I: Au-dela de I'asile d'alienes et de I'hopital
psychiatrique
(Paris: Desclee de Brouwer, 1946) pp.
Foucault-Psychiatric-Power-1973-74
Since then a well-documented study has become available: N.
Simon and J.
Franchi, La Pitie-Salpetriere (Saint Bcnoit la Forel: Ed.
de PArbre a images, 1986).
9. Saint Lazare, lounded in the ninth century by the hospitaller friars of Saint Lazare for the care of lepers, was transformed by Saint Vincent de Paul on 7 January 1632 to take in "persons detained by order ol His Majesty" and the "insane poor. " In 1794 it became a prison lor streetwalkers. See, E. Pottet, Hisloire de Saint-Lazare, 1122-1912 (Paris: Societe franchise d'lmpnmeric et de libraine, 1912);J. Vie, Les Alienes et les correctionnaires a Saint- Lazare au XVII et au XVIII siecle (Paris: F. Alcan, 1930). Foucault refers to it in Histoire de lajolie, p. 62 and p. 136; Madness and Civilisation, p. 42 (page 136 of the French edition
is omitted from the English translation).
10. The Charenton home was the result of a foundation ol the King's counsellor, Sebaslien
Leblanc, in September 1641. In February 1644 it was handed over to the St Jean-de Dieu order ol hospitallers, created in 1537 by the Portuguese Jean Cindad for the service of the poor and sick. See, J. Monval, Les Freres hospitaliers de Saint-Jean-de-Dieu en France (Paris: Bernard Grasset, 1936); A. Chagny, L'Ordre hospitaller de Saint-Jean-de-Dieu, two volumes (Lyon: Lescuyer el fils, 1953). See also, P. Sevestre, "La maison de Charenton, de la londa tion a la reconstruction: 1641 1838" Histoire des sciences medicales, vol. 25,1991, pp. 61 71.
Closed in July 1795, the home was reopened and nationalized under the Directory, on
15 June 1797, to replace the quarters lor the insane at the Hotel Dieu. Its direction was then entrusted to an old member ol the regular order ol Premonstralensians, Francois de Coulmiers, and Joseph Gastaldy was appointed head doctor. See, C. F. S. Giraudy, Memoire
sur la Maison nationale de Charenton, exclusivement detinee au traitement des alienes (Pans: Imprimene de la Societe de Medecine, 1804); J. E. D. Esquirol, "Memoire historique et statislique sur la Maison Royale de Charenton" (1835) in Des maladiesmentales considerees sous les rapports medical, hygicnique et medico-legale, vol. II, 1838, pp. 539 736; and, C. Strauss, La maison nationale de Charenton (Paris: Imprimene nationale, 1900).
11. F. Leuret, Du traitement moral de la Jolie, p. 185: "In an establishment lor the insane that I could name, the number ol patients is such that in the course of a whole year the head doctor can give only thirty seven minutes to each patient, and in another, where the n-um
ber ol patients is even greater ( . . . ) each patient has the right to see the head doctor for only eighteen minutes a year. "
12. Foucault refers here to the distinction established by Esquirol in the field of madness defined as a "usually chronic cerebral affection, without fever, characterized by disorders of sensibility, intelligence, and the will" J. E. D. Esquirol, "De la lolie" (1816) in Des maladies mentales, vol. I, p. 5; Mental Maladies, p. 21. Within the field marked out by this tripartite division of psychological laculties will be inserted the clinical varieties differing
? Irom each other in terms ol ( a ) the nature ol the disorder allecling the laculties; ( b ) the extension ol the disorder; (c) the quality of the humor which allects it. Thus, whereas mania is characterized by "disturbance and over excitement ol the sensibility, intelligence, and will" ("De la manie" [1818J, ibid. vol. II, p. 132; English, ibid. p. 378), in lypemania - a neologism created by Leuret in 1815 on the basis ol Greek root, XVTTTJ, sadness, affliction--"sensibility is painfully excited or injured; the sad, oppressive passions modily the intelligence and will" ("De la lypemanie ou melancoli" |1820|, ibid. pp. 398 481; English, ibid. pp. 199 233).
13. The criterion for the distinction between mania and monomania was the extension ol the disorder, general or partial, that is to say, localized in a facility (intellectual or instinctive monomania, etcetera), an object (erotomania), or a theme (religious or homicidal mono mania). Thus mania is characterized by the fact that "the delirium is general, all the lacul ties of the understanding are over excited and disrupted," whereas in monomania "the sad or gay, concentrated or expansive delirium is partial and circumscribed to a small number of ideas and affections" ibid. vol. II, "De la manie" p. 133; English, ibid. "Mania" p. 378.
V\. In contrast with mania characterized by "over excitement ol the laculties," the group ol dementias--with "acute," "chronic" and "senile" varieties--are distinguished by their negative aspects: "Dementia is a usually chronic cerebral allection without lever, charac tenzed by deterioration ol the sensibility, intelligence and will" ibid. "De la demence" (1814); p. 219; English, ibid. "Dementia" p. 417.
15. Cauterization or "actual cautery" consisted in the application ol an iron heated 111 the lire or in boiling water to the top of the head or the nape ol the neck. See, L. Valentin, "Memoire el observations concernant les bons ellets du cautere actuel, applique sur la tele dans plusieurs maladies," Nancy, 1815. Esquirol recommended the use ol the moxa and "red hot iron applied to the nape ol the neck in mania complicated by lury" D o maladies mentales, vol. I, "De la folie" (1816) p. 154; Mental Maladies, p. 87: "I have many limes applied the iron at a red heat to the neck, in mania complicated with lury," and ibid. , vol. II, "De la manie" p. 191 and 217; English, ibid. "Mania" pp. 400 401 and p. 411. See,
J. Guislain, Trade sur lfalienation menlale et sur les hospices des alienes, vol. II, ch. vi, "Moxa et cautere actuel" pp. 52-55.
