Family strategies and medical power: 'voluntary' committal in a Parisian asylum, 1876-1914.

Recent research in the history of nineteenth century psychiatry has explored the expanding powers of the medical profession and the proliferation of the asylum, that "magic machine"(1) for curing insanity. This medicalization of madness has usually been portrayed as a "top-down" process: "social control imposed from above with greater or lesser success on a population now the unwitting object of medical encadrement."(2) But as historians have begun to study individual asylums and the complexities of committal, more emphasis is being placed on the role played by families in the process. Asylum doctors, it has been suggested, merely confirmed a diagnosis of insanity already made by families, by neighbors, or by non-medical authorities.(3) Consequently, as the American historian Nancy Tomes has argued, "the composition of a nineteenth century asylum population tells more about the family's response to insanity than the incidence or definition of the condition itself."(4) Such arguments imply a more "dynamic and dialectical"(5) interpretation of the process of medicalization, one that requires a careful assessment of family demands for medical services and the degree to which these demands were met, willingly or unwillingly, by the emerging psychiatric profession.(6) In the present stage of research on mental illness and its treatment, it is vital to expand the range of institutional studies.

Asylum records, although difficult to interpret, can shed some light on family decisions to "take the road to the asylum",(7) particularly when committal did not involve the police or judicial authorities. In France, the law of 1838 established placement d'office, or official committal, as the normal means of confinement; it was, in the words of the law, restricted to those who "endanger public order or the safety of individuals."(8) In Paris, this procedure was administered by the Prefect of Police and it was, critics charged, unnecessarily complicated. Local police sent those who appeared to be both unbalanced and dangerous to the Infirmerie speciale, situated alongside the central police detention cells (the Depot).(9) At the Infirmerie, potential patients (referred to as presumes) underwent a psychiatric examination and, if certified as insane (aliene), were taken by a police van to the Admissions Office of the department of the Seine, located on the grounds of the Sainte-Anne asylum. Here they were again examined by a psychiatrist, most likely by the eminent Valentin Magnan, were again certified as insane and, finally, were transported to one of the five asylums in the department of the Seine.(10)

For nearly a century, Parisian psychiatrists denounced the continued existence of the Infirmerie speciale and sought to have patients in police custody transferred directly to the Admissions Office at Sainte-Anne. With considerable justification, and a certain self-interest, they maintained that police control of official admissions implied a punitive, rather than therapeutic, approach to the insane. The prison-like atmosphere of the Infirmerie speciale and the claustrophobic cages of the police van imposed, they argued, an unnecessary hardship on both families and patients. As one doctor described the transfer of patients: "The lunatic is confined to a narrow cage, with the only light coming from a barred opening overhead; he hears the bolt slam shut and the van starts off without his having any idea, in his confused state, where he is going or why he has been locked up."(11) Patients, noted Magnan, arrived at the Admissions Office "feeling that they have been imprisoned"(12) and, consequently, were more difficult to treat.

In 1876, Parisian psychiatrists were influential in having a second, more "humanitarian," type of admission procedure, placement volontaire, re-established in the department of the Seine.(13) This form of committal was intended for the mentally disturbed who did not threaten public order but who required treatment. Relatives (or even friends) could place such a person in any public asylum of their choice without police intervention; they could also withdraw the patient at any time, even if the asylum doctor objected. (This so-called voluntary committal did not, of course, involve the consent of the patient: under the law of 1838 the patient was an aliene and therefore incapable of informed consent.)

When this form of admission was reintroduced in 1876, psychiatrists portrayed it as an enlightened reform that circumvented the horrors of the Infirmerie speciale and assured the speedy treatment (i.e. committal) of mentally disturbed but harmless patients. It also, as one doctor observed, "avoided any formality that could suggest the idea of coercion."(14) From a medical point of view, this was a distinct advantage at a time when a strong "anti-psychiatry" movement in the press and among politicians accused doctors of sequestration arbitraire, the illegal confinement of people with no signs of mental illness.(15) At first, asylum doctors did not foresee any great demand for this new type of admission and paid little attention to it.(16) Nevertheless the demand for this service grew steadily. By the mid-1890s, 'voluntary' patients accounted for 21 percent of all admissions; by 1905 they had risen to nearly 30 percent and in 1912 they reached 32 percent.(17) Sainte-Anne, the most prestigious of the asylums of the Seine(18) and the only one situated within Paris itself, attracted the largest number. By the 1890s, nearly half of its annual admissions, male and female, were 'voluntary'. Sainte-Anne continued to receive a disproportionately high number of such patients right up to the First World War.(19)

By 1890, this unanticipated growth in 'voluntary' admissions had attracted the attention and enthusiasm of asylum doctors. For the next twenty-five years, in their annual administrative reports and in their congresses, they welcomed every increase in 'voluntary' patients, complained of their unequal distribution among the five departmental asylums, and urged that more effort be made to attract such admissions. They argued, for example, that became families were offended by the "promiscuity" of the asylum, that is, the intermingling of classes and medical conditions, separate rooms and better food should be provided for 'voluntary' patients.(20) At a time when asylum budgets were increasingly restricted, there were, as one doctor admitted, "both economic and humanitarian reasons to facilitate such admissions"(21): at least half of all 'voluntary' committals were paying patients, at a rate of nearly 3 francs per day. But doctors were equally eager to attract non-paying 'voluntary' patients. They complained that neither families nor their physicians were aware of this form of medical assistance and that the procedures for free 'voluntary' admission were too bureaucratic. Marandon de Montyel, the senior psychiatrist at the Ville-Evrard asylum, always informed his patients of these procedures when they were being released, so that in case of a relapse, they could be speedily readmitted.(22)

This enthusiasm for one particular form of admission to public asylums is best understood within the context of the professional ambitions and insecurities of Belle Epoque psychiatrists. By the 1890s, the overcrowding in Parisian asylums had become a constant problem. On the one hand, this ever-increasing asylum population and the scant evidence of successful treatment encouraged the antipsychiatric movement to brand asylums as modern Bastilles and psychiatrists as "panalienists", self-appointed experts who "saw madness everywhere except in their own mirrors."(23) On the other hand, psychiatrists now found themselves responsible for up to 500 patients each, with the result that they could treat only the most urgent or 'interesting' cases. Moreover, there were few such 'interesting' cases because asylums had also become 'silted up' with chronic and incurable patients, such as the aged and the mentally handicapped, who, psychiatrists charged, were responsible for the profession's embarrassingly low rate of cure.(24) Increasingly, asylum doctors denounced the large Parisian asylums as "barracks", "depots", and "lock-ups", places of confinement, not of treatment.(25) Rather than physicians, psychiatrists had become, in the words of one frustrated practitioner, "the head custodian" of a population that was, from the medical point of view, uninteresting.(26)

