This short but pithy and informative book is an excellent read.
This similarly short and to-the-point
review from
Medical History will suffice to whet your appetite.
Comments and references that caught my attention:
- 32/33: “John Locke wrote to insist upon The Reasonableness of Christianity (1694): even religion now had to be rational. This pathologization of religious madness led Enlightenment free-thinkers to pathologize religiosity at large. In effect, this was also, much later, Freud’s position. God was an illusion, faith ‘wish-fulfilment’, and belief, though all too real, was a mental projection satisfying neurotic needs, to be explained in terms of the sublimation of suppressed sexuality or of the death wish. In reducing religion to psychopathology, Freud was echoing the more biting of the philosophes, like Voltaire and Diderot, who adjudged Christian beliefs the morbid secretion of sick brains. These days, while the Churches continue to accept, in principle, the reality of visions, spirit possession, and exorcism, they are profoundly suspicious of credulity and deception. The Roman Catholic or Anglican who claims to be assailed by the Devil has become an embarrassment. His priest may try to persuade him that such doctrines are merely metaphorical; and, if he persists, he may be urged to see a psychotherapist.”
- 89: “Foucault claimed that the great confinement essentially involved the sequestration of the mad poor by supporters of the bourgeois work ethic, and in his Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry (1981) Klaus Doerner followed suit. But there is little trace of organized labour in early asylums—indeed, critics accused them of being dens of idleness. And enterprising madhouse proprietors naturally sought rich and genteel patients, who would not be expected to work.”
- 93/94: “The decades around 1800 brought surging faith in the efficacy of personal treatment in sheltered asylum environments. In England, such doctors as Thomas Arnold, Joseph Mason Cox, and Francis Willis (called in to treat George III in 1788) followed Battie’s watchword that ‘management did more than medicine’ and pioneered a ‘moral management’ through which the experienced therapist would outwit the deluded psyche of his patient.”
- 94: “Shortly afterwards, the York Retreat developed ‘moral therapy’, with its emphasis upon community life in a domestic environment designed to recondition behaviour. The York Asylum, a charitable institution, had become bemired in scandal. By way of a counterinitiative, the local Quaker community, led by a tea merchant, William Tuke, established an alternative, the Retreat, opened in 1796. It was modelled on the ideal of bourgeois family life, and restraint was minimized. Patients and staff lived, worked, and dined together in an environment where recovery was encouraged through praise and blame, rewards and punishment, the goal being the restoration of self-control.”
- 98/99: “Criticism thus led not to the abolition of the madhouse, but to its rebirth, and institutionalization was transformed from a hand-to-mouth expedient into a positive ideal. In France the reforms of Pinel and the new legal requirements of the Napoleonic Code were further codified in the key statute of 1838. This formally required each departement either to establish public asylums, or to ensure the provision of adequate facilities. It guarded against improper confinement by establishing rules for the certification of lunatics by medical officers—though for paupers a prefect’s signature remained sufficient. Prefects were also given powers to inspect. Similar legislation was passed in Belgium twelve years later.
A comparable reform programme was put through in England, despite opposition from vested medical interests. Scandals revealing the improper confinement of the sane had already led to the Madhouses Act of 1774. Under its provisions, private madhouses had to be licensed annually by magistrates; a maximum size for each asylum was established; renewal of licences would depend upon satisfactory maintenance of admissions registers. Magistrates were empowered to carry out visitations (in London the inspecting body was a committee of the Royal College of Physicians). Most importantly, certification was instituted. Henceforth, although paupers could continue to be confined by magistrates, for all others a letter from a medical practitioner would be required to make confinement lawful. Further reforms followed. The 1774 legislation was strengthened in a series of Acts passed from 1828, above all establishing the Commissioners in Lunacy, first for the metropolis and then for the whole country. The Commissioners constituted a permanent body of inspectors (made up of doctors and lawyers) empowered to prosecute unlawful practices and to deny renewal of licences. They also took it upon themselves to improve and standardize care and treatment. The Commission ensured eradication of the worst abuses, for example, by requiring that all cases of the use of restraint should be documented. Safeguards against improper confinement were extended. Under an influential consolidating Act of 1890, two medical certificates were required for the detention of all patients.”
- 100: “Similar developments occurred in the United States, where the asylum arrived in the nineteenth century. The success of the York Retreat was the impulse behind the Frankford Asylum in Pennsylvania (1817), the Friends’ Asylum near Philadelphia (1817), the McClean Hospital in Boston (1818), the Bloomingdale Asylum in New York (1821), and the Hartford Retreat in Hartford, Connecticut, founded in 1824. Most early American asylums combined private (paying) and public (charity) patients. As in France, the early asylum era in America was spearheaded by physicians specializing in mental disorders, notably Samuel B. Woodward at the Worcester State Hospital and Pliny Earle of the Bloomingdale Asylum in New York, both of whom integrated medical and moral therapies in a climate of Pinelian therapeutic optimism. They were among the thirteen originators of the Association of Medical Superintendents of American Institutions for the Insane, established in 1844—it later became the American Psychiatric Association.”
