THE TRANSFORMATION OF THE MAD-DOCTORING TRADE
I am willing to pay Adoration to Virtue wherever I can meet with it, with a Proviso, that I shall not be oblig'd to admit any as such where I can see no Self-denial, or to judge of Mens Sentiments from their Words, where I have their Lives before me. (Bernard Mandeville, The Fable of the Bees)
The class of people taking care of lunatics has, within my own experience, very much improved, I remember when almost every man who kept an asylum was an eccentric, or had something peculiar about him, or strange in his appearance, and was more calculated to knock a patient down than to cure him; that was the general character of them. (John Conolly, testimony before the House of Commons Select Committee on the Care and Treatment of Lunatics, 1859)
I think it is a very hard case for a man to be locked up in an asylum and kept there; you may call it anything you like, but it is a prison. (Sir James Coxe, testimony before the House of Commons Select Committee on the Operations of the Lunacy Laws, 1877)
As is by now generally acknowledged, in Britain the massive internment of the mad in what were asserted to be therapeutic institutions is essentially a nineteenth-century phenomenon. Though fugitive references to madhouses can be traced back to the seventeenth century, and perhaps before, and though a recognizable "trade in lunacy" clearly became established over the course of the eighteenth century, only after 1800 did systematic provision begin to be made for segregating the insane into specialized institutions. The birth of the asylum in its turn was intimately bound up with the emergence and consolidation of a newly self-conscious group of people laying claim to expertise in the treatment of mental disorder and asserting their right to a monopoly over its identification and treatment. It is with this increasingly organized specialism that this book is concerned. We seek to understand the growth and development of a collective consciousness and organization among a subset of medical men, the ancestors of the modern profession now called psychiatry. And we have chosen to do so through a focus on the interlocking lives and careers of a handful of elite figures whose practices jointly encompass the entire century.
We are aware, of course, that biography has, for the most part, fallen into disfavour in the history of medicine, as in the history of science more generally. Hagiographies of "great men" written by amateurs who lack even the rudiments of historical training have given the whole genre a bad name. Viewed uncritically, and without attention to structures, context, or culture, the lives of a handful of heroes are transmuted into myths bearing no discernable relationship to the complexities of the past--useful ideological constructs for those bent on creating an idealized fiction as a support for their current professional identity, but useless for those seeking a more balanced understanding of the historical record.
Such deficiencies are by no means intrinsic to a biographical approach. In examining the lives of individuals, nothing precludes our attending to these broader structural and contextual concerns--indeed, to do so is essential if we are really to grasp the meaning and significance of their existence and accomplishments. We take seriously the contention that people make their own history, and paying close attention to individual lives obviously provides us with the most vivid sense of just how they accomplish that task. But we are equally aware that human action is always constrained by and responsive to the wider social and cultural context within which it occurs. In examining this constant interplay of structure and agency we necessarily confront the inherently interactive and collective dimensions of each individual's life. Paradoxically, therefore, the very endeavour to capture what is particular and idiosyncratic about a given actor simultaneously requires us to attend most closely to the realm of the social. Put another way as we shall seek to demonstrate in the chapters that follow, the more we seek to understand the individual dimensions of someone's life, the more inescapably we find ourselves engaged in an essentially sociological enterprise.
How else, after all, are we to understand lives and careers but by attending to the "particular configuration of social institutional, and intellectual options" available to the protagonists we are interested in? In the process of confronting and coping with a given social reality, even in attempting to modify and transform the options available at a given historical moment, individuals may be making their own place in history. Yet their life courses are also at once constituting and revealing the contours of the culture and social structure within which they exist and struggle, succeed and fail.
Nineteenth-century Britain was the first example of a society turned upside down by the advent of industrial capitalism. The maturing of the Industrial Revolution that had its origins in the second half of the preceding century transformed Britain's politics, culture, social organization, even physical landscape. The revolutionary transformation in people's lives was predicated upon the creation of an urban-industrial civilization of a radically novel sort. It brought in its train a massive rise in human productivity, an expansion of manufacturing and commerce, and a profound alteration even of the agricultural sector of the economy, as the values and disciplines of the marketplace systematically penetrated every corner and cranny of British society.
Not least, the new order witnessed massive upheavals in the social structure associated with the birth of a new class society: the fracturing of old social hierarchies and the creation and expansion of whole new categories of collective actors on the historical scene. Of utmost significance for our present purposes, these included not just an industrial and commercial bourgeoisie (and their counterpart, a burgeoning proletariat) but also an ever-greater enlargement of the knowledge-based professional classes. For the vast increase of wealth that was created in the wake of a mature capitalism created manifold opportunities for the sale of services in the marketplace, with human capital and specialised expertise increasingly the resource from which a growing segment of the middle classes drew their sustenance.
