Mad in America

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BEDLAM IN MEDICINE

A VISITOR TO THE “mad” wards of Pennsylvania Hospital at the turn of the nineteenth century would have found the halls astir with an air of reform. A few years earlier, in 1796 to be exact, the lunatics had been moved from unheated, dingy cells in the basement, where they had often slept on straw and been confined in chains, to a new wing, where their rooms were above ground. Here the winter chill was broken by a coal-fired stove, and occasionally the mad patients could even take a warm bath. Most important of all, they now began to receive regular medical treatments—a regimen of care, physician Benjamin Rush proudly told the Pennsylvania Hospital overseers, that had “lately been discovered to be effectual in treating their disorder.”²

The introduction of medical treatments had been a long time coming. In 1751, when Quakers and other community leaders in Philadelphia had petitioned the Pennsylvania colonial assembly for funds to build the hospital, the first in the colonies, they had told of medical care that could help restore sanity to the mad mind. “It has been found,” wrote Benjamin Franklin, who authored the plea, “by the experience of many Years, that above two Thirds of the Mad People received into Bethlehem Hospital [in England] and there treated properly, have been perfectly cured.”³ English mad-doctors had indeed begun making such claims and had even published books describing their effective treatments. However, while Franklin and his fellow Quakers may have hoped to bring such medicine to the colonies, they also had a second reason for building the hospital. There were, they wrote, too many lunatics “going at large [who] are a Terror to their neighbors, who are daily apprehensive of the Violences they may commit.” Society needed to be protected from the insane, and it was this second function—hospital as jail—that had taken precedence when the hospital opened in 1756.

In those early years, the lunatics were kept in gloomy, foul-smelling cells and were ruled over by “keepers” who used their whips freely. Unruly patients, when not being beaten, were regularly “chained to rings of iron, let into the floor or wall of the cell… restrained in hand-cuffs or ankle-irons,” and bundled into Madd-shirts that “left the patient an impotent bundle of wrath.”⁴ A visiting reverend, Manasseh Cutler, described the sorry scene:

The lunatics also had to suffer the indignity of serving as a public spectacle. After the hospital opened, visiting the mad had quickly become a popular Sunday outing, similar to visiting a zoo. Philadelphians were eager to get a glimpse of these wretched creatures, with good sport on occasion to be had by taunting them, particularly those restrained in irons and easily roused into a rage. So frequent were the public’s visits, and so disturbing to the insane, that the hospital managers erected a fence in 1760 “to prevent the Disturbance which is given to the Lunatics confin’d in the Cells by the great Numbers of People who frequently resort and converse with them.”⁶ But even an iron fence couldn’t keep the public at bay, and so in 1762, the hospital, trying to make the best of an unfortunate situation, began charging a visitor’s fee of four pence.

All of this began to change once Rush arrived at the hospital in 1783.

The lunatics could not have hoped for a more kind-hearted man to be their advocate. Born of Quaker parents, Rush was constantly championing liberal, humanitarian reforms. As a young man, he had been a member of the Continental Congress and a signer of the Declaration of Independence. He’d advocated for the abolition of slavery and prison reform, and he brought this same compassion to his treatment of the mad. At his request, the hospital’s governing board built a new wing for the insane patients, which was completed in 1796, and soon many patients were enjoying the comforts of rooms furnished with hair mattresses and feather beds. Those who were well behaved were allowed to stroll about the hospital grounds and engage in activities like sewing, gardening, and cutting straw. Rush also believed that games, music, and friendship could prove helpful, and the hospital even agreed to his request that “a Well qualified Person be employed as a Friend and Companion to the Lunatics.”⁷ The insane, he explained to hospital attendants, needed to be treated with kindness and respect. “Every thing necessary for their comfort should be provided for them, and every promise made to them should be faithfully and punctually performed.”⁸

But such humanitarian care could only go so far. Rush was also a man of science. He’d studied at the University of Edinburgh, the most prestigious medical school in the world at the time. There, he’d been mentored by the great William Cullen, whose First Lines of the Practice of Physic was perhaps the leading medical text of the day. The European mad-doctors had developed a diverse array of therapeutics for curing madness, and Rush, eager to make Pennsylvania Hospital a place of modern medicine, employed their methods with great vigor. And this was treatment of an altogether different type.

They Are Brutes, Aren’t They?

One of the first English physicians to write extensively on madness, its nature, and the proper treatments for it was Thomas Willis. He was highly admired for his investigations into the nervous system, and his 1684 text on insanity set the tone for the many medical guides that would be written over the next 100 years by English mad-doctors. The book’s title neatly summed up his view of the mad: The Practice of Physick: Two Discourses Concerning the Soul of Brutes. His belief—that the insane were animal-like in kind—reflected prevailing conceptions about the nature of man. The great English scientists and philosophers of the seventeenth century—Francis Bacon, Isaac Newton, John Locke, and others—had all argued that reason was the faculty that elevated humankind above the animals. This was the form of intelligence that enabled man to scientifically know his world, and to create a civilized society. Thus the insane, by virtue of having lost their reason, were seen as having descended to a brutish state. They were, Willis explained, fierce creatures who enjoyed superhuman strength. “They can break cords and chains, break down doors or walls… they are almost never tired… they bear cold, heat, watching, fasting, strokes, and wounds, without any sensible hurt.”⁹ The mad, he added, if they were to be cured, needed to hold their physicians in awe and think of them as their “tormentors.”

