Pinel and the Pendulum
Richard L. Holt, M.D.
Medical University of South Carolina in Charleston
Introduction: Pinel, and the Pendulum Considered
The Hospital Salpêtrière sprawls across the northeastern edge
of Paris' sixth arrondissement as it flows into the thirteenth. A bronze statue
of Philippe Pinel stands at its entrance. The statue's gaze seems endlessly
distant, and its right hand is held palm downward and slightly away from the
body; a gesture, one assumes, of beneficence. After all, Pinel was for the institutionalized
mad the great messenger of the revolutionary Enlightenment doctrines of reason,
liberty and compassion. Although he enjoyed contemporary renown as an internist,
Pinel is remembered today as the asylum keeper who in 1795 unchained the patients
of le Bicêtre. This symbolic act of liberation was both more and less
complete than it appears. Insofar as Pinel listened to the stories of his patients
and in many of them found a healing voice, he fostered a new therapeutic gaze.
But it is also true that in these reformed institutions and across society less
tangible and more insidious means of control took the place of physical chains.
A short walk away from Salpêtrière, in the heart of the fifth
arrondissement, Jean Bernard Foucault's pendulum hangs in the Pantheon. Suspended
in 1751 at the Paris world's fair, it was the first terrestrial device to demonstrate
the earth's rotation. Like a giant mesmerist's watch, it drew great crowds of
onlookers as it traced lazily through its daily arc, rendering magically visible
the world's imperceptible turning below. I had taken this very walk almost a
decade ago. At the time, I was sharing a room in the Vietnamese student ghetto
of the fifteenth arrondissement with a friend whose incipient schizophrenia
was tragically materializing. It was April, colder than the Paris springtime
I had expected, and I remember a twinge of disappointment at the pendulum, unmoving
and less formidable than the symbol of conspiracy portrayed in Umberto Eco's
then-latest novel. The pendulum of J.B. Foucault was to my thinking a footnote,
a mere curiosity. By contrast, Pinel's Salpêtrière felt powerfully
alive, a center of real force in the frayed copy of Michel Foucault's Histoire
de la Folie tucked away in my jacket pocket. It was this latter Foucault whose
work introduced me to Philippe Pinel's asylum. As I cut across the darkened
Jardin de Luxembourg on my way home, the proximity of these 18th Century citizens
and their instruments, both in space and in time, held no particular resonance
for me. I have had little occasion to ponder any connection since. That is,
I began to reconsider Pinel and the pendulum during my residency interviews.
Talking with clinicians and researchers from across the country, most expressed
a strong sense of optimism about the future direction of psychiatric medicine.
Accordingly, it was not unusual to find myself engaged in discussions about
how the burgeoning science of mind promised to revolutionize the pursuit of
new clinical questions and answers. Beneath this veneer, however, I sensed a
less than total embrace of biological models of mental illness, and reservations
about the ostensibly atheoretical Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV). The comments I heard usually took the form
of rumblings from the more experienced faculty about the pendulum having swung
too far in "that" direction. The pendulum metaphor was repeated often
enough that I began to suspect something more behind it than semantic currency.
At the same time, I have become aware of an historical tension in psychiatric
discourse vis a vis the narrative offerings of its subject. This intimation
of conflict has led me to question the comfort with which I had heretofore accepted
as natural and navigable the spaces that receive a patient speech act. I refer
not only the physical boundaries of the asylum, ward, clinic and community,
but also the cognitive territories demarcated by the clinical and basic sciences.
Most of all, I have begun to question the alacrity with which we place patients
and their utterances into conceptual spaces: diagnoses and disease models. As
I struggle with the historical and theoretical substrata of psychiatry, I cannot
help but return to that memory of Paris, the coincidence of Pinel and the pendulum.
And so considering the pendulum, I feel less need to trace the origins of a
metaphor than to inquire more fundamentally, "What is this metaphorical
pendulum, and between what extremes does it swing?"
At one extreme, psychiatry's living memory invokes the excesses of psychological expansionism, such as the political abuses of Soviet psychiatry, the expansion and subsequent internecine struggles of postwar psychoanalysis and the rise of the antipsychiatric movement. These events, however, are so copiously documented and commonly the subject of comment that they promise to bear little new exegetical fruit. At the other extreme, the limits of biological reductionism--the advent of the third and later editions of the Diagnostic and Statistical Manual of Mental Disorders and the current hegemony of psychopharmacology--- are perhaps too current to be the subject of meaningful retrospective. But medicine's custodial authority over its subject, the mentally "ill", is now over two-hundred years old; and while the most recent historical iterations and institutional deployments of the pendulum theme are illustrative, they also prove somewhat limiting. In order to sustain the proposition that psychiatric modernity has been defined by deep theoretical division, we must first interrogate the discipline's conceptual foundation, then return to an earlier age to trace out the birth of this conflict. At this nexus, it is my belief that we must confront the figure of Pinel.
Widely cited as a father of psychiatry, Pinel retains an iconic status in Europe commensurate in many respects with that of Benjamin Rush in America. After an early education infused with Catholic religious teaching, Philippe Pinel (1745-1826) received his M.D. degree from Toulouse in 1773, and became known to Paris medical circles primarily through various scholarly publications of moderate distinction. An abiding interest in natural history led him to the Paris Botanical Gardens, where in the early 1790's he encountered scientists and physicians struggling to define their role after the dissolution of the Jacobin dictatorship. In 1793, the second year of the republic, he was appointed as physician to the men's hospital Le Bicêtre outside Paris. Here, in collaboration with the asylum's governor, Jean Baptiste Pussin (1745-1811), Pinel devoted himself to the application of natural historical methods to the study of mental alienation. He treated and described his charges with great compassion, and through the act of removing of their shackles, Pinel quickly became a widely cited exemplar of French Enlightenment reform and reason. After a mere nineteen months at Le Bicêtre, Pinel was elevated to the directorship of La Salpêtrière, the women's asylum in Paris. From this central and highly visible position, Pinel established himself as a major intellectual force in European medicine. And while he did not relish political debate, Pinel from this point onward often found himself "forced to make choices, express allegiances, and side with or against successive ruling powers" (Weiner, 233).