- 101/102: “Throughout Europe, it was the nineteenth century which brought a skyrocketing in the number and scale of mental hospitals. In England, patient numbers climbed from perhaps 10,000 in 1800 to ten times that number in 1900. The jump in numbers was especially marked in new nation states. In Italy, no more than 8,000 had been confined as late as 1881; by 1907 that had soared to 40,000. Such increases are not hard to explain. Positivistic, bureaucratic, utilitarian, and professional mentalities vested great faith in institutional solutions in general— indeed quite literally in bricks and mortar. Schools, workhouses, prisons, hospitals, and asylums—would these not contain and solve the social problems spawned by demographic change, urbanization, and industrialization?”
- 103/104: “In England ‘non-restraint’ was introduced in the 1830s, by Robert Gardiner Hill at the Lincoln Asylum and independently John Conolly at the new Middlesex County Lunatic Asylum at Hanwell on London’s western outskirts. Taking moral therapy to its logical conclusion, Hill and Conolly renounced all forms of mechanical coercion whatsoever: not just irons and manacles but fabric cuffs and straitjackets too. These would be replaced by surveillance under ample trained attendants and a regime of labour, which would stimulate the mind and discipline the body.”
- 105: “…absolute non-restraint was seen by Continental reformers as a quixotically English idée fixe, a foible of doctrinaire liberalism, and it was little imitated. But French and German reformers made resourceful use of the asylum environment in their own ways. Work therapy was widely favoured. Planted in the countryside, the asylum typically became a self-sufficient colony, with its own farms, laundries, and workshops, partly for reasons of economy, partly to implement cures through labour. In France balneological treatments became a key feature of ‘asylum science’ (police intérieure). In Germany, C. F. W. Roller spelt out detailed directives for such matters as non-slip, smell-proof flooring, good drains, apparel, diet, and exercise at the influential Illenau asylum in Baden, where music and movement therapies were also pioneered. Everywhere, the care and cure of the mad became the subjects of the new ‘science’ of asylum management, spread by professional organs such as the significantly named Asylum Journal.”
- 139: “To some extent, psychiatrists were victims of their own propaganda. They had insisted that many of the aberrant and antisocial behaviours traditionally labelled vice, sin, and crime were actually mental disorders in need of the doctor and the asylum. As a result, magistrates deflected difficult cases from the workhouse or jail, but superintendents then discovered to their dismay and cost that rehabilitation posed more problems than anticipated. Furthermore, the senile and the demented, along with epileptics, paralytics, sufferers from tertiary syphilis (GPI), and other degenerative neurological disorders were increasingly shepherded through the asylum gates. For all such conditions, the prognosis was gloomy, and the asylum became a dustbin for hopeless cases.”
- 156: “Pinel’s favourite follower was Jean-Etienne Dominique Esquirol (1772-1840), whose Mental Maladies (1838) was the outstanding psychiatric text of his age. While asserting the ultimately organic nature of psychiatric disorders, Esquirol concentrated, like his mentor, on their psycho-social triggers. The diagnosis of ‘monomania’ was developed to describe a partial insanity identified with affective disorders, especially those involving paranoia, and he further delineated such conditions as kleptomania, nymphomania, and pyro-mania, detectable in advance only to the trained eye. A champion of the asylum as a therapeutic instrument, he became an authority on its design, and planned the National Asylum at Charenton, a suburb of Paris, of which he was appointed director. (It briefly housed the ageing Marquis de Sade.)”
- 156/7: “…the condition known as general paresis of the insane (one manifestation of tertiary syphilis) was elucidated in 1822 by Antoine Laurent Bayle. Although the micro-organism which causes syphilis had not yet been discovered—the bacteriological era lay ahead— the neurological and psychological features of GPI (notably euphoria and expansiveness), combined with the organic changes revealed by autopsy, supported Esquirol’s conviction that psychiatric disorders could be revealed using the techniques championed by such great French pathological anatomists as Laennec who had investigated tuberculosis and other internal conditions. Closely related to GPI, tabes dorsalis was another disorder, prevalent in the nineteenth century, which became the focus of neuro-pathological research. It was the subject of a masterly clinical study published in 1858 by Guillaume Duchenne, which established its syphilitic origin: so definitive was his account that it was soon named ‘Duchenne’s disease’. He was also at the forefront in describing many other neurological disorders involving personality degeneration, including progressive muscular atrophy and locomotor ataxia (lack of coordination in movement).”
- 177: “in the new world, where George M. Beard (1839-83) popularized the concept of ‘neurasthenia’, nervous breakdown produced by the frantic pressures of advanced civilization, which drained the individual’s reserves of ‘nerve force’. ‘American nervousness is the product of American civilization’ , he pronounced with mingled pride and regret. Neurasthenia’s prevalence in the modern era was no mystery, held Beard: the telegraph, railroad, press, and the market-driven rat race of Wall Street had rendered life insupportably hectic, intense, and stressful. Civilization made demands on nervous systems that nature had never anticipated. As with the eighteenth-century ‘English malady’, neurasthenia struck the elite and flagged up civilization and its discontents. Beard’s ideas were given a practical twist by Silas Weir Mitchell, who introduced the ‘Weir Mitchell treatment’—bed rest, strict isolation, fattening up with milk puddings, and passive massage—to counter such fatiguing tendencies amongst the neurasthenic.”
