Madness: A Very Short Introduction - Andrew Scull 2011

Madness confined

Eighteenth-century Bethlem had promiscuously invited outsiders inside its walls. Till 1770, anyone could visit the wards of the ancient foundation. The inmates were mostly unwilling actors in a theatre where the throngs of visitors might inspect the product (and price) of immorality, and the wreck of the human intellect. Public visiting was finally curtailed in 1770, a shutting off as well as a shutting up of the patients that ironically would end up exposing them in time to yet greater abuse. Throughout the 18th century, therapeutics at Bethlem were characterized by relatively uniform purges, bleedings, and vomits, administered seasonally to patients, with the occasional addition of tonics (such as alcohol) and cold bathing, with these heroic interventions being supplemented by a mostly lowering form of diet and regimen. This model of treatment, whereby repletion in the system was countered by depletion and vice versa, was founded on an essentially humoral approach to mental diseases. Overlaid since the late 17th century by a new mechanistic brand of ’Newtonian’ medical science, older principles and even types of treatment had in reality changed remarkably little.

Such therapeutic conservatism was by no means universal, however. As the number of institutions devoted to the confinement of the mad began to grow over the course of the 18th century, so too did opportunities for experimenting with differing approaches to their management. To be sure, in most hands this meant the employment of techniques that emphasized the use of fear, awe, and dread. Chains and other forms of mechanical restraint continued to figure prominently in this regime of coercion, being seen as useful, even essential, adjuncts in the effort to compel right thinking. But elsewhere, very different tactics began to be employed. In Florence, in Paris, in Manchester, Bristol, and York, seemingly independently of each other, those in charge of institutions for the mad began to develop techniques that insisted on minimizing external, physical coercion, which might force outward conformity, but which could never produce what was now seen as the essential internalization of moral standards.

Within what rapidly became the new orthodoxy at the turn of the 19th century, attempts to compel patients to think and act rationally would themselves be stigmatized as irrational. The very effort to tame madness was seen as seriously misguided, and formerly respectable therapeutic techniques were discarded, coming to be seen with a mixture of incomprehension and moral outrage. What was most remarkable about the new approaches, however, particularly in light of the negative image that the madhouse had already acquired and that the new lunatic asylums would subsequently inherit, was how extraordinarily optimistic their proponents were about the efficacy of their chosen remedies, and how tightly their techniques were bound up with the confinement of the insane in what was pronounced to be a therapeutic isolation.

The most famous architects of the new approach, the physician Philippe Pinel in post-revolutionary Paris and the tea and coffee merchant and Quaker William Tuke in York, both termed this new approach ’moral treatment’. Pinel had learned the new techniques primarily from the layman Jean-Baptiste Pussin who ran the wards for the incurably insane at the Bicêtre, the male section of Paris’s Hôpital Général, and not long after, Pinel also took charge of the insane wards at its female counterpart, the Salpêtrière. The myth of him striking the chains from the hands and feet of these inmates at the height of the post-revolutionary Terror is pure fiction, manufactured decades after the fact, but it precisely captures one of the central appeals of moral treatment, its sharp rejection of what was now seen as the harshness and cruelty of the past, including its unequivocal rejection of iron fetters and corporal punishment (though by no means of all forms of restraint). Pinel shared with Tuke the notions that the mad could be induced to collaborate in their own recapture by the forces of reason; that most medical remedies for madness were useless; and that the supposedly continuous danger and frenzy to be anticipated from maniacs were the consequence of, rather than the justification for, misguided methods of management and restraint.

As one contemporary madhouse keeper, Thomas Bakewell, put it:

Certainly authority and order must be maintained, but these are

better maintained by kindness, condescension, and indulgent

attention, than by any severities whatsoever. Lunatics are not

devoid of understanding, nor should they be treated as if they were;

on the contrary, they should be treated as rational beings.

