Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France: Volume 4 (Medicine and Society) - Hardcover

Dowbiggin, Ian

Hardcover

ISBN 10: 0520069374 ISBN 13: 9780520069374

Publisher: California University Press, 1991

Synopsis

Historically, one of the recurring arguments in psychiatry has been that heredity is the root cause of mental illness. In Inheriting Madness, Ian Dowbiggin traces the rise in popularity of hereditarianism in France during the second half of the nineteenth century to illuminate the nature and evolution of psychiatry during this period. In Dowbiggin's mind, this fondness for hereditarianism stemmed from the need to reconcile two counteracting factors. On the one hand, psychiatrists were attempting to expand their power and privileges by excluding other groups from the treatment of the mentally ill. On the other hand, medicine's failure to effectively diagnose, cure, and understand the causes of madness made it extremely difficult for psychiatrists to justify such an expansion. These two factors, Dowbiggin argues, shaped the way psychiatrists thought about insanity, encouraging them to adopt hereditarian ideas, such as the degeneracy theory, to explain why psychiatry had failed to meet expectations. Hereditarian theories, in turn, provided evidence of the need for psychiatrists to assume more authority, resources, and cultural influence. Inheriting Madness is a forceful reminder that psychiatric notions are deeply rooted in the social, political, and cultural history of the profession itself. At a time when genetic interpretations of mental disease are again in vogue, Dowbiggin demonstrates that these views are far from unprecedented, and that in fact they share remarkable similarities with earlier theories. A familiarity with the history of the psychiatric profession compels the author to ask whether or not public faith in it is warranted.

About this title

About the Author

Ian Dowbiggin is a Professor of HIstory at the University of Prince Edward Island.

Excerpt. © Reprinted by permission. All rights reserved.

Inheriting Madness: Professionalization and Psychiatric Knowledge in Nineteenth-Century France

By Ian Dowbiggin

University of California Press

Copyright © 1991 Ian Dowbiggin
All right reserved.
ISBN: 0520069374


Introduction

If cancer is arguably the disease of the twentieth century, then it is equally arguable that mental illness was the disease of the nineteenth century. Or so thought the French republican deputy Léon Gambetta. Speaking before the Corps législatif on 21 March 1870, Gambetta claimed that public concern over the rising number of hospitalized lunatics and the incapacity of asylum psychiatrists to tame insanity was mounting "to the point," he stressed, "where madness seems to be the disease of the century."1 Gambetta may not have been far wrong. Like cancer in this century,2 mental illness in the nineteenth century sparked public fear and revulsion and symbolized mystery and the limits of human power. Physicians knew little about what caused it, what its ultimate nature was, or how to cure it, but they still insisted that the best interests of those who suffered from it were served by early diagnosis by members of organized medicine. Psychiatrists accused nonmedical people who tried to treat it of quackery and ignorance. They argued that mental disease was caused neither by sin nor by personal moral failure, yet they themselves relied on naturalist explanations that ultimately blamed individual life-style for mental illness. These and other contradictions in medical thinking about madness did not escape the notice of people like Gambetta, who concluded that psychiatrists posed a grave threat to public health, self-reliance, and individual freedom.

No theory of mental disease enjoyed as much popularity in the nineteenth century as that of mental degeneracy.3 According to this theory certain families suffered a steady though not necessarily irre-

versible hereditary deterioration over the course of four generations. These families customarily displayed symptoms such as moral depravity, mania, mental retardation, and sterility. Physicians ascribed a variety of causes to degeneracy, including alcoholism, immorality, poor diet, and unhealthy domestic and occupational conditions. However, the principal cause of degeneracy that physicians cited was heredity. Indeed, so strong was the tendency of French mental doctors to regard heredity as a causal factor that they commonly considered mental degeneracy to be simply hereditary weakness, a belief reinforced by the absence (until the end of the nineteenth century) of any clear distinction between innate and acquired characteristics. Thus degeneracy and heredity were virtually synonymous for many French psychiatrists—or "alienists," as they liked to call themselves.4

