Diagnosing Madness: The Discursive Construction of the Psychiatric Patient, 1850-1920

DIAGNOSING MADNESS

STUDIES IN RHETORIC/COMMUNICATION

Thomas W. Benson, Series Editor

Diagnosing Madness

THE DISCURSIVE CONSTRUCTION OF THE PSYCHIATRIC PATIENT, 1850–1920

Cristina Hanganu-Bresch

& Carol Berkenkotter

© 2019 University of South Carolina

Published by the University of South Carolina Press

Columbia, South Carolina 29208

www.sc.edu/uscpress

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Library of Congress Cataloging-in-Publication Data

can be found at http://catalog.loc.gov/.

ISBN 978-1-64336-025-6 (hardback)

ISBN 978-1-64336-026-3 (ebook)

Front cover design by Brock Henderson

To my parents, Marius and Doina, to whom I owe everything, and Art, who believed in me when it mattered,

Cristina Hanganu-Bresch

Madness is a foreign country.

Roy Porter, A Social History of Madness, 1987

The right to restrain an insane person of his liberty is found in that great law of humanity which makes it necessary to confine those whose going at large would be dangerous to himself or others.

Chief Justice Lemuel Shaw, Matter of Oakes, 1845

CONTENTS

ILLUSTRATIONS

SERIES EDITOR’S PREFACE

In the nineteenth century, psychiatric practitioners turned to confinement in what were called insane asylums as the remedy for severe cases of mental illness. The practice generated a large body of textual documentation, especially as it was contested, defended, and administered both in the medical community and in society at large. Cristina Hanganu-Bresch and Carol Berkenkotter examine some of resulting texts from a rhetorical perspective, attending to the ways they exercise a rhetoric of medicine, institutional justifications of the administrative, legal, and institutional practices, as well as various forms of resistance to the regime of confinement, including popular fictions of the horrors of wrongful confinement. This is a deeply humane and reflective book, astute in its critical readings and challenging in its affirmation of the humanity of the psychiatric subject.

THOMAS W. BENSON

PREFACE

This book is the result of years of research spent in archives and libraries on two continents in an attempt to decipher the textual footprints of asylum patients. Some of the results of this research have already been published in Carol Berkenkotter’s book Patient Tales: Case Histories and the Uses of Narrative in Psychiatry, as well as in various journals. Here, we focus on tracing not just the patients’ medical histories but also their life stories before they became patients and after they were discharged. We find that the diagnosis event is the watershed moment in their lives, and so we are looking for the textual—and textural—makeup of this decision. This was our own version of starring the text, in the words of Alan Gross, of placing rhetorical analysis of the written word at the center of the web of cultural practices that made asylums possible in the nineteenth century; thus, we observe firsthand the psychiatric argumentation practices that led to diagnosis and the patients’ efforts to counter those arguments. For a while we inhabited a world of fading calligraphy inscribed in esoterically paginated dusty tomes, amalgamated genres that also hosted occasional patient letters and artifacts (drawings, paintings, diagrams, objets d’art sometimes engraved in what appeared to be the patient’s own blood). Whenever possible, case notes, certificates, and private correspondence were copied, transcribed, and analyzed (in some instance coded); and while we used various analytical frameworks, for the most part we let the texts guide us to what we hoped to be intelligible, plausible approximations of the embodied experience of mental illness for those who found themselves in an asylum. We cover both wrongful and rightful confinement here, although as we shall see, both wrongful and rightful" are terms laden with judgments and assumptions we may find hard to adhere to today. We look at the English-speaking world (specifically, the United States and Britain) because of their shared philosophy of psychiatric confinement and the commonality of language, and to a period covering roughly the middle of the nineteenth to the beginning of the twentieth century, which is also when asylums came under attack from various sectors of the general public. Regrettably, our access to American medical archives has been severely limited because of a restrictive interpretation of laws protecting patient confidentiality; centuries-old asylum archives, containing case notes and worlds that have been only tentatively explored so far, lie beyond our reach. Thus, instead of asylum records, we turned to two other sources: serialized novels and court proceedings, both of which described (and pronounced judgments on) cases of wrongful confinement. The texts we have analyzed here via a variety of heterogeneous methods under the umbrella of rhetoric capture both the larger nuances of historical phenomena and the life details of private citizens caught in the psychiatric system.

