Chapter 9 Chapter 9 The Birth of a Mental Hospital-1

The following stories are familiar to us and have been described in various annals of psychiatry.What these stories prove is what a blessed time it was when madness was at last recognized and treated in the light of truths we had long been blinded to. The noble Quakers ... endeavor to convince their members that if they are unfortunate enough to lose their minds and have not enough means to obtain every kind of medical treatment in expensive institutions and the comforts befitting their station, there is a voluntary fund that can Funding has been provided and, over the past two years, an asylum has been established near Yorktown.This asylum seemed to have many advantages and a great deal of economy.It is a comfort to a man to think that there is a clever charity which has always been capable of devising ways of care and cure, when he is horrified by that dreadful disease which seems designed to humiliate human reason. .

The asylum was situated in pleasant countryside a mile outside York.It does not make one think of a prison, but of a ranch.It was surrounded by a large walled garden, with no iron gates or windows. The following story of the mental patient who liberated Bisetl is also very famous.Pinel decided to unshackle the prisoners in the cell.One day, Couthon visited the court to see if there were any hidden suspects.While others shuddered at the sight of the "handicapped being supported," Pinel bravely stepped forward.It's a battle between the wise and courageous philanthropist and the paralyzed monster. "Pinel took him directly to the insane area. He was distressed by the conditions of the cells, and he wanted to question all the patients. But most of the patients just insulted and abused. There was no point in further questioning. He turned to Pinel: Citizen, are you mad to unchain these beasts? replied Pinel calmly; Citizen, I believe that these madmen are difficult to deal with only because they are deprived of fresh air and free.

"Well, you can deal with them as you wish, but I'm afraid you will become a victim of your own ideas." After finishing speaking, Kutong was helped into the carriage.As soon as he left, everyone breathed a sigh of relief.The great philanthropist (referring to Pinel) got to work right away. " These stories all have an important imaginative element: there was a paternalistic calm in Tooke's asylum, so that the excitement of the patient's heart and the disorder of the mind were gradually quelled; With a word or a gesture he could subdue two beastly lunatics snarling at him; Pinel's wit could tell the difference between a raving patient and a bloodthirsty member of the Convention is the real danger.These images are legendary, widely circulated, and have not declined to this day.

The legend about Pinel and Took has a mythological quality. Nineteenth-century psychiatry considered this to be an obvious fact.But there is an operation, or series of operations, behind these myths.These operations quietly organize the world of insane admissions, methods of treatment, and the concrete experience of madness. The first is Tuke's actions.Since this action was in tandem with that of Pinel, and since he was famous for being embraced by the whole current of "fraternity", his action was regarded as an act of "liberation".But the reality is quite different: "...it has also been observed on exceptional occasions that individuals in our society suffer a great loss because those who take care of them not only are completely ignorant of our principles, but who often treat them like other sick people. They may indulge in unwholesome language and objectionable activities. This often seems to leave an unhelpful influence on the minds of patients after they have regained their sanity, alienating them from their past religious sensibilities, and even They acquire vices which they did not have before." The sanitarium should be an instrument of moral and religious segregation, by which an environment as close as possible to the Quaker community would be recreated around madness.This is done for two reasons.First, evil visions are the cause of pain to every sensitive mind, and the source of every powerful and harmful emotion, such as fear, hatred, and disgust.And these emotions can both initiate and aggravate madness. "It is quite true to think that in large communal asylums there is an indiscriminate mixing of people of opposing religious sentiments and ceremonies, of libertines with moral people, of blasphemy Mixing serious people with serious people will hinder the patient's recovery and aggravate the patient's melancholy and world-weary thoughts. However, the main reason is that religion can play the dual role of natural nature and external constraints, because on the one hand It has become the natural nature of human beings in the customs handed down from generation to generation, in education, and in daily activities. On the other hand, it is also a stable source of compulsion. It is both spontaneous and compulsive. Here In this sense, when reason is lost, it is the only force capable of resisting the unbridled rage of madness; its precepts "have only so far penetrated strongly into early life, . . . become like the nature of man.Even in delusional states of insanity one often feels its conditioning.The effect of strengthening religious principles on the minds of mentally ill was considered to be of great therapeutic effect as a means of treatment. "' That is, in the dialectic of insanity, where reason is concealed but not self-abolished, religion constitutes the concrete form of that element which is impossible to become mad. It bears the invincible element of reason, the quasi-natural nature that continues to exist, and constitutes an atmosphere of stable attraction around madness, "in which case, when the patient is in a lull or recovery state, he likes to be around those who have the same habits and opinions. A society of men". Religion protects the ancient mysteries of reason in the presence of madness, thereby making tighter and more direct the constraints that had raged as far back as classical times. In classical times, the religious and moral environment was imposed from without. Man, the result is that madness is controlled, but not cured. But in the sanatorium, religion is part of the whole activity. This activity shows that there is rationality in madness no matter what the situation. This activity makes man spiritually Insanity restored to health. Religious isolation has a very definite meaning: it is not an attempt to protect the sick from the harmful influence of Quakers, but to place the insane person alone in a moral environment in which He argues with himself and with his surroundings, and is constantly in a state of anxiety by creating an unprotected environment in which he is constantly beset by "disciplines" and "deviances."

