Complaints, Controversies and Grievances in Medicine

Historical and Social Science Perspectives

Jonathan Reinarz, Rebecca Wynter

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317637622
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Recent studies into the experiences and failures of health care services, along with the rapid development of patient advocacy, consumerism and pressure groups have led historians and social scientists to engage with the issue of the medical complaint. As expressions of dissatisfaction, disquiet and failings in service provision, past complaining is a vital antidote to progressive histories of health care. This book explores what has happened historically when medicine generated complaints.

This multidisciplinary collection comprises contributions from leading international scholars and uses new research to develop a sophisticated understanding of the development of medicine and the role of complaints and complaining in this story. It addresses how each aspect of the medical complaint – between sciences, professions, practitioners and sectors; within politics, ethics and regulatory bodies; from interested parties and patients – has manifested in modern medicine, and how it has been defined, dealt with and resolved.

A critical and interdisciplinary humanities and social science perspective grounded in historical case studies of medicine and bioethics, this volume provides the first major and comprehensive historical, comparative and policy-based examination of the area. It will be of interest to historians, sociologists, legal specialists and ethicists interested in medicine, as well as those involved in healthcare policy, practice and management.

Part I

Professionals

1 A culture of complaint

Psychiatry and its critics

Andrew Scull

I venture to suggest that few branches of the medical profession have been as subject to complaints as psychiatrists. The mad (or some of them) were vocal critics of their doctors long before there was such a thing as psychiatry – or at least an organised profession that went by that name. For psychiatry as a term of art only came into broad usage in the English-speaking world a century or so ago. Before the early twentieth century, those purporting to minister to diseased minds called themselves (or were referred to by others) asylum superintendents, medical psychologists, or alienists. Earlier still, in the eighteenth century and through the first part of the nineteenth, they answered to the name ‘mad-doctor’, a label that nicely captures the ambivalence with which society at large always seems to regard those who lay claim to expertise in the treatment of the mentally ill. (As Hilary Ingram reminds us elsewhere in this volume, defining and defending a profession often brings questions of semantics to the foreground.) Complaints about psychiatry continue to the present, as the introduction to this volume similarly makes clear. Indeed, as I shall show in the concluding section of this chapter, in the last half century, the voices of the patients have been amplified by other powerful complainers – by social scientists who have suggested that the psychiatric emperor has no clothes; and, more disturbingly still, by critics from within the profession of psychiatry itself, and not just renegades like Thomas Szasz and Ronald Laing, but mainstream psychiatrists as well.

Complaints have frequently functioned as a motor of change in this arena, as in other fields of medicine. Complaints about the horrors of the ancien régime madhouse and about the confinement of the sane amidst the lunatic played a vital role in generating the moral outrage that fuelled the Victorian lunacy reform movement, and in successive revisions of commitment laws – though it has to be added that the law of unintended consequences operated with particular force in these arenas. The asylums that were one generation’s solution to the problems of serious psychosis became the object of complaints and agitation for a later generation seduced by the siren song of ‘community psychiatry’; and the hedging about of the psychiatric commitments process with legal entanglements likewise became a late-twentieth-century bête noir. But complaints have also been directed against particular forms of psychiatric treatment and have played an important role in creating greater circumspection among psychiatrists about the use of treatments such as lobotomy and the shock therapies, and more recently even in raising concerns about the contemporary reliance on psychopharmacology as the sheet anchor of current psychiatric practice.¹ Though, of course, and as Hera Cook has described elsewhere in this collection, a transatlantic swell was created by critiques of psychoanalysis and US therapy culture – complaining about talking therapies and their rationale also punctuated the late twentieth century.

