Pinel’s followers–Esquirol to a certain extent, Etienne-Jean Georget, and the institution of alienism that grew up around them–were similarly critical of those who, like the brilliant young pathologist Antoine-Laurent Bayle, set out to find a physiological and anatomical base for mental illness through post-mortem research. The search for physical causes and, even more so, the certainty that they would eventually be found, had to wait for subsequent generations.
If brain lesions as causes of mental illness were not of primary importance to Pinel, the imagination was. Already in his early journalism he was well aware of the way imagination could produce physical ills and in turn help to speed their cure. He was convinced of the happy effects ‘consoling and reassuring words’ had on patients in general medicine–in other words, of bedside manner. His founding principle was la douceur, a winning gentleness. The ‘moral treatment’, in today’s terms a psychological treatment, proceeded from these grounds.
Whatever distance our theories and knowledge of brain chemistry may have travelled, Pinel’s procedure once more seems eminently sensible, practical and humane. Through douceur and an attentive listening, the doctor won the patient’s trust and made her tractable to the authority that had to be established from the first. If force ever had to be used, it must be clear that it was used against the grain of the doctor’s wishes and only in a difficult moment when gentleness was impossible–such as in the first, highly agitated states of mania when restraints were to everyone’s benefit.
Pinel distinguished two main kinds of alienation–the word he prefers to folie, or madness. The first was caused by erroneous ideas or pathological reasoning, a very Lockean form of madness. He treated this by attempting to divert the patient, through a kind of theatrical ploy–an appareil–which would shift the patient’s mind on to a new track or demonstrate the error of the thinking he or she was trapped in. In this way a tailor, driven mad by his worry that his fellow revolutionaries would punish him for a momentary expression of sympathy for the guillotined King, was prescribed a staged trial in which the judges ruled his sentiments of the most patriotic. A temporary cure was thus effected.
The second and far more prevalent form of alienation, according to Pinel and his growing school of followers, particularly his favourite and successor Esquirol, was caused by pathological passions–extreme emotions stirred by the traumas of life. Pinel cites the cases of three girls driven mad by fear: one by a ghost ‘introduced’ at night into her room, another by a violent clap of thunder experienced at that certain time of month, the last by the horror inspired when she was tricked into a particular place.
Amongst the overwhelming and oppressive passions capable of driving an individual mad he lists hatred, envy, jealousy, grief and remorse. He notes that these are passions that also serve art. However, when overly strong or in conflict with each other, they can derail reason or send the subject into a melancholy stupor. Sufferers are characterized by external signs such as paleness, loss of appetite, loss of muscular force, laborious breathing interspersed by sobs and either the most violent delirium or a profound passivity. He describes the case of a woman who watched her family being butchered in war, another who lost everything after the death of her father and couldn’t earn her keep; one who had dedicated herself to God and chastity at the age of fourteen, then decided on marriage and, though seemingly happy, her scruples resurfaced after the birth of her fourth child, and the ensuing inner conflict produced delirium. Another young woman, driven mad by the tug of war between God and temptation, refused to eat for a month.
Such diseased passions–so potently part of that pivotal Romantic philosopher Rousseau’s thinking–cannot and should not be entirely removed, according to Pinel. Passion is crucial to the revolutionary personality, after all. However, in the interests of good health, the diseased passion needs to be ‘counterbalanced’. In Rousseau’s La Nouvelle Héloïse, the mentor performs this function. A doctor can do the counterbalancing for a patient with the help of various theatrical ruses. Treatment is most effective when coupled with confinement away from the corruptions and hurly-burly of the city.
Therapeutic confinement, kindness which entails listening to the patient, and constructive occupation are thus the key features of Pinel’s treatment. The confinement is important. Pinel is emphatic, as Freud and Laing were later, that his patients suffer from their families and need to be removed from them. In the asylum those traditional treatments for lowering or raising a patient’s ‘state’–such as bleeding, purging, immersion in freezing water and blistering–gave way to talk and occupation therapies. As well as regular purposeful work, physical exercise and understanding are the keys to cure. The last might include placing the patient in an invented family group–something of a rehearsal for non-institutional life. In this Pinel feels thoroughly modern, as he does in his radical departure of suggesting that convalescent or cured patients be hired as nurses. This would help their reintegration into ordinary working life and also serve as an example of hope to patients who had known them on the other side of that wavering divide between sanity and madness.
