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Daniel Hack Tuke walking a tight-rope.

Abstract

In his Illustrations of the Influence of the Mind Upon the Body in Health and Disease (1872) the eminent British neurologist and psychiatrist Daniel Hack Tuke collects a large number of puzzling cases that defy medical understanding. Although he observes and intuits the role of the imagination in both causing and curing disease, he is unable to come up with a cogent explanation of the phenomena he confronts and therefore often reverts to the then current physicalist terminology of nerves, spasms, paroxysms, etc. Missing from his understanding is the concept of the unconscious that Freud was to put forward a quarter of a century later. Yet Tuke's work is an important landmark in the investigation of the mind/body relationship, notably for its emphasis on the place of irrational elements as a source of illness and well being.

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On the centenary of Daniel Hack Tuke's death on 5 March 1895 the British Journal of Psychiatry reprinted the three-page obituary, complete with picture, originally published in the Lancet. (1) This tribute is a recognition of Tuke's importance to the profession, although he is relatively little known nowadays outside the history of psychiatry, and even there he is overshadowed by his French contemporary, Jean-Martin Charcot (1825-93) and certainly by his junior by a quarter of a century, Sigmund Freud (1856-1939). So who was Daniel Hack Tuke? What was his significance? And why has his reputation been eclipsed?

Daniel Hack Tuke was the scion of a Quaker family with a long history of compassionate reform in mental health. He was the first in the family actually to become a physician. His great-grandfather, William Tuke (1732-1822), was a wholesale tea and coffee merchant in York. Williams eldest son, Henry (1755-1814) had an interest in medicine early in his life, but was directed to carry on his father's business as well as becoming a Quaker minister. Henry cooperated with his father in founding the Retreat at York in 1793 after a young Quaker widow died in a madhouse under mysterious circumstances that aroused suspicions of abuse. The Retreat was fully developed by Henry's son (and Daniel's father), Samuel Tuke (1784-1857), who published in 1813 Description of The Retreat, an Institution near York for Insane Persons of the Society of Friends, Containing an Account of its Origins and Progress, The Modes of Treatment, and a Statement of Cases. (2)

The "moral treatment," as it is known, introduced by Samuel Tuke at the Retreat entailed an enormous advance in the handling of those with mental disorders. The practice of confining lunatics to mad-houses had become widespread by the latter half of the eighteenth century. While the upper and middle classes endeavored to care for deranged family members at home, often in secrecy, (3) those either indigent or without willing relatives were forced into institutions. Madhouses were in effect little other than prisons, where those no longer fit to belong to society were segregated. The abysmal conditions in these places embody a moral judgment on their inhabitants, who were degraded to animal level and methodically brutalized as part of a program of physical coercion and depletion intended to quell them. The inhabitants were envisaged not as sick people but as possessed by demons, and therefore a danger to themselves and to others. Since the insane, in their irrationality, were seen as beyond the pale of rational science, the chief function of medical personnel was custodial rather than clinical. A battery of restraining devices such as chains, whips, and the "English camisole," as the straitjacket was called, were commonly used on patients. These barbaric methods could have caused the sudden death of the young widow that prompted the Tuke family's commitment to reform.

The advent of moral treatment brought both immediate change and her-aided a long-term shift. It has been defined as "A philosophy and technique of treating mental patients that prevailed in the first half of the nineteenth century and emphasized removal of restraints, humane and kindly care, attention to religion, and performance of useful tasks in the hospital." (4) It consisted of a regimen of exercise, work, and amusements, motivated by the belief that such a strategy would help disturbed minds to return to normal or to their highest possible level. By 1817 an American counterpart, "The Asylum for the Relief of Friends Deprived of their Reason," opened in Frankford near Philadelphia. (5) The word "asylum," with its connotations of retreat and shelter, is a telling indicator of the new attitude that sought to transform inmates into orderly people by treating them as though they were sane. After the beginning of the nineteenth century, images of the insane reflect purposeful, rather than useless or meaningless activity. (6) While decent beds, proper food, patience, kindness, cheerfulness, and organized activities were the most visible expressions of moral treatment, even more crucial was the underlying faith in the potential for remodeling the lunatic "into something approximating the bourgeois ideal of the rational individual." (7) This aim of cure, or at least improvement, was to be achieved by deliberately involving the mad in a range of activities in a sort of occupational and recreational therapy as well as by treating them like human beings in the expectation of an appropriate response. These two concepts--belief in the possibility of a restoration to sanity, and the person's active involvement in therapy--mark important milestones in the approach to mental disorders. Although moral treatment was carried out on a secular basis, its religious foundations in the Quaker movement also played a cardinal role in the conviction that the demons thought to cause madness could be exorcized. An element of hope was brought into the realm of the mentally disordered as moral treatment contributed decisively to the notion dawning at the end of the eighteenth century that institutions had the potential to be curative.

