Pinel and the Unchaining of Asylum Patients — Moral Treatment and the 90 Percent Cure Rate, 1793–1877

This is the first part of a series on the history of psychiatry, and it begins in Paris at the end of the eighteenth century. The French physician Philippe Pinel (1745–1826) died 200 years ago this year. Textbooks remember him as the doctor who freed the mentally ill from their chains. The documents of the time give that scene a different lead. And the "moral treatment" that spread after the chains came off went on to produce a remarkable number — nine in ten patients cured — which one hospital superintendent sat down and recounted half a century later.

This series is a history of psychiatry. It is not advice on diagnosis or treatment. If you are struggling with your mental or physical health, please talk to a doctor or a support service. The text includes names of illnesses and expressions that are no longer in use; they are given as they appear in the sources of the time.

The doctor who struck off the chains

In 1793 Pinel became physician at Bicêtre, a public hospice for men on the edge of Paris, and he stayed until 1795. Among its inmates were people with mental illness who were kept in chains.

The scene the textbooks like goes like this. At the height of the French Revolution, Pinel had the iron chains taken off the patients. In France it is known as "Pinel's gesture."

In 1994 the American historian of medicine Dora Weiner examined the story as a psychiatric myth. As she put it, this scene is nearly all that most textbooks say about Pinel. Yet the documentary evidence does not support it. The story has survived anyway.

The man who removed the chains was the ward governor, Pussin

The decisive document turned up in 1978 in the French National Archives in Paris. Its title was "Observations of Citizen Pussin on the Insane," and its author was Jean-Baptiste Pussin, the "governor" in charge of the mental patients at Bicêtre.

Weiner, who found it, laid out the picture in a 1979 paper. It was Pussin who introduced Pinel to handling patients through the mind. It was also Pussin who took off the iron chains and replaced them with straitjackets, in 1797 — two years after Pinel had left Bicêtre. Pinel did the same three years later at the Salpêtrière, the public hospice for women, and later arranged for Pussin to be transferred there.

Pinel himself never hid any of this. In the introduction to his Medico-Philosophical Treatise on Mental Alienation, published in the Revolutionary year IX (1800–1801), he lists Pussin among the people most skilled at handling the insane. A footnote cites Pussin's observations as a nine-page manuscript in Pinel's own possession, dated the first of Nivôse, year VI — 21 December 1797.

In the body of the book Pinel praises the rules Pussin set at Bicêtre. Staff were strictly forbidden to lay a violent hand on a patient, even in retaliation, and anyone who broke the rule was dismissed for good. And the attendants were chosen from among patients who were recovering.

So the hero of the story was not the physician but the ward governor. And what followed the chains was not freedom from restraint. The chains gave way to the straitjacket.

Moral treatment: listening, and sometimes fear

Pinel's thinking is clearest in his "Memoir on Madness," read to the Society of Natural History in Paris on 11 December 1794 and first translated into English by Weiner in 1992. As its abstract summarises, Pinel begins by stating that mental illness is often curable. To reach a diagnosis, the physician must watch the patient's behaviour closely, question him, listen carefully, and take notes. And he urges the Revolutionary government to build asylums where the mentally ill could be treated decently.

This approach came to be called moral treatment. "Moral" here does not mean a lesson in right and wrong. It means treating the patient through feelings and thoughts rather than through drugs or procedures on the body. Pinel wrote that he attached little importance to medicines.

The means were not only gentle ones, though. Pinel's book offers this as a success. A man had stopped eating out of religious terror, and by the fourth day his life was in danger. One evening Pussin appeared at the door of his cell, eyes blazing, voice like thunder, surrounded by attendants rattling heavy chains. A bowl of soup was set down, and the man was ordered to eat it during the night or face the cruellest treatment. After hours of struggle he ate, and in time recovered his reason. Pinel explains that the man's gloomy ideas could be countered only by a strong and deep fear. The chains that had come off returned, as stage props for fear.

The York Retreat: treatment without knowing the cause

At about the same time, something else was beginning in England. In 1791 a woman belonging to the Quakers, the Society of Friends, was placed in an asylum near York. Her family lived far away and asked acquaintances in the city to visit her. The asylum refused, saying she was not in a fit state to be seen by strangers. She died within a few weeks.

