Chapter Nine
Was Insanity Increasing?

In a Maudsley lecture delivered to the Royal College of Psychiatrists in late 1982, Edward Hare contended that the incidence of serious mental disorder had increased sharply over the course of the nineteenth century. He argued that this rise in the number of mad folk accounted for the abrupt development of medical interest in lunacy at the beginning of the century and for the rapid publication of a series of early-nineteenth-century medical treatises on insanity. Moreover, in a wholly "straightforward" way, and without resort to the complications introduced by sociologists, the existence of this "epidemic" provided "a medical explanation of the asylum era." In his view, one could take the argument a step further: the madness that fueled all these changes was what the psychiatric profession now calls schizophrenia; and the transformation of "schizophrenia" in this era from a rare to an all-too-common disorder reflects its probable etiology, as a virulent viral infection laying waste the susceptible members of society.

Dr. Hare's contention is not the first attempt at psychiatric reductionism, nor is it likely to be the last. An earlier flirtation with an infectious etiology for the major psychoses (this time of a bacteriological rather than a viral sort) was attended with some rather bizarre and untoward consequences for those deemed victims of toxicity.^[1] One trusts that its latest incarnation will not be greeted so ingenuously and uncritically.

[1] See Andrew Scull, "Desperate Remedies: A Gothic Tale of Madness and Modern Medicine," Psychological Medicine 17 (1987): 561–77.

I cannot pretend to possess Dr. Hare's talent for diagnosis at a distance (indeed, for diagnosis tout court ); and I concede that the ingenuity of his explanation, its ability to reduce surface complexities to the simplicity of a single underlying somatic cause, would do credit to a professor at the Grand Academy of Lagado.^[2] But I confess that in the last analysis I find his account a trifle speculative, requiring perhaps too large a leap of faith for one of my agnostic disposition. Accordingly, in what follows, I offer the sketch of a rather different version of events, one that leaves but a minute place for the microbes, even though it insists (with Dr. Hare) that insanity was indeed increasing over the course of the nineteenth century.

Was Insanity Increasing?

Upon reflection, one quickly comes to recognize that Society must protect not only the life, but also the property and honor of individuals, as well as public order. Hence the number of the insane that can, on various counts, be prejudicial to public safety is singularly increased.
—J. FALRET,
Des aliénés dangereux et des asiles spéciaux pour aliénés

One of the central paradoxes of the Victorian reforms in the treatment of the mentally ill was the curious fact that the "scientific" discovery of mental illness and the adoption of a more rational approach based on this discovery—an approach that aimed at treating and curing lunatics, rather than neglecting them or incarcerating them in a gaol or workhouse—were associated with an explosive growth in the number of insane people. Edward Hare's recent Maudsley Lecture raises again the interesting question of whether or not this surge reflects a true increase in the incidence of mental illness in nineteenth-century England. As he correctly notes, the aggregate data collected at the time do not allow a "decisive answer," but I am pleased that his reassessment of the probabilities led him to endorse my prior conclusion that its incidence was indeed increasing.^[1]

Hare does dispute, however, the explanation I offered of this increase, which attributed much of it to the development of a more expansive view of madness. Instead of an expansion of the boundaries of what constituted mental illness, he argues that the growth in numbers reflects

[2] See Jonathan Swift, Gulliver's Travels (New York: Modern Library, 1958), 142–54.

[1] Andrew Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (London: Allen Lane; New York: St. Martin's Press, 1979).

a real rise in the most serious forms of mental disorder, more specifically, "a slow epidemic of schizophrenia."^[2] The dispute between us is not purely an academic debate (in the bad sense of that term) since Hare argues that the adoption of his explanation provides some "speculative" support for "a medical explanation of the asylum era" and for a viral etiology of schizophrenia.^[3] I should therefore like to point to some of the evidence that seems instead to favor my own hypothesis, recognizing (as does Hare) that in this matter we can at best obtain an approximation of the truth, given the data with which we have to work.

