Madness
Introduction
In The Treatment of the Insane Without Mechanical Restraints (1856), the Victorian physician John Conolly [document 1, document 2] refers in stark terms to the treatment of the insane in eighteenth century England. He saw it as a century characterized by brutality, distress and darkness in which cages, whips and chains were accompanied by the use of debilitating substances such as quicksilver, camphor, and boiled ground-ivy mixed with sweet oil and white wine. Therapies included purging, bleeding and forced vomiting. These were administered in an attempt to reduce the violence of frenzy or to weaken the animal spirits that were believed to be producing madness. According to the prevailing paradigm of insanity, the lunatic had lost his reason - the essence of his humanity - and so had lost his claim to be treated as a human being. As Michel Foucault states in Madness and Civilization, the lunatic’s ‘unchained animality could be mastered only by discipline and brutalizing.’ The intention of mad-house keepers was thus not to ‘raise the bestial to the human, but to restore man to what was purely animal within him.’ By such reasoning, the use of forcible physical restraint could be justified.
John Conolly repeatedly makes clear his personal distaste for such ‘treatments’. This is dramatically presented in his description of the confinement of William Norris . Throughout his writing, Conolly is at pains to draw a clear line between the dark, savage past and the present-day treatment of the insane. According to Conolly, the salvation of the lunatic lay in moral therapy, administered in the site of the new lunatic asylum.
With the Reformation came the dissolution of monasteries and their provision of parochial care in hospices, almshouses and refuges. Early Modern England offered relatively few establishments catering specifically for lunatics. A large percentage of individuals who were regarded as abnormal were instead held in gaols, workhouses and family dwellings. In 1700 there was only one public madhouse, Bethlehem, often known as Bedlam. Established as a monastic institution in the thirteenth century, it had become, as its popular name suggested, synonymous with the very idea of Unreason. It was notorious in the seventeenth and eighteenth centuries, becoming a site that catered for the morbid desires and curiosities of spectators from home and abroad. Visitors were able to observe the patients in the institution’s galleries. The lunatic keepers adopted the role of showmen, displaying their ‘star’ patients and goading them into antics for the amusement of the crowd. They were even able to purchase nuts, fruits, cheesecake and beer, a situation that led some commentators to compare Bethlehem’s atmosphere to that of a fairground. However, inside the cells treatment was a different matter entirely.
When William Hogarth (1697-1764), composed the eighth scene of A Rake's Progress(1735) he chose the incurable ward of Bethlehem as the most appropriate place for his hero, Tom Rakewell, to end his miserable career. The scene is considered one of the most ‘extraordinary production’s of Hogarth’s pencil’, a vision at once fantastical and horrific, representing coercion and cruelty, and displaying a multitude of moral and social vices that Hogarth sought to condemn. It is important to note, however, that there were public establishments for the insane whose managers sought to distance themselves from Bedlam and its associations. St Luke’s Hospital for Lunatics, for example, banned visitors whilst admitting for the first time medical students. Established in London in 1751, it was a hospital not a madhouse and most importantly, its founding medical officer, William Battie (1703-1776), was amongst the first psychiatrists to argue for the therapeutic benefits of institutionalizing patients.
During the second half of the eighteenth century, the treatment of madness was dramatically changing. In the 1750s, William Battie emphasised the importance of the site of therapeutic care. In the 1790s, the Reverend William Pargeter (1760-1810) published Observations on Maniacal Disorders (1792). This tract was no less groundbreaking in terms of his extension of the scope of treatment and his focus on the role of the specialist physician. Both writers contributed to the evolution in the late eighteenth century of a fundamentally new approach to the care and treatment of the insane, centered not on brutally ‘physicking’ lunatics, but on benevolently managing their disorders. The earlier attempt to ‘minister’ to the lunatic’s body rather than to his or her mind was based on the premise of a Cartesian universe: with the concept of the mind conflated with that of the soul, physicians had almost universally asserted that mental disease had an entirely somatic, or physical, basis. It thus was accessible to physical remedies or restraint. Yet in the latter decades of the eighteenth century, brutal ‘physicking’ gave way to the psychological management of the insane. While the lunatic’s environment, diet, and physical activity became important. What was most striking about psychological management was the way in the patient/physician relationship was reconceived.