Daniel Hack Tuke was thus heir to an illustrious tradition of philanthropy in the field of mental health. The youngest son of Samuel Tuke and Priscilla Hack, he was born on 19 April 1827. His twin-brother died the same day, and his own delicate constitution retarded his education. Although he acquired little Latin and less Greek, he had literary tastes and learned to write English well. After a brief apprenticeship in law, which he found uncongenial, he devoted himself to reading philosophy and poetry. In 1847 he entered the service of the Retreat, where he became involved in the care of patients and studied writings on insanity. He embarked on formal training in medicine in 1850 at St. Bartholomew's Hospital, London, and quickly distinguished himself by winning several prizes. He obtained the M.D. degree at Heidelberg in 1853. As a qualified doctor Tuke returned to York to practice at both the Retreat and the Dispensary (an outpatient clinic) and to lecture on mental diseases at the York School of Medicine. However, in 1859 acute symptoms of tuberculosis forced him to retire to the milder climate of Falmouth on the southwest coast. His health did not permit a return to active practice until 1875 when he became a consulting physician on mental diseases in London, where he remained for the rest of his life. He attained widespread professional recognition: he became a Fellow of the Royal College of Physicians in 1875, a governor of the Bethlehem Hospital (Bedlam), an examiner in mental philosophy at London University, a lecturer on mental diseases at Charing Cross Hospital, editor of the Journal of Mental Science from 1880 onward, and a frequent contributor to that periodical and to Brain. He was appointed president of the Medico-Psychological Association in 1881, and had the honorary degree of LL.D. conferred on him by the University of Glasgow in 1883.

Tuke has been described as "a prolific and suggestive writer, ... encyclopaedic in his knowledge of lunacy." (8) His Manual of Psychological Medicine (1858), compiled jointly with John Charles Bucknill (1817-97), was reprinted in 1862, 1874, 1879, and 1968; it was deemed "the most comprehensive and practical English work upon insanity now extant," (9) and "worthy of acceptance as a standard text-book." (10) His other outstanding work is the Dictionary of Psychological Medicine (1892), designated as "authoritative." (11) He also added a valuable Index Medicus to the Journal of Mental Science during his tenure as its editor.

Tuke had wide-ranging interests that often extended beyond the strictly medical into interdisciplinary studies encompassing the historical, the sociological, the literary, and the legal. While his Biography of William Tuke, the Founder of the York Retreat (1856) is concerned primarily with family history, later he explored broader questions in Insanity in Ancient and Modern Life: with Chapters on its Prevention (1878) and Chapters in the History of the Insane in the British Isles (1882). He reported on the Asylums of Holland: their Past and Present Condition (1854), The Insane in the United States and Canada (1885), and wrote on "The Plea of Insanity in Relation to the Penalty of Death" in the Social Science Review (1866). In keeping with the family tradition of humane caring, he was one of the founders of the After-Care Association to take charge of the poorer convalescents from insanity.

Tuke's pronounced inclination toward the psychological aspects of insanity sets him apart from the dominant trend of the mid-nineteenth century which sought to find the causation of mental disorders in the physical domain. Tuke's predilection for psychology was undoubtedly shaped by the distinctively religious character of the Retreat that led to a reliance "at least in part on the unseen kernel of spiritual healing." (12) But with the emergence and rising prestige of a new branch of medicine, neurology, the emphasis was on the discovery at autopsy of specific pathological changes in the brain (or elsewhere in the body) that could be linked to various forms of mental disorder. This search for identifiable somatic lesions came in the wake of the major findings in pathological anatomy spearheaded by Francois-Xavier Bichat (1771-1801) in France. Through a series of hundreds of autopsies Bichat was able to demonstrate that certain symptoms in the sick patient corresponded to pathological signs in discrete organs. Neurology sought to do the same for mental disorders, but it met at best with only partial success.

The middle ground between mind and body, between demons and lesions as explanations of human behavior and of mental disorders, remained open to variable and not infrequently mistaken interpretations so long as there was relatively little comprehension of either physical or emotional mechanisms. Difficulties in distinguishing between nervous, functional ills and the physical diseases they mimicked were serious and not uncommon. Epilepsy, for instance, was classified as a neurosis, and sometimes designated "hysteroepilepsy" because of the perceived similarity between a hysterical fit and an epileptic seizure, until the meticulous work of the British neurologist, J. Hughlings Jackson (1835-1911) disengaged the two. (13) Likewise, tetanus was thought to be neurotic in origin. On the other hand, ill-defined and potentially fatal "brain fever" was "very real indeed in the minds of both doctors and patients." (14) Its diffuse symptoms, primarily fever with a quick, shallow pulse, accompanied variably by restlessness, delirium, and coma, "were consistent with some forms of meningitis or encephalitis." (15) However, in nineteenth-century fiction it is always triggered by a shock to the nervous system, that is, it devolves from a psychological trauma, even though its manifestations are physical. The interdependence of psychological and physical was thus observed and intuited, but not understood.

