260404the salpetriere in the age of charcot

30
The Salpetriere in the Age of Charcot: An Institutional Perspective on Medical History in the Late Nineteenth Century Author(s): Mark S. Micale Reviewed work(s): Source: Journal of Contemporary History, Vol. 20, No. 4, Medicine, History and Society (Oct., 1985), pp. 703-731 Published by: Sage Publications, Ltd. Stable URL: http://www.jstor.org/stable/260404 . Accessed: 12/05/2012 08:27 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. Sage Publications, Ltd. is collaborating with JSTOR to digitize, preserve and extend access to Journal of Contemporary History. http://www.jstor.org

Upload: dadaaucoeur

Post on 20-Apr-2015

86 views

Category:

Documents


7 download

TRANSCRIPT

Page 1: 260404The Salpetriere in the Age of Charcot

The Salpetriere in the Age of Charcot: An Institutional Perspective on Medical History in theLate Nineteenth CenturyAuthor(s): Mark S. MicaleReviewed work(s):Source: Journal of Contemporary History, Vol. 20, No. 4, Medicine, History and Society (Oct.,1985), pp. 703-731Published by: Sage Publications, Ltd.Stable URL: http://www.jstor.org/stable/260404 .Accessed: 12/05/2012 08:27

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].

Sage Publications, Ltd. is collaborating with JSTOR to digitize, preserve and extend access to Journal ofContemporary History.

http://www.jstor.org

Page 2: 260404The Salpetriere in the Age of Charcot

Mark S. Micale

The Salpetriere in the Age of Charcot: An Institutional Perspective on Medical History in the Late Nineteenth Century

Thirty years ago, the history of medicine was conceived largely as a history of medical ideas. To this older view of the field, scholars in recent decades have added a social and cultural history of medicine, which takes as its natural domain the particular animating contexts of place and time in which these ideas were applied by doctors to patients on a routine basis. In the case of psychology and psychiatry, to examine these ideas in situ means to write a history of the hospital and asylum. Curiously enough, the history of these medical establishments in continental Europe remains very inadequately explored, although several bodies of literature have dealt, either directly or by implication, with this area of inquiry.

The bulk of French medical historiography through the years has been trapped in the commemorative mould. The 'histoire hospitaliere', as it is called, consists mainly of sketches of famous doctors and their discoveries, lists of material reforms and accounts of prominent buildings. These writings are very inward-looking in their treatment of the sub- ject and, as might be expected, 'Whig' interpretations predominate. According to this well-known perspective, medical history provides the story of crude and abusive practices rooted in ignorance and superstition, superseded by humane and rational medical activities, selflessly exercised by licensed practitioners and based on an ever-expanding body of scientific knowledge. The hospital serves as the central institutional setting for this drama. 1

In wholesale opposition to this work, there has appeared since the early 1960s a radically revisionist attempt to write an 'histoire de la folie'. Inspired variously by Marxist theory, the writings of Michel Foucault and the current 'anti-psychiatry' movement in Paris, these interpretations emphasize the themes of social control, moral indoctrination, and class conspiracy. The Whig view is here debunked as bourgeois myth and replaced by an image of the asylum as a highly controlled and coercive

Journal of Contemporary History (SAGE, London, Beverly Hills and New Delhi), Vol. 20 (1985), 703-731

Page 3: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

environment. According to this scheme, the full paraphernalia of moder psychiatry - the concept of lunacy reform, the notion of institutional care, the figure of the professional medical authority, the idea of insanity itself - come to represent a force of social oppression, masquerading as beneficence and official science, but in fact perpetrated on the recalcitrant lower orders by a rising and rationalizing middle class.2

These two antithetical views of hospital history are also found in works outside France, but of course in much less extreme versions. Henry Sigerist in the 1930s and George Rosen in the 1950s provided in a number of closely researched essays a mild statement of the progressivist vision. Writing a 'historical sociology' of medicine, Sigerist and Rosen proposed a loose, three-stage model for the evolution of the European hospital. In its original medieval form, what passed for the hospital, they showed, was essentially an ecclesiastical institution providing spiritual ministration at the hands of a clerical staff. By the early seventeenth century, this had been transformed across the continent into large, centralized and generally state-controlled institutions for the incarceration of 'socially deviant' groups of people in the large cities. This sort of establishment began to give way during the first quarter of the nineteenth century to what Rosen called 'the health-workshop or medical-factory type' of institution. At this stage, diagnostically distinct groups of sick people are given specialized medical care based on state-of-the-art technology and medical knowledge by a professionally trained l6ite. 3

A number of recent analyses, however, have considerably qualified this view of the hospital in the nineteenth century. Writing in an American context, David Rothman and Gerald Grob have underscored an evolution in the mental hospital from an early nineteenth-century period of

optimism, high therapeutic expectations and extensive asylum-building to a time in the 1860s by which 'therapeutic resignation' had set in. Due to a number of factors including overcrowding, governmental underfunding, and the accumulation of chronic cases, the original rehabilitative function of the asylum, as these authors see it, was replaced by an increasingly custodial conception of the hospital with far fewer claims for curability.4 The best recent work on the history of hospitals has come from what might be called the American sociological school. Scholars such as Paul Starr, Charles Rosenberg, Jan Goldstein and Jeanne Peterson, drawing their subjects from both sides of the Atlantic, have chosen to emphasize certain external or non-scientific developments in the field. In these writings, the salient themes from the previous century include the rise of homo medicus to general intellectual respectability, the growth in professional power of the psychiatrist, the development

704

Page 4: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

of institutional bureaucracies and the economic rationalization of hospital budgets.5

By any measure, this literature as a whole includes some excellent and important work. That the history of medicine is no longer considered an arcane or antiquarian pursuit is due in no small part to the spirited confrontation during the last generation between these schools of inter- pretation. 6 However, there is at least one feature of almost all this writing which ultimately proves problematic: nearly all of it is extremely generalized. The great bulk of the work in this area strives above all to present a uniform picture or model, a single historical trajectory followed by certain 'hospital types' in their development toward the twentieth century. In some cases, this is due to the social-scientific approach generally, with its emphasis on broad modernizing processes. In other instances, it is because of the type of research materials on which the arguments are based. Much of this work is derived from a reading of either printed medical texts, national legislation or administrative decrees. While these sources are important, they really provide a picture of medical theories, therapeutic goals and legislative idealism, rather than information concerning the material conditions and actual workaday realities of individual hospitals.

It is at this point that the case study approach and the particularizing imperative of the historian (especially the social historian) become invaluable. The history of the health-care establishment contains a far greater degree of institutional individuality than has been acknowledged up to now. Broad patterns of development can, of course, be discerned; but there is also much to suggest that the history of both general and psychiatric hospitals is full of important cross-cultural divergencies, regional variants, and city/country contrasts. The case study literature that does exist deals with the English and American settings, leaving the continental experience almost wholly unexplored. 7

In the following pages, we shall examine a single medical establish- ment, the largest and arguably most important welfare institution in France for over 250 years, as it existed during the final third of the nineteenth century. By drawing from a wide range of materials (printed and archival, literary and visual, professional and lay) we will get a view of medical events and circumstances as they existed at a single institution and were experienced by staff, patients, and other contemporaries. Since a comprehensive treatment of the subject is impossible in this format, we shall review in condensed form a number of features - some well- known, others less familiar - that were distinctive of the institution during the fin-de-siecle period. From among these concerns, we shall

705

Page 5: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

investigate in greater detail the changing relationship of the hospital to its larger urban environment. Such an examination will not only allow us to visualize the medical enterprise during its great heroic age as it operated in a specific setting, but will also serve as a badly-needed yardstick for judging both in outline and detail the several, very general historical schemes available today for studying the modem hospital.

From its inception over three hundred years ago, the story of the Salpetriere has been a rich and remarkable one; and from the start, the fate of the institution has been inextricably caught up with the history of Paris. The hospital was founded by the royal government in 1656, under the guidance of Cardinal Mazarin, as part of what was euphemistically called the 'Hopital General'. It was constructed on the site of an old arsenal for saltpetre in the south-eastern sector of the city in what is now the thirteenth arrondissement. During its early history, the hospital was in fact a massive 'maison d'internement', a kind of enormous medical poorhouse which kept an assortment of sick and destitute people off the city streets while at the same time providing them with food and shelter. The Salpetriere was reserved for women in this category, while their male counterparts were sent to Bic6tre in Gentilly. 8

Partly charitable and partly coercive in its operations, the hospital in this early moder period corresponds perfectly to the second phase of Rosen's historical model and somewhat more roughly to the Foucaultian concept of institutionalization as a masked form of social normalization.

Throughout the period of the ancien regime, the Salpetriere knew no bounds in the size and scope of its patient population. A variety of sources for the seventeenth and eighteenth centuries cite between six and eight thousand inmates, making it, as Jacques Tenon wrote in his famous Memoires, 'the largest hospital in Paris and perhaps in all of Europe'. 9 The composition of the population at this point included one of those indiscriminate mixtures we would today find unconscionable: not only hundreds of female beggars but the very elderly, the blind, orphaned girls, epileptics, the mentally retarded, women suffering from advanced venereal diseases ('les v6n6riennes') and a host of others who would no doubt be diagnosed differently today. Prostitutes and a wide assortment of 'anormales', civil and political criminals, and religious heretics (after the repeal of the Edict of Nantes) were also included in this promiscuous assemblage. From its mid-seventeenth-century beginnings, several hun- dred women understood as mentally deranged were interned in the hospital grounds as well.10 Part asylum, part prison, part old people's

706

Page 6: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

home, this remarkable hybrid institution housed for over two centuries every imaginable form of social and medical 'misfit' from the lowliest sectors of Parisian life.

