November, 1998

 A Newsletter of the Association for the Psychotherapy of Schizophrenia

and The Anne Sippi Foundation

November - 1998

Volume XIV

AN  INTRODUCTION

By Jack Rosberg

Mathew Knight has come to the United States from Great Britain  for one years training at the Anne Sippi Foundation, where he is learning some of the basic principles of psychotherapy and is an active participant in the development of a  psychosocial rehabilitation program.  I read his paper which will follow my introduction and was impressed with its scholarly style and the breadth of  information that it gives the reader.  I was also struck by some of the issues that are still relevant to our treatment today.  The reader should bear in mind that the material contained in the following paper by Mathew Knight has to do with the treatment of the mentally ill in the years 1600 to 1800.  This is 1998 and we need to understand that treatment for the serious mentally ill patient, has grown very slowly over so many years.  It isn’t enough to point to medication with a sense of pride and say, see what we have accomplished.  We have yet to understand well enough the process of schizophrenia and other serious mental disorders that goes beyond the symptoms and characteristics.  There is no question in my mind, that we have to challenge some of the unproven biological claims that are so dogmatically asserted by much of the psychiatric world. We need to abandon our rigidities and open our minds to new possibilities in treatment without disregarding some of the contributions that have been made in the past.  We need to review some of the champions that contributed to treatment over the years, so that we do not dismiss  the importance of looking at these unfortunate victims of mental illness in a humanistic way.  We cannot continue to believe that the treatment of these conditions is primarily a medical speciality.  There are many professional disciplines that need to be acknowledged and it is critically important that we allow ourselves to see the value of interprofessional harmony.  

I am grateful to Mathew Knight, not only for the excellent paper that follows, but while learning he is also making a contribution.  His willingness, his candor, his aptitude leads me to believe that over the years he will be an important contributor to the most challenging issues facing the mental health professional and that is, that person with schizophrenia and related disorders.   

Should you have any message that you wish to send to him, I would be glad to submit it.

 

Jack Rosberg,

Executive Director

Anne Sippi Foundation

From the Pauper to the King:

 The Birth of  Moral Therapy in England

c1660 - 1800.

 

by Mathew Knight

 

 

 

The social landscape of Seventeenth and Eighteenth Century England was an ever changing era of mercantilism and spatial orientation, against the background of an alliance between the judicial powers of absolutism and the logic of enlightenment. The genesis of an age of reason; in which all unreason - poverty, insanity - was sequestrated, not in a centralised manner, but by localism and community action. Though Foucault’s notion of a ‘great confinement’  from the 1660’s is now generally regarded by historians as  seen on too grand a scale , lunatics, as well as alcoholics, deflowered daughters and all manner of people were placed under lock and key. Institutions of confinement, instruments in the process of education and coercion were geared to a public viewed just as the object of the didactic process of enlightenment. Society had for the first time in history dedicated itself to honouring the values of liberty and property,  and as such the insane were placed outside what the community regarded as society.

 Many early madhouses were not hospitals, but were simply the home of the  keeper. The lunatic was placed there privately, with the costs of confinement met out of the lunatic’s own estate, by his family, or in the case of pauper lunatics - by the parish. These keepers were lay persons, principally clergymen of whom many believed that the connection between religion, the cure of souls, and mad doctoring, the cure of minds, made good historical sense. Others were not even concerned with healing, for the community was purely concerned with placing them out of sight. Madness itself was defined in terms of how mad people were supposed to look and behave, with courts asking whether the accused ‘acted like a lunatic’. It was therefore conceived predominantly in terms of demeanour; gait, physiognomy, and deeds - rather than of disease.

