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| Pinel ordering the chains to be taken off the madmen confined in la Bicetre |
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| Pinel ordering the chains to be taken off the madwomen confined at la Salpetriere (note: this painting hangs in the hospital today). |
A selection from A Treatise on Insanity' (Traité médico-philosophique sur l'aliénation mentale; ou la manie) by Philip Pinel, 1800.
From a historical point of view, this text is significant for two reasons: firstly, as a foundational text of modern psychiatry, and secondly as a remarkable document of the revolution in France. In la Bicetre of Revolutionary France, we find a privileged site to view the world outside its walls (for instance, the soldier who lead the storming of the Bastille would end up there). During the stormy events of the revolution, Pinel tells of how the revolutionary guards broke into the asylum to liberate the victims of the ancient regime which they believed were confined there, only to be set upon by those they set at liberty, before returning them back to their chains and leaving them as they found them (a couple of years later Pinel would effectively repeat this gesture of liberation).
The version of the text used here is the first English translation made in 1806 (unless otherwise stated).
[Work in Progress]
INTRODUCTION
Of all the afflictions to which human nature is subject, the loss of reason is at once the most calamitous and interesting. Deprived of this faculty, by which man is principally distinguished from the beasts that perish, the human form is frequently the most remarkable attribute that he retains of his proud distinction. His character, as an individual of the species, is always perverted; sometimes annihilated. [...] Once the ornament and life of society, he is now become a stranger to its pleasures or a disturber of its tranquility. Impatient of restraint, and disposed to expend the unusual effervescence of his spirits in roving and turbulence, coercion of the mildest kind adds fury to his delirium, and colours with jealousy or suspicion every effort of friendly or professional interest in his fate. His personal liberty is at length taken from him; and taken from him perhaps by his nearest relative or dearest friend. Retaining his original sensibility, or rendered more acutely sensible by opposition to his will and deprivation of his usual gratifications, co-operating with a morbid excitement of his nervous functions, he gives himself up to all the extravagances of manical fury, or sinks inexpressibly miserable into the lowest depths of despondence and melancholy. [...] The figure of the human species is now all that remains to him, "and like the ruins of a once magnificent edifice, it only serves to remind us of its former dignity and grandeur," [i.e., the experience of Humilation] and to awaken our gloomiest reflections-- our tenderest regret for the departure of the real and respectable man.
GENERAL PLAN OF THE WORK
On my entrance upon the duties of that hospital [la Bicetre in 1792], everything presented to me the appearance of chaos and confusion. [...] Symptoms so different, and all comprehended under the general title of insanity, required, on my part, much study and discrimination; and to secure order in the establishment and success to the practice, I determined upon adopting such a variety of measures, both as to discipline and treatment, as my patients required, and my limited opportunity permitted.
Public asylums for maniacs have been regarded as places of confinement for such of its members as are become dangerous to the peace of society. The managers of those institutions, who are frequently men of little knowledge and less humanity [English translators note for his translation in 1806: "The English legislature has taken some cognizance of the crying evils which formerly existed in this country, as they now do in France, from the indiscriminate toleration of empyrical lunatic establishments. More however might and ought to be done."], have been permitted to exercise towards their innocent prisoners a most arbitrary system of cruelty and violence; while experience affords ample and daily proofs of the happier effects of a mild, conciliating treatment, rendered effective by steady and dispassionate firmness.
The successful application of moral regimen exclusively, gives great weight to the supposition, that, in a majority of instance, there is no organic lesion of the brain nor of the cranium.
CIRCUMSTANCES FAVOURABLE TO THE AUTHORS RESEARCHES UPON THE SUBJECT OF INSANITY.
The storms of the revolution, stirred up corresponding tempests in the passions of men, and overwhelmed not a few in a total ruin of their distinguished birth-rights as rational beings.
PERIODS OF ACCESSION OF INTERMITTENT INSANITY
3. Maniacs of all descriptions are subject to a kind of effervescence or tumultuous agitation, upon the approach either of stormy or very warm weather.
PRECURSORY SYMPTOMS OF MANIACAL PAROXYSMS.
