In the early 1800s, medicine in Norway had to cope with high mortality and marginal living conditions. Psychiatry also entered the scene as a component of public health and the development of a national health service. But how did this come about?
In the period from 1814 until the middle of the century, an unparalleled process of nation-building took place in Norway. The aim was to establish independent national institutions and a national infrastructure for all areas, preferably once and for all. Norwegian psychiatry emerged out of this landscape, and the way was paved by two men: the medical doctor Herman Wedel Major (1814 – 54) and his older colleague Frederik Holst (1791 – 1871). This issue of the Journal of the Norwegian Medical Association contains several articles about Major’s role in the formation of Norwegian psychiatry and care of the mentally ill according to new principles (1 – 4). From the outset of his career in community medicine, Frederik Holst (1791 – 1871) was concerned with nation-building in the area of public health and the health services. He saw clearly that many of the urgent problems needed to be solved through group-oriented measures, in line with the ideals of community medicine that had emerged at the end of the 18th century.
Disruptiveness and violence among mentally ill patients were relatively common before effective drugs became available in the mid-twentieth century. The history of psychiatry must be understood in light of this, and the degree of disruptiveness and violence that could be tolerated varied with time and place. A new asylum opened in Christiania (now Oslo) in 1788, erected next to Oslo Hospital. It was built in accordance with the contemporary view regarding disruptive patients. By way of contrast, a «Narrenturm» (Fool’s Tower) was built at the same time in Vienna next to what was at that time the ultra-modern Vienna General Hospital. But both the asylum in old Oslo and the «Fool’s Tower» in Vienna were quite soon to be considered as buildings worthy of condemning. Why?
Holst saw the treatment of prisoners and the mentally ill at that time as unworthy. He therefore quickly raised the issue of conditions in mental hospitals and penitentiaries (5, 6), made systematic inventories and travelled abroad to gather knowledge and experience.
The need to detain and control disruptive persons was common to prisons and hospitals. Measures to combat deviant behaviour traditionally consisted of using strict correctional regimes (7). For prisons, Holst concluded that a so-called panoptic system would be optimal, in other words a building with wings that radiated outwards from a central atrium, so that the prisoners could be monitored from a watchroom in the centre. Control was essential. The ideal of a panoptic construction also had a medical justification for its use in a mental hospital, where it represented a form of detention that enabled disruptive patients to be controlled, but which also offered opportunities for individual treatment. A new hospital in Glasgow, built in 1814, was designed in this manner (8). A new Norwegian mental hospital could also be constructed along similar lines.
The years passed, and Holst’s panoptic hospital project did not come to fruition. The immediate reason for the delay lay in the financing of the project, but at the same time a development was taking place in the field of psychiatry. Because individual patients were being placed increasingly at the forefront, treatment principles were sought after that offered greater opportunities for personalisation. In psychiatry at that time, hospital buildings themselves were regarded as medical instruments. New methods therefore demanded new architecture.
The young doctor Herman Wedel Major entered the scene in the 1840s. He was 23 years younger than Holst, belonged to the next generation of doctors and spent his formative years in a society that was already undergoing an intense process of development (1). Major’s efforts to build up the field of psychiatry are remarkable. His introduction of the control commissions, for example, must have been very far-sighted (2). Psychiatry had not been on Major’s class timetable when he studied for his degree, but his fiancée’s illness was one factor which helped him to obtain an insight into the subject. It had clearly formed his opinion on the needs of individual patients.
Hammerborg’s article on Bergen Mental Hospital («Mentalen») (3) also showed the existence of variations in how psychiatric patients were treated at the time, and that this could be a topic of discussion in the public debate.
Major’s preferred hospital model featured greater medical flexibility than the panoptic design. A hospital of this type opened in Auxerre, France in 1840 as a continuation of an old general hospital (4, 9, 10). It consisted of free-standing buildings, called pavilions. A different solution was chosen for Gaustad. Wings around a central axis, with different degrees of openness and strict control in the individual departments, enabled better adaptation of conditions for the particular patient, and the relocation of patients according to how their condition developed.
In an article about Gaustad Hospital, Hvattum (4) discusses the distribution of patients that the architecture made possible. However, Gaustad’s wings cannot be interpreted as hospital pavilions in the sense in which this word has commonly been used in later medical history. Pavilion hospitals appeared primarily in association with combatting epidemics in the late 1800s. Free-standing pavilions surrounded by trees and plants to prevent miasma served as medical aids to halt the spread of infection. Therefore, this was architecture with a different medical purpose from that of psychiatry.
In 1855, Norway had acquired a modern form of psychiatry according to the standards of that time, and an asylum that conformed to international standards (4). Who was the pioneer behind this, if indeed such a question has any significance? Holst or Major? The community medicine specialist or the clinician? The development of psychiatry in Norway in the first half of the 19th century was a relay race with two runners, where an older and a younger sprinter exchanged the baton at the halfway point. Both were pioneers.