1850 to 1900

The late nineteenth century witnessed an explosion of interest in the problems of mind and mental prob­lems, one that extended across the cultural landscape into art, literature, science, and politics.

In addition to the interest spawned by these intel­lectual currents, the subject of mental disorders drew impetus from “below,” from powerful social con­cerns. On several fronts, much more now appeared to be at stake, for the individual and for society, in the realm of the troubled self.

The Asylum and Society

The once-small asylum had swelled in size and popu­lation far beyond what its creators had initially hoped - or had farsightedly dreaded.

In subtle ways, the institutions’ success in attract­ing patients had the unintended effect Ofheightening fears that the problem of mental illness was somehow worsening. What was only newly visible to the public was considered but newly existent. Moreover, the simple bureaucratic act of generating institutional records itself distorted clinical perceptions. As hospi­tal tallies began to reveal that the same patient might be released only to be readmitted years later, and that new admittees were often related to past inmates — graphic illumination of insanity’s fear­some generational grip - mental disorders of the day were concluded to be far more virulent and insidious than when the institutions originally opened. Such fears were compounded by the consequences of slow but profound demographic shifts that reinforced ra­cial stereotypes. Where asylums based on the Quaker model of moral treatment assumed a homogeneous population, in that physician, patient, and commu­nity shared similar religious and social values, the public institutions had become cultural mixing pots filled with diverse immigrant and working-class populations. Alienists, now mostly salaried employ­ees of the state and no longer beholden to families for private fees, became even further removed from the cultural milieu of their charges.

“Nervous” Disorders

At the same time, the public had become obsessed with ailments of a less serious but more commonplace nature, especially those conditions in which mental and physical attributes blurred together. Rapid in­dustrialization and urbanization brought forth dra­matic transformations in the family, workplace, and society. In turn, the anxieties and inner conflicts that arose from survival in the fast-changing modem world found expression in a slew of somatic com­plaints, ranging from dyspepsia and skin disorders to hysteria and hypochondriasis. Cullen’s and Trotter’s neuroses had been resuscitated - but with a twist.

Owing to the rise of the middle class, a higher level of literacy, and the formation of a consumer culture oriented to such things as the creation of markets for health remedies, such “fashionable” diseases pene­trated faster and deeper into society. Moreover, the unifying metaphor - the nervous system — had meta- mδrphosed well beyond mere “irritation.” Since even Trotter’s time, neurological investigators scored ma­jor accomplishments in understanding how the brain mediates between sense impressions and motive ac­tion. In the age of the telegraph and the dynamo, of centralized bureaucracy and the division of labor, the new model of the nervous system - one part wir­ing diagram and one part administrative flowchart - offered an intuitive, adaptable framework for ex­plaining how human thought or action was guided, executed, and powered. Any number of confusing conditions or troubles could now be plausibly ex­plained by the lay public and medical personnel alike as simply a case of “nerves” - which at once said everything, and nothing. Indeed, so popular was the new framework that some have referred to the late nineteenth century as the “nervous” era.

Secondary Gains

A diagnosis is never socially neutral because the “sick role” associated with an illness has practical consequences for the patient that are as real as any physical manifestations of pathology.

The example of hysteria is only one illustration of a pervasive trend, the appearance of medical disorders as significant resources for the indirect negotiation of social conflicts. In addition to the battleground of household or gender-related politics, a person’s health status might figure heavily in such polarized issues as the responsibility of corporations to protect the public, fitness for employment or military ser­vice, and criminal trials.

In answering the call to pronounce judgment on matters with such public consequences, physicians were expanding their authority over everyday af­fairs. As indicated in the examples just given, some of the more volatile health debates touched on neuropsychiatric conditions, an area of medicine in which diagnostic and explanatory models were insuf­ficiently powerful to enable a designated “expert” to deliver a verdict that would remain uncontested. Many opportunities for professional growth were opened, but the path was uncertain.

