Chapter Six
From Madness to Mental Illness: Medical Men as Moral Entrepreneurs

"From Madness to Mental Illness" was the first paper I published on matters psychiatric. (It was also, as a matter of fact—though in a somewhat different form—the first chapter I completed a couple of years earlier when writing my doctoral dissertation.) It appeared in print in early 1975, a few months after William Bynum had published "Rationales for Therapy in British Psychiatry, 1780–1835," in which he independently developed a closely related line of argument.^[1] When these articles were written, serious historical research on English responses to insanity in the seventeenth and eighteenth centuries, with the important exceptions of Parry-Jones' work on English madhouses^[2] and Hunter and MacAlpine's book on George III's madness^[3] and their wide-ranging anthology of British "psychiatric" texts,^[4] was still in its infancy. My discussion of the place of medicine in the treatment of the mad prior to the nineteenth-century events with which I was principally concerned was accordingly quite brief and limited, stressing only some of the special advantages that eighteenth-century doctors had in asserting jurisdiction over insanity and pointing out that by the latter part of George III's

[1] William F. Bynum, "Rationales for Therapy in British Psychiatry, 1780–1835," Medical History 18 (1974): 317–34.

[2] William L. 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).

[3] Ida Macalpine and Richard A. Hunter, George III and the Mad Business (London: Allen Lane, 1969).

[4] Richard Hunter and Ida Macalpine, Three Hundred Years of Psychiatry, 1535 to 1860: A History Presented in Selected English Texts (London: Oxford University Press, 1963).

reign, theirs was clearty the dominant interpretation of madness in elite and educated circles. Subsequent work by Michael MacDonald^[5] and Roy Porter^[6] has given us a far richer and more nuanced portrait of developments from the late Tudor period to the dawn of the industrial age, presenting some particularly provocative arguments about the sources from which the upper classes adopted a naturalistic and medical perspective on mental disorder, while emphasizing the survival of more eclectic, even magical and supernatural notions among the masses even at the very end of period examined.

A year after "From Madness to Mental Illness" appeared, Roger Cooter published an excellent two-part article exploring the impact of phrenology on early-nineteenth-century medical thinking about madness.^[7] Although I would quarrel with some of the further claims he makes about phrenology's importance, Cooter's central argument is surely well taken: Phrenology served as a vital theoretical mediation in the attempt to assimilate moral treatment into the medical armamentarium. Its doctrines provided a clear physiological explanation of the operations of the brain, one that permitted a parsimonious account of abnormal as well as normal mental functioning, while advancing a coherent rationale for the application of both medical and moral treatment in cases of insanity. His essay constitutes an important elaboration and refinement of my argument about the ways in which medicine succeeded in incorporating moral treatment into its recognized sphere of expertise.

It should be apparent that what follows deals with only one aspect of the rise of a self-conscious profession monopolizing the treatment of the mentally disordered. For England, we still lack a careful prosopographical study of the changing bases of recruitment to the mad-business, or any sustained analysis of the development of an organized profession. Two such attempts have been made, drawing on American materials,^[8] and it

[5] Michael MacDonald, Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth Century England (Cambridge: Cambridge University Press, 1981); "Insanity and the Realities of History in Early Modern England," Pychological Medicine 11 (1981): 11–25; and "Religion, Social Change, and Psychological Healing in England, 1600–1800," in The Church and Healing, ed. W. Sheils (Oxford: Basil Blackwell, 1982), 101–26.

[6] Roy Porter, Mind Forg'd Manacles: A History of Madness in England from the Restoration to the Regency (London: Athlone, 1987); "Being Mad in Eighteenth Century England," History Today, December 1981, 42–48; "The Rage of Party: A (Glorious Revolution in English Psychiatry?" Medical History 27 (1983):35–50; and "Love, Sex, and Madness in Eighteenth Century England," Social Research 53 (1986):211–42.

[7] R. J. Cooter, "Phrenology and British Alienists, circa 1825–1845," Medical History 20 (1976): 135–51.

[8] John Pitts, "The Association of Medical Superintendents of American Institutions for the Insane, 1844–1892: A Case Study of Specialism in American Medicine" (Ph.D. dissertation, University of Pennsylvania, 1978); Constance McGovern, Masters of Madness: Social Origins of the American Psychiatric Profession (Hanover, N.H.: University Press of New England, 1985).

clearly would be extremely helpful to have a comparable analysis of the development of psychiatry in Victorian England. I continue to believe, however, that assumptions about the somatic basis of mental disturbance have played a quite crucial role in legitimizing medical claims to exclusive jurisdiction over the mad throughout the nineteenth and twentieth centuries and have proved similarly crucial in the determination of therapeutic practices during this period. Indeed, I plan to make an examination of these issues the focus of my next book.^[9]

From Madness to Mental Illness: Medical Men as Moral Entrepreneurs

"When I use a word," Humpty Dumpty said, in a rather scornful tone, "it means just what I choose it to mean—neither more nor less."
"The question is," said Alice, "whether you can make words mean so many different things."
"The question is," said Humpty Dumpty, "which is to be master—that's all."
—LEWIS CARROLL,
Through the Looking Glass

This chapter seeks to provide a sociological account of one aspect of a highly significant redefinition of the moral boundaries of English society, a redefinition that saw the transformation of insanity from a vague, culturally defined phenomenon afflicting an unknown, but probably small, portion of the total population into a condition that could be authoritatively diagnosed, certified, and dealt with only by a group of legally recognized experts and that was now seen as one of the major forms of deviance in English society. Where in the eighteenth century only the most violent and destructive among those now labeled insane would have been segregated and confined apart from the rest of the community, by the mid-nineteenth century, with the achievement of lunacy "reform," the asylum was endorsed as the sole officially approved response to the problems posed by all forms of mental illness. In what

[9] For some preliminary discussion, see Andrew Scull and Diane Favreau, "The Clitoridectomy Craze," Social Research 53 (1986): 243–60; idem, "'A Chance to Cut Is a Chance to Cure': Sexual Surgery for Psychosis in Three Nineteenth Century Societies," in 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.

follows, I want to focus attention rather closely on one centrally important feature of this whole process: just how that segment of the medical profession we now call psychiatry captured control over insanity; or, to put it another way, how those known in the early nineteenth century as mad-doctors first acquired a monopolistic power to define and treat lunatics, I shall begin, though, with some general remarks on the sociological importance of the issues I shall be raising here.

In the first place, although the locus of responsibility for lunatics has shifted from the family and the local community to a group of trained professionals who, by reason of their expertise, claim to have a unique capacity for understanding and treating them, this change is by no means confined to the case of mental illness. The symbiotic relationship between psychiatry and insanity, with which I am here concerned, is merely a particularly important example (just how important I shall indicate in a moment) of a much more general trend in the social control practices of modern societies.^[1] Elites in such societies over about the past century and a half have increasingly sought to rationalize and legitimize their control of all sorts of deviant and troublesome elements by consigning them to the ministrations of experts. No longer content to rely on vague cultural definitions of, and informal responses to, deviation, rational-bureaucratic Western societies have increasingly delegated this task to groups of people who claim, or are assumed to have, special competence in these areas. Within sociology, this reality is reflected in the current vogue of "labeling theory" and in the concern with the reactive effects of agents of social control on the problems they are supposed to solve.

The decisions these people take, and the kinds of activities they engage in, form one of the crucial ways in which deviance is now socially organized. Experts are the crucial filters in what Kai Erikson has called "the community screen."^[2] In the process of sorting out certain kinds of behavior from the everyday flow of social existence, and assigning those held responsible for them to one or another of the socially recognized deviant statuses, it is their worldview that is the most widely accepted. Most of the time, it is their theories that are used, albeit in a bastardized, simplified form, by the other elements in what we might call the referral system, those involved in "blowing the whistle" on deviants. Moreover, the experts form the final and decisive part of the screening process. Through their power to legally label, they focus, define, and institutionally fix the deviant's status. In the last analysis, laymen generally de-

[1] Robert A. Scott, "The Construction of Stigma by Professional Experts," in Deviance and Respectability, ed. J. D. Douglas (New York: Basic Books, 1970).

[2] Kai Erikson, Wayward Puritans (New York: Wiley, 1966).

fer to the experts and regard their decisions as authoritative: "Their mandate is to define whether or not a problem exists and what the 'real' character of the problem is and how it should be managed."^[3]

Among the most important of these groups of experts are psychiatrists. To a greater degree than some other experts specializing in the social control of deviance, they possess the attribute of professional autonomy.^[4] They make the most vigorous claims to have an expertise resting on a scientific basis, and their ideology has proved so plausible that their view of deviance is an increasingly important one. At least since the end of World War II, we have been moving away from a punitive and toward what Kittrie has termed a "therapeutic" state; that is, one that enshrines the psychiatric worldview.^[5] Just as "in the eighteenth and nineteenth centuries, a host of . . . phenomena—never before conceptualized in medical terms—were renamed or reclassified as mental illness,"^[6] so over the last few decades most other forms of deviance are being assimilated into a quasi-medical model, being relabeled as illness and therefore "treated" rather than punished.^[7] In such a situation, psychiatrists become perhaps the most strategically important of all experts to study, particularly since "the thrust of the expansion of the application of medical labels has been toward addressing (and controlling) the serious forms of deviance, leaving to the other institutions [law and religion] a residue of essentially trivial and narrowly defined technical offences."^[8]

In what follows, I shall be concerned with how psychiatrists in England first gained control over that type of deviance that must be assumed to form their core area of competence, namely insanity. Given the particular questions I have in mind, I shall not here be concerned with the issue of whether mental illness really is illness, and all that en-

[3] Eliot Freidson, Profession of Medicine: A Study in the Applied Sociology of Knowledge (New York: Dndd, Mead, 1970), 303.

[4] Cf. ibid.; and Freidson, Professional Dominance: The Social Structure of Medical Care (New York: Atherton, 1970).

[5] Nicholas A. Kittrie, The Right to Be Different: Deviance and Enforced Therapy (Baltimore: Johns Hopkins University Press, 1972).

[6] Thomas Szasz, Ideology and Insanity (New York: Doubleday, 1970), 137.

[7] See, for example, Freidson, Profession of Medicine, 248–55; Irving Kenneth Zola, "Medicine, Morality, and Social Problems—Some Implications of the Label Mental Illness" (Paper presented at a meeting of the American Ortho-Psychiatric Association, 20–23 March 1968); idem, "Medicine as an Institution of Social Control," Sociological Review 20 (1972) :487–504; Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, rev. ed. (New York: Harper and Row, 1974); idem, Law, Liberty and Psychiatry (New York: Macmillan, 1963); idem, The Manufacture of Madness (New York: Dell, 1970); and Kittrie, Right to Be Different .

[8] Freidson, Profession of Medicine, 249 (emphasis in the original).

tails. After all, "consequential human behavior stems from the meanings that actors impute to their experience, not from the meanings that an 'objective' observer may impute."^[9] As sociologists, we are interested in how actions are socially defined rather than with what their intrinsic qualities are. In this case, regardless of whether it is correct in some ultimate ontological sense to describe insanity as an illness, once it has been identified as such, people's responses to it are mediated by and through that socially constructed meaning; so we can legitimately ask how it was that that particular social meaning was arrived at and what its consequences are. As Freidson has argued for illness in general, we can choose to focus, not on whether certain persons are mentally sick or not, but on how their life is reorganized because they are called mentally sick.

Just as in the case of bodily illness, where a profession is granted the authority to label one person's discomfort an illness and another's not, so too with mental distress, the psychiatrists possess the ultimate power to assign one person to the status of being mentally ill and to refuse the designation to another. And it is contact with society's official experts in this area, rather than manifestations of specific behavioral or mental disturbance, that most firmly and legitimately affixes the label in the eyes of the laymen. While the situation obviously varies with the nature and degree of one's alienation, the social acceptance (or rather rejection) of someone as crazy often depends on his or her new status being professionally legitimized.^[10] Psychiatrists' labels stick in a way lay ones don't, not least because they are backed by the police power of the state. The psychiatrist can "transform his judgement into social reality."^[11]

Psychiatrists, and other social control experts for that matter, negotiate reality on behalf of the rest of society. Theirs is preeminently a moral enterprise, involved with the creation and application of social meanings to particular segments of everyday life. Just like physicians, they "may be said to be engaged in the creation of illness as a social state which a human being may assume."^[12] Indeed, in view of the indefinite criteria employed to identify and define "mental illness," its status as a socially constructed reality is, if anything, plainer than in the case of somatic illness, and the latitude granted the expert correspondingly wide. When we look at how medicine first "captured" insanity, we are in essence examining the growth and transformation of the moral order of society.

Most psychiatric historians have been inclined to equate the shift from religious or demonological "explanations" of insanity toward a concep-

[9] Ibid., 213.

[10] Derek Phillips, "Rejection: A Possible Consequence of Seeking Help for Mental Disorder," American Sociological Review 28 (1963): 963–73.

[11] Szasz, Manufacture of Madness, 75.

[12] Freidson, Profession of Medicine, 205.

tion of it as illness with the progress of science.^[13] As ideology, an account of the establishment of a medical monopoly over the treatment of insanity in these simplistic terms has obvious value, creating a myth with powerful protective functions for the profession of psychiatry. As explanation, however, its adequacy is distinctly more dubious, inasmuch as it completely ignores the social processes necessarily involved in any such transformation of perspectives.^[14] Its utility is further diminished when one recalls that, whatever one's opinions on the extent of scientifically based knowledge of mental illness today, there would, I think, be a widespread consensus on the lack of any real knowledge base in earlynineteenth-century medicine that would have given the medical profession a rationally defensible claim to possess expertise vis-à-vis insanity. In what follows, then, I hope we can discount the naive "march of progress" school so popular among psychiatric historians and instead give our attention to the social processes involved.