The confused state of medical knowledge about insanity as late as the mid-nineteenth century is illustrated by the table showing its supposed causes in over two thousand cases as presented in the Report of the Pennsylvania Hospital far the Insane in Philadelphia in 1853. (16) An incongruous medley of hypothetical causations is listed, comprising indiscriminately the physical and the emotional. The former category includes want of exercise, exposure to cold or to intense heat or to the direct rays of the sun, tight lacing, injuries to the head, the use of opium or tobacco, lactation too long continued, intemperance, masturbation, engagement in a duel, and ill health of various kinds. The latter encompasses fright, disappointed affections or expectations, nostalgia, mental anxiety, mortified pride, uncontrollable passion, grief, loss of friends, religious or political excitement, anxiety for wealth, and metaphysical speculations.

In scrutinizing the mind/body relationship Tuke was addressing the central and most hotly contested issue of his day. By the last quarter of the nineteenth century, when Tuke was most active professionally, neurology was losing some of its earlier luster. In a few syndromes, notably alcoholism and syphilis, neurologists had indeed been able to establish a somatic cause for mental disorders, but most such disorders remained resistant to direct physicalist explanations. As a corollary to the disenchantment with neurology, psychology began to make a resurgence. (17) The moral treatment practiced at the Retreat implicitly recognized the reciprocity of mind and body. Exactly how this took place, however, was a tantalizing mystery.

This mystery found a focal point in the problem of pain without a discernible lesion. A somewhat facile solution (or excuse) was put forward by those who, like George Beard, the originator of neurasthenia, asserted that medical instruments such as the microscope were as yet inadequate to make the physical damage visible. The challenge of chronic pain in the absence of a bodily lesion became acute, and assumed a legal dimension, in victims of railroad accidents, who complained of various disabilities, and filed claims for compensation, although physicians could not find any ascertainable cause. (18) Often such pain was described as "nervous pain," "sympathetic pain," "neuralgia," "local hysteria," "spinal irritation," or "myalgia." (19)

Curiously, it was a newspaper report on the "Curative Effects of a Railway Collision," not an injury, that provided the immediate impetus to Tuke's intriguing book Illustrations of the Influence of the Mind Upon the Body in Health and Disease, Designed to Elucidate the Action of the Imagination. (20) Published in London in 1872, it went into the second, an American edition in 1874, and was translated into French in 1886. Despite the interest it aroused, IMB found less widespread acceptance than Tuke's writings on insanity, partly, no doubt, because of its innately provocative topic. But this work, though in many respects fascinating, is also beset by intrinsic problems that are worth investigating.

The case that initially attracted Tuke's attention, as he explains in the preface to the first edition, was that of a man struck by "'a violent attack of rheumatic fever'" (ix) while in a Manchester hotel. Dreading a two- to three-month stay in a hotel bed, he resolved to return immediately to his home in London. On the train he is almost "'beside'" himself with pain until "'Crash! smash! bump! and bang! and from side to side of the carriage I went like a billiard ball under a hard cushion hit'" (ix). The anonymous patient is clearly gifted with a graphic literary style. The accident resulted in injuries: "'The compartment was soon seen to be sprinkled with the blood of a hapless victim'" (ix). But as in all good mysteries, a decisive piece is missing: "The rest of this part of the paper was unfortunately wanting," Tuke adds; he learns "from other sources that, as the heading intimated, the patient was cured of his rheumatism" (ix). While there is no good reason to doubt Tuke's rendition, it is made rather less compelling by the unfortunate want of the rest of the account and the reliance perforce on vague "other sources." The passage reads like an excerpt from the opening of a Sherlock Holmes story, not coincidentally, for Conan Doyle was himself a physician who endowed Holmes with powers of observation, reasoning, and deduction similar to those requisite for a medical diagnosis.

IMB is in effect an exercise in detection. The case cited at the outset leads Tuke "to think that the whole subject of the influence of the Mind upon the Body deserves more serious and systematic consideration than it has received" (x). Accordingly he sets himself these five objectives:

1. To collect together in one volume authentic illustrations of the influence of the Mind upon the Body, scattered through various Medical and other works, ..., supplemented by those falling within my own knowledge.

2. To give these cases fresh interest and value by arranging them on a definite physiological basis.

3. To show the power and extent of this influence not only in health in causing Disorders of Sensation, Motion, and the Organic Functions, but also its importance as a practical remedy in disease.

4. To ascertain as far as possible the channels through, and the mode by, which this influence is exerted.

5. To elucidate by this inquiry the nature and action of what is usually understood as the Imagination. (x, sic.)

This is so vast and ambitious an undertaking that it is hardly surprising that Tuke was unable to fulfill all these aims. IMB is therefore most interesting for its delicate balance between the insights it offers and the limitations it reveals in the understanding of the operative psychological mechanisms at that time.