Thus, in the second half of the nineteenth century, mental disorders gained a commanding social pres­ence due to the perceived threat of the asylum popu­lation, the profusion of nervous disorders, and their linkage to a range of polarized issues. This social interest was mirrored by the attention of diverse groups of learned scientists and physicians who com­peted for the privilege of claiming the field of mental disorders as their own. Such groups varied greatly in their institutional location, professional service role, scientific orientation, and political aims. Their dispa­rate agendas led to a jumble of theories regarding insanity; in turn, these theories both strengthened and limited the professional opportunities of their proponents. Let us visit, in turn, the asylum alienists, three types of neurologist (the researcher, the private practice consultant, and the urban clini­cian), and university psychiatrists.

Asylums and Their Keepers

French Alienists and Degeneration Theory. In France, the manifold problems of asylum psychiatry surfaced by midcentury, enshrouding the young pro­fession ofalienisme in an unexpected fatalism.

The degeneration model asserted that hereditary factors were the primary cause of insanity, pathol­ogy occurring when a weak disposition was over­whelmed by intoxicants (alcohol, malaria, opium, cretinous soil), social milieu, or moral sickness. Com­bined effects of physical and moral injuries were especially treacherous. The distinguishing feature of the degenerationist model was its developmental (or “genetic,” in its original meaning) orientation.

Even as enthusiasm for lesion-based systems of psychiatry waned, a new intellectual foundation was emerging from the biological theories of Jean Bap­tists Lamarck, Herbert Spencer, and later Charles Darwin. With evolution supplanting pathological anatomy as the core biology, questions of process overshadowed those of structure. Static taxonomies of disease thus gave way to dynamic systems, in which most mental disorders were stages of a uni­tary disease, stratified not by anatomic location but by a defined temporal order. Simple ailments were linked to severe ones, as the seed is to the tree. Mental illness now had a plot.

For the French alienists, the degeneration model provided a way to navigate past the Scylla and Charybdis then facing the profession, the dual haz­ards posed by either holding to materialist positions that invited political attack or abandoning these in favor of psychological models that were insuffi­ciently “scientific” to silence medical critics. Morel’s solution was to argue that a specific case of mental illness was the expression of a “functional” lesion of the nervous system, one based on its performance as an integrated whole. Although an organic mecha­nism was presumed (satisfying demands for scien­tific rigor), its elaboration was considered unneces­sary for understanding the clinical significance of mental illness. Moreover, the integrationist stance remained agnostic on the precise interaction be­tween mind and body. Religious conservatives need not be enthusiastic supporters of the degenerationist model, but at minimum it was palatable; although the soul no longer held a perpetual lease on the body, neither was it in immediate danger of eviction. Morel himself was deeply religious, finding in the degenerationist model a biological statement of origi­nal sin.

The theory states that the development of the indi­vidual is a reenactment of that of the species as a whole, a viewpoint later encapsulated in Ernst Hein­rich Haeckel’s famous phrase “Ontogeny recapitu­lates phylogeny.” Civilization’s forward progress had depended on the triumph of government and order over barbarism and base desires. Individual survival depended on no less. If anarchy and mob rule were evidence of a breakdown in the social order, a rever­sion to an earlier — and hence evolutionarily lower - state, then madness was its equivalent in the individ­ual, an atavism from a time when emotions ruled the intellect. Because we are biological as well as spiritual entities, the animal beneath the skin can only be controlled, never exorcised. Mental compo­sure depended on an interminable conquest of desire by discipline.

Although heuristically powerful, the degenera­tionist framework offered no immediate therapeutic advantage for institutional practice. Rather, its strength lay in its expansion of psychiatric author­ity beyond the walls of the asylum. With overfilled institutions belying the curability of severe mental illness, alienists faced the prospect of becoming an alliance of mere custodians, should no dramatic treatment appear. Instead, alienists looked out­ward, recasting their medical responsibility to in­clude prophylaxis — society would be served best by staunching the flow of inmates at its source. The new explanations of madness provided alienists with a blueprint for such extramural intervention, one that augmented and did not undermine their institutional base.

