Psychiatry as a profession Esquirol and the clinical approach

If, because of the international influence of the ideas expressed in his book, Pinel is the founder of psychiatry as a medical discipline, he was not a psychiatric specialist in the strict meaning of the term. Although he retained his position at the Salpetriere until his death in 1826 and is known today for his contributions to mental medicine, he had many other medical interests which gave him, in his time, a leading position among the Paris physicians; his Philosophical Nosology, published in 1796 and a classical reference for several decades, deals with general pathology. The case of his pupil and successor, Esquirol, who became the prototype of the psychiatric specialist was very different. At the Salpetriere he was only in charge of the 'section of the insane'. He was later appointed medical director of the Charenton psychiatric asylum near Paris and owned in addition a small clinic, in which he treated his private patients. All his activities were exclusively dedicated to the study and treatment of mental disorders and the teaching of psychiatry. His book On Mental Diseases published in 1838, in which he collected his previous publications, acquired a fame as great as Pinel's Treatise. In 1913 Karl Jaspers recognized that the later great representatives of German psychiatry, such as Griesinger and Kraepelin, were strongly indebted to Esquirol. He, and the school he founded, effectively developed one of the basic tenets of the new medical specialty. For Esquirol, careful objective observation and analysis of the symptoms and the behaviour of the patients was fundamental. He originated the descriptive clinical approach, expanded by his pupils. Even more than Pinel, he was suspicious of unproved theories and, when he eventually suggested relations between pathogenic factors and syndromes, remained extremely cautious in his interpretations. Zilboorg, the psychoanalytically oriented historian of psychiatry, has accused this predominantly descriptive approach of creating a 'psychiatry without psychology' because, lacking psychodynamic concepts, its attempted objectivity remained at an allegedly superficial level.(4) The truth is that it laid the foundations of the present description of the mental disorders. The 'atheoretical' descriptive approach adopted in the present nosological systems—both the American Diagnostic and Statistical Manual and the International Classification of Diseases—whose proclaimed purpose is to emphasize the medical character of psychiatry is, in this respect, a return to Esquirol's principles.

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