6. The nature of the affections most calculated to give birth to periodical mania, and the affinities of this complaint with melancholia and hypochondriasis, warrant the presumption that its seat, primarily, is almost always in the epigastric region, and that from this centre of propagation, as it were by a species of irradiation, the accessions of insanity. [...] The eyes... suddenly appearing red and sparkling, the cheeks flushed, with a vigorous and rapid action of the muscles of the countenance, accompanied by an exuberant loquacity, are certain presages of an approaching paraxysm; and point out the urgent necessity of strict confinement.
MANICAL PAROXYSMS CHARACTERISED BY A HIGH DEGREE OF PHYSICAL AND MENTAL ENERGY.
9. The nervous excitement, which characterises the greatest number of cases, affects not the system physically by increasing muscular power and action only, but likewise the mind, by exciting a consciousness of supreme importance and irresistible strength. [....] If met, however, by a force evidently and convincingly superior, he submits without opposition or violence. This is a great and invaluable secret in the management of well regulated hospitals.
ARE ALL LUNATICS EQUALLY CAPABLE OF SUPPORTING THE EXTREMES OF COLD AND HUNGER?
10. The constancy and facility with which some maniacs support severe and long continued cold, appear to favour the supposition of a singular degree of intensity of the animal heat.
ARE NOT MANIACAL PAROXYSMS THE EFFECET OF A SALUTARY REACTION OF THE SYSTEM?
13. The celebrated Stahl, in his views and treatment of fever, soared above the petty province of philopharmaceutic medicine to the general consideration of a principle of conservation, whose office it is to repel any attack upon the system injurious to its well being, or fatal to its existence. May not the same principle be applied to the theory of insanity?
[English translators note: "How many thousands of lives have been lost while the medical attendant has been indolently waiting upon the coctions and concoctions of the vis medicatrix nature ['nature is her own physician', or 'the healing powers of nature']? See Currie's reports.]
It would, however, appear, that it is only during the vigour of youth, that the system is susceptible of the reaction which has been described to any very salutary extent, since I cannot recollect more than one instance of a cure after the age of forty... .
I may now presume upon the reader's acquiescence, when I assert, that paroxysms of active insanity are, in some circumstances, to be hailed as salutary efforts of nature to throw off disease.
THE VARIETY AND PROFUNDITY OF KNOWLEDGE REQUISITE ON THE PART OF THE PHYSICIAN, IN ORDER TO SECURE SUCCESS IN THE TREATMENT OF INSANITY.
15. The time, perhaps, is at length arrived when medicine in France, now liberated from the fetters imposed upon it, by the prejudices of custom, by interested ambition, by its association with religious institutions, and by the discredit in which it has been held in the public estimation, will be able to assume its proper dignity, to establish its theories on facts alone, to generalize those facts, and to maintain its level with the other departments of nature history. The principle of free enquirey, which the revolution has incorporated with our national politics, have opened a wide field to the energies of medical philosophy.
The history of insanity claims alliance with that of all the errors and delusions of ignorant credulity;-- with those of witchcraft, demoniacal possession, miracles, oracles and divination.
SECTION II THE MORAL TREATMENT OF INSANITY
HAVE THE ENGLISH PUBLISHED ANY NEW RULES ON THE MORAL TREATMENT OF INSANITY
17. English physicians give themselves credit for a great superiority of skill in the moral treatment of madness... . [...] Of the celebrated Willis [who treated George III] it has been said, that the utmost sweetness and affability is the usual expression of his countenance. But, when he looks a maniac in the face for the first time, he appears instantly to change character. His features present a new aspect, such as commands the respect and attention, even of lunatics. His looks appear to penetrate into their hearts, and to read their thoughts as soon as they are formed. Thus does he obtain an authority over his patients, which afterwards co-operating with other means, contribute to restore them to themselves and to their friends." [Editors note: it is not clear if he is quoting another source here, check other translation]
THE AUTHOR'S INDUCEMENTS TO STUDY THE PRINCIPLES OF MORAL TREATMENT.
18. All civilised nations, however different in their customs, and manner of living, will never fail to have some causes of insanity in common; and, it is natural to believe, that all will do their utmost to remedy the evil.
...the gentleman, to whom was committed the chief management of the hospital [of la Bicetre], exercised towards all that were placed under his protection, the vigilance of a kind and affectionate parent. Accustomed to reflect, and possessed of great experience, he was not deficient either in the knowledge or execution of the duties of his office. He never lost sight of the principles of a most genuine philanthropy. [...] He exercised a strict discipline over the conduct of the domestics, and punished, with severity, every instance of ill treatment, and every act of violence, of which they were guilty towards those whom it was merely their duty to serve. He was both esteemed and feared by every maniac; for he was mild, and at the same time inflexibly firm. In a word, he was master of every branch of his art, from its simplest to its most complicated principles.
