yet again, to the love of my life NATSU Acknowledgements My thanks to Katharine Reeve of Oxford University Press, who first suggested this book and who has been supportive and critically constructive throughout. Over the last few months, successive drafts have been read by Hal Cook, Emese Lafferton, Chandak Sengoopta, Desirée Cox-Maksimov, and Natsu Hattori, for whose perceptive comments and candid criticism I am deeply grateful. Drawing upon the marvellous resources of the Iconographical Collection of the Wellcome Trust Library for the History and Understanding of Medicine, Andrea Meyer- Ludowisy has carried out the picture research with the blend of imagination and efficiency which makes her unique. I am delighted to acknowledge the enormous support given to me by members of the staff of the Wellcome Trust Centre, notably my secretaries, first Rebecca Baker and then Emma Ford; retyping of numerous drafts has been done by the tireless and unfailing Sheila Lawler. Thanks also to Jed Lawler for coming to the rescue of a computer illiterate. My thanks also to Mary Worthington, who proved an excellent copy-editor, and finally to Jane Henderson for the index. Contents Acknowledgements 1 - Introduction 2 - Gods and demons 3 - Madness rationalized 4 - Fools and folly 5 - Locking up the mad 6 - The rise of psychiatry 7 - The mad 8 - The century of psychoanalysis? Conclusion: modern times, ancient problems? Further reading Index 1 - Introduction To ‘define true madness’—the speaker is Polonius, labouring, as ever, to be wittily wise—‘what is’t but to be nothing else but mad?’ Shakespeare’s greybeard pedant hit the nail on the head this time: isn’t insanity the mystery of mysteries? Even professors of psychiatry hold the most surprising views on the subject they profess. In a brace of books, The Myth of Mental Illness (1961) and The Manufacture of Madness (1970), Thomas Szasz, Professor of Psychiatry at Syracuse University (New York), denied there was any such thing as ‘mental illness’: it was not a fact of nature but a man-made ‘myth’. He explained further: Psychiatry is conventionally defined as a medical speciality concerned with the diagnosis and treatment of mental diseases. I submit that this definition, which is still widely accepted, places psychiatry in the company of alchemy and astrology and commits it to the category of pseudoscience. Why so? The reason was plain: ‘there is no such thing as “mental illness” ’. For Szasz, who has continued to uphold these opinions for the last forty years, mental illness is not a disease, whose nature is being elucidated by science; it is rather a myth, fabricated by psychiatrists for reasons of professional advancement and endorsed by society because it sanctions easy solutions for problem people. Over the centuries, he alleges, medical men and their supporters have been involved in a self-serving ‘manufacture of madness’, by affixing psychiatric labels to people who are social pests, odd, or challenging. And in this orgy of stigmatization, organic psychiatrists have been no less to blame than Freud and his followers, whose invention of the Unconscious (Szasz alleges) breathed new life into defunct metaphysics of the mind and theologies of the soul. All expectation of finding the aetiology of mental illness in body or mind—not to mention some Freudian underworld—is, in Szasz’s view, a category mistake or sheer bad faith: ‘mental illness’ and the ‘unconscious’ are but metaphors, and misleading ones at that. In reifying such loose talk, psychiatrists have either naively pictorialized the psyche or been complicit in shady professional imperialism, pretending to expertise they do not possess. In view of all this, standard approaches to insanity and its history are vitiated by hosts of illicit assumptions and questions mal posées. Szasz has not been alone. Madness and Civilization, which appeared in French in 1961, the work of the Paris historian of thought Michel Foucault, similarly argued that mental illness must be understood not as a natural fact but as a cultural construct, sustained by a grid of administrative and medico-psychiatric practices. The history of madness properly written would thus be an account not of disease and its treatment but of questions of freedom and control, knowledge and power. Less radically, but equally unsettlingly, two highly respected British psychiatrists, Richard Hunter and Ida Macalpine, were pointing, around the same time, to the profound muddle which psychiatry had got itself into: there is not even an objective method of describing or communicating clinical findings without subjective interpretation and no exact and uniform terminology which conveys precisely the same to all. In consequence there is wide divergence of diagnosis, even of diagnoses, a steady flow of new terms and an ever-changing nomenclature, as well as a surfeit of hypotheses which tend to be presented as fact. Furthermore, aetiology remains speculative, pathogenesis largely obscure, classifications predominantly symptomatic and hence arbitrary and possibly ephemeral; physical treatments are empirical and subject to fashion, and psychotherapies still only in their infancy and doctrinaire. Szasz’s and Foucault’s provocative formulations— which stand traditional progressive (‘Whiggish’) history of psychiatry on its head, recasting its heroes as