La Salpêtrière Hospital before Charcot: A visit described by Pedro Gonzalez Velasco

Abstract

Introduction

Under Charcot's leadership, La Salpêtrière was transformed into one of the world's top neurology centres. However, there is little information regarding the patient care facilities which Charcot would have encountered upon his arrival in 1862.

Development

A paper published in 1860 by Spanish physician Pedro Gonzalez Velasco following a visit to that famous hospital is a valuable testimony to the quality of patient care just prior to Charcot's arrival. Although it essentially praises the institution, the article also describes the largely unsatisfactory conditions endured by patients with severe mental disorders, epilepsy and paralysis, who were locked inside cages with simple straw pallets on the floor for beds and open holes for toilets. Rather than an alienist, Velasco was a well-known surgeon and passionate advocate of positivism. As a personal friend and hospital fellow of Jose Maria Esquerdo's, with similar political affiliations, he had first-hand knowledge of the struggle to improve neuropsychiatric care in Madrid.

Conclusions

Publishing his paper ultimately provided Velasco with a pretext for denouncing the deplorable care conditions endured by similar patients in Hospital General de Madrid. Meanwhile, Charcot would go on to improve the living conditions of inpatients at La Salpêtrière and found the science of neurology.

Resumen

Introducción

Bajo su dirección, Charcot fue capaz de convertir La Salpêtrière en centro puntero de la neurología mundial. Sin embargo, es escasa la información sobre las condiciones asistenciales que pudo encontrar a su llegada en 1862.

Desarrollo

El artículo publicado en 1860 por el español Pedro González Velasco tras visitar al famoso hospicio representa un valioso testimonio sobre los cuidados que recibían los pacientes poco antes de la llegada de Charcot. Aunque esencialmente encomiástico, el artículo describe también la situación, bastante menos satisfactoria, de pacientes con trastornos mentales graves, epilepsia y parálisis confinados en jaulas, con un simple lecho de paja sobre el suelo como única cama y un desagüe para recoger sus deyecciones. Velasco no era alienista, sino un cirujano de prestigio y defensor apasionado del positivismo. Como amigo personal, compañero de hospital y correligionario político de José María Esquerdo, conocía de primera mano la lucha de este por mejorar la asistencia neuropsiquiátrica en Madrid.

Conclusiones

El artículo de Velasco, en última instancia, sirve de pretexto para denunciar las deplorables condiciones asistenciales de esta clase de pacientes en el Hospital General de Madrid. Por otro lado, Charcot tendrá que afrontar no solo el desarrollo de la neurología, sino mejorar también las condiciones de vida de los enfermos en La Salpêtrière.

Introduction

Jean Martin Charcot (1825–1893) completed 1 of his 4 intern years required to earn the title of Interne des Hôpitaux in La Salpêtrière in 1852. After that, however, he would have to wait 10 years before being awarded a hospital position. When at last in 1862 he was named “agrégé en exercise”, the situation did not look promising; he was 37 years old and this massive hospice was not one of the best-ranked in Paris. Together with his old friend Alfred Vulpian, he was responsible for the care of some 500 women, most of them elderly, who were permanently institutionalised due to chronic illnesses and collectively described as “indigents and non-insane epileptics”.¹ Under his leadership, during the next 30 years, this “grand asylum of human misery”² would be transformed into a famous centre for the study of neurology.

However, we find ourselves wondering what care conditions were like at La Salpêtrière at the time of Charcot's arrival, and upon what foundation he managed to build his life's work. Very little information is available from those years.³ This being the case, the article written by Pedro González Velasco (1815–1882) is of particular interest. The doctor from Segovia visited La Salpêtrière in 1860, 2 years prior to Charcot's appointment, and described his impressions upon visiting the legendary Parisian hospital. His article, which came to light only recently, offers a first-hand account of the care provided to mentally ill, epileptic, and paralysed patients in that enormous institution. The doctor's scathing comments about Hospital General de Madrid compared to La Salpêtrière also constitute an interesting source of information about care provided to patients with chronic neuropsychiatric diseases in Spain in the second half of the 19th century.⁴

