|Fig 1. Portrait of Philippe Pinel by Anna Mérimée. 1826. Public domain. From Wikimedia.|
“It is perhaps not going too far to maintain that Pinel has been to eighteenth-century psychiatry what Newton was to its natural philosophy and Linnaeus to its taxonomy.”
-George Rousseau, Historian, 1991
Although modern treatment of mental illness has its limitations, older methods of treatment were both crude and cruel. For centuries they were rooted in notions of madness inflicted by the Hellenic gods, medieval demonic possession, sorcery, witches, and “furies of the womb.” During the seventeenth century Enlightenment, physicians started to suspect organic disorders of the brain as the cause of many mental disorders, including GPI and even hysteria.1 In this vein, Thomas Willis (1622-1675) and Thomas Sydenham (1624-1689) posited the notions of a “nervous distemper” or “spiritus animalis” (pneuma psychikon in Greek), which afflicted certain susceptible patients. By contrast, the prevailing alienists’ (psychiatrists’) view was that organic lesions did not cause symptoms of madness. They were confined.
Callous, merciless treatments of mental illness were designed to prevent violent outbursts of wildly disordered behavior that were common in both organic and psychotic conditions. The madman was a creature set apart, bestial rather than human.2
The asylums started as monasteries, which provided “asylum” or refuge, for the mentally ill. One of the oldest was Bethlem, which began in 1247 as part of the Priory of the New Order of our Lady of Bethlehem in London, near Bishopsgate. Asylums flourished in the eighteenth century as private institutions for the insane, affordable mainly for the wealthy. But treatments were violent and brutal: physical punishments, blood-letting, and purging were commonplace. Disturbed patients were confined against their will, often locked in a cell, placed in a straitjacket, or even chained to the walls. Alongside poverty-stricken vagrants and social delinquents they were upbraided and deprived of humane care. The social reformer Harriet Martineau (1802-76) described these conditions:
In pauper asylums we see chains and strait-waistcoats, three or four half-naked creatures thrust into a chamber filled with straw, to exasperate each other with their clamor and attempts at violence; or else gibbering in idleness or moping in solitude.
William Tuke (1732-1822) in York pioneered the humane treatment of the mentally ill. At the same time in Paris, Philippe Pinel (1745-1826) (Fig 1) also took a kinder, less cruel approach to treatment and furthered the understanding of mental illness.3 Pinel’s father, Philippe Francois Pinel, was a barber-surgeon, and his mother Élisabeth Dupuy’s family were doctors. He studied for the priesthood at Toulouse but changed course to follow his father in medicine, graduating in 1773.
|Fig 2. Pinel, Medecin en chef de la Salpêtrière. painting by Tony Robert-Fleury. 1876. From Wikimedia.|
He practiced in Montpelier, but in Paris was at first refused license to practice so he earned a living as a medical writer, translator, and mathematics tutor. In 1784 he was appointed editor of Gazette de santé, and troubled by a friend’s suicide concentrated on mental illness. From 1786 to 1793 he worked at the Maison de Belhomme, a private madhouse. Not until August 1793, aged forty-eight, was he appointed senior physician at the Bicêtre Hospital where hundreds of male patients included many diagnosed as insane. He was appointed professor of medical pathology and director at Salpêtrière Hospital in Paris in 1794.
