Asylums in the 19th Century: Care, Reform, and Decline

Introduction: Origins of the Asylum

Asylums came into existence in response to a growing social problem: what to do with people who were mentally ill. Of course, they were not called mentally ill in those days but were referred to as victims of lunacy or madness. The perception of madness as an illness came with the rise of psychiatry, and the development of psychiatry as a profession occurred concurrently with the development of asylums. This essay considers the conditions that led to the building of asylums, how asylums were meant to function, and the shift of function that occurred late in the 19th century.

Conditions Before Asylums

Historians disagree about the efficacy of asylums for the treatment of those who were mentally ill, but all agree that conditions before asylums were for the most part degrading and inhumane. This was particularly true if the person was a pauper without funds to pay for care.

In England, the welfare administration — the Poor Law — cared for lunatic paupers. "Institutional care was provided and paid for from the public purse or was purchased by the parish at public expense from institutions run by private proprietors" (Murphy, 2001, p. 29). In London, madhouses were an industry that made lay proprietors rich and respectable. As Hughes (2002) points out, the idea of a "mixed economy" in which both state and private parties are involved in housing the mentally ill goes back to Victorian times. The two systems of "public interest and private profit have operated in parallel..." (p. 328).

The Whitmore House, for instance, was owned and operated by Thomas Warburton, who began at Whitmore as an attendant. When the owner died, he married the owner's widow and thus acquired ownership. He habitually hired brutal, thuggish keepers and failed to supervise them.

A pamphlet written by a former whistle-blowing employee in 1816 — A Statement of the Cruelties, Abuses, and Frauds which are Practised in Mad-Houses — resulted in a hearing. The pamphlet reported that Warburton took in as many people as he could get, whether he had enough beds or not. Two or three people were often placed in the same bed. Crowding was only the beginning. "Brutal forced feeding, using objects such as a long-spouted 'tea-pot' and a large key to crank open the mouth, resulted in smashed front teeth or even suffocation if the spout was pushed in too far and food passed down the windpipe. Mrs. Hodges, the wife of the vestry clerk for St. Andrew Holborn, had died of incompetent forced feeding... Pauper patients were left naked on wet straw beds in unheated rooms; soiled straw, filthy and infested with vermin, was unchanged for days. The limbs of the frail were 'mortified' by cold and neglect; one woman's foot had to be half amputated. Almost everyone was chained to the bedstead at night" (Murphy, 2001, p. 31). Inspectors, when they went to see for themselves, reportedly gagged from the stench.

According to Murphy (2001), Warburton appeared puzzled when called before the Select Committee to explain the appalling conditions. He said the patients "could readily be controlled with a leg lock and manacles" (p. 32) and explained that the only restraint he used was "hobbles," applied "almost in the manner you would put round a cow when milking..." (p. 32). Compounding the misery, patients had nothing to do and almost no medical treatment — certainly nothing that could benefit a mentally ill person. In England, the Madhouse Act of 1828 provided for the First Middlesex County Asylum in Hanwell, West London to be built, but conditions there were poor as well, and no treatment was offered. After the 1845 Lunatic Asylums Act, most of England's counties and boroughs were able to build asylums from public funds to care for paupers who were mentally ill (Dowbiggin, 1997).

Campaigners for public asylums often described the horrors of private madhouses as part of their argument for reform; however, conditions for patients with money to pay were not nearly so awful. Middle-class and wealthy people could go to licensed houses, usually run by doctors who "opened up their own homes to patients as a species of 'paying guest'" (Murphy, 2001, p. 30). These homes tended to be cleaner, and patients were treated with some decency.

The Moral Treatment Movement

Meanwhile, in colonial America, madness was understood as either a divine touch or bedevilment. According to McGovern (1993), mentally ill people were mostly left alone. Later, as political and social changes took place in the mid-18th century, there was less tolerance in society for lunatics and the disruption they sometimes caused. Many of the mentally ill were locked in unheated attics and sheds, kept in pest houses, or confined in jails. Haller and Larsen (2003) argue that "like eighteenth-century Europe, the United States treated insanity severely and punitively" (p. 260). Clearly, something needed to be done to make treatment more humane and to address the growing numbers of mentally ill people in the cities. In Philadelphia, Dr. Benjamin Rush, founder of psychiatry in America, called for a new view of lunacy. The solution, it seemed, was to stop seeing the victims as wayward and to build publicly supported asylums for their humane care and treatment.

The movement to build asylums was revolutionary and an abrupt departure from previous public policy toward mentally ill people (Dowbiggin, 1997). Webster's Ninth New Collegiate Dictionary defines the word asylum as "an inviolable place of refuge and protection giving shelter to criminals and debtors; a sanctuary, a place of retreat and security; an institution for the relief or care of the destitute or afflicted and especially the insane." The asylum had a double purpose — custodial care in a safe place and "a therapeutic environment for those deemed curable" (McGovern, 1993, p. 688). Crowded cities and high stress levels in American society had triggered a need for better care, and asylums were seen as places where expert care could be given.

No discussion of asylums would be complete without considering Dr. Thomas Kirkbride, an influential early advocate of asylums for "moral treatment" in the United States. He was strongly influenced by the ideas of Dr. Benjamin Rush in Philadelphia, who preached the moral treatment of mental illness and was responsible for initiating change in the way people viewed lunatics. Instead of seeing them as moral deviants who required confinement and punishment, enlightened reformers began to view them as sick people who needed to be cured.

Moral treatment was a social movement in the 19th century that began in England and France in the late 1700s with the ideas of William Tuke, a Quaker who believed that people suffering from madness should be treated with tenderness and sensitivity. At the same time, Philippe Pinel in France was instituting similar reforms. Tuke founded the York Retreat in 1796 and ran it according to the principles of the Society of Friends. No shackling was allowed — no mechanical restraints, punishments, or medicine. "The Retreat was designed as an environment that would help them [the patients] internalize discipline and restraint" (Haller & Larsen, 2005, p. 260). Some physical labor was provided as a way to foster wellness, as "the religious foundation of the York Retreat nurtured the belief that those who worked were the instruments of God's will" (cited in Haller & Larsen, 2005, p. 261). It also gave patients something meaningful to do.

In the 1800s, Tuke's son described mental illness as "a distortion or destruction of intellectual and moral powers" (Haller & Larsen, 2005, p. 261). Thus, the new moral treatment was designed to help the mentally ill regain control and restore their intellectual and moral faculties. Instead of shackles and physical restraints, fear was the mechanism used to combat mental illness. "There cannot be a doubt that the principle of fear, in the human mind, when moderately and judiciously excited, as it is by the operation of just and equal laws, has a salutary effect upon society" (cited in Haller & Larsen, 2005, p. 261). Apparently Tuke had some success reintegrating mentally ill persons back into society, because Rush and Kirkbride in America were strongly influenced by his ideas.

Conclusion

Asylums multiplied in direct proportion to industrialization, bureaucracy, and urbanization, while concurrently the number of institutionalized chronically ill multiplied geometrically (McGovern, 1993, p. 691). Although treatments may seem outdated or even quaint by today's standards, they represented a great leap of progress at the time. Wikipedia's entry on psychiatric hospitals provides an extensive collection of pictures and postcards depicting asylums, as well as lists of the largest and best-known institutions — some that still exist today, some still standing but closed, some still standing but no longer used as asylums, and some that have been demolished.