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Pinel, Philippe

PINEL, PHILIPPE

(b. Jonquieres, near Castres, France, 20 April 1745; d. Paris, France, 25 October 1826)

medicine.

Pinel was the son of a master surgeon who practiced in St.-Paul-Cap-de-Joux, a village between Castres and Toulouse. His mother, Élisabeth Dupuy, came from a family that had since the seventeenth century produced a number of physicians, apothecaries, and surgeons. Despite this medical heritage, Pinel’s early education, first at the College de Lavaur and then at the College de l’ Esquille in Toulouse, was an essentially literary one; he was greatly influenced by the Encyclopedists, particularly Rousseau. Having decided upon a career in religion, he enrolled in the Faculty of Theology at Toulouse in July 1761; in April 1770, however, he left it for the Faculty of Medicine, from which he received the M.D. on 21 December 1773. Simultaneously with his medical training, Pinel studied mathematics, an interest that is apparent in his medical writings.

In 1774 Pinel went to Montpellier, where for four years he frequented the medical school and hospitals. He there began to formulate and to practice the principles that he later recommended to his students: “Take written notes at the sickbed and record the entire course of a severe illness.” He supported himself by giving mathematics lessons, conducting a private anatomy course, and writing theses for rich students. He also met Chaptal, who later acknowledged Pinel’s influence upon his intellectual development. In 1777 Pinel presented two iatromechanical papers, on the application of mathematics to human anatomy, to the Société Royale des Sciences de Montpellier; he was named a correspondinmg member in july of that year.

In 1778 Pinel went to Paris. He carried with him letters of recommendation to the geometer Jacques Cousin, who advised him to give up medicine and deveote himself to the exact sciences. He visited libraries and hospital (Particularly P. J. Desault’s service at the Hotel-Dieu) and frequented the salon of Mme Helvetius, into which he had been introduced by Cabanis, and where he met Franklin. Mme Helvetius’s house in Auteuil was a gathering place for the school later called idéologues, and Pinel became acquainted with the sensationalist doctrines of Locke and Condillac, which strongly influenced his work. As a graduate of Toulouse, however, he was unable to practice medicine in the capital.

In 1784 Pinel became editor of the Gazette de sante, in which he published a number of articles chiefly concerned with hygiene and mental disorders, a subject in which he had interested himself following the illness of a friend in 1783. In 1785 he translated William Cullen’s First Lines of the Practice of Physic and three volumes of the Philosophical Transactions of the Royal Society into French. He also wrote articles on medicine for the daily Journal de Paris and, in 1788, published a new edition of Baglivi’s Opera omnia.

Pinel took no active political role during the Revolution, but devoted himself to attempting to aid those who had been proscribed, among them Condorcet. On 25 August 1793 he was appointed, at the instance of his friends Cabanis and Jacques Thouret, médecin des infirmeries of the Hospice de Bicetre, where he was able to begin implementing his ideas on the humane treatment of the insane. (He had previously been a frequent visitor at the Belhomme nursing home for the mentally ill, but had been unable to convince the director—who was primarily concerned with making a profit—to accept his therapeutic notions.) At the Bicetre Pinel had the chains removed from his patients, an event commemorated in both paintings and popular prints. On 13 May 1795 he became chief physician of the Hospice de la Salpetriere, a post that he retained for the rest of his life. Here he was in charge of 5,000 pensioners, aged women, and chronically ill patients; there was a 600-bed ward for the mentally ill, a 250-bed infirmary for acutely ill patients, and, at first, a small infirmary for sick orphans. Pinel was eventually assisted in his work by A. J. Landré-Beauvais, J. E. D. Esquirol, and C. J. A. Schwilgué.

On 4 December 1794 the Convention Nationale (three years after the dissolution of the medical guilds and faculties by the Legislative Assembly) established three écoles de santé, and Pinel, upon the recommendation of Fourcroy and Thouret, was named adjunct professor of medical physics at the school in Paris. In 1795 he became professor of medical pathology, a chair that he held for twenty years; he was briefly dismissed from this position in 1822, with ten other professors suspected of political liberalism, but reinstated as an honorary professor shortly thereafter. Pinel was elected to the Academie des Sciences in 1804 and was a member of the Academy of Medicine from its founding in 1820. In addition to working in hospitals and teaching, Pinel often served as a consulting physician, although he did not have the rich and influential patients that Corvisart or Portal did.