16. "Moxas" are cylinders made Irom a material the progressive combustion ol which was supposed to excite the nervous system and have a Junction ol sensory arousal through the pain it caused. See, A. E. M. Bernardin, Dissertation sur les avantages (/u'on pent retenir de rap- plication du moxa (Paris: Lefebvre, 1803); EJ. Georget, De lafolie, p. 247: Georget recom mended its use in lorms ol insanity involving stupor and insensibility;J. Guislain, Traile sur les phrenopalhies, section IV, p. 458: "This powerful irritant acts on the physical sensibility through pain and the destruction ol living parts, but it also has a moral action through the fear it inspires. "
17.
18.
Ugo Cerletti (1877 1963), dissatisfied with the cardiazol shock used by the Milanese psychiatrist Laszlo von Meduna since 1935, perlected electroshock therapy with Lucio Bmi. On 15 April 1938, a schizophrenic was subjected to this therapy for the first time. See, U. Cerletti, "L'elettroshock" Rivista sperimentale difrenialria, Reggio Emilia, vol. XVIII, 1940, pp. 2 0 9 310; "Electroshock therapy," in A. M. Sackler and others, The Great Physiodynamic Therapies in Psychiatry: An Historical Appraisal (New York: Harper, 1956) pp. 92 94.
From the second hall ol the nineteenth century, the use of ether developed in psychiatry for both therapeutic purposes--notably for calming "states ol nervous excitement" (see, W. Griesinger, Die Pathologie und Therapie derpsychischen Krankheiten [Stuttgart: A. Krabbe, 18451 p. 544; English translation, Mental Pathology and Therapeutics, trans. C. Lockhart Robertson and James Rutherford |New York and London: Halner, 1965] p. 478)--and lor diagnosis. See, H. Bayard, "L'utilisation de Tether et le diagnostic des maladies mentales" Annales d'hygiene publique et medicate, vol. 42, no. 83,July 1849, pp. 201-214; B. A. Morel, "De l'elhcnsation dans la lolie du point de vue du diagnostic et de la medecine legale" Archives
generates de medecine, 51'1 series, vol. 3, 1, February 1854, p. 135: "In certain definite circum stances, etherisation is a precious means for modifying the unhealthy condition and for enlightening the doctor as to the real neuropathic character ol the affection"; and, H. Brochim, "Maladies nerveuses," ? "Anesthesiques: ether et chlorolorme" in Dictionnaire encyclopedujue des sciences medicates, 2mi series, vol. XII, 1877, pp. 376 377.
9 January 197yi 195
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PSYCHIATRIC POWER
19-
On his return trom his travels in France, Italy, and Belgium, Esquirol opened up the dis cussion ol the construction of asylums for the insane, first in his report, Des etahlissements com acre* aux alienes en France, republished in Des maladies mentales, vol. II, pp. 339 /l31, and then 111 his article "Maisons d'alienes" in Dktionnaire des sciences medicates, vol. XXX (Paris: C. L. F. Panckoucke, 1818) pp. 47-95, republished in Des maladies mentales, vol. II, pp. 432 538.
20. Jean Baptiste Parchappe de Vinay (18OO 1866), appointed General Inspector ol the Service lor the insane in 1848, drew up plans for an asylum that would be able to separate categories ol patients and put to work a therapeutic project: Des principes a suivre dans la fon- dation ct la construction des asiles d'alienes (Paris: Masson, 1853). See J. G. H. Martel, Parchappe. Signification de son oeuvre, sa place dans devolution de Vassistance psychiatrique, Medical Thesis, Paris, 1965, no. 108 (Paris: R. Foulon and Co. , 1965).
21.
22.
23.
Henri Girard de Cailleux (1813 188-1), appointed head doctor and director of the Auxerre insane asylum on 20 June 18-10, proposed the construction of asylums in which, 111 line with the principles ol moral treatment, the insane would be isolated, classilied, and put to work. His ideas are developed in, "De I'organisation et de Padministralion des etablisse ments d'alienes" Annales medico-psychologiques, vol. II, September 1843, pp. 230 260; "De la construction, de I'organisation, et de la direction des asiles d'alienes," Annales d'hygienc
publique et de medecine legale, vol. 40, Part 2, July 1848, p. 5 and p. 241.
Appointed by Haussman in i 8 6 0 to the post ol Inspecteur general of the Service for insane for the Seine, Girard de Cailleux, within the lramework of the reorganization ol the Service ol assistance to the insane, in 1861 proposed a program for the construction ol a dozen asy lums in the Paris suburbs, modeled on the Auxerre asylum which he had transformed alter his appointment as director (see the previous note). In May 1867, Saint Anne opened, lollowed in 1868 by Ville Evrard, then Perray Vaucluse in 1869, and later by Villejuil in 1884. See, G. Daumezon, "Essai d'histonque critique de l'appareil d'assistance aux malades mentaux dans le departemenl de la Seine depuis le debut du xixc siecle" Information psychiatrique, vol. I, 1960, no. 5, pp. 6 9; and, G. Bleandonu and G. Le Gaufey, "Naissance des asiles d'alienes (Auxerre-Paris)" Annales ESC, I975, no. I, pp. 93 126.
H. Girard de Cailleux, "De la construction de I'organisation et de la direction des asiles d'alienes," p. 272.
24. J. E. D. Esquirol, "Des maisons d'alienes" (1818) in Des maladies mentales, vol. II, pp. 227 528. This metaphor is promised a fine (uture. Thus, in 1846, Paul Balvet, old director ol the Saint Alban hospital and initiator of the movement ol institutional psychiatry, stated: "The asylum is homogeneous to the psychiatrist, who is its head. Being the head is not an administrative grade: it is an organic relationship with the body that one commands ( . . . ) . He commands in the way that we say the brain commands the nerves. The asylum must therefore be conceived as the psychiatrist's body. " P. Balvet, "De l'autonomie de la profession psychiatrique" in Documents de PInformation psychiatrique, vol.
I: Au-dela de I'asile d'alienes et de I'hopital psychiatrique (Paris: Desclee de Brouwer, 1946) pp. 14 15.
