…throughout history the line between sanity and madness often has been negotiable, and more often than not has been inscribed by gender, race, socioeconomic class and sexual orientation.(26)

The sociologist Mary de Young has written a lucid, literary, extremely approachable history of mental illness in America, paying close attention, as the above quotation indicates, to the social context as well as the medical. If such a history can be ‘enjoyable’ then this is it; the reader is taken through the definition of madness, the experience of it through narrations and pathographies, or first person accounts, and how it was viewed, handled and treated through colonial days to the present. She describes and explains asylums, the patients who inhabited them, and the treatments to which they were subjected over the centuries, from the humoural approach of the ancients to electroconvulsive therapy, surgeries (of body and brain), and of course psychopharmacology.  

As de Young writes, madness is ‘protean’ and ‘socially constructed’, and the history of asylums and psychiatry is deeply political. Black slaves were thought to be mad when they tried to escape from their slavery, and ‘asylum physicians drew a distinctly racialized line between sanity and madness’ (14). Wives could be labeled as mad and institutionalized by their husbands for not paying enough attention to their housewifely duties (e.g. Ann Yale Hopkins) or for disagreeing with them (e.g. Elizabeth Packard). And some neuroscientists postulated that rioters in the turbulent 1960s could be brain damaged and possible candidates for medical treatment to curb their violence; the reader can see where that might lead.

The book is well organized and divided into six chapters plus a preface and conclusion. Apart from the writing style, the use of literary allusions and primary source quotations makes this text appealing to read. The whole of person and whole of society approach, with attention paid to the social and cultural context of ‘madness’, as well as portraits of the major physicians involved, gives a more nuanced and complete picture of how America has viewed mental illness over the centuries.

She emphasizes throughout the impact of the times upon the diagnosis and treatment of mental illness. For example, the influence of the Enlightenment and its focus on the primacy of human reason, and the rise of capitalism changing the caring role of the family. Patients were sent to public institutions to be cared for, and they were, gradually, no longer treated as wild beasts but as persons with whom one could reason. The shift from the population believing their lives were ruled by fate to the worldview of free will and the individual deciding their own destiny had an impact.

De Young takes the reader through the development of the asylum, with Thomas Kirkbride’s ‘moral treatment’ and his meticulously planned buildings, to the rise of ‘scientific psychiatry’, the increase in numbers of patients being admitted to asylums, and the deterioration of their conditions  Deinstitutionalization she concludes as good in policy but bad in practice (122), which she supports with a discussion of the results of homelessness and lack of support for community-based treatment programs.

Effective is her discussion of the asylum patient, and the concept of the ‘moral career’ as postulated by Erving Goffman: ‘a sense of self and identity that is slowly and steadily shaped as much as by the experiences of institutionalization itself as by any real or imputed madness’ (125). De Young writes systematically of the different issues pertinent to the asylum patient, both present and past: admitting the self as opposed to being voluntarily admitted by someone else; involuntary commitment; different roles of patients in the asylum; pseudopatients; spoiled identity and stigma once back out in the community; those who do not write their asylum memoirs (‘the silent and silenced voices’); race; eugenics and involuntary sterilization; and the institutionalization of children, of which little is known.

The therapies for the mentally ill in asylums have a fascinating, if disturbing, history. It reminds the reader just how little we really knew about the mind and its disorders, and how much we still have to learn. The colectomies performed by Henry Cotton in pursuit of his ‘focal sepsis’ theory seem nothing short of ludicrous now. Even at the time–and Cotton only died in 1933–reviews of his patients subjected to surgery showed high mortality rates and little real, long-lasting relief from psychosis. De Young takes us through insulin shock therapy, electroconvulsive therapy and the truly horrifying descriptions of transorbital lobotomies performed by Walter Freeman in the middle of last century.

Now we are in the age of psychopharmacology, which contributed greatly, but not entirely, to the shutting down of asylums in America. It is interesting to note that the successful treatment of two diseases, pellagra and syphilis, significantly contributed to a change in the population of asylums. But it is the advent of antipsychotic drugs such as chlorpromazine that made an enormous difference to the treatment of patients and changed asylum therapeutics.

Mary de Young has provided the interested general reader of medical history with an engaging and informative book, valuable for its thorough research, clarity of expression, and holistic view of madness and society. Highly recommended.

© 2011 Sue Bond

Sue Bond is a writer and reviewer living in Queensland, Australia. She has degrees in medicine, literature, and creative writing.