He Unlocked the Chains of the Insane, Then Built Psychological Ones
Pinel cut Bicêtre's annual mortality rate from 50% to under 13% in a year, mostly through cleanliness; but he denied organic brain causes, and Foucault accused him of replacing iron chains with psychological ones.
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The argument · tap a timestamp to hear it
No license is what forced the case-file system into existence
The medical degree Pinel earned in Toulouse only allowed him to practice in Toulouse, so after arriving in Montpellier and then Paris he could not practice directly. During his four years in Montpellier he instead visited hospitals repeatedly, talked with patients at length, and took copious notes, organizing the information into detailed records. Because he followed the same group of patients over a long period, he could observe how illnesses evolved and thereby identify patterns in their course. This ‘observe—record—track’ method was later carried to Bicêtre, where it became the prototype for building a file on every patient, recording age, temperature, diagnosis, and even comparing patient temperatures against the temperature of the building.
— Holly FreyClassifying the insane with plant taxonomy
The seventh ward at Bicêtre held 200 men judged to be insane, many chained in extremely small rooms with only enough chain to shuffle around inside. Pinel communicated closely with the director, Jean-Baptiste Poussin, gathered as much patient information as possible, organized it into tables, and transferred his knowledge of plant classification to the problem, trying to build finer diagnostic categories rather than simply lumping people together as ‘mad.’ He did not call patients ‘mad’ or ‘insane’ but said they were in a state of ‘mental alienation’—estranged from their own reason.
— Tracy V. WilsonMortality fell from 50% to under 13%
Pinel put a concrete set of practices in place at Bicêtre: moving patients out of prison-style confinement into rooms with as much natural light as possible; no longer using chaining as a routine measure; establishing hygiene standards for the institution; having patients take regular hot baths; and providing what today would be called occupational therapy to help patients overcome the obstacles of daily life. Within a year, the institution's annual patient mortality rate fell from 50% to under 13%. The show states plainly that this was largely just a matter of keeping patients and the environment clean—where disease is spreading, without cleanliness there is no control. In addition, a considerable share of patients were able to return to life outside the institution, whereas at the time the expectation for most people entering an asylum was to die inside it.
— Holly FreyHe measured skulls to prove phrenology was garbage
Pinel recorded age, temperature and diagnosis for every patient, and also measured skulls. This was not because he believed in phrenology—quite the opposite: phrenology was just taking shape during his main working period, built on the craniology that originated in Austria in the 1790s, which held that a person's tendency to violence or madness could be read from the shape of the head. Pinel considered the whole thing useless, and he collected skull measurements precisely to falsify it. He later wrote that the data seemed to confirm his earlier view: strong mental emotions are the most common cause of insanity, and the skulls of the mad have no special conformation not found in any other skull picked at random.
— Tracy V. WilsonHe did not unlock everyone's chains
The image of ‘Pinel breaking all his patients' chains and turning prisoners into patients’ needs discounting. A famous late-19th-century painting by Tony Robert-Fleury depicts him removing chains, and it shows the women's institution. But he did not release every patient bound in irons: where he judged that loosening them would create danger, patients remained confined and tethered. In the paper he read in 1794 he gave several cases of men he called ‘agitated and violent,’ one of whom had been chained for more than forty years. He described their behavior in detail to explain why irons were needed, and wrote that one of the basic principles for dealing with the insane was ‘a judicious mixture of affability and firmness,’ avoiding unnecessary coercion and using only as much force as was needed to restrain them.
— Holly FreyHe denied brain pathology, and that is a real flaw
One of the long-standing criticisms of Pinel's work is that he ignored the physiological causes of mental health problems. His writing discusses at length how life events worsen mental conditions, yet never considers bodily causes—which is strange, because writing on the physiological causes of mental illness goes back to Hippocrates and Galen, and in Pinel's own time Lavoisier, along with his university colleague Michel-Augustin Theret, were already discussing brain chemistry. In 1801 Pinel explicitly argued against bodily causes of madness, writing that ‘the derangement of the understanding is generally considered as the result of an organic lesion of the brain, and consequently as incurable; a supposition that is contradicted by a great number of anatomical facts.’ The show says directly: he was completely wrong on this point.