 Thomas Willis, in his “Essay on the Pathology of the Brain and Nervous Stock”  of 1667 proposed a new approach inspired by the ‘Corporeal Soul’, or mind, making extensive studies in neuroanatomy and neurophysiology by dissection and experiment. Willis wrote that the sensus communis controlled the spiritus animales, the perception of experience, fantasy, imagination and memory - and labelled it ‘psycheology’. The ‘first inventor of the nervous system’ superseded the traditional humoral-chemical explanation of insanity with a neurological-psychological method. Animal spirits were, Willis believed, distilled from blood in the brain as in a gland, their circulation accounting for nervous action. Therefore, as intermediaries between mind and body, actions could be disordered by either - and as such treatment could be mental or physical. Willis believed it “often expedient to change the place of habitation”, thereby removing the person from his/her family, and negating the need to care of ‘household affairs’. Once there, persons suffering from low spirits, depression, melancholy; ‘affective psychosis’- attributed to the heart, needed stimulating:

 

  • The Soul  should be withdrawn from all troublesome and restraining passion… and composed to cheerfulness or joy, pleasant talk or jesting. Singing, Musick, Pictures, Dancing and other pleasant exercises are to be used.   However, “Melancholy being a long time protracted…passes sometimes into madness.” Persons suffering from madness; psychosis accompanied by thought disorder, delusion and hallucination, schizophrenia - attributed to a vice or fault of the brain, needed to have their high spirits lowered, depleted and repressed. Mad people are;
  • more certainly cured by punishments and hard usage, in a strait room, than by Physick or Medicines…. Let the diet be slender and not delicate, their cloathing coarse, their beds hard, and their handling severe and rigid.
  • The dichotomy of treatment methods is further extended by Willis writing that “Curatory…requires threatnings, bonds, or strokes…bloodletting, vomits or very strong purges, and boldly and rashly given…cupping glasses with scarification... Blisterings”. Physical punishment is also accompanied by mental intimidation,  Willis wrote, “there is nothing more effectual or necessary than their reverence or standing in awe of such as they think their tormentors.”  As such, this insight into an early private madhouse, a realm in which any mental, moral, social or political phenomena could be called sick or abnormal, reveals a duality of approaches to treatment, one uplifting - the other, sometimes after failure of the first method, a regime of mental and physical pressure.

    •  Thomas Sydenham  replaced Willis’ neutralising scientific observation, with an inner vision. Relating the spirit to the corporeal constitution, and linking the weakness of the constitution to the weakness of the heart - Sydenham brought together the ‘psycho-physical dimension and the moral dimension.’ Where Willis had emphasised the role of nerves and contribution of supernatural causes, Sydenham proposed that the origin of hysteria was psychological, diagnosing it in one sixth of his patients. Hysteria in women was labelled hypochondria, and in men, melancholia. Of treatment of melancholics, Sydenham paraphrased what a Roman orator had said of the superstitious. “Sleep seems to be a relief from labour and inquietude, but from this many cares and fears arise” as dreams were filled with funerals and apparitions of dead people, both friends and strangers.

    Sydenham applied strong interests to divert the current of ideas from dejection, sending one melancholic nobleman who he had failed to cure to a Dr Robinson in Inverness. This doctor was in fact imaginary, as the nobleman found out after travelling for many days to see him, but the motive of this journey and the cure banished the prevailing irregular ideas he was suffering from. This was Sydenham’s initiative for the ‘quest’, and it proved successful. Indeed, so successfully viewed  were Willis and Sydenham, that until the middle of the 18th Century, doctors were guided by their theories about this ‘complaint’. It was partly due to this that doctors lost their traditional authority, and the image of  the physician was as concerned with politics, economics and literature - knowing little of medicine but as a business, hospitals themselves were even considered Whig or Tory. All the while, pauper lunatics remained outside the purview of medical science, at its theoretical and practical periphery - and as such many were placed in workhouses. From its inception in 1696, St Peter’s Workhouse in Bristol took pauper lunatics, the only provision regarding their welfare, that they were ‘usually’ separated from the sound minded paupers.