Asylums provided alienists with a unique vantage from which to observe directly countless broken lives. Every new admission was an object lesson in the fragility of normal life, of how a single path wrongly taken - perhaps a pint of gin, an act of masturbation, or a flirtation with prostitution - might set a once vigorous individual on a course of dissolution that would end in a locked asylum ward. Such stories provided alienists a rich harvest from which to manufacture their most valued product: advice. Moreover, given the Lamarckian assumption of the day, that a person’s habits over time were eventually transmitted to future generations as heri­table traits, it was not just an individual’s life, but the life of the nation, that was at risk. With dissolu­tion as the key to insanity, mental illness acquired a definite moral as well as biological structure. Unless the alienists’ warnings were heeded, a generation of dissolute citizens would flood the country with ner­vous children, and insane grandchildren in even greater numbers. Madness was the very destiny of a people unfolded.

Alienists thus trumpeted themselves as advisers on matters of social policy, alone competent to pilot civilization past hidden reefs. Their message was especially poignant in France in the 1870s, when the country was recovering from the devastating mili­tary loss to the Prussians and from the turmoil of the Paris Commune. It seemed that one had to look no further than the specter of working-class mobs to see the link between social revolution and morbid degen­eracy. The model gained popular credence through the work of Cesare Lombroso, an Italian author who devised popular categories of criminal insanity. As we shall see, aspects of the degenerationist model penetrated virtually all major conceptual systems of mental illness espoused in the late nineteenth cen­tury. Indeed, the model resurfaces even today, when­ever life-style is evoked as a basis for understanding disease.

Neurology

The latter half of the nineteenth century was neurol­ogy’s “golden age,” in research, private practice, and the urban teaching clinic. Each of these three neuro­logical domains had significant repercussions in the medical conceptualization and treatment of madness.

British Experimental Neurology and Epilepsy. Through the efforts of mostly British, German, and Russian investigators, the reflex became the building block of neurophysiology. In the 1830s Marshall Hall demonstrated the importance of the reflex system in maintaining all vital bodily activities. Following the British philosophical tradition of Volitionalism, how­ever, purposive acts and thought processes were left inviolate. Such dualism of mind and body came under assault by Thomas Laycock. Drawing on German science, in which a natur-philosophic orientation pre­sumed a unity of man in nature and a continuous evolution from animal to man, Laycock argued for a gradual blending of automatic acts, reflexes, in­stincts, emotions, and thought. Laycock’s student, John Hughlings Jackson, is often described as the true originator of modern neurology. Incorporating Hall’s and Laycock’s ideas, Jackson went furthest in constructing a neurological basis for human action. In his classic research on the localization of epilepsy (the major epileptic syndrome long bore his name), Jackson focused on the pattern by which nervous functions disappear in the course of a fit; here was an indirect means of peering into the functional organi­zation of the brain.

Combining Spencer’s evolutionary cosmology with the degenerationist outlook, Jackson constructed a topology of self in which the nervous system was hierarchically layered according to the evolutionary scale. At the lowest or most “primitive” level was the spinal system, which was controlled by the “middle” level, the motor system; this in turn was mastered by the “highest” level, the frontal lobes - the organ of the mind and the acme of evolution. Epilepsy could now be understood as nothing less than a body caught in the visible throes of dissolution. This an­swered Jackson’s clinical puzzle concerning why ab­errations of conscious thought were the first epilep­tic symptoms to appear; nervous functions were lost in precisely the reverse order of their evolution.

Much of the appeal of the degenerationist model resulted from its resonance with fundamental changes then occurring in the social fabric. Issues of social differentiation and hierarchy surfaced in the wake of nationalism which pitted one country’s heri­tage and international standing against another’s; industrialism, which produced a vast laboring un­derclass; and imperialism, which placed whole coun­tries of “primitives” under European stewardship. With religious authority in decline, models of scien­tific naturalism were expected to provide a rational social order in step with the times. Jackson’s model, which dovetailed a neurological “localization of supe­riority” with Spencer’s dictum that “separateness of duty is universally accompanied by separateness of structure,” exemplifies the fact that in the Victorian era visions of the external world could be disaggrega­ted from those applied to the internal one. Jackson’s accomplishment was a paradigm that continues to influence us today, one that all too neatly converged neurological, evolutionary, and social stratifications into a spatial metaphor of unusual power.