All aspects of the mad person’s environment should be employed to rouse the moral feelings, and to induce the patient to control him- or herself. Making use of the vital weapon of people’s ’desire for esteem’, their need to look well in the eyes of others, the mentally disturbed could be induced to collaborate in their own recapture by the forces of reason. Under the direction of a benevolent paterfamilias, and within the confines of a therapeutic environment, inmates could be encouraged and induced, in the words of William Tuke’s grandson Samuel, ’to struggle to overcome their morbid propensities…[and to confine] their deviations within such bounds, as do not make them obnoxious to the family’. What was essential, Pinel concurred, was ’great firmness, but not harsh and forbidding manners; rational and affectionate condescension, but not a soft complaisance that bends to all whims’. Treated in this fashion, madness could thus be reined in amid the confines of domesticity by the invisible, yet infinitely potent fetters of the sufferer’s own desire to please others, assisted by the efforts of the asylum’s guiding influence, its superintendent, and by the careful employment of space itself to reinforce moral boundaries and behaviours.

In Britain, in France, in some of the German principalities, and in the new American republic, the dawn of the 19th century thus witnessed the birth of an extraordinary optimism about the therapeutic possibilities of an asylum reorganized in accordance with these principles. Those promoting the new realm of asylumdom basked in the assurance that their creation marked a clear rupture with the coercion, fear, and constraint of an earlier madhouse regime, the replacement of a ’moral lazar house’ with the ’moral machinery’ through which the mind would be strengthened and reason restored. Reformed asylums were, one mid-century English enthusiast proclaimed, ’the most blessed manifestation of true civilization the world can present’. The principles of a rational, a humane, and above all a curative treatment of the insane were at last at hand.

Nowhere was this utopianism more evident than in the United States, where a veritable ’cult of curability’ arose in the 1820s and 1830s, with claims to cure 70%, 80%, 90% of recent cases of insanity becoming routine. Dorothea Dix, the moral entrepreneur most responsible for America’s embrace of the asylum, constantly informed the politicians she lobbied that ’all experience shows that insanity reasonably treated is as curable as a cold or a fever’. But everywhere, reformers embraced the notion that adoption of their nostrums was the key to eliminating the scourge of insanity. There existed, they insisted, an economics of compassion, for to treat the mad in an institution run on moral treatment lines was to rescue fellow creatures from mental tortures, and to return them to the ranks of productive citizens.

Contrasting such idylls to the horrors faced by the insane in prisons, in workhouses, even at the hands of well-meaning but ignorant relatives, and forcefully distancing their schemes from the horrors of the ancien régime madhouse, enthusiasts for the programme of placing the mad into therapeutic isolation fought successfully to transform public policy, and to create whole networks of specialized institutions, the majority built at public expense for the poor and middling sorts, though attempts were also made to entice the rich to see the advantages of private asylums catering to their mad relations. A century earlier, the corpulent diet doctor George Cheyne had augmented his professional fortunes by proclaiming that milder forms of mental disease - nervous disorders like hysteria, hypochondria, and the spleen were the peculiar province of the hyper-civilized and hyper-refined, those with the most delicate of nerves stretched to breaking point by the pressures and temptations of modern civilized living. In the 1830s and 1840s, such ideas were expanded to encompass the more serious forms of madness.

On the one hand, the Rousseauist myth that the Noble Savage was largely immune to the ravages of insanity was widely canvassed. On the other, the dangers of civilization were made manifest: ’With civilization’, warned the Scottish alienist W. A. F. Browne, ’come sudden and agitating changes and vicissitudes of fortune; vicious effeminacy of manners; complicated transactions; misdirected views of the objects of life; ambition, and hopes, and fears, which man in his primitive state does not and cannot know.’ His famous French contemporary, Jean-Étienne Esquirol, agreed: madness was more common among the rich than the poor, a greater risk to the bourgeoisie and the plutocracy than to the peasant or the worker. Exposed to fewer temptations and less stress than their social betters, the humble and the illiterate were relatively immune to the ravages of mental disorder. All the more reason, of course, for the wealthy to support the construction of asylums run on moral treatment lines, lest they find themselves locked up in the living tomb that was the traditional madhouse.

