No One Cares About Crazy People

by Ron Powers

  As public institutions governed by the City of London, Bethlem and its imitators could not even require admission fees from prospective patients. And indeed, Bethlem Moorfields did not habitually turn away the indigent insane, though waiting lists soon developed. The administrators were virtually obliged to be artful.

  Their most benign strategy was to negotiate discreetly with, say, a wealthy family that wanted to rid its household of an inconvenient relative. After all, the masters of Bethlem were part of the elite society they dickered with. The Monros, a high-bourgeois family of Londoners with Scottish origins, supplied four generations of shrewd physician-administrators at Bethlem; well-connected and deeply scheming men. James, the first, arrived in 1728, and he immediately banned medical students from the premises, no doubt on the theory that they would see more than was healthy for the management. He began the family’s cultivation of the wealthy. And he turned madness into a spectator sport.

  Visitors had occasionally handed over a bit of coin, even to the monks back in the Priory days, for the pleasure of watching their fellow human beings jabber, cavort, fight, howl, copulate, and otherwise act out primal impulses.

  The grounds around Bedlam’s walls afforded far more expansive views. Visitors were not only welcomed but encouraged, at a price. Sometimes they arrived by the horse-drawn busload, wearing waistcoats and top hats or twirling parasols, fashionable promenaders at the Ascot of lunacy. They paid a penny; later, two, and no exceptions. The ladies and gentlemen—and their children—were allowed to mingle with the entertainment, and to scoff and jest in the inmates’ faces.

  In 1815, the City of London moved Bethlem asylum again, to a new building in St. George’s Fields in Southwark. Moorfields had fallen into physical decay surpassing even that of the old sewage-besotted Priory. The last Monro to administer Bedlam, Edward Thomas, assumed control the following year. Edward was forced to resign in 1852, after the Lunacy Commission was shocked to find that he, too, lacked human respect for his patients.

  The late eighteenth century saw the formation of the first movement to rebuke the Bedlam template for dealing with society’s “lunaticks” and “mad” people. (Not until 1930, 683 years after its founding, was Bethlem’s theater of sanctioned state depravity reestablished as Bethlem Royal Hospital, and its era of modern professionalism launched.) As this movement spread through western Europe and the United States, its principles became known as “moral treatment.” Some psychiatric scholars maintain that it remains the most effective of all history’s treatments for the mentally ill.

  Moral care took shape as a concept almost simultaneously in the minds of two men who did not know each other. One was a French doctor; the other, a British Quaker businessman.

  The doctor was a Parisian named Philippe Pinel, a smallish country doctor with a hunger for ideas that caught the temper of the Enlightenment. In 1773, Pinel enrolled at the University of Montpellier, France’s oldest medical academy and the source of medical science’s freshest thought. There, he encountered refinements on an ancient concept known as “vitalism.”

  Vitalism’s tenets would be largely refuted by advances in biophysical understandings of how the mind and the body interacted. Genetic theory would virtually extinguish what remained. Yet vitalism’s core tenets—the necessity of balance between mind and body; the power of nature to heal all sorts of human diseases—led Pinel to a historic approach toward the mentally ill.

  It took a rather convincing demonstration of mass psychosis—the French Revolution—to supply Philippe Pinel with the entrée he needed to put that approach into practice.

  Pinel was living the modest life of a medical journalist and translator when the French Revolution swept the country with its antiaristocratic ideals. The new government, aware of his interest in the insane, appointed him in 1793 as physician-in-chief of the infamous Bicêtre Hospital for men. This converted orphanage, later a prison, was classic in its casual barbarity. Its jailers habitually kept patients confined in shackles, often for the better part of their lives. The chains were bolted to the walls so tightly that those confined by them were obliged to sleep standing up.