    Toward the end of the 17th Century, Bethlem (reopened at Moorfields in 1676, its second site, after being previously destroyed by fire) remained the only public asylum and educated opinion expressed a desire for a greater number of ‘Houses’,  for the purpose of maintaining or ‘correcting’ the insane. John Locke 1690 attempted to place Psychology on a scientific basis by “clearing the ground a little, and removing some of the rubbish that lies in the way of knowledge.”  He proposed that children were not born into a state of original sin, they were a ‘tabula rasa’, and as such, thinking and feeling resulted from education of the senses. Depending on the success of these processes, the mind may either fill with natural ideas and cognitive judgements, or it may end up cognitivelly and emotionally scarred. Madness was therefore a misconception grounded in false consciousness:

  • Mad men put wrong ideas together, and so make wrong propositions, but argue and reason right from then. Idiots make  very few or no Propositions, but argue and reason scarce at all.

    • Therefore, if the reasoning was correct, but the original information was wrong, Locke believed correction was possible, and admission to an asylum was the answer, due to ‘expertise’ in that form of medical treatment.  Daniel Defoe  the journalist and novelist, was incensed by the situation, and wrote expressing anger at many aspects of ill-treatment of the insane, and of the sane. Defoe continued  the distinction of mad men, who lose their reason, and idiots (fools, naturals), who are born without it - and demanded that, as there were no provisions for those born without reason, ‘Fool houses’ be erected, that naturals “without Respect or Distinction” be maintained. Defoe was not aiming to find a ‘cure’ for mad men or naturals, merely to safeguard their welfare during confinement. His rare humanitarian concern thus:

  • Of all persons who are Objects of our Charity, none move my compassion like those whom it has pleas’d God to leave in a full state of Health and Strength but Depriv’d of Reason to act for themselves.

    •  Protesting vehemently against the running of private Mad houses, Defoe’s attack was two-fold; firstly, against the lack of control against exploitation within these houses Secondly, against the increasing tendency for men, ‘thirsting after the puddles of lawless lust’ to dispose of wives, temporarily or permanently, that they had tired of:

  • If they are not mad when they go into these cursed Houses they are soon made so by the barbarous usage they there suffer….Is it not enough to make anyone mad to be suddenly clap’d up, stripp’d, whipp’d, ill fed, and worse us’d…? And what is worse, no Soul to appeal to but merciless Creatures, who answer but in Laughter, Surliness Contradiction, and too often Stripes?
  • Defoe’s directive was therefore to suppress the private Mad houses, licensing  and subjecting them to proper visitation and inspection. Of the people sent there, admissions should only be after due reason, enquiry and authority had been established. Funding of these projects was to come from the more reasoned population, categorised by status and income, and presented an utopian ideal of his surroundings which  Jonathan Swift, a novelist and political satirist, was quick to put down. In Swift’s book, “Gulliver’s Travels”, the island of Laputa - populated by planners, project-makers and overly demanding rationalists, let reality fall by the wayside. Thus Swift presented this ‘utopian state’ as impractical. However in reality, his actions were practical; the strength of his feelings toward the matter made concrete by the provisions in his will partly funding the erection of the first madhouse in Ireland.

    • Entering the ‘long 18th Century, legal consideration of Pauper lunatics occurred. In an Act of Parliament, 1714, pauper lunatics were distinguished from disorderly persons, idle rogues, vagabonds and sturdy beggars. It specifically empowered two magistrates to order confinement of the ‘furiously mad’ for as long as ‘such madness or lunacy should continue. Treatment during confinement was not provided for, but exempted lunatics from the whipping they had previously been liable, and which remained for beggars and the like. It was three decades later, in the 1744 revision of the law that actual treatment of the insane was referred to, the first in legislation to do so. Under the marginal heading, ‘Lunaticks, how to be disposed of, Parishes were ordered not only to remove pauper lunatics to a secure place for public safety, but to be responsible for “curing such a Person during such restraint.”

