MADNESS AND ASYLUMS

Peter Bartlett

INTRODUCTION

It may be best at the outset to tame some demons which haunt the popular understanding of madness and asylums of the past. This popular view is of a history infused with horrors. The eighteenth century was a period where the insane were chained in cellars, left in the dark to rot. The nineteenth century moved the insane into stone fortresses, institutions growing over the course of the century to contain upward of a thousand lost souls, concealed for life behind gothic walls, out of sight and out of mind. These nineteenth-century lunatics, hollering in their isolated cells, were tamed and drugged into submission in the first half of the twentieth century. In this semi-conscious and dazed state they were left to rock back and forth, tied to their chairs for their own protection, until released at the end of the twentieth century to wander aimlessly in the public streets when the combined miserliness of governments and naïve optimism of civil-rights extremists resulted in the closure of medical facilities without development of adequate community alternatives. Over this tale lies the specter of the medical man: the quack in the eighteenth century; the distant, callous, and ineffectual administrator of the nineteenth; the chemical controller of the early twentieth, invested with unchecked legal powers; and later the wronged hero, able to provide solutions if only given the legal authority and financial resources to do so. And throughout lies the question of the condition of the patients themselves: were they really mad, or merely difficult; is mental illness really about medicine, or about social control?

Like many popular myths, this one is not without its bases in fact, but it by no means tells the whole story. Certainly, the close and damp quarters in which eighteenth-century lunatics were chained did exist, but as Roy Porter has shown, the eighteenth century could also be characterized by new and optimistic medical treatment. The nineteenth century certainly saw the exponential growth of institutional care of the insane, but it was not usually confinement for life: roughly two-thirds of those admitted to English county asylums, for example, were released within two years. While contained in the asylum, the life of the patient might be regulated by a tight schedule, but relatively few patients were actually physically restrained for extended periods in padded cells or restrictive clothing. Nor was the schedule punitive. It might, for example, allow for a game of bowls on the lawn in the evening—quite a different image from the oppressive one offered in the popular myth. Certainly, the early twentieth century contained its share of drug treatments, but it also saw the rise of psychology and talking cures. And throughout the last four hundred years, institutional care has never replaced care by families and in the community more broadly. The perceived problems consequent on the release of persons with psychiatric difficulties at the end of the twentieth century are simply not new. Nor is the removal of people from psychiatric facilities into the community necessarily to be understood as a failure: while the perceived failures are visible, successes—and they are many—do not attract notice.

The perception at the end of the twentieth century is that the definition, care, and treatment of mental illness and those it affects are within the province of medicine. That is very much a late modern perspective. The colonization of madness by medicine has been a process spanning much of the last four hundred years, involving boundary disputes with law, politics, religion, and popular understanding. Even now, there are areas where the rout is not complete. In law, medical testimony will be relevant in determining insanity, but it is not necessarily conclusive; and among the public, studies continue to show that when confronted with a troubled person, the care of a friend or minister may be advised as often as a visit to a psychiatrist. The history of madness and the care of the insane is thus not necessarily simply a branch of the history of medicine.

The social and political influences on the development of understanding and care of the insane are complex. Psychiatry has been used for overtly political purposes, as in the confinement of dissidents in pre-revolutionary France and the twentieth-century Soviet Union, but such overtly political cases have never formed a statistically large portion of psychiatric patients. Persons with psychiatric or developmental disabilities have been subject to extremist political programs, as for example in the policies of eugenics most extremely articulated in the practices of Nazi Germany. The temptation is to marginalize these policies as a function of the specific German régime, but the prevalence of eugenic thought in much of Europe and North America for much of the first half of the twentieth century suggests that a much more nuanced approach to the relations between medical science, political thought, and social history is necessary.

Certainly, there can be little doubt that psychiatry has been used as a method of social control. One social response to deviant behavior has often been to understand the individual as mad; but to label this "social control" places a particular critical edge to the analysis. Frequently, the people concerned posed real social problems. It is all very well to refer to the confinement of a violent and delusional person, for example, as social control; that does not mean it is necessarily a bad thing. At the same time, the articulation of madness itself can be understood as influenced by social, political, and philosophical factors. The doctors who developed diagnostic criteria lived in specific cultural climates, and were influenced by contemporary events and theories. Thus when we read in the first part of the twentieth century of women's insanity being caused by "overambition," it seems difficult to divorce this from cultural attitudes toward women in the period.

There is of course a scientific story to be told, but other approaches are also important in the social history of madness and the care of the insane. Homosexuality provides a useful illustration here. Its history can be written from the perspective of the history of scientific medicine: there have been genetic, biochemical and psychological theories about its causes and incidence. That does not entirely explain the rise and fall of homosexuality as a mental disorder, however. Scientific inquiry into homosexuality did not cease when it ceased to be classified as a mental disorder, in the late twentieth century. The scientific investigation of homosexuality continues, suggesting the history of those inquiries has a life separate from the classification of diseases. It further seems that the science does not explain the chronology of medicalization as effectively as external factors. The placement of homosexuality in the medical model occurred in the late nineteenth century, when moral values of sexuality were being re-enforced. It is therefore not surprising that homosexual behavior was articulated in a framework of deviance. Similarly, its removal from medical taxonomy occurred during and after the sexual revolution of the 1960s and 1970s.

In the history of madness and the care of the insane, as in so much of social history, the history of

MOMENTS IN MADNESS: ASYLUMS IN TIME

1377:

Prior of the Order of St. Mary of Bethlehem (later called "Bethlem") caring for insane.

1409:

Valencia (Spain): Father Jofré opens an institution for the insane. By tradition, this is the first institution specifically designed for lunatics in continental Europe.

1656:

Foundation of hôpital-général of Paris. French provincial counterparts follow in 1676. Not curative facilities, but place of early institutional care of the insane among others.

