Keepers

Andrew Scull

  • Mind Forg’d Manacles: A History of Madness in England from the Restoration to the Regency by Roy Porter
    Athlone, 412 pp, £25.00, August 1987, ISBN 0 485 11324 4
  • The Past and the Present Revisited by Lawrence Stone
    Routledge, 440 pp, £19.95, October 1987, ISBN 0 7102 1253 4
  • Sufferers and Healers: The Experience of Illness in 17th-Century England by Lucinda McCray Beier
    Routledge, 314 pp, £30.00, December 1987, ISBN 0 7102 1053 1
  • Illness and Self in Society by Claudine Herzlich and Janine Pierret, translated by Elborg Forster
    Johns Hopkins, 271 pp, £20.25, January 1988, ISBN 0 8018 3228 4
  • Medicine and Society in Wakefield and Huddersfield 1780-1870 by Hilary Marland
    Cambridge, 503 pp, £40.00, September 1987, ISBN 0 521 32575 7
  • A Social History of Madness: Stories of the Insane by Roy Porter
    Weidenfeld, 261 pp, £14.95, October 1987, ISBN 0 297 79223 7

For nearly two centuries now, the treatment of the mad in Georgian England has been almost uniformly portrayed in the darkest hues. Nineteenth-century lunacy reformers pictured the preceding age as mired in ignorance and cruelty, conjuring up indelible images of monstrous madhouse-keepers beating their patients into submission, chaining them up like wild beasts in foul holding-pens filled with shit, straw and stench; of the callous, jeering crowd – urban sophisticates and country bumpkins alike – thronging to Bedlam in their thousands to view the splendid entertainment offered by the spectacle of the raging and raving mad. Generations of Whiggish historians, celebrating the Victorian asylum as a triumph of science over superstition, the very embodiment of an aroused moral consciousness, sang variations on the same theme, seizing on the passage from the madhouse to the mental hospital as decisive evidence of our progress towards ever greater enlightenment and heaping opprobrium on the benighted denizens of an earlier age.

This comforting collective mythology came under savage attack a generation ago, when Michel Foucault launched his sustained assault on the Enlightenment and its values by writing a revisionist history of madness and (Western) civilisation: a history that turned the Whigs on their heads and denounced ‘that gigantic moral imprisonment which we are in the habit of calling, doubtless by antiphrasis, the liberation of the insane by Pinel and Tuke’. In the ideological atmosphere of the late Sixties, such radical criticism attracted many adherents, even (strangely enough) among politicians and public policy-makers, who were determined, for very different reasons, to turf the mentally ill out of the barracks-like bins the Victorians had bequeathed us and to subject them to the tender mercies of ‘care’ in the community. Even among historians, Foucault’s polemic prompted a wholesale reassessment of reform, and though few embraced the full fury of his onslaught on the machinations of bourgeois Reason, little of the earlier complacency and optimism about the Victorian era survived.

None of this work fundamentally altered our view of the 18th century, however. Foucault himself had seen the Classical age as the first decisive step in Reason’s repression of Unreason. From his perspective, the period from the founding of the first Hôpital Général in 1656 to the events of 1789 was in essence the age of the Great Confinement, a movement which swept the idle and insane from the streets, severed their connections with society, and cast them into oblivion-an oblivion in which they were nonetheless compelled, lest they further offend bourgeois sensibilities, to work as a moral duty. Those whom Foucault influenced tended to concentrate their attention on the dramatic 19th-century changes in society’s responses to mental disorder, and to the extent that they cast their eyes back on the pre-reform era, saw little reason to dispute its unsavoury reputation. Even Michael MacDonald, whose splen did Mystical Bedlam used the casebooks of the astrological physician and divine Richard Napier to illuminate the mental world of the 17th century, and to suggest that mental alienation and distress might then have been dealt with in surprisingly sympathetic ways, joined in the chorus of condemnation of the ‘medical brutality’ which followed. ‘The 18th century,’ he confidently announced, ‘was a disaster for the insane.’

