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Medicine, Disease and Society in Britain, 1750 - 1950. Confinement of the insane. Lecture 17. Lecture Outline and Themes. The phenomenon of increased institutionalisation of the insane - The growth of public asylums in the C19 Explanations for this - social & medical, historiography

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lecture outline and themes
Lecture Outline and Themes
  • The phenomenon of increased institutionalisation of the insane - The growth of public asylums in the C19
  • Explanations for this - social & medical, historiography
  • The impact of the First World War on ideas about mental health – exaggerated?
think about
Think about......
  • How this topic fits in with overall course – emphasis on the social
  • Importance of historiography
  • Broad trend vs case study approach

So, for essays.....

  • How would you write a long essay titled “Why did the number of patients in asylums increase from the c18th?” AND “Did WW1 change the perception and treatment of mental illness?”
  • How would you structure it?
  • What are the key points?
  • What do historians say, what approach do they take, and why?
parry jones the trade in lunacy
Parry Jones, The Trade in Lunacy

Increase in numbers of Private madhouses (licensing returns)

1807 1844

Provinces 45 139

London 16 40

Increase in number of recorded lunatics (county returns)

1807 1828

2,248 12,547

moral management
Moral Management
  • York Retreat- founded by Samuel Tuke in 1796 after scandal at York Asylum: humanity kindness and reason
  • Thomas Bakewell founded Spring Vale in 1808

- Insanity believed to be curable

- Emphasis on kindness and calm

- Minimal use of restraint

- Domestic setting created in the asylum

- Reinforced normal social routines, e.g. meals, conversation, recreation, work

- Rural setting - encouraged walking and exercise

  • Emphasis on managing the mind of the patient- Promoting self-esteem, rationality and self-control
  • 1774: Regulation and licensing (London - Royal College of Physicians, Provinces: Justices of the Peace)
  • 1808: Permissive Legislation: right to raise finance for county asylums
  • 1828: Metropolitan Commissioners in Lunacy (extended to provinces in 1842). Improved inspection of asylums.
  • 1834: Poor Law Amendment Act- detention of dangerous lunatics in workhouses for a maximum of 14 days only
  • 1845: Compulsory Legislation: all counties to provide county asylums for paupers.
  • 1873: Lunacy Law Reform Association
    • Wrongful confinement, better standards, public rather than private provision.
growth of asylums in england and wales jones 1993 p 116
Growth of asylums in England and Wales (Jones (1993) p. 116)

Asylums Patients Av.No.

1827 9 1,046 116

1850 24 7,140 297

1860 41 15,845 386

1870 50 27,109 542

1880 61 40,088 657

1890 66 52,937 802

1900 77 74,004 961

confinement not cure
Confinement not cure

Pauper patients % Curable


County Asylums 4,244 15%

Provincial Licensed houses 1,920 33%


County Asylums 17,432 11%

Provincial Licensed houses 2,356 15%


County Asylums 27,890 8%

Provincial Licensed houses 2,204 13%

the significance of historiography
The Significance of Historiography

Even within same broad approach, there is disagreement

1. Emphasis on Social and Economic Factors

  • Foucault – broad perspective, total social control, power in state hands CAUSING confinement
  • Walton – case study, no total social control, argument on effect (not cause) on social and economic life
  • Scull –economic factors, growth of capitalism challenged the way families coped with the mentally ill (like Walton, confinement is an effect)
  • ‘History from below’ – emphasis on individual patients
  • Bartlett – Poor Law authorities identified who was insane, which affected who went to asylum (power and control again, closer to Foucault)
john walton 1981 lancaster asylum case study
John Walton (1981)- Lancaster Asylum Case Study

Investigating ‘social control’ – disagree with Foucault

  • Asylum not used in a systematic way to deal with the disorderly poor.
  • Little evidence that asylums were used to quell political or religious dissent.
  • Few admissions came through the law courts and police rarely involved.
  • ‘Impossible people’, violence, either self-harm or suicide, or directed towards family members was involved in over half the admissions.
  • Concluded that families only used asylums as a last resort.
the significance of historiography12
The Significance of Historiography

2. Emphasis on Medical Factors

Fewer historians emphasis purely the medical.


  • Shorter – alcoholism, tertiary syphilis
  • Scull – asylum was a way for doctors to specialise = rise of psychiatry. Medical education in this area from 1840s
the rise of psychiatry changes in medical view of insanity
The Rise of Psychiatry – Changes in medical view of insanity
  • Mid C18 to early C19 century - insanity was deemed both mental and moral as much as physiological. Bad behaviour, poor judgement, excessive passion or emotion, sexual licence and religious fervour could all be associated with madness. James Cowle Pritchard coined the term ‘moral insanity’.
  • From 1840s - definitions of madness emphasised organic and physical causes rather than behaviour- insanity came to be seen as rooted in the brain.
  • C19 emphasised physiological causes - vice, alcohol, dissipation, over indulgence all harmed the brain. Emotions also emphasised - love and grief, also old age.
  • Under ideas of Social Darwinism the possibility of hereditary defects was emphasised.