1690:

John Locke publishes An Essay concerning Human Understanding. Places the ancient distinction between idiocy and lunacy on a philosophical ground. Idiocy is stated to be the inability to reason, and lunacy correct reasoning based on incorrect and deluded sensation.

1723:

Tsar Peter the Great decrees that institutions for lunatics should be built. Decree not acted upon, apart from one 25-bed unit founded in 1776.

1751:

Opening of St. Luke's Hospital (London), a charitable hospital for the care of the insane.

1764:

Foundation of French dépots de mendicité (workhouses). Another place of institutional care for the insane among others.

1796:

Founding of the York Retreat, and the beginning of moral treatment in England.

1798:

Establishment of the psychiatric service at Charité Hospital, Berlin, when the penitentiary where the insane had previously been held burned down.

1801:

Publication of Philippe Pinel's Traité médico-philosophique sur l'aliénation mental, ou la manie, where moral treatment first discussed.

1805:

Opening of the renovated asylum at Beyreuth, the first modern German institution for the insane.

1808:

First English/Welsh County Asylums Act passed. Allows construction of asylums at public expense, for the accommodation of the insane poor.

1809:

First major Russian mental hospital founded. Development of asylums in Russia slow. By 1910, only 438 psychiatrists in all tsarist domains.

1810

(approx): Monomania first identified by Esquirol.

1820s

(early): General paralysis of the insane, a manifestation of neurosyphilis, identified by Antoine-Laurent Bayle

1828:

English/Welsh Madhouses Act requires private madhouses to be licensed by justices of the peace. Creates inspectorate for London madhouses.

1834:

English/Welsh Poor Law Amendment Act passed. Creates professional bureaucracy that allows for efficient development of county asylum system.

1838:

Law of 30 June 1838 establishes national system of asylums in France.

1839:

John Conolly becomes medical superintendent of the Hanwell Asylum (London). Beginning of the nonrestraint movement.

1844:

Commencement of publication of the first German psychiatric journal, Allgemeine Zeitshrift für Psychiatrie

1845:

New English/Welsh County Asylums Act makes the provision of county asylums mandatory, creating the legal structure of a national framework. Inspectorate, the Lunacy Commission, given a national mandate.

1850s:

Identification of "circular insanity" (mania and depression) by Jean-Pierre Falret and Jules Baillarger. Renamed "manic depressive illness" by Emil Kraepelin in 1899.

1852:

Foundation of the Société Médico-Psychologique, the association of French doctors specializing in mental medicine

1857:

Rise of use of bromides as sedatives.

1877:

Beginning of statutory scheme of boarding out, an early form of community care, in Scotland.

1860:

Benedict-Augustin Morel publishes his taxonomy of mental disorders in Traité des maladies mentales. Insanity had long been thought to have hereditary characteristics, but Morel adds the theory of degeneration, that insanity gets worse in subsequent generations. In the twentieth century, when this argument intersects with genetic thought, the insane are perceived as a new sort of social danger.

1870s:

Jean-Martin Charcot redefines and rejuvenates concept of hysteria

1875:

Robert Lawson of the West Riding Asylum (Yorkshire, England) begins using morphine as sedative and hypnotic for psychiatric patients.

1878:

Benjamin Ball hired as first professor of mental medicine in France, at the University of Paris.

1885:

General Medical Council (United Kingdom) introduces specialist course in psychological medicine. No one takes the examination in the first year.

1886:

Viennese psychiatrist Richard von Krafft-Ebing publishes Psychopathia Sexualis. A variety of sexual behaviors enter the realm of psychiatric pathology.

1887:

Establishment of the Dromokaition on Corfu, by private subscription, to replace the 1838 facility inherited from British occupation of the island. This is the only specialized Greek psychiatric facility until the foundation of a clinic at the University of Athens in 1904.

1889:

Rimsky-Korsakov Institute founded; 1894, Kashenko completed, following public funding appeal. These are the first two significant psychiatric institutions in Moscow. The Bechterev, the prime psychiatric hospital in St. Petersburg, was not completed until 1908.

1893:

Emil Kraepelin publishes taxonomy of mental disorders. To the traditional categories, he adds dementia praecox, later renamed schizophrenia, a category further developed in the eighth (1907) edition of his textbook.

1913:

English/Welsh Mental Deficiency Act 1913 provides a framework for the institutionalization and community supervision of people considered "mental defectives." Parallel legislation introduced in Scotland the same year.

1920:

Rise of prolonged sleep therapy, popularized by Jakob Klaesi (Zurich).

1921:

Dispensaire system established in Union of Soviet Socialist Republics. Serves as administrative basis for the provision of good community care through the 1980s. By 1950s, handling only psychiatric cases. By 1957, 2,300 dispensaires contained in general health centers, and an additional 119 in free-standing centers.

1930:

English/Welsh Mental Treatment Act 1930 allows voluntary admission to madhouses and asylums. Previously, all persons had been legally detained. Parallel legislation introduced in Scotland.

1933:

First use of insulin coma therapy, Vienna.

1933:

Rise of Nazis in Germany. During the Nazi regime, more than 100,000 persons with mental health difficulties or developmental disabilities were killed in an organized program of "euthanasia," in gas chambers located in psychiatric facilities.

1934:

Ladislas von Meduna first induces convulsive shocks for treatment of psychiatric patients (Budapest).

1935:

First lobotomy performed at the Santa Marta Hospital, Lisbon, by neurologist Egas Moniz.

1938:

Ugo Cerletti (Rome) first uses electricity to induce convulsive shocks.

1943:

Penicillin used in the treatment of neurosyphilis. General paralysis of the insane disappears quickly from asylums.

