• In Search of Hysteria: The Man Who Thought He Could Define Madness

    On Jean-Martin Charcot, Dark Star of 19th-Century Neurology

    Jean-Martin Charcot, a man ruled by habit, passed through the gates of the Salpêtrière in a coach at exactly the same time every morning. At the end of the day, he departed, also as if by clockwork. The days and weeks and months unfolded according to an unwavering schedule—lectures on Tuesdays, demonstrations on Fridays, outpatient clinics, inpatient visits, meetings, conferences, private time for writing—everything hinged on the comings and goings of the Master. His schedule was rounded out by soirees on Tuesdays held at his impressive art-filled home on the Boulevard Saint-Germain. Writers, artists, politicians, and physicians attended the salon-style evenings. Eventually even young Sigmund Freud, a perpetually miserable and down-at-the-heels student, would be invited.

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    Despite his charismatic reputation, J.M. Charcot was taciturn, slow of movement and gesture, and almost silent during clinical exams. His students would wait patiently for his pronouncements, usually to be disappointed. Freud idolized Charcot, but found him to be difficult, somewhat remote and inscrutable, his methods opaque. He either could not or would not say how he reached his conclusions, merely that after observing something long enough the nature of it would become clear. According to Pierre Marie (sitting third to Charcot’s right in Andre Brouillet’s painting, above): “More than once his closest pupils heard him answer to their ‘Why?’ or to their ‘How?’ sometimes impatiently, because of his inability to better satisfy them: ‘Oh, why? I cannot tell you, but I know it is this disease, I can sense it.’”

    He was not a natural orator. Each week Charcot gave carefully prepared lectures, memorized in full and delivered with faultless diction but almost no theatricality or bravado. He was deliberate, highly organized, and obsessed with classification and description. This obsession extended to his uncanny ability to mimic almost any disorder of speech, posture, tremor, or gait. His entire research enterprise came to revolve around the idea of re-creation. As another assistant, Pierre Janet, recalled, “Everything in his lectures was designed to attract attention and to capture the audience by means of visual and auditory impressions.”

    Charcot hired the artist-physician Paul Richer (first on his right in the painting, with a pencil and paper) to reproduce the poses of afflicted patients. Charcot also built a photography studio on the premises and hired the medical photographer Albert Londe (seated on the far left of the painting, wearing an apron and cap) to document exemplary cases. The resulting publication, in three volumes, the Iconographie Photographique de la Salpêtrière, may have greater claims to art than to science, but it was a major breakthrough in the classification and understanding of mental illness.

    It is not entirely clear whether the man who inspired the loyalty of students and gratitude of patients was in fact cold and aloof. But the man portrayed in Brouillet’s A Clinical Lesson appears to be more concerned with symptoms than with people, as his reputation would suggest. Charcot is the only man in the painting who is facing away from the patient, the only one who seems more interested in what he is saying than in what is happening behind him. His assistant Joseph Babinski, with his matinee-idol looks, stands center stage, ready to catch the swooning Blanche. Georges Gilles de la Tourette, an odd-looking duck by his own admission, is mercifully rendered in profile. Gilles’s look-alike, Charles Féré, who had just completed an exhaustive study of animal magnetism, sits in rapt attention by the window. Charcot’s son Jean-Baptiste, then a medical student, stands at the rear.

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    Then there is Charcot himself. He stands with his right hand extended in an odd gesture, probably drawn from life, of thumb and forefinger held out as if indicating a measurement of a few centimeters. According to a contemporary, Félix Platel, “There is something mystical in his gaze, astonishing in a materialist. His gaze is oblique—which is surprising in a mask of Bonaparte. The Roman nose is solid and well defined. It is like the tip of the prow of a Roman galley, destined to cleave the waves, despite wind and tide.” It could also be the gaze of a man beginning to doubt what he is saying.

    In the decade of his astounding series of discoveries in neurology, Charcot had become well known in scientific circles, but not beyond. This would change. His decision to tackle hysteria, to lend his considerable reputation to it, brought his fame to another level. He was taking on not just one of the biggest unanswered questions in medicine, but perhaps one of the most intriguing and unsettling aspects of human existence: What makes us who we are, and what can cause us to forget who we are?

    Where others saw feigning, malingering, or attention getting, Charcot insisted he discovered a true disease, hysteria.