We wish to thank the extraordinary librarians at the Wellcome Library for the History of Medicine in London, and in particular to Richard Aspin, the director of Rare Collections, who helped us wade through many square meters of handwritten text. We are also grateful to the Haverford College Quaker and Special Collections staff, in particular Anne Upton, who directed us to the Hinchman archive, which included press clippings and family letters. We would also like to acknowledge the reviewers who helped make parts of this work stronger, in particular the anonymous reviewers for the journals Literature and Medicine and Written Communication, as well as the participants in the Rhetoric Society of America’s 2015 Institute on Theory Building in the Rhetoric of Health and Medicine (especially Jeff Bennett, whose comments on an earlier version of chapter 1 were extremely useful). Last but far from least, we are immensely indebted to Kira Dreher, who, while a research assistant for Carol at the University of Minnesota, helped transcribe and make sense of the Baldwin case notes and contributed a part of that chapter.

It is now time to depart from the plural we. I left the hardest part for last: this book was a difficult project to finish because of the premature illness and death of my coauthor, Carol Berkenkotter. Carol was a shining light in the world of writing studies, a generous, brilliant, beloved scholar who is fondly remembered by her students and colleagues. She was also my mentor, and her work ethic, astuteness, intelligence, and charm will forever be with me. It has been a surreal experience finishing this without her, as she had long set the stage and tone for this research agenda. Thank you, Carol, for sharing your intellect, wisdom, brilliance, and kindness with me and many others who were fortunate enough to work with you.

Cristina Hanganu-Bresch

Introduction

DIAGNOSING MADNESS—IMAGINING THE PSYCHIATRIC PATIENT, 1850–1920

Studies of nineteenth-century psychiatry have generally focused on famous cases, doctors, or paradigm changes and ideological movements. They have more rarely focused on ordinary individual patients’ cases as they appeared in primary documents such as case notes, admission documents, Medical Certificates, and so on. We believe that the study of such documents can add to our modern understanding of mental illness as it was perceived in the English-speaking world (Britain and America) in the late nineteenth century and how the subsequent treatment of the insane came to be. In particular, we want to understand the struggle to diagnose mental illness, which had momentous consequences for the life circumstances of the diagnosed. The act of diagnosing mental illness was a watershed moment, triggering a cascade of medicolegal actions that radically changed the course of the patients’ lives, and which involved extrafamilial authorities to an uncomfortable extent for a large portion of the public. Studying the textual traces of the diagnosis process can help us understand how patients, caught in the mental health system (which in the nineteenth century was the insane asylum), struggled to assert their identity as individuals, provoking in the process debates about the meanings of normality, personhood, identity, and autonomy, to name a few critical topics. Such debates often spilled over into the public sphere via lawsuits, memoirs, newspaper editorials, essays in literary and legal magazines, legislative forums, and so on, forcing ongoing conversations on the issue of the definition, rights, and proper treatment of the mentally ill person.

When asylums mushroomed in early-to mid-nineteenth-century America as a result of the tireless campaigns of humanitarian champions such as Dorothea Dix, they held within the promise of revolutionizing treatment for the insane. As the philosophy went,¹ assuming that they followed a judicious regimen and inpatient routine, patients who were living in such quarters, far removed from the madding crowd, would have the best chance of being restored to sanity. The asylum thus offered a humane (moral) treatment for the insane that stood in sharp contrast with some of the more outlandish treatments of the past, such as chaining inmates, giving them cold baths, or putting them in various confining contraptions such as Benjamin Rush’s tranquilizer chair. The reality of the confinement, however, dared to disagree with the theory. As populations exploded (especially in cities, due to economic and industrial developments that were hard to foretell), so did the number of the mentally ill and the demand for asylum beds; thus, asylums became, in the words of Robin Ion and Dominick Beer, a strange mix of therapy, social control and moral guardianship.²

While psychiatric science made little progress, asylums became overcrowded and inefficient, which led to abuse, neglect, and institutional apathy. In most but the most exclusive establishments, asylum doctors became consumed by management issues and devoted little time to actual patients. Psychiatry, already isolated in large out-of-town asylums, also became ostracized as a discipline from other medical specialties; it became what one scholar has described as a backwater specialty.³ All this, coupled with the realization that a cure for most mental illness was failing to materialize, made the realities of confinement far less idyllic than the original visionaries had prescribed. Thus, it is no wonder that we see, in the second half of the nineteenth century (our focus in this book), more and more discontents with the system.