It is this long-standing consensus of reformers and Whigs, Foucauldians and Anglo-Saxon revisionists, which Roy Porter’s dazzlingly written Mind Forg’d Manacles aims to upset. Examining the ‘long 18th century’ from the Restoration to the Regency, he attempts to provide the first systematic account of the evolution of attitudes to-wards insanity; of the emergence of a medical discourse about madness; of changing social provision for the mad; and even of the experience of being insane, insofar as this can be reconstructed from the surviving writings of mad people themselves. The portrait of the 18th century as the psychiatric dark ages is, he suggests, a gross oversimplification, and in its place he seeks to provide a richer, more nuanced analysis, albeit one drawn almost exclusively from printed sources and from such secondary accounts of limited portions of this territory as we already possess. On the whole he succeeds admirably, and the vigour of his prose, his skills at synthesis and his ingenious use of the materials to hand make the book something of a tour de force. He may at times overreach himself in his desire to overturn the conventional ‘wisdom’, and not all his claims will withstand critical scrutiny, but these are comparatively small flaws which scarcely detract from the magnitude of his accomplishment.

Foucault is among the first of his targets – in some respects, too easy a mark. For the notion of a ‘Great Confinement’ applies poorly to England, where there was no substantial stateled move to confine the mad (or the poor, come to that) during the 17th or 18th century. Indeed, the management of madness on this side of the Channel remained ad hoc and un-systematic, with most madmen kept at home or left to roam the countryside, while that small fraction who were confined could generally be found in the small ‘madhouses’ which made up the newly-emerging private ‘trade in lunacy’. There was no English ‘exorcism’ of madness; no serious attempt to police pauper madmen (on the contrary, a sizeable fraction of the clientele of the new madhouses came from the affluent classes, necessarily so if the new entrepreneurial system was to flourish); and so far from attempting to inculcate bourgeois work habits, ‘what truly characterised’ life in the handful of 18th-century asylums ‘was idleness’.

Other demonologies of Georgian responses to madness postulate a benighted and brutal era, riddled with sadism; a period of therapeutic stagnation or even retrogression, in which a sympathetic therapeutic eclecticism that had earlier held sway was replaced by catastrophically cruel medico-scientistic and mechanical treatments. These notions, Porter successfully argues, are too one-sided. They fail to capture the diversity and confusion that actually characterised the 18th-century scene, and they distort and omit aspects of the changing social response to madness which cannot be assimilated to a Manichean world-view.

Madness, he insists, was for 18th-century Englishmen an extremely broad sociocultural category. Separately or simultaneously, its manifestations could be seen as medical, moral, religious or even satanic. It belonged to the body or the brain, or to the mind or the soul. It extended and ramified in all manner of directions, and its boundaries were vague and uncertain, disputed and negotiable. Between Bedlam madness and the fashionable vapours and melancholy, no clear-cut lines of demarcation could be drawn. It follows that one must recognise the heterogeneity of the responses such diversity drew, and rather than resorting to simplistic generalisations, one should try to map the resulting complexity.

Madness, Porter contends, ‘was a real presence in the popular mind long before psychiatry spelt independent professional expertise’. Our efforts to reconstruct these popular mentalités are hampered, of course, by the limitations of the evidence that has survived, by the fact, above all, that our access to folk beliefs is necessarily mediated through the productions of the literate élite. But the limitations are not decisive ones, and with due caution we can uncover a good deal. Fundamental to most 18th-century views of madness was the belief that the condition was transparent, visible to all who had occasion to view the lunatic: a notion to be sharply contested in the following century, once a professionalised psychiatry succeeded in establishing itself and sought to make the expert diagnostic gaze central to the identification of insanity. Equally widespread was the notion that insanity necessarily involved a disorder of the body – a psychosomaticism as common among the laity as in medical circles.

Tempting as it may be to attribute this insistence on a physical grounding for mental afflictions to the imperialistic activities of the medical profession, Porter demonstrates that patients were every bit as eager as practitioners to incorporate mental disturbance into the realm of the body. Nowhere is this more evident than among those afflicted with the vapours, the spleen, hypochondria and hysteria: that whole complex of mental imbalance and upset which became so fashionable in the 1720s and 1730s, and which George Cheyne christened ‘the English malady’. For sufferer as for healer, an organic condition was a real condition, not a mere maladie imaginaire. Moreover, as long as, ‘ “superstitious” causes and “magical” cures still had their popular currency,’ the thought that these ‘morbid distempers were monsters of disordered minds’ was a terrifying one, suggesting the possibility either of diabolical possession or of the subversion of the soul itself, and rendering doubtful any prospect of cure. Faced, on the one hand, with ridicule for malingering and, on the other, with fears for one’s immortal soul, small wonder that, for sufferers too, placing the blame on the body came to seem preferable.