25. Born 28 September 1745 at Lons le Saulner, Jean Baptiste Pussin, after having been the head of the division of "confined boys" at Bicetre in 1780, was promoted to governor ol the seventh emploi, or the Saint-Prix emploi, corresponding to the "quarters lor the agitated insane. " Pinel met him there when taking up his post as hospital doctor at Bicetre on 11 September 1793 following his appointment on 6 August 1793- Appointed head doctor at the hospital of Salpetnere on 13 May 1795, Pinel obtained Pussin's transfer there on 19 May 1802, and worked with him in the section lor the mad until his death on 7 April 1811. In his "Recherches et observations sur le traitement moral des alienes" p. 220, Pinel praises Pussin and acknowledges his role in the "first developments of moral treatment. " In the 1809 edition of his Traite medico-philosophique, he declares that "fully confident of the rectitude and skill of the head ol internal police, I allowed him free exercise of the power at his command" p. 226. On Pussin, see, R. Semelaigne, "Pussin," in Alenistes et philanthropes: les Pinel et les Tuke, Appendice, pp. 501 504; E. Bixler, "A forerunner of pyschiatric nursing: Jean Baptiste Pussin" Annals of Medical History, 1936, no. 8, pp. 518 519- See also, M. Caire, "Pussin avant Pinel" Information psychiatrique, 1993, no. 6, pp. 529 538;J. Juchet, "Jean Baptiste Pussin et Philippe Pinel a Bicetre en 1793: une rencontre, une complicite, une dette" in J. Garrabe, ed. , Philippe Pinel (Paris: Les Empecheurs de penser en rond,
? 1994) pp- 55 70; and,J. Juchet and J. Postel, "Le surveillan Jean Baptiste Pussin" Histoire
des sciences medicates, vol. 30, no. 2, 1996, pp. 189-198.
26. On the basis of the law of 30 June 1838 a debate began on the nature ol the powers in
charge in the asylums. Thus, the Prefect of the Seine, the Baron Haussmann, on the
27 December i860, set up a commission for "the improvement and relorms to be carried
out in the services lor the insane" which, Irom February to June 1861, discussed whether
an administrative director should be appointed alongside the asylum doctor or whether medical and administrative powers should both be in the hands ol a doctor director, as loreseen in article 13 of the order of application of the law of 18 December 1839. On
25 November 1861, the report concluded that "a single authority would be desirable, that
every administrative or medical element work under a single impulse towards the good that
is oflered" Rapport cle la Commission institute pour la reforme el I'amenagement clu service d'alienes du departement de la Seine (Paris: 1861).
27. P. Pinel, La Medecine clinique rendue plus precise el plus exacte par ^application de I'analyse, ou Recueil el resultats d'observations sur les maladies aigues,faites a la Salpetriere (Pans: Brosson et Gabon, 1804, 2nd edition) pp. 5 6.
28. Falret, for example, puts questioning in the forefront of clinical examination by laying down as principle that "il you wish to know the tendencies, the direction ol the mind, and the dispositions of leelings which are the source of every symptom, do not reduce your duty
as observer to the passive role ol secretary to the patients, ol stenographer ol their words
or narrator ol their actions . . . The lust principle to be lollowed . . . is therelore to change one's passive role ol the observer of the patient's words and actions into an active role, and frequently seek to provoke and call forth symptoms which would never arise sponta neously" J. P. Falret, "Discours d'ouverture: De la direction a impnmer a l'observation des alienes," in Lecons cliniques de medecine menlale Jaites a I'liospice de la Salpetriere (Paris:
J. B. Bailliere, 1854) pp. 19 20.
29. Ibid. 8th Lesson, pp. 221-222: "Sometimes one must artfully lead the conversation to cer
tain subjects one supposes are related to unhealthy ideas or sentiments; these calculated interviews act as touchstones for bringing to light morbid preoccupations. Considerable experience and much art is often necessary to observe certain insane people appropriately" See also, J. P. Falret, De Venseignement clinique des maladies mentales (Pans: Martinet, 1850) pp. 68 71.
30. Hence the numerous declarations that insist on the need to collect observations on the patients in "registers" which recapitulate the history of their illness. P. Pinel recommends "keeping exact journals ol the progress and diverse lorms taking by the insanity through- out its course, Irom its onset to its end" Traite medico-philosophique, section VI, ? xn, p. 256; A Treatise on Insanity, Section VI, p. 246. C. F. S. Giraudy stresses this in his Memoire sur la Maison nationale de Charenton, pp. 17-22. Moreau de Tours notes: "Information obtained about the patient are kept in the register, which must also contain the necessary details on
the progress of the illness ( . . . ) This register is a veritable notebook ol observations, a statistical study ol which is made at the end ol each year, which is a source ol precious documents" J. J. Moreau de Tours, "Lettres medicales sur la colonie d'alienes de Gheel" p. 267. On this form ol disciplinary writing, see M. Foucault, Surveiller et Punish, pp. 191 193; Discipline and Punish, pp. 191-192.
31. In 1817 Esquirol began a clinical class of mental illnesses at Salpetriere, which he contin- ued until his appointment as head doctor at Charenton in 1826. See, R. Semelaigne, Les Grands Alienistes francais (Pans: G. Steinheil, 1894) p. 128; and, C. Bouchet, Quelques mots sur Esquirol ( Nantes: C. Mellinet, 1841) p. 1.
32. At Bicetre Irom 1833 to 1839, Guillaume Ferrus, appointed head doctor at the beginning of 1826, gave "Clinical lessons on mental illnesses," which are reproduced in the Gazette medicalc de Paris, vol. I, no. 65,1833; vol. II, no. 39,1834, p. 48; vol. IV, no. 25,1836, pp. 28, 44 and 45; and in the Gazette des hopitaux, 1838, pp. 307, 314, 326, 345, 352, 369, 384, 399, 471, 536, 552, 576, 599 and 612; 1839, pp. 5,17, 33, 58, 69, 82, 434 and 441. In 1840, after the departure of Ferrus, Leuret organized clinical lessons which he continued until 1847, published in part in the Gazette des hopitaux, vol. II, 1840, pp. 233, 254, 269 and 295.