18. All civilised nations, however different in their customs, and manner of living, will never fail to have some causes of insanity in common; and, it is natural to believe, that all will do their utmost to remedy the evil.
...the gentleman, to whom was committed the chief management of the hospital [of la Bicetre], exercised towards all that were placed under his protection, the vigilance of a kind and affectionate parent. Accustomed to reflect, and possessed of great experience, he was not deficient either in the knowledge or execution of the duties of his office. He never lost sight of the principles of a most genuine philanthropy. [...] He exercised a strict discipline over the conduct of the domestics, and punished, with severity, every instance of ill treatment, and every act of violence, of which they were guilty towards those whom it was merely their duty to serve. He was both esteemed and feared by every maniac; for he was mild, and at the same time inflexibly firm. In a word, he was master of every branch of his art, from its simplest to its most complicated principles.
[gap]
THE TREATMENT OF MANIACS TO BE VARIED ACCORDING TO THE SPECIFIC CHARACTERS OF THEIR HALLUCINATION
27. Of all the powers of the human mind, that of the imagination appears to be the most subject to injury. The fantastic illusions and ideal transformation, which are by far the most frequent forms of mental derangement, are solely ascribeable to lesions of this faculty. Hence the expediency of a great variety of schemes and stratagems for removing these prepossessions. Of the numerous illusions to which the imagination is subject, the most difficult to be eradicated are those originating in fanaticism [i.e., religious fanaticism]. [...] How extremely difficult to level, with his real situation, the ideas of a man swelled up with morbid pride, solely intent on his high destinies, or thinking himself a privaliged being, an emissary of heaven, a prophet from the Almighty, or even a divine personage. What measures are likely to counteract the influence of mystic visions or revelations, of the truth of which he deems it blashpemy to express doubt?
INSANITY FROM RELIGIOUS ENTHUSIASM EXTREMELY DIFFICULT TO CURE.
29.
My plan would have been... from their sight every object appertaining to religion, every painting or book calculated to rouse its recollections; to order certain hours of the day to be devoted to philosophica reading, and to seize every opportunity of drawing apt comparisons between the distinguished acts of humanity and patriotism of the ancients, and the pious nullity and delirious extravagances of saints and anchorites; to divert their minds from the peculiar object of their hallucination, and to fix their interest upon pursuits of contrary influence and tendency.
THE CONDUCT OF THE GOVERNOR OF BICETRE, UPON THE REVOLUTIONARY ORDERS HE RECEIVED TO DESTROY THE SYMBOLIC REPRESENTATIONS OF RELIGION.
30. In the third year of the republic, the directors of the civil hospitals, in the excess of their revolutionary zeal, determined to remove from those places the external objects of worship, the only remaining consolation of the indigent and the unhappy. A visit for this purpose was paid to the hospital de Bicetre. The plunder, impious as it was and detestable, was begun in the dormitories of the old and the infirm, who were naturally struck at an instance of robbery so new and unexpected, some with astonishment, some with indignation, and others with terror. The first day of visitation being already far spent, it was determined to reserve the lunatic department of the establishment for another opportunity. ...the governor..., in order to prevent disturbance, and perhaps an insurrection in the asylum, wished to appear rather to submit to a measure so obnoxious than to direct it. Having purchased a great number of national cockades, he called a metting of all the lunatics who could conveniently attend. When they were all arrived he took up the colours and said, "Let those who love liberty draw near and enrol themselves under the national colours." This invitation was accompanied by a most gracious smile. Some hesitated; but the greatest number complied. This moment of enthusiasm was not allowed to pass unimproved. The converts were instantly informed, that their new engagement required of them to remove from the chapel the image of the Virgin, with all the other appurtenances of the catholic worship. No sooner was this requisition announced than a great number of our new republicans set off for the chapel, and committed the desired depredation upon its sacred furniture. The images and paintings, which had been objects of reverence for so many years, were brought out to the court in a state of complete disorder and ruination. Consternation and terror seized the few devout but impotent witnesses of this scene of impiety [recall the symbolic act of the Cult of Reason to enthrone their goddess in the Notre dam de Paris]. Murmurs, imprecations and threats expressed their hoest feelings. The most exasperated amongst them prayed that fire from heaven might be poured upon the heads of the guilty, or believed that they saw the bottomless abyss opening to receive them. To convince them, however, that heaven was deaf equally to their imprecations and prayers, the governor ordered the holy things to be broken into a thousand pieces and to be taken away. The good-will and attachment, which he knew so well how to conciliate, ensured the execution of this revolutionary measure. [...] It is very certain, that melancholia or mania, originating in religious enthusiasm, will not admit of a cure, so long as the original impressions are allowed to be continued, or renewed by their appropriate causes.
