Philippe Pinel was a French physician who was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients

Psychiatric hospital

Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...

, referred to today as moral therapy. He also made notable contributions to the classification of mental disorders

Classification of mental disorders

The classification of mental disorders, also known as psychiatric nosology or taxonomy, is a key aspect of psychiatry and other mental health professions and an important issue for consumers and providers of mental health services...

 and has been described by some as "the father of modern psychiatry".

Early life

Pinel was born in the rolling hills of Saint-André, Tarn, France. He was the son and nephew of physicians. After receiving a degree from the faculty of medicine in Toulouse

Toulouse

Toulouse is a city in the Haute-Garonne department in southwestern FranceIt lies on the banks of the River Garonne, 590 km away from Paris and half-way between the Atlantic Ocean and the Mediterranean Sea...

, he studied an additional four years at the Faculty of Medicine of Montpellier

Montpellier

-Neighbourhoods:Since 2001, Montpellier has been divided into seven official neighbourhoods, themselves divided into sub-neighbourhoods. Each of them possesses a neighbourhood council....

. He arrived in Paris in 1778.
He spent fifteen years earning his living as a writer, translator, and editor because the restrictive regulations of the old regime prevented him from practicing medicine. The Paris faculty did not recognize a degree from a provincial university like Toulouse. He failed twice in a competition which would have awarded him funds to continue his studies. In the second competition the jury stressed his ‘painful’ mediocrity in all areas of medical knowledge, an assessment seemingly so grossly incompatible with his later intellectual accomplishments that political motives have been suggested. Discouraged, Pinel considered emigrating to America. In 1784 he became editor of the not very prestigious Gazette de santé, a four-page weekly.

At about this time he began to develop an intense interest in the study of mental illness

Mental illness

A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...

. The incentive was a personal one. A friend had developed a ‘nervous melancholy’ that had ‘degenerated into mania’ and resulted in suicide

Suicide

Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

. What Pinel regarded as an unnecessary tragedy due to gross mismanagement seems to have haunted him. It led him to seek employment at one of the best-known private sanatoria for the treatment of insanity in Paris. He remained there for five years prior to the Revolution, gathering observations on insanity

Insanity

Insanity, craziness or madness is a spectrum of behaviors characterized by certain abnormal mental or behavioral patterns. Insanity may manifest as violations of societal norms, including becoming a danger to themselves and others, though not all such acts are considered insanity...

 and beginning to formulate his views on its nature and treatment.

Pinel was an Ideologue, a disciple of the abbé de Condillac

Étienne Bonnot de Condillac

Étienne Bonnot de Condillac was a French philosopher and epistemologist who studied in such areas as psychology and the philosophy of the mind.-Biography:...

. He was also a clinician who believed that medical truth was derived from clinical experience. Hippocrates

Hippocrates

Hippocrates of Cos or Hippokrates of Kos was an ancient Greek physician of the Age of Pericles , and is considered one of the most outstanding figures in the history of medicine...

 was his model.

During the 1780s Pinel was invited to join the salon of Madame Helvétius. Pinel was in sympathy with the Revolution. After the revolution, friends he had met at Madame Helvétius’ salon came to power. In August 1793 Pinel was appointed "physician of the infirmeries" at Bicêtre Hospital

Bicêtre Hospital

The Bicêtre Hospital is located in Le Kremlin-Bicêtre, which is a commune in the southern suburbs of Paris, France. It lies 4.5 km from the center of Paris. The Bicêtre Hospital was originally planned as a military hospital, with construction begun in 1634. With the help of Vincent de Paul, it was...

. At the time it housed about four thousand imprisoned men--criminals, petty offenders, syphilitics, pensioners and about two hundred mental patients. Pinel’s patrons hoped that his appointment would lead to therapeutic initiatives. His experience at the private sanatoria made him a good candidate for the job.