With Jackson’s model, the degenerationist model of insanity now has a firm neurological basis. As Jackson himself argued, mental illness resulted from the dissolution of the higher centers, compli­cated by overactivity in the lower centers. Empirical proof of the connection could be found in the asy­lums, all of which housed a significant number of epileptics. For some time to follow, the ignominy associated with the biological corruption of the epi­leptic would spill over into categories of mental ill­ness. Not clearly inferable from Jackson’s work, how­ever, was the actual involvement the neurologist was to have with the problem of mental illness, for although a solution to grave mental illness might come from a cure for epilepsy, this awaited much further neurophysiological research. The divide be­tween neurology and mental illness was a matter of professional location as well as knowledge, in that few neurologists had access to asylum patients. As for the noninstitutional population, Jackson’s prefer­ence for disease models based on clear organic mechanisms led him to declare that “functional” dis­orders were best left to other aspiring specialties such as gynecology and obstetrics.

Neurology and Neurasthenia in the United States. Neurology as a viable profession in the United States dates from the Civil War, which produced a larger number of soldiers with nerve injuries and severe emotional disorders requiring specialized care. After the war, neurology rode the wave of spe­cialism that was transforming urban medicine. Phy­sicians with graduate training in European medical science hoped to build alternative medical careers by limiting their practice to areas that might benefit from specialized knowledge. Cities provided both the requisite critical mass of varied clinical material and the pool of motivated, affluent citizens to sup­port these ventures.

In 1869 New York neurologist George M. Beard diagnosed Americans as especially prone to nervous exhaustion. His conception of neurasthenia — liter­ally weak nerves - achieved international usage as a major trope of the Victorian era. The condition referred to a cluster of distressing, often vague symptoms that ranged from simple stress to severe problems just short of certifiable insanity. Bodily complaints such as headaches and hot flashes ap­peared alongside psychological ones such as lack of interest in work or sex and morbid fears about trivial issues. Thus burdened, neurasthenics re­treated from the fulfillment of obligations to their families, employers, or social groups. The physio­logical link common to all these cases, Beard sug­gested, was the depletion of the vital nervous forces.

Neurasthenia’s prevalence in the modern era was

no mystery, Beard argued. The telegraph, railroad, daily press, crowded quarters, and financial market had rendered life simultaneously more hectic, in­tense, and stressful. Civilization placed demands on our nervous systems that nature had never antici­pated. Reminiscent of earlier interpretations of hypo­chondriasis, the eighteenth-century “English mala- day,” the presence of neurasthenia served as a marker of advanced society. Once again, mental ill­ness was a conspicuous price of progress. Americans, world leaders in industrialization, paid dearly. Here, too, patterns of incidence were interpreted as clues to social hierarchy. Men thought most likely to suc­cumb were those at the vanguard of social advance, such as inventors and entrepreneurs. Women, whose smaller brains were dominated by their reproduc­tive systems, might be overcome by the daunting task of running a Victorian household or by exces­sive intellectual effort. The ranks of the lower classes, to be sure, did yield a significant number of neurasthenics. But since their hardier constitutions would bear up under all but the worst shocks, such as alcoholism or inveterate depravity, the condition in them was more a badge of shame than one of honor.

For practicing neurologists, the concept of neuras­thenia brought order to chaos and provided a defensi­ble base for the profession’s enlargement. The bewil­dering array of ailments that fell under the category of “functional” disorders (all those without gross ana­tomic damage or known organic cause, such a hyste­ria and hypochondriasis) were unified into a single clinical picture that was comprehensible to both neu­rologist and patient. Briefly stated, nervous energy was a precious quantity that must neither be squan­dered nor misdirected; temporary habits eventually became fixed pathways in the brain and might even be transmited to the next generation.

The reality of the functional diseases had been an open question for the public, which was often far more skeptical than many medical experts. The neur­asthenic model, although lacking a precise organic mechanism, was able to relegitimate these disorders by imparting the cachet of a state-of-the-art scientific theory. Furthermore, the emphasis on brain physiol­ogy was consistent with the growing emphasis in biology and medicine on the central nervous system as the dominant bodily system. This displaced the open-ended physiological models of the eighteenth and early nineteenth centuries in which pathogenic processes might arise from the influence of any of a number of interconnected systems that included the liver, stomach, circulation, or nerves. Previously, any knowledgeable physician might have been able to understand the development of a mental pathology, based on a reading of the balance of the organism as a whole. Now, however, only a nerve specialist was qualified. And as an untreated cold might lead to pneumonia, so a nervous complaint not handled by a neurologist might be the portal to an asylum. In short, by establishing the principle that troubling but otherwise unremarkable mental states might produce morbid bodily changes as dramatic as any physical insult, Beard and his followers were con­structing a neuropathology of everyday life.

