At the beginning of the nineteenth century, French alienists such as Pinel and his pupil Esquirol introduced a new way of understanding insanity which challenged the previous Lockean view of madness as an impairment of the intellectual functions characterised by delusions. This theoretical shift was paralleled by the introduction of a new therapy for madness; 'moral treatment'. This week we will explore how these changes introduced a new way of conceiving the mind and the body.
1. Primary Sources
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Skultans, Vieda, English Madness - Ideas on Insanity, 1580-1890 (1979).
Augstein, H. F., ' J. C. Prichard's concept of moral insanity: A medical theory of the corruption of human nature'. Medical History, 1996, 40, 311-343.
Bynum, W.F., Roy Porter and Michael Shepherd, eds., The Anatomy of Madness: Essays in the History of Psychiatry , 3 vols (1985-8).
Charland Louis C., 'Science and morals in the affective psychopathology of Philippe Pinel', History of Psychiatry, 2010, 21, 38 -53 .
Digby, Anne 'Moral Treatment at the Retreat, 1796-1846', in W. F. Bynum et al. (eds), The Anatomy of Madness, vol. 2: Institutions and Society (1985-8).
Doerner, Klaus, Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry (1981)
Donnelly, Michael, Managing the Mind - A Study of Medical Psychology in Early Nineteenth-Century Britain (1983).
Dowbiggin, I. A. Inheriting madness. Professionalisation and psychiatric knowledge in nineteenth-century France (1991).
Foucault, Michel, Madness and Civilization - A History of Insanity in the Age of Reason , trans. Richard Howard (1995).
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Gauchet, Marcel and Gladys Swain, Madness and Democracy: The Modern Psychiatric Universe ,(1999).
Melling, Joseph and Bill Forsythe, eds., Insanity, Institutions and Society, 1800-1914: A Social History of Madness in Comparative Perspective (1999).
Micale, Mark S. and Roy Porter (eds.), Discovering the History of Psychiatry (1994)
Parry-Jones, William, The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries (1972).
Porter, Roy, A Social History of Madness: The World Through the Eyes of the Insane (1987).
Porter, Roy, Mind-Forg' d Manacles: A History of Madness in England from the Restoration to the Regency (1990).
Scull, Andrew, Museums of Madness: The Social Organization of Insanity in Nineteenth - Century England (Allen Lane, 1979).
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Scull, Andrew, The Most Solitary of Afflictions: Madness and Society in Britain 1700-1900 (1993).
Scull, Andrew, Charlotte MacKenzie and Nicholas Hervey, Masters of Bedlam: The Transformation of the Mad-Doctoring Trade (1996).
Shorter, Edward, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (1997).
Sueur Laurent and Beer D. M., ' The psychological treatment of insanity in France in the first part of the nineteenth century', History of Psychiatry 1997 , 8 , 37 - 53.
Weiner Dora B., 'Esquirol's Patient Register: The First Private Psychiatric Hospital in Paris, 1802-1808' Bulleting of the History of Medicine 63 (1989), pp. 87-97.
This lecture's division:
This division is a functional division, but these two changes—the treatment of the insane, and ideas of insanity –were intertwined.
Although individual doctors had occupied themselves with the care of the insane and had written manuals about madness and its treatment since the time of the ancient Greeks, psychiatry did not then exist as a discipline to which a group of physicians devoted themselves with a common sense of identity. Yet, except for surgery, few other specialities had come to life either. The advent of medical specialisations was a phenomenon of the 19th century. Before the 19th century, looking after the insane was mainly a family affair. But since the Middle Ages, there have been asylums. The urban world has always had to deal with the problem of homeless psychotic individuals or demented individuals, and cities have organised institutions to accommodate them. Among the oldest psychiatric hospitals in Europe was Bethlem. Bethlem was founded in the 13th century as the Priory of St. Mary of Bethlehem, and by 1403 housed 6 insane men, amongst other residents. In later centuries, the hospice was given over almost entirely to the insane, and the name changed to Bethlem, and Bedlam. In 1547, the City of London took over the supervision of Bethlem, and it would remain a city-run asylum until 1948. Traditionally, asylums like Bethlem have been often portrayed as frightening institutions in sources like William Hogarth's The Rake’s Progress. However, private asylums, which were particularly numerous in Britain, must have treated the insane somewhat better because their families paid for their keep, rich inmates were treated according to their social rank.
