Mad, Bad, and Sad: A History of Women and the Mind Doctors

by Lisa Appignanesi

THE RISE AND RISE OF THE NEW SCIENCE

  2

  PASSIONS

  Revolution engenders revolutionary enthusiasms. In Napoleonic France and through the first part of the nineteenth century, medicine takes on a new momentum as a tool both of social good and of what can begin to be called scientific inquiry. First-hand clinical observation–the development of what Michel Foucault calls the medical gaze–is married to a new sense that medicine can encompass both a knowledge of nature and a knowledge of man in society. Where the mad are concerned, the new breed of doctors suppose that it is worth both managing them and acquiring knowledge of how their minds and emotions work. Such knowledge, it is presumed, is not only part of the wider practice of detailed medical observation which comes to be known as la clinique: it will also help to effect cures. The inner experience of madness, madness from the point of view of the sufferer, thus becomes the object of an intense curiosity. In turn this intense curiosity about the mind and the various forms of medical practice that come along with it inevitably have a shaping effect on mind itself and on those descriptions of subjective experience that people bring to doctors and to each other. The files and records that the new science keeps increasingly confine the individual in illness categories, even when she is not confined in an asylum.

  A growing willingness to assume a continuity of sensations between the mad and the sane also marks the moment. The mad are not in any way simply ‘wild beasts’ raging, like Bertha in the Brontë attic, and poised to bite. They are interesting, perhaps subtle. J.E.D Esquirol–with Philippe Pinel, his teacher, the most important pioneer in the new field–traces a long and honourable history for mania and gives it a Greek and biblical pedigree, which includes Oedipus and Orestes.

  The most important term in what would become the French mind sciences, le délire, suggests an experience which encompasses the ecstatic joy of the poet, the hashish smoker and the revolutionary rioter, as well as the more medicalized fever of an English ‘delirium’. Esquirol gives delirium its broad, foundational definition. A man ‘is in delirium when his sensations are not at all in agreement with external objects, when his ideas are not at all in agreement with his sensations, when his judgements and his resolutions are not at all in agreement with his ideas, when his ideas, judgements and resolutions are independent of his volition’. For Esquirol, delirium is a sickness of the soul. Uncontrollable passion and imagination are of its essence: in fact, madness is simply imagination gone awry. Delirium, like the altered states which mesmerism induces, can be experienced by the sane, while the mad are not always deliriously so.

  With this kind of understanding, making distinctions between the undelirious mad and the deliriously sane becomes a subtle business and one necessitating expertise. This had several effects. It helped engender the new profession of alienism–a forerunner of psychiatry–and gave it a certain social power. The status of the mad improved, at least marginally, and certainly in the eyes of urban progressives. Conversely, under the power of the new professionals, claims of madness were now more difficult to reverse: for those with less social power, like women, this could make unwanted confinement difficult to resist or escape.

  While English ‘moral management’, with its private or charitable asylums, had substantially influenced pioneering French doctors, in France the revolutionary state was early invoked to take on responsibility for the mad. A rising profession of medics, keen to carve out their niche in this brave new world of growing ‘specialisms’, did the invoking. They would seek whatever expertise could be garnered from the untrained custodians of the mad, as well as from the travelling charlatans with their magical, mesmeric or faith cures. Each had something to teach–certainly as much as the antiquated pre-revolutionary medics steeped in arcane theories with little observational base. And the new professionals were ready to learn in order to take over. They were also keen to assume the burden of care that the clergy, those retrograde collaborators with the ancien régime, had previously held. Under the aegis of these new enterprising medics, demon possession would give way to scientific diagnoses, though the boundaries of what constituted science remained fluid and permeable. One thing, however, was clear: if the Revolution had freed the people from their metaphorical chains, it must also free the mad from fetters that were all too real.

  This new medical passion for public health went arm in arm with a need to gather what we now call statistics. Freed from manacles, the mad began to be fixed in the categories and paper chains of the new state apparatus with its growing medical bureaucracy. Already on the eve of the Revolution, the surgeon Jacques Tenon, preparing a report on the Paris hospital system for a reforming government minister, found that the best information available lay with the Lieutenant General of the Paris police–an expert on hospital admissions.

