Mad-docs and Englishmen

History - including the history of psychiatry - tends to follow either the principle of great men or that of great movements. The personalised kind has been out of fashion, though, for some time, and so it is a little surprising to find Andrew Scull and his colleagues interpreting the management of mental illness in the 19th century through the lives of seven doctors. These would not have been called "psychiatrists" then, since that word did not arrive from Germany until the end of the period; "mad-doctor" was the usual term in the early 1800s but was gradually replaced by "alienist". Its connotation of strangeness and menace reveals a view of madness that had not long since emerged from attributions of bestiality and witchcraft.

The theme here is essentially one of a profession slowly emerging from the activities of what was at first a small and scattered group of practitioners, few of whom had a university medical qualification. In a series of previous books, Scull has developed the view that, for reasons of personal advantage, doctors succeeded in gaining control of the emerging asylum system, notwithstanding that their medical knowledge had nothing useful to contribute to it. This scenario was carried forward historically, portraying psychiatrists in each period as finding new groups of clients and subjecting them to dubious measures based on unsound theory. Psychiatry emerged from this as little more than a gigantic confidence trick, and mental hospitals fared no better.

Yet in Masters of Bedlam little of this conspiratorial view of the profession is to be found; its historical basis was always uncertain, to say the least. In fact, the seven elite figures whose careers are described may not have been much better than the next man, but they were certainly no worse. They were no doubt concerned with getting on and with earning a living (one of them, Henry Maudsley, became extremely rich), but they were also genuinely concerned - as this book makes clear - with the care of the mentally ill and with the advancement of knowledge. But some of Scull's old fire and brimstone still emerges here and there, as when the lives of a few psychiatric heroes - notably John Conolly - are said to have been "transmuted into myths ... useful ideological constructs for those bent on creating an idealised fiction as a support for their current professional identity".

Most "revisionist" history of psychiatry draws its inspiration from Michel Foucault - who as an historian was incapable of getting his facts right. That influence is not strongly evident in these biographical chapters, except in the discussion of moral treatment - the system of noncoercive management originally developed at The Retreat in York. Although accepting that it was not "brutal coercion, fear and constraint", these authors say it constituted "a prodigiously effective set of techniques for imposing ... conformity and incorporated a rapidly realised potential for deterioration into a repressive form of moral management". It was Foucault who first claimed that the apparent benignity of the moral regime concealed a forced internalisation of external restraints into the mind of the mentally ill person. He, however, quite failed to understand either the Quaker society that developed moral treatment or the culture of evangelical humanitarianism that coloured many English institutions.

Here is where the need for a clinical dimension becomes clear. What was the alternative to a substantial degree of conformity, when people with severe mental illness were being cared for? How else could problems such as suicide, violence, self-starvation, incontinence or destructiveness be prevented? Furthermore, in condemning the Victorian asylums for their "enforced conformity and disciplined subordination", Scull et al overlook the fact that this reflected the general institutional culture of the time. Not only workhouses and orphanages showed these characteristics, but also even the developing public schools.

Clinical understanding would also question the usefulness of judging either institutions on the basis of "cure rates". Samuel Gaskell, for instance, is criticised on the grounds that "cures" were 20 per cent before he arrived at the Lancaster asylum, but only 10 per cent afterwards. This is, in fact, the inevitable secular trend of such an institution; in the early years, it will attract acute cases which are likely to recover, but, as time goes on, the residue with irrecoverable psychoses will steadily accumulate. It is the same today, though the mentally disabled are now mostly "in the community".

Whatever mental hospital life was like for the patients, it was certainly not good for the doctors as time went on. Whereas earlier subjects of the book such as Gaskell, John Bucknill and W. R. F. Browne became superintendents around the age of 30 - there being little competition then - this became ever more difficult with the growth of the medical profession. Many assistant medical officers then endured a professional lifetime of low pay, stultifying routine, minimal freedom and sometimes enforced bachelordom. Research was nonexistent and the development of professional interests virtually impossible.

One theme that recurs throughout these studies - and also remains current today - is the interrelationship of the public and private sectors. The bad reputation gained by the "trade in lunacy" of private madhouses towards the end of the 18th century was one of the strongest factors leading to the establishment of public asylums. But private institutions (mostly small) remained numerous, and several of this group of psychiatric pioneers were involved in running them for at least part of their careers. Furthermore, Sir Alexander Morison and later Henry Maudsley operated mainly as consultants in independent practice, like physicians and surgeons. The market for these services, though, was small and remained so until the 1950s.

Scull, MacKenzie and Hervey have produced an elegantly written work, which is exhaustively referenced, indicating scholarship of an impressive standard. It contains all the essential information about these early figures of British psychiatry. But most of them had nothing to do with Bedlam (Bethlem) and that institution never had a master.

Hugh Freeman is former editor, British Journal of Psychiatry, and an honorary visiting fellow, Green College, Oxford.