The central theme of IMB is summarized in its epigraph: "There is not a natural action in the Body, whether involuntary or voluntary, that may not be influenced by the peculiar state of the mind at the time." This phrase is taken from a John Hunter whom Tuke mentions at the beginning of his "Retrospective Sketch" as a late-eighteenth-century surgeon with an interest in animal magnetism (35-37). Tuke seems to equate "the peculiar state of mind" with what he calls "Imagination." The thrust of his argument is therefore a defense of the role of the imagination in bodily functioning at a period when mainstream medical thinking was firmly wedded to what was scientifically provable, and when such treatments as suggestion, hypnosis, and mesmerism were marginalized alternatives, regarded with considerable skepticism. (21) Tuke is eloquent in his championship of imagination, arguing for its inclusion in the standard medical armamentarium: "I want medical men who are in active practice to utilize this force, to yoke it to the car of the son of Apollo, and rescuing it from the eccentric orbits of quackery, to force it to tread, with measured step, the orderly paths of legitimate medicine" (xi). His use of striking imagery here, together with the classical allusion, energizes his prose. Tuke is perspicacious in envisaging the imagination not only as the cause of disorders such as the hypochondriac's imagined ills, but also for its positive potential as a curative agent. His commitment to philosophy and poetry is thus amalgamated with his study of mental disorders. It is significant that IMB was written during Tuke's fifteen-year enforced rest owing to ill-health, i.e., during a phase when he was not engaged in the daily bustle of practice and had leisure for reflection.

The work is organized into four parts: "The Intellect," "The Emotions," "The Will" (amended in the second edition to "Volition"), and "Influence of the Mind Upon the Body in the Cure of Disease." The sections vary markedly in length, the shortest being that on the will (351-78), and by far the most extensive that on the emotions (141-350). About a hundred pages each are devoted to the intellect (35-139) and to the cure of disease (351-454). Tuke readily concedes that "the influence of the will has not, for us, the same interest as that of the involuntary action of ideas and of the emotions." He posits that the will controls "ordinary movements" whose "essential and patent character" requires "no illustration and but little commentary" (364). The impact of the intellect, too, generates "few illustrations" in contrast to the emotions, where the cases are "abundant" and "the difficulty" resides "in selection rather than collection" (100). Through this concentration on the emotions Tuke tacitly acknowledges that the imagination has greater force in the irrational areas of human life than in the more rational ones, i.e., intellect and will. But this distinction is not openly articulated because Tuke was trying to draw the poetic power of the imagination into the sphere of science in hopes of reconciling the two by demonstrating the imagination's capacity to cause and cure disorders.

In practice Tuke's categories of intellect, emotions, and will are more fluid than he suggests. They serve primarily to structure the work and to lend the appearance of the "systematic consideration" (x) to which he aspires. Yet the cases in all four sections are remarkably alike as examples of either afflictions or cures that appear or disappear in defiance of normal medical comprehension. Often the symptoms are bizarre, and invariably they are mystifying. But in assessing the strange syndromes that Tuke chronicles, the very real possibility of misdiagnosis has to be taken into consideration (22) or simply the unattainability of accurate diagnosis before twentieth-century advances in technology and biochemistry. Many of the weird paralyses, aphonias, and deafnesses would nowadays be recognized as psychosomatic conversion disorders once organic pathologies had been ruled out by appropriate testing. "Psychosomatic," a term introduced by Johannes Heimroth in 1818 to apply to insomnia, is not used by Tuke. On the other hand, he does refer to "Psycho-therapeutics" as a mode of treatment (466). Tuke thus recognizes the cardinal role of the imagination in both the formation and the cure of certain strange disorders. While Tuke's categories may seem rather artificially imposed, his insistence on his fundamental hypothesis that the imagination acts on the body testifies to the acuity of his perception.

Nevertheless, the credibility of IMB is impugned by Tuke's methodology. As in the cure of rheumatism following a railroad accident, many of the examples are reported at second or even third hand. Tuke proposes to cull "authentic Illustrations ... scattered through various Medical and other works" (x) and to supplement these by his own knowledge. That knowledge was inevitably limited, for Tuke had practiced a mere six years before going into involuntary, temporary retirement. In lieu of his personal experience he draws freely on that of fellow practitioners as well as on acquaintances. Tuke is perfectly honest in avowing hearsay as the main source of information about the majority of the cases; he names the people from whom he has collected his illustrations, sometimes qualifying them as "Dr.," at other times offering no hint as to their status. This magpie method must raise doubts about the validity of the evidence. Far from being "systematic" (x) and "reliable" (xii), it is obviously quite haphazard. The authenticity of the illustrations is undermined by their anecdotal origins and the likelihood that their strangeness may well have been heightened in the course of verbal transmission. Some of Tuke's instances read like tall tales--but admittedly so too do some medically documented cases of psychosomatic disorders.