  Statistics–still an unnamed science though a term used in Germany for ‘state-knowledge’, deriving from the word Staat, but there in germ in the new wave of fact-gathering–were needed for shaping policy. They also influenced theoretical speculation. Tenon’s researches led to interesting questions and to a novel field of inquiry: ‘It is certain that among furious lunatics, there are more women than men. A new subject for research. Does this difference originate in the sequelae of childbearing, in the nervous sensations accompanying lactation?’ Though he cannot yet answer his own question, Tenon is keen to arrest the ‘deterioration’ of the sex that ‘perpetuates society’. The new Sainte-Anne hospital, he determines, must have more facilities for mad women than for men, unlike the Hôtel-Dieu where the ratio went the other way. This hospital, Tenon asserts, emphasizing the hopes of the times, will be a machine à guérir, a machine for cures.

  For the new alienism’s key pioneers, Philippe Pinel, author of the seminal Traité médico-philosophique sur l’aliénation mentale, ou la manie (1801; expanded, 1809), and his pupil, Jean-Etienne-Dominique Esquirol, puerperal madness continued to be a strand of diagnosis, just as the size of the population and care for mothers continued to be a preoccupation for the French state. However, unlike their later progeny, both doctors tended to give more weight to social and environmental determinants of madness than to specifically biological ones. In their vision, the biological might act as a trigger, or occasion a susceptibility, but already-existing passionate conflicts or life crises were the weightier determining ‘cause’ of mental illness.

  French psychiatry, born with the Revolution, is initially closely bound up with a cultural and social, rather than a biological or hereditary, imperative. Environmental forces occasion madness, just as they occasion revolution. Interestingly, symptoms, too, express the times. Pinel, Esquirol and their growing number of students are alert to the fact that the mad to some extent choose the shape their symptoms will take: they learn ‘mad’ behaviour from those around them, and in their agitation enact the passions the culture provides: ‘Other illnesses…reveal themselves to us by constant signs, as invariable as their causes…Only madness [la folie], a kind of morbid Proteus, is the transitory and changing image of the interests that govern men, of the emotions that agitate them; and, like the world, a lunatic asylum is a mosaic of the passions.’

  Mimicking Napoleon’s rise and rise to imperial status, the condition of manie ambitieuse–ambitious mania–finds its way into the madhouses. This is the socially-propelled malaise of the soul both Stendhal and Balzac identify in their heroes. It is the ‘dark ambition’ which drives Julien Sorel, the hero of The Red and the Black, on to a path of glory that ultimately ends in crime. Indeed, the two novelists were fascinated by the new science. Convinced of the importance of character expressed through physiognomy, Balzac gives the same detailed, almost clinical attention to his characters as the new ‘moral’ medics give to their patients, enshrining them in the rising naturalistic genre of the ‘case history’ and classifying them by diagnostic kind.

  There is a growing sense through the first part of the century that clues to character, to the workings of the mind itself, are visible on the
surface of the body and can be read by the trained eye. This sense gives rise to the study of physiognomy and to phrenology, the reading of character by the tapping of the skull, on the basis that psychic traits are the expression of particular organs of the brain.

  Citizen Pinel (1745–1826): liberator of the insane

  Philippe Pinel, the doctor in charge of the Parisian madhouses during the Revolution, took on a legendary status through his act of ordering the mad to be liberated from their chains. It was a scene much depicted in popular prints of the time and reinvoked in the writings of his son Scipion as well as in a much reproduced painting of 1887 by Tony Robert-Fleury. This last shows a compassionate Pinel ‘freeing the insane’ (the painting’s title)–symbolized by a beautiful Marianne-like maiden in loosely flowing dress and unleashed hair. While her chains are unlocked, Pinel looks on with a beneficent scientific curiosity.

