BOOK REVIEW / Out of mind, out of sight: 'The Most Solitary of Afflictions: Madness and Society in Britain, 1700-1900' - Andrew Scull: Yale, 29.95 pounds

THIS superbly written, meticulously researched study is a horror story. Society's attitude to and treatment of the insane changed considerably during the 200 years covered by Andrew Scull. But although manacles and whips were eventually abolished, the 19th-century asylum created problems with which our society is still struggling.

In the 18th century, madness was seen as the behaviour of a wild beast which needed taming. Madmen were therefore chained, handcuffed and often beaten. Francis Willis, who treated George III, believed that the mentally ill could only be controlled by fear. Some of the 'madhouses' catering for private patients were well-run, humane establishments, but pauper lunatics were often housed in squalor, chained to their beds, soaked in excreta, and physically ill-treated.

As the 19th century proceeded, pressure for reform increased, culminating in the establishment of a national Lunacy Commission and the Lunatics Acts of 1845, which required the compulsory provision of county and borough asylums to house pauper lunatics. Although the reformers realised that small asylums taking fewer than 200 patients were essential if patients were to be cared for as individuals, cost dictated otherwise. The huge asylums built from the middle of the 19th century onward housed so many patients and were so understaffed that cursory medical supervision was all that could be provided. What began as a human effort to care for the neglected and ill-treated ended as the provision of 'custodial warehouses': dumps in which mental illness inevitably became chronic and incurable.

In 1844, the rate of certified mental illness in the British population was 12.66 per 10,000. By 1890, the figure was 29.6 per 10,000. Why such a horrifying increase in insanity? Scull argues, convincingly, that the provision of large asylums was itself responsible. Because institutions which could remove troublesome people from society came into being, the definition of madness was extended to include a variety of misfits who would not previously have been regarded as crazy. Asylum doctors had a vested interest in increasing their prestige by keeping the diagnosis and treatment of insanity in their own hands and by concealing how little they could do for the majority of their patients. The asylum became a 'culturally legitimate alternative' to coping with disruptive individuals in the community.

Moreover, although Scull does not make enough of this, the great asylums were often built at a considerable distance from the communities they served. A patient living in north London might end up in an asylum in St Albans, which made it difficult and expensive for his family to visit him and therefore increased his sense of being alienated and unwanted. The out of mind were put out of sight as far as possible.

Modern Western society still fails to provide adequate care for the mentally handicapped, the mentally ill and the chronic misfit. We have partially emptied the asylums, but we have not provided adequate alternative community care. Every city displays its quota of citizens who spend their days in aimless wandering: unemployed, unwanted, cut off from everything which makes life worth living. We still have little idea of what to do with such people and are disinclined to provide the money for attempts at rehabilitation.

Scull's indictment of the psychiatric profession is scorching. To my mind, he underestimates the achievements and independence of thought of some of the early reformers, but he has brilliantly demonstrated that good intentions may have disastrous consequences, and that theories of mental illness cannot be separated from the assumptions about society which are current at any particular historical period.