Cristina Hanganu-Bresch, Carol Berkenkotter. Diagnosing Madness: The Discursive Construction of the Psychiatric Patient, 1850-1920. Columbia: University of South Carolina Press, 2019. xii + 180 pp. $51.99 (cloth), ISBN 978-1-64336-025-6.
Reviewed by Allan Beveridge (University of Edinburgh)
Published on H-Disability (April, 2021)
Commissioned by Iain C. Hutchison (University of Glasgow)
A book which promises to examine the history of psychiatry from the patients’ perspective is always welcome. In addition, this book offers to bring a linguistic and literary perspective to the subject. The authors are Christina Hanguna-Bresch, an associate professor of writing and rhetoric at the University of the Sciences in Philadelphia, and Carol Berkenkotter, a professor in the Writing Studies Department at the University of Minnesota, who sadly died before the book was published. They write that they will “attempt to decipher the textual footprints of asylum patients” and are particularly interested in the act of diagnosis, which they rightly describe as a “watershed moment” in the lives of patients (p. xi).
They begin in nineteenth-century America and admit that they are unable to access patient records because of strict confidentiality laws. Instead, they look at medico-legal records. They focus on the issue of wrongful confinement and examine the conflicting voices of the patient, doctor, relative, lawyer, and popular opinion. They examine the case of Morgan Hinchman, a wealthy farmer from Bucks County, Pennsylvania, who was confined in an asylum, and his subsequent court case in 1849, or as the authors style it, the “Hinchman conspiracy trial.” They state that the case “posed one of the most notable challenges to the American commitment system” (p. 9). The authors discuss the arguments of the opposing sides and remark that the question of the sanity of an individual citizen became a matter of public debate. What was at stake was the definition of “normal.” They refer to the work of the medical historian German Berrios, who has contended that, in the nineteenth century, there were two rival versions of descriptive psychopathology. First, there was the view that insanity was just a variation of normal human behavior, and second, there was the view, held by asylum doctors, that insanity was qualitatively different from normal experience and marked a complete break. Berrios characterized these two viewpoints as the “continuity” and “discontinuity” models of madness.
Next, the authors turn to literature, arguing that during this period novels both reflected and molded public opinion about the treatment of the mad. They choose only two novels: Hard Cash (1863), by the English writer Charles Reade, and Put out of the Way (1870), by the American author Rebecca Harding-Davis. Both novels are concerned with wrongful confinement and the authors observe that they share a common purpose: “to reform asylum confinement by exposing the flimsiness of the requisite evidence of madness and the outlandish difficulty of escaping the system” (p. 37). It is here that the authors describe the core conceptual foundations of the book: rhetorical theory. We are given an outline of the theory, which involves such entities as “rhetorical situation,” “exigences,” “rhetors,” “audiences,” and “constraints.” An excerpt gives a flavor of this approach: “We propose to further resolve or, rather, break the circular dynamic between rhetor and discourse (which are both responding to and creating the rhetorical situation) by engaging Barbara Biesecker’s idea of rhetorical situation as hinging on a logic of articulation rather than of influence. Biesecker’s goal is to integrate Derrida’s deconstructionist theory, in particular the idea of differance, into rhetorical theory, and she sees an avenue in the concept of rhetorical situation” (p. 40).
The authors go on to consider asylum admission records and case notes in a chapter with the forbidding subtitle “The Illocutionary Power of Occult Genres.” They look at the Ticehurst Asylum, in the English county of Sussex, and two patients, Henrietta Unwin and Walter Marshall, whose certification process they examine using speech act theory. We are told that the “Notice of Admission,” which they rename a “genre suite,” functioned as “an illocutionary act of complex argumentation” (p. 57). A further chapter looks at Walter Marshall’s testimony in court concerning his incarceration and compares it with the testimony of another Ticehurst patient, Herman Charles Merivale, and his book, My Experiences in a Lunatic Asylum by a Sane Patient (1879).
