This article is a continuation of our look at Theodore Millon’s history of the rise the treatment of mental illness. Thanks to the previously examined reforms effected by Esquirol and Pinel, a new set of legal requirements, known as the Napoleonic ode, was codified in 1838. According to this code, each province had to establish a public asylum or at least ensure that adequate facilities were provided for the severely mental ill in general hospitals. Specific requirements were also set forth to ensure that the mentally ill were protected against confinement by either families or politicians.
One of the main purposes of mental asylums was to help individuals acquire the kind of self-discipline they needed to function independently. This would aid in their recovery. Esquirol believed that patients should be distanced from their families so that they could learn to behave appropriately with strangers. Thus, they would be shamed by negative behavior and taught through reinforcement to behavior properly. Acquiring such competence would allow them to have more confidence in themselves and their abilities to function, leading to their eventually recovery. It was determined that such asylums would be located in attractive rural areas on the grounds that this aesthetic appeal would be soothing. Restraining chains for violent or delirious patients were eventually eliminated and replaced with cold baths.
It was John Conolly (1784-1860), in 1839, who insisted on the removal of all restraining mechanisms from the Hanwell Hospital in England. As the hospital’s superintendent, he insisted on the removal of irons, manacles, straitjackets and fabric cuffs. Instead, he emphasized the importance that attendants guide daily activities whose purpose was to bring discipline and focus to the mind and body. These patients proved very helpful in improving the mental health of patients. Throughout England, Connolly contributed to the reduction or elimination o restraining devices and cold douches that were used throughout the country. Instead, he argued that patients should be helped to perform useful activities such as raising vegetable crops, doing laundry work and tending livestock. He wanted patients to be treated kindly, and insisted that physicians become acquainted with the patients as individuals and educated concerning their personal life circumstances. His work-oriented program became popular throughout Europe.
“Outside the city, asylums soon became self-sufficient colonies with vast gardens, working pastures, and laundries, developed not only to achieve economy but to establish useful therapeutic activities that would help the patients return to normal life. A so-called science of managing asylum life was established, including the design and architecture of the asylum buildings.”
Joseph Guislain (1797-1860), a 19th century psychiatrist, became known among his countrymen in Belgium as the “liberator of the insane.” He suggested exercising care in which mental patients were paired with which. For example, he suggested separating melancholics from one another, as they aggravated one another’s depression, and violent patients were to be kept separate from other violent patients since they tended to be in continual conflict with one another. Instead, patient habitation was carefully engineered to balance defects of one with the benefits of the other.
William A.F. Browne (1805-1885) served as superintendent of the Montrose Asylum in Edinburgh. He imposed reforms similar to those of Esquirol. Writing in 1837 in his work “What Asylums Were, Are, And Ought To Be,” he wrote the following:
“Conceive a spacious building resembling the palace of a peer, airy, and elevated, and elegant, surrounded by extensive and swelling grounds and gardens. The interior is fitted up with galleries, and workshops, and music-rooms. The sun and the air are allowed to enter at every window, the view of the shrubberies and fields, and groups of labourers, is unobstructed by shutters or bars; all is clean, quiet and attractive. the inmates all seem to be actuated by the common impulse of enjoyment, all are busy, and delighted by being so. The house and all around appears a hive of industry.”
He even instituted drama therapy, which allowed patients to express their emotions and thoughts freely. Writing in his “Strong Remedies for Kindness in Custodial Care” in 1837, Browne wrote:
“There is in this community no compulsion, no chains, no corporal chastisement, simply because these are proved to be less effectual means o carrying any point than persuasion, emulation, and the desire of attaining gratification…such is a faithful picture of what may be seen in many institutions, and of what might be seen in all, were asylums conducted as they ought to be.”