All this, needless to say, was an ideal. Throughout France, and even in the capital, far more primitive conditions often prevailed. Then, too, that seemingly salutary idea of partial madness, which linked the mad and the sane in a family of behaviours and imaginings, could equally be used as a way of labelling the more or less sane as ‘mad’ and in need of confinement. From the beginning, what would become psychiatric science wore a Janus face.
Jean-Etienne-Dominique Esquirol (1772–1840)
If Pinel laid the basis for French alienism in the nineteenth century, it was his pupil Esquirol who disseminated his ideas and consolidated the relationship between the new medical expertise and the state.
Born into a wealthy merchant family in Toulouse, Esquirol’s bourgeois background facilitated his dealings with power, especially after 1815 when a reactionary Restoration bureaucracy grew suspicious of the preceding regime’s favourites. Comfortable with those in power, he was nonetheless committed to helping the helpless insane, whose plight he described in rhetoric vivid enough to provoke the most dry-eyed of government ministers into ultimately passing the law of 1838 which was intended to provide departmental asylums for the mad poor throughout France. ‘I have seen them at the mercy of veritable jailers, victims of their brutal supervision. I have seen them in narrow, dirty, infested dungeons without air or light, chained in caverns where one would fear to lock up the wild beasts that luxury-loving governments keep at great expense in their capitals.’
Armed with a medical degree and two years as a public health official in the southern town of Narbonne, Esquirol first arrived in Paris in 1799. At the Salpêtrière, he quickly became Pinel’s favourite student. In order to further the research on madness they were both so interested in, Pinel apparently put up the security for the private asylum Esquirol ran on the rue de Buffon. It became one of the three best in Paris and provided the case work for Esquirol’s thesis of 1805, Des Passions considérées comme causes, symptomes et moyens curatifs de l’aliénation mentale. Aberrant, extreme or insufficient passion is, for Esquirol, at once cause, symptom and means of cure.
Following the death of the Salpêtrière’s concierge, or guardian, the very Pussin from whom Pinel had learned so much about the mad, Esquirol was made the medical head of the asylum. He thus effectively became, as Pinel underlined, the first doctor devoted wholly to the study of insanity. The patients in the Salpêtrière were of course women, and it was in observing and listening to them that Esquirol like Pinel honed the specialization that would become psychiatry.
Pinel’s choice of a second was a good one for the growth of alienism. Esquirol had a talent for public affairs: he inspected facilities for the mad throughout France, produced reports for government as well as books and, in 1817–still a médecin ordinaire, not a professor–he instituted the first formal and highly popular course in maladies mentales. His students were m
any and dedicated. The number of alienists grew and, with them, the use of what was Esquirol’s most popular diagnosis–monomania. This became the mental illness of the times, arguably the first culturally engendered diagnostic fashion, breeding copycat sufferers who, nonetheless, in that symbiosis between mind and symptom so common in the history of mental alienation, really suffered from the named condition. Monomania was also the diagnosis which took psychiatry emphatically into the courts, making doctors expert witnesses in criminal trials where the line between responsibility, free will and extenuating madness was not immediately visible to the ‘lay’ eye.
Astute, dedicated, diplomatic enough to distance himself slightly from Pinel and the liberals who were forced into the sidelines by the Restoration government, Esquirol was appointed Inspector General of the Paris Medical Faculty in 1822. In 1825 he became the director of the Charenton Hospice. He was also the architect of the national law of 1838 that created an asylum in every French département. His monomania flourished during the period of the constitutional monarchy, while the bourgeoisie, like the new alienists, rose and rose, and France enriched itself. By the 1870s when theories of degeneration and hysteria took over, the diagnosis had virtually vanished.