THE MOST VIOLENT AND DANGEROUS MANIACS DESCRIBED, WITH EXPEDIENTS FOR THEIR REPRESSION.
35
The great secret of mastering maniacs... , without doing them injury or receiving violence from them, consists in going up to them boldly and in a great body. Convinced of the inutility of resistance, and impressed with a degree of timidity, the maniac thus surrounded will often surrender without further opposition or reluctance. An instrument of offence will, however, sometimes arm him with extraordinary resolution. A madman shall be suddenly seized with a paroxysm of phrenitic delirium, with perhaps a knife, or a stone, or a cudgel in his hand at the time. The governor, ever faithful to his maxim of maintaining order without committing acts of violence, will, in defiance of his threats, march up to him with an intrepid air, but slowly and by degrees. In order not to exasperate him, he takes with him no offensive weapon. As he advances he speaks to him in a firm and menacing tone, and gives him calm advice or issues his threatening summons, in such a manner as to fix the attention of the hero exclusively upon himself. This ceremony is continued with more or less variation until the assistants have had time, by imperceptible advances, to surround the maniac, when, upon a certain signal being given, he finds himself in instant and unexpected confinement. Thus a scene which threatened so much tragedy, generally ends in an ordinary event. Disturbances will occasionally interfere with the tranquility of all institutions, where the passions are licentiously gratified. Lunatic establishements are peculiarly liable to such commotions. The prevention of conspiracies and tumults by anticipation, is always preferable to their suppression by violence or active contest:-- either will frequently require such a variety and combination of measures as the greatest sagacity and longest experience can supply. Lunatics, even during their lucid intervals and convalescence, are disposed to be passionate upon very slight causes. Quarrels amongst the patients-- specious complaints of injustice-- the sight of a sudden sezure by a maniacal paroxysm-- any object, real or imaginary, of murmur or discontent, may become a source of great disorder, and be communicated, like a shock of electricity, from one end of the hospital to the other. Meetings are called, parties are formed, and commotions stirred up as in popular insurrections, which, if not suppressed in their very commencement, may be succeeded by very unpleasant and possibly by disastrous or fatal consequences. Upon the appearance of tumults of this kind, I have more than once seen the governor of Bicetre brave with wonderful courage the violence that threatened him, move about and mingle in the effervescence with the rapidity of thought, seize the most mutinous, and provide for their instant security, and thus, in a very short time, restore tranquility to the institution.
THE PROPRIETY OF APPEARING TO ASSENT TO THE ABSURD PROPOSITIONS AND FANCIFUL IDEAS OF MANIACS.
36. Other secrets, not less calculated to put an end to disputes and quarrels among maniacs, to overcome their resistance and to maintain order in hospitals, are those of not appearing to notice their extravagance, of avoiding every expression of reproach, of assenting to their opinions, and giving them impulses with such address as to impress them with the conviction that they originate with themselves.
Three insane persons, each of whom believed himself to be a king, and each of whom took the title Louis XVI, quarreled one day over the prerogatives of royalty, and defended them somwhat too energetically. The keeper approached one of them, and drawing him aside, asked: 'Why do you argue with these men who are evidently mad? Doesn't everyone know that you should be recognized as Louis XVI?' Flattered by this homage, the madman immediately withdrew, glancing at the others with a disdainful hauteur. The same trick worked with the second patient. And thus in an instant there no longer remained any trace of an argument.
THE NECESSITY OF MAINTAINING CONSTANT ORDER IN LUNATIC ASYLUMS, AND OF STUDYING THE VARIETIES OF CHARACTER EXHIBITED BY THE PATIENT.
