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.
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.
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?
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.
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.
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.
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.
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.
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.”
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.
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, 2019.
In
Search of Hysteria: The Man Who Thought He Could Define Madness. By By Allan H. Ropper and Brian Burrell. LitHub,
September 20, 2019.
Ep 332, The Psych Files , September 3, 2019
Penguin Random House
Neurology
and psychiatry both struggle to engage with disorders that elude neat
classification. Neurologists deal with well-characterized biological conditions
such as Huntington’s disease. But they also treat ‘in-between’ disorders such
as Tourette’s syndrome (characterized by involuntary vocalizations or
movements), and see people with physical symptoms that are ultimately revealed
as strictly psychological. Most psychiatrists, for their part, work with the
conviction that all mental illness has a biological basis. Yet they insist that
the content of mental suffering matters, and that their task is to heal minds,
not just fix brains.
These
disciplines might seem to have a great deal to say to one another. Instead,
they labour mostly in isolation. How did that happen, and what are the
consequences? In their thoughtful and engaging book, How the Brain Lost its
Mind, neurologist Allan Ropper and writer–mathematician Brian Burrell tackle
that question in an original way: by exploring two medical histories that are
generally told separately.
One
concerns neurosyphilis, a late-stage form of the sexually transmitted disease
syphilis. The other centres on hysteria, a disorder in which psychological
stresses are expressed through a range of physical symptoms.
In the
nineteenth century, neurosyphilis was one of the most ubiquitous and fatal
forms of degenerative mental illness known to psychiatry. Termed general
paralysis of the insane, it was widely supposed by early practitioners to be
caused by bad heredity, ‘weak character’ or moral turpitude. That changed in
1913, when Japanese bacteriologist Hideyo Noguchi, working at Rockefeller
University in New York City, found traces of Treponema pallidum — the
spiral-shaped bacterium responsible for syphilis — in the brains of deceased
people with general paralysis. At the time, as many as one-third of patients in
mental hospitals had symptoms that could now be clearly traced back to syphilis.
Hysteria,
originally thought to be a gynaecological condition affecting only women, was
recast as neurological in part through the efforts of distinguished
nineteenth-century French neurologist Jean-Martin Charcot. The symptoms he saw
in his patients — partial paralysis, convulsions, vision problems and tics —
certainly looked neurological. By the final years of the century, however,
critics of Charcot and even some of his former loyal students (including Joseph
Babinski, who discovered the ‘Babinski reflex’ in infants) had concluded that
the condition was a kind of fraud — a psychological disorder masquerading as a
neurological one. Babinski even proposed that neurology abandon the term
hysteria altogether and replace it with the term ‘pithiatism’: a condition
produced through persuasive suggestion and eliminated in the same way. As the
authors note, hysteria turned out to be “a profound mind problem that makes the
sufferer act as if he or she were diseased”. Neurosyphilis, meanwhile, was a
“brain disease that can produce a simulacrum of mental illness”.
According
to How the Brain Lost its Mind, the unmasking of hysteria as psychological gave
us Sigmund Freud and his new field of psychoanalysis. It also led, eventually, to
the post-war neo-Freudian conceit that problematic behaviours with no
associated disease should nevertheless be treated as medical. But while
psychological understanding of hysteria transformed psychiatry, neurologists
still struggled to help patients with symptoms that a previous generation would
have called hysterical. As many as 30% of the cases seen in neurology
departments elude organic explanation even today, the authors tell us. And the
field does not seem much better equipped to make sense of such cases than it
was in Charcot’s time.
Meanwhile,
the discovery that general paralysis was a symptom of a sexually transmitted
disease galvanized subsequent generations of psychiatrists. They embarked on a
quest, still largely unfulfilled, to find biological foundations for other
mental disorders, especially grave conditions such as schizophrenia. Only later
would it become clear, as the authors point out, that neurosyphilis is “an
unsuitable model for anything clearly unrelated to infection or inflammation in
the frontal and temporal lobe regions”.
Although
the histories of these two conditions are normally seen as separate, Ropper and
Burrell make clear that they interacted in a range of ways. Early on, both
conditions were widely recognized as tricksters or “imitators” of other
maladies, including each other. Some cases of syphilis were almost certainly
misdiagnosed as hysteria, and vice versa. But even more significantly, sex —
and profound anxieties about it — had a deep role in patients’ experience of
both disorders.
Ropper
and Burrell suggest that this was no coincidence. The age of Freud was also the
age of syphilis. Freud, and psychoanalysis more generally, focused on
suppressed sexual fantasies and traumas because, for patients then, the
shameful and terrifying spectre of syphilis hung over every sexual encounter
like “the sword of Damocles” .