1949:

Australian John Cade uses lithium on psychiatric patients. Introduced into Europe by Morgens Schou, a Danish psychiatrist, in 1952. Becomes treatment for mania.

1952:

Chlorpromazine in use on psychiatric patients as treatment for schizophrenia.

1954:

Inpatient psychiatric population peaks in England, at 148,000 (33.45 per 10,000 population). By 1981, inpatient rate drops to 15.5 per 10,000 population. By 1997–1998, inpatient beds total less than 46,000.

1955:

Tricyclics used on psychiatric patients by Roland Kuhn (Switzerland). Becomes treatment for depression.

1959:

English/Welsh Mental Health Act 1959. Major rewriting of legislation. Voluntary admissions become preferred, with confinement only to be a last resort.

1993:

Homosexuality removed from International Classification of Disorders, the international standard of mental disorders coordinated by the World Health Organisation. It had been removed in the American DSM classification almost twenty years earlier.

the ideas cannot be conflated with the history of their application. Stated objectives and descriptions may well be open to challenge by modern empirical research. This has been most controversial when unfortunate and often unforeseen consequences are perceived to challenge the benevolent intentions of historical figures, but the past can equally be seen in a more sympathetic light than perceived by its contemporary commentators. Thus cure for nineteenth-century medical men was something near at hand, but still in the future. The perception that their asylums were full of chronic and incurable cases was their perception, not a twentieth-century gloss. As noted above, late-twentieth-century scholarship instead shows modest success at cure, if that is understood as release from the asylum and return to the community. Twentieth-century scholarship thus shows the nineteenth-century asylum to be more successful than it took itself to be.

The difficulty in confusing the history of ideas with the history of their application is illustrated by the confinement of women. The received history portrays the asylum as a place where women were subject to particular control at the hands of patriarchal ideology. Certainly, the history of psychiatry reflects broader social notions of women and their sexuality, which was portrayed as unbridled passion requiring restraint. Thus the French hydrotherapist Alfred Béni-Barde at the turn of the twentieth century claimed that "the hybrid neuropathy that has seized [hysterics] does not require calming. These female patients must be tamed. That is why cold water succeeds" (quoted in Shorter, p. 125). The social control implications are obvious, but such statements nonetheless do not translate simply into psychiatric practice. Thus for much of the nineteenth century, the large English county asylums admitted women only marginally out of their proportion to the population as a whole. The significant imbalance in an English context arises only in the twentieth century, when at least in theory the ideological marginalization of women was past its peak. This does not of course mean that the ideological history is irrelevant. It does mean that it reflects only one part of the puzzle of how the care of the insane actually worked in practice.

Several points may be drawn from this. First, it is simplistic to portray the history of madness, psychiatry, and the care of the insane as "good ideas gone wrong," and it is misleading to perceive the cast of characters in those histories as composed of heroes and villains. Such an approach diverts attention from the more interesting and detailed analysis of how that history developed. Second, while some scholars have approached the histories with particular emphases (on social control, or on the history of medical science, for example), and while such specific foci may enlighten some points, the histories of madness, psychiatry, and care are multifaceted. A unitary focus risks missing the richness of the tapestry. Third, as political and social factors influenced the development of the histories, they are to be understood not merely according to factors which span international boundaries, but also as a result of their local circumstances. It would be uncontroversial to suggest that the histories developed differently in the twentieth-century Soviet Union than in western Europe, but this can be understood as an extreme example of a general point: Europe is not one culture, and one must therefore think of European histories of madness.

All of this raises its share of difficulties. The history of madness and the care of the insane is not one history: it is a profusion of histories. Since the 1980s there has been an explosion in the academic study of these histories, but the scope for research is yet more vast. In many of the specific histories, research has only just started, and much remains to be done. Here, even more than in other fields, social history is a work in progress.

CARING FOR THE MENTALLY ILL

Until the creation of universal state-funded health services after World War II, and to a considerable degree beyond, care received by the mentally ill has been a function of the individual's financial means. In general up to the early nineteenth century, and often beyond, specialized care of the insane, whether provided by doctor, cleric, or lay person, would be provided only if the patient or his or her family could afford to pay, and the standard of care would depend on what the payer could afford. For the truly well off, such care might involve the complete avoidance of formal institutionalization and the provision instead of one or more paid carers. As insanity and developmental disabilities have long been viewed as a matter of shame, such carers might be formally appointed to other positions in the household, or presented as companion of the individual. In families with leisure, the care might further be left in the hands of relations, sometimes brought in for the purpose. While a doctor's services might form a part of the overall package, day-to-day carers would not be likely to be particularly medically trained.

Alternatively, the well-off might remove the insane person to a private establishment. Such private madhouses have a long history, but became considerably more common through the eighteenth century. They remained a chosen place of care for those with money throughout the nineteenth century, and can be seen to survive in private mental hospitals catering to an exclusive clientele. The private madhouse sector catered to all classes who could afford to pay for care. At the high end of the scale, such as the Ticehurst Asylum in England, patrons might be admitted with their personal servants, and the day was filled with recreation befitting the social standing of the inhabitants. These institutions would not necessarily be controlled by doctors. Instead, particularly prior to the mid-nineteenth century, they might be run by either clerics or laity. From the eighteenth century until roughly World War I, spas provided a variation on such private care, particularly for nervous disorders. While it is difficult to see that care for mental disorder has ever been fashionable, it is certainly true that care in an eighteenth- or nineteenth-century spa imported an air of exclusivity and privilege.

For those without such means, care was not nearly so plush. For families with some means, less expensive private madhouses might be an option for at least the short term. These were not the elegant establishments of the upper class. Sometimes, they might involve simply a family prepared to care for a small number of individuals to boost their own income, but increasingly, these madhouses became businesses in their own right. While not deliberately punitive, the economics of business made them much more Spartan than the establishments of the rich, with fewer attendants and more patients per room. By the mid-nineteenth century, these institutions sometimes contained hundreds of inmates and charged competitive rates, in an institutional environment usually overseen by a doctor.