The unforeseen growth of 'voluntary' admissions provided psychiatrists with the opportunity to defend their medical expertise and to escape a professional cul-de-sac.(27) As early as 1877, an inspector-general of asylums, L. Lunier, greeted the increase in the number of 'voluntary' patients as evidence that "families had more and more confidence in public asylums."(28) In 1890, a young Parisian psychiatrist, Marcel Briand, suggested that the popularity of 'voluntary' admissions was a reflection of medical progress: medical science was now able to diagnose and treat madness at an earlier stage. The result, he argued, was a "change in attitudes, thanks to which families are more familiar with the road to the asylum, which no longer horrifies them."(29) In 1912, as Magnan's successor at the Admissions Office, Briand repeated this claim, welcoming the "more and more numerous" 'voluntary' admissions as an indication that Parisians, "better informed about the benevolent aspects of the law of 1838, increasingly appreciate the nature of the care in our asylums."(30)

But to psychiatrists this growth of 'voluntary' committals symbolized more than the triumph of science and reason over ignorance and fear. It represented a new definition of the asylum and, by implication, a new role for its doctors. When referring to 'voluntary' admissions, psychiatrists increasingly used the term "hospital", or occasionally "hospice" and maison de sante rather than asylum. For example, in 1890 Briand praised the "comfort" and "luxury" of Parisian public asylums and concluded that "[t]he Parisian people today consider them almost like ordinary hospitals, where you can enter or leave whenever you want."(31) In contrast, by the 1890s, asylum doctors frequently associated official or police admissions with imprisonment. As Rouillard, the head of the teaching clinic of the Faculty of Medicine at Sainte-Anne, argued, more 'voluntary' patients were needed in order to show that the clinic was "a true hospital and not a prison."(32)

Asylum doctors argued that the two admission procedures resulted in two different types of patients. Those who passed through the Infirmerie speciale were, they believed, inevitably chronic or incurable patients. Although earlier psychiatrists had praised official committal because it "forced" families to treat the mentally ill,(33) their successors now argued that the horrors of the Infirmerie so appalled families that they delayed admission "until they had lost all hope".(34) Since it was psychiatric dogma that any delay in admission resulted in the "manufacture of chronic cases",(35) it was not difficult to associate chronic or incurable patients with the Infirmerie speciale, which psychiatrists increasingly referred to as the Depot, the term for the police detention cells. On the other hand, became 'voluntary' patients could be taken directly to the asylum, psychiatrists maintained that they were admitted at the acute, rather than chronic, stages of their illnesses and were, consequently, curable. Only the lack of information about free care, it was assumed, could account for any delay in the admission of 'voluntary' patients.

For asylum doctors, frustrated with the state of their institutions and subject to continued public hostility, the growth of 'voluntary' admissions readily became a symbol of their hopes and a refutation of their critics: asylums could be transformed into hospitals where an influx of acute patients would result in reputable cure rates, expanded medical knowledge, and greater professional status. But this medical interpretation of the increasing popularity of 'voluntary' procedures is too self-serving to explain why families chose to "take the road to the asylum". It assumes that family and psychiatric interests were identical and that families accepted the medical definition of the asylum as a place to treat mental illness through total isolation. It also ignores the fact that Parisian families had already demonstrated their reluctance to submit to psychiatric regulation. 'Voluntary' admissions were reintroduced in the department of the Seine in 1876 not simply because psychiatrists argued for them, but because families were circumventing the law. Either they tried to bypass the Infirmerie speciale and take their relatives directly to the asylum, or they used official admissions for non-dangerous family members, to the detriment of the departmental budget.(36)

Moreover, comments by psychiatrists themselves suggest that it was not administrative procedures but psychiatric power that most disturbed families. Paul Garnier, the examining physician at the Infirmerie, admitted that it was difficult to persuade families to commit a relative became they feared that "the patient will be mistreated, that it will make him hate his family and will drive him completely mad."(37) Febvre, a psychiatrist at Ville-Evrard, noted that official procedures "offended" families and "made them fear the impossibility of ever getting their patients back."(38) The regulations for 'voluntary' committal, which allowed families to reclaim their relatives without the consent of the asylum doctor, altered the balance of power between the family and the asylum, a fact that psychiatrists rarely acknowledged and never explored in their medical writings.

The tangled motives that led Parisian families to "knock on the door"(39) of the asylum will continue to elude historians, just as they eluded nineteenth century psychiatrists. Family decisions were complicated, never fully articulated, and often unrecorded. But asylum records provide some useful indications of family attitudes, particularly when the asylum is Sainte-Anne, the most convenient of the Parisian asylums and, in terms of 'voluntary' admissions, the most popular. An analysis of the records of 'voluntary' patients at Sainte-Anne from 1876 to 1913(40) suggests that families had their own definitions of the asylum and of medical treatment, definitions that did not always accord with the hopes or interests of the psychiatric profession.

Although asylum doctors sought to make sharp distinctions between 'voluntary' patients and those admitted under police procedures, asylum records indicate that it was not the method of admission that most clearly distinguished patients, but rather their gender. Men and women had a different experience of the asylum. Both at Sainte-Anne and generally in the department of the Seine, men were most often admitted for alcoholism or for general paralysis, the tertiary and fatal stage of syphilis. At Sainte-Anne, for example, 25 percent of all male patients were diagnosed as alcoholic and another 20 percent as suffering from general paralysis.(41) Male patients, if alcoholic, were quickly released after a brief period of detoxification; if paralytic, they died, usually within a year. Women were more likely to be admitted for depression: at Sainte-Anne, depression accounted for 32 percent of all diagnoses among female patients.(42) Depression was, in medical terms, a less serious condition but one that did not respond quickly to treatment. Consequently, women stayed longer in the asylum and ran a higher risk of being transferred to other asylums. Therefore, although admission rates for men were higher, at any given moment there were more women than men in Parisian asylums. This pattern was familiar to psychiatrists of the period: as one explained, "[i]f you exclude general paralysis and alcoholism, women are more predisposed to madness than men."(43)

Although gender remained the determining factor in patterns of admission, 'voluntary' patients did differ in certain respects from their fellow patients admitted under official procedures. 'Voluntary' committal was, not surprisingly, a family matter and these patients were more likely to be married, although there was little difference in the number of widowed.(44) Nearly forty percent of 'voluntary' patients were admitted by their spouses and, in a rare instance of gender equality, wives and husbands committed each other in roughly equal proportions. If not a spouse, it was usually a parent or a child who made the formal committal, although occasionally it was a more distant relative, a friend, or even an employer.(45) The decision was usually taken by the immediate family either because, as doctors alleged, families sought to keep mental illness a secret or because, in the late nineteenth century, many Parisians were recent arrivals with no other relatives in the city. The immediate family also took responsibility for patients who were released, although there was a slightly greater tendency for mothers to assume the responsibility for such care.

