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Nine
Mind and Body in the Clinic:
Philippe Pinel, Alexander Crichton, Dominique Esquirol, and the Birth of Psychiatry

Dora B. Weiner

... so this league of mind and body, hath these two parts, How the one discloseth the other, and how the one worketh upon the other, Discoverie, & Impression·
The former of these hath begotten two Arts. . .. The first is PHYSIOGNOMIE, which discovereth the disposition of the mind, by the Lyneaments of the bodie. The second is the EXPOSITION OF NATURALL DREAMES....
In the former of these, I note a demodeficience. For Aristotle hath verie ingeniously, and diligently handled the factures of the bodie, but not the gestures of the bodie; which are no less comprehensible by art, and of greater use, and advantage.
—SIR FRANCIS BACON, The Two Bookes of the Proficience and Advancement of Learning (London, 1605)


THE DOCTOR AS CLINICIAN

The vast seventeenth- and eighteenth-century literature about mind and body derives its major themes from philosophers trained in medicine. John Locke discussed sensation and reflection while David Hartley explored the association of ideas. Julien Offray de La Mettrie depicted the body as a machine and Georges Cabanis envisioned the brain as an organ that secretes thought, just as the stomach processes food. All these men were practicing physicians.[1] Materialistic philosophy motivated

An earlier version of the section on Crichton was presented at the thirtieth International Congress of the History of Medicine, Düisseldorf, West Germany, on 2 September 1986 and was published in its Proceedings.

Some of the outstanding general treatments in the vast literature on seventeenth-to-early-nineteenth-century "medical psychology" are the following:

For Great Britain, W. F. Bynum, Jr., "Rationales for Therapy in British Psychiatry, 1780-1835," in Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era, ed. A. Scull (Philadelphia: University of Pennsylvania Press, 1981), 35-57; D. Leigh, The Historical Development of British Psychiatry: Eighteenth and Nineteenth Centuries (Oxford: Pergamon Press, 1961); R. Porter-, "A Rage of Party: A Glorious Revolution in English Psychiatry?" Medical History 27 (1983): 35-50; and G. S. Rousseau, "Psychology," in The Ferment of Knowledge: Studies in the Historiography of Eighteenth-Century Science, ed. G. S. Rousseau and R. Porter (New York: Cambridge University Press, 1980), 143-210.

For France, the outstanding recent contribution is J. Goldstein, Console and Claasify: The French Psychiatric Profession in the Nineteenth Century (Cambridge: Cambridge University Press, 1987). I regret that the present essay had gone to press when this book appeared so that I could not include Goldstein's insightful comments. See also P. Carrette, "Un demisiècle d'assistance aux aliénés avant la loi de 1838," Annales médico-psychologiques, 151ST ser., 1 (1938): 674-680, and the relevant segments of the following books: M. Laignel-Lavastine and J. Vinchon, Les malades de l'esprit et leurs médecins, du 16ème au 19ème siècle (Paris: Maloine, 1930); Y. Pelicier, Histoire de la psychiatrie (Paris: Presses Universitaires de France, 1971); J. Postei and C. Quétel, Nouvelle histoire de la psychiatric (Toulouse: Privat, 1983); and C. Quétel and P. Morel, Les fous et leurs médecines, de la Renaissance au 20èrae siècle (Paris: Hachette, 1979).

For Germany, K. Dörner, Madmen and the Bourgeoisie: A Social History of Insanity (Oxford: Blackwell, 1981); K. W. Ideler, Grundriss der Seelenheilkunde, 2 vols. (Berlin: Enslin, 1835); Th. Kirchhoff, Grundriss einer Geschichte der deutschen Irrenpflege (Berlin : Hirschwald, 1890); E. Kräpelin, "Hundert Jahre Psychiatrie," Zeitschrift für die gesamte Neurologie und Psychiatric 38 (1918): 161-275; and G. Verwey, Psychiatry in an Anthropological and Biomedical Context: Philosophical Presuppositions and Implications of German Psychiatry, 1820-1870 (Dordrecht: Reidei, 1984).

For Spain, D. Desmaisons, Des asiles d'aliliénés en Espagne: Recherches historiqnes et médicales (Paris: Bailliére, 1859), and J. E. Iborra, "La asistencia al enfermo mental en España durante la Ilustraciòn y el reinado de Fernando VII," Cuadernos de historia de la medicina española 5 (1966): 181-215.


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many medical investigators of mental functions to study the bodily substrate of human thought and emotion: from Thomas Willis to Gall and Spurzheim, they dissected and scrutinized nerves and brains. But William Harvey had taught them to conceptualize bodily functions in terms of systems: therefore they focused on circulatory, respiratory, digestive, or nervous physiology. Researchers curious to understand the relationship of mind and body concentrated on the nervous system. However, a categorical difference separates a physiologist, such as Harvey, who experimented on living animals and man, from anatomists or neurologists who work on dead animals and human corpses. It is impossible to apprehend human thought and feeling by studying the inert body and


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brain, and therefore postmortem dissection proved unrewarding for physicians interested in mental illness. They could not ascertain how a nervous fluid might affect the mind, and where in the brain to locate thought, pain, or the emotions. They rather turned to another method favored by their eighteenth-century colleagues in anatomy and physiology, namely the intensive and systematic observation of the living patient, preferably in the clinic.

This practice was fundamental to the diagnostic method of Philippe Pinel (1745-1826), and he stands out as the eighteenth-century clinician who made the mentally ill patient his central concern. His Traité médico-philosophique sur l'aliénation mentale ou la manie (Medico-philosophic treatise on mental alienation or madness) became famous immediately upon publication in 1800:[2] no doubt his mythical feat during the Terror—unchaining the insane at the Sallpêtrière, known in France as le geste de Pinel —served as publicity for the book.[3] Its true merit also found outstanding admirers, including the philosopher Georg Wilhelm Friedrich Hegel; and when Stendhal wanted to buy the Traité in 1806, it was sold out.[4] Pinel's was the only work on the nascent medical specialty, psychiatry, to achieve universal fame.[5] Most commentators underlined the novelty and psychologic aptness of his case histories, and indeed Pinel's first concern was neither theory, nor classification, nor clinical research, nor therapy, even though he made fundamental contributions to all of them. He believed that a doctor, and particularly a doctor concerned with mental illness, must first of all get to know his patients well. To do this, he must listen and observe.

In order to explore the subject of mental illness Pinel also read widely, and he was particularly familiar with contemporary British medical thought, having edited three volumes of a twelve-volume abridgment of


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the Philosophical Transactions of the Royal Society.[6] He found plentiful confirmation for the validity of his approach in a British book that came to his attention in 1798, when his own was already written, but in time for lengthy comment in his Introduction. That book was the work of the Scottish physician Alexander Crichton (1763-1856), an author virtually unknown in the medical literature, entitled An Inquiry into the Nature and Origins of Mental Derangement, Comprehending a Concise System of Physiology and Pathology of the Human Mind, and History of the Passions and Their Effects.[7] Crichton's importance in the context of the present study is threefold: his book, particularly part 3, "On the Passions," confirmed Pinel's belief that his reliance on observation of the patient's feelings, as expressed in words, gestures, moods, and attitudes toward others, offered a reliable—indeed, the only reliable—path toward a diagnosis of mental illness in the living patient. Furthermore, Crichton's work alerted Pinel to German learning in medical psychology. Crichton had resided for three years in various German university towns, learned the language, and acquired a keen interest in contemporary German research and writing in anthropology, natural history, and the literature of what would become psychiatry—then called Erfahrungsseelenkunde. And lastly, Crichton's emphasis on the passions helped shape the thought of Pinel's favorite student and intellectual heir, Jean Dominique Esquirol (1772-1840).[8] For these combined reasons, and because Crichton's career has remained almost totally undocumented, he is discussed at length later in this essay.

The meeting of minds between Pinel and Crichton in the fall of 1798 marks a significant moment in the history of medical ideas. It is surprising, given Britain's close ties to Germany at the time, that her physicians


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only discovered German writings on mental illness at the turn of the nineteenth century. The deafness of French doctors to German thought is more easily explained because, ever since the days of the "sun king," the French saw themselves as the most civilized of European nations, a model for their neighbors on the Continent. Despite the cosmopolitanism of the Enlightenment, French attention continued to focus on France and on Paris, and the dramatic unfolding of the Revolution concentrated all energies on ideas and events at home. French medical thinkers shared in this national involvement. By the turn of the century, however, this introversion gave way to new interests in foreign lands: just as Madame de Stall's De l'Allemagne (1811) revolutionized French attitudes toward German literature and philosophy, so active interest in German medical writings evidenced a new openness to Continental ideas in the French medical milieu. A set of translations and two journals represent significant examples of the new literature: the Recueil des mémoiressur les établissements d'humanité, the Recueil périodique de littérature rnédicale étrangère, and the Bibliothèique médico-chirurgicale germanique all began publication in the Year VII (1798-99).[9] The prominence of translations is significant: ever since German physicians and medical scientists had begun to publish in their own language instead of Latin, the French lost touch, for hardly any Frenchman knew German, and Pinel was typical of his countrymen in this respect.

That is why Crichton's work, with its emphasis on German sources, was a revelation for him. But he also shared Crichton's approach to patients as well as his diagnostic and therapeutic outlook. For Pinel as for Crichton, a reliance on personal and prolonged observation held numerous implications: it demanded a rejection of all "systems" and of almost all ancient as well as modern writers, except the few who were committed to the inductive method and proceeded as medical scientists. It called for a critical reexamination of the traditional a priori categories of mania, melancholia, dementia, and idiocy. It implied a refusal to indulge in speculation about nervous fluids and vapors circulating through the nerves, and it meant renouncing diagnosis based on


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humoral and pneumatic theory with the consequent activist therapeutic regimen of bleeding, purging, sweating, and puking. The new approach relied on data gathered in the clinic.

Pinel developed a method of systematic observation that helped him understand his patients' minds by studying their behavior. In 1793 he had finally reached a position commensurate with his interests and talents when the government appointed him "physician of the infirmaries" at the male division of the General Hospital in Paris, Bicêtre Hospice. From this experience Pinel developed a new conceptualization of mental illness, the conviction of its curability, and the notion that distinct "species" of patients needed to be separately lodged. He incorporated that idea into his detailed prescription about "policing" the asylum, that is, managing it with firmness, but in a humane manner, with the help of attendants restricted to using psychologic treatment only. He was delighted to find his views confirmed on reading Crichton a few years later.