Nonetheless, the realities in a world before disability insurance was that for the bulk of working people, the requirement to pay for care in such a madhouse might tax the family resources to the breaking point, particularly when the insane individual was the primary breadwinner. Such families frequently found themselves, like the respectable poor, trying to care for them at home. As long as the insane person was sufficiently placid and at least one responsible person was able to remain in the home to supervise, this might be an option. When this was not the case, poor relief, the old social safety net, might intervene to provide a small supplement to the family income, or to fund a carer for the individual in the home if possible. Particularly if the individual were violent the poor relief authorities might be prepared to pay for some form of incarceration. In the nineteenth century, this might be in any of a variety of places: a private madhouse, a jail or similar institution, a poorhouse or workhouse in countries where those existed, or in one of a small number of specialized places for the care of lunatics, generally run by religious establishments.

In the first half of the nineteenth century, the institutional ground shifted, and in much of Europe, specialized asylum care became available for the poor. These new institutions developed in parallel to existing private madhouse provision, although their scale eventually dwarfed such private provision. In England at the beginning of the nineteenth century, for example, only a few thousand insane poor were confined. By the end of the century, numbers had grown to close to 100,000. In German-speaking Europe there were 202 public asylums by 1891, and in France 108. In Germany itself, the number of insane persons confined rocketed from one in 5,300 in 1852 to one in 500 in 1911.

It is this explosion of care that has consumed much of the social historians' interests. It did occur in much of Europe, including the United Kingdom, the Netherlands, Switzerland, France, Italy, Sweden, and parts of Germany. It was by no means universal, however. Moscow did not acquire a significant lunatic asylum until the last decade of the nineteenth century, for example, and as late as 1900, two asylums sufficed for all of Portugal. While one of the first specialized facilities for the insane had opened in Spain in the fifteenth century, large-scale asylum-building did not occur there until the twentieth, and in Greece, the first three state-owned institutions were not founded until between 1912 and 1916.

For those nations where the move to institutional solutions did occur, the reasons for this explosion of care are a matter of hot scholarly debate. Andrew Scull places the rise of the asylum in the context of changing economic circumstances in the move toward capitalism. The move from cottage industries to factory work meant that fewer family members worked at home, and fewer could therefore combine work with the care of an insane family member. Further, the downward pressure on wages in the industrial economy made it more difficult to feed an unproductive member of the family. This argument has much to recommend it. Certainly, the case studies of patient records in nineteenth-century asylums would suggest that admissions occurred when a family could no longer cope with the insane person at home, or if the insane person had first been moved to a poor-law facility, when he or she became too unruly or violent to remain in that environment. The bulk of those admitted were either violent or suicidal. Individual admissions were the result of practical problems.

As Scull also points out, the period was one where institutional solutions were in fashion more broadly. Specific eighteenth-century progenitors of the asylum can be identified. In England, charitable medical institutions for the insane underwent a modest spurt of growth from 1751, when St. Luke's Hospital was founded. Eighteenth-century facilities are however notable for their diversity. France certainly had medical establishments for lunatics, the Salpêtrière and the Bîcetre in Paris being the most famous, and these like the eighteenth-century English charitable facilities can be seen as ancestors of the high Victorian asylum: institutions created on a hospital model, with a doctor in charge. At the same time, French eighteenth-century institutional care of lunatics also occurred outside medical settings, in hôpitaux-général, dépôts de mendicité, and religious institutions. Notwithstanding the name, the hôpitaux-général were not curative institutions, and not under medical control. They were instead institutions founded in the third quarter of the seventeenth century for the confinement and control of French riffraff generally, but including the disorderly insane. In 1764, the dépôts were created as workhouses for the poor, but they, too, quickly expanded to include the care of the insane poor. As in much of Roman Catholic Europe, the church also provided care. By 1789, the Chaitains, the Brothers of Saint-Jean-de-Dieu, were operating seven institutions for the insane in France, and other religious orders also offered institutional care. These mixed models of care are reflected elsewhere in Europe. In Berlin, the insane were only moved to a hospital when their previous accommodation, the local penetentiary, burned down in 1798, and in Greece, the bulk of the insane seem to have been lodged in nonspecialized facilities for the poor well into the twentieth century. Even in England, where the asylum movement was strong, a quarter of the poor insane were lodged in poor-law workhouses throughout the nineteenth century.

The move to institutional solutions for social problems also occurs outside the realm of insanity. The growth of the asylum corresponds to the growth of the prison and the workhouse. The asylum may therefore be understood as reflecting a more general trend in the minds of policymakers. This is in turn consistent with the economic analysis. With the wealth flowing from industrialization, expensive institutions became an option in a way that was not previously possible in most of Europe. The broad policy move to institutional solutions may have affected the minds of the families involved as well. It may possibly have become more acceptable to send a family member to an institution as the period progressed.

The changing role of medical professionals also undoubtedly had its effect in the development of the asylum. The eighteenth century rejuvenated medical thinking, and by the beginning of the nineteenth century, doctors and others were, with a new enthusiasm, claiming that insanity could be cured. The new specialist band of alienists, as doctors specializing in mental disorders were then called, argued that the removal of the patient from family surroundings was essential for cure, and indeed that the asylum itself, as a place of order that would reorient the mad person back to their right self, had a curative effect. While such an approach was not the exclusive preserve of medical professionals, the image of the curative asylum enjoyed the support of the benevolent, but also the parsimonious, for while the asylum might be expensive in the short term, it promised the longer term removal of insane persons from poor rolls and their return to productive labour.