"Insanity seldom alleviates fear, so the fear principle is thought to play a very important role in the management of patients." Fear is a fundamental phenomenon in mental institutions.If we remember the horrors of confinement, there is no doubt that fear is an ancient phenomenon.But the terror of confinement, which surrounds madness from the outside, marks the dividing line between reason and irrationality, and has a double power: on the one hand, it restrains the madness, and on the other hand, it controls reason itself, keeping it at a distance.The fear that arises in a nursing home is much deeper.It acts between reason and madness, mediates between them, seeks common ground between the two, and thereby binds them together.Fear, which once ruled everything, was the clearest sign of alienating madness in classical times, now fear has the power to dispel alienation.This allows it to restore the original complicity between the madman and the rational man.It reestablishes a certain reciprocity between the two.Madness no longer causes fear.It itself is terrified of me, Han Zili, and thus completely at the mercy of a pedagogy of wisdom, truth, and morality.

Tucker once recounted how he took in a manic patient in a nursing home.The man was young and extremely powerful.His seizures terrified those around him, even the guards.He was sent to a nursing home chained, handcuffed and his clothes bound tightly with rope.Once he was admitted, all the shackles were removed.He was allowed to eat with the caregiver.His agitation subsided immediately; "his attention was drawn to the new situation." He was taken to his room; the nurse explained to him that everything in the nursing home was based on how each patient could enjoy Arranged for the greatest freedom and comfort possible, he will not be subject to any compulsion so long as he does not violate the rules of the house or the general code of morality.The caretaker stated that although he had coercive means, he was unwilling to use them. "The manic patient felt he was being treated with kindness. He promised to restrain himself." He still sometimes yelled wildly, scaring other patients.The nurse reminded him of the warnings he had made on the first day of admission and his own promise that if he didn't restrain himself, he would go back to his old life.The patient will become more excited when he hears it, but will soon calm down. "He listened attentively to the persuasion and rationale of the friendly interlocutor. After the conversation, the patient usually had a few days or a week better." He was released from the nursing home 4 months later in a full recovery.In this case the patient feels fear directly, but he learns about it not through torture but through conversation.Not only is there a limit to liberty beyond the bounds, but a lauded and simple area of ​​responsibility is marked, within which any manifestation of madness is punished.As a result, the vague notion of guilt that once linked derailment to irrationality has changed.As an originally rational being, the madman no longer feels guilty about being mad.But as a madman, he should feel morally responsible for everything that may cause moral and social harassment in his heart, and he should think that it is himself and not others to bear the punishment he suffers.Determining guilt is no longer the general pattern of relationship between madmen and healthy people, but the specific way in which each madman and his caretaker are interdependent, and it is the way that madmen must have to understand their own madness.

Therefore, we must re-evaluate the meaning that people give Tuke's work: to liberate the mentally ill.Abolish coercion and create a humane environment.These are just some words of defense.The actual operation is quite different.In fact, in the sanatorium Tooke founded, he replaced the unbridled terror of madness with suffocating responsibility; fear no longer reigned within the prison gates, but raged in the name of conscience.Took transfers to the heart of the madman the ancient terror that binds the mentally ill.True, the sanatorium no longer punished the sins of the mad, but it did more than punish.It makes that guilt a part of the order, makes guilt a consciousness of the madman himself, a one-way relationship with the nurse, makes guilt the other-consciousness of the rational man, a kind of awareness of madness. Therapeutic intervention of the human condition.In other words, this sense of guilt makes the madman a perpetual object of punishment, either by himself or by others.Acknowledging his object status and realizing his guilt, the madman will regain his sense of self, become a free and responsible subject, and thus restore his rationality.That is to say, the madman regains his freedom by turning himself into his old object.This transformation process can be accomplished both in labor and observation activities.

Let us not forget that we are in a Quaker world.Here, the sign of God's blessing is the success of one's career.As in Tooke's sanatorium, work first appears as "moral therapy."The compulsion of work itself is superior to all forms of physical coercion.Because when working, you must obey the prescribed working hours, concentrate your attention, and bear the responsibility to make a certain result, which prevents the patient from thinking wildly, otherwise there may be serious consequences.Work also puts the patient into a system of accountability. "Regular jobs are probably the most generally effective. Those jobs that involve a sufficient amount of exercise are undoubtedly the most effective, both morally and physically. They are the best for the patient to do, and the best to prevent the patient's hallucinations. "Through work, people can return to the order stipulated by God's commandments, and make their freedom subject to the laws of morality and reality.Mental work should not be denied.However, all phantasy should be absolutely strictly excluded, because they are connected with passion, desire, and all kinds of induced hallucinations.On the contrary, the study of what is eternal in nature, and what is most consistent with the wisdom and goodness of God, will most effectually narrow the inordinate liberty of the madman, and lead him to discover his responsibilities. "The branches of mathematics and the natural sciences provide the most rewarding subjects of study with which to engage the brains of the mentally ill." In mental institutions, work ceased to have any productive meaning.It is merely an imposed moral control.It limits the liberty of patients, making them subject to order and responsibility.Its sole purpose is to restore to normal a mind trapped in an excess of freedom, which physical coercion can only superficially limit.

