Flesh in the Age of Reason (47 page)

With the rise of enlightened outlooks, the old religious models were
replaced by secular and medical doctrines. The orderly, mechanical, law-governed universe presupposed by the new mechanical philosophy discounted Satanic possession of sufferers’ minds and bodies. After the bloodshed of the witch-craze and the Thirty Years War, respectable opinion turned against ‘Convulsionaries’, ‘Ranters’, and the religious ‘lunatic fringe’, declaring rather that the ‘possessed’ were afflicted by the spleen, hysteria or other morbid conditions. Religious madness, once even an eligible state, was thus psychopathologized, being reduced to a somatic disease. Its teeth were thus drawn.

New theories of insanity filled the explanatory vacuum. Mania and melancholy, physicians now argued, originated not from transcendental powers but from the body; the aetiology of insanity was organic, its source not Satan but the
soma
. Moreover, among the medical community, the old humoral readings of mental disorder, which had highlighted the role of blood or yellow bile (‘choler’) in precipitating mania, and of black bile in melancholia, lost credit as the ‘new science’ pictured the body in mechanistic terms, stressing not the fluids but the solids. The upshot was that, in the medical writings of the first half of the eighteenth century, the idea of ‘mental disease’ in its strict sense was turned almost into a misnomer or a contradiction in terms; the possibility of a diseased mind or soul was virtually ruled out by the ideological and rhetorical strategies of the day. In talking about strange disorders, doctors diplomatically referred to diseases of the body; within what may loosely be described as a dualist or Cartesian framework, the presumption was that the mind or the soul remained absolutely inviolable. Here also lay success for physicians in a turf war: in future it would be they, rather than the clergy, who would have responsibility for the malady.

The comforting conclusion that a lunatic’s soul was not jeopardized by his deranged condition – and that his mad talk was truly not inspired – left the onus upon physicians to explain the real causes, nature and seat of madness. They typically contended that impairment of the mental faculties and operations arose from bodily
defects. Prominent was the model advanced by a number of British iatro-mathematicians and iatro-mechanists in the early decades of the eighteenth century, building upon modified Cartesian models. Archibald Pitcairn, a Scot who taught at the University of Leiden in the Dutch Republic, and his protégé, Richard Mead, grafted onto Descartes’s belief that madness was illusion another Cartesian concept, namely involuntary or reflex muscular motion. A lunatic, Mead thus argued, suffered from the abnormal representation of false ideas induced by the impact of the animal spirits flowing in a chaotic manner; in turn, through some feedback loop, these induced the muscular fibres to produce bizarre and uncontrolled motions in the limbs and extremities.

Authors influenced by the latest in physical science thus portrayed the deranged individual as a hydraulic machine in a state of disorder: irregularities in the circulation of animal spirits would give rise to false sensations and disordered locomotion. Delirium, Mead held, was ‘not a distemper of the mind but of the body’, for, ‘it is very manifest that in reality the defect is not in the rational but corporeal part’. Here lay a plausible and attractive somatic explanation of a terrifying and mysterious disease, one designed to reduce fear and stigma.

This eagerness to ascribe madness to the body was most systematically codified in the teachings of Hermann Boerhaave, the highly influential Leiden medical professor. In true Cartesian manner, Boerhaave and his numerous disciples, in England as well as on the Continent, maintained that the mark of mental illness lay in the production of false images, that is, ideas lacking external reality. At the same time, perfectly aware that such illusion alone was not madness
per se
, they attempted to formulate a more sophisticated variant of the Cartesian doctrine. For the Swiss-born Albrecht von Haller, something other than mere physical sensation must be involved in the perception of external objects; for a mind to become positively crazy, it also had to be convinced of the
reality
of false images.

As anatomical investigations advanced, the workings of the nerves – another somatic answer – were increasingly invoked to explain the production of illusions or delusion. Followers of Pitcairn, in particular his fellow Scot, George Cheyne, in
The English Malady
, speculated about the interaction of the vascular and nervous systems with the brain. Contested notions of the nerves as hollow pipes (Willis and Boerhaave) or as filaments conveying waves or impulses (Hartley) led to rival theories as to how disordered thought, moods and behaviour arose from some organic defect which caused excessive tension, slackness or obstructions in the nervous system.