'Voluntary' patients were also drawn from a somewhat higher social group. Among such male patients, 32.8 percent came from the petty bourgeois or artisan class of shopkeepers, clerks, civil servants, and teachers, whereas among men committed by the police, the proportion was only 22 percent.(46) The number of unskilled and skilled workers among 'voluntary' male patients was also lower: 8.8 percent and 37.1 percent respectively, compared with 13.9 percent and 45.3 percent for official admissions. Among women 'voluntary' patients, the pattern is even more pronounced. There were significantly fewer unskilled and skilled workers in this group(47) and 52.6 percent of these women were recorded as having no occupation, compared with 31.1 percent of official patients. While some of the 'voluntary' women patients with no occupation were elderly, the admission registers indicate that most were the wives of skilled workers or of petty bourgeois and did not work outside the home.(48)

The higher social status of the families who used the procedures for 'voluntary' admission suggests that either they were affluent enough to afford the approximately 100 francs a month required of paying patients, or that they were sufficiently informed about the Parisian welfare system to arrange for free 'voluntary' care.(49) Given the complexities of the French class system, where a skilled worker might earn more than a shop owner or clerk, it was not always the petty bourgeois who paid for treatment. Although the records for paying and free 'voluntary' admissions are not extensive, they do suggest the inadequacies of occupational labels. In some cases, the differences between paying and non-paying patients are clear: the head clerk at the tax office, whose son was an employee at the Treasury, was a paying patient as were most patients identified as proprietors, while the day laborer (homme de peine) whose wife was also a day laborer (journaliere) was a non-paying patient. Butchers, grocers, and bakers usually paid, as did almost all cafe owners, but patients identified as investors (rentiers) could be found in both categories, as could teachers, tailors, soldiers, seamstresses, and clerks.

In some cases, non-paying 'voluntary' patients had received information about the regulations from doctors, as is probably the case with the teaching assistant (maitre-repetiteur) at the prestigious Lycee Louis-le-Grand, who was committed by his friend, a doctor. Others may have been advised by relatives who worked in the public service, as is likely in the case of two female patients whose husbands were municipal policemen. The head shoemaker at the Vaucluse asylum, who was admitted by his wife, a nurse at Vaucluse, had the advantage of already knowing the asylum system and he received free treatment. But how can one explain the paying patient who was a domestic servant, committed by her sister, a laundrywoman? Perhaps her employer paid, but if so, s/he was a generous one, for the patient was being admitted, at her own request, for the fifth time. At Sainte-Anne, at least, patients seemed to be fully aware of the regulations for free 'voluntary' treatment, perhaps because the asylum also operated a free clinic where Parisians could come for consultations or for baths.(50)

At the heart of asylum doctors' enthusiasm for 'voluntary' admissions lay the assumption that such patients suffered from acute rather than chronic conditions. Yet the records of Sainte-Anne indicate that families made the decision to commit not in the early stages of illness but when the situation had become desperate. An analysis of admission diagnoses, for example, indicates a higher rate of chronic or incurable illnesses among 'voluntary' patients.(51) The rate of general paralysis among male 'voluntary' patients was 30.3 percent, compared with 17.4 percent for their official counterparts. These men, usually in their 40s or 50s, often exhibited such violent or bizarre behaviour that nursing homes and hospitals refused to keep them. One such patient, who had been under doctor's care for a year and was not considered dangerous, was committed when he suddenly attacked his wife with a knife.(52) Patients with general paralysis also tended to have delusions of grandeur, spending hard-earned family resources or incurring large debts. Typically, they would hire a cab for a day-long tour of Paris and then refuse to pay the fare. In one case, the family of a cafe owner committed him when he began giving free drinks to all his customers.(53) Although general paralysis was not a major reason for the committal of women, the rate among female 'voluntary' patients was also higher.(54)

The incidence of depression was also significantly higher for all 'voluntary' patients. Depression was not always considered a chronic condition, but patients with this diagnosis stayed longer before release, thereby contributing to the continual overcrowding of Parisian asylums. They were also more likely to suffer a relapse and to be readmitted. Among female 'voluntary' patients, 35.2 percent were diagnosed as suffering from depression, whereas for other women patients the rate was 27.8 percent. Although depression was not a major source of admissions for men, it accounted for 16.3 percent of all diagnoses among 'voluntary' patients, compared to 11.3 percent for men admitted by the police. Alcoholism, which was responsible for the short stay and high release rate of many male official patients, was conspicuously underrepresented among male 'voluntary' patients. It comprised only 13.7 percent of these admissions, a lower proportion than diagnoses of depression.(55)

There was also a higher death rate among all 'voluntary' patients, another indication that they were admitted at a later, more chronic, stage of their illnesses. Male 'voluntary' patients, with a greater incidence of general paralysis, had the highest death rate of all: 42.4 percent, compared to 32.1 percent for other men in the asylum. The death rate for women patients was always lower, but 28 percent of 'voluntary' women patients died, in comparison with 18.8 percent of other women patients. In some cases, death was the result of old age, as there was a slightly larger proportion of elderly patients, particularly women, among 'voluntary' admissions.(56) Even when patients were diagnosed as suffering from conditions not usually considered fatal, such as mania or persecution, the mortality rates for 'voluntary' patients were noticeably higher.

The circumstances surrounding many 'voluntary' admissions reinforce the impression that families turned to the asylum only in periods of crisis or when alternatives had failed. Violence, or the threat of violence, is a recurring theme in the medical certificates and patient files. Of course, families may have exaggerated the violence, either from fear or from an emotional need to justify their actions, but they did not need to do so in order to have the patient committed. 'Voluntary' admission, unlike official procedures, did not require that the patient be dangerous, only in need of treatment. Asylum records suggest that in many cases the fear of violence was valid. One patient, for example, had threatened to kill his mother and sister and had begun digging a grave in the backyard. His mother brought him to Sainte-Anne after he tried to burn his sister's eyes out with a red-hot iron.(57) Wives appear to have used 'voluntary' admission as a temporary means of defense from domestic violence, particularly in the case of alcoholic husbands. In one typical case of alcoholism, the husband had broken the furniture, threatened to strangle his wife, and had provoked numerous complaints from neighbors.(58) But abused wives were not alone in seeking temporary relief from violence through committal. An 80-year-old man committed his son, suffering from general paralysis, when the son became "rude and violent", while the family of a female alcoholic, her doctors noted, lived "under a reign of terror."(59) A suicide attempt, or even the threat of suicide, was also sufficient reason for admission and was noted as such in 12.5 percent of cases.