Pinel's Traité médico-philosophique sur l'aliénation mentale, ou la manie (A Treatise on Insanity), first published in 1801, appears in many ways a typical humanist Enlightenment document. The subject material presented in this "textbook" was familiar to contemporary medical readers: moral therapy, diagnostic classification, asylum management and the "malconformation of the skulls of maniacs and ideots" studied in "the spirit of minute and accurate observation [for] . . . the advancement of natural knowledge" (Pinel, 1). Yet within this hidebound framework, the modern reader may discern the stirrings of a novel clinical gaze, along with a significant and still-resonant ambivalence regarding the ability of basic scientific reason to reveal the essential nature of unreason. And while it is not my intent to argue that Pinel is in any sense a modern psychiatrist, his work does represent a fundamental rearrangement of the conceptual field surrounding the mentally ill patient; a rearrangement that makes modern psychiatric medicine possible. Pinel molds elements of both moral therapy and basic science into his clinical method, while at the same time exposing the limitations of both in his writings. This counter gesturing may not be revolutionary per se, but it is more than mere eclecticism, for it allows significant new forms of practice and new debates to arise. Thus, in a very real sense, Pinel is the father of a new breed of practitioner, and lays the groundwork for two centuries of struggle with the daunting provisionality of the pursuit of a science of psychopathology.
In his Treatise on Insanity and at the asylums of Bicêtre and Salpêtrière,
Pinel reconfigures extant conceptual and methodological strains within medicine
into a new type of institutional praxis. In an effort to reconcile Hippocratic
tradition with positivist science, Pinel challenges the assumptions of both
the English moral therapists and the Continental anatomo-pathologists. Specifically,
through his focus on clinical observation, Pinel reshapes moral therapeutics
from humane asylum keeping into the empirical pursuit of the laws of mental
alienation. A clinical medical gaze thus arises that takes both the individual
patient and the disease state as its subject, a gaze that introduces the patient
narrative as a legitimate object of medical inquiry. Defending this gaze against
the methodological and ideological preoccupation with anatomy and the brain,
Pinel offers a first salvo in the still-recognizable dialectic of medical psychiatry.
Pinel's ambivalence to the anatomo-pathologists and his resulting focus on clinical
empiricism thus represents, in a very real sense, the first form versus function
argument--the first swing of the pendulum--of psychiatric modernity. The endurance
of this dialectic may be attributed as much to Pinel's authority as to its inherent
validity, for he is by no means the first to advance the ideas of humane treatment
and institutional management, or even to distinguish between somatic and psychic
causation. What distinguishes Pinel as a watershed figure is the engagement
of these ideas in the context of an emerging culture of medical surveillance,
a noso-politic that asserts control over the conceptual, legal and institutional
management of the mentally ill.
In short, the present paper will examine the formal/functional dialectic that defines "modern" psychiatric nosology and then use A Treatise on Insanity as a primary text to explore three elements at its foundation. First, we will trace Pinel's part in the emergence of the empirical gaze from the "moral" space of the 18th Century asylum. Second, we will detail Pinel's position in the first form/function debate that emerges from this new empirical deployment; namely, the conflict between clinical and anatomic models of psychopathology. Specifically, Pinel's insistence upon the diagnostic and therapeutic value of narrative will be addressed. Finally, Pinel will be implicated in medicine's struggle for conceptual preeminence within the post-Enlightenment social order. In particular, we will examine the power he and others wielded over the discursive field mental illness, a power that was initially rooted not in efficacy, but in authority. Before discussing the historical particularities of Pinel and psychiatry's pendulum, a brief definition of the pendulum itself seems in order.
Form and Function: A "Pendulum" of Psychiatric Gaze
In The Perspectives of Psychiatry, Paul McHugh and Phillip Slavney examine a dialectic between what they describe as formal and functional methodological approaches to the mind-brain problem:
Forms or functions, patterns or purpose, the expression of mechanisms or meanings: a choice for one or the other seems the vital problem of explaination in psychiatry. It is the origin of most conflicts, and as a means of circumventing the brain-mind disjunction it is provocative of a fundamental dialectic in the field. That there is thesis and antithesis but no synthesis becomes clearer if the contending viewpoints are considered. (McHugh, 10)
Formal methodology is grounded in standardized mental operations, such as algorithms, that proceed "in prescribed ways to the goals of identification and explanation" (McHugh, 14). As such, it is not synonymous with biological psychiatry, but rather tends to define mental phenomena from an external perspective, through patterns, mechanisms and discrete lesions. Functional analysis, by contrast, attempts to penetrate the subject's consciousness in order to gain insight into the meaning of pathological thought and behavioral processes. While functionalist methodology is also based upon observation and may be grounded in biological science, it possesses greater interpretive latitude than its formal counterpart. Models such as Engel's Biopsychosocial model attempt to combine these two perspectives and are certainly workable. In the end, however, the observer must privilege one gaze at the expense of the other.
The irreconcilability of the dialectic between form and function arises because they represent fundamentally different approaches to an inherent uncertainty that exists regarding the patient/subject's internal milieu, a radical otherness that renders all psychological observation inescapably provisional. For example, distinct but affiliated categories of human experience--depression and sorrow, addiction and desire, mania and bliss--are not transferable as such because they do not correspond to stable physical or metaphysical states. Instead, they are "known" only insofar as they are defined and maintained by the operational production and exchange of signs. But even if language were more reliable, the dialectic between form and function would not be effaced, for by its very definition mental illness is a basic rearrangement of individual cognition. A stranger in a strange land, the patient experiences a rupture of perceptual form and the functional emergence of disturbing thought content simultaneously. This being the case, how does the altered mental "self" undo the alteration that most challenges the existence of its premorbid "self"? Where recovery is possible, is it defined primarily formally (by right action) or functionally (by right thinking)?
For the clinician, the form/function question additionally becomes one of causality. Depending on whether it chooses a formal or functional perspective, the psychiatric gaze will assign corresponding causality to behavioral phenomena. But the notion of causality with much of psychiatric medicine is unavoidably speculative and oblique, for its basic substrate is still more often a speech act than anything as concrete as a tissue, pathogen or serum measurement. This means that no matter what orientation one espouses, the struggle that defines the daily endeavor of psychiatry is the hermeneutic status accorded to the patient narrative. In short, it is not the corpus of the patient, but instead his or her utterances that fill the discursive spaces of both perspectives, both extremes of the pendulum. Hence the power of that oscillating metaphor, hung upon the aspiration for an ideal still point at the center of the turning world, a mythic space in which the subterranean content of a delusion, mania or melancholic narrative might be made manifest to the clinical gaze.