During this pre-revolutionary period in the history of the Salpetri&re, a number of things are at once apparent: medically, care for the afflicted individuals at the hospital was simply non-existent. People were subjected to a rigorously prescribed daily routine of religious exercises and work activities at the hands of several hundred soeurs-officieres. A uniformed medical police, or corps d'archers, roamed the hospital grounds to maintain order. The treatment of those designated as insane reinforced the familiar and ghastly portrayals of Swift, Hogarth, and Goya. These people were confined in dark, subterranean cells called 'basses loges', restricted by leg-locks and neck irons, and patrolled by jailers with dogs. As a condition for admission to this area, the mentally ill were required to have an official 'certificat d'incurabilitt'. " As far as can be deter- mined, the first resident doctor for any category of patient at the hospital, and the first medical facility in the form of a one-room infirmary, appeared at the Salpetriere in the early 1780s, over 130 years after the institution had been in operation. 12

From a sociological perspective, the relationship of the Salpetriere to external French society at this time is also striking. With its incomparable patient population and role in dramatic historical events, such as the September massacres of 1792, the hospital quickly became a powerful institutional presence in the popular Parisian imagination. The many literary renditions of the subject, from the novels of Pr6vost to Hugo's Les Miserables, invariably presented the gruesome and macabre side of life within this vast 'lunatic colony'. Incarceration there brought a moral stigma greater than that at Vincennes or the Bastille, and processions of prisoners, prostitutes, or the mentally ill en route to the hospital were often mocked and stoned by bystanders.13

We know from engravings and paintings at the Mus6e Caravalet today that the Salpetriere at this time was located in the open countryside, out- side the old crenellated city walls of the Place Maubert. ' This fact of geography nicely captures the emotional and cultural relationship between the hospital and the town. Those unfortunate groups of people sent to the Salpetriere were in every way marginal - the physical and mental outcasts of society who were safely sequestered beyond the external confines of the city. Interestingly, from early characterisations, the view of the hospital as an island - 'the Mont Saint-Michel of melancholics', as one writer put it - is very prominent. 5 This image of isolation and alienation is expressed in the rather chilling recollection of an early eigtheenth-century writer:

707

Page 7: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

Sometimes, in the middle of a silent night, the residents of the Saint-Marcel and Saint-Victor quarters (nearest the hospital) would hear a clamour rise up, a sort of savage groaning at regular intervals. It was 'the cry of the hospital'. Held in, suppressed for months, the energy and fury that filled the souls of those poor creatures would slowly increase and then burst forth; a riot had started up among them, several thousand at a time.. .with their horrible screams. This cry of alarm coming from the place produced in us a terrifying feeling.16

For hundreds of thousands of Parisians over a 150-year period, then, this was the reality represented by the Salpetriere - a dark and distant presence, a series of sinister human sounds, only occasionally audible, from the strange concatenation of buildings at the city's edge.

Parisians in the late nineteenth century could not claim to share this disquieting experience. The opening decades of the nineteenth century brought the series of events in the history of medicine that Gregory Zilboorg has called 'the first psychiatric revolution', with the Salpetriere serving as the institutional locus for many far-reaching changes.17 Most dramatic in this regard was the work of 'the great emancipator', Philippe Pinel, symbolically breaking the chains of insane women at the Salpetriere. While recent detective work on the subject has to some extent qualified the nature of his achievement, the overall effect of Pinel in bringing the humanitarian ideals of the Enlightenment to the medical world remains indisputable. 8 During his long tenure at the hospital, from 1795 to 1826, a string of reforms was begun including the prohibition of physical violence against patients, the termination of all bloodletting practices, the keeping of extensive case histories, and the making of daily clinical rounds. 9

During the second quarter of the century, a line of Pinel's students worked at the Salpetriere, almost single-handedly forming for a genera- tion what Erwin Ackerknecht has called 'the French school of medicine'.20 The work of J.-E.-D. Esquirol on monomania and the depressive psychoses, of Jean-Pierre Falret on suicide and mental retardation, of Etienne Georget on cerebral anatomy, and much more besides, all came out of the Salpetriere during the period of the Restora- tion and July Monarchy. 2 Therapeutically, this was the period of 'le traitement moral'. Basic improvements at the hospital were made in the diet, hygiene and clothing of patients. The last of the old basement cells for the insane was demolished in 1818 and replaced by a fully aerated and above-ground quartier des folles in the south-eastern sector of the hospital. In June 1838, the loi sur les alienes was finally ratified,

708

Page 8: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

providing, at least in theory, the first comprehensive, national legislative protection for asylum patients across France.22

It was a decade later, in 1849, that the young Charcot first came to the Salpetriere as a medical student. He returned in 1862 in the position of hospital medecin en chef and remained for over thirty years until his death in 1893. Soon after his arrival, he became the powerful presiding figure of the institution, and during the 1880s the Salpetriere was often described as the 'Hopital Charcot'.23 Not unexpectedly, important changes at the Salpetriere took place during the period of Charcot's tenure, as institutional reform gave way to what might be called medical modernization. This modernizing process involved at least three events.

The history of the Salpetriere during the second half of the nineteenth century is immediately marked by an unprecedented expansion of scientific services and teaching facilities. The process began with the construction of an enlarged autopsy room in the late 1860s and a rudimentary laboratory with microscopes and a histological collection in 1872. In January 1882, at the instigation of Gambetta, the National Assembly created for Charcot personally a chaire des maladies du systeme nerveux, the first official position in the Paris Faculty of Medicine dedicated to the study of neurological and psychological disorders. 24 An out-patient clinic, or consultation extere, was erected at the entrance of the hospital in the same year. Using his political connections at the Public Assistance Administration, Charcot obtained special funding for the creation of a remarkable battery of auxiliary medical and scientific services, forming the famous Clinique Charcot. By the early 1880s, he was able to write that 'we now possess a museum of pathological anatomy to which are annexed a casting room and a photographic studio, a laboratory for anatomy and pathological physiology... an ophthalmo- logical office...and a service richly endowed with all the necessary equipment for the practice of electrodiagnostics and electrotherapy'.25 During the summer of 1893, shortly before he died, he was overseeing the construction of chemical and bacteriological laboratories.

Equally significant at this time was the emergence of the Salpetriere as a celebrated teaching institution. Once again, this was almost single- handedly the work of Charcot. Always a dedicated teacher, Charcot gathered around him a group of students with whom he worked in close daily collaboration - 'la charcoterie', as it was called by his critics. 26 By the early 1880s, he had in effect formalized the long French tradition of bedside clinical instruction with his famous 'lecons du mardi' series. A new lecture amphitheatre capable of holding an audience of 500 provided a site for his dramatic weekly demonstrations on hypnotized

709

Page 9: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

hysterics, captured for posterity in Andre Brouillet's enormous canvas, Une Lecon clinique a la Salpetriere (1886).

Dozens of aspiring young doctors and medical students, from Western and Eastern Europe, England, and America, came to the Salpetriere over the years to learn from the great physician. 27 With such a constellation of French and foreign talent, it is not surprising that articles, case histories, and monographs poured out of the Salpetriere'. A special press and two journals (Progres Medical and later Archives de neurologie) were established to publish this burgeoning body of work. During its heyday, from about 1875 to 1895, the 'Ecole de la Salpetri6re' was virtually synonymous with progressive work in the field of neuropathology. 'About twelve years ago', Charcot wrote proudly in 1882, 'I expressed the hope that this great asylum of human miseries, where so many masters of French medicine have distinguished themselves, would some day become a regularly organized centre for research and instruction in the area of the neurological disorders. Gentlemen, look at how our wishes have been realized beyond our fondest hope.'28 By the close of the century, the general asylum of Pinel's day to which medical students had dreaded being assigned had been transformed into a 'temple of science' and an internationally renowned educational centre.

A second important aspect of medical modernization at the Salpetriere involved the staff. By American standards, the primary medical staff of French hospitals at this time remained small, centralized, and hierarchical. In 1885, for instance, the upper level of medical personnel at the Salpetriere, including doctors, surgeons, internes, and exteres, consisted of only forty-three people. 29 Given the large number of patients, it was in effect the enormous support staff of over 500 nurses and nursing assistants (surveillantes, suppleantes, andfilles de service) who provided daily care in the wards. During the age of Charcot, the most significant change in this category of personnel, which has recently been explored by Jan Goldstein, involved the sudden and complete laicization of Paris hospitals and asylums. 30 In the closing years of the Second Empire, the Church had on a number of occasions attacked the teaching of the Paris Faculte as subversively materialistic. With the final parlia- mentary defeat in 1877 of Marshal MacMahon's old Orleanist party, the largely republican medical profession, in concert with a new Prefect of the Seine, struck back. Not surprisingly, given Charcot's intellectual credentials as a good Voltairean, the nation-wide campaign began at the Salpetriere.31

On 1 April 1878, an Ecole municipale des Infirmieres, the first fully laic school of its kind in France, opened along the eastern perimeter of

710

Page 10: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

the hospital. 32 In December of that year, a purge of personnel was set in motion at the Salpetriere, with other hospitals in the city following suit in the next decade. Under the ferocious anti-clerical vigilance of D.-M. Boureville, a former student of Charcot, virtually hundreds of old soeurs-infirmieres were summarily replaced by trained and licensed nurses. A prefectorial arrete of June 1883 ended all obligatory church attendance at the Salpetriere and reduced the number of ecclesiastical personnel. The old religious names borne by many hospital buildings since their founding were replaced with names of medical and scientific figures. Increasingly, doctors and administrators spoke of religious belief only as a therapeutic technique, an occasional means of emotional support for the sick and the senile. 33 The secularization of charity, begun with the founding of the Hopital General and continued with the establishment of the Assistance Publique in 1849, was now brought to completion.