    Today, epilepsy has a set of diagnostic criteria backed by the technology of electroencephalograms, yet hysteria has only a generic and vague profile. In 1870, hysteria drove diagnosticians to distraction. One physician called it a “mockingbird of nosology” because of its tendency to run the gamut from migraine to paralysis, numbness, fainting, sweats, difficulty in breathing, insomnia, and even nymphomania. No one could say whether it was real or imagined, structural or functional, all in the head or lurking in damaged tissue. Charcot decided to find out. At the end of a decade-long investigation involving scores of patients, he was ready to publish.

    In a report of 1878, he rejected the idea of a purely psychological basis for all forms of hysteria. Even though he could not find any anatomical basis for his conclusions, he isolated an extreme form of hysteria as a “physiological disturbance,” or a névrose: a general affliction of the nervous system. Not only was it a true disease, he said, but hysterical attacks had a classic identifying profile consisting of four distinct phases.

    In phase one, the so-called tonic phase, the subject exhibits all the signs of a grand mal epileptic seizure: muscle spasms and jerks, then muscle contractures, eyes rolled upward, rapid breathing, and possibly the loss of consciousness. Phase two, the clonic phase, brought on contortions and postures, culminating in a backward arcing of the entire body, with only the feet and head touching the ground. This is the arc-en-circle depicted by Paul Richer in the diagram mounted on the easel behind the last row of viewers in A Clinical Lesson.

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    The third phase consisted of a series of “attitudes passionnelles,” essentially a range of highly charged emotional states, including ecstasy and even religious rapture, bracketed by sexually suggestive poses. In the final phase, the subject drifted into a languid, sleepy delirium. The phases occurred spontaneously. They were not induced. They could be observed on the ward.

    The contractures of the tonic-clonic phases were difficult to distinguish from real epileptic seizures, but Charcot accomplished this by measuring subtle differences in heart rate, body temperature, and other clinical features. Once he had isolated it, he called it la grande hystérie, or grand hysteria. Where others saw feigning, malingering, or attention getting, Charcot insisted he discovered a true disease, one with distinct and recognizable stages. He then set out to see whether he could produce them on command.

    Charcot introduced hypnosis in 1878, a year after Blanche’s arrival at the Salpêtrière. His peers were mystified. Charcot seemed to be reviving mesmerism. Bad enough that he had elevated a low-priority condition to the status of a disease. Now he wanted to resurrect a discredited technique invented by a crackpot and adopt it as a clinical tool. Only Charcot could have gotten away with it, and he did, with the instrumental help of Blanche Wittman.

    Up to that point, Blanche’s behavior had been intolerable and uncontrollable. Charcot’s assistants diagnosed her with epilepsy, then with hystero-epilepsy, then with grand hysteria. To relieve her convulsions, they tried ovarian compression in the belief that the ovaries were hysterogenic zones. That didn’t work. They tried occupational therapy. She improved. Then they tried hypnotism. Whether it was a survival skill, or due to some sly coaching behind Charcot’s back, Blanche emerged as the ideal hypnotic subject. She became cooperative and responsive, and while under hypnosis could reliably recapitulate the stages of what Charcot decided to call “artificial hysteria.”

    At the Salpêtrière, artificial hysteria—hysteria induced by hypnosis, as opposed to natural hysteria—unfolded in three distinct acts. Brouillet’s painting depicts the opening of Act One, the onset of catalepsy, or the maintenance of unnatural  postures. Charcot’s assistant Joseph Babinski, the man supporting Blanche, has just put her into a hypnotic trance, possibly with a gong. Her left fist is clenched and bent into an awkward state of contracture, indicating that she is not merely swooning. In this stage, Babinski will arrange her limbs in various poses, and Blanche will hold those postures indefinitely. She will also become impervious to pain, to the extent that a needle can and will be passed through her arm or hand, eliciting no reaction. In the second stage, lethargy, her body will become limp and fall as though lifeless until Babinski induces muscle contractures, rendering her rigid, as though in a state of rigor mortis.

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    When posed, Blanche could maintain awkward positions well beyond the ability of a skilled acrobat. The demonstration will reach a climax in the final stage, called somnambulism. This is what the audiences came to see. In a state of extreme suggestibility, Blanche will be induced to act out scenes requiring a full gamut of emotions. She might be told she is being threatened by a dog or a snake, and she will cower, or that she is a general marshaling her troops on the front line of a battle, and she will bark commands. In one demonstration, she was asked to kiss the plaster bust of Franz Joseph Gall, the inventor of phrenology. Upon awakening, she will have no memory of these playacted scenarios and will deny having done them. Yet she will retain some unconscious memories. In one instance, under hypnosis, she was shown a picture of a donkey and told it was a nude photo of her. It shocked her so much that she later smashed the picture when she came across it, even though she professed to have no memory of the hypnotic suggestion.

