To 1850

In the first half of the nineteenth century the treatment of mental illness was marked by two trends: a wave of asylum building and the differentiation of a small band of medical professionals who claimed mental disorders as their special domain. These two developments were linked through a materialist model of mental physiology that had reformist connotations and the arrival of new categories of mental illness that advanced the value of psychiatric expertise.

Written as only a modest, local report of the way Quakers cared for their small number of lunatics, Samuel Tuke's Description of the [York] Retreat (1813) nevertheless launched a worldwide movement of asylum construction. In this system of care later known as "moral treatment," the asylum was envi sioned as a functional microcosm of society at large where troubled persons might reconform to proper social behavior through a vigorous program of occupational therapy and moral suasion. Chains were to be replaced by admonitions, bars by comfortable furnishings, and the inmates' mania quelled by distracting amusements. In the words of John Connolly, an asylum pioneer known for his popularization of the "nonrestraint" method, the combined psychological effect of enlightened architecture and behavioral management had rendered the asylum a "special apparatus for the cure of lunacy." Originally designed for fewer than 30 patients, the new asylums were artificial family environments, heavily dependent on the talents and personality of the superintendent. His burdens included intimate contact with patients and their families; the judicious meting out of an array of mild rewards and punishments; and immediate attention to the smallest administrative problem. A commanding presence, diplomacy, boundless sympathy, worldly wisdom, moral probity, and frugality were all characteristics essential to the task. A medical background was not a necessary qualification -and by no means was it a sufficient one.

The Tuke model of moral treatment was particularly fruitful in developing asylums in the United States, a success attributed to several factors. As civic responsibilities shifted from town to county and later to state government, officials looked to the centralized asylum as the rational (albeit more expensive) site of humane care not available in local jails, almshouses, or homes. Also, it has been argued that in the troubled times of Jacksonian America the well-ordered asylum gained favor as an innovative symbol of social control. Moreover, families increasingly looked to the asylum as a solution to their terrible burdens. It is not clear whether this was due to social changes that rendered them either unwilling or unable to provide home care, or whether they had become convinced by the vaunted success of asylum cures. In either case, the unquestioned ease with which patients were shipped to asylums had prompted even Connolly to warn that the proof of an individual's sanity was quickly collapsing into the simple question of whether he or she had ever been institutionalized.

Although when first constructed the asylums were as likely to be managed by lay authorities as by medical ones, their growth nevertheless provided a base for a new breed of physicians whose practice was limited to mental problems. Such posts were often quite attractive, and an esprit de corps developed among the elite who occupied them. The origin of psychiatry as a profession is typically traced to the; 1840s, when these medical superintendents, or "mental alienists," banded together to form specialized organizations and medical journals. (For example, the forerunner of today's American Psychiatric Association began in 1844 as the Association of Medical Superintendents of American Institutions for the Insane; this predated by four years the American Medical Association.)

The challenge for the first psychiatrists was to expand both their institutional base and their claim to specialized knowledge. The former goal was advanced by championing the idea that insanity was curable if its victims were removed at once from their homes to asylums, where they might receive the full advantages of moral treatment-in combination with a regular medical regimen. Moral treatment as a nonmedical practice was thus neatly coopted. In turn, the growing empire of asylums crystallized the young profession around a privileged therapy. Patients were locked in, but just as significantly, medical competitors were locked out. The alienists also made progress in advertising their expertise. In France, when the Napoleonic code made provision for a legal defense of not guilty by reason of insanity, alienists attracted national attention by their involvement in celebrated homicide trials. In advocating social if not legal justice for insanity's unfortunate victims, the alienists were advancing a political cause of liberal philanthropy (in the heat of Restoration politics) and also a professional one, the elevation of their status to that of experts.

The alienists seized on the concept of monomania, a term coined by Jean Etienne Esquirol around 1810, to argue that a person could be driven by delusions to perform acts for which he or she was not responsible. Descended from Pinel's manie sans délire, monomania referred to a nosological region intermediate between mania and melancholia. Unlike those with nervous or hypochondriack disorders, which comprised the gray zones between everyday preoccupations and total loss of mind, monomaniacs were indeed quite insane, but only in one part of their mind, and perhaps intermittently so. A morbid perversion of the emotions did not necessitate a corresponding loss of intellect. The defining characteristic of the disorder was that, save for a single delusion or disturbance of mind, an afflicted individual might appear entirely normal. Here, then, was a semiotic wall that could not be breached by lay or even nonspecialized medical knowledge. Significantly, at the trials the alienists employed neither arcane technique nor extensive jargon. Their claim to expertise was the discerning eye of a seasoned clinician, a skill that was honed on asylum populations where insanity was visible in all of its protean and elusive forms. Knowledge does not have to be exceedingly learned to be restrictive. It was a sufficient argument that only those with extensive asylum experience could reliably distinguish the true monomaniac from the false.

The term monomania seems to have fallen into fast decline in France after 1838, immediately following the passage of legislation that provided greatly expanded roles for alienists in France. In success, the term lost its ideological edge. Elsewhere, similar concepts of partial insanity and moral insanity (coined by J. C. Prichard in 1835) took root, which played equally vital roles in demonstrating that questions of lunacy were matters best left to experts.

Expansion of the profession depended on communities that held potentially antagonistic viewpoints, a situation that presented the alienists with a difficult balancing act. On one hand, ties were maintained to the nonmedical constituencies who were driving forward institutional reform. On the other hand, general medicine was making great strides in the Paris clinics, where the anatomopathological approach to the localization of disease was launching modern medicine. A new medical standard had to be met. These separate goals found mutual expression in the doctrine of phrenology, a powerful movement in Europe and the United States that was based on the late-eighteenth- and early-nineteenth-century work of Franz Joseph Gall and Johann Spurzheim. Holding to the twin assumptions that psychological faculties were localized in specific regions of the brain and that cranial morphology was a guide to brain structure, the doctrine popularized "reading bumps on a head" as a means of revealing an individual's innermost talents and deficits. Although later generations heaped abuse on it, phrenology has since been credited with disseminating into general culture a materialist philosophy in which the brain was the organ of the mind and with motivating researchers in several fields to explore mental physiology as a serious pursuit. For the alienists, phrenology provided a framework for considering disordered personality, one that incorporated society, the asylum, and general medicine. Through this model, alienists participated in the movement to better society through useful knowledge, explained the effectiveness of moral treatment as a program that strengthened specific mental faculties, and followed the organi-cists' lead in insisting that insanity could be attributed to brain lesions. Moreover, the psychological and physiological models merged: The well-ordered asylum restored the patient by keeping the brain in a tranquil condition.

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