Philippe Pinel - Influence

Influence

Pinel is generally seen as the physician who more than any other transformed the concept of 'the mad' into that of patients needing care and understanding, establishing a field that would eventually be called psychiatry. His legacy included improvement of asylum conditions; broadly psychosocial (incl. milieu) therapeutic approaches; history-taking; nosography (the science of the description of syndromes); broadly-numerical assessments of courses of illness and treatment responses; and a record of clinical teaching.

Pinel's actions took place in the context of the Enlightenment, and a number of others were also reforming asylums along humanitarian lines. For example, Vincenzo Chiarugi, in the 1780s in Italy, removed metal chains from patients but did not enjoy the same renown bestowed on the more explicitly humanitarian Pinel who was so visible from late 18th century revolutionary France. In France, Joseph D'Aquin in Chambéry permitted patients to move about freely and published a book in 1791 urging humanitarian reforms, dedicating the second edition in 1804 to Pinel. The movement as a whole become known as moral treatment or moral management, and influenced asylum development and psychological approaches throughout the Western world.

Pinel's most important contribution may have been the observation and conviction that there could be sanity and rationality even in cases that seemed on the surface impossible to understand, and that this could appear for periods in response to surrounding events (and not just because of such things as the phase of the moon, a still common assumption and the origin of the term lunatic). The influential philosopher Hegel praised Pinel for this approach.

Pinel also started a trend for diagnosing forms of insanity that seemed to occur 'without delerium' (confusion, delusions or hallucinations). Pinel called this Manie sans délire, folie raisonnante or folie lucide raisonnante. He described cases who seemed to be overwhelmed by instinctive furious passions but still seemed sane. This was influential in leading to the concept of moral insanity, which became an accepted diagnosis through the second half of the 19th century. Pinel's main psychiatric heir, Esquirol, built on Pinel's work and popularised various concepts of monomania.

However, Pinel was also criticised and rejected in some quarters. A new generation favoured pathological anatomy, seeking to locate mental disorders in brain lesions. Pinel undertook comparisons of skull sizes, and considered possible physiological substrates, but he got bad press for his emphasis on psychology and the social environment. Opponents were bolstered by the discovery of tertiary syphilis as the cause of some mental disorder. Pinel's humanitarian achievements were emphasized and mythologised instead.

With increasing industrialization, asylums generally became overcrowded, misused, isolated and run-down. The moral treatment principles were often neglected along with the patients. There was recurrent debate over the use of psychological-social oppression even if some physical forces were removed. By the mid-19th century in England, the Alleged Lunatics' Friend Society was proclaiming the moral treatment approach was achieved "by mildness and coaxing, and by solitary confinement", treating people like children without rights to make their own decisions.

Similarly in the mid-20th century, Foucault's influential book, Madness and Civilization: A History of Insanity in the Age of Reason, also known as History of Madness, focused on Pinel, along with Tuke, as the driving force behind a shift from physical to mental oppression. Foucault argued that the approach simply meant that patients were ignored and verbally isolated, and were worse off than before. They were made to see madness in others and then in themselves until they felt guilt and remorse. The doctor, despite his lack of medical knowledge about the underlying processes, had all powers of authority, and defined insanity. Foucault also suggested that a focus on the rights of patients at Bicetre was partly due to revolutionary concerns that it housed and chained victims of arbitrary or political power, or alternatively that it might be enabling refuge for anti-revolutionary suspects, as well as just 'the mad'.

Others have argued that the manipulations and ambiguous "kindness" of Pinel and his contemporaries may nevertheless have been preferable to the harsh coercion and physical "treatments" of previous generations, while recognising its less benevolent aspects and potential to deteriorate into repression. Some have criticised the process of deinstitutionalization that took place in the 20th century and called for a return to Pinel's approach, so as not to underestimate the needs that mentally ill people might have for protection and care.