The strength of Beard’s model lay not in its origi­nality but in its artful extension of medical and social trends. Indeed, by this time, nervous condi­tions represented to family physicians a significant portion of their practice and were also responsible in large measure for the booming market in health products and services. At first, neurologists followed uninventive therapeutic programs, endorsing the standard use of mild tonics and sedatives, dietary restrictions and supplements, massages, low-current electrical stimulation, and visits to water spas and other health resorts. The goal was to help patients restore their “strength” and to maintain a healthy “nervous tone.” Morbid thoughts and other dangers of introspection were to be derailed through outdoor exercise and cheerful admonitions by the doctor and family.

The neurasthenic model also gained impetus as an articulation of a Victorian conception of self, one that incorporated health’s new moral meaning. Char­acter was indeed a matter of destiny, but neither heredity nor rational intent solely determined one’s fortunes. Rather, it was one’s will that mediated between what one could be and what one should be. Not all persons were created equal, nor were they forced to meet stresses and tests of comparable sever­ity. Nevertheless, what individuals made of their lots was inescapably their responsibility. In this worldview, health became a secular measure of moral character. Although illness in general was no longer interpreted as a direct manifestation of God’s wrath, conditions that resulted from a damaged con­stitution were read as the certain consequences of immoral or unnatural habits - a failure of will. Ob­servers noted that unlike malaria or the pox, which might attack the weak and the strong indifferently, mental diseases fell only on those who lacked self­control. The concept of neurasthenia, which focused on activities that damaged the will itself, thus pro­vided an adaptable matrix for the consideration of human character.

The special business of neurologists, in addition to providing the usual treatments for nervousness, was to offer individuals the expert guidance necessary to avoid permanent or worsened injury to the constitu­tion, advice based on their putative knowledge of brain function and human affairs. Thus construed, the role of neurologists combined both intimacy and scientific objectivity. On one hand, neurologists were to be consulted by patients on an expanding variety of personal issues, ranging from major life decisions, such as the advisability of marriage, to minor points of life-style, such as the amount of fat to be included in one’s diet. The role of adviser merged with that of confessor: Critical to the success of the treatment was the patient’s full disclosure of all behavior, no matter how disreputable. Indeed, it was precisely on questions of damage caused by vices that medical treatment so often appeared to hinge. Medical pen­ance, as outlined by neurologists, became the new absolution. On the other hand, in the interest of invading clinical territory already inhabited by ei­ther alienists or family physicians, neurologists were obliged to base their expertise on the emerging laboratory and clinical science of the brain. This dual obligation of scientist and counselor proved dif­ficult to reconcile.

Neurologists learned soon enough what alienists had discovered already: Mental disorders are more managed than cured. Furthermore, such close inter­vention in patients’ lives yielded a clinical paradox. A nervous complaint, successfully treated, might dis­appear only to be replaced by another; or a wide range of treatments might prove equally effective - for a time. Even as they were constructing elaborate scientific justifications for their clinical interven­tion, neurologists were discovering that it was not so much the specific medical treatment that mattered as it was the discipline that patients exhibited in adhering to the treatment plan. With this in mind, S. Weir Mitchell perfected his famous “rest cure,” in which patients were isolated from their families and placed in the full care of a neurologist and nurse. Stripped of all power to make decisions, and con­signed to a state of ultradependency (which included such things as spoon-feedings), patients were sup­posed to rebuild their willpower completely. Focus thus shifted away from external signs and symptoms to the dynamics of the patient-physician relation­ship. The resistance of the patient to being cured became a new index of pathology. Ostensibly follow­ing a somatic program, New York neurologists un­easily awakened to the reality of psychological as­pects of nervous disorders.

