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Reflections on Asylum Archives and the Experience of Mental Illness in Paris

  • Patricia E. Prestwich
Couverture de                Volume 23, numéro 2, 2012, p. 1-343, Journal of the Canadian Historical Association

Corps de l’article

The archives of asylums and psychiatric hospitals are a rich, if demanding, source for both the history of mental illness and for larger issues in social and political history. As an historian of modern France, trained originally in social history and the history of mentalités, I have long been fascinated by how societies have coped with complex and seemingly insoluble problems. This interest first led me to study alcoholism in nineteenth and twentieth-century France, a period when wine producers assiduously developed the image of wine as a symbol of a characteristically French joie de vivre and when France led the world in both alcohol consumption and alcohol-related disorders. For the past 25 years, I have worked and continue to work on a variety of French archives related to the treatment of mental illness. These have included military hospital records on psychological trauma among French soldiers during World War I; a range of records of the first “open” psychiatric hospital in interwar Paris; and the registers of an exclusive private clinic for the treatment of “nervous” diseases. [1] Each archive has its own riches, requires its own structures of analysis, and has its own story to tell. But my formative and perhaps most extensive experience has been with the archives of a major Parisian public asylum, Sainte-Anne, which was opened in 1867 and today is a hospital for the treatment of psychiatric and neurological disorders. Historians in many fields have written of the pleasures of archival research [2] but they are — perhaps understandably — less forthcoming about the day-to-day challenges of what one historian of France has aptly described as “trawling” the “mountain of paper.” [3] The difficulties should not be underestimated, especially at a time of restricted funding for scholarly research. Nevertheless, the effort can be deeply rewarding, often in unexpected ways.

In France, the care and treatment of the mentally ill has constituted an important component of social policy, public order, and definitions of citizenship for over 200 years. During the French Revolution of 1789, access to publicly-funded health care was declared to be the right of all French citizens and one facet of universal republican values. [4] These newly-created “citizen-patients” included the mentally ill who, in both public discourse and medical theory, were now described not as mad but rather as suffering from a “mental alienation” that, with proper scientific care, might be successfully treated. Consequently, during the revolutionary and Napoleonic periods (1789–1815), important reforms were made in the care and treatment of institutionalized patients, most notably by the department of the Seine. In Paris, historian Dora B. Weiner has argued, these improvements were part of a larger plan for a “rational and cost-effective health care organization” for the department. [5] The reforms have been captured and mythologized in the famous painting by Tony Robert-Fleury of the physician Philippe Pinel releasing mental patients at the Salpêtrière hospital from their chains. Similar reforms were implemented in other facilities, most notably at Bicêtre and Charenton. The efforts of Pinel, Etienne Esquirol, and Pinel’s chief attendant Jean-Baptiste Pussin to reform medical theory and practice laid the basis for the international reputation of French psychiatric medicine in the first half of the nineteenth century.

Implementation of the rights of the mentally ill to state-funded health care over the following two centuries would be slow, inadequate, and often controversial. A significant step was taken in 1838, during the Orleanist monarchy (1830–1848), with the law of 30 June 1838, which required a public asylum to be established in each of France’s 86 departments. The asylum would be funded by the departmental council and its proper functioning would be the responsibility of the departmental prefect, the area’s most powerful public official and the representative of the central government. Under this law, care and treatment were free but were based on the forcible detention, or committal, of those certified as mentally ill. Patients lost all civil rights and could not leave the asylum until they were declared by a psychiatrist to be cured or sufficiently improved so as not to represent a danger to themselves or others. The law of 30 June 1838, therefore, sought to assure both public order and medical treatment of the poor, goals that were not easily reconcilable.

