The Chain Of Circumstances Which Led Me To Delve Into The Rules Of Moral Treatment
All civilized nations, though the varied in the influences of climate, customs and way of life, will still have causes of mania in common , as well as similar means of halting it's course. Why wouldn't the French, like the English, want to seek these means by way of observation and experiment. But this type of study demands favorable circumstances. The loss of a friend, who became insane through an excessive love for glory [in 1783], as well as the inadequacy of all medications, and the impossibility of controling him due to his deep sense of independence, enhanced my admiration for the judicieux precepts of the ancients, and my regrets for not having been able to follow them [Pinel, 1801, 50-1, Trans. E. Brown]. ...
Candor necessary in the exposition of facts
One must congratulate those who appear to never fail in treating
any illness and who regale us with stories of their numberless cures. This
ostentation, which should be relegated to comedies, recurs in the finest
theater. Why does this trait occur in people, otherwise worthy of public
esteem? Willis,whose
name is so justly celebrated in England and who, they say cures nine out
of ten maniacs, has never allowed anyone to even glimpse a case where he
has failed. If his lack of success with regard to the queen of Portugal,
had not been a public notoriety, through her confessor, he would
have buried it in silence. The man who cultivates medicine as a branch
of natural history, pursues a more frank and open course. He reveals the
obstacles that he runs into. The comparison of cases renders
useful truths more salient. It is in this spirit that I report the following
history:
[Pinel, 1801, 53-4, trans. E. Brown]
Case 1: A
History Of Mania Where Moral Treatment Would Have Been Necessary
Advantages of reinforcing the effects of medicines through the art of managing the insane
What a benefit it would have been to be able to return a young man,
endowed with such estimible qualities,
to society. How unfortunate it was that his exaggerated principles
of conduct hastened his ruin! In the
treatment of his mania, it was in my power to use a great number of
remedies. I did not have access,
however, to the most powerful of all, which one can hardly find except
in a well ordered asylum. That consists
of art of subduing and taming, that is to say, putting the insane,
in close dependance on a man, who, by his
phycical and moral qualities, is able to exercise an irrestible
force over him, and thereby to change the
vicious chain of his ideas. Some examples, chosen from Bicêtre
asylum for the insane , will make this truth
clear [Pinel, 1801,57-8, Trans. E. Brown].
Case 2: Useful effects of an energetic repression.
Case 3: The
benefit of strongly shaking the imagination of the insane in certain cases.
IX
Intimidate the insane person, but do not
permit violence
The preceeding examples trace the character and fortunate
effects of a methodology of fear, involving a courageous
determination to firmly and consistently oppose the stubborn preoccupations
of the insane, without bitterness, anger or any violation of
the sacred rights of humanity. These examples are sufficient to demonstrate
the tremendous difference between this method and the harsh, I dare
say, horrifying treatment, with its violence and sometimes even murder,
that is conducted in insane asylums, where attendants are not controlled
by active surveillance.
Why does one find in the writings of the ancients, especially
Celsus, a kind of intermediate method, using severe punishments like hunger,
flogging and chains, to repremand the insane, when gentler methods proved
useless? Why are some public and private establishemts still directed by
similar principles?
Dr. Gregory reports a farmer of Herculean stature, in the north
of Scotland, who became famous for curing mania. His method consisted of
putting them to work, some as beasts of burden, some as servants. He reduced
them to obedience by flogging at the least act of revolt.
A very renowned monastery in the south of France was run according
to the same principles. One of the officials made rounds each day. When
one of the insane acted foolishly, made a racket, refused to go to bed
or rejected all nourishment, he ordered him to change his behavior and
warned him that if he did not, he would be whipped the next day. The execution
of the decree was always punctual, and if necessary it was repeated several
times. They were no less exact in rewards than in punishments. If the insane
person showed himself submissive anddocile, they let him eat in the refectory,
beside the governor, to test him. If he forgot himself and committed the
least indiscretion, however, he was instantly smacked on the fingers with
a rod. He was then calmly reminded that he must behave with more reserve.
We regret that Dr. Willis has not yet succeeded in reconciling
the treatment of mania with the strict principles of philanthropy. Since
in his establishment near London, each insane person has a keeper, who
can flog him repeatedly, giving the brutality of the keeper an intederminate
and dangerous latitude.
X
Maxims of kindness and philanthropy to adopt in asylums
It is perhaps too vague to discuss the treatment of all insane
people by flogging and corporal punishment in a general and uniform manner.
How can one be sure that negroes who have lived in servitude in Jamaica,
or Russian slaves, shaped by an oppressive system during their whole lives,
must not be subjected, when insane, to the same hard and despotic yoke?