MONOMANIA
In order to establish the new science of alienism, Esquirol wanted to cut off links to any ancient humoral classifications. Contemporary scientific thinking needed to be reflected in new names. For melancholy, he proposed ‘lypemania’, which never quite caught on as a term. What did was the newly minted condition of monomania, ‘that partial madness dependent on exciting, expansive and buoyant [gaies] passions’. He saw monomania as being ‘intermediate’ between lypemania, or depression, and mania. With the first it shared ‘fixity and concentration’ on a single set of ideas, though the lypemaniac in his partial madness was morose, fearful, and suffered from prolonged sadness. With mania, it shared an exalted nature and excessive moral and physical agitation. In advanced societies, he noted, monomania was caused and characterized by pride, by an abnegation of all belief, by ambition, despair and suicide. In older societies, or in the country, it could as well be characterized by erotic or religious passions.
Esquirol, like his teacher, made copious observations of his patients: physiognomy, minute details of behaviour over time as well as past history, come into play in his notes and, later, in his books with their summaries of cases, treatments, their success and failure. So important was this ‘documentary’ evidence to Esquirol that he called in artists to draw his patients, just as a natural historian might have delicately copied a rare plant in the wild. Esquirol’s physiognomy of the monomaniac has all the elements of a Balzacian portrait: monomaniacs are ‘animated, expansive, hypermobile; the eyes are lively, sometimes shining and look ‘injected’, their walk has an energetic gait. They’re noisy, garrulous, petulant, brave, overcome all obstacles’, unlike the lypemaniac, whose gaze is anxious, whose features are drawn and immobile and who is prey to miserable ideas and a listless sadness and may often refuse food. Excited by ideas of grandeur, wealth and happiness, individuals who are subject to monomania are often impatient and irascible, suspicious of near ones, prone to hallucinations which topple them into delirium, sometimes suicidal. A crisis of failed hopes transforms them into princes, noblemen, empresses, distinguished scholars and inventors, poets and orators whose disquisitions must be listened to.
Amongst his patients at the Salpêtrière, Esquirol notes a young woman who has had some ‘instructions from above’ and thinks she orders the sun, the moon and the clouds. She threatens staff with rain or sun when she grows impatient with her stay at the hospice. Esquirol also mentions an empress, a dauphin, an Apollo Caesar, a sufferer from what came popularly to be known as ‘ambitious monomania’. He identified this as the primary madness of the age of ‘new kings’. Revolutionary upheavals had destroyed traditional hierarchies, dismantled structures of authority and introduced a mobility which crossed over into madness, one in which patients imagined themselves kings and queens. Though on the whole Esquirol and his followers were less likely to diagnose an ‘ambitious monomania’ in women than in men, and in the poor than in the rich, it was nonetheless the disease of the times, and could be caused by an incident of overwhelming passion. People were tipped into monomania, Esquirol notes, when the King, Queen or Danton were guillotined.
That rather porous dividing line between the monomaniac and the ordinary radically single-minded person is not always easy to see. Only when the subject of the monomaniac’s delirium comes into focus does the mania grip him and become visible. When Abraham hears an angel telling him to sacrifice Isaac, Esquirol notes, he is in the grip of a hallucinatory monomania, akin to that suffered by patients he calls religious monomaniacs. Indeed, religious delusions and the classification of these as madness play a substantial part in the building of this new scientific and adamantly secular discipline. In the acute phase of the illness, he states, the partiality of the monomania–when the sufferer is able to reason well across a range of thought unrelated to the driving idée fixe–disappears.
Théroigne de Méricourt
One of Esquirol’s most famous cases of monomania was that of the revolutionary ‘Amazon’, Théroigne de Méricourt, a woman of many sobriquets who was also known as ‘the panther’ and ‘la belle Liégeoise’ after the principality where she was born in 1762. The poet Baudelaire later immortalized her in his Fleurs du Mal, comparing her to Diana:
Have you seen Théroigne, that lover of carnage,
Exciting a barefoot mob to the attack?
