DOMINIQUE ESQUIROL: THE PASSIONS AND THEIR MASTER

In 1805 Esquirol published his medical thesis entitled Des passions, considérées comme causes, symptômes, et moyens curatifs de l'aliénation mentale (On the passions, considered as causes, symptoms, and means of cure for mental alienation).^[162] He dedicated the essay to Pinel "in homage of my gratitude," and declared himself Pinel's disciple throughout a thesis filled with case histories, many of them his own. He derived these from the private clinic that he had established at 8, rue Buffon, across the street from the Salpêtrière, in March 1802, three and a half years before completing his thesis. This clinic began and remained under Pinel's supervision; Esquirol thus publicly committed himself to carrying out his teacher's ideas, in theory as in therapy.^[163]

In his thesis, Esquirol came quickly to the point, stressing the close interrelation of psychologic and somatic phenomena and of feelings and thought:

Few authors have studied the relationship of mental alienation to the passions. Crichton offers exact ideas on the origins and development of the passions and their effects on the organism. Professor Pinel agrees with him, regarding the passions as the most frequent cause of upset of our intellectual faculties.^[164]

Having thus declared his indebtedness to these two authors, Esquirol formulated his own version of psychologic therapy. He based this on Crichton's analysis of the effect that strong emotions could exert on the mental faculties and the organism, and on Pinel's view that the therapist can intervene in order to orchestrate the struggle within the patient—strengthen the rational powers and help them master the emotions and thus promote recovery. For the formulation of his therapeutic strategy, Esquirol also drew on Bordeu's concept of "secondary centers of sen-

[162] (Paris: Didotjeune, 1805).

[163] The 39-page manuscript register of Esquirol's small private hospital for the years 1802-1808 has recently been acquired by the History and Special Collections Division of the Louise M. Darling Biomedical Library at UCLA. See D. B. Weiner, "Esquirol's Patient Register: The First Private Psychiatric Hospital in Paris, 1802-1808," Bulletin of the History of Medicine 63 (1989): 110-120.

[164] Esquirol, Des passions, 20.

sitivity" in the epigastrium and in the precordial region. He did, in fact, revive the traditional notion of hypochondriac localization, but gave it a specific formulation. Why could not a skillful therapist, asked Esquirol, provoke a strong emotion and use it for a curative purpose? In fact, he advocated a psychologic but violent assertion of medical authority and the use of the passions as means of cure. To this end he proposed emotional shocks—des secousses —"physical or psychologic, that shake and one might say threaten the machine, and forcibly redirect it toward health."^[165]

Esquirol saw two potential benefits from this shock treatment: a judicious use of certain emotions by the doctor—for example intense remorse, regret, or joy—could help the patient regain rational command over his feelings. Secondly, Esquirol argued that control over the patient is essential in the asylum, and that individually and carefully administered shock differs categorically from the indiscriminate use of "ducking" in ice-cold water, or strong cold showers on the head or abdomen that others advocated. But there is no gainsaying that awe of the director was the ruling principle in the new clinic, and Esquirol often threatened and occasionally meted out punishment: he used the straitjacket, isolation, food deprivation, and even—if rarely—cold showers. But he never permitted what he called physical violence; the patients were never beaten nor intentionally hurt. His means are mild if compared to the chamber of horrors that J. C. Reil imagined—though Reil fortunately never had occasion to carry out his ingenious strategies for stimulation, excitement, fear, horror, pain, deprivation, and slavish subjection to the asylum director.

The first step in this therapeutic process was what Esquirol called "isolation," that is, removing the patient from home and familiar surroundings, and bringing the man or woman to the clinic for treatment. "Often the first shock to the intellectual and psychologic faculties occurs in the patient's home," commented Esquirol, "among acquaintances, parents, and friends.... I could multiply the examples of the beneficial impact on the psychologic state of mental patients resulting from their experience in an unfamiliar establishment where care, attention, and services are tendered, in contrast with the tortures they had expected and feared that they would find there."^[166] All contemporary specialists agreed on this point, whether it was the Quaker William Tuke or the Savoyard Joseph Daquin or the German physiologist Reil: therapy must take place

[165] Ibid., 70.

