Madness: A Brief History (14 page)

Carl Wernicke (1848-1905), one of Meynert’s pupils, represents German neuropsychiatry at its apogee. His lifelong pursuit of cerebral localization (mapping which regions of the cerebral cortex are responsible for which functions) centred on a consuming interest in aphasia (language and speech disorders). Wernicke found that when patients had strokes in the posterior perisylvian part of the brain, they lost the ability to understand the spoken word or to speak intelligibly. This became known as ‘Wernicke’s aphasia’, and the area of the brain ‘Wernicke’s area’. In his extremely influential three-volume
Manual of Brain Diseases
(1881-3), Wernicke attempted to ground psychiatric symptoms in brain abnormalities, and in particular lent his authority to the concept of cerebral dominance.

Degenerationism

The German somatists staked bold claims for science’s capacity, through slicing up brains under microscopes in the lab or performing animal experiments, to provide explanations for the patho-physiological and neurological mechanisms of psychiatric disorders: functions could be mapped onto structures and their lesions. But they were far from sanguine about cures— and they were unashamedly more interested in diseases than in patients. This pessimism was in part a product of the inmate populations they saw, for asylums everywhere were filling up with those blighted with intractable and irreversible organic diseases, classically GPI (tertiary syphilis). Therapeutic nihilism born of experience bred a new hereditarianism. Pinel and other advocates of moral therapy and asylum reform had hailed the effectiveness of early treatment and environmental manipulation; by the
fin de siècle,
however, the build-up of long-stay cases was blighting hopes, and scrutiny of family backgrounds was pointing to inherited psychopathic taints. Such reflections were systematized into a degenerationist model by two psychiatrists, Esquirol’s pupil J. Moreau de Tours and Bénédict Augustin Morel, and in England by the gloomy genius Henry Maudsley, who, while embracing Darwinian evolution, was principally haunted by the survival of the unfit in modern society.

Physician to two large asylums, Morel turned degeneration into an influential explanatory principle in his
Treatise on Physical and Moral Degeneration
(1857). Produced conjointly by organic and social factors, hereditary degeneration was said to be cumulative over the generations, descending into imbecility and, finally and thankfully, sterility. A degenerate’s family history might sink, over the generations, from neurasthenia or nervous hysteria, through alcohol and opiate addiction, prostitution and criminality, to insanity proper and utter idiocy. Once a family was on the downhill slope, the outcome was hopeless.

Alcoholism—a concept coined in 1852 by the Swede Magnus Huss—provided a model for degeneration, since it combined the physical and the moral, was rife among pauper lunatics, and supposedly led to character disintegration. Valentin Magnan (1835-1916) implanted Morel’s theories into evolutionary biology with his idea of ‘progress or perish’; and such views were dramatized in Emile Zola’s naturalistic novel
LAs-sommoir
(1877), in which Magnan himself appears as an asylum doctor. Degenerationism caught the mood of the times in a France reeling from defeat by Prussia in the war of 1870, and from the subsequent and bloody Paris Commune; it also echoed bourgeois fears of a mass society marked by proletarian unrest and socialism.

Griesinger himself acknowledged his debt to Morel, while Meynert, Wernicke, and other brain psychiatrists further documented the hereditarian dimensions of insanity. Meynert’s successor in Vienna, Richard von Krafft-Ebing, was a qualified exponent of degenerationist thinking. Best known for his
Psychopathia Sexualis
(1886), the founding study of sexual ‘perversion’ (bestiality, exhibitionism, fetishism, sado-masochism, transvestism, and so forth) and ‘inversion’ (that is, homosexuality), he classed such sexual conditions and various other disorders as constitutional degeneration.

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The Vienna-based psychiatrist Richard von Krafft-Ebing (1845-1902) largely owed his fame to his studies of sexual perversion and psychopathology; photogravure, c. 1900.

Paul Möbius (1854-1907) also espoused degenerationism. Exploring the presumed connections between 
genius and insanity (see Chapter 4), Möbius focused on
dégénérés supérieurs,
i.e. individuals of abnormal aptitude. A particularly blatant misogynist in a profession which widely disparaged women’s mental powers, he was also intrigued by hysteria and pathological sexuality: women were slaves to their bodies, he declared in his
The Physiological Feeble-Mindedness of Women
(1900)—‘instinct makes the female animal-like’—and high intelligence in the sex was so singular as to be positively degenerate. Möbius also endorsed the notion of hereditary degeneration in a classification of psychiatric disorders admired by Emil Kraepelin.

Morelian ideas were taken up in Italy by the psychiatrist and criminologist Cesare Lombroso (18361909), who viewed criminals and psychiatric patients as degenerate throwbacks, identifiable by physical stigmata—low brows, jutting jaws, and so forth. Comparable physical evidence of degenerative taints could also be found in non-European races, in apes, and in children.

A more optimistic reading of similar tendencies was taken, predictably enough, in the new world, where George M. Beard (1839-83) popularized the concept of ‘neurasthenia’, nervous breakdown produced by the frantic pressures of advanced civilization, which drained the individual’s reserves of ‘nerve force’.

‘American nervousness is the product of American civilization’
, he pronounced with mingled pride and regret. Neurasthenia’s prevalence in the modern era was no mystery, held Beard: the telegraph, railroad, press, and the market-driven rat race of Wall Street had rendered life insupportably hectic, intense, and stressful. Civilization made demands on nervous systems that nature had never anticipated. As with the eighteenth-century ‘English malady’, neurasthenia struck the elite and flagged up civilization and its discontents. Beard’s ideas were given a practical twist by Silas Weir Mitchell, who introduced the ‘Weir Mitchell treatment’—bed rest, strict isolation, fattening up with milk puddings, and passive massage—to counter such fatiguing tendencies amongst the neurasthenic.