Her eyes and cheeks aflame, she plays her part…
But the sweet Amazon’s soul
Is as charitable as it is murderous;
…And her heart, ravaged by passion, has always
Held a reservoir of tears for the worthy.
The daughter of well-off peasants, Anne-Josèphe Terwagne, as she first was, had a difficult childhood and left home early to become companion to a lady of Anvers who taught her the ways of polite society. Soon thereafter, this reportedly beautiful and adventurous young woman lived as a courtesan and singer, a demi-mondaine courted by a variety of men, one of whom was a jealous marquis, another a castrato who worked in the Sistine Chapel. She travelled widely, went to London and worked as a singer in Paris. With the Revolution, she threw herself into activism. She hosted a political salon frequented by the radical greats of the day–Desmoulins, Brissot, Danton and Mirabeau. Dressed as an Amazon and carrying pistol and sword, she addressed crowds on the rights of women. The Club des Amis de la Loi, which she founded, became the famous Cordelier Club.
Targeted by the royalist press as a Sadean libertine, accused of plotting to kill Marie Antoinette, de Méricourt was forced to flee Paris. In her case history, Esquirol states that she was sent to Liège to foment uprisings amongst the people and that at the time she held a military rank. She was noticed amidst the ‘savage’ crowd that attacked Versailles on 5–6 October 1790. Back in Liège the Austrians arrested her in January 1791. Detention took her to Vienna, where Emperor Leopold asked to see her. So convincing or, as some have said, so ‘seductive’ was Théroigne that he had her set free. By the end of ’91 she was back in Paris and in the thick of revolutionary activity once more, this time heading a ‘bonneted women’s brigade’ on behalf of the radical Jacobins. Esquirol, basing his statements as much on rumour as on fact, says that she played a leading role in the events of September 1792 and that though she may not have taken an actual part in the massacres of the royalists, stories circulated of her having, in good castrating fashion, sliced off the head of a man who was purported to be an ex-lover.
Whatever the truth of this rather conventionally misogynistic attribution conflating radicalism and debauchery, what is generally agreed is that like so many other early leaders, de Méricourt was trapped in the escalating rage of the revolutionaries during that phase of events when the ‘people’ rose against the very bourgeoisie which had initiated the Revolution.
In May 1793, during the uprising of the Paris Commune against the ruling Convention, a crowd of women turned on de Méricourt and whipped her to nakedness. Marat, who was himself to be assassinated in just two months’ time, stepped out of the crowd to save her from the women of his own party and led her away. It was the end of her political life. The public flogging by the very women she had battled for was to haunt the rest of her life and play itself out in the nakedness on which she later insisted.
Feminist commentators have suggested that de Méricourt’s flight into madness after this incident was her way of saying that the Revolution itself had gone mad. Others say her mental imbalance was already long in evidence, but her manic bouts of frenzy which dipped into depression had been masked by the Revolution’s own roller-coaster-like excesses.
Just before the fall of Robespierre in July 1794, one of de Méricourt’s brothers reported her ‘insane’, perhaps to prevent her being lost to the Terror and arrested in the general round-up of Jacobin supporters. When she finally was, the authorities found her to be suffering from persecutory delusions–hardly a surprising condition for the times. Freed, she was committed once more and sent to the Hôtel-Dieu.
From then on, de Méricourt’s life is a story of confinement. In his case history, which falls into the passionate register Pinel and he are so fond of, Esquirol dates her madness from the end of her revolutionary hopes with the establishment of Napoleon’s Directorate. He also mentions that the letter she wrote to Robespierre’s lieutenant Saint-Just, found amongst his papers and dated 26 July 1794, in other words at the time her brother first sought her confinement, already shows signs of a ‘deranged mind’. This fluidity, where deranged thoughts need not be, but, as in de Méricourt’s case, are propelled by external shocks into wholesale madness, is common enough to Esquirol’s case histories.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 8