PINEL IN 1800

The salon of Madame Helvétius in Auteuil opened its doors to Pinel in the 1780s, on the initiative of Cabanis, the hostess's adopted son. Thus Pinel joined a circle of brilliant men and women including the marquis A. N. de Condorcet (1743-1794), later Cabanis's brother-in-law, Benjamin Franklin (1706-1790), who attempted to lure Pinel to America, and Michel Augustin Thouret (1748-1810), a prominent member of the Royal Society of Medicine and the first dean of the Revolutionary Health School of Paris. The friendship of Thouret and Cabanis, who were soon to serve as hospital commissioners of the Seine department, would finally help Pinel reach a worthwhile professional appointment. But while Cabanis, the collaborator and doctor of the comte de Mirabeau (1749-1791), was drawn into participation in public affairs, Pinel's interest remained tied to clinical medicine. Already in his forties, he had trodden a narrow and arid path, winding from adolescence as a cleric to a medical degree in Toulouse in 1773, through twenty years of auto-didactic life in Montpellier and Paris. A careful study of the biographic documents reveals Pinel's early and strong bent toward clinical medicine and psychology.^[35] He left Toulouse in 1773 because the training was entirely theoretical, whereas Montpellier afforded opportunities to gather clinical experience. Pinel did not register for postdoctoral courses but, in his own words,

faithfully attended the daily medical rounds in the main hospital. . .. took written notes at the sickbed and... wrote case histories of the entire course of acute illnesses; that was my general plan for four years.^[36]

[35] See especially the following papers by the late Pierre Chabbert of Castres: "Les années d'études de Philippe Pinel: Lavaur, Toulouse, Montpellier," Monspeliensis Hippocrates 3 (1960): 15-23; "L'œuvre médicale de Philippe Pinel," in Comptes-rendus du 96éme Congrés national des sociétés savantes (Paris: Bibliothèque nationale, 1970, 153-161; "Philippe Pinel à Paris jusqu' à sa nomination à Bicêtre," in Aktuelle Probleme aus der Geschichte der Medizin: Proceedings of the 19th International Congress of the History of Medicine (Basel: Karger, 1966), 589-595. See also D. B. Weiner, "Health and Mental Health in the Thought of Philippe Pinel: The Emergence of Psychiatry during the French Revolution," in Healing and History: Essays for George Rosen, ed. Charles E. Rosenberg (New York: Science History Publication, 1979), 59-85.

[36] Quoted in Chabbert, "Les armies d'études," 22. On the life of medical students in Montpellier, see also C. Jones, "Montpellier, Medical Students, and the Medicalization of 18th-Century France," in Problems and Methods in the History of Medicine, ed. R. Porter and A. Wear (London: Croom Helm, 1987), 57-80.

Beyond this clinical work, Pinel's autobiographic statements also reveal a long-standing interest in the patients' feelings. He wrote in 1793:

During the years when I visited hospitals for my education, . . .I often found that patients responded well to comforting words. . . . Frequently left to themselves, abandoned to dire thoughts about their fate, often isolated from their relatives and all they loved, disgusted by the crudity and harshness of the servants, often plunged into the blackest depression by the ever-present thought of a real or imagined danger, they expressed the liveliest gratitude toward those who empathized with their sufferings and tried to inspire them with confidence in their recovery. It is an excellent remedy to go to their bedside and ask how they are, express an interest in their ailments, encourage them to persevere and to believe in a prompt return to health.^[37]

An early and unusual interest in the psychologic aspects of illness thus distinguished this regular visitor to the Montpellier wards.

Even though he did not register as a student, Pinel undoubtedly attended lectures, particularly those of Théophile de Bordeu (1722-1776), who influenced him decisively. Bordeu developed his own brand of vitalism and posited "secondary centers" of sensitivity outside the brain, in the precordial and epigastric region. We shall see later how useful this concept would prove to be, particularly for Esquirol, in developing strategies for psychologic therapy.^[38] In 1778 Pinel walked all the way to Paris in search of a career but had to spend 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, and all he could secure was a little doctoring on the sly at the maison de santé of the ex-carpenter Jacques Belhomme.^[39] But he used the time to educate himself further.

[37] D. B. Weiner, ed. and tr., The Clinical Training of Doctors: An Essay of 1793 (Baltimore: Johns Hopkins University Press, 1980), 84.

