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Philippe Pinel as an Eighteenth Century Physician

Philippe Pinel as an Eighteenth Century Physician

Edward M. Brown M. D.

1. Towards an Historical Pinel.

Philippe  Pinel, along with  Sigmund Freud, has been one of the great icons in the history of psychiatry. The great symbolic value of such icons necessarily renders an historical understanding of them difficult. Idealizing admirers war against vilifying detractors. 1  The time for debating whether Pinel was a great humanitarian or an agent of social control has, however, passed. 

In recent years we have been fortunate that historians have done much to establish a rich and complex picture of Freud in his historical context. The same is true in the francophone world for Pinel.  Very little of what Pinel wrote, however, has been translated into English and relatively little scholarship establishing  a picture of the intellectual framework out of which his contributions to psychiatry emerged has been done in English. I would agree with the late George Mora, who, in his Review of Dora Weiner's fine biography of  Pinel, which incidentally is still only available in French, urged  anglophone scholars to begin  building on her outstanding work  "toward the delineation, as in the case of Freud, of a 'historical Pinel [BHM, 74.4 (2000) 827-829].'

2. Influences.

In attempting to place Pinel in historical context I want to something other than itemize influences on his thought and practice. Twentieth century scholars have explored these. Walthar Reise has emphasized the ties between Pinel and Condillac. Jackie Pigeaud, stressed the influence of ancient authors, especially Cicero, on Pinel’s thought about the passions. 2  Describing the various influences separately creates  images of Pinel as a scholar, humanist and even a philosopher. Without disputing this images, I would would like to consider Pinel as an eighteenth century physician, which I believe allows a more coherent approach to his thought and work.   Considering Pinel as an eighteenth century physician will allow one to better appreciate how his most important  achievements --the concepts of moral treatment and the curability of madness-- emerged from eighteenth century medicine. 

Putting Pinel's achievements in historical context necessarily involves assessing his relationship with Jean-Baptiste and Marguerite Jubline Pussin, the lay caretakers, whose work with patients at Bicêtre and Salpêtrière Pinel carefully observed and described. At one extreme the myth of Pinel the philanthropist, whose greatest achievement was liberating the insane from their chains,  ignored the contribution of the Pussins. Fortunately this myth has been put to rest through the work of the French psychiatrist Gladys Swain and the American scholar Dora Weiner, who  conclusively demonstrated that the story of Pinel unchaining the insane was  fabricated by Pinel's son Scipion, and was never claimed by Pinel himself.3   More recently, the importance of the Pussins' contribution has been emphasized and  Pinel has been seen as virtually an apprentice. Unfortunately this view has led to minimizing Pinel’s contribution to, as  Jan Goldstein has put it,  merely upgrading moral treatment as practiced by the Pussins’  "to a level suitable to a medicine with scientific pretensions [Goldstein, 1987, 89]." This effort to minimize Pinel’s contribution, however,  begs the question of how Pinel was able to see the pragmatic interventions of the Pussins as a medical treatment in the first place and  makes light of  the fact that Pinel was a very well educated eighteenth century physician who saw what he observed through the lens of that education.  Without an understanding of the  influence of his medical education on his ideas it is impossible to see Pinel historically.

3.Pinel’s Agenda 2

When Pinel arrived at Bicêtre in 1793,   he was a  48 year-old physician.  It is safe to say, therefore, that he did not arrive  as a tabula rasa, but rather as someone with  strong intellectual commitments and something of an agenda.  He made a clear  distinction between his educated background and that of the  lay caretakers, who he nonetheless respected greatly and observed carefully. In a passage which lists what he most valued from his medical education he wrote:

"Can empirics …, deprived of preliminary knowledge of the human intellect,  put order and precision  into their observations, or even into a language able to present their ideas? Can they distinguish one  species of aliénation from another and characterize it by the bringing together  several observed facts? They will never become able to tie the experience of centuries past with the phenomena that strike   their  eyes, of retreating to the limits of a philosophical doubt in uncertain cases and adopting a firm and sure procedure to direct their researches, no less that to dispose of a series of objects in systematic order [tam1, xlvi]. " 

From this passage one can see that from the beginning of his tenure at Bicêtre Pinel’s approach to understanding and treating the insane was very much colored by his medical education. 