  The man who was to make a medical science out of the treatment of madness was born to a poor family in a small town in south-west France. In love with the great illuminating philosophes of the Encyclopédie, with literature and mathematics, he felt the limitations of his first medical degree from the Faculty in Toulouse and went on to the renowned medical school in Montpellier. Here he frequented the city’s several hospitals and already began to develop the medical technique he later encouraged in his own students: he observed the patient carefully, translated what he saw into written notes while at the sickbed, and eventually recorded the entire course of a severe illness. He also talked and listened to the patient. Pinel’s lasting contribution to the new medicine was to underline the importance of observation and of the doctor–patient relationship in fostering a cure.

  From Montpellier, like so many of the heroes of French literature, Pinel felt irresistibly drawn to the capital. Here, although he made medical friends, he was unable to practise: the all-powerful and conservative Faculty of Medicine twice refused him a much needed scholarship and entry to its ranks. The seeds of later rebellion against a powerful medical orthodoxy were sown at this time. The young provincial fell into a depression and dreamt of fleeing the baseness and intrigues of Paris by journeying to America. Instead, in 1784 he accepted the post of editor of the Gazette de Santé, and wrote articles, many of them on hygiene, ‘moral’ treatment and mental disorders. Pinel’s considerable talents as a writer are certainly not inconsequential in the shaping of his reputation and, indeed, of French medicine. The success of the later Traité, sought out by Stendhal, must in part be due to the brilliance of its prose, the narrative impetus of its case studies, as well as Pinel’s interest in the philosophical underpinnings of medicine.

  In 1785, Pinel translated some important texts of Scottish and English medicine: William Cullen’s First Lines of the Practice of Physik and three volumes of the Philosophical Transactions of the Royal Society of London. He also became a regular at the influential salon of the beautiful Madame Helvétius, wife of the philosopher who is known as the father of utilitarianism. Influenced by Locke and Condillac, Helvétius believed that human behaviour is determined by education and environment, that actions and judgements are generated by the natural desire to maximize pleasure and minimize pain. All this was to inform Pinel’s later writing on the mad and his attempt to create better environments for them.

  The tragedy suffered by a close friend sparked his interest in madness. A shy provincial like himself, the friend had fallen into despair and then ‘mania’ when his legal aspirations failed to materialize. Unable to help the younger man once he had all but ceased to eat, Pinel had brought him to the Hôtel-Dieu where a treatment of baths and food seemed to restore him. But his worried family intervened and took him home before he was quite well. The youth escaped their hold, fled to the woods and was found dead only after the wolves had got at him.

  Pinel sought out work at a private madhouse. For five years the maison de santé owned by a former cabinetmaker, Belhomme, served as his observational training ground and allowed him to hone ideas and therapeutic technique. With the Revolution, Citizen Pinel’s star rose. The Comité de Mendicité (Committee for the Welfare of the Poor) wanted to make madhouses centres for cure. In 1793, Pinel was appointed to run the hospice at Bicêtre, which had never had a medical head. (The Marquis de Sade was brought there in 1803.) It was here that Pinel first freed madmen who had been chained for twenty years or more and protected them from the jeering crowds who came to gawk. During his nineteen months at Bicêtre, Pinel listened to each inmate’s life story and carefully tracked symptoms in order to build a sense of the ‘natural history of the disease’.

  Next came a Chair in Hygiene–the equivalent of public health–at the newly formed Ecole de Médecine in Paris where the training emphasis was now on ‘seeing’ and doing, rather than reading and accepting old ‘theoretical’ visions of the body and disease which could so easily occlude the visible. In 1795 Pinel not only became Professor of Pathology, a post he kept for twenty years, but was transferred to the Salpêtrière, the facility for ‘incurably’ mad women. It is to the Salpêtrière–a hospice which numbered some 5000–7000 inmates, about 600 of them mentally ill–that his name has become indissolubly attached. With the help of the General Council of Paris Hospitals which accorded Citizen Pinel two paid medical students to help him with his research into madness, the foundations of the new medical science of alienism were laid, here amidst the women. Freud was later to say that the most humane of all revolutions was launched at the Salpêtrière by Pinel when he freed the mad from their chains.