Charcot’s Parisian Teaching Clinic and Hysteroepi- lepsy. Although Esquirol₁ in the 1840s, ignored hysteria as an uncertain diagnosis of little signifi­cance, by the 1880s the condition had risen to a newfound prominence. This turnabout was directly attributable to the efforts of Jean Martin Charcot, an internationally renowned neurologist whose teaching clinic at the Salpetri⅛re Hospital greatly influenced a generation of students who were des­tined to become leaders in medicine. At the height of his clinical and pedagogic career, Charcot committed his full resources to the vexing problem of hysteria. If successful, one more trophy would be added to his collection that boasted classic descriptions of amyo­trophic lateral sclerosis, multiple sclerosis, tabes, and locomotor ataxia.

Charcot insisted that hysteria was like any other neurological disorder, with a definite, even predict­able, clinical course. The truth of hysteria would surely be revealed once exhaustive clinical observa­tion was combined with the experimental method recently outlined by Claude Bernard. The Salpe- triere provided Charcot with the resources necessary for just this kind of medical campaign: a concentra­tion of scientific equipment and trained personnel to perform exacting measurements and a reliable sup­ply of clinical material. The clinic’s social structure was an equally important factor. The rigorous pro­gram of experimental study that Charcot envisioned necessitated privileged access to human bodies, ac­cess that was of a scale and manner inconsistent with the realities of private practice, where permis­sion would have to be negotiated case by case, if it was obtainable at all. Indeed, Charcot’s experimen­tal protocols called for the incessant monitoring of every conceivable physiological index, including hourly urinary output and vaginal secretions; these humiliations might be followed by the application of painful ovarian compresses. At the Salpetridre, a public charity hospital, Charcot could ignore rebuffs to such requests, for its wards were filled with lower- class women over whose bodies the physician in chief held full dominion.

After some effort, Charcot announced his discov­ery that hysteria indeed had a definite clinical form. A true hysteric attack passed through four complex stages, beginning with Iiysteroepileptic spasm of tonic rigidity and ending with a resolution in grand theatrical movements. Hysteria’s elusive “code” had been broken. At his celebrated clinics, which the elite of Paris attended, Charcot was able to demon­strate the disease in its full glory through hypnotic induction on patients known for their spectacular fits. Because the code was essentially visual, an iconographic reading of the outward manifestations of the body, Charcot devised the technique of making extensive drawings and photographic recordings so that clinicians not present might “see” the disease in its natural progressions.

Charcot’s model Ofhysteria tapped into several cur­rents that aided neurologists in the extension of their social and professional base. With hysteria mastered by science, they now had a justification for reaching outside the walls of the clinic to treat the masses afflicted with its milder forms. Since Charcot’s hyste­ria was constructed in a degenerationist mold, neu­rologists would have a new basis for commenting on such worrisome social problems as crime, adultery, and mob unrest. Furthermore, in the reversal of po­litical fortunes that followed the installation of the Third Republic, secular models of behaviors became useful in anticlerical vendettas. Charcot, for exam­ple, went so far as to identify one type of fit as “reli­gious possession” and to denigrate past examples of stigmata and other miraculous displays as forms of hysteria. Finally, the model provided the first wave of a promised series of incursions by neurologists into a clinical domain that was still dominated by alienists. Charcot, first holder of a French chair on nervous diseases, was establishing the institutional precedent for such an expansion.

Academic Psychiatry

German University Psychiatry and the New Nosology. Through the creation of university chairs of psychia­try, a pattern that began in Berlin (1864) and Got­tingen (1866), Germany soon took the lead in estab­lishing the academic study of mental illness. Unique to the German approach was a psychosomatic orien­tation that held to a fundamental parity between mental, somatic, and even environmental forces and insisted that this parity also be reflected in the rela­tions among academic disciplines. Thus, both psy­chology and neuropathology might be joined in a common medical investigation. Legitimated as an integral part of mainstream medicine, psychiatry also shared in the developments that propelled Ger­many to the position of world leader in medicine by the end of the nineteenth century. Led by Wilhelm Griesinger and then Emil Kraepelin, the German school of psychiatry created a lasting framework for classifying mental disorders.