The current psychiatric observational paradigm tends to privilege the formal features of the narrative, sometimes at the expense of narrative content. For example, the observation that a patient's expressed ideas fail reality testing, are autistic and self-referential can be enumerated to define a speech act as delusional. This data can then be used, along with other data, to confirm or exclude a diagnosis of schizophrenia. One advantage of this formal diagnostic method is that it defines clear standards and limits to the interpretive templates an observer places upon phenomena. This emphasis upon diagnostic reproducibility between observers and across populations leads to high inter-rater reliability. Moreover, such standardization facilitates communication between psychiatrists, as well as to legal, lay and other medical audiences. The rigor demanded of psychiatric nosology by formalist methodology has been critical to its rise from sectarianism. Yet despite its obvious utility, formal emphasis often neglects validity in the pursuit of consistency, and devotes very little consideration to what a narrative may communicate about a patient's motivation, meaning and feelings. This approach at time leads to a discouraging diminution of patient agency, an overemphasis on somatic causality and can lead to a retreat from complex disruptions of mental integration by labeling them pejoratively as "functional".
Despite its limitations, the merit of a consistent taxonomy of the general forms of mental illness is self-evident. By contrast, what value to assign the content of melancholic, manic or delusional speech is often problematic. Within the apparent birdsong of a particular delusion or the ravings of an individual manic there is undoubtedly communication. The notion that the patient's narrative--as well as his or her body-- is psychiatry's subject does not obviate the fact that it might have a subject of its own. For the adept and insightful listener, there must certainly some method to bring this meaning forth from obscurity. Of course, psychiatry has trod down this path before and has in the past been guilty of elaborating the rich content of the human psyche with excessive promiscuity. Mined too deeply, slips of the tongue are parleyed into an enduring literature and mythology of interpersonal conflict: Electra, Oedipus, Hamlet. The child may indeed be father to the man, but a revisionist history is often required to render the ontogeny manifest. Still, the functional power of the patient narrative, its ability to communicate both explicit and unconscious information about an internal world, is undeniable. As such, its interpretive limits can be difficult to judge. In order to empower, insight must be purchased with appropriate rigor, lest it become overly inclusive. The truncated and inferential communiqués of the subconscious mind too easily give rise to interpretations that aspire to wear the mantle of truth. If no psychic phenomenon is deemed beyond the functionalist gaze, its authoritative claim to define pathologic thinking can all too easily grow. What begins as a therapeutic modality can turn into an exercise in philosophical density, and can even be twisted into an instrument of political will.
And so the pendulum swings. Within this new Pantheon, do the sound and fury of our internal voices signify nothing, or too much? Jean-Bernard Foucault's pendulum was a proud statement of an age's ability to unravel the universe's once-hidden meanings and motions. Installed when Pinel was five years old, it had turned through four decades before the unfortunates of Le Bicêtre were unshackled. Little did he appreciate that through its peregrinations, and his own, a discipline and its metaphor would be born. A metaphor, but also an irony, in that a later (Michel) Foucault would deconstruct the nexus of power behind Pinel's struggles over psychiatric doctrine. By this most recent swing, formalist parsimony may have initially reigned in the expansionist theorizing of psychoanalysis. But like its functionalist counterpart, modern biological psychiatry's own aspirations have proven far from humble.
A New Pantheon: Reshaping Moral Therapeutics in the Empirical Asylum
The central question surrounding aberrant behavioral phenomena has changed little since ancient Greek physicians first wondered, what does it mean to be mad? Arrayed with the enduring calculus of loss--the abandonment of reason and balance, the loss of freewill or of humanity itself--madness has forever carried with it a form of otherness. To speak authoritatively of madness, to enter this unreasoned discursive space, has been the province of the philosopher, the cleric and the artist. But Western medicine has since its inception had something to say about mental illness, even if it has not always spoken in a manner recognizable to the modern reader as a disease form. The empirical tradition of Hippocrates (ca. 460 B.C), for example, evolved into a largely analytic ethos by the time it passed through Galen (A.D. 130-201). Medieval medical interpretation relied as much upon abstract suppositions of truth about the essential nature of disease as upon observation of the disease process. Mental derangement was thus seen as a supernatural phenomenon or as an imbalance of humors, and often as both. To the pre-Enlightenment mind, conceptual entities such as dyskrasia and demonic possession were not necessarily contradictory elements of a disease state. In Pinel's words:
The history of insanity claims alliance with that of all the errors and delusions of ignorant credulity; with those of witchcraft, demoniacal possession, miracles, oracles and divination. (Pinel, 47)
As a cultural and intellectual force in Western Europe, Galenic medicine endured largely intact from its rediscovery in the 11th Century until the Age of Reason, when a new concept of mental illness began to emerge--madness as an "alienation" or derangement of the intellect. Pinel invokes the Hippocratic spirit of observation and individual focus, and combines these ancient themes with the new analytic methods of empiricism in order to render mental alienation by degrees less alien. The vantage from which Pinel attempts this synthesis, the asylum, develops into a site for the production of medical knowledge. This space ultimately proves schismatic, for two distinct gazes--one psychic, the other somatic--emerge to fill its wards and color its patients' words. Pinel's empirical asylum thus represents the structural precondition for the historical development of a dialectic between form and function. If the dialectic's metaphoric body is a pendulum, then the reconfigured asylum is its venue, its new Pantheon.
Positivism, based upon the assertion that only through observation and experiment can the contingently valid proposition be raised to the level of factual knowledge, becomes a powerful theme in Western thought at the dawn of the 19th Century. Across Europe, broad rejection of speculative philosophies in favor of knowledge derived from the "positive" fact promises to direct the progress of science, history and politics; and leads to a renewed emphasis on empirical methods. Liberating the community of physicians from Galenic theory, this new empiricism represents a sea change in the process of medical inquiry. Accordingly, a whole new breed of physician/scientist comes into being during the 17th and18th Centuries, with Pinel as a direct heir. Anatomo-pathologists such as Giovanni Morgagni (1682-1771) sought through relentless interrogation of cadaveric anatomy to unearth a new knowledge, to catalogue the actual lesions correlating to each and every human illness, madness included. In Pinel's generation, it was Xavier Bichat who would extend this inquiry into the tissues themselves. Others in France, most notably Pierre Cabanis (1757-1808) and Étienne de Condillac (1714-1780), challenged the extent to which sense-data could escape the operational language of signs. These French thinkers echoed Locke's "sensualistic" analytic method and Hume's critique of naive empiricism. In so doing, they elaborated a concept of mind that--while able to embrace physiology-- was permissive of the less concrete and more numinous operations of human passions. Similar preoccupations regarding the etiologic status of the somatic and psychic dimensions of mental alienation would become central to Pinel's thought.