The movement toward institutional solutions must also be understood in the context of specific national histories: the rise of the asylum becomes possible when local infrastructures are sufficiently developed to make it a real possibility. Indeed, the administrative context of the asylum takes quite different forms depending on the nation involved. In the German states, for example, institutional provision appears to have been linked to universities. With roughly twenty universities, each vying for academic kudos, this was a viable possibility. In England, with Oxford and Cambridge the only universities prior to the opening of University College London in 1828, the university system would have been unable to support a network of asylums. Instead, the English poor law was reorganized in 1834 to include a professional cadre of administrators. While the foundation of the English county asylum system predates the so-called New Poor Law, it is only after 1834 that the asylum system, where admissions were administered by the poor-law authorities, begins to take hold and grow. In France, after a brief hiatus during the upheavals following the Revolution, the involvement of the church returned, and remained for much of the nineteenth century. Not merely did the Catholic Church own and operate its own asylums, it also provided the nursing staff for many of the state-owned facilities throughout the nineteenth century, marking the institutions with some degree of religious flavor and occasionally in ideological conflict with the medical officers. In Belgium, this system continued to the end of the twentieth century, with more than 80 percent of psychiatric institutions still administered by religious bodies.

The asylum regime. For much of the nineteenth century, the routine of daily life in the asylum was one of the prime curative features. Employment would be provided, appropriate to the social class and abilities of the individual. For the poor, this would usually involve needlework or laundry work for women and groundskeeping or farm work for men. Libraries were provided, stocked with morally uplifting literature. The food was not excessive, but a good diet was provided as essential to recovery. Asylums were built to ensure a healthy atmosphere for those confined in them, including proper ventilation for the summer and central heating for the winter. On many of these practical and measurable matters, the asylum offered a standard of living well superior to that of the poor insane person in the community. Unsurprisingly, at least some of those confined wanted to be there. At the same time, it was institutional living, controlled by staff and removed from the individual's family and community. Equally unsurprisingly, some inmates clearly did not wish to return to the asylum on their departure.

For much of the nineteenth century, the asylum's chief claim to cure rested in its regime. The bleedings, cuppings, and blisterings of the eighteenth century, treatments designed to restore to balance the bodily humors upon which early modern medicine was based, fell from fashion, although cold baths, emetics, diarrhetics, wine, and porter were slower to disappear from the landscape of treatment for mental disorder.

It was not until the last quarter of the century that new chemical treatments began to be used in asylums. The first set of these were sedatives: morphine, chloral hydrate, and bromides. Paris asylums alone were using over a thousand kilograms of potassium bromide per year by 1891 (Shorter, p. 200). For general paralysis of the insane (GPI), a psychiatric manifestation of neurosyphilis, fever treatments began around 1890, but were eventually superseded by treatments involving malarial injection about the end of World War I. These methods remained until the discovery of penicillin in 1943. The first half of the twentieth century saw its own additions to medical treatments in the form of coma therapy and shock therapies. As the name suggests, the object of coma therapy was artificially to place the patient in a coma, for periods occasionally up to two hours. Insulin was used to induce the coma, first in Austria by Manfred Sakel in 1933, who argued that coma therapy was a cure for schizophrenia. The procedure became particularly popular in Switzerland and the United Kingdom, although its efficacy was doubtful and its mortality rate significant. The object of shock therapies was to induce a convulsive seizure, which, largely by trial and error, was discovered to have therapeutic effects. The seizures were originally drug-induced, first in 1934 by the Budapest psychiatrist Ladislas von Meduna. In 1938, however, the Italian psychiatrist Ugo Cerletti discovered that the application of electricity to the brain produced a similar effect. Electroconvulsive therapy, or electroshock therapy was born, and within a few years became a very common treatment, particularly for depression. As with coma therapy, repeated treatments might be necessary to produce the desired effect.

The end of World War II marked a return to drug therapies. Chlorpromazine was first used as a treatment for schizophrenia in Val-de-Grâce military hospital in Paris in 1952, and within a year, it was in use throughout the French psychiatric system. Lithium was discovered as a treatment for mania by John Cade in Australia in 1949, and was first introduced into Europe three years later by Morgens Schou, a Danish psychiatrist. Tricyclic medications, so called because of their chemical structure, were first used on depressed patients by Roland Kuhn in Switzerland from 1955. All of these drugs became psychiatric staples, and for the first time, psychiatric drugs became big business. In 2000, psychiatric medications accounted for roughly one-quarter of the prescriptions in the United Kingdom National Health Service.

From asylums to community care. The postwar period saw a move from asylum-based care to community-based alternatives. English asylum accommodation peaked in 1954, with 148,000 beds. By 1997, there was less than one-third this number. The scholarly debate regarding this movement is as fractious as the debate regarding the growth of the asylum movement. Scull argues for an analysis based on economics and the sociology of the medical profession: after the war, money had become tighter and governments no longer wished to provide expensive institutional care; the psychiatric profession, its place of authority now secured, did not require the asylum as a visible symbol of its importance. Certainly, in the final decades of the twentieth century, when government policy throughout Europe tended to move to the right, the continuing trend to reduce the scale of inpatient psychiatric care can be seen as part of a larger political agenda, but that is more difficult to apply to the period after World War II, when governments seemed more willing than ever to become involved in national systems of socialized medicine.

In part, the move can no doubt be understood as a result of new practicalities. While the nineteenth-century moral treatment required the curative regime of the asylum, and coma and shock therapies could be administered only in the closely supervised medical environment available in a psychiatric facility, the new drug therapies could be administered in outpatient clinics. Nonetheless, outpatient clinics did not begin with the introduction of these drugs. Jean-Martin Charcot had such a clinic in Paris as early as 1879, and they were common in German asylums by 1920. Care with families in the Belgian town of Gheel had originated in the eighteenth century, and continued through the nineteenth. From 1857, the Scots boarded out up to a quarter of their poor insane through a scheme given a formal legislative basis, and in 1860, more than half the Welsh poor insane were cared for outside institutions. These initiatives did not necessarily diminish in the twentieth century. The English Mental Deficiency Acts were providing statutory community supervision for 43,850 people by 1939.

