60 Articles 61 Traces: Te UNC-Chapel Hill Journal of History to both the government and industry. Research universities provided the ‘heart’ of these cities, and fostered a community surrounding high-tech industries and homes for sci- Examining Insanity: Te Maudsley entifc workers and their families.78 Silicon Valley provides the best example of the frst and the Public Perception of “city of knowledge”, built around Stanford University, which gained public recognition Eszter A. Neumark Mental Health beginning in the 1970s. Research Triangle Park serves as another example, as it serves as In the winter of 1923, Te New Statesman magazine the research hub for the University of North Carolina at Chapel Hill, Duke University, published an article entitled “Te Study of Insanity,” which and North Carolina State University. Tese “cities of knowledge” would propel medical claimed that at no point in recorded history had “intelligent research into the future, providing continued debate and discovery for the health of the and humane” treatment of mental illness ever been doc- 1 American nation. umented. While this is a bold and perhpas controversial Conclusion argument, it is unarguably food for thought. Has not psychi- From private, individual eforts to widespread government programs, medical re- atric health indeed been surrounded by stigma in the past, as search endured many trials to assume its present part in civilian life. Beginning with it still is today? Mere weeks before this article was published, the changing Public Health Service to the government supported National Institutes the Maudsley Hospital opened its doors in . It was of Health, medical researchers today owe Tomas Parran, Jr. for his persistent eforts in to be a diferent kind of mental health institution, one which gaining government funds. Parran’s career suggests that his eforts, moreso than the war many believed could be the very frst to do the unprecedent- generally, were instrumental in garnering the attention from the federal government for ed and treat mental health patients with intelligence and 2 medical research. Te critical distinction that solidifes this claim is the less noted dif- humanity. ference between research, broadly, and medical research, specifcally. Parran fought for Asylums and “madhouses”3 existed long before the medical research gains, rather than other scientifc research focused on the creation and Maudsley’s conception, as evidenced by magazine articles, maintenance of nuclear power that was prominent after World War II. Without Parran, court documents, and legislation concerning the topic. and other special interest groups such as the Laskers, medical research would have been Historians have also written about the Maudsley Hospi- hard pressed to expand as it did. tal specifcally. Its place among the already existing mental institutions has been explored from historical and medical perspectives; some of the existing literature singles out the Maudsley as a progressive and innovative institution. What remains to be examined, however, are the deliberate steps taken to make this institution diferent from the rest. In this paper, I argue that the Maudsley was designed and built with the intention of normalizing the treatment of mental illness. First, I will describe the conditions that existed before and during the Maudsley’s creation. Ten, I will examine the various factors which contributed to its infuence on public

1 “Te Study of Insanity: Opening of Maudsley.” New Statesman. Feb 1923. 2 Ibid. 3 Te terms “asylum,” “madhouse,” and “institution” were used frequently and interchange- 78 Ibid. ably in many of the sources referenced in this paper. 62 Articles 63 Traces: Te UNC-Chapel Hill Journal of History perception: location and appearance, ties with the practice of medicine, its function as a to nearby towns. Interaction with outsiders, which had been strictly prohibited, was now hospital during World War I, and the media’s portrayal of the Maudsley. allowed in some circumstances. Instead of being confned to their rooms, patients were Before the Maudsley given duties and activities to perform, from working in the kitchen or laundry to partici- 9 It is ftting, considering the revolutionary ambitions behind the establishment of pating in organized sport and music. the Maudsley, that London was home to the frst recorded mental institution in Eu- Despite this kind of progress, the asylums remained heavily stigmatized. As Cam- rope. Records show that the existed as early as 1247 and be- bridge professor German Berrios recounts in his history of British psychiatry: “[the gan admitting psychiatric patients in 1407. Despite its name, the mental sector of this asylums] took society’s rejects and did what they could for them with the limited funds 10 primitive institution resembled a prison more than a hospital. Due to lack of regulation which society was prepared to provide.” Lack of known treatments, proper training, and and oversight during the Middle Ages, anyone could open a so-called asylum and run funds kept the asylums from developing into truly humane environments. Te society it as they saw ft. Tis lack of supervision was obviously problematic in terms of quality and time period in which they were functioning were not