A lesson of Doctor Charcot at the Salpetriere

“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 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.

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.  

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)

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.

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.

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.

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.

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