The rise of psychiatry as an organized profession, with which we shall be concerned in the following chapters, is thus but a particular instance of a much broader phenomenon, what Harold Perkin has termed "the rise of professional society." During the nineteenth century, knowledge--particularly but not exclusively scientific knowledge--increasingly became a resource from which a variety of newly consolidating and self-conscious groups sought to extract a living. Mad-doctors, or as they increasingly preferred to call themselves, alienists or medical psychologists, were merely one of a whole array of groups seeking recognition and social status on this basis.
Unlike their entrepreneurial counterparts in the manufacturing sector, the new professionals were in the business of selling something intangible: skill and expertise rather than material goods. Each such group claimed the ability not only to diagnose and understand problems on a more subtle and sophisticated level than was granted to laymen who lacked their specialized knowledge but also to prescribe remedies and solutions on the basis of their greater technical expertise. To the extent that they could persuade others of their talents and capacities and convince relevant audiences that their performances were worthy of hire, professionals were able to transform their standing in the social division of labour. In alchemical fashion, the abstract human capital they claimed to embody could be transubstantiated into real claims on resources: enhanced power, prestige, and influence, to be sure, but also incomes reflective of the scarcity and assumed social value of the services only they were in a position to provide. Professionals sought, as Perkin puts it, to secure "in strict Ricardian terms a rent for the scarce resource of their esoteric skill. The size of the rent, the difference between the professional fee or salary and the price of common labour, was the measure of the success of each profession in claiming that scarcity value and establishing its status.... Their rewards were negotiated in the wider societal market of prestige and the social value placed on their service rather than by the sale of their labour in the economic market place."
The professional project, moreover, was still more ambitious and complicated than Perkin here implies. For professionals sought to secure not just an economic but also a social "rent" in return for supplying their services. They were not and could not be satisfied, in other words, with an increase in the financial returns accruing to those who engaged in a particular line of work because they simultaneously coveted a comparable elevation of their standing in the social hierarchy--if possible, public recognition that they belonged among the ranks of "gentlemen." Behaviour that was crassly materialistic and self-interested, or that in too-obvious fashion conjured up the offensive odour of "trade," might serve to advance an occupation's economic interests but threatened to prove fatal to its social aspirations. Likewise, forms of employment that implied a subordinate (and thus servile) status were deeply damaging to the attempt to transform a particular occupation into "a calling by which a gentleman, not born to the inheritance of a gentleman's allowance of good things, might ingeniously obtain the same by some exercise of his abilities."
Like others engaged in this project of collective social mobility, mad-doctors had to seek public approval and trust, and as they struggled to establish control over a particular territory and to define and protect the boundaries of their jurisdiction, they necessarily found themselves engaged in a never-ending campaign of persuasion and propaganda. Trust is vital to the professional because he or she needs to secure assent to claims to possess, not just skills and knowledge that the laity lacks, but skills and knowledge the professional argues the public is not even in a position to assess with any degree of precision. Likewise, the laity must come to trust that members of the profession will exercise their skills in a disinterested fashion and in large degree must be persuaded to rely upon the professionals' own valuation of their knowledge. Yet trust was a particularly difficult commodity for mad-doctors to acquire, not least because their involvement in the trade in lunacy prompted endemic suspicion about their motives, and because their claims to possess expertise in the identification and treatment of madness provoked persistent scepticism even among those laymen most heavily involved in the campaign for lunacy reform. The prominent role played by medical men in the whole series of scandals about treatment in asylums and madhouses that erupted in the first half of the nineteenth century only intensified the difficulty of the task they confronted.
Yet, in the face of these and other obstacles, a recognized specialism did emerge over the course of the nineteenth century and secured some significant measure of public support and patronage. As the number of madmen known to the authorities grew from two or three thousand in 1800 to almost one hundred thousand a century later, their guardians successfully constituted themselves as the public arbiters of mental disorder, the experts in its diagnosis and disposal. They created a professional organization to defend and advance their interests and edited journals and wrote monographs to provide a forum for transmitting (and giving visible evidence of) the body of expert knowledge to which they laid claim. During Victoria's long reign, they increasingly dominated public discourse about insanity, and in the process, they elaborated and refined a set of career structures and opportunities for themselves. Fragile as their public standing might be, marginal and somewhat embarrassing as their medical brethren might find them, psychiatrists nonetheless had secured some accoutrements of professional status, if only as the custodians of a chronically incapacitated and generally economically deprived clientele and as advisers on mental hygiene to a broader population concerned to avoid such a dismal destiny.
Even more than most professions, however, psychiatry was to find that its fate was bound up with the burgeoning growth of an administrative state. At every turn, its practitioners discovered that they were dependent upon state approval, supervision, and sponsorship. The overwhelming majority of their nominal clientele could not afford to pay for the services they offered; the cost of confinement in an asylum was prohibitive for all but the most well-to-do segments of the population so the network of asylums for paupers was necessarily constructed and maintained by taxpayers. A major segment of the profession consequently consisted of salaried employees in the public sector and direct dependents of the state apparatus, broadly defined. The pervasive presence of the state made itself felt in other respects as well. Earlier abuses and the persistence of a private, profit-oriented madhouse sector to which rich lunatics were consigned prompted the creation of a state inspectorate, to whose opinions all segments of the profession were necessarily beholden: the superintendents of the pauper asylums because official criticism could prompt their dismissal; and their private-sector colleagues and rivals because the Lunacy Commission could withdraw their license to operate and thus bring about their professional ruin. More broadly, of course, as with other professions, alienists' professional standing and privileges ultimately required political and legal guarantees only the state could provide.