Griesinger was an accomplished internist who also lectured on medical psychology at Tubingen. Believing that further medical progress in mental disease would not come from asylum managers, who lacked training in recent medical advances, or from academic psychologists, who had no direct contact with patients, Griesinger decided to bring psychiat­ric patients into his own general clinic. Although he was known for his promotion of the doctrine that all mental disease was in fact brain dysfunction, Grie- singer’s major focus was on the process by which a person’s ego, the integrated self, disintegrated. Re­jecting nosological systems based on faculty psychol­ogy, which led to a diverse array of symptom-based disease categories, Griesinger maintained that in­sanity was a single morbid process, differentiated by stages of degeneration. This point was reinforced by his acknowledgment of the inherent closeness be­tween sanity and insanity and of the existence of borderline conditions.

In GriesingeFs approach, a mentally ill person was someone who no longer had the same desires, habits, and opinions and thus was estranged from him- or herself (alienated). This judgment could be made only by reference to a patient’s premorbid life, a history that must include family background, mode of living, emotional state, and even the na­ture of the patient’s thoughts on world affairs. Once a full portrait of the individual was constructed (from in-depth interviews with family and friends), symptoms that at first seemed bizarre were now understandable - perhaps even predictable. More­over, the importance of any specific contributing cause, such as alcoholism or prostitution, could not be ascertained without reference to the individual’s case history. Mental illness originated as a conflu­ence of multiple factors, psychological as well as somatic, that interacted early in life, when char­acter was being formed. Developmental knowledge of mental illness thus was joined to a contextual reading of the patient’s past.

With Kraepelin, the German clinical school of psychiatry reached its zenith. Trained as a neuro­anatomist, an experimental psychologist under Wil­helm Wundt, and a mental hospital physician, Krae- pelin brought a diverse background to the problem of mental illness. Insisting on a combination of neu­rological, neuroanatomic, psychological, and even anthropological studies, Kraepelin held that the case study was the sine qua non of psychiatric inves­tigation. Combining Griesinger’s clinical conception of a unified personality with Rudolph Virchow’s new principle of diseases as separate entities, Kraepelin closed the century with a Classificatory system that has been recognized as the foundation of modern psychiatry.

Where Griesinger blended one mental disorder into another, just as hues subtly progress in a single color spectrum, Kraepelin differentiated conditions on the basis of essential clinical syndromes, as re­vealed by their signs, course, and outcome. Drawing from published case reports as well as his own clini­cal work, Kraepelin grouped Morel’s dementia precoce, Ewald Hecker’s hebephrenia (1871), and Karl Kahlbaum’s catatonia (1874) into a single cate­gory of mental disease termed dementia praecox, which began at puberty and progressed inevitably toward early senility and death. Manic-depression, which was known by its favorable prognosis, and paranoia were identified as the second and third types of major psychosis. Into separate divisions Kraepelin placed the neuroses (hysteria and epi­lepsy), psychopathic states (compulsive neuroses and homosexuality), and states of idiocy. Confusion as to which disease was afflicting a mental patient would not last forever, for it was only a matter of time before the disease would resolve into an endpoint that identified the underlying syndrome. For example, true neurasthenia was rare, since most diagnosed cases were simply early instances of a major psychosis or a complication of a cardiac or bowel irritation.

Clinicians worldwide celebrated the immediate ap­plicability of Kraepelin’s nosology to their practices, for cases of his major syndromes were easily recog­nized in any asylum. Moreover, here was a system of mental disease that was based on the highest stan­dards of clinical medicine, one that incorporated a program for continued empirical revision. Contempo­raries did recognize that Kraepelin’s work, at heart a descriptive system, offered little explanation of mental illness, suggested few novel treatments, and indicated mostly fatalistic prognoses. It was a suffi­cient triumph, however, for Kraepelin to have liber­ated the study of insanity from its ancient classifica­tions of melancholia and mania, as well as from the more recent and confusing additions of partial insanities, which continued to multiply, and of neur­asthenia, which threatened to dissolve all distinc­tions. (In addition, by incorporating a measure of despair into the clinical diagnosis, Kraepelin to some extent relieved asylum psychiatrists of their obligation to cure, allowing attention to be concen­trated on description and study.) Accurate diagnosis was to be the avatar of the new scientific psychiatry.

