A Stable is a Boudoir to a Bedlamite: Marx on Asylum Psychiatry

We are currently living through a small renaissance of applications of Karl Marx’s work to the history and future development of mental health fields. But, as far as I know, no mention has been made of the fact that Marx himself wrote an article about English asylum psychiatry for the New York Tribune in 1858 called "The Increase of Lunacy in Great Britain," nor, to my knowledge, do any contemporary authors or groups take into account Marx’s brief remarks on lunacy in various texts about Irish political prisoners. I think it’s clear from what follows that his few remarks on madness will provide little clarity or fodder for the kinds of broad critiques grounded in Marx’s work, so this is not a surprising omission. It would be a mistake to try and find the Marxist approach to mental health in a single text and a handful of remarks about it. Nevertheless, even though Marx’s article is small and the latter remarks are more of a supplement to his main arguments in those texts, they may at least provide us with some indications of what Marx considered noteworthy about the social problem of madness. What follows is a close reading of the newspaper article, supplemented by quotes from his articles on Ireland and my own historical contextualization.

What is the Source of “the Increase of Lunacy?”

Marx’s article appeared in Horace Greeley’s anti-slavery periodical The New York Tribune in August 1858, a decade after The Communist Manifesto and one year before A Contribution to the Critique of Political Economy.1 Marx had continuously written for newspapers since writing his first piece and subsequently being brought on as editor for Cologne’s Rheinische Zeitung in 1842. Famously, Marx's induction into both journalism and censorship was through a long article denouncing a law that punished peasants following ancient custom by gathering wood on now private land. In 1843, none other than Czar Nicholas I asked the King of Prussia to shut down the Rheinische Zeitung. His 1848 return to Cologne to write for the Neue Rheinische Zeitung and subsequent repression served as the motivation for his and his family’s flight to London. By the time his article on lunacy appeared, he’d been living in London for eight years and writing for Greeley’s paper for six. Greeley started the paper "in 1841 as a crusading organ of progressive causes, albeit with a distinctly American and Christian flavor; one contemporary writer described the paper’s political stance as 'Anti-Slavery, Anti-War, Anti-Rum, Anti-Tobacco, Anti-Seduction, Anti-Grogshops, Anti-Brothels, Anti-Gambling Houses.'"2 Marx was first brought on to contribute pieces about post-1848 German politics, but his article on lunacy appears towards the end of a long series of articles on British society and politics for the Tribune through the 1850s.

"London's Overthrow" by Bedlam inmate and arsonist of the York Minster, Jonathan Martin

Marx begins his article by noting that "curiously enough," just as wealth and pauperism grow, so too does insanity. This wouldn’t be remarkable were the number to rise in pace with the total population, but, as he points out, this is not the case. Instead, the "increase of lunacy in Great Britain has kept pace with the increase of exports, and has outstripped the increase of population."3 To illustrate this tendency, he lists official figures of the total population in Britain and Wales alongside the number of lunatics counted in work houses, asylums, licensed houses and "living with friends or elsewhere." By comparing these, he wants to demonstrate that the rate of lunacy has risen from 1 in 847 in 1852 to 1 in 701 in 1857. He then cites figures that purport to show that the proportion of the insane population considered curable to those considered incurable was less than 1 in 5, implying that the frequency of lunacy is not only rising, but becoming increasingly chronic in character. Preempting his method in the empirical sections of Capital, Marx is using contemporary commission reports undertaken by state reformists—in this case, of the County Asylum movement—to expose the contradictions of accumulation and growth. The title notwithstanding, this was actually all Marx wrote about the increase of lunacy itself in the article, but, by positioning these few remarks and Marx’s other references to the cause of lunacy in the context of the "civilization question" in psychiatry, we can infer some of what he thought was behind this rise.

