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

Medical History

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Book Review

Insanity, Institutions and Society, 1800-1914: a Social History of Madness in Comparative Perspective

Author: Joseph Melling and Bill Forsythe (eds.)
Publisher: Routledge, 1999

Reviewed by: Dr. Anne Borsay

The social history of madness is a vibrant area of intellectual enquiry which in the past 20 years has generated an impressive series of monographs and essay collections. This volume is a scholarly addition to the literature. Although its origins lie in a seminar series and a conference, both held at the University of Exeter, the strong focus on institutions during the long nineteenth century provides a natural coherence which is sustained across the comparative perspective, taking in British India and the Cape Colony as well as Wales, Scotland and Ireland. This coherence is consolidated by a substantial introduction and careful editing which has encouraged the contributors to engage with each other over points of similarity and difference. The result is a book which does justice to its ‘main theme’: deciphering ‘the institutional politics of madness and the historical conditions under which asylums came to be defined as necessary to the welfare of the body politic itself’. (p. 23)

The historiographical context for this brief is reviewed by Joseph Melling in the first chapter, paying particular attention to Michel Foucault and Andrew Scull. Whilst recognising the catalytic effect of Foucault’s Madness and Civilisation (1965), Melling rightly criticises his lack of historical specificity and the neglect of class, kinship and political movements in shaping responses to insanity and the dynamics of institutional life. In Museums of Madness (1979), conversely, Scull rooted the rise of the asylum in the industrialising economy, stressing the disruption of family and community networks and the function of bourgeois mad-doctors in policing deviance. Always controversial with psychiatrists, Scull’s thesis has also been questioned by historians. Melling flags three key areas of contention and illustrates them from the chapters which follow: the chronology of modernisation; the role of state medicine in the bid for professional power; and the agency and identity of the actors involved in ‘the making of the institutionalised lunatic’. (p.13) This exercise serves as a useful cohesive device. However, it would be a mistake to see the volume only in terms of its shared ground. Being rich in local detail and related to wider issues, each chapter is worthy of standing alone and warrants reading in its own right.

After the introductory assessment of new research in the social history of madness, the book is divided into four principal parts addressing the English experience of county lunatic asylums, therapeutic regimes in the nineteenth century, the English model at the Celtic peripheries, and the colonial vision. In the final chapter, Andrew Scull rethinks the history of asylumdom. The first part, containing four chapters, opens with a discussion of the mixed economy of care between 1808 (when county justices were permitted but not obliged to build asylums) and 1845 (when they were required to do so). Leonard Smith argues that in the absence of universal provision, the early county asylums competed with public subscription hospitals and private madhouses both for paying and for Poor Law patients. The consequence, he says, was an evolving ‘contract culture’ (p. 38) in which differential rates were thrashed out with particular parishes or counties and every effort was made to minimise costs. Peter Bartlett picks up on the pauper theme to argue on the basis of ‘legal and administrative structures…[that] the county asylum…[was] a Poor Law institution, in which the role of specialist medical professionals has been overplayed’. (p.49) The ‘imagery’ associated with this characterisation was far from consistent; asylums were seen as catering for a social underclass and for respectable workers, whilst also being a challenge to the austere principle of 1834. Yet these contradictions enabled the institution to flourish because it was ‘attractive to advocates and opponents of the New Poor Law, Whigs and Tories alike, and could easily be justified according to the evangelical, paternalistic and utilitarian ideologies’ (p. 52) which infused debates about Victorian social welfare.

A Whig/Tory alliance of local aristocrats was also active in establishing the Devon Pauper Lunatic Asylum in 1845, although the magistrates most supportive of the hospital and its first medical superintendent were of Tory persuasion. Their relationship with the Lunacy Commission is the concern of Bill Forsyth, Joseph Melling and Richard Adair. Disputing the weak and passive view of central regulation, they argue that the Commission ‘interacted effectively and subtly with local interest groups to secure its desired policy outcomes’ (p. 69) from the limited powers and resources at its disposal. A major player in these negotiations was the Poor Law Board. Furthermore, Poor Law officials were closely involved in the management of pauper lunatics. As David Wright shows in his study of the overlooked social process of discharge, it was the relieving officer who investigated the household situation when the medical superintendent and the Visiting Committee decided that a patient was fit for release. Contrary to the orthodoxy of permanent confinement, this was not an infrequent occurrence, for ‘[o]ver one-half of those admitted to the Buckingham Asylum between 1853 and 1872 were discharged, the vast majority of them having stayed fewer than twelve months’. (p.1 06)

