Lunatic ideas and the truth about asylums

Foucault said that madhouses in the 18th and 19th centuries were nothing more than prisons for social nuisances, but he was wrong. They were also hospitals where attempts were made to cure the mentally sick. Roy Porter explores 50 years of Bedlam

Causes rewrite history, and the anti-psychiatry movement launched in the 1960s was no exception. Thanks to the phenomenal appeal of Michel Foucault's Madness and Civilization, originally published in French in 1961, radical new readings of psychiatry's past came to the fore which have now, in their turn, assumed the status of received truths, at least among humanities scholars.

In medieval times, it is now maintained, there were no such things as mental illness or psychiatry. Lunacy of various sorts was recognised - "good" as well as "bad" madness. But the deranged continued to mingle among society at large, and their voices made themselves heard alongside those of the sane, because they had their own truths to tell, be they supernatural or satanic.

According to the anti-psychiatry movement, the Renaissance then brought a marginalisation of lunatics, symbolised by the ship of fools, which expelled and cleansed the crazy at the same time. And the truly dramatic transformation came in the 17th century, with what Foucault styled "the great confinement of the poor". All across Europe, the mad were herded together with other social pests into giant warehouses, the archetype of which was the Hopital General in Paris. This amounted essentially to street-sweeping, an official edict of exclusion and sequestration. With little or no medical warrant, its rationale was not curing the deranged but securing them. Its aim was at bottom political - it was a way of silencing the mad, indeed of turning madness into "unreason", a state utterly negative, emptied of humanity. Foucault was insistent that we should not, (as traditional historical accounts do), anachronistically see such institutions as evolving psychiatric facilities; how could they possibly be that, given that, in his view, the 18th century "had no psychology"?

The new orthodoxy inspired by Foucault thus holds that the institutionalisation of the mad was primarily custodial. The madhouses which developed in the 18th and 19th centuries were places for locking the troublesome away - and there were, or seemed to be, growing numbers of such problem people, as advanced capitalism demanded ever greater discipline, conformity, law and order. The rising count of long-stay inmates was thus a symptom of society's desire to ostracise social nuisances; the high percentage of female patients pointed to the bother patriarchy had with unruly women.

It is easy, especially with respect to the last two centuries, to document this revisionist case from the writings of former whistle-blowers, reformers, and even of patients themselves. True, few lunatic asylums may have been absolute hell, blatant in their brutality, but treatment commonly took a backseat. In 1921, Montagu Lomax, a physician who worked at a large public asylum during the first world war, published The Experiences of an Asylum Doctor, with Suggestions for Asylum and Lunacy Law Reform, an expose accusing the institution of running a regime which had forgotten its curative mission: if people got better it was no thanks to the hospital. Films like One Flew Over the Cuckoo's Nest were to tell the same tale in a grimmer register. Such harrowing findings, of course, proved influential in winning over the public to antipsychiatry, precipitating the closure of numerous institutions.

Much of this revisionist story is true, and a valuable corrective to the once popular, upbeat, inhouse Whiggish histories. Other aspects are plain wrong. There never was a ship of fools, it was a literary fantasy; likewise the "great confinement" was something that happened in Paris, but nowhere else in Europe. Overall, we may be in danger of underwriting a new orthodoxy that is just as skewed as the old.

It would be pointless to debate whether all those involved in handling the insane were truly benign or monsters of malignity bent only on punishment. Equally, it would be a waste of ink to dispute whether, in earlier centuries, such institutions were truly beneficial to the insane. Yet there is today a real risk of underestimating how far madness was all the time understood as an illness, one which was in principle curable, and one which was properly the doctor's business. Asylums may not have cured the insane, but it would be folly to say, in the words of a TLS reviewer back in the 1980s, that they did not even pretend to do so. If anything, their mistake was precisely the opposite: therapeutically, they promised far more than they could deliver.

These caveats may be illustrated by the experience of Bethlem Hospital, which celebrates its 750th anniversary this month. All too often this history has been reduced to a single epithet - "Bedlam" - with all its dreaded Hogarthian connotations. Established as a religious house on October 23, 1247 in Bishopsgate, the Hospital of St Mary of Bethlehem was housing lunatics as early as 1400. We know little about what happened to its first patients, but it must be stressed, pace the account prevalent since Foucault, that medieval opinion had widely adopted the medical interpretations of madness pioneered by Hippocrates and Galen in antiquity. Insanity might be a divine visitation, but it was more commonly regarded as a disorder of the body to be treated with medications.