For all intents and purposes, the insane in England were not really treated as a separate category or type of deviant much before the middle of the eighteenth century. They were simply part of the larger, more amorphous class of the poor and indigent, a category that also included vagrants and various minor criminal elements. They were a communal and family responsibility, and all save the most violent and unmanageable were kept in the community, rather than being segregated into separate receptacles that kept them apart from the rest of society. At this stage, medical interest in and concern with insanity were practically nonexistent. During the course of the eighteenth century, these old, informal mechanisms began to be abandoned. In their place, the response to all forms of deviance assumed an increasingly institutional form. Workhouses, almshouses, houses of industry and correction, all these institutions at first accommodated an essentially mixed, heterogeneous population of the troublesome and dependent and made little effort to classify inmates by age or sex or according to presumed differences in their underlying pathology.

The insane shared in this general trend, and there now emerged a number of institutions specifically concerned with dealing with them as a separate category, a process accelerated by the difficulty of handling them in one of the ordinary mixed institutions. Most of these early

[13] See, for example, Gregory Zilboorg, A History of Medical Psychology (New York: Norton, 1941; paperback ed., 1967); Franz D. Alexander and Sheldon T. Selesnick, The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present (New York: Harper and Row, 1966).

[14] In Szasz's words, we cannot proceed "as if the psychiatric historian were a socially neutral person, discovering historical 'facts'—when, in truth, he is a psychiatric propagandist, actively shaping the image of his discipline" (Manufacture of Madness, 111).

madhouses were private speculations run for profit. Given the difficulties others experienced managing the insane and the lack of restrictions or legal checks on the actual conduct of the business, they were generally a very lucrative investment. And it was precisely at this stage that the medical profession first began to assert an interest in lunacy. A number of doctors trying to gain a share of the lucrative new business, and possibly also to improve the treatment of the insane, began opening madhouses of their own and/or became involved in efforts to set up charity hospitals for the care of lunatics.^[15]

The English medical profession at this time was composed of three separate elements—physicians, surgeons, and apothecaries—each of whom catered to a different clientele. The physicians, the elite's doctors, generally possessed a medical degree and, in London at least, were members of the Royal College of Physicians. But an M.D. was no guarantee of more than a passing acquaintance with classical authors in the fields, with no assurance of clinical experience; and membership in the college depended more on social connections than medical skill. Surgeons had only recently severed their links with the barbers' trade; entry into their ranks was usually by apprenticeship, and their status was distinctly lower than that of the physicians. Apothecaries catered largely to the middle and lower classes; they too were recruited by apprenticeship and lacked any real control over licensing and entry; so that those calling themselves apothecaries might vary from semi-illiterate quacks to highly competent practitioners by the standards of the time.^[16]

[15] For documentation of the societal response to insanity in England before the nineteenth century and of the emergence of medical interest in the treatment of the insane, see Andrew Scull, Museums of Madness: The Social Organization of lnsanity in Nineteenth-Century England (London: Allen Lane; New York: St. Martin's Press, 1979), chap. 1; and William L. 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), passim.

[16] An excellent example of the former was provided by William Finch. In his evidence before the Select Committee of 1815, he produced a certificate of insanity he had received from one such practitioner: "Hey Broadway A Potcarey of Gillingham Certefy that Mr. James Burt Misfortin hapened by a Plow in the Hed which is the Ocasim of his Ellness and By the Rising and Falling of the Blood and I think A Blister and Bleeding and meddeson Will be A Very Great thing. But Mr. James Burt would not AGree to be Don at Home, Hay Broadway" (House of Commons, Report of the Select Committee on Madhouses in England, with Minutes of Evidence and Appendices [1815], 51). The profession as a whole did not succeed in laying down uniform standards for entry until the passage of the 1858 Medical Registration Act. The Apothecaries' Act of 1815 represented an early effort to define the legal status of that segment of the medical profession. Interestingly enough, it was George Man Burrows, one of the most well-known private madhouse keepers of the early nineteenth century and the chairman of the Association of Apothecaries and Surgeon Apothecaries, whose efforts were largely instrumental in securing its passage. See Parry-Jones, Trade in Lunacy, 78, 92–93.

The doctors entering the mad-business were not drawn exclusively from any one of these three classes; nor, so far as one can judge, did they differ significantly from the rest of the profession in skill or respectability. While "doctors" with little claim to the title did enter the field, so too did well-known society physicians and those trained at some of the best medical schools of the time.^[17] By no means was the mad-business a refuge of only the most disreputable elements of the medical profession. To the contrary, those drawn from the most educated and literate elements of the profession were among the most vigorous and effective partisans of medicine's claims in this area and contributed most to its growing dominance of the field.

The earliest lay proprietors of madhouses had often attempted to attract clients by claiming to provide cures as well as care.^[18] This idea that expert intervention could provide a means of restoring the deranged to reason naturally proved an attractive one. However, it was a much more plausible claim when asserted by the medical proprietors of madhouses. To understand why this should be so, one need only recall certain basic characteristics of eighteenth-century medicine.

Unlike its modern successor, eighteenth-century medicine did not involve identifying specific disease entities and then prescribing specialized treatments for them. Rather, it possessed an arsenal of what were regarded as useful weapons against all types of bodily dysfunction. No English doctor went quite so far as the American, Benjamin Rush, who reduced all illnesses to one underlying pathology and prescribed a single remedy, depletion.^[19] Nevertheless, adherents of almost every one of the eighteenth-century medical "systems" exhibited a touching faith in a number of cure-ails—such things as purges, vomits, bleedings, and various mysterious colored powders, whose secrets were known only to their compounders. These theories and their associated remedies were read-

[17] Both William Battie of St. Luke's and John Monro of Bethlem were well-known society physicians. Anthony Addington, one of George III's physicians, had formerly kept a private madhouse at Reading. Other established doctors who kept madhouses (with the university where they were trained) included Francis Willis (Oxford); Thomas Arnold (Edinburgh); Joseph Mason Cox (Edinburgh, Paris, and Leyden); Edward Long Fox (Edinburgh); and William Perfect (St. Andrew's). Ibid., 75–77.

[18] See, for example, David Irish, Levamen Infirmi, or, Cordial Counsel to the Sick and Diseased (London: For the Author, 1700); Thomas Fallowes, The Best Method for the Cure of Lunaticks, with Some Account of the Incomparable Oleum Cephalicum Used in the Same, Prepared and Administered by Tho. Fallowes, at His House in Lambeth-Marsh (London: For the Author, 1705). (Fallowes' M.D. was awarded by himself.)

[19] On Rush, see Norman Dain, Concepts of Insanity in the United States, 1789–1865 (New Brunswick, N:J.: Rutgers University Press, 1964), 14–94; and Richard Harrison Shyrock, The Development of Modern Medicine (Philadelphia: University of Pennsylvania Press, 1936), 28–29.

ily adapted to incorporate the new disease of insanity; it was but a small leap to assert that these things would also cure lunatics.^[20]

The doctors, then, had an advantage when it came to justifying their claims to cure insanity, because everybody "knew" that they possessed powerful remedies whose use demanded special training and expertise and whose "efficacy" against a wide range of complaints was generally acknowledged. They exploited this advantage to good effect. The appearance of a number of books on the medical treatment of insanity added weight to their claim, and such famous medical teachers as William Cullen began to incorporate materials on the subject into their lectures, so that some physicians could assert that they had specialized training in this area.^[21] On this basis, therefore, doctors were gradually acquiring a dominant, though not a monopolistic, position in the mad-business by the end of the eighteenth century. Numerically, they might still be a minority, but the view of insanity as an illness was by now popular in elite circles, particularly after George III began to suffer from recurrent bouts of derangement.

As I have shown elsewhere, during the eighteenth and early nineteenth centuries, conditions in both medically and nonmedically run madhouses generally ranged from the bad to the appalling.^[22] In part because of the lack of legal checks on entry into the business or on subsequent conduct of it, gross exploitation and maltreatment of patients

[20] William Perfect advocated the use of bleedings, setons, and electricity, and the administration of emetics, digitalis, and antimony (W. Perfect, Select Cases in the Different Species of Insanity, Lunacy or Madness, with the Modes or Practice as Adopted in the Treatment of Each [Rochester: Gillman, 1787]; and idem, A Remarkable Case of Madness, with the Diet and Medicines Used in the Cure [Rochester: For the Author, 1791]). See also Thomas Arnold, Observations on the Nature, Kinds, Causes, and Prevention of Insanity, 2 vols. (Leicester: Robinson and Caddell, 1782–86); William Pargeter, Observations on Maniacal Disorders (Reading: For the Author, 1792); and Joseph Mason Cox, Practical Observations on Insanity: In Which Some Suggestions Are Offered Towards an Improved Mode of Treating Diseases of the Mind . . . to Which are Subjoined, Remarks on Medical Jurisprudence as Connected with Diseased Intellect (London: Baldwin and Murray, 1806).

[21] See William Cullen, First Lines of the Practice of Physic, 2 vols. (Edinburgh: Bell and Bradfute, 1808). Among his students who opened madhouses were Arnold and Hallaran.

[22] Cf. Scull, Museums of Madness, chaps. 2 and 3. In Dickens' words: "Coercion for the outward man, and rabid physicking for the inward man were then the specifics for lunacy. Chains, straw, filthy solitude, darkness, and starvation; jalap, syrup of buckthorn, tartarized antimony and ipecacuanna administered every spring and fall in fabulous doses to every patient, whether well or ill; spinning in whirligigs, corporal punishment, gagging, 'continued intoxication', nothing was too widely extravagant, nothing too monstrously cruel to be prescribed by mad-doctors" (Charles Dickens and W. H. Wills, "A Curious Dance Round a Curious Tree" [1852], reprinted in Charles Dickens' Uncollected Writings from Household Words [Bloomington and London: Indiana University Press, 1968], 2:382–83).

were common.^[23] And it was a particular instance of this kind of maltreatment, involving the death under mysterious circumstances of an inmate of the York Asylum, that provoked the decision to set up the York Retreat. Here there emerged an alternative approach to the mentally disturbed that for a time threatened the growing dominance of medicine in this field.

William Tuke, the founder of the Retreat, was a layman with a considerable, and not entirely unmerited, distrust of the medical profession of his day.^[24] His primary concern was with providing humane care for insane Quakers, though he also hoped, if possible, to cure them. Skeptical as he was of medicine's value, he possessed a sufficiently open mind to investigate its claims to have specific remedies for mental illness. With his encouragement, both the first visiting physician, Dr. Thomas Fowler, and his successors made a trial of all of the various medicines and techniques that members of the profession had suggested.

The results must have been a disappointment, though perhaps not a surprise. In Samuel Tuke's words, "The experience of the Retreat . . . will not add much to the honour or extent of medical science. I regret . . . to relate the pharmaceutical means which have failed, rather than to record those which have succeeded."^[25] Fowler found that

the sanguine expectations, which he successively formed of the benefit to be derived from various pharmaceutical remedies, were, in great measure, as successively disappointed; and, although the proportion of cures, in the early part of the Institution, was respectable, yet the medical means were so imperfectly connected with the progress of recovery, that he could not avoid suspecting them, to be rather concomitants than causes. Further experiments and observations confirmed his suspicions, and led him

[23] With mordant wit, William Belcher termed the madhouse proprietor of the period the "Smiling Hyena": "This animal is a non-descript of a mixed species. Form obtuse—body black—head gray—teeth and prowess on the decline—visage smiling, especially at the sight of shining metal of which its paws are extremely retentive—heart supposed to be of a kind of tough white leather. N.B. He doth ravish the rich when he getteth him into his den" (Belcher, 1796, cited in Parry-Jones, Trade in Lunacy, 226).

[24] Cf. Kathleen Jones, Lunacy, Law, and Conscience, 1744–1845: The Social History of the Care of the Insane (London: Routledge and Kegan Paul, 1955), 58–65; and idem, Mental Health and Social Policy, 1845–1955 (London: Routledge and Kegan Paul, 1960), 9. His grandfather's disapproval led Samuel Tuke to relinquish his medical studies and enter the family business instead (Dictionary of National Biography, s. v. "Tuke, Samuel"). Daniel Hack Tuke was the first of the family to qualify as a doctor. He "only overcame the family prejudice against that profession in 1852 after refusing to enter Tuke, Son and Co., giving up a legal career in its early stages and failing lamentably to become a poet" (Jones, Lunacy, Law, and Conscience, 60).

[25] Samuel Tuke, Description of the Retreat: An Institution near York for Insane Persons of the Society of Friends (1813), facsimile ed., ed. Richard A. Hunter and Ida Macalpine (London: Dawsons, 1964), 110.

to the painful conclusion (painful alike to our pride and our humanity), that medicine, as yet, possesses very inadequate means to relieve the most grievous of human diseases.^[26]

Fowler's death in 1801 and the swift demise of his successor meant that the Retreat had three visiting physicians within its first five years of operation. Both of the others arrived convinced of medicine's applicability and value. Both were disillusioned: "They have had recourse to various means, suggested by either their own knowledge and ingenuity, or recommended by later writers; but their success has not been such, as to rescue this branch of their profession, from the charge, unjustly exhibited by some against the art of medicine in general, of its being chiefly conjectural."^[27] Numerous trials had shown that all the suggestions that had been made, with the exception of warm baths for melancholics, were either useless or positively harmful.

Henceforth, the visiting physician confined his attention to treating cases of bodily illness, and it was the lay people in charge of the day-to-day running of the institution who began to develop the alternative response to insanity that became known as moral treatment.^[28] One cannot readily summarize in a phrase or two what moral treatment consisted of, nor reduce it to a few standard formulas, for it was emphatically not a specific technique. Rather, it was a general, pragmatic approach aimed at minimizing external, physical coercion; and it has, therefore, usually been interpreted as unproblematically "kind" and "humane." Instead of merely resting content with controlling those who were no longer quite human, which had been the dominant concern of traditional responses to the mad, moral treatment actively sought to transform the lunatic, to remodel him or her into something approximating the bourgeois ideal of the rational individual; and as part of this process, an effort was made to create an environment that removed the artificial obstacles standing in the way of the "natural" tendencies toward recovery. Tuke was convinced that "there is much analogy between the judicious treatment of children and that of insane persons."^[29] One should seek to reeducate the patients, teach them to reassert their powers of self-control.^[30] This ap-

[26] Ibid., 111.

