This morning I read through two more chapters of Andrew Scull’s Madness in Civilization, which broadly covered the nineteenth century and the gentle transformations from madhouses to asylums to lunatic hospitals, from moral treatment to alienism or psychological medicine to psychiatry, and from madness to mental illness or, still worse, degeneracy.
The term, psychiatry, was invented by a German doctor, Johann Christian Reil in 1808, and he formed the term from two Greek words for soul (psykhe) and medical treatment (techne iatrike). These two words wrestled, it seemed to me in reading Scull’s account, for the spirit of psychiatry through the nineteenth century, and most likely beyond.
Unlike my renounced influence, Michel Foucault, Scull sees the compassion and the humanistic hope behind so much of the efforts to reform medical treatment of the instance through the nineteenth century. He records the great hope bested in the institution of the asylum, publicly operated by a more benevolent state, infused with moral principles, and a kinder form of containment than the private madhouses that so scandalised many of the moral reformers of the nineteenth century. So Queen Victoria’s physician called the modern lunatic asylum “the most blessed manifestation of true civilization that the world can present” (p.25).
So doing Scull points out that only Foucault and his followers – with their condemnation of moral treatment as a “gigantic moral imprisonment” – would cavil that the then modern asylums were an humane improvement on the crowded and abusive madhouses, whose horrors he documents precisely. Indeed the real heroes of his story are not the great doctors and propagandists, like Pinel or Tuke, but the non-medical custodians of the insane who were guided by care and compassion and the careful assiduous and ordinary observation of what treatments seemed to help their patients best. So it is not Pinel’s great moral reordering of medicine that Scull foregrounds, but the practical and careful practice of the lay governor of the Bicetre, Jean-Baptiste Poussin, and his wife Marguerite. It was their daily observation of the effects of different treatments and their morally guided experimentation with different forms of care that Pinel then systematised into a grand theory, and Foucault mistook for ideas remaking reality.
Along the way we meet the rare voices and images that spoke of soul from within the great confinement. Here Scull reproduced in full, John Clare’s poem, I am, although I disagree with him that it fails , even in its darkest moments of lament, to make a “vigorous assertion of personal autonomy and individuality.” We also meet van Gogh, and the kind portrait of his doctor, Felix Rey, which sadly the doctor found horrifying. But by the time van Gogh was painting, doctors and their mad patients were becoming estranged by ideas of degeneracy, and the idea of medical treatment was winning out over the soul in the struggle for the spirit of psychiatry.
Degeneracy was an idea that consumed fin de siècle Europe though first powerfully articulated by a French alienist, Benedict-Augustin Morel, in his Treatise on the Intellectual, Moral and Physical Degeneracy of the Human Race (1857). But it found its most influential expression in Balzac’s fiction and in Max Nordau’s Degeneration. I recall in my university days being mesmerised by this period in culture, and have long been preoccupied with similar themes of cultural decay, but my more ordinary and compassionate side is repelled by the biological determinism of these theories. By 1900 the mad were an incurable burden, and a frustration to the prestige and good will of their treating doctors. So, Tuke’s great grandson, the inheritor of the family tradition of asylums who had lost the great reformer’s optimism, would say with all the cruelty of a heartless administrator, that the insane were “an infirm type of humanity… On admission ‘no good’ is plainly inscribed on their foreheads” (p 243).
His words reflected a greater pessimism among psychiatrists that mental illness could be cured, and this led to a fateful dalliance with eugenics, which culminated most tragically in the compulsory sterilisation of thousands of the mad in Germany and their killing in the t-4 operation that was a prelude to the holocaust. But this was not only a German disease. My own country, my own state, went very close to adopting compulsory sterilisation of the insane and idiotic in the 1930s, and eugenics was widely embraced by the prominent and influential, especially in liberal and progressive circles. It is perhaps one more reason to be grateful for the persistence of religious sentiment since it was faith more than reason that saved many lives here. Scull also quotes the words of Oliver Wendell Holmes, beloved liberal jurist of the United States Supreme Court, son of a doctor who also wrote poetry, who in his 1927 judgement on whether the American constitution prohibited compulsory sterilization wrote:
It is better for all the world if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting Fallopian tubes… Three generations of imbeciles are enough. Oliver Wendell Holmes, 1927 (quoted in Scull, Madness in Civilization, p 266.)
All progressive schemes for the improvement of the human condition – especially in the utopias of public health – are tempted by this rage to order the crooked timber of humanity, most perfectly exemplified in the disorders of madness.
In the late nineteenth century it was in unexpected places in Germany, which was a latecomer to asylums due to its political fragmentation, but a great believer in university research, that psychiatry gave itself over to a rage for order, which yet contained within it a blessed urge for cure. While most German medical research into the mind pursed the dissection of the brain in laboratories, Emil Kraepelin was by accident of his poor eyesight forced to pursue more observational research through the direct treatment of the thousands of patients in Germany’s new asylums. He observed the patients before him, and made careful notes on cards, which he then assembled and reassembled into a classificatory scheme for mental illness, which in some of its essentials still endures with us today. So developed the first diagnostic manual of psychiatric disorders, derived from clinical observations. So too were born the ideas of schizophrenia, which Kraepelin called, as did Jung, dementia praecox, and bipolar disorder.
But this scheme for ordering the disorders of the mind, which is with us still, cannot be dismissed as a ruse of power, as Foucault so dismissively did, a giant grid of surveillance and control, and nor can it be limited to the assertion of a new profession’s power. Kraepelin acted with compassion towards his subjects in a way that many of his less observant professional colleagues did not. And does not madness call for disciplined compassion and imagination from us all? Where would we be, after all, without the imagination’s blessed rage for order?
The maker’s rage to order words of the sea
Words of the fragrant portals, dimly-starred,
And of ourselves and of our origins,
In ghostlier demarcations, keener sounds.
(from Wallace Stevens, The Idea of Order at Key West)
Vincent van Gogh, Portrait of Doctor Felix Rey, Oil on canvas 64.0 x 53.0 cm. Arles: January, 1889 F 500, JH 1659 Moscow: Pushkin Museum source