Transcript Psychiatry & the Asylum 1750-1900

Psychiatry & the Asylum
1750-1900
Basic Chronology of the
Transformation of the Care of the
Insane
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Prior to 1750, little institutional care
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Not part of orthodox medical practice
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Few people actually categorized as insane
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1807, estimated 2,200 insane people in Britain
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1890, 66 public mad houses
90,000 people admitted to them
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Population of the insane grew 4X faster than
the population of Britain as a whole
3 Social Transformations in Care of
the Insane after 1750
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Prior to 1750, care of the insane was basically
custodial
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e.g.: Bethlem Hospital
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Founded 1247
1403: housed 6 men “deprived of reason”
1632: 27 inmates
Moved to new site 1676: 150 inmates
Little in way of medical therapy
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Many never saw a doctor
Standard “treatments”
 Dunking
 Physical restraint
 Bleeding
 Fear
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Benjamin Rush on bloodletting:
It should be copious on the first attack . . . From
20 to 40 ounces of blood may be taken at once.
The effects of this early and copious bleeding
are wonderful in calming mad people. (1812)
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Appalling conditions in institutions for the
insane
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Incompetent doctors (or none at all)
Abuse & neglect of patients
Exploitation of patients
Prisons were no better
Voluntary hospitals slightly better
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Prison reform movement
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John Howard
Resulted in more enlightened public opinion
about institutional care generally
1. Rise of the Moral Cure
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Defined itself in opposition to what had come
before
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Samuel Tuke
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Prominent tea merchant at York
Quaker
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Founded the Retreat in 1796
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Initially tried standard medical therapies
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Rejected these as useless
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Substituted “moral treatment”
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Believed that the insane had lost control of
inhibitions that defined their humanity
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Asylum an environment that emphasized the
self-discipline they had lost
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Distanced them from the environments that
had made them insane
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Run as a family environment
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Superintendent took parental role
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Inmates treated like ill-disciplined children
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Intended to change emotional or intellectual
disorder, not pathology
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Accomplished through behavioural means, not
physiology
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Used restraints
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Rejected physical or emotional abuse
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Work therapy
2. Medicalization of Insanity
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Psychiatry one of most successful
medicalizations in medical history
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Two aspects
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Theoretical understanding of mental illness
Management of mental illness
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1. Theoretical Medicalization
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Accomplished by making diagnosing &
treating insanity exclusively medical in
orientation
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Philippe Pinel
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1745-1826
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Worked at Bicetre &
later the Salpetriere
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Appalled by callous
way mad people were
treated
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I cannot here avoid giving my most decided
sufferage in favour of the moral qualities of
maniacs. I have no where met, excepting in
romances, with fonder husbands, more
affectionate parents, more impassioned . . .
than in the lunatic asylum, during their
intervals of calmness and reason."
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Rejected callous treatment of the insane
Ordered removal of chains
Wrote Medical-Philosophical Treatise on Mental
Alienation or Mania
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Much more could be said about the rise of
psychiatry & influential physicians in this area
of specialization
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Why was medicalization of mental illness
successful?
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Secularization of France supported more
materialist understanding of mental illness
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Disease of the brain, not the mind/spirit
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2. Medicalization of Treatment
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In Britain, the state needed medical assistance
in care of the insane
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Only small number of patients in “public”
institutions, which were for the poor
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Middle and upper classes dependent on private
institutions
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Sites of considerable abuse
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People sent to asylums to get rid of them
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No registers of who was there
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No supervision of any sort
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Several House of Commons hearings in 18th
century related to reports of unethical
confinement
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1774 Madhouses Act
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No one could be admitted without medical
certificate
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Madhouses to be licensed
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Must keep register of inmates
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Did not define who was a physician
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Royal College of Physicians unenthusiastic
about supporting this legislation
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Rapid expansion of private madhouses
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Onset of state-run madhouses
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Needed increased support from physicians
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1828: all madhouses must have physician visit
once a week
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Proper medical records to be kept
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Increasing state surveillance
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Decrease in lay-established asylums
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1854: permanent commission to oversee all
madhouses
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50% lay people
50% physicians
Legal definition of criminal insanity
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1854 M’Naghten case
Physicians asked to provide expert testimony
3. Pauperization of Insanity
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Madhouse (asylum, mental hospital) became
institution of choice for mentally ill poor
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Growth in institutional care can be interpreted
as indication of more humanitarian response to
distress
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Can also be interpreted as increased interest in
controlling deviant behaviour
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Shifts in what constituted deviance over time
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Leads to critique of psychiatry’s role
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Is mental illness found or made?
