A lesson of Doctor Charcot at the Salpetriere

Une Leçon du Docteur Charcot à la Salpêtrière

“Une Leçon du Docteur Charcot à la Salpêtrière” is the title of a painting by Pierre Aristide André Brouillet (1857-1914). It depicts a lesson of Doctor Charcot, at the Salpêtrière Hospital in Paris, France, and was first shown at the Paris salon of 1888′

The painting is a rather large work, painted in bright, highly contrasting colors, measuring 430 cm x 290 cm. Today it hangs, unframed, in a corridor of the Descartes University in Paris, near the entrance of the Museum of the History of Medicine, which houses one of the oldest collections of surgical, diagnostic, and physiological instrumentation in Europe.

To the left of Charcot is the patient Blanche Wittmann, one of the star hysterical patients and hypnotic subjects at the Salpêtrière. She resided at the hospital for 17 years, from 1878 to 1895.

Jean-Martin Charcot

Jean-Martin Charcot

Jean-Martin Charcot had been among the first to treat hysteria as a knowable neurological disorder, despite its vague symptoms that seemed to have no discernible physiological source.

He was born in Paris on November 29, 1825, to Simon-Pierre Charcot, a 27 year-old carriage builder and artisan. The young Charcot first came to the Salpêtrière in 1849 as a medical student. He returned in 1862 in the position of hospital “medecin en chef” and remained there until his death in 1893.

While most medical practitioners saw the Salpêtrière as a place to be avoided, a “Versailles of misery” rather than a site of scientific innovation, Charcot saw its large and diverse patient population as providing an excellent opportunity for the comparative study of disease. It was nothing less, he declared, than an immense “living pathological museum”.

Each week at the Salpêtrière, Charcot presented for study his ailing patients, who these days were most often hysterical women. He discussed their symptoms – for example irrational ramblings and convulsive spasms – before a rapt and eclectic audience of curious scientists, skeptical journalists, and chic socialites.

Charcot considered hysteria a physical ailment. He believed that hysterical symptoms were caused by an unknown internal injury affecting the nervous system. Until Freud hysteria was considered an exclusively female disease.

01A6AYP5; PHOTOGRAPHING THE PATIENT At La Salpetriere hospital, Paris, doctors working with Charcot obtain photographic documentation of hysteria patients in various states. Engraving by L Poyet in ‘La Nature’ 1 September 1883 page 216

Hysteria

Hysteria is derived from the Greek hystera, meaning “uterus,” and reflects the ancient notion that hysteria was a specifically female disorder resulting from disturbances in uterine functions.

Hippocrates (5th century BC) is the first to use the term hysteria. Indeed he also believes that the cause of this disease lies in the movement of the uterus (“hysteron”). The Greek physician provides a good description of hysteria, which is clearly distinguished from epilepsy. He emphasizes the difference between the compulsive movements of epilepsy, caused by a disorder of the brain, and those of hysteria due to the abnormal movements of the uterus in the body.  

A hysterical female patient at the Salpêtrière sticking out her tongue in a supposedly automatic response to the tuning fork used by the physician. Source: Paul Richer, Nouvelle iconographie de la Salpêtrière (Paris, 1889), plate 34.

While hysteria is no longer recognized and started to “fall out of fashion” in the 20th century, this was actually a long and unsteady process.

The first Diagnostic and Statistical Manual of Mental Disorders (DSM-I) of the American Psychiatric Association (APA) — published in 1952 — did not list hysteria as a mental health condition.

Yet it reappeared in the DSM-II in 1968, before the APA dropped it again in the DSM-III, in 1980.

Time and again, researchers of medical history point to evidence that hysteria was little more than a way to describe and pathologize “everything that men found mysterious or unmanageable in women.”

Today the term is no longer used in a formal way. It has been replaced by “conversion disorder”, a type of mental disorder in which a wide variety of sensory, motor, or psychic disturbances may occur. It is traditionally classified as one of the psychoneuroses and is not dependent upon any known organic or structural pathology. 

In simple words, conversion disorder is when a person experiences temporary physical symptoms, such as blindness or paralysis, that do not have a physical cause. (6)

Salpêtrière Hospital, Paris. c. 1881.