The doctrine of hereditary degeneracy was first formulated in the 1850s. It drew increasing attention for the next twenty-five years and enjoyed its greatest popularity in the 1880s and 1890s. After 1900 its popularity waned, yet for the physician Georges Genil-Perrin, a positivist, early twentieth-century French psychiatrist, its rise to prominence represented a progressive step in the early history of psychiatry. With the notion of hereditarianism, he argued, mental medicine liberated itself from "metaphysics" and theology and took its place among the other "positive" sciences. As a result, he also argued, psychiatry's fortunes improved considerably, a process smoothed by the fact that degeneracy theory enjoyed widespread public favor.5

It is somewhat surprising, then, that there has been no historically comprehensive account since Genil-Perrin's of this major chapter of psychiatry's intellectual past.6 This study is intended to fill this gap. Like Genil-Perrin, I shall describe the origins and the evolution of hereditarianism from roughly the mid-1800s to the fin de siècle period, with particular attention to the history of degeneracy theory. Unlike Genil-Perrin, who predictably interpreted matters from the perspective of an early twentieth-century psychiatrist proud of his profession's accomplishments, I shall show that his positivist interpretation does not do justice to the historical reality of nineteenth-century asylum medicine. Genil-Perrin believed that the "liberation" of psychiatry from "metaphysics" and theology was part of a simultaneous improvement in psychiatric

knowledge. Yet after over 150 years of pathoanatomical, biochemical, and physiological research, the same nagging obscurities characterize the domain of mental medicine: somatic pathology is still unclear; "etiology remains speculative, pathogenesis largely obscure, classification predominantly symptomatic and hence arbitrary and possibly ephemeral; physical treatments are empirical and subject to fashion, and psychotherapies still only in their infancy and doctrinaire."7 In 1975 a leading American psychiatrist agreed, stating that mental medicine had yet to reach "an understanding of the basic causes and mechanisms" of psychosis and neurosis.8 If, then, psychiatry's fortunes rose between 1850 and 1900 by virtue of its adoption of degeneracy theory, its progress was not based on a precise understanding of insanity or improvements in the treatment of madness; its shifting status as a medical specialty derived instead from a complex conjuncture of sociopolitical, cultural, and professional circumstances.

What led to the shift toward degeneracy theory? The answer is in part related to the emergence of French mental medicine in the middle third of the nineteenth century as a distinct medical specialty. In the preceding two hundred years insanity had been regarded as a form of social deviance. The insane were housed with beggars, abandoned children, criminals, and prostitutes in general hospitals, created by royal edict in 1662 as a combination workhouse, prison, old people's home, orphanage, and reformatory. Michel Foucault has described the creation of the general hospitals throughout France as "the great confinement" because they constituted an institutional answer to the problems of social deviance in the seventeenth and eighteenth centuries.9 By the nineteenth century the insane were distributed randomly throughout the general hospitals, prisons, poorhouses, and religious hospices of each département . In Paris the medical profession finally began to assume custodial responsibility for the mad during the Empire (1804–1815) and Restoration (1815–1830), yet it was not until the July Monarchy (1830–1848) that doctors outside Paris took a serious interest in the institutionalized insane. Even in early nineteenth-century Montpellier—whose school of medicine was second only to that of Paris in prestige—doctors had tended to ignore the institutionalized lunatics of the city until a pupil of the celebrated psychiatrist J. E. D. Esquirol arrived in 1821 to refurbish the existing

insane asylum in accord with Philippe Pinel's "moral treatment."10 Moral treatment, a form of therapy based on a faith in the healing powers of nature and a rejection of drugs and physical restraint, held that mentally ill persons could regain their senses most quickly if removed from their everyday environment and placed in institutions specially designed to soothe their feelings and protect them from upsetting stimuli. Both because it appeared to be a benevolent way of treating madness and because it endorsed institutional isolation for people who threatened social order, moral treatment encouraged French legislators to pass the Law of 30 June 1838. This law establishing the guidelines for the national system of public asylums accelerated medical involvement in the custodial care of the insane and also marked the beginnings of the psychiatric profession as a corps of state functionaries entrusted with the institutional study and cure of mental disease.