The emergence of ‘the English malady’ marked an important moment in the history of madness, a time when at least certain forms of mental imbalance became ‘not just acceptable but smart’. These kinds of disturbance, at least, were not the peculiar province of the poor. On the contrary, Cheyne spoke for all his fellow physicians when he held that ‘fools, weak or stupid persons, heavy and dull souls are seldom much troubled with Vapours or lowness of Spirits ... [rather the victims are) those of the liveliest and quickest natural parts whose Faculties are the brightest and most spiritual, and whose Genius is most keen and penetrating, and particularly when there is the most delicate Sensation and Taste.’ ‘Thus,’ as Porter says, ‘by a Mandevillian sleight of hand, fashionable physicians flattered melancholy, making the corruption of the oligarchy’s brains as acceptable as the corruption of their politics.’

If this gentrification of some forms of nervous disorder encouraged a certain degree of interest in the subject among fashionable physicians, the more violent and extreme forms of alienation remained beyond their clinical ken (at least until the second half of the century). There were, nonetheless, import ant developments even here. Over the period from the Restoration to the Regency, one can trace in medical speculations on the subject ‘a massive naturalisation of the understanding of insanity. Disturbance ceased to be thought of largely in terms of sin or possession by Superior or Infernal powers,’ and the way was smoothed towards more ‘secular and social mappings of madness’. In parallel with this, medical conceptualisations of mental disorder increasingly moved away from humoural accounts, towards more complex and rhetorically powerful (if no less speculative) iatro-chemical and physical explanations.

Such developments can only be understood as part of a wider movement to render everything natural and rational: a Weberian de-mystification and disenchantment of the world was taking place whose other ramifications included the rise of mechanical science, the extension of man’s domination of nature, and the concomitant progress of material civilisation. For a cosmopolitan élite intent upon replacing the kingdom of darkness by Enlightenment, traditional popular beliefs (especially popular supernaturalism and ‘enthusiasm’) were a ‘deadly’ compound of ‘credulity, superstition and fanaticism’. Robert Burton’s visions of religious madness as a satanic pandemic, a commonplace in Tudor and Stuart England, seemed increasingly incomprehensible to those ‘rational’ 18th-century Christians unconvinced of direct divine (let alone diabolic) intervention in the world. More than this: religious transports – lusting after salvation, dreading damnation, searching for God’s saving grace – ‘struck real fear into the polite and propertied, alarmed lest a popular religion of the heart should foment civil disorders, as in the bad old times of the Civil War’. Medical theorising about madness exercised a powerful attraction here, for one could move beyond ridicule and reasoned refutation of popular credulity and superstition, turning them instead into pathology, mere ‘Methodistical madness’.

In less elevated social circles the belief in madness as psychomachy survived and even, to some degree, flourished. Wesley himself ‘staunchly denied that madness was merely reducible to physical illness’: even though his Primitive Physick advocated the use of drugs and medical treatment (including electricity) in the battle against lunacy, he simultaneously ‘championed belief in a demonomania, and the practice of spiritual healing’. As Porter confesses, we simply don’t know how demonological allegiances shifted during the 18th century, but outside the ranks of the New Dissent, and particularly among the more educated, one can clearly see that the literal belief in Satan, witches, demons and demonic possession was ever more firmly viewed as silly, superstitious, even sick.

All of this helped to humanise and domesticate the mad. Other developments, too, began to create the social space into which medicine moved as it sought to claim a monopoly over the treatment of the insane. Fragmentary evidence suggests that the practice of boarding out lunatics can be traced back into the years before the Restoration. Clearly, however, the ‘trade in lunacy’ became far more visible and important over the course of the 18th century, being but ‘one aspect of the emergence of a thriving service sector in the laissez-faire economy at large’.