[27] Ibid., 115. Pinel's experience at Bicêtre led him to the same conclusion: "My faith in pharmaceutical preparations was gradually lessened, and my skepticism went at length so far, as to induce me never to have recourse to them until moral remedies had completely failed" (Philippe Pinel, A Treatise on Insanity, trans. D. D. Davis [Sheffield: Cadell and Davies, 1806], 109). Here, too, moral treatment involved a rejection of the traditional medical paradigm.

[28] In 1815, William Tuke reported that "very little medicine is used at the Retreat" (House of Commons, Report of the Select Committee [1815] 135, evidence of William Tuke).

[29] Tuke, Description of the Retreat, 150.

[30] Ibid., 139.

proach involved "treating the patient as much in the manner of a rational being, as the state of mind will possibly allow,"^[31] rather than using motives of fear as a way of managing the patient. Far from harshness being necessary to avoid violent outbreaks among the inmates, it tended only to produce them.^[32]

Treated less harshly and more nearly as rational human beings, the patients at the Retreat responded by acting less like the traditional stereotype of the raving maniac. Tuke's contention that "furious mania is almost unknown at the Retreat . . . and that all the patients wear clothes and are generally induced to adopt orderly habits"^[33] agrees with the independent observations of visitors.^[34] The refusal to use chains, the absence of physical abuse or coercion of patients, and the success in restoring them to a measure of dignity and self-respect, all contrasted sharply with the prevailing conditions in most madhouses of the period.^[35] Perhaps even more spectacular were the changes thus effected: Despite a conservative outlook that classified no one as cured who had to be readmitted to an asylum, the statistics collected during the Retreat's first fifteen years of operation seemed to show that moral treatment could restore a large proportion of cases to sanity. Of recent cases (those of less than a year's standing), twenty-one out of thirty-one diagnosed as mania had recovered; nineteen out of thirty cases of melancholia were restored; and four others were sufficiently improved that they no longer required confinement. Even among long-standing and apparently hopeless cases, a respectable number were discharged as cured.^[36] Andrew Duncan was so impressed by his visit to the Retreat that he commented: "The fraternity denominated Quakers have demonstrated beyond contradiction the very great advantages resulting from a mode of treatment in cases on Insanity much more mild than was before introduced into any Lunatic Asylum at home or abroad. In the management of this institution, they have set an example which claims the imitation, and deserves the thanks, of every sect and every nation."^[37]

[31] Ibid., 158.

[32] "Furious mania is very often excited by the mode of management" (ibid., 144).

[33] Ibid., 144.

[34] See also G. De la Rive, Lettre adressée aux rédacteurs de la Bibliothèque britannique sur un nouvel établissement pour la gurérison des aliénés (Geneva: For the Author, 1798); William Stark, Remarks on the Construction of Public Asylums for the Cure of Mental Derangement (Glasgow: Hedderwick, 1810); and Edinburgh Royal Lunatic Asylum, A Short Account of the Rise, Progress, and Present State of the Lunatic Asylum at Edinburgh (Edinburgh: Neill, 1812).

[35] See Scull, Museums of Madness, chap. 3, passim.

[36] Ten of sixty-one classed as maniacs, and six of twenty-one melancholics. Tuke, 202–3. All figures were for the period 1796–1811.

[37] Dr. A. Duncan, Sr., reported in Edinburgh Royal Lunatic Asylum, Short Account . . . of the Lunatic Asylum, 15. Tuke's own comment: "The experience of the Retreat . . . has demonstrated, beyond all contradiction, the superior efficacy, both in respect of cure and security, of a mild system of treatment in all cases of mental disorder" (Tuke, Description of the Retreat, vi).

These results were given considerable publicity through the efforts of a stream of visitors interested in lunacy reform and through Tuke's own writings.^[38] However, though there were exceptions like Duncan, the initial response of most of the medical profession to the claims of moral treatment was one of hostility. In the face of the evidence, they simply tried to reassert the value of the traditional medical approach. Hill's book, perhaps the best-known work on the subject published at this time, assured its readers that "insanity is as generally curable as any of those violent Diseases most successfully treated by Medicine,"^[39] and truculently asserted that "direct medical remedies can never be too early introduced or too readily applied."^[40] Nisbet concurred: "The disease of insanity in all its shades and varieties, belongs, in point of treatment, to the department of the physician alone. . . . The medical treatment . . . is that part on which the whole success of the cure hangs."^[41] And when the 1815 Select Committee asked Dr. John Weir, the official inspector of the conditions naval maniacs were kept under, for his opinion on the value of medical intervention, he qualified his answer only slightly: "In recent cases, and those unconnected with organic lesions of the brain, malformation of the skull, and hereditary disposition to insanity . . . medical treatment is of the utmost importance."^[42] Nor should this reaction come as a surprise. After all, moral treatment challenged the traditional paradigm of what was suitable as a method of treating illness of any sort. Furthermore, the wholesale rejection of standard medical techniques naturally ran counter to the profession's deep intellectual and emotional investment in the value of its own theory and practice.

[38] See Scull, Museums of Madness, 67–68.

[39] George Nesse Hill, An Essay on the Prevention and Cure of Insanity (London: Long-man et al., 1814), 201.

[40] Ibid., 205.

[41] William Nisbet, Two Letters to the Right Honourable George Rose, M.P., on the Reports at Present Before the Honourable House of Commons on the State of Madhouses (London: Cox, 1815), 7, 21.

[42] House of Commons, Report of the Select Committee (1815), 32. Cf. the comments of Sir William Lawrence, who, among his other activities, served as surgeon to Bethlem from 1815 until 1867: "They who consider the mental operation as acts of an immaterial being, and thus disconnect the sound state of the mind from organization, act very consistently in disjoining insanity also from the corporeal structure, and in representing it as a disease, not of the brain, but of the mind. Thus we come to disease of an immaterial being, for which, suitably enough, moral treatment has been recommended. I firmly believe, on the contrary, that the various forms of insanity, that all the affections comprehended under the general term of mental derangement are only evidences of cerebral affections . . . symptoms of diseased brain. . . . Sometimes, indeed, the mental phenomena are disturbed, without any visible deviation from the healthy structure of the brain. . . . We find the brain, like other parts, subject to what is called functional disorder; but, although we cannot actually demonstrate the fact, we have no more doubt that the material cause of the symptoms or external signs of disease is in this organ, than we do that impaired biliary secretion has its source in the liver, or faulty digestion in the stomach. . . . The effect of medical treatment completely corroborates these views. Indeed they, who talk of and believe in diseases of the mind, are too wise to put their trust in mental remedies. Arguments, syllogisms, discourses, sermons, have never yet restored any patient; the moral pharmacopoeia is quite inefficient, and no real benefit can be conferred without vigorous medical treatment, which is as efficacious in these affections, as in the diseases of any other organs (Lawrence [1819], quoted in Richard Hunter and Ida Macalpine, Three Hundred Years of Psychiatry, 1535 to 1860: A History Presented in Selected English Texts [London: Oxford University Press, 1963], 750–51 [my emphasis]).

Those outside the profession, of course, lacked any such prior commitments and so were readier converts. In particular, those laymen who, for a number of years, had been agitating for lunacy reform on humanitarian grounds but who had previously lacked a viable alternative model to existing asylums eagerly seized on moral treatment. Since it was these lay people, primarily magistrates and upper middle-class philanthropists, who were the prime movers in the effort to reorganize the treatment of insanity through changes in the law, their conversion was a highly significant one.

Within two years of the publication of Tuke's Description of the Retreat, which brought the Retreat national attention, a series of revelations about the conditions in other madhouses further undermined medicine's claims to expertise or special competence in the treatment of insanity. Separate investigations of conditions at Bethlem and the York Asylum, hitherto regarded as among the leading institutions under medical control, uncovered evidence of systematic cruelty and maltreatment of patients,^[43] reflected in extremely high mortality rates. This discovery in itself provided a highly unfavorable comparison with the layrun Retreat. Furthermore, the evidence of even the medical witnesses before the Select Committee provided support for William Tuke's contention that "in cases of mental derangement . . . very little can be done by way of medical treatment."^[44]

The evidence given by Charles Best and Thomas Monro, physicians at York and Bethlem respectively, was particularly damaging. The Monro family had been physicians to Bethlem for almost a century, and prior to this Thomas Monro himself had been thought of as one of the foremost experts on the medical treatment of insanity. Like Best, though, the credibility of his testimony was colored by the committee's knowledge of conditions in his asylum, and he was treated as a hostile witness. Under close questioning by the committee, the extent of his medical treatment was now revealed to the public: "In the months of May, June, July, Au-

[43] Cf. Scull, Museums of Madness, chap. 2.

[44] House of Commons, Report of the Select Committee, 135, evidence of William Tuke.

gust and September, we generally administer medicines; we do not in the winter season, because the house is so excessively cold that it is not thought proper. . . . We apply generally bleeding, purging, and vomits; those are the general remedies we apply. . . . All the patients who require bleeding are generally bled on a particular day, and they are purged on a particular day."^[45] Later in his testimony, Monro gave a few more details: all the patients under his care, except those manifestly too weak to survive such a heroic regime, "are ordered to be bled about the latter end of May, or the beginning of May, according to the weather; and after they have been bled they take vomits once a week for a certain number of weeks; after that we purge the patients."^[46] Thereafter, of course, patients were kept chained to their beds at least four days out of every seven.

A committee convinced of the value of moral treatment's emphasis on treating every lunatic as an individual was in principle unlikely to approve of such indiscriminate mass medication. Under the even more hostile questioning he now faced, Monro was forced to make a still more damaging admission. "Do you think," he was asked, "it is within the scope of medical knowledge to discover any other efficacious means of treating Insane persons?" "With respect to the means used, I really do not depend a vast deal upon medicine; I do not think medicine is the sheet anchor; it is more by management that those patients are cured than by medicine. . . . The disease is not cured by medicine, in my opinion. If I am obliged to make that public I must do so ."^[47] The only question that remained was why Monro continued to employ therapies he conceded were useless. He himself had already provided an answer to that: "That has been the practice invariably for years, long before my time; it was handed down to me by my father, and I do not know any better practice ."^[48]

[45] Ibid., 93.

[46] Ibid., 95.

[47] Ibid., 99 (my emphasis). Cf. Ellis' comment, "Of the abuses that have existed, the cause of a great proportion of them may be traced to the mystery with which many of those who have had the management of the insane have constantly endeavored to envelop it" (William Charles Ellis, A Letter to Thomas Thompson, Esq., M.P., Containing Considerations on the Necessity of Proper Places Being Provided by the Legislature for the Reception of All Insane Persons and on Some of the Abuses Which Have Been Found to Exist in Madhouses, with a Plan to Remedy Them [Hull: Topping and Dawson, 1815]). Expertise always flourishes where its techniques are somewhat mysterious; the expert, wherever possible "minimizes the role of persuasive evidence in his interaction with his clientele " (Freidson, Professional Dominance, 110 [emphasis in the original]). Being forced to justify his actions to laymen almost always weakens the professional's authority (cf. ibid., chap. 4, passim). Nowhere is this more clearly the case than when a challenge to produce rational grounds for one's procedures cannot be met.

[48] House of Commons, Report of the Select Committee (1815), 95, (a nice example of medicine's bias toward active intervention). Cf. Thomas Scheft, Being Mentally Ill: A Sociological Theory (Chicago: Aldine, 1966), chap. 4; and Freidson, Profession of Medicine, chap. 12.

St. Luke's Hospital, London's other charity asylum, had not come in for the severe criticism directed at Bethlem. Nevertheless, when its physician, Dr. A. J. Sutherland, was called to give evidence, his answers were extremely circumspect, and he sought to be as noncontroversial as possible. While he felt that medicines for the stomach might be of some indirect benefit, he conceded that "moral treatment is of course more especially important in the treatment of mental disorder."^[49] Similarly, when Dr. John Harness, a commissioner of the Transport Board, was asked "what was his opinion as to the utility of medical treatment of Insanity," he replied: "Although much may be effected by medical treatment, I have before stated that I am not sanguine in the expectation of a permanent advantage from it."^[50]

Doctors at this time played another important role vis-à-vis the insane. Five commissioners selected from the members of the Royal College of Physicians were charged with annually inspecting metropolitan madhouses under the 1774 Act. Even conceding the defects of the act, as the reformers did, their record was hardly one to inspire confidence in a system of medical policing of asylums or in physicians' willingness to judge the work of their colleagues. According to Dr. Richard Powell, the secretary to the Royal College and himself a commissioner, the visits took no more than six days a year to perform. Often as many as six or eight madhouses were visited in a day. No attempt was made to check whether the numbers resident corresponded to those the commissioners had been notified of. The justification for medical visitation was primarily that no one else was competent to assess the medical treatment administered. Yet Powell conceded that, apart from cursory inquiries as to the condition of the patients, no effort was made to discover what medical treatment the patients received, let alone to find out how effective it was.

The most respectable medical figure to appear before the committee was Sir Henry Halford, who was already "indisputably at the head of London practice." A favorite of George III's, he was later physician to George IV and Victoria, and from 1820 to his death in 1844, president of the Royal College of Physicians.^[51] As the official spokesman for the most prestigious branch of the medical profession and an influential figure in elite circles, he obviously presented his evidence with a view to making a strong case for the value of the medical approach and in an effort to rectify the damage done by Best's and Monro's testimony. In practice, his evidence was too rambling and confused for that. Having begun by asserting that medical intervention was valuable, at least in the early stages of the disorder, he subsequently conceded that "our knowledge of insanity has not kept pace with our knowledge of other distem-

[49] House of Commons, Report of the Select Committee (1815), 136.

[50] Ibid., 159.

