Chapter One
Reflections on the Historical Sociology of Psychiatry

The history of the victors, for the victors, and by the victors is not only indecent, but also bad history and bad sociology, for it makes us understand less the ways in which human societies operate and change.
—TEODOR SHANIN,

Foreword to The Agrarian Question and the Peasant Movement in Colombia
by Leon Zamosc

Madness constitutes a right, as it were, to treat people as vermin.
—LORD SHAFTESBURY,
Diaries, 5 September 1851

"Well, in our country," said Alice, still panting a little, "you'd generally get somewhere else—if you ran very fast for a long time, as we've been doing."
"A slow sort of country!" said the Queen. "Now, here, you see, it takes all the running you can do to keep in the same place."
—LEWIS CARROLL,
Through the Looking Glass

For more than a decade and a half now, I have been preoccupied with understanding social responses to madness in Britain and the United States. Some of my work, dealing with the analysis of the origins and implementation of contemporary mental health policies, seems to fall within the conventional boundaries of sociology as the mainstream of the American profession defines them (though this is largely the result of intellectual accident rather than design). For the most part, however, as the contents of this volume reveal, my interests have been heavily historical, a choice that has quite consciously reflected both my intellectual conviction that an adequate sociological understanding is necessarily a historically grounded understanding and, to be candid, the great pleasure I find in rummaging about in the past.

Intellectual choices, of course, are not made in a vacuum, flowing in substantial measure from a complex interaction between biography and circumstance of which we are seldom fully aware. In largely unintended ways, I suspect that my formal education at Balliol and Princeton contributed to my initial interest in psychiatric history. (One's acquisition of a certain intellectual capital and the natural tendency to work over the

years on a set of interrelated problems makes one's early decisions of more moment than is generally realized at the time, so that in retrospect I can hardly be surprised at my continuing fascination with this subject matter.)

Undergraduates at Oxford are not allowed to take a degree in sociology, a peculiar prejudice that has doubtless been reinforced in the present reactionary political climate, given the (not wholly mistaken) notion that there is something inherently subversive about the sustained intellectual analysis of social institutions. The immediate consequence of this policy in my case was that I acquired a rather broad education in philosophy and in a range of social sciences, rather than the narrow indoctrination into a particular academic discipline more characteristic of English university instruction. Because I have always relished the freedom to trespass across established disciplinary boundaries, I think that among sociology's prime attractions for me was my sense of the capaciousness of the intellectual territory it sought to embrace.

This sense of the scope and ambition of the subject reflected the fact that the relatively small dose of sociology I had received at Oxford concentrated heavily on the work of Marx, Durkheim, and Weber, together with such atypical mid-twentieth-century sociologists as Barrington Moore and C. Wright Mills. Mainstream American sociology of the late 1960s, with its narrow, presentist bias, its crude scientism, and its preoccupation with method at the expense of substance, was infinitely less appealing. One might reasonably expect, therefore, that my passage into graduate school in the United States would have produced severe disillusionment. I was fortunate enough, however, to have chosen Princeton for my graduate training: fortunate in that, having cleared certain methodological and statistical hurdles, I (like the rest of my cohort there) was left almost entirely to my own devices, free to pursue my own intellectual whims and fancies.

While not without its hazards—virtually all my fellow students have disappeared without professional trace—this situation did have certain distinct advantages. In particular, when my reading of Foucault and Rothman had led me to an interest in matters psychiatric, no one was disposed to dissuade me from studying lunacy in the nineteenth century simply because the sociological audience for such work might prove vanishingly small. Soon I found myself fascinated by a whole set of interrelated questions about changing social responses to mental disturbance and the mentally disturbed and equally hooked on the pleasures of playing historical detective—a double addiction from which I have neither sought nor wished to escape.

There can be little question that, for many American sociologists, it must seem eccentric for one of their number to exhibit a persistent concern with such topics as eighteenth-century beliefs about madness, a law-

suit launched by an obscure and otherwise unmemorable middle-aged spinster in the late 1840s, the biography of a nineteenth-century alienist, the architecture of Victorian loony bins, and historiographic disputes about the interpretation of nineteenth-century lunacy reform. At the same time, only the most intellectually obtuse could avoid recognizing that a certified member of the sociological community is likely to be greeted with great wariness and suspicion by card-carrying professional historians, even if he somehow escapes being shot at by the border guards who so zealously patrol the artificial boundaries we have erected to distort the study of human society. Yet the intellectual rewards that can flow from resisting entrenched pressures to respect established disciplinary boundaries seem to me amply to justify a refusal to embrace conventional pieties about the territories that belong to the historian or to the sociologist.

One of the most pernicious, albeit widespread, views of the uneasy relationship between these two subspecies of homo academicus, while emphasizing that most historians and sociologists have better sense than to invade each other's ecological niche, suggests that when they do threaten to occupy the same social space, competition is reduced through a kind of division of intellectual labor. In the sociologist's version of this fairy tale, historians are portrayed as underlaborers for the queen of social sciences, engaged in the relentless pursuit of the particular without regard for its general theoretical significance, empiricists whose blind archival burrowings produce mounds of "facts," which then serve as the grist for the grander, explanatory science to ponder and process. As Joseph Gusfield puts it, "Historians tell stories without conclusions. [Historical] sociologists tell stories that are mostly conclusions."^[1]

That this patronizing and, in my view, intellectually misguided set of claims has aroused considerable resentment in historical circles is scarcely surprising. Most historians, after all, quite rightly see themselves as engaged in the task of explaining and not simply reproducing the past and are disturbed at the crude and cavalier approach to the difficulties of reconstructing historical reality characteristic of most sociology of this sort. And, unfortunately but inevitably, there are plenty of examples of a "historical" sociology that eschews any but the most superficial acquaintance with the past and with the tools of the historian's trade, neglects (and even rejoices in an unconcern with) the difficulties and rewards of archival research, and blithely seeks either to cram the complexities of the past into a Procrustean bed of transhistorical "theory" or to reduce social reality to the banalities of lower mathematics, in the worst cases engaging in a little of both.

[1] Joseph Gusfield, Symbolic Crusade: Status Politics and the American Temperance Movement, 2d ed. (Urbana: University of Illinois Press, 1986), 189.

But if there are—all too often—ample grounds for the historian's suspicion of the sociological imagination, there is also good reason for regret that this should be so. The distinction between the idiographic and the nomothetic, valuable enough if it refers to a tension embedded in all attempts to grapple with social reality and to the relative emphasis on the particular or the general to be found in any specific piece of scholarship, threatens to be quite pernicious if it is reified and taken to refer to a real opposition, a binary choice between two mutually exclusive approaches to the study of human society. To the contrary, while generalization based on third- or fourthhand acquaintance with historical reality (and often a superficial and highly selective encounter at that) raises grave questions about the ontological status of the proffered accounts, a resolute emphasis on the uniqueness of events, if taken at face value, simply dissolves into solipsism. Any attempt at description and explanation necessitates a resort to abstraction from the endless particularities of the individual case, a reliance on generalization and the use of analogy, and an explicit or implicit comparison of one set of events with another.

One may quite reasonably object to the grandiosity of much sociological generalization and to the absence of concern among all too many of its practitioners with the constraints and disciplines imposed by the richness of the historical record. One may sensibly take issue with the tendency to value, in Gusfield's terms, the conclusions over the story, heedless of the epistemological difficulties—to say nothing of the empirical distortions and inaccuracies—that such a preference invites. But neither of these arguments confers exemption from the dilemma confronted by all practitioners of the historical and social disciplines: that the ceaseless flux of social reality can be ordered, however provisionally, only by means of reasoned thought and comparison. And this process must of necessity rely on principles of classification imposed upon rather than drawn from that reality.^[2] Historians are as subject to this imperative as sociologists because, ultimately, the distinction between the two disciplines is by and large an artificial and unfortunate one, however, entrenched it has become over the years in institutional structures and no matter how skillfully it is now rationalized by the self-interests of academic guilds.

Undesirable as the separation of history and sociology may be, still it constitutes, as Durkheim would say, a social fact, with whose ramifications one must necessarily come to terms. Responding, as they must, to a variety of factors—pressures to maximize the perceived distinctiveness of one's discipline; the consolidation and entrenchment, through the specialization and professionalization of scholarship, of different criteria

[2] The last part of this sentence paraphrases some astute remarks in A. Salomon, "Max Weber's Methodology," Social Research 1 (1934): 157.

for evaluating intellectual merit; and the parochialism of contemporary academic life, which tends to create powerful linkages between one's nominal disciplinary affiliation and the type of work that is encouraged and recognized as legitimate—it should come as no surprise that historians and sociologists are frequently so much at odds, even (perhaps especially) when cultivating the same territory. But such squabbles are nonetheless regrettable, the more so since neither side possesses a monopoly of virtue.

Justifiably, historians complain that many sociologists neglect the first requisites of historical understanding. But in their eagerness to point out the motes in the eyes of the sociologists, they are all too ready to overlook the beams in their own. For a sensitivity to questions of evidence and interence must be combined with theoretical sophistication and vision, and understanding the particular necessarily depends on an ability to place one's findings within a broadly comparative frame of reference. All too often historians shy away from making their theoretical assumptions and interpretive frameworks explicit and regard comparative statements with ill-concealed suspicion and distaste—as if attending to such matters might contaminate the attempt "to understand the past on its own terms." To the contrary, this evasion leaves one's criteria of selection and relevance underdeveloped and unself-conscious, hence unchallenged and ill thought through; and it constricts one's vision, distorting the sense of perspective so as to leave in obscurity aspects of historical reality that acquire meaning only when placed in a larger contextual frame. The extent to which my own contributions to the history of psychiatry are distinctive is, I like to think, a result of my attempt to marry the traditional concerns of the historian and the sociologist: a willingness to do my historical homework, coupled with a concern with implicit or explicit comparison, with the more general significance of a given set of phenomena, and with issues that transcend the particularities of person and place.

