JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 MEDICO-PHILOSOPHICAL TREATISE ON MENTAL ALIENATION Produced and printed by Servier as a service to medicine Medico-Philosophical Treatise on Mental Alienation: Entirely Reworked and Extensively Expanded (1809) - Second Edition Philippe Pinel. Translated by G. Hickish, D. Healy and L.C. Charland. © 2008 John Wiley & Sons, Ltd. ISBN: 978-0-470-99746-8 JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 MEDICO-PHILOSOPHICAL TREATISE ON MENTAL ALIENATION Second Edition, Entirely Reworked and Extensively Expanded (1809) PhilippePinel Translatedby GordonHickish DavidHealy LouisC.Charland A John Wiley & Sons, Ltd., Publication JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 Thiseditionfirstpublished2008,(cid:2)C 2008JohnWiley&SonsLtd Wiley-BlackwellisanimprintofJohnWiley&Sons,formedbythemergerofWiley’sglobalScientific, TechnicalandMedicalbusinesswithBlackwellPublishing. 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ISBN:978-0-470-99746-8 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Typesetin10/12ptTimesbyAptaraInc.,NewDelhi,India. PrintedinEnglandbyAntonyRoweLtd,Chippenham,Wiltshire JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 CONTENTS ForewordbyDoraWeiner ix Translators’Preface xiii Acknowledgements xix Preface xxi IntroductiontotheFirstEdition xxv GeneralPlanoftheBook 1 1 TheTrueCausesofMentalAlienation 5 I. Intrinsicorhereditaryalienation 6 II. Influenceofadepravedupbringingonlapsesofreason 7 III. Extremeirregularitiesinlifestylelikelytoproducealienation 9 IV. Spasmodicpassionsliabletoleadtoalienation 10 V. Debilitatingoroppressivepassions 11 VI. Cheerfuloreffusivepassionsconsideredascapableofderangingreason 13 VII. Amelancholicconstitution,commoncauseofthemostextremedeviations andmostexaggeratedthoughts 15 VIII. Onsomephysicalcausesofmentalalienation 17 NotestoFirstSection 20 2 PhysicalandPsychologicalAspectsofMentalAlienation 23 I. Disordersofphysicalsensitivityinmentalalienation 24 II. Disturbancesintheperceptionofexternalobjectsinalienation 28 III. Disturbancesinthoughtprocessesinalienation 31 IV. Disturbancesinmemoryandtheprincipleofassociationofideas inalienation 33 V. Disturbancesofjudgementinpsychiatricpatients 35 VI. Emotionsandotheraffectivestatestypicalofpsychiatricpatients 38 VII. Disturbancesoftheimaginationinmentalalienation 40 JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 vi Contents VIII. Characterchangesinalienation 45 NotestoSecondSection 47 3 DistinguishingtheDifferentSpeciesofAlienation 51 I. Maniacalinsanityorgeneraldelirium 55 Thespecificcharacteristicsofmaniacalinsanity 55 Isanepisodeofperiodicmaniacalinsanityaformofchronic maniacalinsanity? 59 Canmaniacalinsanitywithdeliriumalwaysbecured? 60 Canmaniacalinsanityexistwithoutadisturbanceinunderstanding? 60 Anexampleofakindofmaniacalattackwithoutdelirium (maniesansde´lire) 60 Maniacalinsanitywithoutdelirium(maniesansde´lire)marked byblindfury 61 Anotherexampleofmaniacalinsanitywithoutdelirium 62 II. Melancholia,orselectivedelirium 62 Popularmeaningofthetermmelancholia 62 Melancholiaregardedasmentalalienation 63 Twooppositeformswhichmelancholicdeliriummaytake 63 Canmelancholiadegenerate,afterafewyears,intomaniacalinsanity? 64 Varietyofmelancholialeadingtosuicide 64 III. Dementia,orabolitionofthought 67 Themostsalientfeaturesofdementiasometimesobservedamongstthe generalpublic 67 Ideaswhichareinconsistentwithoneanother,andunrelated tooutsideobjects 67 Exampletoclarifythedifferencebetweendementiaandmaniacalinsanity 68 IV. Idiocy,orobliterationoftheintellectualandemotionalfaculties 69 DeficienciesintheFrenchlanguageforexpressingthedifferent degreesofalienation 69 Formofidiotismproducedbystrongandunexpectedaffections 70 Idiocy,aspeciesofalienationcommoninthehospicesandsometimes curedbyanattackofmaniacalinsanity 71 PrincipalfeaturesofthephysicalandmentalcharacteroftheSwissCretins 