Most were small, informal and ephemeral family concerns in the business of peddling discreet silences. Our information about their operations is correspondingly patchy, though Porter marshals enough fragments to show that there were great variations between such places: in their clientele, the skill or otherwise of their proprietors, their size and their opulence. Contrary to the uniformly bad reputation madhouses acquired from the exposés of the early 19th-century lunacy reformers. Porter suggests that some of these establishments may have provided relatively humane care for their inmates. Certainly, the existence of a free trade in lunacy, virtually untrammelled by outside intervention, supervision or control, encouraged experimentation, and very probably contributed to the emergence of new technologies of treatment in the closing decades of the 19th century.

In a variety of ways, then, the 19th-century orthodoxy that segregation from the sane was in the madman’s best interests had its roots in the growing resort to confinement in the Georgian age. Still, the number of lunatics locked up in specialised places remained quite modest at the turn of the century (somewhere between two and three thousand cases over the whole country); and, unlike their successors, 18th-century Englishmen did not believe that the institution was a sovereign remedy for the disordered and disorderly. Madhouses advertised cures, but those cures depended on the charismatic qualities of the proprietor, not on the creation of a therapeutic space or a new form of moral architecture. The archetypical image of late Georgian psychiatry is not Tuke sipping tea with his patients in an institution self-consciously designed and run like a large country house, but the imperious keeper able to reduce the ranting and raving to docility and obedience through the moral force of his gaze.

Perhaps the most dramatic example of the use of this technique came to light in the after-math of George III’s recovery from his attack of ‘mania’ in 1788. At the ensuing Parliamentary inquiry into his treatment, it emerged that Francis Willis, the divine-cum-physician who had treated him, had allowed the King to shave himself with a cut-throat razor. As Frederick Reynolds related the story a quarter of a century later, Edmund Burke immediately demanded to know

‘If the Royal patient had become outrageous at the moment, what power the Doctor possessed of instantaneously terrifying him into obedience?’ ‘Place the candles between us, Mr Burke,’ replied the Doctor, in an equally authoritative tone – ‘and I’ll give you an answer. There Sir! By the EYE! I should have looked at him thus Sir thus!’ Burke instantaneously averted his head, and, making no reply, evidently acknowledged this basiliskan authority.

As Porter notes, the ranks of madhouse keepers included both doctors and ‘laymen’, but it was the former who wrote most frequently on madness and accordingly received most public attention. In so doing, they helped to lay the foundations for a specialist mental medicine. By the last third of the 18th century, Porter estimates that somewhere between thirty and fifty practitioners were specialising in the business of treating the mentally disturbed, many of them operating madhouses. These establishments formed the matrix within which a set of practical skills in managing the mad could emerge, though one must immediately qualify this by noting that even by the close of the century, mental medicine remained ‘eclectic, pluralist and divided’.

Porter devotes a good deal of space to an examination of the theory and practice of these proto-psychiatrists, zealously seeking to rescue them from the neglect or contempt they have encountered at the hands of other historians. It is wrong, he asserts, to dismiss their writings as ‘either tedious or second-hand’. He intends, as well, to emphasise the continuities between 18th-century practices and the Utopian programmes of 19th-century lunacy reformers; to show that the practices of the new moral treatment regime cannot be represented as a distinct rupture with the past; to insist that ‘both in rhetoric and in reality, “moral” forms of therapy were well tried and tested long before the close of the 18th century.’ There is perhaps a measure of truth to some of these claims, but Porter’s eagerness to rescue the reputation of the Georgian age prompts him to some strained interpretations of the evidence and a serious overstatement of his case. I don’t mean to imply that his attitude towards his favoured period is wholly uncritical: he accepts, for instance, that ‘for pauper madpeople, the Georgian madhouse was hell’ (while quite rightly insisting that ‘as yet we know too little about how they were treated previously to be able to say with confidence whether it was a worse, or just a different, hell’). On larger interpretative issues, however, his arguments and judgments strike me as distinctly more dubious.

Take, for example, his affirmative answer to his own question: ‘Was there a moral therapy in the 18th century?’ Other revisionist historians (myself included) have long contended that Tuke’s well-publicised programme at the York Retreat was not an isolated achievement. The whole thrust of this body of work has been directed to demythologising moral treatment, disabusing us of the naive notion that it was the isolated product of individual genius, and tracing some of the broader social roots of the new ethic of rehabilitation which it exemplified. Moreover, such claims have necessarily accorded a crucial place to evidence of virtually simultaneous and multiple discoveries of the principles underlying moral treatment: not just the widely publicised examples of Pinel and Chiarugi on the Continent, but domestic parallels as well, such as the work of John Ferriar at the Manchester Lunatic Asylum in the 1790s, or of Edward Long Fox, from whose Bristol madhouse Tuke recruited Katherine Allen, the Retreat’s first matron.

