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The art of medicine: clinic and compassion in nineteenth-century psychiatry.

If Benedict-Augustin Morel's only contribution to medicine had been his theory of degeneration, his lack of renown might be understandable. But Morel deeply cared for his patients, removing restraints, encouraging early discharge, and boarding out patients in the community. He worked assiduousiy to prevent the warehousing of his patients. Next to his compassion for his patients, perhaps Morel's most striking talent was his keen clinical eye, which empowered him to make one of the outstanding discoveries in the history of medicine.

LIKE A SCENE from La Boheme, two medical students huddle in a cold, rundown Paris garret. They are so poor they have only one suit between the two of them. When one dons the suit, the other curls up in bed shivering under threadbare blankets in a desperate effort to keep warm.

One of the medical students is Claude Bernard, who will achieve fame as perhaps the greatest physiologist of all time.

The other student is Benedict-Augustin Morel (1809-1873). Today, unlike Claude Bernard, Morel is hardly remembered. Yet few individuals better embodied the adventuresome nature of nineteenth-century medicine. Morel's day was a time of brilliant, larger-than-life characters who often sacrificed their own health in the quest to expand the frontiers of medical science and improve the fortunes of humanity. People like Morel and Bernard believed that clinical and experimental science could solve the mysteries that had plagued human health for centuries. If, from out vantage point 150 years later, we find it difficult to share fully their optimism, we still must admire the courage of their convictions and their soaring intellectual bravado.

Morel, a pioneer in psychiatry and public health, also possessed a rare clinical brilliance and a deep learning. Combining these traits with true compassion for his patients, he devised a sweeping theory about humankind's place in the natural and social order--a combination akin to melding William Osler with Charles Darwin.

If Morel has never received his due recognition, it is mainly due to his 700-page Treatise on Degeneracy, in which he argued that the families of many people plagued by mental and physical disabilities were doomed to extinction because of their bad heredity. Morel described how the poor in Europe's burgeoning cities were exposed to a variety of poisonous agents, including tobacco, lead, ergot, and alcohol, all of which caused fearsome health effects. These factors, Morel argued, afflicted countless families whose members passed on their diseases to offspring through inheritance.

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Morel's theory of degenerationrapidly passed from the realm of biology and medicine into popular language. By the end of the century, there arose countless opinion makers, ranging from Dracula author Bram Stoker to sociologist Emile Durkheim and sexologist Havelock Ellis, who used the term "degeneracy:' Meanwhile, Morel's original definition of the word was forgotten. Instead, degeneration had become a pejorative term referring to people with disabilities as a whole. When in the twentieth century psychiatrists ceased using "degenerate" to describe patients, Morel's great contributions to clinical psychiatry largely vanished from memory. Only recently have historians begun to restore Morel to his rightful place in the history of medicine.

Morel's fluctuating reputation began the day of his birth on November 22, 1809, in war-torn Vienna. Aside from Morel's father, a supplier of military equipment to Napoleon's armies, little is known about his parents or his upbringing. In 1831 Morel arrived in Paris where he dabbled in journalism before entering medical school. There he met Bernard, and his medical career accelerated.

THREE KEY NINETEENTH-CENTURY CURRENTS shaped Morel's approach to medicine in general and psychiatry in particular. The first was a movement, led by Henri Saint-Simon and Auguste Comte (who coined the term "sociology"), which held that the progress of science had reached a point in history when researchers could talk realistically about a science of humanity. Comte's own theory of positivism best captured this sentiment and bolstered the view that scientists were on the verge of discovering the natural laws governing society. Such knowledge, it was felt,

would enable scientists to end the illnesses, disabilities, injustice, and conflict which had afflicted human history.

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The second trend that influenced Morel was the growth of psychiatry as one of the first specialties to carve out a separate professional identity in medicine. Largely led by French physicians trained in the hospitals of revolutionary Paris, psychiatry began as an institutional specialty headquartered in the asylums that Western governments started to build in the nineteenth century to house the countless poor with mental disabilities at public expense. Psychiatrists--or "alienists" as they called themselves then --argued that people with mental disabilities were all too often jailed, whipped, neglected, or drugged. The mentally ill, so went the argument, were best off in modern hospitals headed by licensed physicians whose benevolent care provided inmates the opportunity to recover their senses and rejoin society. Alongside their self-avowed compassion, psychiatrists were motivated by the belief that mental diseases were real organic illnesses whose causes anatomists and physiologists would soon discover. Studying people with mental disabilities in asylums enabled psychiatrists to begin the time-consuming task of classifying diseases of the mind on a scientific basis, each with its own symptoms and outcome.

The third influence on Morel was the turmoil within early nineteenth-century Roman Catholicism. Faced with the appalling costs to human health and dignity inflicted on the poor by industrialization and urbanization, more and more Catholic thinkers called on the Church to take an active role in social reform. Catholic intellectuals with a social conscience advocated trade unions under Church auspices and legislation to improve work conditions in factories. The views of these Catholics have often been described as "Christian socialism" and were designed to counteract what was perceived to be the rampant individualism of the day. Between the fall of Napoleon 1 in 1815 and the failed European revolutions of 1848, in the words of one historian, "virtually everyone who considered himself a socialist claimed to be inspired by Christianity or even by Catholicism itself. The Gospels were everywhere, and Jesus, it seemed, was the founding father of revolutionary change."' Reared as a devout Catholic, Motel viewed psychiatry as a means of putting the social gospel into practice.