Even more effective than labor and the observation of others is what Tuke calls "the need to be respected." "This principle in the human mind, though often hidden, undoubtedly influences our general behavior to a great extent. It has a special role when we enter a new social circle." In classical During the period of confinement, the madman was also easily observed, but this observation was basically not to observe himself, but only to observe his terrible appearance and the bestiality revealed.There is at least a reciprocity in this observation, for the normal man sees in the mad man, like a mirror, his impending doom.And the observations made by Tuke were an important element of the asylum's activities.It's more in-depth, but it's less interactive.This observation is in the madman, looking for the elusive signs of madness where madness has crept away from reason and has begun to be independent of it.It is impossible for the madman to react to this observation in any way, since he is purely the observed, he seems to be a newcomer, a latecomer, to the world of reason.Tuke arranged a whole ritual around these observations.Among them are British-style social events, where participants must imitate all formal social event requirements.But in addition to free observation, do not do anything else at will.The purpose of the observation is to spy for any signs of incoherent speech and uncoordinated actions that might indicate madness.For example, the dean and staff regularly invite several patients to a "tea party."The guests "were all dressed in their best clothes and courted each other. They were treated with the best hospitality and with every attention due to strangers. The controls are superb. The whole atmosphere is strange and satisfying." Strangely enough, this ritual event is not intimate interaction, dialogue, or mutual understanding, but an environment organized around madmen.In this environment, everyone behaves the same or like the madman, but he is still a stranger, a typical stranger, because he is judged not only by his appearance but by what he cannot help revealing.The madman goes on and on playing the part of this misnamed stranger.Observation, decorum, and pretense of others silently impose on him a certain social personality.He is constantly challenged with all sorts of things that might expose him.In this way, the madman has to make himself the typical stranger to reason, that is, one who does not reveal his strangeness.It is this identity that the City of Reason welcomes him, and the price he pays is the anonymity he has succumbed to.

We see that partial coercion of the physical body is part of the system in the nursing home.The basic element of the system is to establish a kind of "self-restraint".In self-denial, the patient's freedom is not only constrained by work and observation by others, but is constantly threatened by admissions of guilt.It must be admitted that the patient is not subject to a purely negative operation, but is controlled in a positive operation.The former merely unleashes the shackles and frees the patient's deep nature from madness, while the latter uses a system of rewards and punishments to suppress smoking madness and include it in the activities of moral consciousness.Thus passes from a world of condemnation to a world of judgment.But it is from this that the psychology of madness is made possible, since madness is brought under observation, which requires a constant denial of its apparent pretense.It can only be judged by its actions, not its intentions.Its mysteries will not be sought.Madness is only responsible for the visible part of itself.All other parts fell silent.Madness no longer exists except in the visible part.The intimacy established in the asylum is no longer broken by iron chains and bars, but reciprocity is not allowed, only observational intimacy.When observing, in order to see more clearly, it can monitor, pry and get close, but in fact it is getting farther and farther away from the patient, because it only accepts and recognizes the value of this stranger.The science of psychiatry can only ever be a system of observation and classification as it develops in mental institutions.It cannot be a dialogue.The science of psychiatry can only become a conversation when psychoanalysis dissipates this observational phenomenon so central to nineteenth-century asylums, and replaces its silent magic with the power of words.More precisely, psychoanalysis doubles the one-way observation of the observer with the endless monologue of the observed.In this way, both are preserved!The one-way observation structure of Tian Mental Hospital adds an asymmetrical reciprocity, a new language structure of non-response.

