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the guide to historical resources • Issue 3: Medical History •

Medical History

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Book Review


Masters of Bedlam: the Transformation of the Mad-Doctoring Trade

by Andrew Scull, Charlotte MacKenzie and Nicholas Hervey
Princeton University Press, 1996

Jonathan Andrews

Given the efflorescence in the history of psychiatry over the course of the last quarter century, it is surprising that so few of the new generation of psychiatric historians have ventured into biography. However, largely as a consequence of an historiographical heritage where biographical studies of past figures in medicine were mostly stories of the great and the good and their achievements - the profession's own self-generating hagiography - historical biographies have generally fallen into disrepute. This is a shame, for it is the frequently rather celebratory, self-congratulatory and antiquarian approaches made to biography that have been wanting, rather than something germane to the discipline of historical biography itself. And given that we still lack high quality biographical studies of many of the major players who have shaped psychiatry's past and present, one can only welcome the arrival of Masters of Bedlam. For, in the main, it represents a highly successful attempt to locate the lives and works of some of the most prominent members of Victorian psychiatry's elite in Britain against a broad cultural, contextual and structural background.

The book is divided into nine chapters, the core seven (framed against a brief general introduction and conclusion) dealing with seven specialists in insanity, four English and three Scottish. These subjects are, namely: John Haslam, notorious for his public office as the Apothecary of Bethlem Hospital, but relatively esteemed for his authorship on insanity; John Conolly, onetime Superintendent of Hanwell Asylum in Middlesex, and long distinguished as the pioneer of non-restraint in the treatment of the insane; W. A. F. Browne, Superintendent of Montrose Royal Asylum and latterly Crichton Royal Institution in Dumfries, Commissioner in Lunacy for Scotland and asylum reformer par excellence; Sir Alexander Morison, Visiting Physician to Bethlem, most notable however for his early development of a private consultancy practice outside the asylum walls; Samuel Gaskell, Superintendent of Lancaster County Asylum and latterly an English Lunacy Commissioner; Sir John Charles Bucknill, onetime Superintendent of Devon County Asylum, and a major proponent of non-institutional care of the insane in private dwellings; and finally, Henry Maudsley, founder of the Maudsley Hospital, the archetypal insider-outsider, controversial editor of the profession's primary mouthpiece, the Journal of Mental Science, and an unrepentant critic of traditional asylumdom. If there is a problem in the representativeness of the figures selected, being members of the elite rather than the more numerous 'rank and file' (especially given what M. Jeanne Petersen has stressed was a radical divide between medical professionals at the top of the pile, and those underneath), the authors remain acutely appreciative of this fact (e.g. pp. 8, 61). Indeed, they give full coverage both to those areas where their subjects are reflective and revealing about the norms of contemporary psychiatry, as well as to where they are innovative, unusual or eccentric. Moreover, with careers located on either sides of significant divides, working in both the private and public asylum sector, both within and outside the asylum walls, pursuing endeavours in medical theory, clinical practice, and in legal and forensic medicine, and with profiles and postures adopted both for and against central administration in lunacy, these individuals provide the authors with a welter of opportunity for commentary on a whole range of developments in psychiatry and lunacy administration during this period.

Considering his own background and sympathies as a sociologist tending to emphasise and be interested in broad structural paradigms and discontinuities, above and beyond the influence of individuals on social structures, causality and change, Scull is perhaps an odd advocate of the virtues of biography. And what we have here seems as much an attempt to go beyond biography, as it does to persuade of its merits. On the one hand, the apparent concern to transcend biography, and knit individuals to their contexts, their histories to existing historiography, works beautifully to place mad-doctors' careers in the setting of macro and exogenous shifts - including the 'rise of professional society'; the increasing role of the central state in lunacy provision; and the growth of a capitalist marketplace for medical and all kinds of other services. On the other hand, this sometimes leads to overlong and rather uncomfortable digressions in which the key subject is lost, submerged or only marginally concerned. Thus, for example, while the rise and professionalisation of psychiatry, the history of the professions in general, and the lunacy reform movement are obvious themes in which to locate the mad-doctors with which this book is concerned, we are intermittently treated to extensive asides on these and a host of connected subjects (e.g. pp. 22, 91-8).

