Moreau de Tours: organicism and subjectivity. Part 1: Life and work

Introduction

Jacques Joseph Moreau de Tours (1804–84) was undeniably an important figure in the development of descriptive psychopathology as a scientific enterprise and, according to Henry Ey (1970: v), he was the ‘uncontested and incontestable’ master of modern psychiatry. Certainly, his relevance in the nineteenth century was much greater than is suggested by the scant historiographic interest in the twentieth century (Luauté, 2018a: 9–14). Perhaps for this reason, it is time to update our knowledge of Moreau and his contributions to psychiatry, especially as no translations of his major works were available in Spanish until 2019. The recent publication in French of an excellent volume dedicated to his life and work (Luauté, 2018a) is both important and welcome, as is the Spanish translation (Moreau, 2019) of his main work, Du Hachisch et de l’Aliénation Mentale (Moreau, 1845), a book whose content should be ‘analysed, read and reread’ (Olievenstein, 1980). ¹ The present work analyses the importance of this text within Moreau’s overall body of work and assesses its impact on the development of descriptive psychopathology from the mid-nineteenth century to the present.

Origins

Moreau was born in Montrésor, a small village located 50 km from Tours, in the canton of Loches, on 2 June 1804. ² His legally registered name was Jacques Moreau, and this is the name on his birth certificate as well as marriage and death certificates. Jacques is the name by which Moreau is best known, but he soon started to use another name: Joseph, ³ which was probably his personal preference. In his publications and official texts, however, he was required to use Jacques, although he added a second initial J (as in his thesis of 1830) or wrote both names in full (as on his marriage certificate and in his Knight of the Legion of Honour dossier). In his book on hashish (Moreau, 1845), he chose to put ‘J. Moreau (de Tours)’, seemingly to avoid choosing between the two names (Luauté, 2018c: 17–18). ⁴ Moreau’s use of the toponym ‘de Tours’ in a two-part paper in 1841 appears to be a tribute to the medical school where Moreau began his studies and also to his mentor, Dr Bretonneau. ⁵

Moreau was born into a modest family (Féray, 2018a); his father was a soldier ⁶ and his mother a seamstress. He was the oldest of three children and was born illegitimately (‘anonyme’), although he was recognized by his father when he was three months old, and his parents married when he was one year old. He first studied in Chinon and later in Tours, where he passed the baccalaureate exams in arts. In 1824 he enrolled as an external student in surgery under the tutelage of Pierre-Fidèle Bretonnau at the General Hospital of Tours, where he spent two years. Bretonneau, who was already a famous professor of pathology and internal medicine (Aron, 1979), ⁷ soon adopted Moreau as ‘first intern’ and eventually recommended him – possibly through another of his favourite students, Trousseau ⁸ – for an internship at the Hospital de Charenton in Paris. Its director was Esquirol (1772–1840), after he left La Salpêtrière.

Moreau remained in Charenton for four years, from July 1826 to June 1830, the year when he defended his doctoral thesis. He entered, without competition, as ‘second intern,’ possibly succeeding Trousseau, and within a few days he was already performing clinical work, including writing detailed ‘observations’ (a sort of review of the mental state of the patient), with most of those writings, especially those written between 1826 and 1828, still conserved (Haustgen, 2018).

Moreau’s observations at Charenton

Moreau’s observations are of exceptional interest for several reasons. First, they show first-hand the emergence of the signs and symptoms of mental illness through increasingly subtle descriptions of symptoms. Second, they teach us indirectly about the workings of the great asylums for the alienated and the available therapeutic procedures of that time period. Finally, they illustrate the process of learning his craft from one of the most important alienists of the nineteenth century (Haustgen, 2018).

Moreau’s first observations in Charenton are concise, ⁹ but already contain descriptions of symptoms referring to ideation, mood and psychomotor skills. The essence of mental semiology is found in these notes, and the patient’s discourse is analysed, as are the formal characteristics of delusions: subject, extension, conviction, and so forth. There are also references to awareness of the problem, which today we would consider ‘insight’. For Moreau, never a nosographer, the patient’s diagnosis does not possess an essential relevance, although there are references to states of agitation, delusional episodes and melancholy, bouts and, frequently, to the then common ‘general paralysis’. He often uses more generic terminology, such as ‘mental illness’, ‘disturbance of reason’ or ‘madness.’ Sometimes he uses the Esquirol categories of mania, lypemania, monomania, dementia or idiocy, but never exclusively, as several categories may be present at the same time or successively in the same case. The observations acquire descriptive wealth over time, always including the family history, some reference to character (by means of a precise adjective), alcohol use, or especially, diseases or physical conditions, both past and present.