    The insane were thus removed to private Mad houses, half way houses,(ad hoc  boarding with a cleric or doctor), or to the public asylum. Indeed, partaking of an 18th Century ‘consumer boom’ unregulated private Madhouses sprang up in abundance, and threw into sharper relief what had always been the ‘expertise’ of medical practitioners and lay proprietors, and the needs of the insane and their families. Though the trade in lunacy was making large promises as to curative therapies, comforts and gentleness - alongside good accommodation, air, exercise and diet, the implementation of such ideals was rare. One Mad house keeper wrote, “If a man comes in here mad, we’ll keep him so; if he is in his senses, we’ll soon drive him out of them.” In 1740, an anonymous writer spoke of his concerns in his “ Proposals for redressing some grievances which greatly affect the whole nation” that the care and protection of the insane, deprived of their liberty in institutions and at the mercy of their keepers, was a matter of legal, social and humanitarian concern. Extending Defoe’s proposals, he suggested certain safeguards which eventually became law in 1774. The Act for Regulating Private Mad houses ordered inspection by the College of Physicians in London, compulsory notification of patients detained, and severe punishment (of the Keepers) if they did not abide by these rules. It did not end the evils of private Mad houses, for enforcement was lax, but did increase awareness in the public eye. However, it had no control over ‘single lunatics’ privately boarded in the half way houses, and more importantly, of public Asylums.

    Bethlem, though a small institution, created a disproportionately large image of itself - indeed it was and still is infamous for being representative of man’s inhumanity to man. The nepotistic ‘reign’ of four generations of Monro’s, characterised by supineness, sanctioned the callousness and cruelty below. It can be said that none of the physicians in this period investigated insanity or advanced its treatments. While every person had their own cell, what occurred within those cells more than negated this positive aspect. The case of James Norris epitomises all that was evil in Bethlem; confined in a custom built harness of chains and rods, nearly all his movement was restricted - for eighteen years. Swift wrote of Bethlem as being a place of “phlebotomy, whips, chain, dark chambers and straw.” However, Swift himself became a governor, and tried to commit one of his friends. William Battie also subscribed £50 to become a governor of Bethlem in 1742, though his contribution to the progression of treatment began after, and greatly due to, his time there.

    The treatment of the insane had become a major issue, both politically, socially and scientifically.  Medicine, caught in a web of political demands, social and scientific objectifications and humanitarian promises, instituted a division of labour by making psychiatry a separate branch. Battie, a prime mover in changing public attitudes by means of a new formulation of the nature of insanity, became the first and only psychiatrist to be President of the Royal College of Physicians. He wrote the Locke -derived “ Treatise on Madness” in 1758, presenting, albeit in theoretical and simplified form, the main thrust of what wouuld be Tukean moral therapy. He declared that madness was, “Deluded Imagination, false perception, being then a praeternatural state or disorder of Sensation.” Demythologising and differentiating classic unreason - madness as a sickness - Battie thus differentiated from the views of Locke in that Madness was no longer solely a disorder of the mind, a false association of ideas - it incorporated sensation itself. As such, the mad man could no longer be viewed in absolutist - enlightened terms, as a rational refutation of error. Sensation was a profound and real disorder, and was anchored in the corporeality of nerve substance.

    Battie saw anxiety as a possible trigger of madness, and idiocy as a final stage, and this was the first time that madness had been conceived as a historical process. Battie also accepted that not all madness could be treated, “We should take great care not to do harm where it is not in our power to do any good.” He made an aetiological distinction between the two types of madness he proposed. Original madness was categorised as an internal disorder of the nervous system - as such it would not respond to medical treatment, but may disappear spontaneously. Consequential madness, which Battie, like Locke, believed had deluded imagination as a central component, was an intermediary stage of madness - and would respond to treatment. Battie laid down rules of treatment, and decried other methods.