Most recently of all, as I shall discuss in the concluding sections of this chapter, complaints from the very centre of the psychiatric enterprise – the authors of the two editions of the psychiatric ‘bible’, the Diagnostic and Statistical Manual of the American Psychiatric Association, immediately preceding the one issued in May 2013; and the head of the US National Institute of Mental Health, Thomas Insel, who presides over the vital federal presence in basic mental health research, dispensing billions of dollars – have threatened to destabilise the psychiatric enterprise in its entirety. DSM 5, as it is called, has been labelled a useless, anti-scientific document, a hindrance to progress. Perhaps worse, Insel has complained openly about the mythical status of such ‘diseases’ as schizophrenia and depression.² Complaining about psychiatry scarcely gets more dangerous and delegitimising for the psychiatric profession than that.

Though medical speculations about the origins of madness have an ancient lineage, the emergence of what ultimately became the modern profession of psychiatry – that is, the routine engagement of some medics in the management of the mad – cannot really be traced back much further than the eighteenth century. As the nineteenth-century term ‘asylum superintendent’ suggests, the emergence of what ultimately became a community of practitioners specialising in mental illness was intimately bound up with the parallel creation of a new social space – the madhouse or the asylum. It was in and through the management of these establishments that doctors developed some claims to skill in the management of the depressed, the demented and the deranged, and it was their control over the rapidly expanding network of such places in the Victorian era that ultimately helped to constitute and consolidate their position as an organised, well-defined, but still suspect profession.

The eighteenth-century ‘trade in lunacy’ was produced by and responded to the opportunities created by the growth of a consumer society, the emergence of a market for all sorts of goods and services that had traditionally been supplied on a subsistence basis, if they were supplied at all. It must be understood, as the late historian Roy Porter suggested, as part of the same developments that saw the rise of dancing masters, fencing instructors, hairdressers, pottery manufacturers, and other novel service occupations.³ Those practising the trade in lunacy took over the burdens of coping with some initially small fraction of those whose disturbed emotions, cognitions and behaviours rendered them inconvenient if not positively impossible to live with – rather as undertakers now began to emerge to handle the comparatively unpleasant and stigmatising task of dealing with and disposing of corpses. The mad had traditionally been a liability that fell primarily on the shoulders of their families. The disruptions they visited on the texture of daily life – the uncertainties, the threat, the terror they might provoke – were ones their relations bore primary responsibility for dealing with. In the entrepreneurial culture that prevailed in eighteenth-century England, those who could afford it might for the first time relinquish these problems to others, and where poor lunatics were judged sufficiently threatening and disruptive, the creaky mechanism of the Old Poor Law might occasionally pay to confine pauper lunatics in these new-fangled madhouses.

By no means was the new trade in lunacy a medical monopoly. To the contrary, in its early years, the madhouse business attracted all manner of entrepreneurs willing to speculate in, and earn a living from, trafficking in this particular form of misery. The keepers of madhouses were a heterogeneous lot, for there were no barriers to entry, and no oversight of the industry. And though traditional humoral medicine could readily stretch its explanatory schema to account for mania and melancholia, and its bleedings, vomits, purges and dietary regimens could be easily rationalised as remedies for the excesses of bile and blood that supposedly produced mental turmoil, there was no compelling reason, so far as many potential customers were concerned, to prefer those who professed some sort of medical expertise to others who offered similar services: respite from the travails madness brought in its train, and the shutting up of a source of social shame and embarrassment out of public view. To be sure, the growing numbers of madhouses, and the experience of attempting to control and manage the mentally disturbed day after day, meant that those running these places perforce developed techniques and some measure of skill in the handling of such awkward customers. The very variety of establishments and operators led to experiments with different approaches, and since claims to provide cure as well as care could provide a comparative advantage when it came to securing clients, many were not slow to advance them; some rather bizarre pieces of apparatus – swinging chairs, devices to mimic the experience of drowning, chairs to immobilise the patient and cut him or her off from sources of sensory stimulation – were invented to assist in the task.⁴

One of the key benefits madhouses could potentially offer families was the capacity to draw a veil of silence over the existence of a mad relation in their midst. But this shutting up of the mad in what purported to be a therapeutic isolation could easily be cast in a more sinister light. Drawing boundaries between the mad and the sane is scarcely a simple task. At the margin, ambiguities abound. Madhouses, with their barred windows, high perimeter walls, isolation from the community at large, and enforced secrecy, inevitably invited gothic imaginings about what transpired hidden from view, and such stories almost immediately began to circulate.

