Key Themes

Transformation of madness into mental illness.

Tension between environmental and biological causes of
illness, between somatic and psychological concepts.
Mental illness on the rise (?)
Cyclic optimism and pessimism towards treatment.
Treatment/conception of mentally ill both negative (i.e.
chaining up, burning, witch hunts) and positive (home
care, touched by God).
No exact records of many diseases until post-Industrial
Revolution, but many similar symptoms described.

Lecture 2: A Brief History of

Mental Illness and Psychiatry
Mat Savelli
savellm@mcmaster.ca
Office Hours: Mon 4-6pm
KTH 230A

Historiography

Pre-Institutional History I

First Whig
accounts
Second the
anti-capitalist,
antipatriarchy,
antipsychiatry
revisionism.
Third,
balanced?
Apologists?

Earliest recordings of madness

from second millennium BCE
describing things akin to mania,
depression, and delusions.
Hippocrates and Galen, both
situated madness in brain.
Fall of Roman Empire,
medicine declines. Revived by
Islamic scholars (Al-Razi, Ibn
Sina), treatment wards for mad
found across Muslim world.

Pre-Institutional History II

Trepanation

In Christian Europe, little systematic study of medicine.

Many believed Gods punishment or demonic possession
the culprit for madness. Others cited imbalance of
humours (biological).
Treatment in monasteries. Some witches and madmen
(especially dangerous) burnt at stake, etc Others
treated through prayer, bloodletting, whipping, etc
Not all sufferers poorly most probably stayed at home
with their family.

Practice continued in
some places until
nineteenth century
(and beyond).

Dancing Plague

The Extraction of the Stone of Madness

(The Cure of Folly) Hieronymous
Bosch, late 15th c.
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Bethlem Hospital

Bethlem in Popular Culture

Bedlam marks rising interest in mad as group
16th c. literature madmen, melancholics, suicides,
became common literary types. Shakespeare
referenced madness in half his plays.
Insanity become oft-used topic of ballads and songs.

A defining moment in the history of medicine,

establishment of Bethlem Hospital in London in 14th c.
Henry VIII later assigned it primarily for the mad, by
which point it was already going by the name Bedlam.

This Bethlem is a place of torment;

Heres fearful notes still sounding;
Here minds are filed with discontent,
And terrors still abounding.
Some shake their chains in woeful wise,
Some swear, some curse, some roaring,
Some shrieking out with fearful cries,
And some their cloths are tearing.

Images of Bethlem

Bedlam as Zoo
Hogarths
A Rakes
Progress:
Engraving
Eight

A tale of
18th c.
moral
decline

Open to visitors by 1610. Swarms of people started

visiting, (especially on holidays) to see the freak show,
in which the inmate was regarded as a beast or
monster.
Sold alcohol and snacks on grounds, people would
torment patients by teasing them, getting them drunk.
In 1690, they had to take special precautions to prevent
sexual contact between visitors and women patients.
Foreign tourism guides to London listed Bedlam as a
major attraction. By mid 18th century, 17 000 a year
coming to satiate their curiosity. In 1770, visitors were
banned not due to moral reasons, but because crowds
were becoming impossible to manage.

Pre-Eighteenth Century Notes

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Eighteenth Century

Why the increased interest in madness?

Real increase?
Madness becoming more severe/noticeable because
of the expanding population (civilization causes
madness)?
Most mad still in their homes and on streets.
Variety of explanations for mental illness - possession,
punishment, sin, anxiety, poverty, physical trauma,
illness, thwarted love.
Terms like insanity, madness, lunacy become common.
Violence and dangerousness key determinants in
someone being forcibly confined.
Treatment: bleeding, purging, whipping, restraining.
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Witnesses rise of private

madhouses and small
charity asylums, although
care in the home is still
the dominant model.
Still no such thing as
psychiatrists or a
particular professional
group who specialize
exclusively in the
treatment of the mad.
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Vagrancy Act 1714

Rise of Private Madhouses

Vagrancy Act 1714: differentiated pauper lunatics from

vagrants, sturdy beggars, rogues and others, and charged
Justices of the Peace with apprehending individuals who by
lunacy, or otherwise, are furiously Mad, and dangerous to be
permitted to go Abroad and to see that such individuals were
kept safely Locked up in such secure place within the
County and if necessary to be there Chained.
Confinement would be paid for by the parish.
Lunatics, unlike normal poor, were not to be whipped. No
requirement for treatment, however.
For the first time, the state begins to forcibly confine
lunatics on account of predicted dangerousness.
But where? Bedlam could only hold about 150 people,
beginning of an increase of hospitalization that would last
for 200 years.