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Meanwhile, Morel had begun his own medical career. Jean-Pierre Falret, a leading French psychiatrist of the day, took Morel on as a resident at the well-known Salpetriere hospital, and soon Morel was engaged in efforts to establish a professional identity for the fledgling specialty. Morel travelled extensively across Europe in the 1840s to see how people with mental disabilities were treated in other countries. After a stint at the Mareville asylum, Morel became head psychiatrist at the St Yon asylum near Rouen.

Morel's travels and clinical experience taught him that Europe's masses endured a host of crippling diseases, including cretinism and ergotism. Shocked by the incidence of these and other diseases among the poor, Morel turned the theory of progress on its head. His theory of degeneration said that the very growth of civilization could impede the progress of human history if the necessary public health measures were not taken.

With his emphasis on heredity, Motel has been accused of helping to launch the theory of eugenics, which in the twentieth century culminated in the enactment in numerous industrialized countries of involuntary sterilization laws targeting the mentally handicapped. However, those who blame Motel for eugenics ignore the fact that he rejected the idea, popular among later eugenicists, that people with mental disabilities were highly fertile. On the contrary, he wrote that such people and their families tended to have few offspring. Far from the infamous Jukes and Kallikak families of eugenic lore, which supposedly kept breeding profusely, patients who suffered from degeneracy were mostly infertile.

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If Morel's only contribution to medicine had been his theory of degeneration, his lack of renown might be understandable. But Motel deeply cared for his patients, removing restraints, encouraging early discharge, and boarding out patients in the community. He worked assiduously to prevent the warehousing of his patients.

Next to his compassion for his patients, perhaps Morel's most striking talent was his keen clinical eye, which empowered him to make one of the outstanding discoveries in the history of medicine. Typically asylum physicians of his day first encountered patients when they were admitted to hospital, well after the onset of sickness. It was difficult to discern at that point the full course of the illness, so nineteenth-century psychiatrists normally based their diagnoses on the state of the patient when he or she was admitted. A psychiatric diagnosis was often just a "snapshot" of the underlying illness, and thus incomplete.

In some respects, Morel was susceptible to the fashions of his time, but like the other greats of the history of medicine he also had a talent for "thinking outside the box." During the 1850s he devoted more and more attention to disease outcome, notably dementia, what he called the "terminal state" for most asylum inmates. Then one day a distraught father brought his fourteen-year-old son to see Morel. Once a bright student, this teenager had lost all his earlier intelligence and was rapidly becoming dull and lethargic. When Morel saw the boy later in adolescence, he wrote that it was obvious that the patient suffered from a kind of demence precoce, a premature dementia. "This desperate diagnosis is ordinarily far from the minds of parents and even of the physicians who care for these children,"

Morel added. (2) Families living with schizophrenia today can poignantly relate to these words.

With this case history Morel became the first psychiatrist to use the term dementia praecox, later popularized by German psychiatrist Emil Kraepelin. In 1911, Swiss psychiatrist Eugen Bleuler renamed dementia praecox "schizophrenia." By then, Morel had been written out of the history of schizophrenia as a disease concept, an undeserving casualty of the widespread celebration of all things German in medicine.

Motel's discovery of a form of schizophrenia with early onset and poor prognosis was not the only breakthrough that made the period a revolutionary time in the history of psychiatry. In 1851 his former patron Jean-Pierre Falret had discovered bipolar disorder, the concept that mania and melancholy were not two separate disorders but just distinct phases of the same disease. Considering the many obstacles Morel and Falret faced because of the conditions of asylum psychiatry in their day, their discoveries stand out as stunning achievements in the art of medicine.

MOREL DIED of diabetes in 1873. By then overcrowding and rising rates of chronic disease were steadily transforming mental hospitals into the "snake pits" that muckrakers of later generations would denounce. In the coming years, the profession Morel had done so much to establish would begin splintering into recondite conflicts between biologically oriented and psychodynamically oriented psychiatrists.

But for a brief time in the mid-nineteenth century the field of mental health care had pulsed with the energy and vision of physicians such as Morel, who brought a compassionate and unwavering commitment to their challenging clinical tasks. Later generations might match their dedication, but they would have trouble equalling their selfless resolve to help those less fortunate. We may never see the likes of Morel and his generation again.

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Notes

(1) Edward Berenson, "A New Religion of the Left: Christianity and Social Radicalism in France, 1815-1848," in The French Revolution and the Creation of Modern Political Culture, Volume 3, edited by Francois Furet and Mona Ozouf (London: Belknap Press, 1989), p. 543. Cited in Michael Burleigh, Earthly Powers: The Clash of Religion and Politics in Europe from the French Revolution to the Great War (London: HarperCollins, 2005).

(2) Edward Shorter, A Historical Dictionary of Psychiatry (New York: Oxford University Press, 2005), p. 268.

IAN DOWBIGGIN, a member of the Royal Society of Canada and author of seven books on the history of medicine, teaches history at the University of Prince Edward Island. His Romancing the Home: The Ascendancy of Marriage and Family Counseling in Modern America will be published by University of Kansas Press in 2014. This article first appeared in Synergy.
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Author:Dowbiggin, Ian Robert
Publication:Queen's Quarterly
Article Type:Critical essay
Geographic Code:1CANA
Date:Mar 22, 2013
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