Complaints from neighbors could also provoke a family's decision to commit a relative and, judging from the certificates, asylum doctors found this a reasonable motive. A deaf-mute, who had stayed in her room for fifteen months, was brought to Sainte-Anne by her 72-year-old father because she had become violent and "her screams disturb the neighbors."(60) In another case, a family reported that it was impossible to keep the patient in her room and that "she seeks fights with all the neighbors."(61) One elderly man "threatened the neighbors constantly" and was in a "lamentable state of filthiness" while an elderly woman was committed because she hit the concierge "without any reason and without any previous disputes."(62) Doctors may have maintained that families found mental illness so shameful that they kept it a secret, but privacy was a rare luxury in working-class dwellings and the interests of one relative might well be sacrificed to the larger interests of the family. In some cases, the influence of neighbors could be more positive: one man claimed that he did not realize that his wife, who was diagnosed as suffering from depression, had been selling their household goods and mistreating their children until his neighbors told him.(63)

Usually, families had already tried other means of treatment before they turned to the asylum. In some instances, patients had been in a hospital, a maison de sante, or under the care of a local doctor who finally advised committal. In other cases, families had relied on their own resources, either locking up patients at home or sending them to stay with relatives in the countryside. One patient, a woman who lived alone with her young son, was taken first to a pharmacist and then to a doctor when she began to behave strangely. Neighbors were looking after her until she tried to commit suicide by jumping out a window. Then she was brought to Sainte-Anne. When she was released, her mother took her to the countryside to recuperate.(64)

Families who turned to the asylum only when the situation had become chronic or unmanageable were equally reluctant to abandon their relatives to the exclusive care of the reputed medical experts. Patients in Parisian asylums were, as doctors remarked, "much visited"(65) and, given the overcrowded conditions, families could be as well informed about the medical and living conditions of their relatives as was the asylum doctor.(66) Asylum records of 'voluntary' admissions indicate that families were not willing to defer to medical opinion; rather they were able to use their knowledge and legal powers to intervene on behalf of relatives in the two areas of most importance to patients, namely, release and transfer.

Patients committed by their families had a significantly higher rate of release, whether looked at in terms of overall statistics or in terms of specific diagnoses. Women 'voluntary' patients had the highest general release rate of all patients in the asylum, even though, as a group, they were somewhat older. Their release rate was 48.3 percent, compared with 40.5 percent for official women patients. The release rate for 'voluntary' male patients (46 percent) was slightly higher than the rate for official male patients (45.1 percent), despite a greater number of terminally ill patients and a markedly lower proportion of alcoholics among male 'voluntary' patients. 'Voluntary' patients, whether men or women, who were diagnosed as suffering from depression had a 64 percent rate of release, compared with 48 percent for depressed official patients. There were similar patterns of a higher release rate for 'voluntary' patients suffering from alcoholism and persecution. However, the pattern did not hold true in diagnoses of general paralysis and senile dementia. In these cases, only male 'voluntary' patients were more likely to be released than their official counterparts; female 'voluntary' patients, perhaps because older, were not so fortunate.

In part, these higher release rates among 'voluntary' patients are an indication that many families did not lose touch with their relatives in the asylum. Families were thus available either to accept trial leaves or to assure doctors that they could look after convalescing patients at home. On rare occasions, doctors acknowledged the presence of families as a positive factor that could lead to innovative treatment. At the Villejuif asylum, for example, Dr. Marie arranged with the families of paying 'voluntary' patients to lodge them with local families as a preparation for full release.(67) But usually the relationship between families and psychiatrists was less amicable. Families frequently used their powers under the law of 1838 to force the release of a patient in the face of opposition from the asylum doctor. Psychiatrists resented this challenge to their authority. They grumbled about "the ill-considered impatience of families who, with the text of the law in hand, demand the release of their patient"(68) and blamed the premature release of patients on families who mistook a remission for a recovery.(69) Asylum doctors were careful to note on certificates that they did not agree with the family decision and they took a lugubrious pleasure in pointing out when such releases resulted in readmission or misfortune.

Psychiatrists dismissed this reluctance to defer to their medical expertise as simply the result of families' inclination to yield to pressure from patients or, as one doctor at Sainte-Anne explained, "families . . . often share the emotions and delirious ideas of their patients."(70) In some cases, families were undoubtedly motivated by optimism, affection, or by insistent pleading. In many cases, however, relatives had formed their own judgment about the feasibility of release in the same manner as did the asylum doctors, that is, from visits, information from asylum attendants, and trial leaves. One husband, for example, reported that his wife had asked him to take her out of the asylum "with a sweetness that disarms me." He consented to a trial leave but brought her back as he judged she was not fully recovered.(71) The advice of the asylum physician could be a part of family calculations, particularly when committal had been the result of violence, but relatives were also willing to offer their own diagnoses and to act accordingly. For example, a man who was seeking the release of his sister, whom he and other relatives had visited regularly, wrote to her doctor: "her condition appears to be much improved and I think that with my supervision she can try to re-establish her own home."(72) In some cases, the decision was more informal: relatives simply did not return patients who had been released on a trial leave. Doctors usually accepted this as a de facto release and issued the appropriate certificate. Of one such patient the asylum doctor wrote, "he is far from cured, but is not dangerous and since it is a voluntary admission, I am concluding that he has been released on the responsibility of his family."(73)

The family's decision to have a patient released was also based on less stringent definitions of what constituted a cure. Families often seemed content with some improvement in their relative's condition and were willing to tolerate behaviour that doctors might label abnormal. One husband, asking for the release of his wife because he feared that the asylum was driving her mad, admitted that she still heard voices, "but I do not think that is a reason for interning her."(74) This attitude may suggest a tolerance and affection on the part of immediate relatives, or even a different definition of mental illness. But in many cases, it was the result of economic necessity. Women who relied on a husband's or son's income often used economic need as a reason to request the release of a patient. One mother, who offered the opinion that her son appeared to be cured, argued that an immediate release would enable him to find work. If not, the season would be over and "I will suffer. He helps me out when he works and I am elderly."(75) Husbands of 'voluntary' patients were less dependent on the income of their wives, who often did not work outside the home, but they did need their domestic work. The prolonged absence of a wife could result in the children being sent to relatives and the husband being left to fend for himself. One woman patient, in asking her doctor for a release that she herself seemed to consider premature, argued that "my husband is at the end of his patience trying to cope . . . with the details of housekeeping, which he is not used to."(76)