Offering reflections on historical as well as contemporary issues, as I have done here and elsewhere, carries with it both risks and potential benefits. One's position on contemporary dilemmas may, of course, contaminate one's researches on the past, producing a narrow teleological history that abstracts both selectively and misleadingly from the record to provide a version of developments that neatly confirms one's current political prejudices. Gerald Grob and Jacques Quen have been bitterly critical of "revisionist" historians of psychiatry (most especially of David Rothman) on precisely these grounds, and their objections are not to be minimized, even though they apply with equal or greater force to those using them as a cudgel pour épater les autres . For whatever Rothman's deficiencies in this regard (an issue I discuss on occasion in other chapters), the much more common problem is precisely the reverse: the construction of versions of the past that serve (in ways generally obscured from

those offering such accounts) to legitimate the activities of psychiatrists in the present.

This problem is scarcely unexpected, given that, until recently, much psychiatric history has been written by amateur historians, and a peculiar group of amateurs at that—psychiatrists themselves. Occasionally, as in the case of Richard Hunter and Ida Macalpine, this situation has produced work that, notwithstanding its obvious partiality, has been of lasting value. In the more usual case, however, the resulting distortions have fatally compromised the accounts offered.^[3] Nor have psychiatriststurned-historians been the only offenders in this regard, since the claims of the profession to rest its clinical practice on a scientific basis have led others to accord its activities a privileged ontological status, safe from even moderately searching critical scrutiny. Such "responsible" and sanitized history can expect a generally warm welcome, coinciding as it does with the received wisdom propagated by those whose claim to moral authority over the mad is sanctioned at once by law and by duly certified scientific expertise.

We know, of course, that history is always a matter of reconstruction through the filter of memory and that, to borrow Robert Castel's vivid phrase, all memory is built upon a foundation of forgetfulness (a forgetfulness, one must add, that is anything but random).^[4] Furthermore, there is much in our societies' responses to madness, both past and present, that we are all too ready to consign to oblivion. Perhaps it is for this reason that one of the main functions of the history of psychiatry has traditionally been to provide a seemingly inexhaustible supply of images and exemplary tales documenting our passage from the barbarousness of the past into the enlightenment of the present: a movement from the dark period in which lunacy was not recognized as a condition requiring medical treatment, through a long struggle in which the steady application of rational-scientific principles produced irregular but unmistakable evidence of progress toward humane and effective treatments for those afflicted with mental alienation, to our present state of grace.

Within such a vision, we can persuade ourselves (as each generation before us has done) that we stand on the threshold of those discoveries that will finally banish the mysteries surrounding the etiology of madness, ushering in a Golden Age of understanding and practical treatment. It may well be, indeed, that it is precisely our repressed uncertain-

[3] Splendid (or rather, sobering) examples include Gregory Zilboorg's A History of Medical Psychology (New York: Norton, 1941); and Franz Alexander and S. Selesnick's The History of Psychiatry (London: Allen and Unwin, 1967).

[4] See Robert Castel, "Moral Treatment: Mental Therapy and Social Control in the Nineteenth Century," in Social Control and the State: Historical and Comparative Essays, ed. Stanley Cohen and Andrew Scull (Oxford: Basil Blackwell; New York: St. Martin's Press, 1981), 248–66.

ties about the limits of our current understanding (compounded by the natural anxieties that must attend the daily confirmation of our relative impotence in the face of the more serious forms of alienation) that account for the tenacity and fervor with which so many cling to the myth of progress. To recover the horrors of a prescientific past is to bolster the assurance of escape from darkness into light, an assurance clung to the more desperately the less securely it is anchored in one's mundane experience.

In the last analysis, of course, one's view of the past is necessarily conditioned by the present in ways both large and small, perceived and unperceived. Conversely, to assert that an understanding of the past somehow contributes to a firmer grasp of contemporary realities is to endorse what is too often a banality bereft of any substantive content. Yet the very intractability of the dilemmas we confront in endeavoring to respond to unreason, the peculiar and multiple interpenetrations of past and present that mark the psychiatric domain, the tendency (nowhere more evident and lamentable than here) for "progress" to mask repetitions at once both tragic and farcical, inescapably force historical echoes and parallels into our consciousness.

At the very least, for example, I would hope that those encountering our contemporary reformers and ideologues, who urge deinstitutionalization and praise the virtues of "community," may acquire a certain necessary skepticism from recalling how fervently their nineteenth-century counterparts once preached the gospel of retreat from the world and seclusion within the walls of the asylum.^[5] Similarly, both those who urge liberty for the lunatic and those who on the contrary complain of patients "dying with their rights on" play out scripts with a long and checkered history.^[6] And the metaphysical wager on a biologically reductionist account of mental disorder made by those who like to think of themselves as being on the cutting edge of modern psychiatry turns out to represent the latest twist on an oft-told tale—one whose full implications await a larger and more sustained analysis than has yet been provided.^[7]

I began work on madness and its place in the social order in the early 1970s, the heyday of a romantic antipsychiatry that somehow attracted adherents ranging from the libertarian right to the self-consciously communitarian left. It would be disingenuous to pretend that this intellectual climate was somehow irrelevant to my own concerns and emphases.

[5] See Chapter 13.

[6] See the discussion in Chapter 12.

[7] I plan to provide a history and analysis of the persistent resort to somatic treatments in my forthcoming Desperate Remedies . Elliot S. Valenstein's Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (New York: Basic Books, 1986) provides a useful survey of a portion of the terrain. There is further discussion of this issue later in this chapter.

For example, I largely concur with (and hope to develop in novel and defensible directions) the stress that this diverse literature places on the ways in which the recognition and response to mental disorder are inextricably culture-bound. Likewise, I have consistently argued that "madhouses, mad-doctors, and madmen" must necessarily be viewed in their sociological context, with much unavoidably remaining opaque and hidden from view till one penetrates the screens of ideology and makes sense of the impact of professional interests, changing social structures and relationships, and shifting forms of power. In my judgment, the usefulness of such claims is not to be demonstrated through abstract polemics, but through the examination and explication of concrete instances where these forces are at work.^[8]

At the margin, what constitutes madness strikes me as fluctuating and ambiguous, indeed theoretically indeterminate, making its boundaries the subject of endless dispute and anxiety. Madness is, as Michael MacDonald has so felicitously put it, "the most solitary of afflictions to the people who experience it; but it is the most social of maladies to those who observe its effects,"^[9] for its definitions, its boundaries, its meanings are but a distorted mirror image of the shifting social order. Moreover, those who claim the ability to decide for the rest of us where to draw the necessary moral and political lines continue to suffer from embarrassing intellectual vulnerabilities, to say nothing of an all-too-visible therapeutic impotence. My work, like that of the antipsychiatrists, is thus marked by a pronounced skepticism concerning psychiatry's self-proclaimed rationality and disinterested benevolence, a skepticism rooted in what is, on the whole, a dismal and depressing historical record.

On the other hand, I share with many of my fellow critics neither the perception that mental alienation is simply the product of arbitrary social labeling or scapegoating, a social construction tout court, nor the notion that psychiatry can be dismissed as merely a malevolent or cynical enterprise. I have never been comfortable with such romantic views of those incarcerated as crazy, which in my view elide and ignore the chronic demoralization and all-too-permanent incapacities that so frequently follow the descent into madness and grossly oversimplify their likely etiology. Nor do I find a simplistic portrait of psychiatrists as concentration camp guards or manufacturers of madness analytically helpful or substantively persuasive.^[10] I have thus been increasingly troubled by the dis-

[8] As I hope Chapter 7 (on John Conolly) demonstrates, this approach is valuable even at the level of individual biography. Old-fashioned histories of medicine focused all but exclusively on tales of the accomplishments of great men, wrenched from any broader historical or sociological context. My discussion of Conolly adopts a rather different approach to the life and work of one of the heroes of the pantheon.

[9] Michael MacDonald, Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth Century England (Cambridge: Cambridge University Press, 1981), 1.