The episode moved William Tuke and his fellow Quakers to propose an establishment of their own. It opened on 11 May 1796 as the Retreat. Samuel Tuke's account of it, published in 1813, sets out the rules. Neither chains nor corporal punishment were tolerated on any pretext. Patients were treated as rational beings, as far as their state of mind allowed. The woman superintendent sometimes invited the patients to a tea party, where they dressed in their best clothes and competed in politeness.

Fear appears here too. The account says that fear is rarely weakened by insanity, so it matters a great deal in managing patients. But it was not to be raised beyond what the ordinary rules of the house produced.

What stands out in Tuke's account is how it handles causes. Some held that insanity starts in the mind. Others held that an unseen, unknown bodily disease must always lie behind it. Whichever theory one adopts, Tuke argues, treating the mind is of very high importance. He adds that physicians are generally unable to find where in the body the disease sits. The cause was unknown, and the treatment was decided anyway. The method came before the understanding. This gap between what works and what is understood runs through the whole series.

"Nine in ten are cured"

Moral treatment crossed the Atlantic. In January 1833 Massachusetts opened its first state hospital for the insane, at Worcester. The annual reports of its first superintendent, Samuel Woodward, were striking. Among recent cases discharged, the proportion recovered was 90 percent in the seventh report, 64 of 70 — 91.42 percent — in the eighth, and 91 percent in the ninth, in late 1841. For cases of less than a year's duration, the nine-year average was given as 88 percent.

Other hospitals raised their figures in turn. In the 1842 report of the asylum at Williamsburg, Virginia, its superintendent John Galt described thirteen recent cases admitted that year: twelve had recovered (92.3 percent), and one had died. Leave that one case out of the count, Galt wrote, and the recoveries come to one hundred percent. Leaving the dead out of the reckoning was a practice Woodward had already used.

The numbers were used for money, too. Pennsylvania's Board of Public Charities assumed that 75 percent of those who had become insane between 1864 and 1873 could have been cured by early, proper treatment. On that basis it estimated that treating them would have cost about 4.7 million dollars less than keeping them in poorhouses.

1876: a superintendent counts again

The man who questioned these numbers was Pliny Earle, superintendent of the state hospital at Northampton, also in Massachusetts. He read his paper "The Curability of Insanity" to a meeting at Worcester on 14 December 1876, and published it the following April.

His first point was about counting. Hospitals were counting discharges, not people. Every time the same person was discharged as recovered, the tally rose by one. When the records of women patients at Worcester were reworked, 2,949 admissions turned out to be 2,255 people. Seven of the women had been admitted 106 times between them, and had been reported recovered 92 times — one of them 22 times. Yet two of the seven had died insane in the hospital, and a third was still there. At most four of them had made a lasting recovery.

His second point was about who does the judging. Worcester changed superintendents in 1871–72. In the outgoing superintendent's last three years (1868–71), 516 recoveries were reported against 1,191 admissions: 43.32 percent. In his successor's first three years (1872–75), it was 259 against 1,169: 22.16 percent. Earle knew of no large change in the region the hospital served, such as an epidemic or a war, that would have made insanity more or less common, or harder to cure. Admissions were almost the same, and the recovery rate nearly halved. Earle had long believed that, for the same group of patients, the number reported recovered could differ by at least 25 percent depending on who did the judging.

Earle did not conclude that hospitals should close. Insanity was less curable than many had believed, he wrote, but the hospitals were a public necessity and had sent many people home. A recovery that does not last is still worth something to the person while it lasts. And the sooner treatment begins, the better the prospect of recovery.

What had been done, and what had not

First, what had been done. In Paris and in York, iron chains were given up, and rules against violence toward patients took shape. People with mental illness were treated as persons whose reason was only partly lost, to be observed, listened to, and recorded — and that procedure was written down as part of a physician's work. The idea of an institution where patients were treated decently took shape in the York Retreat and in the state hospital at Worcester. And the hospitals began to keep records. Earle could recount the cures only because the records existed.

What had not been done is just as clear. The cause remained unknown; the Retreat's own account said so plainly. Restraint and fear had not gone away: the chains became straitjackets, and fear stayed on as a tool of treatment. And there was no shared measure of what "recovered" meant. In the same hospital, a change of superintendent nearly halved the recovery rate. Counted by people rather than discharges, "nine in ten are cured" shrank a great deal.

The method of treatment was settled first, and the way of measuring its effect was questioned only later. The causes themselves were still out of reach. The next part turns to a disease whose cause was tracked down: general paresis, in which syphilis attacks the brain.