[38] On Bordeu, see E. Haigh, "Vitalism, the Soul, and Sensibility: The Physiology of Théophile de Bordeu," Journal of the History of Medicine 31 (1976): 30-41. On Cabanis's debt to Bordeu, see M. S. Staum, "Medical Components in Cabanis' Science of Man," Studies in History of Biology 1 (1978): 1-32, particularly 11 and 23-24.

[39] The most informative and best-documented source on the maison Belhomme is R. Bénard, "Une maison de santé psychiatrique sous la revolution: La maison Belhomme," Semaine des hôpitaux 32 (1956): 3990-4000. See also J. Postel, "Les premières experiences psychiatriques de Pinel à la maison de santé Belhomme," Revue canadienne de psychiatrie 28 (1983): 571-576. Postel has also recently published a manuscript detailing Pinel's first cures: "Un manuscrit inédit de Philippe Pinel sur 'Les guérisons opérées dans le 7ème emploi de Bicêtre, en 1794,'" Revue internationale d'histoire de la psychiatric 1 (1983): 79-88.

The French Revolution emancipated this provincial physician, and the essay that Pinel submitted for a prize from the Royal Society of Medicine in 1793 led to his first full-time job.^[40] Arriving at Bicêtre during the Terror, Pinel found himself in the midst of some four thousand imprisoned men—criminals, petty offenders, syphilitics, pensioners, and about two hundred mental patients. In that forbidding fortress he met Jean Baptiste Pussin (1746-1811), the supervisor of the mental ward: appreciating Pussin's outstanding talent, Pinel decided to apprentice himself to that unschooled but experienced custodian of the insane. Here was the "clinic" where Pinel learned to observe mind and body. As a first move, the new physician asked the "governors" of the various sections for medical reports: one of these has recently come to light, namely the "Observations of Citizen Pussin on the Insane."^[41] It provides a picture of the St. Prix ward, where order and cleanliness reigned, violent treatment of inmates was strictly banished, and humane management prevailed. The site-visitors from the National Assembly in 1790 had already recorded their surprise about this ward, remarking particularly that very few of the inmates were chained, in most instances only at night.^[42] Even more than they, Pinel appreciated Pussin's ability to practice a crude classification of new arrivals according to their complexion and temperament which permitted him to house them appropriately. Here was a modest beginning of that "division into distinct species of illness" that Pinel would later practice at the Salpêtrière. He admired Pussin's strict adherence to nonviolence: even if the governor or his underlings faced attack by an inmate, they subdued the attacker without causing injury. Pussin reported that he had to dismiss numerous employees in order to assemble a nonviolent staff. He resorted to a variety of strategies to control unruly patients, including stern warnings, the manipulative use of food and privileges, and physical restraints, if necessary, making sure that these would not cause physical pain. It was Pussin, we learn from his "Observations," and not Pinel, as every textbook tells us, who first struck the chains from the insane at Bicêtre. This strict, nonviolent, nonmedical management of mental patients has been called

[40] The circumstances are explained in Weiner, The Clinical Training, Introductory Essay.

[41] "Observations du citoyen Pussin sur les fous." The manuscript is in the Archives nationales, Paris, 27 AP 8 (doc. 2). For an annotated English translation, see D. B. Weiner, "The Apprenticeship of Philippe Pinel: A New Document, 'Observations of Citizen Pussin on the Insane,'" 136 (1979): 1128-1134.

[42] C. Bloch and A. Tuetey, eds., Procès-verbaux et rapports du comité de mendicité de la Constituante, 1790-1791 (Paris: Imprimerie nationale, 1911), 604.

"moral treatment," owing to a misleading literal translation from the French. "Moral " does not mean "moral" but "psychologic," and it would be helpful if English-language terminology aligned itself with the German where the terms "psychisch " and "Psychiker " were adopted in Pinel's day.^[43]

It was a rare, perhaps unprecedented, role-reversal that occurred at Bicêtre in 1793-1795: the spectacle of a middle-aged doctor who had mastered Greek, Latin, and the entire medical literature apprenticing himself to an unschooled but experienced asylum superintendent. In the Introduction to the Traité, Pinel wrote:

I abandoned the dogmatic tone of the doctor. With the help of frequent visits, sometimes during several hours a day, I familiarized myself with the deviations, shouts, and uncontrolled behavior of the most violent maniacs. I then talked repeatedly with the man who was most familiar with their previous state and their delirious thoughts. I took extreme care to manage his self-esteem, and asked him numerous and repeated questions on the same subject if the answers were not clear. I never objected if he said anything doubtful or improbable, but waited for a subsequent examination to enlighten or correct him. I took daily notes on the observed facts with the sole aim of having as many accurate data as possible.
Such is the course I have followed for almost two years, in order to en rich the medical theory of mental illness with all the insights that the empirical approach affords. Or rather, I strove to perfect the theory and to provide practice with the general principles that it lacked.^[44] [emphasis added]