They find Marshall’s account of suddenly being apprehended and taken to an asylum for no good reason that he could see as “Kafkaesque.” Given that they have previously been underlining the interplay between fiction and the lived experience of asylum incarceration, it seems anachronistic to cite an author from a later period. They consider Merivale’s memoir and suggest, quite plausibly, that the shame and loss of self-esteem brought on by his confinement led to his combative narrative of the “self against the machine.” However, they go on to describe Merivale’s prose as this “stream of digression marked by displays of erudition,” which they compare to Northrop Frye’s depiction of some speech as “a kind of encyclopaedic farrago” (p. 95). Further, they refer to “Merivale’s use of Menippean satire” (p. 101). The more prosaic explanation that Merivale, who suffered from mania, was simply displaying the characteristic speech of that disorder such as flight of ideas and garrulousness, is not considered.
The final chapter looks at how the diagnostic system of Emil Kraepelin (1856-1926) came to be gradually accepted in Britain. They examine the case history of one patient at the Ticehurst Asylum and chart how his diagnosis changed from “unsound mind” to “Manic-Depressive Insanity.” They provide statistical analysis and graphs to illustrate the evolution in his case note entries, but one wonders how much this adds to what is a fairly straightforward story of how medical diagnoses evolve over time as a result of changes in medical knowledge and fashion. More interestingly, they observe that the diagnostic move from “unsoundness of mind” to “Manic-Depressive Insanity” demonstrates “the ‘subjectivity’ of the medical/psychiatric gaze that can only see what the available linguistic and conceptual framework allows it to see” (p. 128).
They then go on to contend that the advent of the Kraepelinian diagnostic system led to the “disappearance” of the patient from the notes. They claim that the rich psychopathological descriptions of patients prior to this vanished, to be replaced by a diagnostic label. But is this true, and can the examination of one patient in a small, private asylum provide the evidence? From my familiarity with a variety of asylum case notes from different places and eras, I can say that they vary greatly. Some are enormously detailed and some, like Richard Dadd’s from the mid-nineteenth century, are disappointingly sparse.
The authors end by saying that the voice of the poor asylum patient has been lost. It would be more correct to say that they didn’t find it. My own work on patient letters from the Royal Edinburgh Asylum contains writings by very many patients from poorer backgrounds. In fact, judging this book by the lights of the history of psychiatry, it falls short. There is a little engagement with or, seemingly, much knowledge of the literature. Roy Porter, probably the most important figure in the historiography of the patient perspective, gets one quote at the beginning of the book, but his extensive work is not cited. Dale Peterson’s groundbreaking A Mad People’s History of Madness is not mentioned, which is especially puzzling as his work contained many texts from America. Jonathan Andrews, who has written eloquently about the patient experience, gets mentioned briefly at the end of the book. My own work gets no mention, although many of the patients in my study of the Royal Edinburgh Asylum expressed sentiments similar to those mentioned in the book and were influenced by popular literature. Some Edinburgh patients wrote, “Imagine my horror at finding myself in a madhouse with perfectly mad folk. I am not insane”—an expression which could have come straight out of Charles Reade’s Hard Cash (1863). There is also the Aberdeen patient Mary Coutts, who protested what she saw as her wrongful confinement by producing a pamphlet entitled Britain’s Siberia. More generally, Andrew Scull, who has written about the asylum system in both Britain and America, is overlooked.
From a history of psychiatry perspective, the research sample is very small. Britain is represented by three patients from a private asylum in England, and America by just one legal case. England is conflated with Britain and the authors seem to be unaware that Scotland had its own lunacy laws, rendering wrongful confinement less likely. In 1908, the British Journal of Psychiatry did not exist and was still called the Journal of Mental Science. The psychiatrist Trevor Turner did not write about “rhetorical history”; it was Kathleen Turner.
The key question is: does the authors’ approach, based on rhetorical theory with borrowings from speech act philosophy and literary analysis, add to our understanding of the experience of the asylum patient or to the history of psychiatry? I would struggle to answer in the affirmative.
. Allan Beveridge, “Life in the Asylum: Patients’ Letters from Morningside, 1873-1908,” History of Psychiatry 9, no. 36 (1998): 431-69.
. Dale Peterson, A Mad People’s History of Madness (Pittsburgh: Pittsburgh University Press, 1982).
. Allan Beveridge, “Mary Coutts’s Account of the Asylum System,” Journal of the Royal College of Physicians of Edinburgh 35, no. 2 (2005): 175-81.
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Allan Beveridge. Review of Hanganu-Bresch, Cristina; Berkenkotter, Carol, Diagnosing Madness: The Discursive Construction of the Psychiatric Patient, 1850-1920.
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