[51] Dictionary of National Biography, s.v. "Halford, (Sir) Henry."

pers," a situation he blamed on "the habit we find established, of transferring patients under this malady, as soon as it has declared itself, to the care of persons who too frequently limit their attention to the mere personal security of their patients, without attempting to assist them by the resources of medicine." "The profession," he acknowledged, had "much to learn on the subject of mental derangement." By the end of his testimony, he had given the impression that medicine lacked reliable knowledge in this area and could offer little by way of effective therapy. In mitigation, he declared that "we want facts in the history of the disease" and coupled this asseveration with the vague hope that "if they are carefully recorded, under the observation of enlightened physicians, no doubt, they will sooner or later be collected in sufficient number, to admit of safe and useful inductions."^[52] As a performance, this was scarcely calculated to convince the somewhat skeptical audience he faced. He had provided neither evidence nor plausible argument to refute the contention of those who favored moral treatment that "against mere insanity, unaccompanied by bodily derangement, [medicine] appears to be almost powerless."^[53] Nor had he succeeded in erasing the unfavorable impression created by earlier medical testimony.

If Monro did not know of any better weapons to use against insanity than the traditional antiphlogistic system, the laymen who were acquainted at first hand with the results of moral treatment obviously thought that they did. Both their testimony before official inquiries and the pamphlets they were busily writing now took on a tone of considerable hostility to medicine's claims to jurisdiction in this area. When Edward Wakefield was asked, "In consequence of the observations you have made on the state and management of the Lunatic Establishments, and the manner of inspecting them, are you of the opinion that medical persons exclusively ought to be Inspectors and Controllers of Madhouses?" his response was:

I think they are the most unfit of any class of persons. In the first place, from every enquiry I have made, I am satisfied that medicine has little or no effect on the disease, and the only reason for their selection is the confidence which is placed in their being able to apply a remedy to the malady . They are all persons interested more or less. It is extremely difficult in examining either the public Institutions or private houses, not to have strong impression upon your mind, that medical men derive a profit in some shape or form from those different establishments. . . . The rendering therefore, [of] any interested class of persons the Inspectors and Controllers, I hold to be mischievous in the greatest possible degree.^[54]

[52] House of Commons, First Report of the Select Committee on Madhouses (1816), 13–14.

[53] [Sydney Smith], "An Account of the York Retreat," Edinburgh Review 23 (1814): 196.

[54] House of Commons, Report of the Select Committee (1815), 24 (my emphasis).

Higgins, who had witnessed at first hand over many months the practices of one of the most famous medical "specialists" in the field, was, if anything, still more hostile. He pointed out that in the aftermath of Dr. Best's departure from the York Asylum and the establishment of an efficient system of lay visitation there, the number of deaths of patients fell from twenty a year to only four. Furthermore, thirty patients were almost at once found fit for discharge. In his caustic fashion he demanded to know "who after this will doubt the efficacy of my medicine—visitors and committees? I will warrant it superior even to Dr. Hunter's famous secret—insane powders —either green or grey—or his patent Brazil salts into the bargain."^[55] Higgins was clearly angered by the efforts of the medical profession to explain away as legitimate medical techniques for "treating" insanity what he perceived as cruelty or to attribute to the progress of the condition itself what he saw as the consequences of neglect. In contemptuous tones, he commented:

Amongst much medical nonsense, published by physicians interested to conceal their neglect, and the abuses of their establishments, it has been said, that persons afflicted with insanity are more liable than others to mortification of their extremities. Nothing of the kind was ever experienced at the institution of the Quakers. If the members of the royal and learned College of Physicians were chained, or shut up naked, on straw saturated with urine and excrement, with a scanty allowance of food, exposed to the indecency of a northern climate, in cells having windows unglazed, I have no doubt that they would soon exhibit as strong a tendency to mortified extremities, as any of their patients.^[56]

William Ellis, though himself medically qualified,^[57] by now possessed firsthand acquaintance with Tuke's work at the Retreat and had absorbed much of the latter's skepticism about the activities of his fellow professionals. His Letter to Thomas Thompson, M.P. (a member of the Select Committee), contained a number of critical remarks directed at them. In particular, he alleged that "the management of the insane has been in too few hands; and many of those who have been engaged in it, finding it a very lucrative concern, have wished to involve it in great mystery, and, in order to prevent institutions for their cure from becoming more general, were desirous that it should be thought that there was some secret in the way of medicine for the cure, not easily to be found

[55] Godfrey Higgins, The Evidence Taken Before a Committee of the House of Commons Respecting the Asylum at York; with Observations and Notes, and a Letter to the Committee (Doncaster: Sheardown, 1816), 48. Dr. Alexander Hunter was, until his death (when he was succeeded by his protégé, Dr. Charles Best), the physician to the York Asylum. In addition to his lucrative trade at the asylum, which included extensive embezzlement of its funds, he energetically promoted his "powders" as a certain, if expensive, home remedy for insanity for those who could not afford his full-time ministrations.

[56] Ibid., 48, footnote.

[57] M.D., St. Andrew's, M.R.C.S.

out. Some medical men have gone so far as even to condescend to the greatest quackery in the treatment of insanity."^[58] To the contrary, Ellis contended there were no medical specifics for the successful treatment of madness, and acceptance of the idea that care of the insane was best left to experts, medical or otherwise, was the surest guarantee of abuse. In his own proposals for reform, therefore, he advocated constant lay supervision of all asylums by local magistrates.^[59]

The propagation of the notion that "very little dependence is to be placed on medicine alone for the cure of insanity"^[60] posed a clear threat to the professional dominance of this field. Given that those most convinced of the truth of this proposition were also the prime movers in trying to obtain lunacy reform, the doctors interested in insanity were unable any longer to ignore or depreciate moral treatment. They had to find some way to accommodate it.

At first sight, moral treatment seemed to be an unpromising basis for any profession trying to assert special competence in the treatment of the insane. In Freidson's words, "One of the things that marks off professions from occupations is the professions' claims to schooling in knowledge of an especially esoteric, scientific, or abstract character that is markedly superior to the mere experience of suffering from the illness or having attempted pragmatically to heal a procession of sufferers from the illness."^[61] Moral treatment had begun by rejecting existing "scientific" responses as worse than useless; and the remedies proposed in their place—warm baths and kindness—hardly provided much of a foundation for claims to possess the kinds of expertise and special skills that ordinarily form the basis for the grant of professional autonomy.

In practice, however, this feature of moral treatment proved an advantage to those bent on reasserting medicine's jurisdiction in this area. The very difficulty of erecting professional claims on such a flimsy basis largely precluded the emergence of an organized group of competitors—lay therapists. Moreover, Tuke had explicitly not sought to create or train a group of experts in moral treatment. To the contrary, he and his followers were deeply suspicious of any plan to hand the treatment of lunatics over to the experts. The essence of moral treatment was its emphasis on humanity, and humanity was not a quality monopolized by experts. Indeed, the grant of a measure of autonomy that accompanied the acceptance of someone as an expert threatened to remove the surest guarantee of humane treatment of the insane: searching inquiry and oversight by outsiders.

[58] Ellis, Letter to Thomas Thompson, 7.

[59] Ibid., 35. Still he thought asylums should be administered on a day-to-day basis by a doctor, a position restated more emphatically in his later work.

[60] [Smith], "York Retreat," 196.

[61] Freidson, Professional Dominance, 106.

Interestingly enough, the earliest recruits to moral treatment were primarily those who were interested in the cause of lunacy reform, but who were unlikely, given their social status, to undertake themselves the task of administering an asylum—magistrates and upper-class philanthropists. The major exception to this generalization, William Ellis (who from 1814 on ran the Refuge, a private madhouse at Hull), was a doctor rather than just an expert on moral treatment. In the absence of any rival helping group, medicine set about assimilating moral treatment within its own sphere of competence.

Even while specifically denying medical claims to expertise in the area of insanity, the promoters of moral treatment had continued to employ a vocabulary laden with terms borrowed from medicine—"patient," "mental illness," "moral treatment," and so on. This failure to develop an alternative jargon itself made the reassertion of medical control somewhat easier, inasmuch as one of the most important connotations of the label "illness," and its associated array of concepts, is the idea that the syndrome to which it is applied is essentially a medical one. Given the critical role of language in shaping the social construction of reality, to employ terms implying that something is a medical problem and yet to deny that doctors are those most competent to deal with it seems perverse.

The lack of a coherent, well-articulated theory as an alternative to the model of insanity had this further consequence: that the denial of the applicability of medicinal remedies implied a view of insanity as essentially irremediable ("incurable") or as remediable ("curable") only by accident or through the operation of spontaneous tendencies toward recovery. Tuke himself seems to have adhered to the latter view. Thus, in his efforts to secure the establishment of asylums for the insane poor, he urged that "though we can do but little by the aid of medicine towards the cure of insanity, it is surely not the less our duty to use every means in our power to alleviate the complaint, or at least place the poor sufferer in a situation where nature may take her own course, and not be obstructed in the relief which she herself would probably bring to him."^[62] And his discussion of the Retreat's success in restoring patients to sanity concludes: "As we have not discovered any anti-maniacal specific, and profess to do little more than assist Nature, in the performance of her own cure, the term recovered, is adopted in preference to that of cured ."^[63] Such modesty may well have been warranted; yet it was scarcely as appealing as the claim that one could actively influence the outcome in the desired direction.

[62] Samuel Tuke, "Essay on the State of the Insane Poor," The Philanthropist 1 (1811):357.

[63] Tuke, Description of the Retreat, 216–17.

All this meant that the challenge moral treatment posed to the medical dominance of insanity was not as clear-cut as it might have been. Furthermore, the medical profession possessed certain initial advantages as it sought to reassert its jurisdiction, advantages that could, however, have proved purely ephemeral. After all, there were, as yet, no legal barriers to the development of an organized rival group of therapists, and language is not immutable. The interested segments of the medical profession now moved to secure what they rightly perceived to be their imperiled position.

The potential consequences of taking Tuke seriously were most clearly articulated by Browne half a century later: "If therapeutical agents are cast aside or degraded from their legitimate rank, it will become the duty of the physician to give place to the divine or moralist, whose chosen mission it is to minister to the mind diseased; and of the heads of establishments like this [lunatic asylum] to depute their authority to the well-educated man of the world, who could, I feel assured, conduct an asylum fiscally, and as an intellectual boarding-house, a great deal better than any of us."^[64] Earlier he had complained that "a want of power or inclination to discriminate between the inutility of medicine from its being inapplicable, and from its being injudiciously applied, had led to the adoption of the absurd opinion that the insane ought not to be committed to the charge of medical men. A manager of a large and excellent institution, entertaining this view, has declared the exhibition of medicine in insanity was useless, and that disease was to be cured by moral treatment only."^[65]

The pernicious doctrine that traditional medical remedies were useless had spread dangerously far, even among those who continued to insist that doctors were the most qualified to treat lunatics. "We must confess," said Spurzheim, "that hitherto medical art has acquired very little merit in the cure of insanity; nature alone does almost everything."^[66] When the Quarterly Review 's correspondent argued for medical control, he simultaneously made the dangerous concession that "the powers of medicine, merely upon mental hallucination are exceedingly circumscribed and feeble. . . . we want principles on which to form any satisfactory indications of treatment. . . . Almost the whole . . . of what may be called the strict medical treatment of madness must be regarded, at present, at least, as empirical, and the most extensive experience proves

[64] William Alexander Francis Browne, The Moral Treatment of the Insane: A Lecture (London: Adlard, 1864), 5.

[65] W. A. F. Browne, What Asylums Were, Are, and Ought to Be (Edinburgh: Black, 1837), 178.

[66] J. G. Spurzheim, Observations on the Deranged Manifestations of the Mind, or Insanity (London: Baldwin, Craddock, and Joy, 1817), 197.

that very little is to be done."^[67] Casting about for justifications for his insistence on medicine's entitlement to preeminence, he found remarkably few. The administration of warm baths now became something that could only be done under careful professional supervision. After all, the use of such a powerful technique had to be guided by an expert assessment of the condition of the individual patient. Cathartics were somehow rescued from the oblivion into which other medical remedies had been cast, once more with the caution that "the practice of purging" was by no means "of so simple and straight-forward a nature as might be at first sight conceived."^[68] Conscious that these contentions might seem less than compelling, he resorted to the argument from experience: "Were it only an account of the frequent opportunities which more strictly medical practitioners have of witnessing aberrations of the intellect, from different sources, these would appear to be the fittest persons for the treatment of lunacy."^[69]

The necessity for a more strenuous and convincing defense of professional prerogatives was clear. In the aftermath of the findings of the 1815–16 Select Committee, the reformers in the Commons attempted to devise a system of strict outside supervision and control of madhouse keepers, to ensure against the repetition of previous abuses. In 1816 and 1817, bills were introduced to set up a Board of Inspection of madhouses for each county, to be chosen annually from among the county magistrates. The proposal was revived in 1819, with the addition of a permanent Board of Inspection for the whole country, which was to visit all houses "at different and uncertain times."

All three of these bills would have empowered the boards of laymen to inquire into the treatment and management of patients, to direct discontinuance of practices they considered cruel or unnecessarily harsh, and to order the discharge of any patient they considered restored to sanity. If one follows Freidson in considering autonomy (the right to deny legitimacy to outside criticism of work and its performance) as the core characteristic of any profession, such proposals to introduce lay control and evaluation of expert performance must clearly be seen as of enormous strategic importance and as likely to provoke intense opposition from those threatened by such control. And that opposition was indeed forthcoming from doctors in the mad-business.

[67] [David Uwins], "Insanity and Madhouses," Quarterly Review 15 (1816):402.

[68] Ibid., 402–3.

[69] Ibid., 403. Ellis, in the same bind, justified medical control of asylums as necessary to ensure that the physical ailments of the insane were properly treated: "Insane patients being liable to every complaint that others are subject to, together with those brought on by the body's sympathising with the mind, it seems now generally admitted that it is necessary to have a medical man to administer such establishments" (Ellis, Letter to Thomas Thompson, 11).