The other important area of family intervention was in the decision to transfer patients to more distant asylums. In the latter half of the nineteenth century, asylums in the department of the Seine were so overcrowded that nearly half their patients--usually chronic and often female--were transferred to provincial asylums, where it was almost impossible for families to visit and where the standards of care were suspect. Patients and families alike dreaded a transfer. Families were so upset that asylum officials kept the departure date of convoys a secret from them in order to avoid "painful scenes" at the railway station.(77) Under the terms of 'voluntary' admission, the transfer of paying patients required consent from the family and the statistics clearly demonstrate that families were unwilling to give this consent, even for patients who were chronically or terminally ill.

The overall transfer rate for both male and female 'voluntary' patients was nearly half that of official patients. The difference is most noticeable in the case of those female patients diagnosed as suffering from depression or senile dementia. These patients ran a high risk of being transferred, yet for those admitted by their families, the risk was cut almost in half. Even when 'voluntary' patients were eventually transferred, families were very effective in delaying this decision as long as possible. The contrast in the length of stay before transfer for official and 'voluntary' patients is striking. On average, male official patients stayed 176 days and female official patients 233 days before being transferred; their 'voluntary' counterparts were transferred after 883 days (for men) and 648 days (for women).(78)

Families clearly wanted their patients nearby, whether for visits or even for eventual release (and there were cases where the family sought the release of a relative after many years of confinement). In some instances, families preferred to take their relative home rather than consent to a transfer. Certain families proved particularly adept at manipulating the system. In 1903, one family removed a male relative from Sainte-Anne because the asylum doctor wanted to transfer him to an agricultural colony for nonviolent chronic patients. After several months, they returned the patient to Sainte-Anne, claiming that he was very dangerous and potentially violent, particularly when under the influence of alcohol. The patient stayed at Sainte-Anne until his death in 1919.(79)

If the family consented to a transfer, this did not necessarily mean that they were abandoning their relative. Middle class patients, particularly if chronically ill, were frequently transferred to the pensionnat at Ville-Evrard, where the fees were higher but the care more comparable to that of a private clinic. Some patients were transferred to asylums in their native provinces where, presumably, nearby family could visit. (The system also worked in reverse: Sainte-Anne was the preferred destination for patients in provincial asylums whose families wanted them returned to Paris.) Families of paying patients might reconsider their choice of asylum if treatment at Sainte-Anne, the most expensive of the Parisian asylums, proved lengthy. One father, whose daughter had been under treatment at Sainte-Anne for a year, wrote to her doctor: "I was prepared to make the sacrifice for such lengthy treatment in the hope that, under your good care, she would completely regain her reason. But, despite some improvement, it will still be a long time before I can take her back without danger so I am transferring her to Vaucluse, where it is cheaper."(80)

In their correspondence and statements, families and patients often referred to Sainte-Anne as a maison de sante rather than as an asylum. Given the widespread prejudice against the insane, this may have been simply a form of denial, but in many instances it was also an accurate description of how many families viewed the asylum, namely as a place that was also for the chronic, the elderly, and those who were not, strictly speaking, mentally ill. In this sense families were not, as some historians have suggested,(81) merely enlarging the definition of mental illness; rather they were changing the definition of the asylum from a place for the treatment of the mentally ill to a source of care, whether temporary or longterm, for a wide variety of conditions. Contrary to 'supply' theories about the development of asylums, which postulate that once the asylums were constructed along medical lines "the working-class family and neighborhood obediently present[ed] its crazy cases"(82), Parisian families were not simply passive users of asylum services. In reality, their demand for certain types of care shaped the structure of institutions that were still developing.

In all likelihood, this varied use of the asylum was not restricted to those more privileged groups who took advantage of the provisions for 'voluntary' committal. By the 1890s, psychiatrists were complaining that asylums were so overcrowded with other patients that "true madness has become rarer and rarer in the asylums of the Seine."(83) In order to return the asylum to its original purpose, as they defined it, asylum doctors began to urge separate care facilities for the elderly, the mentally handicapped, and the 'incurable'. Several such facilities, particularly agricultural colonies, were established in the department of the Seine before 1914. The results of these reforms are evident in the records of Sainte-Anne where, in the last decade before the war, the length of stay and mortality rates for all patients declined, indicating the presence of fewer chronic or incurable patients. Despite a psychiatric ideal of isolation from the community, the development of the asylum must be understood within the context of a complex system of services and institutions for the working classes.(84)

Although families increasingly turned to the asylum for assistance with relatives whose behaviour had become intolerable, they did so--despite the confident rhetoric of psychiatrists--as a last resort and with a clear unwillingness to accept the psychiatric dogma that treatment could only be achieved through isolation. Instead of abandoning their relatives to asylum doctors, they demanded a voice in the release, transfer, or longterm care of "their" patients.(85) This ambivalent behaviour is not unique, nor is it surprising. As Michael Ignatieff has argued in a discussion of prisons, workhouses, and asylums in Britain and France, "the poor were suspicious of institutions, but nevertheless supported them."(86)

Even middle class families who placed relatives in well-appointed private asylums expressed great anxiety about their decision and a need to be consulted about treatment.(87) Placing a relative in one of the public asylums of the Seine could not have been an easy decision, even when families were armed with legal powers under the terms of 'voluntary' admissions. French psychiatrists, unlike some of their North American counterparts,(88) did not welcome family intervention. Moreover, families did not need the press to conjure up images of Bastilles: they needed only to look at the high walls and locked gates of Sainte-Anne. This reluctant and selective, but increasing, use of 'voluntary' admissions should not be interpreted simply as a form of resistance to medical or state power. Rather, it suggests that families had integrated the asylum into their own well-established systems of treatment for the mentally disturbed or chronically ill, systems that made skillful use of various formal and informal resources available in the family, neighborhood, and the larger community. When these resources failed, they turned to the asylum, but not necessarily as a permanent or longterm alternative.