    Charcot believed he could separate mind and brain by treating the human subject as an automaton.

    The crowd appeal of these demonstrations is obvious—they played heavily upon sexual innuendo. Similar demonstrations took place all over Paris in music halls, advertised as hypnotism “à la Charcot.” Some former patients of the Salpêtrière starred in these shows, borrowing heavily from Blanche’s performances. Medical men decried the lay practitioners as irresponsible and dangerous, but it was a case of the pot and the kettle. Charcot wanted to show the extent of a subject’s malleability under hypnosis, but more than that, he claimed to be demonstrating genuine medical pathology.

    Not only was hysteria a disease of the body, but so was the susceptibility to hypnotic suggestion. In other words, according to Charcot, only true hysterics could attain the postures and maintain the poses of artificial hysteria. These could not be faked, so they had to be a pathological sign connected to real hysteria, even diagnostic of it. He called it le grand hypnotisme.

    In 1882, Charcot presented this theory to the French Academy of Sciences as part of his bid for membership. The academy had already accepted his claim for the status of hysteria as a true disease on the strength of his reputation, although without much enthusiasm. They also signed off on his description of grand hypnotism, despite widespread skepticism. The idea had almost no support outside of Paris. According to Charcot’s critics, his four stages of hysteria and three-act demonstrations of hypnosis could be observed only at the Salpêtrière, or in patients who had lived there and had learned the choreography. Moreover, as Hippolyte Bernheim of the Nancy School argued, there was nothing special about susceptibility to hypnosis. Almost anyone could be hypnotized. Yet Charcot pressed on, buoyed by the success of his public demonstrations.

    Why did Charcot medicalize hysteria and hypnosis? There is good evidence that he wanted to demystify all phenomena touted by the church as miracles. He hoped to substitute neurological explanations for religious ones. Auras, visions, imperviousness to pain, miracle cures (especially curing the blind): he wrote all of these off as hysterical symptoms. Epiphanies, the ecstasies of the saints, if not the resurrection itself, could be explained neurologically. Accounts of such religious phenomena, catalogued extensively by Charcot and reenacted onstage by Blanche and other hysterics as attitudes passionnelles, peddled a not-so-subtle form of anticlerical materialism to a hungry audience.

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    None of this fell too far beyond the pale until Charcot began to lay on a theoretical framework. He had proposed two ideas for which he had no real evidence—grand hysteria and grand hypnotism. Absent an anatomical lesion in the brain to explain them, he fell back on something he called a “dynamic lesion” of the nervous system, a transient and undetectable disruption of brain function. The whole enterprise was poised to fall under the weight of its own improbability. Brouillet’s painting depicts the moment when the public demonstrations became untethered from the clinical practice of medicine.

    The first sign of trouble appeared when Alfred Binet, an unpaid intern, quit his post in 1890 and publicly denounced Charcot’s theory. Binet and Charles Féré had recently published an exhaustive history of hypnotism, going back to Mesmer, in which they had summarized and defended both la grande hystérie and le grand hypnotisme. Binet then had a crisis of conscience. The public demonstrations were not genuine, he confessed. The theory of a pathological basis of hysteria could not stand up to facts in evidence. Since the birth of his daughters in 1887, Binet had become increasingly disenchanted with the hijinks perpetrated by the hypnotizers at the Salpêtrière.

    In one instance, they tried to induce a somnambulizing Blanche to take off her clothes and imitate taking a bath. According to Georges Gilles de la Tourette, the chief of Charcot’s lab, “When it came time to take off her corset, her entire body stiffened, and we barely had time to intervene in order to avoid an attack of hysteria, which in her case always begins in this fashion.” Binet abandoned neurology in favor of developmental psychology. (He would go on to develop the first intelligence test, the direct progenitor of the Stanford-Binet Intelligence Scale still in use today.)

    The end came three years later, in 1893, when Charcot died suddenly on a trip to Nièvre, France, at the age of 67. It was a shock to his colleagues, but not to Charcot himself. A lifelong smoker who did no exercise of any kind, he had already diagnosed his own heart problem, and when stricken he knew exactly what was happening. But he did not know what would happen next. At the announcement of his death, the Paris School he had founded ceased to exist. The theory of la grande hystérie was shelved, the Tuesday and Friday clinics came to an end, and most tellingly, Blanche Wittman never again had a hysterical attack.