37. The extreme importance which I attach to the maintenance of order and moderation in lunatic institutions, and consequently to the physical and moral qualities requisite to be possessed by their governors, is by no means to be wondered at, since it is a fundamental principle in the treatment of mania to watch over the impetuosities of passion, and to order such arrangements of police and moral treatment as are favourable to that degree of excitement which experience approves as conducive to recovery. Unfortunate, indeed, is the fate of those maniacs who are placed in lunatic hospitals, where the basis of the practice is routine, and that perhaps under the direction of a governor devoid of the essential principles of morality; or where, which amounts to the same thing, they are abandoned to the savage and murderous cruelty of underlings. Great sagacity, ardent zeal, perpetual and indefatigable attentoin, are essential qualities of a governor who wishes to do his duty, in its various departements of watching the progress of every case, seizing the peculiar character of the hallucination, and meeting the numerous varieties of the disease depending upon temprament, constitution, ages and complications with other diseases. In some unusual or difficult cases, it requires great consideration to decide upon the treatment or experiment most eligible to be attempted. But in the greatest number of instances, especially of accidental mania originating in the depressive passions, the experience of every day attests the value of consolatory language, kind treatment, and the revival of extinquished hope. Severity in cases of this description can answer no other purpose than those of exasperating the disease, and of frequently rendering it incurable.
AN INSTANCE OF VIOLENT MANIA CURED BY PRUDENT AND VIGOUROUS COERCION.
38. "In the moral treatment of insanity, lunatics are not to be considered as absolutely devoid of reason, i.e. as inaccesssible by motives of fear and hope, and sentiments of honour... . In the first instance it is proper to gain an ascendancy over them, and afterwards to encourage them." [Encylopedia Britannica]
THE AFFECTIONS OF THE MIND MOST CALCULATED TO INDUCE INSANITY
42.
It is well known, that certain professions conduce more than other to insanity, which are chiefly those in which the imagination is unceasingly or ardently engaged, and not moderated in its excitement by the exercise of those functions of the understanding which are more susceptible of satiety and fatigue. In consulting the registers of Bicetre, we find many priests and monks, as well as country people, terrified into this condition by the anticipation of hell torments: many artists, painters, sculptors and musicians: some poets extatized by their own productions: a great number of advocates and attorneys. But there are no instances of persons whose professions require the habitual exercise of the judging faculty; not one naturalist, nor a physician, nor a chemist, and, for the best reason in the world, not one geometrician.
DO THE BEST FORMED HEADS BEAR A PROPORTOIN TO THE INTELLECTUAL FACULTIES?
43. It is a very general opinion, that mental derangement depends upon lesions of the head, and especially upon irregularities and disproportions of the cranium. It would be an interesting speculation to determine how far the best proportions of the head are to be considered as external indications of the excellence of the intellectual faculties. That masterpiece of ancient sculpture, the head of the Pythian Apollo
[authors note: "Of all the productions of art which have escaped the ravages of time, the statue of the Apollo is beyond dispute the most astonishing. The artist has conceived his image after an ideal model, and has used no materials but what were necessary to execute and to represent his conception. Its height is above that of life, and its attitude is full of majesty. At the sight of this prodigy, I am disposed to forget the world. I put myself in a more majestic attitude in order to contemplate it with dignity. From admiration I sink into ecstasy."]
, might be taken for a prototype [Kenneth Clark, in his in 1967 television series, on the newly launch BBC colour channel, 'Civilization', took its form as the paragon of civilization, and compared it with the crude ornamentation on the prow of a viking ship and the primitivity of an African tribe mask]. Next in order, might be placed the heads of men most suitably organized for the successful pursuit of the arts and sciences, and progressively downwards every successive degree of malconformation of the head, with its corresponding intellectual capacity, to absolute ideotism and imbecility. But observation is far from confirming these specious conjectures.
In order to attain to some degree of accuracy in my investigation, I have taken for my standard, the admirable proportions of the head of the Apollo, as they are given by Gerard Audran.
HOW FAR MAY LENIENT MEASURES SUFFICE TO CALM THE VIOLENCE AND FURY OF ACUTE MADNESS?
83.
