THOMAS BAKEWELL 1761 1835

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THOMAS BAKEWELL1761 - 1835

• MADHOUSE KEEPER / MORAL THERAPIST and
• MAN OF THE ENLIGHTENMENT

Dr Lisetta Lovett Consultant Adult Psychiatrist /
Senior Lecturer
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OUTLINE

• Context - Views about Mental Illness prior to and
  during the Enlightenment
• Dichotomy between medical and non medical opinion
  on causes and treatment of Mental Illness
• Biographical background
• Thomas Bakewell - attitudes, management
  approaches to Mental Illness
• - criticisms of Mental Health policy
• Case studies

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MODELS OF MADNESS

• Divided from herself and her fair judgement,
  without which we are pictures, or mere beasts.
• Hamlet
• Act 4, scene 5

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• Insanity conceived as a disturbance of reason
• Reason considered to be unique to man
• Madmen have no claim to be treated as a human
  beings
• Brutal and inhuman approaches

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PICTURES OF CONDITIONS
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PICTURES OF CONDITIONS
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PICTURES OF CONDITIONS
A mentally ill patient in a straitjacket attached
to the wall and a strange barrel-shaped
contraption around his legs. Many different
modes of restraint had been tried most were
found counterproductive, triggering the
non-restraint movement photograph after a
wood-engraving, 1908.
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PICTURES OF CONDITIONS
Plate VIII from Hogarths Rakes Progress series,
1735. Now insane, Tom Rakewell sits on the floor
of the gallery at Bethlem Hospital, London,
grasping at his head in the classic pose of the
maniac. His faithful admirer, Sarah Young, cries
at the spectacle whilst two attendants attach
chains to his legs they are surrounded by other
lunatics.
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• If the possession of reason be the proud
  attribute of man, its diseases must be ranked
  among our greatest afflictions, since they sink
  us from our pre-eminence to a level with the
  animal creatures
• Practical Observations on Insanity
• 1813 J.M.Cox

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EARLIER PERCEPTIONS OF MADNESS

• Demonic possession
• Supernatural powers e.g. in Hinduism, Grahi idea
  of lycanthropy, western culture
• Punishment of Fate
• the Lord will smite thee with madness
  Deuteronomy 65
• Imbalance of the Humors
• Witchcraft

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In the Old Testament Nebuchadnezzar, king of
Babylon, has a dream, which Daniel interprets as
a harbinger of madness. When he later spoke with
pride of how he had built his wonderful palace,
Gods voice announces that the Kingdom is
departed from thee, and Nebuchadnezzar is driven
mad, as in the dream.
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GREEK MEDICINE

• Hippocrates (460-357BC)
• the sacred disease appears to be no more divine
  nor more sacred than other diseases, but has a
  natural cause

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HUMORAL THEORY
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TWO KEY DEVELOPMENTS(17th 18th Centuries)

• Influence of the Enlightenment philosophers
• Increasing knowledge of Neuroanatomy and
  Neurophysiology

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PSYCHOLOGICAL MODELS OF MADNESS

• David Hartley Behavioural psychology
• 1749 Observations of Man

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• Psychological approach
• Reformist practice
• Moral Management
• Moral refers to therapeutic focus on the mind
  rather than the body

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MORAL THERAPY

• Aim to influence behaviour through social and
  environmental manipulation to facilitate
  self-discipline and self-control.
• Based on the beliefs that the mad should be
  treated as rational and social beings.

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THOMAS BAKEWELL
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THOMAS BAKEWELL
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FAIR DEAL CAMPAIGN

Royal College of Psychiatrists 2000
Thomas Bakewells Campaign 1808 Are there
parallels?
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DISCRIMINATION and STIGMA

• mental diseases are a most grievous evil there
  can be no doubt that this evil has been
  aggravated, continued and augmented by neglect
  and inappropriate treatment
• Letter to SC 1815
• If the relations had known of his being
  afflicted with gout all Europe would have heard
  of it before now
• insanity is no proof of poverty of blood,
  poverty of intellect or want of virtue why then
  should we be more ashamed of it, or strive to
  conceal it more than gout they are often
  considered objects of horror, odium and disgust
• could we bring ourselves to look insanity more
  fully in the face, to know it more, understand it
  better, that the evils of it would diminish
• 1817 MM
• the vague and erroneous notions respecting
  mental afflictions are very unfortunate for
  cause the sufferers to be thought of with
  feelings of repulsive horror