The difficult begining and slow progress of his career neither discouraged nor embittered Pinel, and his eventual success did not diminish his modesty. Although he is properly considered one of the founders of psychiatry, Pinel’s contemporaries regarded him as a master of internal medicine, a reputation based upon the authoritative classification of diseases that he set out in his Nosographie philosophique, published in 1798.

Pinel’s nosological work should be viewed in the context of the great eighteenth-century concern with classification, of which the works of Linnaeus are exemplary. Specifically medical classifications had been offered by William Cullen and David McBride, in 1769 and 1787, respectively, while Erasmus Darwin’s Zoonomia appeared in 1794-1796. Pinel was aware of the dilliculties that his predecessors had faced, but he approached his task cheerfully, secure in his belief that a disease was “an indivisible whole from its commencement to its conclusion, a regular ensemble of characteristic symptoms.” Since these symptoms could be observed and analyzed, a classification of disease was possible.

Pinel thus divided diseases into five classes—fevers, phlegmasias, hemorrhages, neuroses, and diseases caused by organic lesions. Nearly one third of the Nosographie is devoted to the first class, fevers, which Pinel subdivided into angiotenic, meningogastric, adenomeningic, adynamic, ataxic, and adenoneural forms, corresponding respectively to the inflammatory, bilious, mucous, putrid, malignant, and pestilential fevers of the ancient authors. Pinel subsequently added the order of hectic fevers, which had been described in 1803 by his then disciple Broussais; these six classes were futher subdivided into eight genera and a number of species.

Pinel classified phlegmasias by the structure of the affected membranes (or tissues). He thus arrived at five orders: cutaneous phlegmasias, including eruptive fevers and dermatological diseases; mucous phlegmasias, classified by location, and including opthalmia, quinsy, gastritis, and enteritis; serous phlegmasias, including phrcnitis, pleurisy, and peritonitis; parenchymatous and cellular phlegmasias of the muscle, fibrous, and synovial tissues. In his Traité des membranes of 1800, Bichat acknowledged the influence of Pinel’s book on his own work.

Among Pinel’s third class of diseases, hemorrhage, only those of the mucous membranes (epistaxis, hemoptysis, hematemesis, hemorrhoid, and metrorrhagia) seemed to him to have been studied sufficiently. Among the fourth class, neuroses, Pinel included not only psychiatric illnesses, but also diseases of the sense organs, spasmodic visceral disorders, and dysfunctions of the genital organs. His fifth class, which in the first edition of the Nosographie he called “diseases of which the seat is in the lymphatic system” comprised more generally systemic diseases, scurvy, syphilis, and cancer among them, as well as heart disease, dropsy, and kidney stone.

Pinel composed the Nosographie as a textbook. It went through several editions, among which important variations may be found. In the first, for example, Pinel refused to acknowledge the distinguishing features of scarlet fever and puerperal fever, although he later classified scarlet fever among the eruptive fevers, and remarked on the occurrence in the same epidemic of both simple quinsy and true scarlet fever. He continued to deny the existence of puerperal fever as an entity (as he continued to deny the existence of fevers concomitant to any stage of reproduction), and it was only in the last edition of his book that he recognized it as a special form of peritonitis. Although the Nosographie was a notable success among Pinel’s students and disciplines, it also provoked a number of criticisms. Broussais, in particular, attacked Pinel’s ideas on idiopathic fevers. Pinel chose to ignore his critics, however, and even forbade his followers to respond to them.

Pinel’s other medical writings, from his first communications to the Montpellier Société Royale des Sciences, give evidence of his mathematical training. He drew up precise “tables synoptiques” to determine the frequency of occurrence of certain illnesses, together with their modes of development and their prognoses. He conducted rigorous experiments to measure the effectiveness of various medicines, and devised a numreical methods of evaluation. His own therapy was conservative; he contented himself with a pharmacopoeia of only fifty-five vegetable substances and thirty-nine “chemical products,” which he used sparingly. He recorded his “extreme distaste” for polypharmacy, objected to the use of bloodletting and purges, and proscribed the use of quinie (even for malaria) and opiates (even for severe pain). Nonetheless, Pinel easily accepted new discoveries, including Corvisart’s technique of sounding by percussion and the use of the stethoscope for mediate auscultation, introduced by Laennec. Pinel created an inoculation clinic in his service at the Salpêtrière in 1799 and the first vaccination in Paris was given there in April 1800.