The Bicêtre and Salpêtrière

Soon after his appointment to Bicêtre, Pinel became interested in the seventh ward where 200 mentally ill men were housed. He asked for a report on these inmates. A few days later he received a table with comments from the "governor" Jean-Baptiste Pussin

Jean-Baptiste Pussin

Jean-Baptiste Pussin was a hospital superintendent who, along with his wife and colleague Marguerite, is recognized as having established more humane treatment of patients with mental disorders...

 (1745-1811). In the 1770s Pussin had been successfully treated for scrofula

Scrofula

Tuberculous cervical lymphadenitis refers to a lymphadenitis of the cervical lymph nodes associated with tuberculosis. It was previously known as "scrofula".-The disease:...

 at Bicêtre; and, following a familiar pattern, he was eventually recruited, along with his wife, Marguerite Jubline, onto the staff of the hospice.

Appreciating Pussin's outstanding talent, Pinel virtually apprenticed himself to that unschooled but experienced custodian of the insane. His purpose in doing this was to "enrich the medical theory of mental illness with all the insights that the empirical approach affords. What he observed was a strict nonviolent, nonmedical management of mental patients came to be called moral treatment

Moral treatment

Moral treatment was an approach to mental disorder based on humane psychosocial care or moral discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from psychiatry or psychology and partly from religious or moral concerns...

, though psychological might be a more accurate translation of the French ‘moral’.

Although Pinel always gave Pussin the credit he deserved, a legend grew up about Pinel single-handedly liberating the insane from their chains. This legend has been commemorated in paintings and prints. In fact, It was Pussin who replaced iron shackles with straitjackets at Bicêtre in 1797, after Pinel had left for the Salpêtrière. Pinel followed Pussin's example three years later, after bringing Pussin to the Salpêtrière. In addition, Italian physician Vincenzo Chiarugi

Vincenzo Chiarugi

Vincenzo Chiarugi was an Italian physician who introduced humanitarian reforms to the psychiatric hospital care of people with mental disorders. His early part in a movement towards moral treatment was relatively overlooked until a gradual reassessment through the 20th century left his work...

 is now recognised as having liberated psychiatric patients from chains before Pinel.

While at Bicêtre, Pinel did away with bleeding, purging, and blistering in favor of a therapy that involved close contact with and careful observation of patients. Pinel visited each patient, often several times a day, and took careful notes over two years. He engaged them in lengthy conversations. His objective was to assemble a detailed case history and a natural history of the patient's illness.

In 1795, Pinel became chief physician of the Hospice de la Salpêtrière, a post that he retained for the rest of his life. The Salpêtrière was, at the time, like a large village, with seven thousand elderly indigent and ailing women, an entrenched bureaucracy, a teeming market and huge infirmaries. Pinel missed Pussin, and in 1802 secured his transfer to the Salpêtrière. Pinel created an inoculation clinic in his service at the Salpêtrière in 1799 and the first vaccination in Paris was given there in April 1800. A statue in his honour stands outside the Salpêtrière.

In 1795 Pinel was also appointed as a professor of medical pathology, a chair that he held for twenty years. He was briefly dismissed from this position in 1822, with ten other professors, suspected of political liberalism, but reinstated as an honorary professor shortly thereafter.

Publications

In 1798 Pinel published an authoritative classification of diseases in his Nosographie philosophique ou méthode de l'analyse appliquée à la médecine. Although he is properly considered one of the founders of psychiatry, this book establishes him as the last great nosologist of the eighteenth century. While the Nosographie appears completely dated today, it was so popular in its time that it went through six editions between its initial publication and 1818.

In his book Traité médico-philosophique sur l'aliénation mentale; ou la manie, published in 1801, Pinel discusses his psychologically oriented approach. This book was translated into English by D. D. Davis

David Daniel Davis

David Daniel Davis M.D. F.R.C.P. was a British physician.Born David Davies in Llandyfaelog in Wales, he received his M.D. from the University of Glasgow in 1801. He set up his practice as a physician in Sheffield, living in Paradise Square from 1803 to 1812...

 as a Treatise on Insanity in 1806. It had an enormous influence on both French and Anglo-American psychiatrists during the nineteenth century.