Among the many hotly debated questions about madness accompanying the great asylum reform movements in England (proper treatment, proper residence, level of professional expertise required for its doctors, etc), the question of its origins and the causal mechanisms regulating its appearance rank near the top for popularity and passion. Historically, even when a divine or medical explanation reigned supreme, there have always been those we would today categorize as "social" causes or as triggers of an underlying vulnerability: stress, poverty, abuse, and isolation, among other misfortunes. Between the middle of the eighteenth century to the twentieth, the spectacular rise of mental patients in rapidly developing and industrializing countries convinced many psychiatrists that "civilization" was behind this precipitous increase.4 This was a matter of special concern in Britain, where a series of Metropolitan Commissioners' Reports throughout the nineteenth century attested to this rise with greater accuracy and frequency than elsewhere.5

It is not always entirely clear what "civilization" is in this literature, such that two authors holding "civilization" at fault for the epidemic of madness may have two entirely different explanations for the causal mechanism at play. It often refers to the "degree of cultivation," as in the work of the psychiatrist Andrew Halliday, who held that "the finer the organs of the mind have become by their greater development, or their better cultivation, if health is not made a part of the process, the more easily are they disordered."6 Framing insanity as a problem of cultivation carried clear racial implications, for, according to most of these theoreticians, the "primitive races" were accordingly less likely to be insane. Antebellum American psychiatrists were especially keen to attribute these lower rates to inherited deficiencies and a simple psychic life.7 W.A.F. Browne rejected the idea that there were any inheritable traits disposing certain groups to insanity. He sums up the alternative explanation blaming moral hazard, speed, and intensity of development for driving men mad: "With civilization then come sudden and agitating changes and vicissitudes of fortune; vicious effeminacy of manners; complicated transactions; misdirected views of the objects of life; ambition, and hopes, and fears, which man in his primitive state does not and cannot know.” Browne, for his part, rejected this explanation too, because “these neither constitute, nor are they necessarily connected with, civilization."8 "Civilization" was too broadly defined. Browne instead turned his attention to specific practices and influences that likely had an effect on the psyche, some of which might become more likely or available in urban or developed areas: alcohol use, political instability and change and the rapid change of fortunes.9

"St Stephen's mad-house; or, the inauguration of King William the fourth." circa 1789

Whether they attributed the increased vulnerability of the civilized to biology or history (i.e. whether they thought the higher rates of madness among the “civilized races” was a matter of superior inherited traits or more complex social organization), the idea was that the civilized man’s own greatness exposed him to risk. This framing provided much fodder for the romantic cult of nature in the eighteenth and nineteenth centuries, who "viewed the present as a degenerate retrogression from a golden age of natural virtue."10 Two alternative explanations that weakened the direct causal link between civilization and madness were also put forth, both of which displaced the terms of the debate and reframed the rise as a consequence of concrete advances without implying any direct link between social change and madness. One argued that the higher numbers didn’t show a real increase at all, but were simply the result of better surveillance mechanisms, the rise of psychiatry as a popular profession and the increased availability of treatment options. The number of mad people had not necessarily changed; the state and psychiatric profession’s ability to locate and count them had simply improved. The second argument held that the higher number of people receiving public psychiatric services was a consequence of a lower infant mortality rate. In their view, the mad, being congenitally defective, were among the groups most likely to die as infants or children. The spread of popular medical care in charitable institutions, access to a well-rounded diet and improved environmental conditions meant that more of those babies were growing up to become sick adults.11

Where does Marx fit into this debate? He never explicitly posits a causal mechanism, but, knowing the language and stakes of the debate, we can better situate his remarks and make a good inference on where he might have stood (or at least where he didn't stand). Though he relies on them almost exclusively, Marx does not explicitly discuss the methodology of official commissions and reports. At the same time, his framing of the problem in his 1858 article strongly suggests that he believes these increases are real, or represent an actual numerical increase rather than a mere improvement of statistical measurement. As he put it, there is a "law," an "established fact," that pauperism rises in pace with the accumulation of wealth, and "the same law seems to hold good with respect to lunacy."12 He more explicitly rejects the notion that the increase in lunacy can be attributed to improved social conditions through an amelioration of the infant mortality rate. In a report on conditions in Ireland from 1867, he puts forth the opposite hypothesis that a secular decline in the Irish population is linked to a higher incidence rate of insanity.13