  • Madness, like most other morbid cases, rejects all general methods, e.g. bleeding, blisters, caustics, rough cathartics, the gumms and faetid anti hysterics, opium, mineral waters, cold bathing and vomits. He advocated a complete separation from home and family, “confinement alone is sometimes sufficient, but always so necessary. Without it every method hitherto devised  for the cure of madness would be ineffectual.” Battie emphasised that he was interested in curing, rather than merely confining the insane. Utilising a basic principle that scientific authority overrides social authority; Battie shielded nerves, checked appetites, diverted fixed imaginations and enforced exercise - believing that stimulation of opposite emotions, and occasional narcotics were the manner in which passions were to be lowered. Therefore, by means of discarding traditional ballast which stood in the way of progress, rather than advancing any novel doctrine, Battie’s treatise gave great impetus to a rational study of the insane. He shifted the emphasis from the perspective of madness as one uniform disease, to the management of individual patients, with individual, even unique symptoms.
  • Madness is…as manageable as many other distempers…and that such unhappy objects ought by no means to be abandoned, much less shut up in loathsome prisons as criminals or nuisances to the society.

    • This movement was the beginnings of ‘Moral Management.’ Traditional remedies were harsh and indisciminate. In so far as Madness could be cured, it would not be through medicine, but through management directed to the mind and character. By engaging the patient’s attention, gaining his respect and breaking evil habits and associations - and by placing him/her in an asylum, cures would be maximised. This was manifested when Battie left Bethlem, and founded St Luke’s in Moorfields in 1750. With Battie himself as physician, he became the first teacher of psychiatry, empowered to take pupils. Among those attracted was Sir George Baker, who would attend George III in his illness from 1788 - 1789.

     John Wesley, the Methodist minister, whose enthusiastic and popular approach to the poor had helped starve off the major political and social upheaval in England, and whose concern went beyond spiritual salvation, to a physical salvation, looked around Battie’s St. Luke’s, “I was surprised to observe, that three in four, at least, of those admitted receive a cure. I doubt this is the case of any other lunatic hospital either in Great Britain or Ireland.” Wesley himself tried to further treatment, and find a cure for insanity. Extending his instructions for self-treatment, he used  Benjamin Franklin’s ‘Electric treatment machine’ ten years before any hospital did.

    Battie’s example stimulated the building of other hospitals: Manchester 1766, Newcastle upon Tyne 1767 and York 1777, in which the method of treatment moved from theoretical discussion to one of case histories and preoccupation with physical treatments to regimen and management. However, Battie had, without naming it, laid blame on Bethlem and its monopoly of the insane. He criticised the “few, select physicians, most of whom thought it advisable to keep the cases, as well as the patients, among themselves.” These remarks were aimed at James Monro, who held office at Bethlem from 1728 until he died in 1758, and had not taught other physicians or  pupils.  John Monro - son of James Monro, and now ‘reigning’ over Bethlem - was humiliated and wrote “Remarks on Dr. Battie’s Treatise of Madness”, published within the year. In it he attempted to prove the pointlessness of making madness a topic of medical discussion stating that “Madness is a distemper of such a nature, that very little of real use can be said concerning it.” In line with rationalist tradition, Monro stated that madness was due to a vitiated judgement, that subjects were incapable of advancement or cure, and that thus justified coercion, restraints and physical treatment in their maintenance. This difference of opinion, the progressive against the regressive, created great animosity but it did not last, and indeed when Monro was sued by a former patient on the grounds that he had never been insane, Battie co-operated and was called at a witness. Battie’s use of records and  case histories, psychiatry in law, won the case for Monro, but was also testimony to Battie’s far superior approach to treatment of the insane. 

     This approach became the directive for subsequent treatment of the insane in institutions across the country. Thomas Arnold, in charge of the Leicester Mad house, the third largest in the country, pleaded for humaneness within institutions, aiming for a “mild and indulgent” approach towards the insane. Writing “Operations on the nature, kinds, causes and prevention of insanity, lunacy, or madness” in 1786 Arnold surmised that:

  • Chains should never be used but in the case of poor patients, whose pecuniary circumstances will not admit of such attendance as is necessary to procure safety without them.