The law gave psychiatrists great power and potentially the opportunity for secure careers, but it transformed them into civil servants, or “psychiatric functionaries,” who were accountable to government officials for their actions and the effectiveness of their treatment. [6] Moreover, the law was based on the assurance by the nascent psychiatric profession that patients could be healed and restored to civil society if treated in closed asylums by medical specialists. Later in the nineteenth century, as governments invested more public funds in the treatment of the mentally ill, politicians expected psychiatrists and asylums to fulfill the promise of curing, not simply caring for, the mentally ill. In 1906, for example, Premier Georges Clemenceau, concerned about the inadequate care of patients in public asylums, bluntly reminded prefects of their paramount responsibilities toward these patients, who were often defenceless and not always viewed sympathetically by the public. In a pointed message to officials and psychiatrists, he declared: “The mentally ill are patients: a great number can be cured if they receive the proper medical treatment.” [7]

The great era of asylum-building in France came under the Third Republic (1870–1940), notably between 1880 and 1914, a period of political stability, growing economic prosperity, and increasing social protest. In Paris, Sainte-Anne had been opened in 1867 in the last years of the Second Empire (1851–1870); between 1880 and 1905, the department built five large asylums in the Paris region, as well as other care facilities. This expansion was in response to the persistent overcrowding of the existing asylums, a strong indication of public demand. The expansion of asylums fuelled an already-existing “anti-psychiatric” movement that had begun to emerge in the late 1860s and that would continue, with varying intensity, for the next hundred years. In the 1880s, the French political press found that criticism of the law of 1838 and of asylums could be a powerful political tool; it also sold a lot of newspapers. The press published testimony by former patients of unjust confinement and examples of brutality by asylum attendants. In law courts, families successfully sued asylum directors for mistreatment of patients. Asylums were decried as “modern Bastilles” and psychiatrists were described as civil servants who could never establish a successful career in private practice. As Dr. Paul Garnier noted glumly, the press labelled him and his colleagues as “panalienists,” men who saw the mad everywhere, “except in their own mirrors.” [8] Politicians took this campaign seriously and in the National Assembly proposals to reform the law of 1838 abounded.

Despite the fact that psychiatrists were the target of these attacks, by the 1890s a number of them had become advocates of reform. Adopting the rhetoric of their critics, they condemned French asylums as “prisons” or “leprosaria” rather than hospitals where the ill could be treated and cured. They drew on examples of more advanced treatment of the mentally ill in Europe, Great Britain, and the United States and called for “open” asylums. From the 1890s until the repeal of the law of 1838 in 1990, a number of important reforms were instituted, including psychiatric wards in general hospitals and, in 1922, the establishment of the Henri Rousselle hospital in Paris, an “open” facility where patients could be admitted without being interned. After the traumatic experiences of World War II, psychiatric institutions and treatment underwent a complex and comparatively rapid transformation that was characterized by an emphasis on treatment in the community. [9] These changes had begun before the development in the 1960s of another important anti-psychiatric movement, which was influenced by the works of the sociologist Robert Castel, the psychiatrist Gladys Swain, and the philosophers Marcel Gauchet and Michel Foucault.

This simplified and overly-tidy account of modern French attempts to cope with the problems of mental illness serves to suggest the historical importance of the subject and the wealth of available material. In the past 35 years, there has been a surge of scholarly publications on the history of French psychiatry, a significant portion written by psychiatrists with a passionate interest in the history of their profession. [10] Nevertheless, until recently, the study of individual asylums has not attracted much historical research despite the prominence of the asylum in debates about the treatment of mental illness. In 1987, the American historian of France Jan Goldstein acknowledged the brilliant analysis of authors such as Castel and Foucault, but argued that “work on the history of nineteenth-century French psychiatry has remained, in certain respects, insufficiently historical.” [11] Several years earlier, Marcel Jaeger, a French historian of health care, had offered harsher criticism. In a book entitled Le Désordre psychiatrique, he castigated what he described as a French tendency to view the history of mental illness either through the prism of crisis and horror stories, such as electric shock treatment, or through an ideology of “total” power and disciplinary institutions that turned practitioners, attendants, and patients into simple symbols of oppression or resistance. What was needed, Jaeger argued, was analysis of the “disorder” of the history of mental illness: its complexity, its contradictions, and the absence of any coherence in official policies. [12] In Britain, the United States, Canada, and elsewhere, social historians responded to Michel Foucault’s challenging analysis of the asylum and medical power by emphasizing the need for detailed research in asylum archives. The result was a series of studies of individual asylums, both public and private, that challenged generalizations and raised more questions. In France, there has not been a comparable range of institutional studies, although the situation is beginning to change. About ten years ago, for example, historians responded to charges of a “gentle (douce) extermination” of psychiatric patients during the Occupation and Vichy period (1940–1944) by an extensive examination of hospital archives that resulted in nuanced, carefully documented explanations of the causes of the admittedly high morality rates in wartime asylums. [13] Recently as well, French doctoral students have been encouraged to explore the records of departmental asylums.

