William Tuke. Etching by C. Callet. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

WHO WAS WILLIAM TUKE?

William Tuke (1732–1822) was an English Quaker, tea merchant, philanthropist, and political campaigner best known as the founder of The Retreat at York (1796), a revolutionary new form of asylum in which barbaric “treatments” for mental illness such as bloodletting, manacles, and isolation were abandoned in favour of more humane practices such as warms baths, proper diet and exercise, meaningful work, and benevolent social interaction.

This approach became known as “moral treatment” and played a huge role in driving legislative reform in asylums across the world, emancipating thousands of patients from inhumane medical practices, and influencing the field of psychiatry up until the present day.

A BRIEF HISTORY

The history of humanity’s attempts to treat mental illness is one littered with superstition, ignorance, cruelty, and neglect. Yet despite numerous advances in the treatment of mental illness, these same failings are still very much alive and well in modern mental health care.

Trepanation, from, 'Chirurgia'. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

POSSESSED BY DEMONS

The earliest evidence we have of procedures to cure mental illness are the archaeological unearthings of more than a thousand trepanated neolithic human skulls, some dating as far back as 6500BC, and scattered as far afield as France, Siberia, China, and America.

During neolithic times it was believed that mental illness was the result of demonic possession or punishment from the gods. Therefore the purpose of trepanning, a procedure in which a hole was drilled or chipped into the patients skull with a stone chisel, was to release whatever evil spirit was inhabiting the person’s mind and body.

This idea of possession by evil spirits continued for centuries and dominated the thinking of all the great ancient civilizations from ancient Mesopotamia, to Babylonia, Persia, Assyria and Egypt.

Those fortunate enough to avoid the witch doctors chisel may have been prescribed more progressive practices such as painting, music, and dancing, which were used to try and soothe those afflicted with disturbances of the mind.

But as long as supernatural forces were thought to be at the heart of the problem, the best treatments many could hope for were exorcisms, magic spells, prayers and incantations.

A woman holding her stomach and vomiting into a bucket after self administering an emetic. Coloured etching by I. Cruikshank, 1800.. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

THE FOUR HUMORS

There began a shift in perspective around the 5th century BC with Alcmaeon of Croton being the first to posit the idea that disease arose from a state of disequilibrium within the chemical composition of the body.

This concept gained further prominence with the work of the Greek Physician Hippocrates and his theory of the four humors (blood, phlegm, yellow bile, and black bile), an idea that was further refined and popularised by the writings of the Roman physician Galen.

Although this shift in focus from the spiritual to the physical realm was arguably a step forward in our understanding of mental illness, it also gave rise to numerous fad diets and purging remedies such as bloodletting and blistering, and the administration of laxatives and emetics to induce diarrhea and vomiting, all of which were intended to correct this supposed chemical imbalance.

It wasn’t until 1628, when the English physician William Harvey published scientific proof of the principle of blood circulation, that the four humors theory of disease began to finally, albeit slowly, wither and die. But not before leaving 2000 years worth of futile physical torment in its wake.

James Norris (wrongly credited as William) restrained by chains at the neck and ankles in Bethlem hospital, London. Coloured etching by G. Arnald, 1815. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

THE RISE OF THE ASYLUM

Prior to the mass establishment of asylums people with mental illness were generally cared for by their own family. Those considered merely embarrassing or whose behavior threatened to tarnish the family name were often locked up in cellars or in cages intended for livestock.

Those whose behavior was considered dangerous were thrown in jails where they were often flogged and beaten as a way of trying to tame their conduct. Many others were simply abandoned in workhouses or left to wander the streets as beggars.

Despite the modern notion of early asylums being a kind of primitive mental hospital blighted by misguidedness, in truth they were little more than dungeons specifically designed to house the growing number of people who every other sector of society were ill equipped, both morally and practically, to accommodate.

These were the people who families didn’t want, who doctors couldn’t treat, who priests couldn’t tame, who bosses wouldn’t employ, and who weren’t necessarily criminals but whom society needed some justification to lock them up regardless.

One of the treatments administered in asylums was hydrotherapy. This procedure involved dousing the patient in scalding hot water or locking them in a lidded bathtub full of ice cold water, with both approaches designed to jolt their minds back to sanity.

Rotational therapy involved strapping the patient in a chair that was spun around at 100 rpm, sometimes for hours at a time, supposedly to help shake up and rebalance the blood and brain tissues.

Those deemed too ill to treat were simply chained to the walls of a cold damp cell by their necks. No visitors were allowed, and they were often left to sleep on the floor among their own excrement with nothing but a layer of straw to insulate them from the cold stone floor below.