[10] It is scarcely disputable that traditional asylums for much of their existence resembled cemeteries for the still breathing and that medical hubris has at times served to license dangerous, mutilating, even life-threatening experiments on the dead souls confined therein. (See, e.g., Andrew Scull and Diane Favreau, "'A Chance to Cut Is a Chance to Cure': Sexual Surgery for Psychosis in Three Nineteenth Century Societies," Research in Law, Deviance, and Social Control, vol. 8, ed. Steven Spitzer and Andrew Scull (Greenwich, Conn.: JAI Press, 1986), 3–39; Andrew Scull, "Desperate Remedies: A Gothic Tale of Madness and Modern Medicine," Psychological Medicine 17 [1987]: 561–77; and Valenstein, Great and Desperate Cures .) And only the sociologically blind would deny that psychiatrists are deeply and inextricably involved in the definition and identification of what constitutes madness in our world—in ways that render the notion that mental illness is a purely naturalistic category, somehow devoid of contamination by the social, a patent absurdity. Hence the polemical force of the analogy to concentration camps and of the assertion that maddoctors "manufacture" madness. But to assent to these crude and unnuanced views as revealing the reality hidden behind the smokescreen of ideology is to commit an error as damaging in its way as its antithesis: the view of psychiatry as a straightforwardly and unambiguously humane and scientific enterprise. To examine psychiatry and its ministrations with a critical eye by no means entails the adoption of the romantic idea that the problems it deals with are purely the invention of the professional mind; nor does it require us to embrace the Manichean notion that all psychiatric interventions are malevolent and ill conceived.

position shared by such disparate figures as Thomas Szasz and R. D. Laing, Thomas Scheft and Erving Goffman, and Michel Foucault and his epigones to play down the degree to which behavior recognized as mad was (and is) genuinely problematic—to say nothing of their willingness either to ignore the enormity of the human suffering and the devastating character of the losses sustained by victims of this form of communicative breakdown or to lay the blame for whatever pathology they do acknowledge squarely and solely on the shoulders of a misguided or actively harmful profession. While I have argued elsewhere^[11] that the sources of our current turn away from the asylum are not in the last analysis to be sought in an intellectual disenchantment with orthodox psychiatry and its works (indeed, I have contended that deinstitutionalization and the associated abandonment of the chronically insane has taken place with the active support and connivance of the mainstream of the profession), still the antipsychiatrists cannot escape their share of the responsibility for recent "reforms," if only for unwittingly providing an ideological figleaf with which to camouflage a policy of malign neglect.

The history and current state of both psychiatry and the objects of psychiatric attention are, of course, subjects of enormous complexity. And despite the increased attention they have attracted over the past decade and a half, our ignorance and uncertainties manifestly loom larger than those areas about which we can feel reasonably secure. Faced by such vast expanses of the unknown, the conventional historian seems to opt, on first instinct, for the narrowly circumscribed monograph, implicitly hoping that the accumulation of a whole series of these will ultimately, in Baconian fashion, provide the basis for the inductive con-

[11] See Andrew Scull, Decarceration: Community Treatment and the Deviant—A Radical View, 2d ed. (Oxford: Polity Press; New Brunswick, N:J.: Rutgers University Press, 1984).

struction of a picture of the larger whole. I have my doubts. The more likely result of ceding the field to those "who keep their noses buried in dusty files in the Public Record Office—or County Record Offices or libraries"—while resolutely shying away from broader questions or a broader context is that, for lack of a larger perspective, history will be reduced to simply one damn thing after another, that those noses will be lifted from the dust "only to tell us that they find the detailed process of interaction between the various individuals involved too complex to yield any overall patterns."^[12]

During the 1970s, however, many of those working on the history of psychiatry quite decisively avoided any such narrowness and constriction of vision. If anything, the dominant tendency was to move in the opposite direction. For one of the side effects of the enormous influence of Michel Foucault's Madness and Civilization, with its grandiose attempt to offer a reinterpretation of Western Europe's encounter with unreason from the waning of the Middle Ages to the advent of industrial capitalism, was to provoke a number of other wide-ranging surveys of portions of this territory. These were ambitious studies in their own right even if they lacked some of the rhetorical ostentation and temporal sweep of the original. Books like Klaus Doerner's Madmen and the Bourgeoisie, David Rothman's The Discovery of the Asylum, Robert Castel's L'Ordre psychiatrique, and my own Museums of Madness forced a wholesale reexamination of the transformation of social ideas and practices vis-à-vis the insane during the eighteenth and the first half of the nineteenth century. In the process, they fostered heated debates and reassessments and opened up an array of provocative questions demanding further research. If, in the ensuing decade, peregrinations through the dusty archives have been pursued with a new vigor, they have at the same time been undertaken in an infinitely richer theoretical and historiographic context and, more often than not, have been motivated by the desire to refine or refute some of the assertions made in these larger surveys of the terrain.

The first generation of these more detailed studies are now beginning to see the light of day, first as doctoral dissertations and, increasingly, as articles and monographs. Anne Digby has recently provided us with a searching reexamination of the history of the York Retreat—along with

[12] Quotations from David Philips, "'A Just Measure of Crime, Authority, Hunters and Blue Locusts': The Revisionist History of Crime and the Law in Britain, 1750–1850," in Social Control and the State, ed. Cohen and Scull, 68. This tendency is clearly observable in the work of Gerald Grob, most overtly in his historiographic essays (see, e.g., "Public Policy Making and Social Policy" [Paper, Harvard University, 1978]; "Rediscovering Asylums: The Unhistorical History of the Mental Hospital," Hastings Center Report 7, no. 4 [1977]: 33–41; and "Welfare and Poverty in American History," Reviews in American History 1 [1973]: 43–52), but also in his general histories of American psychiatry, Mental Institutions in America: Social Policy to 1875 (New York: Free Press, 1973), and Mental Illness and American Society, 1875–1940 (Princeton: Princeton University Press, 1983).

its symbolic antithesis, Bethlem, one of the two most famous institutions in the history of Anglo-American psychiatry.^[13] Nancy Tomes and Charlotte MacKenzie have written model studies of nineteenth-century institutions, in the United States and England, respectively,^[14] which concentrated on an upper-class clientele. With their restricted and privileged patient population, these are asylums whose history is in many ways quite different from that of the public hospitals in which the bulk of the insane were confined. But precisely because of the character of those they served, their archives are unusually rich and detailed, making possible, for instance, the reconstruction of the processes leading to commitment, the patients' families' views of mental disorder, and the daily routines of asylum existence in ways that the more voluminous but necessarily more superficial records of the public sector scarcely allow. Moreover, the examination of elite practice has, of course, its own special interest and significance, provided we remain constantly sensitive to the limitations on generalizing the findings.

Others have wrestled with institutions treating the opposite end of the social spectrum. In a splendid series of articles, John Walton has made use of the surviving records of the Lancaster County Asylum to explore how paupers were cast out of the community into the world of the asylum (and, more rarely, were brought back in); and he has exploited the opportunity offered by a more intensive examination of the history of an individual asylum to grasp the relationship of local developments to the broader national picture, as well as to question and, if necessary, to redraw, some portions of the larger portrait others have previously provided.^[15] Ellen Dwyer has contributed a comparative study of the Utica State Hospital (original home of the American Journal of Insanity, now unfortunately renamed the American Journal of Psychiatry ) and the Willard

[13] See Anne Digby, Madness, Morality, and Medicine: A Study of the York Retreat, 1796–19l4 (Cambridge: Cambridge University Press, 1985).

[14] See Nancy Tomes, "The Persuasive Institution: Thomas Story Kirkbride and the Art of Asylum Keeping, 1841–1883" (Ph.D. dissertation, University of Pennsylvania, 1978), published in revised form as A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum Keeping, 1840–1883 (Cambridge: Cambridge University Press, 1984), which deals with the psychiatric division of the Pennsylvania Hospital; Charlotte MacKenzie, "Social Factors in the Admission, Discharge, and Continuing Stay of Patients at Ticehurst Asylum, 1845–1917," in The Anatomy of Madness, 2 vols., ed. W. F. Bynnm, Roy Porter, and Michael Shepherd (London: Tavistock, 1985), 2: 147–74; and idem, "A History of Ticehurst Asylum" (Ph.D. dissertation, University of London, 1987).

[15] See John Walton, "Casting out and Bringing hack in Victorian England: Pauper Lunatics, 1840–1870," in Anatomy of Madness, ed. Bynum, Porter, and Shepherd, 2: 132–46; idem, "The Treatment of Pauper Lunatics in Victorian England: The Case of Lancaster Asylum, 1816–1870," in Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era, ed. Andrew Scull (Philadelphia: University of Pennsylvania Press; London: Athlone Press, 1981), 166–97; idem, "Lunacy and the Industrial Revolution: A Study of Asylum Admissions in Lancashire, 1848–50," Journal of Social History 13 (1979–80): 13–18. Laurence J. Ray has also made use of the Lancashire records covering a somewhat later period: see his "Models of Madness in Victorian Asylum Practice," European Journal of Sociology 22 (1981):229–64.

State Hospital, a controversial institution set up to cope with New York State's overflow of chronic and incurable lunatics.^[16] And focusing on a figure notable "not [for] his originality, but his very lack of it," Samuel Shortt has looked at the theory and practice of late-nineteenth-century psychiatry in a provincial Canadian asylum.^[17]

Nor has the spate of new work been confined to the study of patients and institutions. The interaction between psychiatry and the law has always been the site of highly charged conflicts whose symbolic importance has far outweighed their apparent practical significance. While psychiatrists have repeatedly sought to remove their discourse to a plane where it would be accorded the objectivity of physical science, the legal system has exhibited persistent skepticism and doubts, remaining wedded to a commonsense schema wherein will or intention, the voluntary basis of action, assumed a central place; and, to the doctors' dismay, the law has periodically displayed considerable hesitations over the appropriate criteria and procedures for certifying someone as mad. Portions of this territory have now begun to receive close and epistemologically sophisticated attention.^[18] In a very different vein, Nicholas Hervey has provided a meticulously researched examination of the most important nineteenth-century effort to regulate Victorian psychiatric practice and institutions, the English Lunacy Commission.^[19] And, as I shall discuss at more length later in this chapter, a number of scholars have begun to examine the content of psychiatric theories and therapeutics in greater depth.

This voluminous outpouring of monographs has, quite naturally, presented us with a more nuanced and complex view of the history of madhouses, mad-doctors, and madmen (and even taught us something about

[16] Ellen Dwyer, Homes for the Mad: Life Inside Two Nineteenth-Century Asylums (New Brunswick, N.J.: Rutgers University Press, 1987).