Foucault has argued that since the mid 17th century in Europe and Britain madmen increasingly came to be locked in asylums. Foucault speaks about the 'great confinement' when thousands of insane, or individuals who created disorders in society, began to be locked up. However, historians have shown that this was not the case in Britain. For example, by 1815, Bethlem, the most famous of all British psychiatric hospitals, had only 122 patients. By 1926, when national statistics became available in England, only minimal numbers of individuals found themselves in either private or public asylums. Statistics reveals that by 1926 less than 5000 insane people were confined: 64% of them in the private sector, 36% in the public. Bethlem and another famous asylum, St. Luke's, together had only 500 patients. This in a country of 10 million people.
However, Foucault's insights work better when we look at French history. In contrast to the English tradition in which mainly private asylums looked after the insane, on the continent of Europe the public sector had offered care since the 17th century. In France, in 1656, Louis XIV established the 2 great Parisian hospices for the sick, the criminal, the homeless, and the insane—Bicêtre for men and the Salpêtrière for women.' Bicêtre and Salpêtrière were part of a larger hospice program called the ―general hospitals. These general hospitals were not hospitals as we see them today, but custodial institutions that did not offer therapy. These general hospitals like the Bicêtre and Salpêtrière retained their character as hospices rather than psychiatric hospitals until the end of the end of 19th century.
Part I: Practical Changes
Before the 19th century, medical treatises prescribed some methods to treat the insane. Therefore, physicians already believed that in some cases madness could be treated.
Methods to treat insanity before the nineteenth century included: the use of a variety of narcotics such as opium, laudanum, morphia >- purging (i.e. using rhubarb, castor oil, epsom salt, mercurial pills), the supply of emetics (to make patients throw up,salines, tartrate of antimony); bleeding, e.g. by cupping to the neck and shoulders of leeches to the temples; specific diets; baths, showers; douches; duckings; external restraints - i.e. chains, ropes, beatings
As I mentioned, the idea that madness could be treated was not new at the end of the eighteenth century. Although it is important to remember that in most cases, these methods to treat insanity, such as beating, baths and so on, were used more to calm down the insane, rather than to transform a madman into a sane individual. But the real novelty at the end of the 18th century was the notion that institutions themselves could cure people, that benevolent confinement could improve insanity. This insight broke upon the scene in an almost revolutionary way. Physicians and others began developing new 'gentle' treatments within asylums. This is what historians of psychiatry have called the REFORM MOVEMENT.
The reform movement in psychiatry was an European phenomenon. At the end of the 18th century, a new therapeutic optimism linked to the new role of asylums crossed European medical circles. There are scholars who associate the rise of the reform movement with various influences, some saying that capitalism was responsible, others, the central state. Yet the reform movement originated in a wide variety of social and economic settings, making it unlikely that any single social force such as capitalism offers the answer. For example, in Italy there was a reform movement, but the Italian economy did not see the rise of modern capitalism at the beginning of the nineteenth century. In Britain, the reform movement was initiated by private asylums, and the state initially did not do much to reform the treatment of the insane. Certainly some common elements within different national medical communities can be seen: medical journals circulated widely, important books were quickly translated, and individual physicians took trips abroad to learn what was happening elsewhere. It was this kind of scientific dynamic thinking, largely independent of social settings, that seems to have launched modern psychiatry.
During the second half of the eighteenth century, the treatment of madness was dramatically changing in Britain. In the 1750s, the English physician William Battie, emphasised the importance of therapeutic care in his Treatise of Mental Madness (1758). Battie was the founding medical officer of St. Luke's Hospital in London, an asylum that opened in 1751. Battie also owned 2 large private madhouses and at one point he was president of the College of Physicians. In his Treatise on Madness, he emphasised the role of the management of the insane within the asylum. Indeed it was a kind of isolation cure that Battie recommended: the patient was not allowed to receive visits from relatives or friends, and he was not allowed to be attended by his own servants.' Instead, only the asylum attendants could look after the patient.