All across Western Europe and North America, a veritable mania for the construction of the new institutions for the insane marked the middle decades of the 19th century. In the process, what was proclaimed to be lunacy reform gave birth, not just to a vast new network of asylums, but also helped to create the conditions for a new and increasingly self-conscious group of ’experts’ in the diagnosis and treatment of madness. It was a fraught process at first, for in England in particular, much of the moral energy and outrage that fuelled the drive for reform had arisen from graphic exposures of the abuses that had taken place in more traditional institutions, many of them medically run. At Bethlem, for instance, those converted to the merits of Tuke’s moral treatment had discovered a multitude of scandals: patients chained naked to the wall, suffering from frostbite and loss of their extremities; female patients raped and impregnated by their keepers; a routine of vomits and bleedings; cells redolent of shit, straw, and stench; and, most famously of all, a certain James Norris, an American seaman found confined in a sort of iron cage which encased him from the neck down and was attached by a short chain to an iron bar running from floor to ceiling - an apparatus in which he had been kept for a decade and more, though it left him unable to move more than a foot in any direction. Discoveries like these threatened to call into question the legitimacy of medicine’s authority over madness, the more so since moral treatment was in many ways a lay invention, whose proponents had declared that traditional medical therapeutics were largely useless when mobilized against the ravages of mental illness.

But by making their peace with moral treatment and adopting its tenets, while re-emphasizing that madness was rooted in the body, medical men saw off the challenge. Once more, many of them relied on the notion that had been advanced a century earlier, that to proclaim the mind itself was diseased was to call into question the integrity and immortality of the soul, and thus to undermine both revealed religion and social order. They asserted that a judicious combination of moral and medical remedies was superior to a misplaced reliance on one or another, and produced statistics that ’proved’ the point. And they sought, though without significant success, to uncover differences in the anatomy of mad brains. By mid-century, across a wide variety of national settings, the previously heterogeneous congeries of madhouse keepers had instead become a more and more organized group of specialists. Journals dedicated to the discussion of madness and its treatment had begun to appear in English, French, and German, providing a regular medium of exchange for the emerging profession and a public warrant for its claims to possess a burgeoning expertise in the management of the mad. The simultaneous creation of professional associations of asylum doctors both exemplified and confirmed the trend.

8. James Norris, often mistakenly called William Norris, an American seaman confined in this fashion in Bedlam for more than a decade. This image, drawn from the life, was mass produced and used to great effect by early 19th-century lunacy reformers in England

Henceforth, madness and the branch of medicine devoted to its treatment would be inextricably intertwined. The identification and treatment of madness, the explanation of its aetiology, the very language used to discuss it, all were increasingly the products of the new psychological medicine, and the institutions its practitioners presided over served to isolate the lunatic in a new carceral archipelago. No longer answering to the title of ’mad-doctor’, whose ambiguity and associations with the ancien régime madhouse they disdained, there was as yet no broad consensus among them on what new name to adopt. The French preferred aliéniste, the Germans Psychiater, while their Anglo-American counterparts at first declined both labels, opting for ’medical psychologist’ or asylum superintendent. The latter was an awkward term that at least captured how tightly their identity was bound up with the institutions they headed, asylums that confined them almost as totally as the patients to whom they ministered. The international hegemony of ’psychiatry’ as the preferred term of art would not be established till the dawn of the 20th century, so its use in the remainder of this chapter will be to some degree an historical anachronism. Its decisive merit, though, is that it avoids a whole series of clumsy circumlocutions, so I shall embrace it anyway.

All too soon, of course, the utopian dreams of the reformed asylum’s advocates collided with the recalcitrant reality that mental disorders would not yield so readily to the blandishments of the moral treatment regime. Though the invention of a more benevolent image for the madhouse was a vital piece of ideological work for those who sought to construct publicly funded asylums, the social space that now contained madness could not long sustain the illusions its promoters had so sedulously constructed and promoted. Ironically, what was intended as a grand gesture of reform, a release of the mad from their chains, thus led inexorably to their mass confinement in a vast network of museums of madness. Here the insane were shut up in multiple senses of that term, isolated from the larger society, objects first of pity, then of fear and disdain.