Born in 1745 in the south of France, Pinel received his medical degree from the University of Toulouse and in 1774 he went to Montpellier, where he spent the next four years pursuing graduate studies. This move from Toulouse to Montpellier was of enormous significance for Pinel's education. As Dora Weiner has written, "To go from Toulouse to Montpellier in the 1770s, was to leave a city where a strict theology predominated for a great city rich in traditions and in worldly relations; it was to go from a mediocre school of medicine to the oldest and most distinguished faculty of medicine in France, dating from the XIII century and enriched by greco-roman, judeo-christian and arabic traditions [Weiner, 1999, 40, my translation]." Deciding to go to Montpellier for graduate study in the 1770s also meant choosing  a very distinctive form of medical education.

3. Pinel’s achievement b 2.

Pinel's education at Montpellier  had, I will argue, two important consequences: first that  Pinel sought to emulate Hippocrates' practice  and second that he subscribed to a  set of  psychophysiological theories usually referred to as Vitalism.  That Pinel emulated Hippocrates meant that he valued careful clinical observation, believed in the healing powers of nature, practiced expectant treatment and was predisposed to see the passions as important contributors to health and disease.  That he subscribed to the particular psychophysiological theory that was taught at Montpelier meant that even before he started his work at Bicêtre he was inclined to see mental illness, “as a crossroad", an intersection of diverse pathologies including psychological as well as physiological factors [rey, 2000, 229]. 

5. 18th Century  Paradigms.

Medical education in the eighteenth century varied greatly from one medical school to another in a way that is radically different from what we have become accustomed to. With the decline of humoralism in the seventeenth century physicians no longer had a general theory with the kind of explanatory flexibility that they needed to make sense of the many conditions they treated. Broad principles about how the body worked and what caused disease were in dispute. Different schools of thought and practice operated according to almost incommensurable paradigms. In the early eighteenth century  two contending schools of thought dominated the debate. They were the iatromechanists, who, influenced by Descartes and Newton, saw the body as operating like a machine and the so-called Animists who insisted that the soul governed all the functions of the body.  Starting in the 1730s a third perspective, generally referred to as Vitalism, began to develop at the Montpellier medical school.

6. The influence of Vitalism.

The Montpellier vitalists had enormous  influence in the late eighteenth century.  They provided medical care for the leading aristocrats as well as royal clients. They also contributed numerous articles in Diderot and d'Alembert's encyclopedia on many of the most important topics in the health sciences. Collectively these articles served as a virtual medical textbook of the period.  The status and currency of the ideas which originated in Montpellier throughout the late eighteenth century would have made it hard for Pinel to avoid their influence long after he left that city. Indeed it was not only Pinel was influenced by Montpellier vitalism. Pinel's friend the medical theoretician Pierre-Jean-Georges Cabanis, who wrote the influential On the Relations between the Physical and the Moral Aspects of Man, as well as  Pinel’s student Xavier Bichat, who as much as anyone, influenced the transition from the ‘modern physiology' of the eighteenth century to that of the nineteenth were also influenced by these ideas. 

7.Montpellier Hippocratism.

