On the eve of the French Revolution, what had originally been a gunpowder factory and arsenal became the largest hospital and asylum in Europe. It was called Pitié-Salpêtrière. Professor of History Mark Micale noted that “this remarkable hybrid institution housed for over two centuries every imaginable form of social and medical ‘misfit’ from the lowliest sectors of Parisian life.” Because of it strange mixed population, the French writer Albert Camus once referred to it as a “frightful sewer.”
The Salpêtrière was situated on the south-eastern extreme of Paris. By the time of the revolution, it had a capacity to house 10,000 patients and also served as prison, largely for Parisian prostitutes. During the September massacres of 1792, it was stormed, and more than 100 prostitutes were released while 25 insane women were dragged from their cells and murdered in the streets.
Eighteenth-century Frenchmen remained curious about the mentally insane housed at the Salpêtrière. They were so curious in fact, one newspaper reported:
“In the year 1799, it was fashion to go visit the lunatic asylums and shudder at the wild sayings and violence of the unfortunate beings immured in those refuges of the worst of human infirmities. So numerous were they who would enjoy this cruel pastime that the municipal authorities were compelled to interfere, and order the madhouses to be closed upon all women. The prohibition did but stimulate their curiosity, and the moment the amusement was forbidden to all, each strove to have the privileged enjoyment of it. The commissioners were overwhelmed with applications which they could not always reject.”
By the early 1800s, changes and improvements began on the Salpêtrière facility with more radical changes occurring between 1815 and 1823. One major change was that the dungeons were destroyed. The hospital also underwent refurbishment. Sanitation was improved, dormitories enlarged, ventilation upgraded, and furniture replaced. By the mid 1800s, the hospital was composed of several buildings, and it had several enclosed gardens and grounds where patients could exercise at their leisure. A description of the hospital in 1837 follows:
“The population amounts to six thousand individuals, the greater part consisting of aged and infirm females, the remainder of the patients of the same sex affiliated with mental alienation, epileptic and cancerous diseases. The inmates sleep in large wards, containing from thirty to sixty beds, which however are placed too close to each other. The meals are served up in the wards, there being no dining-rooms. Those who require medical attendance are transferred to the infirmary, containing two hundred and fifty beds, which are mostly occupied by cases of chronic gastric and bronchial affections, diseases of the heart, and paralysis. The number of insane patients averages from nine hundred to one thousand.”
Many of the changes at the Salpêtrière were attributed to the French physician Philippe Pinel. Pinel was a friend of the Encyclopédistes and had instituted a more humane psychological approach (called today moral therapy) for the mentally ill. He became the chief physician at the Salpêtrière in 1794 and retained the post until he died in 1826. Pinel also published an authoritative classification of diseases in 1798 in which he simplified mental disorders reducing them down to one of four basic types:
- melancholia – Pinel described the symptoms as “taciturnity, a thoughtful pensive air, gloomy suspicions, and a love of solitude.”
- mania (insanity) – This was a madness independent of a disorder and patients with mania without delirium were described as perverse and disobedient. Mania with delirium was characterized by indulgence and fury or sometimes carefree, incoherent, and imaginary claims.
- dementia – This was characterized as indulgence, fury, thoughtlessness, extreme incorrectness, and wild abnormalities. Sometimes it was distinguished by a carefree, gay humor with incoherent and absurd suggestions. Other times it involved prideful and imaginary claims.
- idiotism – Described by Pinel as “defective perception and recognizance of objects, is a partial or total abolition of the intellectual and active faculties. This disorder may originate in a variety of causes: such as excessive and enervating pleasures; the abuse of spirituous liquors, violent blows on the head; deeply impressed terror; profound sorrow; intense study; tumors within the cavity of the cranium; apoplexy; excessive us of the lancet in the treatment of active mania. The greatest number of ideots [sic] are either destitute of speech or are confined to the utterance of some inarticulate sounds.”
In 1802, Pinel extended his thoughts on classifications and diseases by publishing La Médecine Clinique. The ideas in this book were based on his experiences at Salpêtrière. In addition, numerous experiments related to physical and psychological studies were being conducted at the Salpêtrière. For instance, Jean-Étienne Dominique Esquirol, a trusted colleague of Pinel’s, and Esquirol’s nephew, a Dr. Miture, tried to cure madness with unorthodox but agreeable remedies. Esquirol’s cures involved music and Miture’s was champagne. Of course, neither cure worked.
In the early 1800s, the Salpêtrière patients were known to walk about in the courts during the daytime. They were supervised by a female staff who were claimed to be kind and gentle. During Pinel’s tenure, nurses were usually members of a Catholic nursing order that undertook most of the daytime care of patients. However, it also resulted in disagreements and power struggles between the nursing staff and Pinel.