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

[18] See especially Roger Smith, "The Boundary Between Insanity and Criminal Responsibility in Nineteenth Century England," in Madhouses, Mad-Doctors, and Madmen, ed. Scull, 363–84; idem, Trial by Medicine (Edinburgh: Edinburgh University Press, 1981); and Ruth Harris, "Murder Under Hypnosis: In the Case of Bompard—Psychiatry in the Courtroom in Belle Epoque Paris," in Anatomy of Madness, ed. Bynum, Porter, and Shepherd, 2: 197–241. For an ethnography of contemporary court proceedings on the question of mental competence, see Carol A. B. Warren, The Court of Last Resort: Mental Illness and the Law, with contributions by Stephen J. Morse and Jack Zusman (Chicago: University of Chicago Press, 1982). And see Chapter 12 below.

[19] Cf. Nicholas Hervey, "The Lunacy Commission 1845–1860, with Special Reference to the Implementation of Policy in Kent and Surrey" (Ph.D. dissertation, Bristol University, 1987).

madwomen).^[20] Almost without exception, though, the new work in the field remains marked by and in many ways deeply indebted to the earlier generation of revisionist studies. Mercifully, in consequence, we have been spared a return to a "public relations" history of psychiatry and have likewise not had to endure a revival of "historiographic nihilism or mindless empiricism."^[21]

Recent scholarship hews to no consistent ideological line. That the socalled revisionist historians of psychiatry likewise did not constitute a unified counterorthodoxy scarcely requires demonstration. The historiographic essay that appears in Chapter 2 of this book was originally prepared for a conference on the meaning of nineteenth-century moral reform, at which David Rothman and I debated our sharply differing interpretations of the "discovery of the asylum."^[22] Those who read even my half of the debate cannot harbor any illusions about the construction of a new revisionist consensus, even in an Anglo-American context, and the divisions between the Anglo-Saxons and the French are, if anything, still more marked.

In one sense, these divisions may seem odd, since all of us writing in the seventies and eighties owe multiple debts to the major figure of the French poststructuralist school, the late Michel Foucault. On the purely mundane level, it was surely the reception accorded to Foucault's work, and the stature he came to occupy in both the academy and café society, that played a major role in rescuing madness from the clutches of drearily dull administrative historians and/or psychiatrists in their dotage, giving the whole topic the status of a serious intellectual subject and thus attracting us to it in the first place. More broadly, whatever else he may have suffered from, Foucault did not lack for intellectual daring, and most of the best recent work in the field for the past fifteen or twenty years can be seen as responding, at least in part, to the intellectual challenges he threw down.

But Foucault was a very peculiar academic animal, in some ways suggestive of an escapee from the bizarre bestiary of Borges' Chinese encyclopedia, whose categories he himself reproduces with such relish at the

[20] See Elaine Showalter, The Female Malady: Women, Madness, and English Culture, 1830–1980 (New York: Pantheon, 1985; London: Virago, 1987); and my discussion in Chapter 11 below.

[21] Bynum, Porter, and Shepherd, "Introduction" to their Anatomy of Madness, 1:5.

[22] The papers delivered at this conference, whose other speakers were David Brion Davis and David Roberts, were subsequently published as a special issue of Rice University Studies 67, no. 1 (1981). Turnabout being fair play, interested readers may wish to consult this to see what Rothman has to say about me. His essay, "Social Control: The Uses and Abuses of the Concept in the History of Incarceration," can also be found in Social Control and the State, ed. Cohen and Scull, 106–17. For an empirical critique of the thesis Rothman advances in The Discovery of the Asylum (Boston: Little, Brown, 1971), see Chapter 5 below.

beginning of The Order of Things: "(a) belonging to the Emperor, (b) embalmed, (c) tame, (d) sucking pigs, (e) sirens, (f) fabulous, (g) stray dogs, (h) included in the present classification, (i) frenzied, (j) innumerable, (k) drawn with a very fine camelhair brush, (l) et cetera, (m) having just broken the water pitcher, (n) that from a long way off look like flies."^[23] Certainly he was not a historian in any ordinary sense of that term, and his work is marked by an audacious unconcern for the canons of historical scholarship and a cavalier way with evidence never likely to command universal assent. Nor is his philosophical baggage such as to guarantee widespread acceptance, at least outside those avant-garde intellectual circles wherein the sun is presumed to rise and set on the Left Bank of Paris. And his labyrinth of language, self-consciously obscure and opaque, "in which," he confesses, "I can lose [even] myself,"^[24] is notoriously ambiguous and impenetrable. Perhaps it is not surprising, in these circumstances, that so many of the Anglo-American obeisances to Foucault involve ritual rather than substance and may be accompanied by complaints that his work is "too abstract, too angry, or too difficult to be of much use."^[25] Yet besides these ritual acknowledgments (themselves a gesture of not inconsiderable significance), there are others who continue "to regard him as a historian and often extract historical details from him."^[26]

In reaching any balanced assessment of Madness and Civilization, we need to bear in mind that Foucault himself later repudiated much of the analysis he had presented there. In part, this turnabout reflected a major shift in his general perspective, involving a heightened emphasis on the inextricable interconnections of power and knowledge (the "power-knowledge spiral") and a stress on the productive effects of power.^[27] In-

[23] Michel Foucault, The Order of Things: An Archeology of the Human Sciences (New York: Pantheon, 1970), xv.

[24] Michel Foucault, The Archeology of Knowledge (New York: Pantheon, 1972), 17.

[25] H. C. Erik Midelfort, "Madness and Civilization in Early Modern Europe: A Reappraisal of Michel Foucault," in After the Reformation, ed. B. C. Malament (Philadelphia: University of Pennsylvania Press, 1980), 252, referring to the responses of Gerald Grob, David Rothman, and Norman Dain.

[26] Ibid., 249, 259. The dangers of treating Foucault as though he were indeed a historian, in the conventional sense of that term, are perhaps suggested by his response to critics who have charged him with gross historical inaccuracies: to query him on such points, he sniffed, is misleadingly to pit "little true facts against big vague ideas" ("Débat avec Michel Foucault," in L'Impossible prison, ed. Michelle Perrot [Paris: Seuil, 1980], 29). As Robert Nye dryly comments, "That, of course, is exactly what the historian must do" (Crime, Madness, and Politics in Modern France [Princeton: Princeton University Press, 1984], p. 15).

[27] See, in particular, the discussions in his Archeology of Knowledge, esp. 14–16, 47, 65, 157, 179; and in "Truth and Power," reprinted in Power/Knowledge: Selected Interviews and Other Writings, 1972–1977 (London: Harvester, 1980). See also his Discipline and Punish: The Birth of the Prison (New York: Pantheon; London: Allen Lane, 1978), for his analysis of penality.

stead of the repressive activities of a psychiatry concerned to stifle and conceal the ultimate affront to bourgeois sensibilities, Foucault and his followers developed a portrait of a far more thorough-going Orwellian nightmare: a system of control and regimentation ("the carceral archipelago") that operated insidiously and all but invisibly, reaching out to encompass the normal, to snare them within an ensemble of "benevolent" interventions and a discourse of personal fulfillment, and in the process serving to manage and manipulate a universe of ever more "docile bodies."^[28] But Foucault also grew increasingly scornful of one of the central features of Madness and Civilization, the attempt "to reconstitute what madness might be, in the form in which it first presented itself to some primitive, fundamental, deaf, scarcely articulated experience"; and he forswore what he had there "come close to admitting[,] an anonymous and general subject of history."^[29]

English-speaking readers, thanks to an interesting variation on Gresham's Law (the appearance of a bad translation precludes the issue of a good one) have access only to a truncated version of Foucault's original argument. For reasons that remain obscure, what appeared in English was the abbreviated text of the French paperback edition, an abridgment that omitted at least 40 percent of the original version, as well as the bulk of the footnotes and references. (Perhaps Foucault did not object too strenuously, since in this version the transitions between madness in the medieval, the classical, and the modern periods seem much more mysterious than in the original, thus according with his later emphasis on the impossibility of explaining epistemological transitions or ruptures.)

On one fundamental issue, whether the reforms of the moral treatment era constituted a rupture with the past, I think Foucault is more correct than not. Roy Porter, in particular,^[30] has recently sought to argue that, on the contrary, the activities of Samuel Tuke and Philippe Pinel exhibit fundamental continuities with earlier views and practices—a contention that, given historians' proclivity for emphasizing continuities

[28] In addition to Foucault's own writings (including the works cited in the preceding note, see also The History of Sexuality, Vol. 1, An Introduction (New York: Pantheon, 1978). Some particularly important related books are Jacques Donzelot, The Policing of Families (New York: Pantheon, 1980); and Françoise Castel, Robert Castel, and Anne Lovell, The Psychiatric Society (New York: Columbia University Press, 1982). Useful, too, as an example of this later stress on "softer" forms of social control is Stanley Cohen, "The Punitive City: Notes on the Dispersal of Social Control," Contemporary Crises 3 (1979):339–63.

[29] Foucault, Archeology of Knowledge, 16, 47.

[30] See Roy Porter, "The Rage of Party: A Glorious Revolution in English Psychiatry?" Medical History 27 (1983), 35–50. Porter has recently elaborated on this theme, and on his criticisms of Foucault, in his Mind Forg'd Manacles: A History of Madness in England from the Restoration to the Regency (London: Athlone, 1987). Compare also the comments in Midelfort, "Madness and Civilization," 258–59.

rather than drastic change, is likely to find a receptive audience. But, granted that Foucault's metaphysics leads him to adopt an overly schematic notion of a radical epistemological break with the past and that one can indeed uncover anticipations and adumbrations of moral treatment earlier in the eighteenth century, still I think he is right to insist on the importance of the change that moral treatment represents. My own reading of the evidence on this point is laid out in two related chapters in this book, one (Chapter 3) examining the shifting sense in which madness was seen as subject to domestication, the other (Chapter 4) focusing on the social roots of the altered perceptions that underlay the development of moral treatment.