[166] Ibid., 43, 41.

in a new and neutral place far from previous emotional ties and from objects that might remind the patient of past upsetting episodes. But it was the initial encounter with the director of the clinic, Esquirol believed, that should impress if not frighten the patient. Again he had models, notably Francis Willis, the man chiefly responsible for the management of King George III's bouts of mental illness. "A great show of force and power, and a threatening demeanor and preparations designed to terrify," commented Esquirol, "can stop the patient's most obstinate and deadly designs."^[167] He recounted the case history of a twenty-year-old surgeon. He told the patient upon his arrival:

Young man, you must stay here awhile. If you want to be comfortable, behave yourself. If you act as if you had lost your reason, you will be treated as if you were mad. You must choose. See these servants? They shall do everything that you ask for, in a reasonable and sensible way. But they obey me only.^[168]

He welcomed a depressed, suicidal young woman in a kindlier way. Recounts the versatile therapist:

I seemed so frightened by her condition, I communicated such concern about the danger of her situation, that she herself asked her parents to let her stay. One must often welcome patients in a pleasant manner, with a kindly smile, with gentle concern and empathy.^[169]

In either case, the patient acknowledged that the director now wielded sole authority. "In surveying the diverse circumstances where the passions can serve in the treatment of insanity," concluded the young psychiatrist, "one is surprised that most students of mental alienation have ignored their use. Some day, perhaps, with sufficient data and with precise records of successful therapy, we will be able to establish the principles of moral treatment."^[170]

This hope took on new dimensions when Esquirol moved to the Salpêtrière as successor to Pussin, in 1811, and faced the challenge of adapting methods used in a small private hospital to a huge public asylum. Esquirol had been watching Pussin's authoritarian ways and he now conceptualized the establishment itself as a "therapeutic tool," using the accommodations and the routines—the food, clothing, outings, work—as so many means of commendation, enticement, reward, pun-

[167] Ibid., 56.

[168] Ibid., 36.

[169] Ibid.

[170] Ibid., 78.

ishment. In a word, Esquirol aimed to achieve the socialization of patients by regulating them, and thus helping them control themselves. This strategy was based on the belief that the fear generated in the mental patient will help dominate his passions, make him conform to social rules, and become "normal." Commented Esquirol:

Those who know the power of habit in human psychology will not be surprised about the influence that new habits can exert on the mentally ill patient: the need to control oneself, to compromise with strangers, is a powerful aid in restoring reason. As establishment specializing in therapy for the insane offers more appropriate care, better trained servants, well-adapted accommodations.^[171]

These words refer to Esquirol's private hospital, but he tried to make them true for the Salpêtrière as well, and they stayed with him as medical director of the Charenton asylum in 1826 and as chief sponsor of the Law of 1838 that still regulates internment of the mentally ill in France. Swain and Gauchet have analyzed this new relationship of powerful director to hapless inmate, and, in Discipline and Punish, Michel Foucault has compared this regimentation of the mental patient to other institutions that imposed uniform behavior on large groups at the beginning of the bourgeois era and of the Industrial Revolution, in the factory, the prison, or the modern hospital, which he calls a "curing machine." Klaus Dõrner has amplified the theme in Madmen and the Bourgeoisie: A Social History of Insanity.^[172] Esquirol's view of the asylum as a "therapeutic tool" can indeed be made to fit into this authoritarian and dehumanizing context. It was not until Sigmund Freud revived Pinel's concept of prolonged and private doctor-patient communication that a relationship was restored in which the patient was again encouraged to speak freely for himself.

Thus a patient-centered approach to mental illness and a focus on the passions did not predominate for long in early-nineteenth-century French psychiatry. Rather, a reductionist materialistic approach, the tradition that emphasized physical causation of mental illness, won increasing favor; it shunted the attention of clinical investigators toward the brain, even the skull, away from mind, thought, and feelings. Crucial

[171] Ibid., 49. The concept of "habit" would be well worth elaborating in this context.