Not only physicians engaged with the treatment of the insane. In Europe there was an old tradition of religious institutions which devoted themselves to the cure of the insane. In the 1790s, the Reverend William Pargeter (1760-1810) published Observations on Maniacal Disorders (1792). This treatise emphasised the importance of the role of the specialist physician. In the late eighteenth century both writers, William Battie and William Pargeter, contributed to the evolution of a fundamentally new approach to the care and treatment of the insane. Both of them focussed on the benevolent treatment of patients' mental disorders, rather than brutal physical treatments such as purging or beating. In Britain another famous supporter of this new approach to the treatment of the insane was William Tuke. Tukewas a Quaker tea-merchant in York who wanted to improve the quality of care available to members of the local Quaker community who suffered from mental disorders. In 1796 he founded a private asylum for Quakers, the Retreat. Another famous supporter of this new approach was John Conolly with his establishment, Hanwell.
This new approach to the treatment of the insane inspired in Britain by William Battie,and then brought into reality by Tuke, is often called moral management, moral treatment, or 'moral therapy', as it was commonly known in the nineteenth century.
The principle underlying the moral treatment of the insane was that insanity was a psychological rather than a physical disorder. Physicians focussed on the emotional rather than on the physical causes of insanity. This moral treatment gave importance to the lunatic's environment, diet, and physical activity. Moral treatment was not so much a specific technique as a range of benevolent treatments designed to involve the patient actively in his recovery. It is best viewed as a pragmatic and humane attitude towards the insane rather than a specific form of treatment. One of the most innovative characteristics of moral treatment was the way in which the patient/physician relationship was reconceived. Combining close supervision and paternal concern, the psychiatrist made an effort to establish a relationship with the patient, or some form of connection. Increasingly, physicians sought to control the passions of the lunatic through their own direct intervention, rather than through the use of physical restraints. Such therapeutic strategies often depended upon the authority or the charisma of the doctor.
Another important element in moral treatment was the employment of the patients.Occupational therapy took various forms: women were employed in household tasks, needlework, and knitting. Men were encouraged to do manual labour such as agricultural work, chopping wood, digging, pumping, mangling and so on. However this occupational therapy proved to be more problematic with men as manual labour was not considered appropriate for upper class men. Moral treatment soon won favour with the public because it embodied a traditional bourgeois emphasis on the virtues of self-discipline, moderation, and industry. While older brutal external restraints, such as the use of chains on the insane, merely forced outward conformity, in contrast, moral treatment sought to cure the insane from within. Only when completely transformed could the lunatic return to society.
As mentioned earlier, the reform movement was a European phenomenon. In Italy for example, there was the physician and psychiatrist Vincenzo Chiarugi in Florence. Chiarugi had been working in the hospice of Santa Dorotea since 1775, but in 1788 he renovated an old hospital, the San Bonifazio to host mentally ill patients. In the following year, Chiarugi printed a set of regulations on how to maintain proper order in asylums.' Chiarugi then published On Insanity (1793-94) in which he argued that asylums were not merely places to isolate mental patients, but they could also be places in which to heal them. He outlined the scenario for doing so. Like Tuke in England, Chiarugi was against using chains on the insane, and in 1788 he unchained his patients.
Perhaps, the most famous psychiatrist associated with freeing the insane was the French Philippe Pinel. Pinel had studied mathematics at Toulouse and then went on to study medicine at Montpellier. He then travelled to Paris as a kind of medical littérateur, writing, translating, and attending salons, but he did not practice medicine. After 1789, Pinel drifted into revolutionary circles. Inspired by a progressive social philosophy he acquired in the salons during the 1780s, Pinel's head was filled with reformist ideals of both a humanitarian and therapeutic nature. During the French Revolution, the Jacobin government asked Pinel to take over the hospice of the Bicêtre. Pinel was an example of the kind of self-made man whom the Revolution had thrown into prominence. His fame became guaranteed in 1793 for removing chains from the madmen at Bicêtre. In 1795, Pinel abolished the chains at the Salpêtrière after becoming director of that institution. In this famous painting, Pinel is portrayed unchaining a female mentally ill patient at the Salpetriere. This image made Pinel the symbol of the new psychiatry that rejected brutal treatments.