The new initiatives toward community alternatives can be seen as growing from older models. While care within the family is still often a very important element of these community alternatives, it is no longer a necessary component. Developing both from models of boarding out and from more sensitive social services and social housing policies responding to people who would never have been institutionalized in asylums in the past, governments now sponsor disability pensions for those who can live on their own or with their families, group homes for those who cannot, and day-care centers for both these groups. There are, of course, ironies to these "new" policies. The disability pensions have much in common with the older poor law relief provided under eighteenth- and nineteenth-century schemes. The group homes are frequently owned in the private sector, with care purchased from them by governments much as care might be purchased from private madhouses in the nineteenth century.

While modern drugs have created new possibilities for community care, the development of these programs from models predating the advent of the drugs suggest that the doctors as well as governments were in favor of blurring the lines between inpatient care and the community. Legal changes in English law are consistent with this view. Up until 1930, all persons admitted to county asylums and private madhouses were legally detained. The Mental Treatment Act 1930 introduced informal admission for the first time. In the Mental Health Act 1959, a preference toward such admissions became formal government policy. Moves were further made to integrate psychiatric populations with general hospital patients. By 1977, one-third of English psychiatric admissions were to psychiatric wards in these general hospitals, rather than to asylums for the insane alone. Italy went one step further, abolishing specialized psychiatric facilities in 1978 and treating all psychiatric patients either in the community or in general hospitals. Such moves can be seen as removing the high legal walls that, as much as their physical counterparts, had separated the psychiatric facility from the community.

In this context, the move to community care can be seen as a piece of a larger policy agenda. The complexity of these movements leads to conflicting results. Certainly, since the 1960s there has been a movement toward greater patient rights. Psychiatric patients sometimes enjoy much greater control over their treatments than before, although these rights often lag considerably behind North American systems. There is also new regulation of clinical trials. The development of the drugs identified above occurred without approval of ethical committees, with remarkably little prior knowledge as to whether the treatment to be given was safe, and with no attention paid to the views of the patients who served as guinea pigs. In psychiatry as in the rest of medicine, considerable movement has occurred toward ensuring that experiments are safe and ethical. At the same time, the movement toward community care has brought with it calls for increased surveillance of people with mental health problems outside hospital, buttressed with enforced treatment regimes. If the values of the broader community have begun to enter the asylum, so controlling values of the asylum have also begun to enter the broader community.

MADNESS, CONTROL, AND MEDICINE

From the above history of the care of the insane, it will be clear that the medical colonization of madness cannot be seen as a foregone conclusion. Even today, the care of the insane can be seen as flowing from an uneasy tension involving doctors, the government, and the public, in which the insane themselves risk being lost in the shuffle: it is simplistic to say that medicine has somehow "triumphed." The history of those administering madness must, like the history of the care of the insane, be understood as infused with a variety of themes.

From politics to medicine. By the early nineteenth century, medical involvement was generally necessary prior to the admission of an individual to a lunatic asylum. This does not necessarily imply an acknowledged expertise in matters of insanity, however. France provides an example of how this involvement might be almost accidental. Prior to the Revolution of 1789, the insane had been confined under lettres de cachet, the Royal Prerogative of confinement without hearing or appeal, that had attained symbolic importance to the revolutionaries as an abuse of royal power. In one such abuse, some political dissidents, whose confinement would be particularly sensitive, were classified by the monarchy as insane, not merely criminal. The lettres de cachet could not be continued by the revolutionary government in their previous form, yet lunatics posed considerable practical problems if left without control. The solution was to take the confinement of lunatics out of the overtly political realm: doctors would decide whether a person was actually insane and requiring confinement. Thus this authority of doctors over confinement does not necessarily originate in an overwhelming case for expertise or ability to cure, but rather in a matter of political expediency.

The movement of the medical profession to create a specialization in mental medicine was a somewhat haphazard affair, marked by contingency. Specialized training was usually limited. In France, courses in mental medicine were occasionally run as adjuncts to the main medical program, but it was not until 1878 that a professor of mental medicine was first hired at the University of Paris. Formal training was similarly sparse in the British Isles. Alexander Morison had instituted a course of lectures in 1823, John Conolly in 1842, and Thomas Laycock in the 1860s, but these courses were badly subscribed. Morison estimated that his course, over twenty years, attracted a total of little more than a hundred students. It was not until 1885 that a certificate course in psychological medicine was introduced by the General Medical Council, and no one applied for the first examination. Professional apprenticeship training did exist formally in the main psychiatric hospitals in France and informally as assistant medical superintendent positions began to appear in England in the second half of the century, but these produced relatively few experts to staff the growing number of facilities. While Jean-Étienne Esquirol by 1820 claimed the care of the insane to be a speciality within medicine, it was a speciality practiced by those trained as generalists.

And what of the disorders which were the subject of this apparent specialization? Here again, one can see a variety of themes in operation. Certainly, there are issues of control and professional interest. The doctors lived in their specific societies, however, and therefore the history of the disorders involves the history of philosophy and political contingency. There are also issues of the history of medical science, but here too the dividing line between science and philosophy and society is fluid.

