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Philippe Pinel

Philippe Pinel

Pinel, Philippe, 1745-1826, French physician, M.D. Univ. of Toulouse, 1773. After moving to Paris in 1778, he was appointed (1793) director of the Bicětre hospital and shortly thereafter of the Salpětrière. His Traité médico-philosophique sur l'aliénation mentale (2d ed. 1809), based on observations in both these hospitals, advocated humane treatment of mentally ill persons, then called the insane, and a more empirical study of mental disease. He further contributed to the development of psychiatry through his establishment of the practice of keeping well-documented psychiatric case histories for research.
Philippe Pinel (April 20, 1745 - October 25, 1826) was a French physician who was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients, referred to today as moral treatment. He also made notable contributions to the classification of mental disorders and has been described by some as "the father of modern psychiatry".

Early life

Pinel was born in Saint-André, Tarn, France the son and nephew of physicians. After receiving a degree from the faculty of medicine in Toulouse, he studied an additional four years at the Faculty of Medicine of Montpellier. 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. The incentive was a personal one. A friend had developed a ‘nervous melancholy’ that had ‘degenerated into mania’ and resulted in suicide. 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 and beginning to formulate his views on its nature and treatment.

Pinel was an Ideologue, a disciple of the abbé de Condillac. He was also a clinician who believed that medical truth was derived from clinical experience. Hippocrates 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. 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 Bicetre and Salpetriere

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 (1745-1811). In the 1770s Pussin had been successfully treated for scrofula 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, 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 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 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 in 1826.

In modern commentary, Foucault's influential book, "Madness and Civilization: A History of Insanity in the Age of Reason" focuses on Pinel, along with Tuke, 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 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, wealth, fame, 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, friendship, bigotry, the desire for reputation, for conquest, and vanity. He noted that a state of love could turn to fury and desperation, and that sudden severe reversals in life, such as "from the pleasure of success to an overwhelming idea of failure, 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' He identified predisposing psychosocial factors such as an unhappy love affair, domestic grief, devotion to a cause carried to the point of fanaticism, religious fears, the events of the revolution, violent and unhappy passions, exalted ambitions of glory, 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 therapuetic conversations seeking to dissuade patients of their delusions. He offered benevolent support and encouragement. Patients who persisently 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 facilitiate 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, camphor and other antispasmodics, as well as vesicants, cauterization, and bloodletting 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 more often than to brain dysfunction. This was consistent with his rarely finding gross brain pathology 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 and a period of seclusion 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".

Inline references

General references

  • Weissmann, Gerald (2008). "Citizen Pinel and the madman at Bellevue". FASEB J. 22 (5): 1289–93.
  • 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

External links

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