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

University of California Press

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...