Marx brings up lunacy most often in his writings on Ireland; here, we can also say for sure that he never considered a racial explanation for why the rate of madness rose among the Irish through the nineteenth century. In an article for the New York Daily Tribune from 1853, he asks those who claim that the social standing of the Irish is improving "If the social amelioration of the Irish people is making such progress, how is it that, on the other hand, insanity has made such terrific progress among them since 1847, and especially since 1851?"14 This question, seen side-by-side with the opening to the "Increase of Lunacy," clearly implies that the rise of insanity is, for Marx, tied up with the social and environmental conditions of the population. To express it in the form of a "law," one could say that as social conditions improve for a population, the rate of insanity should drop (along with the infant mortality rate); as social conditions decline, the rate of insanity should rise. He apparently thought that this law holds strongly enough (and would be broadly understood by his audience) that he only needed to cite a rise in rates of insanity to prove weak social conditions, rather than cite specific social ills that incline a population towards insanity.

Though he never explicitly names a causal mechanism, he comes closest to doing so in his writings on political prisoners, which were heavily informed by debates within the International Working Men’s Association. In "The Irish State Prisoners. Sir Goerge Grey and the International Working Men’s Association" from 1866, General Council member Peter Fox cites statistics and first-hand accounts around the amount of Pentonville prisoners sent to asylums to prove that the “proportion of those who are driven permanently insane by the Pentonville system is by no means small.”15 Fox approvingly cites an account that concludes "it is evident that the Pentonville system breaks down the mind, and that the number of those who are rendered absolutely insane is in direct proportion to the severity of the treatment."16

Marx’s views were expressed only slightly differently and were clearly formed in close alignment with the IWMA’s earlier reports and statements: in an 1870 article titled "The English Government and the Fenian Prisoners," he mirrors the IWMA line that the "silence and the other bad treatment which he has received" made the journalist Martin H. Carey "lose his reason" and that colonel Richard Burke "has lost his memory and his behaviour, manners and speech are those of a madman"17 on account of his imprisonment. In that same article, he cites forced labor as a discrete cause for the high rate of madness amongst prisoners: “In the course of two years more than twenty Fenian workers have died or gone insane thanks to the philanthropic natures of these honest bourgeois souls, backed by the honest landlords.”18 He also cites the case of the inspector of Mountjoy Prison in Dublin, "the despicable brute" Murray, "who maltreated the prisoners so cruelly that some of them went mad."19 We cannot extrapolate a "Marxist theory of mental illness" from these comments, nor can we assume that he thought these social triggers excluded other etiological explanations. What we can say with relative confidence is that Marx thought 1) that the rise of lunacy was in some way tied to the disintegrative social effects of capital accumulation and 2) that the isolation and abuse inside prisons was a discrete cause.

A Tripartite Public-Private Complex

As we go on to see what Marx has to say about his real topic—institutional conditions amidst the rise of the insane population—it is necessary to consider Marx’s choice of topics in the context of the history of institutional provisions for the mad and the debate raging in Britain at the time around that care.

Until the seventeenth century, Bethlem was the only purpose-built and specialized congregate repository for the mad in Britain, and it held fewer than 50 until halfway through that century. Prior to the rapid proliferation of the asylum system in the eighteenth century, Britain’s mad were dealt with in a hyperlocal fashion, in one of about 15,000 distinct administrative units organized at the parish level or smaller.20 Most of the mad were cared for at home, in a non-specialized facility run by the church, wandered begging for alms or ended up in a jail. This situation became increasingly untenable for the English bourgeoisie who believed that general labor discipline was weakened by the possibility of outdoor and local relief. Outdoor relief and its incentives in favor of family-based care for the mad was therefore first supplemented by and eventually overtaken by the workhouse from the end of the sixteenth through the seventeenth centuries.

Over the course of the eighteenth century, two distinct institutional forms of care for the mad expanded rapidly and began to wrest the mad away from the workhouse, one private and one public: wealthy families were willing to pay for the newest medical methods in private residential facilities for their embarrassingly mad members in exchange for discretion while philanthropists and the pious began opening charitable wards for the mad beginning with Norwich in 1713.21 By the end of the century, such institutions were increasingly filled by the order of the state and local authorities. With the Public General Acts of 1714, two or more justices of the peace could order the "furiously mad, and dangerous" to be "safely locked up, in such secure place . . . as such justices shall . . . direct and appoint."22 The Vagrant Act of 1744 added to this the charge of "curing" them, but this was largely ignored for decades. Despite early calls for a county asylum system through the eighteenth century23 and broad condemnation of the private network, a county asylum law wasn't passed until 1808. Thanks to this lag, public asylums were still few and far between until the middle of the nineteenth century while private madhouses continued to outnumber them at a higher ratio than anywhere else in the world at the time.

