William Battie, resident physician and driving force behind the foundation of St Luke's asylum, published what was probably the first English medical monograph devoted to madness in 1758. A proponent of Enlightenment pedagogy, Battie advocated an optimistic view of the treatability of insanity, by management – rather than the ineffective and brutal purges, vomits and blood-letting then regularly practiced at Bethlem.

‘Madness is frequently taken for one species of disorder, nevertheless, when thoroughly examined, it discovers as much variety with respect to its causes and circumstances as any distemper whatever: Madness, therefore, like most other morbid cases, rejects all general methods, e.g. bleeding, blisters, caustics, rough cathartics, the gumms and faetid anti-hysterics, opium, mineral waters, cold bathing and vomits.’

John Monro, physician of Bethlem like his father before him, read Battie's Treatise as a barely veiled attack on the elder Monro's running of the ancient hospital. With filial piety he rushed to publish his Remarks in defence of his father's regime.

‘Notwithstanding we are told in this treatise, that madness rejects all general methods, I will venture to say, that the most adequate and constant cure of it is by evacuation; which can alone be determined by the constitution of the patient and the judgment of the physician. The evacuation by vomiting is infinitely preferable to any other, if repeated experience is to be depended on…’

Dynastic stagnation fulminated against Enlightenment progress and humanity.

Battie's Treatise was a turning point in the medical approach to mental illness. His division of madness into ‘original’ and ‘consequential’ illnesses are forerunners to the ‘organic’ and ‘functional’ terms used to this day, and his promotion of therapeutic optimism through engagement with the patient, rather than restraint and other physical affronts, prefigured the ‘moral therapy’ of the Tukes at the York Retreat later in the 18th century.

Then again, William Battie was an ambitious career physician. His attack on Monro's practice was as much an attempt to break that family's near monopoly on mad-doctoring in London – both John and his father James Monro operated the Bethlem as a private fiefdom, with no medical students allowed in to learn their trade (although sightseers could gawp at the inmates for a penny a time). Despite Bethlem's cruel reputation, it had a waiting list – there was clearly a substantial demand for madhouse places. In parallel with his position at St Luke's (only a stone's throw from Bethlem and operating in direct competition), Battie ran his own private madhouses. Whatever else Battie's ‘management’ might have entailed, confinement (at a fee) was prerequisite – and he died a very, very rich man.