conducive to progress either. In control, as there was no mechanism holding the owners of such facilities accountable for Berrios’ words, “the asylums were not democratic institutions; they were paternalistic and 11 the well-being of their residents. Before the Madhouse Act of 1774, there was no license class-conscious, but so was Victorian society.” Patients at this time were still referred to required to treat the mentally ill, and as a result, practitioners “ran their madhouses as a as “inmates.” Tere was no distinction, in law or in the public sphere, between the crimi- 12 commercial enterprise and with little regard for the inmates.”4 By the end of the eigh- nal and the insane. Tere was still much progress to be made in terms of patient treat- teenth century, England’s infrastructure was quickly growing, and “[l]egislation to regu- ment, despite the promise shown by the burgeoning county asylum system. late the burgeoning institutional sector became the dominant type of lunacy law.”5 Further legislation added to the positive changes brought about by the Madhouse New legislation was passed in the form of the Madhouse Act, which “established and County Asylum acts. Te Lunacy Act of 1845 obligated each English county to the licensing required to house insane patients, with yearly inspections of the premises “provide Asylum for their lunatics.” It was also the frst legislation to distinguish between 13 taking place.”6 As a result of this law and the regulations it introduced, the harsh condi- criminals and mental patients. Strides were made in terms of legal rights, but there tions improved slightly. For the frst time, “madhouse” owners were held responsible for was still much to be done in the way of patient treatment. Despite the eforts to im- the conditions their patients were living in. New facilities were opened, such as the York prove living conditions, quality of life in the asylums was far from ideal. As Te Observer Retreat, where residents were allowed to participate in work and leisure rather than con- put it, “[the] asylums ceased to be prisons, and became repositories, where the mentally stantly restrained.7 In 1808, the County Asylum Act was passed to fund the construction aficted were deposited and left, tending slowly to accumulate as dreadful death-rate 14 of public county asylums. Te Act initially only covered the establishment of twenty from tuberculosis and other diseases in such institutions began gradually to fall.” One facilities throughout the country, but over sixty were built by 1890, when the next wave patient’s account of his experience in an asylum lamented this sort of monotonous of legislation was introduced.8 imprisonment: “the degrading humiliation of being ordered about [. . .] in daily routine Progress was not immediate following the introduction of the new system, but qual- like so many sheep, without the least regard for personal feeling [. . .] is no doubt more 15 ity of life in county asylums gradually improved over the course of the twentieth century. or less unavoidable in a large asylum crowded with patients in all stages of disease.” For Privacy was still minimal, but some institutions allowed patients to walk freely within all of these reasons – the isolation, the shoddy conditions, the lack of information about the hospital grounds; some institutions went as far as organizing supervised excursions mental illness and its causes – it is easy to see why the public may not have viewed these

9 Ibid. 4 “Te History the Asylum,” County Asylums. Published 2003. Accessed April 15, 2016. Www.countyasylums.co.uk. 10 German E Berrios, 150 Years of British Psychiatry: 1841-1991 (London: Gaskell, 1991),17. 5 Clive Unsworth, “Mental Disorder and the Tutelary Relationship: From Pre- to Post-Carceral Legal Order,” Journal of Law and 11 Ibid., 18. Society 18, no. 2 (1991): 259. 12 Ibid. 6 “Te History the Asylum,” County Asylums. 13 “Te History the Asylum,” County Asylums. 7 Ibid. 14 “Te Maudsley Hospital: New Hope for Mental Disease,” Te Observer, March 25 1923, 18. 8 Ibid. 15 , “A Mental Hospital—its Aims and Uses,” Archives of Neurology & Psychiatry 4 (1909), 11. 64 Articles 65 Traces: Te UNC-Chapel Hill Journal of History asylums or their inhabitants favorably. In its overall design, the Maudsley bore a resemblance to the psychiatric clinic opened In the words of medical student Henry Rollin, “mental [. . .] were in efect in 1904 at Ludwig-Maximilians-Universität in . Te three-storey [sic] building facing Denmark Hill housed the pathology laboratory, library, on-call bedrooms, dis- total institutions: the patient population was relatively static; security was tight and, as a pensary and administrative ofces. Before the construction of a purpose-built structure 16 result, contact with the outside world was tenuous to say the least.” Mental illness and in 1933, the outpatient department was also located in the building with a side entrance its treatment were kept shrouded in an air of secrecy. Asylums were built far outside of for patients. Two three-storey structures, linked by bridges, housed six wards, each with the city to prevent the public from having to be exposed to the sight. Patient visitations 24 beds. Patients were segregated by gender, initially into separate blocks but