MENTAL PHYSICIANS AhM THEIR PATIENTS psychological medicine in the English pauper ...

399 Pages·2008·19.28 MB·English

XXX Admissions and Discharges at Wakefield, Wadsley and
Meru3ton Asylums, 1880-1889 267
XXXI "Length of Residence" at Wakefield, Wadsley and Menston
Asylums, 1881-89. 268
XXXII "Condition as to Marriage" of Patients, Nhpperley
Asylum, 1890 269
1XXIII "Showing in Quinquennial Periods the Ages of those
Admitted", Nhpperley Asylum, 1890 270
XXXIV "Probable Causes of the Disorder", Mhpperley Asylum, 1890 271
XXXV "Form of Disease", Nhpperley Asylum, 1890 272
XXXVI "The Religious Persuasion of those Admitted, Mhpperley
Asylum, 1890 273
XXXVII "Occupation or Social Position of the New Cases",
Mhpperley Asylum, 1890 274
IXXVIII "Showing the Lesions and their Frequency in the Brains of
333 Persons who Died Insane, Arranged under the Different
Forms of Insanity" 278
XXXII "Showing the Percentage of the Lesions found in the
Different Forms of Insanity" 279
xr. "Causes of Death During the Year 1890", Mhpperley Asylum,
1890 281
ILI Body Temperatures in the Insane 286
PREFACE
Writing a Ph.D. thesis is rather like travelling on the London
Underground. One emerges from a long unswerving tunnel into a new
station which looks, oddly, mach like the one left behind. The main
difference seems to be the place-name on the wall.
•
In the sans way the conclusion of a thesis feels mach like ignorance
re-located. Travelling conditions have meant that I arrived with mach
the same set of basic experiences, and therefore potential interpretations
of things, as those with which I clambered aboard. There mast have been
junctions along the way, turn-offs in the dark leading to who knows what
new location. Perhaps others will go back and pursue them.
I began the journey with vaguely anti-psychiatric intentions,
enthusiasm and (in retrospect) a remarkably naive set of ideas about the
world's workings. My travelling has brought some changes, perhaps the
greatest of which came from trying to make sense out of my material having
started with such crude beginnings.
Luckily, not all was darkness on the outside. Flashes of reality
occasionally shone through. The period during which I was researching
and writing this thesis saw many turbulent events, some closely connected
with the future provision of health in this country, which set the aca-
demic venture into a realistic perspective. Involving myself in these
events did not always benefit the work in hand, but in some ways the
thesis helped to mediate some ideas, while leaving one band free for
other concerns, and probably both gained some advantage in the end.
Thus in fact, the darkness of the tunnel concealed not only turnings
leading away to new discoveries but also branch-lines of outside experience
leading in. None of this, of course, is revealed in the completed pages,
which show instead the studied image of one point along the track.
This research was made possible by a three year grant from the
Social Science Research Council, to whom my thanks are due. I would also
like to extend special appreciation to Dr Roger Smith of Lancaster Uni-
versity who bears the responsibility for first introducing me to the sub-
ject, and to Dr John Walton, also of Lancaster University, both of whom
provided valuable observations on work in progress.
My gratitude goes also to the staff and students of the Economic and
Social History Department at Sheffield University, particularly to
Dr John Woodward, my supervisor, and to Beryl Moore and Beverley Eaton,
who provided essential support, as did the Crookesmoor Building catering
staff. Thanks also to the staff of the main library at Sheffield Univer-
sity, particularly inter-library loans.
There are many others who gave special assistance at various times
and to each of them I am greatly indebted. My thanks therefore to the
staff of the Walloons Institute for the History of Medicine for the use of
their library facilities, to the staffs of Stanley Boyd Hospital, Wake-
field, Mapperley Hospital, Nottingham, and Middlewood Hospital, Sheffield,
for letting me explore their records and discuss their work, to
Laurence Ashworth, curator of Stanley Boyd Hospital Mhseum, for valuable
information and insights, and to Professor ir.A. Jenner for several long
conversations on the meaning, or otherwise, of the term "psychiatry".
Thanks are also due to each of the following, who in various ways
helped me to keep my sanity: Chris Bacon, Siobhan and Luke Crawley,
Simon Doughty, Ivor Frankell, Guinness the dog, David and Ling Ling Hoyle,
David Jones, Mike Jones, Una Kelly, Keith Macdougall, Ruth/WI:in,
Josgy Materu, Dave Mayan, Bill Paton, Ann Perks, Hosein Piranfar,
Lynda Snawden, Peter Speller and Sue Ward.
(ix)
I owe a special word of thanks to Pam Smith for an excellent typing
job despite inconsiderate revisions by the author and for an amazing
ability to decipher illegible manuscript.
Finally, I would like to extend particular gratitude to
Brian Benjamin of the Working Plents College, Camden Town, London, whose
enthusiasm and encouragement in the early days Of IA/ level evening
classes led me into the academic world in the first place.