    • This is not, as Doerner commented, a mark of a social distinction in treatment - rather it is a measure of social and financial limitations, not an unwillingness to progress. In respect to directives, progress was made in certain private Mad houses. Proprietors concentrated on the use of personal charisma in fostering a rapport with individual patients, which included invitations to eat at the keeper’s table and go for walks with his family. These privileges were in effect part of a behavioural modification programme, the supportive environment in itself a therapeutic tool, and highlights the use of aspects of ‘moral treatment’ before it became codified at the York Retreat. Others however, still employed various forms of ‘physic’, particularly emetics and purgatives. Smith wrote, “There is little doubt that chains, leg-locks, strait-jackets, restraint chairs, bed straps, and other contrivances were in wide usage.” This highlights the tenuous dividing line in psychiatry between treatment and restraint. The use of the strait-jacket/waistcoat exemplifying this distinction: Originally intended as an instrument of restraint that would cause less harm to a disruptive or violent patient than cords or chains - it became raised to the status of a treatment, the justification being that suppression of excitement in a physical manner would also tranquillise the mind, allowing the patient’s reason to return. Indeed, many elements of Thomas Willis’ treatment were still used, and considered by many to be the most effective. Many  Mad doctors - those considered the most successful  - deliberately tried to attain a strong personal influence over their patients, by the use of threat, fear and intimidation. The use of threatening, penetrating gazes - employment of ‘the eye’ - were thought a key method of subduing the lunatic.

  • It is of great use in practice to bear in mind, that all mad people are cowardly, and can be awed by the menacing looks of a very expressive countenance; and when those who have charge of them once impress them with the notion of fear, they easily submit to any thing that is required.

    • Although asylums were built with an image free from Bethlem’s tarnish, there was still corruption within. The York asylum, opened in 1777 after pleas in the newspaper that “something should be done for the relief of those unhappy sufferers who are the objects of terror and compassion to all around them” experienced embezzlement, profiteering and atrocious ill treatment of its patients. One of those unfortunates was a Quaker, Hannah Mills. Her death in 1790 prompted the Quakers of York to open a less restrictive institution, based on the principle of ‘moral treatment’, and the methods of moderation, order and lawfulness. William Tuke took charge of the project, and the York Retreat opened in 1796. The traditional methods of somatic medicine were thought ineffective, and as such the Retreat had an anti-medical approach; it did not give clinical instruction to physicians or pupils, and the role of the physician was taken by an apothecary, Thomas Fowler. It was religious, both as an establishment and as a therapeutic principle, and this was inextricably linked with its view on reason. The Retreat did not analyse insanity, it restored normality. The curative power of nature, untainted by the anarchy of urban life was fundamental to its operation, inmates took walks and performed farm labour - and due to the success of this theory, later institutions were built in the countryside.

    The Tukes were not interested in a ‘talking cure’, as against earlier traditions which emphasised the importance of the voice of the mad, the Retreat saw silence as a prized therapy. The directive was to make people want to be good, the goal being to teach inmates the ‘salutary habit of self restraint’. This was to be achieved by two methods: Firstly, through the use of fear, and secondly, by appealing to the inmates’ self esteem. In this second method, the keeper did not use a domineering manner, it was essential that he ‘accepted’ the inmate as  a rational being - thus producing a perfect fictive situation. The insane were therefore pushed into circumstances that created the illusion of self therapy; proper social and moral conduct bringing an internal restraint of one’s own passions, deviations and violent outbursts. However, the Retreat’s opinion that subjective behaviour stemmed from moral failure meant that the cruelty of external restraint was replaced by an even greater cruelty of inner restraint, by internalising patients’ consciences through guilt. Its legacy is therefore ambiguous. While it helped implant the notion that asylums were right for the mad, at later asylums the exceptional conditions within the Retreat were disregarded. Where the staff and patients at the Retreat were regarded as ‘family’, with the aim of a spiritual bond between them, later institutions were larger, with little or no personal aspect to the treatment.