Trade in lunacy develops during

the 18th century, as private
madhouses start popping up.
Anyone could open up a madhouse
and advertise for patients.
A money making initiative in an
age where people started paying
for new types of services.
Lack of oversight meant many
lunatics kept in atrocious
conditions. Most received no
treatment as these were primarily
places of custodial care.
Wrongful confinement fears.

Im not the lunatic, THATs

the lunatic!

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Regulating Madhouses

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The Age of Enlightenment

Advances in science and medicine generally
couldnt madness be explained?
Belief in improvability, changeability, curability
- reason as the key to every lock. Restore a
patients reason and he could be cured.
Idea that asylum could actually be used to
cure, rather than simply store, a patient.
Transformation of the madhouse into
therapeutic facility.
Transformation of madness into mental
illness.

1774 Act for Regulating Madhouses

law provided for inspection and
licensing of madhouses by the
Royal College of Physicians
Involuntary confinement possible
only after a physician and Justice of
the Peace had reviewed the case.
Marks the beginning of state control
of lunacy more broadly (not just
dangerousness).
Important step in medicalizing
madness.
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Tukes and the York Retreat

Moral Treatment I - Philippe Pinel

Phillippe Pinel
Appointed to head leading French mental hospitals in
1793 where he famously had the chains removed from
patients.
Believed he could improve reasoning ability of mentally
ill.
If treated with dignity, patient more likely to recover.
Individual time with each patient, building case history,
engaging in therapeutic conversation
Patients should be offered support and encouragement,
but punishment could be used if needed as well.

Founded by Quakers in
1796.
Rather than confine the
mad, free to work on the
surrounding farmland.
Dominated by lay people
in both therapeutic theory
and administration.
Kindness, rather than
harsh regimen, the guide
to treatment.
Became the leading model
of moral treatment.
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Moral Treatment II - Rise of the

Treatment Asylum

Jean-Etienne EsquirolDominique
Argued physicians w/
special training should be
charged with care of
mentally ill & it should occur
in special institutions
further medicalization of
madness.
Daily regimen is therapeutic.
Belief that isolation from the
environment that had
caused patients to go mad
was beneficial.

Moral Treatment - Basic Tenets

Pinel removing the chains

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Patients could be managed by kindness and control, understanding

and discipline. They could be treated with dignity and play an active
role in their own treatment. Stress on the humanity of the patient.
Asylum itself had a purpose.
Calm setting, surrounded by large grounds, farmland for asylum
self sufficiency.
Architecture important (i.e. rational, no bars, bright, airy,
segregation of patients by gender/disorder).
Discipline (self-control) and routine (to combat impulsiveness).
Restraint to be used sparingly, not to incite terror or pain.
Stress on doctor-patient relationship, alleviating persons pain.
Orderly life is restorative = scheduling, with work, games,
religious reading, education, all built in. Idleness opposed.
Getting away from emotional turbulence of family life, learning to
behave well with strangers in a communal setting.
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Asylum Building Era

The Failure of Asylums

1800 to mid-1900s, shift from confining

someone in an asylum as last resort to major
option for mentally ill.
From few (private) small hospitals to many
massive state institutions, explosion of pop.
The alienist first specialized professional for
mental illness

The story of good intentions gone bad.

Psychiatrists, as these new medical
professionals were being called, charged with
hundreds of patients each. Therapy gives way
to custodianship as asylums overcrowded.
Notion that patients, once in the asylum,
remained there until their death. Accurate?
By 1900, asylums were full, psychiatrists were
custodians looked down upon by fellow medical
professionals, very little therapy.
Psychiatry lost touch with medicine.
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What caused massive increase in

mentally ill?

