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Man is born free; yet everywhere he is in chains.—Jean-Jacques Rousseau, 17621
AT THE TIME of the French Revolution and the Napoleonic Empire, Philippe Pinel (1745-1826) became physician of the infirmaries at Bicêtre (1793-1795), physician-in-chief at the Salpêtrière Hospice (1795-1826), professor at the Paris Health School, and personal physician to Napoleon. A clinician and researcher, his best-known works are Philosophic Nosography(6 editions; 1798-1818), Treatise on Insanity (2 editions; 1800 and 1809), and Clinical Medicine (1802, 1804, and 1815). He distinguished 4 broad groups of mental disorders: melancholy, mania, dementia, and mental retardation. Pinel showed great compassion toward his patients and sought to integrate mental illnesses into medicine. His humane approach led to later efforts on behalf of the rights of citizens with mental illness, those involuntarily confined, and those claiming innocence of crimes by reason of insanity, all issues involving the Rights of Man. He brought an empirical approach to psychiatry and proposed that in the natural history of mental illness, each illness "represented the intersection of a human being at a specific moment in life with a disease at a particular stage of its development,"2(p726) a harbinger of modern developmental and genetic medicine that asks why a person develops a specific illness at a particular time in his or her life.
Pinel Délivrant les aliénées. 1878. Color lithograph, after the painting by Tony Robert-Fleury (1837-1911), French. Copyright Bibliotheque des Arts Decoratifs, Paris, France/Archives Charmet/Bridgeman Art Library.
Pinel's earliest formulation of his approach to mental illness is found in his Memoir on Madness, which he read to the Society for Natural History in Paris on December 11, 1794. Based on his experience at Bicêtre, it was an appeal to the Revolutionary government to build facilities where mentally ill patients could receive humane treatment. He searched for "fixed principles derived from nature on which to base management and supervision."2(p728) He reported,
The idea of madness should by no means imply a total abolition of the mental faculties. On the contrary the disorder usually attacks only one partial faculty such as the perception of ideas, judgment, reasoning, imagination, memory, or psychological sensitivity.2(p729)
He introduced his model for psychological treatment, discussing the principles of the humane method that made him the founder of psychiatry in France. Pinel emphasized that the patient must be engaged psychologically in treatment. The physician must understand the natural history of the disease and any precipitating events and, based on this knowledge, prepare an accurate case history.
In May 1795, Pinel was assigned chief physician at the Salpêtrière, the women's hospice in Paris. The Salpêtrière was nearly twice the size of Bicêtre; it housed 6700 destitute women, most of whom were elderly and infirm, and served as a women's hospital, prison, and shelter for pregnant young women.3 There were mentally ill, cognitively impaired, blind, and physically handicapped residents. Pinel screened patients and triaged those amenable to psychological treatment to a special teaching ward. He created the model of a hospital within a hospice, preferring that persons with mental illness be housed in a general hospital setting. Pinel freed the women from chains and instituted reforms with the assistance of Jean Baptiste Pussin and Madame Marguerite Jubline Pussin, who had been transferred to Salpêtriere from Bicêtre.
At the beginning of the Third Republic (1878), the Salpêtrière commissioned Tony Robert-Fleury, a specialist in history and genre scenes who was influenced by realism and impressionism, to paint Pinel freeing the women from their chains. Robert-Fleury had won a medal of honor at the Paris Salon in 1870 for his Last Days at Corinth and had painted characters from the French Revolution (Charlotte Corday at Caen, 1874).
Rather than the heroic gesture shown in Charles-Louis Muller's painting of Pinel,4 in this painting, Pinel stands quietly to the left of center, cane in hand. A young woman kneels to his right and kisses his hand in gratitude. Guards, matrons, and other officials surround him. The left half of the painting is peaceful with men and women calmly looking on; a woman holds an infant or a doll, and a man grasps a book, perhaps a hospital registry, under his arm. In the background 2 women, unrestricted in their movements, descend the stairs. In the center, a woman stands in tattered clothing reminiscent of revolutionary dress while an attendant, perhaps Pussin, removes the last of the chains around her waist; other chains lie in a pile on the ground. A concerned woman at Pinel's left, possibly Madame Pussin, observes. The right side of the painting exemplifies the turmoil of the hospice. Chains are attached to vertical iron bars. Under the roof, women appear anxious and distraught as they sit waiting for their release. An agitated woman strains forward in her chains. A woman seems preoccupied and frowns; another lies on the ground convulsing, or possibly in a hysterical fit. An older woman extends her arms out to her in consolation. The patients seem naturally disposed, when treated humanely, to help one another.5
Harris JC. Pinel Delivering the Insane. Arch Gen Psychiatry. 2003;60(6):552. doi:10.1001/archpsyc.60.6.552
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