Mental Health: Despair and Desperate Remedies Hilary Marland Kill or Cure Week 21 Mental Health: Despair and Desperate Remedies Hilary Marland

High Royds Hospital, Menston, Ilkley, Yorkshire: opened 1888

Asylumdom ‘Asylumdom – care in asylums dominated approaches to care and containment of ‘lunatics’ from 18th to 20th centuries throughout Western World. Number of patients confined in asylums grew enormously during this period. By 1900 100,000 people confined in asylums in England and Wales, 150,000 by 1950. In US 1950 500,000 patients. Late 19th century change from early optimism and reform ethos of moral management to despair about growth in asylum populations.

Two explanations for growth Analyses that set the growth of asylums in the context of wider social changes, including the rise of capitalism, urbanization, migration and increasing ‘social control’ (Andrew Scull)(Confinement) Analyses that relate the growth of asylums to medical factors: reforms in the conditions of asylum life, claims for the role of the asylum in curing patients, and the rise of the power of medical practitioners, ideas of expertise. (Cure)

Late nineteenth-century psychiatry Late nineteenth century move from optimism that defined early period of reform and the setting up of county asylums, following acts of 1808 and 1845. Shift from faith in cure to concern with containment. System of moral management compromised. Number of patients rising – including increasing numbers of ‘incurables’. Hopes of cure dashed – asylums overcrowded, inefficient and demoralized. Asylums larger – many with 1,000 or more patients. ‘If lunacy continues to increase as at present, the insane will be in the majority, and freeing themselves, will put the sane in asylums’. The Times, 1877. Late 19th century asylums referred to as ‘psychiatric lumber rooms’ and ‘domiciles for incurable lunatics’.

Provincial Licensed houses 1,920 33% 1860 County Asylums 17,432 11% Confinement not cure Pauper patients % Curable 1844 County Asylums 4,244 15% Provincial Licensed houses 1,920 33% 1860 County Asylums 17,432 11% Provincial Licensed houses 2,356 15% 1870 County Asylums 27,890 8% Provincial Licensed houses 2,204 13%

Growth of asylums in England and Wales Asylums Patients Av No 1827 9 1,046 116 1850 24 7,140 297 1860 41 15,845 386 1870 50 27,109 542 1880 61 40,088 657 1890 66 52,937 802 1900 77 74,004 961

Colney Hatch Lunatic Asylum (later Friern Barnet Hospital)

County Lunatic Asylum, Brentwood, Essex, 1857, from The Builder

Barning Asylum, later Oakwood Hospital, Kent, late 19th century

Claybury Asylum, Essex, 1891, ground floor plan

Claybury Asylum, Essex, recreation hall, c.1893

Claybury Asylum, a dining room, c.1893

Claybury Asylum, kitchen, c.1893

Male patients being washed by orderlies, Long Grove Asylum, Epsom, c

Legislation and Reform 1808 County Asylums Act – magistrates permitted to raise funds to build asylums for pauper patients – 15 by 1844 1845 Lunatics Act – established Lunacy Commission to inspect, report and license all asylums in England and Wales and erection of County Asylums made compulsory 1890 Lunacy Act – introduced legal certification 1930 Mental Treatment Act – extended provision for voluntary admissions and out-patients. 1959 Mental Health Act – made provision for community facilities

Degeneration theory 2nd half of 19th century Influence Darwinian (Origin of Species,1859) theories of evolution in biology and social sciences – emphasized hereditary disposition to madness and inferiority of the insane Range of ‘forms’ of degeneration - Mental degeneration - Sexual degeneration - Artists and New Women - Moral degeneration - drink, crime, prostitution, venereal disease (Emile Zola) - Poverty, population increase and concern about the urban masses/’underclass’ Psychiatry to police or patrol the mental frontiers to guard society against degenerate

Degeneration: French psychiatry Degeneration theory: French influential Heredity Bénédict-August Morel – working in French asylums, launched notion of degeneration 1850s. 4 stage transmission of hereditary defects, with each generation getting worse, leading to idiocy and insanity. Also linked to alcoholism, crime, suicide, epilepsy and GPI. Patients also ‘looked funny’. Valentin Magnan- worked at Sainte-Anne Asylum in Paris. Many patients sent by police, many also alcoholic. Degenerates losers in battle for survival and a social menace. Mental degeneration worse each generation.

Asylums and degeneracy Long term concern with patients’ hereditary connections – predated degeneracy theory. Increasing numbers of cases of mental illness linked to hereditary causation: Brookwood Asylum, Surrey 4% patients associated with hereditary causes 1870-72 cf. 40% in 1890-2. Grim determinism of degeneration and heredity explained asylums’ apparent lack of success in curing patients and lowered the status of psychiatry. Mental illness seen as irreversible product of mental degeneration. Venereal disease one major problem for asylums – General Paralysis of the Insane/neurosyphilis. Incurable. Toronto asylum 1865-75 65 men and 7 women died of disease. Also asylums cared for old and feeble patients moved from workhouses.