Conditions in La Salpêtrière before Charcot

One might imagine that when Charcot began working in La Salpêtrière, he was faced with a chaotic holding pen filled with chronically ill patients who survived in woefully precarious conditions. However, this is not exactly the case. It is true that in the 17th and 18th centuries, the massive hospital complex housed between 6000 and 8000 residents. It served as something between a charitable institution and a correctional centre. Its residents, all female, included beggars, the elderly, the blind, orphans, epileptics, the mentally disabled, “les vénériennes” (prostitutes), and criminals. Philipe Pinel's symbolic “breaking of the chains” spurred legislators between 1795 and 1828 to promote a law, “loi sur les aliénés” of June 1838, which would lead to the first psychiatric revolution and radically change the situation.⁵ After that, hundreds of women walked every day from their sleeping quarters to sewing shops where they made caps and blouses, repaired shirts, sewed ribbons, and worked in laundry facilities. Pinel's students also researched mental illness: Esquirol described monomania and depressive psychoses, Jean-Pierre Falret investigated suicide and mental retardation, and Étienne Georget studied the anatomy of the brain.³

There can be no doubt that the situation improved under Charcot's authoritarian rule. The library of Madrid's Faculty of Medicine houses the doctoral thesis by Boucher, one of Bourneville's students, which recounts the history of La Salpêtrière between 1616 and 1790 (Fig. 1).⁶ In 1883, a little over a year after Charcot was made chair of the new Department of Nervous System Diseases, Boucher visited La Salpêtrière one Sunday in spring when he was finishing his thesis, and recorded his abundant impressions:

“With their bonnets on correctly and shawls neatly crossed in front, women of 80 take the air in the park in the company of their relations, friends, and grandchildren whose happy shouts add a joyful note to this place of human decay and suffering. Here and there, other elderly women […] seated on benches enjoy the fresh air and sun. We see deformities of all types; hunchbacks, bowlegs and other women racked by trembling […]. Among the epileptics and idiots, we often witness endearing scenes; mothers whose love for their children surpasses the horror of their disease visit and bring their beloved offspring sweets and toys that must have cost a full week's savings […]. When the hubbub of the day has died down, and when the sounds of the city grow quiet around this house of rest and suffering, the on-call intern, summoned to an unfortunate patient's bedside, might imagine himself in a vast necropolis, whose silence is periodically shaken by the shrill, wild cries from the quarters for the madwomen and epileptics. But what difference does it make, for he is a doctor exercising his office”.

Figure 1.

La Salpêtrière in 1760 in an engraving by Regaud. Taken from L. Brucher's thesis, 1883.

Dr Velasco's visit to La Salpêtrière

Pedro González Velasco (1815–1882) was an enthusiastic scholar of anatomy and famous surgeon of the 19th century (Fig. 2).⁷ Convinced that it would be useful to preserve pathological tissue samples that show the true appearance of lesions, he dedicated considerable effort and resources to creating an anatomy museum. This museum would later come to be the National Anthropology Museum of Madrid, but the doctor first created it at his own expense. Marginalised in the Spanish university system because of his republican ideals and 19th century positivism, he developed an interest in hospital training and administration on the far side of the Pyrenees. The impressions which he records upon returning from his many journeys are, in fact, a pretext allowing him to criticise the primitive conditions found in Spain compared to those in France.⁸

Figure 2.

Pedro González Velasco (1815–1882). Digitised photograph archive, National Library of Spain.

The weekly newspaper La España Médica, Iberia Médica y Crónica de los Hospitales was published in the mid-19th century as the official chronicle of residential care in Madrid province. The last of the 6 sections into which González Velasco divides his long article about the hospitals and charitable institutions he visited in France focuses specifically on his visit to La Salpêtrière in the summer of 1860.

“Paris has 3 large hospitals for the succour of the insane. The first, Charenton, is for those who can pay considerable sums for care; there are also two free centres: for men, Bicêtre, and for women, La Salpêtrière, that is, the old saltpetre works”. He goes on to say that La Salpêtrière “is a residence for madwomen, epileptics, idiots, those with incurable diseases, and those with additional needs who are not ill”. He is impressed by the huge size of the hospital complex: “a vast establishment with such expanses of garden and gallery that each pavilion has been numbered, and each lane and department is named in order to prevent the confusion that could otherwise arise in an institution that normally houses 4000 to 5000 inmates. Patients are lodged on the lower floors of the different low pavilions”. Accustomed to the deep-seated anonymity preferred by hospital directors and managers in his home country, he was surprised to learn that “all of the wards are named after famous doctors such as Pinel, Esquirol, Georget, etc.”

