Madness: A Brief History (13 page)

Esquirol’s transformation of the classification and diagnosis of mental disorder was made possible by the abundance of data provided by asylums, enabling diagnosticians to build up clearly defined profiles of psychiatric diseases capable of being identified by their symptoms. Observation of asylum patients led to more precise differentiations in theory and practice—epileptics, for instance, became standardly distinguished from the insane. Esquirol himself produced an improved description of
petit mal,
and his pupil Calmeil described ‘absence’, distinguishing between passing mental confusion and the onset of a
grand mal
attack. Esquirol organized a special hospital for epileptics; by 1860, such institutions had also been founded in Britain and Germany, and in 1891 the first US hospital was established in Gallipolis, Ohio.

Similarly, the condition known as general paresis of the insane (one manifestation of tertiary syphilis) was elucidated in 1822 by Antoine Laurent Bayle. Although the micro-organism which causes syphilis had not yet been discovered—the bacteriological era lay ahead— the neurological and psychological features of GPI (notably euphoria and expansiveness), combined with the organic changes revealed by autopsy, supported Esquirol’s conviction that psychiatric disorders could be revealed using the techniques championed by such great French pathological anatomists as Laennec who had investigated tuberculosis and other internal conditions.

Closely related to GPI,
tabes dorsalis
was another disorder, prevalent in the nineteenth century, which became the focus of neuro-pathological research. It was the subject of a masterly clinical study published in 1858 by Guillaume Duchenne, which established its syphilitic origin: so definitive was his account that it was soon named ‘Duchenne’s disease’. He was also at the forefront in describing many other neurological disorders involving personality degeneration, including progressive muscular atrophy and locomotor ataxia (lack of coordination in movement).

Duchenne’s contemporary, Jean-Martin Charcot (1825-93), Clinical Professor of the Nervous System at the Salpêtrière, was the most famous teacher of the
belle époque,
and his clinic became the neurologists’ and psychiatrists’ Mecca (Freud studied under him there). His
Lectures on Nervous Diseases Delivered at the Salpêtrière
(1872-87) brought order to the nosology of those kinds of neurological disorders which shaded into the domain of psychiatry.

Charcot was never an ‘alienist’ (asylum superintendent) in the tradition of Pinel and Esquirol, and, contrary to a popular image, he was by no means exclusively preoccupied with hysteria. He was, first and foremost, a passionate neurologist (hence his soubriquet, the ‘Napoleon of the neuroses’), committed to deploying patho-anatomical techniques, so as to bring order to the chaos of neurological symptom clusters.

Conditions like epilepsy, general paralysis, and
tabes dorsalis,
he granted, ‘come to us like so many Sphinxes’, defying ‘the most penetrating anatomical investigations’. Aspiring to trace their bizarre symptoms to organic lesions, he undertook a massive clinical scrutiny of abnormalities: tics, migraine, epileptiform seizures, aphasia (language and speech disorders), mutism, somnambulism, hallucinations, contractures, and other deficits. Clinical observation, he was confident, would lay bare the natural histories of, and the laws governing, extended families of related neuro-psychological conditions: chorea, St Vitus’ Dance, sclerosis, tertiary neurosyphilitic infections, temporal lobe epilepsy, and a multitude of other neuropathies. ‘These diseases’, he insisted, ‘do not form, in pathology, a class apart, governed by other physiological laws than the common 
ones.’ One valuable part of this project was his further development of James Parkinson’s early work on the ‘shaking palsy’—indeed it was Charcot who first called it ‘Parkinson’s disease’.

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A high-profile neurologist and psychiatrist, Jean-Martin Charcot (1825-93) gained greatest public prominence for his theatrical demonstrations of hysteria.

Charcot similarly insisted that hysteria was no impenetrable mystery, but, like any other neurological disorder, was marked by definite, law-governed, predictable, clinical manifestations. With unlimited access to clinical material at his Salpetriere base, he mobilized a research industry and played a key, but ambivalent, role in the emergence of modern psychiatry.

Psychiatry German-style

The principalities which made up pre-unification Germany developed renowned asylums of their own, notably the Illenau in Baden-Baden, where Richard von Krafft-Ebing (1840-1902), pioneer of sexual psychiatry, gained his early clinical experience. Unlike in France or Britain, however, German psychiatry was chiefly associated with the universities and their research mentality. Perhaps for that reason, Germanspeaking psychiatry became the battleground for fierce theoretical controversies between rival organic and psychological camps.

At the turn of the nineteenth century Johann Christian Reil (who coined the word ‘Psychiaterie’) developed a holistic approach, indebted to Romanticism’s preoccupation with the irrational depths of the psyche. While, as a physician, tracing madness to the nerves and brain, his psychodynamically oriented
Rhapsodies on the Use of Psychological Treatment Methods in Mental Breakdown
(1803) proposed an idiosyncratic variant on moral treatment: the charismatic alienist would master the delinquent mind; a staff trained in play-acting would further the alienist’s efforts to break the patient’s fixed ideas—and all would be combined with salutary doses of therapeutic terror (sealing-wax dropped onto the palms, immersion in a tub of eels, etc.).

Psychological approaches were further developed by J. C. A. Heinroth and Karl Ideler, who drew heavily on Romanticism’s metaphysical plumbing of the inner consciousness. A Lutheran Pietist who taught at Leipzig, Heinroth viewed mental disorder in religious terms, and the aetiological explanations offered in his
Textbook of Mental Distwrba,nces
(1818) was dismissive of the idea of physical causation: ‘in the great majority of cases’, he insisted, ‘it is not the body but the soul itself from which mental disturbances directly and primarily originate.’