In what ways does Porter claim to go beyond this? First, by widening the circle of those entitled to be known as ‘moral managers’ to encompass a much larger group: William Battie, Thomas Arnold, William Perfect, Joseph Mason Cox, Francis Willis, Benjamin Faulkner, William Pargeter, Thomas Bakewell, William Hallaran, and others. But immediately problems arise. Of these figures, only the unfortunately-named Battie was active before the 1780s, and Cox, Bakewell and Hallaran are 19th-century practitioners. As Porter concedes elsewhere, we know remarkably little about Battie’s practice, other than the fact that it made him a very rich man. Hence the only ground for asserting that Battie is somehow the ‘real’ pioneer of moral treatment turns out to be the text of his 1758 Treatise on Madness, a book which Porter insists ‘contains (albeit in a rather schematic and theoretical guise) the key ideas of Tukean moral therapy’.

This simply won’t do. Not least, it raises in acute form the obvious problems of making inferences from theory to praxis. Porter assumes that the two conveniently coincide here because his argument requires it. Elsewhere, he exhibits a more seemly scepticism: Thomas Fallowes, for instance, a quack who flourished in the early 18th century and has the doubtful honour of being the first mad-doctor convicted for illegally confining a patient, promised, in Porter’s words, ‘a veritable pudding time to his clients ... curative therapy, gentleness and comforts – good accommodation, air, exercise and diet’. The reality was, of course, very different: but ‘every proprietor knew he could not cash in by harping on the severity of his treatments, or on his talents as a whip master.’ Why should we assume that Battie was different? Battie’s conviction that ‘management did much more than medicine’ likewise did not distinguish him, even from the benighted practices of the Monro family at Bedlam. And while his insistence on the individual character of madness and its unresponsiveness to universal cures, together with his adoption of Lockian associationism, did mark some tentative steps towards a fresh therapeutics, all of this remained a considerable distance from ‘moral treatment’ as a later generation was to understand the term.

The closing decades of the 18th century witnessed a good deal of therapeutic experimentation among madhouse proprietors, including those Porter re-labels ‘moral managers’. Deriving very different conclusions from Lockian associationism than those underpinning Tukc’s moral treatment, these men stressed that the madman’s loss of contact with our consensually-defined reality reflected how deeply the chains of false impressions and associations were engraved on his system – a conclusion which both licensed and required that extreme measures be taken to jolt the system back into sanity. Shower baths, rotating chairs, tranquillising chairs and other exotic forms of physical restraint and coercion were all employed in a Herculean effort to force the thought processes out of their erroneous pathways. And behind this technology stood the heroic figure of the mad-doctor himself, able, as Pargeter put it, to be at one moment ‘placid and accommodating in his manners, and the next, angry and absolute’, willing to try ‘kindness and mildness’ but never hesitating, in Joseph Mason Cox’s words, to employ ‘irresistible control and coercion’.

Contrast this with Tuke’s insistence that attempts to compel patients to think and act reasonably were themselves irrational: ‘intimidation and coercion,’ he pronounced; ‘may make or modify the symptoms of insanity, but can seldom produce permanently good results.’ Besides, the tamed madman, like the trained tiger, ‘is the result of treatment at which humanity would shudder’. As even Porter is ultimately driven to acknowledge, ‘management took on a very special connotation at the Retreat. For little store was set by the theatrical talents or verbal acrobatics of the doctor in breaking the will of, or outwitting, the lunatics. Instead of Napoleonic generalship or the “terrific system”, the Retreat emphasised community.’ Walking, talking, taking tea with their superintendent, patients were to be taught to restrain themselves by a regime which cleverly exploited their ‘desire for esteem’ within the confines of a carefully – constructed therapeutic environment. All of which, pace Porter, constitutes a distinct departure from the practices of Pargeter, Cox, et al, even if it had its analogues elsewhere.