Driven by the quest for systems through which to order the world, the 18th Century is also notable for its proliferation of medical taxonomies. Following in the footsteps of the eminent 17th Century English physician Thomas Sydenham (1624-1689), William Cullen (1712-1790) and François Boissier de Sauvages (1706-1767) produced the medical classification systems that were well known to Pinel. These works, along with his own training in natural history, guided Pinel's early study, which are permeated with taxonomic themes. In fact, Pinel's Nosographie Philosophique (1798) held the distinction of being the largest work of its kind upon its publication and was a standard text of French medicine throughout his lifetime. Although their aim was a kind of standardization, these botanicals and bestiaries of disease often had little in common with one another except dizzying complexity. As we shall see, Pinel clearly matures beyond the role of encyclopedist through his experience at Le Bicêtre. Yet in spite of Pinel's eventual departure from pure medical taxonomy, it is clear that these works represent the structural framework upon which he relies to build the first flexible clinical nosology.
In addition to classification, one of the general themes of the Treatise on Insanity is the "moral" treatment of insanity, a relatively new tradition in Pinel's era. To avoid possible confusion regarding nomenclature, it is important to underscore the extent to which the notion of moral treatment is imbued with not only religion, but also the scientific and political currency of the Enlightenment. Moral therapy as Pinel and others understood it was therefore not predicated upon rehabilitation through morality, but rather a belief--in the words of Pinel's most eminent student, J.E.D. Esquirol-- that "the application of the faculty of intelligence and of emotions" could be enlisted "in the treatment of mental alienation" (Grob, 27). Moral therapists effected cures of the mentally ill through a tightly controlled institutional setting and a rigorous work schedule rather than moral instruction per se. Restraint and humoral manipulations like bleeding and cupping were still practiced, but such "physicking" gradually diminishes in importance as the psychic dimensions of mental illness attain causal ascendancy. The Retreat at York, founded in 1792 by Samuel Tuke and the Society of Friends, was the first and most celebrated of several well-respected Quaker institutions established upon the therapeutic and humanistic model of moral and environmental therapy. Tuke and other noted moral therapists such as the Florentine neuroanatomist Vincenzo Chiarugi (1759-1829) and the English physician-reverend William Pargeter (1760-1810) were, in general, less interested in the taxonomic particularities of mental illness than in the salubrious effects of gentle management and appropriate surroundings .
As a textbook of moral and environmental therapeutics, A Treatise on Insanity reflects the thinking of Pinel's contemporaries:
The laws of human economy considered in reference to insanity as well as to other diseases, impressed me with admiration of their uniformity, and I saw, with wonder, the resources of nature when left to herself, or skillfully assisted in her efforts. My faith in pharmaceutic preparations was gradually lessened, and my scepticism went at length so far, as to induce me never to have recourse to them, until moral remedies had completely failed. (Pinel, 109)
Closer inspection of Pinel's writing, however, reveals deeps reservations beneath this general endorsement. In particular, Pinel laments the English practitioners' lack of methodological transparency. He singles out King George's celebrated clergyman-psychiatrist Francis Willis, whom "we are informed . . . cures nine lunatics out of ten. The doctor, however, gives us no insight into the nature and peculiarities of the cases in which he has failed of success." Pinel continues with the admonition, "He who cultivates the science of medicine . . . pursues a more frank and open system of conduct . . . for the benefit of his successors in the same rout" (Pinel, 55). He then describes one of his own treatment failures, noting with remarkable detail and sensitivity the circumstances leading to the suicide of a young man who had come to Paris to study law.
Even more than methodological laxity, Pinel deplores the "practice of the celebrated Dr. Willis" to place "every lunatic under the control of a keeper" which leads "in many instances. . . to unbridled and dangerous barbarity"(Pinel, 66). Finally, insofar as "Willis' general principles of treatment are no where developed and applied to the character, intensity and varieties of insanity"(Pinel, 50), they offer no robust intellectual challenge to the outmoded themes of demonic possession or theories of humoral imbalance. Because they provide no suitable foundation upon which to build a new knowledge of psychopatholgy, Pinel can ultimately muster but lukewarm praise for his English colleagues. Impressed more by the humane than curative value of their work, he concludes, "I have discovered no secret; but, I approve of their general principles of treatment" (Pinel, 49).
The significance of Pinel's critique of then-current practices of English moral therapy is twofold. First, it represents a rejection of moral therapy's status as a theoretical proposition immune to empirical scrutiny and validation. Second, it underscores Pinel's disinterest in codifying the existing praxis of moral therapy. Rather, he is intent upon moral therapeutics as a means for building a knowledge of mental illness from the ground up:
Of the knowledge to be derived from books on the treatment of insanity, I felt the extreme insufficiency. Desirous of better information, I resolved to examine for myself the facts that were presented to my attention. . . and forgetting the empty honours of my titular distinction as a physician, I viewed the scene that was opened to me with the eye of common sense and unprejudiced observation" (Pinel,108).
Pinel's goal is to achieve through "unprejudiced observation" valid, not simply internally consistent, categories. And while it is arguable that Pinel practiced a rather conventional form of moral therapy, he did so with unique nosological aspirations and observational methods:
The successful application of moral regimen exclusively gives great weight to the supposition that, in a majority of instances, there is no organic lesion of the brain nor of the cranium. In order, however, to ascertain the species, and to establish a nosology of insanity, so far as it depends upon physical derangement, I have omitted no opportunities of examination after death. I flatter myself that my treatment of this part of the subject will not discredit my cautious and frequently repeated observation. (Pinel, 5)
Pinel's nosographic categories of "ideotism, dementia, melancholy and mania with or without delirium" have not endured, but his preference of clinical over anatomic data is truly novel, and yields some very tangible insights. He is, for example, among the first to recognize that derangements of mood often leave cognition intact, and by suggesting that reason can be systematically engaged to help restore the broken psyche, Pinel pioneers the form of what would later become individual psychotherapy. Moreover, by imbuing the rather modest theoretical construct of moral therapeutics with empirical praxis, he engages the asylum in the positivist production of medical knowledge. From this position, Pinel sets the form/function pendulum into motion as he challenges the etiological presuppositions of the anatomo-pathologists with his psychological perspective.