The same people at the Salpetriere involved in this struggle took up other polemical issues of the day. Throughout the 1880s, for instance, the pages of the Progres Medical are full of arguments by students of Charcot for causes such as the admission to medical school of female candidates, the wider use of Pasteur's inoculation techniques, the establishment of new provincial medical faculties and the passage of more effective welfare legislation. From these controversies, a clear-cut opposition arose between the conservative Academie de M6decine on the one hand and the students of Charcot's Salpetriere and of Claude Bernard's Societe de Biologie on the other. 34 Thus, throughout the late nineteenth century, the sense that the Salpetriere represented a kind of medical avant-garde, a new and aggressive modernity in the face of entrenched opposition, remained strong.

The third and final dimension of the medicalizing process crucial to understanding the Salpetriere in the nineteenth century concerned changes in the composition of the patient pool. In discussing the early history of the Salpetriere, we found a highly heterogeneous population casually thrown together into one huge institutional catch-all. Beginning in the late eighteenth century, this state of affairs began to change. Through a process of institutional differentiation spanning the entire century and involving the progressive sorting out of specific, non-medical groups of people, an old and essentially medieval receptacle for all forms of human suffering developed into something recognizable as the modern hospital, devoted to the treatment of diagnostically discrete categories of patients. Though it is often overlooked or underestimated, this route was traversed by nearly every major hospital in Europe with remote historical origins, but the process was illustrated particularly vividly by the Salpetriere.

711

Page 11: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

Information concerning this transformation is sketchy, but we do at least have a skeleton of dates. The largest group of residents originally at the hospital, the begging poor, was removed during the closing decades of the eighteenth century to special depots de mendicites on the outskirts of the city. In January 1795, the Maison Saint-Lazare, formerly a leprosarium, opened as a retention centre for prostitutes. Women at the Salpetriere under this rubric were transferred at once. During the final years of Napoleon's rule, the corps d'archers of medical police was abolished, and the old prison of La Force was converted into a ward for convalescents. In 1836, with the opening of the Hopital Lourcine, off the Boulevard de Port Royal, women suffering from tertiary syphilitic infections were weeded out of the ranks. 35

By degrees, two groups of patients, the elderly and the mentally ill, emerged as the core of the hospital. During the age of Charcot, the work of institutional differentiation continued within these purely medical sub- populations. In 1862, chronic invalids were removed from the Salpetriere to the Asile National de V6sinet. Beginning in the mid-1870s, the hospital no longer accepted tubercular patients or pregnant women. In 1899, the Service Henri Colin at the Villejuif asylum opened for retention of the violently insane and in 1910 a centre for severely epileptic women was created at the Maison Blanche, leading to further transfers. 36 By the end of the first world war, the hospital had pretty much emerged in the form it retains today of a general health care centre specializing in geriatrics and neurology.

These various phenomena - the application of Pinel's psychiatric humanism, the establishment of scientific and teaching facilities, the declericalization of staff, and differentiation of the patient population - are among the most salient features of the Salpetriere as it evolved in the nineteenth century. Each of these developments is also in broad

agreement with the historical picture of the hospital presented by Rosen and Sigerist. Medical modernization was in fact a movement toward the health-workshop or medical factory.

The process, however, remained incomplete and imperfect until the turn of the century. As Esquirol had realized as early as 1820, the Pinelean improvements were extremely localized (limited really to the

capital city); and the loi sur les alienes was often applied only partly, belatedly, or not at all. 37 At a time when England and Germany were

adopting the 'no restraint' system in their asylums, officials at the Salpetriere continued to employ rather severe forms of physical restraint on patients. 38 Also, despite secularization, the calibre of the lowest-paid attendants at the hospital remained poor, with many recorded instances

712

Page 12: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

of neglect, theft, and abuse. Throughout the late nineteenth century, medical classification of patients at the hospital was very confused reflecting the comparatively crude nosology of psychiatry at the time.

But the fact that these conditions persisted and were often officially understated, does not gainsay the basic fact that for the Salpetriere the nineteenth century was undeniably an age of improvement. The debunking gestures of the Marxist and Foucaultian schools, citing ironically the words 'reform' and 'progress', are in this instance un- warranted. From our investigation, there can be no doubt that life for dependent groups of people at the hospital in 1900 was vastly more salutary than in 1800 or 1700. And if some facts are open to interpreta- tion, others, such as the drop in the number of riots, the declining mortality rate and the disappearance of legal cases concerning wrongful confinement, have been proved conclusively. In the important case of the Salpetriere, a tempered version of Whig medical historiography rests on a sound evidential base.

The historical aspects of the Salpetriere we have been concerned with up to this point are easily accounted for and objectively verifiable. They represent diachronic historical phenomena or broad developmental processes unravelling over the course of a century. They also reinforce certain conventional schemes for the development of the hospital in moder times. However, if we seek a synchronic or cross-sectional pic- ture of the Salpetriere as it existed in, say, 1885, then other characteristics become apparent. While more subjectively experienced at the time and less obvious to latter-day scholars, these features are at least as interesting and important for comprehending our subject as the conditions discussed above.

From the large volume of commentary on the Salpetriere in the late nineteenth century, one image in particular appears time and again: this is the recurrent metaphor of the Salpetriere as a society-in-miniature, as a busy, self-sustaining community within the larger urban environment of Paris. An 1893 tour guide, for instance, states that 'more than Bicetre, the Salpetriere gives the impression of a closed town, a veritable city jealously guarding the secret of its interior life'. 39 For a journalist writing several years earlier, the hospital was 'a city of 5,000 people within that other city, Paris', while another observer described the place as 'a dead city'. Pierre Vallery-Radot, the medical historian, referred to the Salpetriere at the turn of the century as 'an immense hospital town'. And Paul Castaigne, who today heads the neurological unit at the Salptriere,

713

Ana
Texte surligné
Ana
Texte surligné
Ana
Texte surligné
Page 13: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

recently reflected that the hospital he knew as a young resident had 'the charm of an old village'.40 The spontaneous and repeated expression of this view, beginning in the closing decades of the century, is extremely instructive and deserves closer examination.

The vision of the Salpetriere as a city-within-a-city was no doubt derived first of all from its sheer physical size. Throughout the late nine- teenth century, the Salpetriere remained the largest medical or welfare establishment in Europe, probably in the world. The full superficies of the complex covered nearly a quarter of the entire thirteenth arrondisse- ment in south-eastern Paris. In 1886, the hospital included a total of forty- five major buildings and approximately sixty smaller ones of all sorts, standing on fifty-one hectares of land or a surface area of nearly 310,000 square metres.41 'It requires a full day', warned one writer, 'to visit it thoroughly.'42 A routine budgetary report for the institution in 1894 records for that year the cleaning of 273 chimneys, 1,641 gaslights, and 4,692 windows.43 By medieval or modern standards, the Salpetriere was an institutional colossus.

Architecturally, the hospital was no less imposing. Grace Goldin and John Thompson have written in their excellent book that the Salpetriere was the 'derived' rather than 'designed' institution par excellence, adapting as medical structures a wide variety of buildings originally intended as prisons, hospices, barracks, clerical quarters, etc. Also, as the same authors point out, French hospital architecture, until the con- struction of the pavilion surgical wards in the 1890s, reflected prevailing aesthetic tastes rather than more functional criteria.44 As a result, the typical conception of the hospital as uniform and starkly utilitarian in appearance could not have been more inapplicable in the case of the Salpetriere. A wide range of building styles existed on the premises: the stately seventeenth-century classicism of the Batiment Mazarin; an elegant eighteenth-century entrance portal; the long, colonnaded pavilions of the quartier des folles. 45 Not the least curious in this regard was the so-called 'Village Suisse'. This was a string of dwellings for individual mental patients built during the 1850s, with pointed, overhanging roofs in the cosy, popular style of tiny mountain chalets. Scattered across the hospital grounds were also many small decorative gardens in the French geometric style.