soon after in the old institutions were strictly limited.17 Unsurprisingly, a lack of knowledge about the opening by storey: the two wards on the frst storey for men and the two below for women. Te upper foors, allocated to those psychiatric treatment was widespread, keeping the topic of mental illness hushed and with mild disorders, were kept unlocked, and causing unease to envelop it. Te Maudsley hospital was founded on the revolutionary patients encouraged to exercise in the adjacent idea that patients would fare better in an environment that was free of this stigma.18 gardens.24 A New Mental Hospital Te treatment of a mental institution Several steps were taken to implement the concept of destigmatization, one of which as a hospital for somatic illness was intend- was the new hospital’s location. While the traditional asylums were arranged in a ring ed to be a catalyst for removing the stigma 25 surrounding the capital, kept carefully away from the public eye, the Maudsley was built surrounding psychiatric care. If the men- 19 in , one of the quickly-growing suburban boroughs of the city. Tere was Te Maudsley Hospital still stands in the same tal hospital looked and functioned like an “no attempt to hide [it,]” as it was built in “a busy London suburb close to a railway place as it once did, though the building has ordinary hospital, the public would draw the undergone renovations. (Photo courtesy of Wiki- 20 station and on a tram route.” In fact, the new building was located only four miles from media.) conclusion that a mental ailment was not the bustling Charing Cross Station in order to facilitate easy access by students, staf, and much diferent from a physical one. 21 patients. Despite the eforts to make it accessible for people near and far, over half of the Te Maudsley’s red brick buildings, which blended into its urban environment, patients at the Maudsley in the year 1924 lived within a four-mile radius of the build- “resembled a district general hospital or a town hall rather than a prison or asylum.”22 ing. Forty percent came from greater London, and only seven percent of patients lived With only an outpatient department, a postgraduate medical school, and 144 patient over twenty miles away.26 Tis may have also had a destigmatizing efect. Te county beds, it was “a far cry from the barrack-like structures constructed for the county asylum asylums were intentionally built in urban areas outside of London as to avoid an eyesore system.”23 Putting the institution in plain sight allowed its neighbors, onlookers, and asylum being too close to civilization. Tus the patients were of mixed backgrounds and the public to grow accustomed to its presence, and, one could argue, to grow simultane- had minimal interaction with the people of the city. At the Maudsley, not only was the ously accustomed to the idea of psychiatric treatment. Its commonplace appearance was building more integrated into London’s urban milieu, but the patients were mostly from designed to achieve the same efect. As Edgar Jones and Shahina Rahman state: the city as well; the Maudsley patient was not a faceless lunatic, but a neighbor, a friend, 27 or a colleague. Seeing acquaintances go to the Maudsley, receive treatment, and be 16 Henry Rollin, Festina Lente: A Psychiatric Odyssey. London: Memoir Club, 1990. discharged and integrated back into everyday life could efectively shatter the myth that 17 Ibid. 18 Published Minutes of the London County Council, 18 February 1908, item 2, 282. those considered mentally ill should be locked up in an asylum as far away as possible. It 19 Edgar Jones and Shahina Rahman, “Te Maudsley Hospital and the Rockefeller Foundation: Te Impact of Philanthropy on Research and Training,” Journal of the History of Medicine and Allied Sciences 64, no. 3 (2009), 273. as easy to stereotype the asylums from afar, but it was more difcult to stigmatize mental 20 Edgar Jones, Shahina Rahman, and Robin Woolven, “Te Maudsley Hospital: Design and Strategic Direction, 1923–1939,” Medical History 51, no. 3 (2007), 357. 24 Ibid., 362. 21 Edgar Jones and Shahina Rahman, “Framing Mental Illness, 1923-1939: Te Maudsley Hospital and its Patients,” Social History 25 Ibid. of Medicine 21, no. 1 (2008), 12. 26 Ibid. 22 “Te London County Council Maudsley Hospital,” Te Architect 1923: 109, 426. 27 Ibid. 23 Jones et al., “Te Maudsley Hospital,” 358 66 Articles 67 Traces: Te UNC-Chapel Hill Journal of History health when one was seeing it on a personal level. such as depression, peripartum psychoses, and neuroses.32 One analysis of the Maudsley Te factors which made the Maudsley’s approach unorthodox ran deeper than just patient population found that 37.5 percent of adults were admitted with a diagnosis of 33 that of the building’s location and exterior, however. Te old asylums had restricted inter- depression. Jones and Rahman wrote: action with the outside world, as visitation was limited.28 Moreover, a large portion of the No equivalent studies have been undertaken of patients treated in the various LCC asy- patients in traditional mental health facilities were committed against their will and held lums constructed in the London suburbs to enable proper comparison. However, the fact that these mental hospitals were legally