William Norris, the "Insane American" of Bedlam Hospital. Drawing by George Cruikshank in 1815. Norris, confined for over a decade in mechanical restraints, become a symbol for the reformists in the 19th century

Marx's article came 50 years after the 1808 passing of the County Asylum Law, and it begins by noting the continued disproportion in favor of private provisions over a decade after the construction of county asylums became compulsory24: "There exist in England and Wales, for the accommodation of lunatics and idiots of all sorts and of all classes, 37 public asylums, of which 33 are county and 4 borough asylums; 15 hospitals; 116 private licensed houses, of which 37 are metropolitan and 79 provincial; and lastly, the workhouses."25 The chief reasons for the delay in erecting sufficient county asylums were financial and circular: an initial failure to properly invest fed into a self-fulfilling spiral of decay where the mass congregations in public facilities and the wretched conditions this effected convinced administrators that allocating more money was a waste of resources, leaving a vacuum to be filled by unscrupulous private asylum keepers looking to make a profit. In a situation where "the space afforded by these 37 establishments, spreading over the whole country, suffices for the housing of over 15,690 inmates,"26 it should come as no surprise that they roundly failed to have any curative effect and acquired reputations as dens of iniquity.

Lacking enough purpose-built facilities fit for pauper lunatics, and in the absence of any effective regulations on their administration, parishes entrusted mad paupers to the care of private entrepreneurs in exchange for a small fee. Financial speculation was behind the rapid spread of these private homes later known as "mad houses." The bar for entry into the field was simply the ability to advance sufficient capital, and, in hopes of a good return on that investment, private owners would make all manner of unrealistic claims about their capacity to cure the mad or maintain a higher degree of privacy. How private asylum keepers made money from their wealthy clientele is no great mystery. They simply collected inflated fees from individuals or their families who (pardon the double meaning) had more money than sense and were willing to spend big in exchange for discrete and, if one believed the physicians, miraculous treatments. The best among them earned reputations as curative or at least comfortable.

But complaints about the horrid conditions this profit-seeking fostered were widespread and well-known. For the media, the biggest scandals of all involved the indefinite confinement of wealthy aristocrats who were often the victims of their family members’ or husbands’ pernicious legal swindling to steal their estates by getting them declared incompetent.27 Fear and protest around the mistreatment and misdiagnosis of the upper classes led to the formation of the Alleged Lunatics' Friend Society in the 1840s by John Perceval (the son of the Prime Minister Spencer Perceval), which publicized stories of abuse and agitated for more stringent legal protections. As he begins his discussion of private madhouses, Marx briefly mentions the two big scandalous cases of this type in the news that year, namely “the kidnapping of Lady Bulwer into Wyke House, and the atrocious outrages committed on Mrs. Turner in Acomb House, York,”28 before quickly turning his attention to the outrages committed against the poor. In our distance from the media landscape in nineteenth century England and the US, it is easily missed that Marx is going against the grain here by emphasizing the quotidian treatment of the poor masses over the comparably rare mistreatment of the rich minority.29

Generalized profit-seeking on the part of madhouse keepers on provisions for pauper lunatics led to local economies of scale: one could subsidize the care of the mad with the fees charged to the richest patients, but the only way to make a surplus on meager parish allotments in themselves was to find a way to take a large mass of paupers and fit them into the smallest space possible with the cheapest food and the most efficient economy regarding all costs. As Marx put it: “The whole study of the contractors consists, of course, in the one single point of making large profits out of these small receipts, and consequently of keeping the patient at the lowest possible expense.”30 To express this as schematically as possible: consistent small payments scaled up for larger inmate populations and a weak regulatory apparatus created the incentive to hold onto these masses as long as possible while investing as little as possible in rent, improvements, food, or other necessities of life, thus maximizing the size of the return and minimizing expenses. Such a situation institutionalized chronicity.