The physical dimensions of the hospital were reflected in the patient population. The American trend at this time toward small suburban or country asylums contrasted with the reality of the Salpetriere. According to the annual census records, the largest number of people at the hospital at the turn of the century were the elderly and convalescent women,

714

Page 14: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

and from 1823 to 1887 the hospital was officially known as the Hospice de la Vieillesse - Femmes. These people ranged in number at any given time from 2,500 to 2,850 and resided in some thirty-two multi-storeyed dormitories.46 To this figure must be added between 720 and 800 psychiatric patients. These included women with all forms of disorders - mild and severe, violent and non-violent - who were rather unceremoniously, not to say unscientifically, thrown together in five major divisions. Over 250 children also lived at the hospital, either epileptics, retarded girls ('les arrierees'), or children at a small reform school on the premises. Finally, there was a General Infirmary, a kind of hospital within a hospital, which held 180 to 250 patients, including Salpetriere's only male patients. 47 In 1889, the total number of beds (all single by this time) was set at 4,611.48 With a daily population of approximately 5,000, it is very appropriate to speak of the institutional demographics of the Salpetriere. 49 To gain a comparative perspective on these figures, we need only recall that the largest of the new English asylums at this time (Hanwell, Kent, Lancaster) contained between 600 and 900 patients, or that Salpetriere's total population of 5,000 easily exceeded that of many county seats (chefs-lieux) in France.

The Salpetriere of Charcot's day, then, was basically an immense psycho-geriatric institution providing refuge for the aged and a retreat for the mentally ill. A detailed social and statistical analysis of the patient pool cannot be undertaken here;50 but at least one topic, the duration of patients' stay, is particularly relevant to our investigation. An examination of the annual inspection reports and the daily medical registers for the hospital reveals at once the inaccuracy of the view that the Salpetriere housed a purely transient population.51 The shortest tenures at the hospital were about three weeks for patients in the Infirmary with minor neurological problems. For the great majority with graver afflictions, their periods of residence were measured in months and years. At no time during the 1870s and 1880s did the annual turnover rate (the number of patients leaving for different reasons, including recovery, discharges, provincial transfers, forced family removals, deaths and escapes) exceed 30 per cent of the overall population. 52 Elderly people were at the hospital essentially to await their deaths. The many crippled and convalescent women, known as 'reposantes', would also remain permanently unless they found a job or were withdrawn by a family member. Patients with progressive organic diseases of the brain or acute mental illness similarly stayed at the Salpetriere until death or transfer to another asylum. To cite an individual example, Blanche Wittmann, the celebrated hysteric who appears in the Brouillet painting, resided

715

Page 15: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

at the hospital for seventeen years, from 1878 to 1895. For the several hundred patients with diagnoses of mental deficiency ('cretinisme', 'imb6cilite', etc.), many of whom had been admitted as children, their stay at the hospital was also long-term, even lifelong. 53 In other words, the demographic dynamics of the institution, like those of a town or village, were relatively stable and self-contained. For a majority of the residents, the Salpetriere was home, not a one-time institutional experience but the only society they knew.

The Salpetriere of Charcot's day was also, in a major way, a working institution. Patient labour had begun at the hospital under the direction of Esquirol and Ferrus in the 1830s with the introduction of gardening and farming. Moreover, by the third quarter of the century, these

agricultural pastimes had given way to large-scale communal forms of indoor work. Sewing activities of all sorts predominated at the Salpetriere while men at Bicetre were involved mainly in shoe-making. Most of the work took place in small, specialized workshops, or ateliers de travail, scattered across the grounds of the hospital. I Hundreds of women walked every weekday morning from their dormitories to the atelier central de couture, the salle des pansements, the magasin des rideaux, or the atelier de tapisserie to produce bonnets and blouses, mend sheets, or sew lace. Because the Salpetriere also served as the centre for all hospital laundry across the city, many patients worked daily in large washrooms. Other women worked as cooks or nursing assistants. Only paying pensioners or those with the severest infirmities could expect to be exempt from work. ss During the mid-1890s, patients put in each year over 1,200,000 workdays (jourmees) at the hospital. 56

A number of Marxist critics working on the history of psychiatry have of late placed great emphasis on these activities as forms of economic

exploitation and bourgeois moralization.57 It is indeed impossible to overlook the influence of the market model in the development of patient work programmes as well as the vulnerable social status of patients at the Salpetri6re. The sudden adoption of such activities at the hospital was surely a way of rendering productive an old, parasitical and pre- industrial institution midway through the great bourgeois century. It is also important not to overstate this interpretation. In the official 'rhetoric of motivation' at the time, three purposes were repeatedly listed for these

pursuits: alleviation of individual boredom, economic solvency of the institution and retraining for entrance into a working society. 58 These reasons need not be rejected out of hand. Socialization and social

oppression are not synonymous, and 'occupational therapy' is still

recognized today as a valid psychiatric practice. It should also be noted

716

Page 16: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

that patients working at the Salpetriere received a small daily remuneration; that they could choose full, half-, or quarter-days; and that they were explicitly forbidden to do heavy manual labour. 59 To equate a nominal labour force with forced labour is to overstate the factor of economic manipulation here and ignore a number of important qualifications.

A sense of the intricate self-sufficiency of the Salpetriere in the fin-de-siecle era becomes still more apparent when we consider the size and scope of the non-medical personnel. A roster of daily workers from this period, many of them residing at the hospital, reads as follows: 4 masons, 4 carpenters, 5 painters, 3 plumbers, 9 gardeners, 3 mechanics, 56 launderers, 1 electrician, 1 saddler, 3 sewermen ('egoutiers'), 16 cooks, 1 locksmith, 4 metal-workers, 1 carriage repairman ('un charron'), 1 chimney-sweep, 3 street-pavers, and so on, to a total of 202 permanent employees. 60 Two detailed photographic studies of the Salpetriere made at the turn of the century record a dozen small, specialized workshops on the hospital grounds: a facility for mattress-making, a blacksmith's shop, a shoemaker's shop and an atelier for copper-making.61 Miniature trolley tracks and cars running through the hospital brought supplies from the outside world. Narrow paved streets and stone walkways were rather quaintly named after their place of destination: rue de la Cuisine, rue de l'Eglise, rue de la Pharmacie. The entire south-western quarter of the complex was given over to greenhouses, a large vegetable garden, a reservoir, and an orchard. Also on the premises were stables, a cemetery, a fire-fighting team and a small post office. 62

Finally, in attempting to reconstruct the everyday life of the Salpetriere, we should consider not only the material conditions but also the dominant social and emotional atmosphere of the hospital. Evidently, in the late nineteenth century, this atmosphere was of a strikingly communal nature. By the final quarter of the nineteenth century, the old solitary forms of labour among patients at the hospital had, as we know, disappeared, having been replaced by types of work set in collective environments. When patients were not together for work reasons, they were most likely living in enormous, barn-like dormitories holding 75 to 125 people apiece. Throughout this period, hospital wards were still in the large, open European style with few private rooms or portable screens.63 We have also seen that diagnostic classification at the Salpetriere remained primitive until after the first world war. The old, monstrous conglomera- tions of patient, prisoner and prostitute had been sorted out, but other highly disparate groups were still housed together - the old with the young, epileptic patients with hysterics, retarded people with alcoholics. 64 In the psychiatric quarter specifically, the old practice of

717

Page 17: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

cellular isolation was disappearing at this time, as non-violent patients were increasingly allowed to walk freely through the courtyards.

Finally, it becomes clear that the all-important boundary between staff and patients was a quite fluid one at the Salpetriere. The employment registers for the hospital, for instance, are full of patients working as

nursing assistants, of nurses breaking down and requiring medical care, and of staff members retiring in their advanced years to a geriatric wing of the hospital. 65 Indeed, it was apparently possible for a person, through repeated relapses and recoveries, to move in and out of these ranks quite regularly. One contemporary witness, the medical student and writer Jules Claretie, recorded that even emotional and sexual entanglements among personnel and patients were not uncommon.66 Whatever else

may be said about these various realities, they seem to have generated a strong, if informal, sense of institutional sociability within the hospital as a whole.

The Salpetriere was also the site for a wide variety of recreational activities, contributing further to a sustained social atmosphere. In 1872, visitors' days on Thursdays and Sundays were introduced. On these days, a festive, fair-like atmosphere prevailed, as over a thousand friends and relatives flooded the grounds. The Place Pinel at the hospital entrance, 'peaceful and nearly deserted the other five days', one witness wrote, 'becomes animated, full of itinerant merchants conducting business from small booths and boutiques'.67 For those with the interest and ability, a small gymnasium and library were set up in the basement of the old

prison building. A school for youngsters was also located on the premises. Both Protestant and Catholic religious services were available at the Saint-Louis chapel. During a visit in 1872, the writer Maxime de Camp was pleased to find a travelling carnival at the hospital. 68 The asylum inspectors also refer to dances, choral lessons, and makeshift musical

performances. And the annual mi-careme costume ball for patients was a major social event of the year. 69

Even without these special events, 'la vie quotidienne' at the Salpetriere continued as an open and collective affair. In the mid-1860s, a park was cleared in the centre of the hospital which included a network of walkways and courts for boule. Along the north-western edge of the complex stood a string of one-storey, weather-beaten buildings forming the Place du March6. Here patients could purchase vegetables, fruits, and meat from a grocery store, candy and baked goods at a tiny pftisserie, and clothing, paper goods and an assortment of articles de menages from a general store. A small debit de tabac stood nearby. 70

Most surprisingly, the hospital included on its premises a marchand

718

Page 18: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

de vin. Situated near the market-place, the hospital caf6 was open not only to visitors, day workers and staff but to many categories of patients including the thousands of elderly and crippled adults.71 About 330 customers visited the canteen daily, and in addition to the quarter litre served at meal times, consumed over 30,500 litres of wine a year. 72 There is also some evidence that drunkenness was a regular problem among both patients and staff, and on a number of occasions (at least once on the orders of Charcot), the caf6 had to be closed because of it. 73 It is also apparent that the hospital caf6 served, as did caf6s right across France, a central communal function in the daily institutional society of the Salptriere. A single, superb photograph taken by the English photographer H. C. Godefroy in 1904 makes this point effectively: a casual and convivial collection of about twenty people - two waitresses with aprons, men in dark work-clothes, nurses in official garb, and a number of old women with bonnets and shawls - are all clustered around several wooden tables in a narrow alleyway just outside the marchand de vin. Glasses and winebottles are on the tables. Two children are playing at the edge of the alley, and a grinning male figure with tattered pants and an amputated leg appears prominently in the front of the picture. 74 It is an extraordinary scene which, except for the uniformed nurses, could just as well be set in Montparnasse or Montmartre.