  Alienism was only one of Pinel’s undertakings. His contemporaries knew him equally well as a great medical diagnostician and classifier, and in particular through his Nosographie Philosophique of 1798. The book makes thorough use of the new practice of la clinique, that observation and taking of histories which allows the doctor coolly to delineate the whole course of a disease, its symptoms and progress through to its internal appearance post-mortem. A vast hospital also provided ready access to a large number of corpses for autopsy. This is the moment when medicine begins to acquire the systemized status of a science.

  Such was Pinel’s distinction that for a time he served as Napoleon’s physician–a post which must have attuned him to the nature of ambition. It is clear from Pinel’s seminal Traité that his goals are already those of a man intent on setting up a profession that straddles the medical, the scientific and the philosophical.

  The Traité investigates the field of ‘mental alienation’ systematically, drawing together a wide range of those Pinel wants to designate as precursors in the field and setting out best practice. It begins with a section on causes of mental illness. Pinel names five general areas that can play a role in mental alienation: heredity, ‘irregularities’ in the environment, the role of sudden or oppressive or excessive passions, a melancholic constitution; and lastly, physical causes. The second section describes ‘lesions’, or abnormalities, of perception, thought, memory, association and judgement. The third provides Pinel’s classification system with its four main groupings: the many kinds of mania, melancholy, dementia and finally imbecility. Section four moves from observation to best practice: Pinel is intent on advocating the kind of morally managed and enlightened therapeutic institution he believes in, as well as on disseminating the kind of teaching and research that is necessary to the new medicine.

  It is clear that doctors are to take over the burden of care from priests and that religious mania can be contagious and must be carefully restrained. His anticlericalism is both part of Pinel’s revolutionary stance and marks the rise of a competing caring, but now scientific, profession. He also underlines that the most effective treatment, if it is to be repeated successfully across the nation, cannot be based only on personal experience. For the truths of alienation to emerge, research must be carried out across a sufficient population, by regular, detailed observation over many years. In that sense, he is a modern doctor.

  Pinel’s contribution to medical theory lay in his c
ertainty that many kinds of madness were partial and therefore curable: the patient’s reason, in abeyance but reachable, had to be engaged so that she became an accomplice in her cure. This was married to his insistence on the careful observation of symptoms. Such external manifestations of illness were the basis for disease classification.

  Pinel’s empirical bent made him particularly open to English medical management, as well as to the experience of the non-medical guardians in the mental institutions, both male and female. He was alert to the tacit skills of experience, the way the concierges, or guardians–in particular the superintendent at Bicêtre, then at Salpêtrière, Jean-Baptiste Pussin and his wife–managed the mad by appearing to be party to their imaginary ideas, or by diverting them with laughter and trickery until they were calmed or fed. A populist who was also interested in philosophy, Pinel had no compunctions about inviting mesmerists into the Salpêtrière to see what effect their brand of treatment might have on the patients. Such popular forms of mind control and suggestion could all be tapped in the shaping of a field which was still porous.

  Strangely, for a practitioner of that new clinical method which in its non-alienist manifestations liked to localize disease in body parts, Pinel was less interested in the search for any physical and brain-related causes of madness. He believed that brain lesions might produce idiocy, but not the kind of mental alienation so many suffered from. Although he admired anatomical studies of brain lesions and glands, he was sceptical about their usefulness. ‘Can one establish any link between physical appearances manifested after death and lesions in intellectual function observed during life?’ he asked. A lesion in the brain, a swelling of the meninges or brain tissue, after all, does not easily translate into ‘ambitious monomania’, a patient believing she is Queen. Since lesions are unlocatable during a patient’s lifetime, they hold out little use for treatment. Then, too, there is the underlying problem about the similarity of the post-mortem brains of the normal to those who have been mentally ill. This poses a grave obstacle to any theory which wants to make a wholesale link between insanity and brain disease.