During the  late 17th century a hippocratic revival began in France and doctors at Montpellier were prominent in promoting it. They did this not out of antiquarian motives, but because they saw hippocratic ideas as fitting well with and supporting other features of their overall program4 .  The first dimension  of Montpellier hippocratism, was its commitment to the careful description of individual cases and the use of these case descriptions to generalize about disease. Montpellier doctors used Hippocrates to contrast their  commitment to epistemological  empiricism  to the errors of building abstract systems based on limited data, relying on dogma and authority and having recourse to philosophy or theology. Montpellier doctors readily adopted the principles of  Locke and Condillac, which reinforced their hippocratic views 5 .  The success of natural historians like Buffon provided contemporary exemplars, while Hippocratic case descriptions were regarded as models  and hippocratic aphorisms as ideal distillations of specific clinical observations.  As one Montpellier physician put it in his article ‘Observateur’ in the Encyclopédie, “The designation ‘observer’ is an honorable title in medicine 6 .” The beautiful case descriptions that color all of Pinel's work show clearly that he prided himself on being an "observer."

12. Research Program 2.

The careful description of cases was, however,  more than  mere data gathering.  It represented a system of diagnosis and treatment.  In the way natural historians classified plants and animals, doctors like Pinel carefully combined their descriptions of symptoms  into  case histories,  which they combined  into natural histories of diseases and then classified  as species. Armed with a table of species  or a Nosography, a physician could determine the type of illness a new patient suffered from and deduce the proper treatment for that patient. This system, inspired by Hippocrates, was proposed by Sydenham in the seventeenth century and initiated at Montpelier by Boissier de Sauvages in the 1730s 7 . Although Pinel was critical of Boissier's Nosography, he remained deeply committed to this nosographic way of thinking about disease throughout his life [citation]. [Cabanis on nosographie]] In the 1798 he produced his own Nosographie Philosophique, which served as a virtual textbook of internal medicine for many years.  He brought this orientation with him to Bicêtre in 1793.

13. Healing Powers of Nature 2.

The second dimension of Montpellier hippocratism  was the idea of the healing powers of nature  [Moravia, 1972, 1099]8 .   Montpellier doctors argued that iatro-mechanists had betrayed the heritage of Hippocrates by neglecting the individual patient in favor of mechanical universals [Williams, 2002, 159]. By contrast Montpellier doctors saw illness  as a struggle between the  patient and some disturbing agent.  Health was restored when and if the healing powers of nature were able to overcome this agent. A corollary of this view was that the physician’s role was  not to fight disease, like war, with his full armamentarium of medications, but rather to support nature in its healing efforts [Pinel, Nosographie philosophique, 1810, cxvii].  The physician’s role was to observe the course of an illness to determine when and how his intervention might be most helpful. This was known as expectant treatment. 

14.Expectant Treatment 2.

Practicing expectant treatment  required considerable sophistication. Pinel argued that it was not simply a matter of  two styles of practice, active and expectant, but rather that an observant doctor  distinguished between  diseases which are most appropriately treated actively and those which are best treated expectantly. In this view  strong medications were reserved for  situations that were regarded as virtually hopeless  [Weiner, 2003, 704]. According to Pinel, Hippocrates carefully distinguished between the signs of an illness that indicated a fatal outcome from those that did not.  Even when severe and frightening, symptoms ought to be regarded as the salutary efforts of nature in its struggle against powerful harmful influences, rather than purely passive derangements of the body. Pinel would bring these ideas about the healing powers of nature and expectant treatment to Bicêtre and the care of the insane.

8. Vitalism.

The second component of a Montpellier medical education that Pinel absorbed was a particular theory of  psychophysiology, sometimes referred to as Vitalism. The vitalists, in contrast to the iatromechanists and animists saw the organs of the body themselves as centers of activity.   They argued  that the automatic, or what we would call autonomic, activities of the organs of the body were governed by a vital principle, the specific nature of which they could not describe. Health for the Vitalists was an equilibrium between the activity of the organs and illness an imbalance. This was as true of mental illness as it was of physical illness. Certain regional centers such the head, the epigastrium and the pelvis were  of particular importance in vitalist physiology. The epigastrium was regarded as a center with reciprocal connections to many other organs. As a result of this the epigastrium was, in the words of a Montpellier doctor,  "excited by the different sensations that make us experience our needs and by the concern with which we try to provide for them [Encyclopédie, 5, 792]." Its role in exciting the passions  was of particular importance to Pinel because as "everyone" knew "… annoyance, sadness and even pleasure and joy make a sensible impression on the cavity of the stomach." 