Despite the above picture, life at the Salpetriere in the nineteenth century could by no means be described as pleasant. Anyone who has spent time with the medical registers of the hospital will be under no illusions about this. Without doubt, the overriding human realities at the insti- tution were those of death, depression, derangement and a constant senescence of mind and body. 75 Charcot once referred to the Salpetriere as 'le Versailles de la douleur', and even today the sense of a long and heavy past, of accumulated generations of suffering at this one location, remains strong.

Notwithstanding, our investigation leads us to a somewhat revisionist formulation. The Salpetriere of the fin-de-siecle period was manifestly different from the grim monolithic institution of two centuries before. Whatever the case with other asylums of the time, the keynotes of everyday life here were not morbid silence, forced regimentation and imposed uniformity. The sobering aspects of existence were real enough, but there was also a more dynamic side to life at the hospital. The basic material necessities were provided. The physical setting was open, clean, and pleasant. All patients could receive visitors; the majority of them

719

Page 19: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

could walk freely through the complex; and many of them were able to leave the hospital altogether when they chose. The establishment as a whole was animated daily by a wide variety of social and economic activities. To stress just the negative, manipulative aspects of institutional life, or merely to recite a catalogue of horror stories, may be ideologically gratifying in some quarters, but it is a substantial distortion of the truth. As with life in the larger city, the supplements to order, sickness and resignation at the Salpetriere were diversity, spontaneity and a constant self-sustaining activity.

As we have shown, the repeated contemporary characterizations of the Salpetriere as a self-styled medical village were more than superficial descriptive parallels. The hospital at this time was composed of a large, varied, and more or less permanent population ranging from the youngest to the most advanced in age. All of the services and facilities required from birth to death, from the maternity ward to the morgue, existed at the hospital. The wide range of activities that took place at the Salpetriere went far beyond the usual diversionary pastimes of such establishments. Virtually the full range of human activities - social, religious, medical, educational, commercial, occupational, recreational, etc. - occurred there. Economically, the hospital was largely self-supporting, with

arrangements among patients for both production and consumption. And

physically, with its churches and courtyards, its parks and paved streets, the hospital was no less noteworthy. In many of the most essential ways, the Salpetriere in the age of Charcot constituted an institutional subculture in its own right, a kind of independent hospital culture mirroring in miniature the wider world of Paris.

Just how purposefully or consciously this image of the hospital was

developed is impossible to determine. There is little evidence to suggest that we are dealing with a rational plan or systematic model that was

carefully followed by physicians or administrators. Rather, we are

confronting a complicated confluence of forces coming from inside and outside the hospital, which for several decades led to a dramatic convergence of urban and institutional environments. To get a full view of this convergence, we must briefly go beyond the internal features of the hospital discussed so far.

Externally, the physical relationship between the hospital and the city was also transformed during the closing decades of the nineteenth century. The old hospital with its bucolic setting outside the city gates was engulfed by the new and expanding metropolis. The buildings and railway lines of the Austerlitz railway station were completed in the late 1880s, tight against the eastern edge of the hospital. The Boulevard de l'Hopital was

720

Page 20: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

widened to take more horse-drawn, and later motorized, traffic. An aerial segment of the Place d'Italie metro line, running along the northern front of the hospital on huge cast-iron trestles, was erected at the turn of the century. And on the southern circumference of the complex, the area was filling up with new ethnic neighbourhoods. 76 At the time of Charcot's death, the moder, mechanized city was literally pressing in on the Salpetriere from all sides.

Paris came to the Salpetriere in other ways, too, in the late nineteenth century. Surprisingly, the hospital appears frequently in the popular guide books of belle epoque Paris. In these accounts, it usually figures along with the Jardin des Plantes as a major attraction for tourists in the south- eastern quarter of the city. 77 Detailed articles and lithographic prints concerning life at the hospital appeared often through the 1880s and 1890s in magazines such as Le Monde modeme and La Revue illustree. 78 In 1896, one journal ran a monthly column on famous 'promenades m6dicales' in Paris and began with the Salpetriere. 79 The editors of the popular tabloid Le Gaulois for a number of years ran a description of the annual costume party, or 'bal des folles', at the Salpetriere on the society page of their newspaper. 80 And Andre Brouillet's famous Lecon clinique a la Salpetriere, hung in the Salon of 1887, was reviewed extensively as one of the major cultural icons of the day.

Nor is this all: the Salpetriere literally opened its gates to the city at large in the final quarter of the nineteenth century, and people, both medi- cal and lay, seem to have come in their legions. Dozens of French medical students and foreign doctors (like the young Sigmund Freud) came to the Salpetriere during this period. 81 On official visitors' days, as we have seen, hundreds of people filled the hospital grounds. Writers, journalists, social scientists and philosophers, including such notables as Henri Bergson, Emile Durkheim, Guy de Maupassant, and Edmond de Goncourt, were admitted to the hospital to hear the famous Friday morning seances of Charcot. 82 At least one doctor travelling through complained of the excessive number of non-professional spectators on the premises and wondered aloud if this compromised the scientific integrity of the insti- tution. 83 It is even recorded that Jane Avril, Toulouse-Lautrec's famous poster girl, and Sarah Berhardt came to the Salpetriere as visitors. 84

The phenomenon of sudden widespread curiosity about the Salpetriere represents the opposite side of the many internal parallels between the hospital and the city that were mentioned earlier. What all of this establishes is that a fundamental reformulation was taking place in the relationship between the Salpetriere and its urban context during the second half of the nineteenth century - a reformulation that is entirely

721

Page 21: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

unaccounted for in the standard schemes for the development of the modem hospital. During the seventeenth and eighteenth centuries, the Salpetriere was seen as a world apart, an institutional island where an idle and highly stigmatized population was detained. During the first third of the nineteenth century, this view was replaced by the image of the 'asylum'. The mental hospital at this stage was seen as a place of humanitarian protection, a salubrious retreat sheltering patients from the

pressures of the external world. The Salpetriere of Charcot's day, however, represented a different reality still. During this period, an

incomparably more public conception of the hospital appeared. The old ideal of institutional isolation was replaced by that of societal integration. A new, dynamic, two-way relationship developed between the Salpetriere and the external city: popular interest in the hospital increased greatly, as the hospital itself took on the characteristics of the new urban civiliza- tion forming around it. This more open and imitative relationship between the hospital and the world beyond its walls lasted from roughly 1870 to 1910. (After that time, the hospital in effect turned inward and

developed along the lines of the specialized, scientifically-centred, and

technically-rarefied institution we associate today with a moder health- care establishment.)

The causes of the new and reciprocal relationship were many and varied. The general spread of the psychological sciences throughout the nineteenth century brought changes in moral attitudes toward the sick. Mental illness, in particular, came to be viewed less fearfully, not as demonic possession but as a natural affliction. With the removal of the most chastised groups of people, such as beggars, criminals and

prostitutes, and the slow social upgrading of the clientele, the Salpetriere became increasingly approachable. The post-Pinelian period of material reforms in diet, dress and housing also made the idea of the hospital, and of hospitalization itself, more palatable. Finally, with improvements in hospital hygiene beginning in the 1850s and the application of Joseph Lister's antiseptic techniques in the 1870s, epidemics of infectious diseases at these institutions came to an end. At the height of its fame in the 1880s, the Salpetriere had made the transition from an establish- ment known for its riots, plagues, and exorbitant mortality rates to one recognized more for its laboratories, lecture halls, and licensed

practitioners. Other factors contributing to the growing social integration of the

nineteenth-century hospital derive from what Charles Rosenberg has called 'the culture of medicine'. 85 By the nineteenth century, respect for the medical sciences had increased tremendously, and work in the

722

Page 22: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

field was followed by a large and inquisitive non-lrofessional public. Many people were attracted to the Salpetriere to hear Charcot lecture in a prestigious format on subjects which were macabre and sensationalist. Also, as Claude Digeon and Harry Paul have pointed out, it was precisely in the 1880s that intellectual competition between France and Germany was at its highest.86 In the popular medical press of the day, for example, the achievements of Charcot, Pasteur, and Bernard are con- stantly cited in defensive response to the rising industrial and chemical sciences across the Rhine. From this perspective, a trip to the 'School of the Salpetriere' was an act of cultural patriotism.