Just how farcical the notion of asylums possessing benevolent intent was borne out by the fact that many institutions would allow members of the public to pay an entry fee to come and gawk at the most severely ill patients like animals in a zoo. In fact, so self-aware of their own brutality were some asylums that patients deemed too frail or sensitive to handle the treatment regimes could be refused admission.

It’s no coincidence that the word “bedlam”, meaning “a state of uproar and confusion”, is derived from the nickname for Bethlem Royal Hospital, an asylum so notorious for its mistreatment of patients that it has since served as the inspiration for numerous horror films, novels, and TV series.

One of the most shocking cases of maltreatment ever witnessed there was that of James Norris, an American seaman admitted to Bethlam after being diagnosed as a “dangerous and incurable lunatic”.

In 1814 the Quaker philanthropist Edward Wakefield came to inspect Bethlam. He found Norris riveted into a custom-made, cast iron straitjacket that was fastened to his cell wall by a 12” chain, rendering him immobile and confined to his straw-lined trough bed. It turned out that he had been kept in this state of confinement for more than ten years!

This, along with several other controversies that came to light at the time, led to a public outcry. In April 1815 a Select Committee on Madhouses was formed to lobby for change in the conditions of patients kept in asylums and would eventually result in the passage of the County Asylums Act of 1828.

The committee, led by Sir George Rose and Lord Ashley, included, among other notables of the time, William Tuke.

Two men at a shop counter in a tea and coffee retail shop using scales to measure out coffee beans. Engraving by G. Scott, 1805, after Bell. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

REBELLION IN THE BLOOD

When it came to the Tukes, bucking convention appears to have run in the family.

In 1725, Mary Tuke, a 30-year-old spinster opened a grocery shop in Walmgate, York, selling tea, coffee, chocolate, herbs and spices.

At the time, one of the requirements to obtain permission to trade in York was to be a member of the York Merchant Adventurers Company. As an unmarried woman with no male relations within the company she was ineligible for membership and therefore unable to obtain a trading license.

Mary continued to trade regardless. The company issued fines along with threats of imprisonment if she failed to pay. Mary ignored them. She knew that to imprison her for failure to pay the fines would require a special act of parliament. She also knew that such a move would cost the company way more in legal fees than was worth pursuing for sake of disallowing an unmarried woman to trade.

Seven years of legal wrangling later and the issue was finally resolved when Mary agreed to pay a small fine and in return the company would allow her to continue her business uncontested. A face-saving retreat by the company. An astute business move and a groundbreaking legal victory for Mary.

In 1746, at the age of 14, William went to work for his aunty as an apprentice. In 1752, when William was just 20 years old, Mary died and left the business to him.

From these humble beginnings “William Tuke & Sons”, as it would later be named, would grow into a successful tea and coffee merchants, one of just five crown licensed coffee roasters in the country, and a chocolate manufacturer.

The chocolate arm of the business would later be sold to Henry Isaac Rowntree in 1862 to become part of the Rowntree confectionery dynasty, while the tea and coffee business was acquired by Twinings sometime after the second world war.

The Retreat, York. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

THE YORK RETREAT

Before the first brick of the York Retreat was even laid, William Tuke had already engaged in many other displays of political activism including vocal opposition to the East India Company’s humanitarian exploits and campaigning against the Atlantic slave trade.

On the 15th March 1790, a young Quaker widow named Hannah Mills was admitted to the York Asylum with a diagnosis of melancholy. At some point during her stay some fellow Quakers attempted to pay her a visit but were turned away. On the 29th April, just six weeks into her stay, Hannah was dead, with the cause of death being undetermined.

For an otherwise healthy young woman to die so suddenly was suspicious in itself, but coupled with the elusive conduct of the asylum, not to mention the scandalous reputation of asylums in general at the time, and maltreatment seemed a likely explanation.

According to William’s grandson, the physician Daniel Hack Tuke, this incident “led William Tuke to feel very strongly the want of an institution for the insane, in the management of which secrecy should be wholly done away with, and which the friends of the patients might therefore regard with confidence.”.

As for how to bring this idea to fruition: “It appeared to him that this want might be supplied, and his idea carried out into practice, by a Society which had already exerted itself on behalf of other suffering and neglected classes of the human race.”.

When Tuke presented his idea to a Society of Friends meeting in the spring of 1792 his proposal was met with a lukewarm reception and only a small group of supporters seconded his proposal. Tuke was undeterred.

