Apr 202019

Today is the birthday (1745) of Philippe Pinel, a French physician who was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients than was previously available. He also made notable contributions to the classification of mental disorders. Pinel was born in Jonquières, in the modern department of Tarn in the south of France. He was the son and nephew of physicians. After receiving a degree from the faculty of medicine in Toulouse, he studied an additional four years at the Faculty of Medicine of Montpellier. He arrived in Paris in 1778. He spent fifteen years earning his living as a writer, translator, and editor because the restrictive regulations of the old regime prevented him from practicing medicine in Paris. The faculty did not recognize a degree from a provincial university like Toulouse. He failed twice in a competition which would have awarded him funds to continue his studies. In the second competition, the jury stressed his ‘painful’ mediocrity in all areas of medical knowledge, an assessment seemingly so grossly incompatible with his later intellectual accomplishments that political motives have been suggested. Discouraged, Pinel considered emigrating to America. In 1784 he became editor of the medical journal Gazette de santé, a four-page weekly. He was also known among natural scientists as a regular contributor to the Journal de physique. He studied mathematics, translated medical works into French, and undertook botanical expeditions.

At about this time he began to develop an intense interest in the study of mental illness. The incentive was a personal one. A friend had developed a ‘nervous melancholy’ that had ‘degenerated into mania’ and resulted in suicide. What Pinel regarded as an unnecessary tragedy due to gross mismanagement seems to have haunted him. It led him to seek employment at one of the best-known private sanatoria for the treatment of insanity in Paris. He remained there for five years prior to the Revolution, gathering observations on insanity and beginning to formulate his views on its nature and treatment.

Madame Helvétius

During the 1780s, Pinel was invited to join the salon of Madame Helvétius.  After the revolution, friends he had met at Madame Helvétius’ salon came to power. In August 1793 Pinel was appointed “physician of the infirmeries” at Bicêtre Hospital. At the time it housed about four thousand imprisoned men—criminals, petty offenders, syphilitics, pensioners and about two hundred mental patients. Pinel’s patrons hoped that his appointment would lead to therapeutic initiatives. His experience at the private sanatorium made him a good candidate for the job.

Soon after his appointment to Bicêtre Hospital, Pinel became interested in the seventh ward where 200 mentally ill men were housed. He asked for a report on these inmates. A few days later, he received a table with comments from the “governor” Jean-Baptiste Pussin. In the 1770s Pussin had been successfully treated for scrofula at Bicêtre; and, following a familiar pattern, he was eventually recruited, along with his wife, Marguerite Jubline, on to the staff of the hospice.

Appreciating Pussin’s outstanding talent, Pinel virtually apprenticed himself to the unschooled but considerably experienced custodian of the insane. He wrote that he wished to “enrich the medical theory of mental illness with all the insights that the empirical approach affords”. He practiced a strict, nonviolent, nonmedical management of mental patients that came to be called “moral treatment” or “moral management,” though “psychological” might be a more accurate term.

Although Pinel always gave Pussin the credit he deserved, a legend grew up about Pinel single-handedly liberating the insane from their chains at Bicetre. This legend has been commemorated in paintings and prints, and has lived on for 200 years and is repeated in textbooks. In fact, it was Pussin who removed the iron shackles (but sometimes using straitjackets) at Bicêtre in 1797, after Pinel had left for the Salpêtrière. Pinel did remove the chains from patients at the Salpêtrière three years later, after Pussin joined him there.

While at Bicêtre, Pinel did away with bleeding, purging, and blistering in favor of a therapy that involved close contact with and careful observation of patients. Pinel visited each patient, often several times a day, and took careful notes over two years. He engaged them in lengthy conversations. His objective was to assemble a detailed case history and a natural history of the patient’s illness.

In 1795, Pinel became chief physician of the Hospice de la Salpêtrière, a post that he retained for the rest of his life. The Salpêtrière was, at the time, like a large village, with seven thousand elderly, indigent, and ailing women, an entrenched bureaucracy, a teeming market and huge infirmaries. Pinel missed Pussin and in 1802 secured his transfer to the Salpêtrière. It has also been noted that a Catholic nursing order actually undertook most of the day to day care and understanding of the patients at Salpêtrière, and there were sometimes power struggles between Pinel and the nurses.