Starting in 1827, but especially in 1828, phrenological references (skull shape, possible involvement of certain brain lobes), and in particular pathogenic hypotheses often based on the influence of Faculty Psychology, ¹⁰ begin to appear in his notes. For example, he identifies the will and not the imagination as especially disturbed in one case, and describes how the intellect and not the affective sphere is affected in another. Likewise, references are made to the ‘therapeutic’ means of the time: purgatives, bleeding, hydrotherapy, physical containment measures and, especially, medications: antiphlogistics, antispasmodics, emetics, purgatives, and so forth (Haustgen, 2018: 43–4).

Doctoral thesis (1830)

On 9 June 1930, Moreau defended his doctoral thesis ‘De la influence de physique relativement au désordre des facultés intellectuelles et en particulier dans cette varietés du délire désignée par M. Esquirol sous le nom de monomanie’, which he dedicated to his parents and to his teachers, Esquirol and Bretonneau (Moreau, 1930). In this thesis, he acknowledges the influence of Esquirol, but begins to depart from his mentor to defend the ‘somatic’ conception of insanity, which he continued to support throughout his career (Ritti, 1887; Sémelaigne, 1930). Moreau’s arguments to defend this position reflect those of Cabanis (Bollotte, 1973) in the eleventh report, ‘De l’influence du moral sur le physique’ of his main work, Rapports du Physique et du Moral de l’Homme (Cabanis, 1802). ¹¹ For Moreau, moral causes, the passions, can determine insanity but only through alterations in the brain, which are the origin of other physical alterations in the mentally ill, and thus the influence of moral treatment on the physical is through the brain.

Moreau’s thesis is divided into five sections, each of which focuses on different aspects of insanity: 1) the predisposing causes (infection or imitation and heredity); 2) the determining causes (physical accidents that trigger insanity and that can interfere with ‘moral affections’: alterations of intellectual or affective faculties, uncertainty of judgement, excessive sensitivity, vague concerns, stomach aches, tremors, headaches); 3) the course or evolution (distinguishing between the manifestations of the initial period, summarized as a state of ‘erethism’, ‘feverish excitement’ or ‘moral exaltation’, and those of the second period, where intellectual and affective alterations emerge, as well as various physical symptoms); 4) the cure (where he includes the physical therapeutic measures applied at that time in Charenton); and 5) autopsies (where, with great imprecision, he states that ‘the brain mass and its cover seem to move away from the physiological state’) (Haustgen, 2018: 47).

For Moreau, the determinants and initial manifestations of insanity overlap to a greater or lesser extent, constituting the so-called ‘primordial fact’ (fait primordial), as described in his monograph on hashish (Moreau, 1845), although he had already highlighted the importance of excitement in these states in his PhD thesis.

Moreau’s travels

After Moreau had successfully defended his doctoral thesis, Esquirol directed him to accompany some of his patients on ‘therapeutic travels’. ¹² These trips were an important complement to the limited therapeutic measures of the time. Esquirol was a great supporter of these travels, making his intern students accompany him and his most affluent patients.

The first of these trips, to Switzerland and Italy, took place between 1831 and 1832, lasting about 12 months. Although Moreau did not publish his travel notes, he did refer to these in later works (see below). For example, in Du Hachisch (Moreau, 1845: 266–70), he mentions how daily observation of the ‘manic excitement and intermittent délire’ of his patients on this trip confirmed his idea of isomorphism between the dreams produced in normal sleep and the delusional-hallucinatory dreams of pathological arousal, stating that ‘the dream of the waking man is, manifestly, the continuation of the dream of the sleeping man’, the only difference between them being the name (p. 268). ¹³

