Madness: A Brief History (9 page)

Insanity was basically, in those days and for long after, a domestic responsibility—it remained so in Japan till well into the twentieth century. The seriously disturbed were kept at home, whilst the harmless might be allowed to wander, though as evil spirits were thought to fly out of them to possess others, the deranged were feared and shunned.

In Christian Europe too, it was the family which was held responsible for the deeds of its mad members, just as with children; lunatics and ‘village idiots’ typically remained in domestic care—often enough, neglect or cruelty—hidden away in a cellar or caged in a pigpen, sometimes under a servant’s control. Or they were sent away, to wander the pathways and beg their crusts. Insanity was deeply shameful to a family, on account of its overtones of diabolical possession or of bad stock.

More formal segregation began to emerge towards the end of the Middle Ages, often inspired by the Christian duty of charity. Lunatics were sometimes locked in towers or dungeons under public auspices. In London the religious house of St Mary of Bethlehem, founded in 1247 and lastingly known as Bethlem (‘Bedlam’), was catering for lunatics by the late fourteenth century. By then, the Flemish village of Gheel, which housed the shrine of St Dymphna, had gained a reputation as a healing centre for the disturbed. Asylums were also founded at an early date under religious auspices in fifteenth-century Spain, in Valencia, Zaragoza, Seville, Valladolid, Toledo, and Barcelona (the Islamic hospitals in Spain may have been the model).

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This nineteenth-century print shows pilgrims receiving the Eucharist in the chapel of St Dymphna at Gheel. From medieval times, Gheel achieved fame as a healing shrine for the insane and mentally defective.

Religious impulses stimulated many later foundations too, including the asylums set up in eighteenth-century Liverpool, Manchester, Newcastle, and York. In 
Catholic nations, institutions were staffed by brothers and sisters of charity, and the custody and care of the insane remained in the hands of religious orders in many countries right through into the twentieth century. In some nations, denominational differences led to polarized religious asylums, as with rival schooling systems: as late as the last quarter of the nineteenth century, separate Calvinist and Catholic asylums were being set up even in the ‘modern’ Netherlands.

A great confinement?

The state and its protocols also played a part. Michel Foucault famously argued in the 1960s that the rise of absolutism, typified by Louis XIV’s France, inaugurated a Europe-wide ‘great confinement’ of the mad and poor, a movement of ‘blind repression’. Scandalous to law and order, all those ne’er-do-wells tainted by ‘unreason’ became targets for sequestration in a vast street-sweeping operation. Paupers, petty criminals, layabouts, streetwalkers, vagabonds, and above all beggars formed the bulk of this monstrous army of the unreasonable, but symbolically their leaders were the insane and the idiotic. Already by the 1660s some 6,000 such undesirables were confined in Paris’s Hôpital Général alone. Such hospitals were soon cloned in the French provinces, and Foucault drew attention to comparable institutions elsewhere which shut troublesome people away not as a
therapeutic
but essentially as a
police
measure, a custodial act of state, notably the
Zuchthäuser
in German cities and England’s workhouses and bridewells.

This ‘great confinement’, argued Foucault, amounted to more than physical sequestration, it also represented the debasement of madness itself. Hitherto, the mad had exercised a particular force and fascination, be it as a holy fool, witch, or as a man possessed. Halfwits and zanies had enjoyed the licence of free speech and the privilege of mocking their betters. Institutionalization, however, maintained Foucault, robbed madness of all such empowering features and reduced it to mere negation, an absence of humanity. Small wonder, he concluded, that madhouse inmates were likened to, and treated as, wild beasts in a cage: denied reason, that quintessential human attribute, what were they but brutes?

Though there is a certain plausibility in Foucault’s interpretation, it is simplistic and over-generalized. With the exception of France, the seventeenth century did not bring any spectacular surge in institutionalization—it certainly did not become the automatic solution. Different nations and jurisdictions acted dissimilarly. Absolutist France did indeed centralize its responses to ‘unreason’. From the Sun King’s reign, it became the charge of civic authorities to provide facilities for the mad poor (later, under the Napoleonic Code,
prefects
assumed these responsibilities). Families could have mad kin legally restrained upon obtaining a
lettre de cachet
from royal officials, such warrants effectively depriving the lunatic of all legal rights.

In Russia, by contrast, state-organized receptacles for the insane hardly appeared at all before 1850, those who were confined being generally kept in monasteries. And across great swathes of rural Europe, few were psychiatrically institutionalized. Two lunatic asylums still sufficed for the whole of Portugal at the close of the nineteenth century, holding no more than about 600 inmates.

Nor does advanced England square with Foucault’s ‘great confinement’, for state-led sequestration came late. Not until 1808 was an Act of Parliament passed even
permitting
the use of public funds for asylums, and not until 1845, and against those who denounced it as a waste of money or an infringement of freedom, was provision of such county asylums made mandatory. (At that date, there were still no asylums at all in Wales.) No more than around 5,000 people were held in 1800 in specialized lunatic asylums in a nation whose population was approaching ten millions—though there were perhaps as many lunatics again in workhouses, bridewells, and jails. There is little evidence that Parliament or the propertied classes saw ‘unreason’ as a dire threat.