The Bicêtre Hospital superintendent Jean-Baptiste Pussin (1746-1811) was the first to remove chains from patients on the mental ward. (Fig 2) Before him, at the Italian Santa Dorotea Hospital, Vincenzo Chiarugi instituted humanitarian reforms between 1785 and 1788.4, 5 Pinel continued these reforms6 and reduced the use of physical violence and bloodletting. He replaced dark, dirty cells with brighter rooms; patients were permitted to exercise outdoors. His son Scipion probably inflated his role as liberator of shackled prisoners; and it received sparse mention from Esquirol,6 who however, praised Pinel’s compassionate devotion to his patients, by which he explored their varied personal problems. He deliberately strived to persuade mad patients of the falsity of their delusional beliefs. In his Treatise on Insanity 1801, Pinel said:
Few subjects in medicine are so intimately connected with the history and philosophy of the human mind as insanity. There are still fewer, where there are so many errors to rectify, and so many prejudices to remove. Derangement of the understanding is generally considered as an effect of an organic lesion of the brain, consequently as incurable; a supposition that is, in a great number of instances, contrary to anatomical fact.3
|Fig 3. William Tuke. Etching by C. Callet. Wellcome Collection. (CC BY 4.0).|
Often critical of traditional methods and of his contemporaries, he described his approach in Traité médico-philosophique sur l’aliénation mentale ou la manie (1801), where he remarked:
“The managers [of asylums], who are frequently men of little knowledge and less humanity, have been permitted to impose a most arbitrary system of cruelty and violence on their innocent prisoners. However, experience offers ample and daily proofs of the happier effect of a mild, conciliating treatment rendered effective by steady and dispassionate firmness.”
“Far from being sinful people who deserve to be punished, the insane are sick people whose unhappy state deserves all of the sympathy that is owed to suffering humanity.”3
For Pinel “the passions” or emotional (moral)* excess were the most frequent cause of mental illness, insanity, and madness. He described his treatment of the mentally sick as “moral” rather than as “psychological” because he used the word moral to describe the emotional factors. 7
In 1797 he expanded his ideas: he classified illnesses into five groups, describing both symptoms and diseases—melancholia, non-delirious furor, delirium, dementia, and idiocy.8 He revolutionized the classification and concepts of mental illnesses. Jean Esquirol (1772–1840), who was his student, continued his work and established ten new mental hospitals.
In 1792 Pinel married Jeanne Vincent. They had two sons: Charles, a lawyer, and Scipion, who followed his father becoming a physician in mental health. Jeanne died in 1811 and Pinel in 1815 remarried—Marie-Madeleine Jacquelin-Lavallée. From 1805 he was physician to Napoleon Bonaparte, but rejected the offer of becoming court physician. He died aged eighty-one on October 25, 1826, in Paris and was buried in Père Lachaise Cemetery. His statue stands at the Salpêtrière.
The Tuke family
In the same era William Tuke (1732-1822) (Fig 3)—a York tea and coffee merchant—discovered in 1790 that Hannah Mills, a fellow member of the Society of Friends (Quakers), had died in the York Asylum, founded in 1777. There were suspicions that she had been maltreated and her friends had been prevented from visiting her. Likewise, at St. Luke’s Hospital in London he saw:
A young woman without clothing, and lay in some loose, dirty straw, chained to the wall. The form of this unhappy patient haunted him afterwards, and redoubled his exertions, until his plans were carried into practical effect.9
At the same time as Parisian reforms, Tuke decided in 1792 to create The Retreat, a more compassionate mental establishment in York, run by Friends for Friends. He raised funds, consulted widely with those working in mental illness, and visited several asylums to get practical ideas. When it opened in 1796 The Retreat offered very different, humane conditions with sound, caring medical treatment and minimal use of physical restraint. It was named moral treatment. At The Retreat this was influenced by Tuke’s religious precepts of the “divine art of healing.” In 1820, almost blind at the age of eighty-eight, William Tuke handed the management of The Retreat to his grandson Samuel Tuke (1784–1857), an influential Quaker minister and educationalist, who with his son, Dr. Daniel Hack Tuke (1827–1895) (Fig 4), furthered William’s work and publicized his achievements.10
|Fig 4. Daniel Hack Tuke. Etching by C. Callet. Wellcome Collection. (CC BY 4.0).|
In 1847 Daniel was appointed Retreat secretary and house steward. He then read medicine at St. Bartholomew’s Hospital, qualifying in 1852, followed in 1853 by the MD (Heidelberg), and FRCP (1875). In 1853 he worked at The Retreat as assistant medical officer, initiating written detailed patient histories. He started a course on psychological medicine at York Medical School, where Hughlings Jackson and Jonathan Hutchinson were students. With J. C. Bucknill, he wrote A Manual of Psychological Medicine (1858), which as a major textbook ran to four editions. He also wrote a larger two-volume Dictionary of Psychological Medicine (1892), and Chapters in the History of the Insane in the British Isles (London, 1882).11 He died of apoplexy in 1895.