    Many of these methods of moral treatment had been used when King George III had a mental breakdown in October 1788. The second of five separate attacks, he was treated by his physician, Sir George Baker,  Anthony Addington, who had kept a madhouse in Reading for five years before becoming a physician to the King - and the Rev. Dr Francis Willis, who owned a high class private asylum in Greatford and was a physician at Lincoln general hospital.

     Willis was appointed after the ‘failure’ of the other physicians, promising a cure if his ‘moral management’ were followed. Medication was kept to a minimum, his belief that ‘management did more than medicine’, and the treatment was imperious, yet trusting. Willis’ method was decisive and epochal, using strait-waistcoats, occasional blisterings and flogging, crushing the patient’s will. He became the object of fear, ‘a wholesome sense of fear’, but also the object of respect - he allowed the King a razor for shaving, thereby demonstrating confidence in his patient. Compelling docility and submission, he created a climate congenial to restoration, permitting the reading and recital of Shakespeare. The irony that the play was King Lear, “I am a very foolish, fond old man…not in my right mind”,  and that the Kings seem presentable doubles, can make one overlook the credence it is due. The use of adopting another persona, as with at the Retreat, enabled the patient to transcend the mentally or physically deteriorated self, and become ‘sane’, if only temporarily at first, perhaps eventually as a permanent transition.

     In a method reminiscent of early private asylums, Dr Willis did not keep case books, and the fact that he had no written records added to his reputation of having healing magic.  An anonymous visitor to his asylum wrote, “his piercing eye seemed to read their hearts and divine their thoughts as they formed. In this way he gained control over them which he used as a means of cure.” Edmund Burke, himself an expert on mental terror, quizzed Willis about his “power…of instantaneously terrifying [the King] into obedience”. Willis answered by fixing his sight on Burke himself, the power of his gaze rendering Burke immediately silent.

    George III recovered in March 1789, and having effected a ‘cure’, Willis became the subject of nationwide renown - not partly due to coins minted with the phrase ‘The King Restored to Health’ on one side and Willis’ profile on the other. In truth, claims of Willis to have cured the Monarch are at best unproven and, if Hunter and Macalpine are correct in their assertion that the Monarch was suffering from hereditary porphyria, they are untenable.  Not disputed is that the other physicians had failed to stamp their authority upon the “chaos of the King’s condition”.  The case raised public interest in the reform of the treatment of madness in general, and influenced considerably the direction of emergent psychiatry both in Great Britain and on the Continent.

    The late Seventeenth and  the Eighteenth Centuries have been recalled as a disaster for the insane. While it is true that there was grave mistreatment, with respect to both theory and practice, it also holds true that there was a transition from viewing the segregation of the Mad merely as a safety precaution for the patient and for society, to the belief that in an asylum, correction or cures could be maximised. The Nineteenth Century would see this emphasis on the personality of the Doctor replaced with the belief that the asylum was itself the therapy, the cure. However, much of what Nineteenth Century  ‘moral therapy’ claimed as its own had its grounding in this previous era.

    The Seventeenth and Eighteenth Centuries witnessed the emergence of psychology, the role of the nervous system, moral treatment and the first legal undertakings for assisting the welfare for the insane, regardless of social class.  While treatment was extremely subjective, with factors such as who you were, where you were and who was treating you greatly influencing the success in recovery, this fact was true for earlier and later centuries, and remains even to the present day.

    It has been said that Mad-doctoring came of age on the Fifth of December 1788, when the failure of the King’s physicians-in-ordinary to master George III’s delirium was acknowledged by the summons of the specialist Mad-doctor Francis Willis. Indeed, to facilitate the reduction of the Monarch to the level of any member of society, bourgeoisie or pauper, surely marks its recognition in History.