French asylum doctors, recognizing the competition, denounced familial treatment as a source of abuse and chronicity. Families, they maintained, could not treat the unbalanced, they could only enchain them.(89) (Even today, a French medical text can describe the model nineteenth century asylum as a "place of isolation from a tormenting world, a true refuge."(90)) Yet in daily practice, psychiatrists not only had to cope with the needs and views of the family, they were also forced to use the family's resources. Faced with overcrowded conditions, asylum doctors relied on the willingness of families to care for convalescent patients, whether by trial leaves or permanent release. Families often left with specific instructions for the treatment of recovering patients and on occasion they consulted asylum doctors about continued home care. In late-nineteenth century Paris, the exclusion of families from the treatment of the mentally ill was not, therefore, a realistic model, no matter how much it remained an article of faith for the psychiatric profession. Today, when a 'decarceration' movement has rejected the asylum and aspires to treat the mentally disturbed within the community, it is necessary to understand how community demand helped to shape the nineteenth-century asylum and, consequently, to recognize that new methods of treatment or care must be based on a realistic assessment of family resources and needs.

Finally, as a 'post-Foucaultian' generation of historians focuses on the dialectical relationship between families and the asylum,(91) it is important not to lose sight of the individual patient, that ever-shadowy figure of asylum records. Under law, the patient remained the object of family, administrative, or medical decisions. A truly voluntary admission procedure (placement libre in France), with its challenges to medical and family power, was slow to emerge. To what degree did family intervention ameliorate or complicate the patient's situation? Were patients able to use these conflicting systems of treatment to their own advantage? Although current research suggests that patients were not simply 'dumped' in asylums,(92) this says little about the feelings of imprisonment, isolation, and abandonment that patients experienced. Families may have viewed asylums as "regrettable but indispensable necessities."(93) It is unlikely that patients agreed.

APPENDIX

Table 1
Occupations of Patients

                          Male                 Female
                  Official   Voluntary   Official   Voluntary

Unskilled           13.9%      8.8%       18.7%        7.3%
Skilled             45.3      37.1        39.3        29.2
Petty Bourgeois     22.0      32.8         5.6         5.6
Bourgeois            5.6       6.8         2.6         2.6
No Occupation        5.6       9.4        31.1        52.6
Vagabonds            3.8        --         1.2          --
Wine Trade           2.9       3.9          .3         1.6
Concierge             .9       1.2         1.2         1.1

Total cases: Men 4478, Women 2408
Table 2
Admission Diagnoses

                     Male                  Female
              Official   Voluntary   Official   Voluntary

Alcoholism     28.3%       13.7%       5.2%       5.3%
Depression     11.3        16.3       27.8       35.2
General
Paralysis      17.4        30.3        4.6        7.3
Mania           6.4         2.4       13.4       12.3
Persecution    10.6         9.2       18.1       13.3
Senile
Dementia        3.3         3.1        5.2        5.6
Other          23.0        24.9       25.5       20.8

Number of cases: Men 4456, Women 2505.
Table 3
Death Rates

                        Male                   Female
                 Official   Voluntary   Official   Voluntary

Overall            32.1%      42.4%      18.8%       28.0%
Alcoholism         13.9       16.5       14.5        17.8
Depression         22.0       19.0       13.9        14.5
Gen. Paralysis     72.8       75.5       48.7        84.0
Mania              18.8       36.8        9.4        14.7
Persecution        15.0       30.6       10.0        19.0
Sen. Dementia      85.0       79.6       58.0        75.0

Number of cases: Men 3425, Women 1977
Table 4 Release Rate

                        Male                  Female
                 Official   Voluntary   Official   Voluntary

Overall            45.1%      46.0%       40.5%      48.3%
Alcoholism         69.9       80.1        59.0       68.9
Depression         48.0       64.0        47.6       63.9
Gen. Paralysis     14.3       18.2        13.2        4.3
Mania              53.8       55.3        53.8       60.3
Persecution        43.0       50.0        39.0       46.0
Sen. Dementia       9.5       16.3         9.3        7.5

Number of cases: Men 3425, Women 1977
Table 5
Transfer Rates

                        Male                  Female
                 Official   Voluntary   Official   Voluntary

Overall           20.8%        9.1%       38.6%      20.0%
Alcoholism        14.4         2.9        26.5       11.1
Depression        28.0        13.7        35.7       19.3
Gen. Paralysis    11.0         4.0        36.8       10.1
Mania             24.7         7.9        35.0       22.4
Persecution       39.0        16.0        48.0       27.8
Sen. Dementia      4.2         2.0        31.4       17.0

Number of cases: Men 3425, Women 1977.

In all tables above, percentages rounded to one decimal place.

ENDNOTES

Research for this project was funded in part by the Hannah Institute for the History of Medicine, the Medical Research Council of Canada, the Social Sciences and Humanities Research Council of Canada, and the University of Alberta. I am grateful for their support. I also wish to thank Chuck Humphrey for all his help with the computer analysis of the data.

1. "Introduction" in W.F. Bynum, Roy Porter and Michael Shepherd (eds.), The Anatomy of Madness. Essays in the History of Psychiatry, Vol. III (London, 1988), p. 3. For an introduction to recent work in the history of psychiatry, see the three volumes of The Anatomy of Madness (London, 1985-1988). The most recent works on French psychiatry are: Jan Goldstein, Console and Classify. The French Psychiatric Profession in the Nineteenth Century (Cambridge, 1987), Ian Dowbiggan, Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth Century France (Berkeley, 1991) and Yannick Ripa, Women and Madness: The Incarceration of Women in Nineteenth-Century France (Minnesota, 1990).

2. Colin Jones, "Montpellier Medical Students and Medicalisation in Eighteenth Century France" in Roy Porter and Andrew Wear (eds.), Problems and Methods in the History of Medicine (London, 1987), p. 58.

3. Michael MacDonald, "Madness, Suicide and the Computer", in Porter and Wear, Problems and Methods, p. 210.

4. Nancy Tomes, "The Anglo-American asylum in historical perspective", in Christopher J. Smith and John A Giggs, (eds.), Location and Stigma. Contemporary Perspectives on Mental Health and Mental Health Care (Boston, 1988), p. 14.

5. Jones, "Montpellier", p. 58.

6. The term psychiatrist only began to be used after 1860, and for most of the nineteenth century French psychiatrists referred to themselves as alienists. (Grand dictionnaire de la psychologie. [Paris, 1991], p. 610.) In this paper, I have used the term psychiatrist and asylum doctor interchangeably.

7. Prefecture de la Seine, Direction des affaires dpartementales, Rapport sur le service des alienes de la Seine, 1890, p. 205.

8. This was article 18 of the law of 1838. On admission certificates the usual phrase was "the patient is a danger to him/herself or to others".