The hydrotherapy department “has magnificent baths that are made safe by being half-covered”. Patients whose condition so permitted were allowed to go to the workshop “to do needle-work and make bandages and other goods […] providing the store-rooms with sheets, mattresses and other material to satisfy the needs of the institution's vast nursing ward”. Patients received stipends – the amount was not specified – “that are kept in lock-boxes and given to them if they get well and are discharged from the institution. Stipends of patients who die are kept by the establishment”. La Salpêtrière had a school for “needy girls” and another for “idiots, imbeciles and epileptics” that provided an education by means of “the hospital's own methods”. The punishment doled out to “those who so deserved it” was “making them wear their dresses backwards”.

He was surprised by the institution's interest in research, remarking, “it has a group of epileptics and idiots which is ideal for studying dementias”. He notes that “there are 17 visiting professors, a head of the hospital, appropriately trained interns with good rooms, and well-organised care”, but does not list the names of staff members. The centre also offered cultural activities for its interns. The doctor writes “there is an excellent recreation room with an organ and organist […], where dances are held 3 times a week […]”. Masked balls and theatre productions also made appearances. The centre had its own steam-drying system, slaughterhouse, and bread oven. The astonished Segovian observed, “the dining rooms, kitchens, household goods and glassware are equal to those of a rich landlord”.

And yet, not everything was so glamorous; take González Velasco's description of the places where women with severe mental disorders, epilepsy, and paralysis were confined. “[Their rooms] are box-shaped, lined with zinc, sloped and with drains in the bottom leading to large sewers. Rooms are filled with clean straw that is changed every day. Their cells are remarkably spacious and well-lighted with plank flooring […] they have double doors, with large apertures offering a good view in order to examine their occupants”. He admired the absence of offensive odours. “I am certainly forced to bite my tongue”, he wrote in outrage, “when I see this and think back on the stinking courtyard pertaining to the department of the insane at Hospital General in Madrid!”

Dawn of psychiatry in Madrid: José María Esquerdo

In about 1860, neuropsychiatry in Madrid was beginning to take shape in the hands of José María Esquerdo y Zaragoza (Villajoyosa, 1842–Madrid, 1912). His rather scarce body of scientific works was dwarfed even more, if possible, by the gigantic personality of his mentor, the multi-faceted Pedro Mata y Fontanet (1811–1877). Mata y Fontanet proposed the brain as the origin of mental symptoms, and as the chair of the Department of Legal Medicine, he was interested in the penal responsibility of the insane.^9–11 An article signed “Dr. P” (most likely Ángel Pulido Fernández),¹² sketches Esquerdo's complex personality and his fascinating reasons for dedicating himself to the care of the insane. When his wife died barely 4 years after their marriage, “the exaggerated sensitivity and easy moral impressionability which we always observed in him grew extremely marked […], to the point that the smallest thing would trigger an attack of catalepsy”. Dedicating himself to the study of mental disease from that time onward, the Dean of Hospital General specialised in the illnesses of the insane. “A very thin man, nervous to the point of hysteria, and invariably eloquent […], his words spilled forth from trembling lips” (Fig. 3).

Figure 3.

José María Esquerdo y Zaragoza (1842–1912). Taken from Anfiteatro Anatómico Español. 1873;2:30.

Despite the difference in their ages – González Velasco was 27 years older – they maintained a lifelong friendship. They shared a hospital and political ideals (Esquerdo was an active member of Ruiz Zorrilla's Progressive Republican Party and Velasco made no secret of his republican leanings); they were only able to obtain official University positions after the Glorious Revolution which deposed Queen Isabel II in 1868. Many of Esquerdo's ideas appeared in Anfiteatro anatómico español, an anatomy journal funded by González Velasco and a vital source of information for anyone studying 19th century Spanish medicine.¹³ It is very likely that Velasco chose to visit La Salpêtrière during one of his habitual summer tours of Europe because he was aware of Esquerdo's struggle against the violent treatment and restraints used on the insane.