This was widely known, but it gets even worse, for "where there exists no public asylum in the neighbourhood, or where the existing asylum is already overcrowded," the Lunacy Commissioners’ only recourse was to "prevent the licence to continue, or to throw large masses of the insane poor into their several workhouses." These were popularly recognized as the bottom of the barrel, lacking any semblance of therapeutic value: their "wards are gloomy and unprovided with any means for occupation, exercise or amusement. The attendants for the most part are pauper inmates totally unfitted for the charge imposed upon them."31 Due to the lack of sufficient space in the county asylums, and the fact that the cost of provisions was about half that of asylum care, the workhouses were nevertheless being used as the destination of last resort for the insane poor, such that they confined over 7,000 mad paupers when Marx was writing. In this sense, the workhouse as last resort served the dual function of acting as a disciplinary warning against supposed opportunistic malingering and as a cheap dumping ground for patients with a weak prospect of improvement.

A Stable is a Boudoir to a Bedlamite

In this short article, Marx identified how a society organized around capital accumulation exacerbated the social problem of madness at its point of origin (though without identifying precisely how) and in the array of services designed to ameliorate the condition. British society in the nineteenth century produced a tripartite system of residential therapeutics for the mad regulated by the overriding need to economize: at its base was a weak array of purpose-built institutions whose curative aspirations were dashed by being overburdened and underfunded, thereby placing additional pressure on a massive private network whose profit-seeking economies of scale incentivized therapeutic idleness and therefore chronicity, all of which relied on the workshouses lacking any pretense of care or attention. Marx ends his article with long quotes attesting to the rotten conditions this system inculcated: gloomy wards filled to the brim with human bodies, patients sleeping on straw beds, a lack of even the most basic comforts, insufficient ventilation, soiled clothes and sleeping quarters, all built from cold stone and with few openings for light.32

The casual night ward of the West London Union of parishes' workhouse in February, 1857

"Generally speaking," he wrote, "there are few English stables which, at the side of the lunatic wards in the workhouses, would not appear boudoirs, and where the treatment received by the quadrupeds may not be called sentimental when compared to that of the poor insane."33 Whether he intended it to be or not, this choice of imagery is laden with irony: in the rush to open private asylums and cash in on the lunacy craze, entrepreneurs like Dr J. H. Norton, who converted mansions into units for private patients, literally used horse’s stables for paupers.34 In that sense, Marx’s imagery is hardly a metaphor: private care in a horse’s stable was in reality preferable to the hell awaiting patients in the workhouse.

Marx may not have had a coherent theory of madness or psychiatry, but his focus on the actual living conditions of the poorest classes of the mad still serves as a useful counterbalance to the heavy emphasis currently given to the politics of diagnosis and its attendant scandals. In the decades following his article, the private madhouse population began to decline until psychiatry became overwhelmingly public, as it was in most other systems. In the second half of the twentieth century, the pendulum began to swing back towards the public funding of private care, especially in the US where Medicaid is the single largest payer for mental health services financing a network of facilities that’s now 81% private (60% non-profit and 21% for-profit).35 Not unlike the county-private-workhouse feedback loop he described, our current system is likewise composed of a fractured and overutilized public sector systemically reliant upon a large private sector with no necessary incentive to proper care (especially after the patient walks out the doors and stops paying), all regulated by the looming threat of indefinite interment in the commitment centers or the hellish forensic wards and isolation rooms of jails and prisons. Where margins are low, costs are high and transformation is a distant dream, subordinating care to a bottom line guarantees a system teeming with possibilities and intelligent individuals will continue operating at standards one could describe at best as fine, more likely as mediocre and confusing and quite often as shameful and horrific.

Notes

1. Most of this information about Marx’s time as a journalist is from the Introduction by James Ledbetter and the Forward by Francis Wheen in Dispatches for the New York Tribune: Selected Journalism of Karl Marx (London: Penguin Books, 2007).

2. James Ledbetter, "Introduction." in Dispatches for the New York Tribune: Selected Journalism of Karl Marx (London: Penguin Books, 2007), xvii.

3. Karl Marx, "The Increase of Lunacy in Great Britain," in Dispatches for the New York Tribune: Selected Journalism of Karl Marx (London: Penguin Books, 2007), 151.