The second trip was to the Near East ¹⁴ for 11 months, from late 1836 until the end of 1837; ¹⁵ it apparently departed from Marseille, with a first stop in Malta, and ended in Beirut. During the trip, Moreau visited asylums for the mentally ill in Smyrna, Cairo and Constantinople, where he was horrified by the subhuman conditions. He observed that a large number of the mentally ill also roamed freely through towns and villages, many of them considered to be holy men. Moreau suggested that possible causes of mental illness in the Orient were primarily environmental (very warm weather, which produces ‘a kind of numbness of the functions of the nervous system’ that determines the moral constitution and customs), but also ideological (in particular exaltation of religious ideas) and, finally, ‘pharmacological’, ¹⁶ due to the common use of substances such as Datura stramonium and hashish (Moreau, 1843: 103–132).

A therapeutic trip to the Orient, accompanied by one of Esquirol’s patients, turned into a study tour for Moreau, where he experienced his first contact with these substances, which Esquirol’s patient may have taken. ¹⁷ On his return, Moreau, sponsored by Esquirol, competed for one of four positions as an attending physician at the Hospitals of Bicêtre and La Salpêtrière in Paris; ¹⁸ he was successful and was appointed, along with three of Esquirol’s other students: Baillarger, Trelat and Archambault (Ritti, 1887: 18–21). ¹⁹ Later, he took advantage of his trip to the Orient (Luauté, 2018d); first he published papers on the use of Datura stramonium as a treatment for hallucinations (Moreau, 1841) and on the asylums for the mentally ill in the Orient (Moreau, 1843), and then his monograph on hashish (Moreau, 1845).

Although Moreau’s trip to the Orient is the most cited of his travels, his other, later trips, especially those to Gheel, are worth mentioning. He made his first study trip to the colony for the mentally ill in Gheel, Belgium ²⁰ in 1842, following in the footsteps of previous travellers, including his master Esquirol, with whom he shared the idea of the need to ‘live among madmen’, to spend time with them and share their existence to understand them better (Moreau, 1842). In Gheel, the mentally ill lived among the locals, sharing food and shelter, without ‘therapeutic’ cold showers. By then, Moreau had been in Bicêtre for two years, maintaining an intense, ongoing debate with another alienist, Leuret, about the utility of moral treatment as conceived by Leuret and other colleagues in the great French asylums. Moreau had found that, despite the Pinelian dictum of removing the chains from asylum patients, the truth was that most of these patients lived in a deplorable state. Moreau was especially critical of coercive moral treatment, when threats or cold showers were used to force patients to renounce the content of their delusions; if they did so, they were considered to have been cured. This is why his experience in Gheel was important for Moreau; he tried to bring this approach to France, but not without great opposition among his peers, as illustrated by the long debate on the subject that took place between 1860 and 1870 at the Société Medical-Psychologique (Luauté, 2018d: 68–70).

Societé Orientale

Moreau’s first contact with hashish appears to have taken place during his trip to the Orient in 1836–7. In his ‘Mémoire sur le traitement des hallucinations par le Datura stramonium’, Moreau (1841) describes his personal experience of as a ‘hash eater’ and how, among the Orientals, this was consumed at gatherings of close friends, where ‘music and lascivious dances’ performed by the Almahs (dancers) created a particularly intoxicating atmosphere. In Du Hachisch (Moreau, 1845: 9), Moreau uses the Italian term ‘fantasia’ to describe what happened at these events, a term possibly borrowed from Louis-Rémy Aubert-Roche. In his observations on hashish and its use for treatment of the plague, Aubert (1840), referred to his discovery of the substance, glossing over its effects and noting its safety, ²¹ in addition to mentioning the meetings where it was consumed.

Despite Moreau’s initial experiences with hashish, it was not until 1841, after starting to work at the Bicêtre Hospital, that he began his constant experiments with the substance. These were usually done with Aubert-Roche, who had lived in Egypt (see note 21) and Héctor Horeau, a Parisian architect who had also travelled to Egypt between 1837 and 1839. Moreau, with these two men, founded the Société Orientale de France in 1841. This society, whose members included such illustrious names such as Chateaubriand, Lamartine and Victor Hugo, published its work in the Revue de l’Orient, and served as a social springboard for its young promoters (Luauté, 2018d: 65). At society meetings in 1844 and 1845, the members debated the possible therapeutic value of hashish in medicine, with Aubert emphasizing its use in the plague, and Moreau and another physician reporting the use of hashish to treat insanity, but with a warning on the risk of abuse.

