Between 1800 and 1914, no western country was spared the rapid construction of asylums and an apparently insatiable demand for institutional accommodation. Three hundred thousand persons were committed to asylums in England and Wales in the nineteenth-century; by the Great War, close to one-quarter of a million Americans occupied state mental hospitals. The residential population in Ireland and New South Wales approached one in every 300 people. Similar patterns of confinement appeared in France and Germany. Even colonial communities in South Africa and India followed suit. Confinement crossed national, religious, ethnic and class divides; it occurred where national legislation compelled the erection of purpose-built institutions, and where no such legislation existed. Michel Foucault may have been wrong on the precise timing of the “great confinement”; he was nevertheless accurate in his estimation of the impact of the asylum on the social, medical, and political landscape of modern western society.
Monographs on the rise of asylums in different national contexts tell, at least superficially, a remarkably similar tale. In the early part of the nineteenth-century, there emerged a lunacy reform movement based on the premise that madness could be cured given proper institutional treatment. Originally associated with religious institutions such as The York Retreat, moral treatment was co-opted by an emerging group of medical men intent on creating national systems of public asylums under medical control. The period between 1800 and 1860 witnessed legislation enabling, and in some cases obliging, local authorities to provide for their insane poor. In response, counties, provinces, states, districts, and departments constructed purpose-built institutions for the treatment and cure of insanity on humanitarian, financial, and scientific grounds. But the optimism proved to be unfounded. Judged even by the standards of its proponents, these new institutions proved to be a disaster. Asylums originally built for one or two hundred patients tripled in size, apparently sitting up with “chromes” and “incurables”. Many institutions exceeded a thousand inmates. Meanwhile, public officials looked with despair upon the increase in insanity, the relentless demand for accommodation, and the spiralling costs of these institutions. By the turn of the century, the era of therapeutic optimism had been replaced by darker fears of race degeneration and social Darwinism as second and third generation medical superintendents, now reconstituted as psychiatrists, groped for explanations for their professional failure.
The historiography of the nineteenth-century asylum has thus been written in the long shadow cast by the emergence of modern psychiatry. Heated, and at times acrimonious, a debate has ensued over why psychiatry “failed”, and over the relative merits of moral treatment, “non-restraint” and the problematic nature of the medical profession’s claim to “expert” knowledge over the treatment of the insane. The psychiatric gaze has transfixed a generation of historians. There has been relatively little debate, however, over the methodological connexion between the history of psychiatry and the history of confinement — that is, between those who professionally benefited from the creation and expansion of asylums, and why and how people were placed there. The implicit connection between the emergence of a psychiatric profession and the confinement of the insane, enshrined in paradigms of “social control” and “professionalization”, seems to be based upon mutually supporting assumptions.
Regardless of what one might think about either the therapeutic efficacy, or authority, of medical officers within the asylum, there is little evidence to suggest that medical men precipitated or controlled the process of confinement. The early days of “lunacy reform”, for instance, were dominated by “hybrid” institutions. The South Carolina State Asylum, the Lincoln Asylum in England, Illenau in Baden, and the Morningside Asylum in Scotland, accepted pauper, charitable, and private patients. In these institutions, control over admission remained in the hands of a lay board of governors, in association with local poor law authorities. The boards which managed these institutions took a variety of approaches as to the role and authority of medical men within the asylum. In the case of the Gladesville asylum, the first superintendent was not even medically trained, though the board of regents in charge of the South Carolina Asylum hired a local physician as a medical officer. Despite these differences, the rate of admission of patients, and the same problem of overcrowding occurred in all four institutions.
When legislation compelled, rather than permitted, the erection of asylums in departments of France (after 1838), counties of Ireland (after 1843) and England and Wales (after 1845), and districts of Scotland (after 1858), many local authorities actively resisted central interference and restricted the powers of resident medical officers. In England and Wales, often considered the model of a centrally-directed asylum system, county magistrates maintained a strict control over the financing, supervision, and visitation of their asylums, and hired and fired medical superintendents at their own discretion. Richard Hunter in his study of Colney Hatch, one of the largest asylums in the world at mid-century, concluded that medical superintendents “had no control over admissions, never saw patients before they came in, and could only advise when a patient was well enough to be discharged”. In regions like Lower Canada, dominated as it was by the Catholic Church, the control of asylums by religious orders made medical authority even more difficult. In the United States and Canada, no “national” legislation appeared to guarantee the supremacy of medical officers over the admission process, yet the pace of confinement seems no less marked than in England. The multiplicity of the German states may have delayed the emergence of a unified psychiatric profession, but it did not stop the confinement of the insane at a rate similar to that in (relatively) centralized France.
Clearly, the medical profession waged an explicit campaign in various national contexts to enhance the authority of resident medical officers. But this campaign occurred at the same time, rather than prior to, the dramatic increase in patients; and the decentralized nature of most nineteenth-century states, where the establishment of purpose-built institutions was left to local authorities, inevitably undermined collective action. So medical superintendents in these countries could complain bitterly that they had little or no control over who was admitted to their asylums but had little political clout to press their case effectively. The Lunacy Commission in England and Wales, and in Ireland, two national bodies responsible for the enforcement of lunacy laws and sympathetic to medical control over all aspects of the asylum, had few powers of compulsion. Moreover, there are reasons to assume that this state of affairs was not altogether unacceptable to many medical superintendents. With prestige associated with the size and public status of medical institutions, alienists did not actively prevent the enlargement of their own asylums. Andrew T. Scull argues that medical superintendents in England “insisted on burying themselves ever deeper in administrative concerns” rather than fight against the rapid expansion of the county asylums. Thus, apart from their roles in persuading a sceptical public about the therapeutic efficacy of medical treatment in an institutional setting, and their administrative roles in the process of certification, medical superintendents were unable to influence significantly the process of confinement. It was a social phenomenon of dramatic proportions, seemingly outside their control.