     

    Notes:

    1: Doerner, Madmen and the Bourgeoisie, p.15., Porter, Mind Forg’d Manacles,p.111.

    2: Foucault, Folie et Déraison.

    3: Suzuki, Lunacy in Seventeenth and Eighteenth Century England, p.29.

    4: Szasz, The Origin of Psychiatry, p.3.

    5: Butler,  Mental Health, Social Policy and the Law, p.17.

    6: Szasz, The Origin of Psychiatry, pp.1,7.

    7: Hattori, The Pleasure of Your Bedlam, p.284.

    8: Willis, An Essay on the Pathology of the Brain and Nervous Stock.

    9: Ibid.

    10: Ibid.,p.191.

    11: Ibid.

    12: Ibid., p.190

    13: Ibid.

    14: Ibid., p.192.

    15: Ibid., p.191

    16: Swan, The Entire Works of Dr. Thomas Sydenham.

    17: Doerner, Madmen and the Bourgeoisie, p.27.

    18: Koutouvidis, The Contribution of Thomas Sydenham, p.517.

    19: Swan, The Entire Works of Dr. Thomas Sydenham, p.221.

    20: Ibid., p.224.

    21: Doerner, Madmen and the Bourgeoisie, p.28.

    22: Porter, Mind Forg’d Manacles,p.118.

    23: Locke, An Essay concerning Human Understanding, p.236.

    24: Ibid.

    25: Neve, 1996. Lecture Notes.

    26: Defoe, An Essay upon Projects.

    27: Ibid., p.266.

    28: Ibid., p.267.

    29: Ibid.

    30: Swift, Gulliver’s Travels.

    31: Porter, Mind Forg’d Manacles.

    32: Act of 1714, p.299.

    33: Ibid.

    34: Porter, Mind Forg’d Manacles, p.120.

    35: Andrews, In her Vapours…, p.125.

    36: Porter, Mind Forg’d Manacles, p.139.

    37: Parry-Jones, English Private Madhouses, p.241.

    38: Anonymous, Proposals for redressing some grievances, p.366.

    39: Ibid.

    40: Porter, Mind Forg’d Manacles, p.122.

    41: Ibid., p.128.

    42: Ibid., p.124.

    43: Probyn, Jonathan Swift: The Contemporary Background, p.57.

    44: Battie, A Treatise on Madness.

    45: Doerner, Madmen and the Bourgeoisie, p.42.

    46: Battie, A Treatise on Madness, p.408.

    47: Ibid.

    48: Ibid., p.407.

    49: Ibid., p.405.

    50: Ibid.

    51: Porter, Mind Forg’d Manacles, p.131.

    52: Battie, A Treatise on Madness, p.411.

    53: Ibid.

    54: Arnold, Operations on the nature.

    55: Ibid., p.467.

    56: Doerner, Madmen and the Bourgeoisie, p.54.

    57: Smith, Eighteenth Century Madhouse Practice, p.46.

    58: Macbride, Methodical Introduction, p.449.

    59: Smith, Eighteenth Century Madhouse Practice, p.46.

    60: Macbride, Methodical Introduction, p.449.

    61: Digby, Changes in the Asylum, p.223.

    62: Doerner, Madmen and the Bourgeoisie, p.79.

    63: Porter, Mind Forg’d Manacles, p.158.

    64: Bennett, The Madness of King George III, p.70.

    65: Prada, 1997. Discourse: The Theatre as Ephemeral ?

    66: Hunter, Three Hundred Years of  Psychiatry, p.509.

    67: Doerner, Madmen and the Bourgeoisie, p.74.

    68: Hunter, George III and the Mad Business, pp. 271-272.

    69: Hunter, Three Hundred Years of  Psychiatry, p.511.

    70: Porter, Mind Forg’d Manacles, p.210.

    71: Ibid.

    72: Ibid., p.175.

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Birth of Moral Therapy in England