Specifically, Pinel watched and recorded the behavior of each of the two hundred internees at Bicêtre: their dress; their habits and demeanor; their relationships with their companions, the servants, the supervisor; their gestures and gesticulations; their moods and mood swings; their affects as expressed on their faces and in "body language"; their words—mainly their words. Pinel engaged each patient in lengthy and repeated conversations, attempting to learn his personal history, his preoccupations, even if delusional, the precipitating event of his illness. He visited each patient, often several times a day, and took careful notes over two years. His twin objectives were to assemble a detailed case history while also improving his grasp of the natural history of the disease before him. He could often document a logical progression from a man's traumatic life experience to the pathologic symptoms he was observing.

Both in the lecture room and on the hospital ward. Pinel had many opportunities to teach his views to the young generation. It is well known that he sponsored Dominique Esquirol's thesis, published in 1805 and entitled Des passions, considérées comme causes, symptômes, et moyens curatifs de l'aliénation mentale (On the passions, considered as causes, symptoms, and means of cure for mental alienation).[10] The resemblance of this title to that of part 3 of Crichton's book is startling, and we are not surprised to find that Esquirol mentions Crichton in one breath with the abbé de Condillac and Pinel as the main authors who molded his thought. But instead of merely acknowledging Crichton, as Pinel had done when his own book was already in press, Esquirol had time to read the Scottish


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author with care before writing his own thesis. He studied Crichton's volume on the passions and his volume on the mental functions. The contrast struck him and reinforced his conviction that certain passions might be useful as a means of cure. Seventeen years later, when Pinel reviewed Esquirol's paper on hallucinations before the Academy of Sciences, he confirmed that Crichton's "learned research" stood at the cradle of Esquirol's formulations on this subject.[11]

Pinel and Crichton, like many philosophers, dramatists, and observers of human nature before them, analyzed the antagonism between reason and emotion, but they were not interested in this struggle per se. Rather, in observing involuntary irrational behavior, they perceived unconscious psychologic meaning. Pursuing therapeutic strategies, they wondered whether awareness of this meaning might help the patient understand his behavior, realize its harmful consequences, and therefore change his ways. Esquirol, in contrast, following Crichton's emphasis on the passions and citing his own clinical experience, argued that the therapist could use the passions to shock the patient who, as a consequence of that experience, might regain the use of his reason. Since Crichton's analysis of the passions relies so heavily on the German literature on this subject, there is no doubt that Crichton's work forms a hitherto neglected link between German and French thought.

In fact Martin Schrenk, the most percipient German historian of this era, describes two circles of intellectual influences: one reaching from Scottish moral philosophy through Kant and his Anthropologie to Crichton's German student days, back to Britain, via Crichton's book; the other circle originating in German learning as absorbed by Crichton, reaching French psychiatry through Pinel and Esquirol and back to Germany, where Pinel's method of observation and Esquirol's model hospital at Charenton exerted a deep and lasting influence on academic and institutional psychiatry.[12] We shall also see that Henri Ey, in his authoritative biographic sketch of Esquirol published in K. Kolle's Grosse


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Nervenäirzte, emphasized a "similarity of human and scientific outlook" between Esquirol and the German school of "Psychiker," namely Johann Christian Heinroth (1773-1843), Karl Wilhelm Ideler (1795-1860), Johann Christian Reil (1759-1813), and Johann Gottfried Langermann (1768-1832). Ey cannot explain the origin of this resemblance: we suggest that it lies in Crichton's book.[13]

While Pinel's explicit appreciation of Crichton's book brought the British work to French attention, Pinel himself remains the crucial figure in any international overview of early psychiatry. In the past decades, he has become the subject of lively controversy owing to Michel Foucault's Birth of the Clinic of 1963. That controversy has served to explode the myth of Pinel the "chainbreaker," even though every textbook still depicts him as the first to free the insane from their shackles. More interestingly, it has raised the question of Pinel's unique importance among a growing group of physicians who specialized in the theory and treatment of mental illness. Pinel's awareness of German learning and its influence on Esquirol explored in this essay matter in the early history of psychiatry mainly if Pinel was indeed a pivotal figure and founder of this medical specialty. This has recently been disputed by G. Lantéri-Laura and J. Postel, who claim that Pinel was but an "eponym" for a general European development and that the French Revolution attracted the spotlight of history to Paris and enhanced Pinel's stature beyond his intrinsic merit.[14]

In order to assess his role, and the importance of that meeting of minds among Pinel, Crichton, and Esquirol, we shall present Pinel the autodidact, the learned but unemployed modern who rejected traditional systematic theories of mental illness. We will interpret his thought in the context of the French school of scientific social reform known as Ideology, of custodial and therapeutic strategies prevalent at that time, and of the contemporary literature on medical psychology. It is hoped that, viewed in this context, his original contributions to the nascent psychiatric specialty will stand out clearly. As for Crichton, his biography, particularly the German and Russian phases, and his major work remain to be analyzed. But mainly we will assess Pinel's endorsement of Crichton's book and its impact on Esquirol. He came to conceive of the asylum superintendent as the director of a therapeutic program that used the mental hospital as a tool to control the patient's body and used the pas-


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sions as a means of cure. To cure meant to restore the mental faculties as agents of containment and domination over the emotions. In surveying these theories and therapeutic formulations in a broader philosophic context and in historical perspective, we may be justified in interpreting Esquirol's concept of the passions as a manifestation of Romantic Naturphilosophie, brought by Crichton from Germany, a challenge to the rationalism of Ideology and the Enlightenment.

THE SCIENTIFIC STANCE OF MEDICAL IDEOLOGY

Pinel should be seen as an Idéologue and a disciple of Francis Bacon, John Locke, and the abbé de Condillac.[15] The Idéologues conceptualized man as the product of his environment: by changing it, they sought to improve the human condition; they were eager to apply their "science of man" to concrete social situations and to assume the role of public servants. Among physicians, the leading exponents of Ideology were P.J.G. Cabanis (1757-1808),[16] J. L. Moreau de la Sarthe (1771-1826),[17] Philippe Pinel, and Jean Antoine Chaptal (1756-1832), Bonaparte's minister of internal affairs under the Consulate, who had special power


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to transform theory into practice.[18] At the turn of the nineteenth century, the Ideologues exerted a pervasive intellectual influence through their newspaper, the Décade philosophique,[19] their membership in the National Institute, the Normal and Central School faculties, and "free" associations such as the Lycée des Arts, the Philomatic and Natural History Societies, and the Society of the Observers of Man.

Pinel was no typical Ideologue, and we can use the Introduction to the Traité as a convenient guide to delineate his intellectual position. He shared his colleagues' materialistic view of life, and their desire to serve society: his thirty years as physician-in-chief of the Salpêtrière Hospice bear witness to that. Among Ideologue physicians Pinel stands out as a clinician: his lifelong commitment was to minister to physically and psychologically ill patients, particularly the poor. While he followed his friend Cabanis's philosophic postulates with keen attention, Pinel believed that medical truth derived from clinical experience. Despite his interest in theory, Pinel knew that, at the sickbed, philosophy is of little use. And at the sickbed Pinel was at his best—by all accounts a brilliant diagnostician.

The Introduction to Pinel's Traité shows that Hippocrates remained his model because observation of the patient formed the basis of the Greek physician's writings.[20] Among other ancient authors Pinel singled out several whose opinions and attitudes paralleled his own. He praised Aretaeus of Cappadocia, the Greek physician who lived in Rome in the mid-second century A.D. , for dwelling on the distinctive traits of mental alienation, the predisposition to relapses, and the physical and mental excitement that madness provokes.[21] Coelius Aurelianus also found favor with Pinel: this fifth-century Algerian doctor, living in Rome, translated and commented on the writings of the great Greek physician Soranus. Pinel praised Aurelianus because he focused on the precipitat-


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ing events in mental illness, the correct assessment of symptoms, patient management, and especially

the happy talent of choosing the appropriate tone in communicating with mental patients, an imposing gravity or a genuine empathy to earn their respect and esteem by a frank and open manner, to inspire them with both affection and fear, a skill credited to certain Moderns whose true source I indicate here.[22]

The "Moderns" whose "skill" Pinel attributed to Coelius Aurelianus were surely the Quakers at the York Retreat whose originality Pinel thus questioned.[23]

Pursuing his review of the ancients, Pinel lauded Celsus for his attention to the therapy of mental illness, and the management of patients.[24] Galen, however talented, fell victim to his own vanity, in Piners judgment, and to his "rare skill for timely self-advertisement." He was so busy fighting the different sects, Dogmatists, Methodists, Empiricists, and Eclectics, that he had no time or wish to study any specific doctrine in depth.[25] (The veiled allusion to the sterile squabbles of the Paris medical faculty surely struck contemporary French readers.) The fight against Galenism and iatrochemistry, according to Pinel, gave rise to "systems," and those he castigated, like a latter-day Bacon. Thus the scant selective praise from this Enlightened physician typically singles out those rare passages in ancient medical writings that indicate psychologic sensitivity and imagination and that mirror late-eighteenth-century beliefs. With a blindness typical of the Enlightenment, this Idèologue ignored Jewish and Arabic contributors to modern medicine, as well as medieval and even Renaissance writers. Pinel indiscriminately dismissed their work as "sterile language of the Schoolmen" and condemned their unscientific and indiscriminate use of drugs.[26]

Having thus disposed of the ancients and their Renaissance imitators, Pinel proclaimed his allegiance to medical science and greeted modern


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times as a breath of fresh air, a liberation. He admired van Helmont for his auto-experiment with monkshood[27] and praised Georg Ernst Stahl (1660-1734) and Herman Boerhaave (1668-1738) for their scientific teaching of medicine and chemistry—Boerhaave in particular for establishing bedside teaching in Leiden, whence his disciples spread the practice, primarily to Edinburgh, London, and Vienna. By implication, Paris lagged behind. Therefore medical psychology must now build a firm clinical base, precisely what Pinel was engaged in doing. Taking a leaf from the book of biology and citing numerous examples, he argued that medical psychology should now become comparably scientific.[28]

The Ideologues rejected the traditional belief in a soul and adopted Albrecht von Haller's concepts of sensitivity and irritability as the only bases of sensation and movement. "We feel, therefore we are," taught Cabanis, in his famous lectures on the mind/body problem at the Institut de France in 1796.[29] Feelings emanated from matter, experiments in biology assumed major importance, and therefore Pinel particularly appreciated Crichton's reports on plant and animal behavior involving hydatids, polyps, Venus's-flytrap, and the heart rate of the hamster.[30] In the same vein, Cabanis favored examples of animal behavior with implied similarities to humans. He wrote, for instance:

Puppies and kittens smell their mothers approaching from far away. They do not confuse them with other animals of their species and of the same sex.... Kittens often stretch their necks to seek the nipple while their rear and thighs are still lodged in the vagina and in the womb of the mother. (Note: I have witnessed this fact myself.)[31]