There is the usual preoccupation one has come to expect in Scull's writing with the ironies by which mad-doctors rose to prominence, with the contradictions and numerous 'volte-faces' that punctuated their careers. On the whole, these are well observed and lead to some pointed analyses of the self-interest, prejudices and professional imperialism that often underlay the strategies, opinions and actions of medical men with aspirations for pre-eminence. Conolly, for example, emerges as a most unlikely psychiatric patron-saint, beginning as a 'stern critic of asylum treatment' and of the private trade in lunacy (e.g. pp. 53-5, 65), only to end up, in ways that (too intimately for comfort) reflected the changed pattern of his career path, as a devoted champion of asylumdom and a defender of private institutions (e.g. pp. 79, 82). Conolly is convincingly portrayed as, for much of his career, the wrong man in the wrong place, whose claims to distinction rested as much on a distortion of the historical record of non-restraint in which he was complicit, as to his vision as a moral therapist or talents as an asylum administrator (pp. 70-2). Yet one cannot escape the impression that there is something rather hobbyhorse-like about some of this. Indeed, the authors' lens is perhaps too gleefully focused on exposing the ulterior motives of medical men, on cutting them down to size, rather than simply and concisely demythologising the 'pantheon of [psychiatric] heroes' (pp. 48, 158), before moving on to other, equally rich pastures. Occasionally, as a result, the tone of the account is too begrudging, and some interpretations appear narrow, exaggerated and over cynical, as when concerns with being dismissed, losing licences and income, and safeguarding 'professional standing and privileges', are portrayed as the only motivations for pauper asylum superintendents and their private-sector colleagues' feeling 'beholden' to the new Lunacy Commission (p.7).

Taking their lead from sociological and historical studies of professionalisation, from Magali Larson and M. Jeanne Peterson to Harold Perkin, the authors generally portray mad-doctors as rather directed, self-promoting and calculating in their words and deeds, engaged in a 'project of collective [and, indeed, competitive, individual] social mobility' (e.g. p.6). One is prompted to ask whether there is not a natural enough tendency for all existing or nascent professions (academics included) to seek to further and to protect their own interests? Nor, perhaps, in so doing, should a profession be too uniformly portrayed as being either calculating, or necessarily at odds with more widely shared concerns, let alone so self-consciously determined, or able to subordinate other interests, even when they were in competition. While, often, the authors are appreciative of the limits to psychiatric power and self-interest (it is fully conceded, for example, that Conolly was a poor strategist when it came to constructing a medical career, although compromised by his social origins, and that Maudsley's stance on asylumdom was, at the very least, a rather maverick, damaging course to chart), sometimes they seem to want to have it both ways. Overall they appear to neglect, or simply not to credit or be interested in, the place of altruistic, or less selfish motivations for the common good (as mad-doctors saw it), as well as the influence of chance, experience, opportunism and adjustment to circumstances and wider forces of change, as important or motivating factors (e.g. p. 82). Bearing in mind the ongoing debate Scull has had with Gerald Grob (amongst others) as to judging historical actors by their declared intentions (Scull typically and wisely stressing the gap between intention and outcome, and importance of unconscious motivations), the preoccupation with underlying intent and dubious results should not surprise us. But the analysis does intermittently seem to fall into the trap of always seeking to unearth the darker, more egotistic sides of human conduct.. Ultimately, of course, and this once again emphasises the distance at which some more traditional biographical approaches are put, this survey is not about good or bad intentions. Far from it, it is concerned with the consequences of individuals' words and deeds; their impact on and foundations in social structures; their signification as indices of shifting professional, moral and cultural ideologies; and their pertinence to the forces and structures dominating professional formation, status and aspirations.