But American thinking had its darker side too. The trial in 1881 of Charles Guiteau, the assassin of President Garfield, spotlighted issues of heredity, criminality, and moral insanity, since psychiatrists based their defence testimonies on the claim that Guiteau was a degenerate. By 1900 lobbies were urging compulsory confinement, sterilization, and other eugenic measures, as well as the use of psychiatry in immigration control. Psychiatric sterilization gained a hold in the United States long before Nazi Germany.

The neurasthenia diagnosis was also exported to Europe. In the Netherlands and Germany it tended to be integrated into the neuroses at large. In France Pierre Janet outlined a variant of his own known as psy-chasthenia. In Britain it seems to have made less headway because of continuing phlegmatic Anglo-Saxon resistance to pandering to psychic weakness.

Psychiatry and society

In all the advanced nations, psychiatry gained a public face (if little prestige and much distrust) after 1800, and psychiatrists found public employment in universities, especially in Germany, and in asylums. It came of professional age around the mid-century, when medical superintendents (‘alienists’) banded together to form specialized organizations. In England identity was consolidated in 1841 with the forming of the Association of Medical Officers of Asylums and Hospitals for the Insane, which published the
Asylum Journal
(1853), later renamed the
Journal of Mental Science
(1858). In due course it became the (Royal) Medico-Psychological Association, and finally in 1971 the Royal College of Psychiatrists. For its part, the forerunner of the American Psychiatric Association began in 1844 as the Association of Medical Superintendents of American Institutions for the Insane. Professional journals widely emerged, like the
Annales médico-psychologiques
in France and the
Archiv für Psychiatrie,
set up by Griesinger.

Psychiatrists inevitably played a growing role in the public domain, notably in the courtroom. Lunatics and ‘idiots’ had long been, under certain circumstances, made wards of the state, and it was accepted that the insane, not being responsible for their acts, should be exempt from punishment for criminal deeds. In 1799, for example, when James Hadfield tried to assassinate George III, the trial was halted once his lawyer convinced the court that the accused was besieged by religious delusions. (He had grown convinced that only by his death could the world be saved, and that he was sure to be executed for killing the king.) Thereafter juries in England could formally bring in verdicts of ‘not guilty by reason of insanity’, and the accused would be put under psychiatric lock and key.

Telling criminality from insanity had never been thought to require medical expertise: friends and family had been called in to testify in court. This changed from the early decades of the nineteenth century, however, when psychiatric experts staked out new claims to detect ‘partial’ insanity, particularly the Esquirolian monomanias, imperceptible to the untrained eye.

The insanity plea became controversial in Britain
when the trial in 1843 of Daniel M’Naghten for the murder of Prime Minister Sir Robert Peel’s private secretary was stopped on the grounds of insanity. The resulting furore led to new guidelines being drawn up, by the House of Lords, to clarify the legal basis for criminal insanity. The M’Naghten Rules (1844) grounded the insanity defence in the defendant’s inability to distinguish right from wrong. This pre-empted the claim advanced by post-Esquirolian psychiatrists that the grounds should be ‘irresistible impulse’, that is, disorders of emotion and volition, independently of delusions of the understanding. In France by contrast, ‘irresistible impulse’ and partial and temporary insanity figured large in the plea of insanity and
crime passionelle.
Disputes over the insanity defence (who was bad? who was mad?) highlighted conflicts between legal and psychiatric models of the person, and left the public standing of psychiatry dubious.

A dialogue of the deaf?

One half of mankind does not know how the other half lives,’ opens the autobiography of an early twentieth-century British mental patient who signed himself ‘Warmark’. The rich may not understand the poor, nor atheists the God-fearing, but the experience most profoundly closed, ‘Warmark’ suggested, is surely being out of your mind. So can the utterances of the insane make sense?

Some experts say no: the language of the mentally ill is an irredeemable babble. Psychiatry had taken a wrong turn, argued the distinguished British psychiatrists Richard Hunter and Ida Macalpine in 1974, when they wrote,

Today, it is assumed that mental pathology derives from normal psychology and can be understood in terms of faulty inter or intrapersonal relationships and corrected by re-education or psychoanalysis of where the patient’s emotional development went wrong. Despite all efforts which have gone into this approach and all the reams devoted to it, results have been meagre not to say inconclusive, and contrast sharply with what medicine has given to psychiatry and which is added to year by year. [This is because] Patients are victims of their brain rather than their mind. To reap the rewards of this medical approach, however, means a reorientation of psychiatry, from listening to looking.

It is surely significant that when they undertook a full-length study of the madness of King George III, they chose not to read any psychiatric significance into the fantasies he was recorded as uttering while out of his mind, including fears that sinful London was about to suffer a total deluge.

Their call for psychiatry to turn away from listening to the mentally ill did not stem from inhumanity, it was the logical consequence of their psychiatric credo, one that has been widely held. Mental illness, Hunter and Macalpine believed, was not psychogenic. Hence the utterances of the insane were but cries of distress—and not necessarily even good clues to its nature. You don’t crack mental illness by decoding what the mad say: for, they held, mental disease had a biological base.

Powerful psychiatric currents have furthered such tendencies to silence the insane, especially in institutional environments. From the Scientific Revolution, as we have already seen, influential views cast man essentially as a machine, and thus reduced the expressions and complaints of the disordered to secondary manifestations, the screeches and judderings of a faulty engine: something was wrong, but nothing significant was being said. In any case, did not the methods of the natural sciences prescribe observation and objectivity, not interaction and interpretation?