Burrows, in particular, was scathing in his criticisms of these bills. Somewhat disingenuously, he commented: "The provision of this [1817] Bill induces me to conclude that I certainly misinterpreted the import of many of the queries of the Members of the Committee of Inquiry; for I was led to think that a conviction had arisen out of the investigation, that all houses for the reception of insane persons ought to be under the superintendence of men of character and ability, and particularly of medical men."^[70] Assuming that this was so (a large assumption, of course), it was simply absurd to allow the judgment of rank amateurs to override the mature judgment of a competent expert. If the legislature was convinced of the necessity of appointing commissioners to inspect madhouses, these ought, as in the past, to be medical men. One faced a situation in which "the most experienced will acknowledge the liability of being deceived, even where frequent opportunities of judging of the sanity of the mind have occurred. How then can those who are not only casual but unprofessional visitors pretend to decide on any particular case, or prescribe any alteration, or condemn any mode of treatment?"^[71] It made no sense to ask a layman to pass judgment on the curative treatment of a patient, "for if any difference of opinion were to arise upon a question relative to the management or release of a patient, it were surely most proper that the medical opinion should prevail."^[72] Furthermore, allowing "country gentlemen" to visit asylums, unaccompanied by medical men, in order to check for possible abuses, threatened the welfare of the patients in the most serious possible degree. The commotion their visits would cause, and the interference their ignorance might lead them to indulge in, would set at naught the asylum doctor's most skillful efforts to cure his patients. Consequently, the reformers could proceed with their plans only at "the hazard of great injury to the patients."^[73]

[70] George Man Burrows, Cursory Remarks on a Bill Now in the House of Peers for Regulating of Madhouses, . . . with Observations on the Defects of the Present System (London: Harding, 1817), 51. This pamphlet was dedicated: "To the Royal College of Physicians in London, the Constitutional Guardians of the Public Health, and the only Public Body which, by reason of its learning and experience, is truly competent to arrange and to carry into execution an Efficient Plan for the Amelioration of the Condition of the Insane."

[71] Ibid., 23.

[72] Ibid., 24.

[73] Ibid., 25. There is an obvious parallel here with the modern psychiatrist's emphasis that the patient can "be greatly damaged if unskilled action is taken in . . . crucial, precarious therapeutic matters, necessitating the strict control of non-medically qualified mental hospital staff lest they engage in amateur psychotherapy" (Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates [Garden City, N.Y.: Doubleday, 1961], 377–78). As Freidson has shown for the medical profession as a whole, "where dangerous consequences can follow upon improper work . . . the claim of emergency and of possible dangerous consequences is a potent protective device" (Freidson, Profession of Medicine, 45). Cf., in this connection, Burrows' stated objections to the 1817 Bill: "It may be asserted . . . that if the insane be visited in the indiscriminate and judicial manner which this Bill invites and empowers, that neither medical nor moral remedies will be of the least avail. . . . Who can say but some meddling inconsiderate justice might from ignorance . . . interfere; and by doing so blast all prospect of future happiness even of scores of his miserable fellow creatures. . . . The humane and skillful superintendent is, perhaps, on the point of seeing the fruition of all his cares and anxieties; and is anticipating the restoration of the faculties of his charge, and the well-earned remuneration for his troubles and cares; the relatives and friends of the patient, from the depths of despondency . . . are raised to the utmost pinnacle of hope and expectation; when lo! comes a fatal visitation—the patient must not be denied—he must be examined as to the state of his mind—the fatal chord is touched on which depends harmony of his mental with his corporeal frame; a tremendous explosion follows, and in one moment, the toil of months is destroyed: the wavering reason is lost, and sometimes forever!" (Burrows, Regulating of Madhouses, 25, 27, 29–30). If further evidence is needed that the purpose of this protest was the protection of professional prerogatives, Burrows' own version of the type of reform acceptable to the profession provides it: "The fundamental principles of all reformation or improvement in the management of madhouses or in the medical treatment of insane persons, therefore, consist: 1. In the fitness of the qualification of those who are permitted to take charge of them; 2. In having regular members of the faculty as superintendents; 3. In leaving superintendents uncontrolled in their management; 4. In protecting Superintendents against the malicious allegations of patients or outsiders; 5. In employing competent (i.e. Medical) Visitors" (ibid., 79). An opponent summarized his position as follows: "Dr. Burrows contends that Parliament has no right to interfere with the internal management of private lunatic asylums, and that the visits of medical men on the part of patients or their friends, is an intrusion, and no more warranted than the surveillance of the same persons in private practice" (Anonymous, On the Present State of Lunatic Asylums, with Suggestions for Theft Improvement [London: Drury, 1839], 14).

In the Commons, the lunacy reformers, remaining unmoved by these arguments, managed to secure the passage of each of the bills they introduced. The House of Lords, however, proved more receptive and in each instance exercised its veto powers. Undoubtedly, in so doing they were not motivated simply by the desire to protect the prerogatives of the medical profession. A strong faction there was opposed to any effort to extend the scope of central government authority. Aristocratic families with a lunatic in the closet were determined to avoid publicity, and hence the provisions in the 1816 and 1817 bills for a central register of "single lunatics" provoked further opposition.^[74] Furthermore, the High Tories in the Upper House were disposed to reject on principle all type of "liberal" reform—their principal spokesman, Lord Eldon, the Lord Chancellor, once referred to "philanthropists" as "men pretending to humanity but brimful of intolerance, and swollen with malignity, which they all are." ^[75] ,

At the very least, however, the protests of the medical profession provided the Lords with a convenient ideological cloak for their opposition,

[74] Similar concerns had played a part in restricting the scope of the 1763 House of Commons Inquiry and emasculating the 1774 Madhouse Act.

[75] Brenda Parry-Jones, "A Calendar of the Eldon-Richards Correspondence c. 1809–1822," Journal of the Merioneth Historical and Record Society 5 (1965):39–50, cited in W. L. Parry-Jones, Trade in Lunacy, 16–17.

and while votes may actually have been swayed by other considerations, they were justified on these neutral, technical grounds. The Marquis of Landsdowne, who introduced the 1819 bill into the Lords, clearly foresaw the direction the debate would take and sought to reassure his audience that, while some systems of visitation and control by outsiders "might retard the cure of persons so affected," the insane would only benefit from the specific provisions of this bill.^[76] Speaking against the bill, Eldon brushed this assuagement aside and reiterated the standard professional line: "It was of the utmost importance, with a view to the proper care of these unhappy individuals, and with a view to their recovery that they should be under the superintendance [sic ] of men who had made this branch of medicine their peculiar study, and that the superintendence of physicians should not be interfered with." Yet this was precisely what the bill before them sought to do, and in consequence, "he conscientiously believed its regulations would tend to aggravate the malady with which the unfortunate persons were afflicted, or to retard their cure." One of the most objectionable features of the bill from his (and the medical profession's) perspective was that it "gave a number of penalties, half of which were to go to the informer, and it was evident that the informer would be found amongst the attendants and servants in receptacles for lunatics, who would thus be made the judges of the conduct of the physicians, and it would be impossible for the latter, under such circumstances, to resort to many of these means which their experience had taught them were most effectual for the cure of their unhappy patients."^[77] Eldon had the authority of the best medical opinion behind him, when he asserted that "there could not be a more false humanity than an over-humanity with regard to persons afflicted with insanity," and in the division which followed, the bill was rejected 35 to 14.^[78]

Temporarily, at least, the mad-doctors had successfully resisted efforts to restrict their professional autonomy, for with the rejection of the 1819 bill, the reform movement lost its momentum. Their victory was a fragile and uncertain one, however, so long as it rested on a marriage of convenience with political forces whose power was on the wane, and so long as they remained vulnerable to charges from moral-treatment enthusiasts that their expertise had no scientific or practical foundation. If they were to overcome their vulnerability, they had to develop a more sophisticated justification of their privileged position.

As part of this process, from about 1815 onwards, a veritable spate of books and articles purporting to be medical treatises on the treatment of

[76] Hansard's Parliamentary Debates, 1st ser., vol. 40 (1819), col. 1345.

[77] Ibid. (emphasis added).

[78] Ibid. Jones, Lunacy, Law and Conscience, 109–11, condemns this action as "illiberal," but entirely neglects the role of the medical lobbying in ensuring the defeat of these early efforts at "reform," presumably because it would be at odds with her naive Whiggish perspective, which sees the doctors as the purveyors of scientific enlightenment.

insanity began to appear.^[79] Similarly, the claim that instruction in its treatment formed a part of the normal curriculum of medical training, which had been made by earlier generations of mad-doctors, was reinforced when Dr. (later Sir) Alexander Morison, a well-known society physician, began a course of lectures on the topic. These he repeated annually from 1823 to the late 1840s, while the published version simultaneously went through a number of editions. All this activity was probably

[79] Among those which I have consulted are: Matthew Allen, Cases of Insanity, with Medical, Moral and Philosophical Observations upon them (London: Swire, 1831 ), and idem, Essay on the Classification of the Insane (London: Taylor, 1837); Samuel Glover Bakewell, An Essay on Insanity (Edinburgh: Neill, 1833); Nathaniel Bingham, Observations on the Religious Delusions of Insane Persons . . . with Which Are Combined a Copious Practical Description . . . of Mental Disease, and of Its Appropriate Medical and Moral Treatment (London: Hatchard, 1841); George Man Burrows, An Inquiry into Certain Errors Relative to Insanity (London: Underwood, 1820), and idem, Commentaries on the Causes, Forms, Symptoms, and Treatment, Moral and Medical, of Insanity (London: Underwood, 1828); Andrew Combe, Observations on Mental Derangement: Being an Application of the Principles of Phrenology to the Elucidation of the Causes, Symptoms, Nature, and Treatment of Insanity (Edinburgh: Anderson, 1831); John Conolly, An Inquiry Concerning the Indications of Insanity, with Suggestions for the Better Protection and Care of the Insane (1830), facsimile ed., ed. Richard A. Hunter and Ida Macalpine (London: Dawsons, 1964); W. C. Ellis, A Treatise on the Nature, Symptoms, Causes, and Treatment of Insanity, with Practical Observations on Lunatic Asylums, and a Description of the Pauper Lunatic Asylum for the County of Middlesex at Hanwell, with a Detailed Account of Its Management (London: Holdsworth, 1838); R. Fletcher, Sketches from the Casebook to Illustrate the Influence of the Mind on the Body, with the Treatment of Some of the More Important Brain and Nervous Disturbances (London: Longman, 1833); Thomas Forster, Observations on the Phenomena of Insanity (London: Underwood, 1817); William Saunders Hallaran, Practical Observations on the Causes and Cure Insanity (Cork: Hodges and M'Arthur, 1818); John Haslam, Medical Jurisprudence as It Relates to Insanity, According the Law of England (London: Hunter, 1817); Thomas Mayo, An Essay on the Relation of the Theory of Morals to Insanity (London: Fellowes, 1834); John Mayo and T. Mayo, Remarks on Insanity (London: Underwood, 1817); J. G. Millingen, Aphorisms on the Treatment and Management of the Insane, with Considerations on Public and Private Lunatic Asylums, Pointing out the Errors in the Present System (London: Churchill, 1840); Alexander Morison, Outlines of Lectures on the Nature, Causes, and Treatment of Insanity, ed. Thomas C. Morison (London: Longman et al., 1825; 4th ed. 1848); William B. Neville, On Insanity: Its Nature, Causes, and Cure (London: Longman et al., 1836); John Parkin, On the Medical and Moral Treatment of Insanity, Including a Notice on the Establishment for the Treatment of Nervous and Mental Maladies: Manor Cottage, King's Road, Chelsea, Established in 1780 (London: Martin, [ 1843?]); James Cowles Prichard, A Treatise on Insanity and Other Disorders Affecting the Mind (London: Sherwood, Gilbert and Piper, 1835), and idem, On the Different Forms of Insanity in Relation to Jurisprndence (London: Bailliere, 1842); John Reid, Essays on Insanity, Hypochondriacal and other Nervous Affections (London: Longman et al., 1816); Edward J. Seymour, Observations on the Medical Treatment of Insanity (London: Longman et al., 1832); Spurzheim, Deranged Manifestations; John Thurnam, Observations and Essays on the Statistics of Insanity, Including an Inquiry into the Causes Influencing the Results of Treatment in Establishments for the Insane: To Which Are Added Statistics for the Retreat near York (London: Simpkin Marshall, 1845); David Uwins, A Treatise on Those Disorders of the Brain and Nervous System, Which Are Usually Considered and Called Mental (London: Renshaw and Rush, 1833); Francis Willis, A Treatise on Mental Derangement   (London: Longman et al., 1823; 2d ed., 1843).

stimulated at least in part by the increased attention all members of the educated elite were giving to insanity, in the wake of two major parliamentary inquiries into the subject within the short space of eight years and in consequence of the revelations of the second of these about conditions in madhouses. But more importantly than that, it represented an effort to reassert the validity of the medical model of mental disturbance and to ensure a maximum of professional autonomy in the treatment of lunatics.

Dr. Francis Willis explicitly wrote his treatise to emphasize the medical nature of insanity, an endeavor rendered "the more necessary, because derangement has been considered by some to be merely and exclusively a mental disease, curable without the aid of medicine, by what are termed moral remedies; such as travelling and various kinds of amusements."^[80] The language used by John and Thomas Mayo was even more revealing. Their announced purpose in publishing their Remarks on Insanity was "to vindicate the rights of [our] profession over Insanity, and to elucidate its medical treatment,"^[81] two tasks that were obviously closely connected. For the mere existence of a large body of what purported to be technical literature passing on the fruits of scientific knowledge about the management of the insane gave impressive-seeming substance to the claim of expertise, regardless of its practical usefulness or merits. Complicated nosographies like that developed by Prichard bewildered and impressed the average layman; given such an array of diagnostic categories, recognition of the precise form of mental disease an individual lunatic was laboring under clearly became a matter for expert determination.

When medical ideas about insanity had to be presented to a lay audience, the availability of a large body of specialized knowledge was valuable in a different way. For it enabled writers who wanted to advance medicine's cause to circumvent the ordinary requirement that they produce evidence in support of their contentions. Nontechnical discussion of the medical treatment of insanity could be justified on the grounds of the general importance of making the public aware of the potential contribution medicine could make, but any pressures to move beyond vague generalities could now be resisted as being "more properly the province of journals exclusively devoted to technical science."^[82] Such "purely professional" topics would "only be interesting to a comparatively small number of our readers,"^[83] and would simply be above the heads of the majority of lay readers, since they lacked the requisite training.^[84]

[80] Willis, Mental Derangement, 2.

[81] Mayo and Mayo, Remarks on Insanity .