The Pendulum's First Arc: Anatomy and Narrative in the Positivist Agenda
Through a positivist reformation of the concept of moral therapy, Pinel establishes the groundwork for a new clinical gaze, an advance that marks the birth of the asylum/hospital as a site from which to produce and refine medical knowledge. Nonetheless, there was at this time little unanimity upon the operative definition of "empiricism" and its relation to the production of medical knowledge. In post-revolutionary France the taint of ideology was inescapable. As a student of Locke and Condillac, Pinel believes that presuppositionless observation represents the most absolute expression of empirico-logical economy and rigor. But he was also a trained natural historian, and as such he reserves methodological primacy for behavioral observation, insofar as its "truths" are only secondarily dependent upon mental operations, experimentation and the hypothetico-deductive model. If the positivist physician aspires to build medical truth through observation, the clinic must be the privileged site of that empirical enterprise:
[Pinel] established faithful and repeated observation as the main criteria of experimental medicine, and he saw no rupture between ancient and modern medicine, no fundamental difference between observation and experimentation, the former merging into the latter and experimentation ultimately being nothing but observation made under special conditions or restrictions. (Riese, 184)
For Pinel, behind any ideology of gaze there is first and foremost a philosophy of knowledge, and it is the asylum--not the autopsy table or laboratory-- that is best suited to the advancement of a true knowledge of psychopathology.
As a moral therapist and reformer--but mostly as a clinician-- Pinel advances a functional psychology, a medicine whose gaze depends upon the patient narrative, against the anatomo-pathologists of his day. Theirs is a quest for the definitive lesion, whereas Pinel explores the functional derangement of the "passions". To be sure, Pinel does not deny the value of basic science; he was a skilled and respected anatomist and physiologist in his own right. He is rarely openly hostile to somatic medicine, but he does consistently reject the idea that objects can supersede processes as the cause of disease states. To this end, Pinel challenges the etiological presupposition that any particular lesion could causally outrank the clinical observation of the phenomena of mental illness:
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. (Pinel, 3)
This point is critical, for it permanently divides the science of psychopathology after Pinel into two camps, those who view mental illness as the product of some somatic insult, and thus amenable to the refined formalist gaze, and others who see in madness a process that may or may not correspond causally to physical and physiological stigmata, a diathesis whose cure may be functionally effected through the enlistment of will, reason and personal agency. The avatars of these two camps have evolved and alternately predominated over two centuries, but like the pendulum, their fundamental tension remains unchanged in the wake of successive swings.
Examples of Pinel's challenge to the hegemony of the anatomo-pathologists show up in the least likely of places. The third section of A Treatise on Insanity, for example, appears to be little more than a treatment of the cranial correlates of Pinel's diagnostic categories. Physiognomy, much like phrenology in subsequent decades, was a subject of both general and scientific interest at the beginning of the 19th Century. Supported by the scholarly studies of Greding, Haslam and Chiarugi; "malconformations" of the human skull were thought by many to bear strong relation to disease states. Pinel, who had extensively measured mammalian skulls for classificatory proposes early in his career, disputes this claim, noting that "the heads of maniacs are not characterized by any peculiarity of conformation that are not to be met with in other heads taken indiscriminately" (Pinel, 123). Pinel's insistence on controlled data demonstrates the reservation with which he approaches anatomic correlation and medical causation. Given his focus on clinical observation, it is perhaps not surprising that he should proceed with such abiding skepticism in his post-mortem dissections. However, by associating the scientific claims of the anatomo-pathologists with the deplorable treatment of asylum inmates, Pinel extends his critique of method into an indictment of motive:
It is a general and very natural opinion, that derangement of the functions of the understanding consists in a change or lesion of some part of the head. This opinion is, indeed, countenanced by the experimental labours of Bonnet, Morgagni, Meckel and Greding. Hence the popular prejudice that insanity is an incurable malady, and of refusing them that attention and assistance to which every infirmity is entitled. (Pinel, 111)
This passage does not simply expose the limits of a scientific gaze that mistakes correlations with causes; it rhetorically challenges the ability of such a gaze to reconcile itself with the progressive and humanistic agendas of positivism.
Pinel's critique of the anatomo-pathologists thus stands in stark contrast
to that which he proffers against the English moral therapists. While the latter
are found lacking in empirical rigor but appropriately compassionate, the former
engage in the therapeutic nihilism of a weak and incomplete empiricism, a medical
dogma based upon synecdoche that fails to reconstruct the entire patient. In
Pinel's words, "It is a very general opinion, that mental derangement depends
upon lesions of the head . . . [O]bservation is far from confirming these specious
conjectures" (Pinel, 117). Only in the case of mental retardation is Pinel
willing to trust morphology at the expense of hope. Even then, he does so "without
absolutely deciding that there is an immediate and necessary connection between
ideotism and the various structures which I have described" (Pinel, 126).
Despite the fact that Pinel devotes considerable space to his own observations
of the skull, his attitude toward such pursuits is less than sanguine. To Pinel's
sensibilities, such theorizing is reminiscent of the arrogance of the ancien
In the present enlightened age, it is to be hoped, that something more effectual may be done towards the improvement of the healing art, than to indulge it with the splenetic Montaigne, in contemptuous and ridiculous sarcasms upon the vanity of its pretensions. (Pinel, 6)
and to the extent that philosophy, ideology and method cannot be separated, Pinel's asylum mirrors the conceptual space of his traité médico-philosophique. "To avoid false reasoning," Pinel warns, "it is necessary to conduct the investigation upon the principles of accurate analysis and abstraction" (Pinel, 115). Such statements suggest that Pinel's writing of the Treatise is motivated as much by his perception of intellectual flaws within the thinking of fellow positivists as by his compassion for the mentally ill.