    In her final year, Blanche agreed to speak to a reporter about her stint as the Queen of the Hysterics.

    This last point, noted by Babinski, settled the matter. At first diagnosed as epileptic, then as hysterical, then treated with hypnosis, electrotherapy, and massage by a team of physicians over a 15-year period, Blanche was finally cured by the departure of the only audience she cared about. She had lost her Svengali.

    Jane Avril, the most famous dancer at the Moulin Rouge and a favorite model for Henri Toulouse-Lautrec, wrote a memoir of her 18-month stay in the hysteria ward at the Salpêtrière, among the “stars of hysteria,” as she called them.

    There were those deranged girls whose ailments named Hysteria consisted, above all, in simulation of it . . . . How much trouble they used to go to in order to capture attention and gain stardom . . . . In my tiny brain, I was astonished  every time to see how such eminent savants could be duped in that way, when I, as insignificant as I was, saw through the farces. I have said to myself since that the great Charcot was aware of what was happening.

    He was, but he had his reasons to keep the show going. Gilles de la Tourette and Babinski did not. With Charcot gone and with the hospital now trying to disassociate itself from his theories, his two senior assistants had an extremely difficult time. Both lost all academic support and were denied chairs in medicine at the Salpêtrière. Gilles de la Tourette continued to defend Charcot’s legacy, but Babinski backed down and conceded the purely psychological basis for all hysterical phenomena. He renamed the condition pithiatisme, from the Greek, meaning curable through persuasion (the name never caught on). Babinski later discovered a curious hardwiring of the human nervous system: the stroking of the sole of the foot in someone with even subtle brain damage causes the big toe to extend upward while the other toes fan out. This is called the Babinski sign and it is performed thousands of times every day as an obligatory part of any neurological examination. No other neurological sign has had its durability or provided such a degree of certainty concerning damage to the nervous system. It made Babinski one of the most famous eponyms in medicine.

    Toward the end, even Charcot had privately begun to acknowledge his mistake. Le grand hypnotisme, he conceded, was not a true disorder or even a syndrome. Hypnosis, it was becoming increasingly clear, was a universal susceptibility. Under pressure from almost every corner of the research community, he also backed down from his claims about hysteria as a disease of the body, at least in private. In 1891, he admitted that it was, “for the most part, a mental illness.” But Charcot never openly conceded defeat. The painting shows why. His skepticism did not extend to the handful of star hysterics who packed audiences into his amphitheater each week. The standout was Blanche.

    Throughout the 1880s, dancers, magicians’ assistants, models, opera divas, and stage actresses traipsed over to the Salpêtrière to see the one person who embodied the fullest range of emotive performance on the Continent. When Sarah Bernhardt, the on-again, off-again darling of the European theater scene, wished to recapture her popularity upon her return to the Paris stage in 1881, she too headed to the Salpêtrière to see Blanche perform. Jules Claretie, the director of the Théâtre Français, writing for Le Temps in 1884, put it bluntly: “Never has an actor or painter, never a Rachel or a Sarah Bernhardt, Rubens or Raphael, arrived at such a powerful expression. This young girl enacted a series of tableaux that surpassed in its brilliance and power the most sublime efforts by art. One could not dream of a more astonishing model.”

    Hardly anyone uses hypnosis anymore in a hospital setting because it is paternalistic and exposes a subject’s vulnerability.

    Nonetheless, Blanche Wittman lived at the Salpêtrière as an institutionalized mental patient. She was given menial tasks to perform, including laundry and other cleaning, and she was of course called upon to participate in Charcot’s weekly demonstrations. By all accounts, she was one of the greatest improvisational actors of all time. In her final years, Blanche’s insistence on the legitimacy of her role-playing never waned. After Charcot’s death, she went to work in the Salpêtrière’s photo lab, and soon was transferred to the new radiation lab. Like Marie Curie, completely unaware of the dangers, she was exposed to repeated X-rays. Within a few years she began to undergo a series of necessary amputations, first of digits, then of limbs. As she succumbed to radiation poisoning, she refused to repudiate any aspect of grand hysteria. In her mind, it had been as real as epilepsy.