A related set of conditions was no doubt responsible for the reflections of Paris found within the hospital. Medically, a new, more naturalistic understanding of many illnesses required a rehabilitative institutional environment. To prepare patients for re-entry into society meant impor- ting as many elements of the outside world as possible into the hospital setting. Working, playing, socializing, and so forth were so many 'normalizing' activities in the therapeutic process. Even if the intentions of administrators for many people at the Salpetriere were frankly custodial, this too, after the period of the 'traitement moral', required many of the basic amenities of life from external society. Economically, the general expansion in resources of the government during the early decades of the Third Republic was a pre-condition for the new facilities at the hospital. The emphasis on productivity and consumption, we have suggested, represented the penetration of new capitalist values into the arena of the social-welfare institution. And it is also relevant to recall that funding for most health care establishments in France came, not from subscription or philanthropic bequest, but from annual state alloca- tions. Presenting an image of the hospital that was familiar and attractive may also have been a way of insuring steady governmental support.

A final cause of this changing connection between city and institution is slightly more speculative and may best be characterized as socio- cultural. The Salpetriere, as it has been presented here, is simply unthinkable without Paris during the fin-de-siecle period. Walter Benjamin, in a well-known essay, has referred to Paris as 'the capital of the nineteenth century'. By the middle of the century, Benjamin pointed out, Paris had become both the absolute cultural standard for other cities and institutions across the western world and a showcase setting of great art, architecture, and exhibitions open to everyone. 87 The French capital served in effect as the glorious centre of the cultural world where every aspect of life was put on public display, presented as popular spectacle for the Baudelairean flineur.

723

Page 23: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

At a fairly superficial level, Benjamin's reflections suggest that the Salpetriere became one of the fashionable sites of belle epoque Paris, to be taken in, rather voyeuristically, along with Offenbach's can-can, the new Eiffel Tower and the giraffes at the municipal zoo. More deeply, though, we can say that the Salpetriere became implicated in the broad

processes of urban modernization that were also part of the Parisian scene at this time. If the late nineteenth century was full of fun and frivolity, as historical commonplace has it, it was also the rather unsettling time when Paris emerged as a mass industrial city marked by rapid demo-

graphic growth, major technological transformations, and dramatic social shifts. As Richard Sennett has shown in a provocative argument, these

precipitous changes brought about basic alterations in the social 'ecology' of the nineteenth-century city, that is, reorientations in the balance of

relationships between institutional parts and the societal whole. 88 In the cases of Paris and London, Sennett claims, this process most frequently involved relative restructurings of the private and public spheres of city life with many institutions and areas of activity opening up and taking on forms which were more externalized and 'spectacular' (i.e. literally more like a public spectacle). 89 As examples of this important pheno- menon, we may cite the entrance of previously disenfranchised workers into the electoral process; the appearance of many members of the lower classes in public education; the passage of women into the workplace from the home; or the movement of the man of leisure from the private boudoir onto the balconies and boulevards of the city. Indeed, it is this

process which accounts for the openness, for the remarkable cultural extroversion of the age we find so appealing today.

We can now argue quite credibly that the Salpetriere of Charcot's age was caught up in this general experience. The relationship between the

city and the hospital, between populace and patient, underwent a similar

realignment. Material improvements, progress in medical understanding and a propitious intellectual atmosphere brought changes in social attitudes among the new and curious middle classes. The old view of the Salpetriere as a distant and dreaded institution could now be discarded.

Absorption into a large and imposing metropolitan area, accompanied by new therapeutic imperatives, economic motives, and financial

resources, allowed the hospital to turn outward for many new features of its development. The capital city itself effectively became the ultimate institutional model. Confronted at one time by these multifarious forces, the hospital attempted to adapt by increasing its public accessibility and

transforming itself into the image of the city at large.

724

Page 24: 260404The Salpetriere in the Age of Charcot

Micrle: Institutional Perspective

The Salpetrikre of to-day is very different from that of a century ago. The buildings and amphitheatre of the Charcot Clinic have been torn down, and a single row of dilapidated cabins is the only remnant of the old psychiatric quarter. The extensive lands of the hospital were sold for other purposes after the turn of the century. Patients no longer work, and the various shops and stores of former times have been demolished. 90 Scattered here and there - in a rusted dinner bell, an old trolley line, or a sign etched in stone near the old market-place - are the few indications of the Salpetriere as it existed in Charcot's lifetime. All in all, the hospital ranks very low as a cultural attraction.

We have discerned in the hospital at the time of Charcot a number of important features, but we have resisted any temptation to be dogmatic in our conclusions. Time and again, we have found that our case study suggested important qualifications to either an idealized account of medical progress or to opposite and more recent theories of economic self-interest and social normalization. For a really comprehensive history of medical institutions, it is clear the historian must consider fairly and fully the range of internal and external forces at play and the record of successes and failures as well as the motives behind these endeavours.

The attempt to refashion the Salpetriere in the image of the urban community was, of course, unsuccessful. The new equilibrium between city and hospital was always an uneasy one. The hysterics, the epileptics, the aged and the retarded remained, as they do today, problematic groups of people in society, and they continued to arouse in Parisians, if not the outright horror of earlier times, at least considerable anxiety. By the post-first-world-war period, this stage in the development of the Salp6triere had almost come to an end and been replaced by a narrower, more technical and impersonal conception of the institution - in a word, by the hospital as 'medical-factory' or 'health-workshop'. But for a span of about two generations preceding this, a different ideal, the image of the hospital as an open institutional microscosm, had been prevalent. This phase in the history of the Salpetriere has been ignored by historians and social scientists in the field, who sometimes sacrifice much in their search for uniform experiences and general patterns. It is true that the characteristics dominant at the Salpetriere were the results of special circumstances concerning the age, size, location and population of one institution. It is not our intention to posit here any intermediate stage of development experienced by all such establishments. Yet, while the Salpetribre was unique, there are doubtless similarly distinctive histories behind many major health-care establishments across Europe. It is only by drawing on a broad scope of materials to reconstruct the actual

725

Page 25: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

conditions of particular institutions that we can discover the most interesting and important variations in the evolution of the moder hospital. With this brief exercise in institutional portraiture, we have sought to show that the Salpetriere of the late nineteenth century represented one such variation.

Notes

A version of this essay was read in May 1984 at the History of Psychiatry, Section of the New York-Cornell Medical Center. I would like to thank the members of that audience as well as Peter Gay for their comments.

1. Most of the writing in this tradition appears in the countless biographies, ceremonial

speeches, and histories of medical specialties which were produced in the first half of the twentieth century. Two major French books with this approach are Ren6 Semelaigne, Pionniers de la psychiatrie francaise, 2 vols. (Paris 1930-32), and Pierre Vallery-Radot, Deux Siecles d'histoire hospitaliere de Henry IV a Louis-Philippe, 1602-1836 (Paris 1947).

2. The key texts here are three works of Foucault: Maladie mentale et psychologie (Paris 1954); Folie et deraison: histoire de la folie a Ilige classique (Paris 1961), and Naissance de la clinique (Paris 1963). For other examples of works in this spirit, see Klaus Doerner, Burger und Irre (Frankfurt am Main 1969); Claude Quetel, 'L'Asile d'alienes en 1900', L'Histoire, 7 (December 1978), 25-34; Marc Alexander, The Administration

of Madness and Attitudes Toward the Insane in Nineteenth-Century Paris (Johns Hopkins University Dissertation, 1976); and much of the recent writing on work therapy and the 'traitement moral'.

3. Henry Sigerist, 'An Outline of the Development of the Hospital', Bulletin of the

History of Medicine, 4 (July 1936), 573-81; George Rosen, 'The Hospital: Historical

Sociology of a Community Institution', in Eliot Freidson (ed.), The Hospital in Modem

Society (New York 1963), 1-36. 4. Rothman, The Discovery of the Asylum: Social Order and Disorder in the New

Republic (Boston 1971); Grob, Mental Institutions in America: Social Policy to 1875 (New York 1973) and Mental Illness in American Society, 1875-1940 (Princeton 1983).

5. Starr, The Social Transformation of American Medicine (New York 1982); Rosenberg, 'Inward Vision and Outward Glance: The Shaping of the American Hospital, 1880-1914', in Social History and Social Policy, eds. David Rothman and Stanton Wheeler

(New York 1981), 19-55; Goldstein, French Psychiatry in Social and Political Context: The Formation of a New Profession, 1820-1860 (Columbia University Dissertation, 1979); M. Jeanne Peterson, The Medical Profession in Mid-Victorian London (Los Angeles 1978).

6. For the latest episode in the debate, see the exchange between Foucault and Lawrence Stone in The New York Review of Books (31 March 1983), 42-44.

7. Two very successful case studies of the American scene in the late nineteenth century have appeared in the last few years: David Rosner, A Once Charitable Enterprise: Hospitals and Health Care in Brooklyn and New York, 1885-1915 (New York 1982); and Morris

Vogel, The Invention of the Modem Hospital: Boston, 1870-1930 (Chicago 1980). 8. George Guillain and Pierre Mathieu, La Salpetriere (Paris 1925), 9-20.