If Pinel's ambivalence to basic scientific investigation is ideologically bound to a distrust of theorizing, its corollary is a devotion to presuppositionless observation--the receptive clinical gaze:
From systems of nosology, I had little assistance to expect; since the arbitrary distributions of Sauvages and Cullen were better calculated to impress the conviction of their insufficiency than to simplify my labour. I, therefore, resolved to adopt that method of investigation which has invariably succeeded in all the departments of natural history, viz. to notice successively every fact, without any other object than that of collecting materials for future use; and to endeavour, as far as possible, to divest myself of the influence, both of my own presuppositions and the authority of others. (Pinel, 2)
Citing his observations both at the autopsy table and on the wards of Bicêtre, Pinel concludes that "the anatomy and pathology of the brain are yet involved in extreme obscurity" and calls for "circumspection and reserve in deciding upon the physical causes of mental alienation" (Pinel, 133). Pinel's doubt that additional post-hoc reflection will reveal the hidden loci of insanity, along with his belief in "the advantage of obtaining an intimate acquaintance with the character of the patient" (Pinel, 191), amounts to the first functionalist challenge to biological reductionism. Significantly, Pinel's counter-argument is based not simply within the confines moral therapeutics, but also springs from a new and psychodynamically oriented empiricism. To be sure, a nascent tradition of logotherapy, or "talking cures", can be dated back to Greek antiquity, but Pinel's Treatise on Insanity is the first widely disseminated medical text to empirically examine "the value of consoling language and . . . attention to the state of the mind exclusively" in the context of a recognizable model of disease (Altschule, 131).
The psychological orientation of Pinel's quest for a more complete scientific knowledge of insanity is exemplified by the attention to detail with which he treats patient encounters. In the Treatise, for example, Pinel does not rely on second-hand histories and conjecture based upon physical examination to form an understanding of his patients. Instead, he focuses upon the role and form of the patient interview. Earlier in his career, at centers such as Edinburgh and Montpellier, Pinel had noted an aggressively interrogative style that tended to cast the descriptive labor of clinical observation into an act that shaped the individual patient into a case of disease. "How, in the midst of this profusion of questions," he asks in Médicine Clinique (1815), "can one grasp the essential, specific features of the disease?" (Foucault, a111). Pinel engages his own patients in conversation rather than interrogation, not simply as an empathic gesture, but also as a powerful data gathering tool--a tool, he asserts, whose power surpasses not only theory, but also rivals that of autopsy. "By these and other means," he writes, "I have been enabled to introduce a degree of method into the services of the hospital [Bicêtre], and to class my patients in a great measure according to the varieties and inveteracy of their complaints" (Pinel, 6).
Through his often informal and open-ended engagements with patients, Pinel reveals concerns well beyond the quotidian duties of an asylum physician. For Pinel, the personal and pathognomonic meaning of patient narratives are equally valued, for both elements contribute to his diagnoses and therapies. In the case of one young sufferer, Pinel recounts that "he often and earnestly entreated me to rescue him from the arms of death. At those times I invited him to accompany me to the fields, and after walking for some time, and conversing upon subjects likely to console or amuse him, he appeared to recover the enjoyment of his existence" (Pinel, 57). Later, he describes a cure of delusional mania effected through "repeated . . . visits daily [with] . . . the tone of friendship and kindness," during which "[h]e endeavoured from time to time to convince [the patient] of the absurdity of his pretension" Pinel, 192). Similar encounters with other patients are described throughout Pinel's work, often with reference to their instrumentality regarding the ultimate disposition of the case. Pinel's approach represents a real and lasting departure from nihilistic viewpoints--be they demonic or organic--that marginalize the story and agency of the sufferer:
To arrive at a diagnosis, the physician must carefully observe a patient's behavior, interview him, listen carefully, and take notes. He must understand the natural history of the disease and the precipitating event and write an accurate case history. Diagnosis and prognosis can then be made. (Weiner, 1992)
In the generation of "alienists" that arises after Pinel assumes the directorship of the Salpêtrière--and especially in his student J.E.D. Esquirol-- we see the fruition of this approach into a clinical method in many respects as sophisticated as anything since.
The Enduring Gaze: Medical Authority and the Science of Psychopathology
Justifiably, historical status is accorded to Pinel as a humanitarian, liberator, and "father" of modern psychiatry. His biography reads like that of the quintessential post-revolutionary man: inquisitive, reform-minded and intent upon the progressive reorganization of theory, method and ideology. But within the halls of France's most visible hospital, the salons of Paris and across the pages of his oeuvres, Pinel is also instrumental in the formation of a nexus of medical power. The empiricism that became operative in medicine at the end of the 18th Century now carries a long and distinguished pedigree. But the modern medical gaze is as much about power as it is about knowledge. It would thus be naive to accept the positivist reformation of medicine as simply progressive, the successive elaboration of better ideas. As a means of production of medical savoir, the methods born in Pinel's age have been generative of both truth and authority. Well before the advent of germ theory, anesthesia or vaccines, physicians were able to broadly legitimate certain forms of medical practice and to take control of that subset of the population they defined as a therapeutic target. At a critical period in its history, figures such as Philippe Pinel and Benjamin Rush bear responsibility for both the intellectual and the institutional reformation of medicine. From Edinburgh to Paris to Philadelphia, the institutions of the clinic and the medical school do not reflect a sudden efficacy, but rather solidify the paradigmatic extension of medical focus from the cause of disease to the laws of disease. As a result, pathology, nosology, etiology-- concepts unthinkable as such before this transformation--enter the lexicon of the newly potentiated medical professional.
Within this professional community, Pinel is the first physician with the ability to broadly command both the physical and discursive spaces of insanity. As such, he is among those responsible for both the theoretical and the institutional groundwork of psychiatric modernity. Before the 19th Century, most mentally ill people were kept at home, while others became vagabonds. During the 18th Century at sites such as London's notorious "Bedlam" Hospital, lay administrators assumed responsibility for the institutional disposition of the most severely afflicted or those without familial support. In this context, it is important to realize that Pinel's acts of liberation are in no way tantamount to deinstitutionalization. Pinel is a strong, if by no means the first, advocate of removing the patient from the community. The benevolence of humane yet unequivocally institutional treatment conceals a subtler form of control than chains--therapeutic privilege:
It is pleasing to observe so great a conformity of opinion, founded as it appears upon the results of observation and experience, prevail . . . on so important a subject as the utility of public and private hospitals . . . insanity is much more certainly and effectually cured in places adapted for their reception and treatment, than at home under the various influences of family interests and intercourse. (Pinel, 214)
On the question of institutionalization, Pinel is willing to suspend his critical apparatus and accept English physician John Haslam's dictum that "confinement is always necessary in cases of insanity" at face value (Pinel, 215). This notion proved as portable as it was popular, as evidenced by the wide inclusion of references to Pinel, Tuke, Rush and others by asylum keepers over the ensuing decades. By the 1830's asylums were rapidly being erected in America to protect the vulnerable from the excessive ambition and diminished prudence of the post-revolutionary social order. Europeans, although in general less willing to embrace the social etiologies popular among their American counterparts, were just as avid to beneficently sequester the mentally ill.
