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22. PineL - Unchains the Insane

COMMON DENOMINATIORS of those men who have significantly contributed to the progress of Medicine seem to have been: imagination to conceive a regimen contrary to tradition; courage to effect nonconformist procedures; and skill to carry these to a conclusion sufficiently successful to convince doubters and to confound detractors. Possessed of such qualities was Philippe Pinel, eighteenth century French physician, to whom insane patients seemed not freaks or subhuman creatures but ordinary people badly in need of compassion, care, and medical treatment. Pinel felt that treatment must include large measures of patience and of understanding rather than punishment and cruelty.

Medicine in general had its renaissance in the sixteenth century; but at this period progress in psychiatry was abortive. Well into the nineteenth century they were treated, not as sick patients, but like animals or criminals. Restriction by chains and manacles, while customary, perhaps was among the more humane methods of treatment. Incarceration in dank, sunless dungeons was the lot of many patients. Cruel beatings, cold dockings, violent purges, emetics, and physical humiliation were routine. Seldom visited by physicians, the insane were subject to the whims, caprices, and sadisms of ignorant keepers; frequently they were nursed by hardened criminals or put laws impressed from nearby jails.

The latter years of the eighteenth century witnessed a great philosophical movement called the Enlightenment. They true birth of psychiatry paralleled this movement. It was then that a limited number of humanitarian physicians removed chains from the insane. Among them were: Abraham Joy of Geneva, in 1787; Vinecnzo Chiarugi of Toscana in 1788; Pinel of Paris, in 1793; and the Quaker, William Tuke, of York, in 1796. Of these, Pinel was the most influential: his action became most widely known, and his philanthropic and humanitarian gestures, resulting from an advanced understanding of mental disease, were further developed by his pupils and by his pupils’ pupils. From Pinel’s leadership there grew the great French school of psychiatry, which included such physicians as Esquirol, Ferrus, Bayle, Calmeil, Falret, Ballenger, Moreau, and others.

Philipe Pinel was born April 20, 1745, in St. Andrew d’ Alayrac, a small village in southern France. Originally studying to be a priest, he switched to medicine to become a physician, like his father and his grandfather. At Toulouse, he took an exceptional interest in mathematics, in which subject he earned his degree of Master of Arts. He received his medical degree in 1773. Continuing his studies, he spent five years at the University of Montpellier.

Coming to Paris in 1778, Pinel did not begin the practice of medicine for some years, but found himself a modest place in the Latin Quarter, where he earned his living by tutoring in mathematics and by doing medical literary work. He was a frequent visitor to the private hospital of Dr. Belhomme, where mental patients were treated. Having established a minor literary reputation, he was invit3ed to edit the Gazette de Sante. He continued to write and to contribute articles to publications, therein revealing a growing interest in problems of mental disease.

Philippe Pinel has been described as shy, modest, studious, and inertial; and as moral, moderately pious, and conservative. The rational, the scientific, the orderly, and the logical, appealed to him. He was polite, composed, matter-of-fact; yet quick witted and forceful when occasion demanded.

To have lived in Paris during the last quarter of the eighteenth century and the first quarter of the nineteenth century meant to have lived in the very center of a cauldron seething with politics, intrigue, violence, and history. Many of Pinel’s colleagues and contemporaries lost their lives in the rapid changes in power during those revolutionary years. Pinel had to be present, in line of duty, at the execution of Louis XVI: he served in medical positions of trust during the Revolution and through the Terror; he saw Napoleon come and go and served equally well under the restored Bourbons. He was honored and decorated for excellence of service by each of these conflicting governments; yet he remained true to his convictions and steadfast in his efforts to obtain better care for the mentally ill and to relieve them of their afflictions.

As the French Revolution increased in intensity, some of Pinel’s friends became politically influential. These officials united in requesting the studious physician to assume charge of the Bicetre, a combination of prison and insane asylum for men. The decree appointing Pinel was published August 25, 1793. The conditions he found there were almost beyond imagination. Disorder, irresponsibility, and penetrated patients, Pinel was informed that he could not carry out his plan without permission of the Bureau Central and authorization of the Commune. Pinel personally made his plea to these authorities. How ever, almost everyone in power was suspicious of his fellow officers; and there was fear that political enemies might be hidden among Pinel’s patients. After personal investigation, Couthon, president of the Commune, granted permission for Pinel’s experiment but with an implied question as to Pinel’s own sanity in attempting to release “these animals.” Pinel quietly replied, “It is my conviction that these mentally ill are intractable only because they are deprived of fresh air and their liberty.”

Chains were removed first from a small number of patients. The favorable results justified Pinel’s beliefs. Release; treatment like human beings; fresh air and exercise; baths and good food; and above all, pertinence, kindness, firm authority, and an understanding search for the roots of the problems that disturbed these patients, resulted in recoveries of many who once were considered hopeless.