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Animal experiments were not a scientific activity that Idéologue physicians pursued for its intrinsic merit, but rather a source of information to buttress their study of human behavior, emotions, and illnesses. They believed that, like a naturalist gathering knowledge in the field, the practicing physician should gather data in the clinic. The body and, through it, the mind would become the objects of scientific observation: the body would reveal the mind.[32] Pinel and Crichton agreed with Bacon that

the Lyneaments of the bodie doe disclose the disposition and inclination of the minde in generall; but the Motions of the countenance and parts, doe not onely so, but doe further disclose the present humour and state of the mind and will. For... as the Tongue speaketh to the Eare, so the gesture speaketh to the Eye. And therefore a number of subtile persons, whose eyes doe dwell upon the faces and fashions of men; do well know the advantage of this observation.[33]

In agreement with Sir Francis, Pinel and Crichton saw the mental patient as a person in ill health whose body and mind were simultaneously afflicted and whose somatic and psychologic symptoms interacted. Crichton's book offered detailed and perceptive analyses of joy, grief, fear, anger, and love, their physiologic and psychologic manifestations, particularly those that a physician judged dangerous to health. Following David Hartley, Crichton underscored the material origin of motion and even of feelings, "repeated impressions on the sensory organs."[34] Along the lines of "faculty psychology," he singled out one feeling at a time and explored how it affected the patient's mind and body, comparable to an infected wound from which sepsis spreads, or an ailing organ that debilitates and alters body and mind. Gone is the notion that excessively aggrieved persons "lose" their minds completely, go "out of" their minds, or go in -sane. Gone is all moralizing or judgmental comment. Crichton presents us with scientific observations on a clinical syndrome: the madman has become a medical patient.

This view was familiar to Pinel. It agreed with the prevailing philosophy in his circle of forward-looking French physicians. It is surprising that Crichton makes no reference to Ideology, even though he spent the winter of 1785-86 in Paris, where future Ideologues discussed


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and planned medical and political reform—in the press, in the coffeehouses, and especially in the salons.

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]


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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.


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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


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"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]


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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-


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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]


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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.


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PINEL'S ORIGINAL CONTRIBUTIONS TO PSYCHIATRY

Between 1796 and 1798 Pinel published three papers, "Mémoire sur la Maine périodique ou intermittente" (On periodic or intermittent insanity), "Recherches et observations sur le traitement moral des aliénés" (On psychologic treatment), and "Observations sur les aliénés et leur division en espéces distinctes" (On the mentally ill and their division into separate species).[60] Numerous themes call for our attention: Pinel's respect and empathy for the patient; his use of observation, including a new diagnosis; a new concept of the doctor-patient relationship; his guidelines for therapy; the subdivisions in his nosology; his call for a thoughtful administrative policy in the asylum; and the exploration of new avenues for research.

All of Pinel's writings convey the importance of each patient as a special person endowed with reason, personal feelings, and a unique tragic history where the cause of the patient's mental illness lay hidden. The physician-in-chief of the Salpêtrière knew, of course, that the Revolutionary reformers had proclaimed the right of every ailing and needy citizen—the "citizen-patient"—to health care, and he interpreted this right to include the mentally ill.[61] As a public servant who headed the largest hospital in the world, he set an example, but he knew the difficulties of dispensing psychologically sensitive care and therapy to hundreds of inmates. All around him he witnessed young physicians on Paris hospital wards who assumed an increasingly impassive attitude toward the suffering indigent—young medical scientists who favored large series of cases that yielded numerical data. Pinel realized that two contrasting kinds of psychologic therapy were emerging at the end of the eighteenth century: individual care for paying patients and collective management for the poor.

Crucial among Pinel's original contributions is the careful observation of the patient over a long time if necessary. This led him to emphasize two aspects essential to diagnosis: one is a precise record of the precipitating event that may determine the character and course of the illness,


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the other is the physician's knowledge of the natural history of the disease afflicting the patient. Only with such knowledge can the physician accurately assess the signs and symptoms that he must interpret. It was precise observation that led Pinel to diagnose "reasoning madness" ("folie raisonnante "), a definition based on the concept that mental illness often involves one faculty only while the others remain unaffected. In the case of folie raisonnante, reason and logical thinking are intact, but the patient is captive to an insane conviction or delusion, for example that he is the prophet Mohammed. No psychiatrist could undo such madness.

Pinel's most important contribution consists of a new approach to the doctor-patient relationship. It was based on a reinterpretation of the phenomenon of periodicity in "intermittent insanity." Observers of the mentally ill had long mused about the influence of the changing seasons, the phases of the moon and sun, and biorhythms such as the patient's menstrual cycle upon morbidity. These influences of the patient's surroundings or internal milieu (to use Claude Bernard's phrase) could cause regular or irregular successive phases of morbidity and sanity. Pinel now conceptualized intermittence or periodicity anew. He focused on the periods of mental sanity as the moments when a skilled therapist can establish a relationship of trust with the patient. He must build this gradually, through repeated visits and conversation. By timing his interventions with care and using the patient's intact faculties, he may involve the patient in his or her own cure. Pinel thus established a new avenue toward recovery and psychologic treatment.[62] The philosopher Georg Wilhelm Friedrich Hegel praised Pinel for this innovative approach when he wrote:

... true psychologic therapy holds to the point of view that madness is not an abstract loss of reason, neither of intelligence nor of will, but only a derangement, a contradiction within the remaining rationality. Similarly illness is not an abstract and total loss of health (that would mean death), but a contradiction within health. This humane, that is kindly and reasonable treatment—Pinel deserves the highest recognition for his efforts on this behalf—assumes the patient to be rational and clings to this belief and engages the patient in this manner. Similarly the physician deals with the living body, in which health is still to be found.[63]


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Hegel thus saw the dialectic process at work in the struggle of doctor and patient to wrest health from illness.

While diagnosis fascinated Pinel, therapy was never his main interest: a correct diagnosis would produce the appropriate follow-up. As an admirer of Hippocrates he believed in the "healing powers of nature": removing harmful influences and letting nature run her course was often best. He condemned the uncritical and untested use of drugs because he was wary of side effects and iatrogenic symptoms, derided the "hotchpotch" of polypharmacy, and preferred mild natural pharmacologic agents. Diet and regimen seemed aspects of therapy that physicians must supervise closely. He agreed with William Battle that "management does much more than Medicine."[64] Patients must be treated according to their individual needs, with well-designed management and therapy.

In order to administer a mental hospital successfully, the director must follow clear rules. Therefore guidelines for "policing" the asylum form an important part of the Traité, and Pinel outlined them in the Itroduction. He advocated the dignified individualized treatment of the mentally ill citizen-patient, cleanliness, regularity in hospital routine, the banishment of violence even though firmness was of the essence. Mainly, he believed, insanity was a curable illness.

Research was always on Piner’s mind, and to that end he favored couching his nosographic distinctions in the language of the natural sciences. His division of the mentally ill into "separate species" reflects the influence of Boissier de Sauvages, Linnaeus, and Georges Louis Leclerc, comte de Buffon (1707-1788), whom Pinel undoubtedly met at the Jar-din du roi in the 1780s, while studying with his assistant L. J. M. Daubenton, who became Pinel's friend. When Crichton brought the ideas of Blumenbach to Pinel’s attention a few years later, they obviously fell onto well-prepared, fertile ground. The initial objective of Pinel's research was nosographic clarity. That was his first hurdle when he entered the Bicêtre mental ward in 1793, and we have a tantalizing piece of paper, 12 × 15 inches, on which he jotted down his impromptu formulations.[65] Once he subdivided and regrouped the patients, he could observe them to better advantage. He applied the "numerical method," crude statistics.[66] Conversant with skull measurements as an index of in-


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telligence, he discussed them in the Traité but remained skeptical, and the same can be said of dissecting patient brains in order to locate the "seat" of mental illness.[67] He tried to ascertain the therapeutic value of electricity but doubted its effects,[68] and he wrote about the relationship of psychiatry and the law.[69] However, while he was open to new trends and problems, as exemplified by his attention to Crichton's book, his major involvement was a personal relationship with students such as Esquirol and with his patients, a relationship symbolized and reinforced by his residence inside the asylum walls for thirty years.

This secluded residence did not isolate Pinel from the national nor from the international medical scene. He continued to read widely, as the contents of his library indicate, and he followed the latest developments in research: we know that he hardly ever missed a meeting of the Academy of Sciences and wrote frequent reports on new experiments and books. His Introduction to the Traité allows us to assess his familiarity with contemporary developments in psychiatry.

THE INTERNATIONAL CONTEXT OF MEDICAL PSYCHOLOGY IN 1800

In the Introduction to the Traité, Pinel generalized about the important role that experienced laymen played in the management of contemporary asylums and even in the cure of mentally ill persons throughout the Western world. He singled out the concierge of the Amsterdam asylum,[70] Father Pouthion at Manosque in Provence,[71] and Francis Willis, Thomas Fowler, and John Haslam in England. Pinel's facts are faulty,


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since most of the men he listed were not laymen but physicians.[72] His judgment, however, is correct: laymen can make good psychiatric nurses. He might have adduced the example of the Brothers of Charity, experts at psychiatric nursing who played a prominent role in the custody of men incarcerated in France by lettre de cachet, that is, by the king or the courts. In the eighteenth century the Brothers administered thirty-eight charités in France alone; they charged from six hundred to six thousand livres, according to the inmates' ability to pay. They prodded individually programmed custody with carefully graduated privileges and even medical care, if we can believe their admirers.[73] The Brothers' practices seem not to have been widely known at the time of the French Revolution, or perhaps the anti-Catholic temper of the times minimized the Church's achievements and Pinel adopted that attitude. His acknowledgment of Father Pouthion suggests, however, that he was unaware of the Brothers of Charity's expertise, or he would have mentioned them in this context.

One should also emphasize that it was no one's unique accomplishment to strike the chains from the insane at the turn of the nineteenth century. Progressive physicians throughout Europe were replacing traditional heavy iron shackles with leather straps or canvas tunics called "straitjackets." One might cite Dr. Abraham Joly (1748-1812)[74] and Dr. Charles Gaspard de La Rive (1770-1834) of Geneva,[75] Dr. Gastaldy of


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Avignon,[76] and Dr. Johann Theobald Held of Prague (1770-1851).[77] There were undoubtedly many others.