The Retreat has changed with the times. The adult inpatient and residential services closed in 2018.
Pinel, and to a greater extent Tuke, drastically improved both the understanding and care of the mentally ill in a fashion that has continued despite the vagaries of community care. Other asylums were established at the Wakefield West Riding Pauper Lunatic Asylum (founded 1818) under Sir James Crichton-Browne;12 at The Lawn, Lincoln Lunatic Asylum (1819) under Dr. EP Charlesworth; and the Hanwell Pauper and Lunatic Asylum (1832) under Dr. William Ellis followed by Dr. John Conolly. Patients were given useful work, were well fed, and rewarded with activities such as plays and concerts.
However, class privilege was sometimes apparent. For example at Lincoln, “Patients were to be ‘persons of the superior class who shall contribute to the general expense . . . and persons in more limited circumstances whose payments shall be relieved, when opportunity may offer, out of the disposable funds of the charity.’” In the mid-nineteenth century, Dorothea Dix successfully led a similar campaign in American mental institutions.
The misuse of psychiatric diagnosis, treatment, and detention obstructing fundamental human rights is, of course, a related but separate unresolved problem.13
* This use of the word is still seen occasionally, as in: “healers . . . must stand by powerlessly as their patients sicken and die—a tragedy that can cause serious moral injury.” (V.J. Dzau, D. Kirch, and T. Nasca, 2020: https://www.nejm.org/doi/full/10.1056/NEJMp2011027)
- Pearce JMS. Hysteria before Charcot. In: Bogousslavsky J (ed): Hysteria The Rise of an Enigma. Front Neurol Neurosci. Basel, Karger, 2014; 35:1-10.
- Digby A. Changes in the Asylum: The Case of York, 1777-1815. In: The Economic History Review, New Series 1983;36 (2): 218-239.
- Pinel P. Traité médico-philosophique sur l’aliénation mentale ou la manie, Paris: Caille & Ravier, 1801 (an. IX) pp. xxxv, 80-1. translated by D. D. Davis, Cadell and Davies, London, 1806.
- Mora G. Vincenzo Chiarugi (1759–1820) and his Psychiatric Reform in Florence in the Late 18th Century: (On the Occasion of the Bi-centenary of his Birth). Journal of the History of Medicine and Allied Sciences 1959;14 (10):424–433.
- Pinel P. Famous Scientists. famousscientists.org. 20 Jun. 2016. Web. 4/29/2020 <www.famousscientists.org/philippe-pinel/>.
- Wiener DB. “Le geste de Pinel”: The History of a Psychiatric Myth. In: Micale MS, Porter R. (eds) Discovering the History of Psychiatry. Oxford, OUP 1994: 232-244.
- Grange KM. Pinel And Eighteenth-Century Psychiatry. Bulletin of the History of Medicine 1961;35(5):442-453.
- Pinel P. Nosographie philosophique ou La méthode de l’analyse appliquée à la médecine. [Volume 1] Maradan (Paris),1797.
- Tuke DH. William Tuke, the Founder of the York Retreat. Journal of Psychological Medicine and Mental Pathology 1855;8: 507–512.
- Tuke, Samuel (1813) Description of the Retreat (reprinted, London: Process Press, 1996).
- Tuke DH. Chapters in the History of the Insane in the British Isles (London, 1882) – Project Gutenberg Ebook Edition [#31185] 2010 – http://www.gutenberg.org/dirs/3/1/1/8/31185/31185-h/31185-h.htm.
- Pearce JMS. The West Riding Lunatic Asylum. Journal of Neurology, Neurosurgery & Psychiatry 2003;74:1141.
- Szasz T. Psychiatric diagnosis, psychiatric power and psychiatric abuse. Journal of medical ethics1994;20: 135-138.
JMS PEARCE, MD, FRCP, is emeritus consultant neurologist in the Department of Neurology at the Hull Royal Infirmary, England.