It is possible that Moreau’s initial experience with hashish consumption was born out of a curiosity to experience personally the effects described by others years before. However, he soon added another reason: the substance could be a powerful technique for exploring psychopathology, potentially leading to an inquiry into the genesis of insanity (Moreau, 1845: 29–30; see also Caire, 2018).

Club des Hachichins

Starting in 1840 with his arrival in Bicêtre, hashish began to form part of Moreau’s therapeutic and teaching experiments. ²² By the end of that year he had already experimented with Datura in his patients, and probably with opium and ether as well (Moreau, 1845: 190). After Esquirol’s death in December 1840, his nephew Mitivié took over the mental asylum in Ivry-sur-Seine, a private establishment founded by Esquirol. In 1843, Moreau and Baillarger both began working there as attending physicians, while also working at the public asylums of Bicêtre and La Salpêtrière, respectively; a few years later, they became the owners of the Ivry asylum. ²³ In both of the large public asylums and at the Ivry asylum, Moreau began to use hashish to treat mentally ill patients. In 1841 he took over the running of the Sainte-Anne farmhouse, a ‘house of testing, distraction and work’ for the mentally ill in the Bicêtre (Moreau, 1841: 674). Moreau had his students at Sainte-Anne and Bicêtre participating in these experiences with hashish, and he did the same after moving to La Salpêtrière in 1861 (Arveiller, 2017). ²⁴

In addition to the clinical use of hashish and the writing of scientific publications on the topic, Moreau and his friends Aubert-Roche and Horeau were especially interested in the social dissemination of this drug. With the painter Fernand Boissard, who at that time lived in the Hôtel de Pimodan on the Île Saint Louis in Paris, ²⁵ Moreau organized monthly meetings, starting in 1842. These were centred around the consumption of hashish in the form of a paste or jelly known as dawamesc in Egypt (hashish mixed with butter and sweetened with spices, candied nuts and rose petals to hide the bitterness); these meeting were attended not only by doctors but also by artists, writers and members of the intellectual elite of the time. ²⁶ One of them, Theophile Gautier (a poet), published a description of his first experience with hashish (Gautier, 1843) and later a more extensive narrative entitled ‘Le Club de Haschischins’ (Gautier, 1897). This is what the group of ‘hash eaters’ has been called ever since.

Du Hachisch

In 1845 Moreau published a book that would come to be his main work: Du Hachisch et de l’Aliénation mentale. He wanted to report the results of his research supporting his hypothesis on the pathogenic mechanism underlying insanity. The work was a resounding success, bringing the author fame, not only for the timeliness of its appearance, but also – and mainly – for the originality of the ideas it contained. ²⁷

The book starts with an experimental model of hashish-induced ‘insanity’, and its main contribution is a two-fold theoretical proposal: 1) the mechanism that causes insanity can be apprehended and its development explained, and 2) the mental states of dreaming and insanity are identical in nature (Caire, 2018). Moreau describes the primitive source of every fundamental phenomenon of the délire: ²⁸ the ‘initial intellectual modification, always the same’, which underlies all manifestations that he has been able to access through hashish; and what he calls the primordial fact (fait primordial) (Moreau, 1845: 31), which is none other than ‘manic excitement’ (p. 36). ²⁹ This excitement is a kind of ‘disaggregation’ of ideas, a ‘dissolution of the intellectual components of moral faculties’ similar to what happens in the physical world when a body causes a dissolvent action on another body.

The second theoretical contribution of the text is the ‘absolute’ identity (p. 31) between dreaming and délire, a ‘psychological’ identity, not ‘physiological’ (1855: 364). Moreau was not the first to draw the analogy between dreams and insanity. His mentor Esquirol had pointed this out years before, although for Moreau it was not a simple analogy or similarity, but something more radical. Therefore, in his experimental, hashish-induced model of insanity, sleep and wakefulness are confused, in ‘a dream-like state without being asleep’, so that the self-observer, no matter how awake and clairvoyant his conscience is, cannot point out the differences (1845: 37).