[172] See Swain and Gauchet, La pratiqne de l'esprit ; M. Foucauit, Suroeiller et punir: La naissance de la prison (Paris: Gallimard, 1975), translated into English by Alan Sheridan under the title Discipline and Punish: The Birth of the Prison (New York: Random House, 1978). Foucault borrowed the phrase "curing machine," out of context, from the humane masterpiece, Mémoires sur les hôpitaux de Paris (1788), of Jacques Tenon. On Dõrner, see n. 1 above.

elements that strengthened this emphasis were the vehement attack by François Joseph Victor Broussais (1772-1834) against Pinel in Examen de la doctrine médicale généralement adoptée of 1816,^[173] and the thesis that Antoine Laurent Jessé Bayle (1799-1858) presented in 1822, where he proved a correlation between a physical phenomenon and mental illness, namely that "arachnitis," or chronic meningitis, may be accompanied by general paralysis and a progressive and ultimately fatal dementia.^[174] The primacy of the passions, in early French psychiatry, lasted only for two decades, at most.

While it lasted, Pinel and Esquirol stood at the center of French attention, but Crichton was hardly noticed in France. True, he appears in the bibliographies both men appended to their articles written for the Dictionnaire des sciences médicales,^[175] Bidault de Villiers published a synopsis of the Inquiry, and several French contemporaries mentioned his name.^[176] But otherwise he remained unknown, a puzzling fact, given Pinel's eighteen-page analysis in the Introduction to his Traité of 1800. The chief explanation is Pinel's new Introduction for the second edition of the Traité, published in 1809, in which he briefly refers to Crichton's book, and then discusses the various passions in pages where it is not

[173] Examen de la doctrine médicale généralement adoptée et des systémes modernes de nosologie dans lequel on détermine par les faits et par le raisonnement leur influence sur le traitement et sur la terminaison des maladies, suivi d'un plan d'études fondé sur l'anatomie et la physiologie pour parvenir à la connaissance du siège et des symptôraes des affections pathologiques et à la théapeutique la plus rationnelle (Paris: Moronville, 1816), amplified in Examen des doctrines médicales et des systèmes de nosologie, 4 vols (Paris: Delaunay, 1829-1834). On Broussais, see the magisterial chapter in Ackerknecht, Medicine at the Paris Hospital, and M. Valentin, François Broussais, empereur de la médecine (Dinard: Association des amis du musée du pays de Dinard, 1988).

[174] A. L. J. Bayle, Recherches sur l'arachnitis chronique, la gastrite... considérées comme causes de l'aliénation mentale (Paris: Thèse médecine, 1822).

[175] Pinel cites the Inquiry in the bibliography of the article "aliénation" (1812) and Crichton's Synoptical Table of Diseases in the article "nosographie" (1819). Esquirol cites the Inquiry in the articles "folie" (1816) and "délire" (1814) where he adds: "This article was translated by professor Pinel and appears in Crichton's book." He then gives the reference to the translation in the Receuil périodique de littérature étrangère.

[176] See n. 113 above. Swain mentions two contemporaries of Pinel, both of them involved in health care for the poor, who cite Crichton: one is Dr. Jean Marc Gaspard Itard, the physician to "Victor, the wild boy of Aveyron," who refers to psychologic treatment as "the sublime art created in England by Willis and Crichton"; the other is Louis Francois Joseph Alhoy, for a while headmaster of the National Institute for Deaf Children, and subsequently an administrator of the National Welfare Institutions (La pratique de l'esprit, 348 n. 37). The reference by Itard appears at the beginning of his first report on the wild boy, recently reprinted in T. Gineste, Victor de l'Aveyron: Dernier enfant sauvage, premier enfant fou (Paris: Le Sycomore, 1981), 225.

possible to distinguish his ideas from Crichton's and where the Scottish doctor does not appear as an important stimulator of Pinel's thought.^[177] Also, Pinel called his new introduction "Introduction to the first edition," thus presenting his faint and brief allusion to Crichton in 1809 as if it had been written in 1800.^[178]

Was it a lapse of memory to call his new Introduction the "first," or an intentional obfuscation, as some critics suggest?^[179] Friends of Crichton's may well take umbrage at Pinel's elision of his eighteen-page analysis of the Inquiry in the Introduction to the second edition of the Traité. Might he have gone to the extraordinary length of calling his second Introduction the "first" in order to wipe out all memory of his early enthusiasm for Alexander Crichton, at least in the minds of French readers? Whatever the answer, Pinel's main motivation seems clear: he wished to appear as the prime analyst of the passions, and the young Esquirol echoed his thought.