My own scholarly encounter with the records of a nineteenth-century asylum was serendipitous and the result of many individual acts of kindness for which the traditional preface or footnote is an inadequate acknowledgement. Having completed a study of the anti-alcoholic movement in France, I was exploring the possibility of an article on the treatment of alcoholism in psychiatric facilities where, in the late nineteenth century, many alcoholics were committed. When I was making enquiries at the Public Assistance archives in Paris, an archivist suggested I contact the Sainte-Anne hospital. She immediately telephoned the hospital and put me in touch with the two people without whom this study would never have been possible: Dr. Jacques Postel, a psychiatrist and distinguished historian of French psychiatry, and Maurice Goudemand, an associate director of the hospital and later the founder of its museum and historical society. Both men welcomed me as a researcher and allowed me to examine some of the Livres de la loi, the large black ledgers that recorded the admission of each patient. The richness of these documents was immediately evident and I began what turned out to be a large-scale and lengthy study of the hospital from the time it admitted its first patient (diagnosed as an alcoholic) in 1867 to the outbreak of World War I. Previous research had given me some knowledge of nineteenth century psychiatric theories, but I had no training in hospital archives. In hindsight, such innocence was fortunate. With the support of Monsieur Goudemand, Dr. Postel, and the director of the hospital, I was given official permission to consult a variety of records, with the usual legal constraint that I not reveal in any way the identity of individual patients. [14] (French legislation protects medical records for 150 years and researchers who do receive special authorization [une dérogation] to consult the material are not allowed to use cameras or other means of reproduction.) The archival material was stored in the basements of the older buildings. I was handed a large ring of heavy, old-fashioned keys to the locked storage areas, as well as a white coat and a pair of latex gloves for protection. I worked at whatever desk was available in a variety of administrative offices.

Purely by chance, I had been given access to the vast records of one of the most important psychiatric facilities in France. When it was opened in 1867, Sainte-Anne was considered a model asylum, a symbol of the advances in French psychiatric medicine; of the state’s commitment to the health care of its poorer citizens; and of the modernity of Paris itself. It had been designed to treat 600 patients, 300 women and 300 men, in identical but separate facilities; within 20 years the wards housed over 900 patients. Today, in the centre of a modern medical complex, the original asylum remains, with its beautiful symmetrical buildings, covered walkways, and gardens. These nineteenth-century buildings, still in use, have been classified as a historic site, a decision that provoked controversy. In 1877, the teaching clinic for the Faculty of Medicine in Paris was established at Sainte-Anne, an important innovation to remedy the decidedly minimal knowledge of most doctors about psychiatric medicine. For French psychiatrists an appointment to Sainte-Anne symbolized the pinnacle of a medical career and it was there, in the Admissions Office, that the eminent nineteenth century psychiatrist Valentin Magnan made his career, trained a generation of psychiatrists, and promulgated his theories of degeneration [15]. The asylum was much visited by foreign physicians and dignitaries. By 1914, according to the reports of the Inspectors-General of asylums, only in Paris did conditions of care and treatment come even close to the expected norms. [16] The archives of Sainte-Anne, therefore, offered the opportunity to analyze the best type of care available to the mentally ill in a public institution in the late nineteenth and early twentieth century.

Being able to conduct my research at Sainte-Anne itself was an unanticipated but crucial component of the project. Psychiatrists dropped round to look at the old ledgers — whose diagnoses they recognized — and they assured me that they had more success treating patients in this park-like atmosphere than in high rise hospitals. Office personnel, who loaned me a spare desk for my work, helped me to decipher nineteenth century medical handwriting, talked to me about hospital procedures, and in some cases recounted the careers of their grandparents who had also worked at Sainte-Anne. The staff found material for me but they also discussed, with a certain frustration, the destruction of records, including the archives of the first school for psychiatric nurses in Paris, established at Sainte-Anne in 1882. The head gardener gave me a tour of the grounds and allowed me to read his archives as did the person in charge of the laundry. The staff at Sainte-Anne’s medical library welcomed me and gave me full access to their rich collection of nineteenth century books, journals, and printed administrative records. I worked exclusively in the administrative areas of the hospital and did not have any contact with patients, aside from the occasional greetings as they strolled about the gardens or lined up to buy a coffee or sandwich at the snack bar.