Madness is one of the many topics covered in Lawrence Stone’s The Past and the Present Revisited, a collection of his occasional pieces and essay-reviews from the past quarter-century. (A previous edition, issued in 1981, is here revised and enlarged.) From his extraordinary range it would appear that he is willing to take on anything bearing on the making of the modern world. Nor is he afraid to issue trenchant criticisms of what he sees as misguided enthusiasms in the writing of history (intemperate and injudicious quantification, for instance, or psychohistory in virtually all its manifestations, or the latest dogmas and pronouncements of modern French historiography); or to take individual authors (eminent or not) to task for lapses of scholarship or failures of historical imagination. All of this may make Stone sound somewhat arrogant and crotchety, and there undoubtedly is a rather schoolmasterly tone to some of his writing, coupled with a not always warranted assumption that his own current enthusiasms correspond to the way forward for the profession. At times he strays into territory with which he is insufficiently familiar. Here his penchant for stern criticism sometimes lands him in the soup.

His essay on madness is one such occasion, for in the midst of a long and rightly laudatory essay on MacDonald’s Mystical Bedlam and D.P. Walker’s Unclean Spirits, he seizes the opportunity to assault the late Michel Foucault and all his works. As I suggested earlier, Foucault’s historical scholarship is highly vulnerable to criticism, but those who criticise him for being ‘unconcerned with historical detail of time and place or with rigorous documentation’ had better be sure that they have got their own history straight, and, equally important, that they have not misrepresented what Foucault himself has said. Regrettably, Stone is so careless in these respects as to leave himself open to a quite devastating riposte. Foucault himself was not slow to seize the opening his eminent critic offered him, firing off an answering salvo in the correspondence columns of the New York Review of Books. Both this, and Stone’s further misadventures, are reprinted and make sobering and instructive reading.

Foucault, Stone at first claims, had portrayed the Great Confinement as being ‘based on a new principle that madness is shameful, and that the best treatment is forcible isolation from society under management by professionally-trained doctors.’ Further, the French philosopher had attempted ‘to link the treatment of schoolchildren, the poor, criminals and the insane under a single conceptual umbrella’ – a contention that is ‘both unhistorical and misleading’ – and had gone on to argue that this massive segregation ‘was merely the result of a conspiracy of professionals to seize power for themselves ... it was the doctors who were behind the great confinement of the insane.’ Sadly for Stone, none of this is so, as Foucault gleefully pointed out. Stone could not leave well alone, however, and in his attempt to have the last word ended up making a bad situation worse. Some of his earlier criticisms, he now concedes, apply to Szasz and Laing, rather than to Foucault, but the latter is still to blame, because ‘his writings led logically ... to this conclusion.’ Moreover, Foucault has a whole international cabal of disciples, and it is these devotees of ‘Foucaultism’ who have resorted to ‘sociological conspiracy theory about asylums and doctors’. But Foucault is once more to blame, for ‘he has so far done nothing, so far as I know, to repudiate them.’ He has a yet heavier burden on his conscience, one Stone had not come up with before: ‘Can Foucault’s pessimistic evaluation of lunatic asylums be held to have been a factor in the recent discharge of thousands of helpless psychiatric patients onto the pitiless streets of New York?’ Stone thinks it can, and as ‘evidence’ he cites the ‘belief of a certain Dr Gerald Weissmann, a New York physician who has not hitherto come to my attention as an expert on either Foucault or de-institutionalisation.

What can explain this unedifying spectacle? The answer lies in Stone’s passionate attachment to ‘the Enlightenment as an advance in human understanding and sensibility’. When all the layers of sophistication have been peeled away, he remains an old-fashioned Whig at heart, someone who can be roused to fury by the thought that Foucault ‘denies any philanthropic motive to the great reformers of mental treatment in the late 19th century’. At least he has had the integrity to reprint the whole exchange.

Lucinda Beier’s book seeks to reconstruct the experience of physical illness in 17th-century England: an age in which disease and debility were the normal state of affairs – and death never far away. All too often, whether one was suffering from agonising or merely annoying disorders, ‘nothing really helped’: a cruel reality brought forcibly home during outbreaks of deadly epidemic disease. None of which seems to have inhibited the natives, who were enthusiastically self-medicators and medicine-takers, patronising a wide range of healers in search of something, anything, which might offer reassurance or help. Secular and religious approaches to illness existed side by side, the one favouring an active assault on the pathology, the other passive resignation, prayer and faith in God, thus allowing individual patients alternative ways of coping with uncertainty, pain and the prospect of death. Explanations for illness were a similarly eclectic mixture of popular humouralism, astrology and theology, their all-embracing character permitting sufferers to be ‘far more confident about explaining their ailments’ than their 20th-century descendants.