At least prior to the adoption of the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association in 1980, the research evidence demonstrates that even twentieth-century psychiatric diagnoses lacked reliability and validity. Diagnosis remained dependent on clinical supposition and consensus, with the consequence that "the reliability of diagnoses of mental disorders, including those considered most severe, measured by independent rater agreement, often failed to rise over 50 per cent."^[4] Everything we know of the practice of nineteenth-century psychiatrists suggests an even stronger reliance on clinical experience to legitimize and certify the authenticity of the individual practitioners' decisions. Certainly, many of the leading men in the field devoted a good deal of their energies to the elaboration of complex nosologies, encompassing a plethora of subtypes and varieties of insanity, but as Henry Monro noted, those who tried to rely on these categories in their practice were soon obliged to abandon the attempt in despair:

All who have charge of asylums must well know how very different the clear and distinct classification of books is from that medley of symptoms which is presented by real cases. . . . It is useless to attempt to paint pictures with more vivid colours than nature presents, and worse than useless if practical men (or rather, I would say, men obliged to practice) receive these pictures as true representatives.^[5]

[2] E. Hare, "Was Insanity on the Increase?" British Journal of Psychiatry 142 (1983): 451.

[3] Ibid.

[4] S. J. Morse, "A Preference for Liberty: The Case Against Involuntary Commitment of the Mentally Disordered," in The Court of Last Resort: Mental Illness and the Law, by Carol A. B. Warren, with contributions by Stephen J. Morse and Jack Zusman (Chicago: University of Chicago Press, 1982), 82. See also R. L. Spitzer and J. Fleiss, "A Re-analysis of the Reliability of Psychiatric Diagnosis," British Journal of Psychiatry 125 (1974): 341–47; A. T. Beck, "The Reliability of Psychiatric Diagnosis: 1. A Critique of Systematic Studies," American Journal of Psychiatry 119 (1962): 210–16; L. J. Chapman and J. P. Chapman, "Illusory Correlations as an Obstacle to the Use of Valid Psycho-diagnosis Signs," Journal of Abnormal Psychology 74 (1969): 271–80.

[5] Henry Monro, Remarks on Insanity: Its Nature and Treatment (London: Churchill, 1850), 1–2.

Notwithstanding all efforts to alleviate the situation, and with the exception of extreme cases of violent mania or complete dementia, alienists were forced to confess that "the task of declaring this to be reason and that insanity is exceedingly embarrassing and, to a great degree, arbitrary. . . . No palpable distinction exists, no line of demarcation can be traced between the sane and the insane."^[6] Thus, "the practitioner's own mind must be the criterion by which he infers the insanity of any other person."^[7]

"Such emphasis," as Freidson has noted, "is directly contrary to the emphasis of science on shared knowledge, collected and tested on the basis of methods meant to overcome the deficiencies of the individual experience. And its efficacy and reliability are suspect."^[8] In this instance, beyond the initial hard core of easily recognizable behavioral and/or mental disturbance, the boundary between the pathological and the normal was left extraordinarily vague and indeterminate. Hence the frequent and embarrassing disputes between alienists over individual cases in the courts.^[9] In the circumstances, the assumption that identifying who is and who is not mentally ill was an activity governed by some uniform, objective, and unchanging standard will not survive critical scrutiny.

As Hare notes, I have suggested that asylum doctors' professional self-interest provided one set of motives for the adoption of an expansionary view of madness.^[10] But other forces also prompted them to behave in this fashion. On humanitarian grounds, for example, since doctors were convinced that asylums were benevolent and therapeutic institutions and that laymen were incompetent to cope with, and liable to maltreat, the mentally ill, they were impelled to seek out still more cases rather than reject any that were proffered. Moreover, professional "imperialism" provides only one—and to my mind by no means that most important—reason to suspect an ever-wider practical application of the term "mental illness." The asylum provided a convenient and culturally legitimate alternative to coping with "intolerable" individuals within the family, offering, if its proponents were to be believed, a level of care and possibilities of cure far beyond what even the most dedicated family could hope to provide in its midst. So far from being blamed, families were encouraged to place their mentally unbalanced relatives where they could receive professional care and treatment at the earliest pos-

[6] W. A. F. Browne, What Asylums Were, Are, and Ought to Be (Edinburgh: Black, 1837), 8.

[7] J. Haslam, Observations on Madness and Melancholy, 2d ed. (London: Callow, 1809), 37. See also T. Mayo, Medical Testimony and Evidence in Cases of Lunacy (London: Parker, 1854).

[8] Eliot Freidson, Profession of Medicine: A Study in the Sociology of Applied Knowledge (New York: Dodd, Mead, 1970), 347.