obliged to admit [. . .] certifed cases implies that like prisoners. Tis, too, may have added to the stigma. By contrast, the Maudsley admit- the proportion of subjects with major mental illness (schizophrenia, manic-depression ted exclusively voluntary patients. All patients were free to leave after giving twenty-four 34 and other psychotic disorders) was much higher. hours’ notice (including those with illnesses Te state institutions, unlike the Maudsley, were legally obligated to treat those such as schizophrenia, who likely would have sufering from a myriad of psychiatric maladies that spanned the spectrum from mild been held involuntarily at other asylums).29 By to severe. Treatments available as psychiatric intervention were severely limited at the mimicking a hospital in this respect, the Maud- time, and these asylums were responsible for admitting even the most severely afected sley took another step away from the tradi- patients with the lowest chance of recovery.35 It is easy to see how negative associations tional asylum model. Te Maudsley’s approach could have arisen around these institutions; not only could they have been seen as un- challenged the insinuation that mentally ill successful in treating patients, but also as being prison-like, especially considering the people were so dangerous to society that they limited contact society had with the patient population and the large percentage who should be locked away against their will. Te foorplan of Broadmoor Criminal were committed involuntarily. Lunatic Asylum, an English mental asylum Te Maudsley’s patients were also treated opened in the mid-nineteenth century. Many From the perspective of the average English citizen, these institutions were likely and discharged, rather than committed indef- early asylums were built to operate more perceived as places where mentally ill people went to be locked away. Te statistics show like prisons than mental institutions. (Photo initely as they had been at the traditional asy- courtesy of Wikimedia.) that this perception was not unfounded: “In 1936, 6,233 patients were admitted to the lums. In 1931, Edward Mapother, the Maud- London observation wards of whom 3,117 were transferred to mental hospitals (only 10 sley’s frst medical superintendent, declared per cent of these went as voluntary patients) and 1,054 discharged to the care of rela- that treatment at the Maudsley was not “merely treatment for an initial period, but [was] tives.”36 Te idea that they could be quickly treated and return to their lives was likely not intended to continue to recovery if this is possible within a short time—hardly ever yet common in popular perception, as it was statistically not the most common occur- exceeding one year and averaging three months.”30 Te quick discharge time was largely rence. due to the fact that the hospital had a selective admissions process. To avoid “altogeth- In 1923, the Maudsley debuted a feature which moved it further towards reform: er unsatisfactory” patients (such as those who might require restraints or sedatives, or an outpatient department. Tis service was partly introduced to mitigate the stigma whose illnesses were notoriously difcult to cure) the Maudsley did not ofer “emergency of psychiatric treatment, but it also operated as a means of fnding interesting patients services” or treatment for acute crises.31 To make the patient population easier to manage and cases for study.37 It was the frst time the idea of using a medical, clinical setting in and treat, patients with complicated diagnoses such as schizophrenia or acute psychosis the realm of psychiatry had been considered. Tis addition, like the Maudsley’s com- were often, though not always, turned away and referred to asylums outside of London.

Emphasis was placed on the more easily managed conditions including anxiety disorders 32 “, Edward Mapother and the Maudsley,” Medical History Supplement 22 (2003), 5. 33 Jones and Rahman, “Framing Mental Illness,” 8. 28 Festina Lente, 134. 34 Ibid., 8. 29 NA, MH 51/640, Report of the Royal Commission on Lunacy and Mental Disorder, London, HMSO, 1926, Appendix XIII, 35 Edgar Jones, Shahina Rahman, and Brian Everitt, “Psychiatric Case Notes: Symptoms of Mental Illness and Teir Attribution 945. at the Maudsley Hospital, 1924-35,” History of Psychiatry 23, no. 2 (2012), 164. 30 BRHA, C/12/4, E Mapother, ‘Appeal for the endowment of an institute of psychiatry,’ March 1931, 1. 36 Jones et al., “Te Maudsley Hospital,” 363. 31 Jones et al., “Te Maudsley Hospital,” 364. 37 Jones et al., “Psychiatric Case Notes,” 163. 