Eighteenth to Mid-Nineteenth Century 315subsequently had Pussin transferred to the Salpêtrière to help
him reorganize the hospital.
In Italy, Vincenzo Chiarugi (1759–1820), superintendent
of the hospital of Bonifazio published his three volumes,
On Insanity and its Classification(1793/1987). He issued
hospital regulations in which he stated that mental patients
should be given humanitarian care, restraint should be kept
to a minimum, physicians should visit the wards daily, and
a program of recreation and work should be initiated. He at-
tributed insanity to congenital factors and to environmental
influences. John Conolly (1794–1866), a British physician,
practiced enlightened treatment methods for the mentally
ill, including minimal use of restraints when he became res-
ident physician at the Hanwell Asylum in 1839 (Scull,
1985).
EIGHTEENTH TO MID-NINETEENTH CENTURY
Asylums of the Era
Early nineteenth-century British asylums, conducted accord-
ing to principles of moral management, offered cures for
madness and acquired a reputation for achieving them. During
the same period private madhouses multiplied that accepted a
few mentally ill patients for payment. Many were owned or
managed by clergymen or physicians and often remained in
the same family for generations. Some were owned by rep-
utable physicians, of whom William Battie was one.
However, many private madhouses and asylums were
badly managed, and complaints about the conditions in these
places led to a parliamentary inquiry. Findings of inhumane
treatment led to government legislation aimed at providing
proper care and treatment, and establishing an efficient sys-
tem of inspection and licensing of public and private institu-
tions. The belief that the social engineering that organized
and maintained a productive economy could solve the prob-
lems of human need engendered the hope that persons put in
hospitals (and prisons) could be cured, or at least improved,
and rehabilitated to society. These institutions were, in the
main, general hospitals and workhouses intended to provide
minimal housing and care for paupers, those unable to fend
for themselves or unwilling to work.
As it became obvious that mentally deranged or incompe-
tent persons presented special problems, institutions were
built to house them. The inmates of these “lunatic asylums”
included habitual drunkards, petty offenders, vagrants, suf-
ferers of organic diseases (in particular general paresis), as
well as the mad. Over time, the increasing number of indi-
viduals judged to require institutionalization resulted in enor-
mous expansion of these asylums. As a typical example, the
West Riding Asylum in Wakefield, England was built in 1818
to care for 150 patients but within 80 years, it held almost
1,500. Moves to provide help funded by the state were en-
cumbered by problems of indifference. Under pressure of in-
creasing admissions plus accumulation of hopeless cases,
asylum architecture, initially designed to provide environ-
mental stimuli calculated to rouse pleasant and ordered
emotions, was altered. The size of public institutions eventu-
ally reflected not patient needs but cost to the public, and the
institutions tended to become custodial warehouses. Harsh
measures were often used and asylum staff as well as patients
lived a dismal existence (Russell, 1988).Advent of Nosological SystemsIn the latter half of the eighteenth century, nosological sys-
tems organized diseases, described in detail, according to the
model of systematic botany established by Linnaeus, the
Swedish botanist, physician and founder of modern taxon-
omy. William Cullen (1710–1790), a professor of medicine at
the University of Edinburgh, was the most influential classi-
fier of disease of the time. The section on medicine in the first
edition of The Encyclopædia Britannica(1771), utilizes his
system. The discussion of neuroses or nervous diseases states
that melancholy and madness are related, melancholy being
the primary disease and madness an augmentation of melan-
choly. Both are caused by an excessive congestion of blood in
the brain.
Jean Étienne Dominique Esquirol (1772–1840), Pinel’s
student and successor at the Salpêtrière, was one of the first to
apply statistical methods to clinical studies and tabulate psy-
chological causes. He elaborated the concept of monomania,
a type of insanity that does not involve loss of reason, to
designate an abnormally active, garrulous individual with
“delirium” or disturbed thought process confined to a fairly
circumscribed cluster of ideas or interests. The condition
sometimes appears abruptly and abruptly ceases, and often
does not necessitate hospitalization (Esquirol, 1838). His stu-
dent, Jules Philippe Joseph Falret (1824–1902) published a
paper in 1854 on “circular insanity,” which he described as a
clinically coherent and diagnostically distinct illness, charac-
terized by an alteration between manic excitement and de-
pression, typically with brief periods of reason (Sedler &
Dessain, 1983). The DSM-IIIdescription of bipolar affective
disorder is remarkably similar to Falret’s description of cir-
cular insanity; it appears to be a specific disease with a clus-
ter of typical symptoms, a particular course and prognosis,
and a particular response to certain somatic treatments (such
as, lithium, or electrical shock treatment).