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

Categories: MentalHealth, Philosophical