Beier makes judicious use of a wide variety of sources to demonstrate that from the patient’s point of view, and notwithstanding the intellectual changes more traditional medical historians have made so much of (Harvey’s discovery of the circulation of the blood, Sydenham’s forceful advocacy of a return to empirical observation, the growing social importance of apothecaries as general practitioners, the increasing popularity of Paracelsian ‘metallic’ remedies), little changed over the course of the 17th century. She reconstructs a fascinating series of vignettes: the mundane realities of medical practice for provincial physicians and a London surgeon; the structure of the medical marketplace, with its recurrent clashes and competition between licensed and unlicensed healers; the ways in which patients and families experienced and coped with suffering, and the peculiarities of women’s encounters with disease. The very pervasiveness of illness and the fragility of one’s hold on life, together with the fact that sickness and death took place at home, helped to prevent the alienation of the ill and the dying and to provide them with social support and comfort. But ‘social responses to disease varied. There were respectable illnesses, such as gout and ague; frightening but nearly inevitable diseases, such as smallpox; disreputable diseases, such as syphilis; and terrifying diseases, such as the plague,’ whose victims were abandoned ‘by God, by medicine, by their government, by their neighbours’.

In place of a medical profession there was a fragmented marketplace in which clients exercised a large measure of control over what they purchased. Physicians trying to defend their privileges clung desperately to their ability to read Latin and Greek, and to a Classical learning doomed to obsolescence. Surgeons, much neglected by historians, had a sounder claim to expertise and were better-placed to sell their services: Unlicensed healers abounded, undercutting the prices of their licensed competitors – and the latter perhaps only survived and found purchasers for their wares because of the emotional vulnerability of sufferers and their families, driven by sheer desperation and fright to invest unwarranted confidence in licensed healers. And death itself, save where it arrived too rapidly or too violently, was ritualised and socially organised, and very often a leisurely affair, with the sufferer distributing his or her worldly goods, making peace with God, and, through pious behaviour, setting a suitable example for the living.

Many of the same themes recur in an interesting but uneven book on Illness in Self and Society written by two French sociologists. There is much fashionable talk here: about ‘discourse’, about reconstructing the ‘logic’ of lay views of illness, and about hearing those who usually do not speak. The juxtaposition of the historical and the contemporary sometimes seems forced, and the suspicion that such temporal ambition will produce oversimplification and distortion proves not wholly unfounded. Nonetheless, there is much of great interest that emerges from their Durkheimian concern with shifting collective representations of illness; from their focus on certain ‘paradigmatic’ diseases (leprosy, the plague, tuberculosis, syphilis, cancer); and their examination of the transition from an Ancien Régime of Disease, marked by massive epidemics, exclusion, impotence and death, to an era they see as characterised by a ‘duty to be healthy’ and a culture within which ‘impotence in the face of illness has become an unbearable, indeed almost scandalous, failure.’

At the opposite extreme from Herzlich and Pierret’s volume is Hilary Marland’s Medicine and Society in Wakefield and Huddersfield 1780-1870. It is (of course) a revised doctoral dissertation, and a book that memorialises the author’s diligence and industry. Buried in it is much that will be useful to those concerned with such topics as the role of Friendly Societies in the delivery of medical care to the working classes, the social and occupational characteristics of the medical profession, the influence of fringe medical practice, and the provision of medical relief under the Old Poor Law and the New. But it is a ponderously-written treatise unlikely to interest the non-specialist. Even if it did not labour under the additional handicap of the appalling pricing policies of its publisher, that notorious price-gouger from the Fens, one suspects its market would never extend much beyond scholarly libraries.