The most surprising aspect of IMB can, however, be understood only in light of Tuke's ulterior agenda of abolishing, or at least diminishing, the entrenched dichotomy between the mental and the bodily manifestations of the aberrations he records. For he endeavors to fathom along rational lines what may be happening in the patients whose symptoms he recounts. He does not attempt to do this in all the instances; for example, he ventures no explanation for the cure of rheumatism by railroad accident--a puzzle that would indeed demand a Sherlock Holmes. But frequently Tuke moves from pure illustration to a tentative explanation, and when he does so, he applies the accepted concepts of medical reasoning. That is to say, his hypotheses devolve as much from reference to physiological as to psychological processes. So in considering paralysis as a result of loss of muscular power, Tuke comments "that the motor centres are frequently enfeebled by the abnormal play of emotion upon them," and adds immediately: "an emotion may also be conceived to cause a structural change in the higher centres of the encephalon." He concludes that it is "sudden vascular changes in the brain which interfere with its nutrition," thereby causing paralysis "directly, through the direct nerve channels, and indirectly, through the vaso-motor nerves" (246). Even when Tuke is fully aware of the psychological trigger to sickness as in "the fact that moral disgust does in some instances cause the sensation of nausea" (155), he quickly proceeds to "the muscular action excited in vomiting" (156) and from there to the "spasm of the pharynx" (157). Spasms, contractions, "nerve energy" (356)--Beard's favorite formulation, "cerebral ischemia" (258): this is the physicalist terminology that Tuke chooses. He uses such language and offers such explanations of the phenomena he is exploring as part of his effort to convert adherents to "legitimate medicine" (xi) to his point of view. He does in fact in his programmatic announcement declare that he seeks to invest "these cases with fresh interest and value by arranging them on a definite physiological basis" (x). Tuke is performing a difficult tight-rope act in his attempt to mediate between the physicalist and the psychological. Often he seems to bend over backward in espousing the more traditional approach rather than pressing forward to "elucidate ... the nature and action of what is usually understood as the Imagination" (x). Yet this at first puzzling habit of translation into the physicalist language of mainstream medicine has to be seen as a central expression of Tuke's goal of reaching out to conventional practitioners.

Despite this constant resort to physicalist interpretations, Tuke shows a genuine understanding of the potential for "the profound influence of the Mind upon the Body" (xii). Feelings such as fear, anxiety, fright, anger, disappointed ambition, grief and joy are recognized as precipatating bodily responses. A twenty-year-old young lady, on seeing a mouse running under a table at the other end of the room, "uttered an exclamation of alarm, and in an instant entirely lost the power of audible speech" (254). Another woman, after seeing one of her children scalding herself and rescuing her, falls into a catatonic state that still persists three weeks after her admission to hospital (255). Several sufferers from gout are permanently cured by a violent noise or a shout such as the cry "Fire" that forces them onto their feet (406-7). One patient is relieved of constipation by a dream of having taken a purge (402-3). An eight-year-old girl, separated from her mother, exhibits delirium, headaches, and an inability to stand, all resistant to every form of treatment, until she is reunited with her mother when she recovers spontaneously (259-60). Tuke draws attention to the "influence of expectation (or expectant attention)" (92) when a facial expression is transformed as a gun is about to be fired. He appreciates too the placebo effect, quoting a Dr. Frederic Van der Mye who reported giving soldiers small doses of "our wonder-working balsams" to combat scurvy during the siege of Breda in 1625 without letting even their commanders into the secret: "the effect of the delusion was really astonishing; for many quickly and perfectly recovered" (405). Tuke does not query this account, asserting instead: "Such a result of the Imagination as the above shows, as we have said, that its operation is not restricted to affections of the nervous system" (406). Persuasive comments of this type are clearly directed at disbelieving medical practitioners. On the other hand, Tuke himself is quite skeptical about the charming away of warts notwithstanding his own success in curing the patients and nurses at a county asylum he used to visit (404). And he roundly dismisses as "vulgar error" one traditional cure: "stealing a piece of meat from a butcher's shop, rubbing your warts with it, then throwing it away or burying it. As the beef rots the warts decay." In his dry remark: "I dare say that the excitement of the theft was one element in the cure" (404) Tuke is, perhaps reluctantly, subsuming this peculiar ritual under the rubric of imagination.