71 Generalremarksaboutthedifferentkindsofalienation 72 NotestoThirdSection 73 4 In-houseManagement,andRulesToBeFollowed,inEstablishmentsfor theMentallyIll 75 I. Generalplanandinternalarrangementofthehospiceforthementallyill 76 JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 Contents vii II. Onmethodscurrentlyusedtocontroltheinsane 77 III. Necessityofmaintainingconsistentorderinhospicesforthementallyill, andofstudyingtheircharactertraits 81 IV. Theimportanceandextremedifficultyofestablishingfirmorderina serviceforthementallyill 84 V. Paternalisticsupervisiontobeexercisedinthepreparationanddistribution ofmeals 87 VI. DisastrousconsequencesoftheshortageswhichoccurredinYearIVinthe hospicesforthementallyill 88 VII. Variedphysicalexercise,orroutinesofmechanicalwork,afundamental ruleofeveryhospiceformentallyillpatients 90 VIII. Generalpreceptstobefollowedinmentaltreatment 95 IX. Precautionscalledforbyextremeexaltationofreligiousopinions 99 X. Extremerestrictiontobeplacedoncommunicationofderangedpatients withpeopleoutside 101 XI. Supervisionmeasuresrequiredwithcertainperverseor uncontrollablecharacters 104 XII. Preceptstofollowinthemanagementofmelancholicpatients 109 NotestoFourthSection 113 5 ResultsofAncientandModernExperienceintheMedicalTreatmentof theMentallyIll 119 I. Onthepracticeofstrikingderangedpatientsasameansofcuringthem 120 II. Isthepracticeoffrequentblood-lettinginmentalillnessbasedon enlightenedexperience? 123 III. Ontreatmentbybriskimmersionofderangedpatientsincoldwater 124 IV. Treatmenttobefollowedduringthefirstphaseofmaniacalinsanity 128 V. Ontheuseofremediesofvaryingactivity,designedtosupportgeneral measuresoftreatment 135 VI. Considerationsrelatingtomedicaltreatmentinthesecondandthirdstages ofmaniacaldelirium 139 VII. Criticalendingofalienationsometimesproducedbyspontaneouseruptions 142 VIII. Difficultyandimportanceofdeciding,inparticularcases,whether derangementiscurable:aremarkableexample 144 IX. Prudentmeasurestobetakenindischargingconvalescentmentalpatients 146 NotestoFifthSection 149 6 ResultsofObservationsandConstructionofTablesforDeterminingthe DegreeofProbabilityofCuringMentallyIllPatients 153 I. RulesfollowedattheSalpeˆtrie`rehospiceformentallyillpatientstokeep theregistersandconstructthetables 155 JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 viii Contents II. Derangedpatientsadmittedwithnoinformationregardingtheirprevious state,andpatientstreatedelsewherebeforeadmissiontothehospice 159 III. Predispositiontomentalalienationaccordingtoage,maritalstatus orcelibacy 159 IV. Varyingincidenceofalienationdependingonitscauses 160 V. Treatmentmethodfordementedpatientssuggestedbythenatureofthe precipitatingcauseandconfirmedbythecalculationofprobabilities 161 VI. Lengthoftreatmentneededtopreventrelapses 164 VII. Relapsesoccurringaftercureanddischargefromthehospice 165 VIII. Regardingtheproportionofsuccessesandfailuresinthetreatmentof alienatedpatients 166 IX. Doubtfulsuccessoftreatmentincasesofalienationwithinconclusive diagnosticsignsandsymptoms 167 X. GeneralresultoftreatmentofderangedpatientsattheSalpeˆtrie`reinthe years1806and1807 169 Year1806 169 Year1807 170 NotestoSixthSection 172 7 CasesofAlienationWhichAreIncurableasaConsequenceof MalformationsorOtherCauses 175 I. Periodsoflifewheninsanityfrommentalcausesismostlikelytodevelop 176 II. Varietiesofheaddimensionsandchoiceofpartstodraw 179 III. Caseofalienationthatbecameincurablethroughaccidentalcauses 183 NotestoSeventhSection 188 Index 193 JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 FOREWORD Whytranslate,forthefirsttime,thesecondeditionofaTreatisepublishedinFrenchtwo hundred years ago? Because it provides historians of medicine and psychiatrists in the English-speaking world with an authoritative overview of mental illnesses as they were understoodatthebirthofmodernpsychiatry.Thiswork,byPhilippePinel(1745–1826), thefounderofpsychiatryinFranceatthetimeoftheFrenchRevolution,madetheauthor