The second part of the volume includes two chapters on therapeutic regimes. Using case records from Bethlem, Akihito Suzuki identifies a significant mid century shift in how mental disease was represented which undermines the assertion that ‘institutional psychiatry silenced the voice of the mad’. Before Bethlem was reformed in 1852, a charitable narrative – constructed by relatives, friends or neighbours – understood madness in terms of traumatic events and experiences; after 1852 the diagnosis was framed by the medical superintendent from his own observation and in collaboration with the patient who became ‘a legitimate storyteller’ with the capacity to discredit lay readings of his or her behaviour (p. 131). In assessing puerperal insanity, Hilary Marland also detects a change in the reporting conventions. Early in the century, ‘cases were much more likely to be presented individually as narratives of fall, redemption and recovery’. As asylum admissions increased, however, the existence of a captive patient body allowed the emergence of a new form of medical knowledge in which the condition was broken down into ‘typologies, causal factors and prognosis’ (p. 152).

The four chapters in Part Three turn to the fate of the ‘English model’ at the national peripheries of Wales, Scotland and Ireland. Whilst appreciating the importance of the Welsh language and Nonconformity, Pamela Michael and David Hirst are keen to stress the other factors which affected the foundation and reception of the North Wales Asylum at Denbigh. The ‘legitimisation’ of institutional care for pauper lunatics is attributed both to ‘a successful coalition between a modernising local elite and agents of central government’ (p. 175), and to the ability of that same elite to sell the asylum to impoverished rural communities which had previously sustained the insane among their kin with financial support from the Poor Law. Whereas Wales was covered by English legislation, Scotland had its own system of voluntary poor relief revolving around the kirk, and there was no statutory duty to provide institutional places for the insane until 1857. The outcome was a more dominant role for the eight charitable asylums set up between 1782 and 1839.

Emphasising the centrality of the Dundee Royal Asylum for the civic, humanitarian image of the urban middle class, Lorraine Walsh argues for the period up to 1850 that their lay control eclipsed medical influence, encouraging remedial moral treatment which departed sharply from the ‘palliative function’ (p. 188) of the older town hospitals. Like the other nineteenth-century charitable asylums north of the border, Dundee received patients from all social classes. The gradual appearance of state asylums, however, led to the expulsion of paupers. As Jonathan Andrews demonstrates, the Glasgow Royal Asylum and its physician-superintendent were intent upon ‘raising the social tone’ so that repugnant social mixing would neither deter paying clients from seeking admission nor impede their treatment. By 1897, every pauper had gone. This privatisation did not free the Asylum of long-term, chronic patients, many of them female and/or elderly. But, in addition, it had the effect of excluding Catholics, largely from the Irish immigrant community, in violation of the multi-denominationalism that before had been a source of pride.

Insanity also became entangled with religion and race in Ireland itself where, under yet another legislative framework, asylums were the responsibility of the Lord Lieutenant rather than the Poor Law but closely associated with criminality due to the Dangerous Lunatics Act of 1838. At the Ballinasloe Asylum in County Galway researched by Oonagh Walsh, the Board of Governors who implemented Dublin’s decrees were all Protestant members of the middle and upper classes, yet over ninety per cent of the institution’s population was Catholic. Moreover, by the imperialistic 1890s, the symptoms of these patients were being filtered through racial theories, as the asylum physician increasingly endorsed the belief that ‘insanity literally inscribed itself upon the body of the sufferer, and that the face and head, in particular, could be read as a text of abnormality, or excess, or mania’. (p. 235)

The discourses which pronounced the Irish unfit for political independence were still more potent in the empire: the subject of the two chapters in Part Four. Writing of early nineteenth-century British India, Waltraud Ernst maintains that asylums were one of a series of institutions which symbolised the assumed superiority of British colonisation and its civilising mission. ‘Things Indian, including the environment, were frequently pathologised as being implicated in mental breakdown’. And this ‘rationale … served to distract attention from the inequities and inequalities of the colonial regime and from insanitary and psychologically destructive features within the European expatriate community’. (p. 263) Indian doctors and patients, however, resisted the imposition of British asylum-based psychiatry to give colonial medicine indigenous qualities. The growing acceptance of segregation as the ‘progressive’ solution to South Africa’s urban and industrial problems produced a very different local context for the Valkenberg Mental Asylum in the late nineteenth and early twentieth centuries. Though its conditions were to deteriorate due to overcrowding and staffing difficulties, Valkenberg was closed to black patients for whom inferior facilities were available. This racial policy, designed to remove the stigma of mental illness for the white population, was based on universal standards which ignored cultural variations and stripped black people of their identity. For Shula Marks, however, this universalism ‘constrained the more blatant attempts at discrimination’. The flaw was ‘its precise application as an instrument of power in a colonial situation’. (p. 285)