RR 18th September 1983
1
CHAPTER 1: INTRODUCTION
The subject of this thesis is institutions, represented in this
instance by the Victorian pauper lunatic asylums. I had not originally
intended this particular emphasis but was drawn to it as the unavoidable
outcome of my concern with the effectiveness of later nineteenth century
medical involvement with the insane. It is no a study of institutions
as such and does not seek to suggest that the lunatio asylum was a
typical example. What it attempts to do is show how the Victorian insti-
tution was intimately related to fundamental aspects of contemporary
socio-economic organisation through various perceived social problems.
The prison, the orphanage, the barrack school, even the workhouse,
differed from one another in many respects. Each had its own fairly well
defined potential population and its own stated purpose. Some were
reformatory while others were more deliberately punitive. The lunatic
asylum was probably the most benign, with the exception perhaps of the
voluntary hospital and the sanitorium, and was dedicated officially to the
pursuit of health and sanity through medical aid. Its potential popula-
tion were those considered insane and its purpose was to cure them. In
developing a study of the validity of its operation I was led beyond these
official purposes to look at the way in which actual responses to the per6-
oeived problems of insanity were constrained at every turn by considera-
tions which were not of the problems as such but of the social organisation
which their existence disturbed. These constraints were present at all
levels and seem to have been an overwhelmingly powerful shaping force in
the development of what cane to be known as psychiatry. This psychiatry
still retained mach of the benign intent - and certainly the rhetoric - of
its overt purpose but had become overridden by an institutionalising pro-
cess that made of it only another variant of the many other Victorian
institutions in its actual functioning.
2
The history of nineteenth century psychological medicine is in any
case a history of the asylum, though what that term signified changed
greatly in the course of the century. I have attempted to examine the •
asylum of the later part of the century from within: to examine its inner
life and routines, its staffing arrangements and the medical perspectives
which were employed to regulate its function. ,MV approach has been from
the point of view of the needs of those persons in the position of patient
under medical authority. This is not to say that those needs were in any
clear sense accessible to historical analysis but rather that when evalua-
tion has had to be made I have put this consideration foremost. It is a
consideration which has not, perhaps, been uppermost in existing work in
this area and so may prove fruitful in the continued study of the topic.
In this sense I have taken what could broadly be said to be a
psychiatric viewpoint rather than a strictly historical one. In his
examination of Victorian insanity trials, Roger Smith observes, "The
historical task is to understand medical and legal discourse rather than
to promote one or the other". this one instance I must disagree
with him. In compiling this research I have been acutely aware that I am
no neutral "historian" set solely about the business of pure understanding.
I have, of course, attempted this much as far as I am capable. However,
it would be less than honest to say that no other concerns directed my
interpretations, that my own personal values and social beliefs were not at
the same time directing the understanding of my material. Broadly speak-
ing, I have taken the side of the individual patient, not as a champion of
rights or defender of conscience, but out of a sense of sympathy for the
sufferer in society, a sympathy no doubt displaced from elsewhere in my
personal thinking yet relevant still in this historical context.
1. SMITH. Roger: Trial by Medicine: Insanity and Responsibility in
Victorian Trials. Edinburgh, 1981, p.161.
3
In making this approach I have deliberately avoided the use of any
one specific social model. The use of particular assumptions, however,
cannot be avoided andIshall need to make my starting points plain in each
area covered in the thesis if the argument is to be followed. I shall
begin with a discussion of the nature of "mental illness" and then look
at the background to each separate chapter.
The concept of mental illness has a history of contentious debate.
The long-standing model employed by the psychiatric profession sees it as
another form of illness in general, with an origin located in the organ-
ism. A major exponent of this view amongst psychiatric historians is
Richard Minter, who sees only organic bases for insanity, the rest being
epiphenomena of these physical lesions. (1) The same organismoentred
view of mental illness is common to that other main branch of psychiatry,
psychotherapy. Here, the origins may or may not be "physical" but arise
within the organism from unresolved conflicts in dealing with the world
outside. These approaches (which are far more complex than outlined here)
correspond to the "medical model", which begins from an assumption that the
real problem lies within an individual, and then isolates him or her to
effect a solution.
This medical hegemony has been steadily challenged in the course of
the last two decades by critics both inside and outside the medical pro-
fession, who have replaced the emphasis on problems within an individual
with problems between them. The organism-centred medical model was thus
under attack, along with the view of "mental illness" as akin to physical
disease. Foremost, perhaps, of the critics within the profession has been
Thomas Szasz. (2) Szasz sees all behaviour in terns of games-theory.
1. BUNTER, Richard and Ida MacALPINE: Psychiatry for the Poor. 1974.
2. SZASZ Thomas: The Myth of Mental Illness. 1962.
4
Interpersonal relationships and the individual's attempt to "win" games
shared with other players give rise to particular behaviours. The rules
may not, however, be held in common, nor the goals, so that a person's
responses may seem inappropriate to outsiders. Psychiatry is an
organised attempt to isolate people behaving inappropriately and impose
another set of cultural rules upon them. For Szasz, the term "mental
illness" is a false metaphor which aids the cultural imperialism of the
psychiatrists.