  Pinel commenced his reforms at once. He mandated improvement in the quality of food, ordered regular replacement of the feces-and-urine-besotted straw that served as beds, and created exercise regimens for the inmates.8

  The reform that secured Pinel’s place in history was a decision to strike off the shackles of forty-nine Bicêtre inmates. The idea might have originated with the doctor’s assistant, one Jean-Baptiste Pussin, though it is entirely consistent with Pinel’s vision. The directive shocked even the revolutionary Paris Commune, which summoned Pinel to justify it at a hearing. Yet the directive almost immediately justified itself: not one of the newly unchained men bolted from his cell and ran out on a violent spree.

  At about the time Pinel was pioneering his reforms in France, a sixtyish Yorkshire coffee merchant named William Tuke III was mourning the death of a fellow Quaker, a young woman named Hannah Mills. Mills had expired in the darkness of York Lunatic Asylum, built in 1777 in Tuke’s hometown of York, the medieval walled city in northern England.

  Quakerism, the Society of Friends, had originated in Britain the century before, one of many restless Christian groups to break with the Church of England over perceived false doctrine and overweening Puritanism. The Friends gathered adherents to their tenets of pacifism, philanthropy, and social justice. They began to emigrate from England and the Netherlands to America, where William Penn would found a great city, and where the Society of Friends would leave a great legacy of stewardship toward the mentally ill.

  Hannah Mills’s death stunned and galvanized Tuke. A recent widow, Mills had been admitted to York Asylum less than two months before her passing—probably for depression caused by her husband’s death. Whatever was wrong with her, York Asylum deepened it. The young widow lasted forty-five days. Her death was recorded on April 29, 1790. Whether she was a suicide, or perhaps a victim of lethal abuse, or both, has not been documented.

  William Tuke was incredulous that the asylum administrators refused to offer an explanation for the woman’s abrupt passing. Tuke did not fulminate or try to run the York Asylum out of business. That was not the Quaker way. Instead, he commissioned his own asylum and opened it in 1796.

  He did not call it an asylum. Nor did he or his family refer to those who stayed there as “lunatics.” Tuke designed the facility in collaboration with a London architect named John Bevans. Bevans shared Tuke’s hopeful but mistaken belief, nearly identical to Pinel’s, that an open, healthful environment and respectful treatment by caretakers could lead, virtually of themselves, to the restoration of an afflicted mind.

  York’s architecture—a compact, homey three-story brick building—and its placement atop a hill offering views of woods, meadows, and streams, were central to Tuke’s therapeutic vision.9 So was the personal stewardship of the patients administered by him and his kindhearted wife and sons. So were the hearty, healthful meals the Tukes provided.

  William Tuke’s York Retreat was a success, if one discounts the matter of curing mental illness. Tuke never lost his conviction that the “lunatic” condition could be cured. Nor did he ever lose his determination to penetrate the secretive walls of York Asylum, which he believed iniquitous. He pursued this goal for twenty-three years. Eventually he found an ally in the town magistrate, Godfrey Higgins. In 1813, Higgins learned that a man whom he himself had decreed to be “insane” and sentenced to York had managed to get word out that he was being mistreated. Higgins decided to investigate. He used his authority under common law to command entry. What he saw—and heard, and smelled—there repelled him:

  When the door was opened, I went into the passage and found four cells… in a very horrid and filthy situation. The straw appeared to be almost saturated with urine and excrement… the walls were daubed with excrement… I then went upstairs and [the keeper] showed me a room… the size of which he told me was t
welve feet by seven feet and ten inches, and in there were thirteen women.10

  Tuke’s fellow Quakers, meanwhile, had seen their humane influence flow westward across the Atlantic. America’s first incorporated hospital of any kind, Philadelphia Hospital, opened its doors to patients in the prerevolutionary year of 1753. Its cofounders were Dr. Thomas Bond, a Quaker, and Benjamin Franklin. It accommodated a handful of insane patients in a few basement rooms.