The asylum for Pinel represents the embodiment of a humanistic ideal, of reform, an optimistic space in which to effect curative measures. But the asylum has ideological dimensions as well. It is a critical site for the production of medical knowledge, and so it serves to validate the intellectual agenda of the French Revolution:
The principles of free enquiry, which the revolution has incorporated with our national politics, have opened a wide field to the energies of medical philosophy. But, it is chiefly in great hospitals and asylums, that those advantages will be immediately felt, from the opportunities which are there afforded of making a great number of observations, experiments, and comparisons. (Pinel, 46)
During Pinel's lifetime, the mentally ill population emerges as a therapeutic target deeply enmeshed with social policy, political power and social commentary. This trend extended throughout the Continent and across the English Channel, even spanning the Atlantic to America, where the concept of madness became deeply enmeshed with notions of social order. Sadly, while the asylums thrived in this well-intentioned era, within a few decades their primary role became custodial rather than curative, allowing many of the abuses that so outraged Pinel's reformist sensibilities to creep back into common practice within their walls.
Pinel's aim, however, is not simply to reinforce the institutional exercise of statutory power over madness. Rather, in his attempt to reconstruct the forms of medical knowledge in the new French republic, he is among the first to medicalize madness in the novel clinical setting of the asylum. By virtue of his directorship at Le Bicêtre and La Salpêtrière, Pinel asserts--both in word and deed--the importance of medical supervision of institutional patients:
These are the duties, and highly important they are, which peculiarly belong to the governor. There are others, however, and they are certainly of no less importance, which . . . . are connected with the character and province of the physician. (Pinel, 45)
To be fair, Jean Baptiste Pussin, the governor with whom Pinel served at Bicêtre and Salpêtrière, was much esteemed by the great physician, and is treated with much deference throughout the text of the Treatise. But unlike Pussin, Pinel's status and celebrity as a physician-reformer ensured wide dissemination of his clinical perspective on insanity. Moreover, having labored to establish the axiomatic nature of clinical observation, and having addressed nosology and moral therapy earlier in the volume, Pinel reserves the final chapter of A Treatise on Insanity for medical treatment. Pinel begins with what seems like an apologia:
Wearisome treatises, useless compilations, a scholastic dialect . . . have characterized the progress of almost all the sciences. Modern physics, the ancient doctrines of Aristotle, and the fanciful theories of Decartes, are examples perhaps equally illustrative of this truth. [I]f medicine be . . . chargeable with similar incumberances . . . it would however appear that this science be more or less distinguished for its habits of observation and analysis. (Pinel, 220)
H owever, it is clear that along with empirical methodology, Pinel sees the production of medical knowledge as inexorably linked with the day-to-day treatment and management of the mentally ill. It is naturally the physician who is best suited to "discriminate accurately between the different species of the disease, . . . avoid fortuitous and ineffective treatment [and] . . . furnish precise rules for the internal police and government of . . . asylums" (Pinel, 221). The power of medical surveillance flows seamlessly into custodial authority for the physician, a knowledge-power nexus that forms the basis for the roles of psychiatrists and patients alike to this day. Given the benefit of historical perspective, it is easy to question the innocence of Pinel's treatment of "the importance of an enlightened system of police for the internal management of lunatic asylums" (Pinel, 174), a subject upon which medical superintendents opined voluminously well into the next century.
In this context that we now approach the true import of the seemingly anachronistic content of A Treatise on Insanity; for here the notion of mental "illness" begins its conceptual evolution and becomes the subject of a new science. Combining the rhetoric of authority with the power of theoretic parsimony, Pinel deploys the asylum as a means to generate and test provisional hypotheses of madness. Through this process, a reconfiguration of existing opinions regarding the role of science in medicine is achieved, the centrality of clinical observation is ensured, and the promise of dynamically oriented therapies is first explored. As an Enlightenment thinker, Pinel is keen to reject the unicausality of Galenic medicine and its attendant methodological weakness, choosing instead to class diseases as distinct and reproducible entities. But as an idealistic son of the French Revolution he wishes to avoid the perceived arrogance of the ancien régime. Pinel attempts to preserve Hippocratic medicine's strength, its focus on the experience of the diseased individual, without compromising the benefits of the positivist gaze. As a result, he poses himself in square opposition to both somatic reductionism and demonic thinking. In short, Pinel opposes any subtractive gaze-- medical or otherwise--that a priori annihilates the meaning of the individual and his sufferings.
The importance of these developments can hardly be overstated, for they extend well beyond the political and historical context in which they first came into being. Pinel represents a central figure in the establishment of the clinical precondition upon which the dialectic between form and function in psychiatry presently rests. Moreover, Pinel was among the first to translate the naive compassion of the reformists and moral therapists into a new mode of inquiry. He transforms the question "what is madness?" into "what is it like to be mad?" and challenges the clinical gaze to penetrate the otherness of its subject. But insofar as he fails to address certain implications of his nosology, Pinel's thinking is also problematic. For example, the Treatise lacks any experimental or otherwise systematic means for verifying clinical insights. In addition, the political ideological entanglements of his age limited Pinel's ability to move beyond his powerful investigation of mental/medical experience to construct a theory of mind. Because Pinel regarded the extensive pursuit of insight oriented analysis as inappropriately theoretical, it has been left to subsequent generations to realize the full heuristic value of his method. Alongside the questions of method, one must also inquire about Pinel's role in the establishment of the tremendous power that psychiatry has since wielded over its subject. For despite his reformist intentions, Pinel managed his population through subtle forms of control and intimidation. Born of an age that promised certainty--the retreat of ignorance from the light of inquiry--Pinel's legacy is provisionality.
