Madness: A Brief History (12 page)

But if so, precisely which organs and operations were implicated? The old humoral readings of mental disorder, which had stressed the roles of blood and yellow bile (‘choler’) in mania and black bile in melancholia, lost credit amongst the medical community as the ‘new science’ refigured the body in mechanical terms which highlighted the solids (organs, nerves, and fibres) rather than the fluids. Iatrophysics (medical physics) pictured the body machine as a hydraulic system of piping, or as a neurological circuit wiring the limbs to the brain and conducting sensation and motion electrically.

One upshot was that in post-Cartesian medical writings ‘mental illness’ in the strict sense became almost a contradiction in terms: the possibility of the mind or spirit per se being diseased was programmatically ruled out. Within Cartesian and Newtonian frameworks, the soul became definitionally inviolable, and doctors instead referred insanity to lesions of the
body.

Developing that line of thinking, the Oxford-educated London physician Thomas Willis (1621-75) coined the term neurology and elaborated Descartes’ idea of the ‘reflex’. An avid dissector, Willis strove to localize mental functions to particular regions of the brain. His models of the central and peripheral nervous system depended on the operations of animal spirits, superfine chemical intermediaries between body and mind capable of being affected by either.

Proceeding on similar lines were Archibald Pitcairn, a Scot who taught at Leiden in the Netherlands, and his protégé, Richard Mead. Lunatics, argued Mead, suffered from false ideas induced by the chaotic activities of those volatile animal spirits; these in turn fed back into the muscles to produce confused and uncontrolled movements in the limbs. The madman was thus a disordered sensory-motor machine in a state of break-down—delirium, for instance, held Mead, was ‘not a distemper of the mind but of the body’. Such somaticism served to confirm the authority of medicine, while also assuaging anxiety and stigma amongst patients, who would no longer be thought to be ‘lost souls’, clean ‘out of their mind’.

The re-ascription of madness as, at bottom, a bodily disorder was systematized in the teachings of Herman Boerhaave. In true Cartesian manner, that highly influential Leiden professor and his many disciples, notably Albrecht von Haller, maintained that the essential symptoms of madness lay in beliefs which, though lacking objective existence, were mistaken for reality. These delusions had a physical source—melancholy for instance resulted from the ‘dissipation’ (evaporation) of the most volatile parts of the blood and the thickening of its ‘black, fat and earthy’ residue, causing lethargy. Friedrich Hoffmann, professor of medicine
at Halle, already discussed in Chapter 2 , developed a comparable solidist psychopathology based on the vessels, fibres, and pores.

With this somatic turn, the nervous system became the focal point of enquiry and explanation. Followers of Pitcairn, in particular his fellow Scot George Cheyne, speculated about the sympathy of the vascular and nervous systems with the brain. Imaging of the nerves as hollow pipes or as wires conveying waves or electrical impulses produced theories in which disordered thoughts and mood-swings were put down to some defect of the digestive and nervous systems, which led to slackness, excessive tension, or obstruction. The fervent Newtonian Nicholas Robinson maintained in his
A New System of the Spleen
(1729) that it was the nerve fibres which controlled behaviour; pathological laxity in them was the primary cause of melancholia. ‘Every change of the Mind’, he insisted, ‘indicates a Change in the Bodily Organs. ’ Far from being a matter of malingering on the one hand or ‘imaginary Whims and Fancies’ on the other, insanity was thus a genuine malady, rooted in ‘the real, mechanical Affections of Matter and Motion’.

In the New World, Benjamin Rush of Philadelphia, the physician officially acknowledged by the American Psychiatric Association as the ‘father of American psychiatry’, held that practically all mental disorders were due to vitiated blood. His systematic remedy was bloodletting.

The psychological turn

After 1750 a theoretical transformation came about, owing in part to the growing uptake of those philosophical theories of sensation and perception promoted by the empiricist philosopher John Locke and furthered by the
philosophe
Condillac. Replacing Cartesian innate ideas with a model of the mind as originally a blank sheet of paper, John Locke, as we have seen, had suggested in his
Essay on Human Understanding
(1690) that madness was due to faulty associations in the processes whereby sense data were transformed into ‘ideas’. Lockean (mis)-association of ideas became central to new thinking about madness, above all in Britain but also in France.

Lockean thinking was then medicalized in part through William Cullen, doyen of the flourishing medical school set up in 1726 at Edinburgh University, who produced a more psychological paradigm of insanity. Basically imputing madness to excessive irritation of the nerves, Cullen held that the precipitating cause of derangement lay in acute cerebral activity. Insanity (
vesania
) was a nervous disorder, which arose when there was ‘some inequality in the excitement of the brain’, and he coined the term ‘neurosis’ to denote any illness consequent upon such a disorder of the nervous system (by Freud’s day, of course, the meaning of ‘neurosis’ had utterly changed). Yet, within this somatic model, insanity was also for Cullen an ‘unusual and commonly hurried association of ideas’, leading to ‘false judgement’ and producing ‘disproportionate emotions’—in other words, it was a
mental
disorder, albeit one grounded in dynamic neurophysiology. The psychological inspiration for this came from Cullen’s friend, the philosopher David Hume, who held Lockean sense impressions and associations of ideas fundamental to all intellectual operations. Cullen’s importance thus lay in reintegrating the mental into medical discourses on madness. His teachings proved highly influential.