Psychiatry's future looked promising by 1840. Physicians attracted to the study of lunacy willingly accepted the challenge to eliminate the punitive and often barbaric methods that previous custodians of the mad had employed. However, there were clouds on the horizon. With the decline of pathological explanations based on localized structural damage to the body's organs and the rise of medical theories emphasizing functional processes, many doctors began to question their belief that madness had a physical basis. This questioning was potentially calamitous for alienists. If madness and its mood disorders were primarily psychological phenomena without discernible physical lesions, then there was no rationale for exclusively medical intervention in cases of mental derangement nor for claiming that alienists rather than academic psychologists were uniquely qualified to distinguish a morbid mental state from genius or simple eccentricity. These psychiatric difficulties were compounded by the rise in the 1860s of a predominantly lay movement that questioned the need for large, medically supervised asylums as the principal form of public assistance to the insane. These factors combined with a persistent popular and juridical suspicion of psychiatric views on criminal responsibility to convince asylum physicians of the need for a cognitive model of pathology to legitimize their diagnostic, therapeutic, and social approaches to madness.

Philosophic and sociopolitical considerations exacerbated psychi-

atry's troubles. Throughout the century French scholars wrote extensively on the relationship of body to mind. As physicians of mental medicine, psychiatrists were unavoidably implicated in this debate, which many entered in the middle third of the nineteenth century. Some adopted the physiological argument that even the highest mental functions were governed by the natural laws that governed organized matter; others took the more orthodox spiritualist position that these functions were ultimately independent of organic processes. As a result, rifts developed within the profession. When the Catholic reaction of the Second Empire (1852–1870) made the mind-body debate all the more germane, these rifts became a source of embarrassment for psychiatrists because they highlighted fundamental differences of opinion within a group of physicians who were adamantly trying to convince others that they constituted a learned profession united by a scientific body of knowledge. Clericalist attacks during the Second Empire on those who cultivated secular approaches to knowledge also disquieted psychiatrists whose medical training automatically made them suspicious to Catholic officials. Psychiatric anxieties about the possibility of persecution only began to diminish with the end of the monarchical threat to the Third Republic in 1877 and the rise to power of politicians sympathetic to the ideology of naturalist science. By then, however, psychiatrists had developed a wary attitude toward their political and social environment. They came to believe that their claims to expertise were threatened by popular forces inimical to their naturalist and rationalist world view.

I shall contend that it was this profound sense of defensiveness and insecurity that led to the widespread psychiatric acceptance of degeneracy theory in the final third of the nineteenth century. Hereditary degeneracy theory provided asylum physicians with a unitary concept that encompassed pathological behavior and affect in psychological, biological, and social terms.11 It was remarkably eclectic and free-ranging in scope: because it incorporated so many aspects of behavioral and biological sciences under one rubric, it was ideal for disguising the inconsistencies and anomalies of psychiatric knowledge while strengthening physicians' claim to expertise. As a principle for classifying mental diseases, the theory enabled psychiatric clinicians to depict themselves as scientific because it was seemingly based on the etiological notion that there

was a physical cause of insanity: heredity. Degeneracy theory could claim to be both

scientific and somatic; it led to treatments that were moral and were conveyed as such; and it brought the phenomenon of madness into contact with the social world. . . . Above all, it was comprehensible. Its advocates and its converts promised to provide at a stroke solutions to the mysteries of character, personality, talent or the lack of it, crime, and madness.12

Just as important, degeneracy theory and the hereditarianism it spawned constituted an intellectual model that in France, as in nineteenth-century America, imposed "a consoling order upon a continually shifting reality."13 These features of degeneracy theory enabled the psychiatric community to gain the turn-of-the-century confidence and relative unity that Genil-Perrin observed.