68 Articles 69 Traces: Te UNC-Chapel Hill Journal of History monplace appearance and location, was meant to parallel the structure and function of outcomes are often directly correlated to the number of medical personnel available per general hospitals and, in turn, “normalize” mental health treatment. patient, so this also contributed to a better patient care experience or higher discharge In terms of mandatory admissions, the Maudsley was not plagued by the same rate. More time and attention were devoted to each patient: “With a higher stafng legal obligations that the county asylums were. Tis was largely due to its close ties with ratio than [had been] found in county asylums and the beneft of post-graduate trainees, the medical school; unlike the county asylums, which were legally mandated to accept each patient was subject to an exhaustive examination. Tis was not simply an academic all patients, the doctors were able to hand-pick which patients were to be admitted and exercise but driven by the hypothesis that mental illness was causally connected with 44 which ones turned away.38 Medical Superintendent Edward Mapother outlined which recognized diseases.” Tis change further shifted the development of mental illness diseases should be prioritized and admitted most frequently based on perceived treat- treatment towards the world of medicine. ability.39 In addition to Mapother’s already-restrictive list of conditions to be treated, Te idea that mental and somatic illness did not occupy two entirely separate realms the Maudsley’s voluntary admissions policy also contributed to biased patient selection. had already started circulating in the medical world years before and continued to gain Before seeking treatment, each new patient flled out an application which detailed their popularity through the 1920s and ‘30s. “Te immediate post-war period was a time of right to leave the hospital at their own volition. Tis action required that the patient be great optimism in medical circles that major mental illness (schizophrenia and man- physically and psychologically able to sign this waiver; this requirement in itself “weeded ic-depressive psychosis) could be understood and cured.”45 Psychiatric case notes from out” patients who were deemed severely delusional or psychotic, and thus unable to give the Maudsley during the interwar period describe this change: written consent.40 Te Maudsley’s manipulated patient population was designed to yield Before World War I, Frederick Mott (1899) had shown that the psychiatric symp- higher discharge rates than the traditional asylums, a factor which may have caused the toms of general paralysis of the insane (GPI) had an organic basis in the neurological efects of tertiary syphilis. In the 1920s, it was hypothesized that viral or bacterial public perception of the Maudsley to be less grim. infection might play a causal role in dementia praecox and other psychiatric dis- Mental Health from a Medical Approach orders... or that they were the consequence of a metabolic imbalance produced by a Te Maudsley’s skewed patient population may have bolstered the public’s malfunctioning endocrine system. Pituitary and thyroid extract had been given to perception, but the argument can be made that the Maudsley really was treating some patients sufering from shell shock, and in the post-war period trials were extended 46 mental illnesses more efectively than they had ever been treated before. It was the to major mental illness... frst psychiatric facility that worked in close conjunction with a medical school; in fact, Because of these developments, “wide-ranging physical investigations of new pa- Mapother had lectured at King’s College and established formal ties between the Maud- tients” were conducted at the Maudsley in the hopes that links would be found between 47 sley and King’s College Hospital.41 In 1924, the Maudsley was ofcially annexed by the psychological and physiological pathogeneses. In light of these new theories linking .42 For the frst time, the phenomenon of mental illness, as well as mental and physical disease, Mapother “attempted to create an ‘atmosphere of cure’” at 48 its treatment, were being scrutinized by a large number of practitioners, researchers, and the Maudsley based on “diet, fresh air, control of infection, and graduated exercise.” postgraduate students under the feld of medicine. One of the frst interventions to be implemented to this end was increasing patients’ With a growing number of trainee doctors and nurses working at the Maudsley exposure to fresh air, as a theory at the time suggested a link between tuberculosis and 49 during the 1920s and ‘30s, the staf-to-patient ratio was steadily increasing.43 Patient schizophrenia. Tus, open-air therapy was introduced at the Maudsley and a “garden

38 Jones et al., “Te Maudsley Hospital,” 366. Te Maudsley was still under the control of the London County Council, and was villa” with eighteen beds was added in 1931. Case notes from the hospital described the a “county asylum,” but its establishment was funded by Henry Maudsley on certain conditions. Tese stipulations included that the 44 J. Carswell, “Some sociological considerations bearing upon the occurrence, prevention and treatment of mental disorders,” hospital would be a center for teaching and that the focus would be on acute rather than chronic cases. Terefore, the Maudsley was Journal of Mental Science 70 (1924): 347–357; R. Mayou, Te history of general hospital psychiatry,” British Journal of Psychiatry 155 allowed more fexibility concerning the LCC’s regulations than the other asylums. (1989): 764–776. 39 Jones and Rahman, “Framing Mental Illness,” 3. 45 Jones et al., “Te Maudsley Hospital,” 371. 40 “Te Study of Insanity,” New Statesman. 46 Jones et al., “Psychiatric Case Notes,” 157-158. 41 Jones et al., “Te Maudsley Hospital,” 357-358. 47 Ibid., 158. 42 Jones, “Mapother, Lewis, and the Maudsley,” 17. 48 Ibid., 163. 