Historical treatment of the care of the insane
Insane, ASYLUMS AND CARE FOR THE.—During the seventeenth and eighteenth centuries hospital care of the sick of all kinds and nursing fell to the lowest ebb in history (see Hospitals). Institutions and care for the insane, not only shared in this decadence, but were its worst feature. Because of this, many writers have declared that proper care for the insane and suitable institutions developed only in recent generations. As the Church had much to do with humanitarian efforts of all kinds in the past, it has been made a subject of reproach to her. As a matter of fact the Church, from the earliest times, arranged for the care of the insane, and some of the arrangements anticipated some of the most important advances of modern times. It was after the religious revolt in Germany, whose influence was felt in other countries, that the Church's charitable institutions suffered in many ways, and hospitals and asylums of all kinds deteriorated.
Insanity has been known for as long as our record of human history runs. Pinel, the great French psychiatrist, in his "Nosographie philosophique", II (Paris, 1798), 28, gives the details of the treatment of the insane by the priests of Saturn, the god of medicine in Egypt, in special parts of the temples. According to this, those suffering from melancholia were treated by suggestion, by diversion of mind, and recreations of all kinds, by a careful regimen, by hydropathy, by pilgrimages to the holy places. In Greece we know of the existence of insanity from its occurrence in the various myths. Ulysses counterfeited insanity in order to escape going on the Trojan expedition, and ploughed up the seashore, sowing salt in the furrows. When Nestor, however, placed his infant son in front of the plough, Ulysses moved the boy aside, and Nestor said there was too much method in his madness. Evidently at this time (1200 B.C.) the Greeks were quite familiar with insanity, since they could even detect malingering. The stories of Ajax killing a flock of sheep which by illusion he thought a crowd of his enemies, of Orestes and the Furies, of the Bacchae, all show familiarity with insanity. As in Egypt, the insane in Greece were cared for in certain portions of the temples of the god of medicine, Aesculapius. In the famous temple at Epidaurus, part shrine and part hospital, there was a well-known spring, and hydropathy was the main portion of the treatment, though every form of favorable suggestion was employed. Interesting diversions were planned for patients, and they had the distinct advantage of the journey necessary to reach Epidaurus. Insanity was looked upon as a disease and treated as such. The delirium of acute disease had not as yet been differentiated from mania, and melancholy was considered an exaggeration of the depression so often associated with digestive disturbance. The first hospital for insane patients of which there is mention was at the Pirmus.
Among the Romans we have abundant evidence, in their laws, of care for the insane, but we know little of their medical treatment until about the beginning of the Christian Era. In the Twelve Tables curators are assigned the insane even after their majority. They could transact no business legally, but during lucid intervals could make binding contracts. When parents were insane, children could marry without their consent, but this had to be explicitly stated. The insane could make no wills, nor be witnesses of wills except during lucid intervals, but the lucidity had to be proved. With all these careful legal provisions it seems incredible that medical care should not have been given, but all records of it are wanting. At Rome, a series of writers on insanity made excellent studies in the subject, which could only have been made under circumstances that allowed of such careful study of the insane as we have opportunities for in modern times (Celsus, first century; Caelius Aurelianus, about A.D. 200, mostly a translation of Soranus; Alexander Trallianus, 560). Among the Greek writers, Hippocrates (about 400 B.C.), Asclepiades, who wrote shortly before Christ, as well as Aretaeus of Cappadocia, Soranus, and Galen, who wrote in the first two centuries after Christ, show a considerable knowledge of insanity. The great Roman student of the subject, however, was Paulus Aegineta (630), whose writings show such a thorough familiarity with certain phases of insanity as could only have been obtained by actual observation, not of a few patients, but of many.
With the beginning of Christianity more definite information as to asylums for the insane is available. Ducange, in his "Commentary on Byzantine History", states that among the thirty-five charitable institutions in Constantinople at the beginning of the fourth century there was a morotrophium, or home for lunatics. This seems to have been connected with the general hospital of the city. In the next century we have the records of a hospital for the insane at Jerusalem, and it is probable that they existed in other cities throughout the East. Nimesius, a Christian bishop of the fourth century, collected much of what had been written by older authors with regard to the insane, adding some observations of his own, and showing that Christianity was caring for these unfortunates. With the foundation of the monasteries the insane were cared for in connection with these. The Rule of St. Jerome enjoined the duty of making careful provision for the proper treatment of the sick, and Burdett, in his "Hospitals and Asylums of the World", considers that this applied also to those suffering from mental disease. He adds: "It is beyond question that in the earlier times, commencing with provision for the sick, including those mentally ill, by the early bishops in their own houses, the Church gradually developed an organization which provided for the insane, first in morotrophia (i.e. places for lunatics) and then in the monasteries. Evidence of the existence of this system is to be met with in France, Italy, Russia, Spain, Germany, and in some of the northern countries of Europe (op. cit., I). With the foundation of the monasteries of the Benedictines and the Irish monks, hospitals were opened in connection with them (see Hospitals). The insane were cared for with other patients in these institutions, and we have many prescriptions from the olden times that are supposed to be cures for lunacy. The cleric author of "Leechdom, Wortcunning and Star Craft of Early England", a collection of herbal prescriptions made about A.D. 900, gives remedies for melancholia, hallucinations, mental vacancy, dementia, and folly.