Increase in alcoholic admissions Increase in alcoholic admissions. Paris asylums, one-third males labelled alcoholic, and Edinburgh, 15-20% of admissions 1874-1894

Young woman with signs of mental deficiency ‘Stigma’ of degeneration Also associated with Cesare Lombroso, Criminal Man – photographic studies of criminal degenerate faces 1880s and 1890s. Dr Henry Maudsley warned perspective husbands to scrutinize future wives for ‘physical signs…. which betray degeneracy of stock…. any malformations of the head, face, mouth, teeth, and ears…’

Dr Henry Maudsley Son-in-law of John Conolly, the asylum reformer and advocate of non-restraint. Maudsley representative of pessimistic turn in psychiatry. Very influential – editor Journal of Mental Science, prolific author. Emphasized hereditary origins of mental weakness and illness. Argued the mind was simply a function of the brain. ‘There is a destiny made for each one by his inheritance; he is the necessary organic consequent of certain organic antecedents; and it is impossible that he should escape the tyranny of his organization’. Henry Maudsley, The Pathology of Mind (1879), p.88.

Henry Maudsley ‘Degeneration and Despair’

Shift to scientific approaches Rigorous scientific methods rather than vague humanitarian sympathies and management. ‘disorder of the mind means disorder of the brain, and… the latter is an organ liable to disease and disturbance, like other organs of the body, to be investigated by the same methods and subject to the same laws’. G. Fielding Blandford, Insanity and its Treatment (1871).

Biological psychiatry Low status of psychiatry cf. other medical specialisms Towards end of 19th century increased emphasis on research and the laboratory. Germany and other continental European countries and US at forefront. Search for scientific methods, physical evidence of cause of mental disease rather than managing patients Emphasis on post-mortem examinations and patient’s pathology. Study brain and nervous tissue. Mental illness = illness of brain and nerves. 1890s concluded that GPI terminal stage of syphilis and 1913 spirochaete (spinal bacteria) discovered that caused syphilis. Prompted a range of ‘somatic’ therapies in the late 19th century and first half of 20th century.

Somatic therapies Desperate remedies – could be radical and dangerous, spurred by the urge to ‘do something’, to bring down patient numbers in mental hospitals and produce cures. Fever therapy late 19th – early 20th centuries Prolonged sleep 1930s Shock and coma therapies (insulin therapy 1930s; ECT first used 1938, heyday 1950s) Lobotomy, 1935, heyday 1940s-1950s

Electroconvulsive therapy, ECT ECT machine Science Museum, produced 1958-65 Ugo Cerletti (1938) Widespread take up Europe and North America, less dangerous than drug induced convulsions. Treated depression and schizophrenia. Aggressive treatment that was not well understood. Many patients subjected to multiple treatments. Criticized and used less after 1960s

Lobotomy Egas Moniz, 1935, Nobel Prize 1949. Cut connections between the frontal lobes and rest of the brain. Crude approach and crude instruments. Treated depression, schizophrenia and compulsive disorders. US neurologist Walter Freeman, evangelist for the procedure, performed first US lobotomy in 1936. Seen as miracle cure – UK performed huge number of lobotomies, with over 1,000 operations a year at its peak. Sir Wylie McKissock, Atkinson Morley Hospital in Wimbledon – performed over 3,000 lobotomies (a 5 minute procedure). Mid-1950s increasingly unpopular.

ECT, film and literature

Psychoanalytic approaches/therapeutic communities Psychoanalytic approaches after Freud – largely practised with private paying patients, yet also used techniques in asylums New approaches to therapy in asylums aside or alongside somatic treatments e.g. occupational therapy, therapeutic communities, social psychiatry, open door policies 1930s introduction of voluntary admissions and out-patients (e.g. Maudsley Hospital) Changing attitudes – interest in mental hygiene, mental health less stigmatized New drugs (antipsychotics) introduced in 1950s.

End of asylums 1950s onwards end of asylums after c.200 years of dominating care of mentally ill. Ability to cure? Despite new therapies, asylums/mental hospitals seemed unable to cure patients effectively – though new drugs encouraged idea patients need not be in institution 1959 Mental Health Act – faith in community care 1961 Enoch Powell (Minister of Health) ‘Water Tower Speech’ Jonathan Miller's film, in the BBC series ‘Madness’ (episode ‘Brainwaves’), BBC MCMXCI is excellent though grim viewing, on http://www.dailymotion.com/video/x4qzozl (other episodes in this short series are available on YouTube)