Asylums seemed to serve as magnets, drawing forth an endless stream of mad folk from the surrounding community. Most of them seemed to come from the ranks of the poor and the middling sort, and it was the institutions set up at public expense that grew most rapidly. In part, this apparent social location of madness was an illusion. Victorian letters, diaries, and autobiographies provide ample evidence that, despite all the propaganda in favour of reformed asylums, upper- and middle-class families feared them, and had low expectations about the kind of care their relatives would receive in confinement. And certainly only a handful of private asylums - places like Brislington House and Ticehurst in England, the McLean Asylum and the Hartford Retreat in the United States - could offer a regime even remotely approaching the upper-class mode of life. Necessarily, institutionalization thus constituted a degrading experience for those exposed to it. Wealth and social standing allowed certain families to circumvent or postpone the disgrace of incarcerating one of their nearest and dearest in the asylum. Upper- and upper-middle-class families possessed the financial wherewithal to cope with the unproductive and disturbed; the ability to employ large numbers of servants to manage their troublesome relatives; the capacity, if need be, to send them off to a quiet and secluded part of the country, or even abroad; and strong motivation to avoid the scandal and stigma that were still the consequence of having a relative officially certified as mad. Once family tolerance and resources had reached breaking point, though, ties of blood tended to accentuate rather than diminish the desire for seclusion in an asylum.

Among the rich, though, the reformed asylums still roused some of the fears that had first surfaced with the creation of the madhouses more than a century earlier. The very seclusion and secrecy that, on the one hand, was a source of the institution’s appeal, on the other hand aroused anxiety, for these attributes might be exploited by those with corrupt motives to incarcerate the sane among the lunatic, to be rid of an inconvenient relation, for instance, or to seize control of another’s property. Lawsuits alleging such activities surfaced from time to time on both sides of the Atlantic. America had its Elizabeth Packard, a clergyman’s wife whose husband had her confined as mad, only for her to launch a one-woman crusade across several states, impugning the competence and the honesty of the doctors who had confined her, and seeking jury trials for all those threatened with incarceration in a lunatic asylum. England had its equivalents: the titillating and high-profile suit brought by Lady Rosina, the estranged wife of the popular novelist Sir Edward Bulwer Lytton, who had been so ill-advised as to confine her in a madhouse; and the serial complaints of another former patient, Louisa Lowe, who labelled private asylums English Bastilles and spent years agitating against their very existence.

It is perhaps more than coincidental that the majority of these complaints seem to have involved women (though they certainly had their male counterparts). Feminist critics and historians have been inclined in recent decades to see in these agitations the development of some sort of proto-feminist consciousness, a battle by some brave members of their sex against the inclination of Victorian alienists to use their ’science’ to reinforce male prejudices about woman’s place. (That prominent psychiatrists and neurologists like Henry Maudsley and Jean-Martin Charcot, to say nothing of a host of lesser figures, acted in precisely this way is incontrovertible.) Certainly, such well-publicized legal affrays heightened anxieties about both psychiatry and its institutions, and these doubts and fears were exploited and reinforced in still another arena: the realm of fiction.

To be sure, the most famous early Victorian novel to employ madness as a central element in its plot, Charlotte Brontë’s Jane Eyre, left the asylum and the mad-doctor out of the picture entirely. Mad Bertha Mason, hidden in Mr Rochester’s attic, embodies ancient stereotypes about madness and animality. Jane is ’introduced’ to Mr Rochester’s sequestered wife:

In the deep shade, at the further end of the room, a figure ran

backwards and forwards. What it was, whether beast or human

being, one could not, at first sight tell: it grovelled, seemingly, on all

fours; it snatched and growled like some strange wild animal: but

it was covered with clothing, and a quantity of dark, grizzled hair,

wild as a mane, hid its head and face.