In the Introduction to his Traité, Pinel also reviewed contemporary medical writers and academic compendia on mental illness. He dismissed the British and German books and the international journal literature in one footnote each. The books, he wrote, "assemble scattered topics, lay them out in the scholastic manner, and often produce no more than some brilliant hypothesis."[78] The journals contain "scattered data, raw material that a skillful hand must elaborate."[79] This curt rejection of British works is startling, particularly since Pinel was well informed. He cited Battie, Harper, Arnold, Pargeter, Ferriar, Perfect, Haslam, and, of course, Crichton.[80] It is true that, in the body of his Traité, Pinel repeatedly acknowledged indebtedness to certain of these authors, particularly John Ferriar and William Pargeter—that is, those Britishers whose books speak of their practical experience with the hospitalized mentally ill. Nevertheless, Pinel's global rejection of British writings on insanity is surprising, even after making allowance for the anti-British feelings of a patriotic Frenchman in 1800.

It can be explained as follows: as we have seen, Pinel admired the work of practitioners, whether medical or lay, whose successful management of the mentally ill led to their patients' recovery. Therefore he praised the Retreat at York and admired the work of men like William


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Perfect at Mailing Place, Kent, or Thomas Arnold, at Belle Grove, Leicester. But he did not extend his admiration to the theoretical writings of these British practitioners—and how right he was! Thomas Arnold, for example, indulged in the most complex nosologic subdivisions in order to accommodate his observations; he divided insanity into "ideal" and "notional"—corresponding to Locke's "sensations" and "reflections"—and then proposed four "ideal" species of insanity, namely phrenitic, incoherent, maniacal, sensitive, and nine "notional" species: delusive, whimsical, fanciful, impulsive, scheming, vain or self-important, hypochondriacal, pathetic, appetitive. As for William Battie, the co-founder of St. Luke's Hospital for Lunaticks in 1751, one wonders how he could have taught his students how the mind worked while he hewed strictly to humoral pathology and treated his patients with an exhausting regimen of "depletion and revulsion." Pinel tended to shrug his shoulders at his British colleagues' theories while admiring their practical results.

In a different context, Continental observers found it astonishing that King George III's bouts of "madness" should provide a major topic of public discussion and even Parliamentary debate. In more conventional Continental fashion, the Spaniards, for example, kept the manic-depressive illness of King Ferdinand VI a secret even though a significant forerunner in psychiatry, Dr. Andrès Piquer of Valencia (1711-1772), cared for the king and wrote a revealing "Discurso sobre la enfermedad del Rey."[81] The Spaniards considered the king's person sacred and the manuscript lay unknown in the private archives of the duke of Osuna for one hundred years.[82] In contrast with the British physicians in charge of George III, Piquer and his colleagues never manhandled or mistreated their patient nor failed in their "respect for his Royal Person." Though he "did none of the things they prescribed. . . . [m]elancholics must be treated with great gentleness and kindness," wrote Piquer, "and the hotchpotch of medications belongs to quacks rather than physicians who try to know and imitate nature."[83]


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Piquer's younger contemporary, the Savoyard physician, Dr. Joseph Daquin (1732-1815) of Chambéry, wrote a sensitive Philosophie de la folie in 1791, in which he advocated humane treatment.[84] Its tone reminds one of the Confessions that his countryman and friend Jean-Jacques Rousseau had recently published. Daquin mixed traditional and modern attitudes: a humoralist, he spoke of "hot" and "cold" brains[85] and believed in the influence of the moon on "lunatics." Yet he pursued the scientific method to establish his thesis: he regularly examined five men and five women for sixteen years and kept notes on his findings at full and new moon, "lunistice," apogee, and perigee during a total of over eight hundred visits. But he decided against publishing his journal out of discretion and respect for his patients and unfortunately for us.[86]

Across the Alps, the Florentine Vincenzo Chiarugi (1759-1820) served as physician-in-chief at the renovated Bonifazio hospital for mental and dermatologic patients and taught students at the school of practical medicine of Santa Maria Nuova. He undoubtedly collaborated in the humane Regolamento for Florentine hospitals that was issued under the auspices of the enlightened Grand Duke Pietro Leopoldo in 1789. Chiarugi and Pinel were, in fact, the only full-time academic "psychiatrists" of the eighteenth century. In 1793-94, that is, six years before Pinel, Chiarugi authored a two-volume work on insantiy, Della pazzia. Pinel dismissed this book as utterly conventional in the Introduction to the Traité, but the Italian's admirers nevertheless consider him the real founder of "moral management" because he insisted on humane care for demented hospital inmates.[87]


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While Pinel was highly critical of his Italian contemporary, his treatment of the German literature on psychiatry is another matter. His main reference is contained in a footnote that reads as follows:

Faucett

uber Mélancholie

Léipsick, 1785

Avenbrugger

von der stillen, etc.

1783

Greding's

Vermischte, etc.

1781

Zimmermann

van D. Erfahz.

1765

Weickard's

Philosoph. arzt

Léipsick, 1775

These entries indicate that Pinel did not understand what he was writing: it seems likely that he took these references from the Introduction and Appendix of Crichton's book, adding them at the last minute, as his Traité went to press.[88] The footnote exemplifies the damage that the decline of Latin brought to international understanding in the eighteenth century: Germans now wrote in their own language which few foreigners bothered to learn. Not to take German-language scholarship seriously was of course a typical French attitude in 1800. The French Enlightenment expected cultured Germans to speak and write in French, like the "enlightened despot," Frederick the Great.

In contrast with Frenchmen of the late Enlightenment and Revolutionary era, those classical "pagans" whose gaze remained riveted to the Roman horizon,[89] the British had strong and recent German ties. Thus


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a young Britisher like Alexander Crichton might elect to spend three years studying in Germany, something very few Frenchmen are known to have done.[90] "In the summer of [1786]," Crichton's biographers tell us, "Dr. Crichton was prevailed upon by his friend, Dr. [Robert] Pringle, to give up his original plan, and to accompany him to Stuttgart, in order that they might study the language of the country.[91] There Crichton undoubtedly made contact with the local circle of young natural scientists, for his lifelong interest in physiology and psychology took root at that time. Crichton then spent the winter in Vienna, where Maximilian Stoll had recently replaced Gerard van Swieten as the leading physician and where emperor Joseph II had just opened the Narrenturm; three months in Halle, where Crichton lived with the family of the distinguished anatomist Philip Friedrich Theodor Meckel; and the winter of 1787-88 in Berlin. He ended up in Gõttingen in March 1788 for a stay of six months. That is where the famous Johann Friedrich Blumenbach (1752-1840) was then teaching, surrounded by an active circle of students.[92]

What did Crichton learn at Gõttingen about mental illness that he eventually conveyed to Pinel and especially to Esquirol? In German lands, it would seem, interest in mental illness grew out of an entirely different conceptual framework than in Great Britain or France. German doctors traditionally learned their medicine at the universities as a coherent philosophical system, and within this system there reigned the towering figure of Immanuel Kant (1724-1804). His long essay on insanity, "Versuch fiber die Krankheiten des Kopfes," appeared in 1764 in five installments in Kõnigsberger gelehrte und politische Zeitung. Eventually he incorporated his brilliant though abstract classification of mental


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disorders into his Anthropologie.[93] For Kant, the distinctive human trait was reason, and he stressed the power of the rational mind over the emotions. (He once wrote a thank-you letter that became a short essay, on the theme one might paraphrase as "mind over matter.")[94] Crichton adhered to this contrast of reason and the passions, and Esquirol would use it, but in a special way.

While familiar with Kant's philosophy and anthropology, of course, Blumenbach was particularly interested in the development of the individual organism. His curiosity also focused on voyages of exploration and primitive peoples all over the globe, their physical growth and living habits; he owned a famous collection of skulls. His personality and his inquisitive mind inspired a number of young explorers, and Crichton fell under his spell. Blumenbach was also a lifelong friend of Sir Joseph Banks; he visited London in 1791, and we may assume that he saw Crichton on that occasion.[95] Blumenbach coined the concept of the "Bildungstrieb" as in innate biologic drive in 1781. Obviously this term held broad implications for mental illness, for, if the physician could make the patient aware of pathogenic irrational drives and explain their psychologic meaning, then he could chart a path toward the patient's recovery of his health. Crichton translated Blumenbach's brief essay into English in 1792 under the title On generation, a poor equivalent of the German.[96] It should have read On the Developmental Drive. For indeed he dealt with the central problem of contemporary physiology and develop-


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ment and assumed a stance that Timothy Lenoir has recently called "vital materialism."[97]

Some German attitudes toward the mind/body problem found their most famous formulations after Crichton's visit; but since he stayed in touch and received packets of books after his return to England, these writings should be mentioned here—also because they continued to attract attention in France in the early nineteenth century. Friedrich Wilhelm Joseph yon Schelling (1775-1854) reminded philosophers and psychologists that man's body and mind were part of living, ever-changing Nature. Therefore Schelling's Naturphilosophie, first formulated in 1799, gave German medicine a vitalistic and Romantic bent.[98] Many researchers tried to resist this "spiritualistic" development, among them the great physiologist Johann Christian Reil (1759-1813), in the opinion of some, the "German Pinel."[99] He published his first important essay, "Von der Lebenskraft," as the lead article in his new Archiv für Physiologie in 1795. He also wrote a book on psychiatry in 1803. It was entitled Rhapsodieen über die Anwendung der psychischen Curmethode auf Geisteszerrüttungen (Rhapsodies on the use of the psychologic method for the cure of mental derangement) and makes for extremely difficult reading.[100] Yet Reil had many astute and profound thoughts about the mentally ill, even though psychiatry was not his specialty and he never worked in a psychiatric hospital. In contrast with the main body of his book, Reil's Preface adopted Naturphilosophie and exemplified the broad undercurrent of evangelical religiosity in the German attitude toward insanity and a tendency to equate insanity with sin and recovery with salvation. Reil wrote his Rhapsodieen of 1803 with the original intention of contributing a short piece to the journal of his friend Pastor Wagnitz. But the short essay grew to five hundred pages, which Wagnitz refused to publish.[101] Reil's Preface conveys a sense of mission that Naturphiloso-


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phie tried to impart to humanitarians of all nations. In a similar vein, Christoph Wilhelm Hufeland's Journal of the 1790S called upon doctors to become medical missionaries to the poor.

In fact, an active German journal literature, not only books, discussed and publicized philosophical anthropology, natural history, religion, and their implications for mental health and mental illness. Two new journals, Zeitschrift für empirische Psychologie and Magazin für Erfahrungsseelenkunde, began publication in 1783, the latter edited by Karl Philipp Moritz (1757-1793) and Salomon Maimon (1754-1800).[102] Moritz was a friend of Goethe's and a well-published esthete, Maimon a protég<a0233> of Lessing's and Moses Mendelssohn's and a philosopher of whom Kant thought highly. And Erfahrungsseelenkunde was, in fact, the scientific study of psychologic experience, the very specialty that physicians like Crichton and Pinei were about to transform into psychiatry. In the Magazin, Crichton found what he "had not yet met with in any other publication, a number of well-authenticated cases of insane aberration of mind, narrated in a full and satisfactory manner, without a view of any system whatever."[103] Neither of the two editors was a physician. Crichton, in contrast, brought the clinical approach to the perusal of the German case histories.