— Tracy V. WilsonThe ‘Citizen, I am convinced’ story may be invented
In 1849 Chambers' Edinburgh Journal published a story about Pinel, sourced to Pinel's son Scipion Pinel—who also became a psychiatrist. The story goes that during the Terror, a Paris Commune official named Georges Coudon came to Bicêtre hunting ‘traitors feigning madness,’ and after seeing the chains, the filth and the howling madness with his own eyes, asked Pinel whether he himself was mad for wanting to unchain these people. Pinel is said to have replied: ‘Citizen, I am convinced that these madmen have become so unmanageable only because they have been deprived of air and liberty.’ The show says this sounds very cool and very clever, but whether the story is true we do not know—it may be family legend, or it may have been made up by an editor. It certainly added bricks to Pinel's 19th-century legend.
— Holly FreyFoucault: iron chains were swapped for psychological ones
Pinel's writing and work have been argued over almost continuously for nearly two hundred years. Supporters point out how progressive his work was and how many of his ideas still matter today. One particularly forceful critic was the 20th-century philosopher Michel Foucault. Foucault argued that Pinel may have removed the physical shackles from patients, but only replaced them with psychological shackles, describing his work as a form of ‘moral imprisonment’ in which patients were manipulated in subtler ways through treatment. By Foucault's logic, in becoming obedient to the doctor, patients became estranged from themselves. The show also notes that this line of argument in Foucault has problems of its own.
— Tracy V. WilsonIn their own words · checked verbatim
In the course of a year under his leadership at Bicetre, the hospital saw the annual patient mortality rate drop from 50% to less than 13%.
Holly Frey10:22
But what really set Pinnell apart, and the reason that he's so frequently referred to as the father of modern psychiatry, was action. He made the leap from theorizing about this to actually practicing it.
Tracy V. Wilson18:40
one of the fundamental principles of the conduct one must adopt toward the insane is an intelligent mixture of affability and firmness.
Holly Frey22:47
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.
Tracy V. Wilson27:53
Foucault argued that though Pinel might have done away with physical shackles for his patients, he merely replaced them with psychological shackles, describing his work as a, quote, moral imprisonment in which those in treatment were controlled with more subtle forms of manipulation.
Tracy V. Wilson32:59
Brilliant observation plus neglect of basic science. In this, we find the glory and the weakness of the Paris Clinical School.
Tracy V. Wilson34:01
It is for this reason that Pinel is not truly modern. Pinel has sometimes been praised as a practical man who had too much sense to waste time spinning philosophical systems. To praise him thus is to praise him for his defects.
Tracy V. Wilson35:01
Figures
| Total patients at Bicêtre | about 1000 | 6:14 |
| Men judged insane in Bicêtre's seventh ward | 200 | 7:16 |
| Change in Bicêtre's annual patient mortality rate under Pinel | from 50% to under 13% | 10:22 |
| Share of patients Pinel claimed in 1794 to have restored by his methods | one eighth | 12:27 |
| Total patients at Salpêtrière | 8000 | 16:34 |
| Length of time one of the agitated men Pinel cited had been chained | more than forty years | 21:46 |
| Year Pinel received the French Legion of Honor | 1804 | 29:55 |
Glossary
- mental alienation
- Pinel's term for the patient's state of estrangement from their own reason, used to avoid the word ‘mad.’
- moral treatment
- Pinel's therapeutic system; a literal translation, but it actually refers to care at the psychological level, with no moral judgment implied.
- nosography
- The study of classifying diseases and symptoms, which Pinel used to write his textbook.
- phrenology
- The pseudoscience holding that character and mental tendencies can be judged from skull shape; Pinel opposed it.
- Thermidorian Reaction
- The events of summer 1794 that ended Robespierre's Terror and Jacobin rule.
How to listen
Listeners interested in medical history, the history of psychiatry, social reform and institutional design; founders and policy observers who want to understand how a humanitarian reform gets amplified by institutions and then criticized.
The last roughly three minutes are a listener letter about a dog chewing the floor, unrelated to the topic.