Shrieking, violent, dangerous, and destructive, fit only for confinement apart from society, here is the mad-woman as fiend, not victim. But Jane Eyre appears in 1847, just as the asylum is about to become the orthodox response to madness, and the novel’s mad character is subject to domestic confinement, not carted off to a specialized institution. By contrast, Wilkie Collins’ The Woman in White, and Charles Reade’s (at the time equally celebrated) novel Hard Cash, which were published in 1860 and 1863 respectively, make illegitimate confinement of sane characters in asylums crucial features in their melodramatic plots. And Reade, in particular, delights in portraying psychiatrists as bumbling and/or corrupt, experts in studying ’pounds, shillings, and verbiage’, and in not much else. Both books enjoyed runaway success in the marketplace, and both did nothing to enhance the asylum’s image in the eyes of their affluent readership.

It is much harder to know how the poor and unlettered felt about asylums, for they left, of course, few or no written records of their own. Certainly, their straightened social circumstances, the narrow margin many of them experienced between subsistence and starvation, and the crowded character of their living arrangements must have heightened the difficulties they experienced in coping with the disruptions and depredations of the mad. Yet the asylum’s associations with the hated Poor Law and its stigma - England’s county asylums, for example, which confined more than 90% of its institutionalized mentally ill, were administered throughout the 19th century as part of the Benthamite Poor Law, and their inmates were officially referred to as ’pauper lunatics - not to mention its reputation as, in the words of one contemporary, ’the Bluebeard’s cupboard of the neighbourhood’, must have acted as a deterrent to the use of its services. Desperation often won out. The old, the violent, the deluded, those poisoned by over-consumption of alcohol or contact with heavy metals, mothers suffering from post-partum depression, and the myriad victims of what we now know was tertiary syphilis, diagnosed at the time as general paralysis of the insane (a reflection of its deadly mix of neurological and psychiatric deficits) - many of these and other kinds of threatening, troublesome, and impossible people found their way into the asylum. They constituted the heterogeneous population that made up the mad, and were the burden psychiatrists and asylum attendants perforce had to care for and cope with, and to try to comprehend. (The complications of tertiary syphilis alone accounted for 10-15% of admissions - rising as high as 29.2% at the Charenton Asylum in Paris in the last quarter of the 19th century - and alcoholic poisoning and delirium tremens were responsible for about as many.)

The consequence is clear: asylums swiftly began to silt up with what the Scottish psychiatrist W. A. F. Browne called ’the waifs and strays, the weak and wayward of our race’. It would be wrong to think that admission to an asylum was necessarily a one-way ticket to oblivion. The manias of the alcoholic, the depression of new mothers, the despair and debilitated state of some of the poorer sort who found their way into a mental institution, the melancholy of those overwhelmed by the trials of their fraught existence - all of these forms of mental distress at times remitted with care and time in the asylum. In other instances, even in the absence of cure, the temporary respite institutionalization provided from the burdens of the lunatic seems to have sufficed to encourage families once more to resume the attempt to cope with their presence at home. At the margin, therefore, Victorian asylums continued to discharge perhaps one-third or two-fifths of each year’s intake within 12 months, and an annual mortality rate of 10—15% of those resident further reduced numbers. But the obverse of this situation was that every year, a substantial fraction of each year’s intake remained behind, swelling the ranks of the chronic, ’incurable’ patients, and contributing to the remorseless upward pressure on asylum accommodation. Simple mathematics ensured that annual admissions constituted a smaller and smaller fraction of those under ’treatment’, and that the median length of stay in the asylum grew ever longer. It was this horde of the hopeless, and the associated spectre of chronicity, that came to haunt late 19th-century psychiatry, and to influence the larger culture’s view of the nature of madness.

Asylums that housed a hundred or two inmates at mid-century had grown to a thousand and more by century’s end. Mental hospitals (as they were relabelled late in the 19th century) grew into miniature (and soon not-so-miniature) towns, with their own gas works, water supply, chapel, mortuary, and graveyard, sometimes their own police force and fire brigade. The London magistrates, for example, built a series of establishments for a total of up to 12,000 patients on a single site at Epsom. At Milledgeville in Georgia, the Central Lunatic Asylum eventually confined almost 14,000 patients, and a whole series of asylums on New York’s Long Island - Central Islip, King’s Park, and (later in the 20th century) Pilgrim State Hospital - together provided for more than 30,000 inmates. Asylums with patient censuses in the thousands likewise became common in France, Germany, and elsewhere in Europe. The huge hospital at Bielefeld, for instance, founded in 1867, grew to contain upwards of 5,000 inmates.