Yet psychiatrists did not conjure up hereditarian ideas out of nowhere. Hereditarian theory was used in much of contemporaneous French medicine, especially with respect to constitutional and chronic diseases; it corresponded to the prevailing interest in evolutionary biology and anthropology and blended nicely with the more general attitudes toward crime, psychology, and politics pervading French culture near the end of the century. Thus the nineteenth-century French psychiatric fondness for the theory of hereditary degeneracy largely derived from the attempt to solve professional difficulties by adopting a popular biomedical, philosophic, and cultural concept.14 Intellectual accomodation played at least as large a role in the development of French psychiatry between 1840 and 1900 as did intellectual struggle. The way in which psychiatry developed from an uncertain medical specialty linked to political heterodoxy to a generally accredited medical practice can best be understood in the context of the social and scientific changes in France during the same period.

One organization in particular played a crucial role in this historical process: the Paris-based Société médico-psychologique. Its journal, the Annales médico-psychologiques , was launched in 1843, the first exclusively psychiatric journal in France. The Société itself was founded in 1852, after an attempt to found such an organization in 1848 had failed, and soon boasted the membership of virtually all the prominent figures in French psychiatry. The Annales médico-

psychologiques quickly became the forum for France's leading alienists and featured articles on a wide range of issues dealing with psychopathology. The minutes of the Société's meetings, published in the Annales , provide a revealing look at many of the physicians who staffed the asylums of France. The Annales served as the mouthpiece for the Société and consequently for the entire community of French psychiatrists. No other contemporary association or journal could claim the allegiance of so many preeminent medical men.15 Therefore, it was an excellent barometer of French psychiatric attitudes toward French society, general medicine, and the subgroups that made up the psychiatric profession itself.

The Société médico-psychologique is the focus for this study. No other treatment of nineteenth-century French psychiatry has been based on an organization so clearly representative of French alienism as the Société médico-psychologique.16 Biographical material pertaining to some of the Société's central figures provides insight into how theories of insanity were influenced by professional and political motives. Although I stress external factors and their impact on psychiatric thinking, I do not wish to suggest that personal motives are inconsequential. As one historian has written:

Rejecting deterministic interpretations of the sociology of knowledge, I nevertheless believe that things like social structures, institutional constraints, and professional role models more or less strongly bias someone working within their sphere of influence to hold or not to hold certain basic attitudes towards knowledge. Yet in the final analysis it is the individual who, consciously or unconsciously, chooses from among the available alternatives in dealing with the particular problems he faces. . . . [S]ocial forces do not translate in some magical or inexorable way into attitudes held. Rather, it is the negotiating individual who must lie at the epistemological center of any nondeterministic sociology of knowledge. Somehow our notions of the relevance of the social context of scientific activity, and hence our theories about that nexus, must be rich enough to allow for both widespread attitudinal conformity and individual variance.17

The experience of French psychiatry in the nineteenth century is an important chapter in the relatively new field of the history of the professions.18 I shall use S. E. D. Shortt's definition of professionalization as "a process by which a heterogeneous collection of individuals is gradually recognized, by both themselves and other

members of society, as constituting a relatively homogeneous and distinct occupational group."19 Professionalization entails the process whereby occupational groups seek to sharpen the boundaries between themselves and other groups through special licensing and standardized training, to restrict the practice of specific skills to certain occupational groups, and to augment the services the groups provide to society. All these elements of professionalization apply to nineteenth-century psychiatry. Psychiatrists discovered early in the century that as physicians they had been granted important privileges in the diagnosis and treatment of madness, even though they had displayed no conclusive competence in either capacity. The professional history of psychiatry in France for the rest of the century is essentially the story of how physicians developed forms of knowledge that obscured this embarrassing gap between social power and technical effectiveness. This endeavor was crucial not just for the defense of psychiatric prerogatives but also for the expansion of medicine's authority into areas of practice dominated by lay men and women.