Ultimately,
the authors insist, these tangled tales left behind a two-fold legacy. The
history of neurosyphilis bequeathed a tendency to indulge in excessive
reductionism. That of hysteria encouraged a tendency to indulge in excessive
psychologism. And both psychiatry and neurology were left the poorer. As the
authors argue, the majority of patients seen by practitioners in both fields
are afflicted with what they call “in-between states” — forms of distress
informed by both biology and biography. The book is in this sense a plea for
neurology and psychiatry to repair ruptures, join forces and do justice to the
experiences of their patients.
How the
Brain Lost its Mind offers a historical narrative that is mostly nuanced and
often moving. Particularly notable is its focus on patient experience, and how
people with syphilis talked about their suffering. There are occasional slips
into historical clichés that are inaccurate. At one point, the authors claim
that people with mental illnesses were “assumed to be possessed by evil
spirits” right into the nineteenth century, “when medical science chased away
the spirits”. In fact, medical understandings of mental disorders routinely
coexisted with religious, moral and supernatural ones as early as the sixteenth
century. (Medical theories in that era drew on humoral theory, which attributed
both physical and mental illnesses to imbalances in the four bodily ‘humours’.)
Ropper
and Burrell are powerfully focused on giving neurosyphilis its due as
psychiatry’s original “calling card, the core of its legitimacy”, and
rightfully so. I did feel, however, that they were sometimes tempted to
overstate its importance in the birth of biological thinking in psychiatry.
Neurosyphilis mattered, but there were other intellectual factors and forces —
anatomical research, reflex physiology, evolutionary theory, toxicology and
biochemistry — that drove psychiatry’s biological hopes over the years as well.
These
small points aside, How the Brain Lost its Mind is a rich, compassionate and
passionate book that deserves a wide audience. Sceptical of the excesses of both
psychological and biological reductionism, it is a refreshing call for an
intellectual reset and disciplinary rapprochement. I hope it inspires
much-needed cross-disciplinary debates and conversations.
A tale
of two disorders: syphilis, hysteria and the struggle to treat mental illness.
By Anne Harrington. Nature, August 19,
2019.
From the
mid-19th century until the 1950s, when the advent of antibiotics revolutionized
tuberculosis treatment, the primary treatment for the disease was the
Luft-Liegekur, or open-air rest cure. It was in the sanatorium, according to
the German physician Hermann Brehmer, that a strict regimen of diet, light
exercise, outdoor exposure, and rest could successfully cure TB infection.
Both
furniture makers and physicians capitalized on this “cure,” seeking numerous patents
for improvements and variations upon the adjustable chaise-longue, a reclining
chair with a long seat, and the schlafsofa, a sleep sofa that was a fixture of
sanatoria throughout Europe and the U.S. and eventually became a medical icon
throughout the West. As a physician who trained during a period when TB was a
leading medical scourge, Sigmund Freud would have been steeped in the culture
of the sanatorium and the Luft-Liegekur.
It’s no
surprise, then, that along with hypnosis, Freud’s early forays into psychological
medicine included the practice of treatments that sought to import ideals of
comfort and healthy relaxation derived from the long dominance of the open-air
rest cure. Among other practices, he employed massage and cutaneous
electrotherapy, including the use of the faradic brush, an electric brush used
to stimulate the skin.
In “An
Autobiographical Study,” Freud writes candidly that at the start of his
clinical career, “My therapeutic arsenal contained only two weapons,
electrotherapy and hypnotism, for prescribing a visit to a hydropathic
establishment after a single consultation was an inadequate source of income.”
He adds that his knowledge of electrotherapy was derived from neurologist Wilhelm
Erb’s “Handbuch der Electrotherapie,” a work cited three times in the “Standard
Edition of the Complete Psychological Works of Sigmund Freud.” In an 1888
encyclopedia article on “hysteria,” meanwhile, Freud enthusiastically endorses
the rest cure, consisting, as he describes it, of “isolation in absolute quiet
with a systematic application of massage and general faradizations.”
Hydrotherapy
and phototherapy, too, were traditional, asylum-based treatments for hysteria
and other mental maladies that Freud, like all practitioners of his generation,
was well aware of. The latter, which made use of ultraviolet irradiation, was
considered an effective treatment for hysteria, epilepsy, neurasthenia,
migraine, melancholia, mania, insomnia, and a wide variety of other psychiatric,
neurological, and general medical disorders.