    She died in 1913 at the age of 54, and to the end she defended Charcot. In her final year, Blanche agreed to speak to a reporter about her stint as the Queen of the Hysterics. She claimed to have feigned nothing, arguing that no one could have fooled the great Charcot. “If we were put to sleep, if we had fits, it was because it was impossible for us to do otherwise. Besides, it’s not as though it was pleasant!” When asked if there had been any simulation, she replied sharply, “Simulation! Do you think that it would have been easy to fool Monsieur Charcot? Oh yes, there were certainly some jokers who tried! He would look them straight in the eye and say, ‘Be still!’ ”

    The Salon of 1887 ended after two months. The French government bought Un Leçon Clinique and shipped it off to Nice, where it went on display for a number of years before being consigned to storage. It was later cleaned and hung in a neurological hospital in Lyon, out of sight, but not out of mind. In 1887, Eugène Pirodon made an engraving of the painting, and this small reproduction sold very well. It brought the image to the attention of millions. Sigmund Freud purchased a copy and hung it in his examination room in Vienna, and later, after relocating to London, he did the same. Either the painting or the engraving has become the stock image of a quaint form of medical credulity, on par with phrenological heads and orgone boxes. Unfortunately for medical science and for the man himself, it is how Charcot is remembered. He didn’t live long enough to ward off that impression.

    The meaning of any work of art changes over time. Standing in front of Brouillet’s painting today, one finds it difficult to appreciate what it meant to viewers when it debuted. Charcot saw psychiatry and neurology as cooperative specialties. They should, he wrote, “philosophically speaking remain associated with each other by insoluble ties.” The painting marks the moment when that hope was dashed, and the two fell apart in the most confounding way, partly because of Charcot himself—his role in creating the very scene Brouillet depicted—and in a small yet significant way, partly because Brouillet chose to depict it at all. He unwittingly immortalized a catastrophic failure.

    Charcot believed he could separate mind and brain by treating the human subject as an automaton, as a sensorimotor machine. Instead of visiting his patients on the wards, he had them brought to his office. Instead of interviewing them, he examined their bodies in silence. Instead of interacting with them, he let his assistants do it. Onstage, he treated them like servants, speaking freely as if they were not present and could not hear. Charcot thought he was removing any potential bias this way, and in doing so, he seems to have overlooked the mind entirely. Blanche Wittman and his other subjects heard everything, unconsciously processed it, and fed it back in a finely tuned performance.

    Hypnosis does work as a short-term intervention. Hardly anyone uses it anymore in a hospital setting because it is paternalistic and exposes a subject’s vulnerability, although it remains popular in alternative medicine. People undergo hypnosis today for the same reasons therapists used it a century ago. It can help people break habits they may or may not be aware of. It makes use of the subject’s suggestibility, which exists along a spectrum of personality types. Had Charcot used it strictly for the purpose of artificially producing symptoms of hysteria and epilepsy, had he not invested himself in what most of his contemporaries viewed as sideshow antics, he would command greater respect today.

    But Brouillet’s painting, perhaps more than anything Charcot himself ever did, exposed him in flagrante, duping himself in front of a double audience—the one portrayed in the painting and the one viewing it. Had it been an isolated incident of a great scientist exceeding the bounds of the scientific method, the painting might not merit all that much attention. But there is more to be found in it, facts unknown to the viewers of 1887, and a crowning irony even Charcot overlooked. A real neurological disease did indeed lurk behind many of the hysterical symptoms he so painstakingly observed, and he missed it, even though all along it was right there under his Napoleonic nose.


    How the Brain Lost Its Mind

    From How the Brain Lost Its Mind by Allan H. Ropper, MD and Brian David Burrell, published by Avery, an imprint of Penguin Random House, LLC. Copyright (c) 2019 by Dr. Allan H. Ropper and Brian David Burrell.

    Allan H. Ropper and Brian Burrell
    Allan H. Ropper and Brian Burrell
    Brian Burrell's earlier book Reaching Down the Rabbit Hole was a collaboration with Dr. Allan Ropper, in which the two authors describe their bizarre and poignant encounters with patients who are dealing with brain and nervous system disorders at a major teaching hospital. Burrell is a Senior Lecturer in Mathematics at the University of Massachusetts Amherst, where he has taught for 25 years. Burrell's latest book resulted from two years spent shadowing Dr. Ropper at Boston's Brigham and Women's Hospital. Dr. Allan H. Ropper is a Professor of Neurology at Harvard and Executive Vice Chair of Neurology at Brigham and Women's Hospital in Boston. He has over 180 professional publications on varied subjects in neurology and is sought after as a speaker at medical and medical-social events. He has served as an advisor to the Vatican through the Pontifical Scientific Council and was a member of the Defense Health Board of DOD.

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