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Major critiques in 20th century
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“One Flew Over the Cuckoo’s Nest”
“Clockwork Orange”
Myth of Mental Illness (Dr. Thomas Szasz)
Madness and Civilization (Michel Foucault)
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Most intensive period of asylum building in
Britain between 1840 and 1880
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Size of these institutions made effective patient
care impossible
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By end of 19th century, asylums had become
warehouses for the insane
A Bit More About Moral
Architecture
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Mental institutions were generally designed to
be highly visible
Reminded people of consequences of deviant
behaviour
Brandon Mental Hospital on north hill outside
of town; could be seen by everyone in the city
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Physical space laid out like a large Victorian
house
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Impressive entrance & foyers laid out in a
large centre block
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Centre block often contained apartments of
medical superintendent & his family
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Patient wings placed on each side
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Males & females separated
Brandon Mental Health Centre
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Based on unpublished masters thesis (UM) by
Christopher Dooley
“When Love and Skill Get Together:” Work,
Skill and the Occupational Culture of Mental
Nurses at the Brandon Hospital for Mental
Diseases, 1919-1946”
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Prior to 1880, no formal provision for mental
health care in Manitoba
At discretion of local officials
Family
Fend for self
Incarcerated in jails
Deported
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1877
Mental patients incarcerated in gaol at Lower
Fort Garry
Later, moved to Stony Mountain Penitentiary
Housed in basement
Condemned in 1884; had been contaminated
by sewage
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1883: 50 bed facility constructed at Selkirk
Patients under medical care for first time
1891: Conversion of Brandon Reformatory to
asylum for the insane
Named the Brandon Asylum
25 patients transferred from Selkirk
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1910: Asylum burned down
700 patients and staff housed in building on
agricultural grounds
1913: New asylum completed
1000 bed capacity
Renamed Brandon Hospital for the Insane
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1919: Renamed Brandon Hospital for Mental
Diseases
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http://timelinks.merlin.mb.ca/imageref/imager
18.htm
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http://members.tripod.com/hillmans2002/bmhc
tour.html
Unexplored themes in the History of
Psychiatry
Patient’s Lives
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Medicalization of mental illness had little
impact on the experience of patients
In 1920, Dr. C.A. Barager, Medical Sup’t of
Brandon facility reported that only 19.7% of
patients discharged considered cured
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Patients suffered from a wide range of
problems:
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Developmental
Psychiatric
Psychiatric consequences of physical illnesses
Age related dementias
Epilepsy
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Treatments were crude, often ineffective
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Institutional life could be:
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Boring
Dangerous
Humiliating
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Three excellent Canadian studies of
psychiatric care in the late 19th – 20th century
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Reaume, Geoffrey. Remembrance of Patients
Past: Patient Life at the Toronto Hospital for
the Insane 1870-1940. Toronto: Oxford
University Press, 2000.
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Warsh, Cheryl. Moments of Unreason: The
Practice of Canadian Psychiatry and the
Homewood Retreat, 1883-1923. Montreal:
McGill-Queen’s University Press, 1989.
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Chunn, Dorothy E. and Robert Menzies. “Out
of Mind, Out of Law: The Regulation of
Criminally Insane Women Inside British
Columbia’s Public Mental Hospitals, 18881973.” Canadian Journal of Women and the
Law, 10 (1998), 307-337.
Changes in Medical Treatment
Experience of Staff in Psychiatric
Facilities
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Dooley’s thesis
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Tipliski’s doctoral dissertation