There are records of many institutions for the insane. Desmaisons declared that "the origin of the first establishment devoted to the insane in Europe dates back only to A.D. 1409; it was founded in Valencia in Spain under Mohammedan influence" (Des Asiles d'Alienes en Espagne, Paris, 1859). This statement has been often quoted, but is entirely erroneous. We know for instance that there was an asylum exclusively for sufferers from mental diseases at Metz in 1100 and another at Elbing near Danzig in 1320. According to Sir William Dugdale (Monasticon Anglicanum, London, 1655-73), there was an ancient English asylum known as Berking Church Hospital, situated near the Tower of London, for which Robert Denton, chaplain, obtained a license from King Edward III in 1371. Denton paid forty shillings for this license to found a hospital in a house of his own in the parish of Berking Church, London, "for the poor priests and for the men and women in the said city who suddenly fall into a frenzy and lose their memory, who were to reside there until cured; with an oratory to the said hospital to the invocation of the Blessed Virgin Mary". About this same time there is a tradition of the existence of a pazzarella, or place for mad people, in Rome, the conditions of entrance being rather interesting.
Lunatics were cared for, moreover, in special departments of general hospitals. At Bedlam, the London hospital founded in the thirteenth century, this was true (see Bedlam). Evidently the same thing was true at many other places. At first glance this might seem open to many objections. Psycho-paths in modern times, however, have been trying to arrange to have wards for acute mental cases in connection with general hospitals, for patients thus come under observation sooner; they are more willing to go to such hospitals and their friends are more ready to send them. Serious developments are often thus prevented. In this system of psychopathic wards in general hospitals the Middle Ages anticipated our modern views. In another phase of the care of the insane there is a similar anticipation. At Gheel in Belgium the harmless insane are cared for by the people of the village and the neighboring country who provide them with board, and treat them as members of the family. This system has attracted much attention in recent years, and articles on Gheel have appeared in every language. It has its defects, but these are probably not so great as those that are likely to occur in the institutional care of such patients. This method of caring for the insane has been practiced at Gheel for over a thousand years. Originally the patients were brought to the shrine of St. Dympna, where, according to tradition, they were often healed. The custom of leaving chronic sufferers near the shrine, under the care of the villagers, gradually arose and has continued ever since. Nearly every country in Europe had such shrines where the insane were cured; we have records of them in Ireland, Scotland, England, and Germany, and it is evident that this must be considered an important portion of the provision for these patients. In France the shrines of Sts. Menou, or Menulphe, and Dizier were visited from very early times by the insane in search of relief. The shrine of St. Menou at Maillysur-Rose was especially well known and a house was erected for the accommodation of the mentally diseased. At St-Dizier a state of affairs very like that at Gheel developed, and the patients were cared for by the families of the neighborhood. All of this interesting and valuable provision for the care of the insane, as well as the monastic establishments in which they were received, disappeared with the Reformation.
Spain, though not the first country to organize special institutions for the insane, did more for them than perhaps any other country. The asylum at Valencia already mentioned was founded in 1409 by a monk named Joffre, out of pity for the lunatics whom he found hooted by the crowds. The movement thus begun spread throughout Spain, and asylums were founded at Saragossa in 1425, at Seville in 1435, at Valladolid in 1436, and at Toledo before the end of the century. This movement was not due, as has been claimed, to Mohammedanism, for Mohammedans in other parts of the world took no special care of the insane. Lecky, in his "History of European Morals", has rejected the assertion of Desmaisons in this matter, which is entirely without proof. Spain continued to be the country in which lunatics were best cared for in Europe down to the beginning of the nineteenth century. Pinel, the great French psychiatrist, who took the manacles from the insane of France, declared Spain to be the country in which lunatics were treated with most wisdom and most humanity. He has described an asylum at Saragossa "open to the diseased in mind of all nations, governments, and religions, with this simple inscription: Urbis et Orbis" (Traite Med.—philos. sur l'alienation mentale, Paris, 1809). He gives some details of the treatment, which show a very modern recognition of the need to be gentle and careful with the insane rather than harsh and forceful.