Heinroth linked insanity with sin; both were voluntary and hence culpable renunciations of God’s gift,
free will. Moral treatment must expose the lunatic to the healthy and devout personality of the alienist. Rather as for Reil, gentle therapies were to be combined with severe shock, restraint, and punishments. Each case required individual diagnosis and treatment. Eventually the patient would recover self-command.

Slightly later, the Viennese physician Ernst von Feuchtersleben (1806-49) aimed to integrate both psychic and somatic strands into a personality-based psychiatry offered as an ambitious synthesis of neurophysiology, psychology, and psychotherapeutics. Developing something akin to the modern concept of ‘psychosis’, he construed ‘psychopathy’ as a disease of the whole personality.

Other German and Austrian psychiatrists, by contrast, denounced the speculative fantasies of ‘psychi-cists’ like Heinroth, which they associated with the maunderings of speculative Romantic anti-science, and turned in an organic direction. Setting the cat amongst the pigeons in the debate on the nature and causes of insanity was phrenology, a would-be science developed by the Vienna-trained anatomists Franz Joseph Gall (1758-1828) and J. C. Spurzheim (1776-1832). Phrenology controversially maintained that the seat of the mind was the brain, whose configurations both determined and displayed the personality. The brain 
itself was an ensemble of over thirty separate ‘organs’ (acquisitiveness, sexuality, piety, and so forth), each occupying a specific cortical area. An organ’s size governed the power of its operations; the contours of the skull flagged the lineaments of the brain beneath, while the overall topography (hills and valleys) of the ‘bumps’ determined personality.

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Franz Joseph Gall and Johann Caspar Spurzheim, the founders of phrenology, are shown examining a patient by feeling the bumps on his head; watercolour painting, early nineteenth century.

Pious critics condemned phrenology for being materialistic, and Gall, a talented anatomist, was hounded out of Vienna in 1805. Nevertheless, it gained international attention, amongst doctors and the general public alike, because it seemed an aid to selfunderstanding; and it appealed to many alienists, since it posited a real biomedical basis for mental disturbance. Phrenological or not, ‘medical materialism’ of various stripes—the idea of a physical substrate to insanity—buttressed the doctors’ claim that psychiatric practice should be exclusive to the medically qualified, sanctioned laboratory research and gave some credibility to the ragbag of physical treatments, notably sedatives, bathing, purging, and bleeding, which formed the stock-in-trade of the profession.

Amongst German somatists, Maximilian Jacobi (1775-1858) was the pioneer, and the main aetio-logical assumptions were then laid down in J. B. Friedreich’s
Attempt at a History of the Literature of the Pathology 
and Therapy of Psychic Illnesses
(1830). Somatic psychiatry was given its chief impetus, orientation, and authority, however, by Wilhelm Griesinger, professor at Berlin. Enthusiastic in his championing of the materialism underpinning the experimental electro-physiologies of Helmholtz and du Bois-Reymond, Griesinger boldly asserted in his
Pathology and Therapy of Psychiatric Diseases
(1845) that ‘mental illnesses are brain diseases’. His sound bite that ‘every mental disease is rooted in brain disease’ inspired research into brain pathology aimed at discovering the precise cortical location of mental illnesses. Commitment to the somatic origin of such disorders spurred scientific investigation, while also, perhaps, restoring dignity to patients stigmatized by the lunacy diagnosis. For Griesinger it was crucially important that study of mental illness should not isolate itself from general medicine but be integral to it: an oft-repeated cry in the chequered history of psychiatry.

Mental diseases, Griesinger believed, were typically progressive, worsening from depressive states into more disruptive conditions. This reflected a pattern of underlying somatic abnormality, which would begin with excessive cerebral irritation, lead to chronic, irreversible brain degeneration, and end in the disintegration of the ego common in dementia. This stress upon the longitudinal descent from normal to pathological psychic processes, and on the progressive path of psychiatric illnesses, was later taken up by Kraepelin.

Griesinger set the mould for German academic psychiatry, in particular through his call for the alliance of psychiatry and neurology in academic neuropsychiatric clinics. After 1850, university psychiatry prospered in the German-speaking lands, supported by those twin pillars which gave German medical education its prestige, the polyclinic and the research institute. Unlike asylum superintendents in England or the USA, top-flight university psychiatrists rarely shared their patients’ lives night and day, and their orientation was theoretical and investigative rather than bureaucratic and therapeutic. University psychiatry’s primary goal was the scientific understanding of disorders through systematic observation, experimentation, and dissection.

Following Griesinger, his Berlin successor Carl West-phal, and then Theodor Meynert, Carl Wernicke and their co-workers promoted a hard-nosed psychiatry, rooted in prestigious scientific materialism and wedded to histology, neurology, and neuropathology. Much specialized knowledge came to light from their systematic investigations—for instance ‘Westphal’s sign’, the loss of the knee-jerk reflex in neurological disease.

A product of its illustrious medical school, Theodor Meynert (1833-92) spent his entire career in Vienna, from 1870 as professor of psychiatry. Essentially a neuropathologist, drawing heavily upon microscopical techniques, he subtitled his textbook
A Clinical Treatise on the Diseases of the Forebrain
(1884) in protest against the wishy-washy mentalistic implications of ‘psychiatry’. It was axiomatic for Meynert that each stimulus that reached the central nervous system excited a corresponding area in the cortex of the brain; he succeeded in demonstrating certain pathways by which cortical cells communicate with one another and with deeper cells of the cerebrum; and he advanced a systematic classification of mental illness based on his histo-pathological studies. Theoretically the bluntest of somatists, in practice, however, when his organic neuroanatomical programme ran into grave problems, he was reduced to devising some rather nebulous entities, such as the primary and secondary ego, to describe behavioural and cognitive disorders.