To detain maniacs in constant seclusion, and to load them with chains; to leave them defenceless, to the brutality of underlings, on pretence of danger to be dreaded from their extravagances: in a word, to rule them with a rod of iron, as if to shorten the term of an existence considered miserable, is a system of superintendence, more distinguished for its convenience than for its humanity or its success. [...] The character of a superintendent, who is in the habit of discharging the important duties of his office, with integrity, dignity and humanity, is itself a circumstance of great weight and influence in a lunatic establishment.
A coarse and unenlightened mind, considers the violent expressions, vociferation and riotous demeanour of maniacs as malicious and intentional insults. Hence the extreme harshness, blows and barbarous treatment which keepers, if not chosen with discretion and kept within the bounds of their duty, are disposed to indulge in towards the unfortunate beings confided to their care. A man of better feeling and consideration, sees in those effervescences of a maniac but the impulses of an automaton, or rather the necessary effects of a nervous excitement, no more calculated to excite anger than a blow or a crush from a stone propelled by its specific gravity. Such an observer, on the contrary, is disposed to allow his patients all the extent of liberty consistent with their own safety and that of others; He conceals with great address the means of constraint to which he is compelled to resort; yields to their caprices with apparent complacency; eludes with dexterity their inconsiderate demands; sooths with coolness and kindness their intemperate passions; turns to advantage every interval of their fury; and meets with force their otherwise incoercible extravagances.
Cont here
IS CLOSE CONFINEMENT REQUISITE IN ALL CASES AND THROUGHOUT THE WHOLE TERM OF ACUTE MANIA?
84.
Dr. Ferriar observes, that in their paroxysms of violent fury, maniacs ought to have their arms and legs effectually secured; but that we should only have recourse to those measures where it is impossible to avoid them. It is that gentleman's practice in cases of refractory conduct, to confine the offenders to their apartments, where, with their windows closed, they are left in darkness, supplied only with water gruel and dry bread, until they shew signs of repentance, which is seldom long delayed. But before the adoption of that decided measure, he always tries the means of mildness and remonstrance: "For in general," adds the same author, "lunatics have a deep sense of honour, which is more efficacious than coercion in reducing them to propriety of conduct.
Close confinement, solitude, darkness and a spare diet, may no doubt be recurred to occasionally, and for a short time, as a punishment for the improper demeanour of maniacs. But when the paroxysms are of long duration or the disorder of a continued form, restriction in the article of food might be exceedingly prejudicial.
AN INSTANCE ILLUSTRATIVE OF THE ADVANTAGE OF OBTAINING AN INTIMATE ACQUAINTANCE WITH THE CHARACTER OF THE PATIENT.
86. A man... fancied himself to be a king, and always spoke with the voice of command and authority. He had been for sometime at the Hotel Dieu, where blows and other indignities, recived from the keepers, had greatly exasperated his fury. Thus rendered suspicious and unmanageable, it was extremely difficult to fix upon a proper method of treating him. To have recourse to coercive means might still further aggravate his disorder, whilst condescension and acquiescense appeared likely to confirm him in his chimerical pretensions. I determined to wait the further development of his character, and take advantage of any favourable circumstance that might happen.
Cont, p.193
GENERAL POLICE AND DAILY DISTRIBUTION OF THE SERVICES IN LUNATIC ASYLUMS.
DO THE BEST FORMED HEADS BEAR A PROPORTOIN TO THE INTELLECTUAL FACULTIES?
43. It is a very general opinion, that mental derangement depends upon lesions of the head, and especially upon irregularities and disproportions of the cranium. It would be an interesting speculation to determine how far the best proportions of the head are to be considered as external indications of the excellence of the intellectual faculties. That masterpiece of ancient sculpture, the head of the Pythian Apollo
[authors note: "Of all the productions of art which have escaped the ravages of time, the statue of the Apollo is beyond dispute the most astonishing. The artist has conceived his image after an ideal model, and has used no materials but what were necessary to execute and to represent his conception. Its height is above that of life, and its attitude is full of majesty. At the sight of this prodigy, I am disposed to forget the world. I put myself in a more majestic attitude in order to contemplate it with dignity. From admiration I sink into ecstasy."]