Surveillance and trial—thus a new figure of importance has emerged.This image was a crucial factor for the mental asylum of the nineteenth century.Tooke himself promotes this image in his story of a manic patient who is rampant.One day, the patient was walking in the garden of the mental hospital with the nurse. The patient suddenly became excited, walked a few steps away, picked up a big stone, and made a gesture of throwing it at the nurse.The nurse stands still, stares at the patient, then walks over to the patient, "in a firm tone ... ordering him to drop the stone".As the nurse approached, the patient dropped his hands and dropped his weapon; "then he was led obediently and silently back to his apartment".Something new is born.This kind of thing is not repression, but authority.Until the end of the eighteenth century, only abstract, impersonal powers governed the world of madmen.The world was lifeless except madness, and the guards were often chosen from among the inmates.Tooke, on the contrary, sets up a mediating factor between guard and patient, between reason and madness.The space that society provides for insanity is now often haunted by people "from that side".They represent both the authority that imposes confinement and the stern reason that administers justice.The nurses are unarmed, interfering only with observation and words.He approached madness without any means of self-protection or of making himself appear intimidating, and he ran the risk of coming into direct conflict with madness single-handedly.But, in fact, he faces madness not as a flesh and blood, but as a rational being.Thus, before the conflict, he already had the authority of his sanity.In the past, reason could only triumph over irrationality by means of material force and through some kind of practical contest.Now, the outcome has been decided in advance.The failure of the irrational is predetermined by the specific circumstances in which the patient and the rational man meet.The absence of coercion in the asylums of the nineteenth century did not mean that the irrational had been liberated, but that madness had long been subdued. Since this new rationality rules the asylum, madness is no longer an absolute form of struggle, but represents a minor status, expressing an aspect of itself that has no right to self-government and can only survive transplanted into the world of reason .Madness is a state of childishness.In the nursing home, all arrangements are made to make the mentally ill become minors.They are "treated as children with excess energy and unrestrained behavior. Immediate rewards and punishments must be given to them, otherwise there will be no effect. A new education system must be implemented to give new guidance to their thinking. He must first be made 01 obedient, Then encourage them and arrange work for them. This kind of work should use an attractive method to make them feel happy." A legal status determined in the abstract rather than a concrete relationship between persons.For Tuke, minor status is a mode of existence for madmen, and for the Warden, a way of exercising dominion.In the nursing home, the concept of "family" is very emphasized, and the mental patients and caregivers are organized with "family".On the surface, this "family" puts the patient in a normal and natural environment, but in fact it alienates the patient even more.The legal status of the madman as a minor is to treat him as an object of legal protection, and after this ancient (family) structure has become a way of living together, the madman is treated as a psychological The object is fully surrendered to the authority of a reasonable human being.The latter is for the madman a concrete adult figure, in other words, a concrete figure that stands for domination and example. The "family" played a decisive role at the end of the eighteenth century in the great reorganization of the relationship between madness and reason.It is both an imagined picture and a real social structure. "Family" is not only Tuke's starting point, but also the goal he gradually realizes.By assigning to it those original values ​​that have not yet been compromised in society, Tooke enables "the family" to function as a dementor.In his fantasy, the "family" is the environment opposed to the "environment" that people in the eighteenth century regarded as the source of all madness.But he introduces "the family" into the sanatorium in a very practical way, making it appear both to be in conformity with, and at the same time the norm of, the relations that may arise between sick and rational beings.The legal status of minor under the guardianship of the family has deprived the madman of his citizenship.This minor status now becomes a concrete situation that deprives him of his actual liberty.The whole existence of madness, in this world prepared for it, is wrapped up in what we may call in advance "the paternal complex."In the bourgeois family, patriarchal authority is revived around madness.It is this historical accumulation that the psychoanalytic theory later revealed.Psychoanalysis gives this historical accumulation a sense of destiny through a new mythology.This meaning is said to be the hallmark of all Western culture, and even all human civilization.But in fact, this kind of accumulation was gradually formed by Western culture, and it was only finalized at the beginning of this century.At that time, madness was doubly alienated (alienated) in the "family," both by the myth that the purity of patriarchy could cure insanity, and by the reality of the family-formed asylum. alienated (alienated) by their situation.For a period of time to come, although the outcome of the matter is still unpredictable, the irrational discourse will definitely be inextricably linked with the half-real and half-imagined "family" dialectics.Thus, that display of rage which had once had to be interpreted as blasphemy against the gods must now be regarded as a constant attack on the Father.Thus, in the modern world, what used to be the great and irremediable conflict between reason and irrationality becomes an instinctive, stealthy assault on the firm institution of the family and its ancient symbols. In the world of confinement, this evolution of madness converges surprisingly with the development of basic social institutions.We have seen that liberal economic systems tend to place responsibility for the care of the poor and sick in the family rather than in the state.The family becomes the bearer of social responsibility.But it would be strange and inhumane if insane patients could also be entrusted to the care of families.And Tooke builds a simulated family precisely around madness.This is as much a comically simulated regime as it is an actual psychological environment.Due to the shortage of families, Tuke replaced them with a virtual family atmosphere composed of various symbols and actions.Yet, by a very strange interplay, the family will one day be freed from the responsibility of caring for the sick in general, while at the same time retaining the fictional value associated with madness.After the disease of the poor is once again a national issue, mental institutions will still keep the mentally ill in mandatory fictional families, the madman will remain a minor, and reason will long maintain its father figure to the madman . Mental hospitals are shrouded in these fictional values ​​and are therefore immune to historical development and social evolution.In Tuke's mind the question was how to construct an environment that would imitate the oldest, purest, most natural common way of life, that is, the most human environment that differs most from the social environment.In effect, he detached the social structure of the bourgeois family, reconstructed it symbolically in a mental hospital, and let it drift through history.Asylums always go after structures and symbols that are anachronistic, and thus can be completely out of date and behind the times.And precisely where bestiality manifests some suprahistorical presence, some eternal return, there will slowly reappear the ancient wounds of unremembered family feuds, the forgotten traces of incest and punishment. Pinel never advocated any religious segregation.Rather, he is advocating a segregation in the opposite direction of Tooke's practice.The reformed asylum should be good for all patients, except those religious madmen, because "they think they are inspired by the gods and try to attract followers."As Pinel intended, Bicetre and Sarpetelier became a