During a visit to St Luke’s Hospital for Lunatics in London, whilst doing some research into asylum practice, he had witnessed a young female patient chained to the wall and lying naked in a bed of filthy straw. No doubt bringing to mind the plight of Hannah Mills, this image was said to have haunted William and only served to strengthen his determination to bring his plans for a more benevolent asylum to life.

It took another two years of lobbying before Tuke finally managed to convince the Society of Friends to permit the following resolution to be carried:

“That in case proper encouragement be given, ground be purchased, and a building be erected sufficient to accommodate thirty patients, in an airy situation, and at as short a distance from York as may be, so as to have the privilege of retirement; and that there be a few acres for keeping cows, and for garden ground for the family, which will afford scope for the patients to take exercise when that may be prudent and suitable.”.

Despite gaining approval for the plans to move forward, actual funding for the project was less forthcoming and belied the true level of support that Tuke had among his peers. At the suggestion of one of his early supporters, the famous grammarian Lindley Murray, Tuke settled on the idea of using annuities to fund the project. This plan satisfied the Friends and permission was granted to begin searching for a location.

A 12-acre plot on Lamel Hill was purchased for £938 (about £126,000 today, adjusting for inflation). The London architect John Bevans was hired to design the building, and worked closely with Tuke to construct a space that was the physical embodiment of the compassionate philosophy that underpinned it. One such feature was the inclusion of spacious, airy corridors that would offer space to wander and a sense of freedom and openness to even those patients for whom outdoor access was unsuitable.

Even the name given to the establishment, “The Retreat”, was “intended to convey the idea of what such an institution should be, namely a place in which the unhappy might obtain a refuge; a quiet haven in which the shattered bark might find the means of reparation, or of safety.”.

After four years of planning and preparation, The Retreat finally opened its doors in the spring of 1796.

The Retreat, York. Fourth Gallery. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

MORAL TREATMENT

The philosophy underpinning The Retreat was the belief that benevolent stimulation of the emotions and intellect was the most promising mode of rehabilitation and that a tranquil, caring, cooperative social environment would be the optimal circumstances in which to implement such an approach.

The rule book for The Retreat could almost have been written by simply taking every other popular approach to mental illness at the time, and doing the opposite.

For starters, chains, manacles and physical punishment were all forbidden, and the use of restraint was to be considered a last resort. On the rare occasion when it was applied, even patients considered to be in the most violent states of mania were “merely confined by the strait-waistcoat; and left to walk about the room, or lie down on the bed, at pleasure.”.

For suicidal patients intent on self-harm, the superintendent of the retreat had invented a restraining apparatus which prevented the patient from hurting themselves while still allowing them enough room to manoeuvre so as to lie comfortably in bed.

One ingenious way of protecting the patients from abuse or neglect was by adopting an open door policy for medical professionals to visit any part of the establishment, and at any time they wished. The threat of spontaneous inspection ensuring that high standards of care at The Retreat were consistently maintained.

For patients with melancholy, instead of trying to rebalance their excess black bile, attendants at The Retreat attempted “to seduce the mind from its favourite but unhappy musings, by bodily exercise, walks, conversations, reading, and other innocent recreations.”.

Such innocent recreations included excursions to the city and surrounding countryside, and walks in the garden as it was believed that “close confinement is, of all things, the most detrimental”, and that fresh air would be “favourable to the recovery of insane persons.”.

The garden itself offered the chance for patients to occupy themselves in meaningful labor, such as planting flowers, and the growing of fruits and vegetables. It had also been populated with rabbits, sea-gulls, hawks, and poultry as it was believed that interactions with the animals could conjure up positive emotions for the patients.

Visitation wasn’t merely permitted but considered an essential aspect of recovery. Visitors to The Retreat were encouraged to make suggestions regarding any improvements they felt could be made in the care of the inmates. Some patients were allowed to venture out to see friends and relatives in the city.

Diet was another facet of recovery that was utilized to great effect. In contrast to the twice daily “lowering diets” at the likes of Bethlem, which consisted of meager portions of bread, meat, oatmeal, butter, cheese and beer, patients at The Retreat were fed up to four times a day on a “liberal, nourishing diet” that included such luxuries as fruit pudding, broth, soup, tea and coffee.

For patients in the midst of a manic episode or who had difficulty sleeping, opium was eschewed in favor of supplying the patient with as much meat, cheese, bread and beer as they wished so as to induce the same sense of restfulness as is commonly felt after a full meal.

The female superintendent of The Retreat would occasionally host tea-parties wherein “all who attend, dress in their best clothes, and vie with each other in politeness and propriety. The best fare is provided, and the visitors are treated with all the attention of strangers.”.

