1. Narrenturm (‘Fools’ Tower’) situated alongside the Vienna General Hospital, the first modern general hospital in Europe, built by Emperor Joseph II in 1787

Doctors were put in charge of asylums primarily because they were easy to hold accountable to the board of governors. There were few effective medical interventions and the medical superintendent’s role was predominantly administrative and disciplinary. He didn’t even have the power to admit or discharge patients – that was usually held by the local magistrates.

  Asylums started well, often admitting recent cases – many of whom recovered. They soon seized up, however, with those who did not recover and so became overcrowded. Throughout the latter part of the 19th century and early 20th century, the recovery rate in mental hospitals declined steadily because of an increasing concentration of these more severe cases. Therapeutic optimism gradually faded and conditions (though still much better than the workhouse) deteriorated.

  Throughout the 19th century investment in asylums was maintained. They were kept high on the agenda in the US by the influential social reformer Dorothea Dix and the physician Benjamin Rush and in England by strong central support from the influential social reformer Lord Shaftsbury. Initially quite small institutions, they rapidly grew to several hundred inmates each in Europe and up to several thousand in the US, where the building programme started a bit later and continued longer. Between 1903 and 1933 the number of patients in US mental hospitals more than doubled from 143,000 to 366,000. Most of these were in institutions of more than 1,000 beds and US mental hospitals continued to expand. The largest was the Georgia State Sanatorium at Milledgeville which by 1950 housed over 10,000 patients.

 

2. Georgia state sanatorium at Milledgeville: the largest state mental hospital in the usa. At its height in 1950 it housed over 10,000 patients

The non-restraint movement

  Cultural values are strongly reflected in the care of the mentally ill. This is still the case despite the globalization of mental health research. At the start of the asylum movement the UK and US focused on human rights and, particularly in the UK, on treating patients with as little physical restriction as possible. John Connelly, the physician superintendent at Hanwell Asylum, became the leading proponent of managing patients without strait-jackets or chains. He emphasized the value of well trained and unflappable staff and used isolation to allow patients to calm down. A US visitor to Connolly commented that English patients must be more tractable and that the approach would ‘never work at home’. This tradition has continued and the UK became the first country to run some mental hospitals entirely without locked doors (Dingleton in Scotland was a fully ‘open-door’ hospital by 1948 – before the new drugs, see Chapter 3). The UK approach remains unusual in its total absence of mechanical restraints to control agitated patients. Whether its reliance on medication to achieve this is always a good thing is, of course, open to question.