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Console and ClassifyReview - Console and Classify
The French Psychiatric Profession in the Nineteenth Century : With a New Afterword
by Jan Ellen Goldstein
University of Chicago Press, 2001
Review by Lloyd A. Wells, Ph.D., M.D.
Apr 23rd 2002 (Volume 6, Issue 17)

            I am pleased that the University of Chicago Press has reissued this very interesting book, with a new afterward by the author.  The book raises many questions and is intensely thought-provoking.  It can be read as the history of a profession-in-the making, as historical social commentary with echoes of Foucault, and even as a mirror of sorts to twenty-first century psychiatry in the United States.  In my view, the book is not completely successful in any of these areas, but it is extremely stimulating.

            Basically, Goldstein demonstrates in great detail how the French profession of psychiatry developed in the nineteenth century.  At the start of the century, there was much debate about whether mentally ill people should be treated by physicians or priests, whether there was a medical component to madness or not.  By the end of the century, there was a codified professional and legal structure that defined the care of the mentally ill.  The author demonstrates this development meticulously.

            There are many anecdotes and there is rich analysis of the founding role of Pinel and the huge influence of Esquirol on the development of the profession, and the roles that their students and their students’ students played through the century.  The theme of anticlericalism – not shared by all the major figures in the book – was an important one.  The role of the state and especially the law of 1838 is fully considered.  The author also does justice to the role of philosophy, and particularly positivism, in the development of the profession.

            Goldstein begins with a discussion of the concept of profession from several points of view, then gives background on French medicine in the Enlightenment and at the start of the nineteenth century.  She turns to the central figure of Pinel and his moral model of treatment, which she views as “transformation of charlatanism”.  The moral model was largely adapted from non-medical practices applied to the mentally ill by non-physicians, and it was then “scientized” by Pinel and others – especially Esquirol, who studied it, systematized it, and examined “outcomes”, in modern parlance, using statistical technics.  She discusses the political importance of both Pinel and Esquirol and its effects on the development of the profession.  She then examines the diagnosis of monomania – its rise and fall in “popularity” and professional acceptance, and its profound role in forensic and social debate.  She proceeds to an examination of religious and philosophical issues, and then the law of 1838 and the development of an asylum system.  She finishes with a discussion of hysteria and the Salpetriere School headed by Charcot.

            Philosophers, historians of philosophy, and fellow travelers like me will greatly enjoy this book.  A French politician proposed in the early nineteenth century that physicians caring for the mentally ill should have special training in philosophy.  Enactment of this proposal is overdue!  Esquirol proposed the involvement of philosophers with the entire psychiatric enterprise – this remains necessary and insufficiently accomplished!  Esquirol was very serious about the importance of philosophy.  He treated Auguste Comte but also took a course from him in 1829.  Morel, whose work transformed late nineteenth and early twentieth century French psychiatry and has relevance for twenty-first century genomic psychiatry, took a strong philosophical position on the subject of post-partum psychosis, which was viewed as “biological”, stating that a moral treatment could be effective.  A belief in “reciprocal psychosomatic influence” guided many of these great psychiatrists out of a philosophical morass.  The work of Maine de Biran was central, philosophically, for many of the nineteenth century French psychiatrists, and Victor Cousin (perhaps unfortunately), Theodore Jouffroy, Destutt de Tracy, Royer-Collard, and others made major contributions to their efforts.  This book is a treasure hunt for historians of philosophy!

            The recently written Afterword is an excellent essay.  It compares the nineteenth-century French disorder of monomania, long of unhappy memory, with today’s American diagnosis of attention deficit disorder.  Both were disorders of “attention”.  In attention deficit disorder, there is not enough focus of attention, and in monomania there was purportedly too much.  The discussion is excellent.  The author moves on to a discussion of Foucault, and especially the ideas formulated in Discipline and Punish.  She views the debate about and enactment of the Law of 1838 as an encroachment of discipline upon law, in a way consistent with Foucault’s views, and she discusses other ways that the material of this book could be consistent with Foucault’s assertions.

            Anecdotes abound.  One of my favorites involves an interchange between Pinel and the astronomer, Lalande, who was preparing a new edition of his Dictionary of Atheists and had written an essay on Pinel.  Pinel said that he was writing a new edition of his Treatise on Insanity and “was reserving a place in it for Lalande”.

            This is an excellent book with many positives.  For the history enthusiast, there is an excellent index.  Arguments are well formulated and have evidence to back them up.

            There are few negatives, although the point of view of each reader will determine some.  In general, I think the book is less robust in its considerations of events in the last third of the nineteenth century.  The author is overinclusive in her choice of “psychiatrists”.  Charcot, for example, was a geriatrician and neurologist with an interest in the interface of psychiatry and neurology.  Although he reputedly enjoyed being called “the Napoleon of Neuroses”, he certainly viewed himself as a neurologist and not a psychiatrist – his contributions to neurology and neuropathology are legion, and he gave us the clinical neurological examination as it is practiced today, with the addition of the Babinsky reflex by his student.  I also think that the role of Morel in shaping late-nineteenth and early twentieth century French psychiatry is almost absent from the book – there are several comments about Morel, but little acknowledgment of the central role he played in the paradigm shift from a moral to a biological model in psychiatry, though he himself remained an ardent adherent of the view that psychological factors work on physiologic substrates and that the two cannot be separated.

            This is an excellent book, and I recommend it highly to psychiatrists, philosophers with an interest in psychiatry, historians of psychiatry, and other interested people.  American psychiatry has been going through a transformation in the last half-century, and some of the events and processes recorded and discussed in the book provide historical precedent for some more contemporary situations.  The debate about monomania in nineteenth century France and that about attention deficit disorder in twenty-first century America have much in common.  The title is well chosen.  The nineteenth-century French psychiatric profession did indeed console and classify, and modern American psychiatry should perhaps provide more consolation along with its classification and treatment.

 

 

© 2002 Lloyd A. Wells

 

Lloyd A. Wells, Ph.D., M.D., is a child and adolescent psychiatrist at the Mayo Clinic in Minnesota. He has a particular interest in philosophical issues related to psychiatry and in the logic used in psychiatric discourse.


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