The project of organizing insanity into categorical structures, and of identifying new forms of madness can be seen as an example of these intermingling themes. From antiquity, mental illness was understood as of two main sorts, melancholia and mania. The eighteenth century saw a revived interest in theorizing insanity, and, gradually, new categories of insanity were introduced and new theories of causation were articulated. The reasons are manifold. Certainly, there has throughout the period been an advantage to an individual's career in publishing texts detailing the nature and indications of insanity. Publication has always been a way to individual fame for the author. The publication of texts and taxonomies was also an exercise in professional development, however, for the placement of madness into an overtly medical frame emphasizes that it is the province of medicine. In this, the development of uniform systems of classification has a particular importance. Professionalism implies both expertise and objectivity. The development of a common language, uniformly applied by experts guided by ethical and professional principles, is an important part of this process. Disagreements between alienists were actively discouraged by the nascent nineteenth-century professional organizations, and remain controversial to this day.

Indeed, the history of classification in the late twentieth century reflects some of these concerns. Since 1949, International Classification of Diseases has included a section on mental disorders. The classificatory system contained therein and developed in ten-year amendments since that time can be seen as an attempt to introduce order and uniformity into diagnoses and categorization among psychiatrists internationally. The inclusion of mental disorders for the first time in 1949 in part reflects the foundation of the World Health Organization, which coordinates the compilation of the work. While the 1949 edition was considerably expanded overall, the inclusion of mental disorders can be seen as indicative of the increasing acceptance of psychiatric practice by general medicine—a process that had been a project of the alienists for a hundred years. This was arguably particularly important at this time. The abuses of psychiatry under the Nazi regime in Germany had come to light, and a reassertion of the professional nature of psychiatry can be understood as important in this period. Throughout the ongoing development of the ICD, consistency in application has been of particular importance. In the 1993 revision, consistency has been particularly important not merely among those using the ICD system, but also with those primarily in the United States and Canada, where the Diagnostic and Statistical Manual system is used instead of ICD. Prior to that time, there were marked divergences in diagnosis based on similar facts, with North Americans far more likely to diagnose schizophrenia than their European counterparts. Certainly, the desire for consistent categorizations and applications can be seen as scientifically important, but it is also difficult to deny that the prior divergences in practice caused considerable embarrassment to the medical professions concerned. The amendments are also thus in the professions' interests.

The creation of new categories of disorder can be seen as flowing in part from developments in medical science, and in part from social and professional interests. Some important disorders have existed in medical understanding and been developed for hundreds of years. Depression developed from melancholia, a category that has existed since antiquity. The origins of psychotic disorders can be seen in the manias of history. Other disorders have come and gone, however. Monomania was identified by Esquirol in about 1810. It was understood as a single pathological obsession in an otherwise sane mind. By the late 1820s, it was a common disorder. Jan Goldstein notes that it accounted for 45 percent of admissions to the Charenton asylum in Paris between 1826 and 1833, and 23 percent of admissions to Montpellier asylum from 1826 to 1829. By 1870, it had all but vanished. Certainly, a scientific basis was articulated for the disorder, but Goldstein argues that it was also important in the turf war between doctors and lawyers as expertise in criminal insanity matters. Monomania allowed doctors to portray themselves as experts in court, by diagnosing a disorder not readily identifiable to laity. The political purpose was not restricted to self-interested professionalism. A finding of monomania allowed markedly increased flexibility in sentencing, in the context of an otherwise very strict Napoleonic Code. Monomania can thus be seen as lying at the intersection of doctors' political reformist views and professional advantage. When these background factors changed, the diagnosis become much less important, whatever its medico-scientific merits.

Other new diagnoses can be understood as broadening the market for psychiatric services. For much of the nineteenth century in France there was a glut of doctors. Goldstein argues that the rise in hysteria in the second half of the nineteenth century was in part the result of a need for mental specialists to find new markets for their services. Shorter makes a similar claim about the increasing number of neurotic disorders in the second half of the twentieth century. There are social control implications to these developments, as ever more people become involved in the psychiatric universe. At the same time the history of psychiatric administration over the twentieth century has increasingly focused on non-enforced treatment. If we see a rise in social control, it is increasingly social self-control.

The nineteenth century saw insanity as flowing from some combination of physical, moral, and environmental causes. A physical predisposition in the form of weak nerves, heredity, epilepsy, or a brain lesion, for example, was thought usual if not necessary for the onset of mental illness, but that would not usually suffice. While this might be the "predisposing" cause, an "exciting" cause was also necessary. The possibilities here were legion, including overindulgence in alcohol, an excess of religious devotion, bereavement, childbirth, use of drugs, ill-treatment by a spouse, the fear of poverty or unemployment, and overwork. Certainly, there are social control implications to these categories, and the insane might be perceived in heavily moralistic terms. John Hadley, admitted to the Leicestershire and Rutland County Asylum in 1852, was said to possess "a large amount of animal cunning, low trickery, and all the paltry and petty devices of an abandoned character." Not all insanity was due to such moral failing, however. John Kettle, admitted to the same asylum three years earlier had been "remarkable for his steady, industrious and sober habits." His insanity was instead caused by the demise of his business. The doctors might even place the blame on broader social and environmental causes. Thus Elizabeth Spawton's insanity in 1851 was attributed to the "crowded and vitiated atmosphere" to which she was subjected in her many years employment as a factory hand. Economic factors such as those to which John Kettle was subjected and public health in factories were as much issues of social concern as the dissoluteness of the poor that formed the basis of John Hadley's characterization. In each case, the description of the inmate cannot be separated from broader social themes. The latter two cases do emphasize that while nineteenth-century alienism was about social control, it was also about creating broader understandings of how it was that social control became necessary.

