The Therapeutic State by Thomas Szasz

MAY 2002

The Maternity and the Mental Hospital

t first sight, the maternity hospital In England, began to be estab- and the mental hospital are two com- lished more than a hundred years before pletely different institutions. Howev- the dawn of scientific medicine. These er, on closer examination, striking institutions resembled our current nursing A homes and hospices more than they resem- similarities emerge. Neither nor delivery is a dis- ble our hospitals: they were way-stations ease; each is an aspect of the mammalian to the cemetery. Most of their would-be reproductive mechanism. Women delivered beneficiaries viewed entering them with the babies long before there were special build- same dread with which people now view ings called “lying-in hospitals” established entering a nursing home. When persons of to care for them. Behavioral reactions to the rank and wealth fell ill, they were cared for vicissitudes of life are also not diseases; they and died at home. The aim of the early are aspects of the repertoire of human hospitals was social reform, not medical actions. In the past, people who displayed healing. Before the twentieth century, such behaviors prospered or perished, were women from families with even modest celebrated or condemned, long before there means were rarely, if ever, delivered in were special buildings called “mental hospi- maternity hospitals. tals,” ostensibly devoted to their care. The development of mental hospitals fol- Modern medicine begins in the middle of lowed a similar pattern. The early private the nineteenth century, with the develop- madhouses were intended to help wealthy ment of the concept of disease as a patho- persons dispose of their unwanted relatives, logical alteration of cells, tissues, and by disguising coerced rehousing as care for organs. This new understanding was made insanity. After insane asylums became public possible in part by advances in technology, institutions, in the eighteenth century, their and in part by the establishment of large inmate population consisted almost entirely municipal teaching hospitals. The live of paupers. In hindsight, no medical histori- were the “case material” for clinical an doubts that, for the patients, the early instruction, and when they died their corpses hospitals did more harm than good. In the formed the “material” for the pathologist’s case of mental hospitals, this is still the case, postmortem examination. with the judicial system and lawyers as addi- tional beneficiaries. Prior to the twentieth century, hospitals Thomas Szasz ([email protected]) is professor of were places of horror. However, the harm psychiatry emeritus at SUNY Upstate Medical Uni- they could do was limited by the fact that versity in Syracuse. This is adapted from what will be an appendix in his forthcoming book, Libera- most of the sick people who went there were tion by Oppression: A Comparative Study of Slav- hopelessly ill and would have soon died in ery and Psychiatry (Transaction, Spring 2002). any case. This, however, was not true for 33 Ideas on Liberty • May 2002 maternity hospitals and mental hospitals. among women delivered in such institutions The typical woman who entered a lying-in than among women delivered in their hospital was young and healthy. She would homes. probably not have died had she delivered her During the first half of the nineteenth cen- infant at home. Her death was directly tury, the medical profession, resting on new attributable to where she delivered, that is, discoveries in chemistry and physics, began the maternity hospital. Similarly, the typical to acquire prestige and power it had not person admitted to a mental hospital was a enjoyed in previous ages. Physicians claimed young adult in good health. Becoming a to have an explanation for virtually every- chronic mental was a direct conse- thing that ailed the human body. Puerperal quence of being incarcerated for years in an fever was no exception: it was due to bad insane asylum. air, the so-called miasma theory. A few physicians dissented. In the United States, Identifying the Real Beneficiary Oliver Wendell Holmes, and in Austria- Hungary, Ignaz Semmelweis, declared pub- Looking back at the history of lying-in licly that puerperal fever was a contagious hospitals, Irvine Loudon, an English medical disease, transmitted by the “dirty hands” of historian, writes: the doctors. This was bad enough. But Semmelweis [T]he lying-in hospitals were from the made another mistake: he proved it. He early years plagued by recurrent epi- made medical students and doctors wash demics of puerperal fever with appalling their hands with chlorinated lime water mortality rates. By choosing delivery in a before examining patients: “So effective lying-in hospital, women (although they were his methods that between March and seldom knew it) were exposing them- August of 1848 no woman died in selves to a risk of dying that was many in that division,” Loudon writes. As a result, times higher than it would have been if Semmelweis became living proof of the Hun- they had stayed at home in the worst of garian proverb, “Tell the truth, and people slums and been attended in their birth by will bash in your head.” no one except family and an untrained Henrik Ibsen’s famous play An Enemy of midwife. The lying-in hospitals were such the People (1882) is the dramatic story of a a disaster that, in retrospect, it would doctor whose work and fate are loosely have been better if they had never been modeled after the tragedy of Semmelweis. established before the introduction of Dr. Stockmann, a simple country doctor, antisepsis in the 1880s. [The Tragedy of tries to protect people from using the town Childbed Fever, Oxford University Press, bath contaminated with pathogenic bacteria. 2000, p. 59.] His discovery, however, conflicts with peo- ple’s belief in the therapeutic properties of Two points need to be made about this their treasured spa and jeopardizes their eco- account. One is that women did not, as a nomic interests. The city’s leaders and the rule, choose to be delivered in lying-in hos- public denounce Stockman as “an enemy of pitals. Typically, they were dragged there by the people.” impoverished, overburdened relatives who The waters Stockman denounced had to wanted to be relieved of the duty of caring be therapeutic—lest the city’s image be for them. The other point is that the detri- transformed from spa to a source of pesti- mental nature of the lying-in hospital need lence. Similarly, antipsychotic drugs have to not have been a retrospective judgment. It be therapeutic—lest their forcible adminis- was obvious from the start, to many physi- tration be transformed from treatment into cians as well as to many pregnant women. torture; and schizophrenia has to be a brain Physicians could not have helped but notice disease—lest the medical legitimacy of psy- that puerperal fever occurred far more often chiatry itself be undermined. 34