[43] The best overviews of "moral treatment" are E. T. Carlson and N. Dain, "The Psychotherapy That Was Moral Treatment," American Journal of Psychiatry 117 (1960): 519-524; C. Geduldig, Die Behandlung von Geisteskranken ohne physischen Zwang (Zürich: Medical dissertation, 1976); R. Porter, "Was There a Moral Therapy in Eighteenth-Century Psychiatry?" Lychnos: Annual of the Swedish History of Science Society, 1981-82: 12-26; J. Postel, "Naissance et décadence du traitement moral pendant la premiere moitié du 19ème siècle," L'évolution psychiatrique 44 (1979): 588-616; and L. Sederer, "Moral Therapy and the Problem of Morale," American Journal of Psychiatry 134 (1977): 267-277. An interesting account, along the lines of Michel Foucault's views, is A. Scull, "Moral Treatment Reconsidered: Some Sociological Comments on an Episode in the History of British Psychiatry," in Scull, Madness, Mad-Doctors, and Madmen, 105-120.

[44] Pinel, Traité, Introduction, xlviii-xlix. All references are to the first edition, unless noted otherwise. The only English version of this text is in G. Zilboorg's History of Medical Psychology (New York: Norton, 1941), where the translation is, in part, sheer nonsense. A Passage reads: "I held repeated conversations with whatever men knew best their former condition and their delirious ideas. Extreme care is necessary to avoid all pretensions of self-esteem and many questions on the same subject if the answers are obscure. I never object if patients make equivocal or improbable remarks but postpone my questions to a later examination, for the purpose of enlightenment and correction" (340).

All his life, Pinel would acknowledge his debt to Pussin and to Madame Pussin, her husband's talented collaborator.

During the two years' apprenticeship at Bicêtre, Pinel assembled a large collection of case histories where the reader meets individuals in distress whose past and symptoms Pinel had probed in numerous encounters and conversations. Let us adduce two examples, beginning with a musician who had "fallen into madness" because of the Revolution:

While he was convalescing, he recalled a confused memory of his favorite instrument, the violin. I urged his family to provide him with that pleasure, so useful for his total recovery. In a few days he recaptured his old skill and, for eight months, he practiced for several hours daily. Calm and reason were decidedly returning.

At that point, an agitated patient was admitted to the same ward. His presence so upset the musician that he relapsed and became permanently insane.^[45] Next, we cite this intriguing case:

One of the most famous clockmakers in Paris, beguiled by the illusion of perpetual motion that he longed to capture, set to work with indefatigable enthusiasm.... His loss of reason exhibited a unique trait. He believed that his head, severed on the scaffold, got mixed up with that of other victims and that the judges... ordered the heads restored... but, through some mistake, his shoulders now carried the head of an unfortunate companion.^[46]

While Pinel's examples usually depicted men from Bicêtre, he learned about mentally ill and senile women upon his transfer in 1795 to the Salpêtrière Hospice as physician-in-chief. He soon missed Pussin acutely. This immense establishment, with some seven thousand elderly indigent and ailing women, was like a large village with an entrenched bureaucracy, a teeming market and huge infirmaries in disarray. Pinel secured Pussin's transfer in 1802 and obtained the appointment of assistants, Esquirol foremost among them.^[47]

Pinel needed help with clinical teaching, for students crowded into his thirty-bed ward. He and Jean Nicolas Corvisart were the most famous clinicians in Paris at the time.^[48] He was professor of internal med-

[45] Pinel, Traité, 202-203.

[46] Ibid., 66-437.

[47] Other collaborators were A. Landré-Beauvais (1772-1840) and Charles Schwilgué (1774-1808).