In 1802 Pinel published La Médecine Clinique which was based on his experiences at the Salpêtrière and in which he extended his previous book on classification and disease.

Pinel was elected to the Académie des Sciences in 1804 and was a member of the Académie de Médecine from its founding in 1820. He died in Paris

Paris

Paris is the capital and largest city in France, situated on the river Seine, in northern France, at the heart of the Île-de-France region...

 in 1826.

In modern commentary, Foucault

Michel Foucault

Michel Foucault , born Paul-Michel Foucault , was a French philosopher, social theorist and historian of ideas...

's influential book, "Madness and Civilization: A History of Insanity in the Age of Reason" focuses on Pinel, along with Tuke

William Tuke

William Tuke was an English businessman, philanthropist and Quaker. He was instrumental in the development of more humane methods in the custody and care of people with mental disorders, an approach that came to be known as moral treatment.-Career:Tuke was born in York to a leading Quaker family...

, as the driving force behind the shift from physical to mental oppression.

Clinical approach

The central and ubiquitous theme of Pinel's approach to etiology

Etiology

Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....

 and treatment was the "moral", in the sense of social and psychological factors. He observed and documented the subtleties and nuances of human experience and emotion, seeing humans as social animals with imagination. He noted, for example, that: "being held in esteem, having honor, dignity

Dignity

Dignity is a term used in moral, ethical, and political discussions to signify that a being has an innate right to respect and ethical treatment. It is an extension of the Enlightenment-era concepts of inherent, inalienable rights...

, wealth

Wealth

Wealth is the abundance of valuable resources or material possessions. The word wealth is derived from the old English wela, which is from an Indo-European word stem...

, fame

Celebrity

A celebrity, also referred to as a celeb in popular culture, is a person who has a prominent profile and commands a great degree of public fascination and influence in day-to-day media...

, which though they may be factitious, always distressing and rarely fully satisfied, often give way to the overturning of reason". He also spoke of avarice, pride

Pride

Pride is an inwardly directed emotion that carries two common meanings. With a negative connotation, pride refers to an inflated sense of one's personal status or accomplishments, often used synonymously with hubris...

, friendship

Friendship

Friendship is a form of interpersonal relationship generally considered to be closer than association, although there is a range of degrees of intimacy in both friendships and associations. Friendship and association are often thought of as spanning across the same continuum...

, bigotry

Bigotry

A bigot is a person obstinately or intolerantly devoted to his or her own opinions and prejudices, especially one exhibiting intolerance, and animosity toward those of differing beliefs...

, the desire for reputation

Reputation

Reputation of a social entity is an opinion about that entity, typically a result of social evaluation on a set of criteria...

, for conquest

Conquest

-Film and television:* Conquest , a 1937 film starring Greta Garbo and Charles Boyer* Conquest , directed by Lucio Fulci* Conquest , a 1998 British-Canadian film* Conquest , a History Channel series...

, and vanity

Vanity

In conventional parlance, vanity is the excessive belief in one's own abilities or attractiveness to others. Prior to the 14th century it did not have such narcissistic undertones, and merely meant futility. The related term vainglory is now often seen as an archaic synonym for vanity, but...

. He noted that a state of love

Love

Love is an emotion of strong affection and personal attachment. In philosophical context, love is a virtue representing all of human kindness, compassion, and affection. Love is central to many religions, as in the Christian phrase, "God is love" or Agape in the Canonical gospels...

 could turn to fury

Fury

Fury is a form of anger.Fury may also refer to:In fiction:* Bryan Fury, a video game character from the Tekken series* Fury , two superheroine characters...

 and desperation

Desperation

Desperation is a horror novel by Stephen King. It was published in 1996 at the same time as its "mirror" novel, The Regulators. It was made into a TV film starring Ron Perlman, Tom Skeritt, and Steven Weber in 2006....