Increasingly, physicians sought to control the passions of the lunatic, through their own direct intervention, rather than through the employment of physical restraints. Combining close surveillance and paternal concern, ‘rapport’ was established and cooperation engendered. Such therapeutic strategies often depended upon the charisma of the doctor, and in turn had the effect of increasing his prestige and authority. No nineteenth-century doctor was more closely associated with this set of transformations than John Conolly. Observers of the new ‘humane’ treatments that were immortalized first in the late eighteenth century at William Tuke’s York Retreat and at Philippe Pinel's Parisian hospitals, and in the nineteenth century at Conolly’s establishment, Hanwell, believed that moral management was the vanguard of nineteenth-century humanitarianism.
With moral management (or moral therapy as it was commonly known), the lunatic was fundamentally repositioned in relation to the rest of society. This new approach ‘actively sought’, as the historian Andrew Scull suggests, ‘to transform the lunatic, to remodel him into something approximating the bourgeois ideal of the rational individual.’ It is best viewed as a pragmatic and humane attitude towards the insane rather than a specific form of treatment. It won favour with the public because it embodied again a traditional bourgeois emphasis on the virtues of self-discipline, moderation, industry, and perseverance.
The brutal ‘physicking’ of the insane administered by madhouse keepers merely forced outward conformity. In contrast, gentle moral guidance sought to cure from within. Only when thoroughly transformed could the lunatic be reclaimed by society. The premise underlying the moral management of the insane was that insanity was a psychological rather than a physical impairment and in many respects, its emergence represented a challenge to somatic etiologies and the more traditional medical therapeutics preferred by physicians. The professionalization of psychiatry that began in the late eighteenth century with Pinel, for example, had bolstered the reputation of alienists and many others associated with the treatment of lunacy; after the initial threat that moral therapy had posed to physicians, they aggressively reclaimed jurisdiction over the insane through both a political and social process culminating in claims that both moral and medical treatments were vital in curing the lunatic.
The potential value of the lunatic asylum was repeatedly emphasized by John Conolly and other proponents of moral therapy. It was a site which contributed to a pervasive feeling of therapeutic optimism. Although the use of instruments including fetters, handcuffs, leather muzzles and body straps had perhaps made the job of asylum ‘keepers’ easier, the middle of the nineteenth century saw increased support for the methods of non-restraint applied in specially-designed asylums. These methods are detailed by Conolly. By controlling the environment of the lunatic, it was hoped that the asylum would reflect, as the critic Elaine Showalter suggests, not only ‘the best of Victorian medicine but also those domestic values celebrated in Victorian art and fiction; these news sites of therapy and humanity would ‘truly be refuge, retreat and home.’ If properly designed and exploited, the space of the asylum could accompany moral management as a therapeutic tool; properly manipulated it could yield the physician an even greater control over the patient, and over all the ‘impressions’ which reached his or her mind. It was this therapeutic potential of confinement, this concept of moral architecture, which initiated a close collaboration between architecture and psychological medicine.
A central aspect of Conolly’s approach was to seek to reduce or even disguise altogether the patient’s experience of imprisonment in the asylum. Conolly gave enormous attention to the spatial and experiential aspects of the asylum. Consider, for instance, the detail with which he describes every aspect of asylum architecture as it influences the treatment of the insane. The greater the sense of a home, the more domestic and inviting the asylum appeared, the greater would be the prospects of moral therapy. To this end, the asylums constructed under the 1845 Lunatics Act were designed with attention to aesthetic beauty. In their landscaped grounds it was not unusual to find orchards, summer houses, bowling greens, and aviaries. Order was maintained within the asylum through segregation and classification, not only by particular disorders but also according to gender and class. The asylum was clearly designed on the model of a Victorian home and so one could find libraries, galleries, day rooms and the like. Moral therapy also depended also on industry, fostering belief in the values of honest labour. To this end every asylum had brew houses, workshops, laundry rooms and other facilities requiring patients to work. Asylum treatment depended on a system of rewarding good behavior with activity and bad behavior with the curtailment of these social yet therapeutic amenities.