The Problem of the New Science. We have thus seen how, in the second half of the nineteenth century, the great social interest in the problem of mental afflic­tions, mild as well as severe, was met by an equally strong response from a broad array of learned disci­plines. Both inside the asylums and outside, a vast terrain of clinical problems was opened for cultiva­tion by practitioners and researchers representing diverse specialties. Since the late Victorian era was the period in which science and medicine forged their modem image as engines of power, faith grew that even problems as elusive and intractable as mental illness might be mastered by empirical inves­tigation. Moreover, positioned at the nexus of major social and scientific concerns, the mystery of insan­ity gained a special poignancy. As human beings were increasingly revealed to be products of nature, and a nation’s destiny a matter of its biological as well as cultural heritage, the unnatural in humans became a counterpoint to the advance of civilization. Merged together were issues of brain and behavior, willpower and productive vitality, and even national harmony and international struggle. In this context, the derangement of an individual was a sign of a larger social decay, which required immediate solu­tion by the new hero of civilization, the scientist.

The joining of the new medical science to the prob­lem of mental illness was extremely problematic, however, for several reasons. First, there was no one specialty that controlled the field. The profession of psychiatry is a creation of the twentieth, not the nineteenth, century. As we have seen, alienists and the various types of neurologists each brought to the subject their distinct professional agendas, resulting in the proliferation of widely varying conceptual ori­entations. In practice, no single model proved able to bridge the gulf between the disorders that appeared in the asylums and those that surfaced in everyday life.

Second, scientific models of brain and behavior were in transition, proving to be fickle sources of legitimation. Although a new form of scientific knowledge can confer respectability on a particular specialty, the benefit is not permanent. The alienists of the early nineteenth century, who had predicated their expertise on the presumption that lesions of the brain affected specific mental functions, found their prestige fading as neuroanatomic findings failed to confirm their theory. The introduction of the degenerationist model extended the reach of alienists outside of the asylum, but did little to allow the new medical science to peer within it.

Private-practice neurologists were all too happy to point out, soon enough, that alienists in their splen­did isolation had let the latest science pass by. To bolster their own status as experts, they pointed to new theories of an integrated nervous system that supported their reading of the constitutional haz­ards of particular life-styles. Beard’s model of neuras­thenia drew strength from its equal mixing of na­ture and nurture, whereby a single disease category contained an expansive matrix of moral and biologi­cal elements, a framework that empowered the clini­cian to intervene as both counselor and scientist. In due course, however, this approach was undermined by the further elaboration of the brain’s fine struc­ture and a new emphasis on specific disease entities. Further knowledge of nature had constrained nur­ture’s sphere of influence.

Third, science often creates or distorts the very objects it putatively observes. This simple fact led to subtle, unintended consequences in the arena of men­tal disorders. For example, Charcot discovered this paradox, to his misfortune, yielding one of the grand ironies in the development of the human sciences. In the rigorously controlled order of the neurological ward, Charcot’s patients were indirectly cued to pro­duce symptoms in the exact sequence and form pre­dicted by his theory. When it became clear that only patients in the Salpetriere manifested “pure” hyste­ria, contemporaries soon ridiculed Charcot for perpe­trating theatrical creations as true clinical syn­dromes. In his original act of constructing hysteria as a regular neurological syndrome, Charcot had already set in motion his own undoing.

Another example is provided by the difficulties of private-practice neurologists in confronting neuras­thenia. Beard and his followers, unlike Charcot, did not create their patients’ symptoms outright, but they did fall into a different kind of trap. Patients termed neurasthenics had come to these physicians with an array of mysterious, but nonetheless truly bothersome ailments. Neurologists were thus in the position of having to construct a new reality out of the material presented to them, a role that was becoming increasingly common in the nineteenth century as science-based professions were expected not only to manipulate nature, but to construct a new map of reality itself. However, the very act of legitimating the patients’ complaints as a new disease trans­formed the delicate social balance of what was at stake in the symptoms. Indeed, as Mitchell realized, the dynamics of the patient-physician relationship was itself somehow related to the expression of the disorder. Since the organic models of disease provided no means of recognizing these secondary effects, neu­rologists were forced to belabor a theory whose very dissemination had changed the clinical reality under observation. How to integrate the psychological di­mension of mental disorders within a scientific frame­work remained a confounding problem.