The break with earlier (Boerhaavian) somatic theories of madness was clear by 1780. In his
Observations on the Nature, Kinds, Causes and Prevention of Insanity, Lunacy or Madness
(1782-86), Thomas Arnold, who had studied under Cullen before taking over a Leicester madhouse, constructed a nosology (taxonomy) of insanity on the basis of the Lockean philosophy of mind, distinguishing ‘ideal insanity’ (hallucination) from
‘notional insanity’ (delusion). Acknowledging his debt to ‘our British Psychologists, such as Locke, Hartley, Reid, Priestley, Stewart, Kames’, Alexander Crichton’s
An Inquiry into the Nature and Origin of Mental Derangement
(1798) similarly argued that psychiatry should be based on the philosophy of mind.

This emerging model of madness as a psychological condition pointed to an alternative target for psychiatric enquiry: rather than the organs of the body, the doctor had to address the patient’s psyche, as evidenced by his behaviour. The case-history approach this entailed demanded the transformation of the old craft of minding the insane into the pursuit of systematic psychological observation. The years after 1770 brought a spurt in psychiatric publishing along these lines by owners of private madhouses, for instance William Perfect’s
Methods of Cure, in Some Particular Cases of Insanity
(1778). Initially such houses had been rather secretive, but this changed, as new thinking demanded and prized the observation of individual patients and the publicization of findings. The handling by Francis Willis of George III’s first bout of madness (1788-9) similarly highlighted the psychological—and the recovery of the ‘mad king’ bred optimism.

The close of the century brought a remarkable marriage across enlightened Europe between new
psychological thinking and reformist practice in what has been called ‘moral therapy’. Its leading British exponent, the York Retreat, has already been discussed in Chapter 5. Another pioneer was the Florentine physician, Vincenzo Chiarugi, encouraged by the reforming activities of the enlightened Grand Duke of Tuscany, Peter Leopold. Expounded in
On Insanity
(1793-4), a major three-volume text, Chiarugi’s medico-psychiatric theories held that bodily states influenced the mind via the activities of the senses and the nervous system at large. His notion that the ‘sensorium commune’ mediated between the intellect and the senses, between soul and body, offered a psycho-physiological solution to the old Cartesian problem of mind/body dualism. Pondering the aetiology of insanity, Chiarugi backed the Enlightenment view that mental conditions were acquired rather than inherited, and held out high hopes for cure, not primarily by medical means but through humane management. Repudiating the use of force, he touted the superior efficacy of ‘moral control’, a therapy of psychological ascendancy over the patient established by the physician through character, expertise, and moral example.

21
The Florentine physician, Vincenzo Chiarugi (1759-1820) introduced moral treatment into Italy; engraving by de Lasimo, 1804.

In Paris the physician Philippe Pinel pioneered similar psychological approaches at the Bicetre, the main public madhouse for men, and the Salpetriere, its 
female counterpart. His stress on psychogenic factors rested upon enlightened foundations: empirical observation failed to discern any underlying structural abnormalities in lunatics’ brains when examined post mortem. Moreover, philosophically, Pinel was an
idéologue,
influenced by Locke’s thinking as radicalized by Condillac. Contrary to Locke, however, his
traitement moral
was directed to the affective, as opposed to the intellectual, side of the psyche.

Whilst retaining the traditional division of insanity into melancholia, mania, idiocy, and dementia, Pinel also developed new disease categories. His
manie sans délire,
later called
folie raisonnante,
outlined a partial insanity: sufferers would be mad on one subject alone. While the understanding remained sound, the personality was warped. Like other moral therapists, Pinel was an optimist: truly organic brain disease might be incurable, but functional disorders like melancholy and ‘mania without delirium’ were responsive to psychological methods. His
Medico-philosophical Treatise on Mental Alienation or Mania
(1801), which set out his thinking on the moral causation and treatment of insanity, was translated into English, Spanish, and German and proved highly influential.

22
Eight women representing the conditions of dementia, megalomania, acute mania, melancholia, idiocy, hallucination, erotic mania, and paralysis, in the gardens of the Salpêtrière Hospital, Paris; lithograph by A. Gautier, 1857.

Psychiatry French-style

Pinel’s favourite follower was Jean-Etienne Dominique Esquirol (1772-1840), whose
Mental Maladies
(1838) was the outstanding psychiatric text of his age. While asserting the ultimately organic nature of psychiatric disorders, Esquirol concentrated, like his mentor, on their psycho-social triggers. The diagnosis of ‘monomania’ was developed to describe a partial insanity identified with affective disorders, especially those involving paranoia, and he further delineated such conditions as kleptomania, nymphomania, and pyro-mania, detectable in advance only to the trained eye. A champion of the asylum as a therapeutic instrument, he became an authority on its design, and planned the National Asylum at Charenton, a suburb of Paris, of which he was appointed director. (It briefly housed the ageing Marquis de Sade.)

Translating into psychiatric practice the commitment of French hospital medicine at large to close clinical observation, Esquirol developed influential accounts, derived from extensive case experience, of illusion, hallucination, and moral insanity. He also trained up the next cohort of French psychiatrists, who then went on to plough furrows of their own: E. E. Georget wrote on cerebral localization; Louis Calmeil described dementia paralytica; J. J. Moreau de Tours was, as we shall see, a pioneer of degenerationism; while Jean-Pierre Falret and Jules Baillarger offered rival but complementary accounts of the manic-depressive cycle (the former called it
folie circulaire,
the latter
folie a double forme).