- 181: “The insanity plea became controversial in Britain when the trial in 1843 of Daniel M’Naghten for the murder of Prime Minister Sir Robert Peel’s private secretary was stopped on the grounds of insanity. The resulting furore led to new guidelines being drawn up, by the House of Lords, to clarify the legal basis for criminal insanity. The M’Naghten Rules (1844) grounded the insanity defence in the defendant’s inability to distinguish right from wrong. This pre-empted the claim advanced by post-Esquirolian psychiatrists that the grounds should be ‘irresistible impulse’, that is, disorders of emotion and volition, independently of delusions of the understanding. In France by contrast, ‘irresistible impulse’ and partial and temporary insanity figured large in the plea of insanity and crime passionelle. Disputes over the insanity defence (who was bad? who was mad?) highlighted conflicts between legal and psychiatric models of the person, and left the public standing of psychiatry dubious.”
- 182: “Mental illness, Hunter and Macalpine believed, was not psychogenic. Hence the utterances of the insane were but cries of distress—and not necessarily even good clues to its nature. You don’t crack mental illness by decoding what the mad say: for, they held, mental disease had a biological base. Powerful psychiatric currents have furthered such tendencies to silence the insane, especially in institutional environments.”
- 183: “…did not the methods of the natural sciences prescribe observation and objectivity, not interaction and interpretation? The noisiest patients were shunted off into the back wards, and all too often those who were shut up were, indeed, ‘shut up’—or at least nobody attended to what they were uttering, there being less communication than excommunication.”
- 215: “The course of psychiatric illness, he insisted, offered the best clue to its nature, rather than, as in common practice, the raft of symptoms the patient showed at a particular moment. On this basis, Kraepelin wrought a great innovation in disease concepts and classification. Amalgamating Morel’s demence precoce with the notion of hebephrenia (psychosis in the young, marked by regressive behaviour) developed by Karl Kahlbaum and his pupil Ewald Hecker, he launched the model of a degenerative condition which he named dementia praecox, to be decisively distinguished from manic-depressive psychoses (Falret’s ‘circular insanity’). The archetypal dementia praecox sufferer as pictured by Kraepelin on the basis of meticulous clinical experience might be astute and clever, but he seemed to have forsaken his humanity, abandoned all desire to participate in society, and withdrawn into a solipsistic world of his own, perhaps mute, violent, and paranoid. Kraepelin routinely used phrases like ‘atrophy of the emotions’ and ‘vitiation of the will’ to convey the sense that they were moral perverts, psychopaths, almost a species apart. As the precursor to schizophrenia, Kraepelin’s dementia praecox has left an indelible mark on modern psychiatry.”
- 242: “Invasive treatments equally reflect the powerlessness of patients in the face of arrogant and reckless doctors, and the ease with which they became experimental fodder. In a now notorious experiment, hundreds of black mental patients at the Tuskeegee Asylum in Alabama were guinea pigs without their knowledge or consent in an experiment to test longterm responses to syphilis, a minor echo of the atrocities committed by Nazi psychiatrists.”
- 272: “The growing centrality of women to psychiatry over the last couple of centuries is superbly handled in Elaine Showalter’s The Female Malady: Women, Madness, and English Culture, 1830-1980 (New York: Pantheon Press, 1986)…”
- 272: “Andrew Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (London: Allen Lane, 1979)—this has appeared in revised form as The Most Solitary of Afflictions: Madness and Society in Britain, 1700—1900 (New Haven and London: Yale University Press, 1993)”
- 276: “Leonard D. Smith, Cure, Comfort and Safe Custody: Public Lunatic Asylums in Early Nineteenth-Century England (London: Cassell, 1999)”
- 279: “Extracts from nineteenth-century English psychiatric texts may be found in Vieda Skultans, Madness and Morals: Ideas on Insanity in the Nineteenth Century (London and Boston: Routledge & Kegan Paul, 1975).”
- 279: “Autobiographical writings of ‘mad’ people have been anthologized and surveyed in Dale Peterson (ed.), A Mad People’s History of Madness (Pittsburgh: University of Pittsburgh Press, 1982); Michael Glenn (ed.), Voices from the Asylum (New York: Harper & Row, 1974); Allan Ingram, Voices of Madness: Four Pamphlets, 16831796 (Stroud: Sutton Publishing, 1997) and Roy Porter (ed.), The Faber Book of Madness (London: Faber, 1991; paperback 1993). Some attempt at reproducing their ‘view’ is offered in Roy Porter, A Social History of Madness: Stories of the Insane (London: Weidenfeld & Nicolson, 1987).”