In 1826, one newspaper maintained that the Parisian hospital was a “most extensive establishment.” They also noted:
“The kitchen contains four boilers, each of them will hold two oxen, and convert them into soup. They are calculated to contain 1,2000 pounds of meat each. The extent of the wardrobe may be estimated from the following specimen of the lingerie, or store room for clean linen, which contains 38,000 sheets, 19,500 pillowcases, 29,000 women neckerchiefs, 22,000 night caps, and 36,000 chemises.”
In 1828, one Scottish newspaper gave credit to the Salpêtrière and the extraordinary care doled out to the mentally ill by its staff. The paper wrote:
“The allowance of bread … is exactly the double of what is allowed in Bethlem Hospital, London; the profession in France considering it of great importance to the welfare of the inmates, that they shall, on no occasion, suffer from the cravings of inordinate appetite, so frequently an attendant on mental alienation. To guard against this, it is the practice in the Salpetriere for women to make the round of the house during the night, and give extra meat and drink where these are required. The baths are extensive and excellent, being constructed not only for hot and cold water, but so as water may be directed in smaller or larger streams, to any part of the head or body, or in one mass over the whole patient. The attendance of the medical officers … is daily; their visit long and particular. … It is by the authority of the physician … that the different baths already spoken of can be administered, or the removal of a patient from one division of the building to another can be warranted … [or] that any stranger of friends of the inmates can be admitted into the establishment.”
To determine lodgings at the hospital, doctors classified patients in one of three ways: curable, incurable, and idiots. Based on a patient’s classification, lodgings were doled out in the following fashion:
“Tranquil patients, and those under treatment, are lodged in clean and airy wards … Of the incurable, the more intractable and furious patients, some occupy wards, other small cells built round court-yards on the ground-floor. Each of the cells lodges one person, contains no other furniture than a bed, and has a grated window with a shutter. When violent, the patient is confined to her cell, and the shutter closed; the isolation and darkness is often sufficient to restore quiet, without resorting to the straight waist-coat, which is the only means of forcible restraint employed.”
In 1837, according to one book on medical institutions in France, treatments of the mentally ill did not consist of “moral measures.” They did however consist of such treatments as “mild purgatives, baths, douches, and counter irritation by means of blisters [were used]. In some cases of maniacal exaltation, cauterisation of the nape of the neck … Sanguineous depletion [was] not frequently resorted to, nor [were] opium and other sedatives often employed.”
Pinel died on 25 October 1826. However, he was not forgotten. An iconic image of him as the liberator of the insane was painted by Tony Robert-Fleury in 1876 and depicts Pinel among asylum inmates. There is also Pinel’s sculpture by Ludowig Durand from 1885 that stands at the main entrance in Place Marie-Curie, Boulevard de l’Hôpital.
Pinel was succeeded at the hospital by Esquirol, who initiated the first systematic lectures on psychiatry in France and was chief architect of France’s lunacy legislation in 1838. Jean-Pierre Falret followed him contributing to the topic of bipolar disorder and folie à deux, and in 1862, Jean-Martin Charcot was placed in charge. He transformed Salpêtrière into a celebrated psychiatric teaching hospital and a top neurology center. Charcot’s teaching activities at the hospital also helped elucidate the natural history of many diseases that include neurosyphilis, epilepsy, and stroke, and because of Charcot’s work in neurology and psychology, modern psychiatry owes credit to him and his followers.
-  Kathleen M. Woodward, Figuring Age: Women, Bodies, Generations (Bloomington: Indiana University Press, 1999), p. 115.
-  Morning Post, “A Judgment of Paris,” April 9, 1839, p. 2.
-  Edwin Lee, Observations on the Principal Medical Institutions and Practice of France, Italy, and Germany: With Notices of the Universities, and Cases from Hospital Practice. To which is Added an Appendix, on Animal Magnetism and Homœopathy (Philadelphia: Haswell, Barrington, and Haswell, 1837), p. 16.
-  Philippe Pinel, A Treatise on Insanity: In which are Contained the Principles of a New and More Practical Nosology of Maniacal Disorders Than Has Yet Been Offered to the Public (Sheffield: W. Todd, 1806), p. 136.
-  Ibid., p. 165.
-  Chester Courant, “Sapings and Doings,” January 10, 1826, p. 4.
-  The Scotsman, “Literary Notice,” March 29, 1828, p. 6.
-  E. Lee, p. 16.
-  Ibid.