Masters of Bedlam: The Transformation of the Mad-Doctoring Trade 
by Andrew Scull, Charlotte Mackenzie and Nicholas Hervey.
Princeton, 363 pp., £23, February 1997, 0 691 03411 7
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In 1843, the artist Richard Dadd murdered his father and was put away in Bethlem Hospital, Britain’s oldest lunatic asylum; his portrait of the alienist Sir Alexander Morison stares from the cover of Masters of Bedlam, gauntly silhouetted against a mottled sky. He seems to be looking at something he finds hard to bear. The brief biographies of 19th-century alienists through which Andrew Scull, Charlotte MacKenzie and Nicholas Hervey tell the story of the century’s dealings with the mad make it clear that Morison’s haunted expression could have been that of any of the seven ‘mad-doctors’ described here.

The first of them was born in 1764, the last died in 1918. Their life histories spell out a century of passionate idealism, and of vicious in-fighting. Part of these men’s struggle was to make respectable not just the work of the mad-doctor but of doctoring itself, never on a par with the few professions open to gentlemen – church, army, law. The public could see that medicine, and hospitals in particular, killed as many people as it cured. And doctoring the mad – the pauper mad, generally – had a taint of its own. As the alienist Sir John Bucknill acerbically wrote in 1860, ‘the feeling and conduct of the British public towards the insane reminds one of nothing so much as that of the enlightened citizens of the free States of America. Noble and just sentiments towards the negro race are in everyone’s mouth, but personal antipathy is in every man’s heart.’

Lunacy, as Bucknill also pointed out, is not only exhausting for its managers but sometimes catching:

He who efficiently discharges the arduous functions attendant on the care and treatment of the insane, dwells in a morbid atmosphere ... which he, who walks through even the most difficult paths of sane human effort, can little appreciate ... The number of mental physicians who have suffered more or less from the seeming contagion of mental disease, would form perhaps, if enquired into, a proportion of those who really fight in this warfare which might bear comparison even with that of men who fall in the strife of the sword.

Some of those who figure here became eccentric or distraught; others simply venal or hard-hearted. All of them became to a greater or lesser degree disillusioned. The great reform of lunacy treatment – the building of huge, supervised asylums to house and cure the mad – is a story of disappointed hopes, summed up in the therapeutic nihilism of Henry Maudsley at the end of the century. The doctor who had spent his life ministering to diseased minds, he wrote, might wonder ‘whether, notwithstanding impassioned aims, paeans of progress, endless pageants of self-illusions’, humanity’s ‘capacity of degeneration did not equal, and might some day exceed, its capacity of development’.

The telling of this melancholy story is not helped by the book’s joint authorship: some relevant facts are rehearsed several times, others scarcely appear. A chronology placing Parliamentary enquiries in 1807 and 1815-16, and the Act requiring asylums to be provided in 1845, would have been useful. There are few citations from contemporary letters, diaries or literature to broaden the picture, and few links with what else was going on during the century. The worst of the mad-doctoring world seems light years away from the rest of enquiring, energetic Victorianism – no doubt because any patient with money or a caring family stayed out of what the authors call ‘asylumdom’. And who actually were the ‘mad’ who filled these institutions? The book does not make this clear: we only suspect from one cited Report that they included the congenitally retarded, and from another that there were also patients delirious from typhus and tuberculosis, or speechless from strokes. Not enough is explained about attempts at diagnosis and classification, or the fact that general paralysis of the insane was not definitely identified with syphilis until this century.

From Roy Porter’s account, in Mind-Forg’d Manacles, we know that lunacy treatment in the 18th century was chaotic and unsupervised, though by no means always brutal. Nineteenth-century reform was intended to sweep away the chaos and institute a benign and orderly kingdom: pauperism and derangement would both somehow be tamed. When John Haslam, the book’s first biographical subject, took the post of apothecary to the ancient Bethlem (or Bedlam) Hospital in 1795, 18th-century attitudes still prevailed. There were arguments about whether lunatics could be managed without chains and straitjackets, and whether medical doctors were even necessary for their care. Not that it was eccentric to aim for a career in mad-doctoring – George III’s illness had aroused general curiosity, and appointment to an asylum at least provided board and lodging and a few hundred a year. At the upper end of the profession were the acceptable and gentlemanly doctors who treated the rich; but, without a clear career structure, those at the other end of the scale scratched for a living (remember the selling of young Lydgate’s furniture in Middlemarch). A third category of mad-doctors ran small private asylums, but these were regarded with suspicion as tradesmen. And many, perhaps all of these, must have hoped at the start to make some medical breakthrough that would solve the age-old problem of disordered wits.