726

Page 26: 260404The Salpetriere in the Age of Charcot

Mir e: Institutional Perspective

9. B. N., Fonds Francais, mns. 6844, folios 58 and 59; Tenon, Memoires sur les h6pitaux de Paris (Paris 1788), 85.

10. Tenon, Memoires, 85; La Rouchefoucauld-Liancourt, Rapport fait au nom du comite de mendicite. Visites dans les divers h6pitaux, hospices et maisons de charite de Paris (Paris 1791), 63; Marthe Henry, La Salpetriere sous l'ancien regime (Paris 1922), 105-64.

11. On the treatment of the mentally ill at the Salpetriere during this period, the most useful sources are Tenon, Memoires; Pierre J.-G. Cabanis, 'Observations sur les h6pitaux de Paris' (1792) in Oeuvres completes, vol. 2 (Paris 1823), 188ff; and Jean Colombier, Instructions sur la maniere de gouverner les insenses et de travailler d leur guerison dans les asiles que leur sont destines (Paris 1785), 145ff.

12. Philippe Pinel, 'Description de l'etat actuel des folles a la Salpetriere', (1802), cited in Louis Boucher, La Salpetriere (Paris 1883), Document IX.

13. The best evidence here is visual. See Etienne Jeurat's canvases in the Musee Carnavalet, La conduite desjeunesfilles dejoie a l'hopital (1757) and its untitled companion depicting a torchlight procession of the insane through the streets of Paris.

14. See Nicholas Raquet, La Porte Saint-Bernard et l'h6pital de la Salpetriere vus du port de la rapee (1760), also hanging in the Carnavalet.

15. Quoted in Casamir Trollet, De l'assistance publique et des h6pitaux jusqu 'au XIXe siecle (Paris 1889), 140.

16. Cited in Stephane-Pol, 'La Salpetriere', Le Monde modere, 16 (1902), 325. 17. Gregory Zilboorg, A History of Medical Psychology (New York 1941), 175-244. 18. Dora Weiner has discovered that Pinel freed far fewer of his psychiatric patients

than was previously supposed (about 15 per cent of the total) and that he often replaced the old chains with new forms of restraint such as the gilet deforce. See her article 'Health and Mental Health in the Thought of Philippe Pinel: The Emergence of Psychiatry during the French Revolution' in Charles Rosenberg (ed.), Healing and History: Essays for George Rosen (New York 1979), 59-85.

19. Jean Delay, 'Philippe Pinel a la Salpetriere', Medecine de France, 96 (1958), 10-16. 20. Ackerknecht, A Short History of Psychiatry (New York 1959), 36. 21. Ibid., 36-46. 22. E. Lisle, 'Sur le regime moral des alienes de Bicetre', Gazette medicale de Paris,

serie 2, t. 12 (1844), 17-20, 33-44; Eric T. Carlson and Norman Dain, 'The Psychotherapy that was Moral Treatment', American Journal of Psychotherapy, 67 (December 1960), 519-24. For a Foucaultian critique, refer to R. Castel, 'Le Traitement moral. Therapeutique mentale et contr6le social au XIXe siecle', Topique, 2 (1972), 109-29.

23. George Guillain, Jean-Martin Charcot: 1825-1893, sa vie, son oeuvre (Paris 1959), 3-15, 50-58.

24. Journal officiel, 4 January 1882. 25. 'Lecon d'ouverture' to Lecons sur les maladies du systeme nerveux, t. Ill, Oeuvres

completes de J.-M. Charcot (Paris 1890), 5-6. 26. Basic information on the circle of students around Charcot can be found in Fernand

Levillain, 'Charcot et l'Ecole de la Salpetriere', Revue Encyclopedique, 10 (1 March 1894), 108-15 and Henri Ellenberger, The Discovery of the Unconscious (New York 1970), 89-101.

27. Archives de l'Assistance Publique (AAP), Registres d'appointments, 1870-93, 2 K 57 a 80.

28. 'Lecon d'ouverture', Lecons, III, 1-2. 29. Henri Napias, L'Assistance Publique en 1900 (Paris 1900), 615.

727

Page 27: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

30. Goldstein, 'The Hysteria Diagnosis and the Politics of Anticlericalism in Late Nineteenth-Century France', Journal of Modem History, 54 (June 1982), 209-39.

31. The pertinent historical context here, of course, concerns the anti-clerical crusade of the early Third Republic leading to, among other legislative measures, the educational laws of Jules Ferry. For general background, a useful guide is Evelyn M. Acomb, The French Laic Laws (1879-1889) - The First Anti-Clerical Campaign of the Third Republic (New York 1967).

32. Marcel Fosseyeux, 'L'Ecole des infirmieres de la Salpetriere', Paris-Medical (21 November 1925), 2-8.

33. Jean-Francois Piera, Histoire de la laicisation des h6pitaux de l'Assistance publique de Paris (These medical, Creteil, 1979); Napias, L'Assistance Publique en 1900, 32ff.

34. Charles Richet, 'Aux temps hdroiques de la mddicine, 1872-1878', Progres Medical, 50 (16 December 1922), 589.

35. Information on institutional differentiation has been drawn from the following sources: Rouchefoucauld-Liancourt, Rapport, 126; L. Bezard and J. Chapon, Histoire de la prison de Saint-Lazare du moyen age a nos jours (Paris 1925); George Rosen, 'The Fate of the Medical Police, 1780-1890', Centaurus, 5, 2 (1957), 97-113; and Pierre Vallery-Radot, Nos Hopitaux Parisiens (Paris 1948), 17-46.

36. G. Daumezon, 'Essai historique et critique de l'appareil d'assistance aux malades mentaux dans le d6partement de la Seine depuis le d6but du XIXe siecle', L'Information psychiatrique, 1 (January 1960), 5-29.

37. Esquirol, Des Etablissements des alienes en France et des moyens d'ameliorer le sort de ces infortunes (Paris 1819).

38. Girard de Cailleux, Rapport sur les alienes de la Seine traites dans les asiles de Bicetre et de la Salpetriere (Paris 1860), 39; Henri-Charles Monod, 'Les Cellules d'observations des ali6n6s dans les hospices', Archives de neurologie, 18 (September 1889), 308-10.

39. Paul Strauss, Paris Ignore (Paris 1893), 404-05. 40. Maurice Guillemot, 'A la Salpetriere', Paris illustre (24 September 1887), 354;

Alexandre Guerin, 'Une Visite A la Salpetriere', La Revue illustree, 4, 40 (1 August 1887), 97; Vallery-Radot, 'Chroniques: Hospice de la Salpetriere', La Presse rmdicale, 1 (5 January 1946), 9; Castaigne, 'Quelques souvenirs de pres de cinquante ans de vie a la Pitie et la Salpetriere', in Marcel Billion et al. (eds.), L'Hopital a Paris - La Salpetriere (Paris 1982), 61.

41. 'Plan de masse de l'hospice de la Salpetriere', in Napias, L'Assistance Publique, 625; Ernest Peyron, Administration geeirale de l'Assistance Publique en 1889 (Paris 1889), 72-74.

42. Paris Guide - La Vie, par les principaux 6crivains et artistes de la France (Paris 1867), 1936.

43. AAP, 'Questions des ouvriers a la journ6e', (31 March 1894), printed document in unmarked folder.

44. Thompson and Goldin, The Hospital: A Social and Architectural History (New Haven

1975), xxvii, 55-79. 45. Paul Valet, 'La Salpetriere - histoire et batiments', Bulletin de la Montagne Sainte-

Genevieve, t. 3 (1899-1902), 27-38; Louis Hautecoeur, 'L'Architecture hospitaliere et la Salpetriere', Medecine de France, 96 (1958), 21-36.

46. He- ri Breuil, L'Assistance aux vieillards a Paris de 1789 a 1905 (Paris 1909), 92. 47. Napias, L'Assistance Publique, 611-25; Notice sur l'hospice de la Salpetriere,

s.a. (Paris 1896), 10-11.

728

Page 28: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

48. Henry C. Burdett, Hospitals and Asylums of the World, ml (London 1891-1905), 470. 49. While this total figure is extremely high, the level itself remained quite stable through

the final quarter of the nineteenth century. The state of severe institutional overcrowding which Rothman and Grob found in American establishments from the mid-century did not plague the Salpetriere for two reasons: in 1844, a process of forced psychiatric provincialization was begun in which the population overflow of Paris asylums was routinely transferred outside the Department of the Seine. In the decade from 1865 to 1874, for instance, about 1,725 women, usually individuals without family who were judged incurably insane, were involuntarily consigned to institutions in Nancy, Bordeaux, Cannes and Auxerre. Second, at the end of the 1860s, three new establishments (Ville-Evrard, Vaucluse, and Sainte-Anne) were constructed as part of a new network of asylums begun by the Baron Haussmann to relieve pressure on older city hospitals. Thus, after generations of uninter-

rupted expansion, the late nineteenth century for the Salpetriere was a period of stable or slowly declining population rates.

50. Some background on the subject will be useful in passing: as the municipal hospital for women in the Department of the Seine, the great majority of people at the Salpetriere were admitted free of charge to the 'classe du regime commun'. A smaller number of women, from 10 per cent to 15 per cent of the total, were classified as pensionnaires payantes who, for a small charge, received a private room and additional food at meal times. Many patients had previously been vagrants, prostitutes or chronically unemployed. Socially, the great majority of the clientele was from the lower classes, with a slowly increasing minority from petit-bourgeois backgrounds. What Pinel labelled 'the affluent insane' went either to the Charenton hospital or to one of the private maisons de sante across the city.