My views about how seriously Pinel took this psychophysiology and how important it was to his ideas differ from the views of other scholars. While Paul Bercherie has argued that  Pinel's originality lay in the gap he allowed between observation and explanation, I would suggest that this explanatory physiological model was important to Pinel.  Moreover while this psychophysiology has been dismissed by Jacques Postel  as  a pathogenic metaphor, and  as a  “phantasmagoric physiology" by Swain and Gauchet [epigastrium malingering], I would argue that taking these peculiar eighteenth century ideas, which Pinel referred to as "modern physiology," seriously allows one to better understand how  Pinel could see mania as curable and could establish the possibility of psychological treatment. 

 15. Pinel remembers Montpellier.

Looking back at age 67 on his years at Montpellier, Pinel remembered working very hard to absorb as much of what Montpellier had to offer as he could. … [Weiner, 1999, 40-1]. In 1778 after four years at Montpellier, Pinel made his way to Paris, learning English, so the story goes, from a fellow student as they walked across France. When Pinel reached Paris, he was unable to obtain a medical license and spent the next fifteen years teaching mathematics, translating English texts, and editing a medical journal. Between 1783 and 1788 he also worked at a maison de santé, which provided care for mentally ill relatives from wealthy families. It was only in 1793 at the height of the Terror that he was appointed physician to the Bicêtre. While he was influenced by many other things during this fifteen year period, his early exposure to the distinctive ideas taught at Montpellier shaped his reception of those ideas and prepared him to take up his responsibilities at Bicêtre  .

16. Pinel at Bicêtre 2.

When Pinel was appointed physician to the St. Prix ward at Bicêtre in August 1793, he found a ward reserved for two hundred mentally ill men who had not responded to a course of  biological treatments offered at the Hôtel-Dieu and were regarded as incurable. Fortunately the ward  had been very well managed for some time before Pinel's arrival by the lay caretakers, Jean-Baptiste Pussin and his wife Marguerite Jubline Pussin.  It was  orderly, clean, and  treatment was non-violent [Weiner, 1979, 1128-1134].  The Pussins resorted to a variety of strategies to control unruly patients, including stern warnings, the manipulative use of food and privileges, and physical restraints, as well as various coups de théâtre designed to shock patients out of their morbid ways of thinking.  While this strict nonviolent, non-medical management of mental patients came to be called “traitement morale,” in France, perhaps, given its largely custodial intent, it might have been more appropriately referred to, as was done in  England, as   moral management . [Weiner, 1990, 346]. It was Pinel’s interpretation of moral management that saw it as a treatment of an illness.

17. Ideal setting 2.

Because this ward was so well run it provided an ideal setting for Pinel to implement the kind of empirical approach he had learned at Montpellier. Active treatment, in the form of drugs, could be used very sparingly both because they had been tried at the Hôtel-Dieu and failed and because the patients were so well managed by the Pussins. Pinel  states a number of times he was pleased not to have to use medications because their use  would distort the natural progression of the illnesses he wanted to study. Because Pinel did not have to manage the patients he was able  to adopt an expectant attitude towards the patients and utilize the same method of observation that he had seen used in Montpellier. As he stated it, "I took daily notes on the observed facts with the sole aim of having as many accurate data as possible. Such is the course I have followed for almost two years, in order to enrich the medical theory of mental illness with all the insights that the empirical approach affords. Or rather, I strove to perfect the theory and to provide practice with the general principles that it lacked [Trans. D. Weiner, from Pinel, 1801, xlviii-xlix]. 

. Diagnosis.