Given the favorable effects one can generally expect from fear
applied to the cure of the mania, however, shouldn't
the sensitivity of Frenchmen, as long as they preserve a glimmer of reason,
as well as their violent reaction against all abuses of power, lead
one to favor the mildest forms of repression?
All my observations support these principles. What attacks of
rage I seen burst out among the insane when irritated
by visitors to the asylum who make a barbarous sport of harassing
them. How many times has it happened that calm insane patients, on their
way to recovery, have been placed in the infirmary, beyond the surveillance
of the governor, where they have been subjected to the foolish jokes
of nurses, and as a result have had attacks of furor and committed
acts of violence.
By contrast, insane patients transfered to the asylum, designated
on their arrival as beside themselves and very dangerous, because of the
bad treatment they have received, immediately assume the opposite stance,
because we speak to them with kindness, sympathize with their suffering;
and give them consoling hope of a happy fate. Their recovery then proceeds
rapidly without any other intervention. Finally doesn't repeated experience
teach us that to render the effects of fear durable this feeling
must, to the extent that reason returns, be combined with respect? That
assumes that repression has not been characterized by anger or arbitrariness,
that one has only employed appropriate force to overcome the unruly exuberance
of the insane and that one has only been guided by a sincere desire to
lead him back to himself as demonstrated by a frank and immediate explanation
after his repentance. These are the principles that we follow strictly
at the insane asylum at Bicêtre.
We are doubtless without the advantages of Dr. Fowler's establishment
in Scotland with its expansive grounds and fine internal accomodations.
But I can attest after two years of diligent observation that the same
principles of philanthropy prevail in the management of the insane at Bicêtre.
The attendants, under no pretext whatever, ever raise a hand, even as a
reprisal. Straight jackets and seclusion, for short periods, are the only
punishments inflicted. When kind treatment or the imposing trappings of
repression fail, a clever ploy sometimes produces unexpected cures.
Case 4: A
happy expedient used to cure a maniac
Various ways of understand maniacs, based on their ideas
The imagination appears to be, of all the faculties of understanding, the most subject to profound lesions. Nothing is more frequent in mania than fantastic illusions that relate to our physical state. This explains the great number of strategies used to dissipate this kind of phenemonon. One must not minimize the difficulty of overcoming exaltation or fanaticism. On this point my observations agree with those made in England. How to restore health to a man puffed up with pride, who believes himself to be privileged being , an emissary from heaven, a prophet or even a god? What remarks can counterbalance mystical visions and revelations, the truth of which the madman indignantly denies that anyone can doubt?
Case 5: One of them believed that he saw devils everywhere. One day when a group of curious visitors came to the asylum, he threw himself into a rage in their midst, as though they were an army of demons.
Case 6: Another, with a sweet character, constantly invoked his guardian angel or one of the Apostles and was satisfied to fast and pray.
Case 7: I liked to converse sometimes with another madman, who devoted himself, like disciples of Zoroaster, to a cult of the sun, prostrating himself before it as it rose and then devoting his actions, pleasures and pains to it, during the remainder of the day.
Case 8: One can contrast with him another more dangerous maniac, who is ordinarily calm during the day, but who during the night believes himself always surrounded by ghosts and fantoms. He conversed by turn with good and bad angels, and depending on the results of these conversations, was benevolent or dangerous, carrying out acts of kindness or of barbaric cruelty.
The following story will make known the horror and execration such madness can lead to.
Case 9: A case of melancholia, with bigotry
XXII
Skill in the art of managing the mad, by appearing to be party to
their imaginary ideas
Another secret, no less calculated, to end quarrels among madmen, to overcome their resistance and to maintain order, is to not appear to notice their lapses, to avoid every expression of reproach, to appear to agree with their opinions and to adroitly communicate a suggestion which they believe must be their own. In this respect the governess of the hospice appears to me to bring together rare qualities. With astonishment I have seen her approach some of most furious maniacs, calm them with soothing words, and make them accept nourishment that they had refused angrily from all other hands [Pinel, 1800, 92-3].
Case 10: A madman reduced to extreme danger by stubborn abstinence, flared up one day against her and refused the food that she offered, lavished on her the most outrageous terms. This skillful woman began, in an instant, to jump and dance in unison with his delirious words, replied to him with some sallies that made him laugh. Availing herself of this favorable moment to make him eat, she saved his life. How many times have I brawls which might have ended fatally, stopped by clever trickery![Pinel, 1800, 93]
Case 11: Three madmen who believed themselves kings and each of whom took the title of Louis XVI were arguing one day about the rights of royalty, but asserting themselves a little too energetically. The governess approached one of them and pulled him aside: " Why," she asked him in a serious manner, "do you enter into an arguement with these fellows, who are visibly mad? Don't they know that you must be recognized as Louis XIV?" This "Louis", flattered by her homage withdrew immediately, looking at the others with great disdain. The same trick succeeded with the second. As a result, in an instant, there was no longer any trace of a dispute [Pinel, 1800, 93-4].