The history of psychiatric knowledge also reflects the social marginality of asylum physicians. While the history of the professions of western Europe since the French Revolution may be a success story, success for French physicians was not easily achieved.20 Although they had been granted a medical monopoly by Napoleon in 1803, most doctors, "continued to view themselves as an unappreciated and insufficiently rewarded occupational group within French society" until the end of the century.21 As members of the medical profession, then, alienists were part of a socially marginal group; and as members of a barely accredited branch of medicine, they were "marginal twice over."22 Professionalization was intended to mitigate the effects of marginality, and the construction of a body of knowledge such as degeneracy theory played a critical role in this process. By depicting themselves as proponents of the most up-to-date ideas of biological science, psychiatrists could uphold their claims to specialized expertise and gain the approval of powerful social groups whose interests were safeguarded by asylum alienists.23 Government policy makers and the ruling middle class in France were receptive to appeals to the moral influence of science, and psychiatric support for hereditarian concepts like degeneracy theory convinced them that alienists were the professionals most

capable of identifying and treating the pressing psychological problems bred of industrialization and social dislocation.24 Thus, psychiatric thinking mirrored the concerns of France's ruling elite. Indeed, it did more; it naturalized class divisions and reinforced the social organization of acceptable forms of knowledge.25

My interpretation of French psychiatric ideas between the last years of the July Monarchy and World War I stresses the ways in which the alienists of the Société médico-psychologique tried to come to terms with the shifting political and cultural forces that tended to isolate psychiatrists as a professional group. In particular, the antipsychiatric press campaign of the 1860s prompted alienists to mobilize to cover psychiatry's vulnerable flanks while also encroaching upon spheres of authority enjoyed by priests, nuns, lawyers, and lay scholars. By the 1870s the psychiatric community was eager to adopt a clinical model of mental pathology that would assure other doctors and the state that alienists possessed special knowledge that proved the biological reality of mental disease and authorized psychiatrists to "refer simultaneously to the experienced mental state and its underlying physiological counterpart."26 The theory of mental degeneracy was ideal as a model of pathology because it translated cultural and scientific themes into a neutral idiom while justifying the socially utilitarian role of the asylum doctor. Psychiatric theory in late nineteenth-century France was intended to stem the alienation of alienists, increase their acceptance as expert professionals, and disassociate them from a past characterized by wrangling, failed therapies, public hostility, and political heterodoxy.

My interpretation generally agrees with Jan Goldstein's in Console and Classify (1987). Goldstein maintains that the history of French psychiatric ideas such as hysteria and monomania demonstrates that from the beginning to the end of the century French alienists were engaged in a "bid for power through psychiatric knowledge," a project to expand the professional authority of psychiatry through the pursuit of secular and anticlerical goals.27 There was also an anticlerical element in degeneracy theory because its characterization of madness as a biophysical phenomenon authorized alienists to override the religious orders who competed with medicine for control of mental hospitals.

However, anticlericalism was not the only important element of

psychiatric theory in nineteenth-century France. Goldstein minimizes or overlooks the significance of factors that are emphasized here—the revival of "moral treatment" in the 1840s, the physicalist orientation of mental medicine, the role of the Société médico-psychologique, the antipsychiatric movement of the 1860s, the conflict between alienism and academic psychology, tensions between psychiatry and mainstream medicine, and the rise of hereditarianism and degeneracy theory between 1850 and 1914. These factors were crucial because they compelled alienists to reassess their relations with the state, the public, other doctors, and other professionals.

Intent on establishing the proposition that only alienists were capable of diagnosing and treating insanity, psychiatrists in the late nineteenth century were also determined to cultivate an image of political disinterest and neutral expertise. This attitude to a large extent resulted from the alienists' difficulties adjusting to the shifting political winds of France from 1815 to 1871. By posing as specialists with unique insights into matters relating to social policy, they hoped that their services would appear to be indispensable to a state increasingly obsessed with class friction, crime, and the defense of the family. True to the positivist notion that class conflict was ultimately regressive and stemmed from mass ignorance, alienists tended to view themselves less as ideologues and more as scientifically trained, clinically experienced civil servants who practiced their craft in public institutions. It was in this sense that French alienists sought to professionalize in the period preceding World War I. The politics of social defense overshadowed anticlericalism in the medical "bid for power through psychiatric knowledge."

Continues...

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Edition details

• Publisher: California University Press
• Publication date: 1991
• Language: English
• ISBN 10: 0520069374
• ISBN 13: 9780520069374
• Binding: Hardcover
• Number of pages: 227