From these encounters, I began slowly to gain some understanding of the workings of a psychiatric hospital and of medical perspectives on illness and treatment. Even though I was trying to reconstruct the hospital of a century before — a very different world — these insights were invaluable. Retired nurses, who had come to Sainte-Anne in the 1960s when it was still a closed hospital and patients were strapped spread-eagled to their beds, explained me to how they dealt with violence and how they restrained patients with respect. They helped me to understand in very concrete ways that those suffering from psychiatric disorders are, as they often said, “like any other patients.” I also listened as hospital staff expressed their concerns about under-funding, short-staffing, and administrative reorganizations that threatened to reduce the quality of care. Their reactions gave me a deeper perspective on nineteenth century attempts to reform the asylum while dealing with limited funding and bureaucratic red tape. I began to understand why some French historians of psychiatry and particularly of psychiatric nursing are tempted to characterize their history as a story of repeatedly thwarted initiatives. But most of all, the experience convinced me of the importance of an interdisciplinary approach to the history of medicine. Ideally and in hindsight, I would have worked with a team that included a psychiatric nurse and psychiatrist. I did, however, take every opportunity to present my research to medical audiences in France and in Canada.

Working in the hospital itself, I had access to a wider and more varied range of archival materials than would normally be found in official departmental archives. The wealth of material encouraged my hopes of being able to portray in detail the experiences of ordinary patients. As with many of my colleagues, I have been inspired by a social history that has focused on the lives of ordinary people, as well as by the work of the late Roy Porter who enjoined scholars to understand medical history from the patient’s point of view. [17] Moreover, having taught and done research in women’s history, I was aware of the importance of gender as a tool of historical analysis [18] and of the many debates about women and “madness” among feminist scholars. Because Sainte-Anne treated both men and women, its records provided an important male “control group” to assess assertions about women and psychiatry in the nineteenth century. Nevertheless, it is often difficult to find the patient in asylum archives — or in those of other institutions. As the French historian Arlette Farge has written eloquently of archives on the working poor of Paris in the eighteenth century, any institutional archives — whether judicial, educational, or medical — provide only a fragmented view of historical actors and usually only at that moment when they come in contact with the institution. [19] It is often a refracted glimpse, seen, in the case of asylum archives, through the testimony of physicians, attendants, the police, or the patient’s family, who might have taken the decision to intern their relative against his or her will. Often, all the records will reveal is a momentary glimpse at the time of entry, when the patient’s vital particulars were recorded in the Livres de la loi. After that, the patient may disappear from the archives and, as I frequently found, the only trace was an empty file with a name or a sheet with the occasional brief notation: “same condition.”

Such problems are found in many institutional records, but in asylum records they are complicated by the nature of mental illness itself, which in certain of its many manifestations may render the sufferer incapable of describing her or his pain. Mental conditions are sometimes fleeting, sometimes chronic, often partial, and may evolve in unpredictable ways. The appearance of patients in asylum records is frequently an indication of a crisis and represents only one moment in a continuum that could range from an incapacitating mental illness to mental health. Therefore although these women and men were committed to the closed asylum of Sainte-Anne because of what was diagnosed as a mental disorder, it was important for me, in drawing any conclusions, to remember that they may well have lived and functioned reasonably well with these problems for long periods of time — or in certain cases may not have seen them as problems. Nor does their illness define them as human beings.