43 Jones and Rahman, “Framing Mental Illness,” 16. 49 Fresh air was considered therapeutic for tuberculosis patients at the time. 70 Articles 71 Traces: Te UNC-Chapel Hill Journal of History building, which was “orientat- functioning as a hospital providing treatment for shell-shocked soldiers returning from ed to face due south so that the front.54 War had changed every aspect of life in England, and the Maudsley was no patients could enjoy the beneft exception; the treatment of soldiers became the hospital’s priority: of sunlight. Each single room Te frst winter of the Great War had afected the British Army with an unantic- opened directly on to a veranda ipated number of casualties. As the demand for hospital beds increased, the Army so that beds could be wheeled requisitioned many existing asylums. Te Maudsley was occupied in 1916 before it Afer the frst World War, many doctors began to recommend that 50 could ofcially open. It became the neurological annex of the Fourth London Medi- into the fresh air.” While 55 mental patients spend time outside. Hospitals like the Maudsley cal Division (King’s College Hospital). these may seem like primitive and Victualler’s Aslyum (pictuerd here) began allowing patients Te small unit was one of many makeshift medical centers set up in Denmark Hill to spend time on the grounds. (Photo courtesy of Cockney Laurie, interventions rather than state- Wikimedia.) and around Ruskin Park. Soldiers who had been afected by the “strain of the battlefeld” of-the-art medical advance- would arrive by ambulance train, be given medical care if needed, and then be admitted ments, the treatment options 56 to the neurological unit to rest. A discussion of the impact of World War I noted that, 51 available to psychiatrists at the time were quite limited. In addition to the “atmosphere “Te horror experienced at the front lines had enormous repercussions upon soldiers’ of cure” therapies, Maudsley physicians were using all of the existing methods commonly mental health.”57 In fact, “Te British Army reported over 80,000 cases of shell shock (a being used to treat mental illness, including ones for management: forerunner diagnosis to Post Traumatic Stress Disorder). Te condition presented major While there were no treatments for melancholia [depression]...patients sufering difculties in diagnosis and treatment. Common symptoms comprised fatigue, night- from schizophrenia or hypomania could at least be calmed by sedatives and in more mares, sleep deprivation, palpitations and functional paralysis.”58 In response to this in- mild cases by continuous baths. However... sedation tended to be heavy-dosage with fux of patients, a large number of doctors came to the Maudsley with the hopes of con- the associated risk of irreversible coma... Insulin coma therapy for the treatment of 52 ducting research on shell shock, the spectrum of psychiatric disturbances associated with acute schizophrenia was introduced just before World War II. experiencing active warfare. Despite this, head physician Frederick Mott’s approach was County asylums had implemented these methods of sedation but the goal was to largely focused on rest rather than aggressive treatment.59 Addressing how Mott treated manage the symptoms of psychosis rather than to treat or cure the disease. Te Mauds- patients, an article in the British Medical Journal in 1917 noted, “...Mott recommended ley’s ‘atmosphere of cure’ methods went beyond mere symptom management, and at- ‘quiet repose in single rooms’ for the most severe cases, combined with continuous warm tempted to create an environment where the patient could come out of their psychotic, 53 baths because of their calming properties. He also believed in restoring a soldier’s ‘gener- neurotic, or depressed state. By attempting to cure psychological conditions, as is the al bodily condition’ through ‘nourishing, digestible and easily assimilated food.’”60 goal with somatic diseases, the line between the two types of afictions became less def- nite. Te Maudsley’s medicalization of mental illness contributed to its normalization. Te fact that the Maudsley began as a wartime hospital serving mostly as a place where battered veterans could recover added another layer to the complexity of its image, Te Maudsley and Te War character, and reputation. Shell shock likely did not carry as much of a stigma as schizo- It was in 1923 that the Maudsley opened its doors as an ofcial mental hospital, phrenia or psychosis in the eyes of society. Hot meals and warm baths were less “damna- but the roots for an ‘atmosphere of cure’ had been planted years before, during World ble” and much more relatable for the public than lobotomies or electric shock were. Te War I. Te Maudsley had been operating as a teaching hospital for decades, but needs 54 Ibid., 415. changed as the war began, and as early as 1916, the Maudsley’s neurological section was 55 “Te Maudsley at War: Te Story of the Hospital during the Great War,” South London and Maudsley NHS Foundation Trust, Bethlem Museum of the Mind, 2. 56 Ibid., 20. 50 Ibid., 164. 57 Ibid., 15. 51 Ibid. 58 Ibid., 15. 52 Ibid., 165. 59 Ibid., 23. 