Confining a person deemed afflicted with a mental disease to the asylum⁴ was a pharmakon, both drug and poison, for while it purported to treat psychiatric ailments, it came with the high cost of personal liberty. Accordingly, the lexicon typically used to describe people caught in the legal and prison system, including terms such as confinement, inmates, or cell, permeated the medical language used to describe mentally ill patients and to justify their stay in the asylum. As the two worlds—medical and legal—collided in asylum practice, psychiatry became an object of public scrutiny unlike any other branch of medicine. Consequently, diagnosing, or identifying the nature of the mental illness, became one of psychiatrists’ primary concerns, resulting in multiple negotiations among patients, families, doctors, the general public, and often legal professionals.

In this book, we attempt to capture the nature of those negotiations, which are by nature rhetorical. By rhetorical we mean that the work of psychiatrists and patients (as well as that of families, writers and journalists, and legal authorities) is one of constant textual persuasion, involving finely crafted arguments, fluid definitions of disease, and careful linguistic choices that could make the difference between an individual’s personal liberty and asylum confinement. Such arguments concerned not only the nature of psychiatric disease (which is intrinsically controversial) but were also constrained by the gender and social status of the patients, the professional and legal status of the practitioners, and the larger democratizing and professionalizing forces shaping English and American societies at the end of the nineteenth century.

We are aware of the difficulties of diagnosing patients retrospectively,⁵ and that is not our goal here. Rather, we aim to describe some of the ways social and medical actors made sense of mental illness and negotiated diagnoses. In that sense, we try to mirror Robert Aronowitz’s goals in Making Sense of Illness, which took a historical approach to the social constructions of diseases such as Lyme disease, chronic fatigue syndrome, and coronary heart disease among others. By examining the controversial nature of these diagnoses, Aronowitz exposed the agendas that drove clinicians and patients and also defined the experience of illness for both. Unlike Aronowitz, who took a broad historical perspective, our inquiry is firmly grounded in specific texts that were central to the mental patient’s experience during the period we focus on—the late nineteenth and early twentieth centuries. Thus, we are looking at asylums as cultural sites that generate textual ecosystems revolving around the conditions and nature of psychiatric confinement. The primary texts that we investigate in the chapters that follow, although in the public domain, have not been examined elsewhere to our knowledge, except in our own published works, which form the core of chapters 3, 4, and 5. By analyzing some of these under-researched genres and documents, we hope to contribute new knowledge to the literature on the rhetoric of medicine, the social history of psychiatry, and social studies of science. Additionally, we also look at fiction genres such as sensation novels that claim to be based (entirely and truthfully!) on real cases of wrongful confinement; at least one of these novels has been, to our knowledge, under-researched so far in the literature dealing with nineteenth-century psychiatric history.

The common focus in all chapters is capturing the moment in which a person becomes a psychiatric patient—which often occurs at the juncture of the psychiatric diagnosis. We aim to do so through a close examination of a constellation of genres generated by that diagnosis. While social (institutional, literary, medical, legal) forces demand new and specific genres that describe, define, and regulate mental illness, the documents thus produced have the power to alter the same social factors that required them. For example, in both the United States and the United Kingdom, social pressure regarding alleged asylum abuses gave rise to laws that demanded a stricter control of asylums, partly through more rigorous documentation. The resulting documents (admissions records, patient case histories) were the deciding factor in the destinies of both patients and families. Furthermore, some patients wrote and even published memoirs or sued the asylum as a result of their confinement, generating a fresh wave of public discussion surrounding mental illness (in varied genres such as novels, pamphlets, newspaper columns, or legal debates). Such public discussion led, in turn, to new laws, regulations, and attitudes regarding the treatment of mentally ill patients.