Because it is so difficult to glimpse these ordinary patients and to understand their experiences, it proved necessary to read as much archival material as possible, beginning with the fundamental document for all hospital studies, the admissions records. These legal registers were essential in order to answer basic questions: who was committed, why, and what happened to them. The documents were particularly informative because they gave three entry diagnoses, established in the first two weeks of internment. They also recorded whether the patient was committed by the police or by the family, an important legal distinction that gave the family certain rights, particularly in terms of discharge of the patient. Often the registers contained brief notations on the circumstances of committal and they sometimes recorded statements from the patient or family. To be useful, the material had to be coded and analyzed statistically. This quantitative analysis was essential because at the time there were no comparable studies of asylums that could give me the basic information contained in these registers. In later research on Sainte-Anne during the interwar years, I applied the methodology much more sparingly, simply to check whether patterns of admission, diagnosis, and release had changed. I was already aware of the benefits of quantitative analysis, having read the results in a number of works on the social and economic history of eighteenth and nineteenth century France. I also realized that the results would have to be used judiciously, to enhance rather than obscure the experiences of a wide variety of patients. Knowing a methodology in theory is quite different from making the detailed decisions on how it will be applied, but, fortunately, the coding categories were relatively straightforward, given the standardized admission form. Although French psychiatrists of the period were obsessed with classifying mental disorders in minute detail, diagnoses on the entry certificates were fairly basic and could be grouped into standard categories, such as mania, depression, alcoholism, dementia, etc. I read and coded all the entries for every second year from 1867 to 1913 and ended with a data base of about 13,000 individual records. I may have been somewhat overzealous in my sampling, but I do not regret it. While many entries contained only the basic material, others were rivetingly informative. I was very fortunate to find a computer analyst at my university with an interest in history who saw the project as an intriguing challenge. [20] Although at times I risked being swamped by computer printouts, I consoled myself that they were, in a curious way, a useful reminder of the ever-growing demand for care and of the overcrowding that threatened to overwhelm physicians and attendants.

The statistical analysis was an essential step that served not simply to refine the questions I was already asking but, more importantly, to reveal new issues. It confirmed my assumption that most patients were working or lower middle class Parisians, not vagabonds or marginalized people. Because of a range of excellent scholarship on the working classes of modern France, these people were familiar to me. Working class Parisians were ambitious, hard-working, politically aware, often politically active in strikes and revolts, and used to dealing with bureaucracies, including that of the growing French welfare state. Yet their powers were limited, and both women and men depended on their ability to work. Disease, infirmity, and, in the case of women, pregnancy made them vulnerable. My research became in part an exploration of this admittedly unequal encounter between a bureaucratic medical facility and ordinary Parisians whose normal survival skills might have been blunted or erased by illness. This encounter did not end with their admission to Sainte-Anne. Because the quantitative analysis revealed that over 40 percent of patients were released, many within a year of admission, understanding how Parisians were able to leave the asylum became an equally important goal. [21]

The statistical analysis underlined the importance of diagnosis in following the journey of patients through the asylum. It gave me a picture of the ordinary mental problems that brought people to Sainte-Anne, not the “interesting” cases with their complicated classifications and extensive detail that psychiatrists discussed in their professional meetings and their journals. The entry diagnoses — taken on the quick, often with little information and in chaotic circumstances — provide a glimpse of mental suffering that is recognizable today. Although women and men were admitted to Sainte-Anne in roughly equal numbers, there were clear gender differences in the diagnoses. A large number of male patients were diagnosed with alcoholism in its various forms or with general paralysis of the insane, the third and terminal stage of syphilis. Among women, there were numerous cases of depression and the diseases associated with old age, not all of them psychiatric. Diagnoses of mania and manic-depressive disorders were found among both women and men. When I compared these conditions among patients at Sainte-Anne with the research preoccupations of French psychiatrists, as seen in their medical journals, it became evident that many of these patients were not “interesting” in a clinical sense. For example, although about one-third of male patients were diagnosed as suffering from alcoholic disorders, most psychiatrists did not consider them “genuine” psychiatric patients and, with rare exceptions, there was little interest in establishing specialized sections to treat them. [22] Similarly, patients with general paralysis attracted little scientific attention until shortly before World War I when the Wassermann test was developed to diagnose the condition. The diseases of old age, both physical and mental, attracted little clinical interest nor did depression, although in this latter case part of the explanation may be that the standard asylum treatments of rest and good food proved reasonably effective. At a time when Parisian psychiatrists were arguing that the asylum was a centre of treatment, this contrast between uninteresting and interesting conditions raised important questions about how treatment was defined and for whom, questions that proved difficult to answer.

