In Chapter 1, we introduced the ideas of Ren´e Descartes (1596–1650) and John Locke (1632–1704) and suggested that as their ideas gained currency, the period that ensued came to
ENLIGHTENMENT AND MADNESS 95
be called the Age of Enlightenment or the Age of Reason. Recently, historians have demonstrated that the 18th century was more complex than such simple characterizations indicate. Nonethe- less, these terms are still useful for us. This was a period when the power of human reason to understand the world and to govern human affairs was accorded the primary place in philoso- phy, politics, education, and many other areas of life. Man was conceptualized as a creature of rea- son. The gendered term is intentional; women were typically regarded as creatures of emotion rather than reason.
In this period, when men’s rational powers to understand the world were accorded primary status, madness or lunacy, as it was often called, was an example of the failure of reason. The mad, in much of Europe, were usually kept at home or allowed to roam. When a mad person was institutionalized, and few such settings existed anywhere in Europe, treatments typically included bleeding, cold baths, or purging. The most commonly cited medical theory used to justify such treatments was the ancient theory of humors, first formulated by the Greek physician Hippocrates (460–370 BC). Humoral theory asserted that health was regulated by the balance of the four humors in the body:
phlegm, black bile, red or yellow bile, and blood. When these humors became disregulated, emotional and behavioral disturbances would ensue. Bleeding, purging, and other techniques were meant to restore this balance and return the person to health.
During the Enlightenment, madness or lunacy was reconceptualized as a problem of loss of reason. Treatments took on a new cast as reform movements that began in the late 18th century in England and France spread to other sites, including North America. In Italy, in the 1780s, Vincenzo Chiarugi (1759–1820) instituted reforms at Santa Dorotea hospital in Florence and later at Bonifacio Hospital. He out- lawed the use of chains to restrain patients and introduced more humane treatment. In France, after the Revolution of 1789, Philippe Pinel
FIGURE 5.1 Hippocrates
(1745–1826), the newly installed director of the large Paris hospital for women, the Salpˆetri`ere, instituted changes in the care of those thought to be mad. Pinel drew upon the writings of Locke and the French philosophers Voltaire (Franc¸ois- Marie Arouet), Denis Diderot, ´Etienne Bonnot deCondillac, and others who were advocates of the values of the Enlightenment. He instituted a new regime of treatment in which many patients were released from their shackles and treated as reasonable humans, able, with help, to regain their faculties of reason. His program had re- markable success. While it is likely that many inmates had never been mad as, at this time, the poor, debtors, and others were all placed with the insane, Pinel’s approach still clearly marked an improvement over the earlier treat- ments and was gradually adopted in other houses and hospitals that had the insane or mad in their charge.
In York, on the northeast coast of England, another remarkable experiment began in 1796, about the same time as Pinel’s work in Paris.
Local Quakers, concerned about the treatment of some of their members who were suffering from mental disorders, decided to open an insti- tution especially for other Quakers. Under the leadership of a well-to-do Quaker businessman, William Tuke (1732–1822), the York Retreat
96 CHAPTER 5 THE PRACTICE OF PSYCHOLOGY AT THE INTERFACE WITH MEDICINE
FIGURE 5.2 Philippe Pinel
was organized with the belief that mental illness was a state from which a person could recover with the right treatment. Tuke and the Quakers used the model of the God-fearing home as the setting for their treatment. The Retreat’s staff employed an attitude of benevolence, personal care, and opportunities to engage in useful tasks to nurture their patients back to health.
From the beginning, the York Retreat re- ported great success. Many patients treated there were able to leave the retreat and return to their homes. Although it was originally designed to serve Quakers exclusively, before long non- Quakers were also admitted. It should be pointed out that the Retreat was built to house only 30 people and actually began with only about a third of that number. The small size of the pa- tient population, as it turned out, was vital to the success of the treatment.
The success at York led to its imitation elsewhere and was a crucial part of the reforms of the treatment of the insane throughout England, especially after Tuke testified before committees of the British Parliament that were inquiring into the appalling treatment of the insane. Word of the success at York, in Florence, and at the Salpˆetri`ere in Paris gave rise to what was called in English moral treatment. This was treatment based on regarding patients as inherently reasonable and providing humane care that
would help them return to their reason. Patients were expected to act reasonably and contribute their labor by completing household tasks.
In the United States, a positive response resulted from this approach. The physicians who led the efforts to treat the insane were called alienists. This word was used because it was believed that the cause of mental disorders was becoming alienated from one’s reason. American physician, Benjamin Rush (1745–1813), one of the signers of the American Declaration of Independence, began using treatments inspired by Enlightenment ideas, including novel forms of restraint such as the crib, in which patients had to lie still as there was no room to move.
The thought was that as patients calmed down, they would gradually be restored to their senses and their reason would return.
By the 1830s, moral treatment was the stan- dard treatment approach in most of the asylums that had begun to be built in the countryside near many American cities. At first, the patient population was small and there were many suc- cesses. Many patients were able to return to their families. With success, however, came problems.
In the 1850s, Thomas Kirkbride (1809–1883), a Quaker alienist and leader of moral treatment, developed what became known as the Kirkbride Plan for the design of mental institutions and the care of their patients. For their day, these were large institutions whose orderly design was intended to restore order in the minds of the patients housed within. Again, at first these insti- tutions had remarkable success that continued as long as the patient population was small. How- ever, by the last third of the 19th century, such institutions began to be overwhelmed with an increase in patient population and a decrease in support from private and public sources. Moral treatment was labor intensive; it required that staff, usually nurses and orderlies, give a great deal of time and attention to the patients. With increases in patient numbers and decreases in resources, moral treatment devolved into sim- ple palliative care where patients were fed and