, might be taken for a prototype [Kenneth Clark, in his in 1967 television series, on the newly launch BBC colour channel, 'Civilization', took its form as the paragon of civilization, and compared it with the crude ornamentation on the prow of a viking ship and the primitivity of an African tribe mask]. Next in order, might be placed the heads of men most suitably organized for the successful pursuit of the arts and sciences, and progressively downwards every successive degree of malconformation of the head, with its corresponding intellectual capacity, to absolute ideotism and imbecility. But observation is far from confirming these specious conjectures.
In order to attain to some degree of accuracy in my investigation, I have taken for my standard, the admirable proportions of the head of the Apollo, as they are given by Gerard Audran.
HOW FAR MAY LENIENT MEASURES SUFFICE TO CALM THE VIOLENCE AND FURY OF ACUTE MADNESS?
83.
To detain maniacs in constant seclusion, and to load them with chains; to leave them defenceless, to the brutality of underlings, on pretence of danger to be dreaded from their extravagances: in a word, to rule them with a rod of iron, as if to shorten the term of an existence considered miserable, is a system of superintendence, more distinguished for its convenience than for its humanity or its success. [...] The character of a superintendent, who is in the habit of discharging the important duties of his office, with integrity, dignity and humanity, is itself a circumstance of great weight and influence in a lunatic establishment.
A coarse and unenlightened mind, considers the violent expressions, vociferation and riotous demeanour of maniacs as malicious and intentional insults. Hence the extreme harshness, blows and barbarous treatment which keepers, if not chosen with discretion and kept within the bounds of their duty, are disposed to indulge in towards the unfortunate beings confided to their care. A man of better feeling and consideration, sees in those effervescences of a maniac but the impulses of an automaton, or rather the necessary effects of a nervous excitement, no more calculated to excite anger than a blow or a crush from a stone propelled by its specific gravity. Such an observer, on the contrary, is disposed to allow his patients all the extent of liberty consistent with their own safety and that of others; He conceals with great address the means of constraint to which he is compelled to resort; yields to their caprices with apparent complacency; eludes with dexterity their inconsiderate demands; sooths with coolness and kindness their intemperate passions; turns to advantage every interval of their fury; and meets with force their otherwise incoercible extravagances.
Cont here
IS CLOSE CONFINEMENT REQUISITE IN ALL CASES AND THROUGHOUT THE WHOLE TERM OF ACUTE MANIA?
84.
Dr. Ferriar observes, that in their paroxysms of violent fury, maniacs ought to have their arms and legs effectually secured; but that we should only have recourse to those measures where it is impossible to avoid them. It is that gentleman's practice in cases of refractory conduct, to confine the offenders to their apartments, where, with their windows closed, they are left in darkness, supplied only with water gruel and dry bread, until they shew signs of repentance, which is seldom long delayed. But before the adoption of that decided measure, he always tries the means of mildness and remonstrance: "For in general," adds the same author, "lunatics have a deep sense of honour, which is more efficacious than coercion in reducing them to propriety of conduct.
Close confinement, solitude, darkness and a spare diet, may no doubt be recurred to occasionally, and for a short time, as a punishment for the improper demeanour of maniacs. But when the paroxysms are of long duration or the disorder of a continued form, restriction in the article of food might be exceedingly prejudicial.
A state of dependence and constraint may greatly accelerate the cure of a madman who is elated to improprieties of behaviour, by imaginary consequence, or by the recollection of dignities and power once possessed. A monarch [King George III, in the 1806 english translation the text reads here 'a person of high rank...'] falls into a mania, and in order to make his cure more speedy and secure, no restrictions are placed on the prudence of the person who is to direct it; from then on, all trappings of royalty having disappeared, the madman, separated from his family and his usual surroundings, is consigned to an isolated palace, and he is confined alone in a room whose tiled floor and walls are covered with matting so that he cannot harm himself. The person directing the treatment tells him that he is no longer sovereign, but that he must henceforth be obedient and submissive. Two of his old pages, of Herculean stature, are charged with looking after his needs and providing him with all the services his condition requires, but also with convincing him that he is entirely subordinate to them and must now obey them. They keep watch over him in calm silence, but take every opportunity to make him aware of how much stronger than him they are. One day, in fiery delirium, the madman harshly greets his old doctor who is making his visit, and daubs him with filth and excrement. One of the pages immediately enters the room without saying a word, grasps by his belt the delirious madman, who is himself in a disgustingly filthy state, forcibly throws him down on a pile of mattresses, strips him, washes him with a sponge, changes his clothes, and, looking at him haughtily, immediately leaves to take up his post again. Such lessons, repeated at intervals over some months and backed up by the other means of treatment, have produced a sound cure without relapse.