9. The central building at the Hudson River State Hospital in Poughkeepsie, New York, completed in 1871, one of the many museums of madness to be found all across North America and Europe by the late 19th century

As early as 1868, the alienist B. A. Morel was complaining that all across France, public asylums were in a state of ’chaos, in which all the forms of intellectual degradation accumulate pell-mell, without profit to the sick or the doctors whose entire time is absorbed by writing monthly reports…’. One of his British counterparts spoke of ’the intrinsic repulsiveness of the records of sorrow and suffering’ that he confronted on a daily basis, and lamented that ’after the best application of the most sagacious and ingenious measures, the results are so barren and incommensurate, that in defiance of sympathy and solicitude, misery and violence, and vindictiveness should predominate’. And the American neurologist Silas Weir Mitchell chided America’s assembled psychiatrists, complaining that they presided over an assemblage of ’living corpses’, pathetic patients ’who have lost even the memory of hope, [and] sit in rows, too dull to know despair, watched by attendants: silent, grewsome [sic] machines which eat and sleep, sleep and eat’.

Madness appeared to multiply, and simultaneously to become more malignant. In Germany, the ratio of lunatics confined in asylums grew from 1 in 5,300 in 1852 to 1 in 500 in 1911. In England, over a 50-year period, 1859 to 1909, the rate of confinement more than doubled, from 1.6 to 3.7 per thousand of the general population. The promise of the reformed asylum had vanished.

It might be expected that this situation would have created profound crises of legitimacy both for the institutions and for the professionals running them who proclaimed themselves experts in the diagnosis and treatment of madness. And to some degree, this happened. Shorn of most of their curative pretensions, asylums had a difficult time justifying their expense, and a cheese-paring economy soon settled over such establishments. Yet confinement provided its own rationale, for why else were the mad locked up, unless it was unsafe for them to be at large? Mad-doctoring, now increasingly embracing the German term ’psychiatry’ as German medicine moved to the forefront of scientific medicine, remained for the most part a marginal, hobbled, stigmatized enterprise. The physicians’ presence provided a useful service, both to patients’ families, and to the community at large, as well as a medical gloss for the empire of asylumdom. families, and to the community at large, as well as a medical gloss for the empire of asylumdom.

10. Dance in a Madhouse, by the American realist artist George Bellows (1882—1925). Dances were one of the few occasions when the otherwise rigidly segregated sexes were permitted to mingle while confined in the asylum. Attendance was a privilege that could be withdrawn instantly for ’bad behaviour’, and the lunatic ball thus functioned as an occasion for displaying the asylum’s disciplinary power over its inmates, and its ability to control the unruly forces of sex and madness

Besides, intellectuals are skilled at rationalization, at inventing accounts that justify their existence and explain (or explain away) inconvenient facts. And so it proved with madness. First in France, then in the German-speaking world, in Britain, and in the United States, the psychiatric profession began to converge around a new account of madness: one that simultaneously provided a powerful new rationale for segregating the insane; and demonstrated that psychiatry’s apparent therapeutic failings were in reality a blessing in disguise.

As early as 1857, the French alienist B. A. Morel had begun to advance the new concept of ’degeneration’. ’The degenerate human being’, he wrote,

if he is abandoned to himself, falls into a progressive degeneration.

He becomes…not only incapable of forming part of the chain

of transmission of progress in human society, he is the greatest

obstacle to this progress through his contact with the healthy

portion of the population.