[82] David Uwins, "Inquiries Relative to Insanity," Quarterly Review 24 (1820–21): 169.

[83] Ibid.

[84] In the discussion of specific techniques, this point was emphasized over and over again: "It would be altogether inconsistent with our plan to enter into the detail of such cases" (Unwins, "Insanity and Madhouses," 403); "We have not the leisure to enter into any detail respecting the mode of employing this remedial process, and shall therefore merely observe that its use requires always to be regulated by the circumstances and constitutional condition of the patient" (ibid., 402) (which, it goes without saying, were matters only a doctor was competent to evaluate).

Morison's lectures were the most visible sign that members of the medical profession were in fact receiving training. It scarcely mattered that Morison himself had no practical experience that would have given him justification for claiming expertise in this area; or that his lectures were an unoriginal mélange of ideas uncritically assembled from existing works in the field.^[85] Instruction in "a curriculum that includes some special theoretical contact (whether scientifically proven or not) may represent a declaration that there is a body of special knowledge and skill necessary for the occupation,"^[86] which is not otherwise obtainable. Here, the availability of special education, regardless of its specific content or scientific validity, bolstered the medical profession's claims to expertise and esoteric knowledge.

The effort to press these claims proceeded on other fronts as well. The more respectable part of the medical profession used its prestige and ready access to elite circles to promote its cause. As part of this process, medical men running asylums made strenuous and eventually successful efforts to persuade their lay audience that they possessed a more common and/or intense commitment to a service orientation than did their nonmedically qualified competitors. At a time when madhouses were acquiring considerable disrepute, Nisbet took pains to emphasize that "out of thirty-three licenses for the metropolis, only three are in the hands of medical men. The chief part is in the hands of persons unacquainted with medicine, who take up this branch of medicine as a beneficial pursuit, and whose object is to make the most of it."₈₇ Similarly, Conolly urged the importance "of making medical men as familiar with disorders of the mind as with other disorders; and thus of rescuing lunatics from those whose interest it is to represent such maladies as more obscure, and more difficult to manage than they are."^[88] Burrows' writings^[89] and his evidence before the 1828 Select Committee

[85] Morison undertook these lectures primarily as an exercise in self-promotion, and with the hope that the publicity would expand his practice among the upper classes. In these respects he was successful, even though his course attracted a total of only 150 students between 1823 and 1845. Cf. Hunter and Macalpine, Three Hundred Years of Psychiatry, 305–9; Daniel Hack Tuke, The Moral Management of the Insane (London: Churchill, 1854), 78.

[86] Freidson, Professional Dominance, 134–35.

[87] Nisbet, Two Letters, 8–9.

[88] Conolly, Indications of Insanity, 7.

[89] See esp. Burrows, Inquiry into Certain Errors .

of the Honse of Lords likewise both reflected and promoted "the widespread view that lay proprietors were more likely to be corrupt and avaricious than their medically trained colleagues."^[90] So that when the Quarterly Review informed its readers that "the superintendent of a mad-house ought to be a man of character and responsibility," it recommended in the same breath that "be should always be chosen from the medical profession."^[91]

The articles that appeared in the leading journals of the period either were themselves written by a physician^[92] or presented an account of insanity sympathetic to the medical viewpoint.^[93] The profession did not neglect the opportunity to show itself in a favorable light. Those, for instance, who relied on the Edinburgh Review 's summary for an account of the tradings of the 1815—16 Inquiry learned that "it is the decided opinion of all the most judicious and experienced witnesses examined before the Committee, that the proper employment of medicine, though neglected most deplorably in several public asylums, and in almost all the private establishments, has the best effect in cases of insanity."^[94] Similarly, Burrows informed his readers that "from a perusal of the replies to the Questions put by the Committee, it is evident that insanity is greatly under the control of medicine—a fact that strictly accords with my own observations."^[95]

The profession was able to use its representation in Parliament, as well as its position as one of the three ancient learned professions, to ensure that its views received due consideration. When there was a renewed inquiry into conditions in private madhouses, it could call on the services of eminently respectable society physicians like Sir Anthony Carlisle and Dr. John Bright to lend their authority to the contention that this was a medical problem. Medical certitication of insanity (for private patients only) had been required by the 1774 Madhouse Act as an additional security against improper confinement of the sane, and the doctors-now sought to clarify and extend their authority in this area, so as to develop an officially approved monopoly of the right to define (mental) health and illness.^[96] Further efforts to get medicine's special competence vis-à-vis the insane recognized and written into the growing

[90] W. L. Parry-Jones, Trade in Lunacy, 82.

[91] Uwins, "Inquiries Relative to lnsanity," 190.

[92] For example, W. H. Fitton, M.D., "Lunatic Asylums," Edinburgh Review 28 (1817).

[93] Uwins, "Insanity and Madhouses"; idem, "Inquiries Relative to Insanity," 169–94; "Esquirol on the Treatment of the Insane," Westminster Review 18 (1833): 123–38.

[94] Fitton, "Lunatic Asylums," 454–55.

[95] Burrows, Regulating of Madhouses, 97.

[96] Freidson, Profession of Medicine, 5. Cf. Dr. John Bright's complaints about the ease of certification and the vagueness of the qualifications demanded of the certifiers. He could attract support for his recommendation that the signatures of two physicians, surgeons, or apothecaries be required because of the widespread concern that some people would be incarcerated in madhouses by corrupt relatives seeking control of their property. See House of Commons, Select Committee on Pauper Lunatics and on Lunatic Asylums (1827), 154, evidence of Dr. John Bright.

volume of lunacy legislation based on the findings of the 1827 Select Committee was pending in the House of Lords, where a special committee sat to hear the views of the medical profession on the proposed changes. The testimony of men like E. L. Fox, W. Finch and W. T. Monro is indicative of considerable resentment of supervision and inspection by magistrates, particularly when efforts were made by these laymen to meddle with decisions that were properly the prerogative of the professional, such as when a patient was ready for discharge.^[97] While legislation was pending, the Royal College of Physicians appointed a committee of its own to (as Parry-Jones delicately puts it) "enquire into the expediency of the provisions of the 1828 Bill."^[98] And at the same time, a rash of pamphlets written by members of the medical profession appeared, urging that further inspection was "a useless inquisition into private concerns, destructive of all that privacy that is truly desirable for the patient" and that the proposal itself "betrays a want of confidence in their [mad-doctors'] moral and medical character."^[99]

Some outside regulation and inspection of asylums was made inevitable by the continuing revelation in their absence of abuses and maltreatment of patients. Hence, the doctors sought to turn this into a system of professional self-regulation by obtaining a dominant role for medical practitioners. Under the 1828 Act, in the provinces only the medical visitor, and not the magistrates who accompanied him, received payment, while among the newly created metropolitan commissioners in lunacy, five out of fifteen were physicians. This representation was not achieved and maintained without a struggle. As late as 1842, Ashley expressed considerable skepticism about any requirement that commissioners, to inspect asylums, should be medically qualified, arguing that "although so far as health was concerned the opinion of a medical man was of the greatest importance, yet it having been once established that the insanity of a patient did not arise from the state of his bodily health, a man of common sense could give as good an opinion as any medical man he knew [respecting his treatment and the question of his sanity]."^[100] Thomas Wakely, M.P., the editor of the leading medical periodical, the Lancet, defended his profession's prerogatives, terming insanity "a griev-

[97] See House of Lords, Minutes of Evidence Taken Before the Select Committee of the House of Lords on the Bills Relating to Lunatics and Lunatic Asylums (1828).

[98] W. L. Parry-Jones, Trade in Lunacy, 19.

[99] All cited in Hunter and Macalpine, Three Hundred Years of Psychiatry, 791.

[100] Hansard's Parliamentary Debates, 3d ser., vol. 61 (1842), col. 806.

ous disease" and stigmatizing any proposal to have lunatic asylums inspected by lawyers alone as "an insult to the medical profession."^[101] Such a proposal now formed a part of the Licensed Lunatics Asylums Bill, introduced to expand temporarily the jurisdiction of the metropolitan commissioners to allow them to inspect asylums throughout the country, in preparation for a further national reform. When the bill came up again, Wakely renewed his attack: "He objected to the clause appointing barristers to the office of commissioners of lunatic asylums. What could be more absurd than to select members of the legal profession to sit in judgement on cases of mental derangement? Was not insanity invariably associated with bodily disease? The investigations in which the commissioners would be involved would be purely of a medical character, and therefore barristers, if they were appointed, would be incompetent to perform the duties which would devolve upon them."^[102] "On the contrary," observed Lord Granville Somerset, "the commissioners were solely concerned with whether [the lunatic] was treated properly and with kindness," and this could as well be discovered by a lawyer as by a doctor.^[103]

Both sides had their adherents in the debate that followed, and eventually some sentiment emerged for a compromise, whereby the commissioners would operate in pairs, one with legal and one with medical training. This was the solution eventually adopted, so that the number of metropolitan commissioners was expanded to include seven doctors—John Bright, Henry Herbert Southey, and John Robert Hume were joined by Thomas Turner, Thomas Waterfield, Francis Bisset Hawkins, and James Cowles Prichard.^[104] Since the 1844 Commission Report formed the basis of the 1845 reforms, this expanded medical representation was of considerable importance. When the Report discussed the nature of insanity and its medical and moral treatment, the lay members of the commission deferred to the specialized knowledge of their medical colleagues, and thus these sections of the Report faithfully reflected the orthodox medical viewpoint. In turn, this official acknowledgment of medicine's legitimate interest in insanity (and Ashley was now one of the converted) helped shape the legislation and its subsequent implementation.

[101] Ibid., col. 804.

[102] Hansard's Parliamentary Debates, 3d ser., 62 (1842), col. 886.

[103] Ibid., col. 887.

[104] This arrangement was continued when the national Lunacy Commission was set up. It permitted a useful professional division of labor. While the lawyers checked that the legal niceties had been observed with respect to admission and discharge documents, record-keeping, and so on, the doctors attended to more strictly "medical" matters such as diet and clothing.

Simultaneously, the profession was active on the local level, where the magistrates who were engaged in setting up the new system of public asylums were an obvious target for these efforts. In some counties the magistrates were already convinced that insanity was a medical province and hence needed no prompting to place their asylum in the hands of the local doctor. At Nottingham, for instance, Reverend Becher, who was the man most responsible for getting the asylum built, was convinced that the management of insanity "is an art of itself,"^[105] and madness a disease having its basis in organic lesions of the body that only doctors were competent to treat.^[106] In consequence, an apothecary was placed in charge of the day-to-day management of the asylum, subject to the control of a visiting physician "who shall be entrusted with the medical treatment of the patients."^[107] The magistrates at Hahwell and Wakefield followed a similar plan, except that here ultimate authority rested in "the hands of the Resident Physician."^[108]

Elsewhere, however, asylum committees chose to place the daily control of the institution in the hands of a lay superintendent, or even tried to run it themselves. The Staffordshire magistrates chose a layman as their chief resident officer. At the Cornwall Asylum at Bodmin after the first appointment of a surgeon, James Duck, as superintendent proved unsatisfactory, he was replaced by a lay "Governor and Contractor."^[109] The magistrates at Bedford initially also chose this latter plan. Among the candidates they considered to head their asylum were a former assistant keeper at St. Luke's and a house painter, who had some experience looking after a lunatic he had come across in the course of his business.^[110] The magistrates had previously decided that, since the medical care needed by the lunatics was slight, and they "will not . . . require the same species of unremitting attention during the whole of the four and twenty hours as Patients in Hospitals do," that "Mr. Leach, our House Surgeon at the Infirmary who so ably discharges his duties there might from the Contiguity of the Establishments" be induced to attend to the occasional medical needs of the Asylum patients.^[111] At a subsequent

[105] John Thomas Becher, An Address to the Public on the Nature. Design, and Constitution of the General Lunatic Asylum near Nottingham (Newark, Nottinghamshire: Ridge, 1811), iv.

[106] Ibid., xi–xii.

[107] Nottingham Lunatic Asylum, The Articles of Union Entered into and Agreed upon Between the Justices of the Peace for the County of Nottingham; the Justice of the Peace for . . . the Town of Nottingham; and the Subscribers to a Voluntary Institution; for the Purpose of Providing a General Lunatic Asylum (Newark: Ridge, 1811), 17–19.

[108] Middlesex Lunatic Asylum, "Visiting Justices' Minutes" (1830), 2:324, manuscript at the London County Record Office, Middlesex Division.

[109] Jones, Lunacy, Law and Conscience, 118–20.

[110] Bedfordshire County Asylum, "Minutes Book," 15 July 1812, l:7, manuscript at the Bedfordshire County Record Office.

[111] Ibid., 4–5.

meeting held on 27 April 1812, the house painter, William Pether, and his wife were appointed "the Governor and Matron of the Lunatic Asylum with a Salary of Sixty Guineas per Annum."^[112]

Within less than a year, local physicians were seeking their first foothold in the new institution. A letter was received from a Dr. G. O. Yeats offering "to undertake the office of the Medical Superintendent and Physician of this Institution gratuitously."^[113] He justified the need for such assistance by pointing out that there were "a considerable number of lunatics whose diseases will require medical aid." Naturally enough, the offer was accepted.^[114] A few more months went by before Yeats tried to convince the magistrates that medicine could be used not merely to cure the patients' physical ailments, but also to help restore them to sanity. In a second long letter to the managing committee, he argued that "however anxious the legislature has been strictly to confine the inmates of the house and to guard against the possibility of there being restored to the world unfit members of society, yet equal anxiety is expressed that every possible care should be taken by medical means for such restoration. . . . It is very desirable then, in order to render the Asylum, not only a place for incarceration, but one where every facility may be given for the amelioration of the condition and for the cure of the maladies of its unfortunate inmates, that the medical officer be given broader powers over the treatment of the patient."^[115]

The process by which the physician invoked the privileges of his office to subordinate the lay superintendent to medical control, and eventually to squeeze him out altogether, had now begun. Three days later Pether received his new instructions: "It was ordered that the Governor in all matters relating to the Health and Distribution of the Patients with a view to their Convalescence or their Medical Treatment, do obey implicitly the instructions of the Physician."^[116] In February of the following year, Yeats was obliged to submit his resignation as nonresident Medical Superintendent, as he was moving to London; but his colleague, Dr. Thackeray, offered to assume the position, once more gratuitously.^[117]

During Thackeray's term in office, he and various other doctors made efforts to educate the magistrates to the fact that insanity was a disease just like any other disease physicians were called on to treat and that there ought therefore to be provision for a full-time resident medical officer to run the asylum. In 1815, he complained in a letter to the mag-

[112] Ibid., 9.