[9] Roger Smith, Trial by Medicine: Insanity and Responsibility in Victorian Trials (Edinburgh: Edinburgh University Press, 1981).

[10] Hare, "Was Insanity on the Increase?," 453.

sible moment. The attraction was obviously greatest for those with fewer resources for coping with the dependent and economically unproductive. Significantly, the statistics demonstrate that by far the largest portion of the increase in insanity occurred among those drawn from the lowest socioeconomic classes.

Contemporary observers frequently commented on the dynamics of this process: the superintendent of the Northampton General Lunatic Asylum noted in his 1858 report that "persons in humble life soon become wearied of the presence of their insane relatives and regardless of their age desire relief. Persons above this class more readily tolerate infirmity and command time and attention. The occasion may never occur in the one case, which is urgent in the other. Hence an Asylum to the poor and needy is the only refuge. To a man of many friends it is the last resort."^[11] In the words of another asylum superintendent, "Poverty, truly, is the great evil: it has no friends able to help. Persons in middle society do not put away their aged relatives because of their infirmities, and I think it was not always the custom for worn out paupers to be sent to the asylum. . . . It is one more of the ways in which, at this day, the apparent increase of insanity is sustained. It is not a real increase, since the aged have ever been subject to this sort of unsoundness."^[12]

Moreover, the level of disordered behavior or dependency that a family could not or would not put up with was not fixed and immutable, but likely to vary over time, with individual circumstances and with the gradual growth of the perception that there existed alternatives to the retention of the disturbed and troublesome within a domestic setting. (Such a pattern is, however, much more difficult to reconcile to the hypothesis of a viral-induced epidemic of schizophrenia.) Finally, as Maudsley himself suggested, the central government contributed significantly to the process by enacting legislation "whereby the government said in effect, to parish officials, 'We will pay you a premium of four shillings a head on every pauper whom you can by hook or crook make out to be a lunatic and send into an asylum' [thus putting] a direct premium on the manufacture of lunacy."^[13]

Hare makes much of the fact that recovery rates declined over time in Victorian asylums, arguing that "milder" cases should have been more

[11] Northampton General Lunatic Asylum, Annual Report (1858), 11.

[12] James Edmund Huxley, quoted in John T. Arlidge, On the State of Lunacy and the Legal Provision for the Insane (London: Churchill, 1859), 95. For further discussion of Huxley's views on this subject, see Nicholas Hervey, "The Lunacy Commission 1845–60, with Special Reference to the Implementation of Policy in Kent and Surrey" (Ph.D. dissertation, Bristol University, 1987), chap. 6. (Huxley was superintendent of the Kent County Asylum.) John Charles Bucknill, superintendent of the Devon County Asylum and founding editor of the [Asylum] Journal of Mental Science, was equally convinced that it was poverty, not illness, that prompted many asylum admissions.

[13] Henry Maudsley, "The Alleged Increase of Insanity," Journal of Mental Science 23 (1877):45.

likely to recover. It is, however, not at all clear why we should accept this argument. First, there is no obvious warrant for the claim that Victorian psychiatry was more successful in treating milder cases (unless one tautologically assumes an identity between "milder" and "more treatable"). Indeed, "mild" mental symptoms often coexisted with chronic and incurable underlying disease states. Bucknill, for example, while superintendent at the Devon County Asylum, found that

patients have been admitted suffering from heart disease, aneurism, and cancer, with scarcely a greater amount of melancholy than might be expected to take place in many sane persons at the near and certain prospect of death. Some have been received in the last stages of consumption, with that amount of cerebral excitement so common in this disorder; others have been received in the delirium or stupor of typhus; while in several cases the mental condition was totally unknown after admission and must have been unknown before, since an advanced condition of bodily disease prevented speech, and the expression of intelligence or emotion, either normal or morbid.^[14]

Such catalogues of decrepit and all but moribund admissions were anything but exceptional;^[15] and in the light of evidence of this sort, Hare's contention that the admission of milder cases "should have decreased" the asylum death rate^[16] does not seem particularly plausible.