  Dr. Benjamin Rush, a signer of the Declaration of Independence and one of several figures celebrated as “the father of American psychiatry,” joined the medical staff in 1783 and served until his death in 1813. Rush was the first man of science in this country to publicly reject the idea that insanity was caused by demons or witches. In the spirit of Pinel, he joined the argument against the use of those shackles. An eyewitness to the steady expansion of cities on the eastern seaboard, he also was the first American to identify stress as a powerful contributor to madness, if not its cause.

  Philadelphia Hospital retained one noxious legacy of Bedlam: it charged visitors a shilling apiece to visit the hospital basement on Sunday afternoons and gape at the thrashing, screeching crazy people inside. This practice disgusted the newly arrived Quakers and stirred them to action. As William Tuke had in York, they financed and built their own sanctuary for the insane. The Friends Asylum for the Relief of Persons Deprived of the Use of Their Reason opened in Philadelphia in 1813, the young nation’s first private psychiatric hospital. Moral treatment had established a beachhead in America.

  It spread outward from Philadelphia. One of its most prestigious havens was the State Hospital, opened in 1833 as the first state-financed sanctuary, in Worcester, Massachusetts.

  The hospital’s first commission chairman, the future education visionary Horace Mann, supervised the planning stages. Mann got involved in creating the hospital in part because he subscribed to the growing concern that madness was rising rampantly in the young nation. One of his first acts as commission chairman was to oversee a committee that took a census of mad people, the first such survey in Massachusetts. The committee declared that at least five hundred mentally ill people were without protection.11

  Worcester State’s first superintendent was Dr. Samuel Woodward, who at six feet six inches literally towered some thirteen inches above his countrymen of average height. Once the people of Worcester recovered from their first sight of him, they were won over by his kindness and gentle nature. He greeted each arriving patient personally. If they had been transported from another asylum or prison, he would use his own large hands to free theirs from confinement. He assured the forty-two hundred citizens of Worcester that the new sanctuary posed no danger to them, and that “the law of kindness” was an essential tool in restoring the mad to sanity.

  Woodward’s thirteen-year stewardship was marked by a combination of his extreme personal decency, his excusable yet limiting innocence of neurobiology, and by the nature and volume of patients that came to his asylum. He rejected any notion that “madness” was a factor of low character or evidence of internal demons. He sought to reamplify the humane credos of Pinel and Tuke. On the other hand he was attracted to the new pseudoscience of phrenology, the belief that human behavior could be anticipated—and manipulated—by a study of the brain’s physical features. A century later, of course, phrenology was among the baseless theories summoned to justify some of the most immoral treatment the world has ever witnessed.

  The urgency that spurred the proliferation of asylums in this period was prompted by fear. Doctors, city fathers, and ordinary citizens throughout America came to believe with Horace Mann that madness was on the rise. Woodward shared this perception. As had others, they blamed city life, still a new experience in much of the new nation. “Insanity,” summarized one Massachusetts psychiatrist in a paper presented in 1851, “is then a part of the price which we pay for civilization.”12

  Yet perhaps people, including the founders of Worcester, did not pay enough attention to the most plausible source of “epidemic” concerns: the phenomenal rise in the American population as a whole. Immigration and new births had already increased the number of United States citizens from 9.5 million in 1820 to 13 million in 1833. The population boom found its way into America’s young cities. As they grew, it began to seem as though their streets were unaccountably filling up with “mad” people. The fact was, they were filling up with people, and the mad among them, by virtue of their concentration, were more visible than ever before.

  Whatever the cause, the nation’s first generation of public asylums such as Worcester was soon overwhelmed. Before Worcester’s inaugural year ended, Samuel Woodward had yielded to a heartbreaking necessity: set aside his law of kindness and discharge as many nonviolent patients, and even some with criminal pasts, as he could to make room for newer, more violent ones—“the lunatics and furiously mad,” as the term of art had it. These were the kinds of patients the state was sending to the facility from jails and prisons; and Worcester, a state-financed institution, had no choice but to accept them. In fact, Massachusetts law required that all dangerous “lunatics” already in jail be transferred to Worcester. This practical but unforeseen necessity soon began to erode Worcester’s agenda of moral treatment therapy, diminishing the time and space its practitioners needed to do their work. Here was an ominous regression toward the asylum as jail: the very condition that moral treatment had been designed to extinguish.