33. At Salpetriere,Jules Baillarger (1809 189O) took up clinical teaching in 1841. Jean-Pierre Falret, appointed doctor of a section for the insane, in turn began clinical teaching in 1843,
9 January 1974 197
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PSYCHIATRIC POWER
part ol which is published in the Ann ales medko-psychologiques, vol. IX, September 1847, pp. 232 264, and vol. XII, October 1849, pp. 524 579. These lessons are reprinted (with the same title) in: De I'cnseignement clinique des maladies mentale. See, M. Wiriot, L'Ensettlement clinique dans les hbpitaux de Paris entrc Z797/ and 1&48, Medical Thesis, Paris, 1970, no. 334 (Vincennes: Chaume, 1970).
34- J. P. Falret, De renseignemenl clinique, p. 126.
35.
36.
37-
38.
Ibid. p. 127: "The public narration ol their illness made by the insane is an even more precious help to the doctor . . . , the doctor must be powerlul in a very different way in the wholly new conditions ol the clinic, that is to say, when the prolessor makes all the phenomena ol his illness perceptible to the patient in the presence of more or less numerous auditors. "
Ibid. p. 119: "If the patients accept . . . he will give the history ol their illness with the fixed principle ol recounting only that which is completely known to them, and he will Irequently slop to ask them il he is trulhlully expressing the lacts that they themselves have told him earlier. "
Ibid. p. 125: "The account ol their illness, given in all its developments, often makes a strong impression on the insane, who themselves testily to its truth with visible satisfac- tion, and enjoy entering into the greatest detail in order to complete the account, as il they were astonished and proud that someone should take such an interest in them so as to know their entire history. "
Marie Francois Xavier Bichat (1771 1802), alter having been introduced to surgery in Lyon in the department ol Marc Antoine Petit (1762 1840 ) and, in June 1794, becoming the student ol Pierre Joseph Delsaut (1744 1795), surgeon at the Hotel Dieu, devoted himsell, after his appointment in 1800, to pathological anatomy, undertaking to establish the delinite relationships between alterations ol tissues and clinical symptoms. See, Trade des membranes en general et des diverse* membranes en particulier(Par\s: G a b o n , 1 8 ( ) 0 ) . H e set out his conceptions in Anatomie generate appliquee a la physiologic et a la medecine, in four volumes (Paris: Brosson et Gabon, 1801); English translation, General Anatomy, applied to Physiology and the Practice of Medicine, trans. C. Coffyn (London: 1824).
But it was above all Gaspard Llaurent Bayle (1774 1816) and Rene Theophile Laennec (1781 1826) who strove to lound clinical medicine and pathological anatomy in a single discipline. Bayle was one ol the first to formulate the methodology ol the young school ol clinical anatomy in his thesis defended 4 Venlose Year X/24 February 1802: Considerations sur la nosologic, la medecine d'observation et la medecine pratique, suiviies d'observations pour servir a rhistoire des pustules gangreneuses, Medical Thesis, Pans, no. 70 (Paris: Boiste [Gabon], 1802). He sets out the ideas that he will develop and clarify in, Recherches sur la phtisie pulmonaire (Pans: Gabon, 1810); English translation, Researches on Pulmonary Phthisis, trans. W. Barrow (London: Longman, 1815), and in "Considerations generales sur les secours que I'anatomie pathologique peut fournir a la medecine," in Dictionnaire des sciences medicates, vol. II (Pans: C. L. F. Panckoucke, 1812) pp. 61 78. R. T. Laennec renewed pulmonary pathology by endeavouring to "put the diagnosis ol internal organic lesions on the same level as the diagnosis of surgical illnesses," De Vauscultation mediate, ou Trade du diagnostic des malades des poumons et du coeur,fonde principalamenl sur ce nouveau moyen d'exploration, two volumes (Pans: Brosson and Chaude, 2lul revised and expanded edition, 1826) vol. 1, p. xxv; English translation, A Treatise on Mediate Auscultation, and on Diseases of the Lungs and Heart, translated by a Member of the College ol Physicians (London: J. B. Bailliere, 1846), and in his posthumous work, Trade inedit sur I'anatomie pathologique, ou Exposition des alterations visible qu'eprouve le corps humain dans I'etat de maladie (Pans: Alcan, 1884).
On Bichat, see the pages in chapter 8, "Ouvrez quelques cadavres" ol M. Foucault, Naissance de la clinique. Une archeologie du regard medical (Pans: P. U. F. , 1963) pp. 125 148; English translation, The Birth of the Clinic. An Archeology oj Medical Perception, trans. A. M. Sheridan Smith (London: Tavistock and New York: Pantheon, 1973), ch. 8, "Open Up a Few Corposes" pp. 124 148. More generally, see,J. E. Rochard, Histoire de la chirurgie francaise au X. 1X: siecle (Paris: J . B . Bailliere, 1875); O. Temkin, "The role ol surgery in the rise of modern medical thought" Bulletin oj the History of Medicine, Baltimore, Md: vol. 25, no. 3, 1951, pp. 248 259; E. H. Ackerknecht, (i) "Pariser chirgurgie von 1794-1850" Gesnerus, vol. 17, 1960, pp. 137 144, and (ii) Medicine at the Paris Hospitals, M9y\-^\S
? (Baltimore Md: The Johns Hopkins Press, 1967); French translation, La Medecine hospitaliere
a Paris, 179/\-l8/\&, trans. F. Blateau (Paris, Payol, 1986); P. Huard and M. Grmeck, eds. , Sciences, medecine, pharmacic, de la Revolution a rEmpire, 17&9-1&15 (Paris: Ed. Dacosta, 1970) pp. W Vl5; M. J. Imbault Huart, L'Ecole pratique de dissection de Paris de 1750 a
1822, ou I'injlucnce du concept de medecine pratique el de medecine d'observation dans I'enseignement medico-chirurgical an XVIH' siecle, These de doctoral cs lettres, University Paris I, 1973, reprinted University of Lille III, 1975; P. Huard, "Concepts et realites de Peducation et de
la profession medico-chirurgicales pendant la Revolution" Journal des savants, April June
1973, pp. 126 150.