Overall, however, the authors portray both the ambitions and the disappointments of their subjects with remarkable fairness, objectivity and insight, assessing their personal biases and rivalries, and the ambiguities of their achievements to great effect. More often than not, credit is given where credit seems due, as when John Haslam is acknowledged to have been, at least in part, inequitably scapegoated by the 1815-16 Madhouses Committee (pp. 18, 33); and is recognised for integrating (at least in theory) the new ethos of moral therapy into older doctrines of the management of the insane (pp. 27-8), as well as for becoming an internationally acknowledged authority on insanity (pp. 22-3). At the same time, obvious and less than obvious failings are unflinchingly exposed, as with Haslam's intransigence, conservatism and arrogance in the face of the lunacy reformers and all other opponents (pp. 37, 44-7), and his derogatory, dismissive and imprudent treatment of his patients, James Tilly Matthews especially (pp. 34-5). While other criticisms in such areas might arise, Scull and his co-authors are normally sufficiently subtle and perspicacious to anticipate and out-flank such (as on p. 28, where distancing themselves from historiographical tendencies 'to assume a correspondence between someone's published work and their clinical practice'). Indeed, it is a sign of the significant accomplishment these various portraits represent that they remain so persuasive and appreciative of the complexities of personal motivations, actions and career paths, while sustaining such a regular responsiveness to their various meanings as against the broader transitions in contemporary culture and social structures.

There is some particularly impressive and well-researched analysis of the links mad-doctors forged with other interest groups, both lay and medical, central and local, as well as of the social and intellectual origins of each individual subject and the ways in which, whether by hook or crook, they established themselves as members of the medical elite. The authors show themselves very sensitive to the social and economic disadvantages and stigmas of 'trade' with which mad-doctoring was long associated (e.g. pp. 6, 11-14, 49-51), and highly appreciative of the various routes and means taken by such doctors to carve out their own niches and clienteles, to shore up their income and status, and to consolidate their speciality. There are also some revealing insights into the ideological, practical, social and economic consequences of the religious backgrounds of these doctors (e.g. pp. 128, 164-5), as well as of their respective allegiances in political and patronage terms (e.g. p. 154). This account presents no simple, or linear picture of progression to repute and success, paying meticulous attention to the many reversals and ambiguities that punctuated its subjects' careers, and covering both the acquisition and the loss, both the regaining and the costs, of social and professional cachet.

One might question the amount of rehashed material in this book; the chapter on Browne being a virtual identikit of Scull's introduction to The Asylum as Utopia (1991), and the chapter on Conolly being lifted almost entirely from previous articles by Scull already published elsewhere. In essence, in fact, this book is - somewhat inevitably, given its structure - more like a series of articles and conference papers gathered together, than it is a seamless monographic whole. While Scull's is the dominant guiding hand, MacKenzie did much of the original work on Bucknill and much of the material on Morison and Gaskell belongs to Hervey. Given what is said about professional advancement in this book, an irony may appear in the fact that it is made so transparently clear in the acknowledgements and on the front cover to whom most of the credit should accrue, yet academics too must be careful to secure their due recognition. Nevertheless, it is at the very least a testimony to the authors' stylistic sensitivity and a good degree of sympathy and happy compromise on conceptual issues that the book's seam shows as little as it does. A more salient criticism, might be that the book, despite its generally admirable exploitation of a bewildering array of sources, is sometimes too exclusively focused on alienists and their writings, and on printed sources, to the exclusion of the views of other players, patients and local authorities in particular, and also to the neglect of case materials. The major exceptions are a short interlude on Morison's attendance on private patients in single lodgings, utilising extracts from his diaries (pp. 146-8), and an even briefer but equally fascinating section on Bucknill's advice to patients as a Lord Chancellor's Visitor (pp. 218-19). The view of the interests of parochial authorities, and their attitudes to and links with the doctors under consideration, as well as with other medical specialists and with central government, is especially cursory and specialist-centred.