Several countries saw public commissions for the construction of asylums throughout Europe throughout the 19th century. In Norway, asylums were constructed in Bergen, Oslo, Kristiansand and Trondheim. It was around this time that Daniel Hack Tuke (1827-1895), himself a son and grandson of important psychiatric innovators, became an important writer who guided building and treatment programs in both the U.S. and Europe. His great grandfather, William Tuke, had previously initiated an age of hospital reform in England, during which he founded the York Retreat. Daniel Tuke took it upon himself to help educate the British community concerning the plight of the mentally ill, in order to alleviate undue fear and suspicion. He traveled throughout the United States, speaking a great deal with superintendents of the American State Hospital system. He thought that the asylums of the U.S. were superior to those of England and thought they were better fed and more warmly housed, as well as provided better recognition and attention. He noted that only 5 percent of America’s patients were restrained. On the other hand, he was severely critical of Canada’s institutions. Nevertheless, Millon notes that there was discontent among the mentally ill in Europe and the United States:
“Despite the any advances that occurred during the nineteenth century, patients throughout Europe and the United States vented intense wails of protest and disillusionment. Many claimed they were never crazy to start with or that their madness was a consequence of the barbaric hospital treatment to which they were exposed. As more and more patients were confined to institutions, patient protests increased proportionately. Former inmates, seeking to vindicate their sanity and victimization by the sinister actions of their institutions, spoke out in numerous publications and newsletters.”
Millon notes that the ideas of reform which began in Europe quickly made their way to America throughout the 19th century. He notes that part of the rationale for the asylum was the notion that psychosis was an all-or-nothing ordeal and that the purpose of the asylum is to permanently house and care for the perennially mental ill. However, this black-and-white understanding of mental illness soon came to be disputed.
Indeed, anthropologists and sociologists came to the conclusion that at least some mental illness was partially the result of social environment, and that appropriate modification of environment could cure some of these cases. Thus, there were times when the adequately treated patient could be discharged after being treated appropriately. One of the very earliest mental institutions was the Pennsylvania Hospital in Philadelphia founded by the Society of Friends in 1752. They purchased land outside of Philadelphia and established the Frankford Retreat, which was modeled after England’s York Retreat. Its guidebook said that chains could never be used and that a “law of kindness” was to be the rule. This was the first mental institution in the United States.
Connecticut’s state medical society followed suit. They followed the model of the York and Frankford Retreats in 1824, dubbing it the Hartford Retreat. Its guiding physicians, Yale graduates Samuel Woodward and Ely Todd, articulated a similar law of kindness requiring that inmates be treated gently and respectfully. Initially established as semiprivate, it soon became entirely private and is known today as the Institute for Living. In 1826, Massachusetts General Hospital saw the establishment of the McLean Asylum thanks to a monetary grant from a Boston merchant. the establishment’s superintendent, Luther Bell, was read in the works of Tuke and inel and adopted their work and amusement programs.
New England saw the establishment of the State Lunatic Hospital for the mentally ill in 1832. It was established in Worcester under the care of Samuel B. Woodward (1787-1850) who had also participated in the establishment of the Hartford Retreat. It soon became famous for its medical and moral treatment, and, in the words of Woodward, “The hospital was designed to show that mental diseases were as curable, if not more curable than any other disease of equal severity.” He wrote of his results in 1840s, detailing that between 80 and 90 percent of his patients were eventually discharged after successful treatment. This influenced the eventual state-funding of hospitals throughout the country.
In 1850, near the end of his life, Woodward wrote:
“The abandonment of depletion, external irritants, drastic purges and starvation, and the substitution of baths, narcotics, tonics, and a generous diet, is not less to be appreciated in the improved condition of the insane, than the change from manacles, chains, by-locks, and confining chairs, to the present system of kindness, confidence, social intercourse, labor, religious teaching, and freedom from restraint. In this age of improvement, no class of mankind have felt its influence more favorably than the insane.”
It was Dorothea Lynde Dix (1802-1887) who instituted some of the most major reforms in America. A Massachusetts schoolteacher, she believed that severe mental illness could result from inhumane societal conditions. Writing in 1843 with the purpose of petitioning support to expand the Worcester hospital, she wrote:
“I come to place before the legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane, idiotic men and women; of beings sunk to their lowest condition for which the most unconcerned would start with real horror; of beings retched in our prisons, and more retched in our alm houses…(I wish to fix) attention upon a subject only the more strongly pressing in its claims because it is revolting and disgusting in its details.”
She insisted that the state had a medical and moral duty to fund the asylum. She went on to influence the establishment of 30 hospitals in her 40 year career, and was immensely influential in establishing the notion that it is the responsibility of the state to care for the mentally ill.