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. Within this context, all that held back or confounded the development of civilization - whether particular individuals or society as a whole - came under heightened scrutiny, a problem to be solved by the reasoned application of science and medicine. Madness, or, as some might put it, "unreason," stood out as a dark challenge to the light of progress. Indeed, this was the era in which physicians discovered that the insane presented a significant and distinct institutional population, one amenable to medical intervention; that society was wracked by distressing conditions composed of psychic as well as physical ailments; and that the source of most diseases was traceable to the newly dissected nervous system. Because of the numerous ties forged between medicine and the problem of insanity, many consider the modern concept of mental illness to have been itself an Enlightenment product.

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. (Later, Pinel's nosological stance would revolutionize general medicine.) Mental illness resulted when persons of unfortunate hereditary stock were overwhelmed by their social environment, poor living habits, a disruption in routine, or unruly passions. Physical factors, such as brain lesions, fever, and alcoholism, were thought possible but not as common as "moral" or psychogenic factors. Asylum statistics revealed that mental illness was, surprisingly, an intermittent or temporary condition, curable if treated before it had a chance to become somatically ingrained. The physician's best weapon was discovered to be the hospital itself, for its strict regimens were the very tools by which the superintendent might instill into his charges an inner discipline, emotional harmony, and the habits of productive citizenship. In linking, in one stroke, progressive reform to medical advance and, in another stroke, the stability of a patient's inner psychic milieu to the proper management of the external hospital environment, Pinel set in motion the optimistic expansion of institutionally based psychiatry.

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. Physicians, in reaching out to asylum inmates through an expanded medical view of insanity, were at the same time complicit in cementing the new political realities. Pinel may indeed have rescued asylum inmates from base neglect, but the benevolent paternalism of the "clinical gaze" has had its toll. Henceforth, "modern man" is enslaved within a medicalized universe, for there can be no form of protest that cannot be interpreted, and thus dismissed, as pathological in origin.

Foucault's approach has since been shown to be not wholly satisfactory. True, 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 oc curred 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 currents 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 hypochondriacks - 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 func tion, 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. As it happened, when elite physicians looked to the hospital infirmary for new sources of medical advance, they were confronted with the realities of the sick poor. Institutional portraits of disease thus clashed with those derived from private practice - the democratization of hysteria and hypochondriasis was but one consequence. The poor, for their part, had discovered that the nervous disorders served as entry tickets to one of the few sources of medical charity then available.

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 HI 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 célébré 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.

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