The Enlightenment

The eighteenth-century period of the Enlighten­ment has been characterized as the Age of Reason, when the powers of mind reached out to command both nature and human affairs. The goal was the perfectibility of “man” and of “man’s lot” on earth, and the means to this end was rationality tempered by direct observation.

In traditional histories, modern psychiatry dawns with the legendary moment in 1795 when Philippe Pinel, chief physician of the Salpetriere asylum for women, struck the chains from the inmates. The mad were no longer to be considered mere brutes deprived of reason, amusing grotesqueries, but as afflicted persons in need of pity, humane care, and enlightened physic.

Applying the principle of direct clinical observa­tion, Pinel reorganized categories of mania, melan­cholia, dementia, and idiocy to reflect specific, identi­fiable symptom clusters derived from his cases. For example, he distinguished between mania with delir­ium and mania without delirium - a disturbance of will without intellectual deficit.

Recent critics, such as Michel Foucault, view Pi- nel’s accomplishment less favorably. Physical chains were indeed removed, but only to be replaced by internal ones, more insidious for their invisibility - shame and guilt can be just as constraining as iron. Through the guise of humane treatment, patients were coerced into conforming to putative “normal,” “healthy” standards of conduct. Moreover, critics like Foucault hold, it was no accident that insanity was placed under the purview of the large central­ized institutions of Paris, since Pinel’s model fit well with the demands of the emerging political order. The growing asylum populations were themselves only a part of a larger phenomenon. Those who, for whatever circumstances, failed to fulfill their duties as citizens within the new state became managed increasingly through civic institutions, be they alms­houses, jails, workhouses, hospitals, or asylums.

Foucault’s approach has since been shown to be not wholly satisfactory. Tme, it was in this period that the institutional face of insanity was dramati­cally revealed. The pattern is not uniform, however. The model works best in such contexts as France and Germany, where larger asylums for the poor evolved within a spirit of centralized authority and medical police. By contrast, in England, such growth oc­curred mostly in the small private asylums patron­ized by the higher classes, which were directed by lay as well as medical superintendents. The forma­tion of relations between nascent psychiatry and its clientele remains a complicated, poorly understood story. Clearly, though, the growing institutional populations sharply focused both social and medical attention on severe madness as a problem requiring solution.

An exclusive concentration on the institutional history of psychiatry may also obscure the broader social Cinrents that already were greatly expanding the concept of mental illness. Milder forms of insan­ity, such as hypochondriasis and hysteria, had by Pinel’s day gained a status as the period’s quintes­sential medical complaint. These conditions, also known as the vapors, spleen, melancholy, or later “nerves,” referred to an irksome cluster of psycho­logical and somatic (especially gastric) complaints, ranging from ennui to flatulence. Through such works as Richard Blackmore’s Treatise of the Spleen and Vapours (1725) and George Cheyne’s The En­glish Malady (1733), the valetudinarian “hypochon- driack,” known by oppressive moodiness, oversensi­tive skin, and bad digestion, became enshrined as a stock Enlightenment figure.

The arrival of the “nervous” disorders coincided with the emergence of new social functions for the concept of mental illness. Woven out of the perceived interactions between psyche and soma, tempera­ment and life-style, such conceptions offered a fac­ile interpretative matrix for connecting to issues that stretched beyond personal health. In particular, members of polite society found in the “hypochon- driack” disorders a rich social resource. Such com­plaints enabled one to mull endlessly over the minor discomforts of life and were also a self-replenishing well for claims on others’ sympathy. But they served a more subtle function as a conspicuous indicator of social location, for those believed at risk for the ailments were only those of a truly refined and ex­quisite temperament. In the words of the Encyclope­dia Brittanica (1771), hypochondriasis was a “pecu­liar disease of the learned.” Indeed, James Boswell wrote that the suffering Iiypochondriacks - himself included - might console themselves with the knowl­edge that their very sufferings also marked their superiority.

When “furious distraction” or severe mania was the hallmark of the psychically afflicted, the designa­tion of insanity was tantamount to banishment from normal society. In contrast, hypochondriasis was a form of social promotion. There was a collective func­tion, too. Contemporaries explained the dramatic outcropping of the malady as a direct consequence of the unnatural circumstances imposed by the new urban, “civilized” life-style. Sedentary living, rich food, populous towns - all were thought to exact a toll, the price of progress. In short, through the innu­merable discourses on hypochondriasis, the anxi­eties and ambivalences of a rising class found a favorite means of expression.

The new power of the disease categories did not remain for long the exclusive property of the higher classes. By the end of the eighteenth century, physi­cians were chagrined to find that tradesmen and domestic servants were equally likely to exhibit hypochondriack or hysteric complaints.

The popular appeal of the new concepts of mental illness must also be attributed to developments in medical research and theory that stressed the impor­tance of the nervous system to all pathology and that presumed a psychosomatic model of interaction be­tween mind and body. The trend stems from Willis, who looked to the brain as the fundamental organ; his model, though, remained humoral, based on poi­sonous “nervous liquors.” As the extensions of the nervous system became further elaborated in the eighteenth century through the work of Giovanni Morgagni, Albrecht von Haller, and Robert Whytt, a new medical system appeared that was based on the “irritability” and “sympathy” of the muscles and nerves. The renowned Scottish physician William Cullen went so far as to declare that the majority of all diseases were caused by either too much or too little nervous “tone,” a pathological condition that he termed a neurosis. Neuroses, as defined by Cul­len, were afflictions of sense and motion that lacked fever or localized defect - a “functional” as opposed to structural condition. Subsumed within this new category were such afflictions as hysteria, epilepsy, tetanus, asthma, and colic. (Cullen’s model of neuro­ses persisted well into the late nineteenth century.) Through Cullen and his followers, the nervous sys­tem was elevated to central importance within physi­ology, pathology, and nosology, laying the conceptual groundwork by which general medicine was to break away from the neohumoral systems that had domi­nated since the Renaissance.