He had initially embarked on writing a physiology of mind and body in health and disease—until he read John Augustus Unzer's Erste Gründe einer Physiologic der eigentlichen thierischen Natur thierischer Körper[104] and found that Unzer had accomplished the task. Nevertheless Crichton continued to study German thought about anthropology, physiology, and psychology, and his "esteemed friend" Blumenbach kept sending packages with German books and journals. Crichton's indebtedness to German learning is obvious from his repeated citations of a dozen contemporary German authorities. Of particular importance to Crichton was Melchior Adam Weickard's publication, Der philosophische Arzt, and Johann Ernst Greding's Sämtliche medizinische Schriften. Crichton appended eighty-five pages of Greding's Medical Aphorisms on Melancholy and Various Other Diseases to his Inquiry.[105] It was thus the German


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philosophers and physicians who attempted new formulations for the theoretical substrate of psychiatry in the early Romantic era. Crichton found their thought fascinating because of their focus on observation, on individual case histories, and on the natural history of diseases. Yet he developed his own approach.

SIR ALEXANDER CRICHTON (1763-1856): THE MAN AND HIS WORK

We can easily imagine Pinel’s surprise and pleasure when he read the Introduction to Crichton's Inquiry. He discovered a self-assured innovator equally impatient with ancient and modern models: Crichton proposed to practice observation and follow the analytic method including, we are amazed to read, "abstracting his own mind from himself, and placing it before him as it were, so as to examine it with the freedom and with the impartiality of a natural historian."[106] (This attempt at self-analysis seems to foreshadow Sigmund Freud.)[107] Crichton discarded traditional nosologists, even Linnaeus, as "generally and justly neglected."[108] The mainstream of new knowledge, for Crichton, flowed from Germany, that "learned nation."[109] His enthusiasm for Germany


365

Pl. 17. Portrait of Sir Alexander Crichton attributed to C. H. Harlow (no date).


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set him apart from his British medical colleagues whose travels to the Continent had long taken them to Leiden and Paris, and then to Italy and perhaps Vienna. Stuttgart, Halle, and Berlin were unusual places to visit, but Crichton did not mind taking a different track than his colleagues: he did not even mention the large group of British medical practitioners who recorded their experience with mentally ill patients in books during the last third of the eighteenth century.[110] The exception is Dr. Thomas Arnold, whose book Crichton lambastes repeatedly in his Introduction, and quite justifiably so. But Crichton spent little time on a critique of his colleagues—he was so convinced of being an innovator that he preferred to look ahead rather than backward.

He earned lavish praise from Pinel in the Introduction to the Traité of 1800. After heaping scorn on most contemporary writers on the subject, Pinel continued:

I except the research of Crichton, a profound work full of new observations based on the principles of modern physiology. It focuses on the pathogenesis of mental alienation rather than on its history or therapy. I believe I should now give an exact idea of the origins, development, and effects of the human passions on the animal economy, as this author has presented them, and as they should be known, namely as the most usual cause of derangement of our psychologic functions.[111]

Pinel then proceeded to an eighteen-page paraphrase and analysis of History of the Passions and Their Effects. It is strange indeed that until now no one has explored the relationship of Pinel to Crichton.[112] This relationship might have blossomed had Dr. F. R. Bidauh de Villas (1775-1824) carried out his intention of publishing a translation of Crichton's book, a project revealed in a manuscript at the Wellcome Institute, London. Instead, Bidauh wrote a close textual analysis and synopsis of Crichton's book but stopped short of part 3, On the Passions, the most novel and important section. He sent his work to his friend A. A. Royer-Collard, who eventually published it in his Bibliothèque médicale, but only in 1816-1817. By that time, the nascent psychiatry was turning its atten-


367

tion increasingly to brains, not the mind, and thus interest in the work of Pinel and Crichton was on the wane.[113]

Who, then, was Crichton? There are only two monographic studies on Crichton in the literature,[114] and only a few historians of medical psychology acknowledge his work.[115] And yet Crichton, eventually Sir Alexander Crichton, born in Edinburgh in 1763, dead at the age of ninety-three at Seven Oaks, Kent, F.R.S., F.L.S., F.G.S., and a licentiate of the Royal College of Physicians, not only wrote an important early book on psychiatry but served two tsars with distinction as head of the Russian civilian medical department for fifteen years, and then lived in London for another third of a century as a respected member of his profession.[116] Crichton's education was broadly based, and his published writings are heterogeneous.[117] He had studied at the Edinburgh medical faculty with Joseph Black, Alexander Monro, secundus, and especially James Gregory (1753-1821), who influenced him deeply. Indeed, a comparison of the topics and opinions in Gregory's Conspectus medicinae theoreticae reveals striking analogies to Crichton's Inquiry.[118] But theory


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did not predominate in Crichton's training: he served an apprenticeship with the surgeon Alexander Wood and undoubtedly also "walked the wards" of the Royal Infirmary of Edinburgh.[119] Moving to London at the age of twenty-one, he spent one year with another surgeon, William Fordyce, while also attending the hospitals. By the time he reached maturity, Crichton had absorbed three deeply influential British traditions, Baconian empiricism, Lockean Associationist psychology, and Scottish "Common Sense" philosophy. This was so obvious to Crichton that he wrote in his Introduction to the Inquiry; "The most useful of these authors, and their works, I shall now enumerate.... Those of our British Psychologists, such as Locke, Hartley, Reid, Priestley, Stewart and Kaims [sic ] need not be mentioned."[120] And indeed Crichton incorporated these authors' ideas into his work in a casual and familiar manner.

The inductive method was basic to Crichton's approach: that is why he, like Pinel, set so much store by detailed case histories reported without reference to any preestablished "system." The absence of innate ideas and moral values—the tabula rasa —was another essential prerequisite for Crichton's Inquiry. A passage in History of the Passions that Pinel commented on with admiration reads:

The passions are to be considered, in a medical point of view, as a part of our constitution, which is to be examined with the eye of a natural historian, and the spirit and impartiality of a philosopher. It is of no consequence in this work whether passions be esteemed natural or unnatural, or moral or immoral affections. They are mere phenomena, the natural causes of which are to be inquired into.[121]

Further, Crichton mentions the association of ideas as if this were a generally recognized and adopted truth: David Hartley's conclusions had by Crichton's time become obvious assumptions for the nascent psychi-


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atric specialty.[122] For Hartley, association was a material process caused by the vibration and gravitation of particles in a fluid acting on the brain. Crichton combined this explanation with faculty psychology. According to this theory, a defective association acting on a mental faculty such as attention, will, memory, reason, or imagination will result in "derangement."[123] Crichton's ideas of faculty psychology stemmed from Dugald Stewart (1753-1828), with whom he undoubtedly studied at Edinburgh, thus absorbing the ideas of Thomas Reid (1710-1796).[124] Their "Common Sense" approach was of course more serviceable for a physician than the more famous contemporary Scottish philosophy, the skepticism of David Hume. Nor does Crichton mention the Theory of Moral Sentimerits (1759) by another Scottish philosopher, Adam Smith (1723-1790), while a French translation of the work by the marquis de Condorcet's widow stood in Pinel's library, and he mentions it in the Introduction to his Traité.[125]

A Scottish education and training in surgery and medicine both in Edinburgh and London did not leave an inquisitive and ambitious young gentleman with the feeling that his preparation for a career was complete: he needed to undertake a tour of the Continent. Crichton spent four years, from 1785 to 1788, traveling abroad, and for our purposes this is the most intriguing part of his intellectual biography. One month sufficed to obtain the M.D. degree at Leiden, on 29 July, 1785, with a thesis De vermibus intestinorum. It is a mere eighteen pages long and—curious for a thesis in medicine—dedicated to the surgeons Alexander Wood and William Fordyce, his teachers.[126] The season 1785-


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Pl. 18. Title page of Sir Alexander Crichton's M.D. thesis, De vermibus intestinorum (On the worms of the intestines).


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1786, spent in Paris, left no noticeable traces in Crichton's writings (nor have I found any track of his presence in France)[127] However, soon after the publication of his Inquiry, we find "Crickton de Londres" among the foreign associates of the official Société de médecine de Paris, and on 24 February 1835 he was one of 234 foreign corresponding members elected by the Paris Academy of Medicine.[128] Crichton does mention, in Commentaries on Some Doctrines published in 1842, that he "had the honor" of "knowing Pinel personally."[129] (That meeting must have occurred in the winter of 1785-86, when Pinel served as editor of the Gazette de santé. Likely places for an encounter were the Jardin du roi, where Pinel studied, the Helvétius salon, the surgeon Pierre Desault's rounds at the Hôtel-Dieu, or lectures at the Collège de France or the Sorbonne.)

Then followed Crichton's three Wanderjahre, spent at Stuttgart, Vienna, Halle, Berlin, and Gtttingen. Late in 1788, he returned to England. On 7 May 1789 Crichton joined the Corporation of Surgeons in London but disfranchised himself after two years because, say his biographers, he "never liked the operative part of the profession." Rather, he joined the Royal College of Physicians as licentiate on 1 June 1791 and worked at a dispensary in Holborn where he gave clinical lectures "upon a plan similar to that of Götingen University." In 1794 he was elected physician to Westminster Hospital, where he taught "The Theory and Practice of Physic," as we learn from an advertisement in the London Times.[130] Despite this title he actually taught a course in psychiatry since he tells us in the Preface to the Inquiry that he wrote the book for his students. One can indeed imagine each of the three parts as notes for a course: part 1, on the nature and origins of mental derangement; part 2, on the physiology and pathology of the human mind; part 3, on the passions and their effects. The volumes consist of five, eight, and six chapters respectively—each chapter could well have formed the subject matter for one classroom presentation. Crichton lectured at the Westminster throughout the 1790s: we can assume that he interviewed


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Pl. 19. Advertisement on the front page of The Times (London) of 17 September 1794. The advertisement reads as follows:

MEDICAL LECTURES, WESTMINSTER HOSPITAL

THE PHYSICIANS of the Westminster Hospital, propose to read CHEMICAL LECTURES on the Cases which shall come under their care in the course of the Winter.

Dr. CRICHTON will begin his Course of Lectures on the THEORY and PRACTICE of PHYSIC, at the Hospital, on Wednesday the 1st of October, at 9 o'clock in the Forenoon.