The Salpêtrière

The hospital was founded by the royal government in 1656 under the guidance of Cardinal Mazarin. It is located in the 13th arrondissement of Paris, on ground called “Le petit Arsenal”, the site of a gun factory – Salpetre of course means saltpeter, used for manufacturing gunpowder. A variety of sources for the 17th and 18th centuries cite between six and eight thousand inmates, making it the largest hospital in Paris and perhaps in all of Europe.

Part asylum, part prison, part old people’s home, this remarkable hybrid institution housed for over two centuries every imaginable form of social and medical “misfit” from the lowliest sectors of Parisian life.

The first resident doctor appeared in the Salpêtrière in the early 1780s, over 130 years after the institution had been in operation.

During Philippe Pinel’s long tenure at the hospital from 1795 to 1826, a string of reforms was begun including the prohibition of physical violence against patients, the termination of all bloodletting practices, the keeping of extensive case histories, and the making of daily clinical rounds.

By the close of the 19th century, the general asylum of Pinel’s day to which medical students had dreaded being assigned, had been transformed into a temple of science and an internationally renowned educational center.

The more salient features of the Salpêtrière as it evolved in the 19th century are the following:

  1. the application of Pinel’s psychiatric humanism
  2. the establishment of scientific and teaching facilities
  3. the declericalization of staff
  4. the differentiation of the patient population

The largest number of people at the hospital at the turn of the century were the elderly and convalescent women who ranged in number from 2,500 to 2,850and resided in some 32 multi-storied dormitories. To this figure must be added between 720 and 800 psychiatric patients.

Patients with progressive organic diseases of the brain or acute mental illness stayed at the Salpêtrière until death or transfer to another asylum.

In 1886, the hospital included a total of 45 major buildings and approximately 60 smaller ones, of all sorts, standing on 310,000 square meters.

A budgetary report for the institution in 1894 records for that year the cleaning of 273 chimneys, 1,641 gaslights, and 4,629 windows. The complex grew by adapting as medical structures a wide variety of buildings, originally intended as prisons, hospices, barracks, clerical quarters, etc.

By the end of the first world war, the hospital had pretty much emerged in the form it retains today of a general health care center specializing in geriatrics and neurology.

The Salpêtrière of today is very different from that of a century ago. The buildings and amphitheater of the Charcot Clinic have been torn down, and a single row of dilapidated cabins is the only remnant of the old psychiatric quarter.

On the 31st August 1997, Princess Diana died in the hospital after her car crashed in the Pont de l’Alma tunnel in Paris. The BBC reported:

The Princess was taken from the wreckage and rushed to the Pitie-Salpetriere Hospital in south-east Paris. First medical reports indicated that she was suffering from concussion, a broken arm and cuts to her thighs. It later emerged that the Princess had suffered massive chest injuries.At 4.53am it was announced that the Princess had died.
BBC: Princess Diana dies after her car crashes in Paris
Sigmund Freud at the age of 31

Freud in the Salpêtrière

Freud studied at the Salpêtrière from October 1885 to February 1886, using a travel grant he won from the University of Vienna.

In a letter to his fiancé Martha, Freud wrote: “Charcot, who is one of the greatest doctors and whose genius is only limited by his sanity, is quite simply in the process of demolishing my ideas and my plans. I leave his course as if I was leaving Notre-Dame, full of new ideas about perfection.”

It must be noted though that once Freud returned from Paris to Vienna he embarked on his own process of discovery that led him to psychoanalysis.

Charcot held that hysteria, along with the vast majority of neurological and mental diseases and many other chronic diseases, was essentially the result of familial inheritance.

While Freud had initially accepted the notion of “la famille neuropathique” and while he never abandoned a role for heredity in the etiology of the neuroses, by 1892 he was beginning to consider acquired factors, and in particular, disorders in sexuality as the crucial and necessary cause.

Freud believed that hysteria was a result not of a physical injury in the body, but of a ‘psychological scar produced through trauma or repression’. Specifically, this psychological damage was a result of removing male sexuality from females, an idea that stems from Freud’s famous ‘Oedipal moment of recognition’ in which a young female realizes she has no penis, and has been castrated.

Doctor Jean-Martin Charcot

Charcot presented a signed copy of this photograph to Sigmund Freud upon his departure from Paris. The two men never met again after 1886.