Cheyne’s attribution of disorders to the nerves gave expression to an astute patient-management strategy, not least because it dissociated sufferers from any imputation either of downright lunacy on the one hand, or of self-indulgent and perverted malingering on the other. Catering for wealthy and influential patients, Cheyne was aware that couching a diagnosis in tactful terms was not only an essential but a delicate business. Physicians were commonly put on the spot by ‘nervous cases’, because such conditions were easily dismissed by the ‘vulgar’ as tell-tale marks of ‘peevishness’ or, when ladies were afflicted, of ‘fantasticalness’ or ‘coquetry’. Recourse to somatic categories, by contrast, was music to the ears of patients and their families, craving as they did diagnoses which confirmed the reality of their disorders. Foolish people (Cheyne explained) might suppose that the spectrum of maladies which included hysteria and the spleen were ‘nothing but the effect of Fancy, and a delusive Imagination’; such charges were ill-founded, however, because ‘the consequent Sufferings are without doubt real and unfeigned’. Even so, hitting upon
le mot juste
required great tact. ‘Often when I have been consulted in a Case… and found it to be what is commonly call’d Nervous,’ Cheyne mused, ‘I have been in the utmost Difficulty, when desir’d to define or name the Distemper, for fear of affronting them or fixing a Reproach on a Family or Person.… If I said it was Vapours, Hysterick or Hypochondriacal Disorders, they thought me mad or Fantastical.’

His colleague Richard Blackmore chewed over similar difficulties. ‘This Disease, called Vapours in Women, and the Spleen in Men, is what neither Sex are pleased to own’, he emphasized,

for a doctor cannot ordinarily make his Court worse, than by suggesting to such patients the true Nature and Name of their Distemper.… One great Reason why these patients are unwilling their Disease should go by its right Name, is, I imagine, this, that the Spleen and Vapours are, by those that never felt their Symptoms, looked upon as an imaginary and fantastick sickness of the Brain, filled with odd and irregular Ideas.… This Distemper, by a great Mistake, becoming thus an Object of Derision and Contempt: the persons who feel it are unwilling to own a Disease that will expose them to Dishonour and Reproach.

Any such imputations of shamming would be scotched, insisted Dr Nicholas Robinson, once it was made clear that such disorders were not ‘imaginary Whims and Fancies, but real Affections of the Mind, arising from the real, mechanical Affections of Matter and Motion’; for ‘neither the Fancy, nor Imagination, nor even Reason itself… can feign… a Disease that has no Foundation in Nature’. After all, he stressed, one could not ‘conceive the Idea of an Indisposition, that has no Existence in the Body’. So if madness were somatic, the explanations offered rang true and they rendered a shocking condition reassuringly commonplace.

As has just been hinted, Sir Isaac Newton’s achievements provided a further model attractive to physiologists and physicians. The fervent Newtonian Nicholas Robinson maintained in his
A New System of the Spleen
(1729) that it was the nerve fibres which controlled behaviour; a pathological laxity or relaxed state in them was the primary cause of melancholia. ‘Every change of the Mind,’ he thus maintained, ‘therefore, indicates a Change in the Bodily Organs.’ Insanity was assuredly a genuine disorder, he insisted, not a mere matter of ‘imaginary Whims and Fancies’; it arose from ‘the real, mechanical Affections of Matter and Motion’.

These and similar organic interpretations of madness remained highly popular up to mid-century. But thereafter a major theoretical
transformation came about. This was in large measure due to the growing acceptance of associationist theories of mind pioneered by Locke and further developed in France by the sensationalism of Condillac.

In his
Essay concerning Human Understanding
, Locke had suggested that madness was due to some fault in the process of the association of ideas. Locke argued that madmen, unlike imbeciles, had not ‘lost the Faculty of Reasoning’. In fact, madmen, ‘having joined together some
Ideas
very wrongly… mistake them for Truths; and they err as Men do, that argue right from wrong Principles’. One madman, for instance, wrongly fancied himself a king, but he correctly reasoned from that that he should have ‘suitable Attendance, Respect and Obedience’. Another believed that he was made out of glass and drew the correct inference that he should take suitable precautions to prevent his brittle body from breaking. Locke’s doctrine that the madman’s reason was wholly intact had been clearly formulated in the 1677
Journals
, where he had remarked that ‘Madnesse seems to be noething but a disorder in the imagination, and not in the discursive faculty’. Locke’s view that insanity was essentially ‘deluded imagination’ was decisively to shape British thinking about madness in the second half of the eighteenth century.