These circumstances form the broad contours within which the lives and careers of nineteenth-century mad-doctors unfolded. The creation of the profession was, quite naturally, a long and complicated process--just how complex will become apparent in the chapters that follow--and the circumstances and contingencies that confronted those who sought to specialize in the treatment of the mad changed dramatically over the course of the century. In choosing the subjects of our investigation, we have consciously sought to examine those lives that most clearly exhibit the central features and dilemmas that accompanied the development of the profession and that set out, in starkest relief, the enterprise through which these managers of the mad constructed their own peculiar corner of the social universe.
As we have previously indicated, our study encompasses only a handful of figures, all of whom constituted members of the professions elite. They are not, in any statistical sense, representative figures, and without question a prosopographical study of the still largely anonymous and unheralded rank-and-file members of the fraternity of mad-doctors would provide a great deal of additional and exceedingly welcome knowledge about the structure of psychiatric lives and careers in the nineteenth century. But studying members of the elite has its own rewards, and these extend considerably beyond the more nuanced portraits one can draw because of the richer historical records that tend to survive in such cases.
Almost by definition, the most prominent alienists played leading roles in the emergence and evolution of the profession. It was, after all, precisely their performances on this particular stage that brought them their measure of eminence. Their actions helped to define and to stretch the limits of medical involvement with the mad, and their ideas constituted the platform on which the profession laid claim to its privileged place in the social division of labour. Conolly and Browne, for instance, together did much to create the utopian vision of the curative asylum that lay at the heart of lunacy reformers' attempts to reshape the character of society's provision for the insane. Together with Bucknill and Gaskell, they subsequently helped to define the role of asylum superintendent, the institutional niche occupied by most of the profession. Gaskell and Browne, who went on to occupy the post of Lunacy Commissioner in England and Scotland, respectively, exercised supervisory authority over their separate realms of asylumdom, while Bucknill founded and edited the profession's principal journal, the Journal of Mental Science (and was succeeded as editor by Maudsley).
If all these men have traditionally constituted heroes in the profession's pantheon, John Haslam has perhaps occupied a more dubious status: the most prominent of early nineteenth-century mad-doctors, a man of prodigious energies and talents, but the target of some reformers' most biting criticism, and at the very centre of the most notorious asylum scandal of the century in his position as resident apothecary at Bethlem. As we shall see, in the aftermath of this professional disgrace, he nonetheless was to succeed in rebuilding his reputation and practice, all the while taking issue with many orthodox pieties of his day and voicing scepticism about the very technologies and treatments that were to form the foundation for the mainstream practitioners of the emerging profession--a stance in which he was joined by his friend and professional ally, Alexander Morison. Obviously, as their examples demonstrate, professionalization is neither a unidirectional nor a predictable process.
Other dimensions of Morison's career remind us that, despite our retrospective identification of the Victorian era with the striking and sinister asylum buildings that came to contain in ever-larger quantities "the waifs and strays, the weak and wayward of our race," the profession was never wholly confined within the walls of the institutional sector. Building upon an earlier model of practice, where madness was merely one of a number of disorders a general physician might venture to treat, Morison sought to advance an alternative, for the most part noninstitutionally based, approach to treating the ravages of mental disorder. And if this approach seemed for a time destined to be cast aside into the dustbin of history, it was ironically revived in somewhat different form by Bucknill and Maudsley in the later stages of their careers, as they grew increasingly impatient with and critical of the limitations and drawbacks of institutional psychiatry and looked instead to the lucrative rewards of a private, office-based consulting practice, attending principally to a whole new class of "nervous" patients inhabiting "the borderlands of insanity."
As we trust these preliminary remarks suggest, small though their numbers may be, the overlapping experiences and activities of these seven men thus allow us a peculiarly intimate and revealing set of insights into the place of psychiatry in nineteenth-century society; and they capture many of the most crucial aspects of its development during that formative period. Taken together, they provide us with far-reaching access into the social worlds of the mad-doctors. Likewise, they allow us to watch in a particularly revealing context the transition from a "world of nepotism, privilege, and aristocratic patronage to the more openly competitive, upwardly mobile Victorian society"--a setting in which knowledge, effort, and shrewd exploitation of ones opportunities could be translated into the means of securing ones livelihood and the foundation for newly organised communities of professionals. Of no less importance than these aspects of the transformation of the mad-doctoring trade, the chance to examine the development of these men's ideas about madness in the context of their struggles to build their lives and careers brings home in the most forcible of fashions just how intricate and intimate are the ties that bind together the realms of the cognitive and the social. This reminds us once more of how ultimately untenable is the once-fashionable distinction between the external and internal histories of medicine and science.
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