Reproductions of the painting

In the nineteenth century, a considerable number of different versions of the original painting were produced.

Lithograph by Eugène Pirodon (1824-1908) 

Freud had a small (38.5 cm x 54 cm) lithographic version of the painting, created by Eugène Pirodon (1824-1908), framed and hung on the wall of his Vienna rooms from 1889 to 1938.

Freud’s couch on London

Sources

  1. FREUD’S LITHOGRAPH OF CHARCOT: A HISTORICAL NOTE, Wesley G. Morgan, Bulletin of the History of Medicine
    Vol. 63, No. 2 (SUMMER 1989), pp. 268-272
  2. The Salpetriere in the Age of Charcot: An Institutional Perspective on Medical History in the Late Nineteenth Century, Mark S. Micale, Journal of Contemporary History, Vol. 20, No. 4, Medicine, History and Society (Oct., 1985), pp. 703-731
  3. Freud in Paris, Kate Cambor; New England Review (1990-) Vol. 30, No. 2 (2009), pp. 177-189 (13 pages)
  4. The History of Hysteria, Ada McVean B.Sc. 31 Jul 2017
  5. The controversy of ‘female hysteria’; Written by Maria Cohut Ph.D. on October 13, 2020; Medical News Today
  6. Conversion disorder: What you need to know; Written by Bethany Cadman on January 11, 2018; Medical News Today

Winnicott’s “Good Enough Mother”

Seventy years ago, a middle-aged man walked into a BBC radio studio in London to record the first of a series of talks that would radically change the way mothers thought about parenting. The 50 or so broadcasts made by paediatrician and psychoanalyst Donald Winnicott between 1943 and 1962 on a wide range of subjects – from feeding and weaning to jealousy and stealing – popularised his psychoanalytic thinking on the relationship between babies and their mothers to such an extent that some of his catchphrases, such as the good enough mother and the transitional object, have entered everyday speech. (Anne Kampf, The Guardian, 19 April 2013)

Donald Winnicott
Donald Winnicott

David Winnicott (1896 was a-1971) was a British paediatrician and psychoanalyst. Today I pay tribute to the “Good enough Mother”, a concept he introduced in 1953, on the occasion of Mother’s Day 2013. Paul Wadey writes:

“His theories are primarily concerned with abandoning psychopathology in favour of the quality of emotional development of self, and the therapeutic process itself.  In these senses, Winnicott’s theoretical landscape can be simply understood in the form of two overlapping modalities: the first concerning the sense of reality, personal meaning, and selfhood as a distinct and creative centre of ones own experience; the second concerning the ‘use of the transitional object’ in the transitional process from the ‘subjective omnipotence’ of the infant toward a more mature appreciation of objective reality.”

Know your Child
Know your Child

I was introduced to the “Good enough Mother” by my friend Christina in the early 1980s.

The idea of imperfection as something positive was stunning to me.

Winnicott wrote: “There is no such thing as a baby; there is a baby and someone”.

In his introduction to “Human Nature”, Winnicott writes:

“The reader is entitled to know how it is that I come to be able to write about psychology. My professional life has been spent in paediatrics. Whereas my paediatric colleagues mostly specialized  on the physical side I myself gradually veered round towards specialization on the psychological side. I have never left general paediatrics, for it seems to me that child psychiatry is essentially part of paediatrics.”

Mary Cassatt: Under the chestnut tree
Mary Cassatt: Under the chestnut tree

BBC Radio 4’s “Woman’s Hour” introduces the concept like this (in 2005):

“Fifty years ago the analyst and parenting expert Donald Winnicott first documented his idea of the ‘good-enough mother’; the mother who wasn’t perfect and was free, to some extent, to fail. His writings were revolutionary because he argued that failing was in fact a necessary part of parenting, and through the failure of the parent the child realises the limits of its own power and the reality of an imperfect world. “

Parent and Baby's Hands and Feet

Winnicott wrote in a way that made him easy to understand. Here is a sample (My thanks to “The Present Participle“):

“The good-enough ‘mother’ (not necessarily the infant’s own mother) is one who makes active adaptation to the infant’s needs, an active adaptation that gradually lessens, according to the infant’s growing ability to account for failure of adaptation and to tolerate the results of frustration. Naturally, the infant’s own mother is more likely to be good enough than some other person, since this active adaptation demands an easy and unresented preoccupation with the one infant; in fact, success in infant care depends on the fact of devotion, not on cleverness or intellectual enlightenment.  The good-enough mother, as I have stated, starts off with an almost complete adaptation to her infant’s needs, and as time proceeds she adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure.  The infant’s means of dealing with this maternal failure include the following:

1. The infant’s experience, often repeated, that there is a time-limit to frustration. At first, naturally, this time-limit must be short.

