Madhouses, Mad-Doctors, and Madmen

The Social History of Psychiatry in the Victorian Era

Andrew Scull, Andrew Scull

• Publisher: University of Pennsylvania Press
• Year: 2015
• ISBN:
  9781512806823
• Topic: History
• Subtopic: British History
• Index: History

The Victorian Age saw the transformation of the madhouse into the asylum into the mental hospital; of the mad-doctor into the alienist into the psychiatrist; and of the madman (and madwoman) into the mental patient. In Andrew Scull's edited collection Madhouses, Mad-Doctors, and Madmen, contributors' essays offer a historical analysis of the issues that continue to plague the psychiatric profession today. Topics covered include the debate over the effectiveness of institutional or community treatment, the boundary between insanity and criminal responsibility, the implementation of commitment laws, and the differences in defining and treating mental illness based on the gender of the patient.

ANDREW SCULL

1 The Social History of Psychiatry in the Victorian Era

The history of psychiatry has become in recent years an extraordinarily creative and controversial field. One thinks, in particular, of the idiosyncratic and self-consciously opaque pyrotechnics of Michel Foucault, and of the fascinating and sometimes fierce debate between David Rothman and Gerald Grob over the sources and meaning of lunacy reform in nineteenth-century America.¹ The history of English psychiatry remained wedded for a few years longer to a “progressive” metaphysics, whether of administrative historians like Kathleen Jones, or of practicing psychiatrists-cum-historians like Richard Hunter and Ida MacAlpine.² But by the mid-1970s, a few Ph.D. dissertations and a handful of published articles marked the spread of a more skeptical viewpoint there too.³ I must confess that if a Whiggish theory of history is now in rather deserved disfavor when applied to the subject these works are grappling with, it seems appropriate, nevertheless, to regard the historiography as progressing. One only has to compare the newer work with that done by Albert Deutsch, Gregory Zilboorg, or Kathleen Jones, or even by Norman Dain to become aware of the much broader array of issues which are now seen as problematic, the greater range of material that is brought to bear on those questions, and the increased epistemological sophistication of the answers provided.⁴

The work of this new generation of historians, leavened (at least I hope it is leavened) by the contributions of an occasional sociologist, has concentrated heavily upon a reexamination of what was once referred to as “the first great psychiatric revolution,” the transformation of social ideas and practices vis-à-vis the insane which marked the late eighteenth and the first half of the nineteenth century. In one way or another, the essays in this book are all concerned with this “revolution” and its aftermath as these were experienced in England and the United States.

Juxtaposing developments in these two societies makes it evident that a wealth of fascinating comparisons and contrasts exists between them, some of which I shall explore in this essay. Although the “psychiatric revolution” was by no means a uniquely Anglo-American phenomenon, its impact in both societies was powerful, and its timing remarkably similar. Moreover, the interest aroused by the striking resemblances (as well as divergences) in the two experiences of “reform” is heightened when developments in the history of psychiatry are set in a broader cultural context. For Victorianism, as Daniel Howe has recently reminded us, “was a transatlantic culture” rooted in a common heritage,⁵ a heritage whose impact was strengthened and sustained by the efflorescence of printed and other forms of transoceanic communication from the 1830s onward. And if the American variant was at first a largely derivative and provincial version of its English counterpart, it was embedded nevertheless in a very different social matrix, so that by the end of the century, it had become more distinctive, even as the lines of influence between the two societies became more genuinely reciprocal.

The Victorian age saw the transformation of the madhouse into the asylum into the mental hospital; of the mad-doctor into the alienist into the psychiatrist; and of the madman (and madwoman) into the mental patient. And while it would be a grave error to confuse semantics with reality, it equally will not do to treat these verbal changes as no more than a succession of euphemisms masking a fundamentally static reality. As with all mythical representations, the progressive images that this succession of terms is designed to conjure up bear a significant, albeit distorted, relationship to the social order they purport to describe.

We begin, therefore, with the recognition that the advent of the Victorian era coincided to a striking extent with the culmination of a series of dramatic changes in society’s responses to madness. Some of the more obvious of these changes were: The state apparatus assumed a much greater role in the handling of insanity; the asylum became almost the sole officially approved response to the problems posed by the mentally disordered; and the nature and limits of lunacy were themselves transformed. Madness was increasingly seen as something which could be authoritatively diagnosed, certified, and treated only by a group of legally recognized experts. And those “experts” were, of course, medical men—increasingly an organized and self-conscious specialism within the profession of medicine, known to their detractors as “mad-doctors” and among themselves as “alienists” or “medical superintendents of asylums for the insane.” (The clumsiness of the title at least captures the extent to which their professional identity was bound up with their institutional status.) Henceforth, “the character and course of mental illness [were to be] . . . shaped irrevocably by medical intervention.”⁶

It would be foolish, of course, to suggest that medical concern with madness is a uniquely nineteenth- and twentieth-century phenomenon. Eighteenth-century medicine continued to rely heavily on the Hellenic tradition of a humoral physiology, pathology, and therapeutics. As such, it could invoke classical authority in support of a recognizably medical theoretical account and therapeutics of mental disorder. And there is evidence that the Greek tradition had its adherents even during the Dark Ages and the early medieval period.⁷ Still, and despite the lamentable dearth of research into the handling of the insane even so recently as the eighteenth century, certain generalizations may be ventured.⁸ First, the medical-humoral view was only one (though perhaps the most intellectually coherent) of the available ways of accounting for madness. Second, the majority of those practicing medicine—with whatever degree of skill or legitimacy—evinced little interest in or concern with the problems of insanity and the insane. Partly as a consequence, “the care of Lunaticks”⁹ was generally entrusted elsewhere than among medical men: to the madman’s family; to the jailer; to clergymen; or to the workhouse master. Even the emerging “trade in lunacy” in England, which centered around the growth of the private madhouse system, was far from being a uniquely medical enterprise.¹⁰ And if the law was for the most part silent on the issue of insanity, to the extent that lunatics were a focus of concern, they were lumped together with other vagrant groups and were dealt with as amateur magistrates saw fit.