One doubts whether the authors' portrait of Gaskell really manages to persuade that he represents the kind of major influence they claim he was in transforming mad-doctoring during this period, and it seems impossible to dismiss as lightly as one is asked to his decided lack of publications and of therapeutic and administrative originality (p. 161). Indeed, this would seem to account for the disproportionate way in which his career is summed up by the authors in just 26 pages, by far the shortest profile in the book and one that sets a query against his inclusion. Nevertheless, the only seriously unsatisfactory chapter is that on Browne. The latter is, I would argue, severely unbalanced, mostly being devoted to an analysis of his 'What Asylums Were, Are and Ought To Be'. Relying on this text and on Browne's annual reports as Superintendent of Crichton Royal Institution, little use is made of Browne's many other published writings, nor of the clinical records of the asylum he superintended. Browne's thirteen year service as a Lunacy Commissioner is skipped over in a paragraph or so, while the authors barely refer to his rather controversial opposition to the cottage system and boarding out of the insane in private dwellings. (Indeed, they seem unaware of the notorious article, 'Gheel in the North', Browne allegedly penned anonymously in 1866, which raised a storm in the medical press, and continued to be regularly referred to by critics of boarding out for many years).

One can only endorse many of their conclusions as to how the mad-doctoring trade had indeed 'transformed itself' by the turn of the century (p. 273). One must also concur that while critics of asylumdom like Maudsley and Bucknill were allying themselves with an 'upper-class clientele and the medical elite', antithetically they were 'diminishing the public standing of the profession as a whole' (p. 272). Yet, the conclusions also smack a little of jaundice, betraying Scull's recent preoccupation with the history of somatic treatments and incongruously moving off into a wholly new digression on the subject of Freud and psychoanalysis, the relevance of which seems rather strained, and serves merely to reiterate Michael Clark's argument, made some time ago, about the inveterate hostility of nineteenth-entury psychiatry in Britain to psychological approaches (pp. 272-3). The judgement that 'the men who aspired to form the profession's elite sought … to leave the institutional sector behind' and 'were led to adopt intellectual positions … at odds with the interests and outlooks of the rank and file' (p. 274), seems debatable and hyperbolic. Maudsley and Bucknill appear rather unusual, when one compares the careers of men like Clouston, Yellowlees, Blandford, Conolly Norman, Mercer, Orange, Urquhart, Batty Tuke, Hack Tuke and even Savage, who retained loyal links to the asylum sector and the MPA. Institutional careers, as Masters of Bedlam itself confirms, often functioned as hotlines to lucrative private clienteles, while there were obvious incentives for aging superintendents to make way for younger men, and to prefer the flexibility, variety and extra social cachet offered by consultancy practice to the grind and routine of asylum work.

There is a degree of unfortunate overlap and repetition between chapters, partly an ineluctable product of the schema adopted and the regular return to contextual information that is common ground for most of the subjects (e.g. pp. 84-8; 118-19 & 183; 68-9 & 192-3). There are also a few scanning problems; as when concepts, like ‘Christian phrenology’ (p. 242), or individuals, like 'Dr. Sutherland' (p.134) and Dr. Charlesworth (p. 71), are introduced without adequate or previous explication; or when Haslam is said to be 'housed within the Hospital' of Bethlem, but later to be 'living at a considerable distance' (pp. 15, 19). And there are occasional typographical or factual errors, as when we have 'Mr. Doury' for William Drury (p. 134) and 'humoural' for humoral (pp. 90-1). But, when one appreciates the scope of material and range of historical actors covered, it is remarkable that such problems are so scant. At the risk of, like Maudsley, being declared 'humourless', one could question the appeal of some rather flat and inelegant jokes (pp. 41, 265), and (at the risk of self-implication) the propensity towards mammoth-sized sentences, with excessive, Germanic sub-clauses (e.g. pp. 10, 90-1). One might also query the inordinate number and length of the footnotes, which make up 75 pages (over one-fifth) of the book. Indeed, the footnotes are more like commentaries on the text, and however informative, often appear self-indulgent, particularly when one reflects on the regrettable lack of a bibliography.

These comments and criticisms aside, nonetheless, Masters of Bedlam constitutes an expansive and distinguished attempt to wed the biographies of some of the most notable figures in nineteenth-century British psychiatry to the wider transformation of the mad-doctoring trade during the period. It is one that should in many ways serve as a model for historians embarking on biographical studies of professional men, and more generally for anyone concerned with the ways in which individuals both impacted on and reflected wider historical patterns and changes.

March 1997

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