Pinel’s psychiatric work effectively transformed the prison for the insane into a hospital. He did not merely initiate better treatment for the mentally ill, however, but rather concerned himself with establishing psychiatry as a discrete branch of medicine. He published a number of articles on the subject, beginning in 1784, then synthesized his findings in “Recherches et observations sur le traitement moral des alienes” (1799) and Traité medico-philosophique de l’ alienation mentale (1801), to which his 1807 communication to the Institut de France is an important supplement.

Pinel’s classification of mental diseases retained the old divisions of such illnesses as manic, melancholic, demented, and idiotic. He presented these classes (with a disclaimer—it was necessary to retain them “for the time being,” since medicine was not advanced enough for subtler distinctions) as late as 1812. He nevertheless made finer distinctions, isolating mania from delirium, and pointing out that in this state the intellectual functions might be intact, and, in his description of idiocy, citing stupor, the first stage of some types of mental disease. Pinel recognized the relationship between periodic mania and melancholy and hypochondria and stressed the danger of suicide by the melancholic patient. He also mentioned the possibility of altruistic homicide.

In establishing the cause of mental illness, Pinel was wary of “metaphysical discussions or certain ideological ramblings,” and he categorically rejected the notion of demonic possession or sorcery. Faithful to the doctrines of Locke and Condillac, he considered emotional disorders to be the primary factor in precipitating intellectual dysfunctions; he also took into account heredity, morbid predisposition, and what he called individual sensitivity.

Pinel’s psychiatric therapeutics, his “traitement moral,” represented the first attempt at individual psychotherapy. His treatment was marked by gentleness, understanding, and goodwill. He was opposed to violent methods—although he did not hesitate to employ the straitjacket or force-feeding when necessary. He recommended close medical attendance during convalescence, and he emphasized the need of hygiene, physical exercise, and a program of purposeful work for the patient. A number of Pinel’s therapeutic procedures, including ergotherapy and the placement of the patient in a family group, anticipate modern psychiatric care.

Pinel was also concerned with the proper training of infirmary personnel and with the proper administration of an institution for the mentally ill. A generation of specialists in mental diseases, led by Esquirol, was educated at the Salpetriere and disseminated Pinel’s ideas throughout Europe.

Pinel was married in 1792 to Jeanne Vincent; of their three sons, one, Scipion, became a specialist in mental illness. Having been widowed in 1811, Pinel was married again, in 1815, to Marie-Madeleine Jacquelin-Lavallée.

BIBLIOGRAPHY

I. Original Works. Pinel’s writings include Nosographie philosophique ou methode de l’analyse appliquee a la medecine (Paris, an VII [1798]; 6th ed., 1818);“Recherches et observations sur le traitement moral des alineens,” in Memoires de la Societe medicale d emulation de Paris, 2 (an VII [1799]), 215–255; Traité medico-philosophique sur l’alilenation mentale our la manie (Paris, an IX [1801]; 2nd ed., 1809); La medecine rendue plus precise et plus exacte par l’application de l’analyse (Paris,1802; 3rd ed., 1815); and “Resultats d’observations et construction de tables pour servir a determiner le degre de probabilite de la guerison des alienes,” in Memoires de la classe des sciences mathematiques et physiques de l’Institut (1807), 169–205

II. Secondary Literature. See E. H. Ackerknecht, Medicine at the Paris Hospital 1794–1848 (Baltimore, 1967); H. Baruk, La psychiatrie francaise de Pinel a nos jours (Paris, 1967); F. J. V. Broussais, Examen de la doctrine medicale generalement adoptee et des systemes modernes de nosologie (Paris, 1816); P.Chabbert, “Philippe Pinel a Paris (jusqu a sa nomination a Bicetre),” in Comptes rendus du XIXe Congres international de l’histoire de la medecine (Basel, 1966), 589–595; M. Foucault, Histoire de la folie a l’age classique (Paris, 1961); and Naissance de la clinique, une archeologie du regard medical (Paris, 1963); W. H. Lechler, Philippe Pinel. Seine Familie, seine Jugend-und Studienjahre (Munich, 1960); W. Riese,“Philippe Pinel (1745-1826), His Views on Human Nature and Disease, His Medical Thought,” in Journal of Nervous and Mental Disease, 114, no. 4 (Oct. 1951), 313–323; and“An Outline of a History of Ideas in Psychotherapy,” in Bulletin of the History of Medicine, 25 no. 5 (Sept.-Oct. 1951), 442–456; R. Semelaigne, Alienistes et philanthropes, les Pinel et les Tuke (Paris, 1912); and J. Vinchon,“Philippe Pinel,” in Commentaires sur dix grands livres de la medecine francaise (Paris, 1968), 89–106.