While at Bicêtre Pinel adopted the conventional classification of mental disorders: mania, melancholia, dementia and idiocy. This did not mean that he was uninterested in improving the quality of psychiatric diagnosis. He observed patients of all types and carefully described the course of their illnesses . Following the procedures of natural history he attempted to describe individual cases in ways that would allow for generalizations. He described external signs and physical changes and attempted to correlate these with “lesions” of the intellectual or affective faculties. He described facial features, gestures and movements in order to predict attacks of mania. He relied on physiognomy to characterize the stage of the illness and even noted the shape of the skull [Pinel, 1801, lv]. He also attempted to determine a patient’s temperament by observing such physical features as hair color and physique. Temperament was clinically important because Pinel believed, for example, that a patient with a sanguine temperament could be predicted to become unusually dangerous when he was attacked with mania [Pinel, 1801, 89]. 

18. interest in mania 2.

  Pinel’s  attention was primarily drawn to mania. While he regarded the other  categories of insanity as more or less incurable, mania seemed to clearly demonstrate the healing powers of nature at work.   Mania presented very dramatic changes from wild, frenzied behavior to periods of calm and even to apparent cures. To Pinel this seemed to show nature struggling to overcome some harmful influence. He distinguished between two forms of mania: continuous and intermittent. The former is characterized by continuity during the greater part of life with a slow but uninterrupted progression, while the latter presents with long remissions and relapses at regular or irregular intervals [Postel, 1998, 233]. It was intermittent mania that became his model for understanding mental illness and its treatment [Postel, 1998, 216, 230]. 

19. interest in curability 2.

Pinel brought his interest in curing madness to Bicêtre. Such an interest was consistent with his vitalist mentors concern with helping patients overcome the influences that disturbed their health.  Pinel’s personal experience, however,  was crucial. In the early 1780s a friend had become insane. This friend had been treated unsuccessfully with the standard medications at the Hôtel-Dieu, after which no one, including Pinel, could provide adequate supervision, and eventually, the friend wandered off into a forest where he was apparently killed by wolves. Pinel repeated the moving story of his friend’s illness and death, thinly disguised as a case history, in both editions of his Treatise on Insanity. In response to his grief Pinel took a position, illegally, at Belhomme’s maison de santé, where he spent five years, between 1783 and 1788, vainly trying to learn about treating the mentally ill. When appointed to Bicêtre, he noted that the division for madmen attracted his special attention because having had some prior experience with the mad he "felt the strong urge to try every means of restoring alienated reason [Postel, 1998, 231]." This interest in the curability of madness colored what he saw at Bicêtre. 

20. Pathological anatomy 2.

As a physician Pinel was interested in making arguments for the curability of madness that other physicians would accept. Among these arguments was his rejection of the idea that insanity was due to a defect in the brain and his insistence that it was a “nervous disease.” Prior to his assignment to Bicêtre, he states that he believed that much information about the causes of mental illness could be derived from an examination of the pathological state of the brain and its membranes [tam1, 133]. He rejected the work of several well known writers such as Bonnet, Morgagni and Meckel that supported the idea of a relationship between defects in the brain and insanity. On the one hand his position was ethical. He opposed such views because he believed that they led to the prejudice that mental illness is incurable and resulted in the sequestering of the mad from society and denying them the care their disability demanded [tam1,106, tam2, ¶157]. On the other hand his position was empirical and methodological. He had not found such lesions in his observations and, he argued,  the methods others used to establish the presence of pathological lesions in the brains of the mentally ill were faulty. [citation]