Dr. BRADLEY proposes to read a Course of Lectures to comprehend the most useful Parts of the Institutes of Medicine, Materia Medica, and PHARMACEUTICAL CHEMISTRY, to commence the first Week in October.

A Lecture, introductory to the Chemical Courses, will be given by Dr. BRADLEY, at the Hospital, on Wednesday, October 1st, at 10 o'clock in the Forenoon.

Mr. CARLISLE will give a general introductory Lecture, on Saturday, October 4th, at 11 o'clock, wherein he proposes to point out the most advantageous mode of acquiring Surgical Knowledge.

Mr. LYNN and Mr. CARLISLE will afterwards continue to give such occasional Lectures on Surgery, as may be thought most useful to the Pupils; and Chemical Lectures upon every Operation, or important Case which falls under their Care.

For Particulars of the above Courses, and of attending the Practice of the Physicians, or Surgeons, apply to the Apothecary at the Hospital.


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the mentally ill patients in front of his students—for indeed these patients were regularly admitted to his hospital in small numbers—and that he drew the students' attention to the psychologic manifestations of somatic illness.[131] Owing to his book he was asked to testify regarding the sanity of James Hadfield, the madman who attempted to assassinate King George III in 1800. The next year, Crichton became a consulting physician at the Westminster and retained that position to the end of his life.

In 1800, Crichton married and shortly thereafter was appointed physician to Adolphus Frederick, duke of Cambridge (1774-1850), the tenth child and seventh son of King George III. New family connections smoothed his path, or he may have met the young man at Gõttingen, where three of the royal princes were sent for their education in 1786. Being now a courtier, he came to the attention of emissaries from the Russian tsar, who lured him to St. Petersburg in 1804. Were one to pur sue research on Crichton, one would go to Edinburgh, as Tansey has done, but mainly to St. Petersburg, for Crichton spent fifteen years in the service of the tsar. In a pamphlet published in 1817, he describes himself as

Physician-in-ordinary to their imperial majesties the Emperor and Dow ager Empress of Russia; Physician-in-chief of the Civil Department of the Empire; Knight of the Order of St. Vladimir; Honorary member of the Imperial Academy of Sciences of St. Petersburg.[132]

 

Dec

Jan

Feb

Mch

Apr

May

amenorrhoea

3

5

4

5

4

7

asthma

2

9

2

5

1

 

hypochondriasis

1

 

1

1

   

hysteria

2

 

2

     

dyspepsia

   

2

     

epilepsy

 

2

1

2

   

convulsions

       

2

2

palpitations

         

1

Medical and Physical Journal 3 (1800): 16, 112, 208, 303-304, 408-409, 505-506.


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He published a Pharmacopoeia pauperum while in Russia and coedited a short-lived journal, Russische Sammlung für Naturwissemchaft und Heilkunde.[133] (The Leningrad Archives would undoubtedly reveal more publications.) Unfortunately the Sammlung contains no entries signed by Crichton, though plentiful comment by the editors collectively. This indicates much curiosity about the geology, fauna, and flora of Asiatic Russia and China, which may well reflect Crichton's avocations, and a great deal of interest in southeastern Russia, where a cholera epidemic ravaged the population. Indeed, Crichton's medals were undoubtedly rewards for his efforts in fighting this epidemic.

In connection with a subsequent typhus epidemic, Crichton established an essay prize with thoughtful guidelines. He donated a thousand rubles for the best essay on indigenous remedies, and five hundred rubles for the best description of typhus. The instructions to candidates reveal Crichton's interest in susceptibility to the disease. Candidates should take the emotions into account, and inquire

what were the forms and characteristics of the disease among the inhabitants as the enemy came ever nearer to their homes, and later, when national enthusiasm rose to great heights, and finally, when total success rewarded the efforts of the fatherland?
And how did the disease manifest itself among the enemy, first, when he was still blinded by the illusion of victory (an illusion that remained alive among prisoners), and later, when he found himself toppled from glittering heights into abject disgrace?

It might also be worth examining national differences, Crichton continues, between Europeans and Asians, with regard to typhus.

Are there observations indicating that individuals in one nation fall ill more quickly and in larger numbers? are some more resistant to damaging influences or to contagion? or did the illness among them take on special characteristics or curious symptoms?[134]

These questions indicate an astonishing sensitivity to what we would call psychosomatic parameters of illness. Crichton's contribution of a substantial prize, and the deferential tone in which his coeditors thanked him, suggest that this personal physician to the imperial family held a well-paid and favored position at the Russian court.[135] Though eager to


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come home in 1809, he did not obtain the tsar's permission until 1819, and we know little about the remaining third-of-a-century in Crichton's life. He became a respected member of the medical community, with an office in Harley Street, and was a member of the Royal, Geological, and Linnaean Societies of London. Interesting as a biographic investigation might be, we must now focus on the references, ideas, attitudes, and mainly the ideas he transmitted to Pinel and Esquirol about German anthropology, natural history, physiology, and religion, as they affected mental alienation.

THE INQUIRY INTO THE NATURE AND ORIGIN OF MENTAL DERANGEMENT

Crichton's Inquiry consists of three books on different though related subjects and a long Appendix. Book I is entitled "Inquiry into the Physical Causes of Delirium." It deals, in turn, with irritability, sensitivity, consciousness of self, pain and pleasure, and delirium. The first two sections review contemporary physiology and pay homage to Francis Glisson, Felice Fontana, and, above all, Albrecht von Hailer.[136] In chapters 3 and 4, Crichton turns from physiology to psychology, from muscles to nerves, from plants and animals to man. His debt to Locke is pervasive: he argues for a categorical distinction of man from animals. In chapter 3 of the first book, Crichton discusses a complex notion for which scholars had no accurate term: they variously called it consciousness of self, self-feeling, coenesthesis, Gemeingefühl.[137] It combines awareness of perceptions from outside and inside the body, and of relevant mental rune-


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tions such as memory, imagination, and reason. It provides the healthy person with a consciousness of these functions and thus of him- or herself. This awareness is, of course, intact in the healthy person but impaired in the mental patient. But it is chapter 5 of book I, "On Delirium," that interests us most because Pinel translated it immediately upon its appearance in France and published his version in the new journal, the Recueil périodique de littérature médicale étrangère.[138] Delirium is an altered state of consciousness ("lira," in Latin, means a straight furrow) where a variety of different causes can produce similar symptoms. Alcohol, poison, strong emotions, or mental illness can all cause delirium. Crichton ascribed delirium to the action of a nervous fluid, altered in quantity and quality,[139] whereas Pinel dissented, emphasizing "vivid emotions."[140] In another note, Pinel offered a case history of his own.[141]

Pinel also added several translator's comments in which he argued with Crichton. Since these have gone virtually unnoticed in the vast Pinel literature,[142] they may be worth translating here. First, Pinel criticized the British author for basing an argument on a single case history, taken from Greding. Pinel continues:

I have followed a quite different method when I decided to explore the same subject. For two consecutive years, I watched about two hundred mentally ill men in a hospice under my medical direction. I first divided them into separate classes, idiots or imbeciles, melancholics, maniacs; I kept exact records of the continuous or periodic manias. For the latter, I took special notes on the precipitating events of insanity, premonitory signs of periodic bouts, the variety of lesions in the understanding, the progressive series of the other symptoms, their termination, etc. and it is after this research that I published a memoir on periodic insanity.[143]

In another note, Pinel criticized Crichton for generalizing too freely about delirium and failing to classify and compare the phenomena he observed. This, of course, was Crichton's weakest point: as one of four attending physicians at an all-purpose, hundred-bed hospital, Westminster, Crichton had little occasion to observe the mentally ill. Commented Pinel:


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It seems to me that these general considerations of delirium caused by hypochondriasis, melancholy, mania, fevers, or narcotics yield only vague knowledge since these are very different mental states, considering their accompanying symptoms, their history, and their outcome. A surer means of gaining information on this subject is to write the specific history of the different deliria, especially of maniacs, which are the least known. It is with this goal in mind that I have published my Memoir on periodic insanity [where] I traced the distinctive characteristics of maniacal delirium.[144]

In yet another instance, Pinel faulted Crichton for an imprecise differential diagnosis of delirium in drunkenness and insanity. If one pays attention to the other symptoms that characterize the two, what marked differences! exclaimed the French clinician. "Is one delirium adequately explained by the other? The author should have avoided this sort of digression and followed the analytic process. He should have written a history of maniacal delirium according to a long list of observed facts, and derived inductions from these facts only."[145]

This stern rebuke pales when compared with Pinel's most energetic editorial comment, occasioned by Crichton's mention of mind, as distinct from brain. Unaware of a pitfall that may topple the translator, Pinel equates the word "mind" with " âme, " or soul. Pinel jumps to conclusions (sensitized, no doubt, by recent French Revolutonary history, and by his own, long-rejected youth, when he wore the cassock and tonsure). Pinel lectures Crichton as follows:

This opinion of a separate soul, as an immaterial principle, is too dosely associated with theology to be introduced into medicine, in our present state of knowledge. All the more reason to exclude all the explanations the author deduces, in order to present the mechanism of delirium. Purity and severity of taste demand that the functions of the human understanding be explained only through their history. This applies to the healthy state, and to the deviations of illness in insanity. That is, one must go no further than to record the predisposition to delirium, premonitory signs, accompanying psychologic and physical symptoms, outcome, and remedies proven by an enlightened experience.[146]

Crichton would have agreed. Pinel was, in fact, being contentious, and these preliminary comments about Crichton's thoughts on delirium reveal some anxiety on his part. With his book in press, he did not relish being "scooped" by the British author. For our assessment of the two


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writers it is important to underline their similar approach to a differential diagnosis of mental illness: they subjected each deranged faculty to examination through the close observation of the physiologic and behavioral pathology it produced in the patient and thus derived a diagnosis from their observation of mind and body in the clinic.

Book II of Crichton's Inquiry is entitled "The Natural and Morbid History of the Mental Faculties." It contains a straightforward analysis of attention, perception, memory, judgment, imagination, volition, and, surprisingly, "Genius, and the diseases to which it is most subject." Here, Crichton praises "a faithful monitor within us" that warns us "when any exertion of the mental faculties is carried too far and ought to be discontinued."[147] Pinel, in his synopsis, awards this part of Crichton's work no more than half a page.[148] This was because Pinel's attention focused on the third part of the work, namely "On the Passions, Considered as Causes of Mental Derangement, and on Their Modifications and Corporeal Effects." Here, Crichton analyzed joy, grief, fear, anger, and love, and their normal and abnormal impact on psyche and soma. He explained that emotions differ according to their cause: we may view a past action with remorse, an accident with sorrow or grief; anticipation of a future event may trigger anxiety, apprehension, or terror; an aversion may evoke anger, hatred, envy, jealousy, or shame. The effects of such emotions could be expected to vary according to a person's temperament, age, occupation, sex, and so forth.