As I began to think about the vulnerability of patients, the computer analysis alerted me to the importance of tracing the role of the family not simply in committal, but also in care and eventual release. [23] Under French law, most patients were committed by the police, but there was a so-called “voluntary” procedure by which a family could commit a relative and this type of committal, which increased during the period, was regularly recorded in the registers. (The patient, of course, continued to have no say in the decision.) The relationship between psychiatrists and families was complex and ambivalent, but the power of families to intervene was absolute in one particular area, the area of most interest to the patient, namely release. A family could remove its relative from the asylum, even if the physician was opposed to discharge. Clearly, families had their own definitions of illness and standards for treatment, and these did not always coincide with medical views or practices. The family influence was probably exercised more widely than the statistical analysis indicated. By reading the informal notations on the registers, as well as patient files, I was able to conclude that poorer families (who could not pay the fees necessary for a “voluntary” committal) circumvented the problem by bringing relatives, often by force, to the police station or to the asylum. This information raised the question of how much families could or would intervene within the asylum to assure the proper care of relatives or to decide whether they should be released. Both the patient files and printed materials provided good evidence of family strategies in dealing with psychiatrists and asylum employees. Moreover, because in many cases families did not hesitate to give psychiatrists their own diagnosis of the patient’s condition and their recommendations for treatment, the presence of families provided rich anecdotal evidence of popular definitions of mental health and illness.

Finally, quantitative analysis alerted me to the importance of the asylum as a bureaucracy and the way in which Sainte-Anne was able to retain its primacy as a specialized psychiatric centre by transferring large numbers of patients to other facilities. Over 20 percent of those who entered Sainte-Anne were transferred elsewhere, at first only to provincial asylums, but very quickly to a growing network of five new public asylums and other specialized facilities. These transfers were the result of the popular pressure for asylum care that quickly overwhelmed existing facilities. The patients who were transferred tended to be the chronic, the elderly, the mentally challenged or those without family. This choice of patients reflected a growing psychiatric desire to treat only patients who could be cured. It also improved the asylum’s discharge rate, a statistic that would be carefully scrutinized by departmental administrators and politicians. The many patients who were transferred are lost to the historian’s view. Possibly they received better treatment in other facilities, but, tragically, they were often removed from the sight and care of their working class families, who found it much more difficult to make the trip to the suburbs or farther.

The admission registers, important as they were, offered no insights into the care and treatment of patients. Historians of medicine have usually relied on ward books or patients’ medical files for such information. [24] At Sainte-Anne, the ward books apparently no longer exist but this is definitely not the case for patient medical records. Admirably, the administration of Sainte-Anne has meticulously preserved the files of every patient who entered from 1867 until the present. They are carefully filed and stored, on shelves from floor to ceiling, in a series of basement rooms. The sight of these seemingly endless rows of documents overwhelmed me: only a team of researchers with extensive funding could do them justice. I tried several sampling techniques, selecting the files of patients who, from the registers, looked interesting to me. The process was cumbersome, time-consuming, and not very productive. Frequently, the files of my initially “interesting” cases contained no further material. (And I was well aware of the irony that, like the nineteenth century physicians, I too was seeking interesting cases.) Fortunately, physicians and administrators came to my aid again, and I was able to consult a range of patient files that had been retained in various medical and administrative services. These included files from Magnan’s admission service and the teaching clinic of the Faculty of Medicine, as well as files of patients who had died at Sainte-Anne. The records of the teaching clinic contained important examples of the “interrogatoire,” the initial and essential encounter between treating physician and patient. These documents gave me some idea of how psychiatrists were trained to interview patients and how some patients responded. Yet there was almost no evidence of such extensive examinations in the files of other services. Many medical files contained correspondence from family or friends, and the records of patients who died revealed the sad but sometimes evocative inventories of the patient’s personal effects. Rarely was there much information on treatment. Occasionally, there was mention of a patient being placed in a straightjacket or cell but not of a patient being given calming drugs or baths. At best, there were brief observations of the patient’s condition, but far too often they consisted of a long series of dates follow by the simple phrase, “same state.”