By the latter part of the eighteenth century, however, medical interest was clearly on the upswing—a development given further impetus (in England, at least) by George III’s “mania.”¹¹ Whether measured by the volume of medical writings on the subject; the inclusion of lectures on the management of insanity in medical-school curricula;¹² or by the number of medical men practicing in the area, it is clear that doctors were attempting to give some practical substance to their profession’s traditional, if previously neglected, claim to jurisdiction over the insane. That substance involved an effort to minister to the body rather than to the mind diseased; for in a Cartesian universe, with the concept of mind conflated with that of soul, physicians almost universally asserted that mental disease had an entirely somatic basis, and thus was accessible to physical remedies. This somatic emphasis is particularly unsurprising when we recall that to adopt a perspective which allowed disorders of the mind/soul to be the etiological root of insanity threatened to call into question the soul’s immortality and with it the very foundations of Christianity, or to lend substance to the notion that crazy people were possessed by Satan or the subjects of divine retribution—which, of course, made them better candidates for the ministrations of ecclesiastics than for those of physicians.¹³

Still, the growth of medical dominance in the treatment of the insane did not go unchallenged. The early nineteenth century saw the emergence and spread of a new approach to madness, emphasizing the adaptation of treatment to the circumstances of the individual case to a degree which qualitatively distinguished it from more traditional medical therapeutics. Resting upon psychosocial intervention, the new “moral treatment” represented, in Bynum’s words, “a rather damning attack on the medical profession’s ability to deal with mental illness” and was, implicitly, a challenge to the somatic etiology preferred by physicians. The threat was heightened in England by the fact that the domestic version of moral treatment which drew the widest attention not only called into question the value of standard medical interventions, but was itself a lay inspired development. Further compounding medical vulnerability within a few years were the revelations of asylum “abuses” before parliamentary select committees, for many of the most blatant episodes here involved medical men and medically run institutions. William Bynum’s analysis in chapter 2 presents an examination of medical ideas about, and treatments for, insanity, covering the period immediately prior to the introduction of moral treatment, as well as the profession’s response to the challenge offered by the new form of treatment.

Elsewhere, I have suggested that the success of that medical response rested in part upon a careful reworking of the claim that insanity was a somatic disorder, and that the response was essentially a political and social process, culminating in claims that both moral and medical treatment were essential for the adequate treatment of lunatics.¹⁴ But, as Bynum points out, the medical profession’s somatic emphasis threatened to create a series of difficulties for any attempt to assimilate the newly popular moral therapy to the medical armamentarium. His suggestion that phrenology served as a vital theoretical mediation, an intellectual system providing a crucial ideological linkage which smoothed away the logical awkwardness of employing “moral” means to treat a physical disease, is amplified and more carefully specified in chapter 3, where Roger Cooter gives extended treatment to the relationship between phrenology and psychiatry.

But Cooter goes much further than this. He demonstrates the wide influence of phrenology among early nineteenth-century British alienists and suggests some of that doctrine’s multiple attractions for the emerging profession. In particular, he points to the broader social resonance of phrenology with the ideas of social reform and progress, and the ideological and social linkage it provided between the work of the asylum superintendents and attempts to respond to other pressing social issues of the day. On these grounds, too, may rest much of phrenology’s appeal, not just to many of the leading early American asylum superintendents (such as Amariah Brigham, Isaac Ray, Samuel Woodward, and Pliny Earle), but also among the laymen—Samuel Gridley Howe and Horace Mann in particular—who played such important roles in the state asylum movement in the United States.¹⁵ And beyond its symbolic and practical association with reform, phrenology provided a clear physiological explanation of the operations of the brain, one which permitted a parsimonious account of both normal and abnormal mental functioning, and which provided a coherent rationale for the application of both medical and moral treatment in cases of insanity.¹⁶

The centrality of moral treatment to any examination of the history of psychiatry in the nineteenth century has long been recognized. However, this theme has been described all too often in mythological portraits of Pinel literally and metaphorically striking the chains from the lunatics in the Bicêtre and (in the midst of the bloodiest excesses of the French Revolution) inaugurating the first rational and humane approach to the treatment of the mentally disordered. The historiography of psychiatry has undergone a profound transformation since 1965, to which this volume testifies. Yet on the central issue of moral treatment, there is, on one level at least, a fascinating convergence between the old-fashioned directionalist histories, which stress its revolutionary impact and importance, and the work of modern revisionists from Foucault onward, which argues that moral treatment represents a decisive epistemological break in the history of Western responses to madness. Having said this, it hardly needs to be emphasized that the two traditions have evaluated this rupture very differently, and have sought to comprehend its origins and analyze it...

Table of contents

• Cover
• Half title
• Title
• Copyright
• Dedication
• Contents
• Contributors
• Acknowledgments
• Introduction
• Chapter One: The Social History of Psychiatry in the Victorian Era
• Part One: Mad-Doctors and Their Therapies
• Part Two: Institutions and the Inmate Experience
• Part Three: Changes in the Profession and Its Orientation
• Part Four: Psychiatry and the Law