Esquerdo's was not the only Spanish voice crying out for change in this movement, which began in the second half of the 19th century, and demanded better care for epileptics, the demented, and the insane. An article from 1859 advocates “keeping curable and incurable patients in the same pavilion […] because doctors should never let it be known that they can do nothing by confessing that a condition is incurable”, although it did support separate quarters for “raging patients” and “those practicing Onanism”.¹⁴ One exceptionally relevant and almost unknown document on this topic was published in 1877 by the director of Hospital de Locos del Nuncio de Toledo, an asylum for the incurably insane.¹⁵ In 5 years, half of the 117 patients have died, most of “abdominal diseases” (dysentery in almost all cases); however, a third of the dead suffered from “brain impairments such as epilepsy […] and numerous forms of paralysis”. The living conditions he describes are beyond squalid:

Enraged and agitated patients were housed in “disquieting cells that are dark, dirty and poorly ventilated, with corners and crevices full of insects” and in “common dormitories like dungeons, all mixed in together, offering a repulsive sight”. “No blankets […] in the cruel months of winter, and cots of wooden laths that are no more than a foot high […]; they retain the damp in the winter months and in summer, the swarms of insects are the scourge of our unhappy patients”. “They are given 4 ounces of mutton daily (including the bone); many receive only a half ration, while prisoners are given 8 or 9 ounces. The patients have no duties, distractions or any form of pleasure, not even a garden”.

Conclusions

As in other writings by Velasco describing visits to anatomy museums, universities, and hospitals around Europe, the main purpose of the article on La Salpêtrière was to create a comparative study denouncing the terrible conditions endured by patients with chronic neuropsychiatric disorders in the gloomy courtyards of Hospital General de Madrid. When the doctor published his scathing remarks, a new political framework was in effect; with the Liberal Union in power in Spain (1858–1860) and O’Donnell leading the party, some timid degree of freedom of speech was permitted.¹⁶ Velasco took advantage of this climate to launch criticisms that were clearly politically motivated.

Pedro Mata, José María Esquerdo's mentor, met the Majorcan-born chair of Legal Medicine, Mateo Orfila, in Paris. Mata later settled in Madrid, and in 1840, the Directorate of Studies within the Spanish Ministry of Development created 2 chairs of legal medicine. One was in Barcelona and the other, awarded to Mata, was in Madrid.¹¹ Velasco may have thought the time had come to create a chair of psychiatric medicine for Esquerdo. In any case, he was a staunch supporter of creating “a specific department for observing mental disorders and studying different types of dementias, because our medical students leave the faculty without ever having seen or heard of a single case, let alone having studied the changes in the texture of the brain and other organs of the nervous system. Such an oversight! which will result in harm to the poor unfortunates they will later have to treat”.¹⁷ While he was unsuccessful in his quest for a chair of psychiatry, Velasco remains one of the first Spanish doctors to support specialist training in psychiatry and neurology.

Not everything was golden in the “Versailles of pain” as Charcot called it. In 1854, the venerable institution was accused of presenting unsanitary conditions [peu conformes aux lois de l’hygiène] and its inmates were found to suffer from chronic malnutrition; in one wing, 32% of the patients had scurvy.¹⁸ Painter and illustrator Armand D. Gautier (1825–1894) provides us with a squalid rendering of La Salpêtrière's courtyards with its half-naked patients lying on the ground. A surprising opinion was expressed by Philippe Pinel (1745–1826) after his visit to Spain: “Spain has made many advances towards the great objective [of abolishing use of chains]; those who nurse patients in public asylums treat them gently and help them engage in regular work, which has served to cure most of them”.¹⁹

It is clear that the substantial improvements to La Salpêtrière that were commended by Velasco were added after Pinel's time. Furthermore, if these improvements had not been made, Charcot would have found it extremely difficult to carry out his ambitious project. In any case, throughout his 30 years as director, Charcot would come to transform La Salpêtrière into a model centre for the treatment of neurological diseases.

Conflicts of interest

The authors have no conflicts of interest to declare.