Pierre Chabbert

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Pinel, Philippe

Pinel, Philippe

WORKS BY PINEL

WORKS ABOUT PINEL

Modern psychiatry was born of the efforts of few great pioneers. Among them, Philippe Pinel (1745–1826) stands out: his was the first major achievement, at once scientific and humanitarian, in the treatment of insanity.

The oldest of seven children, Pinel was born to pious Roman Catholic family in a small village in the Tarn in southern France. His grandfather and father were physicians; his mother, a very strong character, dominated his youth. Her death, when Pinel was only 15, moved him to take orders. H joined the Oratorians but soon left monastic life, becoming instead deeply imbued with the ne philosophical outlook of Locke, Condillac, Voltaire, and Rousseau.

Pinel was a brilliant student and a great admirer of the classics, of Hippocrates, and of Plutarch; h read Greek, Latin, and also English, from which he was to translate some of the works of his co temporary, William Cullen.

Initially Pinel studied in the Faculty of Letters at Montpellier, but he was above all interested in natural science and mathematics. Personal acquaintance with Paul Joseph Barthez, a renowned pphysician of the faculty at Montpellier, led him tohysician of the faculty at Montpellier, led him study medicine. Studious, reserved, and simple in tastes, Pinel had few friends, but those he ha were close ones, especially Jean Antoine Chaptal, the future scientist. Pinel’s erudition made a variety of careers possible, but once he arrived at Paris he decided to devote himself to psychiatry.

Pinel’s career is inseparable from its political context: The French Revolution made it a duty to protect all individuals, even the insane, against enslavement by others. Pinel first became professor of medical physics, but he was next appointed physician of the hospital of Bicetre, the ancient grange aux gueux (“beggars’ farm”) at the gates of Paris, where “the insane … are treated as criminals, by mercenaries, contrary to either reason or humanity.” Pinel denounced this state of affairs, asserting, “I am convinced that the only reason these insane people are so intractable is that they are deprived of air and liberty” (Semelaigne 1888, p. 35). At that time they were, in fact, kept chained.

Thanks to his persistent efforts, reason triumphed over prejudice, and soon the insane were no longer regarded as possessed by demons, but as mentally ill. This was certainly Pinel’s greatest achievement. However, he refused to accept the excesses of the revolutionary movement: churches were being robbed, and Pinel from within his hos pital coolly condemned the raging iconoclasts and the powerful authorities who supported them. During one uprising the mob was about to hang him; he was saved by the vigilance of a recently “unchained” patient whom he had taken into his personal service.

Beginning in 1795, Pinel held a position at the Salpetriere hospital in Paris. There too he had t start from the ground up, replacing the orderlies, refurbishing the sordid rooms, and eliminating the use of chains. His psychiatric researches led to two fundamental works, La nosographie philosophique (1798), awarded a prize by the Directory, and Le traité médico-philosophique sur Xaliénation mental (1801), his major work. He had a wide audience among medical students; although not eloquent and sometimes absent-minded, Pinel was greatly appreciated in scientific quarters.

The fundamental innovations to be found in Pinel’s works are of several kinds. First, he insisted on the humanitarian treatment of patients. He had a humane, moral attitude toward the mentally ill, having long talks with them in which he “skillfully gave them a drive that they thought was due t their own initiative” (Semelaigne 1888, p. 118 He substituted understanding and gentleness for violence, strait jackets for chains, and insisted on the temporary nature of even this restraint.

Second, he made administrative changes. He distributed patients in several pavilions according to their condition, thus foreshadowing the dynamic organization of the psychiatric hospital of today. He also urged that asylums be governed by physicians.