At times Tuke's intuitive insight into the potential influence of the mind on the body is astonishingly modern. For example, he cites the case of "a distinguished Fellow of the Royal Society" (372), Robert Were Fox, who had told him "that he could, by voluntary effort, increase the frequency of the pulse from ten to twenty beats in the minute" (371-72). In this instance not only are the subject's credentials specified but also, since he lived in Falmouth, Tuke was able himself to verify the information. He finds Fox's pulse, when seated, to be "sixty-three, soft and regular. In the course of about two minutes, it increased in frequency to eighty-two" (372). Asked to describe how he achieved this acceleration, Fox describes it as "partly due to 'a sort of impulse, accompanied by an internal shiver, and partly to an action upon the breathing'" (372). In this auto-control of heart rate Tuke has hit on the principle underlying biofeedback, although it is commonly used to decrease, not to accelerate the pulse. (23) Tuke shrewdly concludes that the will cannot normally influence organic functions directly; however, through the intermediacy of other mental forces (presumably the imagination) it can indirectly exert immense influence over the irregular movements of the muscles and automatic cerebral action. This example shows Tuke's capacity to deduce a cardinal concept in psycho-physiology from one of his "illustrations." Although the illustrations are a random collection of what happened to cross Tuke's path, cumulatively they provide evidence, if not proof, of the influence of the mind on the body. For his grasp of this idea and his endeavor to give it scientific respectability Tuke is an important transitional figure in the history of psychosomatics. His book marks a stage in the move away from the earlier tendency to dismiss the imagination as a form of quackery and charlatanism to a consciousness of its multifaceted input in bodily processes.

Tuke also has a subtle sensitivity to the metaphoric force of words in linking mind and body. His love of poetry leads him to realize that the literal and the figurative may coalesce through an imaginative transference. In citing a line from Joanna Baillie's "Ethwald," "My spirit sickens at the hateful thought" [sic], he points out that "our expressions ... pass insensibly into a description of the actual physical effect" (159). Similarly, he invokes Shakespeare's Venus and Adonis to declare that the phrase "'a burning shame' is not a mere figure but involves and has its origins in the actual sensation of heat" (165). In relation to another line from Shakespeare, this time from King John, "For I am stifled with smell of sin," Tuke observes: "A stifling smell induces muscular contractions in the nasal muscles calculated to avoid it; and a bad moral odor affecting the mind will cause a very similar expression" (207).

In these appeals to poetry to make his point for the reciprocal influence of mind and body Tuke is gathering evidence from "other works" (x), i.e., other than medical. Because the printed word is open to direct evaluation, this practice is less troubling than Tuke's reliance on undocumented hearsay as the source of many of his "illustrations." For instance, in regard to the efficacy of a placebo as a remedy for scurvy, it is the experience of Dr. Frederic Van der Mye that is presented. Who was he? What were his qualifications? When he reports that "many quickly and perfectly recovered" (405), further questions arise: how "many"? What proportion of the total number? How did the others fare? How many failed to respond? The factual rigor mandatory in twentieth-century scientific experimentation is markedly absent in IMB; in essence it is itself imaginative and speculative even though couched in the idiom of physiology. Here the precariousness of Tuke's tight-rope act becomes most evident and most damaging to the acceptability of his enterprise to the medical community.

IMB's capacity to convince is weakened also by an innate shortcoming. Tuke achieves only some of the aims he had set himself: he certainly provides ample illustrations of the influence of the mind on the body; but he fails "to ascertain as far as possible the channels through, and the mode by, which this influence is exerted" (x). His phraseology in this clause of his statement of intent is noticeably tentative ("as far as possible") as if he himself from the outset doubted the feasibility of this facet of his undertaking. To a degree, IMB must be deemed a failed act of detection insofar as it offers data yet lacks a solution to explain them. References to physiological responses account at most only partially for the phenomena recorded. While Tuke collects ample provocative illustrations, he is unable to ascertain the "channels" and "modes" whereby the imagination comes into operation. This is a fundamental limitation of his work. Simply to designate the force as "imagination" does nothing to "elucidate ... the nature and action" (x) of its functioning. On the contrary, the very word "imagination," through its pronounced association with the romantic poets, thrusts the inquiry toward the literary realm, i.e., away from the medico-scientific.

The key concept missing in IMB is that of the unconscious. The "discovery of the unconscious," as Ellenberger traces it in his monumental volume, (24) was a long and slow process. Ellenberger goes as far back as the Greeks, and devotes considerable attention to such practices as shamanism, mesmerism, and hypnotism, which unquestionably elicit hidden parts of the mind. A good hundred years before Tuke, "some perceptive students of human nature had recognized the existence of unconscious mentation," (25) and in the early nineteenth century the Romantic poets, too, were fascinated by what they called the night sides of human nature including dreams and fantasies. There was therefore in Tuke's day at least an experiential cognizance of the existence in the mind of powers beyond its rational capacities. With his interest in psychology Tuke can hardly have been unaware of this tradition. But precisely its irrationality made the concept of the unconscious anathema to the later nineteenth-century's preoccupation with the scientific. In not probing further in this direction, Tuke is balancing on that tight-rope between his own bent toward psychology and his age's preference for physiology.