Perhaps unsurprisingly, Michel Foucault had much to say about the role of moral therapy and the asylum in the development of the profession of mental science. In Madness and Civilization , A History of Insanity in the Age of Reason (1965, trans. Richard Howard; First published as Folie et Déraison: Histoire de la Folie à l’Age Classique [1961]), Foucault positions moral treatment and the asylum as both oppressive and repressive. He insisted, as he did with the penitentiary in Discipline and Punish (1977) that the creation of the asylum represented not an act of generous humanity but an effort to impose a damagingly rationalized system of order on the insane. Before the birth of the asylum, he argues, the mad were in fact better off. They were visible, and, unconfined by their surroundings. Their voices could be heard and could be said to be in dialogue with the voices of reason. The asylum was designed, Foucault believed, solely to induce conformity. Far from liberating the insane from the fetters of the past, to Foucault the asylum signaled the birth of an even more powerful ‘moral imprisonment’ of the lunatic. The driving force behind asylum construction was the desire to prevent dialogues between reason and unreason. Why? Because such dialogues held the potential to undermine society. The asylum’s adjunct, moral therapy, was similarly an effort to force lunatics to develop an understanding of their own moral transgressions. Their behavior could be altered only by internalizing the values of their keepers. The authority of the physician, therefore, was acquired from values derived from bourgeois society rather than from science. Through moral management, itself a fundamental rupture with the past, insanity was repressed and the will of the lunatic, like the criminal was watched, and through surveillance, controlled. To Foucault, the larger development of mental science was not therefore related to an attempt to deepen an understanding of human nature, but stemmed rather from its relationships to sources of power and domination.
Foucault contested the teleological view of history. He generally regarded reform as part of oppressive and dominant discourses of identity. In this light, moral management was a mechanism for inducing conformity and so control. While Foucault’s Madness and Civilization has been variously interrogated and criticized for its empirically weak basis, its rhetorical strength lies in its depiction of the asylum and its proponents as no more than threatening forms of duplicitous control.
Despite the best efforts of physicians like John Conolly and Andrew Wynter, by the 1870s, the poor rate of cure of insane patients had led to the cutting back of financial support for the public asylum system. Moral management, and the optimism that had attended it, slowly but surely decayed as asylums became overcrowded and understaffed. The psychological optimism which had attended the construction of lunatic asylums (and which was engendered in moral therapy) began to decay. Increasingly, the tone of psychiatric commentary was marked by pessimism about the prospects of therapy.
A similar mood can be detected in medical responses to privately-run lunatic asylums. Though physicians discussed the problems of private asylums in the early 1850s, by the end of the decade their validity as caring (if expensive) institutions had similarly reached a critical point. Scandals, abuses, and revelations of wrongful confinement in 1858 were now published in the press on almost a daily basis. The more adverse publicity the private asylum received, the further entrenched became the Victorian public’s morbid fascination with insanity and its home within the asylum. Any popular novelist or writer with an interest in the issues and debates surrounding madness and the private asylum could rely upon the avid interest of a wide reading public. Wrongful confinement, the continued use of coercive physical restraint, the over-reliance on sedatives, the abuses committed by often ill-qualified attendants, the ineffectual lunacy laws, and the pitiful intervention of Commissioners in Lunacy were aspects of life in a lunatic asylum that were used by novelists to great dramatic effect. While insanity, like bigamy, murder, arson, and corruption, was a popular narratological device, the lunatic asylum functioned in a rather different way. Wilkie Collins, Mary Elizabeth Braddon and Joseph Sheridan Le Fanu followed in the tradition of Richardson's Clarissa (1747-48), using the site of the asylum in much the same way that writers of gothic fiction employed castles or convents - as terrifying sites of incarceration. In contrast, writers with a reformist bent like Charles Reade and Henry Cockton saw it as their duty to expose the ills of the asylum. They condemned the double standards which they believed (and offered to prove) were rife in the iniquitous lunacy laws.