The pazzarella at Rome already mentioned was founded during the sixteenth century by Ferrantez Ruiz and the Bruni, father and son, all three Navarrese. This hospital for the insane "received crazed persons of whatever nation they be, and care is taken to restore them to their right mind; but if the madness prove incurable, they are kept during life, have food and raiment necessary to the condition they are in. A Venetian lady was moved to such great pity of these poor creatures upon sight of them that on her death she left them heirs to her whole estate." This enabled the management, with the approbation of Pope Pius IV, to open a new house, in 1561, in the Via Lata. In France and Italy the custom continued during the seventeenth and eighteenth centuries of placing lunatics, particularly those of the better class—though also of other classes when they had patrons who asked the privilege—in male or female monasteries according to their sex. This practice also prevailed in Russia. In 1641 the Charenton Asylum was founded in one of the suburbs of Paris, near the Park of Vincennes, and was placed under monastic rule. After the foundation of the Sisters of Charity of St. Vincent de Paul, the charge of this institution was given to them. During this century the French established a system of colonies by which the insane were transferred to country places for work during intermissions in their condition, and were returned to the central asylum whenever they were restless.
During the eighteenth century there was an awakening of humanitarian purpose with regard to the insane in nearly every country of Europe. St. Peter's Hospital, at Bristol, England, was opened in 1696; the Manchester Royal Lunatic Hospital in 1706; Bethel Hospital at Norwich in 1713; Dean Swift's Dublin hospital in 1745; while the Pennsylvania Hospital of Philadelphia (1751) and the New York Hospital (1771) each contained wards for lunatics. In 1773 the first asylum exclusively for the care of the insane in the United States was opened at Williamsburg, Va. After this, asylums for the insane multiplied, though the system under which the inmates were cared for involved many abuses. Burdett's third chapter is entitled "The Period of Brutal Suppression in Treatment and Cruelty: 1750 to 1850".
In 1792 what has been called the humane period in the treatment of the insane began, when Pinel, against the advice of all those in authority and with the disapprobation of his medical colleagues, removed the chains and manacles and other severer forms of restraint at the great asylum of Bicetre, near Paris, and gave the inmates all the liberty compatible with reasonable safety for themselves and others. At the same time William Tuke was engaged in establishing the retreat near York, which came into full operation in 1795. In this institution very enlightened principles of treatment were carried into effect. Early in the nineteenth century, Dr. Charles Worth and Mr. Gardner Hill, in the Lincoln Asylum, did away with all forms of mechanical restraint. The non-restraint system was fully developed by Dr. John Conolly in the Middlesex County Asylum at Hanwell. In the mean time, at the second institution solely for the insane in the United States, the Friends' Asylum at Frankfort, Pennsylvania (1817), the principles of gentle, intelligent care for the insane were being thoroughly applied and developed. The treatment of the insane was first systematized by Dr. S. B. Woodward, at Worcester, Massachusetts. Dr. Kirkbride of Philadelphia did much to remove the evils of restraint. Miss Dix must ever bear an honored name for her successful philanthropy in doing away with many abuses in England and her native America. In recent years the care of the insane has to a great extent come entirely under the control of the State. This was apparently rendered necessary by the abuses that crept into private institutions for the insane. Even in the State institutions, however, until the last twenty-five years, there were many customs to be deprecated. Mechanical restraints of all kinds were used very commonly in America; within a generation patients were fastened to chairs, or to their beds, or secured by means of chains. The "open door" is, however, now becoming the policy of most institutions. Modes of restraint are very limited and used only with proper safeguard.
Most American institutions are overcrowded, because it seems impossible to increase accommodations in proportion to the increasing numbers of the insane. There are two reasons for this increase. One is an actual increase in the proportion of the insane to the total population because of the strenuous life. Another is that in our busy modern life there is less inclination to keep even the mildly insane at home. Apart from the State institutions, there is a reaction to the old monastic system of care for the insane, and there are many large and well-known insane asylums in America under the charge of religious. The tradition established by Madame Gras at the foundation of the Sisters of Charity of St. Vincent de Paul has borne fruit. In America they have large asylums for the insane at Baltimore, New Orleans, Madison, N. J., and New York.
JAMES J. WALSH