Critics outside the profession have seen psychiatry as a part of
society's regulation of its individual constituents, in which unaccept-
able behaviours are labelled "deviant" and treated accordingly. Com-
bined with ideas from new movements in psychotherapy, such as those of
R.D. Laing and David Cooper, this "anti-psychiatry" school saw what has
become known as "mental illness" as actually the results of problems of
human relationship, viewed from the point of view of those who would con-
trol those results by controlling the individual rather than negotiate
with the individual to seek a resolution of the original problem. The
question of the necessary means to effect this response has concerned
sociological critics of psychiatry and the ensuing conflicts between
labelling theory and the medical model has, in T.J. Scheff's words,
"engendered such furious partisanship" that neither side has absorbed a
great deal from the other.(1)
1. SCHEFF T.J: Labelling Theory of Mental Illness. American Socio-
logical Review, 39, 19741 PP.444-452. The sociological
debate has itself been divided between the "labellers" (of
whom Schaff is one) and the "social controllers", whom be
is criticising, who see an active selection process at work.
N.J. Davis, for example, draws upon Lemert's distinction
between "primary" and "secondary" deviance to point out that
the labelling process did not create the deviant behaviour
initially. See DAVIS. N.J: Labelling Theory in Deviance
Research, Sociological Quarterly", 13, 1972, PP-447-474.
The "social control" model leads us back towards the form,
if not the validity, of the medical model.
5
Complication on the issue of mental illness has arisen from socio-
logical criticism of the concept of illness itself. It is not simply
that a person with an "illness" is also a social actor who must play
(1)
"patient" to conform to social norms, but that even the very notion of
physical "illness" is a culturally constructed concept, independent of
(2)
biological circumstances. Febriga, for example, emphasises that the
term "disease" can be defined using constructs of biological, behavioural
or phenomenological discontinuity. This definition of an "undesirable,
organism-centred discontinuity" isolates the individual, reifies discon-
tinuity as a discrete entity and imports value-judgements in recognising
it as undesirable. "Disease", argues Fabriga, is "dis-ease", a collapse
of personal well-being, arising from, but not identical with, a biological
dysfunction. "Disease" in this sense is not, then, the direct result of
biological dysfunction. It is the response of the individual, who "feel-
ing disarticulated in a social or psychological sense, concludes that he
is diseased".
I.K. Zola the value-laden nature of the concept of illness
by emphasising the moral content of medical rhetoric. Medicine is "good",
not merely as an anti-dote to pain or suffering but because it is "humani-
tariae and argues to release its subjects from the full pressures of legal
or religious condemnation. Nevertheless, in doing so it has taken over
functions of punishment and moral regulation for itself. Stigmatisation
1. See, for example, ROBINSON, David: The Process of Becoming fll, 1971.
The "patient role" is a commonplace of medical knowledge,
having been originally outlined by Talcott Parsons (The
Social System, 1951) and does not conflict with the medical
model, though in the latter's interpretation of mental ill-
ness its validity is very circumscribed, if not redundant.
2. FABRIGA Br.: Concepts of Disease. Perspectives in the Biology of
Medicine, 15, 1972.
3. ZOLA I.K: Medicine as an Institution of Social Control. Socio-
logical Review, NS 20, 1972, PP.487-504.
6
of the individual is replaced by a stigma placed upon an "illness" which
must be exorcised by a doctor. If a patient fails to co-operate in this
exorcism he is punished through disciplinary medical procedure. Not all
conditions are allowed the status of illness. Those which are can be
related to moral, or at least personally meaningful, concepts. A person
asks, why am I ill? Overwork, stress, going out in the cold are all
reasons given for a moral failure to stay healthy. Even when describing
illness to children we use a moral paradigm: a "bad" leg, getting
"better", and so on. "Frankly", says Zola, "it seems hard to believe
that the English language is so poor that a moral rhetoric is needed to
describe a supposedly amoral phenomenon - illnessll.(1)
If we can see even physical illness as socially defined and bounded
by specific cultural values, as both Fabriga and Zola do, then the dis-
tinction between physical and mental "illnesses" is blurred. Szasz's
argument that psychiatrists have made illegitimate use of a medical meta-
phor falls to the ground, though his criticism in terms of cultural
imperialism remains valid. The logical conclusion to the expanded defi-
nition of illness is for this cultural imperialism to apply across the
board, wherever medical men and women involve themselves in their social
regulatory practices. Some writers follow this logic and see medicine as
a major threat to our well-being. Ivan Illich sees the medical establish-
ment as depriving us of cultural choice and of actually causing more damage
than it cures.(2) Zola arrives at similar conclusions.
Without denying that there is much to commend this view it does, like
its anti-psychiatric counterpart, overlook a vitally important considera-
1. ibid., p.492.
2. ILLICH Ivan: Limits to Medicine - Medical Nemesis, The Expropriation of
Health, 1976.
3. ZOLA I.K: op.cit, p.500.