4. George Rosen, Madness in Society: Chapters in the Historical Sociology of Mental Illness (Chicago: University of Chicago Press, 1968), 174–176. See David J. Rothman, The Discovery of the Asylum: Social Order and Disorder in the New Republic (New Brunswick: AldineTransaction, 1990), 112–119 for this theme in American psychiatry.

5. Andrew T. Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (New York: St. Martin’s Press, 1979), 222–228.

6. Quoted in Rosen, Madness, 184.

7. This is true even of Northern psychiatrists who more often rejected the hard racial science of their Southern counterparts like the New York-based Amariah Brigham, who argued in 1832 that "American Savages" (along with Russian, Chinese, Turkish, and Spanish people) were unlikely to go mad because "the inhabitants exhibit but little more mental excitement than the brute creation." Amariah Brigham. "Social psychiatry," in Three Hundred Years of Psychiatry 1535–1860: A History Presented in Selected English Texts ed. Richard Hunter and Ida Macalpine (Hartsdale: Carlisle Publishing, 1982), 824.

8. W.A.F. Browne, The Asylum as Utopia: W.A.F. Browne and the mid-nineteenth century consolidation of psychiatry, ed. Andrew Scull (New York: Routledge, 1991), 62–63.

9. Browne, The Asylum, 65.

10. Rosen, Madness, 182.

11. Scull, Museums, 227–228.

12. Marx, "The Increase," 151.

13. Karl Marx, "Outline of a Report on the Irish Question to the Communist Educational Association of German Workers in London," in Ireland and the Irish Question (Moscow: Progress Publishers, 1971), 148.

14. Marx, "Financial Failure of Government-Cabs-Ireland-The Russian Question," in Ireland and the Irish Question (Moscow: Progress Publishers, 1971), 76.

15. Peter Fox, "The Irish State Prisoners. Sir George Grey and the International Working Men’s Association," in Ireland and the Irish Question (Moscow: Progress Publishers, 1971), 480.

16. Fox, “The Irish’, 481.

17. Karl Marx, "The English Government and the Fenian Prisoners," in Ireland and the Irish Question (Moscow: Progress Publishers, 1971), 257.

18. Marx, "The English," 258.

19. Marx, "The English," 259.

20. Scull, Museums, 22.

21. Scull, Museums, 25.

22. William Parry-Jones, The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries (London: Routledge & Kagan Paul, 1972), 7.

23. See, for example: Anonymous, "Some thoughts concerning the maintenance of the poor. In a letter to a member of Parliament, 1700" in Three Hundred Years of Psychiatry 1535–1860: A History Presented in Selected English Texts, ed. Richard Hunter and Ida Macalpine (Hartsdale: Carlisle Publishing, 1982), 277.

24. Parry-Jones, The Trade, 16.

25. Marx, "The Increase," 152.

26. Marx, "The Increase," 153.

27. This genre dates back to the early stages of the asylum system. For an early example, see Anonymous, "Proposals for redressing some grievances which greatly affect the whole nation, 1740," in Three Hundred Years of Psychiatry 1535–1860: A History Presented in Selected English Texts, ed. Richard Hunter and Ida Macalpine (Hartsdale: Carlisle Publishing, 1982), 366.

28. Marx, "The Increase," 153.

29. See Parry-Jones, The Trade, 222–228 for an extended account of such scandals in the media. For a book-length treatment on the topic, see Sarah Wise, Inconvenient People: Lunacy, Liberty and the Mad-doctors in Victorian England (London: Vintage, 2013).

30. Marx, "The Increase," 154.

31. Marx, "The Increase," 154.

32. Marx, "The Increase," 155–6.

33. Marx, "The Increase," 156–7.

34. Parry-Jones, The Trade, 256

35. Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2020. Data on Mental Health Treatment Facilities (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2021), 1. Though the public funding of an expanding private sector is most extreme in the US, a similar trend has been taking place in Britain as well. See: Denis Campbell and Anna Bawden, "NHS paying £2bn a year to private hospitals for mental health patients," The Guardian, 24 April 2022, https://www.theguardian.com/society/2022/apr/24/nhs-paying-2bn-pounds-a-year-to-private-hospitals-for-mental-health-patients.