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PHILIPPE PINEL (1745-1826) arrived in Paris, France, in 1778 after completing his medical studies in Toulouse and Montpellier. He tutored mathematics, translated medical texts, immersed himself in the study of natural history and the new empirical epistemology of John Locke and of Etienne Condillac, and edited the Gazette de santé (Journal of Health). The mismanagement of a friend's melancholia, leading to his death, stimulated Pinel's interest in mental illness. Subsequently, he worked as a consultant at a private psychiatric clinic in Paris.1(pp68-69) He expressed interest in the psychological effects of popular treatments, such as those of Anton Mesmer ("medicine of the imagination"), without endorsing their explanations.1 In 1793, appointed physician of the infirmaries at Bicêtre, a public hospice for men just outside of Paris, he brought the revolutionary inspiration of the Rights of Man, declared by the French National Assembly in 1789, to the destitute.
Charles Louis-Muller (1815-1892), French. Pinel Orders the Chains Removed From the Insane at Bicêtre, 1849. Oil on canvas. Copyright Bibliothèque de l'Académie Nationale de Médecine, Paris, France. Transparency obtained was produced from a photograph of the painting taken by J. L. Charmet, Paris.
The hospice contained 4000 residents. There were convicted criminals, political prisoners held by lettres de cachet (imprisoned without trial on the authority of the king), beggars who simulated disease to arouse pity, patients with physical handicaps, epilepsy, or chronic illness, and elderly men; among them, 200 were characterized as insane. These men lacked fresh air and sunlight in their cells, slept in beds made of straw, and received only 1 meal each day. The most violent were chained to poles or ceilings. The few attendants were generally trained only in the use of force and punishment.
Pinel commenced his work during the First French Republic in the midst of the Reign of Terror. His elder son, Scipion Pinel (1795-1859), told a dramatic story in a memorial address to the French Academy of Medicine in 1836 about how his father had approached Georges Couthon, a leading member of the Committee of Public Safety, in 1792 asking to remove the chains from the insane. The paralytic Couthon came to inspect the "wild beasts," questioning Pinel's sanity for making the request and warning him, "[W]oe to you if you hide enemies of the people."2 Scipion reported that more than 50 patients with various diagnoses were released from chains. The historian Dora Weiner, quoting French sources,3,4 states that there is not a shred of truth to this story. There is no evidence that Couthon visited Bicêtre or was even in Paris at the time. In Pinel's textbook Treatise on Insanity,5 he clearly credits Jean Baptiste Pussin, governor of the ward for the insane at Bicêtre, with this innovation. Pussin dates the abolition of the chains to 17976; it was an empirical application of the moral (psychological) treatment initiated by Pinel. Pussin also forbade physical punishment by staff and thereafter used straitjackets for restraint. Pinel used Pussin's experience in developing his approach to treatment but "put order and precision into [Pussin's] observations"5(pxlvi,xlix); Pinel subsequently eliminated the chaining of women at the Salpêtrière Hospice in Paris.
In 1849 during the Second French Republic, a time of renewed revolutionary vigor, Charles-Louis Muller (1815-1892) was commissioned by the Academy of Medicine in Paris to create a heroic painting of Philippe Pinel for its meeting room. The painting is probably based on Scipion Pinel's suspect memorial address and his own heroic painting of his father. Muller had previously painted scenes from the French Revolution; his best-known work is Last Roll Call of the Victims of the Terror. A student of Antoine-Jean Gros, he may have modeled the composition on Gros' Napoleon's Visit to the Plague House in Jaffa, which shows Napoleon touching a patient who has been infected with the plague. Pinel is shown in a similar posture to that of Napoleon, depicting science overcoming ignorance.
In a touching scene, the painting shows Pinel liberating the insane from their chains (le geste de Pinel).3 He stands with young physicians and associates in a courtyard of Bicêtre with the Paris skyline in the background. He orders a man, possibly Pussin, to file off the iron cuffs holding the remaining chains to a frail elderly man's arm. To the far right, a man dressed in rags points to his once-bound wrists; yet another holds his shackles high in the air. Others—tormented, disabled, or cognitively impaired—express amazement at Pinel's humanitarianism.3 Some are being helped to walk after periods of long confinement. Jean-Etienne-Dominique Esquirol, Pinel's successor, stands at Pinel's right intently observing the proceedings; with a red notebook and quill in hand, he documents Pinel's activities. Although this painting is not historically accurate (the liberation did not occur in 1792, and Esquirol, never at Bicêtre, did not arrive in Paris until 1799), le geste de Pinel signifies Pinel's far greater therapeutic contribution: the introduction of his moral (gentle but firm, and psychologically sensitive) treatment.
He said that if the physician engages the healthy part of the personality in treatment, a cure is sometimes possible. Indeed, in his first year at Bicêtre, Pinel reported that 25 of the 200 patients recovered. Pinel's psychological approach to treatment represents a paradigm change1 in the treatment of mental illness; we struggle, even today, to fully implement his humane vision.
Harris JC. Pinel Orders the Chains Removed From the Insane at Bicêtre. Arch Gen Psychiatry. 2003;60(5):442. doi:10.1001/archpsyc.60.5.442
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