Mathew Thomson, Oxford, Oxford University Press, 1998, 351pages, US$90.00.

This book covers an important period in the development of specialist social, health and educational services for people with learning disabilities in Britain. Historically, the term mental deficiency had wide currency but contemporary synonyms include: mental handicap, mental retardation and developmental disorders. By 1870 faulty concepts of genetics were beginning to give support to the eugenics movement. For example, the French psychiatrist, Morel, had described his “theory of degeneration” wherein mental disorders did not differ in kind but only in severity. Accordingly, neuroses, psychoses and mental deficiency were increasingly severe manifestations of the same inherited process through the generations. This theory was compatible with Lamarckian genetic concepts which asserted that characteristics acquired by the individual could be inherited by his or her descendants. Increasingly, the mentally ill and mentally deficient were seen as causes of society's ills rather than as consequences of disadvantage. This was fertile ground for the formation of policies of wholesale segregation and sterilisation of the mentally defective. The former had extensive application in Britain whist the latter was rejected (but accepted in Germany and some parts of the USA).

As the title suggests, this book mainly addresses the history of social and political aspects of mental deficiency during the time period covered, rather than developments of bio-medical knowledge in this domain over that time.

This scholarly work makes good use of a wealth of original source materials as well as more widely available published books and articles. This first major historical work on the problem of mental deficiency presents a complex, multilevel and interactive model which belies many of the more simplistic accounts of this subject. The first two chapters deal with parliamentary and civil service responses to mental deficiency. Chapters three to five cover the approaches adopted by professional, voluntary and pressure groups (including the astonishingly under-reported development of community care for this population in the inter-war period). Chapter six describes the local administration of policy according to ideology, need and resources. Chapter seven presents a fascinating account of the “micropolitical” interaction between social services, families and people with learning disabilities themselves. This is thrown into contrast with the development of the burgeoning Welfare State in chapter eight.

The Mental Deficiency Act of 1913 and its consequences are described in detail, including the well-known pitfalls of confusing “moral” criteria with psychometric and psychopathological criteria for the compulsory detention of patients. This led to large numbers of young mothers who were not married and young men with minor offending behaviours being admitted to mental handicap hospitals for long periods. Victorian political philosophy accentuated the freedom of the individual within a framework of rights and responsibilities. This explains, to some extent, the paradoxical unity of conservative and progressive politicians in support of the policies of segregation and, in many cases, even sterilisation. The mentally defective were seen as less autonomous than intellectually intact individuals and thus as having fewer rights and responsibilities. Diminished freedom was justified at the same time as society's duty of care to these individuals was recognised. Therefore, they were subject to policies which curtailed their liberty but were afforded greater resources than many of their peers who presented with similar social problems which were not of developmental origin, for example, habitual criminals and inebriates. However, utilitarian concerns and the just use of finite resources were commonly applied to define services rather than concepts of individual rights. Throughout the book, continuities with periods before and after the subject matter are discussed. Indeed, despite rhetoric of “person-centred services”, the lives of people with learning disabilities are still all too often governed by administrative convenience which diminishes autonomy and predisposes to co-existent mental illness.

This book is of considerable interest to historians of health and social policies, especially those interested in mental health in general and learning disabilities in particular. Furthermore, I would recommend it to mental health workers, given the strength of its coverage of relevant ethical issues. The account of the history and ethics of problems relevant to this population may well prove of relevance to other vulnerable and potentially disenfranchised groups such as those who acquire handicap, disabilities and intellectual impairment later in life.