Haslam is a figure whom we want to like. Did he not reject brutal punishment, solitary confinement in darkened cells (except ‘in the most violent state of the disease’), and terrorisation in general, saying that he could ‘truly declare, that by gentleness of manner and kindness of treatment, I have never failed to obtain the confidence, and conciliate the esteem of insane persons’? This was the approach, known as ‘moral treatment’, that had been pioneered by the Quaker Tuke family at the Retreat, near York. But, alas, an inspection of Bethlem’s crumbling structure in 1814 discovered inmates in leg-irons clamped to the wall, others kept naked on straw because of incontinence, and one, apparently lucid, who had been locked into a network of chains for more than twelve years. Haslam was called before a Parliamentary Committee and had to resign. (As the authors point out, the history of psychiatry has been plagued by the assumption that published work is consonant with the author’s practice.) He later revived his career, but as an opponent of the modern tomfoolery that claimed to deal with lunatics without coercion.

We hope, too, to admire John Conolly and W.A.F. Browne, born thirty and forty years respectively after Haslam. Both were genteel but poor boys who had to struggle for an education; medicine was the obvious career for them. Conolly lectured briefly at the new University of London medical school, was backstabbed (perhaps) into leaving, unsuccessfully tried private practice, and then – though he had always criticised confinement – was glad to be appointed resident physician at Hanwell asylum. He was an efficient administrator, and became well-known and well-regarded. Again, gentle treatment was preached, and possibly even practised during his relatively short stay there. But he made another volte-face after leaving, by proposing that even greater numbers of awkward customers should be squeezed into asylum care – among them ‘immoderate’ young men, and young women ‘of ungovernable temper’. Conolly’s twists and turns were satirised by Charles Reade in Hard Cash, where he appears as Dr Wycherley, ‘bland and bald’, and inclined to ‘found facts on theories instead of theories on facts’.

Both Conolly and Browne interested themselves in phrenology, the contentious study of bumps on the head. Given that so little other theory was available to link the brain with mental disorder, and that up-and-coming alienists were anxious to maintain insanity as a medical matter, this was not so surprising. Phrenology was highly influential until at least the 1830s, though also strongly opposed by the old guard for its materialist and radical associations. It was a nice idea; and those china heads with their neat compartments still look pretty in antique shops. But lack of supporting evidence gradually consigned it to parlour games (‘May I feel your bumps?’) and sideshows at the fair.

By the time What Asylums Were, Are and Ought to Be was published in 1837, Browne was no longer relying on bumps to solve the insanity problem. It was an influential and idealistic book. The asylum that ought to be sounds a delightful place for a holiday – designed for ‘the comfort and cure of the inmates’, provided with spacious grounds and healthy activities, the ‘disagreeable alloys of modern life’ excluded and the ‘more pleasing portions carefully cultivated’. It was perhaps Utopian, he wrote, ‘a sight to dream of, not to see’ (a significant misquotation of ‘Christabel’, which refers to a sight too horrible to look at).

And this was what Browne did see, some twenty years after the publication of his rousing book:

It is right that the real difficulties of the management of large bodies of the insane should be disclosed; it is salutary that the involuntary debasement, the animalism, the horrors, which so many voluntary acts tend to, should be laid bare. No representation of blind frenzy, or of vindictive ferocity, so perfectly realises, so apparently justifies, the ancient theory of metempsychosis, or the belief in demoniacal possession, as the maniac glorying in obscenity and filth; devouring garbage or ordure, surpassing those brutalities which may to the savage be a heritage and a superstition ... These practices ... are encountered in victims from the refined and polished portions of society, of the purest life, the most exquisite sensibility. Females of birth drink their urine ... Outlines of high artistic pretensions have been painted in excrement; poetry has been written in blood, or more revolting media.

After poor, defeated Browne the authors step back, chronologically, to show something of private mad-doctoring, through the career of Sir Alexander Morison, so wonderfully painted by Dadd. Like Haslam, Conolly and Browne, he received his medical training at Edinburgh. His entrée into the private field was gained when he became personal physician to a Scottish peer with good social contacts. He was spared the daily sight of walls daubed in blood and shit, though he did act as visiting physician to asylums, and saw them as a necessary evil for the poor, if their families would not nurse them. Even though, by the 1840s, the idealisation of asylums was at its peak, he managed to keep a practice going and could do things never thought of in institutions: talk with the relatives of patients, find lodgings for them, pray with them, advise them where to take the waters, and sometimes bring them into his own home. The authors see him as an early precursor of the first psychiatrists, who worked with ‘nervous disease’ rather than major insanity.

We come then to a mad-doctor with whom at last we can empathise: Samuel Gaskell, brother-in-law of the novelist. The Gaskells were a nonconformist north-country family, and thus only marginally gentlefolk. As committed Unitarians, both Samuel and his minister brother, William, were dedicated to ideas of rational social progress, and Samuel himself was a workaholic. His friend John Forster described him on their joint holiday, knitting his brows over work ‘as if America were just discovered’. Before he was 30 he was in charge of the 500 inmates of the county asylum at Lancaster.