Conclusion- that medical men were more willing to label a greater range of conditions as insanity and recognised chronic conditions, old age, incurability in insane populations.

shell shock
Shell shock

William Adie: asked what he considered shell-shock to be “....I should say any state of mind or body engendered or perpetuated by fear, which renders the soldier less efficient or enables him to evade his duty with impunity...all these conditions are either engendered by fear, or having been engendered by something else, such as concussion, are perpetuated by fear. ...many of us were suffering more or less from ‘shell shock’, which made us not so efficient, and yet we remained in the line...all sorts of people got out of the line with so-called ‘shellshock,’ and the result was that they evaded their full duty and yet were not punished.”

Partly to do with morale among the troops

2 battalions side by side...(one) had practically no men going down with ‘shell shock’. The other battalion was sending ten men away at a time. “You could have foretold that it would be so by looking to the men’s appearance. In the good battalion the men were always smart, but the others were bad soldiers with bad officers. That is the crux of the matter. Keep up the morale of the troops and you will not have emotional ‘shell shock,’ at least you will reduce it enormously.”

(Evidence to Committee of Enquiry into Shell Shock 1922 quoted Brunton (ed.) (2004) p.267)

shell shock15
Shell shock

‘Dr. Rivers, asked what he thought of the term ‘shell shock’, said he objected to it root and branch. The reason why he objected to the term was that so far as he could see the main factor had been stress, and the shock in most cases was merely the last straw....break down after long and continual strain. These were the men who, especially in the early stages of the war, after some shell explosion or something else had knocked them out badly, went on struggling to do their duty until they finally collapsed entirely. Cases of that kind presented especially severe symptoms. All these cases were much of the same order, only people who broke down before they went over to France did not want stress to cause them to break down; they were ready to break down immediately. The man who got to France had stress. There is no question of that; perhaps, for him, a very big stress indeed. The case of the man totally unfitted for warfare finding himself in the trenches meant a very big stress for him. Stress is relative...

Asked whether there was any doubt in his mind as to the existence of a mental wound arising from emotional shock in contradistinction to any concussion, the witness said he should be inclined to put it in this way, that when a man began to have a series of disturbances of different kinds, such as loss of sleep, etc., he either consciously or more of less unconsciously looked for an explanation, and this tended to centre around some particular experience, in many cases a comparatively trivial experience.’

(Evidence to Committee of Enquiry into Shell Shock 1922 quoted Brunton (ed.) (2004) p.268-9)

W.H.R. Rivers (1864-1922)

- used the Freudian concepts of 'repression' and 'the unconscious’

- treated the soldiers with 'autognosis' which involved dream analysis

- called shell shock 'anxiety neurosis' and he used catharsis and re-education by telling his patients how much faith he had in them in order to make them well again. Rivers used the power of suggestion to create self-belief in the patients.


Matthew Thompson, ‘Status, Manpower and Mental Fitness: Mental Deficiency in the First World War’ in Roger Cooter, Mark Harrison and Steve Sturdy (eds.), War, Medicine and Modernity (Thrupp: Sutton Publishing,1998) 149-66):

  • High proportion of officers among the shell-shocked indicates that diagnosis was a sign of patient-power (a way to escape the horrors of the trenches) as much as medical control.
  • In a 1918 sample of officers only 6 per cent were sent back to duty. By contrast, among the lower ranks, 48 per cent were sent back to the front.
  • Even if the war was a watershed in attitudes and standards of care, it was a watershed which was differentiated according to status, benefiting the neurotic but leaving a ghetto of neglect for the defective and the chronic and incurable mentally ill.
  • The shell-shock-dominated story of First World War psychiatry – of new knowledge and more sympathetic attitudes inaugurating an era of mental hygiene – is flawed: it focuses too exclusively on high-status individuals; lower-status groups experienced very different fortunes.
  • Recap of some the issues on ‘trade in lunacy’ lecture – increased confinement of the insane
  • Looking at ‘the confinement of the insane’ provides a good example of:
    • Social history of medicine
    • Importance of historiography – social/ec vs medical factors but not all historians agree
    • Broad overview approach vs case study
  • Looking at WW1 brings up new questions
    • Essay on shellshock
    • Recent interpretations challenge the overall impact of WW1 on diagnosis and treatment, see Thompson