MEASURES CALCULATED TO ACCELERATE THE REESTABLISHMENT OF CONVALESCENTS.
85.
...to govern men of great penetration and irascibility, such as maniacs most generally are, will require, on the part of the superintendent, a combination of the rarest talents. I have already developed those maxims at considerable length, in the second section of this work. I shall merely in this place illustrate their importance by an appeal to their successful application at one of the most extensive establishments in Europe-- that of Bethlehem Hospital.
The same author proscribes, with equal justice, all corporal punishment and violence: for he adds,
Cont. here
MEASURES CALCULATED TO ACCELERATE THE REESTABLISHMENT OF CONVALESCENTS.
85.
...to govern men of great penetration and irascibility, such as maniacs most generally are, will require, on the part of the superintendent, a combination of the rarest talents. I have already developed those maxims at considerable length, in the second section of this work. I shall merely in this place illustrate their importance by an appeal to their successful application at one of the most extensive establishments in Europe-- that of Bethlehem Hospital.
"It should be the great object of the superintendent to gain the confidence of the patient and to awaken in him respect and obedience: but it will readily be seen, that such confidence, obedience and respect, can only be procured by superiority of talents, discipline of temper and dignity of manners. Imbecility, misconduct and empty consequenecs, although enforced by the most tyranical severity, may excite fear; but this will always be mingled with contempt. In speaking of the management of insane persons, it is to be understood, that the superintendent must first obtain an ascendancy over them. When this is once effected, he will be enabled on future occasions to direct and regulate their conduct, as his better judgement may suggest. He should possess firmness, and when occasion may require, should exercise his authority in a peremptory manner. He should never threaten but execute; and when the patient has misbehaved, should confine him immediately... ."
"When the patient is vigorous and powerful, two or more should assist in securing him. By these means it will be easily effected; for where the force of the contending persons is nearly equal, the mastery cannot be obtained without difficulty and danger."
The same author proscribes, with equal justice, all corporal punishment and violence: for he adds,
"If the patient be so far deprived of understanding as to be insensible why he is punished, such correction, setting aside its cruelty, is manifestly absurd. And if his state be such as to be conscious of the impropriety of his conduct, there are other methods more mild and effectual." (Haslam, Observations on Insanity).
Cont. here
AN INSTANCE ILLUSTRATIVE OF THE ADVANTAGE OF OBTAINING AN INTIMATE ACQUAINTANCE WITH THE CHARACTER OF THE PATIENT.
86. A man... fancied himself to be a king, and always spoke with the voice of command and authority. He had been for sometime at the Hotel Dieu, where blows and other indignities, recived from the keepers, had greatly exasperated his fury. Thus rendered suspicious and unmanageable, it was extremely difficult to fix upon a proper method of treating him. To have recourse to coercive means might still further aggravate his disorder, whilst condescension and acquiescense appeared likely to confirm him in his chimerical pretensions. I determined to wait the further development of his character, and take advantage of any favourable circumstance that might happen.
Cont, p.193
GENERAL POLICE AND DAILY DISTRIBUTION OF THE SERVICES IN LUNATIC ASYLUMS.
89. The natural propensity of maniacs to indulge in passionate emotions, to murmur at trifling inconveniences, and to represent circumstances which they fancy in any degree objectionable in colours the most unfavourable, and exaggerated, must render necessary the strictest discipline and order in every department of their management. [...] In a word, the general government of the hospital, resembled the superintendence of a great family, consisting of turbulant individuals, whose fury it should be more the object to repress than to exasperate, to govern by wisdom than to subdue by terror.
MECHANICAL EMPLOYMENT ESSENTIAL TO THE SUCCESSFUL MANAGEMENT OF LUNATIC HOSPITALS.
94.
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THE ART OF COUNTERACTING THE HUMAN PASSiONS BY OTHERS OF EQUAL OR SUPERIOR FORCE, AN IMPORTANT DEPARTMENT OF MEDICINE.
99. The doctrine in ethics of balancing the passions of men by others of equal or superior force, is not less applicable to the practice of medicine, than to the science of politics, and is probably not the only point of resemblance between the art of governing mankind and that of healing their diseases.