On G. L.
9. Saint Lazare, lounded in the ninth century by the hospitaller friars of Saint Lazare for the care of lepers, was transformed by Saint Vincent de Paul on 7 January 1632 to take in "persons detained by order ol His Majesty" and the "insane poor. " In 1794 it became a prison lor streetwalkers. See, E. Pottet, Hisloire de Saint-Lazare, 1122-1912 (Paris: Societe franchise d'lmpnmeric et de libraine, 1912);J. Vie, Les Alienes et les correctionnaires a Saint- Lazare au XVII et au XVIII siecle (Paris: F. Alcan, 1930). Foucault refers to it in Histoire de lajolie, p. 62 and p. 136; Madness and Civilisation, p. 42 (page 136 of the French edition
is omitted from the English translation).
10. The Charenton home was the result of a foundation ol the King's counsellor, Sebaslien
Leblanc, in September 1641. In February 1644 it was handed over to the St Jean-de Dieu order ol hospitallers, created in 1537 by the Portuguese Jean Cindad for the service of the poor and sick. See, J. Monval, Les Freres hospitaliers de Saint-Jean-de-Dieu en France (Paris: Bernard Grasset, 1936); A. Chagny, L'Ordre hospitaller de Saint-Jean-de-Dieu, two volumes (Lyon: Lescuyer el fils, 1953). See also, P. Sevestre, "La maison de Charenton, de la londa tion a la reconstruction: 1641 1838" Histoire des sciences medicales, vol. 25,1991, pp. 61 71.
Closed in July 1795, the home was reopened and nationalized under the Directory, on
15 June 1797, to replace the quarters lor the insane at the Hotel Dieu. Its direction was then entrusted to an old member ol the regular order ol Premonstralensians, Francois de Coulmiers, and Joseph Gastaldy was appointed head doctor. See, C. F. S. Giraudy, Memoire
sur la Maison nationale de Charenton, exclusivement detinee au traitement des alienes (Pans: Imprimene de la Societe de Medecine, 1804); J. E. D. Esquirol, "Memoire historique et statislique sur la Maison Royale de Charenton" (1835) in Des maladiesmentales considerees sous les rapports medical, hygicnique et medico-legale, vol. II, 1838, pp. 539 736; and, C. Strauss, La maison nationale de Charenton (Paris: Imprimene nationale, 1900).
11. F. Leuret, Du traitement moral de la Jolie, p. 185: "In an establishment lor the insane that I could name, the number ol patients is such that in the course of a whole year the head doctor can give only thirty seven minutes to each patient, and in another, where the n-um
ber ol patients is even greater ( . . . ) each patient has the right to see the head doctor for only eighteen minutes a year. "
12. Foucault refers here to the distinction established by Esquirol in the field of madness defined as a "usually chronic cerebral affection, without fever, characterized by disorders of sensibility, intelligence, and the will" J. E. D. Esquirol, "De la lolie" (1816) in Des maladies mentales, vol. I, p. 5; Mental Maladies, p. 21. Within the field marked out by this tripartite division of psychological laculties will be inserted the clinical varieties differing
? Irom each other in terms ol ( a ) the nature ol the disorder allecling the laculties; ( b ) the extension ol the disorder; (c) the quality of the humor which allects it. Thus, whereas mania is characterized by "disturbance and over excitement ol the sensibility, intelligence, and will" ("De la manie" [1818J, ibid. vol. II, p. 132; English, ibid. p. 378), in lypemania - a neologism created by Leuret in 1815 on the basis ol Greek root, XVTTTJ, sadness, affliction--"sensibility is painfully excited or injured; the sad, oppressive passions modily the intelligence and will" ("De la lypemanie ou melancoli" |1820|, ibid. pp. 398 481; English, ibid. pp. 199 233).
13. The criterion for the distinction between mania and monomania was the extension ol the disorder, general or partial, that is to say, localized in a facility (intellectual or instinctive monomania, etcetera), an object (erotomania), or a theme (religious or homicidal mono mania). Thus mania is characterized by the fact that "the delirium is general, all the lacul ties of the understanding are over excited and disrupted," whereas in monomania "the sad or gay, concentrated or expansive delirium is partial and circumscribed to a small number of ideas and affections" ibid. vol. II, "De la manie" p. 133; English, ibid. "Mania" p. 378.
V\. In contrast with mania characterized by "over excitement ol the laculties," the group ol dementias--with "acute," "chronic" and "senile" varieties--are distinguished by their negative aspects: "Dementia is a usually chronic cerebral allection without lever, charac tenzed by deterioration ol the sensibility, intelligence and will" ibid. "De la demence" (1814); p. 219; English, ibid. "Dementia" p. 417.
15. Cauterization or "actual cautery" consisted in the application ol an iron heated 111 the lire or in boiling water to the top of the head or the nape ol the neck. See, L. Valentin, "Memoire el observations concernant les bons ellets du cautere actuel, applique sur la tele dans plusieurs maladies," Nancy, 1815. Esquirol recommended the use ol the moxa and "red hot iron applied to the nape ol the neck in mania complicated by lury" D o maladies mentales, vol. I, "De la folie" (1816) p. 154; Mental Maladies, p. 87: "I have many limes applied the iron at a red heat to the neck, in mania complicated with lury," and ibid. , vol. II, "De la manie" p. 191 and 217; English, ibid. "Mania" pp. 400 401 and p. 411. See,
J. Guislain, Trade sur lfalienation menlale et sur les hospices des alienes, vol. II, ch. vi, "Moxa et cautere actuel" pp. 52-55.