Soon, this concept of a biologically rooted ’social menace’ spread all across Europe and North America. It surfaced in literature, most notably in the ’naturalistic’ fiction of Émile Zola, where it is portrayed as threatening to trap a decadent society in its deadly embrace - an obsessive theme of the Rougon-Macquart novels. It surfaced in a very different way in Ibsen’s Ghosts, with its graphic themes of drunkenness, incest, congenital syphilis, and madness that shocked and revolted most of its hypocritical bourgeois audience. An inherited morbid constitutional defect, worsening as defective germ plasm was transmitted across generations, came to be viewed as the biological principle underlying all the protean forms of departure from conventional morality: alcoholism, criminality, madness, idiocy, sterility, and death. Such notions were presented as ’science’ for a mass audience in books such as Max Nordau’s Entartung (Degeneration) (1892), with its sustained assault on ’degenerate’ art and artists. Figures like Baudelaire, de Maupassant, and Nietzsche, all of whom descended into syphilitic madness, stood as exemplars of the phenomenon. So, too, did ’le fou roux’, the red-headed madman Vincent van Gogh, whose alcoholism, epilepsy, recurrent venereal infections, self-mutilation, serial involvement with prostitutes and brothels, madness, confinement in an asylum, and eventual suicide might well have made him the poster-child for Nordau’s fulminations (or alternatively, in other times and amongst those with other prejudices, for the persistent romantic notion that madness and creativity are somehow closely allied). In the over-heated culture of the fin-de-siècle, ideas of decadence, degeneration, and biological decay rapidly made their way into the vocabulary of politicians, into conversations about national decline, and hence on to the statute book.

11. Portrait of apatient at the St PaulHospital, St Remy, the private madhouse to which Vincent van Gogh (1853—90) had committed himself in May of 1889, and where he would stay for most of the last year of his life

The mad, it transpired, were ’monstrosities’, ’tainted creatures’, whose inherited defects and biological inferiority were written on their physiognomy. On admission to the asylum, said Daniel Hack Tuke, the great grandson of the founder of the York Retreat and the English version of moral treatment, ’“No good” is plainly inscribed on their foreheads’. Men contemplating marriage were warned to be on the lookout for those ’physical signs…which betray degeneracy of stock… any malformations of the head, face, mouth, teeth, and ears. Outward deformities are the visible signs of inward and invisible faults which will have their influence in breeding.’ More firmly than ever before, psychiatrists insisted that madness was rooted in the body, and they noted that its hereditary nature made it ineradicable. Worse still, legions of the hopelessly biologically defective, shorn of the restraints provided by the veneer of civilization, were liable to reproduce like rabbits, and thus threatened to overwhelm a society that mistakenly kept them alive. Hence, remarked one psychiatrist (and he spoke for many of his colleagues), ’every so-called “cure” in one generation will be liable to increase the tale of lunacy in the next’. These were sentiments that simultaneously reinforced and drew sustenance from the Social Darwinist ideas that circulated widely in late 19th-century culture.

If at one time psychiatry had advanced the claim that the pressures of civilization bore most heavily on the mental stability of those drawn from the ranks of the privileged and the professional classes, now the connections of madness and civilization were turned upside down. ’There is most madness’, intoned the misanthropic Henry Maudsley, the leading psychiatrist of the late Victorian English-speaking world, ’where there are the fewest ideas, the simplest ideas, and the coarsest desires and ways’. Hence its social demography. ’Insanity does not occur’, said the Edwardian psychiatrist Charles Mercier,

in people who are of sound mental constitution. It does not, like

smallpox and malaria, attack indifferently the weak and the strong.

It occurs chiefly in those whose mental constitution is originally

defective, and whose defect is manifested in a lack of the power of

self-control and of forgoing immediate indulgence.

Such people were, not to put too fine a point on it, vermin, ’moral refuse’, parasites whose pedigrees, in the memorable phrase of another British alienist, ’would condemn puppies to [drowning in] the horse-pond’.

