III. Hospital Treatment
The era of real hospitals for the insane began in the 19th century. There had been established here and there in different parts of the world, it is true, certain asylums or places of restraint before the beginning of the 19th century. We find mention in history of such a place established by monks at Jerusalem in the latter part of the 5th century. There is evidence that even earlier than this in Egypt and Greece the insane were treated as individuals suffering from disease. Egyptian priests employed not only music and the beautiful in nature and art as remedial agents in insanity, but recreation and occupation as well. A Greek physician protested against mechanical restraint in the care of the insane, and advocated kindly treatment, the use of music, and of some sorts of manual labour. But these ancient beneficent teachings were lost sight of during succeeding centuries. The prevailing idea of the pathology of insanity in Europe during the middle ages was that of demoniacal possession. The insane were not sick, but possessed of devils, and these devils were only to be exorcised by moral or spiritual agencies. Medieval therapeutics in insanity adapted itself to the etiology indicated. Torture and the cruellest forms of punishment were employed. The insane were regarded with abhorrence, and were frequently cast into chains and dungeons. Milder forms of mental disease were treated by other spiritual means—such as pilgrimages to the shrines of certain saints who were reputed to have particular skill and success in the exorcism of evil spirits. The shrine of St Dymphna at Gheel, in Belgium, was one of these, and seems to have originated in the 7th century, a shrine so famed that lunatics from all over Europe were brought thither for miraculous healing. The little town became a resort for hundreds of insane persons, and as long ago as the 17th century acquired the reputation, which still exists to this day, of a unique colony for the insane. At the present time the village of Gheel and its adjacent farming hamlets (with a population of some 13,000 souls) provides homes, board and care for nearly 2000 insane persons under medical and government supervision. Numerous other shrines and holy wells in various parts of Europe were resorted to by the mentally afflicted—such as Glen-na-Galt in Ireland, the well of St Winifred, St Nun’s Pool, St Fillans, &c. At St Nun’s the treatment consisted of plunging the patient backwards into the water and dragging him to and fro until mental excitement abated. Not only throughout the middle ages, but far down into the 17th century, demonology and witchcraft were regarded as the chief causes of insanity. And the insane were frequently tortured, scourged, and even burned to death.
Until as late as the middle of the 18th century, mildly insane persons were cared for at shrines, or wandered homeless about the country. Such as were deemed a menace to the community were sent to ordinary prisons or chained in dungeons. Thus large numbers of lunatics accumulated in the prisons, and slowly there grew up a sort of distinction between them and criminals, which at length resulted in a separation of the two classes. In time many of the insane were sent to cloisters and monasteries, especially after these began to be abandoned by their former occupants. Thus “Bedlam” (Bethlehem Royal Hospital) was originally founded in 1247 as a priory for the brethren and sisters of the Order of the Star of Bethlehem. It is not known exactly when lunatics were first received into Bedlam, but some were there in 1403. Bedlam was rebuilt as an asylum for the insane in 1676. In 1815 a committee of the House of Commons, upon investigation, found it in a disgraceful condition, the medical treatment being of the most antiquated sort, and actual inhumanity practised upon the patients. Similarly the Charenton Asylum, just outside Paris, near the park of Vincennes, was an old monastery which had been given over to the insane. Numerous like instances could be cited, but the interesting point to be borne in mind is, that with a general tendency to improvement in the condition of imbeciles upon public charge, idiots and insane persons came gradually to be separated from criminals and other paupers, and to be segregated. The process of segregation was, however, very slow. Even after it had been accomplished in the larger centres of civilization, the condition of these unfortunates in provincial districts remained the same. Furthermore, the transfer to asylums provided especially for them was not followed by any immediate improvement in the patients.
Twenty-five years after Pinel had, in 1792, struck the chains from the lunatics huddled in the Salpétrière and Bicêtre of Paris, and called upon the world to realize the horrible injustice done to this wretched and suffering class of humanity, a pupil of Pinel, Esquirol, wrote of the insane in France and all Europe: “These unfortunate people are treated worse than criminals, reduced to a condition worse than that of animals. I have seen them naked, covered with rags, and having only straw to protect them against the cold moisture and the hard stones they lie upon; deprived of air, of water to quench thirst, and all the necessaries of life; given up to mere gaolers and left to their surveillance. I have seen them in their narrow and filthy cells, without light and air, fastened with chains in these dens in which one would not keep wild beasts. This I have seen in France, and the insane are everywhere in Europe treated in the same way.” It was not until 1838 that the insane in France were all transferred from small houses of detention, workhouses and prisons to asylums specially constructed for this purpose.