16. "Moxas" are cylinders made Irom a material the progressive combustion ol which was supposed to excite the nervous system and have a Junction ol sensory arousal through the pain it caused. See, A. E. M. Bernardin, Dissertation sur les avantages (/u'on pent retenir de rap- plication du moxa (Paris: Lefebvre, 1803); EJ. Georget, De lafolie, p. 247: Georget recom mended its use in lorms ol insanity involving stupor and insensibility;J. Guislain, Traile sur les phrenopalhies, section IV, p. 458: "This powerful irritant acts on the physical sensibility through pain and the destruction ol living parts, but it also has a moral action through the fear it inspires. "
17.
18.
Ugo Cerletti (1877 1963), dissatisfied with the cardiazol shock used by the Milanese psychiatrist Laszlo von Meduna since 1935, perlected electroshock therapy with Lucio Bmi. On 15 April 1938, a schizophrenic was subjected to this therapy for the first time. See, U. Cerletti, "L'elettroshock" Rivista sperimentale difrenialria, Reggio Emilia, vol. XVIII, 1940, pp. 2 0 9 310; "Electroshock therapy," in A. M. Sackler and others, The Great Physiodynamic Therapies in Psychiatry: An Historical Appraisal (New York: Harper, 1956) pp. 92 94.
From the second hall ol the nineteenth century, the use of ether developed in psychiatry for both therapeutic purposes--notably for calming "states ol nervous excitement" (see, W. Griesinger, Die Pathologie und Therapie derpsychischen Krankheiten [Stuttgart: A. Krabbe, 18451 p. 544; English translation, Mental Pathology and Therapeutics, trans. C. Lockhart Robertson and James Rutherford |New York and London: Halner, 1965] p. 478)--and lor diagnosis. See, H. Bayard, "L'utilisation de Tether et le diagnostic des maladies mentales" Annales d'hygiene publique et medicate, vol. 42, no. 83,July 1849, pp. 201-214; B. A. Morel, "De l'elhcnsation dans la lolie du point de vue du diagnostic et de la medecine legale" Archives
generates de medecine, 51'1 series, vol. 3, 1, February 1854, p. 135: "In certain definite circum stances, etherisation is a precious means for modifying the unhealthy condition and for enlightening the doctor as to the real neuropathic character ol the affection"; and, H. Brochim, "Maladies nerveuses," ? "Anesthesiques: ether et chlorolorme" in Dictionnaire encyclopedujue des sciences medicates, 2mi series, vol. XII, 1877, pp. 376 377.
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19-
On his return trom his travels in France, Italy, and Belgium, Esquirol opened up the dis cussion ol the construction of asylums for the insane, first in his report, Des etahlissements com acre* aux alienes en France, republished in Des maladies mentales, vol. II, pp. 339 /l31, and then 111 his article "Maisons d'alienes" in Dktionnaire des sciences medicates, vol. XXX (Paris: C. L. F. Panckoucke, 1818) pp. 47-95, republished in Des maladies mentales, vol. II, pp. 432 538.
20. Jean Baptiste Parchappe de Vinay (18OO 1866), appointed General Inspector ol the Service lor the insane in 1848, drew up plans for an asylum that would be able to separate categories ol patients and put to work a therapeutic project: Des principes a suivre dans la fon- dation ct la construction des asiles d'alienes (Paris: Masson, 1853). See J. G. H. Martel, Parchappe. Signification de son oeuvre, sa place dans devolution de Vassistance psychiatrique, Medical Thesis, Paris, 1965, no. 108 (Paris: R. Foulon and Co. , 1965).
21.
22.
23.
Henri Girard de Cailleux (1813 188-1), appointed head doctor and director of the Auxerre insane asylum on 20 June 18-10, proposed the construction of asylums in which, 111 line with the principles ol moral treatment, the insane would be isolated, classilied, and put to work. His ideas are developed in, "De I'organisation et de Padministralion des etablisse ments d'alienes" Annales medico-psychologiques, vol. II, September 1843, pp. 230 260; "De la construction, de I'organisation, et de la direction des asiles d'alienes," Annales d'hygienc
publique et de medecine legale, vol. 40, Part 2, July 1848, p. 5 and p. 241.
Appointed by Haussman in i 8 6 0 to the post ol Inspecteur general of the Service for insane for the Seine, Girard de Cailleux, within the lramework of the reorganization ol the Service ol assistance to the insane, in 1861 proposed a program for the construction ol a dozen asy lums in the Paris suburbs, modeled on the Auxerre asylum which he had transformed alter his appointment as director (see the previous note). In May 1867, Saint Anne opened, lollowed in 1868 by Ville Evrard, then Perray Vaucluse in 1869, and later by Villejuil in 1884. See, G. Daumezon, "Essai d'histonque critique de l'appareil d'assistance aux malades mentaux dans le departemenl de la Seine depuis le debut du xixc siecle" Information psychiatrique, vol. I, 1960, no. 5, pp. 6 9; and, G. Bleandonu and G. Le Gaufey, "Naissance des asiles d'alienes (Auxerre-Paris)" Annales ESC, I975, no. I, pp. 93 126.
H. Girard de Cailleux, "De la construction de I'organisation et de la direction des asiles d'alienes," p. 272.
24. J. E. D. Esquirol, "Des maisons d'alienes" (1818) in Des maladies mentales, vol. II, pp. 227 528. This metaphor is promised a fine (uture. Thus, in 1846, Paul Balvet, old director ol the Saint Alban hospital and initiator of the movement ol institutional psychiatry, stated: "The asylum is homogeneous to the psychiatrist, who is its head. Being the head is not an administrative grade: it is an organic relationship with the body that one commands ( . . . ) . He commands in the way that we say the brain commands the nerves. The asylum must therefore be conceived as the psychiatrist's body. " P. Balvet, "De l'autonomie de la profession psychiatrique" in Documents de PInformation psychiatrique, vol.
I: Au-dela de I'asile d'alienes et de I'hopital psychiatrique (Paris: Desclee de Brouwer, 1946) pp. 14 15.