The reviewing process begins in the book itself with Andrew Scull’s concluding chapter of reflections. Although a narrow chronological spread is initially implied, and several areas of omission (medical therapeutics and the work of clinical-historians, psychiatry’s claims to professional expertise, the perspective of patients and their families) are listed, Scull retreats from these criticisms in acknowledging that ‘a comprehensive overview of the enormous territory the history of psychiatry has now become would necessarily have courted the danger of superficiality’. (p. 296) More serious is his worry that the ‘macro-social concerns’ that inspired his own ‘grand synthesis’ are at risk of being lost in ‘micro-researches’ which fail to tie ‘the history of madness to broader changes in English society’s political, economic and social structures, and … [to] the intellectual and cultural horizons of its people’. (pp. 297-9)

The resurgence of empiricism in a field so indebted to the sociological insights of both Scull and Foucault is testimony to the strength of realism in British historiography. Few now concur with Lord Acton that ‘[t]he true historian takes the individual for his centre’ and ‘[i]f he treats of mobs, or armies, or bodies of men, he invests this multitude with a kind of personality of its own’. Nonetheless, the conservative reaction to the collapse of the post-war consensus has led to caution in applying the theoretical ideas of the discredited 1960s and 1970s. Thus in this volume the party allegiances and political behaviour of the men who governed asylums are meticulously traced, and the participation of the urban middling sort is singled out as pivotal to the Scottish institutions. But there is no sustained discussion of how involvement in the care of the insane impacted upon class development. The power of the poor is similarly handled, negotiation over admission and discharge being construed as evidence of genuine autonomy. Yet how much room for manoeuvre patients and their families really had is contestable, given the economic and professional parameters that fenced in their actions.

The relationship between agency and structure, individual and society, which energises the empirical unpicking of Foucault and Scull, is irrelevant to the postmodernist critiques which have penetrated history during the 1990s. Rejecting the rationality of the Enlightenment, postmodernism insists that historians deal only in images or representations because their sources offer no direct access to the past. Though the moral relativism inherent in this approach has provoked robust attack, even its staunchest opponents concede that the more imaginative use of a wider range of historical materials has been encouraged, with the interrogation of texts for their linguistic properties as well as their provenance. This collection gives the language of psychiatry relatively little consideration. As Joseph Melling comments in his introductory chapter, ‘Most authors replicate the contemporary usage of terms such as insanity, madness and lunacy without attempting an authoritative discussion of the nosologies … which earlier authors have provided’. Instead, the essays sought ‘to locate these terms within the context of the legal and practical transactions which secured the passage of the lunatic from community to asylum and back again’. (p. 19) The fluid definitions of insanity, and the way in which the classification of patients slid between madness and idiocy, undercuts any distinction between language and practice. Furthermore, the emphasis placed on the ‘institutional process’ in forming the ‘lunatic’s identity’ ( p.23) denies the individual the chance to influence his or her sense of self through interacting, positively or negatively, with the asylum environment.

The unbalanced identity of the patient is partly a product of relying on traditional documentary material. One complementary mechanism for the retrieval of the inmate is the writing of mad men and women, dissected by Allan Ingram for the eighteenth century. Others include the architecture and geography of asylums, interpreted for the Victorian period by Thomas Markus and Chris Philo. Mark Jackson has looked for the ‘victim’ in the photography of mental deficiency, while Diana Gittins’s oral history of the twentieth-century Severalls Hospital in Essex has yielded compelling narratives from both patients and staff. Of course, ‘history from below’ has no monopoly of wisdom and must be tempered with finely-grained analysis of the ‘official‘ records at which this volume excels. But when imprisonment for personality disorder without criminal offence is on the political agenda, it is essential not to forget the abuses that accompanied earlier policies of confinement. Searching out the mad themselves is perhaps the best historical reminder.

September 1999

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