villains—have in their turn been robustly rebutted. In The Reality of Mental Illness (1986), Martin Roth, Professor of Psychiatry at Cambridge University, and Jerome Kroll counter-argue that the stability of psychiatric symptoms over time shows that mental illness is no mere label or scapegoating device, but a real psychopathological entity, with an authentic organic basis. These drastic splits within psychiatry as to the nature of mental illness (reality, convention, or illusion?) show how wise old Polonius was. And, following his wisdom, the brief historical survey which follows makes no attempt to define true madness or fathom the nature of mental illness; it rests content with a brief, bold, and unbiased account of its history. Yet psychiatry’s past, as well as its scientific status, has also been hotly contested. ‘The story in its broad outlines is familiar’, wrote Sir Aubrey Lewis, the eminent director of the Institute of Psychiatry, attached to the Maudsley Hospital in London, in a review of Foucault’s book: After the tortures and judicial murders of the Middle Ages and the Renaissance, which confounded demoniacal possession with delusion and frenzy, and smelt out witchcraft in the maunderings of demented old women, there were the cruelties and degradation of the madhouses of the seventeenth and eighteenth centuries, in which authority used chains and whips as its instruments. Humanitarian effort put an end to the abuses. Pinel in France, Chiarugi in Italy, Tuke in England inaugurated an era of kindness and medical care, which prepared the way for a rational, humane approach to the mastery of mental illness. In the nineteenth century the pathology of insanity was investigated, its clinical forms described and classified, its kinship with physical disease and the psychoneuroses recognized. Treatment was undertaken in university hospitals, out-patient clinics multiplied, social aspects were given increasing attention. By the end of the century the way had been opened for the ideas of such men as Kraepelin, Freud, Charcot and Janet, following in the paths of Kahlbaum and Griesinger, Conolly and Maudsley. In the twentieth century psychopathology has been elucidated, and psychological treatment given ever widening scope and sanction. Revolutionary changes have occurred in physical methods of treatment, the regime in mental hospitals has been further liberalized, and the varieties of care articulated into one another, individualized, and made elements in a continuous therapeutic process that extends well into the general community, beginning with the phase of onset, stadium incrementi, and proceeding to the ultimate phase of rehabilitation and social resettlement. 1 The cold-water ordeal is depicted in this seventeenth-century French print: a man is tortured by being tied with rope and lowered into cold water. Violent immersion in cold water was a form of divine ordeal, often used on witches: if they floated they were guilty, if they sank, they were innocent. It was also a supposed cure for madness. ‘This’, concluded Lewis, ‘is the conventional picture, one of progress and enlightenment ... it is not far out. ’ Or is it? Over the past generation, the history of psychiatry as set out by the accounts digested by Lewis has been denied, and controversy has raged as to how to interpret many crucial developments: the rise and fall of the asylum (‘a convenient place for inconvenient people’?); the politics of compulsory confinement and then of ‘decarceration’; the origins, scientific status, and therapeutic claims of psychoanalysis (was Freud a fraud?); the ‘beneficence’ of the psychiatric profession; the justification of such questionable treatments as clitoridectomy, frontal lobotomy, and electroconvulsive therapy; and the role played by psychiatry in the socio-sexual control of ethnic minorities, women, and gay people, and other social ‘victims’—to name just a few. The last thirty years have brought a ferment of original scholarship—often passionate, partisan, and polemical—in all these areas and many more, which shows no signs of abating. Building upon such studies, this book will assess what credibility mainstream views as summarized by Lewis still possess. A bill of fare might be helpful. The next chapter looks at madness understood as divine or demonic possession. Prevalent amongst pre-literate peoples the world over, such supernatural beliefs were then embodied in Mesopotamian and Egyptian medicine and in Greek myth and art. As reformulated and authorized by the teachings of Christianity, they remained current in the West till the eighteenth century, though increasingly discounted by medicine and science. It is to the birth of medical science that Chapter 3 turns, examining the rational and naturalistic thinking about madness developed by Graeco-Roman philosophers and doctors and incorporated in the subsequent Western medical tradition. Lunacy and folly meanwhile became symbolically charged in art and literature: these cultural motifs and meanings of madness are explored in Chapter 4. Taking madness in society, Chapter 5 proceeds to examine the drive to institutionalize the insane which peaked in the midtwentieth century, when half a million people were psychiatrically detained in the USA and some 150,000 in the UK. The ‘new science’ of the seventeenth century replaced Greek thinking with new