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A Clinical Lesson at the Salpêtrière

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A Clinical Lesson at the Salpêtrière ART AND IMAGES IN PSYCHIATRY SECTION EDITOR: JAMES C. HARRIS, MD A Clinical Lesson at the Salpêtrière Hysteria has its laws, its determination, precisely like a nervous ailment with a material lesion. Its anatomical lesion still eludes our means of investigation... Jean-Martin Charcot, 18901(p77),2(p208) N JUNE 1870, JEAN-MARTIN CHARCOT (1825- teria and used it, not so much for therapy, but to inves- 1893) delivered his first lecture on hysteria, a tigate the physiological processes underlying hysteria. lesson on hysterical contractures, at the Because Charcot was a renowned professor of neuropa- Salpêtrière in Paris, France.2 His lecture empha- thy before beginning his work with hysteria, his interest sized a scientific approach to hysteria and fo- in this disorder was taken seriously by other physicians. Icused on not only the physical features but also the psy- Combining histology with a mastery of the anatomical- chological aspects. Thus, he expressed doubt about reports clinical method, he had associated locomotor ataxia with of miraculous religious cures and likened them to the sud- lesions of the posterior spinal roots and columns, linked den recovery of hysterical patients. Charcot was influ- acute and chronic progressive muscular atrophy with le- enced by the work of Pierre Briquet (1776-1881),3,4 who sions of the anterior horn cells, and separated multiple scle- in 1859, based on clinical assessments, published a sys- rosis from Parkinson disease. He was best known for his tematic epidemiologic study describing 430 cases of hys- studies of amyotrophic lateral sclerosis, known then and teria seen over a 10-year period. Briquet considered “hys- now in Europe as Charcot disease. teria as the product of suffering of the part of the brain In 1878, he opened his neurological case demonstra- destined to receive affective impressions and feel- tions to an audience of physicians, artists, politicians, and ings,”4(p60) suggested a role for heredity, proposed a pre- other interested members of the community. His research disposing temperament, and identified male cases but and case demonstrations attracted many prominent phy- noted that they were far less common than female cases. sicians in France, Europe, and America, including Adolf The previous July, Charcot attended the British Medical Meyer and James Jackson Putnam, Russell Reynolds and Society meeting in Leeds, England, where Russell Rey- prominent members of the British Medical Society from nolds delivered a paper that had intrigued him, “Paraly- England, and Sigmund Freud from Austria. (Freud devel- sis, and other disorders of motion and sensation, depen- oped an avid interest in these cases, translated Charcot’s dent on idea.”5 Reynolds wrote “that some of the most work into German, spoke often of his 19 weeks’ visit to serious disorders of the nervous system, such as paraly- Paris, named one of his sons after Charcot, and recognized sis, spasm, pain, and otherwise altered sensations, may the pivotal role that Charcot played in his later work.) Char- depend upon a morbid condition of emotion, of idea and cot’s studies on hysteria were carried out during the Third emotion, or of idea alone...they sometimes associate French Republic. This era (1870-1914), known as La Belle themselves with distinct and definite diseases of the ner- Époque (the beautiful times), supported progress in sci- vous centres, so that it becomes very important to know ence and creativity in art. It was an optimal historical mo- how much a given case is due to an organic lesion, and ment for Charcot’s interests to flourish. how much to morbid ideation.”5(p483) Charcot’s focus on hysteria came about fortuitously Charcot extended these earlier proposals about hys- and unexpectedly. An administrative decision in 1870 re- teria in his subsequent research; he confirmed the pres- sulted in the transfer of care of a group of patients with ence of male hysteria, identified early traumatic experi- epilepsy and hysteria, not thought to be insane, to Char- ences as triggers, and proposed that hysteria was a dynamic cot’s medical ward. The closure of a psychiatric ward in disorder of the nervous system without a clearly identi- the condemned Saint Laure building brought him into fiable anatomy. Unable to identify a specific anatomical contact with these patients; cases thought to be insane site, he sought to document the clinical features. He was had been transferred to another psychiatric unit. The de- skilled in drawing himself, and his hysteria studies led cision was necessitated by the 1838 law that defined con- him to pioneer the use of photography in neurology. In ditions of hospitalization for mental illness and led to the 1876 and 1877, 3 volumes (Iconographie photographique separation of the sane from the insane on hospital units. de la Salpêtrière)1 edited by Désiré-Magloire Bourneville Charcot said it was this event, the transfer of “a service (1840-1909) provided case histories and photographs to of nearly 150 beds where we can study all forms of