Pinel created an inoculation clinic in his service at the Salpêtrière in 1799, and the first vaccination in Paris was given there in April 1800. In 1795 Pinel had also been appointed as a professor of medical pathology, a chair that he held for twenty years. He was briefly dismissed from this position in 1822, with ten other professors, suspected of political liberalism, but reinstated as an honorary professor shortly thereafter. In 1794 Pinel made public his essay ‘Memoir on Madness.’ In it Pinel makes the case for the careful psychological study of individuals over time, points out that insanity isn’t always continuous, and calls for more humanitarian asylum practices.In 1798 Pinel published an authoritative classification of diseases in his Nosographie philosophique ou méthode de l’analyse appliquée à la médecine. Although he is properly considered one of the founders of psychiatry, this book also establishes him as the last great nosologist of the 18th century. While the Nosographie appears completely dated today, it was so popular in its time that it went through six editions between its initial publication and 1818. Pinel based his nosology on ideas of William Cullen, employing the same biologically-inspired terminology of ‘genera’ and ‘species’ of disorder. Pinel’s classification of mental disorder simplified Cullen’s ‘neuroses’ down to four basic types of mental disorder: melancholia, mania (insanity), dementia, and idiotism. Later editions added forms of ‘partial insanity’ where only feelings were affected rather than reasoning ability.

In his book Traité médico-philosophique sur l’aliénation mentale; ou la manie, published in 1801, Pinel discusses his psychologically oriented approach. This book was translated into English by D. D. Davis as a Treatise on Insanity in 1806, although Davis substituted Pinel’s introduction for his own, leaving out among other things Pinel’s strong praise for Alexander Crichton. Pinel’s book had an enormous influence on both French and Anglo-American psychiatrists during the 19th century. He meant by “alienation” that the patient feels like a stranger (alienus) to the world of the ‘sane’. A sympathetic therapist living in that world might be able to journey into the patient’s experience, understand the ‘alienated’, their language, and possibly lead them back into society.

In 1802 Pinel published La Médecine Clinique which was based on his experiences at the Salpêtrière and in which he extended his previous book on classification and disease. Pinel was elected to the Académie des Sciences in 1804 and was a member of the Académie de Médecine from its founding in 1820. He died in Paris in 1826.

The central and ubiquitous theme of Pinel’s approach to etiology (causation) and treatment was “moral,” meaning the emotional or the psychological not ethical. He observed and documented the subtleties and nuances of human experience and behavior, conceiving of people as social animals with imagination. Pinel noted, for example, that: “being held in esteem, having honor, dignity, wealth, fame, which though they may be factitious, always distressing and rarely fully satisfied, often give way to the overturning of reason”. He spoke of avarice, pride, friendship, bigotry, the desire for reputation, for conquest, and vanity. He noted that a state of love could turn to fury and desperation, and that sudden severe reversals in life, such as “from the pleasure of success to an overwhelming idea of failure, from a dignified state—or the belief that one occupies one—to a state of disgrace and being forgotten” can cause mania or ‘mental alienation’. He identified other predisposing psychosocial factors such as an unhappy love affair, domestic grief, devotion to a cause carried to the point of fanaticism, religious fear, the events of the revolution, violent and unhappy passions, exalted ambitions of glory, financial reverses, religious ecstasy, and outbursts of patriotic fervor.

Pinel developed specific practical techniques, rather than general concepts and assumptions. He engaged in therapeutic conversations to dissuade patients from delusions. He offered benevolent support and encouragement, although patients who persistently resisted or caused trouble might be threatened with incarceration or punishment if they were not able to control themselves. Pinel argued that psychological intervention must be tailored to each individual rather than be based solely on the diagnostic category, and that it must be grounded in an understanding of the person’s own perspective and history. He noted that “the treatment of insanity (l’aliénation mentale) without considering the differentiating characteristics of the patients [la distinction des espèces] has been at times superfluous, rarely useful, and often harmful”, describing the partial or complete failures of some psychological approaches, as well as the harm that the usual cruel and harsh treatments caused to patients before they came to his hospital. He saw improvement as often resulting from natural forces within the patient, an improvement that treatment could at best facilitate and at worst interfere with.

Pinel generally expressed warm feelings and respect for his patients, as exemplified by:

I cannot but give enthusiastic witness to their moral qualities. Never, except in romances [novels], have I seen spouses more worthy to be cherished, more tender fathers, passionate lovers, purer or more magnanimous patriots, than I have seen in hospitals for the insane, in their intervals of reasonableness and calm; a man of sensibility may go there any day and take pleasure in scenes of compassion and tenderness.

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 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.

At the most trivial level it ought to be obvious that mental health and diet are linked. When I am not feeling well mentally, I consult my acronym F.E.D.S (Food Exercise Dehydration Sleep). 99% of the time one of these factors is out of whack. In this case, “Food” does not mean that I should eat anything, but that something is out of kilter in what I am eating. Often I am running low on something. I’m not going to make some major claim about specific foods and mental wellbeing. It’s complicated. The usual suspects do show up, however — foods rich in omega-3 fatty acids (cold water fish, seaweed, and walnuts), whole grains, lean protein, leafy greens, and fermented foods with active cultures (yogurt, kefir, kimchi, tempeh etc.) – and are shown to contribute to healthy mental states in one way or another. Walnuts on the list caught my attention, because even in Pinel’s day they were considered “brain food” because they look like brains (well – a little). Walnuts in a salad with leafy greens and maybe some sliced chicken dressed with yogurt would make a great combination of a number of healthy ingredients.