19th-century
asylum keepers, psychologists, and university-based psychiatrists employed a
host of somatic and suggestive therapies to treat these conditions. These
therapies included hypnosis, hydrotherapy, cutaneous electrotherapy,
phototherapy, diet and rest cures, massage, and, with the introduction of
chemically prepared (as opposed to plant-derived) sedatives such as chloral hydrate
in 1869, some early efforts at modern psychopharmacology. Since these treatment
modalities (with the exception of psychopharmacology) usually required
recumbent posture, it seems reasonable to infer that their popularity promoted
an association in the minds of patients and practitioners alike between
recumbence and cure. It would be glib to speak simply of submission to medical
authority when many of these treatments sought to import ideals of domestic
ease and comfort into the psychiatric setting.
Trance
states were initially construed to be a form of “neurohypnotism” or “nervous
sleep,” so it made sense for practitioners to have furniture suitable for
reclining, sleeping, swooning, or becoming entranced while recumbent. During
his 1885–1886 sojourn in Paris at the Salpêtrière Hospital, Freud learned about
hypnosis in the treatment of hysteria from the world-famous neurologist
Jean-Martin Charcot. Upon his return to Vienna, as he embarked upon the private
practice of clinical neurology specializing in the treatment of nervous and
mental disorders, Freud settled into a 10-year dalliance with hypnosis. At the
height of Charcot’s rivalry with Hippolyte Bernheim in the 1880s and 1890s over
suggestibility and the nature of hypnosis, Freud translated both men’s work
into German and wrote prefaces to the three volumes of their writings he
translated. Bernheim and his followers in the Nancy school of hypnotists,
including August Forel, Leopold Löwenfeld, Oskar Vogt, and Otto Wetterstrand,
emphasized the need for a calm, quiet environment for their treatments and encouraged
patients to fall asleep during hypnotic sessions.
The
private practice of German hypnosis doctors, among them some of the leading
contributors to the Zeitschrift für Hypnotismus (Journal of Hypnotism), was
dominated by this approach. This development coincided with the rise of
office-based private practice in Germany and Austria, and the emergence of the
tradition of the reserved office hour. Freud’s early practice of hypnosis was,
in fact, modeled upon the Nancy school’s emphasis on recumbence and sleep.
Thus,
the use of recumbent posture in psychoanalysis evolved in part from these
traditions of sanatorium- and asylum-based somatic therapies as well as from
the broader cultural backdrop of changing notions of comfort and interiority,
eventuating in what I call the medicalization of comfort. The illustration above
nicely illustrates this point. In this image, published in Harper’s Magazine in
1878, the hospitalized patient is seen resting comfortably in a recliner that
closely resembles the standard chaise-longue of the TB sanatorium. His
concerned family members attend him in seated comfort, one of them in what
appears to be a rocking chair. The scene is one of institutionalized
domesticity. At least for the private patient, some trappings of the comforts
of home accompany him during his hospital stay. His recumbent posture signifies
how, by the time Freud began to develop his ideas about the optimal treatment
setting for psychoanalysis, notions of healing and comfort had thoroughly
melded.
This
article is an adaptation from the book :
On the Couch: A Repressed History of the Analytic Couch from Plato to
Freud. By Nathan Karvis, published by The MIT Press, September 1, 2017
Although
the term “hysteria” isn’t used in medical diagnoses today, it was once applied
to an astonishingly wide range of mental and physical symptoms, primarily in
women. Even the disorder’s name is strongly gendered: “hysteria” is derived
from the ancient Greek word for “uterus”; medical texts of that period
attributed the affliction to a displaced, or “wandering,” womb.
Hysteria
has a long history in medicine, surfacing in different cultures at different
times. Its study was widely popularized in the late 19th century, especially in
France, where the neurologist Jean-Martin Charcot set up a clinic for hysterics
at La Salpêtrière hospital in Paris. Although little known today, Charcot’s
experiments with young “hysterical” women became a touchstone both for Sigmund
Freud’s early work and, later, for the founding principles of the Surrealist
movement.
Hysteria
was considered to be a highly complex condition: It was generally thought of as
a mental disorder accompanied by physical symptoms such as fits. Historian Lisa
Appignanesi writes in her 2007 book Mad, Bad and Sad: A History of Women and
the Mind Doctors that in Charcot’s France, the term “described a sexualized
madness full of contradictions, one which could play all feminine parts and
take on a dizzying variety of symptoms, though none of them had any real
detectable base in the body.” (Charcot admitted that men also suffered from
hysteria, but he argued that these cases were generally caused by traumatic
accidents, rather than by a gendered predisposition.)
Charcot’s
research was made famous through the ailing individuals who lived at La
Salpêtrière and whose symptoms were displayed and analyzed in sessions open to
members of the public. Charcot became a celebrity doctor, turning his
semi-staged diagnostic sessions into spectacles for (masculine) public
consumption. The methods of diagnosis and treatment at La Salpêtrière were all
highly visual, creating a sort of theater of hysteria, in which the often young
and pretty “hysterics” acted out their symptoms as if by rote.