In addition to supervising the Bicetre, Pinel was appointed professor of medicine, December 4, 1794, in the new medical school created by the government. This post he retained until he was “purged” as a liberal in 1822.

His work only well under way after two years at the Bicetre, Dr. Pinel was called upon in 1795 to become administrator of the Salpetriere. This institution, today a hospital community of some 6,000 patients and attendants, originally was called the Petit-Arsenal, of Salpetriere, because saltpeter for the Royal Army’s gunpowder was made there; but by command of Louis XIV in 1656 it was converted into a hospital for indigents. In 1660, it was made an asylum for madwomen.

Working with women patients at the Salpetriere, Pinel again put ideas into effect-again in the face of considerable opposition. Chsains and fetters were removed from patients. Pinel had to reorganize and train nurses, guards and medical personnel. Added to these difficulties. Politically the times were growing nap less turbulent. Disturbances, bloodshed, social and personal uncertainty, all kept pace with revolutionary upheavals, the chaos if rapid changes of government, and the rise of Napoleon. Despite these difficulties, Pinel persisted, developing his psychiatric techniques to meet new situations as they arose.

His mathematically trained mind was of great advantages to Pinel in his work at the Bicetre and at the Salpetriere. He began first to keep notes for has win use, then developed and introduced permanent, systematic case records-setting the pattern for what is now the measure of good mental hospital administration. He was first to demonstrate by personal example the value of good research within the hospital.

Pinel’s assistant at the Bicetre was a man named Jean-Baptiste Pussin, who had an unusual ability to handle mentally ill patients and who has been referred to as the first psychiatric nurse. Pinel put great trust in him, and left him in charge as supervisor at the Bicetre. Later, Pussin was to rejoin Pinel in the sane capacity at the Salpetriere.

Philippe Pinel continued to work, and to receive honors, until 1823, when he suffered an incapacitating cerebral hemorrhage. On October 25, 1826, another such attack ended his life.

Through Pinel’s writings on classification of disease (Nosographie philosophique) and his publications on psychiatry (Traite medico-philosophique surla nmanie, which, in second edition, was titled Traile medico-philosophique sur l’ alienation mentale) were well known, their importance pales in comparison with Pinel’s work in development of hospital reform and of reorganization. These forward steps, made in such uncertain times, established new traditions and opened new perspectives for practical psychiatric treatment and for research in psychiatry. In addition to illustrious students who carried on his work, Pinel’s son, Scipion Pinel, followed in the footsteps of his fatter and became a prominent psychiatrist in his own right. A nephew, Casimir Pinel, was a leading psychiatrist in the middle of the nineteenth century. Armand Semelaigne, the first psychiatric historian, was married to Casimir’s daughter; and their son, Rene Semelaigne, devoted thirty-five years to psychiatric history before his death in 1934.

Perhaps Phililippe Pinel’s [hilosophy of handling mental patients is best summed up in a statement of his own in the introduction to the first edition of his Traite; “The habit of living constantly in the midst of true insane, of studying their habits, their different personalities, the objects of their pleasures or their dislikes, the advantage of following the course of their alienation day and night during the various seasons of the year, the art of directing them without effort and sparing them excitement and grumbling, the gift of being able to subdues them by force if methods of kindness fail, the constant picture of all the phenomena of mental alienation, and finally the functions of supervision itself-the combination of all of these must give an intelligent and zealous man an immense number of facts and minute details usually lacking in a narrow-minded physician unless he has taken a special interest during fleeting visits to asylums . . . I abandoned the dogmatic tone of the physician; frequent visits, sometimes lasting, several hours a day, helped me to familiarize myself with the deviations shouting, and madness of the most violent maniacs . . . I take careful notes on the facts observed.”

Pinel was best known to his contemporaries as the professor of internal medicine whose Nosographie philosophique was the bible in Parisian medical circles for twenty years. Today, however, he is remembered first of all as a great psychiatrist: a nab who not only loved his patients and believed that they might be cured, but who replaced vain theories and classifications with exact observations, and who, acting upon the basis of these observations, was better able to help mental patients than anyone before him. He transformed insane asylums from ignominious dungeons into instruments of therapy. He abolished not only chains but many other violent and deleterious forms of treatment, such as severe bleeding, submersion in water, and heroic dosage with medicines. These illogical methods he replaced with: proper physical care; classification and separation of patients for specialized treatment; psychological measures; and work therapy. His employment of statistics as a means of objectively evaluating procedures; his courage to record failures as well as successes; his ethical stature-these all combined to make Pinel a worthy successor to the ancient master of medicine whom he greatly admired-Hippocrates.