William Cullen (1710–90), the most prominent professor in Edinburgh University’s flourishing medical school, produced a more medical version of this psychological model of madness. Cullen basically ascribed madness to the brain; hallucinations for their part were disorders of the senses, while false appetites stemmed from the organs governing the respective passions. As a mark of the centrality of the nervous system to his theory, intensity of cerebral excitement was identified as the key to both the cause and the cure of madness.

Overall, Cullen defined insanity (‘vesania’) as a nervous disorder. Aetiologically, it arose in the ‘common origin of the nerves’, that is, the cortex, and occurred neuro-physiologically when there was ‘some inequality in the excitement of the brain’. Yet insanity was also, in his view, an ‘unusual and commonly hurried association of ideas’ leading to ‘false judgement’ and producing ‘disproportionate
emotions’. This allowed him to view insanity in a Lockean manner as a mental disorder, grounded in dynamic neuro-physiology.

While Cullen thus did not banish the body from his understanding of insanity, he certainly did not understand madness wholly in neuroanatomical terms. He had a philosophical and psychological inspiration in David Hume, whose influence is plain in his account of judgement and its disorders. For Cullen, the keys to judgement were custom and the association of ideas, which Hume reckoned the basis of all intellectual operations.

Since judgement depended on customary associations of ideas, Cullen viewed madness as involving deviations from such habits: ‘delirium is where we do not follow our ordinary train [of thought], but, on the contrary, pursue one inconsistent with all our former established principles or notions.’ Together with an emphasis on the physiology of the nervous system and the pathology of the brain, Cullen’s model of madness called for close scrutiny of the patient’s mental disposition. The significance of his thinking lay in reintroducing the mental element into medical discourse on madness.

The break with the essentially somatic understanding of madness was widespread by around 1780. Applying Cullen’s physiology in conjunction with a philosophy of mind, Edinburgh graduates were actively promoting the new model. In his
Observations on the Nature, Kinds, Causes and Prevention of Insanity, Lunacy or Madness
(1782–6), Thomas Arnold, who had studied under Cullen before taking over a madhouse in Leicester, constructed a nosology of insanity explicitly on the basis of the Lockean philosophy of mind, distinguishing ‘ideal insanity’ (hallucination: seeing what was not there) from ‘notional insanity’ (delusion: mistaking what was present).

Many other physicians advanced rather psychological models of madness.
An Inquiry into the Nature and Origin of Mental Derangement
(1798) by Alexander Crichton – also trained in Edinburgh – held that the philosophy of mind formed an essential component of understanding madness: ‘It is evidently required that he who undertakes to examine this branch of science,’ he wrote concerning psychiatry, ‘should be acquainted with the human mind in its sane state.’ In this respect,
he acknowledged his debt to ‘our British Psychologists, such as Locke, Hartley, Reid, Priestley, Stewart, Kames’. The great French psychiatrist Philippe Pinel (see below) similarly wrote that he had ‘felt the necessity of commencing my studies with examining the numerous and important facts which have been discovered and detailed by modern pneumatologists’, that is, ‘Locke, Harris, Condillac, Smith, Stewart, etc.’

The coming conception of madness as a psychological disorder brought radical changes in the scope and structure of psychiatric knowledge. A physician henceforth had to pay close attention to the patient’s mind. An indication of this change lies in the proliferation of detailed case histories taken and published in the late eighteenth and early nineteenth centuries: in sharp contrast to earlier works, some of the books appearing at this time consisted entirely in the accumulation of case histories.

These new concepts of madness transformed the old craft of caring for the insane into the practice of systematic psychological and psychiatric observation. From around 1780, especially in England, there was a rapid growth of psychiatric publications by private madhouse proprietors: William Perfect’s
Methods of Cure, in Some Particular Cases of Insanity
(1778) was followed by the work of Joseph Mason Cox, William Hallaran and many others in the early decades of the nineteenth century. While private madhouses had been spreading since the late seventeenth century, initially they had hardly been sites for the generation and publication of medical knowledge. All this changed, as the new theories privileged and demanded the observation of the individual patients.