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• They should not only be the abodes of bodily
  health, cheerfulness, active amusements, useful
  employment, and the usages and comforts of common
  life, but they should have the character of being
  such and this character should not only be
  acceptable to the feelings of sober reason, but
  also to the vivid imaginations of those likely to
  become candidates for admission.
• March 1816 MM
• Asylums X
• Insanity X
• to change the image of the institution and reduce
  stigma

Hospitals for the cure of Nervous Fever
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ENGAGEMENT

• A middle aged man with history of depression who
  becomes manic, found to be expensive and
  troublesome to his children, who asked me to make
  their father melancholia again
• Dispute with a son who kept removing his father
  against his will to, his own parish Bakewell
  finally gets a Magistrates order and is able to
  turn the young rogue out of the doors
• the great error was her remaining at home under
  the irritations of family intercourse

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ACCESS TO PSYCHOLOGICAL THERAPIES (Moral Therapy)

• Lunatics are not devoid of understanding they
  must be treated as rational beings
• Keep the mind alert by constant stimulus of
  various objects and rational yet cheerful
  conversation
• Displace morbid ideas or false beliefs by
  promoting a new train of mental images through
  mounting the top of higher hills and looking
  around for different objects an unbounded
  prospect gives the most relief

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• Our long walks over the hills for the gentlemen,
  and our less fatiguing though no less pleasing
  walks for the ladies have a most admirable effect
  in suspending at least the hallucinations of the
  mental disease

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• art and nature have here acted in unison hill
  and dale, groves, water and fountains are
  particularly intermingled, and perhaps no spot
  could be found more proper for an asylum

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• Occupation gardening, knitting, music, writing
• Behavioural management rational talk an
  approving
• smile, rambling reproving looks and
  silence
• Respect and kindness
• Exercise
• Family atmosphere
• Non-restraint they must for their own sake
  be
• secured, but that any abatement of this
  should follow
• quickly with a reduction of coercion
• In 5 out of 6 cases the whip is useless and
  should never be used for violence or extreme
  rudeness

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LINKS BETWEEN MENTAL AND PHYSICAL HEALTH

• Thomas Bakewells views about causes
• 1. Primary illness due to emotional excess
  constitutional causes
• 2. Physical disease of brain
• 3. Secondary to physical illness or physical
  conditions e.g.
• childbirth, starvation, insomnia
• Mental illness both as a physical and
  psychological condition
• Criticises The Retreat deficient in medical
  treatment but I feel grateful for opinion
  of medical attendants
• SL 1815
• On the other hand what then shall we say to
  indiscriminate blood letting at Bethlem which
  can do permanent injury?

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• Disapproved of - blistering, and mercurial
  preparations,
• - cold baths
• - use of opium, foxglove and any
  narcotic
• I am doubtful any narcotic or sedative drug is
  of permanent advantage in these cases (of
  insanity), the real treatment for insomnia
  relaxation
• Advocates
• Mild purgative to all his patients on admission
• Warm baths or pressure steam chairs
• Correct nutrition prohibited salt, meat,
  heavy suppers,
• alcohol, rich soups, pastry

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1808 COUNTY ASYLUM ACT
FUNDING
RECOVERY
ACCESS
INPATIENT SERVICES
FAIR DEAL Royal College of
Psychiatrists 2008 Thomas Bakewell1808
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• ARGUMENTS against PUBLIC ASYLUMS
• 1. Asylums are counter therapeutic lunatics
  are more susceptible of strong mental impressions
  than others. (Asylums) more likely to prevent
  recovery than promote it.
• (The Architecture) "errs the cells open into
  galleries used for exercise (therefore they are)
  exposed constantly to all that is disagreeable in
  the disease
• they are all upon the plan of solitary
  confinement during the night yet nothing could
  be worse
• To achieve cure the mind of the patient had to
  be entirely divested of the idea of incurable
  lunacy the cordial of hope should be
  constantly held up by the hand of humanity
• Asylums increase stigma
• contemplated with feelings of superstitious
  horror by the lower class
• Asylums are Means of Social Control, not care
• a system of coercion and horror nothing more
  than mighty prisons
• 4. Asylums are expensive and inefficient