Second, there are other, at least equally plausible ways of accounting for the decline in cure rates. Many Victorian critics of the asylum system, including Maudsley himself, thought that there was a clear connection between increasing size and decreasing therapeutic efficacy. As John Arlidge put it,

In a colossal refuge for the insane, a person may be said to lose his individuality and to become a member of a machine so put together, as to move with precise regularity and invariable routine; a triumph of skill adapted to show how such unpromising materials as crazy men and women may be drilled into order and guided by rule, but not an apparatus calculated to restore their pristine condition and their independent self-governing existence. In all cases admitting of recovery, or of material amelioration, a gigantic asylum is a gigantic evil, and figuratively speaking, a manufactory of chronic insanity.^[17]

Modern research on "institutionalism"^[18] surely lends considerable credence to this hypothesis. And we know that the average size of English

[14] Quoted in Arlidge, State of Lunacy, 96.

[15] See, for example, Caterham Lunatic Asylum, Annual Report (1873); Hanwell Asylum, Annual Report (1875, 1880); Commissioners in Lunacy, Annual Report (1881).

[16] Hare, "Was Insanity on the Increase?," 449.

[17] Arlidge, State of Lunacy, 102. See also J. C. Bucknill, The Care of the Insane and their Legal Control (London: Macmillan, 1880).

[18] J. K. Wing, "Institutionalism in Mental Hospitals," British Journal of Social and Clinical Psychiatry 1 (1962): 38; J. K. Wing and G. W. Brown, Institutionalism and Schizophrenia (Cambridge: Cambridge University Press, 1970); R. Barton, Institutional Neurosis, 2d ed. (Bristol: Wright, 1965); Ivan Belknap, Human Problems of a State Mental Hospital (New York: McGraw-Hill, 1956); A. H. Stanton and M. S. Schwartz, The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment (New York: Basic Books, 1954).

county asylums rose remorselessly through the course of the nineteenth century, from just over a hundred patients in 1827 to almost a thousand by the end of the century, paralleling the development of a steadily more hopeless and "institutional" environment. Increasingly, within such mammoth institutions, "the classification generally made is for the purpose of shelving cases; that is to say, practically it has that effect. . . . In consequence of the treatment not being personal, but simply a treatment in classes, there is a tendency to make whole classes sink down into a sort of chronic state. . . . I think they come under a sort of routine discipline which ends in their passing into a state of dementia."^[19]

Almost certainly, then, increasing size and the associated changes in the treatment of the inmate population had negative effects on cure rates. In turn, this situation provoked a steadily more pessimistic assessment of the prognosis for insanity among alienists themselves, forced to account for the falling rate of cures despite the advances of medical science. As explanations of mental illness were ever more frequently couched in terms of structural brain disease, defective heredity, and Morelian degeneration, so there emerged an entrenched expectation that most cases of mental illness would prove to be incurable. Expectations of this sort, through their effects on staff morale and the quality of care provided (to say nothing of the negative placebo effect), became a relentlessly self-fulfilling prophecy, further diminishing the underlying recovery rate while providing tautological "proof" of their essential accuracy. I suggest it is this combination of factors, rather than "the admission of less favourable cases,"^[20] that accounts for the dismal therapeutic results of asylum care in the late nineteenth century—though for obvious reasons this was a conclusion that both the psychiatric profession and the lunacy commissioners were reluctant even to consider.

Beyond this, a good deal of contemporary testimony supports my suggestion that the boundaries of what constituted committable madness expanded during the 1800s. A wide range of nineteenth-century observers commented on how much laxer the standards were for judging a poor person to be insane, and how much readier both local poor-law authorities and lower-class families were to commit decrepit and troublesome people to the asylum, individuals who, had they come from the middle and upper classes, would never have been diagnosed as insane.

[19] J. Mortimer Granville, in House of Commons, Report of the Select Committee on the Operation of the Lunacy Law (1877): 396–97.

[20] Commissioners in Lunacy, 1899, quoted in Hare, "Was Insanity on the Increase?," 449.

