Every once in a while you reread a
book that profoundly interested you at the time, and you wonder if it will have
quite the same impact. Will it still seem as important or as revelatory, or
even as engaging a read? Such is the case with Andrew Scull’s seminal work on
the history of psychiatry and the asylum in England and Wales from the
beginning of the eighteenth up to the end of the nineteenth century. Although
it has not reappeared in a new edition, or been updated, it still reveals a
depth and rigor of scholarship that not only marks it out to be an outstanding
work of its period, but one that has stood the test of time.

Reading Scull’s elegant and rhythmic prose is a
pleasure. He marshals an impressive knowledge of the literature and weaves the
together social, cultural, political and scientific factors that shaped the
development of psychiatry as we know it. He uses original material to illustrate
the sincere concerns and laudable intentions of many of the early
practitioners, but a contemporary eye to show the often disastrous
consequences. He attempts to describe and explain how and why madness became
the province of the medical profession, and how the psychiatric institution
emerged.

From the first line, the title
indeed is taken from a line in Michael MacDonald’s wonderful book, Mystical Bedlam,
Scull infuses his work with a profound humanistic concern. He makes the reader
aware that this is not just abstract social history, but the lives of men and
women who in turn suffered abuse, stigma, mistreatment, misunderstanding and
all manner of terror in addition to the unchecked symptoms of their illness.

Although there have been
developments in scholarship in this area in the last dozen years (not least his
own) Scull’s exposition of the tragic fate of the mentally ill, his deep
concern for the personal experience and his sympathy for the human condition
keep this text at the forefront. He is clear that there are points at which he
would take issue with other critiques of psychiatry. He rejects the arguments
of Szasz and what he terms little more than a conspiracy theory of
anti-psychiatry. It is for him a gross oversimplification, an almost adolescent
romanticism that understands little of the suffering involved. But he does not
subscribe to the Whiggish or revisionist accounts either, because they tend to
be too one sided and unbalanced. It seems important to remember that so much of
the history of the development of the asylum was well-intentioned, even if the
results were sometimes worse than ever. This has the makings of a Greek
tragedy, for the good intentions are at once both the greatest strength and the
greatest weakness of the psychiatric reformers.

The final chapter finds Scull in a
more reflective mood. He considers with some sadness the consequences of
deinstitutionalization. It would be interesting to read his present
consideration of what he wrote then: have we continued with a blind allegiance
to the illusion of community care without the necessary supports and
infrastructure, heedless that the freedom it gives to some is the freedom to be
homeless, to be unemployed, to be exploited, to live in substandard housing, to
be easy prey to the criminal and unscrupulous, to be untreated, uncared for and
not to belong?

Nevertheless, there remain some
surprising omissions. He does not, for example, consider the issue of the
criminally insane or their incarceration to any extent. This may be a puzzle in
view of the seminal effect of the M’Naughten case in the recognition of mental
illness being distinct from criminality. He does not interrogate to the degree
that might be expected, the various Lunacy Acts, although the activities of the
Lunacy Commissioners is an important aspect of the book.

But it is really caviling to
complain in this way. The Most Solitary of Afflictions remains a vital
and foundational text for anyone interested in the history of psychiatry. It is
rich in scholarship and detail, and provoking in its argument. Its tone is warm
and pragmatic, devoid of cant and clear and precise. It should be treasured and
we are lucky that there are still people like Andrew Scull who can write as
effectively and as movingly on the history of some of our most dispossessed
citizens. It was a fine read in 1993 and it remains so today.

© 2006 Mark Welch

Mark
Welch, Ph.D. Assistant Professor in the Faculty of Nursing at the University of
Alberta, Edmonton, Alberta and Co-Director of the PAHO/WHO Collaborating Centre
for Nursing & Mental Health.

Categories: Philosophical, MentalHealth