The new contribution of our author concerns the interrelationships of emotion and physiology. In the chapter on grief, for example, Crichton sensitively probed the differences among distress, sorrow, melancholy, anguish, and despair. Then he explained major physiologic effects, for example a behavior such as sighing. When sadness slows the circulation, congestion around the heart ensues. The uneasiness caused by a sense of fullness stimulates the aggrieved person to take a deep breath followed by quick exhalation. This sigh indicates that the heart has pushed blood into the lungs where it was oxygenated and expelled.[149] Crichton favored clinical examples, even though they were rarely his own. The book has no proper ending, but peters out with an odd list of "Conclusions," a brief inventory of "Genera and Species," and the eighty-five-page Appendix of aphorisms translated from Greding's Miscellaneous Works.[150]


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Pinel wanted to convey the gist and flavor of Crichton's work to his readers, and to achieve this he paraphrased Crichton's analyses of grief, fear, terror, anger, and joy. We shall quote two long examples because this earliest printed evidence of Pinel's and Crichton's perception of mind and body in the clinic represents seminal texts of early modern psychiatry. We begin with Pinel's version of Crichton's section on grief—twenty-two pages of text presented in two pages of condensed paraphrase: "Having indicated the origins of human passions," asks Crichton, "how can one conceive of their power to provoke mental alienation, without knowing the history of their effects on the animal economy?" In Pinel’s version, Crichton explains:

The consequences of great sorrow are among the most remarkable; they include a feeling of general listlessness, decline of muscular strength, loss of appetite, small pulse, tightening of the skin, pale face, cold extremities, very evident decline in the vital force of the heart and arteries, leading to an imaginary sense of fullness, a feeling of oppression and anxiety, labored and slow respiration with sighs and sobs; an exhaustion of irritability and sensitivity sometimes so complete as to entail a more or less total torpor, a comatose state, or even catalepsy.
In a less extreme degree there occurs a kind of apprehension ["ennui"] caused by repeated impressions on the sensory organs, a reluctance to move or exercise, sometimes an acute pain in the stomach, much reduced circulation in the blood vessels of the liver and abdominal viscera. Therefrom result marasmus and a wasting state, when sadness has become habitual, that is, has turned into melancholy. The end of both is sometimes an irresistible inclination toward suicide, or a mild delirium, or a state of rage. Prior to total derangement several disturbances may occur: temporary insanity, gloomy appearance, or rather, boorish misanthropy, altered facial expressions, furtive and fierce glances, vague and confused thought, a state resembling stupor or drunkenness, and then suddenly an explosion of the most violent madness.[151]

An equally dramatic and revealing analysis is found in Crichton's differential diagnosis of terror and of anger. Here again, patient behavior alerts the experienced clinician to the possibility of serious complications. We again quote Pinel’s synopsis of Crichton's text:

... terror differs from fear only by its intensity and sudden onset. It has its own characteristics, namely accelerated heartbeats, spasmodic contrac-


380

tion of the arteries, especially near the skin, causing paleness and a sudden dilation of the large blood vessels and of the heart; a sudden arrest of respiration, as from a spasm in the muscles of the larynx; tremors of the body and legs, loss of movement in the arms that hang limp; the impression is sometimes so strong as to cause collapse with deprivation of feeling and speech.
May not such an upheaval, under certain conditions, produce the most serious harm, violent spasms, convulsions, epilepsy, catalepsy, mania, or even death? (Plater, Shenkius, Bonet, Pechlin, Donatus, Van Swieten). It can also lead to a special flux of blood toward certain body parts and dangerous hemorrhages, such as menorrhagia, hemoptysis, apoplexy.
When rapid alternations of hope and terror occur, the debilitating effect of terror can be compensated for and give rise to unheard acts of strength and courage. Terror mixed with amazement can be caused by loud thunderclaps, the spectacle of a raging fire, a dreadful precipice, a pounding cataract, a burning town. This produces specific expressions such as a fixed stare, an open mouth, pale skin, a sensation of cold in the whole body, relaxation of facial muscles, frequently an interruption in the usual trend of thought, and dizziness. . . .

How much harm anger can cause when considered from a medical point of view! It presents two remarkable varieties: a pale face and somewhat livid coloring, with a kind of weakness and trembling in the extremities, or else a red and heated face with flashing eyes and extreme muscular energy. In the latter case, the blood is pushed violently toward the body surface, producing burning heat and a strong and animated tone of voice, convulsive and irregular breathing. The return of the blood through the veins to the heart becomes difficult; it flows back to the muscles and gives them more energy and strength. Its reflux toward the head and other sensitive organs may produce more serious trouble: violent hemorrhages through the nose, ears, or lungs, intermittent or continuous fevers, delirium, or even apoplexy.

One of the strangest effects of anger acts on the secretion of bile, its quantity and quality, as attested to by the most authentic observations (Hoffmann, Tulpius, Pechlin). Hence violent colics, persistent diarrhoea, sometimes jaundice. The only favorable consequence of this passion is an occasional cure of paralysis; but what meager compensation for the innumerable harmful consequences, especially when anger is excessive: sudden exhaustion of muscular and vascular irritability, syncope, convulsions, or even sudden death.

Anger rarely results in permanent madness, even though it alters the rational faculties in such an obvious manner, or interrupts their free use for a short while. But how much a gust of anger resembles a bout of madness! Reddened eyes and face, a threatening and furious mien, harsh


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and offensive language. Is it surprising that anger has been called a brief madness?[152]

It is hoped that these long descriptions of grief, terror, and anger in their mental, behavioral, and bodily expressions convey the reasons why Pinel found Crichton's book so dramatically revealing. (They also exemplify Pinel's elegant style, much superior to Crichton's.) Pinel appreciated his British colleague's clinical detachment, his descriptions free from moralizing comment, and the scientific precision of his observations. He prized the ease with which Crichton moved between physiology and psychology, particularly how he deduced mental phenomena from his observation of physiologic and behavioral symptoms. One example is Crichton's analysis of paleness, which he knew to be caused by a withdrawal of blood from the capillaries but at the same time observed to have been the result of terror. Pinel was impressed by Crichton's awareness of progression in the pathogenesis of mental illness, such as the clinical signs that precede an "explosion of the most violent madness," and his differential diagnoses, as between extreme anger and madness. Many of these qualities that Pinel admired were, needless to say, the very ones he had honed in his own clinical attitude toward the mentally ill patient.

Pinel's French readers did not pay much attention to Crichton, nor was the latter's book ever translated into French. In contrast, the Germans greatly appreciated Crichton's book and translated it twice: in 1798 already, Untersuchung über die Natur und den Ursprung der Geisteszerrüttung attracted attention. This was three years before Pinel's Traité appeared in a German version. The French alienist's praise of Crichton struck the Germans as a confirmation of their own independent judgment. They were understandably pleased by the Scottish author's extensive reliance upon their scholarship in anthropology, natural history, and psychology and touched by his gratitude for the inspiration and hospitality he received from his German hosts. A second translation of Crichton's book, in 1810, contains extensive notes by Johann Christoph Hoffbauer (1766-1827), professor of law and philosophy at Halle, whose book on legal psychology Esquirol later annotated.[153] Johann


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Christian Reil, Hoffbauer's friend and collaborator, granted Crichton, "in passing, his highest regard."[154]

Unlike the British, the Germans criticized Pinel because they found his book unoriginal and disorganized. Most of them saw nothing special in the case histories, since case studies now abounded in the German literature and they argued that humane treatment of the insane was nothing new, nor special to France. Reil derided Pinei's book as a "cock-and-bull story, prolific in some parts but sick in general conception, without principles or originality, even though his nationalistic illusions lead him to claim these."[155] At the same time, Reil borrowed from the Frenchman so copiously that Schrenk calls him a plagiarist.[156] The religiously inclined psychiatrist Johann Christian Heinroth had no patience with Pinel at all. "Pinel's descriptions are neither consistent nor complete," he commented. "First, he groups the symptoms of various illnesses under one category; then, he passes quickly over the most important manifestations…. Overall, he identifies himself as a typically French writer, who never explores anything, who abandons the most important topics as soon as he raises them, and thus he never treats any subject thoroughly."[157] With Crichton, in contrast, the Germans felt a deep kinship, believing themselves experts in the analysis of the passions.

The British author's book appeared at a time when Pinel was still searching for the right word to represent the misery, tension, and loneliness that he witnessed in the men and women for whom he cared. He


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chose "mental alienation" to convey the separation of the patient from society (and also to create a basis for conceptualizing mental illness in terms of the law). Pinel perceived a patient who feels odd in the "normal" world, a stranger (alienus ) in the land of sanity. A sympathetic therapist might well journey into that land of "alienation," learn the language of "in-sanity," understand the "alienated," and lead the patient back into society. Pinel's excellent Austrian translator, Dr. Michael Wagner, found a pertinent equivalent that Crichton may have appreciated, namely "Geistesverirrung, " a term that conveys the image of a patient who has lost his way.[158] Samuel Tuke liked this term; he wrote in The Retreat, An Institution near York:

I adopt this term from an opinion that the aliéné of the French conveys a more just idea of this disorder than those expressions which imply, in any degree, the "abolition of the thinking faculty."[159]

Rather than alienation, Crichton portrayed the antagonism between the mental faculties and the other self, the passions, that gripped body and mind. This was the core problem for the nascent psychiatric specialty that Crichton brought to France from Germany.

Strange as it may sound, Crichton may not even have known of Pinel's extraordinary praise for his book. It is likely that Crichton read the Traité in its guillotined English version of 1806, without the Introduction where Pinel expressed his admiration.[160] Ironically, though Pinel’s Introduction of 1800 formed part of the German, Spanish, and Italian versions, the English translator substituted his own! Pinel's appreciative comments on Crichton have thus remained unknown to the English reading public, including, it would seem, Alexander Crichton. Would he not have mentioned the famous Frenchman's endorsement while reminiscing about psychiatry at the age of eighty, in 1842, when he praised "two witnesses who, for long and extensive experience in the treatment of mental derangement, and for fidelity in their narrations, have not as yet been surpassed—I mean Pinel and Esquiror"?[161] It is sig-


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nificant that he should mention Esquirol in the same breath with Pinel, for it is Esquirol who provides us with evidence of Crichton's impact on French psychiatric thought.