A medical paradigm for treating the mad had been born, and eighteenth-century English medical texts regularly repeated this basic wisdom. In 1751, Richard Mead explained that the madman was a brute who could be expected to “attack his fellow creatures with fury like a wild beast” and thus needed “to be tied down and even beat, to prevent his doing mischief to himself or others.”¹¹ Thomas Bakewell told of how a maniac “bellowed like a wild beast, and shook his chain almost constantly for several days and nights… I therefore got up, took a hand whip, and gave him a few smart stripes upon the shoulders… He disturbed me no more.”¹² Physician Charles Bell, in his book Essays on the Anatomy of Expression in Painting, advised artists wishing to depict madmen “to learn the character of the human countenance when devoid of expression, and reduced to the state of lower animals.”¹³

Like all wild animals, lunatics needed to be dominated and broken. The primary treatments advocated by English physicians were those that physically weakened the mad—bleeding to the point of fainting and the regular use of powerful purges, emetics, and nausea-inducing agents. All of this could quickly reduce even the strongest maniac to a pitiful, whimpering state. William Cullen, reviewing bleeding practices, noted that some advised cutting into the jugular vein.¹⁴ Purges and emetics, which would make the mad patient violently sick, were to be repeatedly administered over an extended period. John Monro, superintendent of Bethlehem Asylum, gave one of his patients sixty-one vomit-inducing emetics in six months, including strong doses on eighteen successive nights.¹⁵ Mercury and other chemical agents, meanwhile, were used to induce nausea so fierce that the patient could not hope to have the mental strength to rant and rave. “While nausea lasts,” George Man Burrows advised, “hallucinations of long adherence will be suspended, and sometimes be perfectly removed, or perhaps exchanged for others, and the most furious will become tranquil and obedient.” It was, he added, “far safer to reduce the patient by nauseating him than by depleting him.”¹⁶

A near-starvation diet was another recommendation for robbing the madman of his strength. The various depleting remedies—bleedings, purgings, emetics, and nausea-inducing agents—were also said to be therapeutic because they inflicted considerable pain, and thus the madman’s mind became focused on this sensation rather than on his usual raving thoughts. Blistering was another treatment useful for stirring great bodily pain. Mustard powders could be rubbed on a shaved scalp, and once the blisters formed, a caustic rubbed into the blisters to further irritate and infect the scalp. “The suffering that attends the formation of these pustules is often indescribable,” wrote one physician. The madman’s pain could be expected to increase as he rubbed his hands in the caustic and touched his genitals, a pain that would enable the patient to “regain consciousness of his true self, to wake from his supersensual slumber and to stay awake.”¹⁷

All of these physically depleting, painful therapies also had a psychological value: They were feared by the lunatics, and thus the mere threat of their employment could get the lunatics to behave in a better manner. Together with liberal use of restraints and an occasional beating, the mad would learn to cower before their doctors and attendants. “In most cases it has appeared to be necessary to employ a very constant impression of fear; and therefore to inspire them with the awe and dread of some particular persons, especially of those who are to be constantly near them,” Cullen wrote. “This awe and dread is therefore, by one means or other, to be acquired; in the first place by their being the authors of all the restraints that may be occasionally proper; but sometimes it may be necessary to acquire it even by stripes and blows. The former, although having the appearance of more severity, are much safer than strokes or blows about the head.”¹⁸

Such were the writings of the English mad-doctors in the 1700s. The mad were to be tamed. But were such treatments really curative? In the beginning, the mad-doctors were hesitant to boldly make that claim. But gradually they began to change their tune, and they did so for a simple reason: It gave them a leg up in the profitable madhouse business.

Merchants of Madness

In eighteenth-century England, the London asylum Bethlehem was almost entirely a place for the poor insane. The well-to-do in London shipped their family lunatics to private madhouses, a trade that had begun to emerge in the first part of the century. These boarding homes also served as convenient dumping grounds for relatives who were simply annoying or unwanted. Men could get free from their wives in this manner—had not their noisome, bothersome spouses gone quite daft in the head? A physician who would attest to this fact could earn a nice sum—a fee for the consultation and a referral fee from the madhouse owner. Doctors who owned madhouses made out particularly well. William Battie, who operated madhouses in Islington and Clerkenwell, left an estate valued at between £100,000 and £200,000, a fabulous sum for the time, which was derived largely from this trade.¹⁹

Even though most of the mad and not-so-mad committed to the private madhouses came from better families, they could still expect neglect and the harsh flicker of the whip. As reformer Daniel Defoe protested in 1728, “Is it not enough to make any one mad to be suddenly clap’d up, stripp’d, whipp’d, ill fed, and worse us’d?”²⁰ In the face of such public criticism, the madhouse operators protested that their methods, while seemingly harsh, were remedies that could restore the mad to their senses. They weren’t just methods for managing lunatics, but curative medical treatments. In 1758, Battie wrote: “Madness is, contrary to the opinion of some unthinking persons, as manageable as many other distempers, which are equally dreadful and obstinate.”²¹ He devoted a full three chapters to cures.

In 1774, the English mad trade got a boost with the passage of the Act for Regulating Madhouses, Licensings, and Inspection. The new law prevented the commitment of a person to a madhouse unless a physician had certified the person as insane (which is the origin of the term “certifiably insane”). Physicians were now the sole arbiters of insanity, a legal authority that made the mad-doctoring trade more profitable than ever. Then, in 1788, King George III suffered a bout of madness, and his recovery provided the mad-doctors with public proof of their curative ways.