world-famous.Buthebecameknownmainlyasthedoctorwhofreedtheinsanefromtheir chains–whichistruemainlyinasymbolicway:hisassistantJeanBaptistePussindidso threeyearsbeforePinelfollowedsuit. In1806,anEnglishtranslationofthefirsteditionofhisTreatiseof1800appeared.Thiswas oneyearafterNapoleonhaddefeatedtheBritishatAusterlitz.Nowonderthetranslator,a patrioticobstetricianfromSheffield,calledFrance‘avastBiceˆtre,’theasylumforinsane menwherePinelservedasphysicianin1793–1795. FurtherbadluckbefellPinelintheEnglish-speakingworldafterthepublication,in1813, ofSamuelTuke’sDescriptionoftheRetreataYork.‘NowweunderstandPinel,’theEnglish publicseemedtosay;‘PinelistheFrenchTuke.’AndsoPinelenteredtheEnglish-language literature of psychiatry as the French counterpart of a rich Quaker tea merchant, and the twins ‘Tuke–Pinel’ have appeared together in the Anglo-American medical literature for twocenturies,whiletheobstetricianDDDavis’swretchedtranslationisstillquotedasthe onlyavailableEnglishversionoftheTraite´ me´dico-philosophiquedel’alie´nationmentale oulamanieof1800. By 1800, Pinel had been professor of internal medicine at the reformed Paris medical schoolforfiveyearsandhadpublishedhisPhilosophicNosography,thetextbookinwhich all French medical students learned diagnosis and the clinical approach, and that went through six editions in twenty years. Pinel was also about to be elected to the Academy of Sciences, an honor he took very seriously since he believed that medicine could only progressbyadoptingthescientificmethod.Whatismostimportantforthepresentbook, however, is that Pinel was appointed physician-in-chief of Salpeˆtrie`re Hospice, the huge Parisianestablishmentformentallyillwomen,in1795,andheservedinthatpositionfor thirty-oneyears,untilhisdeath. By1809,thedateofthesecondeditionoftheTraite´,Pinelhadimportantnewinformationto presenttothemedical,scientificand,indeed,tothesocio-politicalworld.Hehadconducted what he called an ‘experiment’ with the help of his assistant AJ Landre´-Beauvais. They JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 x Foreword had,overalmostfiveyears,1802–1805,closelyexaminedsomeonethousandmentallyill womenhospitalizedattheSalpeˆtrie`re,orabouttobeadmitted.Thedoctorselaboratedand published a table of data that classified these women into the four traditional categories of mania, melancholia, dementia and idiocy, but also used personal information and a differentialdiagnosis.Buttherealpurposeoftheexperimentwastocalculatetheprobability ofcure. Thefocusoncuretellsusthatthisprofessor,medicalscientistandadministratorwasfirst ofalladoctor.Theomnipresenceofcasehistoriesinthepresenttextservestoprovethis point,aswellastoenliventheargument.Buthisfinding,thatonlyabout9%ofthewomen surveyedin1802werecurable,revealedtroublingproblems.Pinelwasapioneerwhohad broadened the purview of medicine, proclaiming that the mentally ill are not culprits or madmen but patients and that it behooves the medical profession to care for them. The revolutionarymessageofthecitizen-patient’sequalrighttomedicaltreatmentemphasized that point. But where were the buildings, the doctors, the nurses and the funding to care for this throng of indigent melancholic, demented and idiot patients, even assuming that the curable ones, mainly maniacal patients, could be taken care of? His student Esquirol wouldaddressthisproblemandprodthegovernmentintopassingtheLawof1838thatstill regulatestheinternmentofmentalpatientsinFrance. Pinelrealizedthathewasworkingonanew,burdensome,troublingandhugelyexpensive issue.Thatiswhy,itwouldseem,hedecidedtopresenthis‘experiment’totheAcademyof Sciencesratherthantothemedicalfaculty.Statesmen,scientistsandmathematicianssuch asChaptal,Fourcroy,Tenon,Cuvier,Lamarck,Laplace,LagrangeandMongewereinhis audienceonJune25,1805andFebruary9,1807,andhemademuchofhismathematical