Ironically, of course, in emphasizing the revolutionary character of moral treatment, Foucault appears to endorse one of the key tenets of the traditional triumphalist vision of psychiatric history. But for him, the revolution does not mark the liberation of the insane from their fetters of iron and shackles of superstition. On the contrary, it constitutes the imposition of an ever more thorough-going "moral uniformity and social denunciation"—the historical moment at which the medical gaze secures its domination over the mad, launching "that gigantic moral imprisonment which we are in the habit of calling, doubtless by antiphrasis, the liberation of the insane by Pinel and Tuke."^[31]

Such ringing denunciations embody a rather complex set of assertions, some of which I think are defensible and correct, others quite dubious or wrong. To reduce moral treatment, for example, to a species of imprisonment, a more thorough-going form of repression, is to mask an important truth behind a screen of rhetorical excess. For moral treatment (like the larger reform it spawned) is Janus-faced: pace Foucault, it cannot be reduced to "the irruption of a bureaucratic rationalism into a preceding Golden Age of permissiveness towards insanity,"^[32] and, from my perspective at least, there are good grounds for preferring the tactful manipulation and ambiguous "kindness" of Tuke and Pinel to the more directly brutal coercion, fear, and constraint that marked the methods of their predecessors; yet one must also recognize that in the not-so-long run, it was the other, less benevolent face of moral treatment that came to the fore. Its latent strengths as a mechanism for inducing conformity made possible the abandonment of the brutal and harsh methods of management that had previously been inextricably connected with the concentration of large numbers of lunatics in an institutional environment. And in placing far more effective and thorough-going means of control in the hands of the custodians while simultaneously re-

[31] Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Pantheon, 1965), 259, 278 (Histoire de la folie à l'âge classique, new ed. [Paris: Gallimard, 1972], 514, 530).

[32] Peter Sedgwick, Psychopolitics (London: Pluto Press; New York: Harper and Row, 1982), 138.

moving the necessity for the asylum's crudest features, the reality of that imprisonment and control simultaneously became far more difficult to perceive. So in a wider perspective, the major—if unintended—contribution of those who introduced the techniques of moral treatment was to make it possible, in a very practical sense, to manage and clothe with a veil of legitimacy the nineteenth- and twentieth-century museums for the collection and confinement of the mad.^[33]

Similarly, the horrors of the nineteenth-century "loony bins" are real enough^[34] so that there is no need to exaggerate their awfulness by conjuring up a contrast with the myth of a primal Arcady prior to the Fall produced by the advent of bourgeois reason. Yet it is precisely such a romantic counterimage that Foucault sees fit to invent, reaching back into the Continental equivalent of Merrie Olde England to draw a portrait of folly freed from pernicious social restraint. In medieval times, he informs us, "Les fous alors avaient une existence facilement errante. Les villes les chaissaient volontiers de leur enceinte; on les laissait courir dans des campagnes éloignées, quand on ne les confiait pas à un groupe de marchands et de pèlerins." More picturesquely still, the mad might find themselves on a perpetual voyage in search of their reason, on one of those ships of fools that supposedly haunted the medieval imagination. (Unlike all the other "vaisseaux romanesques ou satiriques," Foucault hastens to assure us, "le Narrenschiff est le seul qui ait en une existence réelle, car ils ont existe, ces bateaux qui d'une ville à l'autre menaient leur cargaison insensée.")^[35]

What can one say? As Erik Midelfort has pointed out, the ship of fools (like Foucault's other striking image of the medieval leprosaria, waiting across three centuries, "soliciting with new incantations a new incarnation of disease, another grimace of terror, renewed rites of purification and exclusion," till they were populated by the mad)^[36] is simply a figment of the latter's overactive imagination: "Occasionally the mad were indeed sent away on boats. But nowhere can one find reference to real boats or

[33] Cf. the bitter comment of John Thomas Perceval, son of the assassinated prime minister and one of the thunders of the Alleged Lunatics' Friend Society: "The glory of the modern system [of moral treatment] is repression by mildness and coaxing, and by solitary confinement" (Letters to Sir James Graham . . . upon the Reform of the Law Affecting the Treatment of Persons Alleged to Be of Unsound Mind [London, 1846], letter dated 1 August 1845, quoted in 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], 338).

[34] See the discussion in Chapter 8 and my more extended treatment of asylum conditions in Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (London: Allen Lane; New York: St. Martin's Press, 1979). The later chapters of Rothman's Discovery of the Asylum provide a useful comparative perspective on American state hospitals in the nineteenth century.

[35] Foucault, Histoire de la folie, 19 (Madness and Civilization, 8).

[36] Foucault, Madness and Civilization, 3 (Histoire de la folie, 13).

ships loaded with mad pilgrims in search of their reason."^[37] Where the mad proved troublesome, they could expect to be beaten or locked up; otherwise they might roam or rot. Either way, the facile contrast between psychiatric oppression and an earlier almost anarchic toleration is surely illusory.

Foucault's history of madness allocates a central place to the classical age, the period, as he sees it, of the "Great Confinement." Beginning with the founding of the first Hôpital Général in Paris in 1657, the poor, the disabled, the deviant, and the morally disreputable—all those who displayed an incapacity for productive work—were swept up and confined. The mad formed only a tiny fraction of the total, yet Foucault's account portrays the whole episode as constituting a grand confrontation between "reason" and "unreason" that led to a profound shift in social sensibilities: "In the classical age, for the first time, madness was perceived through a condemnation of idleness and in a social immanence guaranteed by the community of labor. The community acquired an ethical power of segregation, which permitted it to eject, as into another world, all forms of social uselessness."^[38] It was "the immorality of unreason" that prompted its segregation from public view, as an affront to bourgeois sensibilities.

Madness, it seems to me, is here accorded a much more significant place in comprehending the ancien régime 's resort to confinement than its quite marginal role actually warrants. Moreover, because he rejects any explanatory schema in which notions of central state power and the economic determination of action play a central role, Foucault neglects the instructive contrast between the Continental and English experiences in this period.^[39] At the same time, he goes badly astray even in trying to account for the French policies, for, as Erik Midelfort points out, "the massive attempt to compel the poor to enter institutions originally set up on a voluntary basis ... has more to do with absolutism and centralization than with bourgeois inspiration."^[40]

Developments elsewhere likewise emphasize the central importance of attending directly to the political realm. In Ireland, for example, the pe-

[37] Midelfort, "Madness and Civilization," 254. See also Peter Sedgwick Psychopolitics, 125–48.

[38] Foucault, Madness and Civilization, 58.

[39] See the sketch of some basic points of comparison in Scull, Museums of Madness, 20–22. Cf. also Klaus Doerner, Madmen and the Bourgeoisie (Oxford: Basil Blackwell, 1981). One particularly salient difference was the private "trade in lunacy." Cf. William Parry-Jones, The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries (London: Routledge and Kegan Paul; Toronto: University of Toronto Press, 1972). The problems of applying Foucault's picture of a "Great Confinement" to the English experience in the eighteenth century have recently received more extended attention in Porter's Mind Forg'd Manacles .

[40] Midelfort, "Madness and Civilization," 256.

culiar quasi-administrative structure English imperialism imposed had far-reaching effects on the establishment and development of district asylums. Where the strength of localism in England ensured that lunacy reformers there faced a protracted and hard-fought battle to secure enactment of their schemes, in Ireland the conversion of a small governing group to the virtues of the asylum solution sufficed to secure the prompt passage of the necessary legislation, seemingly without much in the way of attention or debate. Subsequently, the authorities in Dublin Castle retained much greater powers over the size and operations of the system than were possessed by their counterparts in London, the lunacy commissioners. The United States presents a different pattern again, its federal structure leaving responsibility for coping with insanity to the individual states. As I analyze in Chapter 5, the continued intellectual dependence of the new republic on Europe profoundly influenced America's first experiments with the asylum; but thereafter the history of American psychiatry is indelibly marked by the dispersion of policy-making responsibility among the several states.^[41]

If Foucault's analysis failed to present either a systematic discussion of politics or a serious dissection of economic structures, it also neglected to provide us with any coherent or persuasive account of how professional control over madness was secured by physicians. It is, he claims, "Tuke et Pinel [qui] ont overt l'asile à la connaissance médicale."^[42] But Tuke was a layman, and the whole burden of his version of moral treatment constituted "a rather damning attack on the medical profession's capacity to deal with mental illness."^[43] Moral treatment, at least in its English guise, was a threat to preexisting medical involvement in the mad business, and, as I discuss later, it took a concerted effort on the part of interested medical men to put down the challenge it posed to their emerging hegemony. And though Pinel was an eminent physician, his experience convinced him that medicine was all but useless in madness, and he concluded that the success obtained in applying exclusively a moral regimen "gives great weight to the supposition, that, in a majority of instances, there is no organic lesion of the brain nor of the cranium."^[44] Jan Goldstein's detailed reconstruction of the circumstances surrounding Pinel's

[41] Cf. Grob, Mental Institutions in America, passim. As Chapter 13 below demonstrates, this dispersion continues to be true today. The differing speed and character of current British and American efforts to deinstitutionalize the mentally ill must be understood, at least in part, as a reflection of the differences between the two political systems. Moreover, even within the United States, the marked interstate variations compel attention to the local political apparatuses.

