History of Medicine

THE SALPÊTRIÈRE AND THE BEGINNING OF PSYCHIATRY

         Some of Paris’ largest hospitals originated with far different purposes than medical care. France was exhausted after the Thirty Years’ War, ending in 1648, and a subsequent civil war that further ruined the economy and drove thousands of impoverished citizens into the capital. To prevent public unrest, leading members of the Parlement won a royal edict from the young Louis XIV to create the Hôpital Général, a group of buildings to shelter the poor and to provide both religious and work-oriented instruction. In relation to medical history, three buildings of the Hôpital Général stand out: the Bicêtre (for men), La Pitié (for children), and the Salpêtrière (for women). The Salpêtrière occupied the old city arsenal, its name derived from the saltpeter used to manufacture gunpowder. 

The Salpêtrière shortly after the chapel tower was added (Wikipedia)

A large chapel, whose dome dominates the structure, went up in the later 1600s as part of an overall expansion. 

         The poor and disabled filled most beds. Those with medical/surgical problems went to the Hôtel Dieu, Paris’ central hospital. Mentally ill and epileptic women, categorized at the time as custodial problems, lived in separate divisions, often enchained and ill-treated. In 1684 a prison was added to house prostitutes and other female “undesirables” and soon earned a bad name. 

Prostitutes on the way to the Salpêtrière, by Etienne Seurat, 1755 (Wikipedia)

        In the early 1700s the government dispatched hundreds of women from the prison to populate French colonies in the New World, settled by men. In 1792, during the French Revolution, a drunken mob entered the prison, dragged 45 women out and massacred them. Order was eventually restored and in 1795 authorities abolished the prison.

Medicalization of the Salpêtrière began only in 1780 with the inauguration of an infirmary, followed by a resident doctor in 1783, thereby reducing the number of sick previously dispatched to the Hôtel Dieu.     

         The Revolution brought about extensive changes in the medical world. The new government founded medical schools that accepted students and faculty based on merit. The hospices assumed new medical functions, offering abundant patient material for teaching and study. Autopsies revealed new information on disease processes and bedside teaching flourished. Introduction of the stethoscope and the rediscovery of percussion opened new methods of premortem diagnosis. At the Salpêtrière, an important step was the appointment of Dr. Philippe Pinel as medical director in 1795.

         Philippe Pinel was born in 1745 in the Department of Tarn,

Phillipe Pinel (Wikipedia)

southern France. His father and both grandfathers were physicians. At the University of Toulouse, he studied mathematics and obtained a degree in medicine. He moved to Montpellier to further his medical studies, supporting himself by tutoring in mathematics and Latin. Next, he moved to Paris, surviving at first by tutoring. He advanced slowly, partly due to extreme shyness, wrote medical articles, became editor of the Gazette de Santé, translated William Cullen’s Institutes of Medicine, and met important physicians who appreciated his learning. After the French Revolution, in 1793, he received an appointment as “physician of the infirmaries” at the Bicêtre Hôpital, a hospice similar to the Salpêtrière but reserved for men. 

In Ward 7, containing 700 mentally ill men, Pinel he found the “governor” (administrator), Jean Baptist Pussin, managing the patients without chains or beatings, contrary to the usual practice at the time. Pussin penned a summary of his experience, probably at the request of Pinel, in which he noted that patients responded well to gentle treatment. For those who persisted with violent behavior he used what is now called a straitjacket, allowing the patient some movement without risk to others. Pinel, impressed, presented the novel method of care to the Society of Natural History, a politically neutral haven for physicians during the chaotic revolutionary days, in 1794, acknowledging the work of Pussin.

         The next year, Pinel was transferred to the Salpêtrière as “physician in chief,” and brought Pussin with him. Imbued with scientific sentiments of the enlightenment, Pinel embarked on a study of over 1,000 patients to help plan treatments. He combined statistics and probability techniques and emphasized the value of experiments. He wrote that experiments must “fairly report the proportion of positive and failed results, all of which are instructive. It must therefore be based on the theory of probability which must henceforth be basic to medical therapies.” (Weiner, “Philippe Pinel in the Twenty-First Century”) The historian Edwin Acknerknacht has called him the “actual father of the numerical method in medicine.” 

For the mentally ill, Pinel instituted a kind, though firm, rehabilitation program that included a detailed history of the illness and the patient’s background and usually advised a work program. He reduced bleeding and many medicines as treatments.

1857 Lithograph by Armand Gautier:  Personifications of dementia, megalomania, acute mania, melancholia, idiocy, hallucination, erotic mania and paralysis at la Salpêtrière. (Wellcome Library)

    He found time to write texts, including a book on mental illness and one on internal medicine and taught at the University. His

Pinel's text on mental illness,
first ed.,1801 (year 9 in
Revolution calendar)

students included Xavier Bichat and René Laennec. After the restoration of the monarchy, the liberal Pinel was dismissed from the Salpètriére in 1822. Though an important figure in many ways, he is primarily remembered today as a father of modern psychiatry. Pussin’s role is under-appreciated. Similar approaches to the mentally ill were also underway in England, the German states, and America.

Two striking paintings commemorate Pinel’s work. The first, commissioned in 1849 by the Académie de Médecine, shows Pinel dramatically gesturing toward an attendant, presumably Pussin, who is removing chains from an emaciated, elderly man in the Bicêtre, a depiction that distorts the role of Pussin. (Painting and information on artist viewable at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/207397

        The other, set in the Salpêtrière, shows Pinel supervising the release from chains of a somewhat dazed woman, again ignoring Pussin. It hangs now in the Salpêtrière.

 Pinel at la Salpêtrière (1876) by Tony Robert-Fleury (Wikipedia)

The Salpêtrière today is a huge hospital complex, particularly famous for its neurology center, created by the famous Jean-Martin Charcot. But that story is for another time.

Front entrance of the Salpêtrière today. The chapel dome is behind entrance. (by author)

SOURCES:

 

Ackerknecht, E, Medicine at the Paris Hospital 1794-1848. 1967, J Hopkins Press.

 

Foucault, M, Madness and Civilization: A History of Insanity in the Age of Reason. 1965, Random House.

 

Weiner, D B, “The Apprenticeship of Philippe Pinel.” Clio Medica 1978; 13 (2): 125-33.

 

Weiner, D B, “Philippe Pinel in the Twenty-First Century.” Chapter in Wallace, E R and Gach, J, History of Psychiatry and Medical Psychology. 2008, Springer.

 

Weiner, D B, “The Madman in the Light of Reason: Enlightenment Psychiatry.” Chapter in Wallace, E R and Gach, J, History of Psychiatry and Medical Psychology. 2008, Springer.

 

Kushner, I, “The Salpêtrière Hospital in Paris and Its Role in the Beginnings of Modern Rheumatology.” J Rheumatology 2011; 38 (9): 1990-93.

 

Hurwitz, L J, “L’Hôpital de La Salpêtrière, Paris.” BMJ 1962; Apr 28, 1196-7.

 

Ruiz-Gomez, N and Liebrenz, M, “The Ties that Bind Past and Present: Tony Robert-Fleury, Philippe Pinel and the Salpêtrière.” Forensic Science International: Mind and Law 2021; 2: 1-7. 

 

McHugh, T J, “The Hôpital Général, the Parisian Elites and Crown Social Policy During the Reign of Louis XIV.” French History 2001; 15 (3): 235-53.