Consent and autonomy were respected. In the case of patients who refused to sit and dine with everybody else, they would simply be taken to the larder where they could help themselves to food and retire to their rooms.

It was also ruled that “medications should not be administered, where the aversion of the patient was great; unless the general health strongly indicated its necessity; well aware, that otherwise, the probable good would not be equal to the certain injury.”.

In place of medication and the usual humor balancing ordeals, all of which were considered both “inadequate” and “inefficacious” by The Retreats first physician, Dr. Thomas Fowler, warm baths were used, and to such great effect as to be considered “of greater importance and efficacy, in most cases of melancholia, than all the other medical means which have been employed.”.

This latter point, on efficacy, is an interesting one. It’s easy to romanticize the past. It’s even easier to romanticize approaches to mental illness that sound as kind and well meaning as the examples given above. But as with any approach to mental illness, kind and well meaning is all well and good, but what ultimately matters is whether or not these approaches actually worked.

In 1840, Samuel Tuke and John Thurnam published “Statistics of The Retreat”, in which historical rates of recovery and improvement were published.

Out of every 100 cases, of all descriptions, admitted to The Retreat over 44 years, the average rate of recovery was 47.3%, with 10.6% showing improvement short of complete recovery, for a total patient improvement score of 57.9%.

In 2019 the NHS Improving Access to Psychological Therapies (IAPT) initiative claimed a national average “moving to recovery rate” of 51.9%, with some modern metropolitan areas such as Leeds and Bristol scoring as low as 39%, and the boroughs of Knowsley and Halton achieving rock bottom figures of a 32% and 28% respectively.

It’s also worth noting that IAPT’s recovery scores are mainly derived from the provision of treatment for common mental health conditions such as anxiety and depression, whereas recovery rates for The Retreat also include more complex disorders such as those which today would be classified as “schizophrenia” and “bipolar”.

There are of course too many variables involved in these statistics to be so bold as to make any sort of claim about them acting as proof of The Retreat’s superiority to modern mental health care methods. Though it’s certainly worth considering.

Illustration of a transorbital lobotomy procedure from "Psychosurgery" by Walter Freeman & James Watts

RESURRECTING BARBARISM?

Though treatment methods at The Retreat did indeed go on to have a positive and lasting influence on asylum practice the world over, for reasons not entirely clear, by the mid-to-late 19th century “moral treatment” as a systematic approach had begun to fade into obscurity.

One likely possibility is that advances in medicine, and in particular the development of biological psychiatry, compelled the field to once again begin searching for the biological origins of mental illness and thus medicines and surgical procedures designed to address them.

As a result of this change in direction the late 19th and the first half of the 20th century are littered with “treatments” barbaric enough to make the likes of blistering and rotational therapy appear almost tame by comparison.

Beginning in 1888, the Swiss psychiatrist, Gottlieb Burckhardt, believing that mental illness was caused by brain lesions, attempted, despite little surgical experience, to ameliorate the symptoms of six of his patients by cutting out sections of their cerebral cortex. Complications as a result of the procedure included epilepsy, muscle weakness, sensory aphasia, one death and one suicide.

In 1912 the Estonian neurosurgeon, Ludvig Puusepp, criticized Burckhardt’s attempt as “groundless” and “dangerous”, adding that he was “unable to explain how their author, holder of a degree in medicine, could bring himself to carry them out.”. Two years earlier this same Ludvig Puusepp had himself performed experimental brain surgery on three of his own “manic-depressive” patients.

In the 1910’s, American psychiatrist Henry Cotton began performing surgical procedures based on the idea that untreated bodily infection was the cause of mental illness. Cotton would begin by pulling the teeth of his patients. If symptoms persisted the tonsils were removed. When this didn’t work he would shift his attention to anything from the stomach, gallbladder, spleen, intestines, and even the reproductive organs.

Cotton claimed success rates of 85%, and with it worldwide fame and medical accolades. Later investigations would reveal that in actual fact his procedures resulted in death rates of about 45% due to postoperative infection.

In 1933 the Austrian-American psychiatrist Manfred Sakel introduced the world to Insulin Shock Therapy. During this procedure patients with “schizophrenia” were injected with high doses of insulin in order to induce seizures and a coma which were thought to jolt patients out of their mental illness.

A typical treatment course involved daily injections 6 days a week for 2 months, with each coma lasting around 1-4 hours. Sakel claimed success rates of more than 80%. In all likelihood any successes attributed to this treatment were most likely the result of selection bias, administering treatment to patients with a good prognosis who would have likely experienced some level of improvement regardless.