Fear of the ’feeble-minded’, and of the onslaught of the mentally unfit, fed into the rise of eugenics, the ’science’ of good breeding. Experts sought to encourage the well-born to breed, and to throw up obstacles to the reproduction of the unfit. Where advice did not suffice, isolation in an asylum, or even forced sterilization, were contemplated. Many American states took psychiatrists’ advice and passed marriage laws forbidding the tainted to marry. But such laws proved clumsy and hard to enforce. So some states subsequently opted for compulsory sterilization of the mentally unfit. Such moves were not uncontroversial - in England, efforts to secure legislation along these lines were derailed by opposition, largely from religious sources. Faced with a test case on the question, however, and convinced by the weight of scientific opinion, Oliver Wendell Holmes wrote for a nearly unanimous United States Supreme Court that:

It is better for all the world if instead of waiting to execute

degenerate offspring for crime, or to let them starve for their

imbecility, society can prevent those who are manifestly unfit from

continuing their kind. The principle that sustains compulsory

vaccination is broad enough to cover cutting the Fallopian tubes.

Three generations of idiots are enough.

(Buck v. Bell, 247 US 200, 1927)

The state, the Court held, had a compelling interest in interdicting the reproduction of the mad and otherwise mentally defective, and in the aftermath of its decision, other states rushed to embrace this approach, 40 of the 48 having compulsory sterilization laws on their books by 1940.

These were half-measures, though. The harsh language that fin-de-siècle psychiatry employed to refer to the mad, and the pessimism and despair that marked psychiatric theorizing about mental illness, pointed towards a darker set of conclusions. If madness was incurable and a threat to the future of the race, why should such defectives be kept alive, at great expense and some risk? Why not exterminate the problem, and those who constituted it? Such dark thoughts were only briefly and none-too-firmly broached in much of Europe and North America. Best-selling books such as Madison Grant’s The Passing of the Great Race, largely devoted to rants against immigrants of inferior racial stock, spoke contemptuously of old shibboleths like ’the sanctity of human life’, and insisted that ’The laws of nature require the obliteration of the unfit.’ Charles Davenport, another leading American proselytizer for eugenics, wistfully acknowledged that ’it seems to be against the mores to burn any considerable part of our population’, a reluctance he clearly found deeply regrettable. And the English psychiatrist Samuel Strahan railed against misguided attempts to cure the mad and to restore them to society, for they served only to ’prevent, so far as is possible, the operation of those laws which weed out and exterminate the diseased and otherwise unfit in every grade of life’. But these men and their allies ultimately baulked at implementing the policies to which their logic led them.

Not so the Nazis. With the active and often enthusiastic participation of large portions of the German psychiatric profession, Hitler’s minions copied the compulsory sterilization laws the United States had pioneered. Around 300,000 or 400,000 German patients were sterilized between 1934 and 1939.

(Margaret Smyth, a psychiatrist who headed Stockton State Hospital, boasted that they had only been able to accomplish so much ’in a scientific spirit … after careful study of the California experiment’.) And then the Nazi bureaucracy took matters a chilling step further. As early as the 1920s, German psychiatrists like Alfred Hoche had argued in favour of extinguishing ’useless lives’. The Führer issued a decree in October 1939 making mass extermination official state policy. Under the so-called ’T-4 programme’, psychiatrists established ’review commissions’ which marked mental patients for death, often referred to as ’disinfection’. At first, lethal injections were employed, but as the scale of the programme rapidly expanded, to facilitate matters gas chambers were built, disguised as showers, along with gas ovens to burn the corpses. Between January 1940 and August 1941, at death camps like Hadamar, 70,273 inmates bused in on what were informally called ’killing crates’ by the locals (the meticulous record-keeping was a feature of the regime) were suffocated with carbon monoxide gas, their gold teeth extracted, and their bodies burned in gas ovens. The killings by German psychiatrists would continue for some weeks after the Allies occupied the surrounding territory as the war drew to a close.

12. In their starched uniforms, the staff at Hadamar who conducted the mass killings of mental patients - or as the Nazis called them, ’useless eaters’ - smile proudly at the camera

It was the mentally ill, therefore, who were the first victims of Hitler’s Holocaust, the involuntary human guinea pigs used to develop the techniques then turned on the still larger group the Nazis saw as a threat to ’racial purity’, the Jews. Indeed, some of the gas chambers first put to work to kill the mad were later disassembled and moved to the extermination camps devoted to the Final Solution in occupied Poland, the trained staff often accompanying them. In all, estimates are that between 200,000 and 250,000 mental patients perished in the space of little more than five years.