One of
Charcot’s innovations was to set up a photography studio at La Salpêtrière in
order to document the physical symptoms of his patients, such as the dramatic
and beautiful Augustine. These images were then widely disseminated in Paul
Regnard and Désiré Bourneville’s Iconographie Photographique de La Salpêtrière
(1876–80), an influential book of medical photography. Presented as a
scientifically accurate visual document, the book had a twofold effect: For
male readers, it provided a visual record of the attractive and often scantily
clad hysterics, while for some female consumers, it became a manual of hysteria
and its symptoms to be mimicked, reinforcing the stereotypes associated with
the condition.
In the
photographs, the camera takes the position of a detached voyeur, with the
subjects only looking at the lens and engaging directly with the image-making
when they are photographed in their “normal” or “sane” moments. When engaged in
the throes of a hysterical attack, the women are apparently oblivious of the
camera’s presence, revealing parts of their body that Victorian decency would
otherwise hide from view.
In a
photograph depicting the arc de cercle, or the “arch of hysteria,” which was
believed to show the anguish of the condition—and which Louise Bourgeois would
later famously subvert in bronze with a masculine form—the woman contorts her
body so that she is resting on her feet and shoulders. Her head is hidden, but
her shapely legs and feet are almost completely revealed. The relative distance
of the camera and the profiling of the subject suggest that this photograph is
taken to give the impression of scientific “truth,” but also simultaneously to
place the viewer at a voyeuristic remove, for both scientific study and visual
titillation.
Freud
was a student of Charcot, and achieved renown for his Studies in Hysteria
(1893–95). Charcot’s hysterics, Freud’s work, and the Salpêtrière photographs
together provided a wealth of cultural materials to inform the work of
Surrealist artists. In 1928, French writers André Breton and Louis Aragon
published an article in the journal La Révolution Surréaliste that contained
photographs of Salpêtrière hysteric Augustine and expressed the desire “to
celebrate here the quinquagenary of hysteria, the greatest poetic discovery of
the end of the nineteenth century.” Breton and Aragon continue, praising
“youthful hysterics” and the “delightful” Augustine. “Hysteria is not a
pathological phenomenon and can be considered in every respect a supreme means
of expression,” they conclude. An excerpt from Breton’s novel Nadja, published
that year, appears in the same issue of La Révolution Surréaliste. In this
book, Breton famously wrote “Beauty will be CONVULSIVE or it will not be,”
suggesting that the throes of a hysterical attack happen in a state of
sexualized, uninhibited passion.
Breton’s
advocation of the “convulsive” was taken as a guiding principle for Surrealist
art. Espousing the madness and “paranoiac” sensibilities he believed were
embodied by hysteria, Salvador Dalí took up the visual tropes of the
Salpêtrière photographs in a number of his works.
The
Phenomenon of Ecstasy (1933) is a photo collage depicting the faces of
“hysterical” women in the grip of what looks more like erotic pleasure than
pain. His paintings and drawings—such as Invisible Lion, Horse, Sleeping Woman
(1930)—also repeatedly present women arching their bodies in a way that
resembles the arc de cercle demonstrated by Charcot’s hysterics. In one
drawing, Poems Secrets Nude with Snail (1967), a female subject with her face
partially hidden arches her back to catch the milk from her lactating breasts
in her mouth. With mutilated bodies, exaggerated sexual features, and closed
eyes, Dalí’s women are vulnerable to the viewer’s gaze, disempowered by their
apparent enslavement to their uncontrollable gendered characteristics.
The
fascination with hysteria lasted throughout the key period of the Surrealists’
success. The invitation to the opening event of the 1938 Exposition
Internationale du Surréalisme (overseen by Marcel Duchamp) promised visitors a
night of l’hysterie. During the evening, the experimental collaborative
exhibition was used as a stage for a performance by the actress Hélène Vanel,
trained for the occasion by Dalí and Wolfgang Paalen. She jumped from a pile of
pillows, naked and chained, before splashing in a puddle and eventually
recreating a hysterical attack on a bed, linking the notion of the submissive
female body with mental instability and dependency.
The
Surrealists saw hysteria as a state in which poetic expression could run free,
at the expense of women who were not given a voice, but instead objectified.
Decades later, in 1980, hysteria was finally removed from the third edition of
the Diagnostic and Statistical Manual of Mental Disorders. But for a
significant period of time, this now-supposedly-defunct disease of the mind was
explained away as a fundamental condition of being female, and exploited by
scientists and artists alike.
The Dark
Side of Surrealism That Exploited Women’s “Hysteria”. By Anna Soutter. Artsy, January 18, 2019.
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