Treatment of 'the mad': Therapy or Neglect?
Throughout the 18th and early 19th century, physicians still believed in the Ancient Greek principle that the body was governed by four ‘humours’:
- blood
- phlegm
- yellow bile
- black bile
Too much black bile in the body was said to cause madness in the form of melancholy or mania.
Treatment for the ‘insane’ during this period was dominated by the attempt to rectify the humoral imbalances through evacuative remedies:
- bleeding
- blisters
- purging (emptying the bowel)
- vomiting.
Although this therapy appears barbaric today, it followed approved medical practises of the time.
Bethlem, was however, condemned in its application of treatment (‘physick’), which was seen as both arbitrary and violent. It was not until 1772 that the attendance of medical officers was required in the administration of purges and vomits. Bethlem’s management, in giving unqualified and over stretched staff this control, was in dire need of reform.
The scandalous discovery in 1814 of the Bethlem patient James Norris, who had been restrained in chains for fourteen years, was central to the Parliamentary inquiry into ‘madhouses’ of 1815/16. Mechanical restraints and strait-jackets were widely used at Bethlem, but were generally seen as a necessity rather than a cure. With roughly 260 patients in the 1760s, the skeleton staff of ten or eleven used restraint to prevent ‘the most violent’ patients ‘from doing mischief to themselves’ or others.
The routine dosing of patients, for sedative reasons, was also in common use at Bethlem. The Bethlem physician Richard Hale (1670-1728) was even praised for handling ’maniacs’ not so much ‘with chains and bars, as by sedating them’. Dosing, however, did little more than mask the symptoms.
Despite some aspects of genuine innovation in patient care during the reign of the Monro dynasty, their entrenchment in Bethlem for over 120 years, led to conservative treatment. Practices were, in general, unquestioningly handed down from father to son, with little attempt to pioneer new therapies.
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Inside Bedlam: Custody and Care
The Moorfields building, the second home of Bethlem Hospital from 1676 until 1815, was one of the grandest in the city and lavishly ornamented. Design and function were influenced by Bethlem’s growing popularity as a London show.
Patients were forbidden to use the front garden, as this would have necessitated a rise in wall height, so obscuring the view for the passer-by. By 1770, this public sight-seeing was deemed inhumane and finally stopped.
Bethlem initially housed 120 patients. The majority had individual cells – ‘12 feet by 8 feet 10 inches’, which lacked glazing, while the patients had only inadequate clothing. Cold was traditionally viewed as having a sedative effect upon the patients, and eliminated the dangers of over-heating the brain.
The Parliamentary inquiry into madhouses of 1815/16, criticised the cold and damp conditions of Bethlem. Even when the hospital moved to its new home at St. George’s Field, Southwark, the windows were still unglazed. The Governors believing this dissipated ‘the disagreeable effluvias peculiar to all madhouses’. Glass was finally fitted in 1816.
Rudimentary water supplies and the lack of latrines in both buildings led to dirty and unhygienic conditions, yet staff attempted to maintain a sanitary environment. That the Parliamentary enquiry found ‘the apartments in general…to be clean, and the patients who were not confined tolerably comfortable’, reflects that Bethlem was, in cleanliness, no different to other institutions at the time.
It was, rather, the discovery of the side rooms that was the shocking revelation within the inquiry. Here, incontinent or ‘highly irritated’ patients prone to tearing their clothes, lay virtually naked, chained to their straw beds.
As early as 1684 a matron was employed at Bethlem so that ‘the poore Lunatikes there be kept sweet and clean’. However, even after the move to new premises in 1816, there was much room for improvement at Bethlem.
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‘Iron Fetters, Chains and Cords’: Restraint within Bethlem
During the 1815/16 Parliamentary enquiry into ‘madhouses’, the medical officers at Bethlem Royal Hospital were cross-examined on their use of mechanical restraints. The 1815 Select Committee agreeing ultimately, that restraints were used ‘much beyond what is necessary’.
John Haslam, Bethlem’s apothecary, opposed the use of strait-jackets stating that:
‘The hands are completely secured if the strait-waistcoat be tied tightly, respiration is prevented or impeded, and it is always at the mercy of the keeper how tight he chooses to tie the waistcoat. If the patient be irritated by itching in any part, he is unable to administer the relief by scratching, or if troubled by flies in hot weather, it is a painful encumbrance, and if not changed is liable to absorb a great deal of perspiration, which renders sometimes the skin excoriated.’
Thomas Monro, Bethlem’s physician, and most other witnesses at the 1815 enquiry, considered strait-jackets to be better than chains. Monro, however, also distanced himself from this practice:
'I have nothing in the world to do with the irons; I never gave orders for the patients to be put into irons in the whole course of my life...[chains and fetters] are fit only for pauper lunatics: if a gentleman was put in irons, he would not like it'.
Monro’s testimony worryingly suggests that the use of chains was determined by class rather than medical grounds.
The 1815 Committee condemned Bethlem for its employment of mechanical restraints. Yet restraint was not unique to Bethlem. During the 17th and early 18th centuries, it was seen as a necessary and acceptable feature of asylum life. Even following the Lunacy Reform Movement, and lobbying for non-restraint in the first half of the 19th century, many institutions were slow to curtail the practise.
They had their reasons. Bethlem, in the 1760s, had only 10 or 11 keepers for 260 patients. This discrepancy, and the concern for the safety of large numbers of visitors flocking to Bethlem, must have necessitated a certain reliance on mechanical restraints.
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