The Madness of George III

Insanity of George III
helped change view of
madness in Britain.
First exhibited symptoms in
1788. Led to regency.
Massive public interest,
great outpouring of
sympathy.
Madness no longer equated
primarily with ignorance,
sin, or superstition. If
highest in the land could be
struck down, illness must be
natural, demanding of
sympathy, and amenable to
medicine like any other.

Social Control Thesis

OR
Real Rise?

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Foucault - The Great Confinement

Social Control

Period characterized by growing state authoritarianism.

Confinement of mad an attempt to stamp out deviancy,
especially those who did not accept values of new era
where labour and productivity were ultimate virtues.
Not confined because they needed medical attention or
out of humanitarian desire but because the state needed
to control them. An attempt to silence the mad.
Argues a link exists between the Age of Enlightenment
and the confinement of the insane an attempt to
impose reason on the unreasonable.

Asylums as dumping grounds for unwanted and

unusual.
Scull argues 19th c witnessed mad being segregated
from other deviants by bureaucratic capitalist state
machine and separated from society through the asylum
due to their economic unproductivity.
Madness transformed into mental illness.
Suggests that the existence of the asylum account for a
rise in the mentally ill, rather than vice versa.
Upper middle class trying to impose order and control on
lower classes. Psychiatry not humanitarian, just another
attempt at social control.

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Social Control II

Criticism of Foucault/Social Control

Mad doctors, in Sculls view, saw laymen as incompetent

and harmful to mentally ill; only their special asylums
could heal people and treat them decently.
Attacks the fact that they had little scientific knowledge of
lunacy, so claim on treatment monopoly is invalid.
Development of psychiatric profession as attempt to
establish power and hegemony over madness to boost
own authority. Helped the drive to build asylums by
stating their expertise and monopoly on treatment.
Asylum as their theatre of operation.

For Foucault, period prior to the rise of the state

asylum was the golden age of madness where
mad were free, celebrated as having special insight.
In reality most were probably poor and suffered.
Nothing to celebrate.
Not the state nor a professionalizing elite but
families at forefront of movement to get people into
custodial care. Took advantage of new asylums to
care for family members.
Asylums not dumping grounds as people moved in
and out, many recovered, many left and were readmitted.
Not all mentally ill treated in asylums.

Growing numbers of patients are indicative of the fact that

psychiatrists were willing to label pretty much any undesirable as
mentally ill.
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What about a Real Rise in Mental

Illness

Combination of Factors
Wider diagnostic categories.
People now using resources that were
previously unavailable to them (pauper
asylums).
Lumber room thesis.
Those who would have ended up in jail or
workhouse now in asylums.
Pressures of industrialization made home care
less feasible.
Some degree of social control (i.e.
nymphomaniacs, draptomaniacs, masturbators).
Some real rise in particular illnesses.

Perhaps industrialization and urbanization

responsible for increasing severity of some
mental diseases (i.e. alcoholism, tertiary
syphilis) and creating other entirely new
categories.
Recency Hypothesis schizophrenia is
actually a new disease that was born in the 19th
century, thus explaining the rise.
Immigration led to a rise in mental illness from
social stresses, poor sanitary conditions,
exposure to new viruses, etc
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Freud A True Revolution

Mental
healths
greatest
moment?

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Basic Theory
Mental disorder result of
conflicts between three parts of
the human psyche - the id, the
superego and the ego.
Believed conflicts began in
childhood. When the ego is
overburdened by demands of
the id and superego (anxiety) it
utilizes defence mechanisms
(repression, denial).
These processes unconscious
in nature and have to be
discovered using
psychoanalysis - dream
analysis, free association,
transference. Talking can help!

Or a fatal
blow?

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How Applicable?

Psychoanalytic Movement
Took psychiatrists out of the
asylum.
Widened meaning of mental
illness.
Treatment preserve of the
wealthy?
Strengthened importance of
patient/doctor relationship.
The face of psychiatry?
Stagnation of science?
Many key Freudian concepts
abandoned by mainstream
medicine.