, and that sudden severe reversals in life, such as "from the pleasure of success to an overwhelming idea of failure

Failure

Failure refers to the state or condition of not meeting a desirable or intended objective, and may be viewed as the opposite of success. Product failure ranges from failure to sell the product to fracture of the product, in the worst cases leading to personal injury, the province of forensic...

, from a dignified state—or the belief that one occupies one—to a state of disgrace and being forgotten" can cause mania or 'mental alienation

Social alienation

The term social alienation has many discipline-specific uses; Roberts notes how even within the social sciences, it “is used to refer both to a personal psychological state and to a type of social relationship”...

' He identified predisposing psychosocial factors such as an unhappy love affair, domestic grief, devotion to a cause carried to the point of fanaticism

Fanaticism

Fanaticism is a belief or behavior involving uncritical zeal, particularly for an extreme religious or political cause or in some cases sports, or with an obsessive enthusiasm for a pastime or hobby...

, religious fears, the events of the revolution, violent and unhappy passions, exalted ambitions of glory

Glory (religion)

Glory is used to denote the manifestation of God's presence in the Judeo-Christian religious tradition. God's glory is often associated with visible displays of light, e.g. thunderbolts, fire, brightness....

, financial reverses, religious ecstasy, and outbursts of patriotic fervor.

Pinel believed in developing specific practical techniques, rather than general concepts and assumptions. He engaged in therapeutic conversations seeking to dissuade patients of their delusions. He offered benevolent support and encouragement. Patients who persistently resisted or caused trouble might be threatened with incarceration or punishment if they did not control themselves. He argued that psychological intervention must be tailored to each individual rather than to a diagnostic category, and must be grounded in an understanding of their perspective and history. For example: "the treatment of insanity (l’aliénation mentale) without considering the differentiating characteristics of the patients [la distinction des espèces] has been at times superfluous, rarely useful, and often harmful". He described the partial or complete failures of psychological approaches, as well as the harm that the usual cruel and harsh treatments caused to patients before they came to his hospital. He saw improvement as often coming from natural forces within the patient, which treatment could at best facilitate and at worst interfere with.

Pinel’s approach to medical treatments has been described as ambiguous, complex, and ambivalent. He insisted that psychological techniques should always be tried first, for example "even where a violent and destructive maniac could be calmed by a single dose of an antispasmodic [he referred to opium], observation teaches that in a great number of cases, one can obtain a sure and permanent cure by the sole method of expectation, leaving the insane man to his tumultuous excitement" ... "and [furthermore] seeing, again and again, the unexpected resources of nature left to itself or wisely guided, has rendered me more and more cautious with regard to the use of medications, which I no longer employ—except when the insufficiencies of psychological means have been proven." For those cases regarded as psychologically incurable, Pinel would employ baths, showers, opium

Opium

Opium is the dried latex obtained from the opium poppy . Opium contains up to 12% morphine, an alkaloid, which is frequently processed chemically to produce heroin for the illegal drug trade. The latex also includes codeine and non-narcotic alkaloids such as papaverine, thebaine and noscapine...

, camphor

Camphor

Camphor is a waxy, white or transparent solid with a strong, aromatic odor. It is a terpenoid with the chemical formula C10H16O. It is found in wood of the camphor laurel , a large evergreen tree found in Asia and also of Dryobalanops aromatica, a giant of the Bornean forests...

 and other antispasmodics, as well as vesicants, cauterization

Cauterization

The medical practice or technique of cauterization is the burning of part of a body to remove or close off a part of it in a process called cautery, which destroys some tissue, in an attempt to mitigate damage, remove an undesired growth, or minimize other potential medical harmful possibilities...