From the mid-17th century, Bethlem's rich archives show how the institution, for long England's only public refuge for lunatics, handled the condition of insanity. And that bears little resemblance to the portrait which Foucault painted of the Hopital General and which he applied to Europe at large. Bethlem had a physician and a surgeon; from the 18th century there was a resident apothecary as well. The early physicians included men of eminence, like Edward Tyson, the first medic to dissect an orang-utan. The governors insisted that Bethlem was not a prison for punishment but a hospital for healing.

All prospective patients were given a medical inspection; those who were deemed merely fractious could be diverted to Bethlem's twin institution, Bridewell. Those judged congenital idiots (mental defectives) would be barred, since Bethlem was to be solely for those believed to be insane and curable. The policy was to hold a patient for up to a year; if still deranged at the end of that time, he or she would be discharged as incurable - or, in a later era, sent to the incurables wing.

So what was done to mend the troubled mind? The basic emphasis was upon expelling the matter causing the malady. Emetics, purges and bloodletting were the standard means. To us such therapeutics may seem hopelessly crude, but they squared with reputable medical theories which viewed madness as a product of imbalances of the "humours": melancholy was due to too much black bile, mania to excessive choler. Other strategies were also tried, including hot and cold baths.

During the 19th century, Bethlem caught up, somewhat belatedly, with a prestigious new type of treatment, "moral therapy". This was a psycho-social technique which held that the insane would recover best in cosy, domestic environments which reproduced as far as possible the security and support of the bourgeois home. Having moved to a new site in Southwark (into the building that now houses the Imperial War Museum), from the 1850s Bethlem's interior was bedecked with paintings, caged birds and aspidistras; its grounds boasted bowling greens.

Into the 20th century reliance was still placed upon the healing properties of a soothing environment. By then Bethlem boasted plenty of pianos, and visitors reported it might be mistaken for a posh hotel. And, partly because of greater selectivity in its admissions, with preference being given to acute cases, discharge rates were impressive.

Though 20th-century Bethlem acquired a reputation as a rather conservative establishment, it duly introduced most of the therapeutic innovations which were to enjoy their moment on the stage: malaria treatment for conditions arising from tertiary syphilis; electro-convulsive therapy and psycho-surgery, including leucotomies. These new high-tech solutions mark both the gloom and the hope among the interwar psychiatric profession. On the one hand, since psychiatry clearly lagged behind many other branches of medicine in its search for causes and cures, there was a willingness to try anything: desperate cases required desperate remedies. On the other, optimism grew that, at last, with new technology and surgical procedures, something could be done that was more interventionist than simply waiting for the surroundings themselves to perform a cure. Many of these proved fads, some were disastrous. More valuable were the innovations in adolescent and geriatric therapies introduced at Bethlem after it merged with the Maudsley in anticipation of the setting up of the NHS in 1948.

As Foucault maintained, institutional psychiatry has been put to use to smother social nuisances. The disturbing have been labelled disturbed, certified and shut away, out of sight and out of mind. Recognition of this evil was one of the heartfelt springs behind the introduction of the policy of "community care". But that is only half the story. From the mid-19th century the new psychiatric professionals have claimed that lunacy falls within the medical domain (though cynics might call this an aggrandising professional strategy); and the mad have undergone a long succession of therapeutic interventions. These, however, have never enjoyed the same success as microbiology's magic bullets against infectious diseases.

Partly because of its therapeutic shortcomings, psychiatry has been saddled with an ambiguous status, and has seemed a Cinderella science. In 1900 the Journal of Mental Science pointed to the "apparent inefficacy of medicine in the cure of insanity", and took the dismal view: "though medical science has made great advances during the 19th century, our knowledge of the mental functions of the brain is still comparatively obscure". Some would say that things have not changed much.

Roy Porter is professor of the social history of medicine at the Wellcome Institute for the history of medicine. The History of Bethlem, by Jonathan Andrews, Asa Briggs, Roy Porter, Penny Tucker and Keir Waddington, will be published by Routledge.