In urbanized Europe, and in North America, the rise of the asylum is better seen not as an act of state but as a side effect of commercial and professional society. Growing surplus wealth encouraged the affluent to buy services—cultural, educational, medical—which once had been provided at home. Private madhouse keepers argued persuasively that seclusion was therapeutic. In England around 1800, the confined mad were largely housed in private asylums, operating for profit within the market economy in what was frankly termed the ‘trade in lunacy’. In 1850, more than half were still in private institutions.

The early history of such private asylums is obscure, for they prized secrecy: families would wish to avoid publicity and only from 1774 were they required even to be legally licensed in England. Such receptacles go back, however, to the seventeenth century. When George Trosse went mad in the 1650s (see Chapter 2), his friends carried him off to a physician in Glastonbury who boarded the mad. After the Restoration, 
newspapers began to carry advertisements for such ‘private houses’. By 1800, licensed private madhouses totalled around fifty.

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In a lunatic asylum, surrounded by a variety of other deranged individuals, a half-naked patient, his wrists chained, is restrained by orderlies. The print (1735) is an obvious echo of Hogarth’s
Rake’s Progress
series, indicating the popularity of scenes out of Bedlam.

Early asylums came in all shapes and sizes, some well and others atrociously run. In no country before 1800 was medical supervision a legal requirement, nor did medical overlordship automatically ensure good care. The medical ‘dynasty’ of the Monros at Bethlem—Dr James Monro was succeeded by his son John, who was succeeded by his son Thomas, who was then succeeded by his son Edward, mirroring the four Georges who ran the nation—did not prevent that institution from becoming hidebound and corrupt: quite the opposite in fact. Some of the best initiatives were lay-led, notably the York Retreat (discussed below), whose high repute proved a thorn in the side of the medical profession’s call for a medical monopoly. Nevertheless, a series of Acts passed from the 1820s required medical presence first in public and later in private asylums.

Some early madhouses were huge—several designed largely for paupers and army and navy casualties sprang up in the suburbs to the north-east of London, housing a couple of hundred patients each. Others were tiny: Dr Nathaniel Cotton’s at St Albans, the ‘Collegium Insano-rum’, housed no more than half a dozen in comfortable conditions. Charging up to five guineas a week—a year’s wages for a servant—Cotton obviously catered for a better class of lunatic. Established in 1792, Ticehurst House in Sussex also provided de luxe psychiatry for the rich. Patients brought their own personal servants; a select few were lodged in individual houses in the grounds; and gentlemen lunatics were allowed to follow the hounds.

Foucault claimed that the great confinement essentially involved the sequestration of the mad poor by supporters of the bourgeois work ethic, and in his
Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry
(1981) Klaus Doerner followed suit. But there is little trace of organized labour in early asylums—indeed, critics accused them of being dens of idleness. And enterprising madhouse proprietors naturally sought rich and genteel patients, who would not be expected to work.

It would thus be simplistic to cast the rise of institutional psychiatry in crudely functional or conspiratorial terms, as a new witch-hunt or a tool of social control designed to smooth the running of emergent industrial society. The asylum solution should be viewed less in terms of central policy than as the site of myriad negotiations of wants, rights, and responsibilities, between diverse parties in a mixed consumer economy with a burgeoning service sector. The confinement (and subsequent release) of a sufferer was commonly less a matter of official fiat than the product of complex bargaining between families, communities, local officials, magistrates, and the superintendents themselves. The initiative to confine might come from varied sources; asylums were used by families no less than by the state; and the law could serve many interests. Something similar to the complex negotiation of interests which underlay and drove institutionalization in Georgian and early Victorian England is now being revealed in studies of asylums in twentieth-century Africa and Latin America.

Asylums varied widely in quality. Reformers exposed many as abominations, riddled with corruption and cruelty, where whips and chains masqueraded as therapeutic; and, as Chapter 7 shows, a patient protest literature expressed these charges. Yet asylums could also be supportive. Deranged after several suicide attempts, the poet William Cowper spent eighteen months in Nathaniel Cotton’s St Albans asylum, just mentioned. His autobiography has nothing but praise for the care he received from a doctor ‘ever watchful and apprehensive for my welfare’, and he took one of the staff away with him to be his personal servant. The hundreds of pages of testimony given to the House of Commons Committee on Madhouses (1815) attest the merits of certain private houses, while baring the callous, grasping squalor of others.

Seedbed for psychiatry

The private madhouse served the ‘trade in lunacy’, but it also became a forcing-house for the development of psychiatry as an art and science. The asylum was not instituted for the practice of psychiatry; psychiatry rather was the practice developed to manage its inmates. Ideas about insanity remained abstract and theoretical before doctors and other proprietors gained extensive experience of handling the mad at close quarters in such houses. It had long been assumed that the mad were like wild beasts, requiring brutal taming, and stock therapies and drugs had been used time out of mind: physical restraint, bloodletting, purges, and vomits. Buoyed up by enlightened optimism, however, practical psychiatry was transformed through asylum experience, and the claim became standard that the well-designed, well-managed asylum was the machine to restore the insane to health. Experience and innovation became the watchwords.