25. Born 28 September 1745 at Lons le Saulner, Jean Baptiste Pussin, after having been the head of the division of "confined boys" at Bicetre in 1780, was promoted to governor ol the seventh emploi, or the Saint-Prix emploi, corresponding to the "quarters lor the agitated insane. " Pinel met him there when taking up his post as hospital doctor at Bicetre on 11 September 1793 following his appointment on 6 August 1793- Appointed head doctor at the hospital of Salpetnere on 13 May 1795, Pinel obtained Pussin's transfer there on 19 May 1802, and worked with him in the section lor the mad until his death on 7 April 1811. In his "Recherches et observations sur le traitement moral des alienes" p. 220, Pinel praises Pussin and acknowledges his role in the "first developments of moral treatment. " In the 1809 edition of his Traite medico-philosophique, he declares that "fully confident of the rectitude and skill of the head ol internal police, I allowed him free exercise of the power at his command" p. 226. On Pussin, see, R. Semelaigne, "Pussin," in Alenistes et philanthropes: les Pinel et les Tuke, Appendice, pp. 501 504; E. Bixler, "A forerunner of pyschiatric nursing: Jean Baptiste Pussin" Annals of Medical History, 1936, no. 8, pp. 518 519- See also, M. Caire, "Pussin avant Pinel" Information psychiatrique, 1993, no. 6, pp. 529 538;J. Juchet, "Jean Baptiste Pussin et Philippe Pinel a Bicetre en 1793: une rencontre, une complicite, une dette" in J. Garrabe, ed. , Philippe Pinel (Paris: Les Empecheurs de penser en rond,
? 1994) pp- 55 70; and,J. Juchet and J. Postel, "Le surveillan Jean Baptiste Pussin" Histoire
des sciences medicates, vol. 30, no. 2, 1996, pp. 189-198.
26. On the basis of the law of 30 June 1838 a debate began on the nature ol the powers in
charge in the asylums. Thus, the Prefect of the Seine, the Baron Haussmann, on the
27 December i860, set up a commission for "the improvement and relorms to be carried
out in the services lor the insane" which, Irom February to June 1861, discussed whether
an administrative director should be appointed alongside the asylum doctor or whether medical and administrative powers should both be in the hands ol a doctor director, as loreseen in article 13 of the order of application of the law of 18 December 1839. On
25 November 1861, the report concluded that "a single authority would be desirable, that
every administrative or medical element work under a single impulse towards the good that
is oflered" Rapport cle la Commission institute pour la reforme el I'amenagement clu service d'alienes du departement de la Seine (Paris: 1861).
27. P. Pinel, La Medecine clinique rendue plus precise el plus exacte par ^application de I'analyse, ou Recueil el resultats d'observations sur les maladies aigues,faites a la Salpetriere (Pans: Brosson et Gabon, 1804, 2nd edition) pp. 5 6.
28. Falret, for example, puts questioning in the forefront of clinical examination by laying down as principle that "il you wish to know the tendencies, the direction ol the mind, and the dispositions of leelings which are the source of every symptom, do not reduce your duty
as observer to the passive role ol secretary to the patients, ol stenographer ol their words
or narrator ol their actions . . . The lust principle to be lollowed . . . is therelore to change one's passive role ol the observer of the patient's words and actions into an active role, and frequently seek to provoke and call forth symptoms which would never arise sponta neously" J. P. Falret, "Discours d'ouverture: De la direction a impnmer a l'observation des alienes," in Lecons cliniques de medecine menlale Jaites a I'liospice de la Salpetriere (Paris:
J. B. Bailliere, 1854) pp. 19 20.
29. Ibid. 8th Lesson, pp. 221-222: "Sometimes one must artfully lead the conversation to cer
tain subjects one supposes are related to unhealthy ideas or sentiments; these calculated interviews act as touchstones for bringing to light morbid preoccupations. Considerable experience and much art is often necessary to observe certain insane people appropriately" See also, J. P. Falret, De Venseignement clinique des maladies mentales (Pans: Martinet, 1850) pp. 68 71.
30. Hence the numerous declarations that insist on the need to collect observations on the patients in "registers" which recapitulate the history of their illness. P. Pinel recommends "keeping exact journals ol the progress and diverse lorms taking by the insanity through- out its course, Irom its onset to its end" Traite medico-philosophique, section VI, ? xn, p. 256; A Treatise on Insanity, Section VI, p. 246. C. F. S. Giraudy stresses this in his Memoire sur la Maison nationale de Charenton, pp. 17-22. Moreau de Tours notes: "Information obtained about the patient are kept in the register, which must also contain the necessary details on
the progress of the illness ( . . . ) This register is a veritable notebook ol observations, a statistical study ol which is made at the end ol each year, which is a source ol precious documents" J. J. Moreau de Tours, "Lettres medicales sur la colonie d'alienes de Gheel" p. 267. On this form ol disciplinary writing, see M. Foucault, Surveiller et Punish, pp. 191 193; Discipline and Punish, pp. 191-192.
31. In 1817 Esquirol began a clinical class of mental illnesses at Salpetriere, which he contin- ued until his appointment as head doctor at Charenton in 1826. See, R. Semelaigne, Les Grands Alienistes francais (Pans: G. Steinheil, 1894) p. 128; and, C. Bouchet, Quelques mots sur Esquirol ( Nantes: C. Mellinet, 1841) p. 1.
32. At Bicetre Irom 1833 to 1839, Guillaume Ferrus, appointed head doctor at the beginning of 1826, gave "Clinical lessons on mental illnesses," which are reproduced in the Gazette medicalc de Paris, vol. I, no. 65,1833; vol. II, no. 39,1834, p. 48; vol. IV, no. 25,1836, pp. 28, 44 and 45; and in the Gazette des hopitaux, 1838, pp. 307, 314, 326, 345, 352, 369, 384, 399, 471, 536, 552, 576, 599 and 612; 1839, pp. 5,17, 33, 58, 69, 82, 434 and 441. In 1840, after the departure of Ferrus, Leuret organized clinical lessons which he continued until 1847, published in part in the Gazette des hopitaux, vol. II, 1840, pp. 233, 254, 269 and 295.