Diagnosing Mental Illness and Wrongful Confinement in the Nineteenth Century

The issue of diagnosis is the moving target in all these documents—though gradually, with the dawn of the twentieth century—the once-unquestioned necessity of asylums as the endpoint of mental patient care gets thrown into question as well. Our analysis homes in on how mental disease is a matter of public negotiation much more than a matter of scientific and medical knowledge. Moreover, we wanted to document the concrete consequences of these public negotiations on actual mentally ill patients whose lives were profoundly altered in this process. With our last chapter, we also offer a glimpse into how that public negotiation of sanity gets professionalized—a matter to be debated amid specialists rather than in courts of public opinion.

As Annemarie Jutel explains, the process of diagnosis provides the framework within which medicine operates, punctuates the values which medicine espouses, and underlines the authoritative role of both medicine and the doctor.⁶ Jutel argues that diagnosis refers to both preexisting categories and the process of applying them in practice; it is also a process that reveals what society’s standards for normal are and offers a grid for imposing culturally accepted order.⁷ There is power at play in the diagnosis: for the doctor who makes it (reflecting the authority and consensus of fellow professionals), for the patient (who is henceforth medicalized, or psychiatrized in our case, and may both gain and lose certain rights), for the discipline of medicine at large, and (in modern times) for medical insurance entities. It is also a matter of authority for the state, as the recognition of certain diseases as parts of the accepted nomenclature may trigger consequences—of the economic, legal, and social variety. For example, admitting the existence of PTSD or of the AIDS epidemic has had momentous consequences for a significant group of afflicted patients from multiple points of view, insofar as it has offered the relief of recognition to previously unnamed suffering and has opened avenues for financial, social, and emotional support; but it also has material consequences for the medical profession and research institutes working on cures and clinical practice guidelines, as well as the state, which will have to allot governmental resources for research and treatment.

In the case of mental illness, while no one doubted its existence,⁸ very few could agree on definitions and boundaries—where to carve nature at its joints. The process of imagining and reimagining taxonomies in psychiatry still goes on to this day, though we can trace its modern incarnation to Kraepelinian nosology, something we address in our last chapter. Along the way, we have sought to capture in historical medical texts the inception of diagnosis as a label—and we have tried to corroborate its genealogy in contemporary texts (journalistic and fiction genres). The lessons of the nineteenth-century moral insanity debate, for example, show that diagnosing mental illness as a whole becomes ensnared in controversy the moment it becomes a matter of public discussion. Publicly shared a priori concepts of mental disease will matter more in this instance than professional consensus, and they may even help erode that consensus.

A counterpoint theme to that of diagnosis is the trope of wrongful confinement, which pertains to many of the cases we discuss, and occurs when patients or families dispute the diagnosis and, therefore, the treatment (that is, interference of the state). At a moment when patriarchal familial relationships are tested by modernizing forces such as urbanization, industrialization, capitalism, and population growth, the authority of the family, especially of the patersfamilias, is further undermined by impersonal institutions and regulators. This challenge may lead to public confrontation on the nature of authority affecting a person’s legal competence (these are themes that we particularly address in the first two chapters). The trope thus touches on a variety of aspects: the medicolegal aspects of confinement; the social, political, and legal status of asylums and doctors; Victorian morality; American principles of freedom and justice; the public fears of institutional abuses as well of financially motivated villains taking advantage of the system and working under the guise of familial concern; and, of course, debates surrounding the definition and diagnosis of insanity. We must also point out that the trope is sometimes invoked in cases in which the lens of history shows there was little use for it. Such was the case of Ebenezer Haskell, whose complaint of wrongful confinement in the Pennsylvania Hospital won in court in 1868 despite ample expert testimony and extraneous evidence that there was no evidence of an abuse of power and that he had been suffering from a form of mental illness.⁹

The recurrence of wrongful confinement cases slowly eroded the public trust in psychiatry; public trials, in which diagnoses were fought in court, revealed severe holes in the doctor’s understanding of their own categories and furthermore showed these categories being at odds with the common sense of the common juror. As if the onslaught form the public and legal professions were not enough, psychiatrists were also fending off attacks from fellow professionals as well, such as celebrated neurologist Silas Weir Mitchell, who as late as