21. Nervous excitation.

Having rejected the opinions of others and finding, himself, that comparing patients symptoms with "the results of the opening of  bodies,"  never showed indications of  "general or partial irritation of the substance of the brain,"  Pinel concluded that it was clear that  mania is in general a nervous illness [tam1, 159]." Clinical observation showed that these patients experienced a "strong nervous excitation, a new development of vital energy."  As evidence of this nervous excitation, in the manner of a nosogrpaher, he pointed to "their continual agitation, their furious cries, their impulsive acts of violence, their stubborn wakefulness, their animated gaze, their ardor for the pleasure of love, their petulance, their lively repartees, their belief in the superiority of their own strength  [tam1, 159]." In addition this strong nervous excitation gave rise to   "a new order of ideas, which were “independent of impressions of the senses," as well as "new emotions without any real cause and all sorts of illusions [tam1, 159].[citation] Given these symptoms of nervous excitation, Pinel concluded, one should not be astonished that expectant medicine most often suffices to produce a cure [tam1,159].

22. Mania like Fever.

Pinel’s approach to diseases through the description of  external signs and  natural histories led him to understand mania by analogy with  intermittent fever. He argued that  "when one compares attacks of intermittent insanity with the violent  symptoms of an acute illness, one finds a striking analogy in the ways of nature." Drawing on a corollary of the idea of the healing powers of nature Pinel, like his teachers at Montpellier, believed that diseases passed through phases, which were marked by critical days, that often involved an intensification of symptoms [citation]. He felt that an intensification of manic symptoms could mark a crisis which heralded the resolution of an attack, and consequently did not see such an intensification of symptoms as an occasion for the use of bleeding or “antispasmodic” medications. He argued that  "it would be  be a mistake … to measure the gravity of the danger  by the extent of the trouble and derangement  of the vital functions. …a serious condition may forecast  recovery, provided one practices prudent management [Postel, 1998, 234]".    Over the years Pinel increasingly came to see the natural history of mania as occurring in phases. The importance of separating patients in one phase of the illness from those in another became an important principle of moral treatment.

23. Cause of Mania.

Having established to his own satisfaction that mania was not due to an organic lesion, but was rather a “nervous disorder” that resembled an intermittent fever in its progression, Pinel  considered the cause of mania. One well known view of madness, that of John Locke, argued that madmen  “do not appear …to have lost their faculty of reasoning , but having joined some ideas very wrongly, they mistake them for truths; and they err as men do that argue right from wrong principles [Berrios, 1996, 88].” Pinel was well aware of Locke’s ideas, not to mention those of his French counterpart Condillac. Nonetheless he asserted the primacy of medical over philosophical knowledge. “One can have a just admiration for the writings of Locke,” he wrote, “and agree, however, that the ideas that he gives on mania are very incomplete, when he regards it as inseparable from delusion [délire]. I thought like this author, myself, when I took up at my research on this illness at Bicêtre, and I was not a little surprised to see several madmen [aliénés] who offered at no time any lesion of the intellect, and who were dominated by a sort of instinct of furor, as if the affective faculties alone were damaged [Tam1, 149-50].” This observation led to Pinel’s most memorable diagnostic innovation: Manie sans Délire

24. Crichton and Physiology.

While Pinel may have been surprised by this observation, he did not lack a framework with which to interpret this finding. In the preface to the first edition of his Treatise on Insanity Pinel devoted seventeen pages to reviewing  the work of the little know Scottish physician Alexander Crichton. He expresses admiration for Crichton’s “profound work, [which is] full of new results of observation according to the principles of modern physiology.” What he admired about Crichton was that he "raised a vast perspective that the metaphysician or moralist cannot reach…[that is] a consideration of human passions regarded as simple phenomena of the animal economy, without any idea of morality or immorality…."  In short  Pinel saw Crichton supporting his view that the passions should be studied not as a metaphysician or a moralist, but as a doctor and a natural scientist. Pinel goes on to add that it was his own task to   "give an exact idea of the development and effects of the human passions on the animal economy…as the most common cause of the disruption of our moral faculties." Since we know that three of the major sections of Pinel's Treatise were published  before Crichton's book, it seems clear that Pinel  found  Crichton a kindred spirit who articulated ideas similar to the “modern physiology” that guided Pinel's own study of mental alienation.