Common complications included prolonged comas, brain damage and a mortality rate of between 1% and 10%. Despite this, by 1941, 72% of all asylums in the U.S. were using insulin shock therapy. The practice didn’t fall out of use until the late 1950’s.

In 1934, Hungarian psychiatrist Ladislas von Meduna began experimenting with seizure therapy by injecting camphor, and later Metrazol, into patients diagnosed with “schizophrenia”. The seizures were so severe that patients commonly suffered bone fractures and muscle tears as a result. An X-ray study at the New York State Psychiatric Institute in 1939 discovered that 43% of Metrazol seizure therapy patients had fractured their vertebrae as a result.

The principles on which both insulin and Metrazol shock therapies were based would lead to the development of Electroconvulsive therapy, a practice which is still in use today despite a meager 25% long-term success rate.

Julius Wagner-Jauregg, the first psychiatrist to win the Nobel Prize (1927) for his discovery that patients with paralytic dementia could be cured by infecting them with malaria-infected blood (this actually did work!), also believed that excessive masturbation was the cause of “schizophrenia” in some of his patients, and so castrated them.

Finally, at the 1935 International Neurological Congress in London, Yale physiologists John Fulton and Carlyle Jacobsen presented a study on the surgical removal of the frontal lobes in two chimpanzees, Becky and Lucy, which resulted in the quelling of their temper tantrums and “experimental neuroses”.

Portuguese neurologist, Egas Moniz, who was in attendance at the conference, approached Fulton to inquire as to whether this same procedure could be used to treat mental illness in human subjects.

Whatever Fulton’s response, Moniz got straight to work that same year, testing out the procedure on 20 patients with a range of diagnoses including schizophrenia, panic disorder, and depression.

Early versions of this procedure involved drilling a hole into the skull and then injecting ethanol into the prefrontal cortex in order to destroy the connecting fibers.

The American physician Walter Freeman later developed a streamlined version of the procedure intended to be carried out by psychiatrists without the need for a surgeon.  His approach involved the insertion of an orbitoclast (a long thin surgical pick) beneath the eyelid which would then be struck with a hammer to pierce through the thin layer of bone behind the eye socket and travel up into the brain. The pick would then be raked in various directions in order to separate the frontal lobes from the thalamus.

Complications would include fever, vomiting, incontinence, diarrhea, sinus and vision problems, decreased motor function, dulled emotions, lethargy, disorientation, bizarre compulsions, hyperphagia, and seizures. Patients also often needed to relearn how to eat and use the toilet, and the mortality rate was about 15%.

It was Freeman who performed this same disastrous procedure on 23-year-old Rosemary Kennedy, the sister of President John F. Kennedy, which left her incontinent, unable to speak, and with the mental age of a 2-year-old.

The level of compassion that Freeman had for his patients (nay, victims), not to mention the quality of his work, can be gleaned from his description of a young female patient who, as a result of one of his procedures, was turned into a “smiling, lazy and satisfactory patient with the personality of an oyster.”.

In 1949, Moniz was awarded the Nobel Prize for developing this surgical procedure which later became known as the lobotomy.

Though the procedure began to fall out of favor in the mid-1950’s due to the introduction of psychiatric medication, by 1972 over 40,000 lobotomies had been performed on patients in the U.S., and more than 17,000 in the UK.

Salomon Trismosin's 'Splendor solis'. Watercolour painting. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

WHERE ARE WE NOW?

With the advent of medication and the rapid rise in popularity of talk therapy, the mental health industry has inarguably taken a much needed progressive step back towards Tukean benevolence. What’s not so clear is whether or not this same shift has resulted in any significant improvements in efficacy.

In 1991 around 9 million prescriptions for antidepressants were issued in the UK. By 2015 that number had risen to 61 million, meaning that in the same time the population grew by just 12.5%, antidepressant prescriptions rose 600%. Around 9% of the UK population are now on some type of antidepressant medication.

America, the wealthiest and most prosperous civilization in history, and whose population represents less than 5% of the world’s total, consume 66% of the world’s psychiatric medications. In 2010, sales of psychiatric medication amounted to more than $70 billion in the U.S. alone.

Rates of hospitalization for schizophrenia have remained about the same since the 1980’s. Of all the people with serious mental illness supposedly liberated by the process of deinstitutionalization, that same proportion of the population are now once again simply locked up in jail like they were 250 years ago.

Finally, despite the tens of billions of pounds, dollars, and Euro’s poured into mental health research over the past half-century, and all the mental health awareness campaigns, and anti-stigma campaigns, and blogs, books, videos, websites, and billboards, there have been no significant improvements in suicide rates since the 1950’s when reliable records began.

Much remains to be done!