Pinel and the birth of psychiatry as a branch of medicine

Despite those divergences, it is generally accepted that the work of Philippe Pinel constitutes a turning point. His role has several aspects. He is known worldwide as the physician who 'liberated the insane from their chains' in a dramatic initiative he started in 1793 at the height of the French revolution, at the Bicetre asylum, and completed 3 years later at the Salpetriere asylum. However, the reality is more complex.

Pinel, who was born in 1745, had studied medicine, translated Cullen's books into French, and published scientific papers on various subjects. He acted as a physician in a small Parisian 'madhouse', the Pension Belhomme, in which wealthy lunatics were confined at the request of their families. At that time most of the Parisian insane were confined for a few weeks in the general hospital—the Hotel Dieu. If their state did not rapidly improve, they were considered as incurable and send to Bicetre or the Salpetriere, built a century before, which also received other social deviants such as beggars and prostitutes. Pinel, who was known by his politically influential friends for his progressive scientific ideas, was appointed physician to Bicetre. The division for the insane was under the direction of an overseer (surveillant), Pussin, who had already introduced humanitarian reforms in the care of the patients. Pinel's merit was to approve and systematically to develop Pussin's empirical measures and to propose an explicit scientific theory for their mode of action. Inspired by Crichton's views about the nature of the 'passions', by Condillac's psychology, and by the ideas of Jean-Jacques Rousseau, he created the traitement moral which he claimed to be effective with patients previously considered as incurably ill.

The improvement of the conditions in which the insane were cared for, supported and expanded by Pinel, was not an isolated French phenomenon. In Tuscany, Chiarugi had already in 1789 asserted that the basis of the extensive reforms he had introduced in the local asylum for the insane was that 'it is a supreme moral duty and a medical obligation to respect the mental patient as a person'. In England, where public opinion had been shocked by the inhuman treatment to which King George III had been submitted during his mental illness, a pious Quaker, William Tuke, deeply affected by the conditions in which the wife of a member of the Society of Friends had died in York lunatic asylum, decided to set up a special institution under the government of the Friends 'for the care and accommodation of their own members'. At the Retreat, opened in 1796 near York, physical restraints were largely abolished, and religious and moral values were emphasized in the relations with the patients.

Chiarurgi's reforms did not survive the upheavals caused by subsequent wars and the political divisions of Italy, and Tuke's creation of the Retreat had not been prompted by medical considerations but was the expression of religious humanitarian purposes. The role played by Pinel was decisive, not so much because of the changes he promoted in the conditions of the patients, although they had a profound influence, but because he made the study and treatment of mental disorders a branch of medicine.

In 1801 Pinel published the Medico-philosophical Treatise on Mental Alienation. In it he presented the various clinical manifestations he had observed, proposed a simple nosological system, largely borrowed from older authors, examined possible aetiological factors, and described his 'moral treatment' in detail. The book has remained a landmark in the history of psychiatry, even being considered by the philosopher Hegel as a 'moment of capital importance in the history of humanity'. For Pinel, insanity was a disease and the patient affected by it remained, despite the loss of his reason, a human being. Its study, like the rest of medicine, had to be 'a science which consists of carefully observed facts'. Goldstein(3) has shown that Pinel's main preoccupation was to prove this scientific nature of the new medical specialty by repudiating the previous practices of the 'empirics' and 'charlatans'—the two terms being practically synonymous. He had accepted the method Pussin had developed empirically, he transformed it in his moral treatment by providing a scientific theory of its mode of action. A curiously premonitory aspect of his emphasis on the necessity of a scientific methodology is to be found in his Tables to Determine How Probable is the Curability of Alienation, published in 1808. He provided statistical data on the efficacy of his therapeutic method according to the types of mental disorders and in comparison with spontaneous evolution, and concluded that medicine can only be a true science through the use of the calculus of probability!

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