[48] A good overview of clinical teaching in the early nineteenth century can be gained from M. Wiriot, L'enseignement clinique dans les hôpitaux de Paris entre 1794 et 1848 (Paris: Thèse histoire de la médecine, 1970), and from E. H. Ackerknecht, Medicine at the Paris Hospital, 1794-1848 (Baltimore: Johns Hopkins University Press, 1967). See also J. C. Sournia, La médecine révolutionnaire, 1789-1799 (Paris: Payot, 1989).

icine ("medical pathology" in the contemporary idiom) at the Paris Health School, and.in 1803 he was elected to the Academy of Sciences, succeeding Georges Cuvier (1773-1838).^[49] "This M. Pinel is unique," wrote a student from Strasbourg:

he can't say two words without a hiccup and he doesn't cure his patients better than anyone else.... yet... I admit that he made a doctor of me, though I cannot say exactly how. It was at the sickbed that he taught me to recognize the main symptoms of each illness, and to relate them to the genera and species of his nosographic scheme.^[50]

And François Leuret (1797-1851), the future physician-in-chief at Bicêtre, summed up the students' experience at the turn of the century in Paris: "Under Corvisart one learned quickly; with Pinel, one learned well."^[51]

Pinel taught internal medicine, hut with constant reference to the psychologic parameters of bodily illness. Conversely, he never failed to explain the physical substrate of mental disorders, if these were apparent in the patient. We know this from the case histories of patients seen on this teaching ward, recorded by Pinel's assistants and published as La médecine clinique rendue plus precise et plus exacte par l'application de l'analyse; ou, Recueil et résultat d'observations sur les maladies aigües, faites à la Salpêtrière.^[52] He thus taught what we call psychosomatic medicine, whereas the teaching of psychiatry was initiated by Esquirol at the Salpêtrière in 1817.^[53] Pinel also used his data for research, and with that goal in mind and with Pussin's help he reorganized the wards, particularly the mental ward. In 1802 he wrote:

A hospital destined for sick women and as large as the Salpêtrière, opens a great career for new research on women's diseases that have always and rightly been considered as the most difficult and complicated of all.^[54]

[49] Cuvier became permanent secretary.

[50] P. B. Bailly, Souvenirs d'un élève des écoles de santé de Strasbourg et de Paris pendant la révolution, publiés par... son arriére-petit-fils (Strasbourg: Strasbourg médical, 1924), 17-18.

[51] F. Leuret, "M. Esquirol," Gazette médicale de Paris, 2d set., 9 (2 Jan. 1841): 1-6. The quotation is on p. 1.

[52] For this and further editions, see Appendix, Biobibliographic Note 1.

[53] For a synopsis of Esquirol's course, see his "Introduction à l'étude des aliénations mentales," Revue médicale française et étrangère 8 (1822): 31-38.

[54] Pinel, La médecine clinique, 1st ed. (Paris: Brosson, Gabon et Cie, 1802), Introduction, xxxiv.

Contrasting conditions at the Salpêtrière with his previous experience at Bicêtre, Pinel explained the difference in the Preface to the second edition of the Traité (1809):

Several circumstances made medical treatment quite incomplete [at Bicêtre]. The mental patients had already been treated one or several times at the Hôtel-Dieu, according to the usual methods, and they were then taken to Bicêtre to bring about or reinforce their cure. This rendered my results inconclusive.^[55] The use of iron chains to restrain a great number of madmen was still very much in force (it was only abolished three years later);^[56] and how could one distinguish between the resulting exasperation and the symptoms specific to illness? The defects of the buildings, the lack of subdivisions to separate patients according to their degree of agitation or calm, frequent changes in administration, the lack of baths, and several other necessary facilities—these were many hurdles. . ..^[57] [emphasis added]

At the Salpêtrière I was able to resume the pursuit of my goals: the hospital administration had just transferred the treatment of all female mental patients to that hospice and this was of enormous help to me. The buildings were vast, convenient and easy to subdivide. . .. The barbarous use of iron chains was abolished, just like three years earlier at Bicêtre, and treatment then followed its regular course, according to a new method.^[58]

Distinguished travelers anxious to visit the Salpêtrière and witnessing the order and calm that usually prevailed there, sometimes remarked with surprise, as they examined the hospital, "But where are the madwomen?" Little did these strangers know that this was the most encouraging praise for the establishment, and that their question underlined a remarkable difference in comparison with other hospitals.^[59]

By 1800, Pinel was thus well known in French academic and scientific circles, a widely read author, popular among medical students, and an innovator in hospital administration. He therefore spoke with authority when, in the Introduction to the Traité, he defined the context for the study of mind and body in the clinic, that is, for French medical psychology around 1800.

[55] The "usual methods" were purges, vomits, venesection, and baths. Pinel was well aware of iatrogenic symptoms produced by the administration of drugs and debilitating procedures.

[56] This statement provides additional proof that it was not Pinel who first removed the chains.

[57] Pinel, Traité, 2d ed. (Paris: Brosson, 1809), Introduction, xxxi.

[58] Ibid., i.

[59] Ibid., 193. This passage echoes Pussin.