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ARGUMENTS against PUBLIC ASYLUMS

• Efficacy of early treatment - Such is the nature
  of insanity, that where it has been neglected
  long say for the space if two years no
  permanent recovery is to be expected.
• MM February 1816
• and such cases should be resigned to the care
  of simple humanity or present guardians
• I look upon perfect recovery as a moral
  certainty. But then measures must be taken in
  time.
• Economics the usual stock will upwards of
  twenty thousand. To give accommodation to all in
  large mad-houses would require an expense of ten
  times that necessary to meet all new cases, with
  the very best system of treatment for recovery.
• would it not be better to entirely direct the
  efforts of any new measure to the purpose of
  recovery.

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THE ECONOMICS
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CASE STUDIES

• Depressive Disorder, Depressive Stupor, Manic
  Depression, Pathological Grief, Post Traumatic
  Stress Disorder, Post-natal Depression, Organic
  Disorder due to brain trauma, Alcohol Dependency
• Pathology described included
• nihilistic delusions (soul loss)
• delusions of guilt, poverty
• paranoid and grandiose delusions
• something alive in the stomach causing
  intolerable pain
• I rather believe this fancy arises from having
  no children

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• 28 year old man admitted
• violent case of phrenetic, illusive madness
• in 9 months, convalescent and became extremely
  attached to a little boy his whole business was
  to nurse him his fondness for him contributed
  towards his complete recovery
• After 15 months discharge well for 2 years, but
  relapsed due to hard treatment from his
  landlord, which led him to leave his farm upon
  which he had been brought up

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• we are seldom willing to confess how much we are
  the slaves of feeling It was no doubt, the
  excess of feeling that was the origin of this
  mans madness and which ended in
  self-destruction. It was the excess of feeling
  that was the cause of my devoting life to the
  care of madness.

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• NO.76 Male, single aged 24
• A most strange case of nervous or mental stupor
  he appeared quite incapable of voluntary motion.
• If put in a recumbent posture, he never attempted
  to regain his balance. He appeared entirely
  unconscious of everything around him, never
  spoke.
• of course, in a case like this, I took the
  opinion of my medical friends, and a number of
  things were done in medical treatment.
• purges to keep a very active state of bowels
• hot baths
• light food
• carried into walks, then urged him to step
  foreward
• we then put a spade in his hand, and urged him
  to use it
• At the end of six months, he recovered. I shook
  hands with him in Stafford a polite, sensible
  young man.
• Since writing, the person alluded to has come to
  see me and appeared perfectly well, both in body
  and mind and on the same day NO.77 came to see
  me, in a like pleasing, friendly manner.

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INSIGHTS INTO BAKEWELLS CHARACTER

• The votaries of pleasure may think it a dreary
  life to be in constant attendance at the couch of
  a maniac and to give up every social enjoyment
  which a person in my situation must do, if let
  but resolves to do his duty. In truth, it has
  its troubles and mortifications, such as those
  unacquainted with it, can have no conception of
  but the labour we delight in, physics pain
• in short, to see a fellow-being recover
  perfectly from a state of madness, melancholy, or
  mental stupor is a feast of reason

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INSIGHTS INTO BAKEWELLS CHARACTER

• We sometimes meet with ingratitude from those who
  recover, and our office is looked upon with
  degradation the person to whom my grandfather
  owed his instructions in the treatment of
  Insanity, was a learned good man yet seldom
  designated by any title more honourable than Old
  Conjurer
• Letter to SC 1815

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• The highest proof of humanity (is) to protect
  those who are unable to protect themselves
• this proof is sorely waiting in the case of
  those afflicted with mental disease.

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HARPLANDS HOSPITAL
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ACKNOWLEDGEMENT

• Smith L.D. (1993) To cure those afflicted with
  the disease of insanity Thomas Bakewell and
  Spring Vale asylum
• Smith L.D. (1994) Close Confinement in a Mighty
  Prison Thomas Bakewell and his campaign against
  public asylums 18101830
• Myers E (1997) A History of Psychiatry in North
  Staffordshire 1808-1986 Churnet Valley Books

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