9. Both the central detention cells and the psychiatric service were located at 3 quai de l'Horloge, just near the Palais de Justice or central courts. In 1871, the General Council of the Seine voted to separate the police psychiatric service from the prison and name it the Infirmerie speciale du depot in order, as the Prefect said, "that it not be confused with the Depot, where prisoners are kept." In 1970 the service was finally transferred to the grounds of Sainte-Anne. J.P. Soubrier and M. Gourevitch, "Recherches aux archives de la prefecture sur les origines de l'Infirmerie speciale", Perspectives psychiatriques, 1984, No. 96, pp. 133-4; Archives of the Prefecture de Police, DB 218, letter of the Prefect, February 28, 1872.

10. Valentin Magnan served as the chief examining psychiatrist of the Admissions Office from 1867 until his retirement in 1912 and also gave weekly clinical lessons there. After patients had been certified by Magnan, the fortunate ones were taken across the grounds to Sainte-Anne itself. Others had to endure a longer trip to the more distant asylums of Vaucluse, Ville-Evrard, Villejuif and, after 1896, Maison Blanche, all of which were outside the city limits of Paris.

11. Annales mdico-psychologiques, 1877, vol. 1, p. 428.

12. Proces-verbaux de la Commission de surveillance des asiles publics d'alienes de la Seine, March 19, 1907, p. 105.

13. This type of internment was also authorized under the law of 1838 but had been forbidden, in the 1840s, because of overcrowded conditions in Parisian asylums. Members of the Societe medico-psychologique began to study the question of 'voluntary' admissions in 1868. In 1875, a commission of the Society recommended the reestablishment of the process as a humanitarian reform that would allow families to avoid police procedures. Annales medico-psychologiques, 1877, vol. 1, pp. 99ff.

14. Annales medico-psychologiques, 1877, vol. 1, p. 428.

15. For details of this antipsychiatric movement, see Dowbiggin, Inheriting Madness, chapter 5.

16. Annales medico-psychologiques, 1877, vol. 1, p. 106.

17. Rapport sur le service des alienes, 1905, p. 4; 1912, p. 49.

18. Sainte-Anne housed both the Admissions Office, where Valentin Magnan worked and taught, and the teaching clinic of the Faculty of Medicine, established in 1877. For psychiatrists of the period, a position at Sainte-Anne was the pinnacle of their career.

19. No overall statistics for Sainte-Anne were reported in administrative documents. These estimations have been calculated from the annual reports of asylum doctors. In 1895, for example 58% of male patients admitted to Sainte-Anne were 'voluntary'. By 1903, the figure was 53.6%. Female voluntary admissions for the same years were 64.6% and 60%. Rapport sur le service des alienes, 1895, pp. 193, 197; 1903, pp. 146, 151. Since 'voluntary' placement did not imply the patient's consent, I have used in term in single quotations throughout.

20. Rapport sur le service des alienes, 1890, p. 93 and 1896, p. 172. In fact, 'voluntary' patients received no special treatment in terms of accommodation or diet.

21. Rapport sur le service des alienes, 1889, p. 234.

22. Rapport sur le service des alienes, 1891, p. 139.

23. Dr. Paul Garnier, L'Internement des alienes (Therapeutique et legislation) (Paris, 1898), p. 118.

24. Dowbiggan, Inheriting Madness, p. 141. The cure rate was calculated either on the number of releases in a year or the number of released patients certified as cured. With the most generous calculations, the cure rate in the asylums of the Seine was about 18% (22% for men and 14.5% for women) in 1889 and 16% (20% for men, 12% for women) in 1907. Rapport sur le service des alienes, 1889, p. 25 and 1907, p. 18. Sainte-Anne had by far the highest cure rate of the asylums of the Seine.

25. See, for example, Garnier, Internement des alienes, p. 67.

26. In French, "agent surveillant des surveillants". Rapport sur le service des alienes, 1897, p. 172. Falret, at the Salpetriere, complained that his service got no acute and curable patients, "the only ones of medical interest". Rapport sur le service des alienes, 1894, p. 301.

27. In a perceptive analysis of recent trends in the history of psychiatry, Nancy Tomes has referred to psychiatry as "a discipline trapped by its own medical 'entrepreneurship' in the therapeutic and administrative cul-de-sac of the mental hospital." Nancy Tomes, "The Anatomy of Madness: New Directions in the History of Psychiatry", Social Studies of Science, Vol. 17, 1987, p. 360.

28. Annales medico-psychologiques, 1877, Vol. 1, p. 87.

29. Rapport sur le service des alienes, 1890, p. 205.

30. Rapport sur le service des alienes, 1912, p. 49.

31. Rapport sur le service des alienes, 1890, pp. 205-6.

32. Rapport sur le service des alienes, 1891, p. 75. He also argued that 'voluntary' admission avoided the Depot (Infirmerie speciale) and the police van.

33. Rapport sur le service des alienes, 1879, p. 7.

34. Rapport sur le service des alienes, 1898, p. 92.

35. Congres des medecins alienistes et neurologistes de France, 1897, vol. 1, Rapports, p. 298.

36. Archives de la Prefecture de police, DB218, letters of September 27, 1871 and July 14, 1877 from the Prefect.

37. Garnier, Internement des alienes, p. 64.

38. Rapport sur le service des alienes, 1893, p. 177.

39. Rapport sur le service des alienes, 1893, p. 219.

40. The statistics in this article are based on an analysis of every second year of the admissions records (registres de la loi) of Sainte-Anne from 1873-1913, a total of 7100 cases (4488 men and 2616 women). The admissions records normally give information on the age, marital status, occupation, type of admission, and, for 'voluntary' admissions, the person who committed the patient. These records also give three diagnostic certificates and the result of admission, i.e. release, transfer or death. Not all information was available for all patients, so the number of cases for each statistical table varies slightly.

41. Seven percent of women were diagnosed as alcoholic and 6% as suffering from general paralysis. For the full table of admission diagnoses, see Appendix.

42. Among male patients, the rate of depression was 13%.

43. Rapport sur le service des alienes, 1896, p. 68.

44. The statistics for marital status are:

                  Male                  Female
          Official   Voluntary   Official   Voluntary

Single      38.0%      27.4%       38.0%     27.7%
Married     53.8       66.1        42.0      53.9
Widowed      7.4        5.9        18.6      17.6

45. Of 2430 'voluntary' patients admitted in the period 1876-1913, 39.6% were admitted by a spouse, 19.5% by an immediate relative (a parent or child) and 23.6% by a family member. Although 17.3% were admitted by a friend, often this was a common-law spouse. Mothers committed 5.7% of patients but assumed responsibility for the release of 8.8% of patients.