[42] Foucault, Histoire de la folie, 525 (Madness and Civilization, 271).

[43] William F. Bynum, "Rationales for Therapy in British Psychiatry, 1780–1835," in Madhouses, Mad-Doctors, and Madmen, ed. Scull, 43.

[44] Philippe Pinel, A Treatise on Insanity, trans. D. D. Davis (1806), facsimile ed. (New York: Hafner, 1962), 5.

"discovery" of moral treatment has demonstrated quite conclusively "its non-esoteric, lay origins—which Pinel [himself] so proudly and defiantly proclaimed."^[45] By his own account, his contribution was to convert this "charlatanistic" technique developed by the lay concierges who had dayto-day charge of the insane "into a respectable tenet of official medicine," a scientizing project he accomplished through philosophical specification of the mechanisms of both cause and cure and through the application of statistical methods to measure and confirm quantitatively "the efficacy of the treatment."^[46]

In Pinel's eyes, "the lay concierge, as diligent, perceptive, and talented as he might be, was inalterably the intellectual inferior of the médecinphilosophe . The latter would take the rough-hewn commonsensical knowledge of the former and transform it into something refined, scientific, and esoteric; the elite professional confraternity, at one moment threatened with dissolution by Pinel, was thus fundamentally—and quickly—restored by him."^[47] But not always securely. As Dowbiggin has shown,^[48] in France, too, moral treatment's implied or explicit denigration of the value of medical treatment on occasion threatened the legitimacy of the physician's presence in the asylum, a problem that long persisted and then recurred, much to the discomfort of later generations of alienists. So the role of Pinel and Tuke in ushering in the Golden Age of psychiatry^[49] is at the very least far more complicated and indirect than the reader of Madness and Civilization might surmise.

[45] Jan Goldstein, Console and Classify: The French Psychiatric Profession in the Nineteenth Century (Cambridge: Cambridge University Press, 1987), 72–119.

[46] Ibid., 105 and 101.

[47] Ibid., 77.

[48] Ian Dowbiggin, "The Professional, Sociopolitical, and Cultural Dimensions of Psychiatric Theory in France 1840–1900" (Ph.D. dissertation, University of Rochester, 1986). On French psychiatry in the first half of the century, see also Jan Ellen Goldstein, "French Psychiatry in Social and Political Context: The Formation of a New Profession 1820–1860" (Ph.D. dissertation, Columbia University, 1978), now revised and published as Console and Classify: The French Psychiatric Profession in the Nineteenth Century (Cambridge: Cambridge University Press, 1987). As Goldstein notes, Pinel's protégé Esquirol was far more overtly and forcefully concerned with the maintenance and expansion of professional prerogatives. Compare his typically combative claim that

The physician must be, in some manner, the vital principle of a lunatic hospital. It is he who should set everything in motion; he should regularize all actions, just as he has been called upon to be the regulator of all thoughts. . . . The action of the administration, which governs the material aspect of the establishment and supervises all the employees, ought to be hidden. Never should the administration appeal a decision made by the physician, never should it interpose itself between the physician and the lunatics or between the physician and the non-medical staff (les serviteurs ). The physician should be invested with an authority from which no one is exempt (quoted in Console and Classify, 132).

[49] Cf. Robert Castel, L'Ordre psychiatrique: L'Âge d'or d'aliénisme (Paris: Minuit, 1976) (English translation: The Regulation of Madness: Origins of Incarceration in France [Berkeley: University of California Press; Oxford: Pulity Press, 1988]).

Chapter 6 represents an attempt on my part to examine these issues; it was, in fact, the first essay I published on matters psychiatric. Its focus only on events in the late eighteenth and nineteenth centuries is, I now feel, somewhat misleading. My subsequent researches into seventeenth-and eighteenth-century medical writings, some of which form the basis of the argument presented in Chapter 3 on the domestication of madness, made clear to me that I had underestimated the degree of interest in insanity some medical men displayed at that time. More generally, the passage from an eclectic fusion of the supernatural and the scientific—the religious, the magical, the social, the moral, and the medical—to a purely naturalistic and secular account is unquestionably more complex and convoluted than a narrow focus on nineteenth-century developments would lead one to believe. Michael MacDonald, for example, has plausibly argued, in his splendid Mystical Bedlam,^[50] that a preference for natural causation and a "hankering after the bare Mechanical causes of things,"^[51] which entailed a disposition to reject demonological and supernatural accounts of madness, grew ever more widespread among the English elite in the aftermath of the Restoration, in substantial measure as part of a conscious rejection of religious fanaticism and "enthusiasm."

At the same time, as MacDonald himself concedes, "ordinary men and women were reluctant to abandon beliefs that reinforced their view of the universe as a theatre of spiritual warfare between the forces of good and evil, and they continued to fear the power of Satan and malign spirits throughout the eighteenth century."^[52] Thus (among other things) they remained disposed to see madness in more traditional terms. Furthermore, evidence that a large fraction of the English elite had come to embrace medical accounts of mental disorder during the course of the eighteenth century does not invalidate the claim that the ineffectiveness and scandals associated with medical treatment, in the context of the emergence of the lay vision of moral treatment, posed a potentially powerful threat to medical hegemony at the outset of the following century.^[53] I continue to believe, in consequence, that the account I offer here of the cognitive and legal entrenchment of a medical monopoly over the treatment of madness retains much of its force and relevance.

Recent work has begun to examine in more extended contexts the sig-

[50] Michael MacDonald, Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth Century England (Cambridge: Cambridge University Press, 1981). See also idem, "Religion, Social Change and Psychological Healing in England," in The Church and Healing, ed. W.J. Shells (Oxford, 1982); idem, "The Secularization of Suicide in England, 1660–1800," Past and Present 3 (1986): 50–100; and, for similar arguments, Porter, "The Rage of Party."

[51] Henry Halliwell, Melampronea; or, A Discourse of the Polity and Kingdom of Darkness (London, 1681), 77–78, quoted in MacDonald, "Secularization," 86.

[52] MacDonald, "Secularization," 87.

[53] For other commentaries on this point, see William F. Bynum, "Rationales for Therapy in British Psychiatry, 1780–1835," in Madhouses, Mad-Doctors, and Madmen, ed. Scull, 35–57; and Anne Digby, Madness, Morality and Medicine, esp. chaps. 2–6.

nificance of psychiatry's commitment to the somatic style, and this is likely to be a continuing focus of future research in the field. Reflecting the poverty of its cognitive accomplishments, its persistently dismal therapeutic capacities, and the social undesirability and disreputability of most of its clientele, psychiatry has enjoyed a perpetually marginal and unenviable position in the social division of labor—a profession always, so it seems, but a step away from a profound crisis of legitimacy.^[54] Without question, its repeatedly successful defense of its tenuous social mandate has had multiple sources, many having little to do with its ideological presentation of self: the absence, for instance, of plausible rivals for its role; the continuing social utility of medical discourse as a rationalization for measures of intervention and control directed at the acute and persistent problems posed by the mad; and the real, if sharply circumscribed, impact of medical technology on the more florid manifestations of madness. Still, as a growing body of research repeatedly demonstrates, the organic metaphor, periodically reworked to bring psychiatric language into plausible correspondence with the reigning models of the somatic machine that characterize the medical mainstream, has been (as it continues to be) of quite central importance in establishing the psychiatrists' exclusive jurisdiction over the insane, their expertise as medical specialists, and popular acceptance (however grudging) of that expertise.

Stephen Jacyna, for example, has provided a detailed and searching examination of English psychiatric ideas in the mid-Victorian era,^[55] pointing out the intimate connections between the rise of an aptly named "physiological psychology" and its polemical usefulness "to entrench and to enhance ... professional prerogatives." Reflex models of nervous function had come to dominate British neuroscience by the mid-nineteenth century, and over the next decade and a half it was in terms of reflex action that British alienists increasingly couched their explanations of insanity. But the construction of these connections masked a huge gap between scientific pretensions and reality. The use of reflex theory was crude and casual. What masqueraded as inferences from the latest developments in neurology was in fact simply the restatement of "old doctrines in a novel idiom." For beneath "the thin veneer of modernity" provided by the appropriation of the language of neuroscience there lurked a continuing attachment to a vascular, inflammatory etiology of insanity.^[56]

[54] Cf. Charles Rosenberg, "The Crisis of Psychiatric Legitimacy: Reflections on Psychiatry, Medicine, and Public Policy," in American Psychiatry: Past, Present, and Future, ed. G. Kriegman et al. (Charlottesville, Virginia: University Press of Virginia, 1975), 135–48.

[55] L. S. Jacyna, "Somatic Theories of Mind and the Interests of Medicine in Britain, 1850–1879," Medical History 26 (1982): 233–58.

[56] Ibid., 241, 244, 248.