The number of empty files was at first discouraging. I did not keep track of their extent, but would judge that for every interesting file, I examined five or six that contained no information beyond the basic facts recorded in the admission registers. In reviewing my research notes, I discovered that I had often written “BORING!!” or “FRUSTRATING!!” in the margins. Postmodern theory enjoins us to listen to the silences, but for a researcher with limited time in the archives, the silences can be trying. However, in retrospect and after further research, I have concluded that the extent of these empty files had two effects. First, I became extremely cautious in drawing any conclusions about the patient’s care. In this period, asylum attendants were often not skilled in writing. Simply because observations were not noted in a patient’s file does not mean that attendants were not caring for that patient. A number of these files did record that the patient left the asylum either cured or in better health. It is also possible that the information was kept on other forms that have since disappeared from the files. However, the lack of evidence about individual treatment does suggest that even if psychiatrists were talking about scientific research and individual treatment by the turn of the twentieth century, in reality they still relied on the asylum itself — this world apart, with its discipline, regular routines, calm, and therapeutic labour — to heal the tormented mind. Second, these files led me to reflect further on the problem of silence in mental illnesses. Often, mental pain is more difficult to diagnose than physical pain and for sufferers it is sometimes impossible to describe. Again and again patients fell back on popular clichés to portray their suffering, such as speaking of “black thoughts” to convey their depression. When I was doing the original research, I was naturally drawn to those records where the patient’s narrative was recorded. Later I began to pay more attention to the many files where it was simply noted that the “patient refuses to speak.” In some cases it was clear that the illness itself silenced the patient, but in other records silence was quite possibly an understandable response to the crisis of internment or the powers of the physician. It is difficult to write about silences. I note their presence but have yet to find a way to convey their weight.

Some of the most useful material on the daily life of patients came from administrative files, particularly the personnel records of asylum staff. Asylum attendants lived with the patients and provided both their daily care and their most regular human contact. Yet the personnel records are administrative documents that reflect the administration’s concern with order and discipline. They do provide a glimpse into relations between patients and attendants, but only when things went wrong. Typically, they recorded accusations — occasionally by patients themselves — of attendants’ poor service, neglect, abuse of patients, or simply their breach of the asylum’s many regulations. Usually, the only indication that these underpaid and overworked attendants might have been doing their work well was the notation that the attendant was “kind.” This was the highest praise that psychiatrists or administrators could bestow. “Kindness to patients” was a quality that led to increased wages, promotion, or even civic medals. But, as is frequently the case in the nursing professions, the small and often intimate acts that led to the assessment are unrecorded. Occasionally, and to my delight, these administrative records revealed some patients as ordinary human beings who had a sense of their rights as patients and who, on occasion, vociferously and effectively protested their conditions of care. Not surprisingly — we are talking about France — such protests often focused on the asylum’s food: its poor quality, unappetizing presentation, and unequal distribution. What has struck me most in this attempt to understand the care that patients might have received at Sainte-Anne is its haphazard nature. A patient committed to the asylum in these years might very well have received good treatment by a dedicated psychiatrist and sympathetic attendants. He or she might have left the asylum if not cured at least improved. Equally, a patient might have received treatment more characteristic of a bad novel or the accusations of abuse that were regularly published in the daily newspapers of the time.

Archival records may never convey the anguish caused by mental illnesses, but they can offer eloquent evidence about the treatment of chronic illness, the care of the elderly, the importance of family and community in health care, and the achievements and limitations of medical science. They also give tantalizing glimpses of a less researched but equally important concern, the maintenance of mental health. But, as the example of France suggests, these issues need to be understood within wider political, economic, and social frameworks. For example, from the late nineteenth century, French social welfare policies were strongly influenced by fears of depopulation and therefore favoured younger working class women and families. These policies were in many ways successful and, it has been argued, offered women a social citizenship long before they achieved political rights. [25] The history of the care of the mentally ill provides other perspectives on the formation of the French welfare state. Mental patients were also seen as a responsibility of the state, but were treated less generously and perhaps less sympathetically. Crucially, their rights as citizens were, for far too long, abrogated by their illnesses. Moreover, if French citizens in theory had the right to publicly-funded care, they or their families often had to struggle to make those rights a reality in the face of inadequate and often unsuitable facilities. The law of 30 June 1838 was also designed to maintain public order and, significantly, under this law the committal process began at the local police station. In reality, however, the maintenance of public order often began earlier, in crowded buildings where families or neighbours were confronted with the disruptions that mental illness could bring. There is a wealth of possibilities for exploring these issues, particularly in archives of the more modern facilities, such as “open” hospitals or the mental health units that, in the post-1945 era, were established in the community. But we need to hurry. Public archives are underfunded and hospitals are always desperate for space. Moreover the adoption of computer records in hospitals raises further problems of access and preservation. There will always be skilled historians prepared to tackle the “mountain of paper” or equivalent computer files. The greater challenge will be to convince beleaguered granting agencies of the importance of this research.

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