Moral treatment. The ambiguities surrounding social control, and the mixture of themes in the development of insanity, can also be seen in the creation and development of moral treatment. It was a philosophical advance that reconceptualized insanity to create the intellectual space for the development of this approach. In 1690, John Locke, himself a physician, recast the ancient distinction between idiocy and lunacy in a philosophic framework. While idiocy involved the inability to reason, lunatics could reason, but did so from incorrect and deluded sensations. The placement of insanity in the realm of sensation and unbridled passions was continued by Étienne Bonnet Condillac. The new emphasis on the ability of the insane person to reason provided the intellectual background for moral treatment at the beginning of the nineteenth century, treatment that was based on the patient's ability to correct his or her ways.

The foundation of moral treatment in France was based on political contingency. Philippe Pinel was a provincial doctor from Montpellier, who went to seek his fortune in Paris in 1778. There he was effectively shut out of the medical establishment until the revolution. The system of medical accreditation then in effect meant that his Montpellier qualification had no validity in Paris, and it was only with the revolution that Pinel was able to come to prominence. At that time, he was politically well placed to do so: he had become a partisan of the revolution and in 1790 obtained municipal office in Paris, where several of his friends were in positions of considerable influence. In 1793 he was appointed to the medical directorship of the Bicêtre, and two years later he was transferred to the Salpêtrière. While there, he developed his system of moral treatment, which he published first in 1801. This system marked a move from the physical treatments of the eighteenth century to a system where the alienist interacted instead with the personality of the patient. Hope and encouragement were offered, and deluded ideas directly challenged, by an alienist whose authority was re-enforced through physical and moral means of control. These were not techniques derived from medical theory, but instead from Pinel's observation of his own lay orderlies at the Bicêtre, although Pinel did place the techniques in a scientific context.

Independently but contemporaneously, a similar approach was being taken by William Tuke at the York Retreat, founded in 1796. The Retreat, however, was founded in direct reaction to medical control and its abuses at the charitable York Asylum. Based on a Quaker ethos of dignity, piety, and charity, the Retreat treated its patients as members of a family under the guidance of the superintendent. As with Pinel's version, an attempt was made to connect with the patient at his or her level of understanding, and to build on that. Suitable employment was provided, both to occupy the insane in a reasonably pleasant way, and to prepare them for a return to the community.

Moral treatment was influential across Europe, but particularly in England, where coopted and somewhat modified to emphasize the absence of physical restraints and pervasive surveillance by asylum personnel, it became the basis of the curative asylum of the mid-nineteenth century. Again, there is an issue as to how much this is to be understood as a medical development. The traditional version of history is that the nonrestraint system in England was popularized by John Conolly, the medical superintendent at the Hanwell Asylum from 1839. While certainly the medical specialists adopted it as their own in the middle years of the nineteenth century, Akihito Suzuki has suggested that Conolly himself was not instrumental in the introduction of the approach, which was instead developed by the justices of the peace who formed the administrative board of the asylum.

Much has been made of the shift in emphasis implied by this approach, from control of the body to control of the mind, of the self. Michel Foucault characterizes this as a new technology of power, that where the old treatments had controlled the body of the insane person, the new treatments were a battle to control the individual's mind or self. There is a strong case to be made for this view, in that the object of moral therapy was self-control, in the hope that the individual might reintegrate as a productive member of society. In the twenty-first century, this remains the object of mental health policy. Those who choose not to take their medication, those who choose madness, and as a result who choose not to fit in are characterized as immoral. Certainly, there is a significant social control element, but the ethics of this element is difficult to gauge. Integration is, after all, the object of many of those who have been involved in the psychiatric system. Does this mean that social control is the mutual aim of the carers and the insane person, in which case is it control at all? Or does it instead mean that the social control has worked, and that the controlling view has been truly internalized?

See alsoHealth and Disease (volume 2); and other articles in this section.

BIBLIOGRAPHY

Bartlett, Peter. The Poor Law of Lunacy: The Administration of Pauper Lunatics inMid-Nineteenth-Century England. London, 1999.

Bartlett, Peter, and David Wright, eds. Outside the Walls of the Asylum: The History of Care in the Community 1750–2000. London, 1999.

Bynum, William F., Roy Porter, and Michael Shepherd, eds. The Anatomy of Madness: Essays in the History of Psychiatry. 3 vols. London, 1985–1988.

Castel, Robert. The Regulation of Madness: The Origins of Incarceration in France. Translated by W. D. Halls. Cambridge, U.K., 1988.

Digby, Anne. Madness, Morality and Medicine: A Study of the York Retreat, 1796–1914. Cambridge, U.K., 1985.

Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason. Translated by Richard Howard. Reprint New York, 1973.

Goldstein, Jan. Console and Classify: The French Psychiatric Profession in the Nineteenth Century. Cambridge, U.K., 1987.

History of Psychiatry. A scholarly journal devoted to the history of psychiatry, containing both scholarship relating to the social history of psychiatry and the history of psychiatry as a medical science. Much of the research concerns European psychiatry.

Medical History. A good journal that includes both social and scientific histories of medicine, including a good selection of articles on the history of psychiatry.

Porter, Roy. Mind-Forg'd Manacles: A History of Madness in England from the Restoration to the Regency. London, 1987.

Scull, Andrew. Decarceration: Community Treatment and the Deviant—A RadicalView. 2d ed. Englewood Cliffs, N.J., and Oxford, 1984.

Scull, Andrew. The Most Solitary of Afflictions: Madness and Society in Britain, 1700–1900. New Haven, Conn., 1993.

Shorter, Edward. A History of Psychiatry: From the Era of the Asylum to the Age ofProzac. New York, 1997.

Showalter, Elaine. The Female Malady: Women, Madness and English Culture, 1830–1980. London, 1985.

Social History of Medicine. A scholarly journal devoted to the social history of medicine, with a good selection of articles on the social history of European psychiatry.

Suzuki, Akihito. "The Politics and Ideology of Non-Restraint: The Case of the Hanwell Asylum." Medical History 39 (1995): 1.