Case 12: A more threatening situation, showed me one day, to
its the full extent, the wealth of her methods for mastering
the insane. A young man, who had been calm for several months and had free
run of the interior of the hospice was suddenly seized by an attack. He
slipped into the kitchen, grabbed a knife used for chopping herbs
and became furious at the efforts of the cook and his assistants to disarm
him. He jumped on a table to defend himself and threatened to cut off the
head of the first person to dare to come toward him. The governess, without
being frightened, made a skillful turn. She strongly disapproved of the
attack directed against the madman: "Why," she said, "prevent this strong
and robust man from working with me?" She spoke to him softly, engaged
him to approach her with the instrument that he had seized. She showed
him the method that he had to use to chop herbs and she feigned pleasure
in having such a helper. The madman, deceived by this innocent ruse, occupied
himself with his work. On a signal, he was overtaken by the attendants
and carried to his cell, without danger, while the knife remained in the
governess's hands. I might challenge most skillful man, the most knowledgable
about maniacs, to adopt, with more finesse and quickness, a better
method for dealing with such an alarming situation [Pinel 1800, 94-5].
Revd Dr Francis Willis [1718-1807]
After studying theology at Oxford he practiced as a clergyman and became
a physician relatively late in life. By 1769 he had established a
reputation for treating mental illness, using his home as a madhouse. As
Tea drinking was widely thought to be a dangerous vice that caused nervous
disorders, Willis, it was said, owed a great proportion of his patients
to the importing of tea from China [Macalpine & Hunter, 1969, 272].
His reputation is largely the result of having been called upon to
treat King George III in 1788. At the time he said that he had had twenty-eight
years experience of treating thirty lunatics annually. Nine out of ten
of these recovered, most within six months [Parry-Jones, 1972, 75-6; Macalpine
& Hunter, 1969, 56]. When asked about the cause of the King’s illness,
he responded that from ‘His Mode and Manner of Life for Twenty-seven Years,
I do imagine, that weighty Business, severe Exercise, and too great Abstemiousness,
and little Rest, has been too much for His Consititution [Macalpine &
Hunter, 1969, 56].'
For therapeutic purposes Willis fostered a sense of fear in his patients,
‘because, he was quoted as saying, for a long time, fear provides
the only grip that one can obtain on the mind of a maniac.' Willis
acquired a reputation for gaining control over patients by catching their
eye. One writer noted that he had an eye like Mars, to threaten or command...his
numerous patients stood as much in awe of this formidable weapon, as of
bars, chains or straight-waistcoats [Parry-Jones, 1972,173].'
XIV
A case of melancholia, with bigotry
A missionary, so terrified
a credulous wine grower, with his vivid depiction of the other world, that
the latter believed himself destined for the eternal fires. He no
longer thought of any thing but saving his family. He enjoyed the
crown of marterdom, a seductive image of which his frequent reading of
the lives of the saints had left him. He tried first to commit this horrible
crime on his wife, who succeeded in escaping from him. Soon after he turned
on his two young children and, to win them eternal life, he barbarously
immolated them.
He was brought before
a tribunal. Before his trial, in an act of expiation, he slit the throat
of another inmate. His insanity established, he was condemned to perpetual
confinement at Bicêtre. The isolation of his long confinement exalted
his imagination. He came to believe, that having excaped the sentence of
death, that he was omnipotent, or, in his words, that he was the fourth
person of the Trinity. He believed that his missio was to save the world
through a baptism of blood and that all the rulers of the world, united
against him, could not take away his life.
His madness was limited
to religion. On all other subjects his reason was quite healthy. After
ten years of solitary confinement, his apparent calmness and tranquility
led the governor to grant him permission to mingle with other convalescents.
Four years success with this experiment was reassuring, when, suddenly,
his sanguinary ideas recurred. On the tenth of Nivose [Christmas eve] he
planned an expiatory sacrifice of all the men in the asylum. He obtained
a shoemaker's knife, and seizing a moment when the governer was going to
make rounds, struck him from behind. Happily the knife only grazed his
ribs. He did, however, manage to slit the throats of two fellow inmates.
He would have continued his homocidal course if the attendants had not
come quickly to stop him. It is scarcely necessary to add that his confinement
was now made irrevocable [Pinel, 1800, 72-75].