25. Passions and mania.

Pinel saw  the passions in mania as a somatic force that rose up and overwhelmed the intellect. In manie sans délire a patient’s mania might result from a healthy intellect simply being overcome by passion. Other types of mania might result from individual faculties of the intellect such as judgment, imagination or attention being swamped. The importance of the passions in producing mania seems to have grown in Pinel’s mind. In the second edition of his Treatise on Insanity  he went so far as to classify  the passions that disturbed the mind. Spasmodic passions such as anger and terror can be  lead to madness.  "Repeated outbursts of anger,” Pinel points out, “are always harmful to judgment …, and an extreme irascibility is sometimes the prelude to alienation or disposes strongly to contracting it [tam2, ¶32]."  In the case of debilitating passions such as grief he notes that "Reason can sometimes struggle with more or less advantage against adversity and yield only to  profound and repeated impressions of a bitter sorrow [tam2, ¶35]. In regard to what he calls  expansive passions he adds that “A very lively joy and an unexpected state of prosperity can strongly shake weak minds and lead to derangement of reason [tam2, ¶44].”

27. passions psychosomatic.

Pinel saw the passions as what we would call psychosomatic phenomena. Like his teachers at Montpellier he regarded them as one of the six hippocratic non-naturals, that is to say, external influences on health. In this view well being could be attained by a program of hygiene that governed diet, rest, pleasure and, notably, discouraged intense of emotion from any source [Williams, 1996, 217]. Pinel saw the passions as arising "when our primary desires or our aversions experience obstacles or are not satisfied." He felt that we experienced the passions differently from our primary desires. While "the desire for nourishment is accompanied by a disagreeable sensation in the stomach," for example, passions are experienced in" the precordial region." Furthermore the passions were not stimulated only by the frustration of our basic needs but also by a list of human needs that include "the esteem of men, honors, awards, wealth, celebrity… [which]   are always irritated and rarely satisfied,  often giving rise to the overturning of reason …. " These were the “moral” causes of insanity.  Pinel’s case histories are replete with examples of how these “causes morales” lead to madness.  

28. Passions & epigastrium 2.

While Pinel’s emphasis on these “moral” causes of madness  has led his approach to be regarded as “psychological,” it is important to note that he saw moral causes as operating through a psychosomatic mechanism. Indeed, as the late Kathleen Grange argued in 1961,  “emotional” rather than “psychological” might be a better English translation for the French word “moral.” Passions, or emotions, to speak anachronistically,  might arise from the desire for esteem or wealth but they acquired their force through the action of the epigastrium. To understand this role of this peculiar idea in Pinel’s thinking one must recognize that he accepted  the vitalist theory that an antagonistic relationship between different regions of the body that provides a physiological framework for  the passions  to overwhelm the intellect. 

Vitalist psychophysiology claimed to show how experiences of profound sorrow or overweening greed could create passions whose seat was in the epigastrium where they interacted with the organic functions of the body… [Boury, 2004, 145-6]. From there the passions could rise up to overwhelm the intellect. One influential vitalist compared the passions to wind in a sail, necessary to move forward, but potentially disastrous in a storm.  While this “phantasmogoric physiology” of the passions was superseded early in the nineteenth century, it is worth noting that it made sense in the symptom based medicine of the eighteenth century. Indeed, even today people often feel that their passions reside in their chests and stomachs.  

28. Prodromal symptoms.

Pinel adopted this vitalist physiology insisting   that  "the seat of periodic mania … is almost always in the epigastric region, and that the attack of mania is propagated  from this region, as if by irradiation [tam1, 16-18]."  In taking  this physiological position Pinel was drawing  on the symptoms reported by his patients. He was particularly impressed by the consistent sequence of signs that he observed at the onset of an episode of mania. He noted that in the prelude to an attack of periodic mania patients "complain of a tightening up  in the region of stomach,  disgust for some foods, stubborn constipation, a sensation of heat in the bowels, which they try to relieve with cooling drinks. They experience agitation, vague worries, panic, insomnia. Soon after, the disorder and trouble with ideas are indicated externally by strange gestures, peculiarities of expression and movement, which cannot fail to strike the observer tam1, 16-18]." As Pinel saw it careful observation showed the passions literally rising up to overwhelm the mind.