2. Growing sense of process.

3. The beginnings of mental activity.

4. Employment of auto-erotic satisfactions.

5. Remembering, reliving, fantasying, dreaming; the integrating of past, present, and future.

If all goes well the infant can actually come to gain from the experience of frustration, since incomplete adaptation to need makes objects real, that is to say hated as well as loved. The consequence of this is that if all goes well the infant can be disturbed by a close adaptation to need that is continued too long, not allowed its natural decrease, since exact adaptation resembles magic and the object that behaves perfectly becomes no better than a hallucination. Nevertheless, at the start adaptation needs to be almost exact, and unless this is so it is not possible for the infant to begin to develop a capacity to experience a relationship to external reality, or even to form a conception of external reality”.

Pablo Picasso: Mother and Child
Pablo Picasso: Mother and Child

Jennifer Kunst, wrote in “Psychology Today”:

“Winnicott’s good enough mother is sincerely preoccupied with being a mother. She pays attention to her baby. She provides a holding environment. She offers both physical and emotional care. She provides security. When she fails, she tries again. She weathers painful feelings. She makes sacrifices. Winnicott’s good enough mother is not so much a goddess; she is a gardener. She tends her baby with love, patience, effort, and care.

What I like about Winnicott’s picture of the good enough mother is that she is a three-dimensional human being. She is a mother under pressure and strain. She is full of ambivalence about being a mother. She is both selfless and self-interested. She turns toward her child and turns away from him. She is capable of great dedication yet she is also prone to resentment. Winnicott even dares to say that the good enough mother loves her child but also has room to hate him. She is not boundless.  She is real.”

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Simcha, in Seatlle’s Psychotherapy blog gives a pretty good description of what the “Good enough Mother” does:

Winnicott spoke of the “good enough” mother who adapts to her baby, and in so doing – gives it a sense of control and comfort.  “The good-enough mother,” wrote Winnicott in 1953, “starts off with an almost complete adaptation to her infant’s needs, and as time proceeds adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure.” It is the mother’s responsiveness to her baby’s cries for food or comfort that allows the baby to know he exists, to believe he is in control; he believes in his early months that his mother is, in fact, merely an extension of himself.

Gradually, as the mother begins to present objects to the baby and the baby interacts with these objects, he comes to understand that they have an existence outside of himself – that there is in the universe such a thing as “me” and “not me” (objective reality).

In time, the mother begins to move away from her state of total and constant preoccupation with and instantaneous gratification of the baby.  She begins to offer small doses of “optimal frustration” to  her child, just enough to create a proper environment for the child to learn and build his character (“I will come bring you the cookie shortly, sweetie, as soon as I finish my phone conversation”).

Possibilities and Limitations
Possibilities and Limitations

In an article, Sarah Liebetrau notes:

It is reassuring to note that Winnicott concluded, “almost all mothers are effective and do not have to meet any one’s definition of perfection to be so.”  It is better for us as parents to accept ourselves as we are, and to do the best we can, than to attempt to be ‘perfect’ and then, necessarily, fail. Winnicott seemed to be trying to move away from the popular idea at the time that there was one set, agreed-upon way to raise children, and if you didn’t do it that way, you were a ‘bad’ parent. Winnicott wanted to do away with the notions of ‘good’ and ‘bad’ parents as they are abstract concepts that cannot apply to real people. Instead there is only ‘good enough’ or ‘not good enough’.

Donald Winnicott
Donald Winnicott

I conclude this brief review with a statement that opens the door to a key aspect of Winnicott’s work. The development of the true-self personality, and creativity.

‘Winnicott envisioned the infant as born with the potential for unique individuality of personality (termed a True Self personality organisation), which can develop in the context of a responsive holding environment provided by a good-enough mother.’ Thomas Ogden (1990) (My thanks to Paul Wadey)