Finally, yet another book on the experience of illness, this time of the mental rather than the physical sort, a further effusion from the pen of the prodigiously productive Porter. Its title misleads: this is a collection of stories by and about the insane. And Porter is a splendid spinner of tales, drawing on the autobiographical writings of two dozen mad people to recover their consciousness rather than their unconscious: ‘to explore what mad people meant to say, what was on their minds’. The cast of characters includes Nietzsche, Cowper and John Clare; Sylvia Plath, Laing’s Mary Barnes and Freud’s Dora; Robert Schumann and Vaslav Nijinsky; and poor George III, in his declining years a living facsimile of Lear.

There are also other, less familiar figures. There is, for instance, the remarkable Alexander Cruden, the self-styled Alexander the Corrector: expatriate Scotsman, Protestant fundamentalist, author of a Biblical concordance published in 1737 and still in print today, proof-reader extraordinaire, who was consigned to a series of madhouses for such offences as his obsessional courtship of an affluent widow, Mrs Pain, and subsequently of the wealthy daughter of a former Lord Mayor of London, a woman whom he had never met, and never did manage to meet (‘Like Freud, Cruden never took no for an answer’); and on a subsequent occasion, hauled off by his sister, Mrs Isabella Wild (‘Cruden was plagued by names’), for taking a shovel and using it to whack a malefactor he saw profaning the Sabbath. Cruden’s response to his assorted confinements was to launch a pamphlet war against madhouses, ‘English Bastilles’ which robbed the free-born Briton of his liberties. A monstrous, wholly blinkered egoist, he was forever ‘vindicating’ himself.

As Porter proceeds to demonstrate, the patient as crusader appears in multiple guises: John Perceval, son of the last British prime minister to be assassinated, differed from Cruden in acknowledging that he was mad, not simply a sane man locked up by his enemies. But he found his asylum treatment ‘inquisitorial, inhumane, degrading’, and he insisted that although religious terror had brought on his insanity, ‘the real cause of the appalling severity and prolongation of his condition was the medico-psychiatric treatment he had received.’ On his recovery. Perceval became a lifelong critic of Victorian asylumdom, and one of the prime movers in the wonderfully-named Alleged Lunatics’ Friend Society.

Some of the most devastating passages in the book deals with Freud and his follies. Porter examines, for instance, the case of Daniel Schreber, former chief judge to the Dresden court of appeal, whose Memoirs of his madness Freud used as one of the props for his theory that there was an intimate connection between paranoia and homosexuality. Freud sees Schreber’s fears of castration in terms of his ‘putative desire to be sodomised by Flechsig’ – his physician – ‘and (by derivation) by his brother and father’. Porter points out that Schreber’s fear was well-grounded in reality, ‘for the neuro-anatomist Flechsig made therapeutic use of castration at his clinic.’ Similarly, he notes that Schreber’s father was one of Germany’s best-known paediatricians, a man who placed ‘overwhelming emphasis upon the values of duty, disipline, control, and “unconditional obedience” ’ and who practised what he preached on his own children. Yet Freud, who was most certainly aware of Schreber père’s principles, saw no connection between the father’s unremitting tutorial surveillance and the son’s madness, though it turns out that the latter’s delusions of persecution in middle age exactly reproduced bizarre physical contraptions his father had used and recommended.

Equally sobering are Porter’s discussions of ‘Dora’ (Ida Bauer) and the ‘Wolf Man’, Sergius P., the person Freud helped turn into the ‘eternal patient, a nonagenarian proof of analysis interminable’. Reading Porter’s reconstruction of the events surrounding their ‘madness’ and his examination of what Freud made of their symptoms, one is tempted to adopt his view that the founder of psycho-analysis all too closely resembled the obsessional theorist in Swift’s A Tale of a Tub. Freud even picked up ‘Swift’s trick whereby pseudo-confessions of ignorance are turned into a demonstration of omniscience’.

Porter plausibly suggests that the words and actions of the ‘mad’ can be seen as ‘the struggles of the despairing and powerless to exercise some control over those-devils, spooks, mad-doctors, priests – who had them in their power’. Well yes, this may in part be what is going on here. But, as he himself admits, the evidence he adduces is ‘highly selective and episodic’. An anthropological relativism that refuses to accord ‘the myths advanced by earlier mad-doctors and psychiatrists any privileged truth status’ risks romanticising the mad, and notwithstanding Porter’s protestations that ‘it would be facile’ to portray all of the insane ‘as victims pure and simple of psychiatry’, his clever reconstructions of the patients’ progress make it all too easy to do precisely that.