approach:thecalculusofprobabilityofthepatients’recovery. The academicians were so impressed that they decided to get this report published in theMoniteuruniversel,theofficialgovernmentnewspaper,thefollowingSunday.Butthe responsetohisfindingswasdisappointing. Pinelknewthathisevidencewasincompleteandhiscomplaintsonthatsubject,inthe1809 Traite´,revealdramaticdetails,hithertounknown,aboutthepracticeofhospitalpsychiatryin early19thcenturyFrance.Theprocessofadmissionwaschaotic:womenwereoftenbrought inbythepolicehavingbeenpickeduponthestreets.Noinformationwasavailable,unlessthe womanherselfwaswillingandabletovolunteerit.Similarly,manywomenwereescorted fromtheAdmittingOfficenearNotreDamecathedraland,thoughtheywereinterviewed here, information was not forwarded. The same was true of patients transferred from the Hoˆtel-Dieu, where mental patients traditionally underwent three months of ‘treatment’: venesectionandpurging,astheylaystrappedtotheirbeds.Ifnotcured,theywereshipped totheSalpeˆtrie`reorBiceˆtreasincurable.Hereagain,Pinelreceivednomedicalinformation for about one-third of the patients admitted, and he complains bitterly. A related specific problemwasthat,havingnoinformationaboutanytreatmentsormedicationspreviously administeredtoone-thirdofhispatients,hecouldnotaccuratelyforeseetheeffectofany therapyhemightprescribe.ThissituationinvitescomparisonwithBritishpracticewherethe voluntaryhospitalsselectedthepatientstheyadmitted,rejectingthementallyill:indigent ‘madmen’weresenttoBethlem,payingpatientstoprivate‘madhouses.’The‘apothecary’at JWBK154-FM JWBK154-Hickish June3,2008 19:45 CharCount=0 Foreword xi Bethlem,JohnHaslam,facedasituationsimilartothatofPinelwhoknew,andappreciated, hiswritings. Pinel repeatedly mentions the careful daily notes he took on each patient, and also that he had to fill out certificates for discharge and, quite often, provide a medical opinion forlegalproceedings.Worriedaboutpossibleindiscretionsshouldthesenotesandpapers becomeknown,hedestroyedthemall.Tomakemattersworseforthebiographer,neither hiscorrespondencenorhismanuscriptscanbefound. Soheproceededwiththeadministrationofaserviceforthementallyillthatusuallyheld about three hundred patients, while also caring for an equal number of patients in the generalinfirmary.Inthepresentbookhedescribesatlengthhowhisreformsimprovedthe premisesandlodgings,foodandmedications,andespeciallythepsychologicaltreatment– oddly known as ‘moral’ treatment – of the patients with varied problems and diseases. His reliance on the superintendent Jean Baptiste Pussin and his wife Marguerite Jubline aredocumentedhere,asarehistroubleswithsuppliesandwiththeservantgirls.Hedoes notmentionthelaySisterswhohadadministeredpatientcareforwelloveracentury:he justtellsusthattheygraduallyresigned.(Itwouldseem,however,thattheysetimportant precedentsregardingthedistributionofthepatientsandtheirdailyroutines.) This book presents the far-sighted concerns of a medical scientist and civil servant, the physician-in-chiefofEurope’slargestpublichospice.Itdocumentshisinnovativeattempt toapplythestatisticalapproachtothestudyofillnessandcurability.Atthesametime,itgives usanintimatelookatadeeplyhumanephysicianwhospentcountlesshoursinconversation withpatients,tryingtoascertainwhethertheir‘alienation’mightbereversible,aimingto classifytheirillnesscorrectly,accordingtohisnosology,andlodgingthemappropriately. WefindPinelrepeatedlydenouncingthepoliceandthecivilserviceforbringingwomen tothehospicewithoutinformationabouttheirmedicalhistory;advocatingpsychological therapy instead of strong medications; experimenting with temporary home leave. Pinel neverwaveredfromattentiontothepatientandthepatient’shistoryasthenecessaryfocus ofthephysician’sattentionandcare.Thatiswhyhesharedeverydayofhislife,forthirty years,withthementalpatientsoftheSalpeˆtrie`re. DoraB.WeinerPhD ProfessoroftheMedicalHumanities&History,UCLA