Pinel became well-known amongst European physicians for the textbook he published in 1801, Traité medico-philisophique sul l’aliénation mentale[Medico-philosophical treatise on mental alienation]. This book had such authority that it immediately became THE textbook for those interested in moral therapy. On the basis of his experiences at the Bicêtre and the Salpêtrière, Pinel came to believe that the asylum was a place where moral therapy has to be carried out, and not only a place where the insane should be confined. Pinel began structuring the day with work and routine activities. He was also very much concerned with the principles according to which mental hospitals should be organised and administrated. He believed that asylums should have a rigid policy about what patients were allowed to do, but at the same time he thought that they should inspire a liberal attitude. Above all, asylums must be large enough to allow segregation of the different categories of patients. He described the Salpêtrière with its separate departments for idiots, for incurable agitated patients, for curable agitated patients, for quiet patients, those who were demented, and those suffering from senile dementia etc. In addition, there was a department for mentally ill patients who also suffered from other diseases. Despite his complete rejection of the use of chains as a method of correction, having himself abolished them in the Bicêtre and Salpêtrière. Pinel did resort to the use of the strait-jacket. However Pinel warned against using a strait-jacket for long periods. Both the strait-jacket and the douche may, according to him, be ordered only by the physician. Pinel rejected beatings, saying they were neither effective as a treatment nor did they educate the insane. He considered continuity, a constant routine, and the study of the patient's personality essential parts of moral treatment. He believed that physical exercise or mechanical work should form the basic programme of every mental hospital. That is why, he thought, that members of the nobility, who generally rejected working within asylums, were especially difficult to cure. Religious activities should be carefully restricted because they sometimes provoked dangerous states of ecstasy. Pinel was deeply convinced of the absolute necessity for an early separation of the patient from his family. Families could not look after the insane properly and produced unnecessary anxiety. Contrary to what Tuke did at the Retreat in Britain, Pinel strictly limited any connection with the outside world. Those of you who have read Foucault's History of Madness might remember his description of how Tuke encouraged the insane to meet visitors regularly for dinner and tea. Pinel believed that only isolation could work. In cases of food refusal, Pinel introduced tube feeding. He did not believe that bleeding could treat the insane and rejected sudden immersions in water. On the other hand, he believed that baths and showers could be very effective methods of treatment.
But it was one of Pinel's students, Jean-Etienne Esquirol, who developed the notion of the daily regime itself as therapeutic. Esquirol was born in Toulouse in 1772, the son of an influential family whom the Revolution had reduced to poverty. After drifting about in search of a career, Esquirol migrated to Paris to study medicine. In listening to lectures from hospital to hospital, Esquirol finally met Pinel at the Salpêtrière . Esquirol began to make a name for himself with his 1802 doctoral thesis on the role of the 'passions' in mental illness, and in 1811 he became the administrator of the psychiatric division of the Salpêtrière. Like Pinel, Esquirol believed in the positive effects of ―isolation from the outside world, and felt that this would contribute greatly to diverting the patient from the previously unhealthy passions that had ruled his or her life. Esquirol put into operation Pinel's notion of the therapeutic community: patients and physicians lived as community members in a psychiatric setting. Esquirol also had a private nervous clinic across from the Salpêtriere, where patients would eat with Esquirol's family.
Part II: theoretical changes
These are the main practical changes related to the birth of the modern asylum, but these practical changes cannot be separated from more theoretical changes in the way of thinking about mental illness.
In order to appreciate these changes in ideas about mental illness, we need to go back to Locke and to what he thought about madness. Indeed Locke had formulated a theory of madness that was influential until the end of the 18th century.
In his Essay Concerning Human Understanding (1690), Locke argued that there was no a priori Right Reason, no certain logic of truth, and no inborn ideas. Rather, Locke presents the mind initially as a tabula rasa. Knowledge is composed from unit sensory inputs, which mental operations assemble into conceptions, ideas, and finally thought-chains. Both thinking and feeling arose through the education of the senses. As knowledge was a matter of experience, so was the individual's personality. According to Locke, the individual's character was not assumed to be innate and fixed, determined by humours, or ruled by passions. Instead, the individual's personality was something generated. Within this framework, Locke formulated a massively influential theory of madness. For Locke, as for later Enlightenment philosophers such as Hume and Bentham, passions should not automatically be blamed for madness. On the contrary, Locke believed that the key to insanity lay in reasoning itself.