29.Passions and therapy.

Another experience that persuaded Pinel of the central importance of the passions in understanding mania was his observations on their role in treatment. As early as 1783 he described a case of a man who was about to kill himself by jumping off the London Bridge when he was accosted by thieves. The fear and rage stimulated by his effort to escape from them was so intense, Pinel felt, that it completely overcame his desire to destroy himself and resulted in a permanent cure. Pinel repeated this case history many times. When he arrived at Bicêtre  Pinel saw the coups de théâtre performed by the Pussins as the result of one passion overcoming another. In the case of a man who would not eat because he believed that the only way to escape the torments of the next life was “to emulate the abstinence and mortification of the ancient anchorites,” for example, Pinel asked rhetorically, “Could the sinister course of his ideas be destroyed or counter-balanced by any other means  than by frightening him profoundly?”

This interpretation of the shock value of the passions in the treatment of mania was consistent with vitalist ideas about the treatment of disease. “In mania,” a Montpellier doctor wrote in the encyclopédie, “therapy is directed to the body, in which it aims to produce a shock and a deep disturbance [encyclopedie, x 33b].”  Pinel himself   praised the sixteenth century physician Jan Von Helmont’s recognition that  to cure a patient of the dominant idea that has penetrated his being, "one must destroy it or counterbalance it by another still stronger [principle][Pinel, 1801, xvii]."  While Pinel never advocated the deliberate use of such shock therapy, his student Esquirol made it the centerpiece of his notion of moral treatment.

. Passions and Psychology. To summarize,

Pinel was, as I hope I have shown, a man of his times, whose observations and explanations were colored by late eighteenth century ideas about mind and body. He observed patients carefully and described the course of their illnesses. In mania he saw a disease that could be intermittent, like certain fevers. He noted evidence of great nervous energy  and when he failed to find evidence of organic lesions in the brains of those patients who died, he concluded that mania was a nervous disease.  He understood intermittent mania as the result of the intellect being temporarily overwhelmed by passions arising outside of the brain, in the epigastrium. He believed that he saw evidence that, just as strong passions could cause mania, other passions might lead to its cure. 

What he did with these observations and explanations, however, was, as the late psychiatrist, Gladys Swain pointed out, extraordinary and even revolutionary. Pinel’s understanding of mania as the result of the intellect being overwhelmed by the passions, which had a distinct site of origin in the epigastrium, allowed him to see the mind, though “altered, perverted or annihilated” as still potentially intact.  It allowed him to adopt a new attitude towards  patients that assumed that even in the midst of an attack of mania patients retained some self-awareness, or what we might call an observing ego. 

The case of the patient who sought to emulate the anchorites by refusing to eat demonstrates this new change in attitude toward the mentally ill that was perhaps Pinel’s greatest achievement.  Citizen  Pussin came to the patient’s  cell during the night and threatened him with cruel treatments if he did not eat by morning. Pussin “left him  in a most painful state of mind, fluctuating between the idea of the punishment which menaced him and the frightening prospect of the torments of the afterlife. After an inner struggle of several hours, … he decided to take his nourishment” and this led to his recovery. What is most striking about this case presentation is its final sentence [which interestingly Jan Goldstein fails to quote.] “It was,” Pinel concludes, “during his convalescence that he often confessed to me his cruel agitations and his perplexities during the night of his test [tam1, 59]." I would argue that listening to this patient recount the torments of that night marked a revolution in psychiatry that Pinel’s medical education prepared him to make.