Psychiatric Hospitals In The 18th Century

The history of psychiatric hospitals find its origins in classical workhouses and houses of correction. From the 18th to 20th century, there was a transformation of workhouses into insane asylums and finally into psychiatric hospitals and along with this transformation of institutions came a shift to medical understandings of mental illness. Ultimately, the barbarous practices that occurred within asylums caused another shift in psychiatric care towards deinstitutionalization, psychology outside of asylums, and increased psychiatric medication. There were two prominent figures who laid the foundations for the transformation of the workhouse into a psychiatric institution, William Tuke in England and Philippe Pinel in France. This paper will
briefly explore the foundations of workhouses and houses of correction and discuss the factors behind their change into psychiatric hospitals through the examination of moral treatment, the expansion of mental institutions, and the introduction of medicine and drugs into asylums.
The initial uses of asylums were that of charitable institutions that took the form of houses of correction or workhouses. Inmates in these early asylums were seen as dangerous and disturbed, and it was viewed as necessary to keep these individuals out of the public. Those deemed mad “underwent this process of confinement for a century and a half” until the establishment of the Hopital General in France in 1676 due to a royal edict. In England, a 1575 Act ordered the establishment of houses of correction as a means to punish and control vagabonds. In both countries, there was a “presumed need to segregate the mad from society” and that this need would require “an ever-larger network of new institutions” to accomplish it. The societal perception of madness led to the development of the ‘great confinement’ that remained the primary response to mental illness until the end of the 20th century. The workhouses in 1781 housed primarily “‘beggars, idle persons, petty offenders of both sexes... poor and criminals…aged and infirmed”. The notion that the sick should not be locked up with the insane and that madmen differed from criminals was not established till mid-late 18th century. At this point in the development of psychiatric institutions, confinement was uniform and all encompassing.
The model of workhouses and houses of correction began to shift into privately run asylums in the late 17th century with establishment of a major asylum, the Bethlem Royal Hospital in London. By 1728, wards were being established within hospitals in London to treat individuals diagnosed as chronic lunatics. By the mid-18th century, there were a number of charity funded public asylums that appear in England. Among them were the Manchester Lunatic Hospital established in 1765 and the York Asylum established in 1777. There was a similar expansion in British American colonies with Virginia and Pennsylvania establishing hospitals for the insane and disordered minds in the late 18th century. The asylum was becoming the preferred solution to deal with the mad. However, the early asylums varied greatly in size and conditions. In England, asylums did not legally require medical supervision before 1800.
With the arrival of the Enlightenment Period, attitudes towards the mentally ill shifted towards the notion that it was a disorder that required treatment.
Mental illness came to be seen as an ailment which could be treated and cured. In the early 1780s, there was a movement towards introducing more humane conditions into asylums. This movement developed into moral treatment. Moral treatment was established by French physician Philippe Pinel and English Quaker William Tuke. Moral Treatment was an approach to mental illness based on psychosocial care and moral discipline that was both psychiatry and religious in nature. Scientific and religious leaders in moral reform “viewed madness as a breakdown of internal, rational discipline on the part of the
sufferer”.
Firstly, William Tuke’s contributions to the shift in asylums from workhouses to psychiatric institutions was through his work in moral treatment at the York Retreat from 1796 onwards. Tuke and the English Quakers played a substantial role in the proliferation of moral treatment and the origins of psychiatric care for over a century despite initial resistance from the government. Early pioneers of the York Retreat pushed for humanitarian reforms within madhouses due to the manner in which the mentally ill were treated. While the York Retreat was viewed as the birthplace of moral treatment, it was also the origin of institutional care for mentally ill individuals. William Tuke and his decedents were primarily concerned with “humane care for insane Quakers though he also hoped, if possible, to cure them”. Tuke, and his decedents were associated with the development of moral treatment and institutional care for mentally ill individuals. Samuel Tuke, William Tuke’s son, wrote and published academic articles on the subject further spreading moral treatment as an idea. Tuke and his associates at the York Retreat thought they established a new and innovative method for treating the mentally ill. This was one of the first instances of psychological care being introduced to burgeoning asylums in England.
Meanwhile in France, Philippe Pinel became the head physician at Bicêtre Hopital in 1792. The Bicêtre Hopital was the main public madhouse in France for men only. Pinel was a pioneer for moral treatment in France. Pinel’s understanding of moral treatment differed from Tuke’s understanding. While Tuke’s moral treatment focused on the “moral sense,” Pinel’s understanding was a “therapy of the emotions”. Pinel directed his treatment towards emotional factors, mental experiences, and descriptive factors. Pinel’s work at Bicêtre revolutionized asylums by introducing a medical element to what were at the time places of incarceration for undesirables. The appointment of Pinel was proof in itself that ‘madness’ at institutions was becoming a medical problem. Pinel introduced and formalized the medical function in French mental institutions. The shift from workhouses to psychiatric institutions begun with the “revision of all confinements for madness” and the introduction of medicine. The period of Pinel and Tuke saw a “landmark discussion devoted to the ‘psychopathology of affectivity” and the development of terminology surrounding moral affections which ranged from moral and ethical themes to intellectual and psychological themes. The proliferation of asylums across Europe was in part due to the actions of Philippe Pinel and William Tuke.
In France, Pinel’s student, Jean-Etienne Dominique Esquirol secured a post in Salpêtrière Hospital, the female counterpart to Bicêtre, in 1811.
Similar to his mentor Pinel, Esquirol championed for asylums to be therapeutic institutions. He wrote the ground-breaking psychiatric text, Mental Maladies, in 1838 and did extensive research into psycho-social triggers. Esquirol further developed psychiatric practices in in asylums by studying under cohorts of French psychiatrists. Esquirol expanded on Pinel’s work on moral insanity and affective disorders. As early as 1819, Esquirol had devised a plan for a national system of asylums in France. A national system formed in France with a state led effort for the institutionalization of madness. Esquirol established multiple new mental hospitals in France. Furthermore, Esquirol established the National Asylum in Paris and was appointed director. As director, he emphasized careful selection of attendants and the establishment of a psychiatric
environment.
On the other hand, in England, the national system of asylums began in 1808 with the County Asylum Act, which allowed for magistrates to build asylums within the counties to house madmen and lunatics. The first public asylum that opened in the UK was the Bethlem Hospital. The Bethlam Hospital was formally established through British charity in 1547 by Henry the Eight. With the establishment of the County Asylum Act, it grew into a Hospital to cure lunacy. In 1838, the National Assembly in Britain passed legislation that directed counties to build public asylums as public expenses in order to house individuals deemed insane. Private asylum licenses were allowed in 1828 by the Metropolitan Commissioners in Lunacy public body. The British national expansion of asylums was further proliferated after the work of Tuke through the 1845 Lunacy Act that officially mandated the construction of public asylums, the licensing of private asylums, and the authority of the newly reformed Commissioners in Lunacy over supervision of “the emerging empire of asylumdom”. Overall, between 1808 and 1845, approximately fifteen counties had established asylums.
However, the initial county asylums established were a novel institution and lacked universal provision. Early asylums existed alongside private madhouses and bourgeoning private mental institutions. In this period of time, mental institutions were undergoing a transition that was dubbed a “mixed economy of care, involving public, private, and voluntary sectors”. By 1860, the proliferation of the asylum revolution was in essence complete and the status of mentally ‘insane’ individuals shifted to patients needing early stages of psychiatric care. At the beginning of the 18th century, there were only a few hundred asylums in both France and Britain. However by the arrival of the 19th century, the number of asylums between the nations had grown into the hundreds of thousands.