In an important series of papers,^[57] focusing on the last third of the nineteenth century, Ian Dowbiggin has similarly sought to connect French psychiatry's precarious social and scientific standing to the question of theory choice in the discipline. His discussion demonstrates how, in a very different sociopolitical and scientific setting, the theory of morbid heredity and degeneration "offered a loosely defined yet appealing cognitive model through which psychiatrists could terminate the theoretical conflicts dividing their profession and simultaneously counter their declining image, gain intellectual legitimacy through identification with the more fashionable biological sciences, and accommodate themselves to a general pessimism that characterized nineteenth-century French currents of thought."^[58] Particularly salient in the French context was the persistent threat posed by clerical interest in the problems of insanity,^[59] hence one powerful and culturally specific source of pressures to reemphasize the centrality of the body. But, more generally, the profession's therapeutic impotence, the psychiatrists' own growing despair, the massive overcrowding of French asylums, and the low esteem, even outright hostility, with which psychiatrists were greeted by the French public made them a beleaguered group desperate to hang on to the threads of respectability. Not just the persistent inability to discover cerebral lesions in autopsies performed on the insane, but also the developing rejection of the doctrine of pathological anatomy among members of the Paris School of Medicine forced alienists to modify the basis of their claim that madness was rooted in disorders of the soma. Yet their conviction remained unshakable that insanity was brain disease. It was a proposition, for them, not intelligibly subject to doubt, for to question it was to challenge their claims to objectivity and to scientific status, the very basis of their privileged and authoritative role in the diagnosis and disposition of the lunatic.

But the persistent recourse to somatic theories of mental disorder has a much broader significance than its role in convincing political elites to legislate in favor of medical interests. As Roger Smith has rightly suggested, if we are to comprehend the "more subtle role played by belief as a cultural resource, and not just as a vehicle of professional advance-

[57] See Ian Dowbiggin, "Degeneration and Hereditarianism in French Mental Medicine 1840–1890: Psychiatric Theory as Ideological Adaptation," in Anatomy of Madness, ed. Bynum, Porter, and Shepherd, 1: 188–232; idem, "French Psychiatry, Hereditarianism, and Professional Legitimacy 1840–1900," in Research in Law, Deviance, and Social Control, Vol. 7, ed. Andrew Scull and Steven Spitzer (Greenwich, Conn.: JAI Press, 1985), 135–65; idem, "French Psychiatric Attitudes Towards the Dangers Posed by the Insane ca. 1870," in Research in Law, Deviance, and Social Control, Vol. 9, ed. Andrew Scull and Steven Spitzer (Greenwich, Conn.: JAI Press, 1988), 87–111.

[58] Dowbiggin, "Degeneration and Hereditarianism," 189.

[59] See the extended discussion in Goldstein, Console and Classify, passim, esp. 197–275 and 361–77.

ment," we must necessarily pay close attention to the detailed content of medical theories.^[60] Much of the time, for example, psychiatry has derived, not only its mandate, but also its therapeutics from its metaphysical embrace of the body. Repeatedly, an emphasis on physical pathology has prompted the employment of physical treatments. Henry Maudsley articulated the logic of this position with characteristic bluntness: "That which ... has its foundation in a definite physical cause must have its cure in the production of a definite physical change."^[61] The alternative could be speedily and scornfully dismissed. "No culture of the mind, however careful, no effort of will, however strong, will avail to prevent irregular and convulsive action when a certain degree of instability of nervous element has, from one cause or another, been produced in the spinal cells. It would be equally absurd to preach control to the spasms of chorea, or restraint to the convulsions of epilepsy, as to preach moderation to the east wind, or gentleness to the hurricane."^[62]

As Michael Clark has brilliantly demonstrated,^[63] in this fierce rejection of psychological approaches to mental disorder, Maudsley was entirely representative of his generation. Moreover, his convictions were firmly anchored in the "deep structures" of Victorian psychiatric theory, notwithstanding that somatic-pathological approaches to insanity (borrowing, by now, from the French emphasis on degeneration and morbid heredity), embodied a double failure: they yielded little in the way of increased scientific understanding of the etiology and pathology of insanity; and, equally, they possessed no clear-cut or decisive therapeutic advantages over "moral treatment" or other purely empirical nonmedical methods when it came to curing the insane.

Though we lack a full-fledged study of comparable scope and sophistication for the United States in the same period, it is apparent that not just institutional psychiatrists, but also such emerging specialisms as neu-

[60] Roger Smith, Review of Museums of Madness, Isis 71 (1980):257.

[61] Henry Maudsley, The Physiology and Pathology of Mind (London: Macmillan, 1867), 83. Psychiatrists over the years have been equally enamored of the reverse proposition: that physical interventions cure or modify mental disorder is alleged as "proof" that the condition itself has a physical etiology.

[62] Ibid., 83. Cf. John Gray, editor of the American Journal of Insanity: "If insanity be merely a disease of the mind, pure and simple, we can readily admit the all-sufficiency of moral means of treatment. Believing, however, that it is but a manifestation of physical lesion, ... to which the psychical phenomena are subordinate or secondary, any other conclusion than that which makes medical therapeutics the basis of treatment involves an absurdity" ("Editorial," American Journal of Insanity 21 (1865):558.

[63] Michael Clark, "The Rejection of Psychological Approaches to Mental Disorder in Late Nineteenth Century British Psychiatry," in Madhouses, Mad-Doctors, and Madmen, ed. Scull, 271–312. See also idem, "'The Data of Alienism': Evolutionary Neurology, Physiological Psychology, and the Reconstruction of British Psychiatric Theory, c. 1850-c. 1900" (D.Phil. dissertation, Oxford University, 1982).

rology and gynecology, competitors with the more established professionals for patients on the borderland of insanity,^[64] evinced a similarly thorough-going materialism.^[65] Much of neurological therapeutics, for example, from the elaborate shiny machines for administering static electricity to S. Weir Mitchell's famous "rest cure" (which involved isolation from one's family, rest, diet, massage, and absence of all responsibility), to our eyes depended for its efficacy largely on its psychological impact on the patient. But while acknowledging that individual suggestibility sometimes played a part in a cure, the neurologists remained deeply antagonistic, not merely to psychological explanations of insanity, but to any sustained or systematic attention to mental therapeutics. Mitchell himself, though he accepted that there were some similarities between his rest cure and the activities of exponents of religiously based "mind cures," insisted that the fundamental impact of his approach derived from its contribution to building up the patient's "fat and blood."^[66] And when George M. Beard had the temerity to suggest that "expectation is itself a curative force,"^[67] he met with furious criticism from his colleagues, who denounced him for descending "to the level of all sorts of humbuggery."^[68]

There is ample scope for further interrogation of these nineteenth-century materials, but the work done to date has already opened up a number of further lines of inquiry, exploration of which is only just beginning. In the first place, the twentieth century provides perhaps the most startling examples of the psychiatric profession's predilection for physical treatments, ranging from malarial mosquito therapy through metrazol-induced seizures, insulin comas, electroshock treatment, and surgical treatments for focal sepsis (not to mention several more exotic, if less widely canvassed, forms of therapy). The list extends, of course, to encompass direct surgical intervention on the organ most often held to blame for the outbreak of madness, the brain, with lobotomy being one of only two psychiatric interventions held to warrant the award of the Nobel Prize in medicine!

One can easily comprehend why psychiatry might wish to envelop

[64] On American neurology's conflict with psychiatry in the late nineteenth century, see Bonnie Ellen Blustein, "'A Hollow Square of Psychological Science': American Neurologists and Psychiatrists in Conflict," in Madhouses, Mad-Doctors, and Madmen, ed. Scull, 241–70.

[65] For the gynecological example, see Scull and Favreau, "'A Chance to Cut Is a Chance to Cure.'"

[66] S. Weir Mitchell, Fat and Blood, 3d rev. ed. (Philadelphia: Lippincott, 1884); idem, Wear and Tear; or, Hints for the Overworked (Philadelphia: Lippincott, 1871).

[67] George M. Beard, "The Influence of Mind in the Causation and Cure of Disease: The Potency of Definite Expectation," Journal of Nervous and Mental Diseases 4 (1877):429–34.

[68] William Hammond, in "Minutes of the American Neurological Association," Journal of Nervous and Mental Diseases 3 (1876):429–37.

these episodes in a veil of obscurity, but it is less clear why the rest of us should collaborate in this willful amnesia. For I suspect that their history can provide uniquely powerful insights into the interdependence of the intellectual and the social (a central theme of much of the best recent work in the field) and into the nature of the psychiatric enterprise as a whole. Strategically, too, the latest example of the fascination with facsimiles of more conventional medical therapeutics—the rise of psychopharmacology, associated particularly with the advent of the phenothiazines, the so-called major tranquilizers—appears to have been of quite major importance in the recapture of the commanding heights of psychiatric training programs by biological psychiatry^[69] and in the interprofessional competition between psychiatry and the burgeoning numbers of lay psychotherapists, social workers, clinical psychologists, and the like. Its importance notwithstanding, we have as yet investigated only a small portion of this territory in any depth.^[70]

Equally intriguing is the opposite line of investigation: how medical resistance to psychological approaches was, in different settings, at least partially overcome, permitting the development of dynamic psychiatry, particularly in its Freudian guise. Apart from the intrinsic interest that attaches to this question, it clearly has a vital and direct bearing on how and why twentieth-century psychiatry was able to expand and diversify the territory it was presumed competent to manage.

Not the least important factor was surely the continuing therapeutic and scientific barrenness of work based on pathological anatomy, and the growing recognition of this as the Victorian era drew to a close. Michael Clark has suggested that "it was an acute awareness of just how lowly, despised and vulnerable institutional psychiatry's existing social position was, and a desperate desire to escape its suffocating constraints

[69] As Donald Light has noted, the increasing prominence of psychoanalysis in America in the years after World War II, was reflected, through the late 1960s, in the dominant role analysts began to play in the psychiatric training programs at major medical schools and in the successful "capture" of the brightest young residents by the analytic community during those same years. But the following decade saw a sharp reorientation "toward biology and physiology with a seriousness and depth that are neither cosmetic nor ephemeral . . . a basic shift in how psychiatrists are trained and go about their work" (Donald Light, Becoming Psychiatrists [New York: Norton, 1980], xi). One measure of the psychoanalyric decline is provided by a 1976 survey conducted by the American Psychoanalytical Association, which revealed that the average analyst had only 4.7 patients under treatment, as compared with 6.2 patients a decade earlier, a fall of more than 20 percent. (Figures cited in Anthony Clare, Psychiatry in Dissent, 2d ed. [London: Tavistock, 1980].) Given the social and scientific significance of these changes, it is somewhat surprising that they have yet to attract serious scholarly attention.