complementary figure to Tooke's sanatorium. In a madhouse, religion should not be the moral basis of life, but the Nazis should be a medical object: "In a madhouse, religious opinion should be considered only in strict medical relation, i.e. all other aspects of public worship and political belief should be considered put aside such considerations, and merely inquire whether it is necessary to prevent the exertion of thought and emotion which may arise from it, in order to effectively cure certain insane minds." Emotional and horrific images, thus often triggering madness.Catholicism creates delusional beliefs, encourages hallucinations, and leads to despair and depression.It is not surprising, therefore, that if "inspecting the registers of the asylum of Bicetre we find priests and monks among them, and many countrymen who are frightened mad by horrific descriptions of the afterlife" .It would be even less surprising if we saw a change in the number of people insane because of religion.During the "Ancie Regime" and the French Revolution, when superstition was so powerful, or because the struggle of the republic against the Catholic Church was so severe, the number of melancholics of religious origin multiplied.After the situation stabilized, the "religious appointment" door and the anti-religious struggle were eliminated, this type of delusional symptoms disappeared.In the tenth year of the Republic, 50% of the melancholic patients in Bissetre suffered from religious madness, 33% in the second year, and only 18% in the third year.Therefore, the madhouse must get rid of religion and its various images. A "melancholic person from piety" is not allowed to own religious books.Experience "taught us that such books are the most powerful means of perpetuating insanity, even making it incurable. The more tolerant we are of them, the more difficult it is to appease the anxieties of the patient".In short, a mental institution should be neutral, free from the images and emotions created by Christianity, which lead the mind into hallucinations, fallacies, and quickly lead to delirium.This notion, more than any other, is further removed from Tooke and his dream of building a religious community.Because Tooke believes that this religious community is also a favorable environment for spiritual healing. But Pinel is concerned with reducing the iconographic form of religion, not its moral content.Once "filtered," religion has the power to remove insanity, dispel images, calm emotions, bring people back to basics, and bring them closer to their own moral truth.It is in this respect that religion often has a therapeutic effect.Pinel tells several Voltairean tales.For example, a 25-year-old "strong woman married a frail man".After marriage, she suffered from "a violent attack of hysteria, thinking that she was haunted by a devil who took various shapes to haunt her. A piercing cry." Fortunately, the parish priest paid more attention to natural religion than to practicing exorcism.He believed in the ability to heal disease through the grace of nature.This "enlightened, benevolent and persuasive man dominated the patient's thoughts, and managed to induce her to leave the sickbed, resume the household chores, and even tidy the garden, . All right."When religion returns to this extremely simple moral content, it inevitably joins hands with philosophy, medicine, and all kinds of wisdom and science that can restore sanity to the insane.There are even instances where religion can be used as an initial treatment in preparation for work in a madhouse.For example, there is a young girl who "appears to be docile and devout, but actually has a warm disposition".She is tormented by the opposition between "her own inner tendencies and the strict rules that restrain her behavior".Her confessor, exhorting her in vain to strengthen her faith in God, enumerated examples of a firm and temperate state of holiness, "advising her of the antidote to passion: patience."After she was sent to La Salle Petriere, she was treated "according to the same ethical principles" under Pinel's instructions.Her illness "did only a short period of time".In this way, what the asylum absorbs is not the social theme of religion, which makes people feel like brothers and sisters in the same sect, but the moral force of comfort and trust and resignation to nature.It must continue to engage in the moral enterprise of religion - but without its fanatical content, absolutely in morality, labor and social life. The madhouse is a religious realm without religion, a purely moral realm, a realm of moral uniformity.Everything that can retain traces of the old differences has been destroyed.The last vestiges of religious ceremonies were also removed.In the past, the confinement inherited the almost absolute boundaries of the leprosarium within the social sphere, thus becoming a foreign land.Now the asylum must represent the great continuum of society's morality.The values ​​of family and work, all recognized virtues, ruled the town council.However, this domination is twofold.First, they actually dominate the core of madness.So when insanity produces apparent frenzy and dissonance, solid basic virtues are undisturbed.There is a primitive morality that exists.It is not even generally affected by the most severe forms of dementia.It is this morality that emerges and comes into play in therapy: "I can attest that through therapy often comes the pure virtues and strict principles. Most mental patients who are fortunate enough to enter recovery are loving to their spouses, kind to their children, and loving to their lovers." Enthusiasm. Devotion to duty. I have seen nowhere better than their expression except in fiction." This inalienable virtue is both the truth of madness and its undoing.That's why it's bound to work once it gains dominance.Second, the madhouse eliminates differences, suppresses evil, and eradicates deviant behavior.It condemns all acts contrary to the basic virtues of society, including celibacy-"In the year of the republic and the thirteenth year of the republic, the number of unmarried women who became idiots was seven times that of married women; 2 to 4 times higher. From this we may deduce that marriage is a protective measure for the child and woman against the two most intractable and intractable forms of mental illness. - "Vices such as alcoholism, unrestrained promiscuity, indifference, etc., gradually corrupt reason, and finally lead to complete madness"; Laziness--"General experience proves that in all public madhouses, as in prisons and hospitals, ，保持身体健康、维持良好习惯和秩序的最可靠或许是唯一的方法，是严格执行关于机械劳动的法规。"由此可见，疯人院给自己提出的任务是，实行统一的道德统治，严格对待那些想逃避这种统治的人。 但是也因此而造成一种冷漠态度。如果说法律不能实现普遍的统治，那是因为有些人并不承认它。这个社会阶层的人生活在混乱之中，被人忽视，几乎处于非法状态。“虽然我们看到许多家庭在多年和谐一致的气氛中欣欣向上，但是还有多少家庭，尤其是社会下层的家庭触目惊心地展示着放荡、内证和贫苦无告的情景！根据我的日常记录，这种情况正是我们在医院中加以医治的精神错乱的最主要的根源。” 在皮内尔的主持下，疯人院同时既是整肃道德的工具，又是进行社会谴责的工具。问题在于用一种普遍的方式来推行某种道德，使之从心灵上支配那些不懂得这种道德的人和那些已经精神错乱但尚未表现出来的人。对于第一种人，疯人院必须诉诸被遗忘的本性，起一种唤醒和提醒作用。对第二种人，必须借助于某种社会环境变化，把他从目前的处境中抢救出来。在图克的休养院里，实行的办法是很简单的：实行宗教隔离以达到道德净化的目的。而皮内尔的方法则比较复杂：实施综合道德教育，保证疯癫世界和理性世界之间的道德连贯性。但是他是用实行某种社会隔离来进行的。这种社会隔离将保证使资产阶级的道德成为普遍的事实，并成为一种强加在各种疯癫上的法律。 在古典时期，贫困、懒惰、邪恶和疯癫都以同样的罪名混合在非理性之中。在对贫困和失业进行大禁闭时，疯人也被网罗于其中。而且所有被禁闭对象都被认为形同犯罪，属于人类的原始堕落。现在，疯癫则属于社会缺陷，其原因、模式和界限都未显出与众不同之处。再过半个世纪，精神疾病又将变成一种性欲倒错。但从此时起，主要的、真正危险的疯癫是那种从社会底层产生的疯癫。 皮内尔的病人院作为一个现实世界的避难所，绝不会成为类似图克的休养院那样的返朴归真的空间，而是一个整齐划一的立法领域，一个道德教育场所。在那里，产生于社会外围的各种精神错乱统统被消除掉。病人的生活，看护和医生的行动全部由皮内尔加以安排，以保证这些道德教育能发挥作用。他的手段主要有下述三个： l．silent.皮内尔释放的第五个带镣囚犯曾经是一名教士，因疯癫而被革出教门。他患有自大妄想症，自以为是基督。这是"以请安表现出的最严重的人类傲慢"。他于1782年被送到比塞特尔，被镣铐束缚了12年之久。由于态度傲慢，思想狂妄，他成为整个医院中最引人注目的景观之一，但是他以为自己是在重现基督受难。 "他长期忍受着这种殉难的痛苦和他的躁狂症所招致的无数嘲讽。"尽管他的指妄十分严重，皮内尔仍把他列为第一批释放的12个人之中。但是皮内尔处理他的方式与处理其他人不同。皮内尔二声不响地给他打开铁镣，并且"明确命令每个人都要像他一样自我克制，不与这个可怜的疯人说任何话。这道禁令得到严格的执行，结果在这个自我陶醉的人身上产生了比铁镣和土车的效果要明显得多的效果。他在获得自由后，陷于一种他从未经历过的被遗弃和孤独的处境中，他感到羞辱。最后，经过长时间的脚缭后，他主动加入了其他病人的交往圈子中。从此，他的思想变得比较实际了"。 “释放”在这里的含义是相当矛盾的。上牢、枷锁，不断地被人观察和讥讽，对于这个据安病人来说，正是他的自由的要素。他因此而得到承认，而且他因外界许多人都与他形成一种共谋关系而心醉神迷。因此，他无法从直接感受到的这种现实中解脱出来。但是，解除了枷锁之后，周围人的冷漠和缄默束缚了他，使他那种空洞的自由受到限制。他在缄默中被释放，而陷于一种不被承认的、徒劳展示自己的真实中，因为他不再是一个景观，甚至不再受到羞辱，因而再也不能趾高气扬。现在，受到羞辱的不是他在诸妄时想像的化身而正是他本人。因为肉体束缚已被一种自由所取代，而这种自由几乎无异于孤独；诸妄与奚落的对话已被一种语言的独白所取代，而这种语言在他人的缄默中逐渐枯竭；整出狂妄与凌辱的表演被冷漠所取代。从此，他受到了比上牢和枷锁更真切的禁闭，完全成了自己的囚徒。他本人陷入越轨范畴，而其他人则与耻辱无关。其他人都变得清白了，不再是迫害者。罪恶感转移到内心。它向病人显示，他不过是被自己的傲慢所蛊惑。敌对者的的面孔消失了。他不再感到观看者的存在，而是感到自己不再受到关注，人们转移了观看的目标。其他人不过是在自己前进时不断后退的一个界限。虽然他被解除了枷锁，但是他现在被缄默带上了越轨和耻辱的枷锁。他感到自己受到惩罚，但是他由此又看到了自己无辜的迹象。虽然他摆脱了各种肉体惩罚，但他必须证明自己是有罪的。他的苦难曾是他的光荣，他的解放必然使他受到屈辱。 在文艺复来时期，理性与疯癫不断地展开对话。相比之下，古典对期的拘留就是一种对语言的压制。但这种压制不是彻底的。语言没有真正被消除，而是接入各种事物中。禁闭、监狱、地牢甚至酷刑，都参与了理性与非理性之间的一种无声对话，一种斗争的对话。现在，这种对话停止了。缄默笼罩着一切。在疯癫和理性之间不再有任何共同语言。对渡委的语言只能用沉默不语来对付，因为诱委并不是与理性进行对话时的一个片断，它根本不是语言。在一种最终沉默的意识中，它仅仅表示一种越轨。而且只有在这一点上，才可能重新有一种共同语言，因为它将成为一种公认的罪状。“最后，经过长时间的脚踢后，他主动加入了其他病人的交往圈子……”沉默不语是疯人院生活的一个基本结构，它与忏悔时的彻底坦白相辅相成。当弗洛伊德在精神分析中谨慎地恢复语言交流，或者说，重新开始倾听这种已经被磨损成独白的语言时，他听到的总是那些关于越轨违戒的套话。