DOMINIQUE ESQUIROL: THE PASSIONS AND THEIR MASTER

In 1805 Esquirol published his medical thesis entitled Des passions, considérées comme causes, symptômes, et moyens curatifs de l'aliénation mentale (On the passions, considered as causes, symptoms, and means of cure for mental alienation).[162] He dedicated the essay to Pinel "in homage of my gratitude," and declared himself Pinel's disciple throughout a thesis filled with case histories, many of them his own. He derived these from the private clinic that he had established at 8, rue Buffon, across the street from the Salpêtrière, in March 1802, three and a half years before completing his thesis. This clinic began and remained under Pinel's supervision; Esquirol thus publicly committed himself to carrying out his teacher's ideas, in theory as in therapy.[163]

In his thesis, Esquirol came quickly to the point, stressing the close interrelation of psychologic and somatic phenomena and of feelings and thought:

Few authors have studied the relationship of mental alienation to the passions. Crichton offers exact ideas on the origins and development of the passions and their effects on the organism. Professor Pinel agrees with him, regarding the passions as the most frequent cause of upset of our intellectual faculties.[164]

Having thus declared his indebtedness to these two authors, Esquirol formulated his own version of psychologic therapy. He based this on Crichton's analysis of the effect that strong emotions could exert on the mental faculties and the organism, and on Pinel's view that the therapist can intervene in order to orchestrate the struggle within the patient—strengthen the rational powers and help them master the emotions and thus promote recovery. For the formulation of his therapeutic strategy, Esquirol also drew on Bordeu's concept of "secondary centers of sen-


385

sitivity" in the epigastrium and in the precordial region. He did, in fact, revive the traditional notion of hypochondriac localization, but gave it a specific formulation. Why could not a skillful therapist, asked Esquirol, provoke a strong emotion and use it for a curative purpose? In fact, he advocated a psychologic but violent assertion of medical authority and the use of the passions as means of cure. To this end he proposed emotional shocks—des secousses —"physical or psychologic, that shake and one might say threaten the machine, and forcibly redirect it toward health."[165]

Esquirol saw two potential benefits from this shock treatment: a judicious use of certain emotions by the doctor—for example intense remorse, regret, or joy—could help the patient regain rational command over his feelings. Secondly, Esquirol argued that control over the patient is essential in the asylum, and that individually and carefully administered shock differs categorically from the indiscriminate use of "ducking" in ice-cold water, or strong cold showers on the head or abdomen that others advocated. But there is no gainsaying that awe of the director was the ruling principle in the new clinic, and Esquirol often threatened and occasionally meted out punishment: he used the straitjacket, isolation, food deprivation, and even—if rarely—cold showers. But he never permitted what he called physical violence; the patients were never beaten nor intentionally hurt. His means are mild if compared to the chamber of horrors that J. C. Reil imagined—though Reil fortunately never had occasion to carry out his ingenious strategies for stimulation, excitement, fear, horror, pain, deprivation, and slavish subjection to the asylum director.

The first step in this therapeutic process was what Esquirol called "isolation," that is, removing the patient from home and familiar surroundings, and bringing the man or woman to the clinic for treatment. "Often the first shock to the intellectual and psychologic faculties occurs in the patient's home," commented Esquirol, "among acquaintances, parents, and friends.... I could multiply the examples of the beneficial impact on the psychologic state of mental patients resulting from their experience in an unfamiliar establishment where care, attention, and services are tendered, in contrast with the tortures they had expected and feared that they would find there."[166] All contemporary specialists agreed on this point, whether it was the Quaker William Tuke or the Savoyard Joseph Daquin or the German physiologist Reil: therapy must take place


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in a new and neutral place far from previous emotional ties and from objects that might remind the patient of past upsetting episodes. But it was the initial encounter with the director of the clinic, Esquirol believed, that should impress if not frighten the patient. Again he had models, notably Francis Willis, the man chiefly responsible for the management of King George III's bouts of mental illness. "A great show of force and power, and a threatening demeanor and preparations designed to terrify," commented Esquirol, "can stop the patient's most obstinate and deadly designs."[167] He recounted the case history of a twenty-year-old surgeon. He told the patient upon his arrival:

Young man, you must stay here awhile. If you want to be comfortable, behave yourself. If you act as if you had lost your reason, you will be treated as if you were mad. You must choose. See these servants? They shall do everything that you ask for, in a reasonable and sensible way. But they obey me only.[168]

He welcomed a depressed, suicidal young woman in a kindlier way. Recounts the versatile therapist:

I seemed so frightened by her condition, I communicated such concern about the danger of her situation, that she herself asked her parents to let her stay. One must often welcome patients in a pleasant manner, with a kindly smile, with gentle concern and empathy.[169]

In either case, the patient acknowledged that the director now wielded sole authority. "In surveying the diverse circumstances where the passions can serve in the treatment of insanity," concluded the young psychiatrist, "one is surprised that most students of mental alienation have ignored their use. Some day, perhaps, with sufficient data and with precise records of successful therapy, we will be able to establish the principles of moral treatment."[170]

This hope took on new dimensions when Esquirol moved to the Salpêtrière as successor to Pussin, in 1811, and faced the challenge of adapting methods used in a small private hospital to a huge public asylum. Esquirol had been watching Pussin's authoritarian ways and he now conceptualized the establishment itself as a "therapeutic tool," using the accommodations and the routines—the food, clothing, outings, work—as so many means of commendation, enticement, reward, pun-


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ishment. In a word, Esquirol aimed to achieve the socialization of patients by regulating them, and thus helping them control themselves. This strategy was based on the belief that the fear generated in the mental patient will help dominate his passions, make him conform to social rules, and become "normal." Commented Esquirol:

Those who know the power of habit in human psychology will not be surprised about the influence that new habits can exert on the mentally ill patient: the need to control oneself, to compromise with strangers, is a powerful aid in restoring reason. As establishment specializing in therapy for the insane offers more appropriate care, better trained servants, well-adapted accommodations.[171]

These words refer to Esquirol's private hospital, but he tried to make them true for the Salpêtrière as well, and they stayed with him as medical director of the Charenton asylum in 1826 and as chief sponsor of the Law of 1838 that still regulates internment of the mentally ill in France. Swain and Gauchet have analyzed this new relationship of powerful director to hapless inmate, and, in Discipline and Punish, Michel Foucault has compared this regimentation of the mental patient to other institutions that imposed uniform behavior on large groups at the beginning of the bourgeois era and of the Industrial Revolution, in the factory, the prison, or the modern hospital, which he calls a "curing machine." Klaus Dõrner has amplified the theme in Madmen and the Bourgeoisie: A Social History of Insanity.[172] Esquirol's view of the asylum as a "therapeutic tool" can indeed be made to fit into this authoritarian and dehumanizing context. It was not until Sigmund Freud revived Pinel's concept of prolonged and private doctor-patient communication that a relationship was restored in which the patient was again encouraged to speak freely for himself.

Thus a patient-centered approach to mental illness and a focus on the passions did not predominate for long in early-nineteenth-century French psychiatry. Rather, a reductionist materialistic approach, the tradition that emphasized physical causation of mental illness, won increasing favor; it shunted the attention of clinical investigators toward the brain, even the skull, away from mind, thought, and feelings. Crucial


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elements that strengthened this emphasis were the vehement attack by François Joseph Victor Broussais (1772-1834) against Pinel in Examen de la doctrine médicale généralement adoptée of 1816,[173] and the thesis that Antoine Laurent Jessé Bayle (1799-1858) presented in 1822, where he proved a correlation between a physical phenomenon and mental illness, namely that "arachnitis," or chronic meningitis, may be accompanied by general paralysis and a progressive and ultimately fatal dementia.[174] The primacy of the passions, in early French psychiatry, lasted only for two decades, at most.

While it lasted, Pinel and Esquirol stood at the center of French attention, but Crichton was hardly noticed in France. True, he appears in the bibliographies both men appended to their articles written for the Dictionnaire des sciences médicales,[175] Bidault de Villiers published a synopsis of the Inquiry, and several French contemporaries mentioned his name.[176] But otherwise he remained unknown, a puzzling fact, given Pinel's eighteen-page analysis in the Introduction to his Traité of 1800. The chief explanation is Pinel's new Introduction for the second edition of the Traité, published in 1809, in which he briefly refers to Crichton's book, and then discusses the various passions in pages where it is not


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possible to distinguish his ideas from Crichton's and where the Scottish doctor does not appear as an important stimulator of Pinel's thought.[177] Also, Pinel called his new introduction "Introduction to the first edition," thus presenting his faint and brief allusion to Crichton in 1809 as if it had been written in 1800.[178]

Was it a lapse of memory to call his new Introduction the "first," or an intentional obfuscation, as some critics suggest?[179] Friends of Crichton's may well take umbrage at Pinel's elision of his eighteen-page analysis of the Inquiry in the Introduction to the second edition of the Traité. Might he have gone to the extraordinary length of calling his second Introduction the "first" in order to wipe out all memory of his early enthusiasm for Alexander Crichton, at least in the minds of French readers? Whatever the answer, Pinel's main motivation seems clear: he wished to appear as the prime analyst of the passions, and the young Esquirol echoed his thought.

There is enough internal evidence in these French physicians' writings, however, to permit the conclusion that it was Crichton who drew their attention to recent German medical research and publications. He helped introduce them to concepts such as Blumenbach's Bildungstrieb, Reil's Lebenskraft, and Schelling's Naturphilosophie and, more generally, to contemporary German scholarship in anthropology, natural history, and psychology, with its emphasis on developmental change, instincts, drives, and irrational forces that impel man as a biologic entity and over which he has little control.


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In his biographic sketch of Esquirol mentioned earlier, Henri Ey points to his countryman's deep sympathy for German thought, a set of convictions whose origins puzzle Ey. He alludes to Esquirol's "probable meeting" with J. C. Heinroth in Paris and comments that "agreement in their way of thinking was so fundamental" that no actual encounter was needed because their publications express the "similarity of their human and scientific convictions."[180] An even closer link that Ey might have mentioned exists through J. C. Hoffbauer, who annotated the second German translation of Crichton's book and whose treatise on legal psychiatry Esquirol commented on in turn, in the 1827 French edition.[181] Heinroth and K. W. Ideler explored the relationship between religion, morality, and psychiatry—as did Esquirol, who also shared a fascination for the "passions" with J. C. Reil and a lifelong involvement in asylum administration with J. G. Langermann. There is not room here to explore the "meeting of minds" to which Ey alludes, however rewarding this exploration would be.

This essay is merely designed to underline the importance of Alexander Crichton, who drew the attention of Pinel and Esquirol to German scholarship in psychology and psychiatry at the turn of the nineteenth century. He thus helped open the French medical world to the influence of German thought and served as unwitting ambassador of German medical Romanticism, from Gtttingen to Paris.


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Nine Mind and Body in the Clinic: Philippe Pinel, Alexander Crichton, Dominique Esquirol, and the Birth of Psychiatry
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