[70] The most extensive analysis to date is Valenstein's Great and Desperate Cures . For a more limited analysis of the use of oral and abdominal surgery as a treatment for focal sepsis (and thus, so its proponents believed, for mental illness), see Scull, "Desperate Remedies."

and frustrations, rather than any more vaunting ambition, which drove later-Victorian psychiatrists to broaden and diversify their territory."^[71] And, within their own professional circles, Americans quite openly made a similar diagnosis: "Our therapeutics," C.G. Hill complained, in his 1907 Presidential Address to the American Medico-Psychological Association, "is simply a pile of rubbish."^[72] Two years later, in his address to his fellow neurologists, Weir Mitchell echoed Hill's analysis: "Amid enormous gains in our art, we have sadly to confess the absolute standstill of the therapy of insanity and the relative failure, as concerns diagnosis, in mental maladies of even that most capable diagnostician, the postmortem surgeon."^[73]

But this internal sense of crisis and malaise was clearly insufficient, by itself, to prompt more than public handwringing and lamentations. In the British context, both Elaine Showalter and Martin Stone have suggested that it was a powerful set of social pressures, "the exigencies of war and a mass epidemic of mental disorders"—shellshock among the troops—that constituted the necessary stimulus "to set the mechanism of psychiatric change in motion."^[74] Unquestionably, World War I had similar effects in the United States. Here, however, the effects of wartime experience were to speed up a process that had already acquired considerable momentum in the earliest years of the new century. Once again, even with our present rather imperfect understanding of these changes, it seems clear that external developments were powerfully implicated in producing internal realignments of the profession. Most especially, the extraordinarily rapid proliferation of religiously based mental healing cults (of which Christian Science was the most notable) had prompted a growing "exodus of patients from the doctor's waiting room to the minister's study."^[75] Faced by people voting with their feet for mental therapeutics, many physicians apparently concluded that patients must be saved from themselves, even if this meant that psychological medicine would have to abandon its traditional "antagonism to methods of treatment which appeal to other than physical means."^[76]

[71] Clark, "'Data of Alienism,'" 312.

[72] Charles G. Hill, "How Can We Best Advance the Study of Psychiatry?" American Journal of Insanity 64 (1907): 6.

[73] Silas Weir Mitchell, "[Presidential] Address to the American Neurological Association," Transactions of the American Neurological Association 35 (1909): 1.

[74] Martin Stone, "Shellshock and the Psychiatrists," in Anatomy of Madness, ed. Bynum, Porter, and Shepherd, 2:242–71; idem, "The Military and Industrial Roots of Psychology in Britain" (Ph.D. dissertation, London School of Economics, 1985); Showalter, Female Malady, chap. 7.

[75] Barbara Sicherman, "The Quest for Mental Health in America, 1880–1917" (Ph.D. dissertation, Columbia University, 1967), 269–70.

[76] Edward Wyllwys Taylor, "The Attitude of the Medical Profession Toward the Psychotherapeutic Movement," Journal of Nervous and Mental Diseases 35 (1908): 420. We need to recall that in both societies, even at the zenith of dynamic psychiatry's popularity, powerful elements in the profession remained unalterably opposed to any but somatic approaches and continued to stigmatize those who strayed from the path of scientific medicine as teetering on the brink of quackery. For a somewhat more extended analysis of these issues, see Andrew Scull, "The Social History of Psychiatry in the Victorian Era," in Madhouses, Mad-Doctors, and Madmen, ed. Scull, 19–23.

At present, too, these are aspects of the evolving relationship between psychiatry and the larger social order that we can glimpse only in broad outline. If we are serious about grasping the unfolding effects of professional intervention in the lives of the mad and about understanding the complexities of the interrelationships between psychiatric power and knowledge, we obviously have a large agenda of research before us. The bulk of recent historical work in the field has concentrated on the eighteenth and nineteenth centuries,^[77] and by contrast, our own century, even as it draws to a close, remains for the most part a dark continent in which merely a few prominent landmarks stand out. Only with respect to the last quarter century are things a little better, for this is a territory in which even an ahistorical sociology feels at home and about which it has had something to say.

Indeed, in some respects, sociology has been a participant in, rather than just an observer of, recent events. For the sociological critique of the mental hospital's pathologies, along with labeling theory's portrayal of stabilized mental disorder as ironically the product rather than the object of psychiatry's attentions, played a considerable role ideologically in underwriting the shift from institutional to community care and in prompting the constriction of the permissible grounds for certifying someone as so mad as to need confinement. At the birth of the asylum, reformers conjured up a mythological portrait of its virtues and its startling therapeutic effectiveness. Subsequently, alienists campaigned long and hard (albeit with at best limited success) to persuade the public of the need to adopt broad and easily satisfied commitment criteria: decision rules that would license swift commitment of incipient lunatics to their institutions, before minor eccentricities and mental imbalance passed over into permanent and chronic insanity. Our contemporary myths, embracing exactly the contrary set of assertions, have proved the more powerful since they can claim to constitute the findings of social "science."

One of the virtues of a historical perspective that extends beyond the ideas and events of the past quarter century is that it makes us properly

[77] Among the obvious exceptions to this generalization, besides the somewhat tiresome sectarian squabblings about the history of psychoanalysis, are Gerald Grob's Mental Illness and American Society, 1875–1940 (a useful, if somewhat plodding, administrative history of the American scene); David Rothman's Conscience and Convenience (Boston: Little, Brown, 1980), discussed at length in Chapter 10; and Martin Stone's still unpublished Ph.D. thesis, "Military and Industrial Roots of Psychology in Britain."

skeptical about claims of intellectual breakthroughs and the discovery of utopian solutions to the complex and extraordinarily recalcitrant problems we label mental illness. It also leaves us better placed to assess just how novel and original our current enthusiasms really are. Modern sociological critics of the "total institution" have remained blissfully innocent of the degree to which their findings reproduce observations first made a century and more ago.^[78] And examination of nineteenth-century debates over what constituted adequate grounds for involuntary commitment to an asylum likewise disabuses us rather rapidly of the conceit that our generation has developed some privileged insight into the dangers of unchecked psychiatric authority over the commitment process.^[79] If the social impact of such ideas and criticism turns out to vary sharply over time, it constitutes just one more reminder not only of the profound and inescapable mutual dependence of the social and the intellectual but also of the impossibility of gaining a proper understanding of one without knowledge of the other.

At various times during the past decade, I have been accused both of being viciously anti-institutional^[80] and of wanting to reinstitutionalize the mad en masse .^[81] While I take a certain sly pleasure in having simultaneously ruffled the feathers of the complacent souls who somehow continue to see mental hospitals as "the most blessed manifestation of true civilization"^[82] and of the odd mixture of zealots and penny-pinching politicians who continue to call malign neglect "community care, " I must respectfully decline both labels. Like the late Peter Sedgwick, my knowledge of what went on in the old "loony bins" makes me want to shout "Never again!" to the prospect of a return to an unreconstructed psychiatric Victorianism.^[83] But this must not blind us to the appalling deficiencies of yet another generation of mental health "reforms" or prevent us from recognizing that, as a last resort, sheltered care must remain an option for coping with a minority of the mentally disturbed. Over the past century and a half, we have swung wildly from viewing the asylum as the universal panacea for the defects of the community to seeing the com-

[78] See the discussion of nineteenth-century critiques of the asylum in Scull, Decarceration, chaps. 6 and 7.

[79] In addition to the discussion in Chapter 12 below, see Nicholas Hervey's paper on the wonderfully named Alleged Lunatics' Friend Society of mid-Victorian England ("Advocacy or Folly: The Alleged Lunatics' Friend Society, 1845–63," Medical History 30 [1986]: 245–75).

[80] Seymour Mauskopf, review of Museums of Madness by Andrew Scull, Journal of Interdisciplinary History 11 (1981): 726–29.

[81] Cf. Leonard V. Kaplan, "State Control of Deviant Behavior: A Critical Essay on Scull's Critique of Community Treatment and Deinstitutionalization," Arizona Law Review 20 (1978): 189–232.

[82] George E. Paget, The Harveian Oration (Cambridge: Deighton and Bell, 1866), 34–35.

[83] Cf. Sedgwick, Psychopolitics .

munity itself as a ubiquitous and uniformly desirable solution to the problem of what to do with the mentally defective. But, for all the rhetoric about community treatment, we remain as far as ever from solving the problems of "how to create the economic means of employment, the material apparatus of housing, the ethical structures of friendship and solidarity, for those who through various forms of mental disability cannot purchase these benefits as commodities in the marketplace."^[84] Worse still, I fear the balance of political forces in Britain and the United States gives little prospect of major initiatives being undertaken to mitigate or eliminate the deficiencies of existing mental health policy.

Not just the present, but even the future for the chronically crazy strikes me as grimly unpromising. I wish it were otherwise. But, as Freud once taught us, reality, however harsh, is in the long run preferable to the childish consolations offered by a retreat into the realm of fantasy (appealing as the latter may sometimes seem).

[84] Ibid., 241.