  Still, largely through Woodward’s efforts, his asylum’s national reputation as a “model” of its kind held up. Goodwill persisted among the city fathers—but was now modified by a fear for public safety.

  In 1836, state appropriations funded two new wings, bringing the maximum patient capacity to 229. Still the numbers of applicants—and supplicants—surged higher. Overcrowding, another curse of the older days, continued.

  Five years later, reinforcement of a different kind arrived.

  It arrived in the person of a tiny, sickly woman of devout Unitarian faith, her dark hair parted severely in the middle and tied in a bun behind, which made her ears stick out, and the resolve of a Rottweiler with its teeth sunk into flesh. Dorothea Dix was on the case.

  Dix had lived in the town of Worcester during her childhood. She had lived in a lot of New England places: Hampden, Maine, where she was born (later a part of Massachusetts); then Barnard, Vermont, after her boozy father and migraine-addled mother had fled from Hampden and the path of British infantry in the War of 1812. Then Boston, where she ran a private school; then to the industrialized fogs of England—perhaps not the ideal destination for a four-year sojourn to recover from what is now known as tuberculosis. The disease would recur through her long life and make her an invalid. Yet the overcrowded, sickly, and anxious hordes of London factory workers contributed to one of her most firm beliefs, which until then only Benjamin Rush was known to share: that urban turmoil correlated with vulnerability to insanity. In this, she anticipated René Dubos by eighty years.

  In England Dix had been swept into a cohort of British reformers, many of them Quaker, who introduced her to the madhouse netherworld. Dix came home bristling with the determination to be of use to such incarcerated souls. One day in March 1841, she volunteered to teach Sunday school to some women confined at the East Cambridge (Massachusetts) jail. Afterward, a jailer escorted her around the facility. As she gazed into the cells she heard a scream and demanded to see the source. The jailer reluctantly escorted her to a heavy locked door. He opened it and the chilly air inside blew a heavy stench into their faces. The scream had come from within a group of huddling, half-naked “lunatics” who had been encaged in the hovel for years—in the company of convicted violent criminals, as was still common. She asked the jailer how this could be. He comfortably (and, as things turned out, famously) assured the small lady that she should not bother herself; the insane could not feel heat or cold.

  That encounter settled her life’s course.

  Against the warn
ings of friends who were aware of her health problems, Dorothea Dix embarked upon an eighteen-month itinerary that took her to jails and asylums throughout Massachusetts, barging past guards to interview patient-inmates and their keepers. At the end of her journey, she was convinced that the moral treatment asylums were in fact benefiting patients, but that the jailing of excess “mad” people was rampant and their plight an affront to humanity. She returned to Worcester and in 1843 joined forces with Woodward, Mann, and a well-born reformer named Samuel Gridley Howe to inspire or shame the legislature into action. (Howe had run for and won a seat in the state House of Representatives as a Whig just so he could speak for Dix from the inside.)13 In January she prepared a “Memorial to the Legislature of Massachusetts” (women were not allowed to address the legislature in person back then; they had to submit their thoughts in writing). Her words ring in the pantheon of American oratory—or as oratory-that-might-have-been.

  I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane, idiotic men and women; of beings sunk to a condition from which the most unconcerned would start with real horror; of beings wretched in our prisons, and more wretched in our almshouses. I… arrest and fix attention upon a subject only the more strongly pressing in its claims because it is revolting and disgusting in its details.14

  Mann, Howe, and the others were thrilled. Representative Samuel Gridley Howe introduced the Memorial in the legislature. It was sent to the Committee on Public Charitable Institutions, then shaped into a bill by committee chairman Howe. After debates and modifications, the bill passed both houses, and Samuel Woodward was granted authority to build new housing at the asylum for 150 patients.