Some were fictional. Pulp fiction was another innovation of the emerging consumer society, and Grub Street hastened to produce melodramas with a madhouse setting. One of the most successful of these, first published in 1726 and passing through myriad editions, staying in print for more than three-quarters of a century, was Eliza Haywood’s novella, The Distress’d Orphan. As was customary in such gothic productions, the confinement that structured the story arose from familial conflict over a romantic liaison and the control of a personal estate: Annilia, the daughter of an eminent city merchant, who had lost both parents at a young age and was heiress to a substantial fortune, finds herself nefariously confined as insane by her uncle and guardian, Giraldo, after falling in love with a foreigner, Colonel Marathon. Her uncle is determined that she should marry his own son, Horatio, thus ensuring the passage of her estate as her dowry. The confinement (mimicking what was often the case in reality) was initiated in her own home by the uncle ordering her door locked and ‘one of the Footmen to bring a Smith, that her Windows may be barr’d’, under the pretence of protecting Annilia from her own mischievous and suicidal propensities: ‘for ’tis not Improbable but when she finds she is restrain’d in her Humour she may offer to throw herself out’.⁵

Annilia, however, is not to be so easily intimidated, and her uncle ratchets up the pressure by arranging for her to be carted off to a madhouse, secretly and in the dead of night, her screams silenced by ‘stopping her mouth’.⁶ Here, she finds herself at the mercy of ‘inhuman Creatures’, ‘Ruffians’, ‘pityless [sic] Monsters’ and ‘ill-looked fellows’, wedded to the terrific mode of instilling ‘awe’ and dread in their patients via lashings, mechanical restraint and neglect.⁷ Heywood’s melodrama plays up the symbolic homology between the constraints of the madhouse – its bolts, bars, and chains – and the tyranny of life as a lady, bereft of any semblance of legal and social equality. Only the intervention of her lover, Colonel Marathon, who surreptitiously enters the madhouse and then heroically scales its wall with his ‘trembling’ sweetheart draped across his broad shoulders, allows her to escape back to ‘freedom’ after three months of confinement.⁸ Then the evil are punished, and virtue is rewarded, and the titillating story comes to a satisfying close.

Haywood’s portrait of the mad-business as corrupt and cruel, unconcerned with the mental status of those it confined, struck deep chords with an audience prone to believe the worst about what happened in the madhouse. Nor were such complaints confined to the realm of fiction. Mrs Clerke’s case came before the courts in 1718, and the testimony at the trial made plain that women with fortunes (in this case, a rich widow) were genuinely vulnerable to incarceration as mad in just the ways that were exploited in these literary narratives – all the more so, given the hazy boundaries of those disorders of mind and body being constituted by doctors and owned by sufferers as vapours, spleen and nerves.⁹ Research by the Cambridge historian Elizabeth Foyster into the records of the King’s Bench court has shown that Mrs Clerke’s case was scarcely unique. Women were, indeed, especially liable to false confinement in madhouses, locked away by husbands eager to enforce their authority over the property of wives and to sanction their ‘reasonable’ restraint and correction.¹⁰

Whereas emotionally and socially susceptible females predominated as the victims and complainants in this partly literary and partly literal construction of the madhouse, there were also a fair number of actual and fictional male equivalents suffe...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of illustrations
• Notes on contributors
• Preface
• List of abbreviations
• Introduction: Towards a history of complaining about medicine
• PART I Professionals
• PART II Politics
• PART III Patients
• PART IV Public relations
• Afterword: Going public: the act of complaining
• Index