Cullen’s nosology, in which diseases were classi­fied on the basis of the patient’s presenting symp­toms, be they physical or mental, was essentially psychosomatic in orientation. Medical interest in the inner contents of self also followed in the wake of Lockean theorists who were building a new psychol­ogy of mental associations, and of William Battie and others of the eighteenth century who were ex­ploring the role of the passions in determining men­tal and physical harmony. Perhaps the best example of the strength of the psychosomatic model can be seen in the heroic treatments of the insane, which included the notorious dunking chair. This interven­tion was not simply an expression of random cruelty or cultural atavism. Rather, it was a logical product of the belief that mental shocks were akin to physio­logical action, with effects as powerful as those in­duced by bleeding or purging. Terrifying the mind was a medical recourse used for a broad range of pathological conditions.

To explain the proliferation of the psychosomatic model in this period, sociologists and historians look to the nature of the patient-physician relation­ship. Because medical practice consisted of private consultations, where physicians were dependent on satisfying the whims as well as the needs of their wealthy patrons, medicine was patient-oriented. Treatment was formulated to satisfy the client, a tailored reading of life-style, circumstances, and habits, with heroic treatments applied in response to demands for dramatic action. Similarly, Cullen’s symptom-based nosology was based not on direct physical examination - the physician’s own do­main-but on patients’ descriptions of their com­plaints. Given these circumstances, it was the total­ity of the sick-person’s experience that gave unity to the day’s medical theories, a phenomenological ori­entation in which psychic complaints were on a level ontological footing with somatic disturbances. Medical priorities - and hence realities - were thus set by what patients considered bothersome. We must remember that physicians as professionals were only then developing an institutional base, such as the hospital, wherein they might control their patients and establish internally derived stan­dards of research and treatment.

Finally, the ties forged between the problem of mental illness and medicine must be placed in the context of the new social meaning of health and the expansive role of physicians in the Enlightenment. Historians have described how in this period health itself become a goal, if not an obligation, for individu­als and society to pursue, a secular gauge of progress that could be accomplished in the here and now. In response to a thirst for practical knowledge, medi­cine was “laid open,” translated from Latin texts, and popularized in an explosion of pamphlets and health guides. Health as a commodity generated a tremendous market for physicians’ services and, in the age of Franz Anton Mesmer and electricity, for any treatment remotely fashionable. Psychic disor­der was a particularly fertile niche for physicians to exploit. This was especially true after it was linked by the neurosis model to a broad range of everyday conditions and once its curability in even severe forms was demonstrated. (The work of Pinel and the dramatic turnabout in behavior of mad King George ΠI was particularly effective in this regard.)

Medicine, defined as keeper of the welfare of the human race, extended far beyond matters of individ­ual treatment and grew into an Enlightenment meta­phor for broad political reforms. Guiding thinkers such as the philosophes saw themselves as nothing less than medical missionaries who cured the ills of society itself. Since the individual was a product of society and nature, the science of physiology came to signify the proper functioning of the social as well as individual body. Moral philosophy and biology joined in the new science of man; theories of the perfectibil­ity of human society were interlaced with secular theories of health. Thus, Pinel’s striking of the chains was understood to be as much an act of civic benevo­lence as the first step of a new “medical” approach. Medical progress and benevolent reform commin­gled, a shared task. Furthermore, the problem of men­tal illness and the proper development of mind were of special fascination in an age obsessed with how reason was self-consciously mastering nature and re­constituting society. Through a cause cel6bre like the case of the Wild Boy of Aveyron, the original feral youth, and the contention of Pierre Cabanis that the brain excreted thought like the liver excreted bile, the belief was growing that the forward movement of civilization might depend on scientific forays into the darkness of human pathology.

In sum, madness during the Enlightenment be­came a central cultural concern. Mental afflictions were newly visible in the asylums, in the rise of hypochondriasis and related disorders, and in the investigations into the functions of the nervous sys­tem. With the expansion of the concept of mental illness to include conditions that were not drasti­cally removed from everyday experience and that were considered amenable to medical intervention, mental afflictions became important social resources for the expression of individual and collective anxi­eties. Physicians discovered in the growing popular­ity of these conditions not only a fresh source of patients and an institutional base, but new service roles for themselves as social critics and experts — madness became the very measure of civilization. Thomas Trotter, enlarging on the work of Cheyne, claimed that the nervous diseases resulted when citi­zens’ life-styles and occupations did not fit their constitutions and temperament. He warned that En­gland, owing to a combination of its peculiar cli­mate, free government, and wealth, was the most threatened country. The survival of civilization, with its complex social differentiation of labor, de­pended on the decreasingly likely event of persons working within their proper stations in life - lest the nation degenerate into one of idiots and slaves. Physicians bore the responsibility for “diagnosing” the need for adjustments in the biological - and social - hierarchy.

We must not, however, overstate the extent of in­sanity’s “medicalization.” Persons were transported to asylums not so much because medical treatment was considered necessary as because these people were perceived to be dangerous or incompetent. The insanity defense had become an increasingly popu­lar resort in criminal trials, yet the examination of a defendant’s mental status was as likely to be per­formed by a lay authority as by a medical one. And there existed as yet no professional grouping of psy­chiatrists, let alone regular physicians, who had spe­cialized knowledge of the insane. The concept thus remained a product mostly of general culture, trans­parent for all to read and make judgments upon.