Madness: incongruence between a person's picture of the world and reality, or when a wrong association of ideas took place. In other words, madness was essentially a delusion.
Locke clarified this when spelling out the distinction between fools and the insane:
"A fool is he that from right principles makes a wrong conclusion; but a madman is one who draws a just inference from false principles...A madman fancies himself a prince; but upon his mistake, he acts suitable to that character; and though he is out in supposing he had principalities, while he drinks his gruel, and lies in straw, yet you shall see him keep the port of a distressed monarch in all his words and actions (Locke)."
Delusion was thus the starting point of madness. Thus Locke emphasised the errors of reasoning and he viewed madmen as infants, incapable of thinking straight. The implication of Locke's view on madness was his insistence upon the mind's fragility, the ease of becoming trapped within webs of incorrect associations. When talking about madness Locke stressed reason's mistakes, fed by delusions. Locke's understanding of the operations of the mind, both normal and abnormal, was widely adopted to explain insanity. For experts in mental illness, intellectual delusion became the main feature of insanity until the 18th century.
Pinel moved away from the Lockean view of madness as delusion. According to Pinel, mental illness stemmed from an abnormal intensity of the passions and an unbridled imagination. In practice, this meant both moving away from an emphasis on reasoning faculty to an emphasis on emotions, and going back again to the pre-Lockean exploration of the impact of passions on insanity. Before the 17th century and Locke, the insane were thought to be slaves of their own passions, but they were believed to be clearly different from sane individuals. In the 19th century, with Pinel and his students, insanity was not so clearly separated from sanity. In the early nineteenth century the insane were believed to be disturbed but not completely different from the normal human condition. This was why it was believed that mental alienation could be cured by the application of a moral treatment, which, amongst other things, consisted of curbing excessive feelings. This new way of interpreting insanity implied that pathology and normality came to be viewed more closely than in the past. Psychiatrists came to believe that the madman and the normal man were not as different as they thought in earlier centuries.
We can see these theoretical changes in the work of the most prominent psychiatrists of the time. In his Traité medico-philisophique sul l’aliénation mentale, Pinel turns first to the problem of the cause of mental illness. He points out the extent to which the patient's emotional life is often disturbed.
For Pinel, heredity is the first cause of madness. But, overall, Pinel emphasises the importance of psychological factors in the development of insanity. Indeed the second cause of madness is a bad social environment and a bad education. In fact, treatment of the insane is, according to him, only a form of education. The third cause of madness is an irregular way of life. The fourth is what he calls spasmodic passions (rage, fright). The fifth, enervating or oppressive passions (grief, hate, fear, remorse). The sixth cause is merry passions. Seventh: melancholic constitution. Physical factors are mentioned only as the eighth cause, and among these he includes alcoholism, amenorrhoea, non-bleeding haemorrhoids, fever, pueperium, and head injury.
Thus, most causes of insanity are found in the emotional sphere. Contrary to the findings of 18th century anatomists, who had dissected the insane's brain and had observed different forms of abnormality and degeneration in the brain, Pinel, who also conducted brain dissections, had observed that that insanity could exist without visible brain lesions or cranial malconformations. In cases where the brain had suffered a lesion, Pinel abandoned not only confidence in moral treatment, but all his therapeutic optimism, admitting the incurability of the condition. Yet, he believed that there were many forms of mental illness caused by emotions.
He recognises 4 forms of mental illness: mania (agitated states), melancholia, dementia, idiocy.
Moral treatment aimed to cure mainly mania and melancholia, which were characterised by disorders of the emotional life. The psychiatrist could not treat people affected by dementia and idiocy.
Unlike Pinel, Esquirol did not believe that manic forms of mental illness were caused by the stomach. Instead, he adopted Gall's theory of cerebral localisation, and believed that all forms of mental illness could be located in the brain. Esquirol would try anything that promised some sort of success. He applied mesmerism (hypnotism), Gall's phrenology, treatment with music. Esquirol had a deep understanding of the moral causes of insanity and he recognised that some of the so-called causes, i.e. abuse of alcohol, masturbation etc. were often merely early symptoms of insanity. Esquirol especially emphasised the role that social upheavals and the isolation of modern man played in the genesis of mental illness. It is not a coincidence that one of the French terms for mental disease is 'aliénation', that is 'estrangement'. Esquirol believed that in the insane, human relationships are disrupted and may even be changed into their opposite. On the other hand, he pointed out how much the mental patient and the normal person have in common, particularly when the normal man's attention is distracted. In a sense, the insane lose their capacity for concentration. You will see these characteristics when reading Esquirol for your tutorial.
