Jan W.P.F. Kardaun, MD, PhD
Academic Medical Center, Amsterdam, Netherlands
Most people associate a hospital with medical care but would like to stay there as briefly as possible. In 1656, King Louis XIV of France created a General Hospital for all who needed care. It was spacious, elegantly designed, situated at the outskirts of the city of Paris, and free. But there was one drawback: once you were admitted, you could not get out. Was it a prison? Not really, even though it had a ward for convicted prisoners. It was a refuge for all who had no other means of existence or could not lead a life of their own.
The Hôpital Général des pauvres was an organisation consisting of two sites, Bicêtre (men) and Salpêtrière (women). During the Ancien Régime (1500 – 1789) one could enter l'Hôpital – it was known and feared by this abbreviated name – in one of two ways: voluntary or enforced. Volunteers had not done anything wrong – they were known as the bons pauvres – but had no other means of life, shelter, food. Begging was not allowed; it could result in whipping or the galleys. L'Hôpital offered them a roof, bread, soup, clothing (frock style), a straw mattress (without sheets) to be shared, and no heating. There was plenty of stench, noise, dirt, unrest, but it was a better option than life on the streets and in the gutter. Those sent to l'Hôpital could be categorized as prisoners (convicted by a judge), persons arrested with a lettre de cachet (executive order), orphans, and lunatics (the latter with a fair share of dementia paralytica, syphilitics). The madmen were divided into the peaceful and the aggressive. The latter were usually chained to the walls, and most of their guards carried arms. This situation lasted until 1798, when the Enlightenment and the French Revolution introduced some changes and improvements – some of dubious reputation: in the court of the Bicêtre, in 1790, a new and humane instrument, later to be called the guillotine, was demonstrated on the corpses of three freshly deceased inmates and shown to work splendidly.
Hospitals can be famous for medical discoveries or when their reputation is so great that their name becomes a household word. The ultimate level of fame, however, is when a hospital is referred to in the literature, in books, or in a film.
Such was the case with Abbe Prévost’s 1731 novel about the adventures of a gentleman and Manon Lescaut. It was the kind of book that was forbidden and ordered to be burnt, which did not prevent it from becoming so popular that in the nineteenth and twentieth century half a dozen operas and movies were based on it. In the book the heroine has to spend some time confined in the Salpêtrière because of her alleged immoral behavior. The word Salpêtrière does not occur in the text, mentioning of The Hospital being enough to raise the association with desolate confinement.
In 1839 a short novel by Gérard de Nerval was situated in the Paris of King Henri II mid sixteenth century. This is at first thought amazing, as the General Hospital had not yet been established for another one-and-a-half century, and it would take almost that time before a military hospital would be built on the ruins of a castle at Bicêtre. The protagonist is a young lawyer who looks very much like the king and gradually identifies with him, so he thinks he is the king. His confrères arrange a legal restraint, and have him sent to the Bicêtre, where amidst all the madmen his delusions become even worse. There is no treatment, no cure, but the story ends rather like a fairy tale.
From nineteenth century perspective, Gérard de Nerval describes the situation in the hospital rather mildly though not particularly appealing: barred windows and iron gates throughout, noise, tormenting by other patients, by guards, and by day-trippers who come to look at this “human zoo”. The novel contains several anachronisms and does not aim at historical accuracy, but gives a colorful background to the story of a delusion, based more or less on a historical example. The fact that the hospital described in his novel was called the Bicêtre is only clear from the title of the second edition (Le roi de Bicêtre) , the word is not used in the text. Apparently a brief and vivid title was preferred over the rather long and dull title of the original edition.
The change in the attitude towards possession and lunatism that occurred around 1800 is described by Marie Didier in her 2006 book Dans la nuit de Bicêtre. This period was a turning point in French, European, and psychiatric history. The author side-steps the well-known doctor Philippe Pinel of the well-known painting of liberating the insane of their chains – and focuses on one of his assistants, doctor Jean Baptiste Pussin, who started his career as one picked up from the streets and sent to l'Hôpital as one of the bons pauvres without rights. Hence, he may well have felt consideration for the inmates after he later became Gouverneur des fous de Bicêtre (and in the related womens hospital La Salpêtrière: Médecin des folles). In 1790 the strait-jacket was introduced in Bicêtre, another example of a more human approach – compared to iron chains fastened to the walls. Pussin has always been in the shadow of Pinel, and could have been forgotten entirely, but the archives of Bicêtre have kept him alive.
In this very same period (1797), the Bicêtre briefly had another inmate of low standing who became respectable and famous later in life. As a young man of about twenty-one years, leading a drifting life of theft and swindle, Vidocq entered the Bicêtre in chains, waiting to be transported to the forced labor prison in Brest, but after many escapes and adventures stepped over to the other side of the law. In his later life he became a successful policeman and detective who could easily disguise as a criminal in undercover capacity. In the Bicêtre, he had (according to his memoirs) the opportunity to learn the art of kick-boxing, which shows that prisoners must have had some freedom of movement.
In the nineteenth century the Bicêtre continued to have a mixed role as hospice, asylum, and prison. In the Salpêtrière the select patient population presented an ideal situation to develop a then new branch of medicine, and a school of neurologists originated whose names are still used almost daily in modern hospitals: Charcot, Lasègue, Duchenne, Babinski, Gilles de la Tourette.
It is a big step from there to the 1960ies, where the novel of Georges Simenon Les anneaux de Bicêtre is situated (The bells of Bicêtre). Or, is it? Even though Bicêtre is at that time a modern hospital with excellent neurologists, the main character looks during his recovery and rehabilitation out of the hospital window onto the court of Bicêtre, and sees there the permanent residents. They wear hospital clothes (suit like), spend time smoking, hardly speaking, seemingly having no contact with anyone. They are allowed to leave the compound at certain hours, but seldom do so. They are the modern bons pauvres, who “do not posses anything, have no relatives, no pension, and they are admitted to Bicêtre to save the society the awkward sight of homeless people dying in the streets.”
Yet, this was a vanishing world. In the 1950ies and 60ies, a series of modernization programs were undertaken, and the Bicêtre became a university hospital where princes and princesses and (former) presidents received treatment. In future, we will find out whether this modern hospital can gain a similar place in the literature as the old one.
Abbé de Prévost, Histoire du chevalier des Grieux et de Manon Lescaut. Amsterdam: 1731. English translation: Manon Lescaut (Oxford World Classics). New York: Oxford University Press, 2009. Both French and English texts available on www.gutenberg.org.
Gérard de Nerval, Biographie singulière, Raoul Spifame, seigneur des Granges, 1839. Second edition, 1852, titled: Le Roi de Bicêtre (XVIe siècle) Raoul Spifame. English translation in: De Nerval. Selected Writings. (Penguin Classics). London, etc.: Penguin, 1999; included under the title: The King of Bedlam; Raoul Spifame. French text available from fr.wikisource.org.
Marie Didier, Dans la nuit de Bicêtre, Paris: Gallimard, 2006.
Georges Simenon, Les anneaux de Bicêtre, Paris: Presses de la Cité, 1963. English translation: Bells of Bicêtre. San Diego: Harcourt Brace & World, 1964.
Further reading: the search engines on Internet and Wikipedia offer plenty of detail about the persons, books, and institutions mentioned in this Brief.
Jan Kardaun studied medicine and was trained in epidemiology and public health.