53 Edgar Jones, “’An Atmosphere of Cure’: Frederick Mott, Shell Shock and the Maudsley,” History of Psychiatry 25, no. 4 (2014), 60 Frederick Mott, “Te Chadwick Lecture on Mental Hygiene and Shell Shock During and After the War,” British Medical 415. Journal 2.2950 (1917), 41. 72 Articles 73 Traces: Te UNC-Chapel Hill Journal of History former were cures that most people used for common ailments. Maudsley’s early history ethical implications of creating an asylum out of an institution that was functioning continued to infuence the way it was perceived by the public even after the War; instead as a wartime hospital. Te fact that these publications were contrasting the Maudsley of associating it with “insane asylums,” people continued to associate it with sick soldiers. with the county asylums put it in a category of its own in readers’ minds. Portraying the Although shell shock was deeply debilitating and afected tens of thousands, it is likely Maudsley as a separate entity may have helped to separate it from the stigma associated that because of its clear cause, this condition seemed less ominous to the public. with other asylums. Shell shock was also widely reported in A myriad of articles published at the time also observed this diferentiation between the media. In the midst of war, it is safe to assume the Maudsley’s purpose and other hospitals, and some articles were openly optimistic that newspapers had more signifcant headlines to about the Maudsley’s endeavors. Around 1923, the year the Maudsley ofcially opened report than, say, advancements in psychiatric medi- as a mental hospital, several newspapers and periodicals published pieces that high- cine. But shell shock was a product of war, and thus lighted the Maudsley’s potential as a pioneer of mental health treatment. In March of it was relevant. It was signifcant on a national level, 1923, Te Observer published an article entitled “Te Maudsley Hospital: New Hope as afected men were coming home by the thou- for Mental Disease.” As the title implies, the piece portrays a very positive image of the sands, but also personal enough to impact a large Maudsley’s work since its opening. Te article, written by the paper’s medical consultant, portion of the general public. Tese men were also ofered a glowing review: the author was “deeply impressed by a visit to the Maudsley husbands, fathers, and brothers, so the issue de- Hospital [. . .] Behind the building one saw large gardens and delightful open verandas manded attention. Media at the time spent signif- [. . .] enjoying the natural agenda of physical health, upon which psychical health so cant space discussion these problems. Te Observer largely depends.”65 Tis cheery portrayal contrasted with the bleak portraits of asylums Many veterans of the frst World War published an article in 1916 entitled “Shell-shock: had lasting mental and physical prob- to which people had become accustomed; the article included a grim description of how What it is, and how it is treated.”61 Te Manchester lems from combat. Tis soldier, for broken and restrictive mental health treatment had been like in the past, and praise for example, reported to the King George Guardian reported a 1921 piece: “Insanity ‘induced Military Hospital with uncontrollable the Maudsley’s innovations. It concluded that the Maudsley’s 200 beds were not nearly by shell shock.’”62 A 1936 edition of the same paper movements due to shell shock. (Photo enough to meet the need, and that similar hospitals should be built in “every great city courtesy of Wikimedia.) published “War Victims Who Cannot Return throughout the land.”66 In the same year, Te Manchester Guardian printed a similar piece to Ordinary Life: Suferings of ‘Temperamental’ entitled, “A New Era in Mental Treatment.” Focusing mainly on the voluntary basis of Men.”63 Tough these headlines are by no means admission and the high number of medically trained staf, this article too depicted the free of judgment, the abundance of exposure through the media and had likely neutral- Maudsley in a positive, progressive light, contrasting it with the traditional asylums. It ized some of the public’s negative associations with mental illness. wrote that with the Maudsley’s establishment came “the recognition of a new principle,” Te Maudsley, by way of its brief stint as a shell-shock treatment hospital, was also one that promised hope for “thousands of poor people who might otherwise be con- made newsworthy by its indirect tie to the war. Its dichotomous nature – part asylum, demned to live the whole of their lives in asylums might receive that early treatment that 67 part hospital – did not go unaddressed by the media. One aptly-titled 1915 article from made a cure possible.” Te Observer addressed the issue explicitly; the headline read “Hospital or Asylum?: Te A third article from Te Manchester Guardian focused on another facet of Maudsley’s Case of the Maudsley Hospital, Denmark Hill.”64 Te piece grappled with the legal and reforms: its ties with the medical and scientifc community. “[Te Maudsley] will give every encouragement to meetings between those who ail and those who have yet much 61 “Shell-shock: What it is and how it is treated,” Te Observer, January 23, 1916. 62 “Insanity ‘induced by shell shock,’” Te Manchester Guardian (1901-1959), December 30, 1921. 