The same dilemma faced Freud twenty-three years later when he published the Studies on Hysteria in 1895. Like Tuke, Freud was, as he is at pains to insist, a properly trained neurologist, and also like Tuke, he had strong literary interests. He overtly expresses his concern that "die Krankengeschichten, die ich schreibe, wie Novellen zu lesen sind" ["the case histories I write read like stories."] (26) As with Tuke's "illustrations," Freud's famous early cases--Dora, the Rat-Man, the Wolf-Man, as they are popularly known (27)--read like exercises in detection. But in contrast to Tuke, Freud has a more specific solution to propose than Tuke. In place of the latter's "imagination," Freud postulates a buried area of the unconscious in the mind. Unpleasant, unwelcome, hurtful, frightening, or anxiety-inducing experiences are instinctively repressed as a form of self-protection, but some subsequent occasion may trigger their resurfacing in altered guise as a type of the "psycho-physical phenomena" (xii) that Tuke catalogues. The purpose of psychotherapeutics, or psychoanalysis, as Freud called it, is therefore to ferret out from the patient's past the veiled origins of the current disorder, and by retrieving the painful memories that have been banished, to disarm them. Whether such a process is clinically effective is another matter. Freud and his followers certainly believed so, and the five main and two subsidiary cases chronicled in the Studies an Hysteria seem to validate Freud's treatment, although the outcome of some later cases proved less conclusive.

By surmising the force of the unconscious, Freud was able to suggest the mechanisms (Tuke's "channels" and "modes") whereby "psycho-physical," or psychosomatic disorders become manifest. He projected the mind as layered into three discrete but communicating levels: the id, the ego, and the superego. This conceptualization led Freud to a frequent use of images drawn from archeology as though the mind were organized like a site to be excavated. Freud thus formulated a theory of the influence of the mind on the body that is essentially psychological. In a couple of his earliest cases--Emmy yon N ... and Elisabeth von R ... in Studies an Hysteria--Freud initially applied some physical therapies such as massage and baths to the locus of the complaint, but he quickly abandoned these in favor of the "talking cure" that he acquired partly through his patients' needs. (28) As early as 2 February 1888 he wrote to Fliess that he had put aside his work on brain anatomy whereas his study of hysteria was making rapid progress. (29) This marks the moment when Freud shifts his focus from physical lesions to psychological traumas, although it was only much later, in his treatise of 1923, The Ego and the Id, that he directly formulated his conclusion that our mind "is lived" by "unknown, uncontrollable powers." (30) Given Freud's stylistic precision, his use of the passive tense ("is lived") must be heeded as a particularly emphatic turn of phrase.

Probably even more than Tuke, Freud was aware that he was walking a tight-rope. So long as he worked conventionally in the physicalist domain, he received "nothing but praise." (31) The histological research he conducted between 1883 and 1886 resulted in a paper on the roots and connections of the acoustic nerve. (32) In 1885 he was appointed honorary instructor in neuropathology. But once he had made the transition to the interpretation of disorders in the psychological terminology of the unconscious, repression, and subconscious motivation, he encountered as much opposition, both immediate and lasting, as approbation. (33)

Nonetheless, in opting for this psychological route Freud attained far more enduring fame than Tuke. Their work differs in other respects apart from Freud's appropriation of the unconscious, most notably in his deductive method. Freud's bold theories derive from his own first-hand observations of his patients, through whom he came to learn the value of "just talk" as a cathartic procedure. (34) On the basis of his experience he broke away from physicalist explanations to acknowledge openly the crucial role played by an underlying irrational unconscious for the appearance of syndromes such as those Tuke had collected. Tuke's reputation was eclipsed because he struck too great a compromise with the dominant physicalist currents of his time. His search for rational, scientifically viable etiologies inhibits the freedom of his intuition. Still, his book is an important landmark, itself an "illustration" of the fascination with the mind/body relationship in the third quarter of the nineteenth century because of the challenge it presented to medical thinking. But the absence from Tuke's deliberations of the unconscious, a factor taken for granted in our culture, is indicative of the shortfall in the ability to decipher psychosomatic disorders at that time. (35)

University of North Carolina, Chapel Hill

Notes

(1) British Journal of Psychiatry 166:3 (March 1995), pp. 403-405.

(2) Rpt. London: Dawson, 1964.

(3) E.g. Mrs. Rochester in Charlotte Bronte's Jane Eyre (1847) and the lord's son in Arthur Conan Doyle's Stark Munro Letters (1895).

(4) Evelyn M. Stone, ed., American Psychiatric Glossary (Washington, D.C.: American Psychiatric Press, 1988), p. 66.

