century, the Pennsylvania Asylum initially promoted high levels of community and family involvement, underpinned by a curative ideology. By the last decades of the century, however, a more organic psychiatry had become dominant, justifying the habitual use of sedatives and marking a decline in personal therapy.

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This late Victorian photograph from Colney Hatch Asylum shows a woman suffering from mania, with forearm, hand, and finger movements. Such photographs were widely used for teaching and diagnostic purposes. Colney Hatch opened in North London in July 1851. Initially it held 1,250 patients, but by the time it was renamed as Friern Hospital in 1937, it had been enlarged and held 2,700. The hospital closed in the 1990s.

The institutionalization drive was a sign of the times. It combined the imperatives of the rational state with the expedients of a market economy, and ushered in a progressive therapeutic optimism under a pervasive paternalism—the idea that social and professional elites have the right and responsibility to treat unfortunates. Not least, the asylum idea reflected the long-term cultural shift from religion to scientific secularism. In traditional Christendom, it was the distinction between believers and heretics, saints and sinners, which had been crucial—that between the sane and the crazy had counted for little. This changed, and the great divide, since the ‘age of reason’, became that between the rational and the rest, demarcated and enforced at bottom by the asylum walls. The keys of St Peter had been replaced by the keys of psychiatry. The instituting of the asylum set up a cordon sanitaire delineating the ‘normal’ from the ‘mad’, which underlined the Otherhood of the insane and carved out a managerial milieu in which that alienness could be handled.

Canst thou not minister to a mind diseased?

(Macbeth)

Mechanizing madness

Modern times inherited varied models of madness. Within Christendom, abnormality, as we have seen, had commonly been diagnosed as supernatural, be it diabolical or divine. Renaissance humanism and scientific rationalism by contrast advanced naturalistic and medical concepts. The mechanical philosophy’s orderly law-governed universe discounted satanic possession, while mania and melancholy, insisted enlightened physicians, originated not in the skies but in the soma; the aetiology of insanity was organic.