Finally, he made innovations in therapy. He tried to diversify the treatment of the “raving” patients according to the etiology of their disease. He saw to it that they had games and music to amuse them. “Skill,” he said, “consists less in the use of remedies than in the deeply judicious art of using or not using them at the right times” (ibid., p. 102) He completely rejected unnecessary bleedings and sudden cold baths but made good use of warm, sleep-inducing baths. In addition to such physical measures, he had workshops set up for therapeutic purposes, paying the patients wages. He advocated having farms—to be worked and managed by th convalescent patients—attached to asylums. Far in advance of his time, he proposed the establishment of institutions for convalescents in transition between the hospital and the outside world; this innovation was developed further by his students.

The doctrine that Pinel had worked out was not universally accepted after his death. Although the basic elements of his approach were applied, they were applied incompletely and without the effort and commitment he had had. We do not know if this failure was due to postrevolutionary political reaction, to a lack of medical men capable of carrying on his work, or to the absence of a sufficientl elaborated theoretical structure. In any case, only today are the foundations laid by Pinel being properly developed.

P. Sivadon and P. Sabourin

[For discussion of the subsequent development of PineVs ideas, seeClinical psychology; Mental disorders; Mental disorders, treatment of; Psychiatry.]

WORKS BY PINEL

(1798) 1818 La nosographie philosophique: Ou, la meihode de l’analyse appliquee a la me’decine. 6th ed. Paris: Brosson.

(1801) 1962 A Treatise of Insanity. New York: Hafner. → First published as Le traité médico-philosophique sur l’aliénation mentale.

WORKS ABOUT PINEL

Courbon, P. 1927 Pinel psychiatre. Annales médicopsychologiques 85, part 2:30–52.

Foucault, Michel (1961) 1965 Madness and Civilization: A History of Insanity in the Age of Reason. New York: Pantheon. → First published as Folie et déraison: Histoire de la folie à I’âge classique.

Lechler, Walther H. 1960 Neue Ergebnisse in der Forschung uber Philippe Pinel. Thesis, Univ. of Munich → This work is the result of research conducted by Pierre Chabbert and Walther H. Lechler.

Pinel, C. 1860 Philippe Pinel. Journal of Psychological Medicine and Mental Pathology 13:184–205.

Semelaigne, RenÉ 1888 Philippe Pinel et son oeuvre au point de vue de la medécine mentale. Paris: Imprimeries Réunies.

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Pinel, Philippe

Philippe Pinel

1745-1826
French physician and one of the founders of psychiatry.

Philippe Pinel was born near Toulouse, France, the son of a surgeon. After first studying literature and theology, he pursued medical studies at the University of Toulouse, receiving his M.D. in 1773. In 1778, Pinel moved to Paris, where he worked as a publisher, translator of scientific writings, and teacher of mathematics. He also wrote and published articles, a number of them about mental disorders, a topic in which he had become interested due to the illness of a friend. In 1792, Pinel was appointed chief physician and director of the Bicêtre asylum, where he was able to put into practice his ideas on treatment of the mentally ill, who were commonly kept chained in dungeons at the time. Pinel petitioned to the Revolutionary Committee for permission to remove the chains from some of the patients as an experiment, and to allow them to exercise in the open air. When these steps proved to be effective, he was able to change the conditions at the hospital and discontinue the customary methods of treatment, which included bloodletting, purging, and physical abuse.

Rejecting the prevailing popular notion that mental illness was caused by demonic possession, Pinel was among the first to believe that mental disorders could be caused by psychological or social stress , congenital conditions, or physiological injury. He strongly argued for the humane treatment of mental patients, including a friendly interaction between doctor and patient, and for the maintenance and preservation of detailed case histories for the purpose of treatment and research. In 1795, Pinel was appointed chief physician at Salpêtrière, where he effected reforms similar to those at Bicétre. Pinel remained at Salpêtrière for the remainder of his career. His student, Jean Esquirol, succeeded him and expanded his reform efforts throughout France. The success of Pinel's methods also influenced practices in other countries, including England.