33. At Salpetriere,Jules Baillarger (1809 189O) took up clinical teaching in 1841. Jean-Pierre Falret, appointed doctor of a section for the insane, in turn began clinical teaching in 1843,
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part ol which is published in the Ann ales medko-psychologiques, vol. IX, September 1847, pp. 232 264, and vol. XII, October 1849, pp. 524 579. These lessons are reprinted (with the same title) in: De I'cnseignement clinique des maladies mentale. See, M. Wiriot, L'Ensettlement clinique dans les hbpitaux de Paris entrc Z797/ and 1&48, Medical Thesis, Paris, 1970, no. 334 (Vincennes: Chaume, 1970).
34- J. P. Falret, De renseignemenl clinique, p. 126.
35.
36.
37-
38.
Ibid. p. 127: "The public narration ol their illness made by the insane is an even more precious help to the doctor . . . , the doctor must be powerlul in a very different way in the wholly new conditions ol the clinic, that is to say, when the prolessor makes all the phenomena ol his illness perceptible to the patient in the presence of more or less numerous auditors. "
Ibid. p. 119: "If the patients accept . . . he will give the history ol their illness with the fixed principle ol recounting only that which is completely known to them, and he will Irequently slop to ask them il he is trulhlully expressing the lacts that they themselves have told him earlier. "
Ibid. p. 125: "The account ol their illness, given in all its developments, often makes a strong impression on the insane, who themselves testily to its truth with visible satisfac- tion, and enjoy entering into the greatest detail in order to complete the account, as il they were astonished and proud that someone should take such an interest in them so as to know their entire history. "
Marie Francois Xavier Bichat (1771 1802), alter having been introduced to surgery in Lyon in the department ol Marc Antoine Petit (1762 1840 ) and, in June 1794, becoming the student ol Pierre Joseph Delsaut (1744 1795), surgeon at the Hotel Dieu, devoted himsell, after his appointment in 1800, to pathological anatomy, undertaking to establish the delinite relationships between alterations ol tissues and clinical symptoms. See, Trade des membranes en general et des diverse* membranes en particulier(Par\s: G a b o n , 1 8 ( ) 0 ) . H e set out his conceptions in Anatomie generate appliquee a la physiologic et a la medecine, in four volumes (Paris: Brosson et Gabon, 1801); English translation, General Anatomy, applied to Physiology and the Practice of Medicine, trans. C. Coffyn (London: 1824).
But it was above all Gaspard Llaurent Bayle (1774 1816) and Rene Theophile Laennec (1781 1826) who strove to lound clinical medicine and pathological anatomy in a single discipline. Bayle was one ol the first to formulate the methodology ol the young school ol clinical anatomy in his thesis defended 4 Venlose Year X/24 February 1802: Considerations sur la nosologic, la medecine d'observation et la medecine pratique, suiviies d'observations pour servir a rhistoire des pustules gangreneuses, Medical Thesis, Pans, no. 70 (Paris: Boiste [Gabon], 1802). He sets out the ideas that he will develop and clarify in, Recherches sur la phtisie pulmonaire (Pans: Gabon, 1810); English translation, Researches on Pulmonary Phthisis, trans. W. Barrow (London: Longman, 1815), and in "Considerations generales sur les secours que I'anatomie pathologique peut fournir a la medecine," in Dictionnaire des sciences medicates, vol. II (Pans: C. L. F. Panckoucke, 1812) pp. 61 78. R. T. Laennec renewed pulmonary pathology by endeavouring to "put the diagnosis ol internal organic lesions on the same level as the diagnosis of surgical illnesses," De Vauscultation mediate, ou Trade du diagnostic des malades des poumons et du coeur,fonde principalamenl sur ce nouveau moyen d'exploration, two volumes (Pans: Brosson and Chaude, 2lul revised and expanded edition, 1826) vol. 1, p. xxv; English translation, A Treatise on Mediate Auscultation, and on Diseases of the Lungs and Heart, translated by a Member of the College ol Physicians (London: J. B. Bailliere, 1846), and in his posthumous work, Trade inedit sur I'anatomie pathologique, ou Exposition des alterations visible qu'eprouve le corps humain dans I'etat de maladie (Pans: Alcan, 1884).
On Bichat, see the pages in chapter 8, "Ouvrez quelques cadavres" ol M. Foucault, Naissance de la clinique. Une archeologie du regard medical (Pans: P. U. F. , 1963) pp. 125 148; English translation, The Birth of the Clinic. An Archeology oj Medical Perception, trans. A. M. Sheridan Smith (London: Tavistock and New York: Pantheon, 1973), ch. 8, "Open Up a Few Corposes" pp. 124 148. More generally, see,J. E. Rochard, Histoire de la chirurgie francaise au X. 1X: siecle (Paris: J . B . Bailliere, 1875); O. Temkin, "The role ol surgery in the rise of modern medical thought" Bulletin oj the History of Medicine, Baltimore, Md: vol. 25, no. 3, 1951, pp. 248 259; E. H. Ackerknecht, (i) "Pariser chirgurgie von 1794-1850" Gesnerus, vol. 17, 1960, pp. 137 144, and (ii) Medicine at the Paris Hospitals, M9y\-^\S
? (Baltimore Md: The Johns Hopkins Press, 1967); French translation, La Medecine hospitaliere
a Paris, 179/\-l8/\&, trans. F. Blateau (Paris, Payol, 1986); P. Huard and M. Grmeck, eds. , Sciences, medecine, pharmacic, de la Revolution a rEmpire, 17&9-1&15 (Paris: Ed. Dacosta, 1970) pp. W Vl5; M. J. Imbault Huart, L'Ecole pratique de dissection de Paris de 1750 a
1822, ou I'injlucnce du concept de medecine pratique el de medecine d'observation dans I'enseignement medico-chirurgical an XVIH' siecle, These de doctoral cs lettres, University Paris I, 1973, reprinted University of Lille III, 1975; P. Huard, "Concepts et realites de Peducation et de
la profession medico-chirurgicales pendant la Revolution" Journal des savants, April June
1973, pp. 126 150.
On G. L.