, and bloodletting

Bloodletting

Bloodletting is the withdrawal of often little quantities of blood from a patient to cure or prevent illness and disease. Bloodletting was based on an ancient system of medicine in which blood and other bodily fluid were considered to be "humors" the proper balance of which maintained health...

 in certain limited cases only. He also recommended the use of laxatives for the prevention of nervous excitement and relapse. In general, Pinel traced organic causes to the gastrointestinal system and peripheral nervous system

Peripheral nervous system

The peripheral nervous system consists of the nerves and ganglia outside of the brain and spinal cord. The main function of the PNS is to connect the central nervous system to the limbs and organs. Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the blood–brain...

 more often than to brain dysfunction. This was consistent with his rarely finding gross brain pathology

Pathology

Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....

 in his post-mortem examinations of psychiatric patients, and his view that such findings that were reported could be correlational rather than causative.

Pinel was concerned with a balance between control by authority and individual liberty. He believed in "the art of subjugating and taming the insane" and the effectiveness of "a type of apparatus of fear, of firm and consistent opposition to their dominating and stubbornly held ideas", but that it must be proportional and motivated only by a desire to keep order and to bring people back to themselves. The straitjacket

Straitjacket

A straitjacket is a garment shaped like a jacket with overlong sleeves and is typically used to restrain a person who may otherwise cause harm to themselves or others. Once the arms are inserted into the straitjacket's sleeves, they are then crossed across the chest...

 and a period of seclusion

Seclusion

The act of secluding, i.e. shutting out or keeping apart from society, or the state of being secluded, or a place that facilitates it . A person, a couple, or a larger group may go to a secluded place for privacy, or because the place is quiet...

 were the only sanctioned punishments. Based on his observations, he believed that those who were considered most dangerous and carried away by their ideas had often been made so by the blows and bad treatment they had received, and that it could be ameliorated by providing space, kindness, consolation, hope, and humor. Because of the dangers and frustrations that attendants experienced in their work, Pinel put great emphasis on the selection and supervision of attendants in order to establish a custodial setting dedicated to norms of constraint and liberty that would facilitate psychological work. He recommended that recovered patients be employed, arguing that "They are the ones who are most likely to refrain from all inhumane treatment, who will not strike even in retaliation, who can stand up to pleading, menaces, repetitive complaining, etc. and retain their inflexible firmness." Pinel also emphasized the necessity for leadership that was "thoughtful, philanthropic, courageous, physically imposing, and inventive in the development of maneuvers or tactics to distract, mollify, and impress" and "devoted to the concept of order without violence", so that patients are "led most often with kindness, but always with an inflexible firmness." He noted that his ex-patient and superintendent Pussin had showed him the way in this regard, and had also often been better placed to work with patients and develop techniques due to his greater experience and detailed knowledge of the patients as individuals.

Pinel expressed warm feelings and respect for his patients, as exemplified by: "I cannot but give enthusiastic witness to their moral qualities. Never, except in romances, have I seen spouses more worthy to be cherished, more tender fathers, passionate lovers, purer or more magnanimous patriots, than I have seen in hospitals for the insane, in their intervals of reasonableness and calm; a man of sensibility may go there any day and take pleasure in scenes of compassion and tenderness". He argued that otherwise positive character traits could cause a person to be vulnerable to the distressing vicissitudes of life, for example "those persons endowed with a warmth of imagination and a depth of sensitivity, who are capable of experiencing powerful and intense emotions, [since it is they] who are most predisposed to mania".

General references

• Weiner, Dora. Comprendre et Soigner, (Fayard, Paris, 1999).
• Goldstein, Jan. Console and Classify, (Cambridge U. P. 1987).
• George A. Bender and Robert Alan Thom, Great Moments in Medicine: A History of Medicine in Pictures (Detroit: Parke-Davis & Co., 1961) ASIN: B0006AXIUI http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1033738

External links

• A Treatise on Insanity by Philippe Pinel, translated into English. Free full text from Google books.
• Who Named It? - Philippe Pinel