(5) Norman Dain, "American Psychiatry in the 18th Century," in American Psychiatry Past, Present and Future, ed. George Kriegman, Robert D. Gardner, and Wilfred D. Abse (U of Virginia P, 1975), pp. 24-26.

(6) Sander L. Gilman, Seeing the Insane (New York: John Wiley & Sons, 1982), p. 146.

(7) Andrew Scull, "Moral Treatment Reconsidered," in Andrew Scull, ed., Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era (U of Pennsylvania P, 1981), p. 111.

(8) The Dictionary of National Biography (Oxford UP, 1953), p. 1224.

(9) Medical-Chirurgical Review, October 1860; cited in Allibone's Critical Dictionary of English Literature (1891; rpt. Detroit: Gale Research, 1965), p. 2469.

(10) Beck's Medical Jurisprudence 11 (1860), I, p. 716.

(11) The Oxford Companion to Medicine (Oxford UP, 1986), II, p. 1401.

(12) Anne Digby, "Moral Treatment at the Retreat" in The Anatomy of Madness, ed. W.F. Bynum, Roy Porter, and Michael Shepherd (London and New York: Routledge, 1985), p. 69.

(13) George F. Drinka, The Birth of Neurosis: Myth, Malady, and the Victorians (New York: Simon & Schuster, 1984), pp. 74, 106-107.

(14) Audrey C. Peterson, "Brain Fever in Nineteenth-Century Fiction," Victorian Studies 19 (June 1976), p. 445.

(15) Peterson, p. 447.

(16) Reprinted in Lynn Gamwell and Nancy Tomes, Madness in America: Cultural and Medical Perceptions of Mental Illness Before 1914 (Cornell UP, 1995), p. 105.

(17) Neurology and psychiatry were still more closely interrelated fields in the nineteenth century than today. Even now the Board Certification held by American psychiatrists attests to their qualifications in psychiatry and neurology. Although the examinations are quite distinct, no formal separation between these two specialties has ever been implemented.

(18) See Wolfgang Schivelbusch, Geschichte der Eisenbahn (Munich: Carl Hanser, 1978); and Anselm Hollo, tr., The Railroad Journey: Trains and Travel in the Nineteenth Century (New York: Urizen Books, 1979), pp. 135-45.

(19) A.D. Hodgkiss, "Chronic Pain in Nineteenth-Century British Medical Writings," History of Psychiatry 2:5, part I (March 1991), pp. 27-40.

(20) Abbreviated to IMB. Philadelphia: Henry C. Leas Son & Co., 1884.

(21) Not so by Tuke, however, for in 1884 he published Sleep and Hypnosis.

(22) The distinguished French psychologist Pierre Janet, for example, diagnosed a fourteen-year-old girl admitted to hospital in 1890 as suffering from a neurosis; on her death a few days later the autopsy revealed a hydatic cyst on the brain. See "Kyste parasitaire du cerveau," Archives generales de medecine, 7th Series, 28:2 (1891), pp. 464-72.

(23) Tuke also introduces the case of Colonel Townsend who could slow down his heart and respiratory rate (372), but he did not examine him personally.

(24) Henri F. Ellenberger, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (New York: Basic Books, 1970).

(25) Peter Gay, Freud: A Life for Our Time (New York: W.W. Norton, 1988), p. 128.

(26) Sigmund Freud, Gesammelte Werke (London: Imago, 1952), I, p. 227; Standard Edition, tr. and ed. James Strachey (London: The Hogarth Press, 1955), II, pp. 160-61.

(27) "Fragment of an Analysis of a Case of Hysteria" (1905); "Notes Upon a Case of Obsessional Neurosis" (1909); "From the History of an Infantile Neurosis" (1918).

(28) See Lilian R. Furst, "Anxious Patients/Anxious Doctor: Telling Stories in Freud's Studies on Hysteria," LIT 8 (1998), pp. 259-77.

(29) Letter of 2 February 1888. Briefe an Fliess, Abhandlungen und Notizen aus den Jahren 1887-1902 (London: Imago, 1950), p. 63; Complete Letters of Sigmund Freud to Wilhelm Fliess, ed. and tr. Jeffrey M. Masson (Harvard UP, 1985), p. 19.

(30) Signmund Freud, Ich und Es, Gesammelte Werke XIII, 237; Ego and Id, Standard Edition XIX, 12.

(31) Ellenberger, p. 477.

(32) "Uber den Ursprung des Nervus accusticus," Monatsschrift fur Ohrenheilkunde [Journal for Ear Diseases] (1886).

(33) See Gay, Freud, passim.

(34) Lilian R. Furst, Just Talk: Narratives of Psychotherapy (U of Kentucky P, 1999), pp. 29-42.

(35) My thanks to Diane M. McKenzie, reference librarian at the University of North Carolina's Health Sciences Library, and to Janice H. Koelb, my research assistant, for their decisive and willingly-given help.
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