Gaskell’s reforms were imaginative – locks, chains and bars were removed, food and heating improved, windows opened up for light and ventilation. Classification of patients was attempted for the first time in the asylum’s history, the quiet ones being separated from the noisy and violent; 35 acres of moorland were bought for walks and light farming. There were workshops and classrooms, and amusements and tasks provided for all the hours of the day. Attendants were educated in the enlightened aims of the new regime and dressed in less police-like uniforms. There were pets for the inmates to care for – and the quieter women patients were paired with orphan babies, to their mutual advantage. The authors do not say whether all these improvements led to a higher rate of discharge or recovery. Gaskell had little faith in the usual medical treatments – purges, bleedings, douches and the rest – but this could be seen as good sense. Later, he became an ultra-diligent inpector for the Lunacy Commission, poking under beds and into cupboards, to the annoyance of asylum staff. The authors admit that Lancaster asylum was probably a more pleasant environment than the workhouse or the ‘community’, but criticise Gaskell for fostering a ‘dull, protective environment, where merely keeping the patients alive became an end in itself’. Given the time and place, what more could he have done?

There is no record here of Gaskell devastatingly losing his faith in the asylum system. He did have a lonely and eccentric old age, but this was put down to the effects of a traffic accident. The book ends with two very different men, Bucknill and Maudsley, born ten and 28 years after Gaskell. Bucknill, whose eloquence on the subject of the alienist’s lot I quoted earlier, was very much the public man rather than the private philanthropist. He wrote, organised, lectured, edited and laid the foundation for what was to become the psychiatric profession. His prescription for patients was still ‘moral treatment’ – kindness and calm rather than force – and in boarding out some patients in hostels and private lodgings he set up an excellent experiment And, of course, he lost his faith in asylum care: ‘The author’s fullest and latest experience has convinced him that the curative influences of asylums have been vastly overrated.’ Some forms of mental disturbance, he believed, ran their course in a quiet environment and improved without much intervention: general practitioners could do a great deal for ‘nervous cases’ on the quiet. These views, put forward in the 1870s and 1880s, were heretical to those who had invested so much hope in the notion of the large, benign community that would re-educate as well as contain those who had lost touch with sanity.

It is ironic that Maudsley’s name is the only one of these seven now known to the general public, through the South London hospital named for him. Maudsley is something of a demon king arriving on the scene, after his well-meaning predecessors. He became a dominant figure in medical psychology, but was disliked for his bleakly nihilistic view of the causes and care of insanity, as well as for his personal prickliness. He prided himself on being a vociferous materialist who saw no other factor in madness than ‘the deranged functions of the supreme nervous centres of the body’; this derangement, he considered, was above all hereditary. Furthermore, as a neo-Lamarckian, he believed it could be inherited from an acquired characteristic – you could be mad not just because there was madness in the family but because your parent or parents were wicked. Physical degenerations were ‘transmitted as evil heritages to future generations: the acquired ill of the parent becomes the inborn infirmity of the offspring’. Lunatics in fact were the waste products of the evolutionary process, ‘morbid varieties fit only for excretion’, who poisoned society as waste products did the body.

No doubt on a bad day some of the earlier alienists had seen things the same way, but none had quite said so. It was more appropriate to the uneducated asylum warders (and who these people actually were we are not told), the ones who had to clean up the filth. In Maudsley’s misanthropic view, the prospects for the human race were not good. Not only were the insane something between human and animal – ‘Whence came the savage snarl, the destructive disposition, the obscene language, the wild howl, the offensive habits ... unless he has the brute nature within him?’ – but, as crime and madness were almost indistinguishable, a steady degeneration was everywhere in progress. Needless to say, Maudsley’s attitude to the contemporary ‘woman question’ was misogynistic. But then: ‘It is useless to say smooth things when things are not smooth.’ And so ended – within the scope of this book – a century of high hopes disappointed.

It is the gulf between this story of blindfold struggle and the century’s discovery of psychology that is striking. It was a century obsessed with investigating the complexity and hiddenness of the mind long before Freud officially unveiled the unconscious in his first book in 1895. (Some of Freud’s and Breuer’s patients in the Studies in Hysteria might well have been in institutions if they had not been middle-class Viennese.) Writers such as Maupassant and Poe were exploring the byways of the mind, and towards the end of the century titles like Multiplex Personality, Das Doppel-Ich and Les Maladies de la personnalité abounded. Connections between the unconscious or subliminal, hysteria, hypnotic trance and multiple personality were being probed by Charcot, Janet and many others. William James’s Principles of Psychology, published in 1890, was acquainted with all this work; but it was a world away from the asylum. James had experienced moments of near-madness himself – and they had opened his eyes.

Being driven mad was always a familiar idea for writers (Ophelia, Lear, the Bride of Lammermoor); yet the only mention in Masters of Bedlam of a mad-doctor talking to individual patients about what had brought them to him is in reference to Morison, the private physician. In the end it was the ‘shell shocked’ survivors of the trenches who brought psychology into the neurological wards. Masters of Bedlam’s story reminds us just how innovative was the forgotten psychiatrist W.H.R. Rivers, revived by Pat Barker in her magnificent trilogy about the Great War, and how Maudsleyan were most of his contemporaries. Whether, in any case, the therapeutic answer to serious mental illness, once dreamed of, will ever be found remains uncertain. It is as though, once the last thread connecting the individual with the rest of his kind is snapped, the drift is towards an unimaginably lonely place.

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