对此我们何必大惊小怪呢？在这种年深日久的缄默中，越轨违戒的主题已经控制了言语的源头本身。 2镜象认识。在图克的休养院里，疯人受到观察，而且他知道自已被观察。但是这种直接观察只能使疯癫间接地了解自己，除此之外，疯癫无法直接把握自己的性状。但是，在皮内尔那里，观察仅仅在疯癫所限定的空间内而不在其表面或其外部界限之外进行。疯癫能够看到自己，也能被自己看到。它既是纯粹的观看对象，又是绝对的观看主体。 “有三个精神错乱的人，都自以为是国王，都自称是路易十六。有一天，他们为君王的权利争吵起来，各不相让，有点动火。看护走近其中一个，将他拉到一边问：'你为什么和那两个显然疯疯癫癫的人争论？不是所有的人都知道你就是路易十六吗？'受到这番恭维后，这个疯人高傲地瞥了那两个人一眼，便立刻退出争吵。同样的花招在第二个病人身上也发挥了作用。争吵顿时便烟消云散了。”这是第一阶段，即狂想亢奋的自傲阶段。疯癫得以观察自己，但却是在他人身上看到自己。它在他人身上表现为一种无根据的要求，换言之，表现出一种荒谬。但是，在这种谴责他人的观察中，疯人确认了自己的正确性和自己指委的正当性。狂妄与现实之间的裂痕只有在客体对象中才能被认识，而在主体中完全被掩盖住了。主体成为直接的真理代表和绝对的裁决者：自我陶醉的权威痛斥和剥夺他人虚假的权威，从而肯定自己设想的正确无误。作为纯粹的指妄，疯癫被投射到他人身上，而作为彻底的无意识状态，它却被全盘接受下来。 正是在这一点上，镜子作为一个合作者，成为一个消解神话的工具。在比塞特尔，还有一个自以为是国王的病人。他总是“居高；陶下地以命令的口吻”说话。有一天，当他稍稍平静下来，看护走近他，问他，如果他是一位君主，为什么不结束对自己的拘留？为什么还和各种病人混在一起？从此，看护每天都提同样的问题，“他一点点地使病人看到自己装腔作势的荒谬，并指点他看另一个疯人，后者也一直认为自己拥有最高权力，因而成为一个笑柄。开始，这位躁狂症患者感到震惊，后来便对自己的君主头衔产生怀疑，最后逐渐认识到自己是痴人说梦。这种出人意料的道德转变仅用了两个星期。经过几个月的考验，这位病人康复回家，成为一个称职的父亲。”这个阶段是妄想消沉的自卑阶段。由于疯人自以为与谁妄的对象同一，就像照镜子一样，他在这种疯癫中认识了自己，因为这种疯癫的荒谬性是他早已斥责过的。他的坚实的权威主体在这种他所接受的、因而丧失神秘密性的客体对象中消解了。现在，他受到自己的冷峻审视。其他代表理性的人一言不发地支撑着这面可怕的镜子。在这些人的沉默中，他认识到自己确实疯了。 我们在前面已经看到，18世纪的医术试图用何种方法和用什么样的神话方式来使疯人认识到自己的疯癫，以便将他从中解救出来。但是，现在的做法则具有截然不同的性质。它不是用关于某种真理、甚至是虚假真理的强烈印象来驱散谬误，而是用疯癫的自负而非疯癫的失常来医治疯癫。古典主义思想谴责疯癫对真理的置若罔闻。而从皮内尔开始，疯癫将被视为出自内心的冲动。这种冲动超越个人的合法界限，无视他应遵守的道德界限，从而导致自我神化。在以前几个世纪，疯癫的初始模式是否定上帝，而在19世纪，其模式是自认为上帝。这样，疯癫在自身表现为受屈辱的非理性时，就能够发现自己的解救途径。因为当它陷于自己的绝对主观的访妄时，它会意外地在同一个病人那里获得关于那种指妄的荒谬而客观的图像。真理巧妙地，似乎通过一种意外的发现（不是通过18世纪的暴力形式）而显示出自己。在这神反馈性观察活动中，真理除了自身之外绝不会看到其他任何东西。但是疯人院在疯人中设置的镜子，使疯人在肆言放行后必然会惊愕地发现自己是一个疯人。疯癫摆脱了使它成为纯粹的观察对象的枷锁，但是它却失去自己自由的本质，即自鸣得意的自由。它开始对自己所认识的真理负责。它使自己陷于一种不断自我对照的观察中。它最终因成为自己的客体对象而戴上羞辱的枷锁。这样，意义就与羞愧联系起来。这羞愧是由于意识到自己与他者同出一辙，意识到自己已经在他着身上蒙受羞辱而产生的。在能够认识和了解自身之前就已自惭形秽。 3.无休止的审判。由于这种镜子作用，正如缄默所起的作用一样，疯癫被迫不断地审判自己。此外，它每时每刻还受到外界的审判；不是受道德或科学良心的审判，而是受某种无形的常设法庭的审判。皮内尔所憧憬的疯人院就是一个小型的司法世界。他的设想在比塞特尔，尤其是在萨尔佩特利耶尔得到部分的实现。为了使审判能发挥作用，审判必须具有威严的形象。在疯人的脑子中必须有法官和执法人的形象，这样他才能懂得自己处于一个什么样的审判环境中。因此，恐怖无情的司法气氛也应是医治疯人的一部分条件。在比塞特尔，有一位因恐惧地狱而患宗教指妄的病人。他认为，逃脱天罚的唯一办法是严格禁食。为了抵消这种对未来审判的恐惧，就需要让一种更直接、更可怕的审判出场。 "若想遏止不可抗拒地折磨着他的邪恶观念，除了用一种强烈而深刻的恐惧印象外，还能有什么办法呢？"一天晚上，院长来到这位病人房间的门口，"摆出一副吓人的架势；他怒目毗裂，吼声如雷。他身后跟着一群工作人员，手持重镣，并摇晃得丁当乱响。他们把汤放在疯人身边，命令他在当夜喝掉，否则就会受到残酷的待遇。他们退出后，疯人陷入在眼前的惩罚和来世的惩罚之间做出选择的极其痛苦的困境。经过这几个小时的思想斗争，前一种选择占了上风，他决定进食。" 疯人院作为一个司法机构是完全独立的，不承认其他权威。它直接判决，不许上诉。它拥有自己的惩罚手段，根据自己的判断加以使用。旧式的禁闭一般来说不属于正常的司法形式，但是它模仿对罪犯的惩罚，使用同样的监狱、同样的地牢、同样残酷的体罚。而在皮内尔的疯人院中，司法完全自成一体，并不借用其他司法机构的镇压方式。或者说，它使用的是18世纪逐渐为人所知的医疗方法，但是，它是把它们当作惩罚手段来使用。把医学变成司法，把治疗变成镇压--这种转换在皮内尔的"慈善"和"解放"事业中并非是一个无足轻重的吊诡。在古典时期的医学中，由于医生对神经系统性质的各种古怪认识，浸洗和淋浴被当作灵丹妙药，其目的是使机体解除疲劳恢复元气，使枯萎的纤维得以放松。诚然，他们还认为，冷水淋浴除了令人愉快的效果外，还有骤然不快的感觉所造成的心理效应，即打断病人的思路，改变情绪的性质。但是，这些认识依然属于医学思辨范畴。而在皮内尔那里，淋浴法则明显地成为一种司法手段，淋浴是疯人院中的常设治安法庭所惯用的惩罚手段："它被视为一种压制手段。它常常能够使对之敏感的疯人服从体力劳动的一般律令，能够制服拒绝进食的顽症，并能制服被某种想入非非的古怪念头所支配的精神病人。” 总之，一切安排都是为了使疯人认识到自己处于一个天网恢恢的审判世界；他必须懂得，自己受到监视、审判和谴责；越轨和惩罚之间的联系必须是显而易见的，罪名必须受到公认。“我们可以利用洗澡的机会，用一个龙头突然向病人头上喷射冷水，提醒病人认识自己的越轨或疏忽。这样常常能用一种突如其来的强烈印象使他仓皇失措或驱散原来的偏执想法。如果那种想法仍顽固不化，就重复进行冷水淋浴。但是一定要避免使用强硬的语气和刺激语言，否则会引起反抗；要使疯人懂得，我们是为了他而不得已使用这种激烈措施；有时我们可以开个玩笑，但不要过火。”这种十分明显的惩罚必要时可经常反复使用，以此使病人认识到自己的过失。这一切都应为了最终使司法过程变为病人的内心活动，使病人产生悔恨。只有产生了这种结果，法官才能同意停止惩罚，因为他们可以断定，这种惩罚会在病人的良心中继续进行。有一位躁狂症患者有撕扯衣服和乱摔手中东西的习惯。对她进行了多次淋浴，并给她穿上一件紧身衣。她终于显得“深感羞辱而神情沮丧”。但是，院长担心这种羞愧可能是暂时的和表面的。“为了使她有一种恐惧感，院长使用一种冷静而坚定的态度对她说话，并宣布，以后她将受到最严厉的对待。”预期的效果旋即产生：“她痛哭流涕近两个小时，一再表示悔悟。”这种过程反复了两次；过失受到惩罚，过失者低头认罪。 然而，也有一些疯人不为所动，抵制这种道德教化。这些人被安置在疯人院的禁区，形成一批新的被禁闭者。对他们甚至谈不上用司法手段。当人们谈到皮内尔及其解放活动时，往往忽略了这第二次幽闭。我们在前面已经看到，皮内尔反对将疯人院改革的好处提供给那些“宗教狂人，他们认为自己受到神灵的启示，竭力招揽信从者，他们以服从上帝而不服从世人为借口挑动其他疯人闹事，并以此为乐”。但是，禁闭和牢房也同样适用于“那些不能服从一般的工作律令的人，那些用邪恶手段折磨其他被收容者和不断挑动其他人争斗并以此为乐的人”，以及那些“在疯癫发作时有不可抑制的偷窃病的”女人。宗教狂热导致的不服从，拒不工作和偷窃，是对抗资产阶级社会及其基本价值观的三种重大罪行，即使是疯癫所致也不能宽有。它们应受到最彻底的禁闭，受到最严厉的排斥，因为它们都表现为对道德和社会一律化的抗拒，而这种一律化正是皮内尔的疯人院的存在理由。 过去，非理性被置于审判之外，从而被武断地弓版给理性的权威。现在，它则受到审判）但不仅仅在它进入疯人院时为了识别、分类和使它从此变得清白而对它进行审判。它已经陷于一种无休止的审判中。审判永远跟随着它，制裁它，宣布它的过失，要求它体面地改过自新，甚至驱逐那些可能危害社会秩序的人。疯癫逃脱了那种武断的处置，其结果却是进入了一种无休止的审判。疯人院为这种审判配置了警察、法官和刑吏。在这种审判中，根据疯人院所要求的生活美德，任何生活中的过失都变成了社会罪行，应受到监视、谴责和惩罚。这种审判的唯一后果是，病人在内心永远不断地悔悟。被皮内尔“释放”的疯人以及在他之后受到现代禁闭的疯人，永远被置于受审的地位。如果说他们已不再被视为罪犯或与罪犯相联系，他们仍每时每刻受到谴责。他们受到指控，却从未见到指控的正文，因为他们在疯人院的全部生活就构成了这种指控的正文。在实证主义时代，皮内尔创立的并引以为荣的疯人院不是观察、诊断和治疗的自由领域，而是一个司法领域，在那里，疯人受到指控、审判和谴责，除非这种审判达到了一定的心理深度，即造成了悔悟，否则疯人永远不会被释放出去。即使疯癫在疯人院外是清白无辜的，但在疯人院中将受到惩罚。在以后一段时间里，至少直到我们这个时代之前，疯癫一直被禁闭在一个道德世界之中。 除了缄默、镜像认识、无休止的审判外，我们还应提到疯人院特有的第四种结构。这种结构是在18世纪末确立的，即对医务人员的神化。在上述结构中，这种结构无疑是最重要的，因为它不仅确立了医生与病人之间的新联系，而且也确立了精神错乱与医学思想的新联系，并且最终决定了整个现代疯癫体验。在疯人院的前三种结构中，我们发现它们与禁闭的结构相同，只是发生了位移和形变。但是，由于医务人员的地位发生变化，禁闭的最深层意义被废除了，具有现代意义的精神疾病就有可能出现了。