Conclusion: Pinel, and the Pendulum Revisited
In retrospect, several enduring themes are interwoven through the last two centuries of medical psychiatry, the span of its putative modern age. The acknowledgement of the phenomenological opacity of psychiatry's subject and the introduction of the mind-brain problem has given rise to a dialectic between formal and functional analyses of mental illness. In Pinel's wake, the patient speech act has been subjected to psychoanalysis, behaviorism, and cultural interpretation; yet it still remains enigmatic, in spite of the most recent advances of neuroscience. The debate first takes shape toward the end of the18th Century with the emergence of competing empirical models upon which to build the nascent science of psychopathology. The site of emergence for these two gazes is Pinel's empirical asylum, from which vantage he offers a critique of both the anatomo-pathologists and the moral-environmental therapies of his day.
The specific debate between clinical and anatomo-pathological perception waged in that era represents a watershed in the intellectual and institutional status of the notion of mental derangement. The central arguments of this dialectic regarding the nature of medical perception can, and should, be marshaled to challenge the epistemological assumptions of current diagnostic instruments such as the Diagnostic and Statistical Manual or to expose the inherent contradictions of conciliatory syntheses such as the biopsychosocial model. The basic challenge of what was to become psychiatry was defined in Pinel's lifetime, and still remains--how most profitably to deploy the positivist gaze against the impenetrable otherness of the patient. Through its historical struggles, psychiatry tacitly acknowledges the problematic nature of the patient narrative, even when there is disagreement upon how to approach it. The current rift between biomedical and dynamic psychiatry is therefore not an argument over whether or not psychiatry is a science, but rather the most recent iteration of the functional/formal dialectic within that science.
Finally, with the advent of a medical science of mental illness, an accompanying institutional drive to speak authoritatively about--and to expand--those subject to its gaze has arisen. It seems almost intuitive that a new way of looking at the mentally ill should give rise to new powers and institutions. However, there is perhaps equal validity to the assertion that it was an institution, the asylum, that gave rise to Pinel's novel psychiatric perception. In any case, it would be a mistake to assume that the rise of medical psychiatry proceeded in lockstep with its increasing efficacy. Notably, medical personnel were able to exert a tremendous amount of control over large populations well before the production any significant or legitimate evidence that they could accurately diagnose, treat or even care for the mentally ill patient. The exercise of power has much to do with the manner in which the patient speech act has historically been interpreted. This struggle for interpretive preeminence over narrative is at the heart of both psychiatric medicine's claims and crises of legitimacy.
At or very near the birth of the modern conceptual arrangement of psychiatric medicine is the figure of Philippe Pinel. Le Bicêtre and Salpêtrière were among the first institutions in which the patient narrative is considered at all, much less outside a demonic or mechanistic context. Pinel unchained his patients, but more importantly he listened to them. In doing so, he introduces the patient utterance as a legitimate object of study, with all of its attendant epistemological quandaries. In addition, Pinel pioneered the use of clinical observation to build nosological categories from the ground up, a necessary precondition to liberate his subject from Galenic theory, Christian theology and various homespun medical pseudo-philosophies. Finally, Pinel proclaimed a new authority for the emerging discipline of psychiatry over mere asylum-keeping: morally as a reformist, intellectually as an empirical clinician, and institutionally as the head of one of France's largest and most visible medical institutions. Pinel is present--and in part responsible--for the introduction of that dialectical pendulum that has for two centuries swung between formal and functional analyses of narratives of madness. In the details of his Treatise on Insanity, we may find the release of a now-familiar mass whose alternating dominances have undergone various periodic iterations, but whose fundamental physics have proven remarkably durable.
Altschule, Mark D., Origins of Concepts in Human Behavior: social and cultural factors. Hemisphere Publishing Corp., Washington, D.C. 1977.
Churchland, Patricia Smith. Neurophilosophy: Toward a Unified Science of the Mind-Brain. Massachusetts Institute of Technology Press, Boston. 1986.
Fishbein, Gerald M., "Was modern psychoanalysis born during the French Revolution? Philippe Pinel, an early precursor of modern analysis." Modern Psychoanalysis, 1995, 20(2): 165-174.
Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception. Translated by A.M. Sheridan Smith. Vintage Books, New York. 1994 (1963, Tavistock)
Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason. Translated by Richard Howard. Vintage Books, New York. 1988 (1961).
Gauchet, Marcel and Swain, Gladys ( Translated by Catherine Porter). Madness
The Modern Psychiatric Universe. Princeton Press, 1999.
Gerald, Donald L., "Chiarugi and Pinel considered: Soul's brain/ person's mind." Journal of the History of the Behavioral Sciences. Fall 1997, 33(4): 381-403.
Grob, Gerald N., The Mad Among Us: A History of the Care of America's Mentally Ill. The Free Press (Macmillan), New York, 1994.
Gamwell, Lynn and Tomes, Nancy. Madness in America: Cultural and Medical Perceptions on Mental Illness Before 1914. Cornell University Press, New York. 1995.
Mackler, Bernard. Philippe Pinel, unchainer of the insane. F Watts, New York, 1968.
Marshal, Robert J., "Pinel: the first modern psychoanalyst." Modern Psycho-analysis, 1995, 20(2): 175-87.
McHugh, Paul and Slavney, Phillip. The Perspectives of Psychiatry. Johns Hopkins University Press, Baltimore. 1986.
Pinel, Philippe. A Treatise on Insanity (Traité médico-philosophique sur l'aleniation mentale; ou la manie / Medico-Philosophical Treatise on Mental Alienation or Mania, Translated by Paul F. Cranefield). Hafner Publishing, Inc. New York, 1962 (1801)
Riese, Walther. The Legacy of Philippe Pinel; an inquiry into thought on mental alienation. Springer Publishing, Inc., New York, 1969.
Rothman, David. The Discovery of the Asylum: Social Order and Disorder in the New Republic. Little, Brown and Co., Boston. 1971.
Sadler, John; Wiggins, Osborne and Schwartz, Michael (eds.). Philosophical Perspectives on Psychiatric Diagnostic Classification. Johns Hopkins University Press. Baltimore. 1994.
Starr, Paul. The Social Transformation of American Medicine. Harper Collins, New York, 1982.
Weiner, Dora B., "'Le geste de Pinel': The History of a Psychiatric Myth." in Discovering the History of Psychiatry, Micale, Mark S. and Porter, Roy, Eds.; Oxford University Press, New York, 1994
Weiner, Dora B. "Philippe Pinel's 'Memoir on Madness' of December 11, 1754: a fundamental text of modern psychiatry." Am J Psychiatry, 1992 Jun, 149(6): 725-32.
Wing, JK. Reasoning About Madness. Oxford University Press, Oxford, 1978.