51. The Archives de l'Assistance Publique in the Marais houses over 1,100 registers in the large folio format which deal with various medical and administrative aspects of the Salpetriere from 1790 to 1940. I would like to thank Florence Greffe, Chef du service de la documentation at the archives, for permission to examine the psychiatric records in the collection.

52. AAP, Serie Q: Populations - malades hospitalises (La Salpetriere), 3 Q 1, 10 a 15; Napias, 614; J.-A.-E. Constans et al., Rapport General d M. le Ministre de l'Interieur sur le Service des alienes en 1874 (Paris 1878), 450-71, Tableaux IB, IIB.

53. AAP, Serie R: Registres d'observations medicales (la Salpetriere), 1885-1891, 6 R 42, 1-311 and 6 R 50, 1-216; Serie Q: Registre des deces (La Salpetriere), 1871-1893, 3Q2.

54. AAP, S6rie L: Administration Generale (La Salpetriere), 1893-1899, 1 L 2; Armand Husson, 6tude sur les h6pitaux consideres sous le rapport... du service des salles de malades (Paris 1862), 289.

55. Paul Parent, Vieux Hopitaux Parisiens (Paris 1943), 48-55. Beginning in the 1850s, the startling category of 'alienee travailleuse' appears in the hospital records.

56. Napias, 614; Burdett, Hospitals of the World, I, 339-47. 57. See the work above of Doemer, Quetel, and Alexander as well as Gerard Bleandonu

and Guy Le Gaufrey, 'Naissance des asiles (Auxerre-Paris)', Annales - ESC, 30 (1975), 93-121.

58. Jacques L.-A. Calvet, Sur les origines historiques de travail des malades dans les asiles d'alienes (These medical, Paris 1952). Calvet traces these work activities to the seventeenth century (i.e., to a pre-industrial age) when they were initially introduced to fight 'Christian idleness'.

59. These protective measures are listed in the 'Reglement du Service interieur' of 20 March 1857, section XXI, articles 150-63, reproduced in Recueil des lois, ordonnances

729

Page 29: 260404The Salpetriere in the Age of Charcot

Journal of Contemporary History

et decrets applicables l 'administration gdnerale de 'Assistance Publique (Paris 1887), 37-58.

60. Napias, Assistance Publique, 615. 61. Bibliotheque historique de la Ville de Paris (BHVP), Fichier Photographique, N.A.

XLIX, nos. 35-37. Most of the photographs in this collection were taken by Eugene Atget in 1899 or H. C. Godefroy in 1904.

62. BHVP, Fichier Photographique, P.M. XLIX, nos. 3-6, N.A. XLIX, nos. 34, 49, 58-69; H. Sutherland Edwards, Old and New Paris: Its History, Its People, Its Places, II (1893-1894), 210ff.

63. Cent Ans d'Assistance Publique, 1849-1949, s.a. (Paris 1949), 83, no.231. 64. AAP, Serie R: Registre des diagnostics (La Salpetriere), 1880-83, 6 R 90. 65. AAP, S6rie K: Personnel, Registres d'appointments (La Salpetriere), 1870-1893,

2 K 57 a 80. 66. Claretie, Les Amours d'un Interne (Paris 1881). 67. Paris Guide, 1937. 68. De Camp, 'Les Alienes de Paris', Revue des Deux Mondes, Pt. I, t. 90 (15 October

1872), 54-55. 69. Constans et al., Rapport General, 195; Husson, Etude sur les hopitaux, 291. 70. BHVP, Fichier Photographique, N.A. XLIX, nos. 46 and 47; Les Etablissements

hospitaliers - plans, cartes, dessins, gravures, photographies, cartes postales, VI (Paris 1912), 144. This second source consists of a series of scrapbooks in the Public Assistance Archives.

71. Les Etablissements hospitaliers, VI, no. 144. It seems to me that this fact goes far in reinforcing the point Grob and Rothman have made that the late-nineteenth-century hospital became more concerned with consoling chronic patients than treating potentially curable cases for immediate release.

72. Comptes administratifs des recettes de depenses des hopitaux (Paris 1880-1890), Tableau I: 'Etat des principaux articles de consommation livr6s aux divers 6tablissements

par les magasins g6enraux'; Husson, Etude, 290. 73. In this regard, see the candid remarks of Maxime de Camp, 'Les Alienes de Paris',

Revue des Deux Mondes, Pt. I, t. 88 (1 August 1870), 535. 74. BHVP, Fichier Photographique, N.A. XLIX, no. 30. See also nos. 27, 31-33. 75. The oppressive daily atmosphere of the Salpetriere is also captured in a narrated

tour of the psychiatric quarter by Leon Daudet, 'A la Salpetriere', La Chronique medicale

(1898); and in Andre Baillon (pseudo.), Chalet 1 (Paris 1926), an autobiographical account

by a former inmate at the hospital. 76. 'Boulevard de l'H6pital', in Jacques Hillairet, Dictionnaire historique des rues de

Paris, I (Paris 1963), 636-40; BHVP, Fichier Photographique, N.A. XLIX, no. 5. 77. 'Ignotus', (Felix Platel), Paris Secret (Paris 1889), 22-33; Paris-Guide - La Vie,

s.a. (Paris 1867), 1935-42; Henry S. Edwards, Old and New Paris, II (London 1894),

chapter 29. 78. From among many such articles: Alexandre Gu6rin, 'Une Visite a la Salpetriere',

La Revue illustree, 4, 40 (1 August 1887), 97-103, 171-77; Maurice Guillemot, 'A la

Salpetriere', Paris illustre, nos. 22, 23 (24 September 1887 and 1 October 1887), 354-65,

370-74; 'Les Folles A la Salpetriere', s.a., Le Monde illustre, 32 (7 July 1888), 5-6; 'Souvenirs d'un asile', s.a., Le Petit Bleu (16 November 1902), uncatalogued article at

the Bibliotheque Charcot. The best illustrations dealing with the hospital are those of Daniel

Vierge, published between 1887 and 1892, and which can be found at the BN, Cabinet des Estampes, Dc 369.

730

Page 30: 260404The Salpetriere in the Age of Charcot

Micale: Institutional Perspective

79. Dr Berassis, 'Promenades medicales: Hospice de la Salpetriere', La Revue therapeutique des alcaloides (July 1896), 204-05.

80. 'Bloc-Notes Parisien: Le Bal des folles', s.a., Le Gaulois (22 March 1903), A-1. 81. Of course the Salpetriere is well known also for this visit by the future founder

of psychoanalysis. Freud was in Paris from October 1885 until February 1886. During his sojourn, he sat in on Charcot's lectures, worked in the hospital laboratory on an anatomical project, attended Charcot's glamorous soir6es, and explored the capital city for the first time. See Freud's delightful letters from Paris to his fiancee in Letters of Sigmund Freud, ed. Ernst Freud (New York 1960), 171-211; his essay entitled 'Report on My Studies in Paris and Berlin', (1886), Standard Edition, I, 1-16; and a useful secondary source by Leon Chertok: 'Freud in Paris: A Crucial Stage', International Journal of Psychoanalysis, 51 (1970), 511-20.

82. For descriptions of Charcot's lectures as popular cultural events, see Jules Claretie, La Vie a Paris - 1881 (Paris 1882), 123-31; 'X', 'M. Charcot a la Salpetriere', Annales politiques et litteraires, 3e ann6e (June 1885); and Axel Munthe's rather malevolent account in The Story of San Michele (New York 1929), 200-05.

83. Joseph Delboeuf, 'Une Visite a la Salpetriere', Revue de Belgique, 54 (15 October 1886), 121-47.

84. 'Une Heure chez Sarah Bernhardt', s.a., La Chronique medicale (1897), 609-16. 85. Rosenberg,'Inward Vision and Outward Glance', 21. 86. Paul, The Sorcerer's Apprentice: The French Scientist's Image of German Science,

1840-1919 (Gainesville, Florida 1972), 1-59; Digeon, La Crise allemande de la pensee francaise, 1870-1914 (Paris 1959).

87. Benjamin, 'Paris, Capital of the Nineteenth Century', in Reflections: Essays, Aphorisms, Autobiographical Writings, tr. Edmund Jephcott (New York 1978), 146-62. Benjamin's essay is essentially a Marxist analysis of certain architectural and institutional structures in mid-nineteenth-century Paris (the shopping arcades, the boulevards, the great exhibitions, etc.) and their material and sociological bases. For a recent discussion of the piece, refer to Anne, Margaret and Patrice Higonnet, 'Facades: Walter Benjamin's Paris', Critical Inquiry, 10, 3 (March 1984), 391-419.

88. Sennett, The Fall of Public Man: On the Social Psychology of Capitalism (New York 1974), 126.

89. Ibid., 125-55. 90. Jean Franchi, 'Le Groupe hospitalier Piti6-Salpetriere: aujourd'hui et demain', in

Billion (ed.), L'Hopital a Paris, 67-79.

Mark S. Micale is a Junior Fellow at the Harvard Society of

Fellows. He is currently working on an intellectual biography of Jean-Martin

Charcot.

731