In the words of William Ley, superintendent of the Littlemore Asylum, "Orders for the admission of Paupers into the County Asylum are given more freely than would be thought right as regards the imputation of Lunacy, towards persons equally debilitated in body and mind who have the means of providing their own care."^[21] Over time, this tendency grew more marked. Just over twenty years later, John Joseph Henley, the general inspector of the Local Government Board, informed a Select Committee of the House of Commons that in his inspectors' experience, "there is a disposition among all classes now not to bear with the troubles that may arise in their own houses. If a person is troublesome from senile dementia, dirty in his habits, they will not bear it now. Persons are more easily removed to an asylum than they were a few years ago."^[22] Workhouse authorities, too, according to the medical inspector of the London workhouses, routinely used asylums to "relieve their wards of many old people who are suffering from nothing else than the natural failing of old age" as well as to rid themselves of troublesome people in general.^[23]

As a result, Mortimer Granville noted, "it is impossible not to recognise the presence of a considerable number of 'patients' in these asylums who are not lunatic. They may be weak, dirty, troublesome, but they are certainly no[t] . . . affected with mental disease."^[24] Those who had been acquainted with the county asylum system from its very earliest years could not help but notice the change in the implicit definition of mental illness, the enormous and striking difference "between the inmates of the old madhouses and the modern asylum—the former containing only obvious and dangerous cases of lunacy, the latter containing great numbers of quiet and harmless patients whose insanity is often difficult to determine."^[25] At least for these well-placed observers, there could be no question but that

the law providing that madmen, dangerous to themselves and others, shall be secluded in madhouses for absolutely needful care and protection, has been extended in its application to large classes of persons who would never have been considered lunatics when this legislation was entered upon. Since 1845, medical science has discovered whole new realms of lunacy, and the nicer touch of a finikin civilization has shrunk from the contact of imperfect fellow creatures, and thus the manifold receptacles of lunacy are filled to overflow with a population more nearly resembling that which is still at large.^[26]

[21] Littlemore Asylum, Annual Report (Oxfordshire, 1855), 5.

[22] House of Commons, Report of the Select Committee, 166.

[23] Ibid., 152. See also Commissioners in Lunacy, Annual Report (1861): 15.

[24] J. Mortimer Granville, The Care and Cure of the Insane, 2 vols. (London: Hardwicke and Bogue, 1877), 1 : 264.

[25] Buckhill, Care of the Insane, xxvii.

[26] Ibid., 4.

Hare argues that mild cases could not have provided the reservoir from which the increased asylum population was drawn, because such cases would not have seemed sufficiently urgent to warrant the construction of so many beds. But the definition of "urgent" in this case is obviously a matter of complex social construction, not something engraved in stone. I see no reason to doubt that those committing patients in 1880 were convinced that their reasons for doing so were urgent and compelling—though one may reasonably question whether the same justifications would have seemed equally compelling some thirty or forty years earlier.^[27] Nor should it surprise us that what constituted adequate grounds for commitment should shift over time in this fashion. After all, the past quarter of a century has witnessed a move in just the reverse direction, toward a much more restricted view of the appropriate criteria for involuntary commitment.^[28]

Conclusion

Ultimately, of course, the most satisfactory way of deciding between the rival hypotheses offered by Hare and myself would be to look at a random sampling of admissions over time, to see whether the increase occurs among mild or severe cases. Unfortunately, there must be serious doubt about whether the quality of the surviving records is adequate for this purpose. Case records for upper-class asylums were extensive, as in

[27] Comparative cross-sectional data provide substantial presumptive evidence in support of my argument that the supply of asylum beds itself altered the apparent incidence of insanity, and thus the demand for institutional provision for the insane. As Nicholas Hervey points out, for example ("Lunacy Commission," 379, n. 82), the boroughs of Maidstone and Canterbury were of equal size and located in the same county. The former, which provided an asylum for its insane, rapidly acquired double the number of pauper lunatics to be found in the latter, which did not. The lunacy commissioners noted this phenomenon in their 1861 Report , but entirely missed its significance. By contrast, Edward Jarvis had concluded, using statistics from Massachusetts, that the rate of committal to mental hospitals was always greatest in the immediately adjacent areas and decreased as the distance from the asylum increased. See "The Influence of Distance from and Proximity to an Insane Hospital, on Its Use by Any People," Boston Medical and Surgical Journal 42 (l7 April 1850): 209–22. In a subsequent article, Jarvis discussed how the asylum created an expanded demand for its services: "The opening of these establishments for the cure or protection of lunatics, the spread of their reports, the extension of the knowledge of their character, power, and usefulness, by means of the patients they protect and cure, have created, and continue to create, more and more interest in the study of insanity, and more confidence in its curability. Consequently, more and more persons and families, who, or such as who, formerly kept their insane friends and relations at home, or allowed them to stroll about the streets or country, now believe, that they can be restored, or improved, or, at least made more comfortable in these public institutions, and, therefore, they send their patients to these asylums, and thus swell the lists of their inmates" (Jarvis, "On the Supposed Increase of Insanity," American Journal of Insanity 8 [1852]: 344.