[113] Ibid., 2 January 1813, 39.

[114] Ibid., 41.

[115] Letter from Dr. G. O. Yeats to the Committee of Magistrates on the Asylum, 21 April 1813. Miscellaneous Papers Relating to the Foundation of the County Lunatic Asylum, Bedfordshire County Record Office.

[116] Bedfordshire County Asylum, "Minutes Book," 24 April 1813, 46, manuscript at the Bedfordshire County Record Office.

[117] Ibid., 5 February and 5 March 1814.

istrates of "the insufficiency of the present Medical Means to fulfill the benevolent designs of the Institution. Their asylum affords a solitary example in which a large and important medical establishment is conducted without the assistance of a Resident director in the character of House apothecary. The defect in its constitution by totally precluding the employment of all remedies requiring attention to their effects and by preventing the observation and accumulation of Facts for the advancement of the Science of medicine greatly limits its service as a Medical Institution."^[118] Such a state of affairs was rendered the more deplorable because proper classification of the varieties of mental disease revealed that each major subtype was almost certainly the consequence of an underlying physical pathology—mania reflected a disorder of the brain, melancholia a dysfunction of the abdominal viscera, and nervousness a disturbed state of the nervous system.

Thackeray felt that "if there be any foundation for this classification of mental disease, great encouragement I think is held out in it for placing a Lunatic Asylum on the footing of a Medical Institution."^[119] The magistrates clearly did not. Dr. Maclean, who had replaced Leech as House Surgeon at the Infirmary, continued to hold that post and to perform the duties of secretary and head apothecary at the infirmary, so that his attendance on the asylum patients was a distinctly part-time affair; and Thackeray still contributed his services on a voluntary, unpaid, visiting basis. On Maclean's resignation from his various posts in June 1823,^[120] the governors ordered that his successor should perform these same duties, and in September a Mr. Harris accepted the appointment.^[121]

Further efforts were now made to dislodge the layman, Pether, and to replace him with a resident medical officer. The large proportion of chronic derelicts among the asylum population here posed a problem for those advocating a greater role for medicine, since it was not clear what benefits, if any, the increased expenditure for a full-time medical officer would bring. Thackeray conceded the difficulty but sought to persuade the magistrates that it was a temporary state of affairs, the consequence of the failure to employ medical treatment while such cases were still curable, a mistake they should take care to avoid in the future. As he explained,

The present state of the house in which there are but few subjects under medical treatment may perhaps have led to the idea that little occasion exists for the establishment of such a department. Were this state a perma-

[118] Thackeray to the Magistrates' Committee, 7 August 1815, Miscellaneous Papers Relating to the Foundation of the Lunatic Asylum, Bedfordshire County Record Office.

[119] Ibid.

[120] Bedfordshire County Asylum, Visitors' Book A, 2 June 1823.

[121] Harris was in fact a surgeon, an occupation that to this day takes the title "Mr." in Britain.

nent condition of the house the conclusion would be just; but it should be regarded [as] wholly an accidental one, depending on the Infancy of the Institution. The asylum is at present filled chiefly with patients whose disorder from their long standing, discourage every hope of benefit from medical exertion. In the progress, however, of time recent cases of derangement will be continually presenting themselves, when much encouragement will be offered for the active interference of Art.^[122]

For a while, the magistrates still proved recalcitrant. Thackeray and Harris submitted further memoranda in support of their position and obtained testimonials reinforcing their coutentions from other physicians who happened to visit the asylum. Finally, the magistrates bowed to the weight of professional opinion: "Dr. Thackeray and Mr. Harris having separately called the attention of the magistrates to the expediency of providing regular resident medical aid to the Institution and the Magistrates having noticed a similar suggestion centered in the visitors' journal by the Medical Superintendent of the Bicêtre of Paris and another foreigner and Dr. Thompson of the twenty-fifth of July last, and having taken the same into their consideration, resolved to recommend the subject to the next court of Quarter Sessions."^[123] Pether's position swiftly became untenable, as he lost almost all his remaining authority. Finally, in 1828 he resigned his position as general manager, and was succeeded by Harris.^[124] Paramount authority over all aspects of asylum administration now rested in medical hands.

The activities, both local and national, we have just been discussing all made use of, and owed much of their success to, the arguments developed in the medical literature of the period. For it was the contentions advanced here that convinced almost all the educated classes that insanity was indeed a disease and that its treatment ought therefore to be entrusted to doctors. Consequently, I now want to devote some time to a consideration of just what such arguments were.

Moral treatment lacked a well-developed ideological rationale for why it should work. Tuke had explicitly eschewed any desire to develop a theoretical account of the nature of mental disturbance and had refused to elaborate moral treatment into a rigid "scientific" therapy.^[125] In the past, "the want of facts relative to this subject, and our disposition to

[122] Memorandum from Dr. Thackeray, M.D., Miscellaneous Papers Relating to the Foundation of the County Lunatic Asylum, Bedfordshire County Record Office (emphasis in the original).

[123] Bedfordshire County Asylum, Visitors' Book, 5 February 1827.

[124] Ibid., 6 October 1828.

[125] For instance, he was "far from imagining that this Asylum is a perfect model for others, either in regards to construction or management. If several improvements have been successfully introduced, it is probable that many others remain unattempted" (S. Tuke, Description of the Retreat, xxii).

hasty generalization, have led to many conclusions equally unfriendly to the progress of knowledge, and the comfort of patients."^[126] He therefore resisted efforts to achieve a premature systematization of knowledge and encouraged a pragmatic approach: "I have happily little occasion for theory, since my province is to relate, not only what ought to be done, but also what, in most instances, is actually performed."^[127] He even refused to choose between a psychological and somatic etiology of insanity, arguing that "whatever theory we maintain in regard to the remote causes of insanity, we must consider moral treatment of very high importance."^[128] If its origins lay in the mind, "applications made immediately to it are the most natural, and the most likely to be attended with success"; if they lay in the body, "we shall still readily admit, from the reciprocal action of the two parts of our system upon each other, that the greatest attention is necessary to whatever is calculated to affect the mind."^[129]

Undoubtedly, though, the nature of the therapy he advanced, and the manner in which advocates of moral treatment persistently and explicitly denied the value of a medical approach, could, at the very least, be more readily reconciled with a mental rather than a somatic etiology of insanity. Francis Willis was not alone in accusing those favoring moral treatment of propagating the doctrine that "mental derangement must arise from causes, and be cured by remedies, that solely and exclusively operate on the mind."^[130] Physicians stigmatized this as an "absurd opinion"^[131] but were obviously afraid of the threat it posed to their position.

The single most effective response to an attack along these lines would have been to demonstrate that insanity was in fact caused by bio-physical variables. A somatic interpretation of insanity would place it beyond dispute within medicine's recognized sphere of competence and make plausible the assertion that it responded to medicine's conventional remedies for disease. The trouble was that the doctors could not

[126] Ibid., viii.

[127] Ibid., 138. This refusal to reduce moral treatment to a set of formulas and the insistence that it rested on a commonsense approach to the problem of insanity, aimed at eliminating artificial obstacles to recovery, made for a refreshing lack of dogmatism. At the same time, the adoption of these positions was a crucial factor in weakening the ability of the proponents of moral treatment to resist takeover and transtormation by those espousing a less modest ideal; for by denying that schooled human knowledge and intervention were needed to cope with insanity, those advocating moral rather than medical treatment at least delayed the rise of an occupational group claiming training in their new therapy.

[128] Ibid., 131.

[129] Ibid., 131–32.

[130] Willis, Mental Derangement, 2d ed., 4. This was an idea he thought could not "for a moment be rationally entertained" (ibid.). I shall show why in a moment.

[131] Browne, What Asylums Were, 178.

show the existence of the necessary physical lesions, and this inconvenient fact was already in the public domain.^[132]

Unable to produce scientific evidence in support of their personal predilection tot a somatic interpretation,^[133] the doctors invented an ingenious metaphysical argument that, dressed in the trappings of science, proved an equally satisfactory functional alternative. They began by postulating a Cartesian dualism between mind and body. The mind, which was an immortal, immaterial substance, identical with the Christian doc-

[132] "In three fourths of the cases of insanity, where they have been subjected to, dissection after death, the knife of the anatomist has not been able, with the most scrutinizing care, to trace any organic change to which the cause of the disease could be traced" (Nisbet, Two Letters, 21–22). For even more pessimistic conclusions (from the medical viewpoint), see Haslam, Medical Jurisprudence ; House of Commons, Report . . . on Pauper Lunatics (1927), 50–52, evidence of Sir Anthony Carlisle.

[133] That insanity was a somatic disease was asserted with complete confidence and virtual unanimity in the medical literature of the time: "Madness has always been connected with disease of the brain and its membranes" (Haslam, Medical Jurisprudence, 238); "Insanity, always originates in a corporeal cause: derangement of the intellectual faculties is but the effect" (Burrows, Regulating of Madhouses, 102); "Insanity it must be contended for, is as much within the province of medical acumen, as any other disorder incidental to animal life. . . . Insanity, it will be shewn, is, in every instance, associated with organic lesion" (Hallaran, Practical Observations, 2); "Instead of delirium, derangement and insanity, being merely menial disorders, each of them must be, in fact, and in its origin, a bodily one" (Willis, Mental Derangement, 5; 2d ed., 3); "I believe that insanity is as much a bodily disease as a fever or a bunyon on any finger. . . . It is a disease of the brain just as much as dyspepsia [is] of the stomach" (House of Commons, Report . . . on Pauper Lunatics [1827], 65, evidence of Dr. Edward Wright, superintendent of Bethle); "The remote causes of insanity may be . . . undefined anti countless; but the proximate cause, or in fact the discase itself, will always be found to arise from the diseased state of the structure of the brain" (Andrew Halliday, A General View of the Present State of Lunatics and Lunatic Asylums in Great Britain and Ireland, and in Some Other Kingdoms [London: Underwood, 1828], 5); "Madness is sometimes immediately excited by mental circumstances but even when that is the case, the disorder is bodily" (Uwins, Disorders of the Brain, 229): "Insanity may be defined as 'disordered' function of the brain generally" (Neville, On Insanity, 18); "[Insanity is] strictly a bodily disease having its origins in organic lesions of the brain" (Browne, What Asylums Were, 4); "Insanity has been considered in all cases, to be a disease of the brain" (Ellis, Treatise on . . . Insanity, 146, and of. chap. 2, 22–40); "Now it was well known, that insanity never existed without some organic affection of the human body—that the mind itself never became deranged or disordered in its functions but from some derangement in the structure of the human frame. . . . In general, there was an inflammatory attack going on, requiring to be treated and subdued and when subdued the derangement disappeared" (Thomas Wakeley in Hansard's Parliamentary Debates, 3d ser., vol. 66 [1844], col. 1278). See also Mayo and Mayo, Remarks on Insanity, which emphasizes "the physical phenomena" of insanity; Prichard, Treatise on Insanity, 234–49; and Morison, Outlines of Lectures, 4th ed., 422–23. A few doctors located the cause somewhere other than the brain: "I would say, that where a hurt or disease or disorder exists in the brain, there is at least an equal number where it exists in the stomach" (House of Commons, Report . . . on Pauper Lunatics [1827], 52, evidence of Sir Anthony Carlisle); Prichard (Treatise on Insanity, 249) concurred. But for Burnett, "both reason and science favour the idea that insanity is not and ought not in the first instance, and often to the very last, to be regarded as a disease of the brain, but as a disease floating in the blood, having no fixed or local character" (C. M. Burnett, M.D., Insanity Tested by Science, and Shown to Be a Disease Rarely Connected with Organic Lesion of the Brain, and on That Account Far More Susceptible of Cure than Has Hitherto Been Supposed [London: Highley, 1848],5). Halliday informed the public of the importance of the "discovery" that insanity had a somatic basis: the earlier, mistaken notion that insanity was a disease of the mind could not but lead to a deep therapeutic pessimism, since neither doctors nor anyone else could act on this immaterial substance. However, "truth has taken the place of fiction, and madness is found to proceed in all cases from some real tangible bodily ailment. It can now be treated according to the known rules of practice—made amenable to the ordinary discipline of the apothecary's shop—and is often more easily removed than less important diseases that have made a temporary logement in the human frame" (Halliday, Present State of Lunatics, 444).

trine of the soul, was forced in this world to operate through the medium of a material instrument, namely the brain.^[134] This was an apparently innocuous distinction, but once it had been conceded, the doctors had no trouble "proving" their case. For to argue that the mind was subject to disease, or even, in the case of outright idiotism, death, was to contradict the very foundation of Christianity, the belief in an immortal soul. On the other hand, adoption of a somatic viewpoint provided a wholly satisfactory resolution to the dilemma: "From the admission of this principle, derangement is no longer considered a disease of the understanding, but of the centre of the nervous system, upon the unimpaired condition of which the exercise of the understanding depends. The brain is at fault and not the mind."^[135] The brain, as a material organ, was liable to irritation and inflammation, and it was this which produced insanity.^[136] "But let this oppression [of the brain] be relieved, this irritation be removed, and the mind rises in its native strength, clear and calm, uninjured, immutable, immortal. In all cases where disorder of the mind is detectable, from the faintest peculiarity to the widest deviation

[134] Laymen were assured that "the connection of the faculties of the mind with the brain, or, to speak more accurately, their dependence on this organ, is a point . . . certainly demonstrated by the labours of modern physiologists anti pathologists," (Neville, On Insanity, 18). But no one explained just how these two things were connected, or how it was that a purely psychological therapy, like moral treatment (which the doctors were in the process of claiming as their own) could affect a physical disorder. Burrows comments that "to discuss the validity of this or that hypothesis would be plunging into an inextricable labyrinth" (Burrows, Inquiry into Certain Errors, 7); Browne dismissed the question as unimportant: "In what manner this connection between mind and matter is effected, is not here inquired into. The link will, perhaps, ever escape human research". (Browne, What Asylums Were, 4); Bingham gravely informed his readers that "it is not impossible that a vomit may be the accidental cause of dislodging a foolish notion which has long stuck in the brain" (Bingham, Religious Delusions, xiv–xv), but left the precise mechanism through which this was accomplished to their imagination. Fortunately, this was scarcely a pressing problem, save in a purely logical sense, since the moral-treatment people themselves had not developed a clearly articulated theory of how or why their treatment worked. Consequently, the doctors were not challenged on this vulnerable point in their argument.