This work, dedicated to the memory of his teacher Esquirol, consists of some 436 pages divided into three parts. The first, about 30 pages, focuses on historical aspects of hashish. The last part, about 40 pages, concerns the therapeutic use of the substance, mostly (30 pages) comments on clinical cases. The second section is the key part of the text, not only for its length, but also for the thesis that the author develops. This section starts by introducing the physiological aspects of hashish use, with the rest divided into four chapters: the first describes the psychological phenomena induced by hashish consumption; the second describes the physiological and pathological conditions favourable to the appearance of hallucinations; the third focuses on hallucinations in insanity and also summarizes the information presented in the previous chapters; and the fourth presents the views of the authors who preceded Moreau (Pinel, Esquirol) and other contemporaries (Leuret, Lelut, Baillarger).

Despite the enormous success of this work, the criticisms came quickly, even from authors who reviewed it positively (Bayard, 1846; Brigham, 1846; Delasiauve, 1846; Lasègue, 1846). The main criticism focused on the weakness of the last part of the book, on the therapeutic part, particularly the limited number of case studies and discussion regarding the clinical application of hashish to treat mental disorders (the first trials date from mid-1841, and the last from July 1843); ³⁰ the inconclusive findings of those trials given the long periods of time, in some cases, between substance use and improvement, made it difficult to establish a cause–effect relationship, and the difficulty in drawing practical conclusions from this. ³¹

Other critics called into question the existence of a fait primordial as a morbid primitive psycho-cerebral fact underlying the origin of all phenomena and its importance in the genesis of insanity. There were also criticisms concerning: the choice of the term ‘excitement’, which was equivocal even for Moreau himself (Moreau, 1845: 36; 1855: 365); the absolute identical nature of the dream state and délire (furiously contested by Brierre de Boismont (1797–1881), whose critique Moreau answered in his 1855 work); and finally, the absence of references to the physical and moral consequences of the abuse of hashish, as noted by Delasieuve and Lasègue (Arveiller, 2013; Caire, 2018: 84).

Hashish and alienism after Du Hachisch

Moreau’s work focuses only on the use of hashish in mental disorders. However, its use in other conditions such as plague, tetanus, rabies, cholera, chorea, asthma, migraine, various neuralgias, and delirium tremens was already known (Arveiller, 2013; Caire, 2018). Moreau himself was interested in the role of hashish in cholera (Moreau, 1848) and rabies (Moreau, 1852), and one of his pharmacology interns at Bicêtre – Edmond De Courtive – even pointed out, presciently, its probable value in the terminal stage of cancer (De Courtive, 1848: 422–4). ³²

In Moreau’s wake, other authors played a role in the use of hashish to treat mental disorders. First, some of his disciples, including Benjamin Ball, whose first publication described the use of hashish in a patient with hallucinations, with positive results (Ball, 1856). Another was Edouard Berthault, whose thesis was dedicated to this substance (Berthault, 1854). Less predictably, other alienists – including Aubanel and Rech (Arveiller, 2013) ³³ – also tested the substance on their patients, despite their support for the moral treatment of mental illness. Outside France, authors such as Brigham (1846), who reviewed Moreau’s work for The American Journal of Insanity (the predecessor to the current American Journal of Psychiatry), as well as Woodward (1850) and Gray (1860), also experimented with the drug, but with mixed results (Arveiller, 2013). Moreau himself, after replacing Lelut at La Salpêtrière in 1861, began to prescribe hashish to patients with hysteria; although he was initially very excited about its potential, he later admitted that the results were poor and it may even worsen symptoms (Caire, 2018).

Years later, Berthier (1868) carried out a systematic update on the use of hashish to treat mental disorders, after using it to treat 86 patients in the department at Bicêtre, with satisfactory results. However, in contrast to Moreau’s concept of substitution (see note 16), he emphasized the hypnotic effect of hashish to calm agitation and insomnia.