Psychoanalysis centered on
Vienna, primarily upper
middle class Jewish
intellectuals.
This background, combined
with the intensity of treatment,
and the uselessness of
psychoanalysis regarding
severe mental disorder
ensured that it stayed a very
middle class movement.
Other key contributors include
Jung, Adler, Anna Freud, etc.
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Pre-WWII climate

Fevers, Comas, and Shocks

Amidst a climate of desperation

(overcrowding of asylums), desperate
search for new methods and cures begins
since psychoanalysis was out of the reach
for many patients (and theoretically
repugnant for many practitioners).
Psychiatrists, sick of being simple
custodians, sought to reintegrate into
mainstream medicine.

Julius Wagner-Jauregg develops malarial fever

therapy effectively treating the psychoses of
G.P.I. by inducing fevers through the injection of
malaria.
Manfred Sakel pioneers insulin-coma therapy to
treat schizophrenia, whereby patients were put
into frequent artificial comas by injections of
insulin for a period of a few weeks.
Ladislas von Meduna, believing the epilepsy and
schizophrenia are mirror image diseases
attempts to treat schizophrenia by inducing
epileptic seizures through Cardiazol.

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Electro-Convulsive Therapy (ECT)

OR

1938, Cerletti & Bini pioneer ECT by

using electrical stimuli to induce seizures
for treatment of severe psychosis
(practiced on stray dogs). Although they
chose electroshock for their method,
electricity only for induction of
convulsions its the convulsion and not
electric current that produces the effects.
Brief electrical stimulus which induces a
cerebral seizure, typically 6-12 sessions.
Still used to treat major mood disorders,
very occasionally schizophrenia.

Significance of new somatic

treatments
Psychiatrists often did not (and do not) understand
exactly how some of these treatments work.
Punishing or curing? If patients become docile and
manageable, perhaps its out of fear.
Health risks (memory loss in ECT, broken bones, etc).
Re-establishes connection between psychiatry and
medicine.
Preserves interest and exploration into biological
understandings and treatment of mental illness in a
period where psychoanalysis is ascendant.

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Psychosurgery

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Walter Freeman
Moniz inspires Walter Freeman, begins
propagandizing lobotomies across the US.
Introduces the transorbital lobotomy
using a medical ice pick to chip away at
the frontal lobe through the eye socket.
Drives around US with bag of tools
providing demonstrations on more than
3000 people.
Lost medical license when a patient died.

1935, Egas Moniz hears that

monkeys underwent emotional
changes after removal of part of
their frontal brain lobes.
In Lisbon, Moniz tries it out
(drilling holes into patients heads
and cutting with wire) claims
incredible results for leucotomy.
Awarded the Nobel Prize in 1949.
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10

The Psychopharmaceutical
Revolution

Lobotomy Fallout
Tens of thousands underwent
lobotomy procedures, including
JFKs sister.
Could result in drastic change of
personality, some patients turned
into vegetables.
Issues of informed consent
highlighted.
Focus on research ethics, clear
methodology.
Danger of scientific bandwagon
jumping.

Everything changes
with the discovery
of chlorpromazine
in early 1950s, the
first explicitly antipsychotic
pharmaceutical
medicationbut
well talk about that
later.
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Has Mental Illness Increased?

Considerations:

42

Causes of a Real Rise in Insanity

New medical speciality (psychiatry) seeking out patients.

Psychoanalysis brought an entirely new group of people
into the mentally ill equation.
Do new treatment options give rise to new disorders
(and did the asylum give rise to new patients)?
The mentally ill themselves as catalysts (i.e. patient
support groups for PTSD, eating disorders people now
have a language to describe their issues).
Combating stigma by medicalizing a problem
alcoholism.
What about a real rise?
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Idea that real rates of insanity have increased

typically insist that the Industrial Revolution and
urbanization are responsible. Why?

Dietary changes (gluten and potatoes)

Alcohol availability and consumption
Toxins (i.e. insecticides, latex)
Medical care improvements (saving those that would
have died previously)
Infectious agents (syphilis, vaccines affecting the
brain, polio epidemic)
Pet cats

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Conclusions

Lobotomy

Treatment of mentally ill not as good or

bad as many critics/defendants propose.
Both biological/psychological approaches
wax and wane over time, not always
mutually exclusive.
Large rise in people labelled mentally ill
compared to the mad not much
agreement on why.

http://www.pbs.org/wgbh/amex/lobotomist/program/
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