63 “War Victims Who Cannot Return to Ordinary Life: Suferings of ‘Temperamental’ Men,” Te Manchester Guardian (1901- 65 “Te Maudsley Hospital: New Hope for Mental Disease,” Te Observer, 18. Mar 25 1923. 1959), July 4, 1936. 66 “Te Maudsley Hospital: New Hope for Mental Disease.” Te Observer, 18. Mar 25 1923. 64 “Hospital or Asylum?: Te Case of the Maudsley Hospital, Denmark Hill,” Te Observer (1901-2003). June 13, 1915. 67 “A New Era in Mental Treatment,” Te Manchester Guardian, February 1, 1923, 8. 74 Articles 75 Traces: Te UNC-Chapel Hill Journal of History to learn before they can set about curing with confdence,” praised the author.68 It also provision of a changing and varied patient population for its growing army of trainees mentions that the atmosphere of such a place will facilitate well-being as much as the and researchers.”73 Te Maudsley’s operation was eventually interrupted by the turmoil of doctors’ interventions: “from the interview-rooms, where doctor and patient frst meet, World War II. At the outbreak of the confict, the hospital was evacuated and remained to the garden, where patients who are well enough may roam or work or play tennis, the unused for the next several years.74 In 1948, the Maudsley resumed function and was hospital is designed to make its occupants feel normal.” 69 Te article, entitled “A New amalgamated with the Bethlem Royal Hospital later that same year.75 Mental Hospital,” exuded optimism that the Maudsley would be a place where doctors Despite these signifcant changes towards the middle of the twentieth century, could come to learn and work, and eventually be able to cure mental illness. the impact of the Maudsley’s establishment and early years was not negated. Clinical While these articles – and many more not cited here – portrayed the Maudsley’s pro- director Aubrey Lewis wrote in 1970 that the “atmosphere of cure” practices that had gressive measures positively, there were undoubtedly some in circulation that were less become known as “Maudsley psychiatry”, “represented practices that were empirically optimistic. However, in an online search of archived major British newspapers, it was dif- based, that avoided extremes but which were assessed critically using statistically vali- fcult to fnd any.70 Since it seems from the available literature that the media’s portrayal dated research [. . .] the particular strengths of the hospital and institute lay in social and of the Maudsley was relatively positive, it is probable that the favorable coverage played a epidemiological psychiatry.”76 Such was the legacy that remained around the Maudsley. role in infuencing the public’s perception. More signifcantly, these headlines were an in- Te model created by its founders, centered on providing patients with humane treat- dication that the Maudsley’s campaign to make the view of mental illness more favorable ment from legitimate medical personnel and a placing them in a healthy environment, was yielding results. continued to be associated with the hospital even after its practices had been modifed. Later Years and Legacy Te Maudsley, and its efort to destigmatize insanity, not only created a rudimentary Te 1920s and ‘30s were formative years in the history of the Maudsley Hospital. model that future mental institutions could imitate and expand upon, but also made In these years the hospital progressed the most towards its goal of creating a humane the crucial frst steps in creating a more accepting and open-minded society in terms of environment for the mentally ill. Many of the great minds behind the hospital’s reforms, mental illness. such as clinical director Aubrey Lewis, physician Frederick Mott, and medical super- intendent Edward Mapother, were most active during this time. Decades passed, and as management and clinicians rotated through, the Maudsley’s strategic direction also evolved. Financial factors and pressure from the medical community to make advance- ments in psychiatric research shifted the emphasis from creating an “atmosphere of cure” to focusing on developing new treatment techniques beginning around the 1930s.71 Mapother had intentionally attempted to shield patients from experimental “cures,” believing they were “intrusive, unpleasant and dangerous interventions with no objective scientifc evidence to support their use.”72 However, the superintendents that succeeded Mapother were less cautious: “In its [later] operation, the Maudsley did not adhere to the founders’ strategic plan but, in the absence of efective treatments, focused on the

68 “A New Mental Hospital,” Te Manchester Guardian. January 30, 1923, 6. 69 Ibid. 70 It is important to note that I used the University of North Carolina at Chapel Hill’s online library database for my search, which 73 Jones and Rahman, “Framing Mental Illness,” 1. returned mostly material from Te Observer and Te Guardian. Tis may have skewed my perception of the fndings. Research of a 74 P. H. Allderidge, “Historical Notes on the Bethlem Royal Hospital and the Maudsley Hospital,” Bulletin of the New York Acade- wider scope may have produced more varied results. my of Medicine 47, no. 12 (1971), 1545. 71 Jones, “Aubrey Lewis, Edward Mapother, and the Maudsley,” 15. 75 Ibid. 72 Jones et al., “Te Maudsley Hospital,” 398. 76 Jones, “Aubrey Lewis, Edward Mapother, and the Maudsley Hospital,” 38.