[28] See Chapter 12.

the Ticehurst Asylum casebooks now at the Wellcome Institute. But, as Hare notes, almost none of the increase in the incidence of mental illness occurred among private patients, so that for our present purposes, these materials are unlikely to be very helpful. On the other hand, precisely because the county asylums were so overcrowded, and were filled with paupers, their individual case records are generally too skimpy to be useful for answering this question.

I would suggest, however, that the class-specific pattern of the increase in insanity does pose certain difficulties (though I grant these are not necessarily of an insuperable sort) for Hare's argument. Somehow, the slow epidemic of schizophrenia was a class-specific epidemic, so that on top of the highly speculative claim that it had a viral origin, one must add the further hypothesis that the upper classes—whether for constitutional or environmental reasons—were mysteriously immune to its ravages.

It may well be that we shall have to be satisfied with an assessment of the general plausibility of each argument and with the extent to which it makes sense of the wide variety of data and observations that have survived. However, since Hare felt free to draw on comparative data to buttress his case, perhaps I may be allowed to do the same. Examining the growth of French psychiatry in the nineteenth century, Robert Castel argues that theoretical developments made possible a similar expansion of the boundaries of madness there. Particularly as alienists began to ground their decisions in predictions about patients' likely behavior in the future, they created a substantial area of indeterminacy. As he puts it, "By abandoning reference to real behavior in favor of surmises concerning future behavior, psychiatry begins to arrogate to itself a margin of interpretation (and thus of intervention) whose bounds are no longer discernible."^[29] Ian Dowbiggin has demonstrated that this theoretical possibility proceeded to have a substantial practical effect: "By citing heredity and degeneracy, alienists were able to extend the boundaries of mental pathology to encompass marginally deviant affective symptoms and make a plausible case for the reality of partial insanity. Hereditarianism had the 'halo' effect . . . of convincing juries, magistrates, and the public that psychiatry was authorized to expand conventional medical taxa into areas of behavior previously managed by religion and law."^[30]

Samuel Shortt's monograph on Richard Bucke and the London Provincial Asylum in Ontario suggests that a similar broadening of the basis for committing people as mad was characteristic of late-nineteenth-

[29] Robert Castel, The Regulation of Madness: Origins of Incarceration in France (Oxford: Polity Press; Berkeley: University of California Press, 1988), chap. 4.

[30] Ian Dowbiggin, "The Professional, Sociopolitical, and Cultural Dimensions of Psychiatric Theory in France 1840–1900" (Ph.D. dissertation, University of Rochester, 1987), 386.

century Canada. Reviewing the data on Ontario admissions in the last quarter of the century, he documents, for example, the disproportionate admission of the elderly, generally suffering from "'senile decay,' a term signifying not threatening behavior but confusion and forgetfulness of varying severity."^[31] And overall, he concludes that "a major reason for admission was the inability or unwillingness of friends, family, or community to cope in alternative fashion with harmless but chronically disorderly and unproductive behavior."^[32]

Of still more direct relevance, the one careful study we possess of the composition of asylum populations at the turn of the century is Richard Fox's examination of legal commitments in California between 1906 and 1929. Using a random sample of commitments from San Francisco in this period, Fox demonstrates that

two thirds of those committed were odd, peculiar, or simply immoral individuals who displayed no symptoms indicating serious disability, or violent or destructive tendencies. The reported behavior of this 66 per cent included primarily nervous and depressive symptoms and a wide variety of fears, beliefs, perceptions and delusions. In these cases the examiners noted that behaviors which they and various witnesses deemed inappropriate, but failed to indicate any reason why the individual, for his own protection or that of the community, had to be detained.^[33]

It goes almost without saying that this finding accords very well with my hypothesis and provides little or no support for Hare's.

[31] S. E. D. Shortt, Victorian Lunacy: Richard M. Bucke and the Practice of Late Nineteenth-Century Psychiatry (Cambridge: Cambridge University Press, 1986), 51.

[32] Ibid., 52.

[33] Richard W. Fox, So Far Disordered in Mind: Insanity in California (Berkeley: University of California Press, 1978), 148.