epi- illustrate the characteristic syndromic features.1 Char- lepsy and severe hysteria,”2(p180) that led him to shift his cot described 4 stages of a hysterical seizure, the epilep- focus to these interesting clinical problems. That shift of toid (tonic seizures often preceded by an aura), contor- interest was encouraged by Bourneville (known for de- tions and acrobatic postures (arc-in-circle, or arching the scribing tuberous sclerosis complex), who had previ- back into a semicircle), emotional gestures and verbal- ously interned with Charcot, been assigned to the epilepsy/ ization, and final delirium. Moreover, he suggested that hysteria ward, and moved back with the patients under hypnosis was an experimental technique to study hys- his care from the old ward to the new one. He stimu- (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 62, MAY 2005 WWW.ARCHGENPSYCHIATRY.COM 470 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 lated Charcot’s interest in hysteria and provided an op- her left arm and hand held in a rigid, contorted posture portunity for Charcot to write about it in his weekly medi- (thumbnail). Opposite her is an 1878 painting by medi- cal journal, Progrès Médical. Charcot was also joined in cal artist Paul Richer (1849-1933) of a woman convuls- the study of these patients by Joseph Babinski (1857- ing, assuming the arc-in-circle posture. Written on the 1933), who was his chief house officer in the late 1880s. corner of the Richer painting are the words periode de con- Witnessing the frequency of seizures in patients with hys- tortions(duringthecontortions).BabinskisupportsBlanche; teria, Charcot proposed the diagnostic term hystero- the female clinic supervisor (Marguerite Bottard) extends epilepsy. Gradually he realized, in dialogue with Babin- her arms toward her and she and a younger nurse (Mlle ski and others, that individuals with hysteria were Ecary) look on in anticipation of her falling onto the bed assuming the postures of other patients with epilepsy on and demonstrating the final stages of a hysterical attack. the unit and realized that separating them from patients Charcot assumes an authoritative attitude and gestures with epilepsy was essential. After Charcot’s death, Bab- as he engages the audience. Sixteen of his current and former inski aggressively rejected his teacher’s views on hyste- physician associates encircle him in the front rows, facing ria.2 He developed neurological methods to distinguish him in reverse order of seniority. The older generation is hysteria from epilepsy, especially his extensor toe sign, near the back of the portrait along with philosophers, writ- which he felt absolutely differentiated them.6 ers, and friends of Charcot. Opposite Charcot, Georges Gilles On Tuesday each week Charcot saw consultations, and de la Tourette, wearing a white apron, leans toward him. on Fridays he offered formal lectures and conferences. At Bourneville is shown near the center of the room. On the his case conference, he would replicate hysterical symp- table beside Charcot, on his right, are a reflex hammer and toms under hypnosis, shift them around the body, and in- what is thought to be a Duchenne electrotherapy appara- duce artificial equivalents of the 4-stage attack (grande hys- tus. Richer, pen in hand, carefully draws Blanche Witt- térie). Pierre Andre Brouillet (1857-1914) immortalized man’s body contortions. Others in the painting include Léon 2,7,8 1 such demonstration in 1887. Brouillet was a genre le Bas, the hospital administrator; Jean-Baptiste Charcot, artist of the Belle Époque period and a student of Jean-Léon his son, then a medical student; Jules Claretie, journalist, 8 Gérôme (1824-1904). He produced history paintings, por- author of an 1881 novel about hysteria (Les Amours d’ un traits, or group portraiture canvases in the academic tra- Interne), and administrator of the Comedie Francais; and dition as opposed to the avant-garde impressionism of his Pierre Marie, who subsequently assumed the Charcot chair. day. His Charcot lesson attracted favorable notice in re- Outside the window, one looks onto buildings where older views of the salon d’art of 1887 where it was first displayed; it was later sold to the Academy Beaux-Arts for 3000 francs. AlithographicreproductionbyLouisEu- DEBOVE BALLET BERBEZ JOFFROY BABINSKI ECARY gene Pirodon (1824-1908) was popular; CORNIL BURTY DUVAL CHARCOT BRISSAUD MARIE CHARCOT BOTTARD Freud hung one in his offices in Vienna and above his analytic couch when FÉRÉ RICHER WITTMAN he moved to London. There were also newspaper versions of the painting. Charcot’s demonstrations drew such GOMBAULT CLARETIE widespread public attention that they RIBOT ARÈNE NAQUET were held in an auditorium with benches GUIGNON BOURNEVILLE PARINAUD to seat 400. They were attended by medi- VIGOUROUX calstaffandotherinterestedpersons.The backdrop to the platform in the audito- LE BAS GILLES rium where Charcot stood was the 1878 LONDE Tony Robert-Fleury (1837-1911) paint- H BERBEZ DE LA TOURETTE ing, Pinel Delivering the Insane,9 which shows Pinel freeing the women from chains; 1 woman lies on the ground in the midst of a convulsion.
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