Since that time, relatively few reports were published on the prescription of hashish in mental asylums, a potential sign that this approach had fallen into disuse by the end of the century, for a variety of different reasons, ranging from the emergence of uncontrollable effects to the recognition of the pathogenic nature of hashish, and possible iatrogenic drug addiction (Arveiller, 2013). ³⁴

La Psychologie morbide

By 1859, Moreau had accumulated substantial clinical experience and had also published numerous articles on the clinical aspects of illnesses observed in the course of his routine clinical practice (epilepsy, general paralysis, mental weakness). At that time, he had become one of the most renowned alienists in Paris, after more than two decades at Bicêtre and as one of the three directors (with Baillarger and Mercé) of the prestigious asylum at Ivry. In this year, Moreau (1859) published one of his most important works, La Psychologie morbide dans ses rapports avec la philosophie de l’histoire ou de l’influence des névropathies sur le dynamism intellectuel.

In this mature work, Moreau takes up the old theme of the relationship between genius and insanity, but introduces, for the first time, a reference to the common pathological element, based on the science of the time, which he calls morbid psychology (today known as psychopathology). More surprisingly, in this book, Moreau places genius close to idiocy (Moreau, 1859: v). Although this work provoked a critical response, it was very influential, not only among Moreau’s students, but also for other authors who undertook the study of genius, such as Cesare Lombroso (1888). ³⁵

La Psychologie morbide includes, apart from the full exposition of Moreau’s somatic conceptions of madness (Saladini, 2018), the specific arguments that support his descriptions of the intimate experiences that link, from their origins, insanity, idiocy and genius (Luauté, 2018a). For Moreau, heredity was the essential cause of insanity and the basis for a whole series of conditions. He thought that environmental conditions, which he called ‘determining or occasional’ causes, were pointless or insignificant, and therefore he did not believe in the curative effect of methods such as education (Moreau, 1859: 9–13; see also Luauté, 2018b). For Moreau, there was no clear demarcation between insanity and reason but, between the madman and the sane man, there was an intermediate class (which he called ‘mixed state’) of affective or intellectual ‘mestizos or mulattos’, on the border of insanity. This included, to give one example, a long list of exceptional spirits, creators of philosophical or theological systems, reformers, inventors, the enlightened, and mystics. From this pathological viewpoint, Moreau even dared to tackle feelings of love and criminals, whose acts could be attributable to an inherited morbid psychology (Luauté, 2018b).

La Salpêtrière and Moreau’s legacy

Moreau resided at the Ivry mental asylum from 1844 to 1852, ³⁶ and his two children were born there. Paul, also an alienist and a student of his father at La Salpêtrière, was the author of the first treatise on child psychiatry (Moreau, 1888) and, at the end of the nineteenth century, was director of the Ivry asylum. ³⁷ Jacques Moreau’s other son, Georges, was a renowned painter (Walusinski, 2018a, 2018b). In the early 1860s, Moreau decided to leave Bicêtre, moving to La Salpêtrière to occupy the position vacated by Lelut. He had great prestige, and in 1864, at the age of 60, he became President of the Societé Médico-Psychologique, the society he had founded, with others, in 1852. However, in the same year Moreau developed an illness that kept him from his duties for several months; ³⁸ also in 1852, his colleague Marcé died. ³⁹

In 1869 Moreau published Traité Pratique de la Folie Névropathique (Vulgo Hystérique), his last major work, in which he applies his organicist theories to hysteria, based on 51 case studies at La Salpêtrière. In this work, he points out the existence of a neuropathic diathesis of hereditary base. In a kind of scientific testament, Moreau notes, in the foreword to the work, his satisfaction at the impetus of the organicist theses among the younger generations (Moreau, 1869: v–ix).

Moreau died on 26 June 1884, after a brief illness. ⁴⁰ Until his last moments, he continued his work at La Salpêtrière (Ritti, 1887). After his death, the Moreau de Tours prize was established at the request of his widow, and the prize, with a small financial endowment, was awarded from 1888 to 1958. In 1958, at the request of Henry Baruk, the Societé Moreau de Tours was established to honour his work (Estingoy, 2018: 198–9). This society was very active for three decades, and published the society’s Annals, until it was dissolved in 1988 (Luauté, 2018a: 281–7).

[Part 2 will be published in History of Psychiatry 32(3), with a list of publications by J-J Moreau de Tours.]