Pinel and Equirol believed that insanity did not appear only when there was a delusion. They noticed that some individuals had obsessions only in some emotional spheres, and could reason rationally when dealing with most aspects of their daily life. This was a new way of looking at mental disorders, as in previous centuries insanity was thought to take over the entire individual.
Early-nineteenth-century psychiatrists began to wonder how to diagnose individuals who appeared diseased in some aspects of their psychological functioning, and healthy and well ordered in others. Again, the role of passions was crucial in understanding this problem. This is the problem of the so-called partial insanity or reasoning insanity, which were at the core of much early nineteenth-century psychiatric debate. In his work [Traité medico-philosophique sur l’aliénation mentale, Pinel paid attention to what he called 'manie sans délire' [Mania without delirium]. This was a form of mania in which the individual preserved the integrity of their reason, while abandoning themselves to the most unusual acts. Pinel stressed that in manie sans délire it was the emotions that were primarily involved, and that mania could exist without lesions of the intellect. Pinel also believed that the maniac's behaviour was caused by a perverse constitution or inadequate education.
To deal with the problem of these forms of insanity, around 1810 Esquirol introduced the term 'monomania' to indicate a fixed idea, a single pathological preoccupation in an otherwise sound mind. Esquirol believed that some individuals have a perfect ability to reason, but that their will is weak: they cannot resist some pathological instincts. Monomania as described by Esquirol was a partial insanity. It was a mental illness recognisable only to those with special expertise and clinical experience.
While introduced by French psychiatrists, similar ideas could be found in Britain as well. In the 1830s, the British physician and ethnologist, James Cowles Prichard, developed the notion of 'moral insanity' to indicate a disorder of the emotions, instincts and the will. Prichard defined 'moral insanity' as follows:
This form of mental derangement has been described as consisting in a morbid perversion of the feelings, affections and active powers, without any illusion or erroneous conviction impressed upon the understanding: it sometimes co-exists with an apparently unimpaired state of the intellectual faculties. (Prichard, 1835)
Prichard created the category of 'moral insanity' to refer mainly to affective and volitional alienation. Like Pinel and Esquirol, Prichard believed that passions could cause insanity, and that a form of madness without delusions was conceivable. Reasoning insanity, monomania, and moral insanity show how early-nineteenth-century psychiatrists developed diagnostic categories in an effort to address the case of individuals who displayed uncontrollable passions, but who were otherwise able to reason and judge rationally.
The introduction of concepts like monomania and moral insanity have been very important outside medicine as well. During the 19th century psychiatrists began playing a role in a forensic setting. When individuals committed violent crimes, or individuals who had a good reputation suddenly murdered someone, psychiatrists were called to examine such cases and testify in courts. Psychiatrists began arguing that monomania could diminish responsibility in criminal cases. Basically they argued that individuals who were affected by monomania did not lose their reason, but were not completely sane so they could not be punished as a normal individual. This is the important problem of responsibility of the insane. Today in courts you can see that lawyers appeal to madness to reduce the punishment of their clients. Lawyers say that an individual can be suddenly carried away by strong passions. This way of thinking about insanity and crime had not always been present in Western history, and it emerged in the 19th century when physicians began conceptualising insanity in a new way. The idea to reduce a punishment on the basis of certain circumstances such as insanity is a product of nineteenth century psychiatry.
Throughout the nineteenth century, psychiatrist became increasingly interested in these kinds of mental illness. You don't find many psychiatric treatises about the idiot, as you do about these less severe forms of insanity. On the one hand you can see how psychiatrists broadened the range of people who might be insane, i.e. individuals who masturbate were considered insane, people who did not conform to the social values of their society could be considered insane etc. At the same time, you can see how psychiatrists began questioning what insanity and normality is and the boundary between the two. But this is another issue and we will talk about psychiatry in the second half on the nineteenth century in 2 weeks when we look at German psychiatry.