46. Male 'voluntary' admission had a slightly higher proportion of bourgeois patients--6.8% compared with 5.6% among men committed by the police. For the full table of occupations, see Appendix.

47. Among female 'voluntary' patients, 7.3% were unskilled and 29.2% were skilled workers. Among official women patients, 18.7% were unskilled women workers and 39.3% were skilled women workers.

48. A sampling of registers for the 1880s indicates that over 50% of married women listed as having no occupation were the wives of petty bourgeois and another 25% were married to skilled workers.

49. The Seine was the only department in France to provide free 'voluntary' internment. It required a police investigation into the financial status of the family, a condition that was not welcomed by families. Officials were allotted 160 non-paying 'voluntary' places in Parisian asylums per year.

50. The cases cited in the two preceding paragraphs are taken from the admissions records of 1885 and 1887, where paying and non-paying patients are clearly identified. The cases, in order of citation are: Registre de la loi, 1887 (men) #45; 1885 (men) #153, #77; 1887 (women) #80, #145; 1887 (men) #206; 1885 (women) #123.

51. The admission diagnoses are taken from the first two certificates in asylum registers, the certificate issued immediately and the certificate issued after 24 hours. Both certificates were required by law.

52. Registre de la loi, (men) 1879, #175.

53. Registre de la loi, (men) 1903, #26.

54. "Voluntary" women patients had a 7.3% rate of admission for general paralysis, compared with 4.6% for other women patients.

55. Sainte-Anne may have been untypical of the region's asylums in that few of its patients were mentally handicapped. Such patients may have been placed directly in more distant and cheaper asylums because relatives anticipated longterm care, or they may have been sent to the Bicetre hospital where D.M. Bourneville had organized special facilities for mentally-handicapped children.

56. Among 'voluntary' women patients, 17.3% were over the age of 60, compared with 14.9% among official women patients. Among male patients, the proportion of those over 60 was the same (9%), whether official or 'voluntary', but there were slightly more men in the 50-59 age group among 'voluntary' patients: 17.6% compared with 15.2% for official male patients.

57. Patient file, #100796.

58. Registre de la loi, (men) 1895, #21.

59. Registre de la loi, (voluntary) 1915, #84 and #86.

60. Registre de la loi, (women) 1891, #258.

61. Registre de la loi, (women) 1877, #32.

62. Registre de la loi, 1887 (men), #200 and 1887 (women), #199.

63. Patient file, #88488.

64. Registre de la loi (women) 1895, #16.

65. Rapport sur le service des alienes, 1894, p. 89.

66. Rapport sur le service des alienes, 1894, p. 89. At Sainte-Anne, there was one doctor for approximately 400 patients and doctors regularly complained that they were not able to see most patients, let alone treat them.

67. Rapport sur le service des alienes, 1911, p. 300.

68. Annales medico-psychologiques, 1888, vol. 2, p. 393.

69. Rapport sur le service des alienes, 1897, p. 67.

70. Rapport sur le service des alienes, 1889, p. 151.

71. Patient file, #126429.

72. Patient file #135329, 1908.

73. Registre de la loi, 1891 (men), #123.

74. Patient file, #129978, 1906.

75. Clinic, patient file, #140432.

76. Patient file, #118305, 1903.

77. Commission de surveillance, June 12, 1900, p. 199.

78. This is the median length of stay. If the interquartile ratio, i.e. the middle 50% of the data, is calculated, the differences are even greater: official male and female patients were transferred after 618 and 619 days respectively; for voluntary' patients the figures are 2315 days for men and 1611 days for women.

79. Registre de la loi, (men) 1903, #227.

80. Patient file, #118305.

81. Tomes, "The Anglo-American asylum", p. 13.

82. Michael Ignatieff, "Total Institutions and Working Classes: A Review Essay", History Workshop, 1983, No. 15, p. 172.

83. Rapport sur le service des alienes, 1892, p. 211.

84. An excellent of example of such interconnections is found in Richard Fox's study of the California committal process where he argues that the high percentage of aged women in asylums was in part became almshouses became "specialized institutions for the care of aged and destitute men." Richard W. Fox, So Far Disordered in Mind. Insanity in California (Berkeley, 1978), p. 131.

85. Families often referred to patients in a possessive fashion as "ma malade", "mon malade" or "notre malade".

86. Michael Ignatieff, "Total Institutions", p. 172. Ignatieff credits this insight to M.A. Crowther, The Workhouse System, 1834-1929: The History of an English Social Institution.

87. See, for example, Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840-1883 (Cambridge, 1984), pp. 113, 122-23; Charlotte MacKenzie, "A Family Asylum: A History of the Private Madhouse at Ticehurst in Sussex, 1792-1917", Ph.D. thesis, University College, London, December 1986, pp. 278-9, 319.

88. While psychiatrists in private asylums had an obvious motive for keeping the families of patients informed and pleased, there is some evidence from research on North American asylums for the poor that doctors encouraged a more cooperative relationship with families. See, for example, Constance McGovern's study of the Pennsylvania State Lunatic Asylum where, she argues, working class families "interacted with it quite comfortably." Constance M. McGovern, "The Community, the Hospital, and the Working-Class Patient: The Multiple Uses of Asylum in Nineteenth-Century America", Pennsylvania History, 1987 (54) 1, p. 27.

89. When accused of unlawful confinement, psychiatrist frequently retorted that the only such proven cases were to be found within families. Rapport sur le service des alienes, 1905, p. 187.

90. Grand dictionnaire de la psychologie p. 611.

91. The term 'post-Foucaultian' is from Nancy Tomes, "The Anatomy of Madness", p. 358.

92. For example, Tomes, A Generous Confidence, p. 123 and MacKenzie, "A Family Asylum", p. 317; Ellen Dwyer, Homes for the Mad. Life Inside Two Nineteenth Century Asylums (New Brunswick, N.J.), 1987, p. 3. Much, but not all, of the evidence for a family involvement in medical decisions comes from studies of private asylums. In contrast, a recent study of a public asylum in Alabama suggests that doctors in that asylum had much more control. John Starrett Hughes, "The Madness of Separate Spheres: Insanity and Masculinity in Victorian Alabama" in Mark C. Carnes and Clyde Griffen (eds.), Meanings for Manhood. Constructions of Masculinity in Victorian America, (Chicago, 1990), pp. 53-66.

93. Fox, So Far Disordered in Mind, p. 10.