There is enough internal evidence in these French physicians' writings, however, to permit the conclusion that it was Crichton who drew their attention to recent German medical research and publications. He helped introduce them to concepts such as Blumenbach's Bildungstrieb, Reil's Lebenskraft, and Schelling's Naturphilosophie and, more generally, to contemporary German scholarship in anthropology, natural history, and psychology, with its emphasis on developmental change, instincts, drives, and irrational forces that impel man as a biologic entity and over which he has little control.

[177] Pinel, Traité, 2d ed., Introduction, xxii.

[178] Walther Riese discovered the discrepancies when he translated the Introduction of 1800 in 1969. See The Legacy of Philippe Pinel: An Inquiry into Thought on Mental Alienation (New York: Springer, 1969), 23-49. The two Introductions are conveniently printed side by side and provided with some editorial comment in J. Postel and P. H. Privat, "Les deux Introductions du 'Traité médicophilosophique' de P. Pinel," Annales médico-psychologiques 129 (1971): 14-48. The totally revised Introduction to the second edition, written in 1809, was translated by Gregory Zilboorg, who mistakenly believed it to be the first Introduction because Pinel gave it that title. See Zilboorg's A History of Medical Psychology, 329-341.

[179] P. H. Privat, Philippe Pinel: Son temps, son eruvre (Paris: Thèse médecine, 1969). What must give one pause is Pinel's lack of generosity toward other colleagues: his denigration of Chiarugi, whom he dismissed in Introduction, Traité, xli; his failure to acknowledge Joseph Daquin's feelingful dedication of the second edition of Philosophie de la folie in 1804; and his covert indebtedness to Dr. James Carmichael Smythe (1741-182l) that Othmar Keel has studied and that Jacques Postel has gleefully echoed. See O. Keel, Lénéalogie de l'histopathologie: Une révision déchirante: Philippe Pinel, lecteur discret de J. C. Smythe (Paris: Vrin, 1979), and J. Postel, "Un nouveau mensonge par omission de Philippe Pinel, déouvert par Othmar Keel, lecteur indiscret et perspicace," Information psychiatrique 57 (1981): 619-622.

In his biographic sketch of Esquirol mentioned earlier, Henri Ey points to his countryman's deep sympathy for German thought, a set of convictions whose origins puzzle Ey. He alludes to Esquirol's "probable meeting" with J. C. Heinroth in Paris and comments that "agreement in their way of thinking was so fundamental" that no actual encounter was needed because their publications express the "similarity of their human and scientific convictions."^[180] An even closer link that Ey might have mentioned exists through J. C. Hoffbauer, who annotated the second German translation of Crichton's book and whose treatise on legal psychiatry Esquirol commented on in turn, in the 1827 French edition.^[181] Heinroth and K. W. Ideler explored the relationship between religion, morality, and psychiatry—as did Esquirol, who also shared a fascination for the "passions" with J. C. Reil and a lifelong involvement in asylum administration with J. G. Langermann. There is not room here to explore the "meeting of minds" to which Ey alludes, however rewarding this exploration would be.

This essay is merely designed to underline the importance of Alexander Crichton, who drew the attention of Pinel and Esquirol to German scholarship in psychology and psychiatry at the turn of the nineteenth century. He thus helped open the French medical world to the influence of German thought and served as unwitting ambassador of German medical Romanticism, from Gtttingen to Paris.

[180] H. Ey, "J. E. D. Esquirol,' in Grosse Nerveruärzte, ed. K. Kolle, 3 vols. (Stuttgart: Thieme, 1956-1963), 2:87-97.

[181] See n. 153 above.