In 1795, Pinel was appointed to the faculty of the newly opened medical school in Paris, where he was professor of medical pathology for the next 20 years. He was elected to the Academy of Science in 1804 and the Academy of Medicine in 1820. Besides his work in hospitals, Pinel also treated patients privately as a consulting physician. Although he is regarded today as a pioneering

figure in psychiatry, during his lifetime Pinel was known chiefly for his contributions to internal medicine, especially his authoritative classification of diseases in the textbook Nosographie philosophique (1798), in which he divided diseases into five classesfevers, phlegmasias, hemorrhages, neuroses, and diseases caused by organic lesions. Pinel's extensive contributions to medical research also include data on the development, prognosis, and frequency of occurrence of various illnesses, and experiments measuring the effectiveness of medicines. Pinel established an inoculation clinic at Salpêtrière in 1799, and the first vaccination in Paris was given there in April of the following year.

In addition to transforming psychiatric facilities from prisons into hospitals, Pinel did much to establish psychiatry formally as a separate branch of medicine, publishing numerous articles on the topic which were collected in "Recherches et observations sur le traitement moral des aliénés" (1799) and his book Traîte medico-philosophique de l'aliénation mentale (Medical-Philosophical Treatise on Mental Alienation or Mania,1801), which is considered a classic of psychiatry. Pinel's practice of interacting individually with his patients in a humane and understanding manner represented the first known attempt at psychotherapy . He also emphasized the importance of physical hygiene and exercise, and pioneered in recommending productive work for mental patients. In addition, Pinel concerned himself with the proper administration of psychiatric facilities, including the training of their personnel.

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Philippe Pinel

Philippe Pinel

The French physician Philippe Pinel (1745-1826) was the major figure in early efforts to provide humane care and treatment for the mentally ill.

Philippe Pinel was born on April 20, 1745, in the hamlet of Roques. At 17 he entered the Collège d'Esquille in Toulouse to prepare for the priesthood, but he soon decided to study medicine. He received his doctorate in 1773 and continued his medical education at the University of Montpellier, France's leading medical school. In 1778 he settled in Paris, where he devoted himself to general studies in science while tutoring in mathematics. Pinel's work on clinical medicine, Nosographie philosophique (1789), was a standard textbook for 2 decades, and several 19th-century schools of thought on clinical medicine trace their origin to it.

Pinel's interests in the mentally ill gradually developed, and in 1793, through the aid of friends in the Revolutionary government of France, he was appointed physician-in-chief at l'Hospice de Bicêtre, a large mental institution in Paris. There he encountered the characteristic cruel treatment of mental patients, as they were beaten, locked in dirty cells, and generally made to suffer in the hands of ignorant keepers. Perhaps worst of all, they were commonly restrained with chains. Pinel immediately insisted that the restraints be removed, and, in spite of warnings that unchained patients would become violent, he unchained 49 inmates on May 24, 1793. All responded favorably.

In 1795 Pinel assumed the responsibility for the mental patients at l'Hôpital de la Salpêtrière, where he continued his policy of nonrestraint and brought about many significant and far-reaching reforms in the care and treatment of mental patients. Humane treatment under the watchful eye of trained and compassionate personnel in the institution made possible the recovery of many otherwise doomed patients. Pinel also introduced the practice of keeping case histories, which proved a valuable source of information in later efforts to understand insanity. The new concepts of the care of the mentally ill were published in Pinel's Traité médico-philosophique sur l'aliénation mentale (1801; Treatise on Insanity, 1806).

Pinel was professor of hygiene and pathology at the University of Paris from 1794 until 1822, when he was removed by the government because of his past association with persons involved in the Revolution and because he had served as a consulting physician to Napoleon I for a few years after 1805. However, at the time of his death, on Oct. 25, 1826, Pinel was still active at Salpêtrière.

Further Reading

The best source of information on Pinel's ideas and methods is his Treatise on Insanity, translated by David Daniel Davis (1806; repr. 1962). A good recent study of Pinel, especially for the relation he felt to the medical ideas of Greek antiquity, is Walter Riese, The Legacy of Philippe Pinel (1969). □

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Pinel, Philippe

Philippe Pinel (fēlēp´ pēnĕl´), 1745–1826, French physician, M.D. Univ. of Toulouse, 1773. After moving to Paris in 1778, he was appointed (1793) director of the Bicêtre hospital and shortly thereafter of the Salpêtrière. His Traité médico-philosophique sur l'aliénation mentale (2d ed. 1809), based on observations in both these hospitals, advocated humane treatment of mentally ill persons, then called the insane, and a more empirical study of mental disease. He further contributed to the development of psychiatry through his establishment of the practice of keeping well-documented psychiatric case histories for research.

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