By the late-nineteenth century, a pervasive sense of threat and disillusionment shadowed many discussions in and beyond the world of medico-psychiatry. In place of self-confident declarations about growth, prosperity and improvement, commentators characteristically discussed the dangers of degeneration and debated the prospects of ‘regeneration’. The world of mental science was not immune to such influences and anxieties. Towards the end of the century the asylum, previously hailed as the site of moral therapy and cure, became overcrowded and underfunded, as well as physically decrepit. Pessimism replaced curative optimism. From the 1870s onwards, a more biologically deterministic model of insanity emerged. Unsuccessfully grappling with its irrationality, insanity was increasingly regarded with ‘resignation and fear’ (Skultans, 131).
There was no doubt that insanity had become a threatening social problem, no longer able to be dealt with by the asylum, moral therapy or individual will-power. The psychiatrist Henry Maudsley, a key proponent of late-nineteenth century psychiatric Darwinism, concluded that to understand insanity as a ‘disease of the so-called immaterial part of our nature we may look upon as exploded even in its last retreat.’ (Maudsley, Responsibility in Mental Disease, 13-16). Maudsley and many of his colleagues now believed that the lunatic had a genetic predisposition to madness. His professional success was grounded in his belief that insanity was a hereditarily transmitted genetic disorder of the brain. The theory of heredity played a central role in late Victorian explanations of abberant behavior. It was also central in reformulating ‘madness’ because it was directly related to Darwinian theories of evolution and the social sciences. Maudsley believed that the laws of selection and survival operated as strongly in the mental world as they did in the social world.
The decline of the asylum and the popular denigration of its medical superintendents led to a reappraisal of the role of the ‘mad doctor’. Psychiatrists such as Maudsley and Wynter no longer cast themselves as humanitarian reformers ministering to the mind, but as ‘skilled’ social authorities and ‘as experts on laws of heredity and the operations of the mind.’(Showalter, The Female Malady, 105). Insanity had once again become a physical rather than a psychological impairment. Yet it was now subject to rigorous scientific methodologies hinged onDarwinian theories of evolution and biology. A central aspect of Darwinian psychiatry was that the doctors, empowered by their elevated status, cast themselves as ‘high-priests of science’ (Greenslade, Degeneration, Culture, and the Novel, 17). They saw themselves as psychiatric police whose job was not to cure lunacy but rather to separate the sane from the insane.
In psychiatric literature of the period, the failure of the asylum as a site of treatment, like the failure of moral therapy as a curative treatment, was linked to the emergent discourse of degeneration, a discourse which incorporated a terrible evolutionary irony: Bénédict Augustin Morel, a French doctor and alienist, believed that the insane and other degenerates posed no serious threat to the progress of mankind because they could only engender their own extinction. Degenerates like lunatics were ‘simply the inevitable spin-off in the stern and remorseless process of evolutionary struggle.’ (Pick, Faces ofDegeneration, 208). The power of evolution had become central in scientific belief. It meant in principle that man had no power to alter social arrangements and effect change. For the field of mental science, this led to a neglect of reform.As a result, madness, like degeneration, was in fact to remain a threatening force within society. The vision of ‘outcast London’ in the 1880s, for example, attests to this prevalence of poverty, criminality, and madness and it significantly contributed in the world of mental science to the late-nineteenth century therapeutic pessimism of ‘Psychiatric Darwinism.’