In Belgium, in the middle ages, the public executioner was ordered to expel from the towns, by flogging, the poor lunatics who were wandering about the streets. In 1804 the Code Napoleon “punished those who allowed the insane and mad criminals to run about free.” In 1841 an investigation showed in Belgium thirty-seven establishments for the insane, only six of which were in good order. In fourteen of them chains and irons were still being used. In Germany, England and America, in 1841, the condition of the insane was practically the same as in Belgium and France.
These facts show that no great advance in the humane and scientific care of the insane was made till towards the middle of the 19th century. Only then did the actual metamorphosis of asylums for detention into hospitals for treatment begin to take place. Hand in hand with this progress there has grown, and still is growing, a tendency to subdivision and specialization of hospitals for this purpose. There are now hospitals for the acutely insane, others for the chronic insane, asylums for the criminal insane, institutions for the feeble-minded and idiots, and colonies for epileptics. There are public institutions for the poor, and well-appointed private retreats and homes for the rich. All these are presided over by the best of medical authorities, supervised by unsalaried boards of trustees or managers, and carefully inspected by Government lunacy commissioners, or boards of charities—a contrast, indeed, to the gaols, shrines, holy wells, chains, tortures, monkish exorcisms, &c., of the past!
The statistics of insanity have been fairly well established. The ratio of insane to normal population is about 1 to 300 among civilized peoples. This proportion varies within narrow limits in different races and countries. It is probable that intemperance in the use of alcohol and drugs, the spread of venereal diseases, and the over-stimulation in many directions induced by modern social conditions, have caused an increase of insanity in the 19th as compared with past centuries. The amount of such increase is probably very small, but on superficial examination might seem to be large, owing to the accumulation of the chronic insane and the constant upbuilding of asylums in new communities. The imperfections of census-taking in the past must also be taken into account.
The modern hospital for the insane does credit to latter-day civilization. Physical restraint is no longer practised. The day of chains—even of wristlets, covered cribs and strait-jackets—is past. Neat dormitories, cosy single rooms, and sitting- and dining-rooms please the eye. In the place of bare walls and floors and curtainless windows, are pictures, plants, rugs, birds, curtains, and in many asylums even the barred windows have been abolished. Some of the wards for milder patients have unlocked doors. Many patients are trusted alone about the grounds and on visits to neighbouring towns. An air of busy occupation is observed in sewing-rooms, schools, shops, in the fields and gardens, employment contributing not only to economy in administration, but to improvement in mental and physical conditions. The general progress of medical science in all directions has been manifested in the department of psychiatry by improved methods of treatment, in the way of sleep-producing and alleviating drugs, dietetics, physical culture, hydrotherapy and the like. There are few asylums now without pathological and clinical laboratories. While it is a far cry from the prisons and monasteries of the past to the modern hospital for the insane, it is still possible to trace a resemblance in many of our older asylums to their ancient prototypes, particularly in those asylums built upon the so-called corridor plan. Though each generation contributed something new, antecedent models were more or less adhered to. Progress in asylum architecture has hence advanced more slowly in countries where monasteries and cloisters abounded than in countries where fixed models did not exist. Architects have had a freer hand in America, Australia and Germany, and even in Great Britain, than in the Catholic countries of Europe.
Germany approaches nearest to an ideal standard of provision for the insane. The highest and best idea which has yet been attained is that of small hospitals for the acutely insane in all cities of more than 50,000 inhabitants, and of colonies for the chronic insane in the rural districts adjacent to centres of population. The psychopathic hospital in the city gives easy and speedy access to persons taken suddenly ill with mental disease, aids in early diagnosis, places the patients within reach of the best specialists in all departments of medicine, and associated, as it should be, with a medical school or university, affords facilities not otherwise available for scientific research and for instruction in an important branch of medical learning. A feature of the psychopathic hospital should be the reception of patients for a reasonable period of time, as sufferers from disease, without the formality of legal commitment papers. Such papers are naturally required for the detention and restraint of the insane for long periods of time, but in the earlier stages they should be spared the stigma, delay and complicated procedure of commitment for at least ten days or two weeks, since in that time many may convalesce or recover, and in this way escape the public record of their infirmities, unavoidable by present judicial procedures.
There should be associated with such hospitals for the acutely insane in cities out-door departments or dispensaries, to which patients may be brought in still earlier stages of mental disorder, at a period when early diagnosis and preventive therapeutics may have their best opportunities to attain good results. In Germany a psychopathic hospital now exists in every university town, under the name of Psychiatrische Klinik.