[135] Browne, What Asylums Were, 4.

[136] Morison, Outlines of Lectures, 35–37.

from health, it must and can only be traced directly or indirectly to the brain."^[137]

The failure to observe physical lesions of the brain in most cases of insanity could now be explained in either of two ways, neither of which threatened the somatic interpretation. On the one hand, it might be that existing instruments and techniques were simply too crude to detect the very subtle changes involved.^[138] On the other hand, it could be that insanity in its early stages was correlated only with functional changes in the brain, which only at a later stage, when the patient became chronic, passed over into structural ones.^[139]

The intuitive appeal of this explanation to an audience of convinced Christians was enormous and suffered scarcely at all from its extrascientific character.^[140] And by "proving" that insanity was a somatic complaint, it decisively reinforced medical claims to jurisdiction in this area. The obvious achievements of moral treatment could not be simply overlooked—they were too well established in the public mind for that. However, it could be, and was, just absorbed into the realm of ordinary medical techniques.

Moral treatment now became just one weapon among many (even if a

[137] Browne, What Asylums Were, 4. For the elaborations of this entire somatic ideology that most clearly reveal that ultimately theological grounds on which the explanation was offered (and accepted), see Morison, Outlines of Lectures, 34–44, and Halliday, Present State of Lunatics, 5–8. Revealing in a rather different sense was Burrows' contention that "no impression, perhaps, has been more detrimental than the scholastic dogma, that the mind, being independent of the body, can simulate all its functions and actions; can sicken, be administered to, recover, and relapse; and that consequently all but mural remedies must be secondary, if not nearly useless, every other being incompatible with an immaterial essence like mind" (Burrows, Inquiry into Certain Errors, 6–7). One is led to ask, detrimental to what? And it is difficult to avoid the conclusion, detrimental to the claim that insanity is a medical problem, one that only doctors are qualified to handle.

[138] Morison, Outlines of Lectures, 411. Morison produced a subtle and ingenious argument to show that the changes in the brain must be slight in the early stages of the disease. It was a common observation that recent cases of insanity recovered in greater numbers than those of long standing. This must mean that the changes in the structure of their brains had not proceeded very far, for serious structural changes would naturally be irreversible, and hence impossible to cure. Ibid., 422.

[139] Neville, On Insanity, 60. The proof of this position was that "cases of any standing that terminate fatally are, we may venture to say, never investigated by the skillful pathological anatomist without obvious traces of structural disease being discovered" (ibid., 60–61 [emphasis in the original]).

[140] Parenthetically, it may well be that scientific theories under some circumstances are not very effective weapons for converting laymen, since they may depart too radically from the lay world-view and/or be too complicated to lend themselves to a convincing simplistic presentation to a lay audience. For propaganda purposes, quasi-theories like this one, which don't really have a scientific status, may be a better way of persuading laymen that one has expertise, simply because they provide a closer fit with the preconceptions of the expert's audience. In this case, there is a rather delightful irony: the doctors were forced to rely on spiritual assumptions to prove a materialist case.

particularly valuable one) that the skillful physician used in his battle against mental illness. Texts like Prichard's included a chapter on moral treatment as a matter of course,^[141] while those who rejected the conventional medical methods were accused of unnecessarily reducing their chances of curing their patients. In support of this position, certain maddoctors claimed to have cured a higher percentage of their patients than had the Retreat^[142] and attributed this to their willingness to use both moral and medical means.^[143] Others claimed to provide proof of the efficacy of medical means in certain cases, proof that took the form of citing instances of insanity known to the author where the patients had recovered at some time after the administration of traditional medical remedies.^[144]

A number of doctors now proposed a truce. Extremists on both sides might argue for the unique value of a moral or a medical approach. But all reasonable men could see that a judicious combination of these two therapies was likely to be more valuable than either taken by itself.^[145] "To

[141] Cf. Prichard, Treatise on Insanity .

[142] Burrows claimed he had cured "on recent cases, 91 in 100; and on old cases, 35 in 100" (Burrows, Inquiry into Certain Errors, 48).

[143] Burrows commented that "insanity was formerly in that asylum [the Retreat] scarcely considered to be a remediable complaint; and consequently, medical aid was resorted to only when patients were affected with other disorders" (Burrows, Commentaries, 558). For himself: "Having the fullest conviction of the great efficacy of medicine in the majority of cases of insanity, I have ever viewed with regret the little confidence professed by the benevolent conductors of the Retreat in its powers; and have always considered that the exercise of a more energetic remedial plan of treatment was the only thing required to render the system they pursue perfect" (Burrows, Inquiry into Certain Errors, 31).

[144] Prichard, having defended medical treatment as "the use of remedies which act upon the body and are designed to remove the disorder of cerebral or other functions, known or believed to be the cause of derangement in the mind," cited a string of such cures following the use of bleeding, purges, vomits, opium, digitalis; and the like (Prichard, Treatise on Insanity, 250–56). Thurnam conceded that "perhaps we cannot produce any facts which actually prove that pharmaceutic treatment, considered separately, has in any particular institution influenced the results on any large scale; yet we cannot doubt that the proportion of recoveries is greater, and in particular, that the mean mortality will be less in a hospital for the insane, in which attention is paid to a discriminating and judicious medical treatment," (Thurnam, Statistics of Insanity, 100–101). After all, if insanity was a medical problem, no other conclusion made sense. The same resort to petitio principii was apparent in his account of the results of his own treatment of cases at the York Retreat: given a belief that insanity was a physical disease, "I caannot but attach great importance to the use of physical means in the treatment of mental disorders, for if insanity really depends on some morbid conditions of the bodily frame, it follows, as at least highly probably, that everything tending to the restoration or maintenance of bodily health must be of primary importance in its treatment" (ibid., 98).

[145] Looking back on the time when the threat to medical control was greatest, Browne commented: "Benevolence and sympathy suggested and developed, and in my opinion, unfortunately enhanced the employment of moral means, either to the exclusion or to the undue disparagement of physical means, of cure and alleviation. I confess to have aided at one time in this revolution; which cannot be regarded in any better light than as treason to the principles of our profession " (Browne, Moral Treatment of the Insane, 5 [emphasis added ]). Most doctors who were converts to moral treatment continued to give their primary loyalty to medicine, and so emphasized that medical skill still had a role (e.g., Browne and Ellis). Gardiner Hill did not, and his case provides us with an interesting indication of a profession's response to a heretic from within its own ranks who challenges its competence. Hill had every right to be recognized as one of the outstanding figures of nineteenth-century psychiatry. It was his efforts at Lincoln that showed the feasibility of the total abolition of mechanical restraint. His practical demonstration convinced Conolly, who then adopted it at Hanwell, from which it spread to become the reigning orthodoxy in all British asylums. Conolly achieved high place in the psychiatric historians' pantheon of heroes and wide-spread honor in his own time. Hill, within two years of his first success, was forced to resign from Iris position at Lincoln, assailed over a period of years in the Lancet as a charlatan, saw his achievement attributed to E. P. Charlesworth, his nominal superior at Lincoln, and remained a perpetually marginal figure in his chosen profession. His response was to write a series of books vindicating his claim and attempting to gain public recognition of his accomplishment, books that, given his isolation, took on an increasingly paranoid tone (Robert Gardiner Hill, A Lecture on the Management of Lunatic Asylums, and the Treatment of the Insane [London: Simpkin Marshall, 1839]; A Concise History of the Entire Abolition of Mechanical Restraint in the Treatment of the Insane [London: Longman et al., 1857]; Lunacy: Its Past and Present [London: Longman, Green et al., 1870]). The enmity of the medical profession anti the venom of the attacks in the leading medical periodical of the time seem puzzling at first sight. But we must remember that, in Browne's words, Hill was a "traitor" to his profession: from the outset he had insisted that "in the treatment of the insane, medicine is of little avail, except (of course) when they are suffering from other diseases, to which lunatics as well as sane persons are liable. Moral treatment with a view to induce habits of self-control, is all and everything . [In consequence] the use of the lancet, leeches, cupping, glasses, blisters, drastic purgatives, and the practice of shaving the head are totally proscribed in this Asylum" (Management of Lunatic Asylum, 45 [emphasis in the original]). When, in the teeth of the interests of die profession, he persisted in this opinion (it was reiterated word far word in Abolition of Mechanical Restraint, 72), he was rewarded with ostracism anti abuse. For further discussion of Conolly and Hill, see Chapter 7.

those acquainted with the workings of the malady and its peculiar characteristics," said Neville, "it will be easy to perceive the errors and partial views of such as profess to apply a medicinal agent only, as a specific, or those who advocate a course of moral treatment only for a cure. There is no doubt that a cooperation of medicinal and moral means is requisite to effect a thorough cure."^[146] Now while from one perspective this attitude represented a concession, particularly when compared with earlier emphases on the exclusive value of medicine, the concession was a harmless one. For it left the physician, as the only person who could legitimately dispense the medical side of the treatment, firmly in control. Thus, Neville thought that moral and medical treatment could be carried out only "under the guidance of persons of sound protessional education, and mature experience of the disease,"^[147] while Ellis commented: "From what has been said on the treatment of the insane in Lunatic Asylums, it

[146] Neville, On Insanity, 14. Cf. Bingham, Religious Delusions, esp. pp. 62–63.

[147] Neville, On Insanity, 14.

will be obvious, that, according to my notions, no-one, except a medical man, and a benevolent one, ought to be entrusted with the management of them."^[148]

And indeed, that was exactly what did happen. By the 1830s almost all the public mental hospitals had a resident medical director. Moreover, the magistrates' committees, which in several instances had been heavily involved in the day-to-day administration of asylums, increasingly left everything to the experts. The metropolitan commissioners, not entirely approvingly, commented in 1844 that the pattern at Bedford was being generally emulated, with "almost the entire control of the County Asylum being delegated to the Medical and General Superintendent."^[149] Similarly, in the private sector, the more reputable private institutions acquired either a medical proprietor or a full-time resident medical superintendent.^[150] Symptomatic of medicine's gains in this respect was the appointment of a resident physician to run the York Retreat, where moral treatment had originated and which, for the first forty-two years of its existence, had had a succession of lay superintendents.^[151]

Finally, the asylum doctor solved the problem of restricting access to his clientele and transforming his dominance of the treatment of mental illness into a virtual monopoly, in a typically professional manner, by arranging "to have himself designated as the expert in such a way as to exclude all other claimants, his designation being official and bureaucratic insofar as it is formally established by law."^[152] The Madhouse Act of 1828 introduced the first legal requirements with respect to medical attendance: each asylum had to make arrangements for a doctor to visit the patients at least once a week and for him to sign a Weekly Register.

[148] Ellis, Treatise on . . . Insanity, 314. Cf. Browne, What Asylums Were, 178: "But to whom, rather than the well-educated physician, is such a sacred and momentous trust to be consigned?"

[149] Metropolitan Commissioners in Lunacy, Report (1844), 25–26. The metropolitan commissioners were concerned lest the superintendent's power was becoming unduly autocratic: "We consider that the appointment and dismissal of servants is a trust of great importance, which is vested in the Visiting Justices for the purpose of checking any undue power or influence being used by the superintendent over the servants of the Asylum" (ibid., 26). But by the time of their Seventh Report, in 1853, their successors, the national commissioners, had concluded that such a concentration of power was desirable and that lay interference in all aspects of asylum affairs ought to be kept to a minimum.

[150] For example, by 1831, forty-four out of sixty-eight provincial licensed houses were described as having a proprietor with medical or surgical qualifications (W. L. Parry-Jones, Trade in Lunacy, 78). Numerous families in the mad-business, many of whose fathers had been laymen, now obtained medical qualifications. Among the more notable examples were the Coxes, the Bakewells, the Finches, and the Warburtons.

[151] The appointment was of Dr. Thurnam, later the first superintendent of the Wiltshire County Asylum at Devizes, and took place in 1838 (Thurnam, Statistics of Insanity, 15).

[152] Freidson, Professional Dominance, 161.

Where an asylum contained more than a hundred patients, it had to employ a medical superintendent. These requirements were stiffened by the 1845 Lunatics Act, which required, among other things, that all asylums keep a Medical Visitation Book and a record of the medical treatment of each patient in a Medical Case Book. And from 1846 on, the lunacy commissioners, who included a large contingent from the medical profession, manifested a steadily growing hostility to nonmedically run asylums. With the help of elite sponsorship, the asylum doctors were now able to drive competing lay people out of the same line of work and to subordinate those who stayed in the field to their authority. And their position controlling the only legitimate institutions for coping with the mentally ill gave them powerful leverage to discourage any future efforts to enter the field.^[153]

[153] Two final points: First, notice that the lay people the asylum doctors had to convert to the recognition of medical expertise weren't at all the same as those they had to persuade/coerce/treat. Members of the upper class shared the medical profession's universe of discourse; their "clients" did not. A crucial sociological question that therefore arises concerns the means by which the experts on insanity maintained their professional authority in the context of the asylum. (Such an analysis is presented in Scull, Museums of Madness, chap. 5). Second, what this account has emphasized, and what Freidson has suggested, is true for the professions in general: When this emerging profession sought to establish its dominance and authority, "the process determining the outcome was essentially political and social rather than technical in character, a process in which power and persuasive rhetoric were of greater importance than the objective character of the knowledge, training, and work" (Freidson, Profession of Medicine, 79).